Download to the patient guide to lab services

TABLE OF CONTENTS
MISSION STATEMENT .............................................................................................................................. 3
GENERAL INFORMATION AND SERVICES ........................................................................................ 3
SUPERIOR RESOURCE .................................................................................................................................... 4
PROFESSIONAL SERVICES ............................................................................................................................. 4
REPORTING ................................................................................................................................................... 4
KEEPING YOU INFORMED ............................................................................................................................. 6
DEDICATION TO EXCELLENCE ...................................................................................................................... 7
QUALITY ASSURANCE / QUALITY CONTROL PROGRAMS .............................................................................. 7
QA Mission Statement.............................................................................................................................. 7
Quality Assurance (QA) plans ................................................................................................................. 7
Internal Quality Control (QC) ................................................................................................................. 7
Proficiency Testing. ................................................................................................................................. 8
Laboratory SOP manuals ........................................................................................................................ 8
PROFILES ................................................................................................................................................... 10
ORGAN OR DISEASE PROFILE ...................................................................................................................... 10
GENERAL PROFILES/ COMBINATIONS ......................................................................................................... 11
COMPRHENSIVE LIST OF PROCEDURES ......................................................................................... 14
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It’s All About Life
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Mission Statement
ICL will be known for service and technology leadership and for the integrity of the information we
provide. By exceeding customer expectations, we build the partnerships that will improve health care and
build confidence of the people we come to serve.
“ICL is established to contribute to the
maintenance and enhancement of the
quality of life throughout Ethiopia
by encompassing a system of human and
physical resources designed to met the
changing health care needs of the
population it serves.”
GENERAL INFORMATION AND SERVICES
In the early days of modern medicine, physicians relied mainly on the diagnostic tools of observation,
experience, and intuition when considering treatment options for patients.
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Today’s physicians don’t have to operate on instinct alone. Dramatic advances in testing capability have
made laboratories the primary diagnostic resource now used by physicians – their “sixth sense.” Years of
intensive research have provided the medical profession with an array of sophisticated, highly reliable
laboratory procedures that help pinpoint existing health conditions, predict the onset of others, and in
some cases, determine effective treatment options.
The vast volume of information that can now be relayed to a physician within hours of submitting a
patient’s blood, urine, or tissue sample to a clinical laboratory enables these professionals to prescribe
both appropriate treatments and preventive measures with greater confidence. The result is clinical
testing has become the gateway to higher quality, more responsive patient care.
Superior Resource
As one of the largest independent clinical laboratories in the continent, ICL serves as a gateway to quality
health and full partner in the physician / patient relationship. By providing patients, physicians and
hospitals with the accurate, reliable data they need in a timely fashion and by pioneering new, cuttingedge clinical procedures, ICL plays a critical role in the process of patient diagnosis, treatment and
monitoring.
ICL hopes to offer clinical laboratory services across Ethiopia through its sophisticated organization of
facilities, delivery service and communications. ICL in partnership with Bioscientia in Germany perform
a wide range of routine and esoteric clinical procedures for physicians, hospitals, researchers and other
clinical laboratories.
Professional Services
Our professional service department provides proper specimen handling and rapid, dependable delivery of
laboratory results through a nationwide telecommunications and transportation network.
The professional service department provides blood collection, direct specimen pickup, a controlled
environment for specimen transport, and delivery of laboratory test results and supplies. For service
information in your area, please contact our Customer Service department .
Reporting
Most frequently ordered tests are completed and usually reported within same dayfollowing receipt of
specimens in our laboratories. Those requiring longer testing time are reported as soon as results are
available.
ICL’s computerized reporting system offers
• Chart-ready printouts with reference intervals (normal ranges) for comparison.
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• Flagging of abnormal results.
• Cumulative patient result with graph
Reports can also be obtained via a graph for cummlative reports. (see below example of a Glucose
cumulative result of over a year testing)
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Test results may be delivered by
• Professional Service Representative through regularly scheduled service stops
• Telecommunication from our central computer to Physicians office teleprinters.
• Facsimile
• Direct pick up from any ICL location
Keeping You Informed
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ICL as part of its service, offers seminars, lectures, continuing education programs and publications (Test
Reviews) to health care providers. ICL plans to utilize this medium to discuss current technical issues
that affects health care field with emphasis to laboratory medicine.
In addition ICL will maintain an active World Wide Web site to provide its clients up-to-date information
regarding new tests and changes in tests procedures.
Dedication to Excellence
At ICL, quality is not compromised for expediency. Test results from every section of the laboratory are
routinely monitored for reliability, precision, and accuracy by both internal and external quality control
programs.
Quality Assurance / Quality Control Programs
ICL’s QA and QC programs are integral parts of its daily operation. The programs are overseen and
administered by dedicated laboratory professional working for the improvement of testing quality.
Standardized QA and QC programs are implemented and monitored by the managers and reviewed by the
directors of the laboratory.
QA Mission Statement
To facilitate the delivery of accurate testing and reporting to our customers by providing high quality
programs, information, standardized policies, and training materials to our employees
Quality Assurance (QA) plans
A written QA plan documents a systematic process for monitoring and evaluating testing quality and
resolving identified concerns. Testing quality is monitored and evaluated through
1. the routine collection of information about various aspects of lab operations and testing and
2. periodic assessment of collected information in order to identify and address concerns about
testing quality and opportunities for improvement.
A QA committee, consisting of laboratorians and service staff meets weekly to review performance
monitors and to resolve issues that lead to a monitor’s “threshold” level being exceeded. The committee
also evaluates the effectiveness of remedial actions taken. The effectiveness of the overall plan and the
appropriateness of each aspect of care are reviewed on an annual basis.
Internal Quality Control (QC)
ICL’s Quality Control program allows for the assessment of accuracy and precision of patient results
generated by our laboratories. Control samples with known analyte concentrations are routinely
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interspersed and analyzed with patient samples submitted for testing. Our computerized control
algorithms, based on the widely accepted, state-of-the-art Westgard rules, alert the laboratorian of
statistically or clinically significant analytical anomalies as they occur during the run. The laboratorian is
charged with taking immediate and appropriate corrective action. This highly responsive computer
assisted quality control process helps to detect and correct potentially erroneous results before they are
released to clients and patients.
Retrospective on-line QC inquiry for any ICL test is available to all laboratorians via the laboratory
computer system. This valuable QC information provides up-to-date feedback to the laboratorians,
supervisors and directors on the performance of the assay. Quantitative QC data, including monthly lotto-date and cumulative statistics, are summarized in graphic format each month for retrospective review
by department personnel.
Proficiency Testing.
ICL participates in an internally and externally administered blind quality surveillance programs. This
proficiency programs serves to test ICL’s complete testing service; specimen logistics, testing protocol,
laboratorian performance and quality assurance checks.
Laboratory SOP manuals
Written standard operating procedures (SOP’s) in our laboratories provide, among other things
1. Repeat criteria when controls are out of the established ranges.
2. How to handle patient results that are significantly abnormal clinically (high or low) and
3. Resolution of instances in which duplicate test results disagree or in which the coefficient of
variation for the assay is high.
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PROFILES
Profile Policy
ICL’s policy is to provide physicians, in each instance, with the flexibility to choose appropriate tests to
assure that the convenience of ordering test combinations/profiles does not distance physicians who wish
to order a test combination / profile from making deliberate decisions regarding which tests are truly
medically necessary. All the tests offered in test profiles / combinations may be ordered individually.
ICL encourages physicians to contact their ICL representative if the testing configurations shown here do
not meet individual needs for any reason, or if some other combination of procedures desired.
Organ/ Disease Panels
Electrolyte Profile
Panel includes
Carbon Dioxide
Chloride
Potassium
Sodium
Hepatic Function Panel
Panel Includes
Albumin, Serum
Alanine Aminotransferase (ALT)
Alkaline Phosphatase, Serum
Asparate Amintrasferase (AST)
Bilirubin, Direct
Bilirubin, Total
Hepatitis Panel
Diagnostic
Hepatitis A Antibody, IgM
Hepatitis B Core Antibody, IgM
Hepatitis B Surface Antigen
Diagnostic Follow-up
Hepatitis Be Antigen
Hepatitis Be Antibody
Hepatitis Bs Antibody
Patient Management
Hepatitis Bs Antigen
Hepatitis Be Antigen
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Hepatitis Be Antibody
Prevaccination Panel( HBV)
Hepatitis Bs Antigen
Hepatitis B Core Antibody, Total
Hepatitis B Core Antibody, IgM
Vaccine Follow-up(HBV)
Hepatitis B Surface Antibody
Lipid Panel / Cardiac Risk Evaluation
Panel Includes
Cholesterol, Total
High Density Lipoprotein (HDL)
Low Density Lipoprotien (LDL)
Triglycerides
LDL/HDL Ratio
Metabolic Panel, Comprehensive (CHEM
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Panels Include
Albumin
A/G Ration (calculation)
Alkaline Phosphatase
Asparate Aminotransferase (AST)
Alanine Aminotrasferase (ALT)
Bilirubin, Total
BUN
Calcium
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Carbon Dioxide
Chloride
Creatinine
Globulin, Total (calculation)
Glucose
Potassium
Protein, Total
Sodium
Metabolic Panel, Basic (CHEM 7)
Panel Includes
BUN
Carbon Dioxide (CO2)
Chloride, Serum
Creatinine, Serum
Glucose
Potassium, Serum
Sodium, Serum
Thyroid Panel
Panel Includes
Free Thyroxine Index (FTI)
Thyroxine (T4)
T3 Uptake
Thyroid Panel with TSH
Panel Includes
Free Thyroxine Index (FTI)
Thyroxine (T4)
T3 Uptake
Thyroid Stimulating Hormone (TSH)
Additional General Panels
Disseminated Intravascular Coagulation
Panel Includes
PT and PTT
Platelet Count
D-dimer
Fibrinogen
Anemia Panel A
Panel Includes
CBC with Diff and Platelet
Iron
Iron Binding Capacity (IBC)
Reticulocyte Count
Anemia Panel B
Panel Includes
CBC with Diff and Platelet
Ferritin
Folate (Folic Acid)
Iron
Iron Binding Capacity
Reticulocyte Count
Vitamin B12
Bone/ Joint Panel
Panel Includes
Uric Acid
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Calcium
Phosphorus
Alkaline Phosphatase
Total Protein
Albumin
Cardiac Injury Panel
Panel Includes
LDH (Lactate Dehydrogenase)
CK (Creatine Kinase)
CK Isoenzymes
Troponine
Myoglobin
Coagulation Panel
Panel Includes
Prothrobmin time
Partial Throboplastin time (PTT)
Platelet Count
Bleeding time
Collagen Disease Arthritis Panel
Panel Includes
Sedimentation Rate (ESR)
RF (Rheumatoid factor) latex
Uric Acid
ANA (Antinuclear Antibody)
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C-Reactive Protein (CRP)
Diabetic Panel
Panel Includes
Fasting Blood Glucose (FBS)
Sodium
Carbon Dioxide
Potassium
Chloride
Cholesterol
Triglycerides
Creatinine
Hemoglobin A1C
Fructosamine
B2 microglobulin, urine
Ovarian Function Panel
Panel Includes
Estradiol
Follicle Stimulating Hormone (FSH)
Free Thyroxine Index (FTI)
Luteinizing Hormone (LH)
Prolactin
T3 Uptake
Thyroid Stimulating Hormone (TSH)
Thyroxine (T4)
Testicular Function Panel A
Panel Includes
Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Prolactin
Testosterone, Total
Pancreatic Panel
Panel Includes
Amylase
Lipase
Calcium
Glucose
Parathyroid Panel
Panel Includes
Calcium
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Phosphorus
Magnesium
Alkaline Phosphatase
Total Protein
Albumin
Creatinine
Urine Calcium
Renal Panel
Panel Includes
BUN/ Creatinine
Creatinine, 24 hr Urine
Protein, Total, 24 hr Urine
Creatinine Clearance
Total Protein
Albumin
Sodium
Potassium
Chloride
Carbon Dioxide
Glucose
Rash Panel
Panel Includes quantitative antibodies for
Adenovirus
Herpes Simplex
Rubella
Rubeola
Prenatal Panel A
Panel Includes
ABO Grouping and Rh Typing
Antibody Screen
CBC with Diff
Hepatitis Surface Antigen
Rubella
Syphilis (RPR)
Prenatal Panel B
Panel Includes
ABO Grouping and Rh Typing
Antibody Screen
CBC with Diff
Hepatitis Surface Antigen
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HIV 1/2 Antibodies
Rubella
Syphillis (RPR)
Transitional (Metastatic Disease) Panel
Panel Includes
Lactate Dehyrogenease (LDH)
Asparate Aminotransferase (SGOT)
Alkaline Phosphatase
Total Protein
Albumin
Calcium
Carcinoemryonic Antigen (CEA)
C-reactive protein
ESR
Febrile Agglutinins Panel
Panel Includes
Salmonella Typhi O Antibody
Salmonella Typhi H Antibody
Rickettisia OX19
TORCH (Toxoplasmosis, Rubella,
Cytomegalovirus, Herpes)
Panel Includes
Toxoplasmosis, IgG
Rubella, IgG
Cytomegalovirus, IgG
Herpes, IgG
Rheumatic Fever Panel
Panel Includes
ASO Antibody Titer
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COMPREHENSIVE LIST OF PROCEDURES
SET-UP: Mondays, Thursdays
1.25 DIHYDROXYCHOLICALCIFEROL SEE VITAMIN D
1.4-METHYLIMIDAZOL ACETIC ACID
REQUIREMENT: 10 ml urine from a 24 h collection. Put 5-10 ml acetic acid in the 24h urine container before collection. Quote
volume.
REF. RANGE: <3.8 mg/24h
METHOD: HPLC
SET-UP: once weekly
RESULTS READY: 2 days later
1-HYDROXYPYRENE
REQUIREMENT: 10 ml urine
REF. RANGE: <1µg/L METHOD: GC-MS SET-UP: once weekly RESULTS READY: 2 days later 3-ALPHA-ANDROSTANDIOL
GLUCURONIDE REQUIREMENT: 2 ml serum
REF. RANGE: Female: 90-200 ng/100mL Children: 0-12 years: 5-42 ng/100mL Male: 250-700 ng/100mL Children: 0-12 years: 542 ng/mL METHOD: RIA SET-UP: once weekly
RESULTS READY: two days later
4-OH-BUTYRIC ACID (LIQUID ECSTASY)
REQUIREMENT: 2 ml serum REF. RANGE: Detection limit: 1 mg/L
METHOD: GC-MS SET-UP: once weekly
RESULTS READY: two days later
5-FLUOROURACIL REQUIREMENT: 1 ml serum
REF. RANGE: Therapeutic range: 0.05 – 0.3 µg/mL Toxic: >0.4 µg/mL
METHOD: HPLC
SET-UP: once weekly
RESULTS READY: two days later
5-HIAA (U) – 5-HYDROXY INDOLEACETIC ACID (SEROTONIN METABOLITE)
REQUIREMENT: 10 ml 24h urine.
Put 0.5 ml of 25% hydrochloric acid in the shipping tube, mix well. Do not use acetic acid. Please state 24 h urine volume.
REF. RANGE: 2– 9 mg/24h
METHOD: HPLC
SET-UP: daily
RESULTS READY: next day
5-OH-TRYPTOPHAN
REQUIREMENT: 2 ml EDTA plasma
REF. RANGE: <0.01 mg/dL
METHOD: LC-MS
SET-UP: once weekly
RESULTS READY: two days later
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5-S-CYSTEINYLDOPA
REQUIREMENT: 3 ml EDTA plasma, FROZEN
FREEZE IMMEDIATLY
REF. RANGE:
Normal: <2.0 µg/L Borderline: 2.0-3.2 µg/L Melanoma possible: >3.2 µg/L
METHOD: HPLC
SET-UP: once weekly
RESULTS READY: two days later
6-MERCAPTOPURINE SEE AZATHIOPRINE
6-THIOGUANIN-NUCLEOTIDE
REQUIREMENT: 3 ml 3 EDTA blood
REF. RANGE: therapeutic range: 100-450 pmol/8x10high8 ery
In transplant patients (triple therapy with Azathioprine): 100 – 450
In chronic inflammatory bowel disease (Azathioprine): 250 – 450
Under chemotherapy (6-Mercaptopurine): 500 – 1000
Patients under Thioguanine therapy show 5 – 10 times higher 6-TGN values.
METHOD: LC-MS
SET-UP: once weekly
RESULTS READY: two days later
8-OH-2-DESOXYGUANOSINE
REQUIREMENT: 10 ml urine, FROZEN
REF. RANGE:
Preliminary range: 0.1-3.5 µmol/mol crea
METHOD: LC-MS
SET-UP: once weekly
RESULTS READY: two days later
11-DESOXYCORTISOL (COMPOUND S)
REQUIREMENT: 2 ml serum, FROZEN
REF. RANGE:
Premature: 1.4 µg/100ml
<12 years: 0.02-0.25 µg/100mL
Adults: 0.05-0.3 µg/100 mL
After metapyrone: 5-15 µg/100mL
After ACTH: <0.45 µg/100 mL
METHOD: RIA
SET-UP: Wednesdays
RESULTS READY: same day
17-HYDROXY-CORTICOSTERONE
REQUIREMENT: 10 ml of 24h urine (approx. 30 ml urine mixed with 6 N hydrochloric acid)
PH between 2-5. Please quote the 24hr volume
REF. RANGE:
Male: 5-23 mg/24h
Female: 3-15 mg/24h
No children’s reference ranges available
METHOD: photometric
Set-up: once weekly
Result ready: two days later
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17 KETOSTEROIDS
Requirement: 10 ml of 24h urine (approx. 30 ml urine mixed with 6 N hydrochloric acid)
PH between 2-5. Please quote the 24hr volume
Ref. Range:
Male: 9-22 mg/24h
Female: 6-15 mg/24h
Children (3-15 years):
Male: <13 mg/24h
Female: <10 mg/24h
METHOD: photometric
SET-UP: once weekly
RESULT READY: two days later
17-OH-PROGESTERONE
REQUIREMENT: 1 ml serum
REF. RANGE:
Female:
Follicular phase: 0.1 -1.0 ng/mL
Luteal phase: 0.9 – 5.0 ng/mL
Post-menopausal: 0.19 – 1.0 ng/mL
Oral contraception: 0.14-0.7 ng/mL
Male: 0.6-3.4 ng/mL
Children:
1 day old: <22.3 ng/mL
2 days – 1 month: <22.2 ng/mL
1 month-6 months: <5.1 ng/mL
6 months – 1 year:<1.4 ng/mL
1 year – 10 years: <1.1 ng/mL
10 years – 20 years: <2.5 ng/mL
METHOD: RIA
SET-UP: Mondays, Wednesdays, Fridays
RESULTS READY: same day
17-OH-PREGNENOLONE (S)
REQUIREMENT: 2 ml serum
REF. RANGE:
Adults: 30-350 ng/100mL
Prematures: <3600 ng/100mL
Newborn: <829 ng/100mL
Children:
1 month–1 year: 36-760 ng/100mL
1 year-15 years: 15-235 ng/100mL
METHOD: RIA
SET-UP: every two weeks
RESULTS READY: one week later
17-OH-PREGNENOLONE (U)
REQUIREMENT: 10 ml 24h urine collection. Please state 24h urine volume.
REF. RANGE: 95-500 ng/24h
METHOD: RIA
SET-UP: every two weeks
RESULTS READY: one week later
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18-OH-CORTICOSTERONE
REQUIREMENT: 2 ml heparin plasma or serum
REF. RANGE:
Resting: 12-55 ng/100mL
After Exertion: 23-145 ng/100 mL
After ACTH: <250 ng/100 mL
Premature: <670 ng/100 mL
Newborn: <550 ng/100 mL
Children:
0-1 year: 5-220 ng/100 mL
1-2 years: 18-155 ng/100 mL
2-15 years: 6-85 ng/100 mL
METHOD: RIA
SET-UP: once weekly
RESULTS READY: two days later
21-DESOXYCORTISOL
REQUIREMENT: 2 ml serum or 10 ml urine from a 24h collection.
Please state 24h urine volume.
REF. RANGE:
In serum: 2-15 ng/100 mL
<45 ng/100 ml after ACTH
In urine: 7-50 ng/24h
SET-UP: weekly
RESULTS READY: two weeks later
21-HYDROXLASE ABS
REQUIREMENT: 2 ml serum
REF. RANGE:
Normal: <10 abs-ratio
Borderline: 10-15 abs-ratio
SET-UP: once weekly
RESULTS READY: two days later
25-HYDROXY-CHOLECALCIFEROL SEE VITAMIN D
AB-GAMMA TEST (ABO IRREGULAR ANTIBODIES)
REQUIREMENT: 2 ml serum or plasma
REF. RANGE: negative
SET-UP: daily
RESULTS READY: same day
NOTE: Always state if patient is pregnant
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ABO Grouping and Rho(D) Typing
Synonyms Blood Grouping and Rh Typing; Blood Type; Group and Type; Type and Rh
Test Includes ABO blood grouping and Rh typing
Specimen Requirement Whole blood or Clotted blood
Volume 5 mL
Container Lavender-stopper (EDTA whole blood) tube or red-stopper tube (no serum-separator tube).
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; bacterial or other contamination
Use Determine ABO blood grouping (A, B, ABO, O) for transfusion candidates. Group and typing of expectant
mothers and newborns may indicate potential for ABO hemolytic disease of the newborn. Rho(D) typing is used
to determine Rh immune globulin candidacy for pregnant and postpartum patients.
Methodology Hemagglutination
Testing Schedule : Daily
Ace See Angiotensin-1-Converting Enzyme
ACETYLSALYCYLIC ACID
REQUIREMENT: 10 ml urine
REF. RANGE: see report
SET-UP: once weekly
Testing schedule: Referred to Bioscientia
Result ready with in 10 days
Acetylcholine Receptor Abs
Specimen Requirement: 2 Ml Serum
Ref. Interval:
normal: <0.25 nmol/L
borderline: <0.40 nmol/L
Use:- Contributed to diagnosis of myasthenia gravis.
Limitation:- Poor concordance between antibody titer and clinical activity. Use of nonhuman substrates may
produce false-negative results. Antibodies are not found in congenital myasthenia.
Method: RIA
Additional Information:- Antibodies to acetylcholine receptors are present in 90% of patients with generalized
myasthenia gravis and in 75% to 80% of patients with ocular disease.. Receptor modulating antibodies are present
in 90% of myasthenic patients, and may be useful in patients with recent onset of disease.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
ACETONE
REQUIREMENT: 10 ml urine
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REF. RANGE: <50 mg/L
SET-UP: once weekly
RESULTS READY: two days later
Acetylcholinesterase Assay (A.F.)
Specimen Requirement: 20 ml amniotic fluid
Ref-Interval: see report
Use:-Erythrocyte cholinesterase is measured to diagnose organophospate and carbamate
toxicity and to detect atypical forms of the enzyme. Cholinesterase is irreversibly inhibited by organophospate
insecticides and reversibly inhibited by carbamate insecticides. Serum or plasma pseudocholinesterase is a better
measure of acute toxicity while erythrocyte levels are better for chronic exposure. (Serum level returns to normal
prior to normalizing of red cell levels). Acetylcholinesterase is increased in amniotic fluid in cases of neural tube
defect. Limitations:-Values decrease as erythocytes become senescent
Additional Information:- . The RBC level is increased in hemolytic states such as the thalassemias,
spherocytosis, hemoglobin SS, and acquired hemolytic anemias. It is decreased in paroxysmal nocturnal
hemoglobinuria and in relapse of megaloblastic anemia. (It returns to normal with therapy)
. True cholinesterase (acetylcholinesterase-RBC cholinesterase) is not normally present in amniotic fluid.
Presence of acetylcholinesterase activity and increased levels of alpha-fetoprotein in amniotic fluid are
presumptive evidence of an open neural tube defect (eg anencephaly, open spina bifida, of omphalocele) in the
fetus.
Acid-Fast Bacilli (Mycobacteria)Smear
.............................................................................
Synonyms Mycobacteria Spmear (Sputum)
Specimen Requirement First morning sputum (not saliva.
Volume 5 mL sputum or respiratory aspirate.
Container Sterile container with tight screw-capped seal.
Causes for Rejection Inadequate quantity of specimen, including swab specimens without visible evidence of
tissue present. Specimens received after leaking transport container into specimen bag. Trach-suction devices
will often leak if the cap with tubing is not removed and replaced by a solid cap. Specimens received after
prolonged delay, usually 72 hours.
Use Isolate and identify mycobacteria
Testing Schedule : Daily
Acid Phosphatase (Prostatic & Total)
Specimen Requirement: 1 ml serum, FROZEN
Ref. Range:
Prostatic: <3.5 U/L
Total:
Female: <6.5 U/L
Male: <6.6 U/L
Use: Staging of carcinoma of prostate, with other parameters; minimal role in establishing the diagnosis of
carcinoma of prostate, with other parameters ; minimal role in establishing the diagnosis of primary
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carcinoma of prostate, helpful role in diagnosis of metastatic adenocarcinoma of the prostate and/ or
extension beyond prostatic capsule; monitor therapy and follow patients' response to treatment.
Limitations: Specimens stored for any length of time, even at 4 degree cent, will lose activity especially if
exposed to air. immunoassay methods do not detect early carcinomas consistently and, like enzyme
methods, there may be false-positives. Acid phosphatase maybe increased in disease other than
adenocarcinoma of prostate (eg, in infarct). Specimens drawn after recent rectal digital examination, TUR,
bladder catheterization, and/or other manipulation of the prostate may have elevated values. The enzyme
may be increased with prostatitis and may be increased with urinary retention. Acid phosphatase is
increased by radioimmunoassay in up to 27% of patients bengin hypertrophy.. Acid phosphates exhibit
diurnla variation.
Method: naphtalin phosphate
Additional Information:Prostate-specific antigen (PSA) is more sensitive than prostatic acid phosphatase, but neither test is specific
for adenocarcinoma of the prostate. Neither is 100% sensitive. The organ specificity, sensitivity and
diagnostic value of PSA is an advance which should be used with acid phosphatase in staging and follow-up
of prostatic carcinoma. Serum PSA is superior to PAP in predicting disease recurrence in stages C and D
prostate cancer treated by combination endocrine therapy Benign prostatic hyperplasia causes definite
increase in PAP, whereas intracapsular prostate cancer shows normal levels.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
ACINUS CELL ABS
REQUIREMENT: 1 ml serum
REF. RANGE: <1:10 titer
METHOD: indirect IF
SET-UP: once weekly
Testing Schedule : Referred to Bioscientia
Result ready with in 10 days
ACTH - Adrenocorticotrophic Hormone (Intact)
Specimen Requirement: 1 ml EDTA plasma; centrifuge cool and freeze immediately. SEND FROZEN.
Ref. Interval: <46 pg/mL
Use:- Evaluate the etiology of Cushing's syndrome; differenitate pituitary from extra pituitary causes of
corticosteroid excess and deficiency syndromes; evaluate ectopic ACTH production by neoplams, examine results
of transsphenoidal surgery; follow up patients after bilateral adrenalectory for diagnosis of Nelson syndrome.
(Nelson syndrome is the development of tumor of the anterior pituitary gland and skin pigmentation following
bilaterla adrenalectomy).
Limitations:- The ATCH level is affected by stress, which may obscure the normal diurnal change. ATCH level
must be correlated with cortisol levels.
Method: CLEIA
Additional Information:- Cortisol excess of any source is " Cushing's syndrome." Increased ACTH from the
pituitary, causing the adrenal cortices to produce excessive cortisol was described by Cushing and called
“Cushing’s disease". ACTH secretion is stimulated by insulin, metyrapone and vasopressin and suppressed by
dexamethasone, whereas in adrenal adenomas, adrenal carcinomas, and ectopic ACTH producing tumors, ACTH
and cortisol are not suppressed by high-dose dexamethasone.. Measurement of plasma lipotroin provides an
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alternative and possibly better index, than ATCH for diagnosis of Cushing's syndromes and follow-up of treated
Cushing's diseases.
In primary adrenal insufficiency (Addison’s disease) due to destruction of the glands by tumor, infection or
immune mechanisms, ACTH plasma concentrations are elevated and cortisol levels are depressed. ACTH
increases are found with congenital adrenal hyperplasia (adrenogenital syndrome). In secondary adrenal
insufficiency (secondary to pituitary insufficiency). ACTH and cortisol both are low. For sequential follow-up,
ACTH should always be drawn at the same time each day.
ACTH was increased in 30% of patients with oat cell carcinoma and 26% with large cell carcinoma of lung in a
series of 110 patients with lung cancer. Urinary free cortisol is the test of choice for the separation of Cushing's
syndrome from entities, including obesity, which mimic it.
The increased ACTH of pseudo-Cushing's syndrome does not exhibit normal circadian rhythms and fails to
suppress with dexamethasone. Pseudo-Cushing's syndrome is a reversible entity related to alcohol abuse.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Adenovirus Abs
Specimen Requirement: 1 ml serum
Ref. Interval:
<1:10 titer abs not detectable
1:10 - 1:20 titer abs from previous infection
>1:20 titer fresh infection suspected
Use:- Establish the diagnosis of adenovirus infection; useful in differential diagnosis of respiratory ailments ,
hemorrhagic cystitis, and keratoconjunctivitis.
Limitation:- complement fixation testes are of low sensitivity, particularly in children.
METHOD: EIA
Additional Information:- There are 41 different types of adenovirus, and many injections are both asymptomatic
and persistence.
Alanine Aminotransferase ALT (SGPT)...........
Synonyms ALT; Glutamic Pyruvate Transaminase; GPT; SGPT; Transaminases
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Collection Avoid hemolysis. Separate from cells within 45 minutes. Separate serum and cap tightly.
Storage Instructions Refrigerate
Causes for Rejection Gross hemolysis; excessive lipemia; improperly labeled specimen.
Reference Interval 0-50 IU/L
21
Use A liver function test, ALT is more sensitive for the detection of hepatocyte injury than for biliary
obstruction. ALT is more specific for liver injury than AST (SGOT). Useful for hepatic cirrhosis, other liver
disease. Increased in Reye's syndrome, with AST. Test for hepatitis including non-A, non-B hepatitis. Acute
hepatitis A or B can be confirmed serologically, as can hepatitis C. Negative serological findings in the presence
of hepatitis-like chemistry abnormalities may also suggest acute drug-induced hepatitis, an impression supported
by resolution after removal of the offending agent. The combination of increased AST and ALT with negative
hepatitis markers occurs in a number of other entities including infectious mononucleosis. Sensitive to heart
failure. ALT has been used in combination with anti-HBc as an indirect test for non-A, non-B, hepatitis in blood
donors.
Limitation Grossly hemolyzed samples can generate somewhat spurious results. The activity in red cells is six
times that of serum. Elevations are reported in trauma to striated muscle, rhabdomyolysis, polymyositis and
dermatomyositis, but the CK (CK-MM fraction) is increased in such patients and it is preferable to consider
diseases of skeletal muscle. ALT is less sensitive than is AST to alcoholic liver disease. Increased ALT is
found with obesity.
Methodology Kinetic
Additional Information In Children with acute lymphoblastic leukemia, high ALT activity at diagnosis is
associated with rapidly progressive ALL. A number of drugs, including diphenylhydantoin, heparin therapy and
many others, cause ALT increase. Acetaminophen hepatotoxicity may be potenitated in alcoholics, in whom
coagulopathy and extremely abnormal aminotransferase levels are described, ALT less than AST . The hepatitis
C virion has been detected by polymerase chain reaction and reverse transcriptase of HCV-RNA sequences in
patients with elevated ALT and positive anti-HCV1.
Testing Schedule : Daily
Albumin, Serum ................................................
Synonyms Protein
Specimen Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Gross hemolysis; lipemia; improperly labeled specimen
Reference Interval 3.5-5.5 g/dL
Use Evaluation of nutritional status, blood oncotic pressure, evaluation of renal disease with proteinuria, and
other chronic diseases.
High albumin may indicate dehydration. Look for increase in hemoglobin, hematocrit in such patients.
1
Ulrich PP, Romeo JM, Lane PK, et al, “Detection, Semiquantitation, and Genetic Variation in Hepatitis C Virus Sequences Amplified From the Plasma of
Blood Donors with Elevated Alanine Aminotransferase.” J Clin Invest, 1990, 86(5): 1609-14
22
Low albumin is found with use of I.V. fluids, rapid hydration, overhydration; cirrhosis, other liver disease,
including chronic alcoholism; in pregnancy and with oral contraceptive use; many chronic diseases including the
nephrotic syndromes, neoplasia, protein-losing enteropathies (including Crohn's disease and ulcerative colitis),
peptic ulcer, thyroid disease, burns, severe skin disease, prolonged immobilization, heart failure, chronic
inflammatory diseases such as the collagen diseases and other chronic catabolic states. Starvation,
malabsorption, or malnutrition: In the absence of I.V. fluid therapy and in patients without liver or renal disease,
low albumin may be regarded as an indication of inadequate body protein reserves. It is described as the most
common nutrition-related abnormality in patients with infection. Serum albumin has a half-life of about 18-20
days. Its half-life is decreased in patients with catabolic states: infection and with protein loss through the
kidneys (eg, nephrosis), gastrointestinal tract, and skin (eg, burns). Its prognostic application is most useful in
patients with weight loss, anorexia, stress, surgical therapy, hemorrhage, and infection. Total iron binding
capacity <240 µg/dL and/or low transferrin levels would support an impression of inadequate protein reserves.
Absolute lymphocyte counts of less than 1500/mm3 may also be seen with protein malnutrition. In severe
malnutrition, albumin has been reported as <2.5 g/dL, total lymphocytes as <800/mm3 and TIBC as <150 µg/dL.
Albumin levels <lq[2.0-2.5 g/dL may be the cause of edema (eg, nephrotic syndrome, protein-losing
enteropathies).
Albumin, prealbumin, and transferrin are regarded as |negative| acute phase reactants (ie, these proteins decrease
with acute inflammatory/infectious processes).
Low albumin values are associated with longer hospital stay.
Methodology Colorimetric
Testing Schedule : Daily
Aldolase
Specimen Requirement: 2 ml serum
Ref. Interval:
Newborn: 9.3-23.2 U/L
1-6 months: 4.9-15.1 U/L
7-12 months: 5.1-11.0 U/L
Children: 4.4.-9.3 U/L
Adults: 6.8-8.5 U/L
Use:- Evaluate muscle wasting process. High levels are round in progressive Duchenne's muscular dystrophy
(MD). Elevations occur in carriers of MD, in limbgirdle dystrophy and other dystrophies, in dermatomyositis,
polymyositis, and trichinosis, but not in neurogenic atrophies ( eg, multiple sclerosis or in myasthenia gravis)
Limitation:- Serum aldolase elevation is not specific for muscle disease. In recent years the assay of creatine
kinase ( CK) has been preferred for evaluation of muscle disease. It is more specific for skeletal muscle
degeneration.
Method: enzymatic
Additional Information:- In the progressive dystrophies, aldolase levels may be 10 to 15 times normal when
muscle mass is relatively intact as in early stages of the disease. When advanced muscle wasting is present, values
decline. In the inflammatory myopathies (eg, dermatomyositis) serum aldolase ( as well as CK) levels may be
applied to monitoring the response to steroid therapy. Elevated aldolase levels may be found with hepatitis, other
liver disease, myocardial infraction, hemorrhagic pancreatitis, gangrene, delirium tremens, and in some cases of
neoplasia. In cases of acute viral hepatitis, increase inserum aldolase tends to parallel ALT (SGPT) levels.
23
The level of serum aldolase B (RIA method) may be decreased (<20 ng/mL) in some patients with epithelial
malignancy (cases studied included esophageal, hepatic, pancreatic, lung, and breast cancers). After successful
surgical resection, serum aldolase B levels recovered to normal range. (20-60 ng/, L).
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Aldosterone
Specimen Requirement: 2 ml serum or EDTA plasma, FROZEN.
Ref. Interval:
For EDTA plasma:
3-22 ng/dL (upright sitting, blood drawn 8.00h – 10.00h)
2-14 ng/dL (supine position, blood drawn 8.00-10.00h)
For serum:
3-34 ng/dL (upright sitting – blood drawn 8.00-10.00)
2-19 ng/dL (supine position – blood drawn 8.00-10.00h)
2-23 ng/dL (upright sitting, blood drawn 16.00-18.00h)
Use:- The principal use of aldosterone measurement is in the diagnosis of primary hyperaldosteronism, which is
most commonly caused by specific type of adrenal adenoma. Primary aldosteronism caused by adrenal tumor is
Conn's syndrome. Secondary aldosteronism is more common. Work-up is especially indicated in the younger
patients with hypertension and hypokalmia not induced by diuretic agents. Beeler and Catrou use criteria of serum
potassium < 3.5 mmol/L, 24-hour urine potassium≥ 50 mmol/L, to begin work-up of a hypertensive patient for
aldosteronism. Low plasma renin activity suggests primary aldosteronism and provides indication for aldosterone
measurement in a hypertensive subject with renal potassium wasting. Secondary aldosteronism may occur in
congestive heart failure, cirrhosis with ascites, nephrosis, potassium loading, sodium depleted diet, toxemia of
pregnancy and other states of contraction of plasma volume, and Bartter's syndrome. Renin is high in secondary
aldosteronism, low in primary aldosteronism.
Limitations: Decreased perfussion of the kidney leads to increase aldosterone and rennin. Aldosterone may be
falsely elevated in chronic renal failure when assayed by direct RIA .
Method: CLIA
Additional Information
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Aldosterone (U)
Specimen Requirement: 30 ml 24h urine use our boric acid tubes, adjust to pH 2-7. Please state 24h urine
volume. Stop all medication 3 weeks before test.
Ref. Interval: 2–26 mcg/24h
Method: RIA
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
a-FODRIN IgA ABS
REQUIREMENT: 1 ml serum
REF. RANGE:
24
<12 U/mL 12-18 U/mL – borderline >18 U/mL – positive
METHOD: RIP (radioactive immuno precipitation)
SET-UP: once weekly
Testing Schedule : Referred to BIOSCIENTIA
Alkaline Phosphatase, Serum
Synonyms Alk Phos; AlP; Phosphatase, Alkaline
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Separate within 45 minutes and refrigerate.
Causes for Rejection Hemolysis; plasma specimen; specimen collected in EDTA tube; improperly labeled
specimen.
Reference Interval
• Male 1-2 years: 25-500 IU/L, 2-10 years: 100-400 IU/L, 10-15 years: 150-530 IU/L, 15-20 years: 60-400
IU/L, 20-60 years: 40-150 IU/L, 60 years and older: 50-160 IU/L.
• Female 1-2 years: 25-500 IU/L, 2-10 years: 100-400 IU/L, 10-15 years: 70-490 IU/L, 15-20 years: 45-300
IU/L, 20-60 years: 40-150 IU/L, 60 years and older: 55-165 IU/L
Use Causes of high alkaline phosphatase include bone growth, healing fracture, acromegaly, osteogenic sarcoma,
liver or bone metastases, leukemia, myelofibrosis, and rarely myeloma. Alkaline phosphatase is used as a tumor
marker.
In rickets and osteomalacia, serum calcium and phosphorus are low to normal, and alkaline phosphatase may be
normal or increased.
Hypervitaminosis D may cause elevations in alkaline phosphatase.
In Paget's disease of bone there is often isolated elevation of serum alkaline phosphatase. Some of the highest
levels of serum ALP are seen in Paget's disease.
Hyperthyroidism, by its effects upon bone, may elevate alkaline phosphatase. There is evidence that thyroid
hormone (T3) acts to stimulate bone alkaline phosphatase activity through an osteoblast nuclear receptormediated process.
Hyperparathyroidism,in ome patients. Pseudohyperparathyroidism.
Chronic alcohol ingestion (in chronic alcoholism, alkaline phosphatase may be normal or increased, but often
with high AST (SGOT) and/or high bilirubin and especially with high GGT; MCV may be high).
Biliary obstruction (tenfold increase may be seen with carcinoma of the head of pancreas, choledocholithiasis);
cholestasis; GGT also high. Cholecystitis with cholangitis. (In most patients with cholecystitis and cholangitis
who do not have a common duct stone, alkaline phosphatase is within normal limits or only slightly increased.)
Sclerosing cholangitis (eg, with ulcerative colitis), although importantly, 3% of cases of symptomatic sclerosing
cholangitis may have normal serum ALP. Endoscopic retrograde cholangiography might be considered then in
patients with diseases known to be associated with primary sclerosing cholangitis and with appropriate
symptomatology even though ALP level is normal. Primary or metastatic tumor in liver: there may be marked
increase and GGT is often high. Only three laboratory markers were consistently abnormal, in evaluating for
metastatic carcinoma of breast, prior to clinical detectability of metastases: these were alkaline phosphatase,
GGT and CEA.
Cirrhosis, especially in primary biliary cirrhosis, in which fivefold or more increases are seen.
25
Gilbert's syndrome: Increase in intestinal alkaline phosphatase is seen.
Hepatitis: Moderate increases in alkaline phosphatase occur in viral hepatitis, but greater elevations of the
transaminases (AST (SGOT), ALT (SGPT)) are usually found.
Fatty metamorphosis of liver (moderate increase occurs in acute fatty liver).
Diabetes mellitus, diabetic hepatic lipidosis.
Infiltrative liver diseases (eg, sarcoid, TB, amyloidosis, abscess).
Sepsis. Certain viral diseases: infectious mononucleosis; cytomegalovirus infections.
Postoperative cholestasis. Pancreatitis, carcinoma of pancreas, cystic fibrosis.
Pulmonary infarct (1-3 weeks after embolism. Healing infarcts in other organs, including kidney, may also cause
increased alkaline phosphatase); other situations in which angiofibroplasia occurs, such as healing in a large
decubitus ulcer.
Tumors, especially hypernephroma; neoplastic ectopic production (Regan, Nagao isoenzymes).
Fanconi syndrome.
Peptic ulcer, erosion. Intestinal strangulation or obstruction, or ulcerative lesion. Steatorrhea, malabsorption
(from bone, secondary to vitamin D deficiency). Ulcerative colitis with pericholangitis, other erosive lesions of
colon.
Congestive heart failure.
Parenteral hyperalimentation of glucose, intravenous albumin administration.
Familial hyperphosphatasemia.
Idiopathic.
Drugs — estrogens (large doses), birth control agents, methyltestosterone, phenothiazines, oral hypoglycemic
agents, erythromycin, or any drug producing hypersensitivity or toxic cholestasis. Many commonly and
uncommonly used drugs elevate alkaline phosphatase, and tenfold increases may be seen with drug cholestasis.
Causes of low alkaline phosphatase are said to include: Hypothyroidism — but most hypothyroid patients have
normal alkaline phosphatase.
Pernicious anemia — in very few patients.
Hypophosphatasia: Very low alkaline phosphatase values are found in the presence of normocalcemia or
hypocalcemia. This diagnosis may be confirmed by quantitation of urinary phosphoethanolamine.
Malnutrition has been reported to relate to low values, but in practice, diseases causing malnutrition relate often
to high alkaline phosphatase results (eg, disseminated neoplasia).
Some drugs (clofibrate, azathioprine, estrogens and estrogens in combination with androgens) lower serum ALP
activity.
Methodology Kinetic
Testing Schedule : Daily
Alpha-Fetoprotein (AFP) Serum
Synonyms AFP maternal serum,
Special Instructions The following information must be provided: gestational age on specimen date, how
gestational age was determined (LMP, EDC, US), patient's weight, patient's date of birth, patient's race (white,
black, Asian, other), insulin-dependent diabetic status. Also indicate relevant patient history, such as prior neural
tube defects, Down syndrome, ultrasound anomalies, or previous AFP specimen. Complete information is
necessary to perform the test. Specimens must be collected before amniocentesis.
26
Specimen Serum
Volume 3 mL
Container Serum-separator tube
Collection Avoid hemolysis; send complete specimen in the original tube. Do not pour off.
Storage Instructions Separate serum from cells and refrigerate.
Causes for Rejection Hemolysis
Use Detect open neural tube defects (85% efficiency)
Methodology AFP by enzyme immunoassay (EIA)
Reference Interval Tumor Marker normals: 0-15.0 ng/mL. Normal values apply only to males and to
nonpregnant females. These results are not interpretable for pregnant femals. See table.
Distribution of AFP Values
No.
0- 15.1of
15. 20.0
Subj 0 ng/m
ects ng/
L
m
L
Healthy
subjects 226 10 0%
Male
112 0% 3%
338 97 1%
Female
%
total
99
%
Carcino
ma
10 0%
51
Testicul 138 0% 1%
ar
38
1%
254 %
Semino
12
0%
ma
34
11 0%
%
92
Nonsem
inoma
%
91
%
Primary
20. 100. >40
110
10 480. ng/
0.0
0
mL
ng/ ng/m
m
L
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
24
%
0%
18%
0%
19
%
4%
0%
0%
8%
8%
3%
76
%
0%
6%
Heptace
llular
Pancreat
ic
GI
Nonmal
27
ignant
Diseases
Cirrhosi
s
108
89
81
%
83
%
3%
7%
6%
8%
7%
2%
3%
0%
Hepatiti
s
Use Diagnose hepatocellular carcinoma: With sensitive immunoassay procedures, elevation of AFP will occur in
90% of patients with hepatocellular carcinoma. Values in >1000 ng/mL are almost always secondary to
hepatocellular carcinoma. Gonadal and extragonadal germinal tumor types include endodermal sinus tumor
(yolk sac tumor), embryonal carcinoma, teratocarcinoma, and choriocarcinoma. AFP increases occur as well
from extragonadal locations, retroperitoneum, and mediastinum. Monitor therapy with antineoplastic drugs, in
patients being treated for hepatoma or germinal neoplasm. Differential diagnosis of neonatal hepatitis versus
biliary atresia in newborns. The use of AFP in intrauterine testing is not discussed under this test number.
Limitations High in some cases of nonmalignant liver disease (eg, massive hepatic necrosis, acute
hepatisis, alcoholic cirrhosis, and chronic active hepatitis). Cases of hepatocellular carcinoma from the
U.S. are not as consistently AFP rich, as are many cases from other regions.
Testing Schedule : Daily
Amino Acids In Plasma (Quantitative)
Specimen Requirement: 2ml EDTA plasma (NOT heparin plasma). Centrifuge immediately. Plasma may be
stored at +4°C for no more than 2 days prior to shipping. SEND FROZEN.
Method: LC-MS
IMPORTANT! For this test it is imperative that the patient's date of birth is quoted on the request form. The
results are age dependent!
Reference Interval ( in µmol/L)
Amino Acids In Urine (Quantitative)
Specimen Requirement: 30 ml random urine mixed with hydrochloric acid to give a pH value of 4-6. SEND
FROZEN.
Samples sent for this test will be assayed for urinary creatinine. This is necessary for correct reference range assignment.
Method: LC-MS
IMPORTANT! For this test it is imperative that the patient's date of birth is quoted on the request form. The
results are age dependent!
Reference Interval ( in µmol/mmol creatinine)
N.B. If urinary amino acids are detected for which no reference range is given, then the result is to be interpreted
as 'abnormal' or possibly disease-specific
28
Amino Acids In Csf (Quantitative)
Specimen Requirement: Minimum 1 ml csf, FROZEN. Sample cannot be used if heavily blood-stained. If only
slightly blood-stained, then centrifuge and remark on request form.
This test should be performed together with a quantitative amino acid analysis in plasma. Send both samples
together FROZEN.
Method: LC-MS
IMPORTANT! For this test it is imperative that the patient's date of birth is quoted on the request form.
Reference Interval (in µmol/L)
PS. Results for those amino acids for which no reference ranges are given are to be interpreted as 'abnormal'or
disease-specific
Ammonia (P)
Specimen Requirement: 1 ml EDTA plasma, centrifuge and freeze immediately. SEND FROZEN
Ref. Interval:
Female: 19-82 mcg/dL
Male: 25-94 mcg/dL
Use:- Ammonia is elevated in liver disease, urinary tract infection with distention and stasis, Reye's syndrome,
inborn errors of metabolism including deficiency of enzymes in the urea cycle, HHH syndrome
(hyperornithinemia, hyperammonemia homocitrullinuria), some normal neonates (usually returning to normal in
48 hours), total parenteral nutrition, ureterosigmoidostomy and sodium valproate therapy. Ammonia determination
is indicated in neonates with neurological deterioration, subject with lethargy and/or emesis not explained, and in
patients with possible encephalopathy. They are mainly of use in the diagnosis of urea cycle deficiencies (any
neonate with unexplained nausea, vomiting, or neurological deterioration appearing after first feeding); and they
play an important part in the detection of Reye's syndrome.
Limitation: Ammonia determinations are not reliable predictors of impending hepatic coma. Ammonia levels are
now always high in all patients with urea cycle disorders. High protein diet may cause increased levels. Ammonia
levels may also be elevated with gastrointestinal hemorrhage. If portal hypertension develops with cirrhosis,
hepatic blood flow is altered, leading to elevated blood ammonia levels.
METHOD: UV photometry
Additional information:
Amphetamines Screen (U)
Specimen Requirement: 10 ml urine
Ref. Interval: not detectable
Use: Drug abuse evaluation, toxicity assessment
Limitation: Some over the counter cold and antiallergy medications may cross react in certain immunoassay
screens;
Method: CEDIA
Additional Information:- Amphetamines are stimulants that tend to increase alertness and physical activity..
Half-life is 10-20 hours. Usually detectable 24-48 hours after use.
Amphetamines increase the heart and breathing rate and blood pressure, dilate pupils, and decrease appetite. The
user can experience a dry mouth, sweating, headache, blurred vision dizziness, sleeplessness, and anxiety.
Extremely high doses can cause people to flush or become pale; they can cause a rapid irregular heartbeat,
tremors, loss of coordination and even physical collapse. People who use a large dose over a long period of time
may develop an amphetamine psychosis; seeing , hearing and feeling things that do not exist , having irrational
29
thoughts or beliefs and feeling that people are out to get them. People in this extremely suspicious state frequently
exhibit bizarre and sometimes violent behavior. Tolerance to the drug id developed after repeated use. Lifethreatening overdoses are rare.
Amphetamines Confirmation (U)
Specimen Requirement: 10 ml urine
Ref. Interval: not detectable
Method: LC-MS/MS
Amylase, Body Fluid .......................................
Synonyms Cyst Fluid Amylase
Special Instructions State source of fluid on the request form (eg, pleural, peritoneal, pericardial, synovial, cyst).
Specimen Body fluid (eg, ascitic fluid, pleural fluid, etc)
Volume 2 mL
Container Clean container, no preservative
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Improperly labeled specimen
Use Pancreatitis with or without pseudocyst formation or pancreatic pleural fistula is the most common cause of
amylase elevation in pleural fluid. Rupture of the esophagus is the second most common group and malignant
effusion is the third. Other causes include pancreatic ascites and pancreatic duct trauma. Defect in the wall of the
gastrointestinal tract (eg, perforated peptic ulcer) will allow pancreatic secretion to enter the peritoneal cavity.
Similarly, peritoneal fluid amylase elevations may be found in the presence of necrotic bowel. Peritoneal fluid,
containing such amylase, can find its way into a pleural space.
Methodology Maltopentose
Amylase, Serum ...............................................
Synonyms AML
Specimen Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Improperly labeled specimen
Use Work-up for abdominal pain, epigastric tenderness, nausea, and vomiting. Such findings characterize acute
pancreatitis as well as acute surgical emergencies such as gastrointestinal perforation (eg, peptic ulcer with
perforation) or bowel infarct. Amylase is used in the differential diagnosis of acute or chronic pancreatitis, which
may or may not in an individual be related to alcoholism. Hypercalcemia related to pancreatitis is described with
hyperparathyroidism and other entities. About 80% of subjects with acute pancreatitis have increased serum
amylase within 24 hours.
Methodology Enzymatic
Testing Schedule : Daily
Amylase, Urine .................................................
Test Includes Amylase on random or timed urine collections
Special Instructions Request form must state date and time collection started, date and time collection finished,
and urine volume.
30
Specimen Urine (timed)
Volume 10 mL aliquot
Container Plastic urine container, no preservative
Collection Collect timed specimen. Instruct the patient to void at the beginning of the collection period and
discard the specimen. Collect all urine including the final specimen voided at the end of collection period.
Storage Instructions Refrigerate
Causes for Rejection Presence of acid preservative (pH <3); improperly labeled specimen
Use Work-up for abdominal pain, epigastric tenderness, nausea, and vomiting. An enzyme with molecular
weight of 45-55,000 daltons, urinary amylase is used in the differential diagnosis of pancreatitis. It is very useful
in diagnosis of pseudocyst of the pancreas, where the urine amylase may remain elevated for weeks after the
serum amylase has returned to normal, after a bout of acute pancreatitis.
Methodology Enzymatic
Anaerobic Culture ............................................
Synonyms Anaerobic Culture, Abscess; Anaerobic Culture, Body Fluid; Anaerobic Culture, Wound; Culture,
Anaerobic; Wound Anaerobic Culture
Test Includes Isolation and identification of potential anaerobic pathogens, and initiation of drug susceptibility
tests when indicated (additional charge) (test 180349)
Special Instructions Gram's stain (008540) is recommended with all anaerobic cultures (additional charge).
Request form must state specific site of specimen, age of patient, current antibiotic therapy, clinical diagnosis,
and time of collection. If an unusual organism is suspected, such as Actinomyces, this information must be
specifically noted on the request form. Aspirations are preferable to swabs. A thin smear for Gram's stain
obtained from the same site is strongly recommended and must be ordered separately. Culture samples must be
collected to avoid contamination with indigenous anaerobic flora from skin and mucous membranes. Because of
resident anaerobic flora, the following sites are inappropriate for anaerobic cultures: throat and nasopharynx,
sputum, bronchoscopy specimens, gastrointestinal contents, voided or catheterized urine, urogenital swabs (eg,
vaginal and/or cervical), and specimens from superficial wounds.
Specimen Requirement Pus, tissue, or other material properly obtained from an abscess, biopsy, aspirate,
drainage, exudate, lesion, or wound. To ensure proper growth of organisms place swabs/specimen in anaerobic
transporter. Do not refrigerate.
Volume Swab in anaerobic transporter or 0.5 mL pus, other fluid or tissue from aspirated site in anaerobic
transporter
Container Anaerobic transporter
Collection Some anaerobes will be killed by contact with molecular oxygen for only a few seconds. Overlying
and adjacent areas must be carefully disinfected to eliminate contamination with indigenous flora. Ideally, pus or
other fluid obtained by needle aspiration through intact skin or mucosal surface which has been cleaned with
antiseptic should be collected. Sampling of open lesions is enhanced by deep aspiration using a sterile plastic
catheter. Curettings of base of an open lesion are optimal. If irrigation is necessary, nonbacteriostatic sterile
normal saline may be used. Lower respiratory samples must be obtained by transtracheal percutaneous needle
aspiration, transbronchial biopsy, transthoracic needle biopsy, or open lung biopsy by physicians trained in these
procedures. If swabs must be used, collect two, one for Gram's stain (ordered as additional test), one for culture.
Anaerobic transports must be used for swabs and for aspirates. Specimens are to be collected from a prepared
site using sterile technique. Contamination with normal flora from skin, rectum, vaginal tract, or other body
surfaces must be avoided.
31
Storage Instructions Specimens for anaerobic culture should be maintained at room temperature. Under these
conditions anaerobes will survive 24-72 hours when properly collected in the anaerobic transport tube.
Patient Preparation Sterile preparation of the aspiration site is imperative.
Causes for Rejection Unlabeled specimen; specimen which is not received in appropriate anaerobic transport
tube (eg, specimen in cotton plugged tube); cotton-tipped swab which has not been stored in oxygen-free
atmosphere; specimens refrigerated. Note: Refrigeration inhibits viability of certain anaerobic organisms. If an
unacceptable specimen is received, the client will be notified and another specimen will be requested before
disposal of the original specimen. Specimens from sites which have anaerobic bacteria as indigenous flora will
not be cultured anaerobically (eg, throat, feces, colostomy stoma, rectal swabs, bronchial washes, cervicalvaginal mucosal swabs, sputa, skin and superficial wounds, voided or catheterized urine, ulcer surfaces,
drainages onto contaminated surfaces).
Use Isolate and identify anaerobic pathogenic organisms; determine susceptibility of isolates (extra charge).
When actinomycetes are suspected a specific request must be made. Anaerobic cultures are indicated
particularly when suspected infections are related to gastrointestinal tract, pelvic organs, associated with
malignancy, related to use of aminoglycosides; or occur in a setting in which the diagnosis of gas gangrene or
actinomycosis is considered. Anaerobic culture is especially indicated when an exudate has a foul odor or if the
exudate has a grayish discoloration and is hemorrhagic. Frequently, more than one organism is recovered from
an anaerobic infection.
Contraindications Bronchoscopically obtained specimens are not ideal as the instrument becomes contaminated
by organisms normally contaminating the oropharynx during insertion. Culture of specimens from sites harboring
endogenous anaerobic organisms or contaminated by endogenous organisms may be misleading with regard to
etiology and selection of appropriate therapy. Special sheathed catheters are available to reduce oropharyngeal
flora contamination of bronchial aspirate cultures.
Testing Schedule : Prelimnary report evey 24hrs and Final Report in 5 days.
Androstendione
Specimen Requirement: 1 ml serum
Ref. Interval: Please contact Customer Service for detail of Reference Interval for this test
Use:- Evaluate androgen production in hirsute females; less useful in evaluation of other aspects of virilization.
Very elevated in congenital adrenal hyperplasia due to C21 hydroxylase deficiency.
Limitation:- Poor correlation of plasma levels with clinical severity.
Method: Immunlite 2000 by DPC
Additional information:- Androstenedione is increased in cases of hirsutism, including Stein-Leventhal
syndrome, and in other virilizing conditions as well as in congenital adrenal hyperplasia, Cushing's syndrome,
ectopic ACTH-producing tumor, and ovarian hyperplasia of tumor. About 60% of cases of female hirsutism will
show elevations of androstendedione. Marked diurnal variation exists, with a peak around 7AM and a nadir
around 4 PM. Levels rise sharply after puberty to peak about 20 years of age. An abrupt decline occurs after
menopause.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
ANGIOTENSIN-1-Convertlng ENZYME (ACE) (S)
Specimen Requirement: 2 ml serum
Ref. Interval: 12-68 U/L
Use: - High in sarcoidosis, more often when the disease is active.
32
Limitations:- Test lacks specificity and sensitivity for diagonosis of sacrcoidosis.
Elevations have been reported in about 35% to 80% of cases of sacrciodosis Elevations have been found in
patients with diabetes mellitus, Gaucher's disease and leprosy. Twenty five percent of 86 patients with acute
histoplasmosis had elevated levels. Increased in some patients with primary biliary cirrhosis, amyloidosis,
myeloma, Melkersson- Rosenthal syndrome, some alpha- antitrypsin variants, and hyperthyroidism. It has been
found increased in some cases of hyperparathyroidism and in some instances of oncogenic hypercalcemia. Thus, it
is not a specific marker for the diagnois of sarcoidosis. Positives are also reported in patients with extrinsic allergic
alveolitis, coccidioidomycosiss, beryllium disease, asbestois, silicosis, and alcoholic liver disease.ACE activity is
decreased during starvation, independent of the level of thyroid activity (as monitored by T3 levels). ACE is
physiologically decreased by administration of captopril, enalapril, and lisinopril. Hemolysis and lipemia interfere
with these methods.
Method: kinetic, enzymatic test
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Antibody Screen ..............................................
Synonyms Indirect Antiglobulin Test; Indirect Coombs'
Test Includes Antibody screen (ID and titer of clinically significant antibodies if screen is positive)
Specimen Requirement Clotted blood or serum
Volume 10 mL (clotted blood) or 3 mL (serum)
Container Red-stopper tube. Do not use serum-separator tube.
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; bacterial or other contamination
Use Detect atypical IgG antibodies prior to transfusion or during pregnancy. The technique is designed to detect
IgG antibodies specifically. Antibodies detected by the antibody screen are identified, and titration is performed
if the antibody identified is considered to be clinically significant during pregnancy.
Contraindications Specimens known to test positive for red cell antibody screening should not be submitted for
Antibody Screen testing.
Methodology Antiglobulin test
Antinuclear Antibodies (ANA) .......................
Synonyms ANA; FANA
Test Includes ANA titer and pattern designation
Specimen Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use Detect antibodies to nuclear antigens. Sensitive assay for screening for ANAs in patients suspected of
having SLE.
Limitations Males and females older than 80 years of age have a 50% incidence of low titer ANA. Various
medications can induce a “lupoid” condition and elevated ANA titers. Usually the titer decreases following
removal of the drug.
Methodology EIA
33
Testing Schedule : After 10 working Days
Anti Streptolysin (ASO)
Specimen Requirement: 2 ml serum
Ref. Interval: <200 U/mL
Use:- Document exposure to streptococcal infection. Elevate titers are seen in 80% to 85% of patients with acute
rheumatic fever and in 95% of patients with acute glomerulonephritis.
Limitations:- False-Positive ASO titers can be caused by increased levels of serum beta-lipoprotein produced in
liver disease and by contamination of serum with Bacillus cereus and Pseudomonas sp. ASO is not sensitive to
squelae of streptococcal pyoderma. Test is subject to technical false-positives due to oxidation of reagents.
Method: haemolysis inhibition reaction
Additional information:- Streptolysin is a hemolysin produced by group A streptococci. A rise in titer begins
about 1 week after infection and peaks 2-4 weeks later. I the absence of complications or reinfection, the ASO titer
will usually fall to preinfection levels with in 6-12 months.
Testing Schedule : Daily
Anti Thrombin
Specimen Requirement: 2 ml citrate plasma, FROZEN
Ref. Interval: 75-125%
Use: Elevate hypercoagulable state, fibrinogenolytic state, and response to heparin. Test for the hereditary
deficiency of antithrombin III ( autosomal dominant) which is characterized by predisposition to thrombosis.
Acquired deficiencies associated with severe cirrhosis, chronic liver failure, DIC, thrombolytic therapy, pulmonary
embolism, nephrotic syndrome, or postsurgical state (especially liver transplant or partial hepatectomy). Also used
to evaluate decreased synthesis or increased loss/consumption. Changes induced by drugs must be considered.
Antithrombin III levels might also be of use in cases of suspected heparin failure, suspected DIC, or personal or
familial history of thromboembolic disease. The test is indicated in the later cases especially prior to heparinizaion,
general orthopedic surgery, prolonged bedrest, pregnancy, postpartum, or postoperative state or oral contraceptive
use. AT III deficiency has been found not to be an inherent feature of SLE.
Limitations:. Of specimen contains heparin ( as with specimen drawn after heparin flush or patient receiving
heparin), results may be erroneous. Patients receiving coumarin type anticoagulants may have increased AT III
levels.
Method: chromogenic substrate
Additional Information: Antithrombin III has been shown to inhibit the activity of activated factors XII, XI, IX
and X, as well as, II (thrombin). Antithrombin III is the main physiologic inhibitor of serine proteases generated
during coagulation, in particular factor Xa, where it appears to exert its most critical effect. AT III is a “heparin
cofactor.” Heparin interacts with AT III and thrombin, increasing the rate of thrombin neutralization (inhibition)
but decreasing the total quantity (of thrombin) inhibited.
. Individuals with antithrombin III deficiency will show resistance to anticoagulation with heparin but can be
anticoagulated with coumarin derivatives, in which case atithrombin III levels have been shown to rise.
Antithrombin III levels may be decreased in women during hormonal contraceptive therapy. A significant number
of patients with mesenteric venous thrombosis may have AT III deficiency.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
34
Apolipoprotein A1
Specimen Requirement: 2 ml serum
Ref. Range: 1.1-2.1 g/L
Use: Evaluate the risk of coronary artery disease.
Method: nephelometric
Additional information: Apolipoprotein is the protein component of a lipoprotein complex. Apolipoprotein A is
the main component of HDL,chylomicrons, and VLDL. Measurement of apoliprotein A is more useful than the
measurement of HDL in predicting patients with high risk of coronary artery disease. Levels of apolipoprotein A
are inversely correlated with the risk of premature coronary artery disease. Apolipoprotein B is the major
component low density lipoprotens. The relative proportion of apolipoprotein B to apolipoprotein A is more
effective in differentiationg those with or without ischemic heart disease than the measurement of lipid or
lipoprotein cholesterol. An adverse Apo B/Apo A profile at a young age is potentially a marker for coronary heart
disease
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Aspartate Aminotransferase ..........................
Synonyms AST; GOT; Serum Glutamic Oxaloacetic Transaminase; SGOT; Transaminases
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Gross hemolysis; improperly labeled specimen
Reference Interval 0-6 months; 0-120 IU/L;
Use A wide range of disease entities alters AST (SGOT), with origin from many organs. When an increased
AST is from the liver, it is more likely to relate to disease of the hepatocyte. Other enzymes, including alkaline
phosphatase and GGT, are more sensitive indicators of biliary obstruction.
Causes of low AST: uremia, vitamin B6 deficiency (this can be corrected), metronidazole, trifluoperazine.
Causes of high AST: chronic alcohol ingestion, not limited to overt chronic alcoholism; cirrhosis. In alcoholic
hepatitis, AST values usually are <300 units/L. In hepatitis, look for high AST/LD (LDH) ratio, >3, and very
high AST peaking at 500-3000 units/L in acute viral hepatitis (ie, in clinical acute viral hepatitis the
transaminases may be increased 10 times or more above their upper limits of normal). AST increases are found
in other types of liver disease, including earlier stages of hemochromatosis; chemical injury (eg, necrosis related
to toxins such as carbon tetrachloride). Some instances of cholecystitis cause increased AST.
AST and ALT (SGPT) are increased in Reye's syndrome. In infectious mononucleosis, LD (LDH) is commonly
considerably higher than AST. Trauma (including head trauma and including surgery) and other striated muscle
diseases, including dystrophy, dermatomyositis, trichinosis, polymyositis, and gangrene cause AST increases.
Both AST and ALT elevations are found with Duchenne's muscular dystrophy. Look for high CK in myositis,
high LD5 (or isomorphic pattern in some instances of polymyositis) on LD isoenzymes.
35
In myocardial infarction AST peaks about 24 hours after infarct and returns to normal 3-7 days later. In acute MI
without shock or heart failure, ALT is not apt to increase significantly. AST increases in congestive failure with
centrilobular liver congestion, in which high LD5 on LD isoenzymes is found, and in pericarditis, myocarditis,
pancreatitis, and other inflammatory states including Legionnaires' disease. In renal infarction LD is usually
high, out of proportion to AST. Lung infarction and other disease entities leading to necrosis including large,
necrotic tumors cause increased AST; LD is commonly also increased in such instances. Shock (LD also usually
increased); hypothyroidism (LD and/or CK not infrequently increased in myxedema); hemolytic anemias (LD
high with increased LD1) and certain CNS diseases may increase AST.
Very high AST levels usually are caused by liver disease and/or by shock.
Drugs: A large number of commonly used drugs have been reported to elevate AST: isoniazid, phenothiazines,
erythromycin, progesterone, anabolic-androgenic steroids, halothane, methyldopa, opiates, indomethacin,
salicylates in children, and other drugs. Hepatotoxicity from drugs may cause high aminotransferase activity
with elevation of AST/ALT ratio.
Acetaminophen hepatotoxicity deserves special mention. In alcoholics, apparently moderate doses of the
analgesic have caused severe hepatotoxicity. Doses of 2.6-16.5 g/24 hours are reported with total bilirubin 1.323.9 mg/dL, AST 1960-29,700 units/L, and ALT 12,000-12,550 units/L. The characteristic pattern included
mild to severe coagulopathy and AST greater than ALT by a considerable margin.
Macroenzyme causing unexplained increase of AST is described with normal levels of CK and ALT.
Methodology Kinetic
Testing Schedule : Daily
ASPERGILLUS IgG & IgM (EIA)
Requirement: 1 ml serum
Ref. Range FOR BOTH: < 50 U/mL
Use:- confirm the presence of precipitating antibodies to Aspergillus sp.
Limitations: A negative test does not rule out aspergillosis.
Method: EIA
Additional Information: Aspergillus precipitins are seen in 90% of patients with fungus balls, 70% of patients
with allergic bronchopulmonary aspergillosis, and less often in patients with invasive aspergillosis. Both
sensitivity and specificity are poor.
Aspergillosis immunodiffusion: Sera can be tested against a polyvalent antigen mixture, or a series of species
prepararions. Cross reactions occur in cases of histomplasmosis, coccidioidomycosis and blastomycosis, or may
indicate antibody to an Aspegillus species other than Aspergillus fumigatus. Bands due to reaction with C-reactive
protein can be removed by sodium citrate.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
BILHARZIA (SCHISTOSOMA) ABS
Specimen Requirement: 1 ml serum
Ref. Interval:
<1:16 abs not detectable
1:16 - :32 borderline.
>1:32 abs detectable
Use:- Support a clinical diagnosis of schistosomiasis.
36
Limitation:- Test does not differentiate between recently acquired infection and chronic multiple exposures and
so is simply reported as positives or negative. Test does not differentiate between intestinal and vesical
schistosomiasis.
METHOD: Haemagglutination
Additional information Demonstration of eggs in bladder or bowel biopsy is definitive, and the examination is
now sensitive and specific, but its present role in clinical decision making is not yet established
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Bilirubin, Direct ..................................................
Synonyms Bilirubin, Conjugated
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate. Protect from light.
Causes for Rejection Gross hemolysis; prolonged exposure to light; improperly labeled specimen; gross lipemia
Reference Interval 0-0.40 mg/dL
Use Evaluate liver and biliary disease. Increased direct bilirubin occurs with biliary diseases, including both
intrahepatic and extrahepatic lesions. Hepatocellular causes of elevation include hepatitis, cirrhosis, and
advanced neoplastic states. Increased with cholestatic drug reactions, Dubin-Johnson syndrome, and Rotor
syndrome. In the latter two syndromes, the level is usually <5 mg/dL.
Contraindications Measurement of direct bilirubin is usually not necessary when the total bilirubin is <1.2
mg/dL.
Methodology Colorimetric
Additional Information Theoretically, direct bilirubin should not be increased in hemolytic anemias, in which
bilirubin increase should be in the indirect bilirubin fracion in the absence of complications. In practice, some
increase in the direct fraction may be encountered in patients with hemolytic anemia in whom complications
have not been proven.. Some methods have shown the direct bilirubin to be spuriously high. This may be due
to different concentrations of sodium nitrite, which may convert some of the unconjugated bilirubin to
conjugated bilirubin. Direct bilirubin is the water soluble fraction. When increased in serum, bilirubin should
become positive in the urine. Physiologic jaundice, occurring 2-4 days after birth, is due to lack of liver
glucuronyl trasferase.
Testing Schedule : Daily
Bilirubin, Total ....................................................
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate. Protect sample from light. Bilirubin
deteriorates rapidly when exposed to light.
Causes for Rejection Gross hemolysis; improperly labeled specimen; gross lipemia.
Reference Interval 0.1-1.2 mg/dL
37
Use Causes of high bilirubin: Liver disease: hepatitis, cholangitis, cirrhosis, other types of liver disease
(including primary or secondary neoplasia); alcoholism (usually with high AST (SGOT), GGT, MCV, or some
combination of these findings); biliary obstruction (intrahepatic or extrahepatic); infectious mononucleosis (look
also for increased LD (LDH), lymphocytosis); Dubin-Johnson syndrome; Gilbert's disease (familial
hyperbilirubinemia) is encountered as a moderate elevation with otherwise unremarkable chemistries.
Anorexia or prolonged fasting: 36 hours or more may cause moderate rise.
Pernicious anemia, hemolytic anemias, erythroblastosis fetalis, other neonatal jaundice, hematoma and following
a blood transfusion, especially if several units are given in a short time.
Pulmonary embolism and/or infarct, congestive heart failure.
Drugs: A large number of drugs can cause jaundice by in vivo action or by chemistry methodology. Drugs
causing cholestasis and/or hepatocellular damage include diphenylhydantoin, azathioprine, phenothiazines,
erythromycin, penicillin, sulfonamides, oral contraceptives, anabolic-androgenic steroids, halothane,
aminosalicylic acid, isoniazid, methyldopa, indomethacin, pyrazinamide, and others.
Methodology Colorimetric
Additioanl Information Interpretation of increased bilirubin is greatly enhancec by other chemistry results. In
acute viral hepatitis with jaundice , for instance, the transaminases ALT (SGPT) and AST (SGOT) are
consistently increased, while an isolated elevation of bilirubin is seen in Gilbert’s disease. Obstruction causes
increases in bilirubin and alkaline phosphatase greater than and out of proportion to the transminases. Amylase
and lipase are useful in differential diagnosis of obstructive jaundice. In intrahepatic cholestasis, the
transminases are not as increased, relative to bilirubin, as they are in hepatitis.
Testing Schedule : Daily
Bilirubin, Total and Direct, Serum .................
Synonyms Bili D/I; Bilirubin, Total, Conjugated and Unconjugated
Test Includes Conjugated (direct) bilirubin; total bilirubin; indirect bilirubin (calculated)
Specimen Requirement Serum
Volume 3 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate. Protect from prolonged exposure to
light.
Causes for Rejection Severe hemolysis; specimen not protected from light; improperly labeled specimen;
severe lipemia
Use Liver and biliary tests are useful in the differential diagnosis of jaundice from bilirubin overproduction
(hemolysis), decreased uptake (Gilbert's), decreased conjugation (hepatocellular disease, neonatal immaturity,
Crigler-Najjar, drug inhibition), decreased excretion into bile (hepatocellular disease, familial, drug-induced,
pregnancy, obstructive bile duct disease).
Methodology Colorimetric
Testing Schedule : Daily
Blood Culture, Routine ...................................
Synonyms Culture, Blood, Routine
Test Includes Isolation, identification, and susceptibility testing are performed
Special Instructions Request form must state clinical diagnosis and time of collection. List current antibiotic
therapy, clinical diagnosis, and any special organisms suspected or to rule out. Must indicate if culture is for
Brucella or Francisella.
38
Specimen Requirement Whole blood
Volume 10-20 mL; 5-10 mL per bottle as indicated on bottle. Pediatrics: 1-3 mL in one pediatric bottle.
Container One aerobic and one anaerobic blood culture bottle. Do not vent.
Collection Blood cultures should be drawn prior to initiation of antimicrobial therapy. If more than one culture is
ordered, the specimens should be drawn separately at no less than 30 minutes apart to rule out the possibility of
transient bacteremia by self-manipulation by the patient of mucous membranes in the mouth caused by brushing
teeth, etc or by local irritations caused by scratching of the skin.
* Suspected sepsis, meningitis, osteomyelitis, arthritis, or acute untreated bacterial pneumonia: Obtain two blood
cultures from two different sites, such as the left and right arms.
* Fever of unknown origin such as that caused by an occult abscess: Obtain two blood cultures initially. If those
are negative, obtain two more 24-36 hours later. The yield beyond three or four cultures is virtually nil in this
condition.
* Suspected early typhoid fever and brucellosis: Obtain four blood cultures over 24-36 hours due to low-grade
bacteremia involved in these rarely seen diseases.
* Endocarditis (acute infective endocarditis): Obtain three blood cultures from three separate venipuncture sites
during the first 1-2 hours and begin therapy.
* Subacute infective endocarditis: Obtain three blood cultures within the first 24 hours, ideally within no less
than hourly intervals. If all are negative at 24 hours, obtain two more. The yield beyond five blood cultures in
subacute and endocarditis is virtually nil.
The time of collection must be indicated. Strict aseptic technique is essential. If present remove the plastic cap
from the blood culture bottles, swab the stoppers with 2% tincture of iodine and allow to dry. Collect 20 mL
blood in a sterile plastic syringe and inoculate at least 10 mL blood (as indicated on bottle) into each bottle or use
Vacutainer® and butterfly collection set and monitor the fill using the graduations on the side of the bottle.
Storage Instructions Preincubate or maintain specimen at room temperature. Do not refrigerate.
Patient Preparation The major difficulty in interpretation of blood cultures is potential contamination by skin
flora. This difficulty can be markedly reduced by careful attention to the details of skin preparation and
antisepsis prior to collection of the specimen. Skin preparation: First cleanse the venipuncture site with
isopropanol. Then use tincture of iodine to disinfect the site using progressively larger concentric circles. Iodine
should remain in contact with skin for about 1 minute to ensure disinfection. The venipuncture site must not be
palpated after preparation. Blood is then drawn. Following venipuncture, alcohol is used to remove the iodine
from the site.
Use Isolate and identify potentially pathogenic organisms causing bacteremia; establish the diagnosis of
endocarditis
Methodology Culture
Testing Schedule : Daily
Interpretation of Positive Blood Culture
Virtually any organism, including normal flora, can cause bactermia.
A. Negative culture result does not necessarily rule out bacteremia; false-negative results occur when
pathogens fail to grow.
B. Positive culture results does not necessarily indicate bacteremia; false-positive results occur when
contaminants grow.
Gram-negative bacilli, anaerobes, and fungi should be considered pathogens until proven otherwise.
The most difficult interpretation problem is to determine whether an organism that is usually considered normal
skin flora is a true pathogen.
39
Body Fluid Culture, Sterile, Routine .............
Synonyms Culture, Body Fluid, Sterile, Routine; Sterile Body Fluid Culture
Test Includes Isolation and identification of potential aerobic pathogens and Susceptibility testing.
Special Instructions Indicate the specific source and pertinent clinical history on the request form.
Specimen Requirement Aseptically aspirated body fluid (eg, cerebrospinal fluid, synovial, peritoneal fluid)
Volume 2 mL minimum
Container Sterile tube or other sterile leakproof container, blood culture bottle.
Collection Contamination with normal flora from skin, rectum, vaginal tract, or other body surfaces should be
avoided. If anaerobes are suspected, order Anaerobic Culture.
Storage Instructions Maintain specimen at room temperature.
Patient Preparation Swab skin over the site of puncture with 2% tincture of iodine in concentric circles. Note:
Iodine should remain in contact with skin for at least 1 minute prior to puncture to ensure complete antisepsis.
Following puncture, 70% alcohol is used to remove iodine from skin.
Use Isolate and identify pathogenic organisms from normally sterile body fluids
Methodology Culture
Testing Schedule : Daily
Bordetella Pertussis Abs (Whooping Cough) IgA, IgG & IgM
Specimen Requirement: 1 ml serum
Ref. Interval:
IgA:
<15 U/mL - abs not detectable
15-22 U/mL - borderline
>22 U/mL – abs detectable
IgG:
<20 U/mL – abs not detectable
20-30 U/mL – borderline
>30 U/mL – abs detectable
IgM:
<9 U/mL – abs not detectable
9-14 U/mL – borderline
>30 U/mL – abs detectable
Use: Evaluate acute infection with or immunity following vaccination for Bordetella pertussis.
Method: EIA
Additional information: Patients with acute infections develop lgG, lgM and IgA antibodies to febrile
agglutinogens; and IgM and IgA antibodies are probably diagnostic. Following vaccination, IgG and IgM
antibodies can be demonstrated, except in infants. IgA antibodies do not develop.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Brucella Abs Agglutination
40
Specimen Requirement: 1 ml serum
Ref. Interval: <1:80 titer
Use: Support the clinical diagnosis of brucellosis.
Limitations: Previous vaccination may have an effect on the titer. There are cross reactions with proteus OX19,Yersinia enterocolitica, Francesella tularensis, and Vibriocholerae.
Method: Agglutination
Additional information: Brucella agglutinins appear during the second week in acute cases and peak in 3-6
weeks. With newer ELISA assays, IgG and IgM antibodies to Brucella are used both for initial diagnosis and for
follow-up of patient.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
C1-Esterase Inhibitor (Activity)
Specimen Requirement: 2 ml citrate plasma FROZEN
Ref. Interval: 70-130%
Use: C1 esterase inhibitor is decreased in hereditary angioneurotic edema; decrease may be functional or
quantitative.
Method: coagulation chromogen
Additional information: the more common for (85% of patients) of hereditary angioneurotic edema is due to an
absolute decrease in the amount of C1 esterase inhibitor. A less common form (15% of patients) is due to a
functional defect. The initiating stimulus of clinical attacks is often unknown.
Angioedema may also be an acquired illness. The acquired form includes nonhereditary C1 esterase deficiency;
drug-induced, allergic, and idiopathic forms; angioedema associated with autoimmune disease, especially with
systematic lupus erythematosus and hypereosinophilia; angioedema occasionally associated with malignancy; and
anigedema caused by physical stimuli
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
CA 125 (Tumor Marker)
Specimen Requirement: 1 ml serum
Ref. Interval: <35 U/mL
non-specific values: <65 U/mL
Use: Tumor marker for monitoring disease progression in nonmucinous common epithelia neoplasms of the
ovary. It may be found in patients with adenocarcinoma and adenosquamous carcinoma of the cervix. It may
prove to be useful in detection of advanced, extrauterine carcinoma of endometrium.
Limitation: CA 125 is not specific for tumors of the ovary and can not distinguish benign from malignant tumor. It
is not a screening testElevations bear correlations with tumor stage, but normal levels are reported with large
volume tumors. High levels are descried with peritonitis and with hepatic cirrhosis.
Method: CLIA
Levels >65 units/mL are associated with malignancy in over 90% of cases with pelvic masses.
41
CA 125 is most useful in monitoring progression or recurrence in cases of known ovarian carcinoma. For this
purpose, levels >35 IU/mL may be significant; although a lower level does not repace a second-look
operationTherefore, CA 125 remains a useful tool to follow these patients.
Because of the high frequency of false-positive results associated with common being conditions, CA 125 is not
useful as a screening test for ovarian carcinoma. Some of these being conditions are menstruation, pregnancy,
benign pelvic tumors, pelvic inflammatory disease, ovarian hypersimulation syndrome, and peritonitis.
a favorable report of the use of CA 125 to monitor endometriosis in infertile women has appeared.
Use of additional markers, such as CA 15-3, TAG 72, and placental alkaline phosphase, with CA 125 has been
advocated to enhance specificity.
Testing Schedule : Daily
CA 15-3 (Tumor Marker)
Requirement: 1 ml serum
Ref. Range: <28 U/mL
Use: Monitor patients for systematic recurrence of breast carcinoma. Limitations: Like CEA, CA 15-3 fails as a
reliable marker for early breast cancer. It lacks specificity for primaries of breasts.
Method: CLIA
Additional Information: There was good correlation of CA 15-3 levels with tumor stage of breast cancer, and
CA 15-3 was better than CEA in detection of metastases.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Calcitonin
Specific Requirement: 1 ml serum, FROZEN
Ref. Interval:
Female: <4.6 pg/mL
Male: <11.5 pg/mL
Use: Detect and confirm C-cell hyperplasia (the precursor of medullary carcinoma of thyroid) as well as tumor
marker for diagnosis and management of medullary carcinoma of the thyroid gland Multiple endocrine neoplasia
(men) type II includes medullary carcinoma of the thyroid, hyperparathyroidism, and pheochromocytoma. This is
Sipple’s syndrome. An important use of calcitonin assay is in the follow-up of patents with medullary carcinoma
and the work up of their families to detect early, sub clinical cases. Indications for calcitonin assay include family
history of unspecified type of thyroid cancer, calcified thyroid mass, thyroid tumor associated with hypercalceima
and/or pheochromocytoma, amyloid-containing metastic carcinoma with unknown primary site and the presence
of mucosal neuromas.
Limitations: Most subjects with microscopic medullary carcinoma and all with C-cell hyperplasia have normal
basal calcitonin levels; provocative testing is needed.
Occasional spurious high results are encountered. Hemolysis can cause spurious high levels. The purity of
standards may vary and antibodies in various assays may lack uniform specificities.
Method: CLIA
Additional information: .
Recently, calcitonin gene-related peptide (CGRP) has been suggested as a useful test together with calcitonin, as
tumor makers in MEN type II.
42
CEA is next most useful, after calcitonin, as a marker for medullary carcinoma. CEA generates less fluctuation
than calcitonin in calculation of doubling time. Medullary carcinomas may produce other substances, including
ACTH and serotonin
The direct manifestation of high calcitonin level is secretory diarrhea in 30% of patients with medullary thyroid
carcinoma.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Calcium, Serum .................................................
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Gross hemolysis; EDTA contamination; improperly labeled specimen
Reference Interval 0-6 months: 8.9-11.0 mg/dL; 6 months and older: 8.5-10.6 mg/dL
Use Work-up for coma, pancreatitis and other gastrointestinal problems, nephrolithiasis, polydipsia, polyuria,
azotemia, multiple endocrine adenomatosis.
Causes of high calcium:
* Hyperparathyroidism — look also for high ionized calcium, measured or calculated. Hyperparathyroidism may
coexist with other endocrine tumors (multiple endocrine adenomatosis syndromes).
* Carcinoma, with or without bone metastases. Humoral hypercalcemia of malignancy (HHM), (tumor induced
hypercalcemia) is seen especially in primary squamous cell carcinoma of lung, head and neck, but other
important tumors include primaries in the kidney, liver, bladder, and ovary. It is probably caused by
parathormone-like peptides. The most common solid tumors causing bone metastases are primaries in the breast
and lung. Other neoplasms may also cause hypercalcemia. Differences between HPT and humoral
hypercalcemia of malignancy include low dihydroxyvitamin D, reduced calcium absorption, and the presence of
a nonparathyroid tumor. Alkaline phosphatase more than twice its upper limit is more suggestive of cancer than
of hyperparathyroidism. Especially if there is only a brief duration of symptoms, anemia, hypoalbuminemia, and
other findings suggestive of malignant disease, chloride/phosphorus ratio <29 mmol/L, chloride <100 mmol/L,
high serum LD (LDH) and/or phosphorus, think first of malignant neoplasm. The chloride/phosphorus ratio is
predominantly of value when it is <29 mmol/L, to provide evidence against a diagnosis of primary
hyperparathyroidism. Laboratory results which would favor malignancy include anemia, increased LD and
alkaline phosphatase, decreased serum albumin and chloride, and chloride/phosphorus ratio <29 mmol/L.
Parathyroid hormone-related protein was recently purified and identified by molecular cloning as a 141-amino
acid peptide with limited homology to PTH itself. Both peptides activate the PTH receptor to produce
hypercalcemia. PTH-related protein is now recognized as the cause of hypercalcemia in most solid tumors,
particularly squamous, and renal carcinomas.
* Myeloma
* Leukemia and lymphoma, especially T-cell lymphoma/leukemia and Burkitt's lymphoma.
* Dehydration is an extremely common cause of slight increases of calcium.
* Sarcoidosis (a fraction of patients have high serum calcium; usually without low serum phosphorus). More
have hypercalciuria.
* Chronic hypervitaminosis D. Vitamin A intoxication, isotretinoin (a vitamin A derivative).
43
* Prolonged immobilization (probably uncommon), in patient with increased bone turnover (eg, Paget's disease
of bone, malignancy, children).
* TB, histoplasmosis, coccidioidomycosis, berylliosis
* Milk-alkali syndrome: prolonged use of calcium-containing materials and alkali (eg, CaCO3 or other
absorbable alkali ulcer remedies with high milk intake) now rare.
* Idiopathic hypercalcemia of infancy (uncommon)
* Endocrine: hyperthyroidism, Addison's disease, acromegaly, pheochromocytoma (rare cause of
hypercalcemia)
* Advanced chronic liver disease
* Bacteremia
* Familial hypocalciuric hypercalcemia (dominant inheritance); the best test for familial benign hypercalciuria
(FBH) is a plot of fasting serum PTH against fasting urine calcium excretion
* Aluminum induced renal osteomalacia
* Rhabdomyolysis
* Several commonly used drugs cause in vivo elevation, including calcium salts, lithium, thiazide/chlorthalidone
therapy, other diuretics; vitamins D and A and estrogens (rapid increase in patients with breast carcinoma).
In any case of hypercalcemia, it is desirable to measure magnesium and potassium levels. A helpful mnemonic
for the differential diagnosis of the more common causes of hypercalcemia is DCHIMPS (drugs, cancer,
hyperparathyroidism, intoxication with vitamin D or A, milk alkali syndrome, Paget's disease of bone,
sarcoidosis).
Causes of low calcium:
* Low albumin and low total protein relate to common, usually slight decreases of calcium. The routine method
measures total calcium, about half of which is bound to plasma proteins. Since the metabolically active form of
calcium is the ionized state, the patient's serum protein level should be considered when interpreting a calcium
result. For example, a patient's ionized calcium may be normal when the total calcium is elevated in the presence
of elevated proteins and, conversely, may also be normal when the total calcium is low and the proteins are low.
* High phosphorus: renal insufficiency, hypoparathyroidism, pseudohypoparathyroidism
* Vitamin D deficiency, rickets, osteomalacia (Alkaline phosphatase is a test for osteomalacia. Calcium,
phosphorus, and alkaline phosphatase can all be normal in osteomalacia.)
* Milkman's syndrome
* Malabsorption or malnutrition with interference with vitamin D and/or calcium absorption
* Renal tubular acidosis
* Pancreatitis, acute
* Dilutional: I.V. fluids
* Bacteremia
* Hypomagnesemia
* Anticonvulsants and other common drugs, most by in vivo action, can depress calcium. Barbiturates in elderly
may cause calcium decrease. Other drugs, including calcitonin, corticosteroids, gastrin, glucagon, glucose,
insulin, magnesium salts, methicillin and tetracycline in pregnancy.
Methodology Colorimetric
Testing Schedule : Daily
CANDIDA ABS Iga, Igg & Igm
Specific Requirement: 2 ml serum
Ref. Interval:
44
IgA:
<60 U/mL - not detectable
60-80 U/mL - borderline
>80 U/mL - antibodies detectable
IgG:
<40 U/mL - antibodies not detectable
40-100 U/mL - borderline
>100 U/mL - antibodies detectable
IgM:
<60 U/mL - antibodies not detectable
60-80 U/mL - borderline
>80 U/mL - antibodies detectable
Use: Detect candidasis in immunocompromised patients.
Limitation: Latex test is relatively insensitive.
Method: EIA
Additional information: Detection of specific Candida sepsis is particularly important in immunocompromised
patients due to the life-threatening nature of the illness. Unfortunately, the sensitivity of Candida antigen tests are
too low to rule out candidemia despite a negative test result. Consequently, a negative result does not preclude the
use of empiric antifungal therapy. A positive test, however, provides useful information.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Carbohydrate Antigen (CA) 19-9 ....................
Synonyms CA 19-9
Test Includes Long-term serial monitoring of results, color graphic summary report
Special Instructions CA 19-9 values obtained with different methodologies cannot be used interchangeably in
CA 19-9 testing. It is recommended that one assay method and one tube of specimen (serum or plasma) be used
consistently to monitor a patients course of therapy.
In order to receive more clinically useful serial results, submit the same specimen type each time this procedure
is ordered.
Specimen Requirement Serum or plasma
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube or lavender-stopper (EDTA plasma) tube
Collection If tube other than serum-separator tube is used, transfer separated serum or plasma to a plastic
transport tube.
Storage Instructions Refrigerate
Causes for Rejection Gross hemolysis; recently administered isotopes
Use Monitor gastrointestinal, pancreatic, liver, and colorectal malignancies
Limitations CA 19-9 is not a screening test.
Methodology Enzyme immunoassay (EIA)
Testing Schedule : Daily
45
Additional Information CA 19-9, a carbohydrate antigen related to Lewis blood group antigen, has been shown
to be elevated in sera of some patients with gastrointestinal tumors. CA 19-9, as a tumor marker, is helpful in
post-therapeutic monitoring to determine the success of therapy or the development of recurrence when used
serially, CA19-9 has been reported as positive in 70% to 80% of pancreatic carinomas, 50% to 60% of gastric
cancers, 60% of hepatobiliary cancer. Serum levels may differentiate pancreatic cancer from pancreatitis. The
test may also be positive in patients with non-neoplastic disease, particularly inflammatory disease of the bowel,
cirrhosis, and autoimmune conditions including rheumatoid arthritis (33%), systemic lupus erythematosus
(32%) and scleroderma (33%).
Carbon Dioxide, Total .......................................
Synonyms CO2
Specimen Reaquirement Serum
Volume Entire collection
Container Serum-separator tube (send entire tube)
Storage Instructions Tube must be stoppered until ready for analysis to prevent release of CO2 into the
atmosphere.
Causes for Rejection Improper collection and storage; improperly labeled specimen
Reference Interval 21-32 mmol/L
Use Evaluate the total carbonate buffering system in the body, acid-base balance. High results may represent
respiratory acidosis with CO2 retention, or metabolic alkalosis (eg, prolonged vomiting). Low value may
indicate respiratory alkalosis as in hyperventilation or metabolic acidosis (eg, diabetes with ketoacidosis).
Methodology Enzymatic
Testing Schedule : Daily
Carboxy-Haemoglobin
Specimen Requirement: 2 ml heparin blood
Ref. Interval:
non-smoker: <5%
smoker (5-20 cigarettes per day): <9%
heavy smoker (>20 cigarettes per day): <13%
Use: Determine the extent of carbon monoxide poisoning, toxicity. Check on effect of smoking on the patient;
work up headache, irritability, nausea, vomiting, vertigo, dysponea, collapse, coma, convulsions. Work up persons
exposed to fires and smoke inhalation.
Limitation: Carbon monoxide levels are of limited value in screening for smoking, since it is cleared rapidly.
Carcinoembryonic Antigen (CEA) ..................
Special Instructions State whether patient is a smoker or nonsmoker on the request form. Values obtained with
different assays should not be used interchangeably. If in the course of monitoring a patient the assay method
used for determining CEA levels serially is changed, additional sequential testing should be carried out to
confirm baseline values. It is recommended that one type of specimen (serum or plasma) be used consistently to
monitor a patient's course of therapy.
In order to receive more clinically useful serial results, submit the same specimen type each time this procedure
is ordered.
Specimen Requirement Serum or plasma
46
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube or lavender-stopper (EDTA plasma) tube or green-stopper
(heparinized plasma) tube
Collection Specimen should be free from hemolysis. If tube other than serum-separator tube is used, transfer
separated serum or plasma to a plastic transport tube.
Storage Instructions Refrigerate
Causes for Rejection Hemolysis
Use Monitor patients with various type of malignancies; evaluate response to therapy and as a possible indicator
of recurrence and prognosis
Limitations CEA results should not be interpreted as abssolute evidence for the presence or absence of
malignant disease but should be used in conjunction with information from other test procedures and
from clinical evaluations of the patient tested. CEA levels are elevated in smokers; patients with
inflammation including infections, inflammatory bowel disease, and pancreatitis; some patients with
hypothyroidism; cirrhosis; and in some patients with noncolorectal neoplasms espaecially gastric,
pancreatic, breast and ovarian. CEA is not a screening test for occult cancer. Many negatives occur in
patients with early carcinoma. Negative in some patients with even metastatic colorectal and other
neoplasms: a minority of such patients do not have high CEA levels. Radiation therapy may also induce
a transient rise in CEA. Benign diseases usually do not cause CEA levels >5-10 ng/ml.
Distribution of CEA values in subjects by diagnostic group
Percent (%)
No.
0- 3.1- 5.1 >10.
of
3.0 5.0
0
Subj ng/ ng/m 10. ng/m
ects m
L
0
L
L
ng/
m
Healthy Subjects
Nonsmo 1045 93. 5.6 0.9 0.1
ker
560
4
15.0 3.8 0.0
Smoker 1605 81. 8.9 1.9 0.1
2
Total
89.
2
Malignant Disease
Colorect 191 41. 8.9 10. 38.7
al
132
9
16.7
5
31.8
Pulmon
152 36. 9.9 15. 15.1
ary
29
4
17.2
1
24.1
Mamma
21
68. 19.0 6.6 19.0
ry
63
4
4.8 17. 3.2
Gastric
10
41. 10.0
2
0.0
Pancreat
4
14.
ic
47.
3
Ovarian
6
3.2
Other
88.
0.0
47
gyn
9
90.
0
Nonmalignant Disease
132 52. 21.2 19.
27
3
7.4
7
49
88. 10.2 3.7
30
9
16.7 4.1
57
81. 22.8 6.7
16
6
6.3 17.
76.
5
7
0.0
54.
4
87.
5
Cirrhosi
s
Divertic
ulitis
Ulcerati
ve
colitis
Rectal
polyps
Pulmon
ary
Hepatiti
s
Testing Schedule : Daily
6.8
0.0
4.1
0.0
5.3
6.3
CARDIOLIPIN ANTIBODIES (Igg & Igm)
Specimen Requirement: 1 ml serum
Ref. Interval FOR BOTH: <12 U/mL
Use:- Diagnosis of acute infract of myocardium (acute MI, or AMI).
Limitations:- At onset of acute infraction of myocardium, all enzymes and isoenzymes are normal. It is desirable
to draw cardiac enzymes at onset for a baseline. Myositis, various myopathies, rhabdomyolsis, and Reye’s
syndrome are reported to cause elevations of CK-M. Thus, the test is not entirely specific for AMI, and
confirmation by LD isoenzyme studies may be indicated.
Method: ELISA
Additional Information:- Actue MI: Ck and Ck-Mb (Ck2 MB) have been widely considered to peak about 1
day following onset, as does AST in usual hospital practice.
CK-MB, LD1, LD1: LD2 ratio, total CK and total LD classically increase with acute M1. The use of AST
(SGOT) in diagnosis of AMI includes its application with ALT (SGPT). Myocardial injury can generate an
AST/ALT ration > 3.1 or a two fold increase in this ratio
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Catecholamines (P) (Adrenallne, Noradrenaline & Dopamine)
Specimen Requirement: 2 ml FROZEN EDTA plasma, no longer EGTA plasma
How to obtain a sample:
1. The blood should be drawn from the patient (who is lying down) approx. 30 min. after a canule has been
positioned.
2. Put 5 ml of whole blood in the EDTA tube, mix by tipping to and fro carefully and cool immediately (do not
freeze yet).
3. Centrifuge cool to obtain plasma.
48
4. Put the plasma into a normal Bioscientia tube, add patient data, freeze and send frozen.
Ref. Range:
Adrenaline: <84 ng/L (459 pmol/L)
Noradrenaline: <420 ng/L (2482 pmol/L)
Dopamine:
<85 ng/L (560 pmol)
Use:- Diagnose pheochromocytoma and those paragangliomas which may secrete epinephrine, norepinephrine or
both. Such tumors may cause paroxysmal or persistent hypertension. Others recommend plasma catecholamines
when urninary collections are not diagnostic. Work-up of multiple endocrine adenomatosis, type II. Used also in
diagnosis of disorders related to the nervous system and in assessment of resuscitation.
Limitations:- Normotensive pheochromocytoma has been reported. False-positive results are common.
Epinephrine secretion increased in response to cold and hypoglycemia. Depending on methods, drugs which may
affect plasma norepinephrine levels include alpha-and beta-adrenergic blockers, vasodilators, clonidine,
bromocriptine, theophylline, phenothiazine, tricyclic antidepressants, labetalol, calcium channel blockers,
converting enzyme inhibitors, bromocriptine, chlorpromazine, haloperidol, and cocaine plasma catecholamines are
less sensitive than are urinary catcholamines. In general fractionated catecholamines result in values more
consistent than those from plasma.
Method: HPLC
Additional Information:- the adrenal medullary catecholamines (epinephrine, norepinephrine and their precursor,
dopamine) are rapidly metabolized materials with intense vasoactivity, among many other properties. They can be
synthesized by extra adrenal cells or neoplasm of the APUD system. They are pathogenic in the expisodic
hyhpertension of pheochromocytoma, and will be elevated during and immediately after such a paraoxysm.
However levels may be normal during asymptomatic intervals. Urine catecholamines metanephrines, VMA and
HVA provide additive information. Extra-adrenal pheochromocytomas may represent 15% of adult and 30% of
childhood pheochromocytomas; the most common location is the superior para-aortic region between the
diaphragm and lower renal poles.
A clonidine-suppression test has been described; failure to suppress plasma catechoamines with clonidine supports
the diagnosis.
Plasma neuropeptide Y, a 36 amino acid peptide, is a marker for nervous system tissue its value remains to be
established. Plasma levels can be assayed by immunoradiometric methods. Increased levels have been found with
pheochromocytomas, neuroblastomas and in some subjects with other neuroendocrine tumors such as carcinoids,
medullary carcinoma of thyroid, and small cell carcinoma of lung.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Catecholamines (U) (Total) (Adrenaline, Noradrenaline & Dopamine)
Specimen Requirement: 30 ml 24h urine. Immediately after collection, mix the 24h urine well. Please state 24h
urine volume. Prepare the shipping tube to contain
0.5 ml of 25% hydrochloric acid, fill tube with urine and mix well. Ensure pH value between 2-4. Do not use
acetic acid or boric acid. Metanephines, VMA and Homovanillic acid can also be performed in these specimens.
Diet: It is recommended that the patient has no intake for 2 days prior to urine sampling of the following: nuts,
citrus fruits plus no cocoa, coffee or vanilla-containing products.
Medication: If clinical condition allows it is also recommended that the patient stops taking catecholamines
(epinephrine, norepinephrine, dopamine), MAO-inhibitors or catecholamine-reuptake inhibitors at least 2 days
prior to sampling.
REF. RANGE:
Adrenaline: <27 µg/24h (<150 nmol/24h)
49
Noradrenaline: <97 µg/24h (<570 nmol/24h)
Dopamine: <500 µg/24h (<3240 nmol/24h)
Method: HPLC
Note: These are always performed together; Dopamine is no longer offered singularly. For all tests at least 2 urine
tubes are required.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
CBC Complete Blood Count With Differential
Synonyms CBC
Test Includes Differential count; hematocrit; hemoglobin; mean corpuscular volume (MCV); mean corpuscular
hemoglobin (MCH); mean corpuscular hemoglobin concentration (MCHC); percentage and absolute counts;
platelet count; red cell count; white blood cell count
Specimen Requirement Whole blood
Volume 5 mL whole blood
Container Lavender-stopper (EDTA whole blood) tube
Collection Invert immediately and gently mix with anticoagulant.
Storage Instructions Maintain specimen at room temperature up to 24 hours.
Causes for Rejection Hemolysis; clotted specimen; specimen diluted with I.V. fluid; tube not filled with
minimum volume; improperly labeled specimen
Use Evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characteristics,
state of hydration and dehydration, polycythemia, hemolytic disease of the newborn, inherited disorders of red
cells, white cells, and platelets; manage chemotherapy decisions; determine qualitative and quantitative
variations in white cell numbers and morphology, morphology of red cells and platelet evaluation
Methodology Automated cell counter
Testing Schedule : Daily
Ceruloplasmin (S)
Specimen Requirement: 1 ml serum SEND IMMEDIATELY
Ref. Interval:
Adults and children >1 year: 0.2-0.6 g/L
Infants 0-5 days: 0.05-0.4 g/L
Use: Decreased in most instances of Wilson’s disease (hepatolenticular degenteration); hence, ceruloplasmin is
used in evaluation of chronic active hepatits, cirrhosis and other liver disease. In Wilson’s disease, there is
decreased ability to incorporate copper into apoceruloplasmin. As a result free copper levels in plasma and in
tissue, especially liver and brain, are greatly increased.
Ceruloplasmin is low in Menkes ‘kinky hair syndrome (in Menkes syndrome the defect is secondary to poor
absorption and utilization of dietary copper), and with protein loss such as the nephritic syndrome, malbsorption,
and with some cases of advanced liver disease in which decrease of serum proteins have occurred.
Ceruloplasmin is high in a variety of neoplastic and inflammatory states, since it behaves as an acute phase
reactant, although levels rise more slowly than “acute phase reactants”. Increases are described with carcinomas,
leukemias, Hodgkin’s disease, primary biliary cirrhosis, and with oral contraceptive use.
Limitation: A normal ceruloplasmin does not rule out Wilson’s disease. Serum copper should be measured in
addition
50
Additional Information: Laboratory parameters of Wilson’s disease include decreased serum ceruloplasmin,
decreased serum copper concentration, increased 24-hour urine copper excertion, increased liver copper
concentration, and abnormal liver functions studies.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Cervical/Vaginal Cytology
Synonyms Cervical Smear; Pap Smear; Vagnial Cytology
Applies to Herpes Smear; The Bethesda System; Vira Pap; Vira Type; Vulvar Cytology
Test commonly includes Fast smear, cervical scraping smear, vaginal pool smear, lateral vaginal wall smear ,
direct scraping smear
Patient Care Preparation: Patients are advised to avoid douches 48-72 hours prior to examination; however,
this should not preclude taking of the smear. Provide relevant information include age and last menstrual period (
LMP)
Specimen Requirement Endovervical and cervical scrape or brush are recommended in all cases. Aspiration of
posterior vaginal fornix fluid ( vaginal pool) may also be used and is actually the smear of choce for hormonal
evaluation and is particularly useful if endometrial cancer is being sought ; however it is no a substitute for cervical
specimens. Endometrial aspirations are not advised for routine use. For lesions of the vagina or vulva, scrapings
made directly from the lesion are most diagnostic. Cellular samples obtained by scraping the upper lateral vaginal
wall may be used for hormonal evaluation; however , due to variation in site chosen and technique in obtaining the
smear, a true reflection of hormonal status may not result. Container: Glass slides with frosted ends; spray fixative
containing 95% ethanol and water or liquid fixative such as PRO-FIX TM ( Lerner laboratories, Stanford, CT),
also containing ethanol and water. Hair spray should never be used to fix Pap smear slides. The slides may be sent
to the laboratory in cardboard slide containers; if the smears are wet-fixed in 95% alchol in a Coplin jar, this may
be sent to the laboratory. Collection: preferred fixatives: Spray or liqueid fixatives as mentioined above or 95%
ethanol. Patient identification of specimen: Each slide must labled with patient’s name and site sampled, written
with graphite pencil on the frosted end of the slide. It is possible to lable nonfrosted slides only with a diamond
point pen. The speculum must be introduced without lubricant; in certain cases, running the speculum through
warm saline will prove helpful prior to insertion into atrophic, stenotic, or small introitus.
Sampling:
Endocervix: Gentle scrape or brush of endocervical canal
-
Scrape_ Rotate narrow end of spatula in the cervical os and gently smear onto labled glass slide and fix
immediately
Brush- use a tapered synthetic fiber brush to sample endocervical cells and mucous. Do not scrub onto the
slide; rather, lightly roll brush ove the slide.
Ectocervical scrape: with spatula thoroughly scrape the entire ectoccervix with emphasis on the
squamocolumnar junction. Spread material evenly onto labeled glass slide and fix immediately.
Vaginal pool smear: Use pipette, tongue blade, spatula, or lip of speculum to obtain material ( fluid) from the
posterior fornix. Place drop of fluid directly on glass slide and spread fluid evenly over the slide with glove. This
material may contain cells from the vagina, cervix , enometrium, fallopian tubes , and ovaries. Immediate fixation
is imperative. The vaginal pool smear is valuable for cytohormonal as well as radiation effect evaluation. This
smear will detect approximately 90% of endometrial carcinomas when the cellular and hormonal patterns are
interpreted in combination. Although this is not the smear of choice for cancer detection, up to 90% of cervical
51
carcinomas may be detected in this smear. A vaginal pool smear may be obtained in children with a nasal
speculum.
Cervical scraping smear: Made by introducing cervical spatula through the external os endocervical canal,
rotating 360 , sampling the entire squamoculumnar junction, and spreading onto slide with immediate fixation.
Although not the smear of choice for cancer detection, it will detect approximately 97% of early cervical lesion.
Perhaps 25% of endometrial lesions will be detected by this method.
Fast Smear: Combines vaginal pool and cervical scrapping smear material on one slide and detects 90% of
endometrial carcinomas and 97% of cervical carcinomas; it is therefore considered the smear of choice for cancer
detection. First, the vaginal pool material is obtained, and one drop placed 1 inch from the end of the glass slide.
Do not smear. Obtain cervical scraping as described above, remove quickly, and mix with lower part of vaginal
pool material. Over open fixative container, quickly, and mix with lower part of vaginal poor material. Over open
fixative container, quickly draw gloved fifth finger from combined drop to opposite end of slide twice.
Immediately drop into fixative.
Lateral Vaginal Wall Smear: Scraping from upper lateral one-third of vaginal mucosa. Used in cythohormonal
evaluations.
Direct scraping smear: Direct scrape of grossly visible lesion, smeared and fixed as previously described.
Causes for rejection: Improper fixation, lack of identification Special Instructions: Include pertinental clinical
history such as age, LMP, parity, postmenopausal status, surgery , exogenous hormones, history of such as age,
LMP , parity , postmenopausal status, surgery, exogenous hormones, history of carcinoma, radiation,
chemotherapy, abnormal vaginal bleeding, and history of previous abnormal pap smears.
Interpretive possible panic interval: Any smear with definitely malignant cells should ideally be verbally
relayed directly to the clinician in addition to forwarding the formal report.
Use: diagnose primary or metastatic neoplasms; diagnose cervical dysplasia ( cervical intraepithelial)
Cervical/Vaginal Cytology
Traditional
Class
Bethesda System
ADEQUACY OF THE SPECIMEN
Satisfactory for evaluation
Satisfactory for evaluation but limited by…( Specify reason)
Unsatisfactory for evaluation…(Specify reason)
1
2
3,4,5
GENERAL CATEGORIZATION ( optional)
With normal limits
Benign cellular changes: see Descriptive Diagnoses.
Epithelial cell abnormality: see Descriptive Diagnoses.
52
Descriptive diagnoses
Bengin Cellular changes
Infection
Trichomonas vaginalis
Fungal organisms morphlogically consistent with Candida spp
Predominance of coccobacilli consisten with shift in vaginal flora
Bacteria morphologically consistent with Actinomyces spp
2
2
3,4,5
2 or 3+
3
3 or 4
Cellular changes associated with herpes simplex virus
Reactive Changes
Reactive cellular changes associated with:
Inflammation ( includes typical repair)
Atrophy with inflammation ( atrophic vaginitis)
Radiation
Intrauterine contraceptive device ( IUD)
Other
Epithélial cell abnromalities
Squamous cell
A typical squamous cells of undetermined significance : Qualify+ low
grade squamous intraepithelial lesion ( LSIL) encompassing : HPV*mild
dysplasia/CIN 1
High grade squamous intraepithelial lesion ( HSIL) encompassing:
Moderate and severe dysplasion, CIS/cin 2, and CIN 3
Squamous cell carcinoma
5
2
2 or 3+
5
5
5
5
5
Glandular cell
Endometrial cells,
Endometrial cells, cytologically benging in a postmenopausal
Women A typical glandular cells of undetermined significance:
qualify +
Endocervical adenocarcinoma
Endometrial adenocarcinoma
Extrauterine adenocarcinoma
Adenocarcinoma, NOS
Other Malignant Neoplasms: Specify
Hormonal Evaluation ( applies to vaginal smears only)
Hormonal pattern compatible with age and history
Hormonal p[attern incompatible with age and history: specify
Hormonal evualtion not possible due to : Specify
53
Cellualar changes of human papillomavirus ( HPV)- previously termed koilocytosis, koilocytotic atypia,
and condylomatous atypia- are included in the category of LSIL+ A typical squamous or glandular cells of
undetermined significan should be further qualified, if possible, as to whther a reactive or
premalignant/malignant process is favored.
neoplasia (CIN); diagonose genital infections with herpes. Candida sp, Trichomonas vaginalis
cytomegalovirus and Actinomyces: aid in the diagnosis of vaginal adenosis cervicovaginal endomitriosis
condyloma, human papillomavirus infection lymphogranulama venerum and in evaluating hormonal
fuction ( formerly referred to as MI, maturation index): useful in suggesting chlamydial infection
Limitations: Failure to obtain adequate ectocervical endocervical, or vaginal cell population is considered
to indicate an unsatisfactory smear. Use of lubricating jelly on the speculum will interfere with the
cytologic assessment and cause a suboptimal specimen. Inflammatory smears should not be assessed for
hormonal status, as the inflammation will itself alte the maturation of the mucosa. Because the smears are
only a screening method, a lesion may be completely missed due to sampling error. Chlamydial infection
must be documented with associated culture. Additional Information: Suggested criteria for follow-up.
•
•
•
•
•
No atpical cells-annual cytologic follow up in women of reproductive age
Inflammation with associated change-annual follow up
Inflammation with possible underlying dysplasia – clear inflammation and repeat smear
Low grade dysplasia (mild CIN) (LSIL) – colposcopy with biopsy
In postmenopausal women an atypia of atrophy may appear to mimc a high grade dysplasia
Frequently an estrogen proliferation test, in which topical vaginal estrogen is applied and a
subsequent smear taken, is advised. In a true dysplasia, such estrogen will cause the cells to mature,
however, dysplasia will persist; in atropic atypia, maturation will occur, but no dysplasia, such
estrogen will cause the cells to mature, however, dysplasia will persist; in atropic atypia, maturation
will occur, but no dysplasia will be identified.
In patients of childbearing years who have had three consecutive annual normal smears, a smear
biannually is acceptable. Patients on oral contraceptives should have smears every 6 months. When a
colposcopic biopsy fails to reveal a high grade lesion seen on the smear, a cone biopsy should be
considered.
If the smear is repeated too soon ( less than 6 weeks). A lesser degree of atypia or dysplasia may be
noted. The does not negate the original findings and he abnormality should be pursued. A strong
association between HPV DNA and cervical dysplasia and neoplasia has been found. Specific subtypes
are considered more causal of neogenesis. Because of the increased frequency of finding this lesion in
young adults, the importance of pap screening should not be underestimated. There some proponents of
detecting the HPV in cervical swab specimens and/or biopsies by ViraPap and in situ hybridization to
identify high-risk patients. This remains controversial at present. The listing. Human papillomavirus
DNA probe Test in the molecular pathology chapter , is intended to provide a modicum of discussion
relevant to papillomavirus and cervical vaginal cytopathology.
The practitioner and patients should insist o smear review by licensed cytotechnologists and board
certified pathologists and should be cautious about simply seeking the lowest price conferences of
54
leading cytopathologists and gynecologists held at Bethesda in 1998 and 1991. formulated
recommendations for uniform diagnostic terminology for cervical/vagina cytology. Such
recommendations eliminated reporting by classes. These conference sponsored by the national cancer
institute. Led to a new classification, the Bethesda System (IBS). See table.
The practitioner and patients should insist on smear review by licensed cytotechnologists and board
certified pathologists and should be cautious about simply seeking the lowest price.
Chlamydia Antibodies, IgG ......... ...........
Specimen Requirement Serum
Volume 1mL
Minimum volume 0.5 mL
Container serum-separator tube
Storage Instructions maintain serum at room temperature.
Causes for Rejection Hemolysis, lipemia, gross bacterial contamination.
Reference Interval
• Negative: less than 0.91
• Equivocal: 0.91-1.09
• Positive: greater than 1.10
Use aid in the diagnosis of chlamydial infection
Methodology EIA
Chloride, Urine ...................................................
Synonyms Cl, Urine; Urine Cl
Special Instructions State 24-hour volume on test request form.
Specimen Requirement Urine (timed or random)
Volume 10 0 mL aliquot of entire collection
Container Plastic urine container, no preservative
Collection For a 24-hour collection, instruct patient to void at 8 AM (or 8 PM), and discard the specimen. Then
collect all the urine including the final specimen voided at the end of the 24-hour collection period (ie, 8 AM (or
8 PM) the following day). Container must be labeled with patient's name and date and time collection started
and finished.
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Improperly labeled specimen
Reference Interval 110-250 mmol/ 24 hours
Use Evaluate electrolyte composition of urine, acid-base balance studies. Distinguish whether or not a case of
metabolic alkalosis is chloride-responsive (salt responsive). Sherman and Eisinger discuss bicarbonate excretion,
blood volume, potassium depletion, and the differential diagnosis of metabolic alkalosis with loss of gastric juice
(emesis, intubation) and after diuretics. Chloride depleted patients excrete urine with low chloride, <10 mmol/L.
Such patients are chloride-responsive (ie, they respond to chloride sufficient to return body stores to normal).
Metabolic alkalosis with low urine chloride is also found with villous tumors of the colon.
55
Endogenous or exogenous corticosteroids produce urine chloride values >20 mmol/L. Such patients are chloride
resistant. The finding of chloride resistant metabolic alkalosis may provide a stimulus to identify an ACTH or
aldosterone producing neoplasm (eg, Cushing's syndrome or Conn's syndrome). In Bartter's syndrome with
metabolic alkalosis, there is usually increased urine chloride. The complex relationships of chronic pulmonary
disease with metabolic alkalosis are mentioned by Sherman and Eisinger.
Methodology Colorimetric; ion-selective electrode (ISE)
Cholesterol, Total .............................................
Specimen Requirement Serum
Volume 2 mL
Container 15-mL red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Improperly labeled specimen
Reference Interval Children and adolescents (19 years and younger): acceptable: <170 mg/ dL, borderline: 179199 mg/ dL; adults (older than 19 years): desirable: <200 mg/ dL, borderline high: 200-239 mg/ dL; high: >=
240 mg/ dL. See the LIPID Appendix for additional information.
Use Evaluate lipid status and metabolic disorders. High levels of cholesterol that reflect high levels of HPLs may
be caused by an inherited defect in lipoprotein metabolism, by disease of the endocrine system, by liver disease,
or by renal disease. Low levels of cholesterol in the plasma may reflect an inherited deficiency of either LDL or
HDL, or they may reflect impairment of liver function. Various hormone conditions are also related to
cholesterol levels. Increased serum cholesterol in hypothyroid persons shows an increased LDL and decreased
HDL. Low cholesterols are found in cases of hyperthyroidism, severe liver disease, pernicious anemia, and with
increased estrogens. Pregnancy is accompanied by a moderate increase. Cholesterol is increased in early
hepatitis, obstructed bile ducts, primary biliary cirrhosis, nephrotic syndrome, and diabetic meningitis. Finally,
through much controversy, it appears that cholesterol is implicated in atherosclerosis and heart disease. Evaluate
risk of coronary arterial occlusion, atherosclerosis, myocardial infarction, and complications including the
demise of the patient.
Increased in primary hypercholesterolemia, secondary hyperlipoproteinemias including nephrotic syndrome,
hypothyroidism, primary biliary cirrhosis, and some cases of diabetes mellitus. Low levels have been found in
cases of malnutrition, malabsorption, hyperthyroidism, myeloma, macroglobulinemia of Waldenström,
polycythemia vera, myeloid metaplasia, myelofibrosis, chronic myelocytic leukemia, analphalipoproteinemia
(Tangier disease), abetalipoproteinemia (Bassen-Kornzweig syndrome) (acanthocytosis), and in some
individuals who subsequently present with carcinoma. Levy points out that the weak inverse relationship with
cancer, mostly colon carcinoma, is limited to cholesterol levels <190 mg/dL and is limited to men.
Hypocholesterolemia may occur with sideroblastic anemia or in the thalassemias.
Cholesterol relates to coronary heart disease risk. Since premature mortality from coronary arterial disease is
rampant and since cholesterol levels are available as a test which can detect a modifiable risk factor, serum
cholesterol remains a critical and genuinely newsworthy topic and an important test. Effective intervention is
available when cholesterol studies identify subjects likely to benefit, asymptomatic persons as well as those with
recognized coronary disease.
Methodology Enzymatic
Testing Schedule : Daily
56
Coagulation Study
Specimen Requirement: 5 ml citrate plasma, FROZEN
Includes: PT, PTT, Thrombin time, Factors VIII and IX
See under individual tests for specimen REQUIREMENT in this test list
Use: detect specific cogulation factor deficiency which may be present on a congenital bases or may be acquired
secondary to a number of organ specific or generalized disease processes. Triplet has provided a broad
discussion of abnormalities that have been seen in association with liver, renl, immune, lymphoproliferative, and
other disease processes.
Limitation: Factors II, VII, IX, X may be increased in patients taking oral contraceptives. Interpretatios of results
may be limited if patient is receiving anticoagulant therapy or if test is done more than 2 hours after collection.
Additional Information:
Stage II, intrinsic pathway coagulation deficiency states include the hemophilia A (factor VIII deficiency), and B
(Factor XI deficiency), and C (Factor XI deficiency). Results of differential APTT testing using specially treated
normal plasma and serum can be used to support these diagnoses. The reagents are commercially available or may
be prepared in the laboratory.
Testing Schedule : Daily
Coccidioides Abs
Specimen Requirement: 2 ml serum
Ref. Interval: <1:10 titer – abs not detectable
Use: Diagnose and evaluate the prognosis of coccidioidomycosis
Limitation: When low titers are obtained, a diagnoses of cocidioidomycosis must be based on susbsequent
serological tests and on clinical and mycological studies. Cross re action may occur in sera from patients with
active histoplasmosis. False-negative results often occur in patient with solitary pulmonary lesions.
Method: CF
Additional Information:Low titers are usually associated with mild and localized disease. Patients with CF titers
> 1:16 should be observed for evidence of pulmonary or extrapulmonary dissemination.The higher the CF titer,
the poorer prognosis in assessing the extent and severity of both acute and chronic coccidioidomycosis. Falling CF
titers indicate an improved clinical status. Specific Igm antibodies may be detected early in the course of the
disease.
The tube precipitin test is effective in detection of early disease, 1-3 weeks after infection. These antibody levels
are not prognostic.. A negative test does not exclude coccidioidomycosis.
Finding CF antibody in CSF makes the diagnosis of coccidioidal meningitis (if fungal osteomyelitis of the basal
skull can be excluded
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Cold Auto Antibodies
Specimen Requirement: 5 ml whole blood, allow to clot warm (37 degrees C waterbath), centrifuge warm,
separate serum; send in blood clots and serum as well as 2-3 ml EDTA blood.
Ref. Range: <1:32 titer
Use:- Useful in supporting the diagnosis of primary atypical pneumonia ( infection with Mycoplasma
pneumoniae).
57
Limitations:- False-negatives may occur if serum is refrigerated on the clot; only half of patients with M.
pneumoniae injection will have positive test; there are many positive results associated with a wide and
nonspecific variety of other conditions.
Method: Agglutination
Additional Information:- The most common use of elevated cold agglutinin in high titers is an injection with
Mycoplasma pneumoniae. Fifty-five percent of patients with disease have rising titers. In primary atypical
Mycoplsma pneumoniae, cold agglutinins are demonstrated 1 week after onset; the titer increased in 8-10 days,
peaks at 12-25 days, and rapidly falls after 30. Antibiotic therapy may interfere with antibody formation. Ninety
percent of these are severely affected or have prolonged illness.
Cold agglutinis are usually IgM autoantibodies directed against the li antigens of human RBCs. These antibodies
may be found in patients with cold agglutinin disease or may occur transiently following a number of acute
infectious illness. Cold agglutinins of cold agglutinin disease are usually monoclonal IgM kappa. Cold antibodies
of IgG, IgA or IgM type directed against li antigens may be found in infectious mononucleosis. Antibodies
reacting near physiologic temperatures are more likely to be clinically important. Detection of cold agglutinins
may be particularly important in patients where cold blood is to be used as in a blood cardioplegia unit.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Complement Component
Use: Assess patients with hereditary dificiency of compliment component or acquired decrease in levels which
may be seen due to hypercatabolism in hereditary angioneurotic edema, or consumption or loss as in vasculitides,
glomerulonephritides, immune complex diseases
Additional Information: compliment is an array of almost 25 proteins which can interact sequentially to produce
a number of biologically active products which are implicated in the pathophysiology of numerous diseases with
an immunologic bases compliment is most often “ activated “
Through either the “ classical “ pathway beginning with antigen- antibody complexes (usually on some biologic
surface) or the “ alternate “ pathway which is less clearly understood but may be independent of antigen and
antibody. Calcium is also necessary.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Coombs Test, Direct
Specimen Requirement: 5 ml EDTA blood
Ref. Interval negative
Use: Determine if a positive direct antiglobulin is due to compliment costing the patients red blood cells; this
should be evaluated in instances of any autoimmune hemolytic anemia. About 10% to 13% of instances of warm
autoimmune hemolytic anemias react only to compliment DAT. The compliment DAT is used in work up of the
cold agglutinin syndrome and in paroxysmal cold hemoglobinuria. Work up of drug indused antibodies, cold
autoimmune hemolytic anemia, cold agglutinin disease, paroxysmal cold hemoglobinuria, collagen diease may
include compliment active antiglobulin testing.
Limitiation; serum separator tubes and red top tubes may cause false positive due to in vitro sensitization with
compliment. Harmless cold autoagglutinins coating previously refrigerated patient red cells may give weak
positive results with such antiglobulin serum.
Additional Information: A positive polyspecific antiglobulin with a negative lgG implies that the positive
direct test is due to compliment. lgG DAT alone, without compliment DAT, is found in 20% to 40% of instances
58
of warm reactive autoimmune hemolytic anemia and about 50% or more of such patients have both lgG and
compliment coating their erythrocytes.
Testing Schedule : Daily
Coombs Test, Indirect
Specimen Requirement: 5 ml EDTA blood
Ref. Interval: negative
Use: Detect sensitization of erythrocytes in vitro (ie, screen for unknown antibodies in serum by use of known
red cells). Such detection of antibody in patient’s serum by normal reagent red blood cells is in very wide use,
especially to screen for unexpected antibodies in pretransfusion testing and the first trimester of pregnancy, in Rh0
(D) –positive as well as in Rh0 (D)- negative expectant mothers. Evaluate potential cause of hemolysis.then
indirect antiglobulin test is used in panels, in titers, and in full crossmatches.
Limitation: Abnormal proteins and cold autoagglutinins may interfere and cause delays in interpretation. Test
will not detect all antibodies (eg, antibodies in low titer, antibodies to low- incidence antigens).
Additional Information: The antibody screen is the “screen” portion of the “type and screen”. It is done routinely
with compatibility testing (crossmatch) and on mother’s serum during prenatal care and at the time of delivery. A
positive indirect antiglobulin test must be followed up with antibody identification. The indirect antiglobulin is
done on patient serum with red cells of known antigenic type. The direct antiglobulin is done on patient red cells.
A common drug cause of positive indirect antiglobulin tests is methyldopa, which causes as much as 25% of
positive DAT reactions in hospital patients
Testing Schedule : Daily
COPPER (S)
Specimen Requirement: 3 ml serum
Ref. Interval:
Male: 70-140 mcg/dL
Female: 85-155 mcg/dL
Patients on contraceptive treatment: >200 mcg/dL
Use: It is used, along with serum ceruloplasmin and urine copper to screen for Wilson’s disease and more often,
in monitoring the nutritional adequacy of parenteral or enteral nutrition, especially when copper deficiency may be
suspected because of ongoing gastrointestinal losses of the element . The test is done in suspected copper toxicity
in premature infants when they are acutely ill and may not be able to assimilate the copper in their prescribed
nutrition; in acute copper intoxications; or in “Indian childhood cirrhosis, “ an illness not limited to Indian
children. Serum copper is low in menkes syndrome. Copper in the CSF is reported to mirror the neurotoxicity of
copper in wilson’s disease. Liver copper is used to confirm wilson’s disease and menkes syndrome and may be
measured in liver disease of uncertain etiology.
Limitations: Serum ceruloplasmin is an acute-phase reactant type protein, and since it binds a large portion of
serum copper, both serum copper and ceruplasmin increase under the influence of inflammatory conditions and
estrogen. Serum copper is therefore elevated in pregnancy, in patients on estrogens and estrogen-containing
contraceptive drugs, in rheumatoid arthritis, and a number of other pathologic entities. It may be low with low
serum proteins as in nephrosis, malabsorption, and malnutrition without necessarily reflecting inadequate liver
copper stores. It is reduced under the influence of ACTH or glucocorticoids, or valproate therapy. Although serum
copper levels are usually ordered to work up possible cases of wilson’s disease, menkes syndrome and ICC serum
59
copper alone is of only limited value. Elivations in liver tissue copper are found in wilson’s disease but may occur
also in other types of liver disease, especially primary biliary cirrhosis.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Cortisol ..............................................................
Synonyms Compound F; Hydrocortisone
Specimen Requirement Serum
Volume 1 mL
Minimum Volume 0.3 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube. Blood should be
drawn at 8 AM and 4 PM to evaluate baseline diurnal variation (see Cortisol, AM & PM).
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
Use Establish the diagnosis of adrenocortical insufficiency, Addison's disease, adrenocortical hypersecretion,
Cushing's syndrome. Malfunction of the organs in the hypothalamic — pituitary — adrenal cortex axis will
result in alteration of the cortisol levels. First among adrenal function tests for most needs. Elevated levels are
found in the newborn period.
Methodology Immunochemiluminometric assay (ICMA)
Additional Information Cortisol is the major adrenal glucocorticoid steroid hormone, and is normally
under feedback control by pituitary ACTH and the hypothalamus.
Causes of low cortisol include pituitary destruction or failure, with resultant loss of ACTH to stimulate
the adrenal, and metabolic errors or destruction of the adernal gland itself (adrenogenital syndromes,
tuberculosis, histoplasmosis).
Causes of increased cortisol, which may present initially simply as loss of normal diurnal variation,
include pituitary overproduction of ACTH, production of ACTH by a tumor (notably oat cell cancers),
and adrenal adenomas.
Testing Schedule : Daily
Coxsackie B1- B6 & A9
Specimen Requirement: 2 ml serum
Ref. Interval: <1:10 titer
Use:- Establish the diagnosis of Coxsackie B Virus infection.
Limitations:- Viral neutralization.
Method: CF
Additional Information:- Coxsackie B virus causes a wide variety of clinical illness, including pleurodynia
(Bornholm's disease), meningitis, rash, pulmonary infection, pericarditis, and a generalized systemic infection.
Approximately 50% of clinical myocarditis and pericarditis is caused by Coxsackie B. Since culture is frequently
unrewarding diagnosis may hinge on serologic studies.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
60
Creatine Kinase (CK), Total, Serum ..............
Synonyms CK; CK, Serum; CPK; Creatine Phosphokinase, Total, Serum
Special Instructions State sex of patient on the request form.
Specimen Requirement Serum
Volume 2 mL (adults), 0.2 mL (pediatrics)
Container Red-stopper tube or serum-separator tube
Collection Separate serum from red cells. Avoid prolonged contact of serum with red cells.
Storage Instructions Refrigerate
Patient Preparation Avoid exercise before venipuncture. Increases may be anticipated in the immediate
postoperative period following surgical procedures involving incision through muscle.
Causes for Rejection Hemolysis; use of anticoagulant
Reference Interval Total CK: male 54-186 IU/ L, female: 41-117 IU/ L;
Limitation Intramuscular injection increase serum CK activity. Elevated following exercise. Normal at onset
of acute MI unless the subject has been exercising or doing physical work. Elevation of CK following acute MI
may not be observed until 6 or more hours after onset.. CK returns to normal in approximately 48-72 hours after
acute MI. Total CK can be normal in acute MI when CK-MB is increased. Low CK does not rule out myositis
in patients with the connective tissue disease. Decreased with pregnancy.
Use Test for acute myocardial infarct and for skeletal muscular damage; elevated in some patients with myxedema
(hypothyroidism); elevated in patients with malignant hyperthermia syndrome. Elevated in muscular dystrophy:
CK is a marker for Duchenne's muscular dystrophy, with elevations of 20-200 times normal. CK is increased in
female carriers of this X-linked disease, and in muscular stress, in polymyositis, dermatomyositis, and with muscle
trauma. Elevated in myocarditis. Documentation of postictal state (recent grand mal seizure).Extremely high
values are seen in some instances of myositis and in the postictal state. CK may be elevated in a number of
entities, including the eosinophilia-myalgia syndrome. Marked increases occur with rhabdomyolysis including that
with cocaine intoxication. CK is sometimes increased with cerebrovascular accident. Malignancy (advanced) may
show increased CK. Cardioversion with multiple shocks may release CK-MB and may result in a false-positive
diagnosis of myocardial infarction. Low CK may reflect decreased muscle mass. It has been reported with a
number of entities, including metastatic neoplasia, patients with steroid therapy, with alcoholic liver disease and
with connective tissue diseases. Overnight bedrest may lower CK 10% to 20%.
Methodology Kinetic — 340 nm spectrophotometric
Additional Information High CK is found after trauma, surgery, and exercise; these entities are not
accompanied by elevation of CK-MB. To distinguish myglobinuria from hemolobinuria, serum CK and
LD may be helpful. CK is normal with uncomplicated hemolysis but LD is usually increased. When
mygolboin is released, 40-fold elevation of CK may be anticipated with only moderate increase in serum
LD.
Testing Schedule : Daily
Creatine Kinase (CK), MB and Total .............
Synonyms CK-2; CK-MB and Total CK
Test Includes CK-MB isoenzyme quantitation; total CK
61
Special Instructions State sex of patient on the request form.
Specimen Requirement Serum
Volume 3 mL (adults), 0.6 mL (pediatrics)
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Patient Preparation CK is most commonly elevated in acute myocardial infarction (AMI) in which it has its
greatest usefulness. Collection of specimen at onset of symptoms to establish baseline values is needed. A
patient at onset of acute myocardial infarction (AMI) will have normal results, but some patients reach medical
attention at or beyond CK peak. To support the diagnosis of AMI, three CK isoenzyme determinations have
classically been recommended, one on admission, a second 12 hours after admission, a third 24 hours after
admission. Another at 48 hours may be needed. CK-MB usually peaks between 15 and 20 hours after the onset
of a myocardial infarction. Pappas summarizes current literature regarding timing as follows. In non-Q wave,
incomplete occlusion, nontransmural MI, CK-MB peaks on the average 15 hours from onset. In Q wave
(complete occlusion) (transmural) infarction, CK-MB average peak is 17-20 hours after onset of symptoms. He
emphasizes the importance of a sample for CK-MB drawn 16 hours after onset. When increased CK-MB values
have returned to normal, CK isoenzyme determinations are usually no longer required.
Causes for Rejection Hemolysis; use of anticoagulants citrate or fluoride (they inhibit CK activity)
Reference Interval Total CK: male 54-186 IU/ L, female: 41-117 IU/ L; CK-MB; <12 IU/ L if Total CK is
<400 IU/ L, <3.5% of total CK if total CK >400 IU/ L.
Use MB is the myocardial fraction associated with MI and occurs in certain other states. MB can be used in
estimation of infarct size. MB increases have been reported with entities which cause damage to the myocardium,
such as myocarditis, some instances of cardiomyopathy, and with extensive rhabdomyolysis, Duchenne's
muscular dystrophy, malignant hyperthermia, polymyositis, dermatomyositis, mixed connective tissue disease,
myoglobinemia, Rocky Mountain spotted fever, Reye's syndrome, and rarely in rheumatoid arthritis with high
titer RF. CK-MB does not generally abruptly rise and fall in such nonacute MI settings, as it does in acute
myocardial infarct (AMI).
Limitation Triglycerides >300 mg/dL will cause >20% loss of CK-MB activity. The diagnosis of myocardial
injury should not be based solely on MB isoenzyme, but rather should be supported by clinical findings, ECG,
and often other laboratory parameters.
Metholdology Immunochemical — kinetic at 340 nm
Testing Schedule : Daily
Creatinine Clearance .......................................
Synonyms Clearance, Creatinine
Test Includes Serum creatinine; urine creatinine
Special Instructions Request form must state date and time collection started, date and time collection finished,
and patient's height and weight. Request form should state 24-hour urine volume.
Specimen Requirements Serum and urine (24-hour)
Volume 2 mL serum and 10 mL aliquot of entire urine collection
Container Red-stopper tube or serum-separator tube and plastic urine container
Collection Instruct the patient to void at 8 AM and discard the specimen. Then collect all urine including the
final specimen voided at the end of the 24-hour collection period (ie, 8 AM the next morning). Screw the lid on
securely. Tube must be labeled with patient's full name and date and time for a 24-hour collection. Submit both
urine and serum simultaneously.
62
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation Avoid cephalosporins. Have patient drink water before the clearance is begun, and
continue good hydration throughout the clearance. If possible, drugs should be stopped beforehand.
Causes for Rejection No blood creatinine drawn; improperly labeled specimen
Reference Interval
• Male: younger than 12 years: 50-90 mL/ minute, 12 years and older: 97-137 mL/ minute.
• Female: younger than 12 years: 50-9- mL/minute, 12 years and older: 88-128 mL/ minute.
Note: Creatinine clearance reference intervals are based on a body surface area of 1.73 square meters.
Use Renal function test; estimate glomerular filtration rate (GFR); evaluate renal function in small or wasted
subjects; follow possible progression of renal disease; adjust dosages of medications in which renal excretion is
pivotal (eg, aminoglycosides, methotrexate, cisplatin)
Methodology Colorimetric
Testing Schedule : Daily
Creatinine, 24-Hour Urine ................................
Synonyms Urine Creatinine, 24-Hour
Test Includes Urine creatinine in mg/dL and mg/24 hours
Special Instructions Record total 24-hour urine volume on the request form.
Specimen Requirement Urine (24-hour)
Volume 10 mL aliquot of entire collection
Container Plastic urine container, no preservative
Collection If the specimen is a 24-hour collection instruct the patient to void at 8 AM and discard the specimen.
Then collect all urine including the final specimen voided at the end of the 24-hour collection period (ie, 8 AM
the next morning). Screw the lid on securely. Transport the specimen promptly to the laboratory. Container must
be labeled with patient's full name, date and time collection started, and date and time collection finished.
Storage Instructions Refrigerate
Causes for Rejection Times not indicated; improperly labeled specimen
Use Renal function test when used as part of creatinine clearance; crude marker for completeness of 24-hour
urine collections when collected for other purposes
Methodology Kinetic
Testing Schedule : Daily
Creatinine, Random Urine ...............................
Synonyms Urine Creatinine, Random
Specimen Requirement Urine (random)
Volume 10 mL
Container Plastic urine container, no preservative
Collection Label the urine container with the patient's full name and the date and time of collection.
Storage Instructions Maintain specimen at room temperature.
Methodology Kinetic
Testing Schedule : Daily
63
Creatinine, Serum ............................................
Specimen Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Hemolysis; improperly labeled specimen
Reference Interval 0.5-1.5 mg/ dL
Use A renal function test, providing a rough approximation of glomerular filtration.
Causes of high creatinine include renal diseases and insufficiency with decreased glomerular filtration (uremia or
azotemia if severe); urinary tract obstruction; reduced renal blood flow including congestive heart failure, shock
and dehydration; rhabdomyolysis causes high serum creatinine, which may be elevated out of proportion to
BUN, or to the reduction in renal function.
Causes of low creatinine include small stature, debilitation, decreased muscle mass, some complex cases of
severe hepatic disease. In advanced liver disease, low creatinine may result from decreased hepatic production of
creatinine and inadequate dietary protein as well as reduced muscle mass.
Additional Information Serum creatinine level is proportional to lean body muscle mass. It is unaffected by
most diet or activity, and is freely filtered by the glomerulus. Both BUN and creatinine are often ordered to
follow renal problems. Creatinine overall is the more reliable index, but each has pitfalls. As creatinine
increases in chronic renal failure, the hematocrit decreases, total carbon dioxide and bicarbonate fall, and serum
phosphate and BUN increase.1
Methodology Kinetic
Testing Schedule : Daily
CRP Ultrasensitive
Specimen Requirement: 1 ml serum
Ref. Interval: <5 mg/L
Relative risk of myocardial infarct (after exclusion of an inflammatory process):
CRP (mg/L) risk
</=0.55: 1.0
0.56-1.14: 1.1-2.9
1.15-2.10: 1.6-4.3
>/=2.11:
1.8-4.6
Use:- Used similarly to erythrocyte sedimentation rate. CRP is nonspecific acute phase reactant used as an
indicator of infectious disease and inflammatory states including active rheumatic fever and rheumatoid arthritis.
Progressive increases correlate with increases of inflammation /inquiry. CRP is a more sensitive, rapidly
responding indicator than ESR. CRP may be used to detect early postoperative wound infection and to follow
therapeutic response to anti-inflammatory agents.
Limitations: frozen specimens may give false-positive results; oral contraceptives may affect results.
Method: Immunoassay with TRACE
Additional Information: CRP is a pentameric globulin with mobility near the gamma zone. It is an acute phase
reactant which rises rapidly, but nonspecifically in response to tyissue injury and inflammation.It is particularly
useful in detection of occult infections, acute appendicitis, particularly in leukemia and in postoperative patients.
In uncomplicates postoperative recovery, CRP peaks on the third postop day and returns to preop levels by day 7.
It may also be helpful in evaluation of extension or reinfarction after myocardial infarction and in following
1
Hakim RM and Lazarus JM “Biochemical Parameters in Chronic Renal Failure”, Am J Kindney Dis, 1988, 11(3);238-47.
64
response to therapy in rheumatic disorders. It may help to differentiate Crohn's disease (high CRP) from ulcerative
colities (low CRP) and rheumatoid arthritis (high CRP) from ulcerative colitis (low CRP) and rheumatoid arthritis
(high CRP) from uncomplicated lupus (low CRP) When used to evaluate patients with arthritis. Serum is the
preferred specimen. There is no advantage to examining synovial fluid for CRP.
Testing Schedule : Daily
Crystal Examination, Miscellaneous Fluid ..
.............................................................................
Test Includes Determination of presence of crystals in body fluids
Special Instructions Request forms must state source of fluid.
Specimen Requirement Body or synovial fluid
Volume 1 mL
Container Green-stopper (heparin) tube
Collection Container must state collection site.
Storage Instructions Refrigerate
Causes for Rejection Improperly labeled specimen
Use Determine the cause of inflammation
Methodology Polarized light
Cryoglobulin, Qualitative (S)
Specimen Requirement: 5 ml serum DO NOT FREEZE or REFRIGERATE. Allow blood to clot at 37°C.
Centrifuge warm
Ref. Interval: not detectable
Use: Cryoglobulins may be present in macroglobulinemia of waldenstrom, myeloma, chronic lymphocytic
leukemia, lupus, chronic active hepatitis, and viral infections.
Methodology: cold precipitation
Additional Information: These are proteins which precipitate from blood at low temperatures. A precipitate from
serum which forms overnight at 4oc and dissolves at 37oc is called a cryglobulin.
Croglobulins may be divided into three classes. Type I are monoclonical immunoglobulin and are usually
associated with lymphoproliferative disorders. Type II are mixtures of a monoclonal IgM and polyclonal IgG, and
are associated with macroglobulinemia and chronic active hepatitis. Types III are mixtures of polyclonal IgM and
polyclonal IgG. These are found in a wide variety of disorders.
A high percentage of patients with cryoglobulinemia have clinical symptoms, and of these the most common are
vascular (ie, purpura and digital necrosis). Raynaud’s phenomenon is also common.
Patients with SLE who are rheumatoid factor negative but cryglobulin positive are likely to develop renal disease
than those who are rheumatoid factor positive and cryoglobulin negative.
Cyclic Amp (C-Amp)
Specimen Requirement: 2 ml EDTA plasma FROZEN
Ref. Interval: 5-25 nmol/L
65
Use:Differential diagnosis of hyperparathyroidism. In hyperparathyroidism there is increased cAMP in 24-hour
urine specimens, also in humoral hypercalcmia of maligancy and vitamin D deficiency. The plasma concentrations
of immunoreactive parathyroid hormone-related protein correlate with levels of excreted cyclic AMP.
Limitation: There is some overlap between results of patients with hyperparathyroidism and those of normal
subjects. Urinary cAMP is reported increased in hypercalcemic cancer patients.
Additional Information:. There is a role for cAMP excretion measurement in the evaluation of Zollinger-Ellison
Syndrome and differentiation of spordic cases from those of multiple endocrine neoplasia type
Cyclic Amp (C-Amp) Urine
Specimen Requirement: 10 ml urine, FROZEN.
Ref. Interval:
Male: 200-500 mcmol/mol creatinine
In infants and children higher values than the normals given can be measured. These values can be considered
unremarkable.
Female: 220-500 mcmol/mol creatinine
In infants and children higher values than the normals given can be measured. These values can be considered
unremarkable.
Methodology: RIA
Set-Up: once weekly
Results Ready: one week later
CYSTICERCOSIS IgG Abs
Specimen Requirement: 1 ml csf
Ref. Interval: negative
Use:- Establish the diagnosis of cysticercosis which is most commonly found in the cerebrum. It occurs in almost
any tissue.
Limitations:- Cross reactions in patients with tapeworm or Echinococcus
Methodology: EIT
Additional Information: - The tapeworms (Cestodes) include Taenia solium the pork tapeworm. In > 80% of
proven cases of cysticercosis, serum and CSF titers of hemaglutinating antibodies are high. After complete cyst
removal, antibodies disappear in a few months.
Cytomegalovirus (CMV) Antibodies, IgG .....
.............................................................................
Synonyms CMV Ab, IgG, Quantitative; CMV Antibodies
Test Includes A quantitative result
Special Instructions Identify specimen as acute or convalescent. Acute and convalescent specimens must be
submitted on separate request forms.
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use Aid in diagnosis of CMV infection
66
Methodology Enzyme immunoassay (EIA)
Additional Information CMV causes an infectious mononucleosis syndrome clinically indistigusihable
from heterophil positive mononucleosis, a very common entity. Significant CMV titers are found almost
universally in patients with AIDS, and CMV genome has been demonstrated in the cells of Kaposi’s
sarcoma. CMV is a significant cause of postcardiotomy, post-transplant, and postpump hepatitis
syndromes.
Testing Schedule : Daily
D-dimer ............................................. ...........
Synonyms Latex
Specimen Requirement Plasma
Volume 2 mL
Minimum Volume 1 mL
Container Blue-stopper ( sodium citrate plasma) tube
Collection When specimen is collected for multiple tests , the order of draw is 1) sterile culture tubes, 2)
nonadditive(red-stopper) tubes,3) coagulaation ( sodium citrate [ blue-stopper], heparin [ green-stopper] tubes,4)
serum –separator tubes, and 5) other additive (EDTA [ lavender-stopper], heparin [ green-stopper], etctubes. If
only coagulation tests are being drawn draw 5 ml into another tube , discard and then collect coagulation tests.
This collection procedure eliminates contamination of the specimen with tissue thromboplastins and crosscontamination from additives such as heparin and EDTA. Collect nine parts whole blood to one part 3.2%sodium
citrate using plastic collection material, or draw one blue-stopper ( sodium citrate) tube untill the vaccum is
depleted to ensure q 9:1 ratio. Centrifuge immediately at 3500 rpm for 15 minutes. Carefullr remove the plasma ,
aliquote 2 ml of plasma into a plastic transport tube , and freez immediately. If hematocrit (Hct) is greater than
55%, use the following formula to calculate the volume of anticoagulant required for 5 ml of anticoagulated blood:
X=(100-Hct)/ (595-Hct). X is the volume of anticoagulant required to prepare unit volume of anticoagulated
blood. Carefully remove the plasma from cells without disturbing the cells . To avoid delays in turnaround time
when requesting multiple tests on frozen samples please submit separate frozen specimens for each test requested.
Storage Instruction Freeze
Causes for Rejection Specimen not frozen; improperly labeled specimens; clotted specimen; hemolysis;
dilution by i.v fluids.
Refernce Interval 0.0-0.4 microgram/ liter
Use Test for the detection of deep vein thrombosis ( DVT) ; evaluate acute myocardial infarction, unstable
Angina, Disseminated Intravascular Coagulation ( DIC).
Methodology Immunoturbidimetric.
Testing Schedule : Daily
Delta-ALA / Delta Aminolaevulinic Acid
Specimen Requirement: 30 ml 24h urine (during collection keep cool and protect from light). Please state 24h
urine volume.
Ref. Interval FOR ADULTS: <7.5 mg/24h
Use: Diagnose porphyrias,lead or mercury poisoning ALA is increased also in tyrosinemia. Porphobilinogen and
Delta Aminolevulinic Acid are the tests of choice for acute intermittent porphyria.
Limitation: ALA may be normal during latent period of acute intermittent porphyria, hereditary coproporphyria,
porphyria variegata. For the diagnosis of lead poisoning, measurement of blood and urine lead, and free
erythrocyte protoporphyrin are other available options.
67
Methodology: column chromatography with photometric detection
Additional Information: Conversion of ALA to porophobilinogen is inhabited by lead and mercury; thus, lead
poisoning causes increased urinary delta-ALA as well as increases of coproporphyria and of free erythrocyte
protoporphyrin
Drug Screen (U)
Specimen Requirement: 10 ml fresh urine
Ref. Interval: not detectable
Drugs include:
Amphetamines
Barbiturates
Benzodiazepines
Cocaine (as Benzoylecgonine)
Hashish (as THC-COOH)
Methadone (as EDDP)
Opiates (Codein, Dihydrocodeine, Heroin, Morphine)
Creatinine
Methodology:
CEDIA (for the drugs)
Jaffe’ (for Creatinine)
NOTE: Each analyte group can be requested individually
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Echinococcus Abs
Specimen Requirement: 2 ml serum
Ref. Interval:
IHA granulosus: <1:64 titer
Low titers <1:128 must be checked with a control. False negatives are possible.
multilocularis (EIA): not detectable
Use: Support a diagnosis of echinococcosis.
Limitations: Serum from 50% of patients with cysticercosis cross react in this assay. False-positives in some
patients with cirrhosis and lupus; and false-negative with some large cysts or dead cysts. Sensitivity of serological
testing is 60% to 90%.
Additional Information: Peripheral blood eosinophilla occurs but is not always found. After surgical removal of
the cyst, there is generally a rapid decline in antibody within a year; failure to observe the decline indicates
incomplete cyst removal. The newer ELISA tests are more sensitive than the more traditional hemagglutation and
latex assays
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
68
Endomysium IgG Abs (Transglutaminase)
Epstein Barr Virus By Immunoblot IgA, IgG & IgM SPEC.
Specimen Requirement: 1 ml serum
Ref. Interval FOR ALL: not detectable
Use:- Diagnose Epstein-Barr virus infection, heterophil-negative mononucleosis, hereditary sex-linked
lymphadenopathy.
Limitations:- Despite much publicity, these tests are neither sensitive nor specific for chronic fatigue syndrome .
Additional Information:- Epstein Barr virus is a herpes group virus which is almost ubiquitous. It is the cause of
classic infectious mononucleosis, and is causally implicated in the pathogenesis of Burkett's lymphoma, some
nasopharyngeal carcinomas, lymphoproliferative disorders in immunocompromised patients, and rare hereditary
lymphoproliferative disorders. The serologic response to EB virus includes antibody to early antigen, which is
usually short lived, IgM and lgG antibodies to viral capsid antigen (VCA), and antibodies to nuclear antigen
(EBNA).
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Erythropoietin
Specimen Requirement: 1 ml serum (not heparin or EDTA plasma)
Ref. Interval: 5-25 mU/mL
Use: Investigate obscure anemia and the anemia of end-stage renal disease. Certain tumors may produce
erythropoietin, giving rise to otherwise unexplained polycythemia (eg, hemangioblastoma of cerebellum,
pheochromocytoma, hepatoma, nephroblastoma, and rarely leiomyomas, renal cysts, and renal adencarcinoma). It
may be used to differentiate types of polyacythemia.
Limitations: Increased with pregnancy.
Additional Information: In the anemia of renal disease the serum erythropoietin level is generally lower than
expected. Plasma erythropoietin is inappropriately low in adult nephrotic syndrome mostly because of
renal/urinary loss of the protein and this contributes to the anemia. In chronic iron deficiency the level of
erythropoietin is increased, but the increase may not be as high as expected for the degree of anemia.
Erythroprietin was given twice a week for 21 days, 600units/kg, intravenously.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Estradiol
Specimen Requriment serum
Volume 0.8 ml
Minimum Volume 0.3 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
Reference Interval
Male : less than 54pg/ml
Menstruating female ( day of cycle relative to LH peak )
• Follicular (-12) : 19-83pg/ml
69
• Follicular (-4) : 64-183pg/ml
• Midcycle (-!_) : 150-528pg/ml
• Luteal (+2) :58-157pg/ml
• Luteal (+6) : 60-211pg/ml
• Luteal (+12) : 55-150pg/ml
• Postmenopausal ( untreated ) : 0-31 pg/ml
Note the above results were obtained with the Bayer Centaur ICMA method. Estradiol results obtained with
different assay methods cannot be used interchangeably in serial testing. It is recommended that only one assay
method be used consistently to monitor serial patient results.
Use This estradiol method is designed for the investigation of fertility of women in the reproductive age and for
the support of in vitro fertilization.
Methodology ICMA
Testing Schedule : Daily
Factor II
Specimen Requirement: 1 ml citrate plasma, FROZEN
Ref. Interval: 70-120 %
Use: Document specific factor deficiency
Limitations: Interpretation of results may be limited if patient is receiving anticoagulant therapy or if test is done
more than 2 hours after collection.
Methodology: BCT
Additional Information: Prothrombin, a vitamin K dependent, single polypeptide chain coagulation protein is
synthesized in the liver. It achieves a plasma concentration of about 10mg/dL and has a half-life of about 3 days.
Factor V, phospholipids, and calcium ions accelerate the rate of this conversion.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Fatty Acids, Nonesterified Ffa (Free Fatty Acids)
Specimen Requirement: 1 ml serum freeze immediately SEND FROZEN.
Ref. Interval:
Female: 0.10-0.45 mMol/L
Male: 0.10-0.60 mMol/L
Use:- Screen for presence of fecal fatty acids and neutral fat. Increases in neutral fat are commonly associated with
pancreatic exocrine insufficiency. Increase in stool fatty acids is likely to be associated with small bowel disease.
Limitations:- Castor oil or mineral oil droplets cab mimic neutral fat .
Methodology: colormetry
Additional Information:- The test consists of determination of the presence of neutral fats and of total fats
representing fatty acids. The results are reported semi quantitatively.
Presence of steatorrhea can be established by the results of a 72-hour fecal fat analysis. Maldigestion or
malabsorption may cause steatorrhea. Patients with maldigestion excrete excess triglyceride and fatty acid. One
may not be able to differentiate maldigestion from malabsorption (pancreatic vs intestinal steatorrhea) by
comparing fecal triglyceride/fatty acid or fecal fat concentration. The influence of extra pancreatic lipase (eg,
gastric lipase) must be considered Cholesterol, is decreased with pancreatic insufficiency and is increased as a
result of exogenous pancreatic enzyme substitution.
70
Ferritin, Serum ...................................................
Specimen Requirement Serum only
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Reference Interval Male: 22-322 ng/ mL; female: 10-291 ng/ mL.
Causes for Rejection Plasma specimen; hemolysis
Use Diagnose hypochromic, microcytic anemias. Decreased in iron deficiency anemia and increased in iron
overload. Ferritin levels correlate with and are useful in evaluation of total body storage iron. In
hemochromatosis, both ferritin and iron saturation are increased. Ferritin levels in hemochromatosis may be
>1000 ng/mL.
Methodology Immunochemiluminometric assay (ICMA)
Limitations Ferritin escapes from necrotic hepatocytes. In the presence of liver disease, inflammatory disease
such as rhematoid arthritis, with malignancy or with iron terapy, iron deficiency may not be relflected by low
serum ferritin. Ferritin determinations are not reliable in infants on iron therapy. Bone marrow aspiration may be
needed in some settings, such as low-normal ferritin and low serum iron in the presence of apparent anemia of
chronic disease, low-normal ferritin in the presence of liver disease.1
Additional Information The serum ferritin is, other than a bone marrow examination, the most reliable indicator
of total body iron stores. When combined with the serum iron and percent saturation of iron binding capacity/
transfferrin, it can usually differentiate the microcytic hypochromic anemias into iron deficiency anemia (ferritin
low, iron low, saturation low, TIBC high, transferrin high), the anemia of chronic disease (ferritin normal or high,
iron low, normal to low tranferrin or TIBC) or thalassemia (ferritin normal or high). In adults, serum ferritin level
<= 10 ng/ mL indicates iron deficciency. High serum ferritin levels may be associated with inflammation, liver
disease, megaloblastic anemia, hemolytic anemia, sideroblastic anemia, thalassemia, iron overload
(hemochromatosis, hemosiderosis), malignant diseaases including leukemia and malignant lymphoma and are
described with CEA elevations in patients with brease cancer. Very high levels indicate iron overload. Oral and
injected iron increase ferritin levels. Increased serum ferritin may be a risk factor in primary hepatocellular
carcinoma.2
Testing Schedule : Daily
Fibrinogen, Quantitative ...................................
Synonyms Clottable Fibrinogen; Factor I; Fibrinogen Level; Heat Precipitate Fibrinogen; Quantitative
Fibrinogen
Specimen Requirement Plasma
Volume 4 mL
Container Blue-stopper (sodium citrate plasma) tube
1
Sheehan RG, Newton MJ and Frenkel EP, “Evaluation of a Packaged Kit Assay of serum Ferritin and Application to Clinical Diagnosis of Selected Anemias,”
Am J Clin Pathol, 1978, 70:79-84
2
Hann HW, Kim CY, London WT, et al, “Increased Serum Ferritin in Chronic Liver Disease: A Risk Factor for Primary Hepatocellular Carcinoma,” Int J
Cancer, 1989, 43(3):376-9.
71
Collection If multiple tests are being drawn, draw coagulation studies last. If only a fibrinogen is being drawn,
draw 1-2 mL into another tube, discard, and then collect the fibrinogen tube. This collection procedure avoids
contamination of the specimen with tissue thromboplastins.
Storage Instructions Maintain specimen at room temperature.
Patient Preparation Patient should not receive heparin within 1 hour of specimen collection. Patient should not
exercise.
Causes for Rejection Hemolysis; clotted specimens; thawed specimen; tubes not full; improperly labeled
specimen
Use Identify congenital afibrinogenemia, disseminated intravascular coagulation, and fibrinolytic activity
Methodology Modified thrombin time
Additional Information Fibrinogen, while of primary importance as a coagulation protein, is also an acute-phase
protein reactant. As such it is increased in disease processes involving tissue damage/ inflammation. It is not
often employed clinically as a measure of acute phase response as cdoncurrent hemorrhage (fibriongen
concentration rises initially) and DIC (rise or fall in fibrinogen depending on method) renders interpretaiton
problematic.
Filariasis IgG ABS
Specimen Requirement: 2 ml serum
Ref. Interval: <10 MONA
Use: Used to support a diagnosis of filariasis, microfilariasis.
Limitations: Because purified speecies-specific antigens have not been made, testing lacks sensitivity and
specificity. Tests measuring lgG4 subclass antibodies may eliminate some cross reaction.
Methodology: Eit
Additional Information: For screening, an antigen prepared for Dirofilaria immitis will detect antibody
responses to several clinically significant microfilariae. However, sensitivity and specificity are poor.. Morpholoic
examination of a blood film remains the bedrock of diagnosis.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Fluoride
Specimen Requirement: 2 ml serum
Ref. Intrval: <30 mcg/L
therapeutic range: 100-300 mcg/L
Use: Evaluate fluoride toxicity
Folate (Folic Acid) ............................................
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection Avoid hemolysis. Separate serum and refrigerate. Avoid exposure to light.
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
Reference Interval >2.6 ng/ mL
72
Use Detect folate deficiency; monitor therapy with folate; evaluate megaloblastic and macrocytic anemia;
evaluate alcoholic patients and those with prior jejunoileal bypass for morbid obesity or those with intestinal
blind-loop syndrome
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Follicle-Stimulating Hormone (FSH), Serum
Synonyms FSH; FSH, Serum; Pituitary Gonadotropin
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube. Avoid hemolysis.
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
Use Excessive FSH and LH are found in hypogonadism, anorchia, gonadal failure, complete testicular
feminization syndrome, menopause, Klinefelter syndrome, alcoholism, castration. FSH and LH are pituitary
products, useful to distinguish primary gonadal failure from secondary (hypothalamic/pituitary) causes of
gonadal failure, menstrual disturbances and amenorrhea. Useful in defining menstrual cycle phases in infertility
evaluation of women and testicular dysfunction in men. FSH is commonly used with LH, which also is a
gonadotropin. Both are low in pituitary or hypothalamic failure. FSH and LH levels are high following
menopause. Urinary collections for FSH escape the problems of pulsatile, episodic secretion. They are used
mainly for children being worked up for precocious puberty.
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Fructosamine......................................................
Specimen Requirement Serum or plasma (gray)
Volume 2 mL
Container Red-stopper tube or serum-separator tube or gray-stopper (sodium fluoride plasma) tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Gross hemolysis; improperly labeled specimen; gross lipemia
Use Evaluate diabetic control, reflecting diabetic control over a shorter time period (2-3 weeks) than that
represented by hemoglobin A1c (4-8 weeks). Indicated as an index of longer term control than glucose levels,
especially in diabetic subjects with abnormal hemoglobins and in type I diabetes in children. Fructosamine levels
may be useful in evaluating geriatric populations. Glycated albumin, because of its short half-life, lends itself as
a test to monitor and control gestational diabetes.
Methodology Colorimetric
Additonal Information Fructosamine is found in the plasma of both normal and diabetic individuals.
“Fructosamine” is the term used to describe proteins that have been gglycated (ie, are derivatives of the
nonenzymatic reaction product of glucose and albumin). Recently, it has been advocated as an alternative test to
hemoglobin A1c for the monitoring of loong-term diabetic control. Fructosamine and hemoglobin A1c do not
73
measure exactly the same thing, since fructosamine has a shorter half-life and probably is somewhat more
sensetive to short-term variations in glucose levels. However, this is not necessarily a disadvantage.
Fructosamine is clearly superior in patients with abnormal hemoglobins because of the interference of abnormal
hemoglobins in the anion-exchange chromatography methods for Hb1c.
Gamma Glutamyl Transpeptidase (GGT) ....
.............................................................................
Synonyms Gamma GT; GGT; GT
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation The patient should fast for 8 hours prior to collection of the specimen. Since there are false
elevations in patients on phenytoin and phenobarbital, such patients would be better served with orders for one
of the alternate tests — leucine aminopeptidase (LAP) or 5´ nucleotidase.
Causes for Rejection Gross hemolysis; improperly labeled specimen; gross lipemia
Reference Interval Male:0-85 IU/L; Female: 0-70 IU/L
Use A biliary enzyme that is especially useful in the diagnosis of obstructive jaundice, intrahepatic cholestasis,
and pancreatitis. GGT is more responsive to biliary obstruction than are aspartate aminotransferase (AST)
(SGOT) and alanine aminotransferase (ALT) (SGPT).
Increased in hepatoma and carcinoma of pancreas. Useful in diagnosis of metastatic carcinoma in the liver.
Increasing levels in carcinoma patients relate to tumor progression, and diminishing levels to response to
treatment. CEA, alkaline phosphatase, and GGT used together are useful markers for hepatic metastasis from
breast and colon primaries. GGT is elevated in some instances of seminoma.
Useful in diagnosis of chronic alcoholic liver disease, but some heavy drinkers do not have GGT increases.
Serial determinations of serum GGT, AST, and ALT levels can distinguish recovering alcoholics who resume
drinking from those who remain abstinent. Increase in body mass is positively correlated with increased GGT
levels. With MCV of red cells, GGT is useful as a test for alcoholism.
GGT is the test for cholestasis during or immediately following pregnancy. Commonly elevated in cirrhosis and
hepatitis. The transaminases, AST and ALT rise higher in acute viral hepatitis; these tests with GGT and other
parameters are best used together in work-up of liver disease.
Increased in systemic lupus erythematosus. Very high levels are common in primary biliary cirrhosis. High GGT
is found in infants with biliary atresia. It is increased with hyperthyroidism and decreased in those with
hypothyroidism. GGT is comparable in many ways to two other biliary tests, LAP and 5´ nucleotidase. In some
cases, five tests (including alkaline phosphatase and bilirubin) are necessary to evaluate the biliary tract. GGT
usually is the most sensitive.
In ascitic fluid, very high GGT is said to suggest hepatoma as opposed to cirrhosis or liver metastases.
Limitations Acetaminophen toxicity ha been reported to cause an in vivio increase. The combination of high
alkaline phosphatase and normal GGT does not rule out liver disease completely. Activity is not significantly
increased in sera of patients with lymphoma (unless there is hepatic involvement by the lymphoma).
Methodology Kinetic
Testing Schedule : Daily
74
Gastrin
Specimen Requirement: 2 ml serum, fasting (at least 12hrs) sample. FROZEN
Ref. Interval:
Use: Diagnose Zollinger-Ellison (Z-E) syndromek; diagnose gastrinoma. Gastrin > 1000 pg/ML (SL :> 476.6
pmol/L) with gastric acid hypersecretion (basal acid secretion over 15 mmol/hour in a patient with peptic ulcer
who has not had surgery) establishes unequivocally the diagnosis of 2 of Zollinger-Ellison sundrome. Antral Gcell phyperplasia may relate to high gastrin levels and duodenal ulcer.
Limitations: Gastric hyperacidity must be documented. Gastic ulcer, chronic renal failure, hyperparthayroidism,
pyloric obstruction, carcinoma of stomach, vagotomy without gastric resection, retained gastiric antrum and short
bowel of syndrome have been reported with moderate elevations of gastrin levels. Gastrin levels are increased
with pernicious anemia. H2-receptor blockers ( cimetidine) may result in elevated levels. Overlap of serum gastrin
values between gastrinoma and other states occurs. Up to 40% of Z-E patients have gastrin values between 100500 pg/ML (SI: 47 7-238.3 pmol/L), while a few patients with gastric or duodenal ulcer without gastrinoma, have
results in this rage. At least half of patients with the Z-E syndrome lack diagnostic serum gastrin levels, although
in nearly all, fastering with a normal screening gastrin level.
Methodology: CLEIA
Additional Information:- Gastrin is secreted by antral G cells and stimulates gastric acid production, antral
motility, and secretion of pepsin and intrinsic factor. The principle forms of gastric in blood are G-34(big gastrin,
half-life 5 minutes) and G-14 (minigastrin, half-life 5 minutes). Each of these polypeptides circulates in
nonsulfated (I) or sulfated (II) forms. Instilling acid into the stomach normally inhibits gastrin secretion. Elevated
gastrin levels should be interpreted in light of gastric acid secretion and other parameters. The neuroendocrine
tumors associated with the Zollinger-ellison syndrome are characterized by elevated rates of gastric HCI secretion
and upper gastrointestinal ulcer disease. Gastrin levels > 500-600 pg/mL and hyperchlorhydria
Cord blood: 20-290 pg/mL
Up to 4 days: 20-183 pg/mL
Adults: <115 pg/mL (after 12-hr fasting)
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Glucagon
Specimen Requirement: 2 ml EDTA plasma, FROZEN
Ref Interval: 60-177 ng/L
Use: Diagnose glucagonoma. Glucagonoma may be present in three different syndromes. The first consists of
characteristic skin rash, necrolytic migratory erythema, diabetes mellitus or impaired glucose tolerance, weight
loss, anemia, and venous thrombosis. This from usually shows very high glucagons levels, 1000 pg/ML (
Sl:>1000 ng/L). The second form is associated with severe diabetes, and the third from with multiple enodorcine
neoplasia syndrome. This form may have relatively lower glucagons levels. It may be overproduced with
neuroblastoma.
Methodology: RIA
Additional Information: Glucagon is normally secreted by a2-cells of pancreatic islets, and exerts a
counterbalancing effect to insuling in regulation of glucose metabolism. Very high levels of glucagons are send
with glucagonomas, and elevations are also in diabetic ketoacidosis, stress, uremia, hepatic cirrhosis,
hyperosmolality, acute pancreatitis, burns, trauma, surgery, and hypoglycemia. Decreased values are found in
cystic fibrosis, chronic pancreatitis, and in the postpancreatectomy state. Over 75% glucagonomas have
metastasized at time of diagnosis.
Testing Schedule : Referred to BIOSCIENTIA
75
Result ready with in 10days
GC (Neisseria gonorrhoeae) Culture & sensitivity
.............................................................................
Synonyms Culture for GC Only; Culture for Neisseria gonorrhoeae Only; GC Only; Genital Culture (GC)
Only; Gonorrhea Culture; Jembec Culture; Neisseria gonorrhoeae Culture. Test include ID and sensetivity.
Specimen Requirment Body fluid, discharge, pus, swab of genital lesions, urethral discharge (best for men
when available).
Volume 0.5 mL or one swab inoculated to Jembec plate
Container Jembec or Thayer-Martin plate available from the laboratory. Prewarm plate before inoculation.
Collection Do not collect urethral specimens until at least 1 hour after urinating. Collection directly from male
urethral discharge is desirable. Collect anorectal specimens from the crypts just inside the anal ring; anoscopy
useful. Prostatic fluid yields fewer positives than does urethral culture.
Endocervix: Swab endocervical canal. Avoid contaminating swab with vaginal secretions. Cultures from the
urethra or vagina are indicated from females when endocervical culture is not possible.
Urethra: Strip the urethra toward the orifice to express exudate. Use a sterile swab to obtain the specimen.
Vagina: Use a speculum, moistened only with warm water, not lubricant. Obtain a specimen from the posterior
vaginal vault or from the vaginal orifice if the hymen is intact.
Swab samples should be rolled over the surface of the Jembec plate.
Storage Instructions Inoculated Thayer-Martin plates should be placed in CO2 incubator or candle jar within 15
minutes of collection. Jembec plates should be sealed with CO2 tablet in ziplock bag and preincubated at 35°C if
possible prior to shipment at room temperature.
Causes for Rejection Inappropriate specimen received; mislabeled specimen; unlabeled specimen; specimen
received after prolonged delay (usually more than 72 hours); specimen received in expired transport container
Use Isolate and identify N. gonorrhoeae; establish the diagnosis of gonorrhea
Methodology Culture on selective medium, DNA probes for identification
Testing Schedule : Daily
Genital Culture, Male
Synonyms Culture, Genital, male
Test Includes Culture;isolation, identification and senstivity.
Special Instructions Specify specimen source and pertinent clinical information on the test request form.
Specimens from other sources, such as genital, stool, urine, upper and lower respiratory specimens, cannot be
cultured under the aerobic bacterial culture test number. If specimens are incorrectly submitted with an order for
aerobic bacterial culture, the laboratory will process the specimen for the test based on the source listed on the
request form. The client will not be telephoned to approve this change, but the change will be indicated on the
report.
Specimen Requirement Swab of prostatic fluid, or urethral discharge. Use swab to transport to the laboratory
and recovery of Neisseria gonorrhoeae; swab should also be sent in transport device.
Volume One swab and one inoculated Jembec
Container Culture collection swab
Collection
Males: Using small wire swab, gently scrape the anterior urethral mucosa or, use a swab to collect specimen of
urethral discharge.
76
Storage Instructions Maintain specimen swab and Jembec at room temperature. Do not refrigerate.
Causes for Rejection Inappropriate specimen transport device; mislabeled specimen; unlabeled specimen;
specimen received after prolonged delay (usually more than 72 hours); specimen received in expired transport
Use Isolate and identify potentially aerobic pathogenic organisms including group B Streptococcus; establish the
diagnosis of gonorrhea, medical/legal cases
Limitation Does not include Trichmonas vaginalis, Chlamydia trachomatis, Ureaplasma urealyticum,
Mobiluncus sp, or yeast.
Methodology Culture
Testing Schedule : Daily
Genital Culture, Female
Synonyms Culture, Genital, female
Test Includes Culture;isolation, identification and senstivity.
Special Instructions Specify specimen source and pertinent clinical information on the test request form.
Specimens from other sources, such as genital, stool, urine, upper and lower respiratory specimens, cannot be
cultured under the aerobic bacterial culture test number. If specimens are incorrectly submitted with an order for
aerobic bacterial culture, the laboratory will process the specimen for the test based on the source listed on the
request form. The client will not be telephoned to approve this change, but the change will be indicated on the
report.
Specimen Requirement Swab of vagina, cervix, discharge, aspirated endocervical, endometrial, discharge. Use
swab transport to the laboratory and recovery of Neisseria gonorrhoeae; swab should also be sent in transport
device.
Volume One swab
Container Culture collection swab in transport and Jembec
Collection Females: Do not use lubricant on speculum. Cervical mucous should be removed first before
inserting swab into endocervical canal, move swab from side to side allowing several seconds for absorption of
organisms by the swab. Return swab to the transport tube and label.
Storage Instructions Maintain specimen swab and Jembec at room temperature. Do not refrigerate.
Causes for Rejection Inappropriate specimen transport device; mislabeled specimen; unlabeled specimen;
specimen received after prolonged delay (usually more than 72 hours); specimen received in expired transport
Use Isolate and identify potentially aerobic pathogenic organisms including group B Streptococcus; establish the
diagnosis of gonorrhea, medical/legal cases
Limitation Does not include Trichmonas vaginalis, Chlamydia trachomatis, Ureaplasma urealyticum,
Mobiluncus sp, or yeast.
Methodology Culture
Testing Schedule : Daily
Gestational Glucose Tolerance (Diagnostic)
Synonyms Glucose Tolerance, Gestational; O'Sullivan Diagnostic Replaced by Recommendations From the
Third International Workshop-Conference
Test Includes 100-g glucose load; plasma glucose measured fasting, and at 1, 2, and 3 hours
Specimen Requirement Plasma
Volume 2 mL
77
Container Gray-stopper (sodium fluoride/potassium oxalate) tube, serum-separator tube, or red-stopper tube
(separate blood within 45 minutes of venipuncture)
Collection Draw a fasting blood sugar before administering 100-g glucose, and draw blood at 1, 2, and 3 hours.
The subject should remain seated and not smoke throughout the test.
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation For 3 days prior to the test, patients should eat an unrestricted diet of 150 or more grams of
carbohydrate and be permitted unrestricted physical activity. Patients should be instructed to eat and drink
nothing except water for at least 8 hours and not more than 14 hours before the test. Patients should also be
advised to discontinue, whenever possible, all nonessential medication that can affect glucose metabolism at
least 3 days before testing.
Causes for Rejection Improper specimen labeling
Use Diagnose gestational diabetes
Contraindications Patient with known history of diabetes mellitus
Methodology Enzymatic
Giardia lamblia, Direct Antigen Detection …
Synonyms Stool for Giardia lamblia
Test Includes Rapid test for Giardia lamblia Antigen
Specimen Requirement Stool
Volume 2 g (thumbnail size portion of stool), 2 cc liquid stool
Minimum Volume 2 g, 2 cc stool in formalin portion of O & P transport kit
Container O & P transport/preservative kit (formalin only)
or Sterile Container.
Collection Fecal specimens for parasitic examination should be collected before initiation of antidiarrheal therapy
or antiparasitic therapy. The highest yield on hospitalized patients occurs when diarrhea is present on adimssion
or within 72 hours afer admission is usually caused by Clostridium difficile toxin rather than parasites or the
usual stool pathogens. The following recommendations are made for efficient and cost-effective diagnosis of
diarrheal disease in patients admitted with gastroenteritis.
• Submit one or two specimens per diarrheal illness immediately. Consider requesting the Rapid test for
Giardia ( test number 00000 Giardia lamblia by Rapid and Ova and Parasites examinations) if that is the
primary susepected organism.
• If those are negative, submit an additional specimen after 5 days.
• Patients who are immunocompromised by AIDS, malignancy, or immunosuppressive therapy may
require additional testing for unusual stool pathogens (eg. Cryptosporidium – test number 44035).
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Inappropriate specimen transport device; mislabeled specimen; unlabeled specimen;
specimen received after prolonged delay (usually more than 72 hours)
Use Rapid detection of Giardia lamblia from clinical samples
Contraindications Do not collect specimen for 1 week after barium or laxative administration.
Methodology ELISA
Glucose, Body Fluid .........................................
Synonyms Glucose, Pericardial; Glucose, Peritoneal; Glucose, Pleural; Glucose, Synovial
Special Instructions Request form must state site of fluid (ie, pleural, peritoneal, pericardial, synovial).
Specimen Requirement Any fresh body fluid
78
Volume 1 mL
Container Sterile container
Collection Collect aseptically into sterile tube. Label with patient's name, request form number, and room
number. Put on ice.
Storage Instructions Refrigerate
Patient Preparation On synovial fluid collection only, patient should fast for 8 hours.
Causes for Rejection Improperly labeled specimen
Use Decreased fluid glucose concentration is usually associated with septic or inflammatory processes; in pleural
effusion, very low glucose is a facet of rheumatoid effusion: pleural fluid glucose <50 mg/dL characterizes
rheumatoid effusion. It is often much less.
Methodology Enzymatic
Testing Schedule : Daily
Glucose, Cerebrospinal Fluid ........................
Synonyms Cerebrospinal Fluid Glucose; CSF Glucose
Specimen Requirement Cerebrospinal fluid
Volume 1 mL
Container Clean sterile tube
Collection If three tubes are available, this test should be run on tube #2. A request for a plasma glucose should
be made at the time of the spinal tap to coincide with the CSF glucose. Tubes must be labeled with patient's full
name, date, time of collecting, and with the number indicating the sequence in which tubes were obtained.
Storage Instructions Refrigerate
Causes for Rejection Improperly labeled tubes
Reference Interval 40-70 mg/dL
Use Evaluate meningitis, neoplastic involvement of meninges, other neurological disorders; diagnose
neuroglycopenia, even in the presence of normal plasma glucose, especially in chlorpropamide (Diabinese®)
poisoning
Methodology Enzymatic
Testing Schedule : Daily
Glucose, Plasma ...............................................
Synonyms Blood Sugar; Fasting Blood Sugar; FBS; Random Blood Glucose
Specimen Plasma
Volume 5 mL
Container Gray-stopper (sodium fluoride/potassium oxalate plasma) tube
Collection Label specimen as plasma.
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Gross hemolysis; improperly labeled specimen
Reference Interval 65- 109 mg/dL
Use Evaluate carbohydrate metabolism, acidosis and ketoacidosis, dehydration, diabetes mellitus, or
hypoglycemia
Methodology Enzymatic
Testing Schedule : Daily
79
Glucose, Quantitative, Urine ..........................
Synonyms Sugar, Quantitative, Urine; Total Reducing Sugars, Urine; Urinary Sugar Test
Specimen Requirement Urine (24-hour or other timed collection)
Volume 50 mL aliquot
Container Plastic urine container with boric acid or sodium fluoride
Collection Collect 24-hour urine with 1 g boric acid or sodium fluoride preservative. Mix well. Container must
be labeled with patient's name and date and time collection started and finished.
Storage Instructions Refrigerate
Patient Preparation Void at 8 AM (or 8 PM) and discard the specimen. Then collect all the urine including the
final specimen voided at the end of the 24-hour collection period (ie, 8 AM (or 8 PM) the following day).
Causes for Rejection Specimen not kept cold; no preservative; improperly labeled specimen
Reference Interval 0-500 mg/24 hours
Use Aid in the evaluation of glucosuria, renal tubular defects; manage diabetes mellitus
Methodology Enzymatic
Glucose, Serum ................................................
Synonyms Blood Sugar
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Collection Label specimen as serum.
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation Patient should fast for 12 hours.
Causes for Rejection Gross hemolysis; patient not fasting; blood stored overnight on clot; improperly labeled
specimen
Reference Interval 65-109 mg/dL
Use Diagnose diabetes mellitus; evaluate disorders of carbohydrate metabolism including alcoholism; evaluate
acidosis and ketoacidosis; evaluate dehydration, coma, hypoglycemia, of insulinoma, neuroglycopenia. A
fasting glucose <gq[140 mg/dL on more than one occasion is adequate for the diagnosis of diabetes mellitus. An
OGTT is not necessary in this setting. Infants especially with tremor, cyanosis, convulsions, and respiratory
distress should have stat glucose, particularly if there is maternal diabetes, postmaturity, asphyxia, hemolytic
disease of the newborn, possible sepsis. Babies too large or small for gestational age should also have glucose in
the first 24 hours of life. Random blood sugars can be used to monitor therapy in diabetics or evaluate presence
of insulinoma.
Limitation Mild glucose impairment can exist with fasting glucose within the normal range. Measurement of
plasma glucose withour spinal fluid glucose can miss neuroglycopenia. Fingerstick glucose determination in
shock are lower than venous glucose and are dangerously misleading.1
Methodology Enzymatic
Testing Schedule : Daily
Glucose Tolerance Test (GTT), .....................
Synonyms GTT; OGTT; Oral Glucose Tolerance Test
1
Madsen JK, Haunsoe S, Helquist S, et al, “Fingerstick Glucose Determination in shock,” Ann Intern Med,1991,114(12): 1020-4.
80
Test Includes Fasting blood glucose 30 minutes, first hour, second hour, and hourly thereafter up to time
specified. Pregnant females will not have 30 minute sample drawn.
Special Instructions Nonpregnant adult dose: 75 g; pregnant adult dose: 100 g; children up to 12 years old: 1.75
g/kg body weight, not to exceed 75 g.
Specimen Requirement Serum or plasma
Volume 2 mL each tube
Container Serum-separator tube or gray-stopper (sodium fluoride/potassium oxalate plasma) tube
Collection Submit 2 mL serum or plasma for fasting and each time interval (30 minutes, 1 hour, 11/2 hours, 2
hours, etc). Separate serum or plasma from cells within 45 minutes of venipuncture. Label each tube with
patient's name and time interval.
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Patient not arriving in a fasting state; stressed patient (surgery, infection, corticosteroids)
should not have GTT; specimens that are not labeled with hourly times
Use Indications vary somewhat between authorities. Some use the OGTT in individuals whose FBS varies
between 115-150 mg/dL on two or more occasions; others would use further fasting plasma glucose and 2-hour
postprandial glucose determinations for such subjects. Some use the GTT infrequently or not at all.
The GTT only establishes the presence of glucose intolerance. It is used in patients with borderline fasting and
postprandial glucose to support or rule out the diagnosis of diabetes mellitus. Some use it in unexplained
hypertriglyceridemia, neuropathy, impotence, diabetes-like renal diseases, retinopathy, re-evaluation of prior
diagnosis made under substandard conditions and with necrobiosis lipoidica diabeticorum. The OGTT is used to
work up glycosuria without hyperglycemia (eg, to work up renal glycosuria). It is used to predict perinatal
morbidity in pregnancy, to diagnose gestational diabetes. Risks of fetal abnormality and perinatal mortality are
increased with abnormal carbohydrate metabolism in pregnancy.
When a glucose level <50 mg/dL coincides with symptoms of hypoglycemia, a 6-hour glucose tolerance test is
advocated, but many consider the alternatives better.
Glucose intolerance is due to obesity in some subjects. Abnormal curves may be caused by Cushing's syndrome,
pheochromocytoma or acromegaly.
Contraindications FBS >140 mg/dL on two occasions or postprandial blood glucose >200 mg/dL on two
occasions are indicative of diabetes mellitus, in the nonstressed subject, and obviate the need for an OGTT.
OGTT is contraindicated in the presence of obvious diabetes mellitus.
Methodology Enzymatic
Testing Schedule : Daily
Gram's Stain .....................................................
Special Instructions Indicate the source of the specimen on the test request form. Label slide and slide holder.
Specimen Requirement Material from infected area
Volume Smear (air-dried) made at bedside or immediately after collection is preferred or one made in laboratory
from swab or clinical material.
Container Clean glass slides, swab in transport or clinical material in sterile container
Collection Carefully select material from infected area with a sterile swab. Gently roll swab onto a clean glass
slide to make a thin smear. Air dry the slide. Do not fix.
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Inappropriate specimen transport device; mislabeled specimen; unlabeled specimen;
specimen received after prolonged delay (usually more than 72 hours)
Reference Interval Depends on site of specimen.
81
Use Determine the presence of microorganisms and to evaluate the type of specimen by type of cells seen
(eg, PMN, epithelial)
Limitations Organism isolation and identification will usually be performed only if culture is requested.
Request for Gram’s stain will not lead to stain for mycobacteria (TB). For detection of tubercle bacilli, an acidfast stain must also be requested. Certain organismas do not stain or do not stain well with Gram’s stain (eg.
Legionella pneumophila). As many as 30% of cases of bacterial meningitis have a negative Gram’s stain.
Gram’s stain is not reliable for diagnosis of cervical, rectal, pharyngeal, or asymptomatic urethral gonococcal
infection. In acute bacterial meningitis in adults, the most frequent error was misidentification of Listeria as
Streptpcoccus pneumoniae in smears.
Additional Information Gram stain is recommended with all lower respiratory specimens, wound specimens,
tissue specimens, and sterile body fluids. Gram stains are usually scanned for the presence or absence of white
blood cells (indicative of infection) and squamous epithelial cells (indicative of mucosal contamination). A
sputum specimen showing more than 25 squamous epithelial cells per low powered field, regardless of the
number of white blood cells, is indicative that the specimen is grossly contaminated with saliva and the culture
results cannot be properly interpreted.
Gram’s stain is the most valuble diagnostic test in bacterial meningitis that is immediately available1. Orgainsms
are detectable in 60% to 80% of patients who have not been treated, and in 40% to 60% of those who have been
given antibiotics. Its sensitivity relates to the number of organisms present. The sensitivity of the Gram’s stain
is greater in gram-positive infections, and is only positive in 50% of the instances of gram-negative meningitis.
It is positive even less frequently with listeriosis meningitis or with anaerobic infections.2 Culture and Gram’s
stain should have priority over antigen detection methods if only a small volume of CSF is available.
Testing Schedule : Daily
Group A Streptococcus Screen
Synonyms Streptococcus Group A Latex Screen; Throat Swba for Group A Streptoccocal Antigen .
Applies to Enzyme immunoassay for Group a Streptococcus (GAS) antigen
Specimen Requirement Throat swab; many laboratories request tow swabs, one for culture if the rapid
screen is negative
Container: Rayone or Dacron swabs rather than cotton swabs enhance the chance of detection.
Collecion: Rigorous swabbing of the tonsillar pillars and posterior throat increased the probability of
detection of streptococcal antigen.
Special Instructions: Some laboratories favor submission of dry swabs for anteing testing. Consult the
laboratory for their specific recommendations.
Interpretive use: Screen for the presence of group A streptococall antigen
Limitation: many reviews have indicated a sensitivity of 75% to 80% and a specificity of 95% to 98% for
the rapid methods. Sensitivity varies between manufactures. Some kits are capable of detecting 10 colongy
forming units (CFUSs) while others require 106-107 CFU/mL. Specimens which yield less than 10
colonies on culture usually are negative by rapid method. Adequate specimen collection on younger
patients may be difficult, and thus, contribute to the false-negative rate. A positive result can be relied upon
as a rational basis to begin therapy. A negative result is only presumptive, and a culture should be
performed to reasonably exclude the diagnosis of group A streptococcal infection. Careful attention to
the details of the mthod and the use of appropriate controls are required to assume adequate performance.
1
Greenlee JE, “Approach to Diagnosis of Meningitis – Cerebrospinal Fluid Evaluation,” Infect Dis Clin North Am, 1990,4(4):583-98.
82
Grop A streptococcal antigen disappears rapidly following antibiotic therapy. Thus a history of prior
therapy should be sought when assessing pharyngitis.
Contraindications: thest test may become negative 4 hours after therapy has been stated.
Methodology: The streptococcal group carbohydratge antigen is extracted from the swab is used for
collection by use of acid or enzyme reagents. The extraction mixture is added to particles coated with
antistreptococcal anitboy. If the streptococcal antigen is present, visible agglutination occurs due to antigen
cross-links with antibody-coated latex within 10 minutes. Enzyme immunoas say methods ( EIA) are also
used. Testing Schedule : Daily
Additional Information: Rheumatic fever remains a concern in the United States and serious complication
including sepsis, soft tissue invasion, and toix shock-like syndrome have been repoted to be increasing in
frequency. Therefore , timely diagnosis and early institution of appropriate therapy remains important.
Timely therapy may reduce the actue symptoms and overall duration of streptococcal pharyngitis. The
sequalae of poststreptococcal glomerulonephritis and rheumatic fever and dmined by early therapy.
Group B Streptococcus Screen
Synonyms Streptoccocus aglacitiae Latex Scrren; Streptoccocus Group B Latex Screen
Replaces Counterimmunoelectrophoresis for Group B Streptococal Antigen
Test commonly Includes Latex screen for group B beta Streptococcus antigen
Specimen Requirement Cerebrospinal fluid, blood , urine, endocervical, endometrial material, or amniotic
fluid
Container: Sterile container, red top tube
Storage Instructions: Set up cultures. If a specimen for antigen detection cannot be tested immediately, it
may be sotred at 2 C to 8 C for 1 day or frozen at 220 C for longer storage. Storage is inconsistent with the
role of the test for rapid diagnosis.
Turnaround time: About 1 hour state
Interpretive Use: Rapid detection of group B streptococcus antigen in body fluids. Early intrapartum
detection of group B Streptococus antigen is usually an indication for chemoprophy laxis. Latex testing
may be useful in instances in which there has been prior antibiotic therapy. Cultures are needed.
Limitations: Latex screens have greater sensitivity than CIE procedures. Sensitivity is relatively low, 15%
to 21%, for rapid group B streptococcal antigen is usually an indication for chemoprophy . Latex testing
may be useful instances in which there has been prior antibiotic therapy. Cultures are needed. Limitation:
Latex screens have greater sensitivity than CIE procedures. Sensitivity is relatively low, 15% to 21% , for
rapid group B streptococcal antigen tests
2
5X106
colony forming units were required to be present for antigenic detection. Concentrated urine
may be used for screening. Testing CSF and serum, as well as , culture of the organism should be
considered . Shortcomings of latex detection are addressed in the listing, Bacterial Antigens, Rapid
detection Methods.
Methodology: Polystyre3ne latex particles coated with antibodies specific for the group B Streptococcus
antigen agglutinate in the presence of the homologous antigen.Controls for nonspecific agglutination of
latex particles are generally used. See package insert directions relevant to heat inactivation. Urine may be
concentrated to increase sensitivity of the method. Injection can be diagnosed by detecton of group B
specific carbohydrate antigen of baxterial cell wall, which may be pre3snet in body fluids, serum and
cerebrospinal fluid and which is excreted in urine. Counterimmunoelectrophoresis ( CIE) has been a
83
method for indication of the group B Stre Streptococus antigen. Alternatively, swab specimens collected
during antepartum visits may be cultured on appropriate media.
Additional Information: Goup B Streptoccocus is currently one of the most significant human pathogens
in the neonatal period. The most common mode of acquisition by the neonate is exposure to the maternal
genital flora in utero through ruptured membranes or by contamination during passage through the birth
canal. Rapid identification of Group B Streptococus carriers is important in management of premature
rupture of the membranes because the effectivness of intrapartum prophylactic ampicillin may be
compromised by awaiting the results of conventional cultures. Infection is manifested in two major forms,
early onset septicmic injection manifest in the first few days of life and late onset meningitis which occurs
during the first few months of life.
Inreased isolation of strains of Group B Streptococcus resistant to erythromycin (9%) or intermediate
susceptible clindamcin (9.5%) and cefoxitin (15.3%) have been reported. Nineteen perfect exhibited a
multiple antibiotic resistance pattern. Penicillinase production and resistance to ampicillin were not
encountered in the particular series. Susceptibility testing may be useful in selecting alternate antibiotic
regimens. Testing Schedule : Daily
HCG see Human Chronic Gonadotropin
HDL see High Density Lipoprotein Cholesterol
Helicobacter (Campylobacter) pylori, IgA
Synonyms Anti-H. pylori, IgA; Helicobacter pylori Antibodies
Test Includes Semi quantitative result for IgA
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use Diagnose H. pylori infection in patients with duodenal disease and for monitoring the eradication of H.
pylori following antimicrobial therapy; identify the small percentage of H. pylori infected patients who fail to
mount a systemic IgG response and demonstrate IgA antibodies only and for those patients who have chronic
mucosal infections.
Additional Information Circulating antibodies to H.pylori are predominantly of the IG class. A systemic
response of the IgA type is usually less pronounced but, if significant, may indicate a more severe inflammation.
A few patients develop only antibodies to IgA. IgM antibodies are rarely found and appear to be of minor
importance.
Methodology Enzyme immunoassay (EIA)
84
Helicobacter (Campylobacter) pylori, IgG
Synonyms Anti-H. pylori, IgG; Helicobacter pylori Antibodies
Test Includes Quantitative result for IgG
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Reference Interval Negative
Use Aid in the diagnosis of H. pylori infection; determine the cause of chronic type B gastritis or ulcers of the
stomach or duodenum. Although earlier ELISA tests for IgG antibodies to H. pylori had poor specificity, more
recent studies have shown both high sensitivity (96%) and high specificity for H. pylori associated with chronic
gastritis. H. pylori serology has become a standard tool for investigating the epidemiology of H. pylori
infections.
Methodology Enzyme immunoassay (EIA)
Hematocrit
Synonyms Hct; Microhematocrit; Packed Cell Volume; PCV
Specimen Requirement Whole blood
Volume 5 mL
Container Lavender-stopper (EDTA whole blood) tube
Collection Invert tube gently to mix.
Storage Instructions Maintain specimen at room temperature up to 24 hours.
Causes for Rejection Hemolysis; clotted specimen; tube not filled with minimum volume; improperly labeled
specimen.
Reference Interval Birth: 47-67%; 1-2 weeks: 42-63%; 3-4 weeks: 38-54%; 1-6 month: 32-48%; 6mo –3 yr: 3040%; 3-13 yrs:32-45%; 13yrs and older: male 40-51%, female: 34-46%.
Use Evaluate anemia, blood loss, hemolytic anemia, polycythemia, and state of hydration
Methodology Automated cell counter
Testing Schedule : Daily
Hemoglobin
Synonyms Hgb
Specimen Requirement Whole blood
Volume 5 mL
Container Lavender-stopper (EDTA whole blood) tube
Collection Invert tube gently to mix.
Storage Instructions Maintain specimen at room temperature up to 24 hours.
Causes for Rejection Hemolysis; clotted specimen; tube not filled with minimum volume; improperly labeled
specimen.
Use Evaluate anemia, blood loss, hemolysis, polycythemia, and response to treatment.
Methodology Automated cell counter
Testing Schedule : Daily
85
Hemoglobin (Hgb) A1c ....................................
Synonyms Hb A1c
Specimen Requirement Whole blood
Volume 7 mL
Container Lavender-stopper (EDTA whole blood) tube only
Collection Send entire tube to the laboratory.
Storage Instructions Store at room temperature.
Use Clinically, hemoglobin A1c values are used most frequently to assess glucose control in insulin-dependent
diabetics whose glucose levels are very labile and in whom single blood glucose measurements may not
accurately reflect the level of control present over the preceding few weeks. Hemoglobin A1c measurements are
of less value in stable diabetics, because urine and blood glucose determinations provide simple, economic, and
reliable means for assessing glycemic control. In these patients, fasting glucose concentrations are fairly
consistent from day to day and there is a significant correlation between hemoglobin A1c and single fasting
glucose levels. Although measurement of hemoglobin A1c may provide a unique means of evaluating control in
diabetics who have wide fluctuations in blood glucose levels, it is not a substitute for urine and blood glucose
levels that are used to regulate insulin dose. Hemoglobin A1c measurements are less sensitive in detecting what
is now defined as diabetes than is the GTT.
Limitations Misleading high levels of glycated hemoglobin are found in patients who have elevated levels of
fetal hemoglobin are found in patients who have elevated levels of fetal hemoglobin (Hb F); high levels of Hb F
are found in young children under 2 years of age and in some hemoglobinopathies. This is true also for
hemoglobins H,I,J and N. Low values derive from blood containing hemoglobin S, G, D, C or E.
Methodology Immunoassay
Testing Schedule : Daily
Hepatitis A Antibody, Total ....... ...........
Synonyms Antibody to Hepatitis A Virus; Anti-HAV Total; HAVAb Total
Specimen Requirement Serum or plasma
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube
Collection If tube other than serum-separator tube is used, transfer separated serum or plasma to a plastic
transport tube.
Storage Instructions Refrigerate
Use Evaluate hepatitis A
Methodology Microparticle enzyme immunoassay (MEIA)
Hepatitis A Antibody, IgM .......... ...........
Synonyms Antibody to Hepatitis A Virus, IgM; Anti-HAV, IgM; HAVAb, IgM
Specimen Requirement Serum or plasma
Volume 1 mL
Minimum Volume 0.5 mL
86
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube.
Collection If tube other than serum-separator tube is used, transfer separated serum or plasma to a plastic
transport tube.
Storage Instructions Refrigerate
Use Differential diagnosis of hepatitis; the presence of IgM antibody to hepatitis A virus is good evidence for
acute hepatitis A.
Methodology Microparticle enzyme immunoassay (MEIA)
Hepatitis B Core Antibody, IgM ...........
Synonyms Antibody to Hepatitis B Core Antigen, IgM; Anti-HBc, IgM; HBcAb, IgM
Specimen Requirement Serum or plasma
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube
Collection If tube other than serum-separator tube is used, transfer separated serum or plasma to a plastic
transport tube.
Storage Instructions Refrigerate
Use IgM antibody to hepatitis B core antigen is a reliable marker for acute disease for a hepatitis B viral
infection. At times this marker is the only one demonstrated for the diagnosis of a hepatitis B viral infection.
Methodology Microparticle enzyme immunoassay (MEIA)
Testing Schedule : Daily
Hepatitis B Surface Antibody ..... ...........
Synonyms Antibody to Hepatitis B Surface Antigen; Anti-HBs; HBsAb; HBsAg Ab; Hepatitis Bs Antibody
Special Instructions To order this test with quantitative results, see Hepatitis B Surface Antibdoy, Quantitative
(follows).
Specimen Requirement Serum or plasma
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube
Collection If tube other than serum-separator tube is used, transfer separated serum or plasma to a plastic
transport tube.
Storage Instructions Refrigerate
Use Presence of hepatitis B surface antibody is an indicator of clinical recovery and subsequent immunity to
hepatitis B virus. This test is useful for evaluation of possible immunity in individuals who are at increased risks
for exposure to the hepatitis B (ie, hemodialysis unit personnel, venipuncturists, etc). Evaluate the need for
hepatitis B immune globulin after needlestick injury; evaluate the need for hepatitis B vaccine and follow
immune status after hepatitis B vaccine.
Methodology Enzyme immunoassay (EIA)
Testing Schedule : Daily
Hepatitis B Surface Antigen ....... ...........
Synonyms HAA; HBsAg; Hepatitis Associated Antigen
Specimen Requirement Serum or plasma
87
Volume 2 mL
Minimum Volume 1 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube
Collection If tube other than serum-separator tube is used, transfer separated serum or plasma to a plastic
transport tube.
Storage Instructions Refrigerate
Use Test blood donors (HBsAg positive individuals are rejected). Hepatitis B surface antigen is the earliest
indicator of the presence of acute infection. Also indicative of chronic infection. Test is useful in the differential
diagnosis of hepatitis.
Methodology Enzyme immunoassay (EIA)
Testing Schedule : Daily
Hepatitis C Virus Antibody ........ ...........
Synonyms Antibody to Hepatitis C Virus; Anti-HCV
Specimen Requirement Serum or plasma
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube
Collection If tube other than serum-separator tube is used, transfer separated serum or plasma to a plastic
transport tube. Avoid hemolysis.
Storage Instructions Refrigerate
Use Assess exposure to hepatitis C virus infection; test blood units for transfusion safety
Methodology Enzyme immunoassay (EIA)
Testing Schedule : Daily
Herpes Simplex Virus (HSV) Types I/II, IgG
Synonyms Herpes-1; Herpes-2; HSV-1; HSV-2
Test Includes A semiquantitative result (index) for the presence of antibodies to either HSV-1 and/or HSV-2
Specimen Requirement Serum
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Excessive hemolysis; lipemia; gross contamination
Use Detect IgG antibodies to either HSV-1 and/or HSV-2
Methodology Enzyme immunoassay (EIA)
High Density Lipoprotein Cholesterol (HDLC)
Synonyms Alpha-Lipoprotein Cholesterol; HDLC; HDL Cholesterol; HDL Cholesterol Electrophoresis
Specimen Requirement Serum
Volume 2 mL
88
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation Patient should be on a normal diet and maintain a stable weight for a week prior to testing.
Any drugs should be discontinued for 3-4 weeks if possible. Test should not be done until 3 months after a
myocardial infection or similar traumatic episodes such as severe infection or inflammation.
Causes for Rejection Improperly labeled specimen
Use A protective substance utilized for prediction of coronary arterial disease, especially useful in individuals
with high serum cholesterol levels. Low HDLC is an important predictor of risk of coronary atherosclerosis and
coronary heart disease. HDL may act as a protective scavenger molecule (reverse cholesterol transport). The
liver is the major site of cholesterol excretion.
Methodology Precipitation; enzymatic
Testing Schedule : Daily
HIV see Human Immunodeficiency Virus
Human Chorionic Gonadotropin (hCG),Qualitative, Serum
Synonyms Beta Subunit, hCG; hCG, Beta Subunit, Qual, Serum; Pregnancy Test, Serum
Special Instructions State date of last menstrual period
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; gross lipemia; plasma specimen
Use Qualitative detection of the beta subunit of human chorionic gonadotropin (hCG) provides a sensitive and
specific test for the detection of early pregnancy, diagnosis of ectopic pregnancy or threatened abortion; follow
up molar pregnancy
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Human Chorionic Gonadotropin (hCG), , Quantitative, Serum
Synonyms hCG, Beta Subunit, Quant
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Causes for Rejection Gross hemolysis; plasma specimen
89
Use Determine the presence of hCG in patients with gestational trophoblastic disease; evaluate and monitor male
patients with testicular tumors; follow up molar pregnancy. The quantitative hCG assay should be used for
nonroutine detection of hCG (eg, ectopic pregnancy, threatened abortions, miscarriages, or very early
pregnancy). hCG is used in prenatal testing for trisomy 21 (Down syndrome). In combination with serum estriol
and serum AFP, the detection of Down syndrome is greatly increased.
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Human Immunodeficiency Virus DNA Amplification
Synonyms HIV DNA Amplification Assay: HIV DNA PCR TEST; Human immunodeficiency Virus ( HIV)
Proviral DNA by Polymerase Chain Reaction Implication; PCR for HIV DNA
Test commonly includes HIV DNA is detected by amplifying specific proviral DNA sequences from peripheral
blood lymphocytes and subsequent hybridization with a specific HIV DNA probe.
Abstract Human immunodeficiency virus ( HIV) is the causative agent of acquired immune deficiency syndrome
( AIDS). Currently, testing for HIV is based on evidence of circulating antibody to the viral proteins.
Commercially available tests are remarkably accurate with a low false-positive rate (1:135,000). However,
accuracy of the test is compromised during the time interval between infection and the development of antibody to
HIV. The exact time to seroconversion is controversial but certain cases of accidental exposure have shown
seroconversion to occur within 2-3 months. Babies born to HIV-injected mothers will be seropositive for HIV due
to transplacental antibodies. Studies have shown that only 30% to 50% of babies born to HIV infected mothers are
actually infected with the virus. Thus, the serologic test is unreliable for assessing HIV infection in these
populations.
This virus contains an RNA genoma that will incorporate into host DNA as proviral DNA. The target cells of this
virus are the CD4 ( T4) T-lymphocytes ( helper T cells) and monocytes macrophage populations; however, during
infection, few such peripheral blood cells contain HIV. To detect the incorporated viral genome, the DNA must be
amplified. This procedure specifically increases the amount of DNA withing the HIV genome, and the amplified
DNA product is detected by specific binding to an HIV probe. The DNA detection assay has been useful for the
diagnosis of HIV in infants and for monitoring individuals with a known exposure to HIV.
Specimen Requirement Peripheral blood lymphocytes from 10-20 mL whole blood Container: Two yellow top
( ACD) , lavender top ( EDTA), or greet top ( sodium heparin) tubes should be collected. Type of tube is
dependent on the laboratory performing the tes. Storage Instructions: Tubes oof blood can be sent directly to the
laboratory at ambient temperature and should arrive within 48 hours of collection. Causes for refection:
speciments with inadequate volume or more than 48 hours of collection. Causes for rejection: Specimens with
inadequate volume or more than 48 hours old may be rejected. Turnaround time: 2 weeks is usually required
turnaround time may vary with individual laboratories.
Interpretive Reference Interval: No HIV viral DNA detected in peripheral blood lymphocytes.
Use: HIV detection in patients with unusual or in determinant HIV serology. It may also be useful in patients with
immunodeficiency syndromes characterized by a negative HIV serology and western blot tests.
Methodology: DNA amplification is used , polymerase chain reaction (PCR). DNA is extracted from peripheral
blood lymphocytes. The proviral HIV DNA is exponentially amplified by using specific primers that bind to
regions of the HIV genome. Using a series of denaturation, annealing , and polymerization steps the original
proviral DNA can be amplified 105 to 106 fold ( see figure in the polymerase Chain Reaction listing in the
chapter). The amplified HIV DNA probe can be hybridization with an HIV specific DNA probe. Hybridization
with the HIV DNA probe can be detected using autoradiography or enzymatic detection procedures.
Additional Information: Currently the diagnosis of HIV infection is dependent on the detection of specific
antibodies. The antibody screening test commonly used is the enzyme linked immunosorbent assay ( ELISA) with
90
a confirmatory Western blot or immunoblot. These serologic assays will identify individuals with prior exposure
to HIV or passively obtained antibody such as babies born to HIV-positive mothers. In addition, serologic tests
may not identify patients with recent active injection. Due to this problem, other rests have also been used to
document the presence of HIV, such as viral antigen assays, viral culture and the detection of viral DNA. Viral
culture of HIV is a prolonged procedure taking 3-4 weeks. It suffers from a lack of sensitivity in that HIV cannot
be consistently isolated from serpositive patients. Studies using in situ hybridization have shown that few
peripheral blood mononuclear cells may actually harbor HIV proviral DNA ( 1 in 10,000). This makes it difficult
to directly assay for HIV proviral DNA. Thus, DNA amplification assays have been developed to detect HIV
DNA. The assay most commonly used is the polymerase chain reaction ( PC), which can amplify a single copy of
DNA by 105 to 106 to 106 fold 8. The PCR test for HIV DNA is useful in resolution of unsatisfactory HIV
antibody test results and in determination of the status of children born to mothers with positive HIV serology.
Without the need for viral culture.
Testing Schedule : Weekly
Human Immunodeficiency Virus (HIV), Preliminary Test With Confirmation
Synonyms HIV-1; HIV , Prelim Test/Confirm
Test Includes HIV antibodies using recombinant protein-based EIA Confirmation by different method .If EIA
results are repeatedly positive, Confirmation analysis will be performed at an additional charge.
Special Instructions Coded name designations are recommended to ensure confidentiality. (name must be on
test tube for results to released.)
Specimen Requirement Serum or plasma
Volume 4 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube or lavenderstopper (EDTA plasma) tube
Collection No pour-offs
Storage Instructions Refrigerate
Methodology Enzyme immunoassay (EIA); recombinant HIV antigen;
Additional Information Human Immmunodeficiency virus (HIV), the etiologic agent of the acquired
immunodeficiency syndrome (AIDS) is a cytopathic retrovirus. This test uses a viral lysate as the antigen source
and detects antibodies by specific immune binding and subsequent color development (enzyme immunoassay
(EIA) technology). Sensitivity and specifity of this assay are 100% and 99.7% respectively.
Testing Schedule : Daily
Human Immunodeficiency Virus 1 (HIV-1) RNA, Quantitative
Synonyms HIV-1 Plasma Viremia; HIV-1 RNA by PCR, Quantitative; HIV viral load
Test Includes Serial monitor report
Specimen Requirement Plasma
Volume 1 mL
Minimum Volume 0.5 mL
Container Screw-cap polypropylene frozen transport tube
91
Collection Collect whole blood in lavender-stopper (EDTA) tube or yellow-stopper (ACD) tube. Centrifuge
blood at 800-1600x g at room temperature within 4 hours of draw to separate cells from plasma. Transfer plasma
to a plastic screw-cap transport tube and freeze. To avoid delays in turnaround time when requesting multiple
tests on frozen samples, please submit separate frozen specimens for each test requested.
Causes for Rejection Specimen not frozen; heparinized plasma
Use Detect and quantitate HIV in plasma (viral load)
Testing Schedule : Daily
Homocysteine, …. ......................... ...........
Specmen Requirement Plasma or serum
Volume 1 ml
Minimum Volume 0.3 ml
Container Lavender-stopper (EDTA plasma) tube, gree-stopper (heparinized plasma) tube, re-stopper tuve, or
serum-separator tube
Collection Immediately place collection tube incrushed ice until it can be precessed. EDTA plasma is the
preferred specimen, separate plasma from cells immediately to avoid a false elevationof homocysteine, after 1hour
at room temperature, a 10%increase may be seen, transfer plasma or serum to a plastic transport tube, (see Causes
for Rejection.) homocysteine results increase by approximately 35% and 75% for samples not centrifuged and /or
not separated from the clot for periods of 4 hours and 24 hours, respectively. Specimens not placed on ice
immediately may exhibit a 10% to 20% increase in concentration.
Storage Instructions Refrigerate
Patient preparation A fasting specimen is preferred to establish baselne balues or monitor treatment,
Causes for Rejection Specimen received not separated from cells (do not respin an SSTtm or gel barrier tube to
harvest additional serum); any sample that is grossly hemolyzed (e.g., bright red or chery red); any whole blood
tube without a gel separator; plasma from a light blue-stopper or yellow-stopper tube used for coagulation studies
(liquid citrate tubes have a dilutional effect of approximately 1.2 on this assay and are not approved for use)
Reference Interval
Male: 6.3-15.0 µmol/L
Female: 4.6-12.4 µmol/L
Hyperhomocysteinemia can be categorized clinically as1:
Moderate: upper limit of normal to 30µmol/L
Intermediate: >30-100µmol/L
Severe: >100 µmol/L
Use This test is intended for use in screening patients who may be at risk for heart disease and stroke.
Limitations This test is not intended for use in the diagnosis of folate or vitamin B12 deficiency. Anemia Profile,
Megaloblastic, Serum (706960)
Methodology Immunoassay
92
Additional Information Severe homocysteinemia is typically causecd by a rare inborn error of metabolism.1,2 the
most common defect that can produce levels >100 µmol/L is homozygous cystathionine-beta-synthase (CS)
deficiency, which occurs with an incidence of 1 per 300,000 live births. About 1% of the population has
heterozygous CS deficiency, a condition that typically results in moderate to intermediate
hyperhomocysteininemia. Individuals with CS deficiency are at increased risk for occlusive vascular ddisease.1,2
individuals with a thermolabile variant of the enzyme methylene-tetrahydrofolate reductase can have high normal
to moderately elevated levels of homocysteine.1,2Homocysteine can be considered to be an independent risk factor
for the development of cardiovascular disease.1,2,3 Patients with cardiovascular disease, including heart disease,
stroke, peripheral vascular disease, and thromboembolic disease generally have higher homocysteine levels than
matched controls. The results of a large number of epidemiological studies have been analyzed through a metaanalysis.1The increased risk, or odds ratio (OR), for coronary artery disease in patients with increase homocysteine
levels was estimated to be 1.7. The OR for stroke was estimated to be 2.5 and the OR for peripheral vascular
disease was estimated to be 6.8. Several conditions, other than specific genetic defects or cardiovascular disease,
have been associated with hyperhomocysteinemia.1 These include vitamin deficiency, advanced age,
hypothyroidism, impaired kidney function, and systemic lupus erythematosus, Medications including nicotinic
acid, theophylline, methotrexate, and L-dopa have been reported to cause elevated homocysteine levels.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Iron and Total Iron Binding Capacity (TIBC)
Synonyms Fe and TIBC; Iron Indices; Iron Profile; TIBC; TIBC and Iron; Total Iron Binding Capacity;
Transferrin Saturation
Test Includes Percent of saturation; serum iron; total iron binding capacity
Specimen Requirement Serum
Volume 4 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation Patient should be drawn fasting in the morning (circadian rhythm affects Fe). Have sample
drawn before patient is given therapeutic iron or blood transfusion. Iron determinations on patients who have
had blood transfusions should be delayed for at least 4 days.
Causes for Rejection Hemolysis; specimens clotted on anticoagulants (these bind iron); improperly labeled
specimen
Use Differential diagnosis of anemia, especially with hypochromia and/or low MCV. The percent saturation
sometimes is more helpful than is the iron result for iron deficiency anemia. Evaluate thalassemia and possible
sideroblastic anemia; work-up hemochromatosis, in which iron is increased and iron saturation is high. Decrease
in iron level after performance of Schilling supports the diagnosis of vitamin B12 deficiency, vide infra. Evaluate
iron poisoning (toxicity) and overload in renal dialysis patients, or patients with transfusion dependent anemias.
Use of TIBC in iron toxicity may be less useful than previous believed. TIBC or transferrin is a useful index of
nutritional status.
Uncomplicated iron deficiency: Serum transferrin (and TIBC) high, serum iron low, saturation low. Usual causes
of depleted iron stores include blood loss, inadequate dietary iron. RBCs in moderately severe iron deficiency
are hypochromic and microcytic. Stainable marrow iron is absent. Serum ferritin decrease is the earliest indicator
of iron deficiency if inflammation is absent.
Anemia of chronic disease: Serum transferrin (and TIBC) low to normal, serum iron low, saturation low or
normal. Transferrin decreases with many inflammatory diseases. With chronic disease there is a block in
movement to and utilization of iron by marrow. This leads to low serum iron and decreased erythropoiesis.
Examples include acute and chronic infections, malignancy and renal failure.
93
Sideroblastic anemia: Serum transferrin (and TIBC) normal to low, serum iron normal to high, saturation high.
Hemolytic anemias: Serum transferrin (and TIBC) normal to low, serum iron high, saturation high.
Hemochromatosis: Serum transferrin (and TIBC) slightly low, serum iron high, saturation very high.
Protein depletion: Serum transferrin (and TIBC) may be low, serum iron normal or low (if patient also is iron
deficient). This may occur as a result of malnutrition, liver disease, renal disease (eg, nephrosis) or other entities.
Liver disease: Serum transferrin variable; with acute viral hepatitis, high along with serum iron and ferritin. With
chronic liver disease (eg, cirrhosis), transferrin may be low. Patients who have cirrhosis and portacaval shunting
have saturated TIBC/transferrin as well as high ferritin.
Chronic dialysis for renal failure: monitor iron levels in patients undergoing dialysis. To follow treatment of iron
overload with deferoxamine or with regimen of recombinant human erythropoietin and phlebotomy.
Contraindications Parenteral iron before sample is drawn will cause misleading high iron results. Recent blood
transfusion may have only a small positive effect on iron.
Methodology Colorimetric
Testing Schedule : Twice a week (Result avaliable on Monday and Thrusday)
Iron, Serum .................................... ...........
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Severe hemolysis; improper labeling; improper collection; specimen contamination by
anticoagulant
Use Aid in the evaluation of a number of conditions involving red cell production and destruction, iron
metabolism, or iron transport
Methodology Colorimetric
Testing Schedule : Daily
Lactic Acid .................................... ...........
Synonyms Blood Lactate; Lactate; Plasma Lactate
Specimen Requirement Perchloric acid supernatant from oxalated whole blood or plasma
Volume 5 mL
Container Gray-stopper (sodium fluoride/potassium oxalate) tube
Collection Avoid hand-clenching and if possible, avoid use of a tourniquet. A tourniquet with patient clenching
and unclenching hand, will lead to build-up of high potassium and lactic acid from the hand muscles, and pH
will decrease. It is best to avoid a tourniquet for electrolytes and lactic acid, or to release it after blood begins to
flow into tube. If the tourniquet is released before blood is drawn, wait about a minute before drawing. Keep
gray-stopper tube on ice.
Whole blood lactic acid: Draw tube and quickly add 5 mL of the gray-stopper tube whole blood to 5 mL of 8%
(w/v) perchloric acid (7 mL of 70% (w/w) perchloric acid diluted to 100 mL with deionized water). Note: Use
1:1 blood to 8% (w/v) perchloric ratio if less blood is obtained. Shake mixture vigorously for about 30 seconds.
Refrigerate for 5 minutes to ensure complete protein precipitation. Centrifuge 5-10 minutes at approximately
3000 xg. Remove the clear supernatant and send to laboratory. Note: A second centrifugation of the supernatant
may be necessary to obtain a clear protein-free solution.
94
Plasma lactic acid: Draw blood in gray-stopper tube. Mix well by gentle inversion at least six times. Return to ice
bath to cool. Within 5 minutes from draw, separate the plasma from blood by centrifugation at 400xg for 10
minutes. Avoid excessive forces which contribute to hemolysis.
Storage Instructions Refrigerate
Patient Preparation Patient should not be on any intravenous infusion that would affect the acid-base balance.
Patient should be in a fasting and resting state (should not exercise).
Aftercare Solutions of perchloric acid can become explosive if allowed to dry. Always rinse glassware and
working surfaces copiously with water.
Causes for Rejection Whole blood: specimen not treated with perchloric acid; supernatant not separated from
precipitate; supernatant not clear. Plasma: specimen not separated from cells within 15 minutes of draw; marked
hemolysis; slight or moderate turbidity.
Use Hypoperfusion is the most common cause of lactic acidosis and hyperlactacidemia may be the only marker
of tissue hypoperfusion. Suspect lactic acidosis when unexplained anion gap metabolic acidosis is encountered,
especially if azotemia or ketoacidosis are not present. Evaluate metabolic acidosis, regional or diffuse tissue
hypoperfusion, hypoxia, shock, congestive heart failure, dehydration, complicated postoperative state,
ketoacidosis or nonketotic acidosis in diabetes mellitus, patients with infections, inflammatory states, postictal
state, certain myopathies, acute leukemia and other neoplasia, enzyme defects, glycogen storage disease (type I),
thiamine deficiency, and hepatic failure. A spontaneous form of lactic acidosis occurs. It is a prognostic index in
particular clinical settings, especially in critically ill patients in shock. A relationship to renal disease also exists.
With skin rash, seizures, alopecia, ataxia, keratoconjunctivitis, and lactic acidosis in children, consider defective
biotin metabolism. Phenformin, ethanol, methanol, and salicylate poisoning and ethylene glycol may cause
lactic acidosis. Acetaminophen toxicity causes lactic acidosis, sometimes with hypoglycemia. Cyanide,
isoniazid, and propylene glycol are among the causes of lactic acidosis. Lactic acidosis may be due to inborn
errors of metabolism.
Methodology Lactate — pyruvate; spectrophotometry
Lactic Acid Dehydrogenase (LDH) ......
Synonyms LD; LDH
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Excessive hemolysis; improperly labeled specimen
Use Causes of high LD: Neoplastic states* (especially with high alkaline phosphatase, very high total LD, and
isomorphic pattern of LD isoenzymes); hypoxic cardiorespiratory diseases; hemolytic anemia*; megaloblastic
anemias*, including pernicious anemia* (levels may be >2000 units/L and LD isoenzymes reveal LD1:LD2 flip);
infectious mononucleosis*; inflammation; hypothyroidism (some cases*); myocardial infarct: LD begins to rise
about 12 hours after infarct and usually returns to normal after CK (CPK) and AST (SGOT), isoenzymes usually
most useful 48 hours from onset to reveal LD1:LD2 inversion*; pulmonary infarct (rarely, triad of LD, bilirubin,
AST increases occurs); other lung diseases.
Diseases of liver*, including cirrhosis. Total LD in cirrhosis is usually not greatly increased. In acute viral
hepatitis, LD is not greatly elevated and AST is usually three or more times higher (in relation to the upper limit
of normal) than LD; chronic alcoholism is usually associated with some combination of high MCV (mean
corpuscular volume), triglyceride, alkaline phosphatase, AST (SGOT), ALT (SGPT), GGT, bilirubin, and low
folate*.
95
Renal infarct* — high LD, out of proportion to AST and alkaline phosphatase; seizures, other CNS diseases;
acute pancreatitis; collagen diseases; excessive destruction of cells*; fracture, other trauma, including head
trauma, muscle damage; muscular dystrophy; focal necrosis; shock, hypotension; intestinal obstruction. *LD
isoenzymes may be useful.
Other causes of increased LD include specimen tube artifact, such as serum contact with clot or exposure to heat.
Chemistry profile with very high LD and no glucose may relate to unseparated serum and cells in a tube at
room temperature or higher. Since LD is found in virtually every tissue in the body, the diagnostic value of an
elevated level is limited.
Methodology Kinetic
Testing Schedule : Daily
Lead (B)
Specimen Requirement: 2 ml heparin blood, use plastic syringe and tube
Ref. Interval:
Female <45 years: up to 300 µg/L
(under exposition: up to 1.44 µmol/L)
Female >45years: up to 400µg/L
(under exposition: up to 1.93 µmol/L)
Male: up to 400 µg/L
(under exposition: up to 1.93 µmol/L)
Use: Evaluate lead toxicity, poisoning.
Limitation: Lead poisoning is not ruled out by normal blood levels; clinical findings and heme synthetic
enzymes must also be evaluates.
Methodology: AAS
Additional Information: Great care is required to avoid contamination in the collection of specimens for
lead analysis. Lead can be measured in tissue and urine. Another test that may be used to evaluate lead
intoxication is free erythrocyte protoporphyrin (FEP). FEP concentrations >35mg/dL are consistent with
undue absorption of lead. However, FEP is also elevated in iron deficiency, sickle cell anemia, and chronic
infection. Erythrocyte zinc protoporphyrin is a more specific indicator of lead toxicity and, therefore,
superior to FEP. Normal values for erythrocyte zinc protoporphrin are <100 ng/dL. Inhibition of
erythrocyte delta aminolevulinic acid dehydrates is a very sensitive measure of lead toxicity. However, a
blood lead assay is the definitive test for recent acute exposure if sample collection is meticulous.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Leishmania IgA & IgG & IgM
Specimen Requirement: 2 ml serum
Ref. Interval:
IgA: negative
IgG: <1:40 titer – abs not detectable
IgM: <1:20 titer – abs not detectable
Use: Support the clinical diagnosis of visceral leishmaniasis, cutaneous leishmaniasis, and
mucocutaneous leishmaniasis .
Limitations: Cross reactivity with trypanosomiasis; false-positives in malaria
Methodology for IgG & IgM: IF
96
Additional information : Serodiagnosis of visceral leishmaniasis is more reliable than serodiagnosis
of cutaneous disease, although this has been improved by the use of direct agglutination tests. An
ELISA test is positive in 85% of cases. Leukopenia , thrombocytopenia, and anemia are round. Bone
marrow aspiration provides diagnostic organisms. L. Tropica, which usually causes cutaneous
disease produced visceral infection is soldiers returning from desert storm.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Lipase, Serum ............................... ...........
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Improperly labeled specimen
Use Diagnose pancreatitis, more specific for pancreatitis than is serum amylase; diagnose peritonitis,
strangulated or infarcted bowel, pancreatic cyst
Contraindications Urine specimens are inappropriate for lipase. Lipase activity is usually absent in urine,
possibly from inactivation of the enzyme.
Methodology Colorimetric
Testing Schedule : Daily
Lipid Panel .................................... ...........
Test Includes Cholesterol, total; HDL cholesterol; LDL cholesterol calculation; triglycerides; LDL/HDL ratio
Special Instructions State patient's age and sex on the request form.
Specimen Requirement Serum
Volume 5 mL
Container Red-stopper tube or serum-separator tube
Collection Separate serum from cells within 45 minutes of venipuncture. Lipid profiles are best avoided for up
to 3 months following acute myocardial infarction, although cholesterol can be measured in the first 24 hours.
Storage Instructions Refrigerate
Patient Preparation Patient should be on a stable diet ideally for 2-3 weeks prior to collection of blood and
should fast for 12-14 hours before collection of the specimen.
Causes for Rejection Hemolysis
97
Use Abbreviations used are as follows: HDLC, high density lipoprotein cholesterol; LDLC, low density
lipoprotein cholesterol; VLDLC, very low density lipoprotein cholesterol. Evaluation of hyperlipidemia as an
index to coronary artery disease. Investigation of serum lipids is indicated in those with coronary and other
arterial disease, especially when it is premature, and in those with family history of atherosclerosis or of
hyperlipidemia. In this sense, the expression |premature| is mostly used to include those younger than 40
years of age. Patients with xanthomas should be worked up with lipid profiles, but not those with
xanthelasmas or xanthofibromas in the sense of dermatofibromas. Those whose fasting serum is lipemic
should have a lipid profile, but the serum of a subject with high cholesterol but normal triglyceride is not
milky in appearance. The patient with high cholesterol (>240 mg/dL) should have a lipid profile. Patients
with cholesterol levels between 200-240 mg/dL plus two other coronary heart disease risk factors should also
have a lipid profile. In addition to application in programs for evaluation of risk factors for coronary arterial
disease, lipid profiling may lead to detection of some cases of hypothyroidism. If a patient has low LDLC,
but very low HDLC, he/she may still be in jeopardy (Castelli of the Framingham study); therefore,
LDLC/HDLC ratios are useful. Primary hyperlipoproteinemia includes hypercholesterolemia, a direct risk
factor for coronary heart disease. Secondary hyperlipoproteinemias include increases of lipoproteins
secondary to hypothyroidism, nephrosis, renal failure, obesity, diabetes mellitus, alcoholism, primary biliary
cirrhosis, and other types of cholestasis.
Decreased lipids are found with some cases of malabsorption, malnutrition, advanced liver disease. In
abetalipoproteinemia, cholesterol is <70 mg/dL.
Testing Schedule : Daily
Lithium
Synonyms Eskalith Lithonated
Abstract Lihium is used in the treatment of depression and particularly for manic depressive psychosis. It
should be monitored
Patient Care Aftercare – Follow urine Osmolality, ECGs, thyroid profile, BUN, creatinine, and sodium.
Avoid sodium depletion.
Specimen Requirement serum container: Red top tube Collection: Collect at a standard time from last dose,
6-12 hours recommended. Storage instructions: Refrigerate a minimum of 2mlserum. Serum specimens are
stable for 24 hours at room temperature. Separate serum immediately. Causes for rejection: Specimen
collected in tube containing lithium heparin, hemolysis TURNAROUND TIME: 1.2 hours if in house.
Interpretive Reference Interval: Therapeutic: 0.6-1.2 mEq/L (SI: 0.6-1.2 mmol/L). for acutemania; 0.8-1.0
mEq/L (SI:0.8-1.0mmol/L) for protection against future episodes in most patained at levels <0.4mEqL
(SI:>4.0mmol/L) POSSIBLE PANIC RANGE: Toxic:>1.5mRq/L(SI:>1.5mmol/L). Toxicity can become
serous when levels rise to levels>2.0mEq/L (SI:>2.0mmol/L). Levels >4.0mEq/L (SI:>4.0mmol/L) are
associated with cama. death. A narrow therapeutic index exists for lithium.
use: Monitor therapeutic drug level, evaluate coma
Limitations: Lithium toxicity can occur with normal serum lithium levels. Thiazides can cause significant
rise in serum lithium.
Methodology: Flame photometry, atomic absorption spectro-photometry (AA), ion -selective electrode (ISE)
Additional Information: lithium as lithium carbonate is used as a psychoactive agent in the treatment of
manic depressive disorders. Lithium therapy demands daily monitoring of serum lithium levels until the
proper dose schedule is determined. Tremor, gastrointestinal symptoms, urinary frequency, and weight gain
were less frequent at lower level. intoxication never occurs suddenly. Several days to a week before full-blown
symptoms develop, a patient will experience lethargy, drowsiness tremor, muscle twitching, dysarthria,
98
anorexia and vomiting or diarrhea. A fully developed case of intoxication shows coma to semicoma, rigidity,
hyperactive reflexes and seizures at timor, muscle twitching dysarthria, anorexia and vomiting or diarrhea. A
fully developed case of intoxication show s coma to semicoma, rigdity, gyperactive reflexes and seizures at
times. There is a incidence or pulmonary complications. It is advisable to perform periodic plasma sodium
determinations. Low plasma sodium levels are associated with lithium retention ; high levels with lithium
elimination. Varying degrees of nephrogenic diabetes insipidus have been reported to occur in 33% of lithium
treated patients. Lithium significantly inhibitis antidiertic hormone induced water transport in kidney. Lithium
interferes with solute and water absorption form the gastrointestinal system producing nausea, vomiting,
diarrhea, and abdominal pain. These symptoms may occur at any time, at any serum level. They most
commonly occur duing early treatment stages and usually cearl spontaneously or by adjustment of dosage.
Chronic thium administration has goitrogenic effect on 4% of lithium-treated patients, with or without
hypothyroidism. In general, lithium administration results in slightly decreased serum and transiently elevated
leveles of TSH in neary 33% of these patients. Lithium affects the cardiac conduction system by incomplete
substitution of rother cations, especially sodium and potassium. These electrolyte changes account for the
usually unimportant and reversible T- wave depression observed in 10% to 20% of patients on lighium
therapy.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Lower Respiratory Culture ........ ...........
Synonyms Bronchoscopy, Sputum Bacterial Culture; Culture, Lower Respiratory; Sputum Culture;
Transtracheal Aspirate Culture
Test Includes Isolation and identification (additional CPT code) of aerobic bacteria considered pathogenic in the
lower respiratory tract. Susceptibilities performed, at additional charge, when appropriate. Anaerobe culture is
not appropriate from expectorated sputum. See Anaerobic Culture requirements.
Special Instructions Specimens from other sources, such as genital, stool, urine, upper and lower respiratory
specimens, cannot be cultured under the aerobic bacterial culture test number. If specimens are incorrectly
submitted with an order for aerobic bacterial culture, the laboratory will process the specimen for the test based
on the source listed on the request form. The client will not be telephoned to approve this change, but the change
will be indicated on the report.
Specimen Requirement Sputum (first morning specimen preferred), aspirates, biopsy, tissue
Volume 5-10 mL sputum, 1 g tissue, 10-50 mL lavage fluid, 5 mL bronchial washing
Container Screw-capped container
Collection Sputum: The patient should be instructed to brush his/her teeth and/or rinse mouth well with water
before attempting to collect the specimen to reduce the possibility of contaminating the specimen with food
particles, oropharyngeal secretions, etc. After the specimen has been collected, the specimen should be
examined to make sure it contains a sufficient quantity (at least 1 mL) of thick mucus (not saliva). Only the
screw-capped container should be submitted to the laboratory.
Storage Instructions Refrigerate
Patient Preparation The patient should be instructed to remove dentures, rinse mouth, and gargle with water.
The patient should then be instructed to cough deeply and expectorate sputum into proper container. Be sure the
patient understands the difference between sputum and saliva.
Methodology Culture
Testing Schedule : Daily
99
Luteinizing Hormone (LH), Serum .......
Synonyms ICSH; Interstitial Cell Stimulating Hormone; LH
Special Instructions State patient's age and sex on the request form.
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Use The primary clinical use of LH measurement is in evaluating the normalcy of hypothalamic-pituitarygonadal axis. Measurement of serum gonadotropin levels will allow for distinguishing between primary gonadal
failure and deficient gonadal stimulation. LH measurement may also be of clinical importance because growth
hormone and LH are frequently the first hormones to be affected by pituitary disease. The serum analysis of LH
has also been found to be very useful in the diagnosis and treatment of infertility in women.
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Magnesium, Serum ..................... ...........
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Use Magnesium deficiency produces neuromuscular disorders. It may cause weakness, tremors, tetany, and
convulsions. Hypomagnesemia is associated with hypocalcemia, hypokalemia, long-term hyperalimentation,
intravenous therapy, diabetes mellitus, especially during treatment of ketoacidosis; alcoholism and other types of
malnutrition; malabsorption; hyperparathyroidism; dialysis; pregnancy; and hyperaldosteronism. Renal loss of
magnesium occurs with cis-platinum therapy. Alfrey also adds amphotericin toxicity to the causes of
hypomagnesemia.
Magnesium deficiency is described with cardiac arrhythmias. The concept that magnesium deficiency may cause
arrhythmias is repeatedly expressed.
Increased magnesium levels relate mostly to patients in renal failure. Marked increases may be found in such
patients who take magnesium salts (eg, as antacids which contain magnesium). Increased serum magnesium is
also found with Addison's disease and in pregnant patients with severe preeclampsia or eclampsia who are
receiving magnesium sulfate as an anticonvulsant. Hypermagnesemia may occur in patients using magnesiumcontaining cathartics. High magnesium levels are manifested by decreased reflexes, somnolence, and heart
block.
Indications for measurement of serum magnesium include the presence of unexplained hypocalcemia, instances
in which hypokalemia is unresponsive to potassium supplementation, and in patients who have cardiac disorders
in which hypomagnesemia may be especially hazardous such as congestive failure, ventricular ectopy, digitalis
use, or left ventricular hypertrophy. Serum magnesium is indicated only selectively in patients on diuretics: those
on high dose thiazides, loop diuretics or hydrochlorothiazide in doses >50 mg/day.
Because an association between aminoglycoside therapy and severe hypomagnesemia is described, a
recommendation is published to measure serum magnesium in subjects receiving aminoglycosides.
Recommendations also exist to measure it in patients on cyclosporine.
100
Methodology Colorimetric
Testing Schedule : Daily
Malaria Smear see Parasite Examination, Blood
Manganese (B)
Specimen Requirement: 3 ml EDTA blood
Ref. Interval: 3.9-15.1 mcg/L
Use: follow managanese therapy in parenteral nutrition, especially in liver disease, or with excessive
gastrointestinal losses; evaluate suspected managanese toxicity or exposure, especially neurological
syndromes and movment disorders.
Limitation: in evaluating toxicity, serum level may have returned to normal while the neurological
damage persisits. Levels are reportedly reduced mildly in epilepsy, and raised in hepatitis or jaundice.
Managanese levels are 60% lower than normal in hemodialysis patients.
Methodology: AAS
Additional information: Toxic exposure may occur from dry cells, fungicide (maneb), and in the still
industry or chemical industry. Managanese levels in tears are 50-fold higher than in serum.
Mercury (B)
Specimen Requirement: 2 ml heparin blood
Ref. Interval: <10 mcg/L
tolerable: <50 mcg/L
Use: Evaluate for mercury toxicity, neurological findings related to orgnic mercurials, inhalation of
mercury vapors
Limitation: Methyl mercury must be measured in whole blood or erythrocyutes.
Methodology: AAS
Additional Information: Organic methyl mercury is a new important environmental mercurial
contaminant.. Ingestion of mercury-laden fish leas to severe neurologic deficits. Inhalation of mercury
vapors can lead to pneumonitis inorganic mrcurials depost in kidneys, liver, heart striated muscle,
marrow, brain and lungs. Gastrointestinal symptoms, stomatitis, colitis, anema, and pheripheral
neuritis can relate to mercury poisoning ingestion of inorganic mercurials restuls in a serious medical
emergency.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Microalbumin, 24-Hour Urine .... ...........
Synonyms Albumin, Timed Urine
Specimen Requirement Urine
Volume 10 mL aliquot
Minimum Volume 1 mL
Container Plastic urine container
Collection Collect 24-hour or timed urine without preservatives. Indicate total volume and hours of collection.
Do not acidify. Mix well. Send 10 mL aliquot. State time and total volume. Samples with a pH <4 or >8 yield
results which are too high or too low respectively.
101
Storage Instructions Refrigerate
Causes for Rejection Bloody specimen; specimen frozen
Use Attempted prediction of subsequent development of proteinuria, diabetic nephropathy and early mortality in
type I and/or II diabetes.. This test may prove useful in the management of patients with relatively early diabetes
mellitus, to try to avoid or delay the onset of diabetic renal disease.
Methodology Turbidimetric
Testing Schedule : Daily
Myoglobin, Serum
Specimen Requirement Serum
Volume 0.8 mL
Minimum Volume 0.3 mL (this volume does not allow for repeat testing)
Container Red-stopper tube or serum-separator tube
Collection If red-stopper tube is used, transfer separated serum to a plastic transport tube,
Storage instructions Refrigerate
Causes for Rejection Gross hemolysis; plasma specimen
Reference Interval <50.0 ng/mL
Use Diagnose skeletal or myocardial muscle injury. Serum myoglobin is generally detectable earlier that is
CK or CK-MB increase in patients with acute myocardial ingarction.1 Serum myoglobin was found also in
50% of patients with acute coronary insufficiency. It is thought to define a population of small infarcts of
myocardium. It correlates with size of infarct.1 Diagnose rhabdomyolysis.2 Myoglobin appears with
trauma, ischemia, malignant hyperthermia, exertion, dermatomyositis, polymyositis, and muscular
dystrophy.3
Limitations Lacks specificity in diagnosis of acute MI, since increased myoglobin levels occur after
intramuscular injections.4 Increased serum myoglobin has been reported after a high voltage electrical
accident.4 As an index of myocardial infarct, myoglobin returns rapidly to baseline levels.1
Methodology Immunochemiluminochemiluminometric assay (ICMA)
Additional Information Serum myoglobin is rapidly cleared by the kidneys. Urine myoglobin levels were
not detected after myocardial infarct.4 Elevator myoglobin levels may be associated with cocaine abuse.5
Other conditions which cause elevation of serum myoglobin include open heart surgery, exercise,
progressive muscular dystrophy, shock, and renal failure.1 It is increased in azotemic subjects and not
effected by dialysis.6
Occult Blood, Stool ..................... ...........
Synonyms
Blood, Occult, Stool; Colo-Rect®; Colo-Screen®; Hema-Chek®; Hemoccult®, Stool;
HemoQuant®; Quick-Cult®
Specimen Requirement Stool
Volume 5 g
Container Collection card or sterile leakproof container with screw-cap
Storage Instructions Maintain specimen at room temperature.
102
Patient Preparation Patient should not receive vitamin C (ascorbic acid) for 3 days prior to occult blood testing
by guaiac. Vitamin C does not affect the HemoQuant® test. Antacids may cause false-negative guaiac tests. A
high bulk, red meat free diet with restriction of peroxidase-rich vegetables (turnips, horseradish, artichokes,
mushrooms, radishes, broccoli, bean sprouts, cauliflower, apples, oranges, bananas, cantaloupes, grapes), has
been recommended for 72 hours prior to guaiac testing, and during testing, to decrease the incidence of falsepositives. Therapeutic iron causes false-positives with guaiac tests in over half of healthy subjects. Alcohol and
aspirin, especially together, and other gastric irritants (steroids, rauwolfia derivatives, all nonsteroidal antiinflammatory drugs, colchicine) should also be avoided.
Causes for Rejection Inappropriate specimen transport device; mislabeled specimen; unlabeled specimen;
specimen received after prolonged delay (usually more than 72 hours)
Use Detect occult blood
Methodology Guaiac is a leuko-dye. Commercially generated tests based on it include Colo-Screen® (Helena
Laboratories), Color-Rect® (Roche Diagnostics), Hema-Chek® (Miles Laboratories), Quick-Cult® (Laboratory
Diagnostics), and Hemoccult® II (SmithKline). The peroxidase-like activity of hemoglobin or nonspecific
oxidants catalyze the reaction of peroxide and the chromogen orthotolidine to form blue oxidized orthotolidine.
New methodology, based on heme-derived porphyrin fluorescence, is more expensive (HemoQuant®). It
detects peroxidase-negative heme-derived porphyrins, peroxidase-positive hemoglobin, and free heme.
Immunologic tests have been developed, but enteric degradation of hemoglobin interferes with immunologic as
well as guaiac tests. Immunologic tests do not react with drugs, red meats, or nonhemoglobin peroxidase
compounds.
Testing Schedule : Daily
Osmolality, Serum ...................... ...........
Synonyms Osmol; Serum Osmolality
Special Instructions State patient's age on the request form.
Specimen Requirement Serum, frozen
Volume 2 mL (adults), 0.2 mL (pediatrics)
Minimum Volume 0.2 mL
Container Red-stopper tube
Collection Pediatrics: Blood drawn from heelstick for capillary. Separate serum from cells as soon as possible
after clot formation. Transfer specimen to plastic transport tube before freezing. To avoid delays in turnaround
time when requesting multiple tests on frozen samples, please submit separate frozen specimens for each test
requested.
Storage Instructions Freeze
Causes for Rejection Hemolysis; plasma specimen
Use Evaluate electrolyte and water balance, hyperosmolar status, and hydration status; evaluate dehydration,
acid-base balance; evaluate seizures; clue to alcoholism, methanol toxicity, ethylene glycol ingestion; evaluate
antidiuretic hormone function, liver disease, hyperosmolar coma, evaluate hypernatremia. Osmolarity measures
the concentration of particles in solution.
Methodology Freezing point depression
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Ova and Parasites Examination ...........
Synonyms Parasitology Examination
103
Test Includes Concentration of material and examination of specimen for ova and parasites by conventional
iodine/saline and trichrome staining. This will not detect Cryptosporidium, Cyclospora cayatenenais, or
Microsporidium.
Special Instructions Include any pertinent clinical and travel history on the test request form. Request form
must indicate special request for Cyclospora, or Cryptosporidium (additional charge).
Specimen Requirement Sputum, feces, and urine
Volume 3-4 mL sputum, 5 mL feces, 15 mL urine
Minimum Volume 3 mL
Container O & P transport container
Collection Feces: Submit in a parasite preservative kit. Please inoculate both the PVA and the formalin tubes.
Fresh feces should not be submitted. State the preliminary diagnosis.
Sputum: If paragonimiasia or echinococcosis is suspected, submit specimen in 10% formalin.
Urine: For suspected Schistosoma haematobium, collect urine sample without preservatives at mid-day.
Other sources: Contact the laboratory for specific instructions.
All: Multiple specimens may be necessary to recover ova or trophozoites. Three specimens are recommended
(each is charged).
Storage Instructions Maintain specimen at room temperature.
Patient Preparation Usual aseptic technique
Causes for Rejection Because of risk to laboratory personnel, specimens sent on diaper or tissue paper or
specimen contaminating outside of transport container may not be acceptable to the laboratory. Specimen
containing interfering substances (eg, castor oil, bismuth, Metamucil®, barium specimens delayed in transit and
those contaminated with urine) will not have optimal yield; unlabeled specimen; specimens not received in O &
P preservative transport containers.
Use Establish the diagnosis of parasitic infestation
Contraindications Administration of barium, bismuth, Metamucil®, castor oil, mineral oil, tetracycline therapy,
administration of antiamebic drugs within 1 week prior to test. Purgation contraindicated for pregnancy,
ulcerative colitis, cardiovascular disease, child younger than 5 years of age, appendicitis or possible appendicitis.
Methodology Formalin concentrate and trichome stain
Testing Schedule : Daily
Ovarian Function Panel ............ ...........
Test Includes Estradiol; follicle-stimulating hormone (FSH); free thyroxine index (FTI); luteinizing hormone
(LH); prolactin; T3 uptake (THBR); thyroid-stimulating hormone (TSH, high sensitivity); thyroxine (T4)
Specimen Requirement Serum
Volume 3 mL
Minimum Volume 2 mL
Container Red-stopper tube or serum-separator tube
Collection If red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
Testing Schedule : Daily
104
Parasite Examination, Blood .... ...........
Synonyms Blood Smear for Parasites; Loa loa Smear; Microfilarial Smear; Parasitology Examination for
Malaria; Plasmodium Smear; Wuchereria Smear; blood film
Specimen Requirement Blood smears or 10-15 mL heparinized or EDTA blood
Volume Films (two thin and two thick) or 10-15 mL heparinized or EDTA blood
Container Glass slide, Vacutainer® tube with EDTA or heparin
Collection Air dry
Storage Instructions Maintain specimen at room temperature.
Patient Preparation Prepare sterile venipuncture site
Causes for Rejection Specimen clotted or unlabeled
Use Establish the diagnosis of Plasmodium or other parasitic infection; diagnose malaria, parasitic infestation of
blood; evaluate febrile disease of unknown origin
Methodology Wright's stain; microscopic examination of thick and thin peripheral blood Romanovsky dye (in
particular Giemsa) stained smears. Thick films are more difficult to interpret but greatly increase sensitivity (by
concentrating cells and organisms). Thick smears require considerable experience with malaria. They increase the
number of cells examined in a given time period by a factor of about 12
Testing Schedule : Daily
Parathyroid Hormone See PTH Intact
Partial Thromboplastin Time (PTT), Activated
Synonyms Activated Partial Thromboplastin Time; APTT; PTT; PTT, Activated
Test Includes Control time not reported anymore; patient time
Specimen Requirement Citrated blood, whole blood
Volume 4.5 mL
Container Blue-stopper (sodium citrate) tube; do not open.
Collection If multiple tests are being drawn, draw coagulation studies last. If only a PTT is being drawn, draw 12 mL into another Vacutainer®, discard, and then collect for the PTT. This collection procedure avoids
contamination of the specimen with tissue thromboplastins.
Storage Instructions Maintain specimen at room temperature. Note: If testing cannot be performed within 24
hours, the specimen should be centrifuged and an aliquot of frozen plasma submitted.
Patient Preparation Draw specimen 1 hour before next dose of heparin if heparin is being given by intermittent
injection; not applicable to patients on continuous heparin infusion therapy. Do not draw from an arm with a
heparin lock or heparinized catheter.
Causes for Rejection Hemolysis; clotted specimens; thawed specimen if more than 24 hours after venipuncture;
tubes not full; improperly labeled specimen
Use Evaluate intrinsic coagulation system and monitor heparin therapy; aid in detecting classical hemophilia A,
Christmas disease; detect congenital deficiencies of factors II, V, VIII, IX, X, XI, and XII; detect the presence of
dysfibrinogenemia, disseminated intravascular coagulation, liver failure, congenital hypofibrinogenemia,
vitamin K deficiency, congenital deficiency of Fitzgerald factor, congenital deficiency of prekallikrein, high
molecular weight kininogen, circulatory anticoagulant
Methodology Partial thromboplastin time assay
Testing Schedule : Daily
105
Phosphorus, Serum ................... ...........
Synonyms Inorganic Phosphate, Blood; Phos; PO4
Specimen Requirement Serum
Volume 2 mL
Container Plastic transport tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation Patient should be fasting.
Causes for Rejection Hemolysis; gross lipemia; improperly labeled specimen
Use Causes of high phosphorus: Youth; exercise; dehydration and hypovolemia; high phosphorus content
enema; acromegaly; hypoparathyroidism; pseudohypoparathyroidism; bone metastases; hypervitaminosis D;
sarcoidosis; milk-alkali syndrome; liver disease, such as portal cirrhosis; catastrophic events such as cardiac
resuscitation, pulmonary embolism, renal failure; diabetes mellitus with ketosis; serum artifact — sample not
refrigerated; overheated, hemolyzed sample, or serum allowed to remain too long on the clot.
Although phosphate accumulation occurs as renal disease progresses, hyperphosphatemia is not a feature of early
renal failure; it does not usually develop before renal function has diminished to about 25% of normal. Osteitis
fibrosa in uremic subjects, from excessive bone turnover, relates to hyperphosphatasia. The role of
hyperphosphatemia in promotion of such secondary hyperparathyroidism is well established. A relationship to
osteomalacia in hemodialysis patients exists.
Causes of low phosphorus: (Hypophosphatemia may occur with or without phosphate depletion. Serum levels
vary as much as 2.0 mg/dL during the day.)
Very severely malnourished subjects may have low phosphate levels, but even in starvation, phosphorus levels
usually are normal. Antacids, diuretics, and long term steroids are among the common agents bearing a
relationship to severe hypophosphatemia. Recent carbohydrate ingestion decreases phosphorus, as does
intravenous glucose administration; cases of hypophosphatemia relate to I.V. carbohydrate, dialysis,
hyperalimentation, prolonged intravenous administration of phosphate-free fluids, metabolic states involving
glucose, potassium, and pH. Depletion of phosphate occurs in diabetic ketoacidosis. Like potassium, phosphorus
returns to the cell with therapy of diabetic ketoacidosis and serum levels may diminish significantly during
treatment. Osmotic diuresis induced by glycosuria in poorly controlled diabetes may lead to urinary phosphate
losses with negative phosphorus balance. PO4 levels may prove useful in initiation of insulin therapy, in diabetic
ketoacidosis and other situations of insulin lack; with hyperglucagonemia, corticosteroid and epinephrine use,
and in respiratory alkalosis. Association of hypophosphatemia with impaired glucose metabolism is thought to
reflect decreased tissue sensitivity to insulin. Alcoholism and other hepatic disorders are found very frequently
among patients with low PO4. Alcoholic ketosis and alcohol withdrawal are among causes of
hypophosphatemia. There is a slight decrease in serum phosphorus in the last trimester of pregnancy.
Primary hyperparathyroidism and other causes of calcium elevation, including ectopic hyperparathyroidism
(pseudohyperparathyroidism).
Patients with sepsis, including Legionnaires' disease and other respiratory infections. Twenty-two percent of
instances of respiratory infections had serum phosphorous <lq[2.4. Halevy and Bulvik report gram-negative
septicemia as a common cause of severe hypophosphatemia among 55,000 chemistry profiles of hospitalized
patients they studied. (Hypophosphatemia impairs bactericidal activity).
Vitamin D deficiency; osteomalacia, inherited and sporadic forms of hypophosphatemic rickets. In work-up for
osteomalacia, look for decreased calcium and phosphorus and increased alkaline phosphatase. Biopsy, however,
can be abnormal even when these biochemical parameters are within normal limits.
106
Renal tubular disorders (Fanconi syndrome, renal tubular acidosis); use of antacids that bind phosphorus (look
for hypercalciuria, low urinary phosphorus, high alkaline phosphatase); dialysis, vomiting; saline or lactate I.V.;
steatorrhea, malabsorption, severe diarrhea, nasogastric suction; hypokalemia; negative nitrogen balance;
decreased dietary PO4 intake; recovery from severe burn injury; salicylate poisoning; acute gout; tumor-related:
described as including hemangiopericytomas (uncommon pathologic entities) and neurofibromatosis;
transfusion of blood; arteriography.
The signs and symptoms of phosphate depletion may include neuromuscular, neuropsychiatric, gastrointestinal,
skeletal, and cardiopulmonary systems. Manifestations usually are accompanied by serum levels <1.0 mg/dL.
Severe hypophosphatemia is most common in elderly patients and is often found in postoperative subjects.
Complications of hypophosphatemia: Effect on RBC 2,3-diphosphoglycerate and oxygen dissociation.
Depression of myocardial function (contractibility), decreased cardiac output; respiratory failure and respiratory
muscle weakness; increased incidence of sepsis, impairment of bactericidal activities. CNS consequences:
polyradiculopathy, paresthesias, tremor, ataxia, weakness, slurred speech, stupor, coma, seizure; joint stiffness;
myopathy; renal stones, hypercalciuria secondary to renal phosphate leak; insulin resistance, glucose intolerance.
Rhabdomyolysis may complicate marked hypophosphatemia. A mortality rate of 20% is described in patients
whose phosphorus concentration was 1.1-1.5 mg/dL.
Methodology Colorimetric
Testing Schedule : Daily
Pinworm Preparation ................. ...........
Synonyms Cellulose Tape Test; Enterobiasis Test; Enterobius Verm Exam; Enterobius vermicularis
Preparation; Ova and Parasite, Pinworm Preparation; Scotch® Tape Test
Volume One slide
Container Glass slide
Collection Collect specimen as soon as possible after patient arises and prior to defecation or bathing. Pat the
perianal area with the sticky side of cellophane tape (do not use frosted tape), attach to a glass slide, and ship
slide in a slide mailer.
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Use of nontransparent Scotch® Tape; Scotch® Tape on both sides of the slide; specimen
which is not inside a covered container; use of frosted slide; tape sent sticky side up; unlabeled specimen
Use Detect cases of pinworm infestation (enterobiasis), E. vermicularis parasitic infestation
Methodology Microscopy
Testing Schedule : Daily
Plasminogen
Requirement: 1 ml citrate plasma, FROZEN
Ref.Interval: 75-150%
Use: Determine plasminogen and plasmin activity in plasma, study dysplasminogens, monitor
thrombolytic therapy, evaluate DIC.
Methodology: chromogenic test
Additional Information Acquired decrease is seen in some cases of DIC, liver disease, Lasparaginase therapy (of acute leukemia), neonatal hyaline membrane disease, and following
107
surgery. Plasminogen assay has application to the monitoring of antifibrinolytic therapy. After
streptokinase therapy for acute myocardial infarction, the radial immunodiffusion assay did not show
as great a decrease in plasma plasminogen as did a fluorogenic synthetic substrate assay. This was
shown to be the apparent result of lack of specificity of the RID assay antibody to plasminogen.
Decrease in Plasminogen activity may be associated with tendency to thrombosis altered molecular
forms have been described. Inhibitors of plasmin (eg, antiplasmin) are important in the regulation of
fibrinolysis. There is evidence that regular vigorous physical exercise (participation in sporting
activities) increases fibrinolytic activity of blood by decreasing plasminogen activator inhibitor capacity.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Platelet Count ............................... ...........
Synonyms Platelets; Thrombocyte Count
Specimen Requirement Whole blood and peripheral blood films
Volume 5 mL whole blood
Container Lavender-stopper (EDTA whole blood) tube; light blue-stopper (sodium citrate) tube may be
submitted when platelet clumping is a problem.
Collection Mix tube 10 times by gentle inversion.
Storage Instructions Maintain specimen at room temperature up to 24 hours.
Causes for Rejection Hemolysis; clotted specimen; tube not filled with minimum volume; improperly labeled
specimen
Use Evaluate, diagnose, and/or follow up bleeding disorders, drug induced thrombocytopenia, idiopathic
thrombocytopenia purpura (acute or chronic), disseminated intravascular coagulation, leukemia states,
chemotherapeutic management of malignant disease states; investigate purpura, petechiae; evaluate response to
platelet transfusions, steroids, or other therapy
Methodology Automated cell counter
Testing Schedule : Daily
Potassium, Serum ...................... ...........
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Hemolysis; improperly labeled specimen
Use Evaluate electrolyte balance; followed patients on diuretic therapy and with renal diseases, particularly saltlosing nephropathy; evaluate patients being treated for acidosis; prevent cardiac arrhythmias; evaluate
alcoholism with delirium tremens; evaluate and treat ketoacidosis in diabetes mellitus; evaluate acid-base
balance, water balance; manage intravenous therapy; evaluate anion gap; evaluate muscular weakness, leukemia,
diseases of the gastrointestinal tract including laxative abuse, large villous adenomas, emesis, fistulas and tube
drainage; detect, diagnose, and manage mineral corticoid excess (primary aldosteronism, Cushing's syndrome,
tumor with ectopic ACTH production, some cases of congenital adrenal hyperplasia); licorice ingestion.
Potassium is increased in oliguria, anuria, urinary obstruction, renal failure due to shock (decreased removal of
potassium), and renal tubular acidosis. Potassium is decreased in three ways;
108
* inadequate intake
* excessive loss due to diarrhea or vomiting or decreased reabsorption due to increased secretion of
mineralocorticosteroids
* movement into the cell as occurs with conditions causing alkalosis
Methodology Ion-selective electrode (ISE) or flame photometer
Testing Schedule : Daily
Potassium, Urine ......................... ...........
Special Instructions State 24-hour volume on the request form.
Specimen Requirement Urine (24-hour)
Volume 10 mL aliquot of entire collection
Container Plastic urine container, no preservative
Collection If the specimen is a 24-hour collection instruct the patient to void at 8 AM and discard the specimen.
Then collect all urine including the final specimen voided at the end of the 24-hour collection period (ie, 8 AM
the next morning). Screw the lid on securely. Mix well. Container must be labeled with patient's full name and
dates and times of collections.
Storage Instructions Refrigerate
Causes for Rejection Improperly labeled specimen
Use Evaluate electrolyte balance, acid-base balance; evaluate hypokalemia; Carroll and Oh point out that urinary
loss of 40 mmol/24 hours in the presence of hypokalemia <3 mmol/L is excessive. In the presence of such
hypokalemia, urine excretion is helpful to separate renal from nonrenal losses. Excretion <20 mmol/24 hours is
evidence that hypokalemia is not from renal loss. Renal loss >50 mmol/L in a hypokalemic, hypertensive patient
not on a diuretic may indicate primary or secondary aldosteronism. The kidneys do not respond quickly to
potassium deprivation. There is renal wastage of potassium in secondary aldosteronism. Glucocorticoids,
including endogenous steroids in Cushing's syndrome, are among the causes of kaliuresis.
Methodology Ion-selective electrode (ISE) or flame photometer
Pregnancy Test, Serum see HCG, serum
Pregnancy Test, Urine ................ ...........
Synonyms hCG, Urine; Human Chorionic Gonadotropin (hCG), Qualitative, Urine
Specimen Requirement Urine (first morning)
Volume 2 mL
Container Plastic urine container
Collection Deliver specimen to the laboratory immediately following collection.
Storage Instructions Refrigerate
Causes for Rejection Gross contamination with blood or bacteria
Use Confirmation of pregnancy; normal or ectopic (latter is best done by the more sensitive type assay such as
RIA); evaluation of threatened abortion, trophoblastic tumors, support for the diagnosis of testicular tumors,
ectopic hCG production by nontrophoblastic tumors
Methodology Rapid test kit
Testing Schedule : Daily
109
Prenatal Infectious Disease Antibodies, IgG, Quantitative
Test Includes Index results for antibody levels to Toxoplasma, CMV, rubella, and herpes simplex types I/II
Specimen Requirement Serum or plasma
Volume 6 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube or lavenderstopper (EDTA plasma) tube or blue-stopper (sodium citrate plasma) tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use Detect TORCH antibodies; aid in the diagnosis of congenital infection
Methodology Enzyme immunoassay (EIA)
Testing Schedule : Daily
Prenatal Panel A (With Hepatitis B Surface Antigen)
Synonyms Prenatal A Super Profile + Diff + HBsAg
Test Includes ABO grouping and Rh typing; antibody screen (includes ID and titer of all irregular antibodies
detected); CBC with differential; HBsAg; rubella antibodies (IgG); syphilis serology
Specimen Requirement Serum, whole blood
Volume One 10-mL (red-stopper) serum tube, two 5-mL (EDTA lavender-stopper) whole blood tubes, two
peripheral blood films, and one additional 10-mL (serum-separator) serum tube
Container One 10-mL red-stopper (nonserum-separator) tube, two 5-mL lavender-stopper (EDTA whole blood)
tubes, two clean glass slides, and one 10-mL serum-separator tube
Collection Gently invert lavender-stopper tubes immediately to mix specimen with anticoagulant. Make two
fresh blood films on glass slides. Centrifuge only the serum-separator tube within 45 minutes of venipuncture.
Storage Instructions Refrigerate the red-stopper, serum-separator, and lavender-stopper tubes. Maintain blood
films at room temperature up to 48 hours.
Causes for Rejection Hemolysis; clotted specimen; specimen diluted with I.V. fluid; tube not filled with
minimum volume; improperly labeled specimen
Use Evaluate woman's health status in early pregnancy; evaluate for anemia, leukemia, reaction to inflammation
and infections, peripheral blood cellular characteristics, state of hydration and dehydration, polycythemia,
hemolytic disease of the newborn, and ABO incompatibilities
Testing Schedule : Daily
Prenatal Profile B (With HIV Antibodies)
Test Includes ABO grouping and Rh typing; antibody screen (includes ID and titer of all irregular antibodies
detected); CBC with differential; HBsAg; rubella antibodies (IgG); syphilis serology
Specimen Requirement Serum, whole blood
Volume One 10-mL (red-stopper) serum tube, two 5-mL (EDTA lavender-stopper) whole blood tubes, two
peripheral blood films, and one additional 10-mL (serum-separator) serum tube
Container One 10-mL red-stopper (nonserum-separator) tube, two 5-mL lavender-stopper (EDTA whole blood)
tubes, two clean glass slides, and one 10-mL serum-separator tube
Collection Gently invert lavender-stopper tubes immediately to mix specimen with anticoagulant. Make two
fresh blood films on glass slides. Centrifuge only the serum-separator tube within 45 minutes of venipuncture.
110
Storage Instructions Refrigerate the red-stopper, serum-separator, and lavender-stopper tubes. Maintain blood
films at room temperature up to 48 hours.
Causes for Rejection Hemolysis; clotted specimen; specimen diluted with I.V. fluid; tube not filled with
minimum volume; improperly labeled specimen
Use Evaluate woman's health status in early pregnancy; evaluate for anemia, leukemia, reaction to inflammation
and infections, peripheral blood cellular characteristics, state of hydration and dehydration, polycythemia,
hemolytic disease of the newborn, and ABO incompatibilities
Testing Schedule : Daily
Progesterone, Serum… .............. ...........
Special Instructions Request must include patient’s age and sex. If female, state weeks of gestation and
LMP.
Specimen Requirement Serum
Volume 1mL
Minimum Volume 0.3 mL (this volume does not allow for repeat testing)
Container Red-stopper tube or serum-separator tube
Collection if a Red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
Reference Interval See table.1
Male
Female
(ng/mL)
(ng/mL)
<0.3-1.2
Pregnancy:
1st trimester:
11.2-90.0
2nd trimester:
25.5-89.4
3rd trimester:
48.4-422.5
I
II
III
IV
V
Tanner Stage
<0.3
<0.3
<0.5
<1.1
0.2-0.8
<0.3
<0.5
<4.5
<13.0
0.2-9.5
Use Establish the presence of a functioning corpus luteum or luteal cell function; confirm basal body
temperature measurements for the occurrence of ovulation; obtain an indication of the day of ovulation;
111
evaluate the functional state of the corpus luteum in infertility patients; assess placental function furing
pregnancy; ovarian function testMethodology Immunochemiluminometric assay (ICMA)
Additional Information Progresterone and 17-α-hydroxyprogesterone are weak androgens. Increased in
congenital adrenal hyperplasia due to 21-hydroxylase, 17-hydroxylase, and 11-β-hydroxylase deficiency. It
is decreased in threatened abortion, primary or ssecondary hypogonadism, and short luteal phase syndrome.
Testing Schedule : Daily
Prolactin
Specimen Serum
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube. Venipuncture itself
can elevate prolactin level. Therefore, some recommend insertion of heparinized scalp vein followed by a 30minute rest, before sample is drawn. Draw between 8 AM and 10 AM (levels subsequently increase).
Storage Instructions Refrigerate
Patient Preparation Phenothiazines especially may cause hyperprolactinemia. TSH level is recommended
before or with sampling for prolactin, to rule out primary hypothyroidism. Prolactin secretion is inhibited by
levodopa, dopamine, bromocriptine, and thyroid hormones. It is influenced by estrogens and antihypertensives.
Causes for Rejection Plasma specimen
Use First test for work-up of galactorrhea (inappropriate lactation). Pituitary function test useful in the detection
of prolactin secreting pituitary tumors (microadenomas, macroadenomas) with or without galactorrhea, with or
without structural evidence of sellar enlargement. An adult female premenopausal patient having amenorrhea
and galactorrhea is highly suspect of pituitary prolactinoma and is a candidate for radiologic evaluation of the
pituitary as well as serum prolactin levels. Elevated prolactin may be associated with corpus luteum
insufficiency or anovulation. Sequelae of hyperprolactinemia include amenorrhea, anovulation, and decreased
bone density.
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Prostate-Specific Antigen (PSA), Serum
Synonyms PSA
Test Includes Long-term serial monitoring of results; color graphic summary report
Special Instructions Values obtained with different assays should not be used interchangeably. If in the course
of monitoring the patient, the assay method used for determining PSA levels serially is changed, additional
sequential testing should be carried out to confirm baseline values.
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If red-stopper tube is used, transfer separated serum to a plastic transport tube.
112
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; plasma or whole blood specimen
Use Prostate specific antigen (PSA) is a glycoprotein produced exclusively by the epithelial cells lining the
prostatic ducts and acini. Normally, it is secreted into the prostatic ducts and is present only in prostate tissue,
prostatic fluid, and seminal plasma. PSA is produced by normal, hyperplastic, and cancerous prostatic tissue. In
recent years, urologists have found serum PSA to be the most sensitive marker for monitoring patients with
known prostate cancer. In these patients, serum PSA levels are used to predict survival and tumor recurrence
following therapy. Serum PSA levels are frequently monitored in conjunction with another serum marker for
prostatic cancer: prostatic acid phosphatase (PAP). Although PAP is not as sensitive for prostatic cancer as PSA,
concurrent use of the two markers has been shown to enhance efficacy in monitoring progression of disease and
response to therapy.
Methodology Microparticle enzyme immunoassay (MEIA)
Testing Schedule : Daily
Protein Electrophoresis, 24-Hour Urine
Synonyms Electrophoresis, Protein, 24-Hour Urine; Globulins, 24-Hour Urine; Urine Electrophoresis, 24-Hour;
Urine Protein Electrophoresis, 24-Hour
Test Includes Densitometric scan; quantitation of total urine protein, urine albumin, urine alpha1, urine alpha2,
urine beta, urine gamma globulin fractions if present; quantitation of M-spike if present
Special Instructions Record total 24-hour urine volume on the request form.
Specimen Requirement Urine (24-hour)
Volume 60 mL aliquot
Container Plastic urine container, no preservative
Collection Instruct patient to void at 8 AM and discard the specimen. Then collect all urine for the next 24 hours,
including the 8 AM void the next morning. Label container with the patient's name, date and time the collection
started and ended. Measure total volume. Mix well.
Storage Instructions Refrigerate at 2°C to 8°C.
Use Evaluate myeloma, macroglobulinemia of Waldenström, lymphoma, amyloidosis; differentiate between
normal renal function, glomerular proteinuria, and tubular proteinuria. Increased glomerular permeability leads
to higher concentrations of large proteins in the glomerular filtrate. Diminished tubular reabsorptive capacity
results in a marked increase in urinary excretion of low molecular weight problems.
Methodology Electrophoresis on agarose media
Protein Electrophoresis, Body Fluid ...
Synonyms Electrophoresis, Body Fluid
Test Includes Determination of proteins seen in the electrophoresis; densitometric scan; total protein;
Special Instructions State source of body fluid and patient's age on the request form.
Specimen Requirement Body fluid
Volume 6 mL
Container Sterile container
Storage Instructions Refrigerate at 2°C to 8°C.
Methodology Electrophoresis on agarose media
Protein Electrophoresis, Cerebrospinal Fluid
Synonyms CSF Electrophoresis; Electrophoresis, CSF; Globulins, CSF; Spinal Fluid Electrophoresis
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Test Includes Total protein CSF; determination of proteins seen in the electrophoresis; densitometric scan
Specimen Requirement Cerebrospinal fluid
Volume 5 mL
Minimum Volume 3 mL
Container Sterile tube
Collection The third tube of a routinely obtained 3-tube set of CSF should be used for protein electrophoretic
study.
Storage Instructions Refrigerate at 2°C to 8°C.
Causes for Rejection Gross hemolysis; less than 3 mL CSF
Use Quantitate CSF protein fractions, aid in diagnosis of inflammatory, demyelinating disease of CNS
Methodology Electrophoresis on agarose media
Protein Electrophoresis, Random Urine
Synonyms Electrophoresis, Protein, Random Urine; Globulins, Random Urine; Urine Electrophoresis, Random
Urine; Urine Protein Electrophoresis, Random Urine
Test Includes Densitometric scan; quantitation of total urine protein, urine albumin, urine alpha1, urine alpha2,
urine beta, urine gamma globulin fractions if present; quantitation (in %) of M-spike if present
Specimen Requirement Urine (random) (Note: For 24-hour urine specimens, order test 003368.)
Volume 60 mL aliquot
Container Plastic urine container, no preservative
Collection Collect first morning urine; mix well.
Storage Instructions Refrigerate at 2°C to 8°C.
Use Evaluate myeloma, macroglobulinemia of Waldenström, lymphoma, amyloidosis; differentiate between
normal renal function, glomerular proteinuria, and tubular proteinuria. Increased glomerular permeability leads
to higher concentrations of large proteins in the glomerular filtrate. Diminished tubular reabsorptive capacity
results in a marked increase in urinary excretion of low molecular weight problems.
Methodology Electrophoresis on agarose media
Protein, Total, Body Fluid .......... ...........
Specimen Requirement Body fluid
Volume 2 mL
Container Clean container
Collection Tube must be labeled with patient's full name and type of fluid collected.
Storage Instructions Refrigerate
Patient Preparation Usual aseptic aspiration procedure
Causes for Rejection Improperly labeled specimen
Use Evaluate effusions; diagnose transudate versus exudate
Methodology Spectrophotometric
Testing Schedule : Daily
Protein, Total, Cerebrospinal Fluid ......
Synonyms Cerebrospinal Fluid Protein; CSF Protein; Protein, CSF
Specimen Requirement Cerebrospinal fluid
Volume 1 mL
Container Clean plastic tube
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Collection Usually three clean sterile tubes are used from lumbar tray for count and culture in addition to protein
and glucose with collection of 1 mL in each tube labeled #1, #2, #3 in order of collection. Tube #1 is used for
protein and glucose.
Storage Instructions Refrigerate
Causes for Rejection Gross hemolysis; bloody tap
Use A nonspecific but reliable indication of CNS pathology such as meningitis, brain abscess, meningovascular
syphilis, CVA, neoplastic diseases, multiple sclerosis, and other degenerative processes causing neurologic
disease
Methodology Coomassie brilliant blue
Testing Schedule : Daily
Protein, Total, Quantitative, 24-Hour Urine
Special Instructions Indicate 24-hour urine volume on the request form and urine container, if applicable.
Specimen Requirement Urine (24-hour)
Volume 50 mL aliquot of entire collection
Container Plastic urine container, no preservative
Collection Instruct patient to void at 8 AM and discard the specimen. Then collect all urine including the final
specimen voided at the end of the 24-hour collection period (ie, 8 AM the following day). Mix well. Screw the
lid on securely. Container must be labeled with patient's name and date and time collection started and finished.
Storage Instructions Refrigerate
Causes for Rejection Grossly bloody specimens; incomplete collection; specimens containing Pyridium®;
improperly labeled specimen
Use Evaluate proteinuria (eg, following urinalysis in which proteinuria is detected); evaluate renal diseases,
including proteinuria complicating diabetes mellitus, the nephrotic syndromes (eg, lipoid nephrosis,
membranous, proliferative glomerulopathies, metal poisoning (eg, gold, lead, and cadmium), renal vein
thrombosis, systemic lupus erythematosus (SLE), constrictive pericarditis and amyloidosis); work up other renal
diseases including malignant hypertension, glomerulonephritis, Goodpasture's syndrome, Henoch-Schönlein
purpura, thrombotic thrombocytopenic purpura, collagen diseases, cryoglobulinemia, toxemia of pregnancy,
drug nephrotoxicity, hypersensitivity reactions, allergic reactions and renal tubular lesions; manage myeloma
and macroglobulinemia of Waldenström (Bence Jones proteinuria); evaluate hypoproteinemia; tubular
proteinurias include Wilson's disease and Fanconi syndrome.
Methodology Spectrophotometric
Testing Schedule : Daily
Protein, Total, Serum .................. ...........
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Hemolysis; improperly labeled specimen
Use Evaluate nutritional status; investigate edema.
In the entities which follow, the diseases listed are sometimes increased or decreased as indicated, but are not
always so.
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Causes of high total protein: dehydration; some cases of chronic liver disease, including chronic active hepatitis
and cirrhosis; neoplasms, especially myeloma; macroglobulinemia of Waldenström; tropical diseases (eg, kalaazar, leprosy, and others); granulomatous diseases, such as sarcoidosis; diseases in which total protein is
sometimes high include collagen disease (eg, lupus erythematosus (SLE), and other instances of chronic
infection/inflammation).
Causes of low total protein: pregnancy; intravenous fluids; cirrhosis or other liver disease, including chronic
alcoholism; prolonged immobilization; heart failure; nephrotic syndromes; glomerulonephritis; neoplasia;
protein losing enteropathies; Crohn's disease and chronic ulcerative colitis; starvation, malabsorption or
malnutrition; hyperthyroidism; burns; severe skin disease; and other chronic diseases.
Very low total protein (<4 g/dL) and low albumin cause edema (eg, the nephrotic syndromes).
Methodology Colorimetric
Testing Schedule : Daily
Prothrombin Time (PT) ............... ...........
Synonyms Prothrombin Time Assay; Protime; PT
Test Includes Patient time; INR
Specimen Requirement Blood
Volume 4.5 mL
Container Blue-stopper (sodium citrate) tube
Collection If only a prothrombin time is being drawn, draw 1-2 mL into another Vacutainer®, discard, and then
collect the prothrombin time. This collection procedure avoids contamination of the specimen with tissue
thromboplastins. Specimen should arrive in the laboratory within 24 hours of collection.
Storage Instructions Maintain specimen at room temperature. Note: If testing cannot be performed within 24
hours, the specimen should be centrifuged and an aliquot of frozen plasma submitted.
Causes for Rejection Hemolysis; clotted specimens; tubes not full; lipemia; improperly labeled specimen;
thawed specimen if more than 24 hours after venipuncture
Use Evaluate extrinsic coagulation system; detect congenital deficiencies of factors II, V, VII, X; evaluate
deficiency of prothrombin, dysfibrinogenemia, afibrinogenemia (complete), heparin effect, coumarin or warfarin
effect, liver failure, disseminated intravascular coagulation (DIC), vitamin K deficiency
Methodology Spectrophotometry
Testing Schedule : Daily
Prothrombin Time (PT) and Partial Thromboplastin Time (PTT)
Synonyms Partial Thromboplastin Time (PTT) and Prothrombin Time (PT); PT and PTT
Test Includes PT and PTT
Specimen Requirement Whole blood
Volume 4.5 mL
Container Do not open blue-stopper (sodium citrate) tubes.
Collection If only a prothrombin time is being drawn, draw 1-2 mL into another Vacutainer®, discard, and then
collect the prothrombin time. This collection procedure avoids contamination of the specimen with tissue
thromboplastins. Specimen should arrive in the laboratory within 24 hours of collection.
Storage Instructions Maintain specimen at room temperature.
Methodology PTT: partial thrombin time assay; PT: prothrombin assay
Testing Schedule : Daily
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Pyruvate (B)
Specimen Requirement: Request special tubes or mix exactly 3ml blood with 3ml 7% perchloric acid
immediately, mix well. Centrifuge for 10 minutes and send the supernatant
(minimum: 2.5 ml).
Ref. Interval:
<15 years: 60-100 mcmol/L
Adults: 39-82 mcmol/L
Use: Evaluate chronic hemolytic anemia.
Methodology: photometric
Additional Information: - Pyruvate kinase is the most common enzyme defect in anaerobic red cell
glycolysis (embden-Meyerhof glycolytic pathway) and the most common cause of congenital non
spherocytic hemolytic anemia. Reductions of red cell pyruvate kinase activity to < 20% of normal
indicates hereditary PK deficiency. Slight to moderate decrease or red cell Pk activity can be seen in
some patients with leukemia and in aplasia
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Rapid Plasma Reagin (RPR), Qualitative
Synonyms Nontreponemal Test; Rapid Plasma Reagin, Qual Test; RPR; STS; Syphilis Serology
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use Test for syphilis
Methodology Charcoal flocculation
Testing Schedule : Daily
Renin
Specimen Requirement: 1 ml EDTA plasma, draw and centrifuge cool, freeze immediately, transport
FROZEN. The specimen should be obtained either at the end of one hour's rest or at the end of four
hours upright / light activity.
Ref. Interval:
2.4-29 mcU/mL in persons on a normal diet having been recumbent for at least 20-30 min.
3.3-41 mcU/ml in persons having been moving in an upright position for at least
15-30 minutes
The above values are basal values (i.e. without stimulation).
Use: - Evaluate the role of rennin in the differential diagnosis of hypertension. The patient with primary
aldosteronism is characterized by low plasma rennin and high serum and urine aldosterone. Subjects
with secondary aldosteronism may have elevated rennin in contrast to those with primary
aldosteronism. Secondary aldosrunism occurs with accelerated hypertension and occurs in
pregnancy. Evaluate renovascular hypertension
117
Limitations: Disease entities besides Conn’s syndrome cause hypertension with low rennin levels.
Salt restricted diets increase supine rennin levels by a factor of 2; upright rennin levels by a factor of
6. Renin increases in pregnancy, patients on oral contraceptives and with salt loss, Addisons’
disease, diuretics, and certain types of renal disease.
Methodology: ILMA
Additional Information: There exists a rennin-aldosterone axis, involving angiotensin, which
regulates sodium and potassium balance, plasma volume, blood pressure and low sodium induce
rennin release. Renin causes increased aldosterone through stimulation of angiotensin .
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Respiratory Syncytial Virus (RSV) by Immunology/Serology
Synonyms RSV by EIA; RSV Testing
Specimen Requirement Nasopharyngeal washes or aspirates, frozen
Volume Washes not to exceed 2.5 mL
Container Sterile leakproof container
Collection Nasal wash or aspirate using routine collection and transport procedure. Nasal swabs are not
considered as sensitive for RSV detection. Avoid using collection containers with preservatives or transport that
may contain interfering substances. Obtain sample during acute phase of illness when greatest amount of viral
shedding occurs. Transfer specimen to plastic transport tube before freezing. To avoid delays in turnaround time
when requesting multiple tests on frozen samples, please submit separate frozen specimens for each test
requested.
Storage Instructions Freeze
Causes for Rejection Inappropriate specimen transport device; mislabeled specimen; unlabeled specimen;
specimen received after prolonged delay (usually more than 72 hours); expired transport
Use Evaluate lower respiratory tract infections in young children. Severe life-threatening infections due to
respiratory syncytial virus can occur during the first few years. Acquired immunity is incomplete and reinfection
can occur later.
Methodology Immunoassay
Reticulocyte Count ..................... ...........
Test Includes Reticulocytes are expressed as a percentage in a total of 1000 RBCs.
Specimen Requirement Whole blood
Volume 5 mL
Container Lavender-stopper (EDTA whole blood) tube
Collection Invert tube gently 10 times after venipuncture. Specimen must be received in laboratory within 24
hours of venipuncture.
Storage Instructions Maintain specimen at room temperature up to 24 hours.
Causes for Rejection Hemolysis; specimens more than 24 hours old; clotted specimen; tube not filled with
minimum volume; improperly labeled specimen
Use Evaluate erythropoietic activity. Increased in acute and chronic hemorrhage, hemolytic anemias. Evaluating
erythropoietic response to antianemic therapy. The test is underutilized, especially when one considers it is at a
pivotal decision making conjuncture. The reticulocyte production index will indicate whether one is working
with a hyperproliferative or nonproliferative anemia, and thus what testing should be subsequently ordered.
Contraindications Patients receiving a large number of blood transfusions
118
Methodology Supervital staining
Testing Schedule : Daily
Rheumatoid Arthritis (RA), Quantitative, Serum by Hemagglutination
Synonyms Modified Waaler-Rose Procedure; RF Assay; Rheumaton™
Test Includes Assay which quantitates rheumatoid factor if present
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use Detect rheumatoid factor in serum
Methodology Hemagglutination
Testing Schedule : Daily
Rotavirus, Direct Detection by Immunoassay
Specimen Requirement Stool
Volume 2 mL liquid stool or 1 g semiformed stool
Container Screw-capped container
Collection As soon as possible after onset of disease, preferably 3-5 days after onset. Collection from diapered
children can be facilitated by using a disposable diaper |inside out| or by using a |saran wrap| diaper to capture the
next stool specimen.
Storage Instructions Refrigerate immediately after collection.
Causes for Rejection Swab specimens; diapers; unlabeled specimen; specimen transported at room temperature;
inappropriate specimen transport device; unlabeled specimen; specimen received after prolonged delay (usually
more than 72 hours); expired transport
Use Detect rotavirus in stools of patients suspected of having viral gastroenteritis
Methodology Immunoassay
Rubella Antibodies, IgG ............. ...........
Synonyms German Measles Antibodies
Specimen Requirement Serum or plasma
Volume 2 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube or lavenderstopper (EDTA plasma) tube or blue-stopper (sodium citrate plasma) tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use Recommended for immune status determination
Methodology Enzyme immunoassay (EIA) — recombinant based
Testing Schedule : Daily
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Rubella Antibodies, IgM ............. ...........
Synonyms German Measles Specific IgM
Test Includes Semiquantitative result reported
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use For the in vitro detection of IgM antibodies specific for rubella. IgM antibodies are associated with acute
viral infections. IgM detection is useful in the following situations: evidence of infection can be obtained from
only one acute phase specimen if the IgM results are positive; the IgM test can also be used to differentiate
between primary infection and re-exposure.
Methodology Enzyme immunoassay (EIA)
Testing Schedule : Daily
Rubeola Antibodies, IgG ............ ...........
Synonyms Measles Antibodies
Test Includes Result (index) reported quantitatively
Special Instructions Identify specimen as acute or convalescent. Acute and convalescent specimens must be
submitted on separate request forms.
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; lipemia; gross bacterial contamination
Use Determine status or, with paired sera, aid in the diagnosis of recent infection
Methodology Enzyme immunoassay (EIA)
Selenium (S)
Specimen Requirement: 2 ml serum
Ref. Interval: 43-143 mcg/L May be used diagnostically in cardiomypopathy of known cause, especially where
nutritional factors are suspected.
Limitation: Some controversy exists regarding the “best” marker for selenium status.
Methodology: AAS
Additional Information: Selenium is excreted in feces from the bile, in sweat and skin losses, and the
remaining 50% to 70% in the urine. Significant breath losses occur only in toxic states.
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Selenium (U)
Specimen Requirement: 10 ml from a 24h urine collection. Please state 24h urine volume.
Ref. Interval: 2-31 mcg/L
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
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Semen Analysis, Basic .............. ...........
Synonyms Sperm Count, Semen Analysis
Test Includes Ejaculate volume; motility quality estimate; percent motile; percent normal morphology; pH;
seminal cytology; sperm concentration; total motile; viscosity and liquefaction status
Special Instructions This procedure must be scheduled with the laboratory performing the test. The patient
should have between 2 and 7 days of sexual abstinence before producing the specimen. This test requires a fresh
specimen; therefore, this procedure is available only at sperm testing facilities. Results are within 3 days.
Specimen Requirement Ejaculate
Volume Entire ejaculate
Minimum Volume Laboratory will attempt to analyze any specimen submitted.
Container Sterile specimen containers ) or specimen collection kit. Specimen collection supplies are provided
by the laboratory performing the test.
Collection Ejaculate should be collected at the laboratory performing the test or delivered to that laboratory
within 45 minutes of collection. Coitus interruptus should be avoided as a collection method because of the great
potential for loss of the initial portion of the ejaculate, which contains the majority of the sperm cells. Collection
using a special silastic condom may provide a higher quality specimen than masturbation. A small perforation in
the end of the condom's pouch allows for the collection of a specimen for infertility diagnosis and falls within
the principles of the Roman Catholic Church. Specimen should be kept close to the body (inside a shirt or coat)
to avoid temperature extremes during transport.
Storage Instructions Maintain specimen at room temperature. Processing should begin within 70 minutes of
specimen collection.
Patient Preparation Patient should abstain from sexual activity for 2-7 days prior to producing the specimen.
Causes for Rejection Specimens older than 1 hour; insufficient sperm may prevent adequate estimate of percent
normal morphology
Use Diagnose male factor infertility, including oligozoospermia, azoospermia, asthenozoospermia, and
teratozoospermia
Methodology Macroscopic and microscopic examination of semen
Serotonin (B)
Specimen Requirement: 2 ml EDTA blood, FROZEN
Ref. Interval: 150.5-185.9 µg/L
Use: Diagnose carcinoid syndrome.. Ectopic Production may occur from oat cell carcinomas of lung, islet cell
tumors of pancreas, and medullary carcinoma of the thyroid. Carcinoid tumors occur multiple endocraen
neoplazian types I or II
Limitation: Seriotonin assays are not widely available and only rarely used
Methodology: HPLC
Additional Information:. Most serotonin in blood is usually concentrated in platelets, which release it during
platelet aggregation. Serotonin may be measured to confirm the diagnosis of carcinoids syndrome
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Sodium, Serum ............................ ...........
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
121
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Gross hemolysis; improperly labeled specimen
Use Electrolyte, acid-base balance; water balance; water intoxication; diagnose dehydration.
Hypernatremia occurs in dehydration. For instance, nasogastric protein feeding with insufficient fluids may
cause hypernatremia. Hypernatremia without obvious cause may relate to Cushing's syndrome, central or
nephrogenic diabetes insipidus with insufficient fluids, primary aldosteronism, and other diseases. Severe
hypernatremia may be associated with volume contraction, lactic acidosis, azotemia, weight loss, and increased
hematocrit as evidence of dehydration. The corrected serum sodium is often high in nonketotic hyperosmolar
coma. (A corrected Na+ is calculated by increasing Na+ by 1.3-1.6 mmol/L for each 100 mg/dL increment in
serum or plasma glucose). 100 mg equals 5.56 mmol/L. The corrected serum sodium level calculated in
nonketotic hyperosmolar coma: apparent mild hyponatremia with very high glucose may actually mean
(corrected) hypernatremia.
Hyponatremia occurs with nephrotic syndrome, cachexia, hypoproteinemia, intravenous glucose infusion, in
congestive heart failure, and other clinical entities. Serum sodium is a predictor of cardiovascular mortality in
patients in severe congestive heart failure.
Hyponatremia without congestive failure or dehydration may occur with hypothyroidism, the syndrome of
inappropriate secretion of antidiuretic hormone (SIADH), renal failure, or renal sodium loss.
The differential diagnosis of hyponatremia includes Addison's disease, hypopituitarism, liver disease including
cirrhosis, hypertriglyceridemia, and psychogenic polydipsia. Diuretics and other drugs may cause hyponatremia.
Sodium decreasing to levels <115 mmol/L can lead to significant neurological dysfunction with cerebral edema
and increased intracranial pressure.
The differential diagnosis of hyponatremia includes determination of urine sodium and osmolality and serum
urea nitrogen (BUN). BUN is often decreased in SIADH.
Methodology Ion-selective electrode (ISE) or flame photometer
Testing Schedule : Daily
Sodium, Urine .............................. ...........
Special Instructions Request form must state date and time collection started, date and time collection finished,
and 24-hour urine volume.
Specimen Requirement Urine (random or timed, ie, 8-, 12-, or 24-hour)
Volume 5 mL aliquot
Container Plastic urine container, no preservative
Collection Instruct the patient to void at 8 AM and discard the specimen. Then collect all urine including the
final specimen voided at the end of the 24-hour collection period (ie, 8 AM the next morning). Screw the lid on
securely. Container must be labeled with patient's full name, date and time collection started, and date and time
collection finished.
Storage Instructions Refrigerate
Causes for Rejection Improperly labeled specimen
Use Work up volume depletion, acute renal failure, acute oliguria, and differential diagnosis of hyponatremia.
Division of hyponatremia into hypervolemia or not, edema or not, and urinary Na+ less than or greater than 10
mmol/L provides a classification of hyponatremia. History of diuretics, other drug intake, setting of osmotic
diuresis or not, serum/plasma electrolytes and other factors are needed.
Methodology Ion-selective electrode (ISE) or flame photometer
122
Stool Culture ................................ ...........
Synonyms Culture, Stool, Comprehensive; Enteric Pathogens Culture, Routine; Feces Culture, Routine; Routine
Culture, Stool
Test Includes Isolation and identification of Salmonella, Shigella, Campylobacter, and E. coli O157 (additional
CPT code for identification). Susceptibility testing will be performed at additional charge.
Special Instructions Specify specific pathogen if not Salmonella, Shigella, Campylobacter, or E. coli O157.
Specimens from sources, such as genital, stool, urine, upper and lower respiratory specimens, cannot be cultured
under the aerobic bacterial culture test number. If specimens are incorrectly submitted with an order for aerobic
bacterial culture, the laboratory will process the specimen for the test based on the source listed on the request
form. The client will not be telephoned to approve this change, but the change will be indicated on the report.
Specimen Requirement Rectal swab or stool (fresh random) in fecal transport system
Volume 5 g, 5 mL, or one swab
Container Fecal transport system is required. Diapers are not acceptable. Culture collection swab may be used
to collect rectal swabs or a swab of fecal material, then swab should be placed in C&S vial (fecal transport
system).
Collection Stool: Specimen should be collected in sterile bedpan, not contaminated with urine, residual soap, or
disinfectants. Those portions of stool which contain pus, blood, or mucous should be transferred to sterile
specimen container.
Rectal swab: Pass swab beyond anal sphincter, carefully rotate, and withdraw. Swabbing of lesions of rectal wall
or sigmoid colon during proctoscopy or sigmoidoscopy is preferred.
Duodenal or sigmoid aspirate: Specimen should be collected by a physician trained in this procedure.
Stool specimen can be divided for other types of cultures by laboratory. Miscellaneous tests and ova and
parasites tests should be split into appropriate containers and transport prior to shipping to laboratory.
Hospitalized patients who develop diarrhea while hospitalized should be tested for Clostridium difficile by
detection of either toxin A or toxin B testing or both. Studies have shown that patients who have been
hospitalized for 3 days and who did not present with GI symptoms are unlikely to have diarrheal disease due to
Salmonella, Campylobacter, Shigella, or E. coli 0157.
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Specimens sent on diaper or tissue paper; unlabeled specimen; specimen frozen;
specimens not received in fecal culture transport system (C&S vial); expired transport. Specimen contaminating
outside of transport container may not be acceptable to laboratory.
Use Detect bacterial pathogenic organisms in the stool; diagnose typhoid fever, enteric fever, bacillary dysentery,
Salmonella infection.
Indications for stool culture include:
* bloody diarrhea
* fever
* tenesmus
* severe or persistent symptoms
* recent travel to a third world country
* known exposure to a bacterial agent
* presence of fecal leukocytes
Contraindications A rectal swab culture is not as effective as a stool culture for detection of the carrier state.
Methodology Aerobic culture on selective media
Testing Schedule : Daily
123
T3 Uptake ...................................... ...........
Synonyms T3 Resin Uptake; Thyroid Hormone Binding Ratio (THBR)
Test Includes T<i[7 if T4 is ordered
Special Instructions This test reflects assessment of thyroxine-binding globulin (TBG) and should not be
ordered alone.
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Use Thyroid function test for the diagnosis of hypothyroidism or hyperthyroidism, used with thyroxine (T4) or
equivalent to provide free T4 index, FTI. An indirect measure of binding protein, the T3 uptake reflects available
binding sites (ie, reflects TBG). T3 uptake is not a measurement of serum T3. It should never be used alone;
rather, its usual application is use with thyroxine (T4).
Methodology Cloned enzyme donor immunoassay (CEDIA)
Testing Schedule : Daily
Testosterone, Total, Serum ....... ...........
Special Instructions State patient's age and sex on the request form.
Specimen Requirement Serum
Volume 1 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
Use An indicator of LH secretion and Leydig cell function. Evaluate gonadal and adrenal function. Helpful in the
diagnosis of hypogonadism, hypopituitarism, Klinefelter syndrome and impotence (low values) in males, and
hirsutism, anovulation, amenorrhea, and virilization in females, due to Stein-Leventhal syndrome, masculinizing
tumors of ovary such as Sertoli-Leydig cell tumor, tumors of the adrenal cortices, and congenital adrenal
hyperplasia (high values).
Hirsutism in females is most commonly caused by anovulation and excessive ovarian androgen production.
Adrenal causes are uncommon. Contemporary investigation for female hirsutism includes
dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, and testosterone. Testosterone is used in investigation
of male precocious puberty. Male pseudohermaphroditism includes defective testosterone synthesis, androgen
insensitivity syndromes, 5-alpha-reductase deficiency, and testicular dysgenesis.
Methodology Immunochemiluminometric (ICMA)
Testing Schedule : Daily
124
Thyroglobulin, Quantitative ...... ...........
Test Includes Antithyroglobulin antibodies
Specimen Requirement Serum or plasma (heparinized only)
Volume 3 mL
Minimum Volume 0.4 mL
Container Red-stopper tube or serum-separator tube or green-stopper (heparinized plasma) tube
Collection If tube other than serum-separator tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Patient Preparation Patient should fast for 12-14 hours prior to collection.
Use Thyroglobulin is elevated in three types of thyroid disorders: goiter and thyroid hyperfunction, inflammation
or physical injury to the thyroid, and differential thyroid tumors.
Those thyroid cancer patients who have no remaining thyroid tissue, following surgery and/or irradiation, would
not be expected to have a source of thyroglobulin. Thyroglobulin then is a tumor marker useful to assess the
presence of residual papillary-follicular carcinoma of thyroid, following resection, including tumors which fail to
concentrate radioiodine. High values are found with many instances of tumor dissemination; thus, thyroglobulin
assays are used to monitor postoperative thyroid carcinoma patients. Such assays are best used in concert with
total body scans. Possibly it will be useful in patients with bone metastases in whom the primary site is
unknown.
Low or undetectable levels in thyrotoxicosis are a clue to thyrotoxicosis factitia (surreptitious use of thyroid
hormone). The assay may be useful to support a diagnosis of subacute thyroiditis.
The absence of thyroglobulin from the serum of neonates suggests congenital athyreosis.
Thyroglobulin is useful in the management but not diagnosis of differentiated thyroid carcinomas. Thyroglobulin
may prove useful as an indicator of T4 therapy in patients with solitary nodules.
Methodology Chemiluminescent enzyme immunometric
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Thyroid Peroxidase (TPO) Antibodies
Synonyms Antimicrosomal Antibody; Antithyroid Microsomal Antibody; Thyroid Peroxidase Autoantibodies;
TPO Antibodies
Specimen Requirement Serum
Volume 1 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Refrigerate
Causes for Rejection Excessive hemolysis; anticoagulated specimen; bacterial contamination
Use Used in differential diagnosis of hypothyroidism and thyroiditis
Methodology Enzyme immunoassay (EIA)
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
Thyroid-Stimulating Hormone (TSH), Serum
Synonyms Thyrotropin; TSH, High Sensitivity, Serum
Specimen Requirement Serum
Volume 1 mL
125
Minimum Volume 0.6 mL
Container Red-stopper tube or serum-separator tube
Collection If red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Separate serum and refrigerate.
Causes for Rejection Gross hemolysis; plasma specimen
Use Thyroid function test. Investigation of low T4 (RIA) result; the differential diagnosis of primary
hypothyroidism from normal, and the differential diagnosis of primary hypothyroidism from
pituitary/hypothalamic hypothyroidism. TSH is high in primary hypothyroidism. Low TSH occurs in
hyperthyroidism. Evaluation of therapy in hypothyroid patients, receiving various thyroid hormone preparations:
low values are found in states of excessive thyroid replacement. Normal result on a sensitive TSH assay is
acceptable evidence of adequate thyroid replacement. This assay has a sensitivity of 0.03 µIU/mL.
Follow-up of patients who have had hyperthyroidism treated with radioiodine or surgery. Follow-up, low T4
newborn results.
TSH had been used in the TRH stimulation test for borderline thyrotoxicosis. Such testing was not often needed
even before the introduction of sensitive immunoassays for serum thyrotropin, and is now mostly, but not
completely, obviated.
The highly sensitive TSH assays can be considered as a test for thyroid disease. A result within the accepted
reference interval provides strong evidence for euthyroidism.
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Thyroxine (T4) .............................. ...........
Synonyms T4, Total; Tetraiodothyronine
Specimen Requirement Serum or plasma
Volume 1 mL
Container Red-stopper tube or serum-separator tube or lavender-stopper (EDTA plasma) tube
Storage Instructions Refrigerate
Use Thyroid function test. Decreased in hypothyroidism and in the third stage of (painful) subacute thyroiditis;
increased with hyperthyroidism, with subacute thyroiditis in its first stage and with thyrotoxicosis due to
Hashimoto's disease. Used to diagnose T4 toxicosis.
Methodology Cloned enzyme donor immunoassay (CEDIA)
Testing Schedule : Daily
Total Protein see Protein, Total
Tri-iodothyronine (T3) ................. ...........
Synonyms T3; T3 Hormone; T3, Total; Total T3
Specimen Requirement Serum
Volume 2 mL
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
126
Use Thyroid function which is particularly useful in the diagnosis of T3 thyrotoxicosis, in which T3 is increased
and T4 is within normal limits. T3 toxicosis is occasionally found in Graves' disease. It occurs with a single toxic
nodule, multinodular thyrotoxicosis, and following treatment with T3 (Cytomel®). It is increased in and
occasionally helpful for confirmation of diagnosis of conventional hyperthyroidism, in which commonly both T3
and T4 levels are increased. T3 is needed in patients with clinical evidence for hyperthyroidism, in whom the
usual thyroid profile is normal or borderline.
Reported to be normal to slightly increased with familial dysalbuminemic hyperthyroxinemia.
Recommended for patients with supraventricular tachycardia, for patients with fatigue and weight loss not
otherwise explained, or for those with proximal myopathy and in whom T4 levels are not elevated.
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Toxoplasma ABS IgG & IgM
Synonyms Toxoplasma Antibodies; Toxoplasmosis Titer
Replaces Sabin-Feldman Dye Test
Test Commonly Includes IgG and IGM antibody specific for Toxoplasma gondii
Specimen Requirement: 1 ml serum
Ref. Interval:
IgG abs:
<2 IU/mL antibodies not detectable
2.0–2.9 IU/mL borderline
>/= 3 IU/mL antibodies detectable
IgM abs:
<0.50 Index: antibodies not detectable
0.50-0.59 Index: borderline
> /= 0.60 Index: antibodies detectable
Use: Support the diagnosis of toxomplasmosis; document past exposure and/or immunity to Toxoplasma gondii
Limitations: Diganosis of neonatal injection may be difficult because injuection outstrips demonstrable antibody
response. Toxoplasmosos occurs in advanced AIDS. The absence in such patients of anti-Toxoplasma
antibodies on immunofluorescence assay does not exclude the diagnosis.
Methodology: MEIA
Testing Schedule : Daily
Additional information: Toxoplasma gondii is endemic in cats and is excereted by them. Humans are easily
exposed to cyst forms, either in caring for pets or in causal environmental contact. The majority of individuals
develop antibody without any clinical disease, and self –limited lymphadenitis is the most common clinical
presentation in symptomatic injection. Congenital toxoplasmosis and injuection in an immunocompromised host
( AIDS) are more serious, and can produce a fatal cerebritis or disseminated illness. Congenital toxoplasmosis
can now be diagnosed in utero by detection of IgM antibody in fetal blood. Diagnosis is supported by high or
rising IgG antibody titer, or the demonstration of IgM antibody. The recent availability of IgA anti-Toxoplasma
amy be useful ion detection of congenital toxoplasmosis. However, IgM is still the established technique. The
median C cell count in subjects with AIDS and toxoplasmosis, at presentaitn, was 50/mm3
127
Triglycerides ................................ ...........
Specimen Requiremnt Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube. Do not use glycerinated Vacutainer® tubes.
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation Patient should be fasting 12-14 hours. The patient should be on a stable diet 2 weeks prior
to collection of blood.
Causes for Rejection Nonfasting specimen; specimen collected in a glycerinated tube; improperly labeled
specimen
Use Evaluate turbid samples of blood, plasma, and serum; work up of chylomicronemia; evaluate
hyperlipidemia; occasional cases of diabetes mellitus and/or pancreatitis are detected by hypertriglyceridemia.
High levels may occur with hypothyroidism, nephrotic syndromes, carbohydrate-sensitive hypertriglyceridemia,
glycogen storage disease, and in hyperlipoproteinemias type I, IIb, III, IV, and V. Some alcoholics have
hypertriglyceridemia which disappears with abstinence. Extremely high triglyceride levels may occur with
alcohol abuse. Triglyceride is needed for calculation of LDLC (low density lipoprotein cholesterol)
concentration. Disturbances in triglyceride metabolism relate to diabetes and are a risk factor for atherosclerotic
disease, but not an independent one.
Although the role of hypertriglyceridemia as a risk factor for coronary arterial disease has been controversial, a
more consistent association for women exists and analysis of preliminary data supports triglyceride levels as a
predictor in men with lower LDL cholesterol levels and with cholesterol values <220 mg/dL.
In familial combined hyperlipidemia, hypertriglyceridemia may be found before hypercholesterolemia.
Nevertheless, a strong case is not available for primary triglyceride evaluation of healthy persons without
positive family history of coronary disease or other risk factors. Some knowledgeable authorities favor testing
with lipid profiles, including triglycerides, for reasons discussed elsewhere in this listing.
In exogenous hypertriglyceridemia, chylomicrons float as a layer in the tube of refrigerated, stored serum.
Methodology Enzymatic
Testing Schedule : Daily
Upper Respiratory Culture, Routine
Synonyms Culture, Upper Respiratory, Routine; Ear Culture; Nasopharynx Culture; Nose Culture; Sinus
Culture; Throat Culture
Test Includes Isolation of potential aerobic pathogens. Susceptibility testing, when indicated, performed at
additional fee.
Special Instructions Throat specimens submitted for isolation of Neisseria gonorrhoeae must indicate this
pathogen. Specimens from other sources, such as genital, stool, urine, upper and lower respiratory specimens,
cannot be cultured under the aerobic bacterial culture test number. If specimens are incorrectly submitted with an
order for aerobic bacterial culture, the laboratory will process the specimen for the test based on the source listed
on the request form. The client will not be telephoned to approve this change, but the change will be indicated on
the report.
Specimen Requirement Throat swab, nasopharynx swab, nares swab, sinus aspirate
Volume One swab or aspirated material
Container Culture collection swab in transport
128
Collection Throat: Depress tongue and rub swab vigorously over each tonsillar area and posterior pharynx. Any
exudate should be touched, and care should be taken to avoid the tongue and uvula. Place swab in transport.
Nasopharynx: With patient's head immobilized, insert swab into nostril until it reaches posterior nares. Leave
swab in place for 15-30 seconds. Rotate and remove. Place swab in transport.
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Unlabeled specimen; inappropriate specimen transport device; mislabeled specimen;
unlabeled specimen; leaking specimen; specimen received after prolonged delay (usually more than 72 hours);
expired transport
Use Isolate and identify potentially pathogenic organisms from throat, sinus etc; evaluate pharyngitis; evaluate
nares for staph
Methodology Culture
Testing Schedule : Daily
Urea Nitrogen, Serum .................. ..........
Synonyms Blood Urea Nitrogen; BUN
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Causes for Rejection Improperly labeled specimen
Use High BUN occurs in chronic glomerulonephritis, pyelonephritis and other causes of chronic renal disease;
with acute renal failure, decreased renal perfusion (prerenal azotemia) as in shock. With urinary tract obstruction
BUN increases (postrenal azotemia), for example as caused by neoplastic infiltration of the ureters, hyperplasia
or carcinoma of the prostate. BUN is useful to follow hemodialysis and other therapy. |Uremia| was defined by
Luke as an expression of a constellation of signs and symptoms in patients with severe azotemia secondary to
acute or chronic renal failure. Causes of increased BUN include severe congestive heart failure, catabolism,
tetracyclines with diuretic use, hyperalimentation, ketoacidosis, and dehydration as in diabetes mellitus, but even
moderate dehydration can cause BUN to increase. Corticosteroids tend to increase BUN by causing protein
catabolism. Bleeding from the gastrointestinal tract is an important cause of high urea nitrogen, commonly
accompanied by elevation of BUN/creatinine ratio. Nephrotoxic drugs must be considered.
Borderline high values may occur after recent ingestion of high protein meal and muscle wasting may cause an
elevation as well.
With creatinine, BUN is used to monitor patients on dialysis.
Low BUN occurs in normal pregnancy, decreased protein intake, with intravenous fluids, with some antibiotics,
and in some but not all instances of liver disease.
As described by DeCaux et al in 1980, in the syndrome of inappropriate secretion of antidiuretic hormone
(SIADH): findings include hyponatremia with serum or plasma Na+ <lq[128 mmol/L, hypo-osmolality (<260
mOsm/kg with urine osmolality >300 mOsm/kg) with low BUN. Such findings occur In situations in which
patients are overhydrated. Clinical findings included absence of edema or evidence of heart, liver, thyroid, renal
or adrenal disease. Hypouricemia, with uric acid levels in 16 of 17 patients <4 mg/dL, is reported with the
syndrome of inappropriate secretion of antidiuretic hormone. (SIADH can be seen with higher serum sodiums
and higher osmolalities. Urine osmolality is greater than serum osmolality in SIADH.
DeCaux in 1982 presented criteria modified from the 1980 paper.)
Osmolality (mOsm/kg H2O) is calculated as follows: Osmolality = [Na+ (mmol/L)] x [2 + glucose (mg/dL)]/18 +
[BUN (mg/dL)/2.8].
129
Methodology Enzymatic (urease)
Testing Schedule : Daily
Uric Acid, Serum .......................... ...........
Synonyms UA
Specimen Requirement Serum
Volume 2 mL
Container Red-stopper tube or serum-separator tube
Storage Instructions Separate from cells within 45 minutes and refrigerate.
Patient Preparation At least 4-hour fast preferred
Causes for Rejection Improperly labeled specimen
Use An increased uric acid level does not necessarily translate to a diagnosis of gout; about 10% to 15% of
instances of hyperuricemia are caused by gout. The overlap between uric acid levels in those with and without
gout is shown in a study in which the lowest level in a gouty subject was 6 mg/dL, while the highest uric acid in
a nongouty person was 9.5 mg/dL.
Elevations of uric acid occur in renal diseases with renal failure and prerenal azotemia (eg, dehydration) as well
as gout. Other drugs causing increased uric acid concentration include diuretics, pyrazinamide, ethambutol,
nicotinic acid, and aspirin in low doses.
Excessive cell destruction: neoplasia, even before as well as following chemotherapy and radiation therapy,
especially lymphoma and leukemia; hemolytic anemia, resolving pneumonia and other inflammation;
polycythemia, myeloma, pernicious anemia, infectious mononucleosis, congestive heart failure, large
myocardial infarct.
Endocrine: hypothyroidism, hypoparathyroidism, hyperparathyroidism, pseudohypoparathyroidism; diabetes
insipidus of nephrogenic type, Addison's disease.
Lead poisoning (saturnine gout) from paint, batteries, and moonshine. A causal relationship between plumbism
and gout was recognized before 1876. Gout as a common complication of subclinical lead poisoning is
described among the Roman aristocracy.
Acidosis: lactic acidosis, diabetic ketoacidosis, recent alcohol ingestion, alcoholic ketosis. Shock and hypoxia
relate to hyperuricemia. Attention has been directed at the cause of hyperuricemia in the intensive care unit;
severely increased uric acid levels in acutely ill patients is explained by degradation of ATP with degradation of
accumulated nucleotides to purine metabolites, uric acid among them. Such ATP degradation may occur with
strenuous exercise and the adult respiratory distress syndrome. With metabolism of ethanol to acetyl CoA, the
degradation of ATP explains the hyperuricemia of alcohol use. Hyperuricemia becomes then a marker for cell
injury crisis.
Toxemia of pregnancy, diet, weight loss, fasting or starvation. Decreased urate clearance: cyclosporine-induced
hyperuricemia.
Triglyceride increase bears an association with hyperuricemia, as do diabetes mellitus and obesity.
Hyperuricemia bears an association with obesity, hypertension and statistical association with myocardial
infarct.
Hereditary gout: Lesch-Nyhan (X-linked) with deficiency of hypoxanthine-guanine phosphoribosyltransferase.
Gout with partial absence HPRT. Increased 5-phosphoribosyl-1-pyrophosphate synthetase. Glycogen storage
disease type I.
Only a minority of individuals with hyperuricemia develop gout.
Three types of kidney disease are caused by precipitation: acute uric acid nephropathy, nephrolithiasis, and
chronic urate nephropathy.
130
Hyperuricemia in early essential hypertension correlates with renal vascular resistance and inversely with renal
blood flow. Increased serum uric acid may indicate renal involvement.
Low uric acid: Drugs: In two-thirds of Ramsdell's and Kelley's series of hypouricemic patients, drugs apparently
bearing a relationship to low serum uric acid levels included aspirin (high doses), x-ray contrast agents, glyceryl
guaiacolate or allopurinol. Corticosteroids and probenecid cause low uric. Massive doses of vitamin C are
uricosuric.
Poor dietary intake of purines and protein; tea, coffee.
Renal tubular defects, Fanconi syndrome, late in Wilson's disease, outdated tetracycline, cystinosis,
galactosemia. Look for hypophosphatemia. Heavy metal poisoning. Malignant neoplasms. Hypereosinophilic
syndrome.5
Xanthinuria (deficiency of xanthine oxidase).
Hypouricemia is reported with acute intermittent porphyria, severe liver disease (especially obstructive biliary
disease) and as an isolated defect in the tubular transport of uric acid.
With increased renal clearance of urate, hypercalciuria and decreased bone density.
Diabetes.7
With hyponatremia, serum hypo-osmolarity: Beck has described low uric acid with the syndrome of
inappropriate secretion of antidiuretic hormone (SIADH): 16 of 17 patients with this syndrome were
hypouricemic, with serum urate <lq[4.0 mg/dL. All 13 patients with other causes of hyponatremia had serum
urate <gq[5.0 mg/dL.8 Volume expansion, as with SIADH, causes decreased uric acid. The combination of low
uric and low Na+ may also be found in instances of liver disease and was anticipated with ticrynafen.
Azlocillin is reported to cause decrease of serum uric acid levels.9 Drug effects on uric acid metabolism are
published in tabular form.
Idiopathic hypouricemia commonly is transient. Familial hypouricemia has been described.
Methodology Uricase
Testing Schedule : Daily
Urinalysis, Complete (With Microscopic Examination)
Synonyms Complete Urinalysis; UA Complete
Test Includes Color, appearance, specific gravity, pH, protein, glucose, occult blood, ketones, leukocyte
esterase, nitrite, bilirubin, urobilinogen. Microscopic examination of urine sediment.
Specimen Requirement Urine (random)
Volume 10 mL
Container Plastic urine container
Collection A voided specimen is usually suitable. If the specimen is likely to be contaminated by vaginal
discharge or hemorrhage, a clean catch specimen is desirable.
Storage Instructions Refrigerate
Causes for Rejection Specimen delayed in transport; decomposition or bacterial overgrowth; insufficient
quantity of urine; improperly labeled specimen
Use Detect abnormalities of urine; diagnose and manage renal diseases, urinary tract infection, urinary tract
neoplasms, systemic diseases, and inflammatory or neoplastic diseases adjacent to the urinary tract
Methodology Reagent strip
Testing Schedule : Daily
131
Urine Culture, Comprehensive . ...........
Synonyms Culture, Urine, Comprehensive
Test Includes Quantitation and identification (additional CPT code) of up to two organisms at >100
colonies/mL. Susceptibility testing performed at additional charge.
Special Instructions Urine specimens cannot be cultured under the aerobic bacterial culture test number. If
specimens are incorrectly submitted with an order for aerobic bacterial culture, the laboratory will process the
specimen for the test based on the source listed on the request form. The client will not be telephoned to approve
this change, but the change will be indicated on the report.
Specimen Requirement Urine
Volume To fill line on transport tube (<ax[20 mL) mixed with stabilizing tablet
Container Urine culture transport with preservative
Collection First morning specimens yield highest bacterial counts from overnight incubation in the bladder, and
are the best specimens. Colony count clinical interpretation standards are based on controlled studies from first
early morning collections. Forced fluids or random specimens dilute the urine and may cause reduced colony
counts. Hair from perineum will contaminate the specimen. The stream from a male may be contaminated by
bacteria from beneath the prepuce. Bacteria from vaginal secretions, vulva or distal urethra may contaminate
transport. Organisms from hands or clothing might contaminate. Receptacle must be sterile. Read Patient
Preparation.
Storage Instructions Specimen placed with stabilizing pill at room temperature or in sterile container
refrigerated
Patient Preparation Clean catch specimen: Thoroughly instruct patient for proper collection of |clean catch|
specimen. Patient must be instructed to thoroughly cleanse skin and collect midstream specimen. The patient
should be instructed to follow the directions provided with the urine collection kit as follows.
Males: Wash hands thoroughly with soap and water. Rinse them well and dry with a paper towel.
Tear open the towelette packages so that the towels can be easily removed with one hand as they are needed.
Open the urine container. Do not touch any of the inside surfaces of the container or the lid.
Pull back the foreskin to completely expose the head of the penis.
Wash the head of the penis thoroughly using first one towelette then the other. Discard the used towelettes into
the toilet bowl.
Pass a small amount of urine into the toilet bowl, then pass a sample into the container. Do not allow the
container to touch the legs or the penis. Keep fingers away from the rim and inner surface of the container. Fill
the container half full.
Replace the lid on the container. The urine specimen should be refrigerated within 10 minutes of collection or
taken immediately to the laboratory.
Females: Wash hands thoroughly with soap and water. Rinse them well and dry with a paper towel.
Tear open the towelette packages so that the towels can be easily removed with one hand as they are needed.
Open the urine container. Do not touch any of the inside surfaces of the container or the lid.
Remove undergarments and sit on the toilet seat with legs spread widely apart.
With one hand, spread labia apart to expose the vulva. Keep this hand in place during the washing and urinating
procedure.
Use one towelette to wash the vulva well passing the towelette only from front to back, not back and forth.
Repeat this procedure using the second towelette. Discard the used towelettes into the toilet bowl.
Begin urinating into the toilet bowl then without stopping the stream, insert the container to collect the specimen.
Do not allow the container to touch the legs, vulva, or clothing. Keep fingers away from the rim and inner
surface of the container. Fill the container about half full.
132
Replace the lid on the container. The urine specimen should be refrigerated within 10 minutes of collection or
taken immediately to the laboratory.
Apply the completed patient label to the specimen cup. Most patients, with instruction, do better with privacy
than an attendant can.
Catheterized specimen: Do not collect urine from the drainage bag when an indwelling catheter is in place
because growth of bacteria can occur in the bag itself. Rather, clean catheter with an alcohol sponge, puncture
with sterile needle, collect in sterile syringe. Catheter tips are contaminated by the urethra as they are withdrawn;
do not culture them.
Causes for Rejection Unrefrigerated specimen older than 2 hours may be subject to overgrowth and may not
yield valid results; unlabeled specimen; mislabeled specimen; specimen in expired transport container; specimen
received after prolonged delay (usually more than 36 hours for urine)
Use Isolate and identify bacteria present in low numbers in the urinary tract; isolate and identify bacteria from
females presenting with |urethral syndrome| for whom Urine Culture, Routine was not diagnostic.
Methodology Culture
Testing Schedule : Daily
VDRL
Synonyms Serum VDRL; Venereal Disease Research Laboratory Test, Serum
Applies to Syphilis Serology
Replaces Kahn Tes; Kline Tes; Mazzini; Wassermann
Test Commonly Includes Determination of serologic response to treponema injection
Abstraction VDRL is a reaginic (nontreponemal) test for suphilis
Specimen Requirement 1 ml serum
Interpretive Reference Interval Nonreactive
Use: Screeing test for syuphilis. May be used to asses adequacy of treatment.
Limitations: Nonspecific positive reactions may be found in malaria, infectious mononucleosis, injectios
hepatitis, leprosy, brucellosis, SLE, atypical pheumonia, typhus, and other entities. See table. Reactive testes due
to related treponemal
Potential Causes of False_Positive Serologic Tests for syphilis.
Reaginic or nontreponemal tests
(RPR, VDRL)
Bacterial
Infectious Causes
Noninfectious causes
Pneumococcal
pneumonia
Scarlet fever
Leprosy
Lymphogranuloma
venereum
Relapsing fever
Bacterial endocarditis
Malaria
Rickettsial disease
Psittacosis
Leptospirosis
Pregnancy
Chronic liver disease
Advanced cancer
Intravenous drug use
Multimple myeoloma
Advancing age
Connective-tissue disease
Multiple blood transfusions
133
Chancroid
Tuberclosis
Mycoplasmal
pneumonia
Trypanosomiasis
Viral
Vaccinia (
vaccination)
Chickenpox
HIV
Measles
Injectious
mononucleosis
Mumps
Viral hepatitis
Treponemal tests
Lyme disease
Systmeic lupus
( FTA-ABS, MHA_TP)
Leprosy
erythematosus
Malaria
Injectious
mononucleosis
Relapsing fever
Leptospirosis
From Hook EW 3d and Marra Cm, “Acquired Syphilis in Adults,” N Engl J Med, 1992,326:1060-9
Infections also occur. Other pathogens include T.Pallidium subspecies pertenue, which causes yaws; T. carateum
which causes pinta and T. pallidum subspecies endemicum, the cause of nenvenereal or endemic syphilis.
False- positive results may occur in the first few days of postnatal life. False-negative tests due to prozone
phenomenon indicates that repeat testing with diluted serum should be performed in individual who test negative
despite high clinical suspicion.
The serum VDRl may be negative in as many as 25% of subjects who have late neurosyphilis. The specific tests (
eg, FTA-ABS) remain reactive. Treponemal tests ( eg, FTA-ABS) become reactive before nontreponemal (
reaginic) tests such as VDRL.
Contradictions: Positive result in cord blood may be due to passive transfer from mothers’ blood Methodology:
Flocculation procedure detecting the presence of regain, antibody to nontreponemal cardiolipin antigen.
Additional Information: Despite false-positive results due to now well known causes, VDRL remains an
extremely useful screeing test for syphilis. VDRL becomes positive starting 2 weeks after the chancre appears,
and by 6 weeks, 90%of cases will be positive. By 9-12 weeks, the secondary stage, 100% of patients should be
reactive. With therapy the VDRL reverse to negative. Even without treatment the VDRL may become negative
yars after injection. Thus, in tertiary syphilis, the VDRL may be negative. The VDRl test can be done on CSF
and is useful in diagnosis of CNS syphilis ( see VDRL, Cerebrospinal Fluid). Positive VDRL tests should have
confirmatory testing with a Treponema-specific test. The VDRL test is recommended as a screen for uveitis or
unexplained ocular inflammation.
Methodology: Agglutination
Vitamin B12 ................................... ...........
Synonyms B12; Cobalamin, True
Specimen Requirement Serum
Volume 2 mL
134
Minimum Volume 0.5 mL
Container Red-stopper tube or serum-separator tube
Collection If a red-stopper tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions Refrigerate
Patient Preparation Fasting specimen preferred; must draw before Schilling's test, transfusions or B12 therapy is
started.
Causes for Rejection Plasma specimen
Use Detect B12 deficiency as in pernicious anemia; diagnose folic acid deficiency; evaluate hypersegmentation of
granulocyte nuclei; follow up MCV >100; diagnose macrocytic anemia; diagnose megaloblastic anemia;
evaluate alcoholism, prenatal care; evaluate malabsorption, neurological disorders, or the elevation of B12 as
seen in liver cell damage or myeloid leukemia
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
Vitamin B12 and Folates ............. ...........
Test Includes Vitamin B12 and folate
Specimen Requirement Serum
Volume 3 mL
Minimum Volume 1 mL
Container Red-stopper tube or serum-separator tube
Collection If a serum-separator tube is used, transfer separated serum to a plastic transport tube. Protect from
light.
Storage Instructions Refrigerate
Causes for Rejection Plasma specimen
Methodology Immunochemiluminometric assay (ICMA)
Testing Schedule : Daily
VMA
Specimen Requirement: 2 x 30 ml 24h urine. Immediately after collection, mix the 24h urine well. Please state
24h urine volume. Prepare the shipping tube to contain 0.5 ml of 25% hydrochloric acid, fill tube with urine and
mix well. Ensure pH value between 2-4. Do not use acetic acid or boric acid. Catecholamines, Homovanillic acid
and Metanephrines can also be performed in these specimens.
Diet: It is recommended that the patient has no intake for 2 days prior to urine sampling of the following: nuts,
citrus fruits plus no cocoa, coffee or vanilla-containing products.
Medication: If clinical condition allows it is also recommended that the patient stops taking catecholamines
(epinephrine, norepinephrine, dopamine), MAO-inhibitors or catecholamine-reuptake inhibitors at least 2 days
prior to sampling.
Ref. Interval:
< 2 years: <2.4 mg/24h
< 8 years: <3.7 mg/24h
<16 years: <5.0 mg/24h
>16 years: <6,6 mg/24h
Method: HPLC
Testing Schedule : Referred to BIOSCIENTIA
Result ready with in 10days
135
Westergren Sedimentation Rate ..........
Synonyms Erythrocyte Sedimentation Rate; ESR; Sedimentation Rate, Westergren; Sed Rate
Specimen Requiement Whole blood
Volume 5 mL
Container Lavender-stopper (EDTA whole blood) tube
Storage Instructions Refrigerate
Causes for Rejection Hemolysis; clotted specimen; underfilled tube; specimen older than 24 hours; improperly
labeled specimen
Use Evaluate the nonspecific activity of infections, inflammatory states, autoimmune disorders, and plasma cell
dyscrasias
Methodology Westergren
Testing Schedule : Daily
White Blood Cell (WBC) Count . ...........
Synonyms Leukocyte Count; WBC; White Count
Specimen Requirement Whole blood
Volume 5 mL
Container Lavender-stopper (EDTA whole blood) tube
Storage Instructions Maintain specimen at room temperature up to 24 hours.
Causes for Rejection Hemolysis; clotted specimen; tube not filled with minimum volume; improperly labeled
specimen
Use White cell enumeration; evaluate myelopoiesis, bacterial and viral infections, toxic metabolic processes;
diagnose/evaluate leukemic states
Methodology Automated cell counter
Testing Schedule : Daily
White Blood Cells (WBC), Stool ...........
Synonyms Fecal Leukocyte Stain; Stool for White Cells; WBC, Stool; White Cells, Stool
Test Includes Evaluation of fecal material for presence of WBC by direct smear
Specimen Requirement Stool
Volume 1 g
Container Plastic container with polyvinyl alcohol (PVA) (from Ova and Parasites collection kit)
Storage Instructions Maintain specimen at room temperature.
Causes for Rejection Insufficient specimen volume
Use Assist in the differential diagnosis of diarrheal disease
MethodologySimplestain
Testing Schedule : Daily
136
Lipid Appendix
Over the past 30 years, the National Cholesterol Education Program (NCEP) published three reports as
knowledge regarding lipid function and cardiac risk assessment has grown. The 2001 report contains
guidelines revised from those published in 1993 on treating high blood cholesterol in adults. The latest
guidelines, Adult Treatment Panel III (ATP III), maintains the same emphasis on treating LDL cholesterol
levels as does the earlier one. Changes do include raising the risk level for HDL cholesterol to 40 mg/dL,
and recognizing triglyceride levels as an independent risk factor. A secondary target of therapy, the
metabolic syndrome, is recognized for the first time. Initial assessment now depends upon a 9- to 12-hour
fasting specimen. This index includes a summary of ATP III and a compilation of various lipid reference
intervals.
ATP III GUIDELINES
(NIH Publication No. 01-3305, May, 2001)
•
Step 1: Determine lipoprotein levels - complete lipoprotein profile (total cholesterol, LDL and HDL
cholesterol, triglycerides) after 9- to 12-hour fast.
ATP III Classification of LDL, Total, and HDL Cholesterol
LDL Cholesterol Primary Target of Therapy Total Cholesterol Primary Target of Therapy
<100 mg/dL
Optimal
100-129 mg/dL
Near optimal/above optimal 200-239 mg/dL
Borderline high
130-159 mg/dL
Borderline high
High
160-189 mg/dL
High
HDL Cholesterol
Very high
<40 mg/dL
Low
60 mg/dL
High
190 mg/dL
•
•
<200 md/dL
240 mg/dL
Desirable
Step 2: Identify atherosclerotic disease which confers high risk for CHD events (CHD risk
equivalent): Clinical CHD, symptomatic carotid artery disease, peripheral arterial disease, and
abdominal aortic aneurysm.
Step 3: Determine presence of non-LDL major risk factors:
o Cigarette smoking
o BP 140/90 mm Hg
o HDL <40 mg/dL (HDL >59 mg/dL is a negative risk factor and removes one risk factor
from the total)
o Males > 44 years; females >54 years
o CHD in male first-degree relative <55 years of age, in female first-degree relative <65 years
of age
o Diabetes
137
•
•
Step 4: Assess short-term CHD risk if 2 or more risk factors other than LDL are present without
CHD or CHD risk equivalent. See following Framingham tables.
o >20% - CHD risk equivalent; 10% to 20%; <10%
Step 5: Determine risk category to establish LDL goal of therapy, to determine need for therapeutic
lifestyle changes (TLC), and to determine level for drug consideration.
LDL Goals and Cutpoints for TLC and Drug Therapy in Different Risk Categories
LDL Goal
(mg/dL)
Risk Category
•
•
•
•
Initiate TLC
(mg/dL)
Consider Drug Therapy
CHD or risk
equivalents
(10-year risk >20%)
<100
100
130 mg/dL
(100-129 mg/dL drug optional)
2+ risk factors
<130
130
10-year risk 10%-20%: 130
mg/dL
10-year risk <10%: 160 mg/dL
0-1 risk factor
<160
160
190 mg/dL
(160-189 mg/dL drug optional)
Step 6: Initiate therapeutic lifestyle changes if LDL is above goal. Diet, weight management,
increased physical activity.
Step 7: Consider adding drug therapy if LDL exceeds levels in Step 5.
Step 8: Identify metabolic syndrome and treat, if present, after 3 months of TLC.
Step 9: Treat elevated triglycerides.
ATP III Classification of Serum Triglycerides (mg/dL)
<150
Normal
150-199 Borderline-high
200-499 High
500
Very high
Reference: Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III) - National Cholesterol Education Program; NIH
Publication No. 01-3305, 2001, JAMA, 285:2486-97.
Lipid Reference Intervals and Coronary Heart Disease (CHD) Cut-Points
Adults (>19 y)
Children and Adolescents
CHD CutPoints
Total cholesterol1
<200 mg/dL
Desirable blood cholesterol
<170 mg/dL
200-239 mg/dL
Borderline-high blood
cholesterol
170-199 mg/dL Borderline
138
Acceptable
Adults (>19 y)
240 mg/dL
Children and Adolescents
High blood cholesterol
200 mg/dL
High
CHD CutPoints
Triglycerides2
<150 mg/dL
Normal
Not established
150-199 mg/dL Borderline-high
200-499 mg/dL High
500 mg/dL
HDL cholesterol2
Very high
<40 mg/dL as the cut-point for increased CHD
risk
Not established
CHD CutPoints
LDL cholesterol1,2,3
<100 mg/dL
Optimal
<110 mg/dL
100-129 mg/dL Near optimal/above optimal
130-159 mg/dL Borderline-high
160-189
190
Risk of CHD
Total cholesterol/HDL
ratio4*
1
4
LDL/HDL ratio *
Apo B level
Ratio of Apo A-1/Apo B
Female
3.3
5.0
4.4
2 x average risk 9.6
7.1
3 x average risk 23.4
11.0
Risk of CHD
Female
1
Male
/2 average risk 1.0
Average risk
Apo A-1 level
130 mg/dL
Very high
/2 average risk 3.4
Average risk
110-129 mg/dL Borderline
High
Male
1.5
3.6
3.2
2 x average risk 6.3
5.0
3 x average risk 8.0
6.1
Reference
132±20 (mg/dL)
Diagnosed
CHD
98±15 (mg/dL)
Reference
83±13 (mg/dL)
Diagnosed
CHD
114±23 (mg/dL)
Risk of CHD
Male
Female
Average risk
1.4
1.6
139
Acceptable
Not established
Not established
Not established
Not established
Not established
High
Adults (>19 y)
Ratio of Apo B/Apo A-1
2 x average risk 1.1
1.1
3 x average risk 1.0
1.0
Risk of CHD
Male
Female
Average risk
0.7
0.6
2 x average risk 0.9
0.9
3 x average risk 1.0
5
Lipoprotein (a)
Children and Adolescents
Not established
1.0
6
<30 mg/dL (lowest risk groups)
Not established
*Other factors affect CHD risk such as hypertension, smoking, diabetes, severe obesity, and family history
of premature CHD
1
The Expert Panel. Report of the National Cholesterol Education Program Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults, Arch Intern Med, 1988, 36:36-69.
2
Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel III) - National Cholesterol Education Program; NIH Publication No. 013305, 2001, JAMA, 285:2486-97.
3
Friedewald WT, Levy RI, and Fredrickson DS, "Estimation of the Concentration of Low-Density
Lipoprotein Cholesterol in Plasma Without Use of the Ultracentrifuge,"Clin Chem, 1972, 18:449-552.
LDL cholesterol calculated by Friedewald formula: [LDL cholesterol] = [total cholesterol] [triglycerides/5] - [HDL cholesterol]; where [triglycerides/5] = [VLDL cholesterol]
4
Kannel WB, Castelli WP, and Gordon T, Ann Int Med, 1979, 90:85.
5
Grinstead GF, "Lipoprotein(s): Review and Update,"AACC Lipids and Lipoproteins Division Newsletter:
The Fats of Life, 1990, 4(1):1, 3-8.
6
Concentrations >30 mg/dL are associated with a two- to fivefold increase in risk. The significance of
elevated Lp(a) in nonwhite populations is still under investigation.
FRAMINGHAM TABLES - Estimate of 10-Year Risk for Men
(Adapted from "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(19):2486-97.)
Age
Points
(y)
20-34 -9
35-39 -4
40-44 0
45-49 3
50-54 6
55-59 8
140
Age
Points
(y)
60-64 10
65-69 11
70-74 12
75-79 13
Points
Total Cholesterol
20-39 40-49 50-59 60-69 70-79
(mg/dL)
(y)
(y)
(y)
(y)
(y)
<160
0
0
0
0
0
160-199
4
3
2
1
0
200-239
7
5
3
1
0
240-279
9
6
4
2
1
11
8
5
3
1
280
Points
20-39 40-49 50-59 60-69 70-79
(y)
(y)
(y)
(y)
(y)
Nonsmoker 0
0
0
0
0
Smoker
5
3
1
1
8
HDL
Points
(mg/dL)
60
-1
50-59
0
40-49
1
<40
2
Systolic BP
Untreated Treated
(mm Hg)
<120
0
0
120-129
0
1
130-139
1
2
140-159
1
2
2
3
160
Point Total
10-Year Risk
(%)
<0
<1
141
Point Total
10-Year Risk
(%)
0
1
1
1
2
1
3
1
4
1
5
2
6
2
7
3
8
4
9
5
10
6
11
8
12
10
13
12
14
16
15
20
16
25
17
30
FRAMINGHAM TABLES - Estimate of 10-Year Risk for Females
(Adapted from "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(19):2486-97.)
Age
Points
(y)
20-34 -7
35-39 -3
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 12
70-74 14
142
Age
Points
(y)
75-79 16
Points
Total Cholesterol
20-39 40-49 50-59 60-69 70-79
(mg/dL)
(y)
(y)
(y)
(y)
(y)
<160
0
0
0
0
0
160-199
4
3
2
1
1
200-239
8
6
4
2
1
240-279
11
8
5
3
2
13
10
7
4
2
280
Points
20-39 40-49 50-59 60-69 70-79
(y)
(y)
(y)
(y)
(y)
Nonsmoker 0
0
0
0
0
Smoker
7
4
2
1
9
HDL
Points
(mg/dL)
60
-1
50-59
0
40-49
1
<40
2
Systolic BP
Untreated Treated
(mm Hg)
<120
0
0
120-129
1
3
130-139
2
4
140-159
3
5
4
6
160
143
MICROBIOLOGY TESTING:
Important
It is vital that correct protective containers and plastic bags are used when sending such specimens.
FEACES:
Pathogenic stool bacteria
incl.Salmonella/Shigella
Yersinia
Campylobacter
Pseudomonas, Klebsiella, etc.
Staphylococcus
plus susceptibility testing, if found to be relevant to obtain clear result.
enteropathogenic organisms for Children under 3 years
incl.Salmonella/Shigella
Yersinia
Campylobacter
Pseudomonas, Klebsiella, etc.
Staphylococcus
Rotavirus-Ag-EIA
Adenovirus-Ag-EIA
EHEC (SLT-I/II) Toxin- EIA
plus susceptibility testing, if found to be relevant to obtain clear result.
Adenovirus
Rotavirus
Salmonella and Shigella
Campylobacter jejuni/coli
Yersinia
EHEC
EIEC
ETEC
Dysbacteria
(aerobic and anaerobic organisms groups)
Clostridium difficile toxin-ELISA
Clostridium perfringens toxin-ELISA
Aeromonas /Plesiomonas
Bacillus cereus
Staphylococcus aureus
Listeria
Vibrio-group
General parasites
incl.concentration procedure, smear
for ova and parasites
Entamoeba histolytica/dispar
Giardia lambia antigen (EIA)
144
antigen (EIA)
Cryptosporidium ssp. antigen(EIA)
Entamoeba histolytica/dispar
direct smear and/or concentration procedure with smear, EIA
Giardia lambia
direct smear and/or concentration procedure with smear, EIA
Cryptosporidium ssp.
direct smear and/or concentration procedure with smear, EIA
Enterobius vermicularis (scotch tape)
BIOPSY
Helicobacter pylori
URINE
Culture and sensitivity
incl.bacterial count ,quant.
inhibitor test
Gardnerella vaginalis
0va in urine (Schistosoma)
URICULT
Culture and sensitivity
BLOOD CULTURES, SWABS, PUNCTURE FLUID AND OTHER
Culture and sensitivity
CSF
Culture and sensitivity
Meningitis screening
VAGINAL AND GENITAL SWABS
Culture and sensitivity
incl. microscopy
Mycoplasma/Ureaplasma
Neisseria gonorrhoeae
Gardnerella vaginalis
THROAT SWAB
Culture and sensitivity
Beta-haem. Streptococcus
Corynebacterium diphtheriae
BRONCHIAL FLUID, TRACHEAL FLUID, SPUTUM
Culture and sensitivity
incl. cytology
145
Actionomyces/Nocardia
NASOPHARYNGEAL SWABS
Bordetella pertussis
request special swab
HAIR, NAILS AND SKIN SCRAPINGS
Fungal culture
Identification of dermatophytes or clinically significant fungi
SERUM, CSF, URINE, BRONCHIAL LAVAGE
Antigen detection for Cryptococcus sp.
fungal culture
ALL MATERIALS
Fungal culture
Identification of clinically significant fungi
susceptibility testing (MIC, E-test),
for selected non-topical drugs. Upon request
MOLECULAR GENETIC ANALYSES
For specimen requirements, turnaround times and prices for theses analyses, please contact us
Achondrogenesis
Achondroplasia (ACH)
Acromesomelic dysplasia (CDMP1-gene)
Acute lymphatic leukemia; t(9;22), bcr/abl (190) (ALL)
Adrenal hyperplasia, congenital (CAH)
Alagille-syndrome (molecular genetic analysis)
Albright syndrome
Alexander syndrome
Alpha-1-antitrypsin deficiency (genotyping)
Alzheimer`s disease type 1 (APP-gene)
Alzheimer`s disease type 3 (PSEN1-gene)
Alzheimer`s disease type 4 (PSEN2-gene)
Androgen Insensitivity Syndrome
Angelman Syndrome (SNPRN-gene)
Angiotensin 1 Converting Enyzme gene
Aniridia (AN)
Antley-Bixler-Syndrome
146
Apert-syndrome
Apolipoprotein B (ApoB)
Apolipoprotein E (ApoE) Alzheimer disease, type-III-hyperlipidemia
Arginase deficiency (ARG-deficiency)
Argininosuccinic acid lyase deficiency (Argininosuccinic aciduria)(ASL-deficiency )
Argininosuccinic acid synthetase deficiency (Citrullinemia, ASS-deficiency)
Aristaless-Related HomeoboxGen (ARX) related disorders
Arthrogryposis multiplex congenita (AMC)
type 2B
Arylsulfatase A-Deficiency
Ataxia teleangiectasia
ATM-gene polymorphisms (1066-6 T>G, L1420F, T7271G) for breast cancer risk
Autoimmune polyendocrinopathy candidiasis-ectodermal dystrophy (AIRE-gene)
AZF factor, Ychromosomal deletions
BCR/ABL Chronic myeloic leukemia; t(9;22), bcr/abl (210)
Beckwith-Wiedemann
syndrome
(WBS
methylation
status
of
KCNQ1-gene
- UPD analysis of 11p (for a total of 3 samples - Patient and Parents)
Bloch
Sulzberger-Syndrome
or
Incontinentia
pigmenti
deletion
or
(for
(IP2;
I
Brachydactyly type C (CDMP1-gene)
BRCA1/2
Breast-/Ovarian
cancer
please contact us for information about seperate BRCA1 or BRCA2 testing
Burkitt's lymphoma
Byler-disease (PFIC1)
gene
CADASIL
first
stage
(exons
3-6;
about
second stage (remaining exons of the total 33 coding exons)
Carbamyl phosphate synthase I deficiency (CPSI-deficiency )
Carnitin-Palmitoyl_Transferase I deficiency
Carnitin-Palmitoyl_Transferase II deficiency
Ceroid lipofuscinosis, neuronal 2, late infantile type
CHARGE-association
CHEK2-gene polymorphisms (1100 delC; 1214 del4bp) for breast cancer risk
Chloride Diarrhea, familial (SLC26A3-gene)
Chondrodysplasia, Grebe type (CDMP1-gene)
Chorea Huntington
147
88%
of
know
Chronic
primary
secondary
screen
Granulomatous
(CYBB
screen
and
exon
2
(CYBAand
Cleidocranial Dysplasia (RUNX2-gene)
Congenital Alveolar Proteinosis
SFTP
all
10
Congenital nephrotic syndrome (NPHS1)
Craniosynostosis, FGFR associated
Crigler Najjar Type 2
Cystic fibrosis (Middle East Panel)
Cystic
fibrosis
(stage
1:
(stage 2: deletion analysis of the CFTR-gene)
Cystic
fibrosis
(not M.E. panel)
Cystinosis
Cytochrome P450
33
most
complete
common
sequencing
mutations
in
of
the
the
Caucasi
CYP1A2-gene
Dentato-Rubro-Pallido-Luysiane Atrophie (DRPLA)
Denys-Drash syndrome (DDS)
Dihydropteridine Reductase Deficiency (DHPR)
Dihydropyrimidine
(5-fluorouracil-associated toxicity)
Duchenne/Becker muscular dystrophy
Dehydrogenase
(DMD)
deletion
point mutation
Dysautonomia (familial) or Riley Day Syndrome
Dystonia, dopa responsive
Dystonia, torsion
Ehlers-Danlos syndrome type VIIA/B (EDS)
Factor II (Prothrombin mutation)
Factor V gene (Leiden mutation)
Factor X deficiency
familial adenomatous polyposis (FAP)(APC-gene)
familial chloride diarrhea (SLC26A3-gene)
Familial Mediterranen fever (FMF) 1st stage
Familial Mediterranen fever (FMF) 2nd stage incl. 1st stage
Familial Mediterranen fever (FMF) 3rd stage incl. 1st and 2nd stage
Fanconi anemia
Fascioscapulohumeral Muscular Dystrophy (FSHD)
148
(DPD)
analy
Fatty acid oxidation disorder (functional assay: Acylcarnitin profile)
Fragile X syndrome (FMR 1 gene)
Friedreich Ataxia
Galactosemia
Glucocorticoid Deficiency (MC2R-gene)
Glucose Transporter Type 1 (Glut-1) Deficiency Syndrome (SLC2A1-gene)
Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency
Glutathione S-transferase gene (GST)
GSTP-gene
Glycogen storage disease type 1b (GSD1b; G6PT1-gene)
Glycogen storage disease type 3b (GSD3b; AGL-gene)
GM-CSF receptor (Exon 13)
Haemochromatosis gene
Hallervorden-Spatz disease
Hemophilia A
complete gene analysis
Hemophilia B
Hereditary
Motor
and
Sensory
Neuropathy
Stage
1
Stage 2 (Exon 2+3 MPZ + Exon 2 Cx32
Stage 3 (PMP22)
Stage 4 (ERG2)
Stage 5 (PRX)
Holocarboxylase Synthetase Deficiency
Hypercholesterinemia LDL-receptor gene analysis
Hypereosinophilic
RT-PCR
CKIT D816 Mutation
CKIT Exon 11 Mutatuion
Hyperexplexia (Kok disease)
Hyper-IgD syndrome
Hyper-IgM-Syndrome
Hypochondroplasia (HCH)
hypokalemic periodic paralysis type 1 and 2
Hypophosphataemia (autosomal dominant)
Hypophosphataemia (X-linked)
Kearns-Sayre-Syndrome
Kniest Dysplasia (COL2A1-gene)
Lactose intolerance
Lafora-Syndrome (EPM2A and EPM2B-gene)
149
(HM
FIP1L1-PDG
LDL-receptor gene
Leber's hereditary opticus neuropathy (LHON)
Lesh-Nyhan Syndrome
Limb girdle muscular dystrophy LGMD type 2A
Limb girdle muscular dystrophy LGMD type 2B
Limb girdle muscular dystrophy LGMD type 2B
Limb girdle muscular dystrophy LGMD type 2F
Lowe-Syndrome
Lymphoma (B-cell receptor rearrangement; IgH rearrangement)
Lymphoma t(11;14) translocation
Lymphoma t(14;18) translocation
Marfan syndrome
Maturity-Onset Diabetes of the Young type 3 (Mody III)
Medium chain acyl CoA dehydrogenase deficiency (MCAD-deficiency)
MELAS
Menkes disease (functional test)
MERRF
MERRF, MELAS und NARP
Metaphyseal chondrodysplasia (Schmid type) (MCDS) = hot spot analysis
Metaphyseal chondrodysplasia complete gene analysis incl. hot spots
Methylenetetrahydrofolate reductase (MTHFR)
Microsatellite analysis (maternal contamination of fetal specimen)
Mitochondrial DNA Depletion Syndrome
Morbus Gaucher Type I
Morbus Meulengracht (UGT1A1 promotor TA insertion)
Morbus Pompe (functional assay)
Morbus Wilson
Mucopolysaccharidosis
type
Sanfilippo syndrome A, Sulfamidase deficiency, Heparan sulfate sulfatase deficiency
Multidrugresistance gene (MDR1)
Multiple endocrine neoplasia type 1 (MEN1)
Multiple endocrine neoplasia type 2 (MEN 2a) (MEN 2b)
Muscular dystrophy, congenital, 1A (MDC1A; LAMA2-gene)
Myeloproliferative disorders (JAK2-gene mutation V617F)
Myotonic dystrophy type 1 (Curshmann-Steinert)
Myotonic dystrophy type 2
N-acetyl glutamate synthetase deficiency (NAGS-deficiency )
N-Acetyltransferase 2 (NAT2)
Nail-Patella Syndrome (NPS)
150
IIIA
Neurofibromatosis type 1 (NF-1)
Neurofibromatosis type 2 (NF-2)
Niemann-Pick-disease type A or B
genetic
Niemann-Pick-disease type C
genetic
Noonan-Syndrome
Norrie disease
Oculopharyngeal muscular dystrophy (OPMD)
Ornithine transcarbamylase deficiency (OTC-deficiency)
Osteogenesis imperfecta Type I
Osteopetrosis
PAI-1 Gene analysis
Parkinson`s diasease (SNCA-gene)
Paternity
testing
each additional child
further
person
at
a
later
complex (parents, 1 child)
each additional child
further person at a later date to case already completed
date
to
simple
(pare
case
alre
Pelizaeus-Merzbacher Disease
sequencing
Prader Willi syndrome (molecular genetic analysis)
Primary lateral sclerosis (Alsin-gene)
Progressive Myoclonic epilepsy (EPM2A or EPM2B-gene)
Progressive Myoclonic epilepsy (Lafora-Syndrome: EPM2A and EPM2B-gene)
Progressive
Myoclonic
epilepsy
expansion 12-bp Repeat
three point mutations
Retinoblastoma
sporadic cases
Rett sydrome (MECP2-gene)
Rhesus (Rh) incompatibility
Sensorineural Hearing Loss (SNHL)(Cx26)
Sickle cell anemia
Sjögren-Larsson-Syndrome
Smith-Lemli-Opitz-syndrome
genetic
Sotos-Syndrome
spastic paraparesis type 3; spastic paraplegia type 3
151
(Unverricht-Lundborg
spastic paraparesis type 4; spastic paraplegia type 4
spastic paraparesis type 7; spastic paraplegia type 7
spinal muscular atrophy (SMA; SMN1- Gene)
Spinocerebellar ataxia (SCA 3)
Spinocerebellar ataxia (SCA 1,2,3,6,7, and 17)
Spondyloepimetaphyseal dysplasia, congenital type
Stickler Syndrome type1
Succinate dehydrogenase (subunits B and D)
Surfactant
Protein
B
Deficiency
Tay
Sachs:
Jewish
(congenital
Alveolar
Proteinosis;
4
all 10 exons
GM-CSF receptor (Exon 13)
Screening
(805G>A;1278insTATC;
IVS12+1G>C
complete HEXA-gene
T-cell receptor (TCR) gamma rearrangement
Thalassemia,
Haemogram (required for genetic analysis)
(required for genetic analysis)
molecular genetic analysis
Thalassemia,
Haemoglobin
differentiation
(required
molecular genetic analysis
Haemo
for
Thanatophoric dysplasia (TD I an II)
Thiopurine Methyltransferase (TPMT) deficiency
Thyroid hormon-resistance (THRß-gene)
tuberous sclerosis (TSC1 and TSC2)
tumor necrosis factor receptor-associated periodic syndrome (TRAPS)
Uniparental
disomy
2, 4, 5, 6, 7, 8, 10, 11, 13, 14, 15, 16, 20, 21, 22 (price per chromosome)
Usher-Syndrome type 2A
Vanishing
White
EIF2B1
EIF2B2
EIF2B3
EIF2B4
EIF2B5
all 5 genes
Very Long Chain Acyl-CoA Dehydrogenase (VLCAD) Deficiency
Von Hippel-Lindau syndrome (VHL)
deletion analysis (MLPA)
Waardenburg syndrome Type I and III (WS I/III)
Waardenburg syndrome Type II (WS II)
152
of
Matter
genetic
Wilms tumor (WT1)
Wiskott-Aldrich syndrome
X-linked familial exudative vitreoretinopathy
Zellweger syndrome
complementation
153
THERAPEUTIC DRUG MONITORING
The application of therapeutic drug monitoring to optimization of drug therapy in individual
patients should be considered an adjunct to the physician's clinical judgment in assessing the
course and effectiveness of treatment.
If the serum drug concentration does not fit the clinical picture, it may be that the effects of
disease and age or drug interactions are responsible for alterations in the pharmacokinetic
disposition of the drug. Knowledge of the drug's pharmacokinetic profile is important to
interpretation of results.
For drugs with a well-defined clinical response, small intra- and interindividual variability, and a
high therapeutic index (ie, low toxicity), there is little need for therapeutic drug monitoring. This is
especially true for acute or short-term drug therapy where there is no advantage to monitoring
drug levels. For treatment of chronic disorders, such as antihypertensive therapy, if the desired
response can be readily assessed by a noninvasive technique, such as blood pressure
monitoring, there is a low cost/benefit ratio to serial drug monitoring.
For other drugs, where there are poor dose-response relationships, optimal therapeutic efficacy
requires individualized dosing based on the laboratory measurement of serum drug
concentrations. To be effective, however, a correlation must exist between serum concentrations
of the drug and the desired pharmacologic effect (ie, a well-documented therapeutic range).
Drugs which have a narrow therapeutic window and a low therapeutic index may exhibit toxicity at
concentrations close to the upper limit of the therapeutic range and are good candidates for
clinical monitoring.
Pharmacokinetic Concepts and Terminology
The time course following administration of a drug is characterized by individualized patterns of
absorption, distribution, metabolism, and elimination.
Absorption is defined as the crossing of drugs through various sites (intestines, muscle, etc) into
the circulatory system. For oral administration, absorption takes place in the gastrointestinal (GI)
tract. Drugs with limited solubility, such as phenytoin, may be poorly absorbed from the GI tract
and may result in low serum levels. Most orally administered drugs are rapidly absorbed and
154
reach peak serum concentrations within 1-2 hours (see Figure
1).
The drug distribution phase is the time required for the drug to penetrate and equilibrate with its
site of action and other extravascular tissues. The pharmacokinetic term used to express the
apparent volume of distribution is its Vd. The Vd is calculated by dividing administered drug dose
by the actual serum drug concentration achieved. This volume does not necessarily pertain to a
physiological space but is conceptually regarded as a single body compartment to account for all
drug within the body (see Equation 1).
Vd =
dose
[serum]
A drug's volume of distribution is inversely proportioned to the degree of plasma protein binding.
Drugs such as warfarin and ibuprofen which are extensively bound to plasma proteins (>97%)
have a very low Vd.
The degree of plasma protein binding has a significant impact on drug distribution and the
pharmacologic activity of the drug. The total drug concentration in plasma is comprised of proteinbound drug, bound to proteins such as albumin and alpha-1-acid glycoprotein, and drug that is
unbound, or free.
It is the free drug that is physiologically active and exerts a pharmacologic effect. The proteinbound drug is inactive because conformationally it is too large a molecule to cross cell
membranes and bind with drug receptor sites at the target organ.
155
Alterations in the degree of plasma protein binding by drug interactions, age, and disease can
completely change our interpretation of drug levels and their biological effect. An excellent review
of these phenomena has been presented by Cross and Longa.1
Metabolism and elimination determine the duration of the drug's pharmacologic activity and are
the result of biotransformations that take place primarily within the liver and are followed by
excretion by the kidneys.
Drugs undergo hepatic metabolism to produce more soluble forms as a means of detoxification
and subsequent elimination through renal excretion. Clearance of a drug by glomerular filtration is
reduced in patients with decreased renal function and will affect the biologic or elimination halfhalf-life
t1/2 of the drug. The t1/2 is the time required to reduce the plasma concentration by one-half.
Increases in half-life caused by disease and age or drug interactions will significantly effect serum
drug levels and may produce toxicity in patients if the amount of the dose and the dosing
schedule is not appropriately modified.
SteadySteady-state drug concentrations provide the best correlation between serum drug concentrations
and clinical status (see Figure 2). At steady-state the amount of drug being eliminated from the
body is equal to the amount administered. The steady-state drug concentration is usually
achieved after three to five half-lives of a given drug. Loading doses circumvent the necessity of
waiting
156
three to five half-lives to achieve a maximum therapeutic
effect.
The dosing interval and the biologic half-life determine the extent of drug accumulation. As seen
from Figure 3, patients receiving a drug at a dosing interval longer than the half-life of the drug
will exhibit large fluctuations between the peak and trough levels. Shorter intervals lead to less
variation. To be effective the serum concentration must be maintained within the therapeutic
range for the
drug.
157
The therapeutic range is defined as the range of serum drug concentrations associated with the
desired therapeutic effect and a low risk of toxicity in the majority of patients. Some patients may
require serum levels exceeding the upper limit and some below the lower limit to realize optimum
benefit from the drug. The therapeutic range should be viewed only as a guide to establishing the
appropriate serum concentration for each patient.
Timing of Specimen Collection
Ideally, for therapeutic drug monitoring, the specimen should be collected after the absorption
and distribution phases are complete and steady-state has been achieved. Drug levels obtained
before steady-state has been achieved could be interpreted improperly as being subtherapeutic
and prompt an increase in dosage. This could result in toxicity.
For routine serum monitoring of drugs with short half-lives, such as the aminoglycosides, both a
steady-state peak and trough level should be obtained. Refer to the specific drug for collection of
peak levels. Trough levels are collected just prior to the next dose. For drugs with a long half-life,
steady-state trough levels provide sufficient clinical information.
To determine possible toxicity, a specimen collected at any time following administration of the
drug is generally adequate. To determine half-life at least two specimens should be collected
after the peak sampling interval and before administration of the next dose. Half-lives may be
helpful in establishing possible toxicity and the need for therapeutic intervention.
Altered Pharmacokinetics
In vivo disposition of drugs varies with age and disease and with drug-drug interactions. These
factors are responsible for the intra- and interindividual variations encountered and make sound
clinical interpretation a scientific challenge.
Age
There are age-related pharmacokinetic differences among the neonate, infant, child, pubescent
child, adult, and geriatric adult that can be attributed to changing metabolic functions and proteinbinding characteristics.
Metabolic rates and metabolic pathways for microsomal enzymatic biotransformations and
clearance of drugs change significantly as a newborn infant matures. Neonates clear drugs very
slowly, progressing to much faster in infants and children as compared to adults. For example,
approximately 25% of a dose of theophylline is metabolized to caffeine in the neonate, while this
pathway is insignificant in children and adults.2
158
As a general rule of thumb, children metabolize drugs twice as fast as adults and need higher
maintenance doses to obtain the same therapeutic effect. As a child enters puberty, the rate may
slow abruptly and drug levels should be monitored carefully to avoid toxicity.
In geriatric patients, drugs are cleared at a slower rate than adults due to a combination of
decreasing metabolic activity and the onset of reduced renal function. Dosages must be scaled
back to account for these alterations in drug disposition in order to avoid toxicity.
Drugs that are highly bound to serum proteins are affected significantly by changes in protein
concentration or binding affinities. Any factor that disturbs the equilibrium between bound and
free drug will exert a pharmacologic effect as the % free is increased or decreased.
For example, neonates have a higher % free of phenytoin because of displacement by
unconjugated bilirubin at albumin binding sites. The lower therapeutic range for phenytoin in
neonates (6-15 g/mL) reflects the higher percentage of biologically active free phenytoin.
In geriatric patients who typically have lowered serum albumin concentrations, or patients of any
age that have decreased albumin levels because of disease, the % free drug is increased
because of the limited number of albumin binding sites. Consequently, these patients should be
maintained at lower total drug levels.
From Equation 1 it can be seen that the serum concentration is inversely proportional to the Vd.
Any changes in the volume of distribution will impact the serum drug level. Increases in body fat
will increase the volume of distribution for lipophilic drugs and decrease the volume of distribution
for hydrophilic drugs. The converse would be true for decreases in the percentage of body fat.
As people age, total body water decreases, lean body mass is reduced, and the percentage of
body fat increases. Lipid-soluble drugs such as desmethyldiazepam, a metabolite of diazepam,
are stored in a increasingly larger body compartment. This will temporarily decrease the serum
level of the drug and will prolong the half-life from an average of 20 hours at age 20-90 hours at
age 803. If the drug is prescribed as a maintenance dose the available lipid binding sites will
become saturated and the serum concentration of the drug will begin to increase. Therapeutic
monitoring will prevent toxicity from developing.
Disease Processes
Renal glomerular disease reduces the clearance of drugs and drug metabolites and increases its
biologic half-life as manifested by an increase in serum concentration. For the aminoglycosides,
159
such as gentamicin and tobramycin, which themselves are nephrotoxic, this can have a
significant impact.
Protein-losing enteropathies and hyperalbuminuria due to renal glomerular disease will interfere
with the normal protein-binding characteristics of the drug and will increase the amount of the
pharmacologically active free form. This was alluded to above under AGE.
AGE
Hepatic disease may lead to hypoalbuminemia and increase the free drug fraction. Also, for those
drugs that are cleared by the liver, such as propranolol or lidocaine, reduced cardiac output, as in
congestive heart failure, will result in higher serum levels due to reduced hepatic perfusion.
Drug-Drug Interactions
If given a choice, single drug therapy is preferable to multiple drug therapy. The practice of
polypharmacy to treat multiple disease processes, especially in elderly patients, creates potential
problems in properly interpreting drug levels and adjusting dosage.
Whenever another drug is added to the regimen, drug levels should be obtained after three to five
half-lives to evaluate possible drug-drug interactions.
Examples of drug-drug interactions are abundant in the medical literature. For example,
phenytoin, which is usually about 90% protein-bound, is affected by concomitantly prescribed
drugs that can displace phenytoin from its albumin attachment. In particular, valproic acid can
increase the free fraction of phenytoin by 30% to 100%. Phenytoin toxicity may develop at
therapeutic serum concentrations. Monitoring free drug levels would provide more clinically
relevant information than total drug levels in cases such as this.
Patients on digoxin that are subsequently prescribed quinidine should be closely monitored to
avoid possible toxicity. Quinidine decreases the renal clearance of digoxin, thus prolonging the
half-life of digoxin, and this could lead to digitalis toxicity if the dose of digoxin is not reduced.
Footnotes
1. Longa GJ and Cross RE, "Laboratory Monitoring of Drug Therapy. Part II: Variable Protein
Binding and Free (Unbound) Drug Concentration,"Bulletin of Laboratory Medicine, 1984, 80:1-6.
2. Thomson AH, "Therapeutic Drug Monitoring in the Neonate,"Syva Monitor, 1993, 11(1):1-5.
3. Jenike MA, "Psychoactive Drugs in the Elderly: Antipsychotics and Anxiolytics,"Geriatrics, 1988,
43(9):53-4.
160
SI UNIT CONVERSION TABLE
Analyte
Acetaminophen (Datril®, Tylenol®),
serum
Conventional
Units
Conventional
to SI
(multiply by)
SI Units
g/mL
6.62
units/L
NA
units/L
NA
Adrenocorticotropic hormone (ACTH) pg/mL
1
ng/L
1
Alanine aminotransferase (ALT)
units/L
NA
units/L
NA
Albumin, serum
g/dL
10
g/L
0.10
Aldolase, serum
units/L
NA
units/L
NA
ng/dL
0.0277
nmol/L
36.10
2.77
nmol/d
0.361
Acid phosphatase
mol/L
SI to
Conventional
(multiply by)
0.151
Aldosterone
serum
urine
g/24 h
Alkaline phosphatase
units/L
NA
units/L
NA
Alpha1-antitrypsin
mg/dL
0.01
g/L
100
g/mL
1
mg/L
1
ng/mL
1
g/L
1
Alpha1-fetoprotein
amniotic fluid
serum
Aluminum, serum
g/L
0.0371
mol/L
26.95
Amikacin, serum
g/mL
1.71
mol/L
0.585
161
Conventional
Units
Analyte
Aminolevulinic acid (delta), urine
Conventional
to SI
(multiply by)
SI Units
SI to
Conventional
(multiply by)
mg/24 h
7.626
mol/d
0.131
g/dL
0.59
mol/L
1.69
Amylase, serum
units/L
NA
units/L
NA
Androstenedione
ng/dL
0.0349
nmol/L
28.7
Angiotensin converting enzyme (ACE) units/L
1
units/L
1
Antidiuretic hormone (ADH)
(vasopressin)
1
ng/L
1
Ammonia, plasma
pg/mL
Arsenic
blood
g/L
0.0133
mol/L
75.2
urine
g/L
0.0133
mol/d
75.2
Aspartate aminotransferase (AST)
units/L
NA
units/L
NA
direct
mg/dL
17.1
mol/L
0.0584
total
mg/dL
17.1
mol/L
0.0584
Bilirubin, serum
Bromide, plasma
g/mL
0.0125
mmol/L
799
blood
g/L
8.897
nmol/L
0.112
urine
g/g creatinine
8.897
mol/g
creatinine
0.112
Caffeine, serum
g/mL
5.15
mol/L
0.194
Cadmium
Calcitonin
pg/mL
1
ng/L
1
ionized
mg/dL
0.25
mmol/L
4
serum
mg/dL
0.25
mmol/L
4
urine
mg/24 h
0.025
mmol/d
40
g/mL
4.23
mol/L
Calcium
Carbamazepine (Tegretol®), serum
0.236
Carbon dioxide
mEq/L
1
mmol/L
1
Carboxyhemoglobin
%
NA
%
NA
Carcinoembryonic antigen (CEA)
ng/mL
1
g/L
1
mol/L
53.7
Carotene, serum
g/dL
0.0186
Catecholamines, fractionation, urine
g/24 h
5.91
Ceruloplasmin
Chloramphenicol, serum
mg/dL
g/mL
162
nmol/d
0.169
10
mol/L
0.10
3.09
mol/L
0.323
Conventional
Units
Analyte
Chlordiazepoxide (Librium®), serum
g/mL
Conventional
to SI
(multiply by)
3.3
SI Units
mol/L
SI to
Conventional
(multiply by)
0.303
Chloride
serum
mEq/L
1
mmol/L
1
urine
mmol/24 h
1
mmol/d
1
Cholesterol
mg/dL
0.0259
mmol/L
38.61
HDL
mg/dL
0.0259
mmol/L
38.61
LDL
mg/dL
0.0259
mmol/L
38.61
Cholinesterase, serum
units/L
1000
kU/L
0.001
g/L
19.2
nmol/L
0.052
ng/mL
3.17
nmol/L
0.316
Codeine, serum
ng/mL
3.34
nmol/L
0.299
Complement C3 activator
mg/dL
10
mg/L
0.10
Chromium, plasma
TM
Clonazepam (Klonopin
), serum
Compound S (11-deoxycortisol)
g/dL
0.029
mol/L
34.5
serum
g/L
0.0157
mol/L
63.7
urine
g/24 h
0.0157
mol/d
63.7
blood
g/dL
15
nmol/L
0.067
fluid
g/g
1.5
nmol/g
0.67
urine
g/24 h
1.5
nmol/d
0.67
blood
g/dL
27.6
nmol/L
0.036
urine
g/24 h
2.76
nmol/d
0.362
Copper
Coproporphyrins
Cortisol
C-Peptide, serum
ng/mL
0.33
nmol/L
3.03
Creatine kinase (CK)
units/L
NA
units/L
NA
serum
mg/dL
88.4
mol/L
0.0113
urine
mg/kg/24 h
8.84
mol/kg/d
0.113
mg/24 h
0.0088
mol/d
113.1
Creatinine
Cyanide, blood
g/mL
38.4
mol/L
0.026
Cyclic AMP, urine
g/L
3.04
mol/L
0.329
8.32
mol/24 h
0.120
Cystine, urine
mg/24 h
163
Analyte
DHEA
Conventional
Units
ng/dL
Conventional
to SI
(multiply by)
0.0347
SI Units
nmol/L
SI to
Conventional
(multiply by)
28.8
DHEA sulfate
g/dL
0.026
mol/L
38
Diazepam (Valium®), serum
g/mL
0.0000035
mol/L
286
Digitoxin
ng/mL
1.31
nmol/L
0.765
Digoxin (Lanoxin®)
ng/mL
1.28
nmol/L
0.781
g/mL
2.95
mol/L
0.339
Doxepin (Sinequan®), serum
ng/mL
3.58
nmol/L
0.279
Erythropoietin
mIU/mL
1
IU/L
1
Estradiol (E2), serum
pg/mL
3.67
pmol/L
0.272
Estriol (E3), serum
ng/mL
3.47
nmol/L
0.288
Estrone (E1), serum
pg/mL
3.70
pmol/L
0.27
Ethanol, blood
g/dL (%)
217
mmol/L
0.00461
g/mL
7.08
mol/L
0.141
mol/L
0.0621
Disopyramide (Norpace®), serum
Ethosuximide (Zarontin®), serum
Ethylene glycol, serum
mg/L
16.1
Fecal fat
g/24 h
1
Ferritin, serum
ng/mL
1
g/L
1
52.6
mol/L
0.019
Fluoride, plasma
g/mL
g/d
1
Folate
red cell
ng/mL
2.265
nmol/L
0.442
serum
ng/mL
2.265
nmol/L
0.442
Follicle stimulating hormone (FSH)
mIU/mL
1
IU/L
1
Gamma glutamyl transferase (GGT)
units/L
NA
units/L
NA
Gastrin, serum
pg/mL
1
ng/L
1
Gentamicin, serum
g/mL
2.09
mol/L
0.478
Glucose
blood
mg/dL
0.0555
mmol/L
18.02
CSF
mg/dL
0.0555
mmol/L
18.02
urine
mg/dL
0.0555
mmol/L
18.02
Glutamine, CSF
mol/dL
10
mol/L
0.1
Fraction of total
100
Hb
Glycohemoglobin
% of total Hb
0.01
Gold, plasma
mg/L
5.08
mol/L
0.20
Growth hormone (GH)
ng/mL
1
g/L
1
164
Analyte
Conventional
Units
Conventional
to SI
(multiply by)
SI Units
SI to
Conventional
(multiply by)
Haloperidol (Haldol®), serum
ng/mL
2.66
nmol/L
0.376
Haptoglobin, serum
mg/dL
10
mg/L
0.10
Human chorionic gonadotropin (hCG),
mIU/mL
serum
1
IU/L
1
17-Hydroxycorticosteroids (17OHCS), urine
2.76
mol/d
0.362
5-Hydroxyindoleacetic acid (5-HIAA),
mg/24 h
urine
5.2
mol/d
0.19
17-Hydroxyprogesterone
ng/dL
0.030
nmol/L
33.0
Imipramine (Tofranil®), serum
ng/mL
3.57
nmol/L
0.280
mIU/L
1
mg/24 h
Insulin, blood
IU/mL
1
Iron
g/dL
0.179
mol/L
5.587
Iron binding capacity, total (TIBC)
g/dL
0.179
mol/L
5.587
Isopropanol, blood
g/dL (%)
16.6
mmol/L
0.06
17-Ketogenic steroids, urine
mg/24 h
3.467
mol/d
0.288
17-Ketosteroids
mg/24 h
3.467
mol/d
0.288
Lactate dehydrogenase (LD)
units/L
NA
units/L
NA
blood
mg/dL
0.111
mmol/L
9.01
CSF
mg/dL
0.111
mmol/L
9.01
blood
g/dL
0.0483
mol/L
20.70
urine
g/24 h
0.00483
mol/d
207.04
Lidocaine (Xylocaine®), serum
g/mL
4.27
mol/L
0.234
Lipase, serum
units/L
NA
units/L
NA
Lipids, total
mg/dL
0.01
g/L
100
Lithium, serum
mEq/L
1
mmol/L
1
Lorazepam, serum
ng/mL
3.11
nmol/L
0.321
Luteinizing hormone (LH)
mIU/mL
1
IU/L
1
Lysergic acid diethylamide (LSD)
ng/mL
0.0031
mol/L
323
serum
mg/dL
0.4114
mmol/L
2.43
urine
mg/24 h
0.0411
mmol/d
24.31
Lactic acid
Lead
Magnesium
165
Analyte
Conventional
Units
Conventional
to SI
(multiply by)
SI Units
SI to
Conventional
(multiply by)
Manganese
plasma
g/L
18.2
nmol/L
0.055
urine
g/L
18.2
nmol/L
0.055
blood
g/L
0.005
mol/L
200
urine
g/L
0.005
mol/d
200
ng/mL
0.004
nmol/L
247
5.07
nmol/d
0.197
Mercury
Meperidine (Demerol®), serum
Metanephrines, urine
g/24 h
Methadone, serum
ng/mL
0.00323
Methanol, blood
g/dL (%)
312
mmol/L
0.0032
g/mL
5.29
mol/L
0.189
1
g/L
1
g/mL
3.61
mol/L
0.277
Nortriptyline (Aventyl®), serum
ng/mL
3.80
nmol/L
0.263
5± Nucleotidase
units/L
NA
units/L
NA
serum
mOsm/kg
NA
mmol/kg
NA
urine
mOsm/kg
NA
mmol/kg
NA
Oxalate, urine
mg/24 h
11.4
mol/d
Parathyroid hormone, intact
pg/mL
1
Methsuximide (Celontin®), serum
Myoglobin, serum
N-Acetylprocainamide (NAPA), serum
ng/mL
mol/L
309
Osmolality
Pentobarbital (Nembutal®), serum
ng/L
0.088
1
g/mL
4.42
mol/L
0.266
ng/mL
4.11
nmol/L
0.243
Phenobarbital, serum
g/mL
4.31
mol/L
0.232
Phenylalanine, blood
mol/dL
10
mol/L
0.1
free
g/mL
3.96
mol/L
0.253
serum
g/mL
3.96
mol/L
0.253
total
g/mL
3.96
mol/L
0.253
Phencyclidine (PCP), serum or urine
Phenytoin (Dilantin®)
Phosphorus
serum
mg/dL
0.323
mmol/L
3.10
urine
g/24 h
32.3
mmol/d
0.031
Porphobilinogen (PBG), urine
mg/24 h
4.42
mol/d
0.226
166
Conventional
Units
Analyte
Conventional
to SI
(multiply by)
SI Units
SI to
Conventional
(multiply by)
Potassium
blood
mEq/L
1
mmol/L
1
urine
mEq/24 h
1
mmol/d
1
Pregnanediol, urine
mg/24 h
3.12
mol/24 h
0.321
Pregnanetriol, urine
mg/24 h
2.97
mol/24 h
0.337
Primidone (Mysoline®), serum
g/mL
4.58
mol/L
0.218
Procainamide (Pronestyl®), serum
g/mL
4.23
mol/L
0.236
Progesterone
ng/mL
3.18
nmol/L
0.314
Prolactin
ng/mL
1
g/L
1
Propoxyphene (Darvon®), serum or
urine
ng/mL
0.003
mol/L
339
Propranolol (Inderal®), serum
ng/mL
3.86
nmol/L
0.259
CSF
mg/dL
10
mg/L
0.10
serum
g/dL
10
g/L
0.10
urine
mg/24 h
0.001
g/d
1000
Protoporphyrin, free erythrocyte (FEP)
g/dL
0.0178
mol/L
56.18
Protoporphyrin, zinc (ZPP)
g/dL
0.016
mol/L
62.5
Quinidine, serum
g/mL
3.08
mol/L
0.250
g/mL
0.00724
mmol/L
138.1
g/mL
4.20
mol/L
0.238
ng/mL
0.00568
mol/L
176
blood
mEq/L
1
mmol/L
1
urine
mEq/24 h
1
mmol/d
1
T3 uptake (T3U)
%
1
AU*
1
Testosterone
ng/dL
0.0347
nmol/L
28.8
Protein
Salicylate, serum
TM
Secobarbital (Seconal
), serum
Serotonin
Sodium
Theophylline, serum
g/mL
5.55
mol/L
0.18
Thiocyanate, serum
mg/dL
172
mol/L
0.0058
Thyroglobulin
ng/mL
1
g/L
1
Thyroid-stimulating hormone (TSH)
IU/mL
1
mIU/L
1
Thyroxine binding globulin (TBG)
g/mL
1
mg/L
1
Thyroxine (T4)
g/dL
12.9
nmol/L
0.0075
167
Analyte
Thyroxine, free (FT4)
Conventional
Units
SI Units
SI to
Conventional
(multiply by)
12.9
pmol/L
g/mL
2.14
mol/L
Transferrin
mg/dL
0.01
g/L
100
Triglycerides
mg/dL
0.0113
mmol/L
88.5
Triiodothyronine (T3)
ng/dL
0.0154
nmol/L
65.1
Urea nitrogen, blood (BUN)
mg/dL
0.357
mmol/L
2.80
serum
mg/dL
0.059
mmol/L
16.9
urine
mg/24 h
0.0059
mmol/d
169
Tobramycin, serum
ng/dL
Conventional
to SI
(multiply by)
0.0075
0.467
Uric acid
Valproic acid (Depakene®), serum
g/mL
6.93
mol/L
0.144
Vancomycin, serum
g/mL
0.690
mol/L
1.45
mg/24 h
5.05
mol/d
0.198
mol/L
28.65
Vanillylmandelic acid (VMA), urine
Vitamin
A
g/dL
0.0349
B6
ng/mL
4.046
nmol/L
0.247
B12
ng/mL
738
pmol/L
0.001355
C
mg/dL
56.78
D3 (calcitriol, 1,25-dihydroxy)
pg/mL
2.4
E
mg/L
2.322
mol/L
0.43
3.24
mol/L
0.308
mg/dL
0.066
mmol/L
15.01
serum
g/dL
0.153
mol/L
6.54
urine
g/24 h
0.0153
mol/d
65.36
Warfarin (Coumadin®), serum
Xylose, plasma
g/mL
mol/L
0.018
pmol/L
0.417
Zinc
NA = not applicable.
AU = arbitrary unit.
168
169
Alphabetical Index of Procedures
Glucose, Serum ............................................. 28
Gram's Stain .................................................. 29
HCG ............ See Human Chronic Gonadotropin
HDL .. See High Density Lipoprotein Cholesterol
Acid-Fast (Mycobacteria) Broth-Based Culture
and Smear ................................................... 12
Acid-Fast (Mycobacteria) Broth-Based Culture
and Smear and Susceptibility .................... 12
Alanine Aminotransferase ALT (SGOT) ......... 12
Albumin, Serum ............................................. 13
Alkaline Phosphatase, Serum ........................ 13
Alpha-Fetoprotein (AFP) X-tra Profile ............. 14
Amylase, Serum ............................................ 15
Amylase, Urine ............................................... 15
Antibody Screen ............................................ 16
Antinuclear Antibodies (ANA) .......................... 16
Aspartate Aminotransferase .......................... 16
Bilirubin, Direct ............................................... 17
Bilirubin, Total ................................................. 17
Bilirubin, Total and Direct, Serum ................. 17
Calcium, Serum ............................................. 19
Carbohydrate Antigen (CA) 19-9 ................... 20
Carbon Dioxide, Total .................................... 20
Chloride, Urine ............................................... 21
Cholesterol, Total ............................................. 21
Complete Blood Count (CBC) With Differential
....................................................................... 21
Cortisol ............................................................. 22
Creatine Kinase (CK), MB and Total ............... 23
Creatine Kinase (CK), Total, Serum ............... 22
Creatinine Clearance ..................................... 23
Creatinine, Random Urine .............................. 23
Creatinine, Serum .......................................... 24
Crystal Examination, Miscellaneous Fluid ..... 24
Cytomegalovirus (CMV) Antibodies, IgG ..... 24
Ferritin, Serum ................................................ 25
Fibrinogen, Quantitative .................................. 25
Folate (Folic Acid) .......................................... 25
Fructosamine ................................................. 26
GC (Neisseria gonorrhoeae) Culture Only ..... 26
Genital Culture, Routine ................................ 27
Gestational Glucose Tolerance (Diagnostic) . 27
Glucose Tolerance Test (GTT), Blood, 3
Specimens .................................................... 29
Glucose, Body Fluid ...................................... 28
Glucose, Cerebrospinal Fluid .......................... 28
Glucose, Plasma ............................................ 28
Glucose, Quantitative, Urine ............................ 28
Hematocrit ........................................................ 30
Hemoglobin (Hgb) A1c ................................... 30
Hepatitis A Antibody, IgM .............................. 31
Hepatitis A Antibody, Total ............................. 31
Hepatitis B Core Antibody, IgM .................... 31
Hepatitis B Surface Antibody, ...................... 31
Hepatitis B Surface Antigen .......................... 31
Hepatitis C Virus Antibody ............................ 31
Herpes Simplex Virus (HSV) Types I/II, IgG 32
High Density Lipoprotein Cholesterol (HDLC)
....................................................................... 32
HIV............ See Human Immunodeficiency Virus
Human Chorionic Gonadotropin (hCG), Beta
Subunit, Qualitative, Serum ...................... 32
Human Chorionic Gonadotropin (hCG), Beta
Subunit, Quantitative, Serum ..................... 32
Human
Immunodeficiency
Virus
(HIV)
Antibodies,
Preliminary
Test
With
Confirmation .............................................. 33
Human Immunodeficiency Virus 1 (HIV-1) RNA,
Quantitative ................................................ 33
Iron and Total Iron Binding Capacity (TIBC) 34
Iron, Serum .................................................... 34
Lactic Acid ...................................................... 34
Lactic Acid Dehydrogenase (LDH) ............... 35
Lipase, Serum ................................................ 35
Lipid Panel ..................................................... 35
Lower Respiratory Culture ............................ 36
Luteinizing Hormone (LH), Serum ............... 36
Magnesium, Serum ....................................... 36
Malaria SmearSee Parasite Examination, Blood
Microalbumin, 24-Hour Urine ....................... 37
Occult Blood, Stool ........................................ 37
Organism Identification, Anaerobic Bacteria 37
Organism Identification, Bacteria ................. 38
Osmolality, Serum ......................................... 38
Ova and Parasites Examination ................... 38
Ovarian Function Profile II ............................ 38
Parasite Examination, Blood ......................... 39
170
Partial Thromboplastin Time (PTT), Activated
....................................................................... 39
Phosphorus, Serum ....................................... 39
Pinworm Preparation ....................................... 40
Platelet Count .................................................. 40
Potassium, Serum ........................................... 40
Potassium, Urine ........................................... 40
Pregnancy Test, Serum .......... See HCG, serum
Pregnancy Test, Urine ................................... 41
Prenatal Infectious Disease Antibodies, IgG,
Quantitative ................................................ 41
Prenatal Profile B (With HIV Antibodies) ......... 41
Prenatal Profile I (With Hepatitis B Surface
Antigen) ....................................................... 41
Prolactin .......................................................... 42
Prostate-Specific Antigen (PSA), Serum .... 42
Testosterone, Total, Serum ........................... 47
Thyroglobulin, Quantitative ........................... 48
Thyroid Peroxidase (TPO) Antibodies .......... 48
Thyroid-Stimulating Hormone (TSH), Serum
....................................................................... 48
Thyroxine (T4) ................................................ 48
Triglycerides ................................................... 49
Tri-iodothyronine (T3) ..................................... 48
Upper Respiratory Culture, Routine ............. 49
Urea Nitrogen, Serum ................................... 49
Uric Acid, Serum ........................................... 50
Urinalysis, Complete (With Microscopic
Examination) .............................................. 50
Urine Culture, Comprehensive ..................... 50
Vitamin B12 ..................................................... 51
Vitamin B12 and Folates ................................ 51
Westergren Sedimentation Rate .................. 51
White Blood Cell (WBC) Count .................... 52
White Blood Cells (WBC), Stool .................... 52
Protein Electrophoresis, 24-Hour Urine ....... 43
Protein Electrophoresis, Body Fluid ............. 43
Protein Electrophoresis, Cerebrospinal Fluid 43
Protein Electrophoresis, Random Urine ....... 43
Protein, Total, Body Fluid .............................. 43
Protein, Total, Cerebrospinal Fluid ................ 43
Protein, Total, Quantitative, 24-Hour Urine .... 44
Protein, Total, Serum ..................................... 44
Prothrombin Time (PT) .................................... 44
Prothrombin
Time
(PT)
and
Partial
Thromboplastin Time (PTT) ........................ 44
Rapid Plasma Reagin (RPR), Qualitative Test
....................................................................... 44
Respiratory Syncytial Virus (RSV) by
Immunoassay ............................................ 45
Reticulocyte Count ......................................... 45
Rheumatoid Arthritis (RA), Quantitative, Serum
by Hemagglutination ................................... 45
Rotavirus, Direct Detection by Immunoassay
....................................................................... 45
Rubella Antibodies, IgG ................................. 45
Rubella Antibodies, IgM ................................ 45
Rubeola Antibodies, IgG ................................ 46
Sodium, Serum .............................................. 46
Sodium, Urine ................................................ 46
Stool Culture .................................................. 47
T3 Uptake ....................................................... 47
171