manual by IE1eG8

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									HAMAD MEDICAL CORPORATION


          DEPARTMENT OF
 LABORATORY MEDICINE & PATHOLOGY




 LABORATORY PROCEDURES
      FOR THE CLINICIAN




              2001
CONTRIBUTORS

Henrik Hellquist, MD, PhD, SAPath, FCAP
  Chairman of the Department

Bahram Azadeh, MD, DCP, FRCPath.
  Consultant Head - Anatomic Pathology Division

Sittana Shamseldin El Shafie, MBBS, MSc., FRCPath.
    Consultant Head - Microbiology Division

G.C. Ejeckam, MBBS, FCAP, FRCPath., FRCP(C)
   Anatomic Pathology Division

Mohd. Osman Abdel Rahman, MBBS, DCP, MRCPath.,
  Consultant Head - Chemical Pathology Division

Abdulrazzaq Haider, MD, FRCPath. (Resigned)
  Consultant Cytopathologist

Zeinab Osman Fawzi, MBBS, DCP, MRCPath.(Part II)
   Specialist - Haematology

Ajayeb Al-Marri, M.Sc., Ph.D.(Immunology), UK
   Head of Immunology Section

Amina A. Al-Zaman, M.Sc.
  Supervisor - Hematology & Cytogenetics Division
Fatima Al-Lanjawi, B.Sc.(Chemistry)
   Supervisor - Endocrinology

Fatima Abdulla, B.Sc.(Zoology)
   Supervisor - Anatomic Pathology Division

Mohd M. Al-Sayrafi, B.Sc., M.Sc.(Clin. Chemistry) (USA)
  Supervisor - Clinical Chemistry

Aisha Al-Malki, M.Sc.
   Supervisor - Blood Bank

Halima Al-Musleh, B.Sc.(Zoology/Chemistry)
  Supervisor - Haematology




                                                          1
Sabah Mohd Bujassom,
   Supervisor - Microbiology

Abdul Rahman Mohd Abdul Rahman Al Abdulla
  Incharge - Blood Donor Unit

Khadija Hassan Al-Najjar, B.Sc.(Biology)
  Sr. Technologist Incharge - Cytogenetics

Samira M. Al-Eshaq, B.Sc.(Chemistry)
  Sr. Technologist Incharge - Clinical Chemistry

Samira Ali, B.Sc.(Zoology)
  Sr. Technologist Incharge - Immunology

Naila Ali Fakhroo, B.Sc.(Zoology/Chemistry)
   Sr. Technologist - Haematology

Edgar Bondoc, B.Sc.(Med. Technology)
  Technologist - Endocrinology

Muna Ibrahim Al-Zeyara, B.Sc.(BioMed Science)
  Technologist - Cytogenetics

Tahani Waleed Al-Kuwari, B.Sc.(BioMed Science)
  Technologist - Immunology

Muna Mohd. Jaber Al-Tamimi, B.Sc.(BioMed. Science)
  Technologist - Hematology


Secretarial and Computer Work by : Hana Ali (1995)
                                             Mohd. Mushtaq Ali Khan (1995)
                                             R. Viswanath (1995)




                                                                             2
                         TABLE OF CONTENTS
                                                                                           PAGE


Introduction                                                                                     7


Chapter I :
  GENERAL INFORMATION AND INSTRUCTIONS
       Request, and Samples.............................................................. 9
       Specimen Transport................................................................. 10
       Causes of Rejecting a Specimen............................................ 10
       Criteria for Stat Testing........................................................ 11
       STAT Clinical Chemistry Tests.............................................. 12
          a Blood tests.................................................................... 12
          b Fluids............................................................................13
          c Urine Tests....................................................................13
       STAT Blood Bank Request Areas........................................... 13
       STAT Haematology Tests........................................................ 14
       STAT Microbiology Tests....................................................... 14


Chapter II
  DIVISION OF ANATOMICAL PATHOLOGY :
     Histopathology
       Handling Surgical Specimens................................................. 17
       Handling Special Case (Frozen Section)............................... 18
       Tuberculous and Fungal Cases................................................ 18
       Cervical Biopsy........................................................................18
       Lymph nodes ..........................................................................18
       Placenta ..................................................................................19
       Product of Conception and Foetuses .................................... 19
       Muscle Biopsies ..................................................................... 19
       Transport of Muscle Biopsy to the Laboratory .................... 20
       Kidney Biopsy ........................................................................ 20
       Estrogen and Progesterone Study ......................................... 21
       Electron Microscopy.............................................................. 21
       Histopathology Reports ......................................................... 21




                                                                                                       3
    Cytopathology
        Handling Cytology Specimen ................................................ 25
        Gynecological Specimen ....................................................... 25
        Non-gynecological Specimens .............................................. 25
        Miscellaneous ......................................................................... 26
        Fine Needle Aspiration (FNA)............................................... 26
        Semen analysis ........................................................................26

    Forensic Pathology
        Hospital Autopsies .................................................................       29
        Medico-legal Autopsies .........................................................           29
        Autopsy Request…………….................................................                      29
        Sudden Infant Death Syndrome (SIDS) .................................                      29


Chapter III
  CHEMICAL PATHOLOGY :
    Clinical Chemistry
        Chemistry ( Blood & Urine ).................................................               33
        Chemisty of Body Fluid..........................................................           55
        Therapeutic drug monitoring & Toxicology..........................                         59
        Miscellanious chemistry tests.................................................             65
        Tests to be introduced.............................................................        65

    Endocrinology tests.................................................................. 69

Chapter IV
  HAEMATOLOGY / CYTOGENETICS :
    Haematology
        CBC (Coulter Profile) ........................................................... 81
        Reporting of Critical Value ................................................... 82
        Peripheral smear ..................................................................... 82
        Reticulocyte count ................................................................. 82
        Sickling test ............................................................................ 83
        Malaria ................................................................................... 83
        Kleihauer test ......................................................................... 84
        Heinz body ............................................................................. 84
        Hb Electrophoresis………………………………………….. 84
        Osmotic Fragility …………………………………………….. 85
        ESR ........................................................................................ 85
        Coagulation tests citrated 3.8%...........................................…. 85


                                                                                                          4
      Tests for Heparin ....................................................................   88
      Tests for hyper coagulability state.........................................             88
      Tests for patients with suspected haemostatic defect.......……                            90
      Special Haematology...............................................................       91

    Cytogenetics
      Specimens and tests ................................................................ 97


Chapter V
  DIVISION OF MICROBIOLOGY
    Bacteriology/Parasitology
      Specimens and Request Forms .............................................. 101
      Improper Specimen and Reason for Rejection .................….. 101
      Specimen Collection and Transport....................................... 102
      Antibiotic tests ...................................................................... 102
      Blood Culture / Bone Marrow Culture.................................. 103
      Cerebrospinal fluid................................................................. 103
      Anaerobic Cultures ............................................................... 104
      Ear swabs ……...................................................................... 104
      Eye swabs ……..................................................................... 105
      Exudates Body fluids......................……………................... 105
      Synovial Fluid ....................................................................... 105
      Tissue and Biopsies ............................................................... 105
      Wound Swab ......................................................................... 105
      Scrapings .............................................................................. 106
      Nasal Swab ........................................................................... 106
      Nasopharyngeal Swab ........................................................... 106
      Sputum and Endotracheal Secretions .................................... 107
      Throat swab .......................................................................... 107
      Genital Ulcer ......................................................................... 108
      Prostatic Secretion ................................................................ 108
      Seminal fluid.......................................................................... 108
      Seminal Vesiculitis & Epididymitis………………………… 109
      Urethral Swab .........................……………………………... 109
      Vaginal & Endocervical swabs……………………………… 109
      Acid Fast Bacilli…………………………………………….. 110
      Stool specimen………………………………………………. 111
      Parasitology ………………………………………………… 112
      Classification of parasites …………………………………… 114




                                                                                                     5
Immunology tests ..................................................................……… 121
              Normal Values..............................................................…. 136


Chapter VI
TRANSFUSION MEDICIINE :
         Blood Bank
              Function.................................................................................   139
              Urgent Requests (Stat)...........................................................           139
              Routine Requests...................................................................         139
              Request Forms.......................................................................        139
              Collection of Specimens........................................................             140
              Tests Performed in the Blood Bank.......................................                    140
              Issuing Blood of blood components......................................                     141
              Transfusion reaction...............................................................         142
              Emergency tansfusion............................................................            143
              Operationg room...................................................................          143

         Donor Unit
              Blood Donor procurement policy.......................................... 147
              Blood Donation for Patients receiving blood.....................…. 147




Test Index.......................................................................................... 148


Departmental Telephone Directory................................................ 157




                                                                                                                6
                             INTRODUCTION
This laboratory, being the only one in the country serves in addition to HMC
hospitals, all Health Centers, Army and Police Clinics, Medical Commision,
Preventive Medicine and QGPC. About 3 millinon tests are performed every year
and the staff works 24 hours a day, seven days a week to meet the demands.
Clinical and some environmental specimens are examined and research is also
encouraged in this department. Since its establishment in 1982, this department
has been undergoing continuous development to keep up with the advancement in
laboratory technology. It has grown considerably in size and function and we
have felt that it is time to reorganise it to streamline its structure in order to
improve its performance and expand its investigative capabilities.            The
Department has been divided into five divisions and the divisions were further
subdivided into sections. Each division is headed by a medical consultant with
the relevant qualification and wherever appropriate, sections are headed by a
consultant specialised in that particular discipline. The divisions are Anatomical
Pathology consisting of Histopathology, Forensic Medicine and Cytopathology
sections; Chemical Pathology Division consisting of Clinical Chemistry and
Endocrinology sections; Division of Haemotololgy and Cytogenetics consisting of
Haemotology and Cytogenetics sections; Transfusion Medicine Division and
finally, the Microbiology Division with its three sections Bacteriology,
Immunology and Parasitology.
The Clinical Laboratories are expensive to run due to the high cost of equipment
and reagents. It should, therefore, be used judiciously in order to keep the
standards. There should be continuous dialogue between the Laboratory and the
Wards for better patient care. I am strongly in favour of an integrated system
where the clinicians, the haematologists, the pathologists, the microbiologists and
the clinical chemists work closly together, rather than communicating through the
phone or by paper. This manual shoud brief you on laboratory procedures and
requirements to perform tests efficiently in order to provide you with results to
your satisfaction, promptly and reliably. The manual is a product of collaborative
work of members of this department. It consists of six chapters covering general
information, guidelines and tests done in the five laboratory divisions.
Requirements for each test, type of specimen, method of collection and transport
of specimen are given. Wherever appropriate, the normal values are listed. Stat
tests done in all divisions are defined and the last pages contain an index for quick
reference and the departmental telephone directory. I hope you find it useful in
your day to day practice.


Dr. Kamal Elhag
The Editor.




                                                                                    7
Preface to the 2nd Edition



Since the first edition of "Laboratory Procedures for the Clinician" was printed in
1995, the laboratory has witnessed a continuous progress and improvements have
been achieved in several areas. A high number of new tests are now available and
are listed in this booklet as appropriate. The Laboratory Department is a
discipline of service and its major objective is to meet the daily requests from the
clinicians so to assist in good health care. However, active participation in
laboratory development and introduction of new high technology in Hamad
Laboratory are almost equally important. We can foresee major changes in the
near future with the implementation of computerisation, establishment of new
divisions and sections, etc, which will enable us to serve the hospital in an even
more appropriate, efficient and professional way. And as always, your feedback
is invaluable to us.



Dr. Henrik B. Hellquist
Chairman




                                                                                   8
CHAPTER I
GENERAL INFORMATION AND INSTRUCTIONS
1. Requests and Samples
  All routine request forms and samples are accepted daily from Saturday-
  Thursday, between 7 a.m. to 2 p.m. Stat tests are received 24 hours a day in the
  respective sections.

2. Request Forms
  a. Forms must all be properly filled by the Requesting Physician .
  b. Forms should have the following information:
  1. Patient's name, hospital number, room number, date and time of collection.
  2. Type of specimen, age, sex, clinical data, and tests requested.
  3. Medication being administered to the patient.
  c. All requested tests must be marked clearly (X) in the box to the left of the
     test name.
  d. The name and stamp of the requesting physician must be shown.

3. Specimens
  Specimens must have the following information:
  a. Patient's name, hospital number, room number, and date and time of
     collection.
  b. Always fill the plain tube first, if you have more than one type of tubes to
     fill.
  c. Please note that the color codes for anticoagulants may change with
     different brands. Please check the proper anticoagulant used.
  d. No leaking or dirty containers are accepted.
  e. Disposable plastic syringes should be used.
  f. Rapid collection with minimal stasis should be ensured.
  g. Samples should not be drawn from the site of an I.V. infusion.
  h. The right volume of blood should be drawn.
  i. Thorough mixing of blood with anticoagulant is done by inverting the
     container several times.
  j. Infectious specimens must be labeled with a precaution label.

4. 24-Hour Urine Collection
  Discard first morning specimen on day one (record the time). Collect all
  specimens during the remainder of the day and evening. Collect the first
  morning specimeday two (must be the same time as in day one) and stop
  collection.




                                                                                 9
5. Specimen Transport
  Precautions must be taken when handling blood samples to prevent infection.
  Specimens transported within the hospital should be kept in an upright
  position to prevent leakage. High-risk samples should be identified and
  carried in closed . Specimen transported from outside the hospital should be
  kept at 18-22°C in a cold box carried in a leak-proof transport box with a
  fastenable lid.

6. Releasing Results:
  a. Routine test results are released within 24 hours of receiving specimens.
  b Rest of the tests are done in batches according to laboratory schedule.
     Resultareleased within 24 hours from completing the test.
  c. Normal Range of each test is reported whenever appropriate, provided that
     the appropriate informati(No. 2) is given.

7. Causes of Rejecting a Specimen
  1.   Improper collection (wrong container).
  2.   Excessive hemolysis.
  3.   Chylous serum.
  4.   Gross contamination of the specimen.
  5.   Leaking or dirty containers.
  6.   Unlabeled or improperly labeled specimen.
  7.   Improperly filled request form.

IMPORTANT NOTE
  Physicians and other medical personnel should be aware of the laboratory
  desire and obligation to provide the most relevant and appropriate services to
  patients and should recognize that efforts to communicate potential limitations
  of specimens/tests are not efforts to limit the availability of service or avoid
  work, but are efforts to provide optimal care to patients.

INTERFERENCES
  HEMOLYSIS, LIPEMIA, ICTERISM AND MANY DRUGS, INTERFERE
  WITH MOST OF THE TESTS EITHER ANALYTICALLY OR
  PHYSIOLOGICALLY




                                                                                10
STAT REQUESTS:
CRITERIA FOR STAT TESTING
WHEN IS AN INVESTIGATION URGENT ?
Definition of Urgent Requests ( STAT)
Urgent requests are given the priority and will be accepted any day at any time.
They are defined as those where immediate results are required to save a life or
prevent severe suffering or injury. On arrival, the specimen will be processed and
the result will be telephoned or sent as soon as possible.
The following categories of tests are proposed to define the degree
of urgency and the expected Turn around Time

CATEGORY 1
TURN AROUND TIME <30 MIN.
  * The test is required to diagnose an imminent life-threatening condition.
  * Patient must exhibit clinical symptoms of a potentially life-threatening
    condition.
  * Specific therapy will be initiated in response to the test result.

CATEGORY 2
TURN AROUND TIME <1 H
  * A test is required to diagnose a non-life-threatening condition (disease) or to
    diagnose a potentially life-threatening condition, but the patient does not
    manifest the symptoms of impending death.
  * The test result is required to decide whether the patient should be admitted.
  * The test is indicated if its findings will result in significant alteration of
    therapy that can decrease patient's morbidity and possibly result in earlier
    discharge.

CATEGORY 3
TURN AROUND TIME <12 H
  * The test is useful for documenting and confirming a diagnosis or for
    establishing a prognosis, but will not result in immediate alteration of the
    therapy.
  * The test result may lead to a change of therapy, but the change need not be
    instituted immediately
  * Stat collection of the sample is required because the test is time dependent.
CATEGORY 4
TURN AROUND TIME, NOT CRITICAL
The test result cannot be justified as being needed stat by any of the above criteria
(e.g., chronic disease).




                                                                                   11
The following tests are available as STAT in the Clinical Chemistry
section:

A. BLOOD TESTS
      TEST NAME                      CATEGORY

      Alcohol                              2, 3
      ALT ( GPT)                           2, 3
      Ammonia                              2
      Amylase (Pancreatic)                 2, 3
      Anti thrombin III                    2
      AST (GOT)                            2, 3
      Bicarbonate                          2
      Bilirubin, Direct ( pediatrics only ) 2
      Bilirubin, Total                     2

Bilirubin is used to guide the therapy of neonatal jaundice and may indicate the
need for an exchange transfusion. Bilirubin, therefore, should be available as a
stat test for pediatrics only.

  -    Blood gases                         1, 2
  -    Calcium                             1, 2
  -    Carboxy hemoglobin                  1, 2
  -    Chloride                            2
  -    Creatine kinase                     3
  -    Creatine kinase-MB                  3
  -    Creatinine                          2, 3
  -    Fibrinogen                          2
  -    Glucose                             1, 2, 3
  -    Iron ( in suspected iron            2
       poisoning only )
  -    Lactic acid                         2
  -    Osmolality ( Calculated )           2, 3
  -    Phosphorus ( pediatrics only )      2, 3
  -    Pseudo cholinesterase               2, 3
  -    Potassium                           1, 2
  -    Sodium                              1, 2, 3
  -    Urea nitrogen                       2




                                                                              12
THERAPEUTIC DRUGS
TEST NAME                   CATEGORY

 -   Acetaminophen             2, 3
 -   Acetylsalicylic Acid      2, 3
 -   Carbamezepine             1, 2, 3
 -   Digoxin                   2, 3
 -   Ethosuximide              1, 2, 3
 -   Phenobarbital             1, 2, 3
 -   Phenytoin                 1, 2, 3
 -   Primidone                 1, 2, 3
 -   Theophylline              2, 3
 -   Valproic Acid             1, 2, 3

FLUIDS
TEST NAME                   CATEGORY

 - CSF Glucose                 2, 3
 - CSF Protein                 2, 3

URINE
TEST NAME                   CATEGORY

 - Osmolality                   3
 - Potassium                    3
 - Sodium                       3

Test from the following areas are considered STAT in Blood Bank
TEST NAME                           CATEGORY

 -   Accident & Emergency             1,2
 -   Operating theatre, Recovery room 1,2
 -   Labour room                      1,2
 -   SICU                             1,2
 -   Dialysis Unit                    1,2
 -   Any requests coming from any ward in case of bleeding will be treated as stat.


NOTE : Blood and blood components prepared for patients are
            reserved for two days only.




                                                                                 13
The following tests are available as STAT in the Haematology section:

TEST NAME                                          CATEGORY

 -   Coulter Profile                              1,2
 -   Differential Count                           3
 -   Malaria Parasite                             2
 -   Prothrombin Time (PT)                        1,2
 -   Activated Partial Thromboplastin Time (APTT) 1,2
 -   Thrombin Time (TT)                           1,2
 -   Fibrinogen Degradation Products (FDP)        2
 -   Sickle Cell Screen                           1,2
     If the patient is going for surgery

 If the clinician needs any other test as stat, he should contact the consultant..



The following tests are available as STAT in the Microbiology section:
TEST NAME Categories are not applicable for Microbiology tests.

 ·            Cerebro-Spinal Fluid (C.S.F.).
 ·            Blood cultures.
 ·            Swab for Diphtheria.
 ·            Throat swab, urine and stool from Pediatric.
 ·            Sputum samples from patients with post influeral pneumonia.
 ·            Specimens from neonates.
 ·            Specimens collected from patients during surgery.
 ·            Specimens from suspected Gas Gangrene.
 ·            Specimens collected by special procedures e.g. Bronchial lavage
              Biopsy, Aspirated Fluids (peritoneal, synovial etc.)
 ·            Specimens collected from patients prior to commencement of
              antibiotic therapy.




                                                                                     14
  HISTOPATHOLOGY PROCEDURES


         Division of Anatomic Pathology



                     Prepared By


           Fatima Abdulla, B.Sc.(Zoology)

       Supervisor - Anatomic Pathology Division



G.C. Ejeckam, MBBS, FCAP, FRCPath., FRCP(C) (1995)

            Anatomic Pathology Division



                    Reviewed By


     Bahram Azadeh, MD, DCP, FRCPath. (2001)

         Head of Anatomic Pathology Division




                                                     15
16
INTRODUCTION
  Anatomic Pathology Division is made up of four sections at the moment viz.
  Histopathology, Cytology, Forensic Medicine and Electron-microscopy.

  The unifying concept for all these sections is the examination of tissues and
  cells whether obtained by biopsy, aspiration, excision or by cytological
  procedures on a living patient and at autopsy.

HANDLING OF SURGICAL SPECIMENS
  A) All specimens should be sent in 10% buffered formalin. This solution is
     available at the Histopathology Laboratory.
  B) Specimen from different sites, for example; fractional curettages of
     endometrium and endocervix should be sent in separate containers.
  C) Large specimen should be sent in large containers and on the same day of
     the surgery preferably and where possible.
  D) Squeezing of big specimen through "turtle neck" container is undesirable
     and should be strongly discouraged.
  E) Large specimen such as uterus can be opened horizontally from the Os to
     the fundus in a clean single incision. This will ensure proper fixation of the
     endometrial and endocervical contents.

Method :
  This can be achieved easily by the surgeon by first pushing a probe through the
  cervical Os and out at the fundus. Then with a long blade sharp knife, cut
  above the probe making sure the lower surface of the knife is just in contact
  with the probe. Extend the cut to the fundus but not through it. This will cut
  the uterus into two equal halves.
  (Fig.I)




                                                                                 17
  F) All specimen must be accompanied by properly filled request forms. The
     information on the form should include clinical history, operative findings,
     menstrual history,name of attending consultant in the particular case and
     name of the doctor completing the form. Names, not signatures, are
     required. Where stamps areused, .

HANDLING OF SPECIAL CASES
  a) Frozen sections : The surgical pathologist on duty on the date of the frozen
     section should be notified 24 hours ahead of time for all scheduled cases.
     However, intra-operative frozen section cabe requested when necessary.
  b) Tissue for frozen sections should be sent immediately to Histopathology
     section fresh or in normal saline.
  c) Lymph nodes or any other specimen suspected of tuberculosis should not be
     sent for frozen section. Frozen sections will not be performed on such
     specimen as this will contaminatethcryostat and endanger the lives of the
     technologists.
  d) If the frozen sections are cancelled, the Histopathology laboratory should be
     notified at onc. The cryostat, the technologist and pathologist are usually
     tied up waiting for a frozen section and where this procedure is no longer
     necessary, it is important to inform the lab so that routine functions can
     continue uninterrupted.
  e) Use of frozen section simply to have an early diagnosis when no further
     operative procedures are contemplated on is strongly discouraged. Frozen
     sections are used for decision making process and this should be strictly
     adhered to.

TUBERCULOUS AND FUNGAL CASES
  It is desirable to add to the Histopathology diagnosis results of cultures for
  these micro-organisms. Tissue for culture should be sent to the laboratory fresh,
  in clean, where possible sterile specimen containers. Appropriately completed
  request forms indicating studies required should accompany the specimen.

CERVICAL BIOPSY
  Cervical biopsies following CIN lesions on PAP smears should include
  Transformation zone (T-Zone).

LYMPH NODE BIOPSY
  a) All lymph node biopsies should be sent Fresh to the laboratory and handed
     over to Histopathology staff without delay.



                                                                                 18
  b) A whole lymph node should be removed and as much as possible the node
     or capsule should not be grabbed with the forceps. Lymph node biopsy by a
     senior member of the surgical team is advised and preferred.
  c) All specimens requiring special investigations shall need consultations with
     the surgical pathologist before sending the tissue.

PLACENTAS
  a) All placentas sent to the laboratory should be accompanied by duly
     completed request forms.
  b) The information on the request forms should include; gross appearance of
     placenta, shape, size, weight, fibrin deposits, infarcts, missing parts,
     marginal sinus, bleeding, signs of abruptio, trauma.
  c) The membrane should be described to reflect state of membrane viz;
     rupture, multiple pregnancies, insertion of umbilical cord and colour of
     amniotic fluid.
  d) Length of cord and number of vessels seen should also be described.
  e) Ratio of the weight of placenta / foetus is also important. For microscopy,
     the following are considered adequate indications:-
     i)     Severe intrauterine growth retardation.
     ii)    Unexplained intrauterine death.
     iii)   Suspicion of intrauterine infection.
     iv)    Premature rupture of membrane.
     v)     Any other unusual macroscopic findings (tumor, hydrops)

PRODUCT OF CONCEPTION AND FOETUSES
  1. All conception products in the 1st trimester should be sent for
     Histopathology.
  2. All foetuses measuring 20 cm crown to heel should be sent for
     Histopathology. Also corresponding placenta would have been sent for
     Histopathology.
  3. Well sized foetuses and babies will require an autopsy consent.

MUSCLE BIOPSIES
  Certain precautionary measures must be taken before, during and after a muscle
  biopsy is done, otherwise the desired diagnostic results will never be achieved.




                                                                                19
Choice of muscle and site of biopsy
   i) The muscle to be biopsied should be involved by disease but not severely
        so. Very weak or wasted muscles will yield no useful information. Such
        muscles will contain mainly fat and connective tissue with little muscle.
   ii) For practical purposes these groups of muscles should be biopsied;
        quadriceps femoris, deltoid, biceps brachi and occasionally gastrocnemius
        muscles.
   iii) Do not take muscle biopsy from sites of infections, trauma or EMG needle
        insertions.
   iv) Obtain muscle biopsy from the equator of the muscle chosen. This will
        avoid tendinous insertions of the muscle which differ anatomically from the
        rest of the muscle.
   v) If local anaesthesia is used, muscle should not be removed from muscle
        tissue infiltrated with an anaesthetic.

Transport of muscle biopsy to the laboratory:-
   i) Phone the laboratory to stand by for the muscle biopsy. Phone No. 2048,
        2047.
   ii) Transport the biopsy immediately to the laboratory moist in saline.
   iii) The biopsy should be accompanied by full clinical history which should
        include:
        a) Distribution of muscle weakness.
        b) Tendon reflexes if applicable.
        c) Values of enzyme studies.
        d) Results of EMG.
   Mere mention of "Myotonia" on "generalized muscle weakness" can never be
   sufficient.

KIDNEY BIOPSY
   i) Transport all renal biopsies immediately to Histopathology laboratory fresh
       moist in saline.
   ii) The biopsy should be accompanied by full clinical history which should
       include clinical findings, results of urea, creatinine if available, provisional
       clinical diagnosis, presence or absence of raised blood pressure, history of
       drug intake and history of other medical disorders. For transplant rejected
       kidneys, type of donor is required and how long the transplant had been in
       coporis before rejection .Previous renal disease if known should be given.




                                                                                    20
ESTROGEN AND PROGESTERONE STUDY
  Breast samples requiring estrogen / progesterone assay can be sent fresh, as in
  frozen section or in 10 % formalin to the laboratory and handed to the staff.

ELECTRON MICROSCOPY
  All samples must be sent fresh. Contact the pathologist if in doubt.

HISTOPATHOLOGY REPORTS
  i) Call 2046 or 2047 for all reports.
  ii) Histopathology reports will usually take 48 hours to 10 days from the day of
      receipt in the laboratory. Please note tsome specimens will require extra
      days for fixation before processing. Some may require extra sections,
      decalcification, special stains and special studies like immunoperoxidase
      studies. All these extend the time of release of report. Call the secretaries
      for inquiries, 2047, 2046.




                                                                                 21
22
   CYTOLOGY PROCEDURES


    Division of Anatomic Pathology



                Prepared By

  Peter Bahame, MBCHB, MRCPath. (1995)
         Consultant Cytopathologist



                Reviewed by

Abdulrazzaq Haider, MB, ChB, FRCPath. (2000)
          Consultant Cytopathologist




                                               23
24
HANDLING CYTOLOGY SPECIMEN
  i) Gynaecological specimen:
  ii) All gynaecological slides for Pap smears should be fixed immediately in
       95% alcohol. The slide should be accompanied by full clinical history
       which should include age, LMP, Exogenous, hormones intake and history
       of radiation. Avoid taking smears after using lubricant. Avoid air drying of
       the smear.
  iii) Non-gynaecological specimens:

A) Respiratory system :
   Source of specimen : Sputum, bronchial wash, bronchial brush, broncho-
   alveolar Lavage (BAL), Endotracheal tube (ETT). Sample should be :
   1. Collected in sterile tube
   2. Transported immediately to the lab.
   3. In a case of sputum an early morning deep cough specimen is required
      (not saliva) and repeat for three consecutive days (not more).

B) Urinary system :
   Source of specimen : Voided urine, catheterized urine, bladder washing
   (obtained during cytoscopy) hydrocoele specimen. Sample should be :
   1. Collected in sterile tube
   2. Sent fresh immediately
   3. Must not contain any additives

C) Gastro-intestinal tract :
   Source of specimen : Oesophagus, stomach, the duodenum, biliary tract and
   pancreas, rectum and colon. Sample should be :
   1. Collected in sterile tube
   2. Sent immediately to the lab.
   3. Adequate history and clinical data must accompany the samples.

D) Fluids from body cavities :
   Source of specimen : Pleural fluid, pericardial fluid, peritoneal , synovial fluid
   (joints), Cerebrospinal fluid (CSF), and Cul-de-sac fluid. Sample should be :
   1. Collected in heparinized tubes (green topped, beadless)
   2. Must be sent immediately to the lab.
   3. Samples from suspected TB. cases must be sent in a sealed bag and a note
       writon the form towarn laworkers.




                                                                                    25
E) Miscellaneous:
   Source of specimen : From any abscess, cysts from anorgan in the body, nipple
   discharge and buccal smear. Sample should be :
   1. Collected in sterile tubes
   2. No additives
   3. Sent immediately to cytology
   4. In case of buccal smears contact cytology lab. No. 3061.

F) Fine Needle Aspiration (FNA) :
   Source ofspecimen : Breast, thyroid, parathyroid gland, lymph node, spleen,
   lung, liver, salivary gland, abdominal aspiration, pelvis, kidney, skin scraping,
   bone and soft tissue, prostate, pleura and mediastinum.
   FNA Cases should be scheduled and cytology section 3061 should be contacted
   24 hours before the procedure. All samples musbe by full clinical, obstetric
   and gynaecological histories.
   1. Contact cytology lab. Ph. 393061
   2. Give adequate history and site of the m.

G) SEMEN ANALYSIS :
   1. Collected in sterile tubes
   2. No additives
   3. Sent immediately to Cytology
   4. Give adequate history
   5. Should be sent immediately or within 30 minutes after collection of
      specimen

IN CASE OF EMERGENCY OR EXTREME DIFFICULTY CONTACT
THE FOLLOWING:
   Consultant Pathologist 392041
   Consultant Pathologist 392042
   Supervisor                392017
   Technical Incharge        393164
   You can also be transferred where necessary to any of the above by calling
   392047 or 392046.




                                                                                  26
FORENSIC MEDICINE PROCEDURES


      Anatomic Pathology Division




                Prepared By


   Ismail Sebatan, MBBCH, DFMT (1995)
      Consultant Forensic Pathologist



               Reviewed By


  Bahram Azadeh, MD, DCP, FRCPath. (2001)
     Head of Anatomic Pathology Division




                                            27
28
                                 AUTOPSIES
   Two types of autopsies are performed. One is a Hospital autopsy and the other
   is a Medicolegal autopsy.

HOSPITAL AUTOPSIES
  These autopsies are performed on inpatients who have died in the hospital. The
  autopsy is performed on the basis of a consent signed by the parents or legal
  guardian of the child or in the case of an adult signed by father, brother or son,
  a husband. Telephone or verbal consents are not acceptable. Death certificates
  (Notification of death) in such cases must not be issued and the chart should be
  sent to the pathologist.

MEDICO-LEGAL AUTOPSIES
  These autopsies are performed in case of death under the following
  circumstances:-
  a) As a result of violence, misadventure, negligence,misconduct, and
      Malpractice.
  b) During pregnancy or following pregnancy in circumstances that might
      reasonably be attributable thereto.
  c) Suddenly or unexpectedly.
  d) From any cause other than disease.
  e) Under such circumstances as may require investigation.

AUTOPSY REQUEST.
  Make a brief summary of the history for the pathologist, and note aspects
  requiring special attention. All tubes, catheters and drains must be left in place.
  Call pathologist (staff or resident) to notify him or her of the case and to
  discuss it. Autopsies are performed daily at any time during normal working
  hours. Autopsy outside this period is by arrangement with the pathologist. The
  gross autopsy takes 1 1/2 to 2 1/2 hours or more, depending on the size of the
  patient and complexity of dissection. The body can usually be released to
  relatives about 4 hours after the autopsy is begun. Do not promise the family
  that a body will be released at a certain time without consulting the pathologist.
  Reports : Preliminary : available 24 to 48 hours after autopsy. Final (with
  detailed gross and microscopic description of all viscera) : available 1 to 2
  months after autopsy.

SUDDEN INFANT DEATH SYNDROME (SIDS)
   The pathologists are available to explain SIDS, or crib death, to parents and can
   provide explanatory literature. The pathologists can also refer newly-bereaved
   parents to other parents' who have had an SIDS.


                                                                                  29
30
   CLINICAL CHEMISTRY PROCEDURES


            Division of Chemical Pathology




                         Prepared by


Mohd. M. Al-Sayrafi, M.Sc.(Clinical Chemistry), Member AACC
             Act. Supervisor - Clinical chemistry

            Samira M. Al Eshaq, B.Sc.(Chemistry)
        Sr. Technologist Incharge - Clinical Chemistry

           Akram T. Murtaga, B.Sc.(Biochemistry)
            Sr. Technologist - Clinical Chemistry



                        Reviewed By


    Mohd. Osman Abdel-Rahman, MBBS, DCP, FRCPath.
           Head of Chemical Pathology Division




                                                              31
32
I- CHEMISTRY ( BLOOD & URINE )


1. Alanine Aminotransferase
Synonyms :              ALT, GPT , SGPT
Specimen :              1 mL BLOOD
Container :             RED TOP Tube
Reference Range :       MALE        =               up to 40 U/L
                        FEMALE      =               up to 30 U/L
Turn Around Time :      1 day

2. Albumin
Synonyms :                ALB
Specimen :                1 mL BLOOD
Container :               RED TOP Tube
Reference Range :         Infant :                  29 - 55 g/L
                          1 year to adult :         35 - 50 g/L
Turn Around Time :        1 day
Conversion Factor :       (/10) ==> g/dL

3. Alkaline Phosphatase
Synonyms :                ALP
Specimen :                1 ml BLOOD
Container :               RED TOP Tube
Reference Range :         Adults 39 - 117 U/L
                          "Childhood to puberty = 3 times the adults'"
Turn Around Time :        1 day

4. Alkaline Phosphatase isoenzymes
Synonyms :                Alkaline Phosphatase Fractionation
Specimen :                3 mL BLOOD
Container :               RED TOP Tube
Reference Range :         For non Fasting Adult:
                            Liver                 14.7 – 87.5 %
                            Bone                  12.5 – 85.3 %
                            Intestine                0 - 6.4 %
 Turn Around Time :       2 Weeks

5. Amino Acids
Synonyms :                AA.
Patient Care :            Infants,preferrably,4 hours. Fasting. Children &


                                                                             33
                         Adults; (12 hours. Fasting)" .
Specimen :               2 mL BLOOD 5 mL spot urine (1st morning sample)
Container :              GREEN TOP Tube
                         Plain urine container
Reference Range :        Details with report.
Turn Around Time :       2 weeks.

6. Ammonia
Synonyms :               NH 3, AMON
Specimen :               FULL TUBE OF BLOOD IN ICE.
Container :              GREEN TOP, LAVENDER TOP Tube.
Reference Range :        Neonate           64 - 107 mol/L
                         <2 weeks          56 - 92 mol/L
                         Children          21 - 50 mol/L
                         Adults            11 - 35 mol/L
Turn Around Time :       3 hours

7. Amylase (Pancreatic):
Synonyms :               P-AML
Specimen :               2 mL BLOOD
                         2nd morning urine
Container :              RED TOP Tube.
                         Plain urine container
Reference Range :        Serum       17-115 U/L
                         Urine       up to 800 U/L
Turn Around Time :       1 day

8. Anti thrombin III
Synonyms :               AT III, Functional AT III
Specimen :               3 mL BLOOD
Container :              Blue Top Tube
Reference Range :        80 - 120 %
Turn Around Time :       1 day

9. Arsenic
Synonyms :               As, Arsenic
Specimen :               3 mL BLOOD
Container :              Whole blood (Heparin) collected in metal free
                         container.
Reference Range :        2 – 23 µg/L
                         Chronic poisoning    100 – 500 µg/L
                         Acute poisoning      600 – 9300 µg/L


                                                                           34
Turn Around Time :        Contact laboratory

10. Aspartae Aminotransferase
Synonyms :             AST, GOT, SGOT
Specimen :             2 mL BLOOD
Container :            RED TOP Tube
Reference Range :      Male    up to 37 U/L
:                      Female   up to 31 U/L
Turn Around Time :     1 day

11. Bence Jones Protein
Synonyms :              BJP
Specimen :              Preferably 24 hr urine otherwise Early morning,
                        fasting and second voided urine .
Container :             Plain urine container
Reference Range :       Negative
Turn Around Time :      2 weeks

12. Bicarbonate : (Venous)
Synonyms :              CO2, tCO2
Specimen :              2 mL BLOOD
Container :             RED TOP Tube
Reference Range :       Newborn   13-22 mmol/L
                        Child     20-28 mmol/L
                        Adult      22-29 mmol/L
Turn Around Time :      1 day

13. Bilirubin (Direct)
Synonyms :                D.Bili., Conjugated Bilirubin, C.Bili.
Specimen :                2 mL Blood
Container :               RED TOP Tube
Reference Range :         Up to 7 mol/L
Turn Around Time :        1 day
Conversion Factor :       /17.1 mg/dL

14. Bilirubin ( Total )
Synonyms :                T.Bili.
Specimen :                2 mL BLOOD
Container :               RED TOP Tube, Lav. top or Li Heparin
                          pediatrics only
Reference Range :         up – 1 d              < 100 mol/
                          1–2d                  < 140    mol/


                                                                          35
                         3–5d                    < 200 mol/
                         1 mon – adult           up to 17 mol/
Turn Around Time :       1 day
Conversion Factor :      /17.1 mg/dL

15. Blood Gases (Arterial)
Synonyms :             ABG, BG
Patient Care :         Patient should be supine, relaxed. The patient's
                       temperature, and FIO2 must be recorded
Specimen :             Arterial blood IN ICE
Container :            Heparinized syringe or capillary
Reference Range :      pH          7.35-7.45
                       pCO2         Newborn, Infant        27-40 mm Hg
                       Adult        Male                   35-48 mm Hga
                                    Female                 32-45 mm Hga
                       pO2          Adults                 83-108 mm Hg


CALCULATED VALUES :

TCO2                                     23-27 mmol/L
HCO3                                     22-26 mmol/L
Standard Bicarbonate ( SBC )             22-26 mmol/L
Buffer Bases ( BB )                      46-54 mmol/L
Base Excess "Blood" (BEb)                2-2
Base excess (BEecf)                      2-2
Respiratory Index ( RI )                 0-10
O2 Saturation                            95-99%
Alveolar-arterial O2 Gradient (A-aDO2) 0.93-1.73 kPa
Hematocrit (Adult Males)                 41-53%
Hematocrit (Adult Females)               36-46 %
Conversion Factor :        For pCO2 & pO2       /0.133 mm Hg
Turn Around Time :         10-20 minutes

16. Blood Gases ( Venous )
Synonyms :              Venous Blood Gases
Specimen :              Heparinized Venous Blood
Container :             Heparinized Syringe, GREEN TOP Tube IN ICE
Reference Range :       pH                      7.32-7.42
                        pCO2                    40- 55 mm Hg
                        pO2                     18-41 mm Hg
                        TCO2                    25-29 mmol/L


                                                                          36
                         HCO3                      24-28 mmol/L
                         O2 Saturation             40-70 %
Turn Around Time :       10-20 minutes

17. Calcium
Synonyms :               Ca
Specimen :               2 mL BLOOD ( Fasting Morning is Desirable )
                         Spot (First Morning Sample), or 24 hours Urine
Container :              RED TOP Tube / Plain urine container
Reference Range :        Serum:
                            Birth to 1 month                1.75-2.87 mmol/L
                            1 month to 1 year               2.15-2.79 mmol/L
                            1 year and up                   2.02-2.60 mmol/L
                         Urine Spot                         1.30-8.93 mmol/L
                         24 hrs     "VARIES WITH DIET"
                         Low Ca. Diet            up to 3.7mmol/24h
                         Average Ca. Diet        2.5-6.2mmol/24h
                         High Ca. Diet           6.2-7.5mmol/24h
Turn Around Time :       1 day
Conversion Factor :      Serum /0.2495 ==> mg/dL
                         Urine /0.02495 ==> mg/24h

18. Calcium (Ionized)
Synonyms :               Ionized Calcium
Specimen :               Serum, Plasma, or Whole Blood
Container :              RED TOP, GREEN TOP Tube, Heparinized
                         syringe or capillary. Collect anaerobically, leave
                         stoppers in and do not use tourniquet.Place on ice
                         and deliver to lab immediately.
Patient Care :           Patient should be recumbent for 30 minutes prior
                         to collection.
Reference Range :        1.18-1.35 mmol/L
Turn Around Time :       1 day
Conversion Factor :      /0.2495 ==> mg/dL

19. Carboxy Hemoglobin
Synonyms :             Carbon monoxide, CO, COHb
Specimen :             2mL Blood (venous or arterial) Contact Lab.
                       Before Collecting Draw before patient is started
                       on oxygen if possible
Container :            Green Top, Lavender Top Tube IN ICE
Reference Range :      Nonsmokers              < 1.5 %


                                                                              37
                      Smokers                  1.5-5.0 %
Turn Around Time :    2 hours

20. Carotene
Synonyms :            Carotene
Specimen :            10 mL BLOOD / Prevent exposure to light
Container :           RED Top Tube, "
Patient care :        Patient must fast a minimum of 8 hours.
Reference Range :     Infant          0.37-1.30 mol/L
                      Child           0.74-2.42 mol/L
                      Adult           1.12-3.72 mol/L "NORMAL DIET"
Turn Around Time :    1 day
Conversion Factor :   /0.0186 ==> g/dL

21. Chemotrypsin
Synonyms :            Chemotrypsin
Specimen :            Stool
Container :           Plain stool container
Reference Range :     Normal                    > 6 u/g
                      Further investigation necessary 3 – 6 u/g
                      Pathogenic                 < 3 u/g
Turn Around Time :    one week

22. Chloride
Synonyms :            Cl
Specimen :            2 mL BLOOD
Container :           RED TOP Tube
Reference Range :     96 – 110 mmol/L
Turn Around Time :    1 day

23. Cholesterol
Synonyms :            CHOL.
Specimen :            2 mL BLOOD
Container :           RED TOP Tube
Patient Care          - Optimum patient condition at the time of
                         drawing is: no change in diet for three weeks,
                         stable body weight. Fasting is not essential
                         blood.
                      - Posture may be a significant factor: cholesterol

                          values may be 10% to 15% lower after 20 minutes
                          in standing to a setting position values are about


                                                                           38
                          6% lower after 20 minutes.
                      -   Increases of 2% to 5% in cholesterol may be
                          seen if tourniquet is applied for two minutes
                          during sampling. Emotional and physical
                          stress may also be factors influencing
                          cholesterol levels.
                      - FASTING FOR 14 HOURS IS REQUIRED
                          IF TRIGLYCERIIDES OR LDL-C ARE
                          REQUESTED.
Reference Range :     <5.17mmol/L                Desirable blood cholesterol
                      5.17-6.18 mmol/L           Border line-high blood
                                                 cholesterol
                      >6.18mmol/L                High blood cholesterol
Turn Around Time :    1 day
Conversion Factor :   /0.0259 ==> mg/dL

24. Copper
Synonyms :            Copper
Specimen :            3 ml Blood
                      Spot, or 24 hours URINE
Container :           Plain tube ( metal free container)
                      Plain urine container
Reference Range :     Serum        6 years         90 – 190   u/g
                                   12 years        80 – 160   u/g
                                   Adult Male 70 - 140        u/g
                                   Adult Female 80 – 155      u/g
                      Urine        3 – 35      ug/day
Turn Around Time :    Contact laboratory

25. Creatine Kinase
Synonyms :            CK, CPK, Creatine Phosphokinase, Total CK
Specimen :            2 mL BLOOD
Container :           RED TOP Tube
Patient Care :        Increases may be anticipated in immediate
                      postoperative period following surgical
                      procedures involving incision through the
                      muscles.
Reference Range :     Newborn                   3 x the adult value
                      3 weeks - 3 months        1.5 x the adult value
                      Adult Male                35-232 U/L
                      Adult Female              21-160 U/L
Turn Around Time :    1 day


                                                                               39
26. Creatine Kinase- MB ( mass measurement )
Synonyms :              CK-MB, CPK-MB
Specimen :              5 mL BLOOD / Collection of specimen at onset
                        of symptoms to establish baseline values is
                        needed.
Container :             RED TOP Tube
Reference Range :       < 5 g / ml
                        Relative Index CK-MB/Total CK Relative
                        index  3 % suggests that CK-MB may be of
                        myocardial origin.
 Turn Around Time :     1-3 hours

27. Creatinine
Synonyms :                Creatinine
Specimen :                2 mL Blood / Spot, or 24 hours urine
Container :               RED Top Tube / Plain urine container
Reference Range :         Serum 1-4 Days            27-88 mol/L
                                       up to 1 Year 18-35 mol/L
                                       1-5 Years    27-44 mol/L
                                       5-10 Years 44-71 mol/L
                                       Male         62 - 124 mol/L
                                       Female       53 - 97 mol/L
                          Urine        Male         8.8-17.7 mmol/24h
                                       Female       7.1-15.9 mmol/24h
Turn Around Time :        1 day
Conversion Factor :       mol/L /88.4 ==> mg/dL

28. Creatinine Clearance
Specimen :               2 mL BLOOD, and 24 hours URINE
Container :              RED Top Tube / Plain urine container
Patient Care :           Avoid cephalosporins. If possible, drug should
                         be stopped before hand. Have patient drink water
                         before the clearance is begun and continue good
                         hydration through out the clearance. Test can be
                         done for shorter periods.
Causes for Rejection :   No blood Creatinine is requested. Urine
                         specimen is not timed.
Special Instructions :   Blood should be requested at the same day.
                         Requisition should STATE date and time
                         collection started, date and time collection
                         finished, patient age, height and weight

                                                                            40
Reference Range :           Child                102 - 140 mL / min / 1.73 m2
                            Adult Male           85 - 125 mL / min / 1.73 m2
                            Adult Female         75 - 115 mL / min / 1.73 m2
Calculation :               urine volume per seconds x urine creatinine /
                            serum creatinine x 1.73 / surface area of body in
                            square meters
Turn Around Time :          1 day
Conversion factor :         x 60 ==> mL / min. / 1.73 m2

29. Cryoglobulin ( Qualitative ) : Contact Lab. for appointment
Specimen :               3 mL Blood
Container :              RED Top Tube
Patient Care :           Patient should be fasting
Collection :             Specimen must be drawn in a prewarmed
                         vacutainer or syringe and transferred to a
                         prewarmed tube and kept at 37C while clotting.
                         SEND TO THE LAB IMMEDIATELY keeping it
                         warm by carrying the tube under the ARMPIT or
                         holding it in the PALM.
Reference Range :        Negative.
Turn Around Time :       1 week

30. Cystine (Qualitative)
Synonyms :                  Sodium Nitroprusside Test, Homocystine
Specimen :                  10 mL spot urine
Container :                 Plain urine container
Reference Range :           Negative.
Turn Around Time :          2 days

31. Delta Aminolevulinic Acid
Synonyms :               -ALA, ALA
Specimen :               24 hours urine
Container :              Dark urine container.
Reference Range :        Up to 53 mol/24h
Turn Around Time :       2 weeks

32. Fetal Fibronectin
Synonyms :                  FFN
Specimen :                  Cervicovaginal swab
Container :                 Specimen collection package contains a sterile
                            dacron swab and transport Vail containing
                            extraction buffer. (Please contact lab. To provide


                                                                                 41
                          these swabs)
Stability :               72 Hours
Reference Range :         Negative
Turn Around Time :        Twice a week

33. Fibrinogen
Synonyms :                Fibrinogen, FBG
Specimen :                3 mL BLOOD
Container :               BLUE TOP Tube
Collection :              If multiple tests are being drawn, draw
                          coagulation studies last. If only fibrinogen is
                          being drawn, draw 1-2mL into another vacutainer
                          or syringe, discard and then collect the fibrinogen
                          tube. This collection procedure avoids
                          contamination of the specimen with tissue
                          thromboplastin.
Causes For Rejection :    Tube not full, tube clotted, specimen more than
                          one hour old.
Reference Range :         2.00 - 4.00 g/L
Turn Around Time :        1 day
Conversion Factor :       ( x 100 ) ==> mg/dL

34. Galactose : (Please contact lab. for appointment)
Synonyms :               Galactose
Specimen :               1 mL Blood, Spot Urine
Container :              GREEN TOP Tube, Plain urine container
Reference Range :        Blood Neonates           0.06 - 0.28 mmol/L
                                                  Others up to 0.04
mmol/L
                         Urine Neonates           up to 3.33 mmol/L
                                                  Others up to 0.22
mmol/L
Turn Around Time :       1 week

35. Galactose-1- phosphate Uridyltransferase in erythrocytes
Synonyms :               Galactose (Please contact lab. for appointment)
Specimen :               2 mL Blood
Container :              Lithium heparin Tube.
Reference Range :        Normal activity
Turn Around Time :       1 day




                                                                                42
36. Gamma Glutamyl Transferase
Synonyms :            -GT, GGT, GT
Useful for            Cholestatic liver disease
                      Drug and alcohol abuse
Specimen :            2 mL BLOOD
Container :           RED TOP Tube
Reference Range :     Male                      11-50 U/L
                      Female                    7-32 U/L
Turn Around Time :    1 day

37. Glucose ( Fasting )
Synonyms :                Fasting blood sugar, FBS
Specimen :                2 mL BLOOD.
Container :               GRAY TOP.
Patient Care :            8 hours fasting for FBS
Reference Range :         Serum           Premature Infant   2.2-3.6 mmol/L
                                          Child              3.3-5.6 mmol/L
                                          Adult              3.9-5.8 mmol/L
                                          >60 years          4.4 - 6.4 mmol/L
                          Urine     Spot Negative
Turn Around Time :                                  1 day
Conversion Factor :       Serum ( / 0.0555) ==> mg/dL
                          Urine ( / 5.55 ) ==> mg/24h

38. Glucose (Random )
Synonyms :                RBS
Specimen :                2 mL BLOOD
Container :               GRAY TOP.
Reference Range :         Dependent on time and content of last meal.
                          Values of >11.1mmol/L support the diagnosis of
                          diabetes mellitus.
Turn Around Time :                                1 day
Conversion Factor :                               ( / 0.0555 ) ==> mg/dL

39. Glucose Tolerance Test
Synonyms :              GTT, OGTT
Specimen :              1 mL BLOOD
Container :             GRAY TOP Tube
Patient Care :          Patient should not smoke due to glucose
                        stimulation by nicotine.
Collection :            After fasting overnight, not less than 8 hrs, blood
                        specimen and second voided urine are obtained.


                                                                                43
                              administer oral glucose solution. Weigh patient
                              for proper loading dosage. Children receive
                              1.75g/kg body weight up to 75g. Usual adult
                              dose is 75g. 100 g is used for possible gestational
                              diabetes mellitus. Draw blood at 120 minutes.
In pregnant subjects: Indication for GTT is a positive gestational diabetes
screening test: 50g oral glucose load, sample drawn in one hour. A positive
gestational screening test is glucose greater than 7.8 mmol/L.
Interpretation : (Women non-pregnant)

               Venous plasma glucose mmol / L

_______________________________________________________________
                          Fasting              2 hours
_______________________________________________________________
Diabetes unlikely         5.5 7.8
Imaired glucose tolerance 5.5 - 7.8            7.8 - 11.1
Diabetic                  < 7.8                 > 11.1
Turn Around Time :        1 day
Conversion Factor :       ( / 0.0555 ) ==> mg/dL

40. Glucose 6-Phosphate Dehydrogenase (Quantitative)
Synonyms :              G-6-PD, G6P-DH, GPD
Specimen :              2 mL BLOOD
Container :             Lavender Top Tube
Reference Range :       118 - 144 mU/billion cells
Turn Around Time :      2 days " Contact lab. for appointment "

41.Glucose 6-Phosphate Dehydrogenase (Screen)

Synonyms :                  G-6-PD Screen
Specimen :                  1 mL BLOOD
Container :                 LAVENDER TOP Tube
Reference Range :                                       Normal
Limitations :               A blood enzyme screen performed after a
                            hemolytic episode often will NOT detect G-6-PD
                            deficiency even if present because the most
                            deficient cells have been destroyed ; this
                            procedure can only differentiate between normal
                            and grossly deficient samples. Test may need to
                            be repeated (if initial result is normal) after the
                            patient recovers from an undiagnosed episode of


                                                                                    44
                          anemia. This screening test may show normal
                          activity in female heterozygous.
Turn Around Time :                                 1 day

42. Glycosylated Hemoglobin
Synonyms :              HbA1c, Glycated hemoglobin
Specimen :              1 mL BLOOD
Container :             LAVENDER TOP Tube
Reference Range :       4.3 – 6.0 % of Total Hb
Turn Around Time :      5 days

43. High Density Lipoprotein Cholesterol
Synonyms :              Alpha1 Lipoprotein Cholesterol, HDL - C,
                        HDL Cholesterol
Specimen :              5 mL BLOOD
Container :             RED TOP Tube
Patient Care :          Refer to "Cholesterol"   (page 37)
Reference Range :       Adult Male 0.83 - 1.87 mmol/L
                        Adult Female 1.01 - 2.49 mmol/L
Turn Around Time :      2 days
Conversion Factor :     ( / 0.0259 ) ==> mg/dL

44. 5-Hydroxyindoleacetic Acid ( Quantitative )
Synonyms :              5-HIAA
Specimen :              24 hours Urine
Container :             Urine container with 25 mL Glacial Acetic Acid
                        as a preservative.
Patient Care :          Avoid bananas, avocados, chocolate, plums,
                        eggplant, tomatoes, plantain, pineapples, walnuts,
                        acetaminophen, naproxen mephenesin,
                        methocarbamol, imipramine, isoniazid,
                        monoamine oxidase (MAO) inhibitors,
                        methenamine, methyldopa, phenothiazines, for
                        48-hours for food items & 7 days for the drugs
                        prior to and during the collection, however, if
                        drugs can not be stops they must be written in the
                        request form..
Reference Range :       5 - 37 mol/24h
Turn Around Time :      2 - 4 weeks
Conversion Factor :     ( / 5.2 ) ==> mg/24h




                                                                             45
45. Iron and Total Iron Binding Capacity
Synonyms :               Fe and TIBC
USEFUL FOR               Screen for haemochromatosis
                         Verification of acute iron poisoning in children
NOTE:                    The proper test for identificaion of iron
                         deficiency is “ Ferritin, serum.”
Specimen :               5 mL BLOOD
Container :              RED TOP Tube
Patient Care :           Specimen should be drawn fasting in the
                         morning. Sample should be drawn before patient
                         is given therapeutic iron, or blood transfusion.
                         Iron determination on patients who have had
                         blood transfusion should be delayed several days.
Sampling Time :          Morning . Marked daily variations occur.
                         Serum iron levels are 30% higher in the morning.
Reference Range :        Iron Male            10.6 - 28.3 mol/L
                               Female          6.6 - 26.0 mol/L
                         TIBC                 45 - 80       mol/L
                          Per cent Saturation       14 – 50%
Turn Around Time :                                   IRON 1 day          /
TIBC 1 week
Conversion Factor :                                  ( / 0.179 ) ==> g/dL

46. Ketone Bodies ( BLOOD )
Synonyms :             Acetone
Specimen :             1 mL BLOOD
Container :            RED TOP Tube
Reference Range :      Negative
Turn Around Time :     2 hour

47. Lactate Dehydrogenase
Synonyms :             LDH, LD
Specimen :             2 mL BLOOD
Container :            RED TOP Tube
Reference Range :      230 - 460 U/L
                       Newborn (1-3 days) up to twice the adult values
Turn Around Time :     1 day

48. Lactic Acid
Synonyms :                Lactate, LA
Specimen :                2 mL BLOOD ( Arterial or Venous ), IN ICE
Container :               GRAY TOP Tube.


                                                                             46
Collection :              Avoid hand clenching and use of a tourniquet.
Reference Range :         Arterial   0.5 - 1.6 mmol/L
                          Venous     0.5 - 2.2 mmol/L
Turn Around Time :        2 hours

49. Lead
Synonyms :                Lead
Specimen :                3 mL BLOOD
Container :               LAVENDER TOP( EDTA) Tube
Reference Range :         Below 10 ug/dl is acceptable
Turn Around Time :        Contact laborator

50. Lipase :
Synonyms :                LIP
Specimen :                2 mL BLOOD
Container :               RED TOP Tube
Reference Range :         0 - 190 U/L
Turn Around Time :        2 days

51. Lipid Profile :
Synonyms :                Coronary Heart Disease Risk Index
Test Includes :           Total Cholesterol, Triglycerides, HDL
                          Cholesterol, LDL Cholesterol
Replaces :                Lipoprotein electrophoresis
Specimen :                5 mL BLOOD
Container :               RED TOP Tube
Patient Care :            See "Cholesterol"      (page 37)
Reference Range :         See individual tests.
Turn Around Time :        2 days.

52. Low Density Lipoprotein Cholesterol
Synonyms :              Beta Lipoproteins, LDLC, LDL
Specimen :              5 mL BLOOD
Container :             RED TOP Tube
Patient Care :          See "Cholesterol"     (page 37)
Methodology :           Calculated As Follows;
                        LDL = total chol. - [HDL + ( 0.45 x triglyceride)]
Reference Range :       < 3.36 mmol/L Desirable LDL cholesterol
                        3.36 - 4.11 mmol/L Borderline-high-risk LDL
                        cholesterol
                        > 4.12 mmol/L        High-risk LDL cholesterol
Turn Around Time :      2 days


                                                                             47
Conversion Factor :       ( / 0. 0259 ) ==> mg/dL

53. Magnesium
 Synonyms :               Mg
Specimen :                2 mL BLOOD, 24 hours Urine
Container :               RED TOP Tube, Plain Urine Container
Collection :              Draw without venous stasis
Reference Range :         Serum;
                             Newborn ( 2 - 4 days ) 0.50 - 0.90 mmol/L
                                                      Adult 0.65 - 1.05 mmol/L
                          Urine :      3.00 - 5.00 mmol/24h
Turn Around Time :        1 day
Conversion Factor :       ( / 0.41 ) ==> mg/dL

54. Metanephrines ( Total )
Synonyms :              Meta
Specimen :              24 hours Urine
Container :             Plastic urine container + hydrochloric acid
Patient Care :          The following substances are known to interfere:
                        diatrizoate, chlorpromazine, hydrazine dervatives,
                        imipamine, MAO inhibitors, methyldopa,
                        phenacetin, ephedrine, epinephrine IVP dyes,
                        labetalol hydrocholoride, and most psychoactive
                        agents.
                        Medication should be discontinued at least
                        48 – 72 hours before collection if possible
Reference               Up to 5.1 mol/24h OR
                        < 1 Y 0.0006 - 2.64 mmol/mol creatinine
                        1 - 2 Y 0.15 - 3.09       mmol/mol creatinine
                        2 - 5 Y 0.20 - 1.72       mmol/mol creatinine
                        5 - 10 Y 0.25 - 1.55      mmol/mol creatinine
                        10 - 15 Y 0.0006 - 1.07 mmol/mol creatinine
                        15 - 18 Y 0.0006 - 0.38 mmol/mol creatinine
                        Adult      0.03 - 0.69    mmol/mol creatinine
Turn Around Time :      4 - 6 weeks
Conversion Factor :     ( / 0.0051 ) ==> g/24h
                        ( / 0.574 ) ==> g/mg creatinine

55. Methemoglobin
Synonyms :                MetHb
Specimen :                2 mL BLOOD
Container :               GREEN TOP, LAVENDER TOP Tube IN ICE


                                                                             48
Reference Range :          Up to 1.5 % of total Hb
Turn Around Time :         2 hours (Contact Lab. Before Collecting Sample)

56. Microalbuminuria
Microalbuminuria is an amount of albumin in urine above normal (20 mg/l) but
below that detected by current dipstick for urinary protein (>300mg/l).
Useful for :                Detecting diabetics (andothers) at risk for renal
                            failure.
Specimen :                  First morning (midstream) urine collected
                            immediately after rising, 24 hours is the best for
                            this test, or timed overnight 10-hour
Container :                 Plain urine container.
Reference Range :           24-Hour excretion: <30mg/24hours
                            Ecretion rate: <20 g/min
                            Random: 20 mg/l: 2 mg/molcreatinine.
Turn Around Time :          7 days
Conversion Factor :         ( x 1000 ) ==> mg/L OR mg/24h

57. Mucopolysaccharidoses
Synonyms :             MPS
Specimen :             2 mL Random Urine (NOT 1st morning urine)
                       Bacterially infected specimens are unsuitable.
Container :            Plain urine container
Reference Range :      Negative
Turn Around Time :     2 days

58. Myoglobin ( Qualitative )

Specimen :                 10 mL Spot Urine
Container :                Plain Urine Containe
Reference Range :          Negative.
Turn Around Time :         2 days

59. Osmolality ( Calculated )
Specimen :                2 mL BLOOD
Container :               RED TOP Tube
Calculatio [1.86 Na (mmol/L) + Glucose (mmol/L) + Urea (mmol/L) + 9]
Reference Range :         273 - 304 mmol/kg
Turn Around Time :        1 day




                                                                                 49
60. Osmolality
Specimen :               5 mL BLOOD, 2 mL Spot Urine
Container :              RED TOP Tube, Plain urine container
Reference Range :        Serum Neonate May be as low as 266 mOsml/kg
                          Children. & Adults 275 - 295 mOsml/kg
                         Urine Neonate = 75-300 mOsml/kg
                         Children. & Adults (Random) = 50-120 mOsml/kg
                         (depending on fluid intake)
Turn Around Time :       1 day

61. Oxalate
Synonyms :               Calcium Oxalate, Urine Oxalate
Specimen :               24-hour urine
Container :              Urine container containing 10 mL concentrated HCl
Patient Care :           Avoid intake of oxalate rich food, like spinach,
                         chocolate, rhubarb, or oxalate precursors such as
                         vitamin C for 24 hours before collection.
                         Pyridoxine is said to diminish oxaluria. The
                         patient should be on usual fluid and food intake.
Reference Range :        Children       0.14 - 0.42 mmol/24h
                         Adult Males 0.08 - 0.49 mmol/24h
                         Adult Females 0.04 - 0.34 mmol/24h
Turn Around Time :       4 - 6 weeks
Conversion Factor :      (/ 0.011) ==> mg/24h

62. Phenylalanine Test
Synonyms :               PKU, Phenylketoneurea, Ferric Chloride Test
Specimen :               10 mL Freshly voided random urine.
Container :              Plain urine container
Reference Range :        Negative
Turn Around Time :       1 day

63. Phosphorus
Synonyms :               Inorganic Phosphate, PO4
Specimen :               2 mL BLOOD ( Fasting morning ). Timed or Random
                         Urine
Container :              RED TOP Tube, Plain urine container
Reference Range :        Serum Cord           1.20 - 2.62 mmol/L
                                 24 hours     1.13 - 2.78 mmol/L
                                 24 - 48 hours 1.78 - 3.07 mmol/L
                                 Infants       1.45 - 2.10 mmol/L
                                 Children      1.45 - 1.78 mmol/L


                                                                             50
                                  Adult         0.87 - 1.45 mmol/L
                          Urine 13 – 42 mmol/24h "Diet Dependent"
Turn Around Time :        1 day
Conversion Factor :       Serum ( / 0.323 ) ==> mg/dL
                          Urine ( / 32.3 ) ==> g /24h

64. Porphobilinogen ( Qualitative )
Synonyms :              PBG, Watson-Schwartz Test
                        "Qualitative Screen for Urobilinogen and
                        Porphobilinogen"
Specimen :              5 mL Fresh Random Urine
Container :             Clean Dark Container
Reference Range :       Negative
Turn Around Time :      2 days

65. Porphobilinogen ( Quantitative )
Synonyms :              PBG
Specimen :              Collect random urine sample .It advisable NOT to use
                        the first voided morning sample, late evening sample
                        after 8p.m. or samples obtained following excessive
                        fluid intake. Or 24 hr. Avoid exposure to direct light.
Container :             Clean Dark Container
Reference Range :       Urinary PBG          8.8 mmol/24hr
                        24 hr PBG           8.8 mmol/d
Turn Around Time :      2 days

66. Potassium
Synonyms :                K
Specimen :                2 mL BLOOD, Random or Timed Urine
Container :               RED TOP Tube, Plain urine container
Collection :              Avoid very small needles if possible. Avoid stasis, .
                          avoid use of tourniquet, avoid hand-clenching, if
                          possible.
Reference Range :         Serum Premature-48 hours 3.0 - 6.0 mmol/L
                          Newborn                        3.7 - 5.9 mmol/L
                          Infant 4.1 - 5.3 mmol/L
                          Child 3.4 - 4.7 mmol/L
                          Adult 3.6 - 5.1 mmol/L
                          "Potassium levels in plasma have been shown to be
                          0.1-0.7mmol/L lower than in serum"
                          Urine = 25-125 mmol/24h (Varies with diet)
Turn Around Time :        1 day


                                                                                  51
67. Protein Electrophoresis
Synonyms :               SPE, UPE
Specimen :               2 mL BLOOD, 10 mL Spot Urine
Container :              RED TOP Tube, Plain urine container
Reference Range :        Serum Albumin           32 - 50 g/L
                                    1-globulin    1 - 4 g/L
                                    2-globulin    6 - 10 g/L
                                    - globulin   6 - 13 g/L
                                    - globulin   7 - 15 g/L
                         Urine = No monoclonal gammopathy detected.
Turn Around Time :       1 - 2 weeks
Conversion Factor :      ( / 10 ) ==> g/dL

68. Protein (Total)
Synonyms :                Total Protein
Specimen :                2 mL BLOOD
Container :               RED TOP Tube
Limitations :             Venous stasis during venipuncture can lead to
                          increased values. Values decrease by 5-10% upon
                          recumbency, as in hospitalization.
Reference Range :         Premature           36 - 60 g/L
                          Newborn             46 - 70 g/L
                          One week            44 - 76 g/L
                          7 month-1 year      51 - 73 g/L
                          1 - 2 years         56 - 75 g/L
                          3 years - Adult     60 - 80 g/L
Turn Around Time :        1 day
Conversion Factor :       ( / 10 ) ==> g/dL

69. Protein (Quantitative ), Urine
Specimen :                24 hours urine
Container :               Plain urine container
Reference Range :         0.03 - 0.15 g/24h
Turn Around Time :        1 day
Conversion Factor :       ( / 0.001 ) ==> mg/24h

70. Pseudocholinesterase
Synonyms :               Cholinesterase, PCHE, PCE
Specimen :               2 mL BLOOD
Container :              RED TOP Tube
Use Screen preoperative patients for succinylcholine (suxamethonium) anesthetic
sensitivity..


                                                                             52
Monitor organophosphorus or carbamate insecticide poisoning, in which level is
decreased; "ESTABLISH PATIENT'S BASELINE VALUE BEFORE
EXPOSURE."
Reference Range :        5400-13200 U/L = 5.4-13.2 U/mL
Turn Around Time :       1 day

71. Pyruvate
Synonyms :                PK
Specimen :                3 mL BLOOD
Container :               LAVENDER TOP Tube
Reference Range :         Normal
Turn Around Time :        Contact lab. for appointment before collecting the
                          blood.
72. Pyruvate Kinase
Synonyms :                PK
Specimen :                2 mL BLOOD
Container :               LAVENDER TOP Tube
Patient Care :            Blood for LA. and Pyruvate should be collected at
                          the same time.
Reference Range :         0.03 – 0.08 mmol/L
Turn Around Time :        3 days Contact lab. for appointment before collecting
                          the blood.

73. Sodium
Synonym :                 Na
Specimen :                2 mL BLOOD, Random or timed urine collection.
Container :               RED TOP Tube or a plain urine container
Reference Range :         Serum        135 - 145 mmol/L
                          Urine        27 - 287 mmol/24h
                          (Varies markedly with dietary intake of sodium)
Turn Around Time :        1 day

74. Triglycerides
Synonyms :                Triglycerols
Specimen :                2 mL BLOOD ( 12 - 14 hours Fasting )
Container :               RED TOP Tube
Patient Care :            See "Cholesterol"
Reference Range :         "Reference Values Vary by Age"
                          Desirable      Male       0.45 - 1.81 mmol/L
                                        Female    0.40 - 1.53 mmol/L
Turn Around Time :        1 day
Conversion Factor :       ( / 0.0113 ) ==> mg/dL


                                                                                 53
75. Troponin T
Synonyms :                Trop. T, TnT, Cardiac T
Specimen :                3 mL BLOOD
Container :               RED TOP Tube
Reference Range :         up to 0.10 ng/ml
Turn Around Time :        1 day

76. Urea Nitrogen
Synonyms :                BUN, Urea, Blood Urea Nitrogen
Specimen :                2 mL BLOOD, 24 hours Urine
Container :               RED TOP Tube, Plain Urine Container
Reference Range :         Serum       Birth-1 year        1.4 - 5.7 mmol/L
                                   1 year - Adult        1.7 - 8.3 mmol/L
                          Urine = 333- 714 mmol/24h
Turn Around Time :        1 day
Conversion Factor :       Serum         ( / 0.357 ) ==> mg/dL
                          Urine        ( / 35.7 ) ==> g/24h

77. Uric Acid
Synonyms :                Urate, U.A.
Specimen :                2 mL BLOOD, 24 hour Urine
Container :               RED TOP Tube, Urine Container with 10 mL 12.5 M
                          NaOH
Reference Range :         Serum Adult Male            202 - 416 mol/L
                                   Adult Female      143 - 357 mol/L
                          Urine         1.5 - 4.5 mol/24h
Turn Around Time :        1 day
Conversion Factor :       ( / 59.48 ) ==> mg/dL       ( / 0.0059 ) ==> mg/24h

78. Vanillylmandelic Acid
Synonyms :              3-Methoxy-4-Hydroxymandelic Acid, VMA
Specimen :              24 hour Urine
Container :             Urine container with hydrochloric acid
Patient Care :          MAO inhibitors may produce false low value. Coffee,
                        tea, bananas, vanilla, and chocolate should be omitted
                        before testing.
Reference Range :       0 - 1 years up to 9 mol/24h
                        1 - 4 years up to 15 mol/24h
                        4 - 15 years up to 20 mol/24h
                        15y - Adult 35 - 45 mol/24h OR
                        0.86 - 4.00 mmol/mol creatinine
Turn Around Time:       2 - 4 weeks


                                                                             54
Conversion Factor :        ( / 5.05 ) ==> mg/24h
                           ( / 0.571)==> g/mg creatinine

79. Zinc
Synonyms :                 Zinc
Specimen :                 3 ml Blood
Container :                Plain tube ( metal free container)
Reference Range :          70 – 150 ug/dl
Turn Around Time :         Contact laboratory


ANTICOAGULANTS COLOR CODES USED CURRENTLY IN THE
TUBES

Red Top : No additive silicone ocated vacutainer

Red + Yellow : Gel and clot activaor

Green Top : Sodium Heprin

Gray Top : Potassium oxalate + Sodium fluoride

Blue Top : Buffered Sodium Citrate

Lav. Top : 7.5 % EDTA (K3)

II.   CHEMISTRY OF BODY FLUIDS

1. Amniotic Fluid Bilirubin
Specimen :             10 mL Amniotic Fluid
Container :            Brown sterile plastic or glass container.
Collection :           Protect specimen from exposure to light; aluminum
foil
                       is useful. Requisition MUST include weeks of
                       gestation.
Reference Range :      Approximately 0.2 - 0.6 mol/L
                       "See Report for Details"
Limitations :          Contamination of the sample with either maternal or
                       fetal blood or meconium may give erroneous results.
Turn Around Time :     1 day "Call For Appointment Before Specimen
                       Collection "



                                                                             55
2. Amniotic Fluid Creatinine
Specimen :            2 mL Amniotic Fluid
Container :           Brown Plastic or Glass Bottle
                      Requisition MUST include weeks of gestation.
Special Instruction : Correlation of maternal serum and amniotic fluid
                      creatinine levels is recommended.
Reference Range :     At 37 - 38 weeks > 177 mol/L
                      At 36 weeks 141-159 mol/L
Limitation :          Elevation of maternal creatinine may cause increases
                      in the amniotic fluid creatinine.
Comment :             In addition to creatinine, Amniotic fluid urea nitrogen
                      has been suggested as a marker for fetal renal maturity
                      and as a predictor of respiratory distress syndrome
                      (RDS).
Turn Around Time :    1 day

3. Amniotic Fluid Lecithin/Sphingomyelin Ratio
Synonyms :               L/S Ratio.
Specimen :               10 mL Amniotic Fluid
Container :              Sterile brown plastic or glass tube protected from light,
                         aluminum foil is useful. Requisition MUST include
                         weeks of gestation.
Reference Range :        Immature Lung L/S < 1.5
                         Boarder Line L/S = 1.5 - 1.9
                         Mature Lung L/S > 2.0
                         > 3.0 in diabetes
Turn Around Time :       1 day " Call For Appointment Before Specimen
                         Collection. Send Sample To Lab.Immediately After
                         Collection."

4. Body Fluids Analysis
Synonyms :              Ascitic Fluid, Peritoneal Fluid, Pleural Fluid, Fluid
                        Analysis,....etc.
Test Includes :         Albumin, Cholesterol, GGT (-GT), Lactic Acid, LDH,
                        Total Protein (PLEASE SPECIFY)
Specimen :              5 mL Body Fluid
Container :             Clean Tube, ( RED TOP, LAVENDER TOP, GREEN
                        TOP )
Reference Range :       Pathologic fluids such as pleural or peritoneal
                        (transudates or exudates are examined ). No normal
                        ranges exist, because such fluids by their very nature


                                                                                56
                         are not normal. Very high -GT in ascitic fluid is said
                         to suggest hepatoma as opposed to cirrhosis or liver
                         metastases.
Turn Around Time :       1 day

5. Body Fluid Amylase
Specimen :            2 mL Body Fluid
Container :           RED TOP Tube (Clean Container with no preservative
                      added)
Reference Range :     Pathologic fluids such as pleural or peritoneal
                      (transudates or exudates are examined ). No normal
                      ranges exist, because such fluids by their very nature
                      are not normal.
Turn Around Time :    1 day

6. Body Fluid Glucose
Specimen :               2 mL Body Fluid
Container :              Clean Plain Tube ( RED TOP)
Reference Range :        Usually similar to plasma glucose concentration.
                         Since body fluids accumulations are themselves
                         abnormal, provision of a digital range would be
                         misleading.
Turn Around Time :       1 day

7. Body Fluid Lipase
Specimen :               2 mL Body Fluid ( Pleural or Peritoneal )
Container :              Clean Plain Tube (RED TOP)
Reference Range :        Since body fluids accumulations are themselves
                         abnormal, provision of a digital range would be
                         misleading.
Turn Around Time :       1 day

8. Body Fluid pH
Specimen :               1 mL Body Fluid ( i.e., Pleural )
Container :               Lithium Heparin Tube ON ICE
Collection :             Collect anaerobically in syringe rinsed with 0.2 mL of
                         heparin.
Reference Range :        pH about 7.4
                         Since body fluids accumulations are themselves
                         abnormal, provision of a digital range would be
                         misleading.



                                                                                  57
Turn Around Time :         1 day

9. Cerebrospinal Fluid Glucose
Synonyms :                   CSF Glucose
Specimen :                   1 mL Spinal Fluid
Container :                  Clean Sterile Test Tube
Patient Care :               Blood glucose is needed also. Ideally, it should be
                             drawn two hours before the lumbar puncture, The
                             equilibration time.
Special Instruction :Do not store. Must be delivered to laboratory stat.
Usually 3 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 labeled 1,2,3 in
order of collection, third tube goes to Chemistry.
Reference Range :            In fasting patients, 2.8 - 4.4 mmol/L. Values may be
                             somewhat higher in children, 2.5 - 5.6 mmol/L. CSF
                             glucose should be 60 - 70 % of plasma glucose.
Turn Around Time :           1 - 4 hours
Conversion Factor :          ( / 0.0555 ) ==> mg/dL

10. Cerebrospinal Fluid Lactic Acid
Synonyms :               CSF Lactic Acid
Specimen :               1 mL Spinal Fluid
Container :              Clean Sterile Tube
Reference Range :        0.6 - 2.4 mmol/L
Turn Around Time :       1 day

11. Cerebrospinal Fluid LD
Synonyms :               CSF LD, CSF LDH
Specimen :               1 mL Spinal Fluid
Container :              Sterile Container
Reference Range :        About 10% of serum levels.
Turn Around Time :       1 day

12. Cerebrospinal Fluid Protein
Synonyms :                CSF Protein
Specimen :                1 mL Spinal Fluid
Container :               Clean Sterile Tube
Limitations :             Fresh blood in the specimen (traumatic tap) will
                          invalidate the protein result.
Special Instruction : Do not store. Must be delivered to laboratory stat.




                                                                                    58
Usually 3 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 labeled 1,2,3 in
order of collection, third tube goes to Chemistry.
Reference Range :            Lumbar CSF
                             0 - 1 month     0.30 - 1.70 g/L
                             1 - 6 months 0.30 - 1.00 g/L
                             6 months & up 0.15 - 0.50 g/L
                             Ventricular CSF protein is generally lower
Turn Around Time :           1 - 4 hours

13. Cerebrospinal Fluid Protein Electrophoresis , oligoclonal banding
USEFUL FOR:              Diagnosis of multiple sclerosis
                         Abnormalities of the spinal fluid in multiple sclerosis
                         include increases in total protein primarily due to
                         spinal fluid- specific IgG synthesis.
                         The IgG populations migrate as discrete bands rather
                         than a broad homogeneous band.
                         The presence of oligoclonal bands is unrelated to
                         disease activity.
Synonyms :               CSF Electrophoresis
Specimen :               5 - 7 mL CSF, blood is also required , for comparison
Information :            Most CSF proteins reflect their counterparts in the
                         serum (from which they are derived). CSF protein is
                         only approximately 1/200 as concentrated as serum
                         protein, necessitating concentration (usually 100 x ),
                         so sample volume required is 5 mL or more.
Container :              Clean Sterile Tube
Reference Range :        0-1 band
Turn Around Time :       1 - 2 weeks


III.   THERAPEUTIC DRUG MONITORING & TOXICOLOGY

Reasons for Monitoring Serum ( Plasma ) Drug Levels

1. The drug has a narrow, well-defined therapeutic range.
2. The drug exhibits great interindividual variations in utilization and
   metabolism.
3. The drug does not produce the desired therapeutic effect.
4. Secondary disease or physiologic state alters drug utilization.
5. The drug produces symptoms of toxicity.
6. Noncompliance is suspected.


                                                                                   59
7. Drug interactions are suspected.
8. Medicolegal verification of treatment is required.


TESTS AVAILABLE

1. Acetaminophen
Synonyms :                  Anacin-3, Datril, Liquiprin, Paracetamol, Panadol,
                            Panex, Phenaphen, Tylanol, Tampra
Specimen :                  2 mL Blood. " To be drawn 4 hours after the ingestion"
Container :                 RED TOP Tube
Therapeutic Range :         66 - 199 mol/L
                            Hepatic damage may occur if serum concentration is >
                            790 mol/l at 4hr or > 300 mol/l at 12 hrs after
                            uingestion. Half-life may be used to judge toxicity.
                            Usual half-life is 1-3h. if halfe-life is 4 hr toxic
                            damage to liver is probable. Draw 2 samples, 4hrs
                            apart. Drawing time should be indicated.
Half Life :                 Neonates 2 - 5 hours
                            Adults        1 - 3 hours
Turn Around Time :          1 - 4 hours
Conversion Factor :         ( / 6.62 ) ==> g/mL

fig.




2. Alcohol
Synonyms :                  ALC, Ethanol, Ethyl Alcohol, Blood Alcohol, EtOH
Specimen :                  The specimen tube should be COMPLETELY
                            FILLED.
Container :                 RED TOP, GREEN TOP, BLUE TOP, LAVENDER
                            TOP, and GRAY TOP Tube.


                                                                                60
Patient Care :            Do not use alcohol wipe to clean venipuncture site.
                          Hexachlorophene-based, iodine-based, or mercury-
                          based antiseptics not containing alcohol may be used.
Reference Range :         Negative.
                          10.9 - 21.7 mmol/L ( Intoxication )
                          65.1 - 108.6 mmol/L ( Comatose )
                          > 86.8        mmol/L ( Fatal )
Peak Serum Conc :         40 - 70 minutes on an empty stomach.
                          "Food In The Stomach Can Decrease The Absorption
                          Of Alcohol"
Turn Around Time :        1 hour
Conversion Factor :       ( / 0.217 ) ==> mg/dL

3. Acetylsalicylic Acid
Synonyms :                Aspirin, ASA, Salicylate.
Specimen :                2 mL Blood
Container :               RED TOP, LAVENDER TOP Tube
Therapeutic Range :       0.20 - 1.45 mmol/L < 0.72 mmol/L for analgesic
                          1.09 - 1.45 mmol/L for anti-inflammatory
Toxic Levels :            Mild 2.17 mmol/L
                          Severe 3.62 mmol/L
                          Lethal 4.34 mmol/L
Time to Achieve Steady State : 1 - 5 days of chronic dosing.
Peak Serum Conc :         1 - 2 hours
Half Life :               Dose dependent 3 hours at lower dose
                          5 - 6 hours after 1 g
                          10 hours with higher doses
Turn Around Time :        1 - 4 hours
Conversion Factor :       ( / 0.0724 ) ==> mg/d

4. Carbamezepine
Synonyms :                Epitrol, Tegretol
Specimen :                2 mL Blood
Container :               RED TOP Tube
Sampling Time :           Trough ; Immediately prior to next oral dose.
Peak :                    3 hours after an oral dose.
Therapeutic Range :       ( 17 - 51 mol/L )
                          Patients who require higher levels. ( 34 - 51 mol/L ),
                          should be carefully monitored. If other anticonvulsants
                          are given ( 17 - 34 mol/L ).
Toxic Levels :            In multiple drug regimen ( > 34 mol/L )
                                                      ( > 51 mol/L )


                                                                                  61
Time To Steady State :     2 - 6 days from chronic dosing.
Half Life :                Initial = 18 - 55 hours
                           Multiple dosing, child = 8 - 14 hours
                           Multiple dosing, adult = 12 - 17 hours
Turn Around Time :         1 - 4 hours
Conversion Factor :        ( /4.23 ) ==> g/mL

5. Digoxin
Synonyms :               DGN, Lanoxicaps, Lanoxin
Specimen :               5 mL Blood
Container :              RED TOP, GREEN TOP, LAVENDER TOP Tube
Collection :             Blood specimen must be drawn 6 hours after the
                         administration of the last dose.
Special Instruction :    "BE SURE PATIENT IS NOT ON DIGITOXIN"
Therapeutic Range :      1.15 - 2.56 nmol/
Toxic Levels :           > 2.6 nmol/L       Panic > 3.8 nmol/L
Time To Achieve Steady State : 5 - 7 days of chronic dosing and normal renal
                         function.
Half Life :              Premature      61 - 170 hours
                         Full term       35 - 45 hours
                         Infants        18 - 25 hours
                         Children              35 hours
                         Adults         38 - 48 hours
                         Anephric Adult > 4.5 days
Turn Around Time :       1- 4 hours
Conversion Factor :      ( / 1.28 ) ==> ng/mL
                         Therapeutic and toxic range are not well defined and
                         many factors affect interoperation of plasma drug
                         concentrations. Concentration monitoring is not
                         indicated in majority of patients on maintain treatment,
                         especially if clear response has been obtained.
                         Monmay be valuable in certain circumstances, as
                         follows:
                         *When is an initial poor response to treatment.
                         *In helping to confirm a diagnosis of digxin toxicity.
                         *When previous drug history is uncertain.

6. Lithium
Synonyms :                 Li, Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate,
                           Lithotabs.
Specimen :                 2 mL Blood
Container :                RED TOP Tube


                                                                                     62
Collection :             Collect at a standard time from last dose ( 12 ) hours .
Therapeutic Range :      For acute mania 0. 6 - 1.5 mmol/L
                         For protection       0.8 - 1.0 mmol/L
Time To Achieve Steady State : 3 - 7 days after chroinc dosing
Peak serum conc.:        0.5 - 2 hours
Half Life :              18 - 24 hours. Can increase to > 36 hours in elderly or
                         patients with renal impairment.
Turn Around Time :       7- 24 hours

7.Phenobarbital
Synonyms :               PHNO, Phenobarbitone, Phenylethylmalonylurea,
                         Barbita, Luminal, Solfoton
Specimen :               2 mL Blood
Container :              RED TOP, LAVENDER TOP Tubes
Sampling Time :          Just prior to next dose ( for periodic monitoring )
Special Instruction :    "LEVEL MAY INCREASE WHEN CONCOMITANT
                         DRUG THERAPY IS GIVEN" ( e.g., Phenytoin )
Therapeutic Range :      Infants & children 65 - 129 mol/L
                         Adults 86 - 172 mol/L
Time To Achieve Steady State : Adult 10 - 25 days
                              Child    8 - 15 days of chronic dosing
Peak serum Conc.:        1 - 6 hours
Half Life :              Neonates 45 - 500 hours
                         Infants 20 - 133 hours
                         Children 37 - 73 hours
                          Adults 53 - 140 hours
Turn Around Time :       1 - 4 hours
Conversion Factor :      ( / 4.31 ) ==> g/mL

8. Phenytoin :
Synonyms :               PTN, Dilantin, Diphenylan Sodium,
                         Diphenylhydantoin
Specimen :               2 mL Blood
Container :              RED TOP, LAVENDER TOP Tube
Sampling Time :          Trough, immediately before next dose
Therapeutic Range :      40 - 79 mol/L "Toxicity is measured clinically, some
                         patients require levels outside the suggested
                         therapeutic range."
Time To Achieve Steady State : Variable ( 8 - 50 days )
Peak Serum Conc.:        Oral 4 - 12 hours     IV. 2 - 3 hours
Half Life :              Children, about 10 hours
                         Adults 20 - 40 hours


                                                                                63
Turn Around Time :         1 - 4 hours
Conversion Factor :        ( / 3.96 ) ==> g/dL


9. Theophylline
Synonyms :               Aminophylline, Elixophylline, Slo-phylline, Sustaire,
                         Theo-Dur, Theolair, Theospan.
Specimen :               2 mL Blood
Container :              RED TOP, LAVENDER TOP Tube
Sampling Time :          Through , just before next dose
Therapeutic Range :      Adult 56 - 111 mol/L
                         Neonatal Apnea 33 - 61 mol/L
                         Ped. Asthma 44 - 111 mol/L
Time To Achieve Steady State : Adult 2 days of chronic dosing
                         Child 1 - 2 days
                         Infant 1 - 5 days
                         Newborn 120 hours
                         Premature 150 hours
Peak Serum Conc. :       IV. bolus; 30 min. after end of 30 min. infusion
                         Continuous infusion; 16 - 24 h after the start or change
                         of constant IV. infusion
                         P.O. liquid, fast-release tablet; 1 hour post dose
                         P.O. slow-release; 4 hours post dose
Half Life :              Children 2 - 9 hours
                         Adults 7 - 9 hours
Turn Around Time :       1 - 4 hours
Conversion Factor :      ( / 5.5 ) ==> g/mL

10. Valproic Acid
Synonyms :               Depakane, Depakote, Sodium Valproate
Specimen :               2 mL Blood
Container :              RED TOP, GREEN TOP Tube
Sampling Time :          Trough, just before next dose
Therapeutic Range :      350 - 690 mol/L
Toxic Levels :           690 - 1040 mol/L
Time To Achieve Steady State : 2 - 3 days of chronic oral dosing.
Limitations :            Monitor AST, ALT levels, CBC, platelet count and
                         other coagulation parameters in patients on this drug.
Peak Serum Conc.:        1 - 4 hours after oral administration 3 - 5 hours after
                         divalproex enteric coated)
Half Life :              4 - 14 hours, Children
                         8 - 17 hours, Adults


                                                                                   64
Turn Around Time :      1 - 4 hours
Conversion Factor :     ( / 6.93 ) ==> g/mL


IV.    MISCELLANEOUS CHEMISTRY TESTS

1. Chloride ( Sweat )
Synonyms :              Cystic Fibrosis Sweat test, Sweat Chloride
Specimen :              Sweat "Pilocarpine is iontophoresed into the skin to
                        stimulate locally increased sweat gland secretion. "
Patient Care :          Patient should not receive any Intra Venous fluids, for
                        at least 48 hours prior to the test.
Reference Range :       Values of 0 - 50 mmol/L normal. in children, values
                        over 60 mmol/L on at least two occasions are
                        diagnostic.
                        In adults , values over 70 mmol/L are diagnostic.
Limitations :           Causes for false High Results :
                        Adrenal insufficiency, ectodermal dysplasia, hereditary
                        nephrogenic diabetes insipidus, hypothyroidism,
                        malnutrition, fucosidosis, glucose 6-phosphatase
                        deficiency, mucopolysaccharidosis.
                        Causes of false Low Results
                        Edema, and hypoproteinemia.
Turn Around Time :      Contact laboratory for appointment. Test is performed
                        twice a week.

2. Stone Analysis
Synonyms :              Calculus Analysis, Nephrolithiasis Analysis, Renal
                        Stone, Biliary Stone
Specimen :              Kidney stone, Gall stone
Test Includes :         Qualitative analysis for ammonia, calcium, carbonate,
                        cholesterol (gallstone), cystine, magnesium, oxalate,
                        phosphate, urates.
Container :             Glass bottle or plastic urine container
Collection :            Specimen should be washed free of tissue and
blood,
                        and submitted in a clean, dry container.
Rejected If :           Insufficient stone volume for complete analysis.
Instruction :           Specify source of stone on requisition.
Turn Around Time :      1 - 3 weeks




                                                                             65
V.    TESTS TO BE INTRODUCED IN THE FUTURE

The clinical chemistry section is planning to introduce the following tests as soon
as possible.

Chemistry


Amniotic Fluid Pulmonary Surfactant
Apolipo Protine A1
Apolipo Protine B
Carnitine
Catecholamines Fractionation
Cerebrospinal Fluid Clearance ( Alb./Ig.)
Cerebrospinal Fluid Oligoclonal Bands
High resolution Protein Electrophoresis
Lactate Dehydrogenase Isoenzymes
Low Density Lipo Protine
5' Nucleotidase
TDM & Toxicology
Diazepam
Drugs Of Abuse Screen

REMARK : Please advise us if you would like to see any other test introduced in
the clinical chemistry section.




                                                                                  66
ENDOCRINOLOGY (RIA) PROCEDURES

        Chemical Pathology Division




                  Prepared by


       Fatima Al-Lanjawi, B.Sc.(Chemistry)
            Supervisor - Endocrinology


      Edgar Bondoc, B.Sc.(Med. Technology)
           Technologist - Endocrinology




                  Reviewed by


Mohd. Osman Abdel-Rahman, MBBS, DCP, FRCPath.
       Head of Chemical Pathology Division.




                                                67
68
17-ALPHA HYDROXYPROGESTERONE
Synonyms :         17-alpha- OHP
Patient Care :     No radioactive isotopes
Specimen :         Blood (serum)
Container :        Red top tube.
Amount of blood :  3.0 ml.
Turn around time : 2 weeks
Normal Range :     Female
                       Follicular phase :0.5 – 2.4 nmol/l
                       Luteal phase : 0.81 - 9 nmol/l
                   Male :                up to 6.5 nmol/l
                   Newborn :             <2.1 - 7.6 nmol/l

25- HYDROXY VITAMIN D
The measurement of 25-OH-D is becoming increasinly important in the
management of of patients with rickets, neonatal hypocalcaemia, pregnancy,
nutritional and renal osteodystrophy, hypoparathyroidism, and postmenopausal
osteoporesis.
Specimen :               Blood (serum)
Container :              Red top tube
Amount of Blood :        2.0 ml
Turn around time :       3 weeks
Reference range :        10 - 50 ng/ml

ALDOSTERONE
Primary aldosteronism is characterized by hypertension with renal potassium
wasting. It is found in fewer than one percent of subjects with hypertension..
Patient Preparation:      No recent radioactive scans or other radioactivity .
                          Diuretics, antihypertensive drugs, cyclic progestogens,
                          estrogens, and licorice should be terminated 2-4 weeks
                          before testing. Patient should be in a normal sodium diet
                          for 2-4 weeks (135 meq or 3 g of Na/dy). Supine sample
                          should be drawn early, before the inpatient arise. If an
                          upright sample is indicated, patient should have been up
                          for two hours or more. Replacement of potassium deficit
                          is recommended before samples for aldosterone are taken.
                          A random measurement of aldosterone is of no diagnostic
                          utility unless plasma renin is determined simultaneously.
Specimen :                Blood (Serum)
Container :               Red top tube.
Amount of blood :         3.0 ml.
Collection :              Specify exact source of specimen . Specify patient's


                                                                                 69
                        position .
Special Instruction :   Transport at once to laboratory in ice.
Turn around time :      2 weeks .
Normal Range :          Supine :      80 - 450 pmol /L
                        Standing : 110 - 860 pmol /L

ALPHA - FETOPROTEIN (AFP)
This service is available only as a tumor marker.
Patient preparation :    Avoid recent isotope scan.
Specimen :               Blood (serum)
Container :              Red top tube.
Amount of blood :        2.0 ml.
Turn around time :       One week.
Normal range :           Normal non-pregnant adults = 0-10 KU/l
                         Pregnant adult levels may vary according to gestational
                         period.

BETA-HUMAN CHORIONIC GONADOTROPIN
Synonyms :         Beta Subunit
Specimen :         Blood (serum)
Container :        Red top tube.
Amount of Blood :  3.0 ml
Turn around time : 2 days.
Reference Range :  Normal non-pregnant < 5 lU/l.

C-PEPTIDE OF INSULIN
Synonms :             Connecting peptide Insulin, pro Insulin C- Peptide
Patient Care :        Patient should fast for a minimum of 10 hours for basal
                      values. No recent scans or other radio activity.
Specimen :            Blood (serum)
Container :           Red top tube
Amount of Blood :     5 ml
Special Instruction : Keep specimen in ice
Turn around time :    6-8 weeks
Normal Range :        0.64-2.83 ng/ml

CANCER ANTIGEN 15-3 (CA 15-3)
Specimen :         Blood (serum)
Container :        Red top tube
Amount of blood :  3.0 ml
Turn around time : 2 - 4 weeks




                                                                                   70
CARBOHYDRATE ANTIGEN 19-9 ( CA 19-9 )
Detects the sialylated form of the Lewis blood group antigen and so is not present
in the 10% or so of individuals who lack this antigen. It is used mainly for
montioring pancreatic cancinoma.
Elevated values may be caused by a varity of malignant and malignant conditions,
including:
-      Cholangiocarcinoma
-      Pancreatic cancer
-      Colon cancer
Specimen :               Blood (serum)
Container :              Red top tube.
Amount of blood :        3.0 ml.
Turn around time :       2- 4 weeks.

CARCINO EMBRYONIC ANTIGEN (CEA)
CEA is an oncofetal glycoprotein antigen. It is present in embryonic tissues and
certain epithelial malignancies.
Specimen :               (1) Blood       (2) Effusion fluid.
Container :              Red top tube.
Amount of blood :        3.0 ml.
Turn around time :       2 - 4 weeks.
Normal range:            Smoker :      0-7.5 g/L
                         Non-smoker : 0-4.5 g/L

CORTISOL
The circulatory cortisol level is normally subject to circadian rhythm
Synonym :                Compound F; Hydrocortisone.
Specimen :               Blood (serum or plasma)
Container :              Red top tube.
Amount of Blood :        1.0 ml.
Sampling time :          A.M. and P.M. levels.
Turn around time :       3-4 days.
Normal range :           Morning       166-828 nmol/L
                         Night          80-440 nmol/L

CYCLOSPORINE (Monoclonal whole blood)
Synonym :           Sandimmune; Applies to Cyclosporine A.
Specimen :          Whole blood.
Container :         Lavender top tube.
Amount of blood :   3.0 ml.
Turn around time :  One week.
Therapeutic range : There are different requirements for optimal whole


                                                                                   71
                       blood levels for each individual depending on the clinical
                       state of the individual Dose is adjusted to maintain trough
                       blood levels based on clinical evaluation.

DEHYDROEPIANDROSTERONE SULFATE
Synonyms :         DHAS; DHEA - S.
Abstract :         DHEA and its sulfate DHEA-S are the major precursors
                   of 17 ketosteroids: DHEA-S is predominantly an adrenal
                   androgen. DHEA-S is the most abundant circulating C-19
                   steroid. It is a precursor of dehydroepiandrosterone.
Specimen :         Blood (serum)
Container :        Red top tube.
Amount of Blood :  1.0 ml.
Turn around time : Two weeks.
Reference range :  Female :        Prepubertal:          0.3 -1.6 mmol/l
                   Adult:          1.89 -11 .m mol/l
                                   Post menopausal:      0.3 -1.6 mmol/l
                   Male :          Prepubertal:          0.3 -1.6 mmol/l
                   Adult:          5.4 - 9.0 m mol/l

ESTRADIOL (E2)
Specimen :             Blood (serum)
Container :            Red top tube
Amount of Blood :      3.0 ml.
Sampling time :        In females, the portion of the menstrual cycle may be
                       needed for interpretation.
Turn around time :     One week.
Reference range :      Follicular :      88 - 418 pmol/L
                       Mid cycle         228 - 1960 pmol/L
                       Luteal            294 - 1102 pmol/l
                       Postmenopausal: 73 - 323 pmol/L
                       Male :            73 - 275 pmol/L

FERRITIN
Specimen :             Blood (serum).
Container :            Red top tube.
Amount of blood :      3.0 ml.
Turn around time :     One week.
Reference range :      Male :        24 - 336 ug/L.
                       Female :      11 - 304 ug/L.

FOLATE (Red Blood cells Folate)
Patient preparation : Patients should be fasting overnight. Collect blood prior


                                                                                  72
                        to transfusion or initiation of folate therapy.
Specimen :              Whole blood
Container :             Lavender tube.
Amount of blood :       3.0 ml.
Special instruction :   Avoid hemolysis. Protect from light.
Turn around time :      One week.
Reference range :       338 - 1970 nmol/L

FOLATE (Serum folic acid)
Patient preparation : Patients should be fasting overnight. Collect blood prior
                      to transfusion, or initiation of folate therapy.
Specimen :            Blood (serum)
Container :           Red top tube.
Amount of blood :     5.0 ml.
Special instruction : Avoid hemolysis. Protect from light.
Turn around time :    One week.
Reference range :     0 - 6.8 nmol/L

FOLLICLE STIMULATING HORMONE (FSH)
Specimen :         Blood (serum)
Container :        Red top tube.
Amount of blood :  2.0 ml.
Turn around time : One week.
Reference range :  Follicular :      4-9 IU/L
                   Midcycle :        5-23 IU/L
                   Luteal :          2-5 IU/L
                   Post menopausal : 17-114 IU/L
                   Male :            1-19 IU/L

FREE PSA
Specimen :              Blood (serum)
Container :             Red top tube
Amount of blood :       2.0 ml

FREE T4
Synonyms :              FT4; Free thyroxine; Unbound T4.
Specimen :              Blood (serum)
Container :             Red top tube.
Amount of Blood :       2.0 ml.
Turn around time :      3 days.
Normal range :          8 - 21 pmol/L.




                                                                                  73
GASTRIN
Patient care :        The patient must be fasting overnight, preferably 12 hours
                      or more. No recent radioactiveisotopes.
Specimen :            Blood (serum)
Container :           Red top tube.
Amount of Blood :     5.0 ml.
Turn around time :    6-8 weeks.
Normal range :        0-108 pmol/L Fasting

GROWTH HORMONE
Synonyms :         GH, hGH, Somatotropin.
Patient care :     Patient should be fasting. Draw blood from rested patient
                   for patient suspected with hypersecretion. However, basal
                   reading for patients suspected for hyposecretion, it should
                   be withdrawn without avoiding stress.
Specimen :         Blood (serum)
Container :        Red top tube.
Amount of Blood :  2.0 ml.
Turn around time : Two weeks.
Normal Range :     Male : 0 - 10 ug/L
                   Female :            0 - 20 ug/L

HOMOCYSTINE
Specimen :            Blood (serum)
Container :           Red tope tube in ice
Turn around time :    One month
Reference range :     5 - 15 umol/L
                      Over 60 years 5 - 20 umol/L

IMMUNOGLOBULIN E
Synonyms :         IgE
Specimen :         Blood (serum)
Container :        Red top tube
Amount of Blood :  3.0 ml
Turn around time : One week.
Reference Range :  Normal adult = 0-241 KU/L

INSULIN
Synonym :             Immunoreactive Insulin.
Patient care :        The patient should be fasting for at least seven hours.
                      Blood for plasma glucose (in a fluoride container) should
                      also be sent. Avoid radioisotopes prior to collection of
                      specimen.


                                                                              74
Specimen :               Blood (serum)
Container :              Red top tube
Amount of Blood :        5.0 ml
Turn around time :       One week
Normal range :           2-23U/l Fasting,

LUTEINIZING HORMONE
Specimen :         Blood (serum)
Container :        Red top tube
Amount of blood :  2.0 ml.
Turn around time : One week.
Reference range :  Female:
                        Follicular:              2 - 11 IU/L
                        Mid-cycle:               24 - 103 IU/L
                        Luteal :                 1 - 13 IU/L
                        Post menopausal :        11 - 59 IU/L
                   Male:                         1.0 - 9.0 IU/L

METHOTREXATE II
Specimen :            Blood (serum)
Container :           Red top tube
Special instruction : Prior appointment
Reference range :     After 24 hours 5 - 10 umol/L
                              48 hours 0.5 - 1 umol/L
                              72 hours > 0.2 umol/L

PARATHYROID HORMONE (Intact )
Parathyroid hormone is an 84 amino acid peptide that circulates in at least four
molecular forms.
Synonyms :             Parathormone; PTH. Intact PTH.
Patient care :         Fasting patient.
Specimen :             Blood (serum)
Container :            Red top tube.
Amount of Blood :      5.0 ml
Turn around time :     One week
Normal range :         9 - 55 pg/ml

PROGESTERONE
Specimen :               Blood (serum)
Container :              Red top tube.
Amount of Blood :        2.0 ml.
Special instructions :   Request form should be completed with patient`s sex, last
                         menstrual period (LMP) and trimester of pregnancy.


                                                                                   75
Turn around time :    One week.
Normal range :        Female
                         Follicular :    0.98 - 5 nmol/L
                         Luteal :        16 - 59 nmol/L
                         Postmenopausal :<0.25 - 2.5 nmol/L

PROLACTIN
Patient care :        May rises in response to physoilogic stimuli or stress such
                      exercise and while nursing. Multiple medications can
                      cause a rise in prolactin level including phenothaitazines
                      and other pschtropic drugs, metoclopramide, opiates,
                      amphetamines, alph- methyl dopa, estroge cimetidine, and
                      others.
Specimen :            Blood (serum)
Container :           Red top tube.
Amount of blood :     2.0 ml.
Turn around time :    One week.
Normal range :        Female :
                          < 50 years 80 - 641 mU/L
                          > 50 years 66 - 471 mU/L
                      Male :             63 - 315 mU/L

PROSTATE SPECIFIC ANTIGEN
Synonym :          PSA.
Abstract :         Marker for adenocarcinoma of prostate PSA may also be
                   increased in benign entities. Serially measured, PSA is
                   extremely useful in monitoring presurgical as well as post
                   surgical patients and in anticipation of recurrence.
Patient care :     Fasting specimen preferred.
Specimen :         Blood (serum)
Container :        Red top tube.
Amount of Blood :  3.0 ml.
Turn around time : One week
Normal Range :     Male :        0-4.0 ng/ml

RENIN
Patient care :        Antihypertensive drugs, steroids, cyclic progesterone,
                      estrogens, diuretics, licorice should be terminated at least
                      2 weeks and preferably 4 weeks before a renin-aldosterone
                      work- up is to begin. A normal sodium diet is requested
                      for 2-4 weeks unless renin activity is to be measured
                      following salt depletion for aldosteronism.


                                                                                76
Specimen :              Whole blood
Container :             Lavender [EDTA] top tube (pre-chilled).
Amount of blood :       5 ml.
Special instruction :   Send in ice to the laboratory. Specify posture collection.
Turn around time :      6-8 weeks.
Normal range :          (Normal salt intake)
                        Supine :      0.5 - 2.6 ng/ml per hour.
                        Upright :     1 - 4.2 ng/ml per hour.

SKELETAL ALKALINE PHOSPHATASE (SALP)
Specimen :         Blood (serum)
Container :        Red top tube
Amount of Blood :  2.0 ml
Turn around time : 4 weeks
Reference range :  0 - 21 ug/L

SOMATOMEDIN - C
Synonyms :         IGF- 1; Insuline-like Growth Factor-1, Sm-C.
Patient care :     Overnight fast is preferable. No recent administration of
                   radioisotopes.
Specimen :         Whole blood
Container :        EDTA; lavender top tube.
Amount of Blood :  3.0 ml.
Turn around time : 6-8 weeks.

TACROLIMUS II (FK506)
Specimen :            Whole blood
Container :           EDTA tube
Special instruction : Prior appointment
Reference range :     Varies

TESTOSTERONE
Specimen :              Blood (serum)
Container :             Red top tube
Amount of Blood :       2.0 ml
Turn around time :      One week
Normal range :          Male :       10.4-34.7 nmol/L
                        Female :     0.7-3.47 nmol/L

THYROID STIMULATING HORMONE
Synonyms :     S-TSH; Thyrotropin
Specimen :     Blood (serum)
Container :    Red top tube


                                                                                     77
Amount of Blood :      2.0 ml
Turn around time :     3 days.
Reference range :      0.34 -5.6 mIU/L

TRI-IODOTHYRONINE
Synonyms :         T3; Total T3
Specimen :         Blood (serum)
Container :        Red top tube
Amount of blood :  1.0 ml
Turn around time : 3 days
Normal range :     1.34-2.73 nmol/L

URINE ALDOSTERONE
Specimen :            24 hours urine collection
Container :           Plastic container
Special instruction : Refrigerate urine during collection
Turn around time :    2 weeks
Reference range :     3.9 - 55.6 pmol/24 hours

URINE CORTISOL
Synonyms :            Urinary free cortisol.
Patient care :        Patient should avoid spironolactone, or quinacrine. Avoid
                      patient stress.
Specimen :            24 hour urine.
Container :           Plastic container.
Special instruction : Refrigerate urine during collection if preservative is not
                      used.
Turn around time :    3-4 days.
Reference range :     116 - 600 nmol/24 hours.

VITAMIN B-12
Patient Care :         Fasting specimen preferred. Draw before transfusions or
                       B-12 therapy is started.
Specimen :             Blood (serum)
Container :            Red top tube
Amount of Blood :      2.0 ml
Turn around time :     2 days
Reference range :      133 - 675 pmol/L




                                                                              78
  HAEMATOLOGY PROCEDURES

   Division of Heamtology & Cytogenetics




                   Prepared by

Halima Al-Musleh, B.Sc., M.Sc.(Applied Hematology)
            Supervisor - Hematology

    Naila Ali Fakhroo, B.Sc.(Zoology/Chemistry)
           Sr. Technologist - Hematology



                   Revised by:
Zeinab Osman Fawzi, MBBS, DCP, MRCPath(Part I)
             Specialist - Hematology




                                                     79
80
Introduction
Hematology is the study of blood and its disorders and deals primarily with the
cellular elements of blood & their diseases and with disorders of plasma
components which may be disorganised during disorders of hemostasis. This
document aims to present a summary of tests that are currently carried out in
Hematology or may soon be available. These tests are carried out when suitable
correctly labeled blood specimens are combined with correctly completed request
forms, are received in the Laboratory. The tests are classified into stat and routine
tests depending on justified categorization by the appropriate clinician.

1.Tests performed on specimens collected in EDTA tube (Lavender top)
  include the following

1-1. Complete Blood Count (CBC) - Coulter Profile
This comprises estimation of Hemoglobin (Hb), Hematocrit (Hct), Red Blood
Cells (RBC) count, White Blood Cells (WBC) count, RBC indices and platelet
count + automated differential count.
Sample :                               Whole blood (3 ml) in EDTA Tube
                                       Samples must reach the lab as soon as possible but not
                                       later than 2 hours after collection
           Normal Values                      Critical Value              Normal Value
            (Adults)                            (Adults)                    (Adults)
WBC        3.6 - 10 [x 109/ l]                < 2 > 50 x 109 / l          Poly 40 - 75%

RBC        M     4.5 - 6.5                                                Lymph 20 - 45%
           F     3.8 - 5.8[x1012/ l]                                      Mono    2 - 10%

Hb         M     14 - 18                      <6 > 18 g/dl                Eosinophil 1 - 6%
           F     12 - 16 [g/dl]               < 6 > 17 g/dl               Basophil 0 - 1%

Hct        M     40 - 54
           F     37 - 47 [Ratio]

MCV        76 - 96 [fl]

MCH        27 - 32 [pg]

MCHC       32 - 36 [g/dl]

Platelet   150 - 440 [x 109/ l]               < 30 x 10 9/ l

RDW** 11.6 - 14.5
**(Red cell size DistributWidth)




                                                                                              81
Normal Value                        * Critical Value            Normal Value
(F.M.T. 1st day)                    (F.M.T. 1st day)            (F.M.T. 1st day)

WBC         10 - 26 X 10 9 /L       <5     > 30 X 10 9 /L       Poly 32 - 62 %
RBC          4 - 6 X 1012 /L                                    Band 10.1 - 18.1 %
                                                                Lymph 26 - 36
                                                                Mono 5.8 % (mean)
Hb          14.0 - 20.0 g / dL      < 12 g / dL                 Eosinophil 2.2 % (mean)
                                                                Basophil 0.6 % (mean)
Hct         53 - 55 %
MCV         98 118
MCHC        29.7 - 33.5
Platelet    150 - 440 X 10 9 /L     < 20 X 10 9 /L
* Reporting of Critical Lab. values Appropriate action by technician is to
  call a nurse or a physician immediately. The name of the nurse or physician
  and the time of relaying the report should be noted and documented in the lab.
     Telephone reporting of lab. values.         The Technician who is making the
     report must identify him/herself to the receiving party.
     Laboratory values must be repeated by the person receiving the information in
     order to minimize the posibility of reporting error by telephone. The name
     antitle of the person receiving the report must be given to laboratory
     technologist.

1-2. Peripheral Smear
   This is a thin film examined for morphological assessment of RBCs, WBCs
   and platelets. Manual differential counts are done on the smear. The film
   should be air dried and stained with Wright Stain. Peripheral smears are
   prepared from all samples that show any abnormality on the Coulter profile.
   Peripheral smear examination is of unquestionable value in sorting out
   hematological abnormalities.

1-3. Reticulocyte Count
   Principle:                A supravital stain is used to stain remnants of RNA in
                             the cytoplasm of young RBCs (reticulocytes). The
                             number of reticulocytes in 1000 RBCs is determined
                             and reported as %.
     Specimen :              Whole blood (1 ml) in EDTA Tube or part of the CBC
                             specimen
     Significance:           Reticulocyte count is an index of red-cell production
                             by the bone marrow. Increased reticulocyte count



                                                                                   82
                           occurs in compensated or uncompensated anemias
                           e.g. hemolysis, bleeding etc.; while decreased
                           reticulocyte count occurs in marrow failure as in
                           aplastic anemia.
                           Normal Range for Adults and Children = 0.2 - 2%
                           Normal Range for Full term-Cord blood = 2 - 6%

1-4. Sickling Test
   Principle:           When whole blood is mixed with sodium metabisulfite
                               which is a strong reducing agent that
                        deoxygenates the hemoglobin & the mixture is
                        sealed to prevent    reoxygenation. Sickle shaped red
                        blood cells are formed if there is HbS within such
                        cells.
   Specimen:            Whole blood (1 ml) in EDTA Tube (or part of CBC
                        sample)
   Significance:        Positive Sickling test occurs in HbS diseases or trait.
                        In homozygous HbS anemias or HbS + C disease
                        marked sickling is usually visible after incubation of
                        the mixture of blood & metabisulfite for 1 hour or less
                        at 37o C. In HbS trait the process is slower and the
                        changes are less marked and incubation as long as
                        12 hours may be necessary for the changes to develop.
The Laboratory will inform the Nurse/Doctor immediately if the sickling
result is positive.

1-5. Malaria - Blood film for Malaria
    Principle:              The diagnosis of Malaria is usually based on
                            demonstration of the parasite in blood. The thick
                            smear is used as a screening test to establish the
    presence of parasite and the thin smear is used to          identify species of
the organism. The blood smears             should be obtained at the time of
admission of the                    patient, irrespective of the periodicity of the
fever. If                           these smears are negative, new smears should
be made                             at various times between 6-12 hours after the
next                                chill, since the blood will then contain the
larger                              trophozoites and more mature forms.
   Specimen:              1 ml whole blood in EDTA tube (or part of CBC
                          specimen)
   The Laboratory will inform the Nurse/Doctor immediately if the patient
   has malarial parasite.




                                                                                 83
1-6. Kleihauer Test
   Principle:             This is a quantitative cytochemical test for detecting
                          HbF in RBCs.
   Specimen:              1. Whole blood (1 ml) in EDTA Tube.
                          2. Cord blood (1 ml) in EDTA Tube. (as positive
                              control).
   Significance:          The test is used to detect fetal RBCs in maternal
                          circulation, thus estimating the amount of trans-
                          placental-hemorrhage (TPH) in cases of foeto-
                          metarnal Rh incompatibility or unexplained fetal
                          anemia. If four or less fetal cells can be seen using a
                          40 mm objective, this means that no more than 4 ml of
                          fetal red cells are present in the maternal circulation.
                          It is also used in case of high HbF levels to detect
                          hereditary persistence of fetal hemoglobin (HPFH).

1-7. Heinz Body
   Principle:             Heinz bodies represent precipitated denatured
                          hemoglobin and appear as single or multiple, round,
                          oval bodies in RBC on blood film.
   Specimen:              Freshly drawn whole blood using heparin or EDTA as
                          anticoagulant.
   Significance:          Heinz bodies are found in the presence of unstable
                          hemoglobins (such as Hb Zurich), in splenectomized
                          patients, in some hemolytic disorders. eg. G6PD
                          deficiency and glutathione deficiency.

1-8. Hb Electrophoresis
   Principle:             Electrophoresis is the movement of charged particles
                          in an electric field. In alkaline buffer (PH 8.2 to 8.6)
                          hemoglobin is a negatively charged molecule and will
                          migrate towards the anode (+).             The various
                          hemoglobin move at different rates depending on their
                          net negative charge, which in turn is controlled by the
                          composition (amino acids) of the hemoglobin
                          molecule (globin chain).
   Specimen:              2 ml of blood collected in EDTA, sodium citrate or
                          heparin is suitable.




                                                                                84
2. TESTS DONE ON OTHER TYPES OF ANTICOAGULANTS
2-1. Osmotic Fragility
(Please contact the laboratory in advance)
    Principle:             The test determines the resistance of the red cells to
                           hemolysis in varying concentrations of hypotonic
                           saline. It is normally carried out at room temperature.
    Specimen:              2 ml or more in Heparin Tube. (green top)
    Significance:          This test is done to establish the presence of
                           spherocytes in peripheral blood. For confirmation of
                           Hereditary Spherocytosis.

2-2. E S R
   Principle:               Erythrocyte sedimentation rate determines the rate of
                            settling of erythrocytes in their native anticoagulated
                            plasma. The blood is drawn into & allowed to settle
                            in a vertical graduated tube and the result is read after
                            one hour. The test is done at room temperature (22-
                            24°C)
   Specimen:                Citrated blood ( Black Top)
   Ratio of anticoagulant to the blood = 1:4
   Macro tube : 2.4 ml blood
   Micro tube : 1.6 ml blood
   Nomal range: (Westergreen) Male 0-15 mm
                                  Female 0-20 mm
   Significance:            ESR is useful in disorders associated with an
                            increased production of acute-phase proteins. It is a
                            non-specific test which will be raised in any
                            inflammatory condition. Low normal results are
                            obtained in cases of polycythaemia.

2-3. Coagulation Tests
   (Citrated - 3.8 % Trisodium Citrate - Blue top container).
   2-3-1. Prothrombin Time (PT) :
      Specimen:           2.7 ml whole blood (up to the blue line of the blood
                          container)
      Ratio of anticoagulant to the blood = 1 : 9
                       Normal Range: Differs from batch to batch of reagent.
                       Normally it is 12-15 seconds.
                       * INR (International Normalized Ratio) is a standardized
                          way of expressing the PT results as it cancels the effect
                          of the variation of reagent on PT result. It is practically
                          only useful for oral anticoagulation monitoring.


                                                                                   85
   Significance:       The PT is an assessment of the extrinsic and common
                       pathways of blood coagulation. It is prolonged in
                       proportion to decreasing concentration of factor II, V,
                       VII, X and fibrinogen or in presence of an inhibitor to
                       any of these factors.
2-3-2. Activated Partial Thromboplastin Time (APTT) :
   Specimen:           Same as P.T. (The test is usually carried out on the
                       same sample for P.T.)
   Significance:       The PTT is an assessment of the and common
                       pathways of blood coagulation. It will be prolonged
                       in deficiency of prekallikrein, HMWK (High
                       Molecular Weight Kininogen) factXII, XI, IX, , X,
                       V, II and fibrinogen,or by inhibitor directed against
                       involved factors or complexes.
   Range:              Differs from batch to batch, normally it is 30-45
                       seconds.
2-3-3. Thrombin Time (TT) :
   Principle:        Thrombin is added to plasma and the clotting time
                     measured.
   Specimen:         Same as for P.T & P.T.T
   Significance:     The thrombin time is affected by the concentration
                     and function of fibrinogen and by the presence of
                     inhibitory substants, including fibrinogen/fibrin
                     degradation products (FDP) and heparin.
   Normal Range:     Differs from batch to batch, normally it is 7-10
                     seconds.
2-3-4. Factor II, V, VII and X :
   Bio assay based on the one-stage Prothrombin Time:
   Principle:          When a range of dilutions of plasma standard are
                       added to a plasma almost totally deficient in a single
                       factor, the resulting prothrombin times show a linear
                       relationship to factor concentration when plotted on
                       double-log graph paper.
   Specimen:           Citrated blood / 2.7 ml.      (Please contact Lab. in
                       advance).
   Normal Range:       50-150% of normal activity.




                                                                            86
2-3-5. Factors VIII: C,IX, XI, XII
   Principle:          When a dilution of a standard or test plasma is added
                       to a plasma almost totally defiin a single factor, the
                       degree of correction of the prolonged time is
                       proportional to the factor activity in the added plasma
                       and linear plots can be obtained using log/log graph
                       paper.
   Specimen:           Citrated blood / 2.7ml
                       (Please contact Lab. in advance)
2-3-6. Solubility Test for Factor XIII Activity :
   Principle:            Fibrin cross-linked by the action of factor XIII is
                         insoluble in 5 mol/l urea solution. In the absence of
                         factor XIII activity a fibrin clot will dissolve within 1
                         hour at room temperature.
   Specimen:             Citrated blood / 2.7 ml
                         (Please contact Lab. in advance)
2-3-7. Inhibitor (Anticoagulant ) Screen :
   Principle:           A circulating anticoagulant or inhibitors affecting the
                        PTT may act immediately or be time-dependent. In
                        order to detect both types of inhibition, normal plasma
                        and test plasma samples are mixed and tested
                        immediately and then after incubation at 37o C for 90
                        minute.
   Specimen:            Citrated blood / Two tubes; 2.7 ml in ea
                        (Please contact Lab. in advance)
   Significance:        Circulating anticoagulants are acquired inhibitors of
                        blood coagulation factors.              They include
                        Immunoglobulins arising either in congenitally
                        deficient individuals as a result of the administration
                        of the missing factor or in previously hemostatically
                        normal subjects as part of an auto immune process.
                        They may also be derived from break down products
                        of the protiens eg. fibrinogen.
2-3-8. Activated Protein C Resistance (APC) Test :
   Principle:          Coatest APC Resistance provides an APTT-based
                       assay for semi-quantitative determination of the
                       response towards human APC. The prolongation of
                       the basal APT clotting time after addition of APC is
                       shorter in plasma from individuals with Factor V



                                                                                87
                           Leiden than from individuals with normal response to
                           APC (Normal Factor V).
      Specimen:            Citrated 3.8% trisodium citrate-Blue top container.

2-4. Tests For Heparin
   2-4-1. Hepaclot :   (Heparin level)
      Principle:          The anti-Xa activity of anti thrombin III (A.T - III) is
                          enhanced by addition of heparin. The inhibition of
                          factor Xa by heparin is measured in a modified factor-
                          X assay.
      Specimen:           Citrated blood (Please contact Lab. in advance)
                          Blood should be collected between 2 and 4 hours after
                          the injection of heparin.
      Significance:       Hepaclot is a clotting method for the measurement of
                          unfractionated heparin or Low molecular Weight
                          Heparins (LMWH) concentration in blood. It is used
                          for monitoring heparin therapy.
      Therapeutic Range: 0.2 - 0.6 iu/ml
   2-4-2. Reptilase Time :
      Principle:           Reptilase, a purified enzyme from the Bathrops Atrox
                           snake is used to replace thrombin in the thrombin
                           time test.
      Specimen:            Citrated blood / 2.7 ml
      Significance:        The snake venom (reptilase) is not inhibited by
                           heparin and will give normal clotting times in normal
                           plasma in the presence of raised FDP, abnormal or
                           reduced fibrinogen concentration.

2-5. Tests for Hyper Coagulability States

   2-5-1. Euglobulin Lysis Time (ELT) :
      Principle:          When plasma is diluted and acidified, the precipitate
                          which forms contains plasminogen activators,
                          plasminogen and fibrinogen.           The precipitate is
                          dissolved, the fibrinogen is clotted with thrombin and
                          the time for clot lysis to occur is estimated. Lysis time
                          of less than 60 minutes indicates increased
                          fibrinolysis.
      Specimen:           Sodium Citrate / 2.7 ml Blood
                          (Please contact Lab. in advance)


                                                                                 88
      Significance:        This test is done for detection of defective fibrinolysis.
                           It is a relatively sensitive test for plasma plasminogen
                                    activator.
   2-5-2. Ethanol Gelation Test :
      Specimen:           Citrated blood / 2.7 ml
      Significance:       Ethanol Gelation test is screening test for detection of
                          fibrin monomers. The test can provide evidence of
                          early DIC before the production of late products of
                          fibrin degradation.

   2-5-3. D-Dimers :
      Principle:           The test samples containing D-Dimers when mixed
                           with latex particle suspension coated with mouse anti-
                           human D-dimer monoclonal antibodies agglutinate the
                           particles.
      Specimen:            One volume of anticoagulant to 9 volumes of blood is
                           used.
      Significance:        D-dimer is a cross-linked fragment that is produced by
                           the digestion of fibrin by plasmin. Because the test is
                           sensitive to split product of fibrin (and not fibrinogen)
                           produced as a result of thrombin activity, it is helpful
                           in the diagnosis of hemostatic failure due to
                           intravascular coagulation and helps to differentiate
                           this from failure due to pathological fibrinolysis as the
                           principal cause.

   2-5-4. Fibrin Degradation Product (FDP) :
      Principle:         A suspension of latex particles in buffer is sensitized
                         with specific antibodies to purified FDP fragments D
                         and E. The suspension is mixed on a glass slide with
                         a serum dilution. Aggregation indicates the presence
                         of FDP in the sample.
      Specimen:          Exactly 2 ml of Venous Blood in FDP Tubes
Note: Contact Hematology Lab. to get FDP Tube.
These tubes contain reptilase to ensure rapid clotting and a proteolytic
inhibitor (Trypsin Inhibitor) to prevent in vitro fibrinolysis.
       Significance:         The measurement of the products of plasmin digestion
                             of Fibrinogen or Fibrin provides an indirect test for
                             fibrinolysis.




                                                                                   89
Tests done on Patients with suspected hemostatic defect
   2-5-5. Bleeding Time :
       Principle:         A standard incision is made on the volar surface of
                          the forearm and the time the incision bleeds is
                          recorded.
       Significance:      The bleeding time is an in vivo test of platelet
                          function, and vascular integrity in the presence of
                          platelet count of more than 100 x 109/L. It must be
                          understood that this is not a test that is very well
                          controlled & reproducible.
       Normal Range:      2.3-9.5 mins.
   It is prolonged in case of moderate-severe thrombocytopenia, platelet
   dysfunction and vascular abnormalities.

  2-5-6. Platelet Aggregation :
      Principle:           The aggregation of in PRP, whole blood or
                           platelets suspension cabe measured by an impedance
                           ag.
      Specimen:            4 tubes of citrated blood/ 2.7 ml of whole blood in
                           each if platelet rich plasma is used and 2 tubes if
                           whole blood is used.
      Significance:        When       platelet  hadysfunction     is   suspected,
                           platelets aggregation studies should be performed in
                           which the platelets are exposed to various aggregating
                           reagents (thrombin, ADP, collagen, adrenaline,
                           ristocetine and arachidonate)and the platelet response
                           noted.
Note: The release of ATP from platelets dense granules as a measure of platelet
      secretion response can also be measured.

   2-5-7. Clot Retraction Test :
      Principle:          Fresh whole clotted blood is placed in a 37o C water
                          bath and inspected for the presence of a retracted clot.
      Specimen:           Contact Lab. in advance
                          Blood collection must be done in Hematology Lab.
                          3 ml of fresh whole blood is placed in a 13x100
                          mm glass test tube and inspected at 1, 2, 4 & 24
                          hours for clot retraction.
      Significance:       Results are reported as normal, if clot retraction has
                          occurred at 2 to 4 hours, poor, if retroccurs after 4
                          hours and within 24 hours and none, if no retraction
                          occurs after 24 hours. Clot retraction usually is
                          deficient when the platelet count is below 50,000/ul


                                                                                90
                           and in a rare inherited disorder of platelet function
                           Glanzmann's thromboasthenia.

SPECIAL HEMATOLOGY
Please Contact Hematology Lab. for the following tests for appointment:

1. Ham's Test :
     Principle:            The RBC of patients with paroxysmal nocturnal
                           hemoglobinuria (P.N.H.)are usually susceptible to
                           lysis by complement. The patient's red blood cells are
                           mixed with normal serum and also with the patients
                           own serum and incubated at 37°C. Selected ssamples
                           are inactivated to destroy the complement after
                           incubation, all tubes are inspected for hemolysis.
      Specimen:            1 ml of whole blood in EDTA tube +
                           2 ml of whole blood in plain tube (red top)
      Significance:        Positive Ham's test is obtained in P.N.H and certain
                           types of congenital dyserythro poietic anemias

2. Bone Marrow :
   Examinaof Bone marrow smears may prove helpful in estimating the relative
   number and morphology of blood cells and their precursors being produced by
   the marrow. Bone marrow aspiration and biopsy are carried out by the phys.
      Aspirate:            Smears are immediately prepared and air dried, to
                           detect presence of fragments, the slide is held against
                           light where they will appear like sand grains. The rest
                           of the aspirate is allowed to clot for preparation of a
                           clot section. If surface marker or cytogenetic studies
                           are needed, some of the marrow should be put into the
                           appropriate containers.
      Biopsy:              Using a Jamshidi needle the physician obtains a
                           biopsy which is sent in formalin to the Histopathology
                           Lab. for processing.

3. Perl's Test for Iron (Prussian Blue Reaction) :
   The Prussian Blue reaction is produced when hemosiderin or ferritin is present
   in the sample. Storage iron, which is contained in macrophages, can be
   evaluated only in the marrow particles on the film.
   In Iron deficiency, blue staining granules are absent or reduced. Storage iron
   is increased in most other anaemias, infections, hemosiderosis. Smears can be
   examined for siderocytes and sideroblasts . Siderocytes are red blood cells
   that have one or more iron containing granules. When the granules are found


                                                                                91
   in nucleated RBCs, the cell is called sideroblast. Increased number of
   sideroblast are seen in megaloblastic anemia, alcoholism and following
   splenectomy. Ring sideroblasts are seen in sederoblastic anemia.
       Specimen :        Air dried bone marrow aspirate smears. Air dried
                         blood smears can be used for examination of
                         siderocytes only.

4. Cytochemical Tests
   Specimen collection for cytochemistry stain :
   Blood, bone marrow films, tissue touch preparations and cytocentrifuge
   preparations may be used, with either EDTA or Heparin serve as
   anticoagulants.    This applies to cytochemistry stains except alkaline
   phosphatase where EDTA must be avoided. In that case, heparin is the
   recommended anticoagulant. Cytochemical methods applied to hematopoietic
   cells allow the demonstration of specific enzymes or other substances in
   individual cells. They are particularly useful for the study of immature cells.
   Most are applied in the diagnosis and classification of leukemias.
   a) Myeloperoxidase Reaction :
      The main value of this is in the distinction between acute myeloid and
      acute lymphoblastic leukemia. Although myeloperoxidase is generally
      considered to be a marker for cells of myelocytic lineage, a negative
      peroxidase reaction should not be considered pathognomonic of acute non
      myelocytic leukemia.
   b) Acid phosphatase Reaction :
      Is used in the classification of lymphoproliferative disorders. Almost all
      acute and chronic T-cell lymphoproliferations are characterized by a strong
      acid phosphatase reaction. In T-ALL the reaction is localized to the Golgi
      zone.In B-cell disorders the reaction is often weak or negative with the
      exception of cases of Hairy cell leukemia, the cells of which show a strong
      acid phosphatase activity (tartaric acid-resistant phosphatase).
   c) Esterase : Two types of esterases are used :
      1)Specific Esterase :       The reaction is found in mature and immature
                                  granulocytes.
      2)Non-Specific Esterase : It gives distinct patterns in lymphocytes (a
                                  dot-like reaction) and in monocytes ( a
                                  diffuse positive reaction). It has 3 main
                                  applications in leukemia and
                                  lymphoproliferative disorders:
          1) In AML it facilitates the diagnosis of monocytic leukemia, the
             cells of which give a strong reaction with non specific esterase.
          2) In ALL it helps to identify T-ALL, it gives a dot-like reaction with
             non specific esterase.


                                                                                92
        3) In chronic B and T lymphoid leukaemias it helps to distinguish
           T-PLL (positive reaction) from B-PLL (negative reaction).
d) Neutrophil Alkaline Phosphatase :
   Alkaline phosphatase activity is present in varying degrees in neutrophili
   granulocytes and certain B lymphocytes. Increased values are found during
   infections, pregnancy (the last trimester), polycythaemia vera and
   leukaemoid reactions low or absence of activity is seen in CML.
e) Nitroblue Tetrazolium (NBT) Test :
   Principle:         Test is helpful in identifying patients with chromic
                      granulomatons disease (CGD). It rises in bacterial
                      infection in patients not having the CGD.
   Specimen:          1.0 ml blood in heparin       (please contact the lab in
                      advance)
   Interpretation:    Negative in CGD. High in bacterial infection.




                                                                            93
94
 CYTOGENETICS PROCEDURES


  Haematology & Cytogenetics Division



                 Prepared by:

   Khadija Hassan Al-Najjar, B.Sc. (Biology)
   Sr. Technologist Incharge - Cytogenetics

Muna Ibrahim Al-Zeyara, B.Sc. (Biomed. Science)
          Technologist - Cytogenetics




                Reviewed. By:

             Amina Al-Zaman, M.Sc.
Supervisor - Hematology & Cytogenetics Division




                                                  95
96
TYPES OF SPECIMENS
   -   Peripheral blood
   -   Cord blood
   -   Bone marrow - Aspirate
   -   Amniotic fluid
   -   Fibroblast. (Biopsy)

SPECIMEN COLLECTION
  Peripheral Blood and Cord Blood
     1    Clean the area with 70 % alcohol
     2    Draw 2-10cc blood sample.
     3    Place in a heparinized green top tube
     4    Mix the sample gently to prevent coagulation
     5    Send the sample immediately to the laboratory

    Bone Marrow
     1   Collect 2-3cc of Aspirate
     2   Place it in a sterile container containing prewarmed heparinized
         unsupplemented medium
     3   Send immediately to the laboratory

    Amniotic Fluid
     Collect 10-20cc of the sample in a sterile plastic container. This should be
     quickly transported to the lab.

    Fibroblast
     Place the biopsy in a sterile container supplemented with Ham's F10 media
     and Pen-strep. If the media is not available, sterile saline may be used.
NOTES :
·   Routine bloodspecimens are cultured only on Satand Wednesdays weekly.
·   Specimensshould be collected on the same day culturing
·   Call the lab prior to taking for - Bone Marrow
                                     - Amniotic fluid
                                     - Fibroblast

If there is any difficulties or any point for clarification please get in touch with us
at ext 3030 & 3062 the sample collection.




                                                                                     97
98
 BACTERIOLOGY / PARASITOLOGY
         PROCEDURES

            Division of Microbiology




                    Reviewed by


Dr. Sittana Shamseldin El Shafie, MBBS, MSc,FRCPath.
             Head of Microbiology Division.




                                                       99
100
INTRODUCTION
The main task of Microbiology Laboratory is to isolate and identify clinically
significant microorganisms from clinical specimens, determine their antimicrobial
susceptibilities and monitor antimicrobial chemotherapy. Microbial serology is
currently done in Immunology Laboratory. The laboratory functions 24-hours a
day, however, specimens for routine examination are processed only during
normal working hours(7-3). During the off-duty hours, we keep a skeleton staff
usually two technologist in the afternoon shift and one in the night shift to deal
with urgent requests only.

SPECIMENS AND REQUEST FORMS
1. Collect specimens before the commencement of antimicrobial therapy.
2. Specimens should be collected as early as possible in a working day, so as to
   be processed and are ready for reading the following morning.
3. The specimen should be collected aseptically from the area, where suspected
   pathogens are most likely to be found.
4. The specimen should be submitted in a sterile container in sufficient
   quantity to allow full analysis.
5. The request form should be completed properly and must contain the
   following information:
   a).    The name and telephone number of the requesting doctor.
   b).    The patients name, sex, age and nationality.
   c).    The location of the patient.
   d).    Relevant clinical data and probable diagnosis.
   e).    Antibiotic therapy, if any.
   f).    The source of the specimen.
   g).    The test required.
This information is essential, as it helps us to set up the relevant culture media and
to test the appropriate antibiotics. Furthermore, interpretation of the findings may
not be possible without having sufficient information about the patient.

IMPROPER SPECIMENS AND REASONS FOR REJECTION
We aim to provide you with satisfactory results which help you to manage your
patients properly. Processing unsatisfactory specimens may result in false reports
which can be misleading. To avoid all this, please send good quality specimens
and fill in the request forms properly and legibly. Any specimen unsuitable for
culture, due to its nature or method of colleection and/or transport will be rejected.
Unsatisfactory requests may also be rejected. However, no specimen will be
discarded until the requesting Doctor or the Ward nurse has been informed.
The following specimens will not be accepted:
1.     Specimen for routine tests, submitted after 3:00 pm.
2.     Specimen in a leaking container.
3.     Endotracheal tubes.
4.     Foley's catheter tips.
5.     Semen for culture except from urology.
6.     Specimens for culture, submitted in unsterile containers.
7.     Unlabeled or improperly labeled specimen.


                                                                                   101
8.       Improperly filled request form.
9.       Specimens received after prolonged delay (over 2 hours) except swabs &
         urine collected in a Boric acid container.
10.      Replicate specimens (except blood) submitted on the same day.
11.      Stool for A.F.B except AIDS's patients.
12.      24 hours pooled sputum or urine.
13.      Specimens not representing the site of infection.
         Eg : Nasal swabs from patients with sinusitis.
14.      Urine specimen for culture if the Boric acid container not filled till the line
         indicated.

SPECIMEN COLLECTION AND TRANSPORT

ANTIBIOTIC TESTS
1. Antibiotic Assays :
   Levels of potentially toxic drugs (Amikacin, Gentamicin, and Vancomycin)
   are measured. The purpose of these tests is to show that appropriate
   bactericidal levels are achieved and to guard against toxicity.
      Antibiotic blood levels should be requested 24 hours after commencement of
      therapy. 2 - 5 ml blood samples are required. The first should be collected ½
      an hour after the antibiotic infusion is completed and is designated as Peak.
      The second is taken immediately before the next dose is due and is designated
      Trough.
      -For patient on once daily dosing a random sample is taken 6-14 hours after
      the infusion.
2. Antibiotic Susceptibilities :
   Every clinically significant isolate is tested against the relevant antimicrobial
   agents (Usually 12-16 drugs). Initially, first line drugs are reported together
   with the antibiotics the patient is receiving. If the isolate is found resistant, the
   next line of drugs will be reported.
      First line drugs are those least toxic, with minimum side effects and
      inexpensive.
      Second line drugs are those with broader spectrum activity, rather expensive
      and/or known to have side effects.
      Third line drugs have very broad spectrum activity, are toxic, very expensive
      and/or can induce drug resistance.

3. Serum Bactericidal Activity :
   Serial dilutions of the patient's serum are tested against the organism recovered
   from him. This test is done to monitor antimicrobial chemotherapy in certain
   infections, where antibiotic penetration in the infected tissues is impaired
   (e.g. infective endocarditis, chronic osteomyelitis, infected prosthesis). Blood
   samples should be collected in the same manner as for antibiotic levels (Peak


                                                                                     102
   and Trough). FOR THIS TEST, PLEASE INFORM THE LAB IN
   ADVANCE.

BLOOD CULTURE
  Blood for culture is collected in sets of special fluid media. Each set consists
  of two bottles, aerobic and anaerobic. Prior to collection, clean the skin with
  povidone iodine followed by 70% alcohol. Do not touch the venepuncture site,
  unless sterile gloves are used. Simultaneously, disinfect the diaphragm tops of
  the culture bottles with 70% alcohol. Allow the skin to dry and draw the
  required amount of blood (usually 5-10ml for adults and 1-2ml for children) in
  two culture bottles (one set). Mix the bottles immediately after introducing
  the blood, to avoid clotting. Record the time and date of collection and send
  the bottles to the laboratory. If there is any delay, please keep the bottles at
  room temperature. Do not refrigerate.
   For reliable results, at least three sets of cultures (six bottles) should be taken,
   preferably at the height of the fever. The second set should be collected, not
   less than two hours after the first. Ideally, the third should be collected next
   day. However, in an emergency situation, the third set may be collected in the
   same day. In this situation, try to draw blood from a different site.
   If leptospirosis, Brucellosis, Fungaemia, or infection with cell wall deficient
   bacteria is suspected, please indicate in the requisition form as these organisms
   require special culture procedures, which are not done routinely.
   For pediatric patient only one bottle (aerobic) is available and the amount of
   blood drawn is 1-2ml..

   Labeling Blood Culture bottle
   When attaching patient information on the blood culture bottle, please do not
   apply the sticker over the bar-code line. Please stick the label at the lower end
   of the bottle.

BONE MARROW CULTURE
 Please collect in blood culture bottles and send to the laboratory as soon as
 possible. Bone marrow is usually cultured for ordinary microorganisms as well
 as others, not readily recoverable from peripheral blood, such as Mycobacteria,
 Brucella spp. Salmonella spp.
  For Mycobacterial culture, two Bactec 12B bottles are supplied by the
  Laboratory for TB culture. Both should be inoculated with the specimen.

CEREBROSPINAL FLUID
 CSF should be collected aseptically in three sterile screw-capped tubes and
 immediately sent to the laboratory. Fastidious organisms may not survive
 prolonged storage at temperatures below that of the body. Please DO NOT
 REFRIGERATE.



                                                                                    103
  Send :     1st tube to Chemistry
             2nd tube to Microbiology for cell count, smears and culture.
             If tests for syphilis serology are required, please send a third tube to
             immunology.
   The following tests are done:
      -      Microscopy :
             Cell count (Polymorphs, Lymphocytes & Red cells) total &
             differential.
             Gram smear.
             India Ink preparation for Cryptococcus spp.(If required)
      -      Latex antigen detection of :
             Niesseria meningitidis.
             Streptococcus pneumoniae.
             Haemophilus influenzae type b.
             Group B Streptococcus.
             Escherichia coli type K12.
             Cryptococcus neoformans.
      -      Culture for :
             Conventional Bacteria and for the following special micro
             organisms, whenever necessary:
             Brucella spp.
             Mycobacterium spp.
             Cryptococcus spp.

ANAEROBIC CULTURES
  Most anaerobic bacteria are highly sensitive to atmospheric oxygen and if a
  specimen is exposed to air, even for 30 minutes many organisms may be
  killed. Aspirated fluids are always more reliable than swabs. Specimens for
  anaerobic culture should be collected in the appropriate transport media and
  immediately sent to the laboratory. If transport media is not available, fluids
  may be collected in a sterile syringe, the air expelled and the fluid transferred
  into a plain vacutainer tube.
  Swabs should be well charged with the exudate (pus, secretions etc. ), placed
  in a transport medium (Stuart, culturette etc.) and immediately sent to the
  laboratory.
  The minimum incubation period for anaerobes is 48 hours. Isolates will then
  be identified and tested for antimicrobial susceptibilities. You should not,
  therefore expect anaerobic culture results in less than three days.

EAR SWAB
  Please send two swabs in transport media, one for smear and the other for
  culture.




                                                                                  104
EYE SWAB
  Please send two swabs for routine microscopy and culture. For newborn
  infants and in cases of suspected gonococcal ophthalmia, please use
  charcoal swabs or send an ordinary swab in charcoal transport medium.
  If chlamydia is suspected use the special chlamydia swab and send the
  specimen in chlamydia transport medium.

EXUDATES AND BODY FLUIDS
  Draining sinuses and open wound are often contaminated with commensals
  that obscure the infecting agent. Cleaning the surface with sterile saline and
  water (no disinfectant should be used) should precede collection of material
  for culture. Try to collect fluid or pus. Use swab only if collection of fluid is
  not possible. Fluids should be collected under aseptic conditions in a sterile
  syringe or container. As anaerobes are often involved in such infections, the
  syringe should be evacuated of air, the fluid transferred into a plain vacutainer
  tube and immediately sent to the laboratory. If there are blood clots, rinse the
  syringe with an anticoagulant, prior to collection. If a swab is used, it should
  be well soaked with the exudate from a deep site within the sinus or the
  abscess wall.
  Please specify if AFB or FUNGUS is suspected.

SYNOVIAL FLUID
  The specimen should be collected aseptically in a sterile plain container and
  sent to the laboratory as soon as possible.           PLEASE DO NOT
  REFRIGERATE.
   Synovial fluid is routinely examined as follows:
     Microscopy :
     Gram smear for inflammatory cells and bacteria
     Smear for A.F.B., if required.
      Culture for:
      Neisseria gonorrhoea
      Brucella spp.
      Other aerobic and anaerobic bacteria
      Mycoplasma spp. & ureaplasma, if requested.
      Mycobacterium spp., if required.

TISSUE AND BIOPSIES
   Tissue, lymph node and other biopsy material should be collected and sent to
   the laboratory under sterile conditions. The specimen should be sent in a sterile
   plain container with a few drops of sterile normal saline. (NO FORMALIN,
   please).

WOUND SWAB
 Clean the surface with sterile saline and water before collection (no
 disinfectant should be used). Try to take fluid or pus. Use swab only if
 collection of fluid is not possible. The swab should be well soaked with the


                                                                                 105
   exudate from a deep site within the sinus or the abscess wall. It should be sent
   to the laboratory as soon as possible, preferably in a suitable transport medium.
   The following tests are done:
     Microscopy:
     Gram smear
     Smear for A.F.B., if required.
      Culture for:
      A wide range of aerobic and anaerobic bacteria.

SCRAPINGS (Skin, Nail, Hair, Nasal)
  1. For Fungus:
     Collect the skin scrapings, hair or nails after cleaning the surface with 70%
     alcohol. After drying, scrape the lesion with a sterile scalpel. Place the
     scrapings in a sterile wide mouth container and send to the laboratory.
  2. For Leishmania:
     Clean the lesion with 70% alcohol. allow to dry and moisten the area with
     saline and scrape the edge with a sterile scalpel. Tissue fluid should also be
     obtained from the edge of the lesion. Spread the scrapings and/or fluid on
     glass slides. Allow to dry and send to the laboratory without delay.
  3. For Mycobacterium leprae:
     Skin or nasal scraping is collected as for Leishmania.

NASAL SWAB
  The nose is the carrier site of several bacteria, but these do not normally cause
  infection at this site. Nasal swabs are usually cultured to investigate carriers
  (Staph. aureus and Strept. pyogenes) in an event of a hospital outbreak.
  However in rare occasions such as Rhinoscleroma, Actinomycosis, Diphtheria
  etc., culture of a nasal specimen is required. If you feel that you are dealing
  with such an unusual situation, please consult the Microbiologist for the most
  suitable specimen and method of collection.

NASOPHARYNGEAL SWAB / PERNASAL SWAB
  Nasopharyngeal swabs are requested for patient with meningitis to exclude
  carriage of Neisseria meningitidis, Haemophilus influenzae & Streptococcus
  pneumoniae. Pernasal swab is requested for Bordetella pertussis and the
  laboratory must be informed before the specimen is collected, so that the
  necessary media can be freshly prepared. A fine wire swab is used to collect
  the specimen. It is introduced through the nose and pushed gently until it
  touches the posterior pharyngeal wall, rotated slightly and removed. The swab
  is then placed in a special transport medium with the tip immersed into the
  agar.




                                                                                 106
SPUTUM AND ENDOTRACHEAL SECRETIONS
  The sensitivity and specificity of examination of sputum and Endotracheal
  secretions are open to questions, since they are always contaminated with
  oropharyngeal flora. This flora often overgrows the causative agent and in
  times may inhibit it. The rate of recovery of causative agents from properly
  collected specimens from patients with lower respiratory tract infection has
  been estimated as 50 to 90%. Even when a potential pathogen is recovered, its
  role in the causation of infection is uncertain. Microscopic examination of
  these specimens is often more valuable than culture. Correct interpretation of
  sputum findings depends greatly on the value of specimen, clinical data and
  the expertise of the Microbiologists. Therefore, please make sure that the
  specimen is properly collected.
  1. Sputum:
       For routine microscopy and culture, collect sputum in a sterile clear plastic
       cup. The patient should first rinse his mouth with water, cough deeply and
       expectorate directly into the cup. The specimen should be sent immediately
       to the laboratory. An early morning sample is prefered.
  2. Endotracheal Secretions :
       Using a fine tube, aspirate bronchial or deep tracheal secretions from a
       deep site down the trachea. Please do not send tip of endotracheal tube,
       because it is usually heavily contaminated and is unsuitable for culture.
       ETT for patient on mechanical ventilation should be sent twice a week for
       Microbiology.
  Specimens from lower respiratory tract will be tested as follows:
     Microscopy:
     Gram smear
     Smear for A.F.B., if requested.
     Pneumocystis carinii stain, if requested.
     Culture:
     Only satisfactory specimens will be cultured for :
     -         Aerobic and anaerobic bacteria.
     -         Fungi.
     -         Culture for the following pathogens will also be done, if required
     -         Mycobacterium spp.
     -         Mycoplasma pneumoniae.
     -         Legionella spp.

THROAT SWAB
  Use a tongue blade to depress the tongue, swab the tonsils, pharynx or any area
  of inflammation in the throat. Please avoid touching the tongue and the mouth.
  Place in transport medium and send immediately to the laboratory.
  Note: Culturette swab contains transport medium
  Throat is routinely cultured for B Haemolytic streptococci. If Diphtheria,
  Vincent's angina or other infection is suspected, please specify.


GENITAL ULCERS


                                                                                 107
   The fluid on the ulcer and superficial scrapings are required. Please scrape
   gently and aseptically and collect the fluid into a capillary tube. Any amount
   can be helpful. The specimen will be examined by dark field microscopy,
   special stains and/or culture procedures for Spirochaetes and other fastidious
   organisms.

   PROSTATITIS (PROSTATIC SECRETION)
   1. Acute Bacterial Prostatitis :
       Prostatic massage is contraindicated.. In this situation, usually there is
       heavy overflow of prostatic fluid and bacteria in urine. Some patients may
       also have bacteraemia.
       Specimens:
       a). Mid stream urine specimen for culture (see urine)
       b). Collect two sets of blood culture (see blood cultures)
   2. Chronic Bacterial Prostatitis :
       Although bacterial prostatitis is uncommon, it is easier to treat and so all
       men with symptoms referable to the prostate should have a Stamey urine
       test.
   Stamey Urine Technique :
       The glans should be cleaned with sterile water and dried each time before
       obtaining a specimen.
           a) First urine sample (VB1; urethral specimen), should not exceed 5 -
              10 ml.
           b) Second sample (VB2; bladder); about 20 ml.
           c) Perform prostatic massage and collect the secretions (EPS).
           d) Third urine sample, post prostatic massage (PPM); 5 ml or less.
           e) Collect specimen in plain sterile container and send immediately to
              the laboratory.
   3. Laboratory tests :
        All specimens will be evaluated microscopically for evidence of
        inflammation and predominance of a particular pathogen. WBC and viable
        bacterial count will be performed. Results of this test may help
        differentiate between different types of prostatitis (Bacterial, non bacterial
        and prostatodynia).

SEMINAL FLUID
  Culture of such a specimen may be misleading, as ejaculate is a mixture of
  prostatic fluid and semen, may be inhibitory to some pathogens and is often
  contaminated by urethral and skin bacteria. However, if prostatic massage
  cannot be done, semen culture may be arranged with the consultant
  microbiologist.




SEMINAL VESICULITIS & EPIDIDYMITIS


                                                                                   108
   Seminal fluid is required and should be submitted for culture as soon as
   possible. Please arrange with lab before sending the specimen. For TB
   epididymitis a biopsy will be required.

URETHRAL SWAB
  The urethra should be cleaned with sterile water and dried, prior to obtaining
  the specimen. A sterile charcoal swab should be used.
   The following tests are done:
      Microscopy:
      Gram smear.
      Antigen detection of:
      Chlamydia : Use special swab for chlamydia in a special transport medium.
      Culture for:
      Neisseria gonorrhoea
      Mycoplasma
      Ureaplasma
      Other conventional organisms

VAGINAL AND ENDOCERVICAL SWABS
  For cervical specimen a sterile bivalve speculum to expose the endovervix.
  For vaginal swabs no speculum is required. To exclude group B streptococcus
  comage a low vaginal swab and a rectal swab is needed. Some swab can be
  used to collect specimen from both vagina and rectum, starting with swabing
  the vagina. Specimens should be collected from the endocervix with fine wire
  swab and the swab removed carefully without touching the vaginal wall or
  perineum.
   Please send separate endocervical swabs for Chlamydia Vaginal swabs are not
   suitable for these organisms.
   The specimens are examined as follows:
       Microscopy for:
       Inflammatory cells
       Evidence of bacterial vaginosis
       Evidence of clue cells
       Yeasts
       Trichomonas vaginalis
       Culture for:
       Neisseria gonorrhoea
       Mycoplasma spp. & ureaplasma,if requested.
       Other aerobic and anaerobic bacteria.
       Antigen detection for chlamydia, if requested. The specimen should be sent
       in special Chlamydia swab in Chlamydia transport medium.
Note for IUCD related infection, please send whole device for microbiology-
place in a sterile container.




                                                                              109
ACID FAST BACILLI
  Successful recovery of Mycobacterium spp. depends on proper collection of
  specimens and suppression of contaminating bacteria that may overgrow
  mycobacteria. While culture is necessary to confirm the diagnosis and to prove
  cure, quantitative smear is a reliable parameter of response to therapy.
  Therefore, initially cultures and smears shall be performed on three specimens
  from each patient. For follow up, smears will be done 2 weeks after start of
  therapy and then weekly until negative. Follow up cultures will be done only
  after three months of therapy.
   Specimens for AFB:
   1. Aspirated pus and exudates : Aspirated samples are preferable to swabs.
      Swab samples will not be cultured.
   2. Body fluids (CSF, pleural, synovial etc.) : These should be collected in
      sterile plain tubes.
   3. Bone marrow : 0.5-1 ml should be directly inoculated into two
      middlebrook 12B Bactec vials. The vials may be obtained from the
      laboratory.
   4. Gastric washing (lavage) : This is used in the diagnosis of Pulmonary
      Tuberculosis, but due to the discomfort that it may cause to the patient and
      the possibility of contamination with commensal mycobacteria, this method
      should be used only if a suitable sputum specimen cannot be obtained.
   5. Lymph node : Aspirates collected by fine needle procedure should be
      inoculated into 12B Bactec vials or sent to the lab in a sterile container. If
      Bactec vials is inoculated directly, please also prepare and smear and send
      along with the bottle for AFB stain.

   6. Specimens for M.leprae : Nasal scrapings or scrapings from the ear lobe
      are suitable specimens for the detection of M.leprae. Transfer the scrapings
      and the serous fluid obtained to a clean glass slide. Allow to dry and send
      to the laboratory in a petri dish obtained from the Lab.
   7. Tissues : Portions of tissues from surgical or autopsy material should be
      send in a sterile container with some normal saline. DO NOT ADD
      FORMALIN.
   8. Urine : For the diagnosis of Urinary Tuberculosis, three early morning
      urine specimens (EMU) should be collected on three consecutive days.
   9. Stool Specimen for TB culture may be accepted from AIDs patient after
      discussion with the Microbiologist.

ANY 24 HOUR SPECIMEN COLLECTION IS UNACCEPTABLE DUE TO
OVERGROWTH OF CONTAMINATING BACTERIA.




                                                                                 110
STOOL SPECIMEN
  Stool specimens are examined for Rota virus, ova and parasites and are
  cultured for the intestinal pathogens; Shigella, Salmonella, Camphylobacter,
  Vibrios, Yersinia and Enteropathogenic E.coli (children <2 years). Fresh
  specimens are required, since delay in transport will adversely affect Shigella
  and trophozoites. If a stool specimen could not be obtained, a rectal swab may
  be collected instead. The following tests are done:
    - Occult blood.
    - Microscopy for ova and parasites.
    - Antigen detection for Rota Virus (watering diarrhea in children less than
        10 years and the elderly).
    - Antigen detection for Cl. Difficile toxin A.
    - Culture for Salmonella, Shigella, Camphylobacter routine.
        E.coli (EPEC) for children < 2 yrs.
    - E.coli 0.57 - 7H for patient with bloody diarrhea and when requested.
    - Cl. difficile for bloody diarrhea, pseudo membranous colitis and when
        requested.
    - Vibrio cholera when requested or if there is rice-water stool.
    - Culture for other intestinal pathogens. eg: aeromonas and pleisiomonas.




                                                                              111
                            PARASITOLOGY

BILHARZIAL PARASITES (SCHISTOSOMES)
  1. Urine sample should be taken at mid day preferably after some physical
     exercise. Collect terminal urine. Do not miss the last few drops.
  2. For intestinal bilharzia (Schistosoma mansoni), if stool examination is
     negative, rectal snip can be examined for ova as a crush-preparation smear.

ENTEROBIUS VERMICULARIS
  1. Stool should be collected from the patient first thing morning before he/she
     takes a bath or goes to the toilet (stool examination is positive in 5% only)
  2. A cellotape swab may be used at the same time
  3. If one patient is positive, all members of the family should be considered
     positive

EXTRA-INTESTINAL PARASITES (TISSUE PARASITES)
  Examples :Toxoplasma
              Hydatid cyst
              Cysticercosis
  1. These parasites are difficult to detect. So infection is often diagnosed
     serologically
  2. Send a serum sample for antibody detection
  3. If tissue or fluid available, please send for parasite detection.

SPECIAL PRECAUTIONS IN LABORATORY DIAGNOSIS OF
PARASITIC INFECTIONS
FILARIAL PARASITES : (Wuchereria bancrofti)
   Most microfilaria identified in this country is Wuchereria bancrofti
   1. Collect whole blood in a tube with anti-coagulant ( CBC tube ).
   2. Blood must be collected at mid-night.
   3. If blood is collected in daytime, the patient must be given intravenous
      Diethyle carbamazine in a dose of 2 mg./kg body weight 20 min. before
      collection.     This should induce microfilaria to enter peripheral
      blood.
   4. Sample should be sent to the lab immediately, and if there is any delay, it
      must be kept at 4 0 C.

GIARDIA LAMBIA
  1. Stool sample must be collected and sent to the lab with all details about the
     patient.
  2. If examination is negative for any trophozoite or cysts, two to three stool
     samples should be collected on two to three consecutive days and sent to
     the lab for further examination because cyst production is intermittent.




                                                                               112
INTESTINAL PROTOZOA
  1. Among amoebae, only one species is pathogenic, it is Entamoeba
     histolytica
  2. Non-pathogenic species are reported because all Entamoeba spp. have the
     same mode of transmission.

INTESTINAL NEMATODES
  1. Stool should be collected and sent to the lab immediately to avoid hatching
     of the larvae (Rhabditaform larvae) which resemble those of Strongyloides
     stercoralis.
  2. Nationality of the patient and other information must be on the request
     form.

LEISHMANIA TROPICA
  This parasite causes skin lesions (ulcers) and can be picked from the ulcer by a
  syringe containing saline. The needle should be inserted in the margin of the
  ulcer not in the middle. The margin is rich with macrophages infected with the
  parasites (amastigotes)

LEISHMANIA DONOVANI
  Lymph node biopsy or bone marrow and examined for amastigotes.

MALARIAL PARASITES :- (Plasmodium)
  1. Collect whole blood in a tube with anticoagulant
  2. Sample should be sent to the lab immediately.
  3. Request form must include all information about the patient such as :
     Age, Sex, Nationality, Clinical finding etc.

TRICHOMONAS VAGINALIS
  This can be detected in a wet vaginal or urethral smear. These specimens
  (vaginal or urethral) should be collected in a swin transport medium such as
  culturette. Send the swab immediately to the laboratory.




                                                                               113
                   CLASSIFICATION OF PARASITES

                           Prepared by
Muna Mohd Jaber Al Tamimi Bach. of Bio-Med. Science., University of Qatar.

This table shows classifications of different types of the most important parasites
according to their pathogenisity, and the diseases that may cause to the human
being.
     PARASITE                     PATHOGENISITY                DISEASES
A. PROTOZOAN PARASITES :
1. Entamoebahistolytica                  path                 *A
   (large invasive)                                           * Amoebic
                                                                Dyscentery
2.   Entamoeba coli                      non path.            -
3.   Entamoeba gingivalis                non path.            -
4.   Entamoeba hartmanni                 non path.            -
5.   Entamoeba polecki                   non .                -
6.   Endolimax nana                      non path.            -
7.   Iodamoeba butschlii                 non path.            -
8.   Dientamoeba fragilis                non path.            -
     (flagelates)

B.   FLAGELLATES :
1.   Giardia lambia                      path                 * Giardiasis.
                                                              * Lambliasis.
2.   Trichomonas vaginalis               path                 * vaginal
                                                                Trichomaniasis
                                                              * Urethritis.
                                                              * inf. of Prostate.
3.   Trichomonas hominis                 non path
4.   Trichomonas tenax                   non path             * may cause
                                                                 Phorrhea
                                                               (poor oral hygiene)
5.   Chilomastix mesnili                 non path              -
6.   Enteromonas hominis                 non path              -
7.   Embadomonas intestinalis            non path              -
8.   Blastocystis hominis                path (for babie      * Blastocystosis
                                             until 10 yrs)

C. CILLIATES
1. Balantidium coli                      path.                * Balantidiasis




                                                                                    114
D. HEMOFLAGELLATES
I. Mastigophoral Parasites
1. Trypanosoma rangeli       non path.
2 T.gambiense                path            * African
                                              Trypanosomiasis
                                              [sleeping sickness]
3. T. rhodesiense            highly path.    * African
                                                Trypanosomiasis
4. T. cruzi                  path            * American
                                              Trypanosomiasis
                                                 (chagas clis)
5. Leishmania donovani       path            * kalaazar(Visceral
                                                  Leishmaniasis)
6. L. tropica                path            * Cutaneous
                                                 Leishmaniasis
7. L. mexicana               path            * Cutaneous
                                                 Leishmaniasis
8. L. braziliensis           path            * American
                                             *Mucocutaneous
                                             * Chicle Ulcer
                                             * Naso-oral
                                                 Leishmaniasis

II. Sporozoal Parasites
  1. Isospora belli          path             * Intestinal
                                                 coccidosis
                                                 (coccidia)
 2. Isospora hominis         path             * Intestinal
                                                  coccidosis
 3. Sarcocystis              path             * Sarcocystis
                                infections
 4. Toxoplasma gondii        path             * Toxo plasmosis
 5. Pneumocystis carinii     path             * Pneumocystosis
                                              * Interstitial plasma
                                                 cell pneumonia
                                                 associated with
                                                 (AIDS) patients.
 6. Babesia equi             path.            * Babesiosis
                                                (piroplasmosis)
 7. Babesia bigemina         path.            * Babesiosis
                                               (piroplasmosis)
 8. Babesia microti          path             * Babesiosis
                                               (piroplasmosis)
 9. Plasmodium falciparum    path.            * Malignant
                                             (Subtertian Malaria)
10. P. malariae              path             * Quartan Malaria




                                                                115
11. P.vivax                          path   * Tertian Malaria
                                               (benign M.)
12. P.ovale                          path   * ovale tertian
                                                Malaria

E. HELMINTHS
I. Flukes (Trematodes) of Blood :
   1. Schistosoma mansoni            path   * Schistosomiasis
                                               mansoni
                                            * Intestinal
                                              Bilharziasis
  2. S. japonicum                    path   * Schistogamiasis
                                                Japonica oriental
                                                Blood fluke inf.
  3. S. mekongi                      path   * Mekongi River
                                              Schistosomiasis
  4. S. haematobium                  path   * S.haematobia
                                              (urinary
                                               Bilhariziasis)


II. The lung Flukes :
    1. Paragonimus westermani       path    * Oriented Lung
                                               Fluke
                                                (paragonimiasis)
                                            * pulmonary
                                              distormiasis
III. The Liver Flukes :
     1. Fasciola hepatica           path    * Fascioliasis
                                            * Sheep liver fluke inf.
    2. Fasciola gigantica           path    * Fascioliasis
    3. Clonorchis sinensis          path    * Clonorchiasis
                                            * Chinese liver fluke
                                                inf.
    4. Opisthorchis viverrini       path    * Opisthorchiasis
    5. Dicrocoelium dendriticum     path    * Dicrocoeliasis
       (small liver fluke)

IV. The Intestinal Flukes
    1. Fasciolopsis buski            path   * Fasciolopsiasis
    2. Heterophyes heterophyes       path   * Heterophysiasis
    3. Metagoninus yokogawai         path   * Metagonimiasis
    4. Echinostoma plocanum          path   * Echinostoma inf




                                                                    116
F. THE TAPEWORMS                            (Cestoda)
    1. Taenia saginata               path   *Taeniasis(Beef
                                                  tapeworm inf.)
    2. Taenia solium                 path   * Taeniasis
                                            * Pork tapeworm inf.
    3. Diphyllobothrium latum        path   * Diphyllobothriasis
                                            * B12 dificinecy
                                               (Megaloblastic
                                               Anemia)
                                            * Fish worm inf.
    4. Hymenolepsis nana             path   * Hymenolepiasis
       (dwarf tapeworm)                     * D warf tapeworm inf
    5. Hymenolepsis diminuta         path   * Rat tapeworm inf
       (rat tapeworm)
    6. Echinococcus granulosus       path   * Hydatidosis
                                            * Hydatid disease
    7. Echinococcus multilocularis   path   * multilocular
                                               hydatidosis
    8. Dipylidium caninum            path   * Dog tapeworm inf.
                                            * Double-pored
                                               tapeworm inf.

G. I. Nematodes
   1. Trichuris Trichiura            path   * Trichuriasis
                                            * Whip worm inf.
   2. Trichostrongylus sp.           path   * Tricho Strongylosis
      T. orientalis
                                               - T. axei
                                                - T. colubriformis
   3. Enterobius vermicularis        path   * Enterobiasis
                                            * Pin worm inf.
                                               oxyuriasis
   4. Ascaris lumbricoides           path   * Ascariasis
                                            * large ground worm
                                                inf.
   5. Toxocara canis                 path   * Visceral larva
                                               migrans (etiologic
                                                agent)
   6. Toxocara cati                  path   * Human Visceral
                                               larva migrans
   7. Capillaria philippinensis      path   * Intestinal
                                               capillariasis
   8. Capillaria hepatica            path   * Hepatic capillariasis
   9. Trichinella spiralis           path   * Trichinosis
   10. Necator americanus            path   * Hookworm inf.
                                            * Ancylostomiasis
   11. Ancylostoma duodenale         path   * Hook worm inf
                                            * Ancylostomiasis


                                                                  117
   12. Strongyloides stercoralis   path       * Strongyloidiasis

II. The Blood + Tissue Nematodes of Man
    1. Wuchereria bancrofti         path   * Bancroft's filariasis
                                           * Elephantiasis
   2. Brugia malayi                path    * Malayan Filariasis
                                           * Elephantiasis
   3. Loa loa                      path    * loiasis
                                           * African eye worm
                                                inf.
   4. Onchocerca volvulus          path    * Onchocerciasis
                                           * river blindness
   5. Mansonella streptocerca    path      * Streptocerciasis
   6. Guinea worm or Medina worm path      * Inflammation and
                                               calcification




                                                                     118
   IMMUNOLOGY PROCEDURES

          Division of Microbiology




                 Prepared by:


          Samira Ali, B.Sc.(Zoology)
        Supervisor - Immunology Section


Tahani Waleed Al-Kawari, B.Sc.(BioMed. Science)
       Senior Technologist - Immunology



                 Revieved by:

   Ajayeb Al-Marri,M.Sc., PhD (Immunology)
         Head of Immunology Section




                                                  119
120
GENERAL IMMUNOLOGY RULES :-
  1. HLA Typing tests and Immunophenotyping of blood cells be scheduled in
     advance, since this test requires viable cells.
  2. Whenever a sample shows Positive result in the Screening test, further
     tests will be carried out automatically to quantitate or confirm the results.
  3. In some infectious diseases, a convalescent sample is recommended to be
     drawn 10-14 days after the acute sample.
  4. Causes for rejection : Excessive hemolysis, chylous serum or gross
      contamination of the specimen.
              TESTS AVAILABLE            (In Alphabatical Order)
1) Acute Leukemia Immunophenotyping
   Specimen :       3 ml Blood / Bone Marrow
   Container :      EDTA Tube (lavender top tube)
   Use :            To distingush acute myloblastic leukemia, common acute
                    lymphoblastic leukemia, and T cell acute lymphoblastic
                    leukemia. Confirmation of diagnosis of acute leukemia
                    and rapidly determine the leineage, almost all leukemia
                    cell population using surface marker analysis.
   Methodlology :   Flow Cytometry.
   Limitations :    Requested by haematology lab consultant

2) Alpha 1-Antitrypsin, Serum (Applies to Specific Protein Analysis)
   Synonyms :          A-1-Antitrypsin; A1AT; AAT; Acute phase protein.
   Specimen :          3ml Blood
   Container :         Red Top Tube.
   Normal Range :      85-213 mg/dl
   Use :               Detection of hereditary decreases in the chronic
                       obstructive lung disease and liver disease.
   Contraindications : If CRP positive, retest AAT in 10-14 days.
   Methodology :       Nephelometry.
   AAT is one of the alpha globulins which together are called "acute phase
   reactions". These rise rapidly, but nonspecifically in response toinflammatory
   insults.

3) Anti Cardiolipin Antibody (Applies to Anti-phospholipid Antibody)
   Synonyms :       ACA-IgG & IgM.
   Specimen :       3ml Blood
   Container :      Red Top Tube.
   Normal Range : ACA-IgG< 13 GPL ACA-IgM < 11 MPL.




                                                                               121
   Use :              Differential diagnosis of recurrent thromboses, Lupus-like
                      syndromes, false-positive VDRL or RPR, recurrent fetal
                      loss.
   Methodology :      Enzyme immunoassay "Micro ELISA."

4) Anti-Sperm Antibody
   Specimen :      3 ml Blood
   Container :     Red Top Tube
   Normal Range : < 75 u/ml
   Use :           Determine presence of sperm antibodies infertility studies.
   Methodology :   Enzyme Immunoassay (Micro ELISA) Presence of Sperm
                   Antibodies has not been clearly association with disease
                   states.

5) Anti-DNA
   Synonyms :         Antibody to Double-stranded DNA; Antibody to Native
                      DNA; Anti-Double-stranded DNA; Anti-ds-DNA; DNA
                      Antibody;
   Specimen :         3 ml Blood
   Container :        Red Top Tube
   Normal Range :     < 40 Iu/mL
   Use :              Confirmatory test for Systemic Lupus Erythematousus
                      (SLE); Monitor clinical course and response to treatments.
   Methodology :      Enzyme Immunoassay "Micro ELISA."

6) Antimitochondrial Antibody
   Synonyms :      AMA; Mitochondrial Antibody
   Specimen :      3 ml Blood
   Container :     Red Top Tube
   Normal Range : < 1:20 is considered non-diagnostic
   Use :           Tests for mitochondrial antibody are recommended in
                   differential diagnosis of chronic liver disease and to
                   provide confirmation evidence for a diagnosis of primary
                   biliary cirrhosis.
   Methodology :   Indirect immunofluorescence.

7) Antinuclear Antibody
   Test commonly includes titres and pattern of nuclear fluorescence on all positive
                    samples.
   Synonyms :       ANA; ANF; FANA.
   Specimen :       3 ml Blood
   Container :      Red Top Tube


                                                                                122
   Range :           < 1:40
   Use :             Screening test for autoimmune diseases, systemic lupus
                     erthematosus, and chronic active hepatitis.
   Methodology :     Indirect immunofluorescence on HEP-2 cell line tissues
   Limitations :     This test is not specific for any one collagen vascular
                     disease For specific test for SLE see listing for "anti-DNA."
                     Men and Women over 80 have a 50% incidence of low titre
                     ANA. Various medications can induce a "Lupoid"
                     condition and elevated ANA titre.

8) AntiStreptolysin O Titre, Serum
   Synonyms :       ASO
   Specimen :       5 ml Blood
                    Causes for Rejection : Excessive hemolysis.
   Container :      Red Top Tube.
   Normal Range :    < 200 Iu/ml
                    A rise in titre of four or more dilution increments between
                    acute and convalescent specimen is considered to be
                    significant regardless of the magnitude of the titre.
   Use:             Document exposure to streptoccoccal infection.
   Methodology :    Agglutination, Neutralization "Hemolysis inhibition" for
                    specimen with > 200 IU/ml.

9) Beta-2-Microglobulin
   Synonyms :      B2-Microglobulin
   Specimen :      3 ml Blood
   Container :     Red Top Tube
   Normal Range : 0.7 - 3.4 mg/L
   Use :           Evaluate renal disease, activity of chronic lymphocytic
                   leukemia, activity of AIDS.
   Methodology :   Microparticle Enzyme Immunoassay “MEIA”.

10)Brucella Agglutinins    (Applies to Febrile Agglutinins)
   Synonyms :       B. Melitensis
   Specimen :       5ml Blood
   Container :      Red Top Tube
   Normal Range : < 1:80
                    The most meaningful reference is less than a four fold titre
                    rise on paired sera drawn 10-14 days apart.
   Use :            Supports the clinical diagnosis of brucellosis: Note that
                    previous vaccination may have an effect on the titre.
   Methodology :    Tube agglutination


                                                                               123
11)Brucella Agglutinins - 2ME     (Applies to Febrile Agglutinins)
   Synonyms :       B.Melitensis 2ME
   Specimen :       3 ml Blood
   Container :      Red Top Tube
   Normal Range : Negative
   Use :            Support the clinical diagnosis of active brucellosis using 2
                    mercapto ethonal which detects Brucella-IgG Antibodies.
   Methodology :    Tube agglutination.

12)Ceruloplasmin
   Specimen :        3 ml Blood
   Container :       Red Top Tube
   Normal Range :    18-45 mg/dl
   Use :             Decreased in most instances of Wilson's disease; hence,
                     ceruloplasmin is used in evaluation of chronic active
                     hepatitis, cirrhosis and other liver disease.
   Limitation :      A normal ceruloplasmin does not rule out Wilson's disease.
                     Serum copper should be measured in addition.
   Methodology :     Nephelometry.

13)C3 Complement, Serum
   Synonyms :     C3; Complement C3
   Specimen :     3 ml Blood
   Container :    Red Top Tube
   Normal Range : Available for all ages. (See page 136)
   Use :          Quantitation of C3 is used to detect individuals with inborn
                  deficiency of this factor or those with immunologic disease
                  in whom complement is consumed at an increased rate.
                  These include lupus erythmatosus, chronic active hepatitis,
                  certain chronic infections, streptococcal and membrano
                  proliferative Glomerulonephritis, and others.
   Methodology :  Nephelometry .
   Limitations :  Detects both biologically active and inactive C3.

14)C4 Complement, Serum
   Synonyms :     C4; Complement C4
   Specimen :     3 ml Blood
   Container :    Red Top Tube
   Normal Range : Available for ages. (See page 136)
   Use :          Detect individuals with inborn deficiency of this factor or
                  those with immunologic disease in whom hypercatabolism
                  of complement causes reduced levels. These diseases


                                                                             124
                     include Lupus erythmatosus, serum sickness, certain
                     glomerulonephritides, chronic active hepatitis, and others.
   Methodology :     Nephelometry.
   Limitations :     Complement proteins are acute phase reactants and have
                     short half-lives, serum level is a balance of synthesis and
                     catabolism. Serial measurments are more useful than single
                     values.

15)CA 125      (Applies to ovarian carcinoma; Tumor Markers)
   Specimen :         5 ml Blood
   Container :        Red Top Tube
   Normal Range : Absolute Reference Ranges are not established.
   Use :              Tumor Marker for monitoring of subjects with diagnosed
                      ovarian carcinoma.
   Limitations :      CA 125 is not specific for tumors of the ovary and cannot
                      distinguish benign from malignant tumors. It is not a
                      screening test.
   Methodology :      Microparticle Enzymes Immunoassay “MEIA”

16)C-Reactive Protein
   Synonyms :       Acute Phase Reactant; CRP
   Specimen :       3 ml Blood
   Container :      Red Top Tube
   Normal Range : <6 mg/L
                    Positive samples will be titered if it is requested as CRP
                    quantitative.
   Use :            CRP is nonspecific acute phase reactant used as an
                    indicator of infections disease and inflammatory states,
                    including active rheumatic fever and rheumatoid arthritis.
   Methodology:     Agglutination.

17)Cytomegalovirus Antibody (Applto CMV-IgG; CMV-IgM)
   Test commonly includes IgG and IgM test of acute sera in neonates, patients
   suspected of having CMV infection, immunosuppressed patients and maternity
   causes. Acute and convalescent specimens are recommended.
   Synonyms :        CMV; Cytomegalic Inclusion Virus Titre.
   Specimen :        3 ml Blood
   Container :       Red Top Tube
   Normal Range : < 1:100
   Use :             Establish diagnosis of infection.




                                                                             125
   Limitions :       Hetrophil antibodies and presence of rheumatoid factor
                     may cause false-positive IgM results. Fetal IgM antibody to
                     maternal IgG may also cause false-positive results.
   Methodology :     Enzyme immunoassay "Micro ELISA".

18)Haptoglobulin, Serum
   Specimen :       3ml Blood
   Container :      Red Top Tube
   Normal Range : 27-139 mg/dl
   Use :            Decreased to absent levels occur more with intravascular
                    than extra vascular hemolysis.         It is low in the
                    megaloblastic anemias, infectious mononucleosis and liver
                    disease. It elevated as an acute phase reactant , in
                    inflammatory disorders eg. collagen disease, infections,
                    tissue destruction, and with advanced malignant neoplasms.
   Limitation :     During inflamation or steriod therapy, Normal
                    concentrations do not rule out hemolysis.
   Methodology :    Nephelometry.

19)Hepatitis A Antibody, IgM
   Synonyms :       Antibody to HAV-IgM; Anti-HAV,IgM ; HAVAB
   Specimen :       5 ml Blood
   Container :      Red Top Tube
   Normal Range : Negative
                    IgM antibody develops within a week of symptom onset,
                    peaks in 3 months, and is usually gone after 6 months.
   Use :            Diferential diagnosis of hepatitis.      Presence of IgM
                    antibody to hepatitis A virus is good evidence for acute
                    hepatitis A.
   Methodology :    Micropartical Enzyme Immunoassay “MEIA”.

20)Hepatitis B Core Antibody
   Synonyms :       AHBC; Antibody to Hepatitis B core Antigen; Anti-HBc;
                    Antihepatitis B core; core Antibody; HBcAb
   Specimen :       5 ml Blood
   Container :      Red Tube
   Normal Range : Negative
   Use :            Used in the differntial diagnosis of hepatitis syndromes. It
                    also used, in conjunction with other B virus serological
                    Markers, to assess the stage of hepatitis B infection.
   Methodology :    Micropartical Enzyme Immunoassay “MEIA”.



                                                                              126
21)Hepatitis B Core Antibody -IgM
   Synonyms :       AHBC-IgM; Anti-HBc-IgM; HBcAb-IgM
   Specimen :       5 ml Blood
   Container :      Red Top Tube
   Normal Range : Negative
   Use :            The HBc-IgM appears in acute infection patients
   Methodology :    Micropartical Enzyme Immunoassay “MEIA”.

22)Hepatitis Be Antibody
   Synonyms :        Anti-HBe; HBeAb
   Specimen :        5 ml Blood
   Container :       Red Top Tube
   Normal range :    Negative
   Use:              Used in the differential diagnosis, staging, and prognosis of
                     hepatitis B infection .
   Methodology :     Microparticle Enzyme Immunoassay “MEIA”.

23)Hepatitis Be Antigen
   Synonyms :        HBeAg
   Specimen :        5 ml Blood
   Container :       Red Top Tube
   Normal Range : Negative
   Use :             Differntial diagnosis and a marker for infectivity.
   Methodology :     Micropartical Enzyme Immunoassay “MEIA”.

24)Hepatitis B Surface Antibody
   Synonyms :        Antibody to Hepatitis B Surface Antigen; Anti-HBs,
   HBsAb;            HBsAgAb; Hepatitis Bs Antibody replaces Australian
   Antigen           Antibod.
   Specimen :        5 ml Blood
   Container :       Red Top Tube
   Normal Range : Protective level >10 IU/ml
   Use :             Presence of HBsAb indicates past infection with resolution
                     of previous hepatitis B infection. Evaluate possible
                     immunity in individuals who are at increased risks to
                     further exposure to the hepatitis B. Evaluate need for
                     hepatitis B immunoglobulin after needle stick injury.
                     Evaluate need for hepatitis B vaccine.
   Methodology :     Microparticval Enzyme Immunoassay “MEIA”.




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25)Hepatitis B Surface Antigen
   Synonyms :        HAA; HBsAg; Hepatitis Associated Antigen
                     Replaces Australian Antigen; Serum Hepatitis marker
   Specimen :        5 ml Blood
   Container :       Red Top Tube
   Normal Range : Negative
   Use :             Used in the differential diagnosis of hepatitis B viruses. To
                     evaluate risk in needlestick injuries in health facilities, and
                     guide use of hepatitis B immunoglobulin.
   Methodology :     Micropartical Enzyme Immunoassay “MEIA”.

26)Hepatitis C Serology
   Applies to Non-A Non-B Hepatitis, HCV antibodies
   Specimen :        5 ml Blood
   Container :       Red Top Tube
   Normal Range : Negative
   Use :             Screening of Hepatitis C Virus Antibody.
   Methodology :     Micropartical Enzyme Immunoassay “MEIA”.

27)Herpes Simplex Antibody
   Synonyms :      Herpes Simplex I and II; Herpes I and II
   Specimen :      5 ml Blood
   Container :     Red Top Tube
   Normal Range : < 1:100
   Use :           Detection of HSV I and HSV 2 infection.
   Methodology :   Immunofluorescence.

28)HLA-B27
   Synonyms :         B27; HLA-Antigen B27; Tissue Typing; W27
   Specimen :         10 ml Blood / Contact lab for appointment.
   Container :        Yellow Top Tube (ACD Tube)
   Normal Range :     Requires clinical correlation
   Use :              Evaluation of spondyloarthritis and other disorders
                      associated with these Loci
   Methodology :      Lymphocytotoxcity Technique.
   Limitations :      This test should not be considered a screening procedure
                      for ankylosing spondylitis.

29)Immunoglobulin A
   Synonyms :     IgA; Quantitative IgA.
   Specimen :     3 ml Blood / Requisition must state patient's age.
   Container :    Red Top Tube


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   Normal Range :    Available for all ages   (See page 136)
   Use:              To evaluate humoral immunity to monitor therapy in IgA
                     myeloma.
   Limitation :      If samples containing macroglobulins, cryoglobulins or
                     cold agglutinins are handled at incorrect temperatures, false
                     low values may result.
   Methodology :     Nephelometry.

30)Immunoglobulin G
   Synonyms :     IgG; Quantitative IgG.
   Specimen :     3 ml Blood / Requisition must state patient's age
   Container :    Red Top Tube
   Normal Range:  Available for all ages. (See page 136)
   Use :          To evaluate humoral immunity. To monitor therapy in IgG
                  Myeloma. Evaluate patients, especially children and those
                  with lymphoma, with propensity to infections.
   Methodology :  Nephelometry.

31)Immunoglobulin M
   Synonyms :     IgM Quantitative IgM
   Specimen :     3 ml Blood
   Container :    Red Top Tube
   Normal Range : Available for all ages     (See page 136)
   Use:           To evaluate humoral immunity. To establish the diagnosis
                  and monitor therapy in macroglobulinemia of waldenstron
                  or plasma cell myeloma. IgM levels are used to evaluate
                  likelihood of in utero infections or acuteness of infection.
   Methodology :  Nephelometry

32)Infectious Mononucleosis Screening Test
   Applies to Heterophil Agglutinins; Mono test; Monospot test; Monosticon Dri-
   Dot test. Replaces Davidson Differential; Paul-Bannel. Test commonly
   includes screening for the presence of heterophil antibodies.
   Specimen :         3 ml Blood
   Container :        Red Top Tube
   Normal Range : Negative /         If positive, quantitation will be done.
   Use:               Diagnosis of infectious mononucleosis.
   Methodology :      Agglutination.

33)Lymphocyte Subset Enumeration
   Test commonly includes Lymphocyte subpopulation enumeration. Must
   schedule with laboratory in advance.


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   Synonyms :         Immunodeficiency profile; Immunophenotyping
                      Lymphocyte typing.
   Specimen :         3 ml Blood or Bone Marrow
                      Blood specimen must be collected fresh on day of test
                      and delivered to laboratory immediately
   Container :        EDTA Tube (purple top tube)
   Normal Range :     See page 137
   Use :              Evaluation      of    thymus-depedent       or     cellular
                      immunocompetence enumeration of T-helper; T-Suppressor
                      ratio; study of lymphoproliferative disorders for clonality
                      and lineage.
   Methodology :      Flow cytometry.

34)Mycoplasma Serology
   Synonyms :     M.pneumoniae titre, mycoplasma pneumoniae titre.
   Specimen :     3 ml Blood
                  Acute and convalescent sera drawn 10-14 days apart are required.
   Container :    Red Top Tube
   Normal Rang:   Negative
   Use:           Support for the diagnosis of M.pneumoniae i
   Limitations :  False-positive occur in pancreatitis
   Methodology:   Indirect hemagglutination (IHA)

35)Parasite Screen
   Test commonly      includes Echinococcus, Entamoeba, Schistosoma and
   Leishmania
   Specimen:          3 ml Blood / Acute and convalescent specimens are recommended.
   Container :        Red Top Tube
   Normal Range :     < 1:64
   Use :              Support diagnosis of suspected parasitic infestation.
   Methodology :      hemagglutination (IHA).
   Additional Information : Parasite screen is not a specific test. Antibodies
   will rarely be present unless tissue invasion has taken place. Because of cross
   reactions and failures to develop antibody serologic diagnosis does not replace
   demonstration of the parasite itself or its egg as a definitive diagnostic
   procedure.

36)Parietal Cell Antibody
   Synonyms :        Antiparietal cell Antibody; PA
   Specimen :        3ml Blood
   Container :       Red Top Tube


                                                                               130
   Normal Range :     < 1: 20
   Use :              Useful in the differential diagnosis of pernicious anemia and
                      gastritis
   Limitations :      Nonspecific : found in 20% to 30% of patients with a
                      variety of autoimmune disorders and 16% of asymtomatic
                      people older then 60 years.
   Methodology :      Indirect immunofluorescence. (IFA).

37)Pregnancy Test
   Specimen :         First morning specimen of urine.
   Container :        Plastic urine container
   Normal Range :     Non pregnant Females : Negative.
                      Normal Pregnant Females : Positive
   Use :              Diagnosis of Pregnancy
   Methodology :      Immunoassay.

38)Protein C, Protein S and Free Protein S
   Specimen :        3 ml Blood
   Normal Range : 70 - 140 %
   Use :             Investigation of patients with thromboses, especially
                     venous thromboses in young adults. Study of patients with
                     hypercoagulable state.
   Methodology :     Enzyme Immunoassay (Micro ELISA)

39)Respiratory Syncytial Virus Antigen
   Synonyms :       RSV
   Specimen :       Nasophryngeal Aspirates collection. Specimen should be
                    collected in container contain (PBS) Phosphate Buffer
                    saline pH 7.2 + 2 (asking PBS from the lab.)
   Normal Range : Negative
   Use :            Identification of respiratory syncytial virus in specimens
                    particularly infants and young children.
   Methodology :    Enzyme Immunoassay.
   Limitations :    Avoid blood contamination samples.

40)Rheumatoid Factor
   Synonyms :      RF / Applies to Rheumatoid factor, synovial fluid.
   Specimen :      3 ml Blood or Synovial fluid
   Container :     Red Top Tube
   Normal Range:   < 20 I/ml
   Use :           Help in the differential diagnosis and prognosis of arthritis
   Methodology :   Agglutination.


                                                                               131
41)Rubella Serology
   Applies to IgG Antibodies to Rubella; IgM Antibodies to Rubella.
   Specimen :        3ml Blood
   Container :       Red Top Tube
   Normal Range : Absence of antibody indicates susceptibility to rubella,
                     Presence of IgM antibody indicates acute infection
                     orvaccination, Presence of IgM antibody requires
                     interpretation.
                     IgG indicates past exposure or Immunity to Rubella.
   Use :             Aid in diagnosis of congenital rubella infections; evaluate
                     susceptibility to infections.
   Methodology :     Enzyme linked immunoassay. (Micro ELISA)

42)Syphilis-IgG          (Applies to syphilis Serology)
   Specimen :         3 ml Blood
   Container :        Red Top Tube
   Normal Range :     Negative
   Methodology :      Micro ELISA.
   Use :              Screening test for syphilis

43)RPR
   Applies to syphilis serology
   Synonyms :          Rapid Plasma Reagin Test, Serologic test for syphilis, STS;
                       syphilis screening test. / Replaces VDRL ;Wassermann
   Specimen :          3 ml Blood
   Container :         Red Top Tube
   Normal Range : Non Reactive
   Use :               Monitoring treatment. This is a nontreponemal test and is
                       associated with false positive reactions due to current
                       infections, pregnancy,drug addiction, collagen vascular
                       disease and Gaucher's disease.
   Methodology :       Agglutination.

44)FTA-ABS, Serum
   Synonyms :     Fluorescent Treponemal Antibody-Absorption;
                  Serological Test for Syphilis
   Specimen :     3 ml Blood
   Container :    Red Top Tube
   Normal Range : Non Reactive
   Use :          To confirm presence of Treponema pallidum antibodies,
                  establish the diagnosis of syphilis.


                                                                               132
   Limitations :     False positive may found in patients with disease associated
                     with increased or abnormal globulins, antinuclear
                     antibodies, lupus erythematosus, pregnancy and drug
                     addiction. As many as 2% of the general population may
                     have a false positive.
   Methodology :     Indirect immunofluorescence (IFA).

45)Salmonella Titer (Widal test)
   Test commonly includes Agglutination of "O" & "H", a salmonella antigens
   for group A & B
   Synonyms :        Widal Test ;Thyphoid Agglutinins.
                     Applies to Febrile-Agglutinins, widal agglutination test.
   Specimen :        5 ml Blood
   Container :       Red Top Tube
   Normal Range : A convalescent Titer less than four fold higher than the
                     acute titer.     Titers on a single specimen are not
                     diagnostically significant.
   Use:              To detect antibodies to specific salmonella antigen
   Limitation :      Numerous false-positive due to cross reacting bacterial
                     antibodies and hetrospecific anamnestic responses. Clinical
                     correlation is mandatory. Single determinations are without
                     value. Blood and Stool cultures should be obtained
   Methodology :     Agglutination.


46)Smooth Muscle Antibody
   Synonyms :     Antismooth Muscle Antibody ; SMA
   Specimen :     3 ml Blood
   Container :    Red Top Tube
   Normal Range : < 1:20
   Use :          Useful in the differential diagnosis of liver disease .
                  Antismooth Muscle are found mainly in chronic active
                  hepatitis
   Limitation :   Presence of antinuclear antibody may interfere with the
                  interpretation of smooth muscle antibody.
   Methodology :  Indirect immuno fluorescence.

47)Thyroid Antimicrosomal Antibody
   Synonyms :      Antithyroid Microsomal Antibody; Microsomal Antibody ;
                   Thyroid autoantibodies.
   Specimen :      3 ml Blood
   Container :     Red Top Tube


                                                                              133
   Normal Range :    < 1:10
   Use :             Used in differential diagnosis of hypothyroidism and
                     thyroiditis
   Limitations :     Should be used in conjunction with antithyroglobulin test.
   Methodology :     Hemagglutination test.

48)Thyroid Antithyroglobulin Antibody
   Synonyms :      Antithyroglobulin antibody; Thyroglobulin antibody
   Specimen :      3ml Blood
   Container :     Red Top Tube
   Normal Range : < 1 : 20
   Use :           Useful in detection and confirmation of autoimmune
                   thyroditis, Hashimoto's Thyroiditis.
   Limitations :   Must be used in conjunction with antimicrosomal test.
                   Other autoimmune hemolytic anemia, may be positive for
                   thyroid antibodies.
   Methodology :   Hemagglutination test.

49)Tissue Typing for HLA Class I & II
   Synonyms :        Histocompatibility testing; HLA Typing, Human leukocyte
                     Antigen; lymphocyte crossmatch; Organ Donor Tissue
                     Typing; Transplant tissue typing
   Specimen :        10 ml Blood
   Container :       ACD tube (yellow top tube) for donor;and receipient.
                     recipient.
   Storage :         Should be tested immediately. Do not refrigerate or freeze.
   Use :             Tissue Typing may aid in determination of campatibility of
                     kidney or bone marrow trasplant.

50)Tissue Typing - Cross Matching
    Synonyms:            Lymphocyte Crossmatch
    Specimen :           10 ml Blood
    Container:           ACD tube (yellow top tube)
    Storage :            Should be tested immediately. Do not refrigerate or
                         freeze .
    Use:                 Cross Match aid in determination of maternal
                         antibodies against Paternal cells and matching
                         between donor and receipient of an organ for
                         transplantation.


51)Toxoplasmosis Serology


                                                                             134
   Synonyms :        Toxoplasmosis titer.
                     Test commonly includes IgG and IgM antibody specificity.
   Specimen :        3 ml Blood. / Acute and convalescent specimens are
                     recommended
   Container :       Red Top Tube
   Normal Range :    < 1:100
   Use :             Support for the diagnosis of toxoplasmosis; documentation
                     of past exposure and/or immunity to toxoplasma gondii
   Limitation :      Diagnosis of new infection may be difficult because
                     infection outstrips demonstantibody response
   Methodology :     Enzyme immunoassay (Micro ELISA)
                     Diagnosis supported by high or rising IgG antibody titer, or
                     the presence of IgM antibody.

52)VDRL          (Applies to Syphilis Serology)
   Synonyms :       Veneral Dieases Research Laboratory Test.
   Specimen :       CSF
   Container :      Red Top Tube
   Normal Range : Non Reactive
   Use :            Screening test for syphilis. May be used to assess adequacy
                    of treatment .
   Limitations :    Nonspecific positive reactions may be found in Malaria,
                    infectious mononucleosis, infectious hepatitis, leprosy,
                    brucellosis, SLE, atypical pneumonia and typhus. Reactive
                    tests due to related treponemal infections will also occur.
   Methodology :    Flocculation procedure detecting the presence of reagin an
                    antibody to nontreponemal cardiolipin antigen.




                                                                              135
NORMAL RANGES

                IgG                 IgA            IgM           C3              C4
                Range               Range          Range         Range           Range
                mg/dl               mg/dl          mg/dl         mg/dl           mg/dl

1 month         251 - 906           1.3 - 53       20 - 87       53 - 124        7.0 - 25
2 months        206 - 601           2.8 - 47       17 - 105      59 - 149        7.4 - 28
3 months        176 - 581           4.6 - 46       24 - 89       64 - 131        8.7 - 27
4 months        196 - 558           4.4 - 73       27 - 101      62 - 175        8.3 - 38
5 months        172 - 817           8.1 - 84       33 - 108      64 -            7.1 - 36
6 months        215 - 704           8.1 - 68       35 - 102      74 - 171
7-9 months      217 - 904           11 - 90        34 - 126      75 - 166        9.5 - 37
10-12 months    249 - 069           16 - 84        41 - 149      73 - 180        12 - 39
1 year          345 - 1213          14 - 106       43 - 173      84 - 174        12 - 40
2 years         424 - 1051          14 - 123       48 - 168      81 - 170        9.2 - 34
3 years         441 - 1135          22 - 159       47 - 200      77 - 171        9.4 - 36
4-5 years       463 - 1236          25 - 154       43 - 196      86 - 166        13 - 32
6-8 years       633 - 1280          33 - 202       48 - 207      88 - 155        12 - 32
9-19 years      608 - 1572          45 - 236       52 - 242      89 - 195        10 - 40
Adult           639 - 1349          70 - 312       56 - 352      83 - 177        15 - 45

 Changes in circulating lymphocyte populations and serum immunoglobulin levels
                                    with age

Cells          1 day – 11 months               1 – 6 years               Adult      .

CD3               64 (58 – 67)                 64 (62 – 69)          63.0 – 85.0
CD4+              41 (38 – 50)                 37 (30 - 40)          31.0 – 55.0
CD8+              21 (18 – 25)                 29 (25 - 32)          17.0 – 38.0
CD4 : CD8         1.9 (1.5 – 2.9)              1.3 (1.0 – 1.6)       1.20 – 2.40
CD19              23 (19 - 31)                 24 (21 – 28)          5.00 – 20.0
CD56              11 (8 – 17)                  11 (8 – 15)           6.00 – 41.0




                                                                                        136
      BLOOD BANK PROCEDURES

        Division of Transfusion Medicine




                    Prepared by :

Aysha Al-Malki M.Sc.(Hematology/Transfusion Medicine)
     Supervisor – Division of Transfusion Medicine



                     Revised by:

Dr.Zeinab Osman Fawzi, MBBS, DCP, MRCPath (Part I)
      A/Head of Division of Transfusion Medicine




                                                        137
138
FUNCTION
  The Blood Bank Laboratory provides 24 hours service, seven days per week,
  including Holidays and performs the following functions :
  a. Pre-transfusion testing on patient's and donor blood (ABO and Rh Typing
      Screening for allo-antibodies, compatibility testing).
  b. Pre-natal screening (grouping , antibody screening , identification and
      titration).
  c. Investigation of hemolytic disease of new borns and immune hemolytic
      anemia.
  d. Transfusion Reaction Investigation.
  e. Preparation of blood component.
  f. Screening of blood for infective agents.

BLOOD COMPONENTS PREPARED IN BLOOD BANK
  1. Packed red cells (PRC)
  2. Fresh Frozen plasma (FFP)
  3. Platelet Concentrate (P.C)
  4. PRC (Filtered/Irradiated/Washed)
  5. PC (Filtered/Irradiated)
  6. Cryoprecepitate
NOTE : Blood and blood components prepared for patients are reserved for
two days only.

URGENT REQUESTS (STAT)
 For the STAT requests, properly labelled specimen together with its correctly
 completed request form will be processed immediately after being received in
 the Blood Bank. The specimens given priority and classified as urgent are
 those which come from the following locations :
  1. Accident & Emergency
  2. Labour room
  3. Operating theatre, Recovery room
  4. SICU
  5. Dialysis unit
  7. Any request coming from any ward provided that adequate justifications
     were given.

ROUTINE REQUESTS
  All routine will be performed within 24 hours after receiving the specimen ,
  except for some tests that may need more than 24 hours. All ELISA tests are
  Routine tests (namely tests for AIDS and Hepatitis, HIV 1,2 confirmatory
  tests).

REQUEST FORMS
  1. Transfusion request forms must be stamped by physician responsible for or
     involved in the receipient's care.




                                                                           139
   2. All requests must contain sufficient information for Positive Identification
      of patients. It should contain patient's full name, sex, age, location, doctor
      in-charge, clinical diagnosis,      history     of   previous     transfusion,
      pregnancies and preferably a list of medications that the patient has
      recently received or is currently receiving.
   3. In case, blood or blood component are requested transfusion request forms
      must contain type of blood component and number of units required and
      special requirement (washed / filtered, irradiated components).


COLLECTION OF SPECIMENS
  1. Blood samples must be drawn into correctly labelled stoppered tubes, (For
     the amount of specimen and type of tube please refer to "Tests performed
     in the Blood Bank" ).
  2. The patients should be properly identified before blood collection, both
     verbally and by their identification bracelet.
  3. Collect blood from one patient, label all samples and fill in his form before
     moving to another patient
  4. Improperly labelled blood specimens will not be accepted and will be kept
     in Blood Bank and another blood sample should be sent with the correct
     information.
  5. Hemolyzed samples are not suitable for Blood Bank tests.
  6. It is permissible to collect blood from an infusion line if the patient is
     receiving intravenus fluid, provided the tubing is flushed with saline and
     the first 5 ml of blood is withdrawn and discarded.
   Failure to stick to these criteria may cause serious technical problems.
NOTE:     Patients with recent history of transfusion may not need a sample if they
          are going to have fresh frozen plasma (FFP) or platelet concentrate
          (PC). For PRC crossmatch a fresh sample is needed if the patient has
          received blood or blood components more than 48 hours prior to the
          request.

TESTS PERFORMED IN BLOOD BANK
  10ml clotted (plain tube without jell) is needed to perform ABO grouping,
  Antibody screening and crossmatching) However, an extra sample may be
  needed in some cases for further investigation.
  1. ABO Grouping / Rh Typing :
     Specimen : Clotted ( plain tube without jell ) or anticoagulated blood.
     Minimum amout of blood required : Adult = 3 ml, Pediatric = 1 ml.
  2. Antibody Screening : ( Indirect Coombs)
     Specimen : Clotted blood (plain tube without jell )
     Minimum amount of blood required : Adult = 5 ml , Pediatric = 3 ml.
  3. Direct Coombs :
     Specimen : Anticoagulated blood (CBC tube )
     Minimum amount of blood required : Adult = 2 ml , Pediatirc = 1 ml.
  4. Antibody Identification :


                                                                                 140
       Specimen : Clotted blood ( Plain tube without jell )
       Minimum amount of blood required : Adult = 10 ml , Pediatirc = 1 ml
   5. Antibody Titration :
       (This test is mainly done to determine the titre of anti-D)
       Specimen : Clotted blood ( Plain tube without jell )
       Minimum amount of blood required : Adult = 7 ml
   6. Crossmatching :
       Specimen : Clotted blood ( Plain tube without jell )
       Minimum amount of blood required : Adult = 7 ml , Pediatric = 5 ml.
   7. Red Cell Antigen Typing :
       Specimen : Anticoagulated blood ( CBC tube )
       Minimum amount of blood required : Adult = 3 ml. Pediatric = 1 ml
   8. Antibody Absorption :
       Specimen : Clotted blood
       Minimum amount of blood required : Adult = 10 ml, Pediatric = 7 ml
   9. Antibody Elution :
       Specimen : Anticoagulated blood
       Minimum amount of blood required : Adult = 5 ml, Pediatric = 3 ml.
   10. Elisa tests :
                    1.    HIV 1,2
                     2.   HTLV-1
                     3.   HBsAg *
                     4.   HBcAb *
                     5.   HCV *
*These tests are done on donor's blood only;        Can be done on patients by
arrangement.

ISSUING BLOOD OR BLOOD COMPONENTS :
   1. The Nurse or the Nursing aide who comes to collect the blood should
      present the patients adresograph.
   2. Both technologist and person picking up the blood will check :
      a. Patient's name and chart number shown on the requisition form with that
         presented by the person picking up the blood.
      b. Donor Unit number on the requisition form and blood unit.
   3. They will sign the Transfusion log book, which will remain in the Blood
      Bank. Time and date of release will also be entered.

PACKED RED CELLS TRANSFUSION :
  1. For any one patient , only one unit of blood will be issued from the Blood
     Bank at any given time.
  2. It may be necessary to carefully warm the blood collected immediatly
     from the blood bank before transfusion into the patient
  3. Blood should be administered as soon as possible after it is issued.
  4. Blood must not be stored in unmonitored common, fridges in nursing
     stations or other areas.



                                                                             141
   5. If the transfusion cannot be initiated within 30 minutes, the blood should
      be returned immediately to Blood Bank for proper storage.
   6. If the unit has been lying outside the fridge for more than 30 minutes and
      then returned, Blood Bank should be informed because the blood
      temperature may rise above 8°C, which increases the risk of bacterial
      contamination and makes the unit unsuitable for reissue by Blood Bank
   7. Transfusion of unit of blood should not take more that four hours.
   8. If transfusion of a unit of blood appears to take more than 3-4 hours due to
      any clinical reasons, it is advised to request the Blood Bank to divide the
      blood into aliquots so that one can be refrigerated while the other is being
      transfused.
   9. A new crossmatch is needed if more than 3 days have elapsed after the
      administration of the initial portion of the red blood cells.

FRESH FROZEN PLASMA TRANSFUSION :
  Fresh frozen plasms is kept frozen at -30oC. When needed it has to be thawed
  and this will take about 30 minutes. Thawed plasma has to be used within six
  hours after thawing. If not requested within six hours of thawing the Blood
  Bank will discard it.

PLATELET CONCENTRATE TRANSFUSION :
  Platelets are stored agitated at room temperature. It should not be stored at any
  time in the fridge. When pooled it should be used within four hours.
  You should return the platelets to the Blood Bank if they will not be used
  immediately.

CRYOPRECIPITATE TRANSFUSION :
  Cryoprecipitate is kept frozen at -30oC. When needed has to be thawed and
  this will take about 15 minutes. If more than one unit is requested it will be
  pooled by Blood Bank staff and the shelf life will be decreased to four hours
  only. During this four hours it should not be stored in the fridge. If not
  requested within four hours of pooling the Blood Bank will discard it.
IN ALL CASES of blood components requisition, Units should only be taken
from Blood Bank when patient is ready to take the transfusion to avoid
deterioration and wastage of the unit.

TRANSFUSION REACTION
  Any adverse symptoms or physical signs occuring during transfusion of blood
  or its components should be considered as a potentially life-threatening
  reaction and the following actions must be taken:
  1. Stop the transfusion immediately to limit the amount of blood infused.
  2. Notify the responsible physician.
  3. Keep the intravenous line open with infusion of normal saline.
  4. At the patient's bedside, check all labels, forms and patient's identification
     to determine if the patient received the intended component.


                                                                                142
   5. If the responsible physician thinks it is a transfusion reaction, REPORT the
      suspected transfusion reaction to Blood Bank personnel IMMEDIATELY.
   6. Send the required blood sample (10ml blood in plain tube and 3ml in
      EDTA tube carefully drawn to avoid mechanical hemolysis) to Blood Bank
      as soon as possible together with the discontinued bag of blood and the
      administration set without the IV needle.
   7. Also send separate, patient's blood samples to Chemistry and Microbiology
      for Bilirubin (total & conjugated) and Culture respectively.
   8. However, if the physician does not think the reaction was transfusion
      related the transfusion can be resumed with caution

EMERGENCY TRANSFUSION
  A COMPLETE CROSSMATCH REQUIRES 30 MINUTES AFTER THE
  TIME THE SPECIMEN IS RECEIVED IN BLOOD BANK.
   In case of extreme emergency, blood can be released in a matter of minutes
   only if the attending physician makes a written request for uncrossmatched
   blood.
   1. "O Rh Negative packed cells" can be issued within 3-4 minutes from the
      time the request is received in Blood Bank .
   2. Under all circumstances, a blood specimen must be taken from the patient
      before the start of transfusion.
   3. "Type specific" blood (of the patient's own ABO and Rh group) can be
      issued within 10 minutes from the time the request and specimen are
      received in Blood Bank .

IMPORTANT
  1. A maximum of two (2) units of uncrossmatched blood will be issued at a
     time.
  2. In all cases, the crossmatch will be completed even if the blood has already
     been transfused.
  3. If an issued unit was found to be incompatible the ward will be informed
     immediately to stop the transfusion.

OPERATING ROOM
  1. More than one unit may be if requested.
  2. In case of emergency, blood may be released before completion of cross-
     matching (See Emergecy Transfusion).
  3. Blood requests for elective surgery must be sent to Blood Bank by
     1:00p.m. the day before the scheduled surgery and preferably in the
     morning.
  4. Two units for each patient will be placed in Blood Bank refrigerator in the
     Operating Theatre by 7:30a.m. on the day of surgery. Any additional units
     reserved for a particular patient will be retained in Blood Bank until
     requested and till 24 hours after the surgery if not requested.




                                                                               143
144
  BLOOD DONOR UNIT PROCEDURES

        Division of Transfusion Medicine




                   Prepared by


           Dr. Akram Al-Hilali, FRCPath
             Consultant - Hematology



                    Revised by

Dr.Zeinab Osman Fawzi, MBBS, DCP, MRCPath (Part I)
      A/Head of Division of Transfusion Medicine




                                                     145
146
BLOOD DONOR PROCUREMENT POLICY
  In case of planned surgery, the surgeon needs to tell the patient or his family to
  arrange for blood donors atleast 24 hours before the date of the surgery.
  The number of donors will be decided by the surgeon depending upon the type
  of the surgery.

BLOOD DONATION FOR PATIENTS RECEIVING BLOOD
    1. It is the policy of the HMC that every patient being prepared for surgery
        should provide blood donors from his family and friends. Surgeons
        arranging for such surgery are expected to provide the patient with Donor
        Request form stating the number of donors requested; This number should
        be in the range of the number of units expected, from experience, to be
        needed for the surgical procedure.
        Exemptions from such donation can be issued by the supervisor of the
        Donor Room when he is convinced of the reasons for failure of the patient
        to provide donors. The treating physician is not to give such exemptions
        and is requested not to put pressure on Blood Bank officials to do so.
    2. The Surgeons must make sure that the patients for planned surgery have
        their blood groups determined before their donors are sent to the donor unit
        so that it is possible to make sure that blood of the appropriate patients
        blood group will be available at the time of surgery.
    3. Patients needing blood in the A/E will, of course will not be requested to
        provide donors at the time of admission or transfusion. However, after the
        patient is stabilized, and while in Hospital, the attending physician is
        expected to request the faimly to provide donors, the number being
        comparable to the number given.
    4. Non-surgical patients receiving blood transfusions for various reasons and
        also those receiving blood components repeatedly (like platelet
        transfusions) should also be requested by the treating physician to provide
        donors every now and then. It is not expected to get a number of donors
        that match the number given, but the faimly should show some support to
        the Blood Bank as a result of the repeated provision of blood and its
        components.
    5. For patients needing platelet transfusion on long term basis (like
        Hematology/Oncology patients) it is possible to arrange platelet apheresis
        on the cell separator using some family members lined up at the outset of
        treatment. This process needs to be discussed between the treating
        physician and the consultant-in-charge of the Blood Bank in order to
        arrange screening of such donors and calling one of them as needed. This
        way more plentiful, and fresh, platelet transfusions can be made available.
    6. All physicians are requested to help improve the Blood Bank stock and
        thus improve expectations when the Blood Bank is requested to provide
        blood and its components.
It is due to the fact that the volunteer donors are still not as many as we wish,
this kind of family-based procurement of blood has to continue.
Donor Unit Working Hours : 7:00 A.M. to 9:30 P.M (From Saturday -
Wednesday) and Thursday from 8:00 AM to 1:00 PM.



                                                                                 147
TEST INDEX
17-Alpha Hydroxyprogesterone …………………………………………. 69
25- Hydroxyvitamin D …………………………………………………… 69
5-Hydroxyindoleacetic Acid (Quantitative ) …..………………………… 45
ABO grouping / Rh typing ………………………………………………. 140
Acetaminophen …………………………………………………………… 60
Acetylsalicylic Acid ……………………………………………………… 61
Acid fast bacilli …………………………………………………………… 110
Acid phosphatase Reaction ………………………………………………. 92
Activated Partial Thromboplastin Time (APTT) ………………………… 86
Activated Protein C Resistance (APC) Test ……………………………… 87
Acute leukemia immunophenotyping……………………………………… 121
Alanine Aminotransferase ………………………………………………… 33
Albumin …………………………………………………………………… 33
Alcohol …………………………………………………………………… 60
Aldosterone ………………………………………………………………. 69
Alkaline Phosphatase …………………………………………………….. 33
Alkaline Phosphatase isoenzymes ……………………………………….. 33
Alpha - Feto Protein (AFP) ……………………………………………… 70
Alpha 1-Antitrypsin, Serum (Applies to Specific Protein Analysis) …….. 121
Amino Acids ……………………………………………………………... 33
Ammonia …………………………………………………………………. 34
Amniotic fluid ……………………………Cytogenetics………………… 97
Amniotic Fluid Bilirubin …………………………………………………. 55
Amniotic Fluid Creatinine ……………………………………………….. 56
Amniotic Fluid Lecithin/Sphingomyelin Ratio ………………………….. 56
Amylase (Pancreatic) …………………………………………………….. 34
Anaerobic cultures ……………………………………………………….. 104
Anti-DNA ………………………………………………………………… 122
Anti-Sperm Antibody …………………………………………………….. 122
Anti Cardiolipin Antibody ……………………………………………….. 121
Anti thrombin III …………………………………………………………. 34
Antibiotic assays …………………………………………………………. 102
Antibiotic susceptibilities ………………………………………………… 102
Antibiotic tests …………………………………………………………… 102
Antibody Absorption ……………………………………………………. 141
Antibody Elution …………………………………………………………. 141
Antibody Identification …………………………………………………... 140
Antibody Screening …. (Indirect Coombs) ……………………………… 140
Antibody Titration ……………………………………………………….. 141
Anticoagulants color codes used currently in the tubes …………………. 54


                                                                             148
Antimitochondrial Antibody ……………………………………………..         122
Antinuclear Antibody …………………………………………………….             122
AntiStreptolysin O Titre, Serum ………………………………………….      123
Arsenic ……………………………………………………………………                     34
Aspartae Aminotransferase ……………………………………………….          35
Autopsies …………………………………………………………………                    29
Bence Jones Protein ………………………………………………………              35
Beta-2-Microglobulin …………………………………………………….             123
Beta-Human Chorionic Gonadotropin ……………………………………       70
Bicarbonate (Venous) …………………………………………………….             35
Bilharzial parasites (Schistosomes) ………………………………………    112
Bilirubin ( Total ) …………………………………………………………             35
Bilirubin (Direct) …………………………………………………………              35
Bleeding Time ……………………………………………………………                  90
Blood culture ……………………………………………………………..                103
Blood Gases (Arterial) …………………………………………………...          36
Blood Gases (Venous ) ………………………………………..………….           36
Body Fluid Amylase ……………………………………………………...             57
Body Fluid Glucose ………………………………………………………               57
Body Fluid Lipase ………………………………………………………..              57
Body Fluid pH ……………………………………………………………                  57
Body Fluids Analysis …………………………………………………….             56
Bone marrow - Aspirate …………...Cytogenetics……………………….   97
Bone Marrow ………………………Hematology ……………………….             91
Bone marrow culture………………..Microbiology………………………       103
Brucella Agglutinins - 2ME ……………………………………………..         124
Brucella Agglutinins ……………………………………………………..            124
C-Peptide of Insulin ………………………………………………………             70
C-Reactive Protein ……………………………………………………….              125
C3 Complement, Serum ………………………………………………….              124
C4 Complement, Serum …………………………………………………..             124
CA 125 ……………………………………………………………………                      125
Calcium …………………………………………………………………..                    37
Calcium (Ionized) ………………………………………………………...             37
Cancer Antigen 15-3 (CA 15-3) ………………………………………….        70
Carbamezepine …………………………………………………………...                61
Carbohydrate Antigen 19-9 (CA-19-9) …………………………………..    71
Carboxy Hemoglobin …………………………………………………….               37
Carcino Embryonic Antigen (CEA) ……………………………………...      71
Carotene ………………………………………………………………….                    38
Cerebrospinal fluid ……………………………………………………….             103
Cerebrospinal Fluid Glucose ……………………………………………..        58


                                                             149
Cerebrospinal Fluid Lactic Acid …………………………………………                        58
Cerebrospinal Fluid LD ………………………………………………….                             58
Cerebrospinal Fluid Protein ………………………………………………                          58
Cerebrospinal Fluid Protein Electrophoresis , oligoclonal banding ………   59
Ceruloplasmin …………………………………………………………….                                  124
Cervical Biopsy …………………………………………………………..                                18
Chemistry of body fluids …………………………………………………                            55
Chemotrypsin …………………………………………………………….                                   38
Chloride …………………………………………………………………..                                    38
Chloride ( Sweat ) ………………………………………………………...                             65
Cholesterol ………………………………………………………………..                                  38
Cilliates …………………………………………………………………...                                  114
Clot Retraction test ………………………………………………………                              90
Coagulability States Tests ………………………………………………..                         88
Coagulation Tests ………………………………………………………...                              85
Complete Blood Count (CBC) - Coulter Profile …………………………                 81
Copper ……………………………………………………………………                                       39
Cord blood ……………………………………………………………….                                    97
Cortisol …………………………………………………………………...                                   71
Creatine Kinase …………………………………………………………...                               39
Creatine Kinase- MB ( mass measurement ) ……………………………..                  40
Creatinine …………………………………………………………………                                    40
Creatinine Clearance ……………………………………………………...                            40
Crossmatching ……………………………………………………………                                   141
Cryo precipitate …………………………………………………………...                              142
Cryoglobulin ( Qualitative ) ………………………………………………                         41
Cyclosporine ……………………………………………………………...                                 71
Cystine (Qualitative) ……………………………………………………...                           41
Cytochemical Tests ……………………………………………………….                               92
Cytomegalovirus ………………………………………………………….                                 125
D-Dimers ………………………………………………………………….                                     89
Dehydroepiandrosterone Sulfate ………………………………………….                        72
Delta Aminolevulinic Acid ……………………………………………….                           41
Digoxin …………………………………………………………………...                                    62
Direct Coombs ……………………………………………………………                                   140
E S R ……………………………………………………………………...                                     85
Ear swab ………………………………………………………………….                                     104
Electron Microscopy ……………………………………………………..                              21
Elisa tests …………………………..Blood Bank………………………...                          141
Endotracheal secretions …………………………………………………..                           107
Enterobius vermicularis …………………………………………………..                           112
Esterase …………………………………………………………………...                                   92


                                                                              150
Estradiol (E2) ……………………………………………………………                             72
Estrogen and Progesterone Study ………………………………………..                  21
Ethanol Gelation Test …………………………………………………....                      89
Euglobulin Lysis time (ELT) …………………………………………….                     88
Extra-intestinal parasites (Tissue parasites) ………………………………         112
Exudates and body fluids …………………………………………………                       105
Eye swab …………………………………………………………………                                 105
Factor II, V, VII and X …………………………………………………...                     86
Factors VIII: C,IX, XI, XII……………………………………………….                     87
Ferritin ……………………………………………………………………                                72
Fetal Fibronectin ………………………………………………………….                          41
Fibrin Degradation Product (FDP) ……………………………………….                  89
Fibrinogen ……………………………………………………………….                               42
Fibroblast (Biopsy) ……………………………………………………….                         97
Filarial parasites (Wuchereria bancrofti) ………………………………...          112
Fine Needle Aspiration (FNA) …………………………………………..                    26
Flagellates ………………………………………………………………...                            114
Fluids from body cavities ……………….Cytopathology………………..             25
Flukes (Trematodes) of blood ……………………………………………                     116
Folate (Red Blood Cells Folate) …………………………………………                   72
Folate (Serum Folic Acid) ………………………………………………..                     73
Follicle Stimulating Hormone (FSH) …………………………………….                 73
Free PSA ………………………………………………………………….                                73
Free T4 ……………………………………………………………………                                 73
Fresh Frozen Plasma Transfusion …………………………………………                   142
Frozen sections ……………………………………………………………                            18
FTA-ABS, Serum …………………………………………………………                              132
Galactose ………………………………………………………………….                               42
Galactose-1- phosphate Uridyltransferase in erythrocytes ……………….   42
Gamma Glutamyl Transferase ……………………………………………                       43
Gastrin …………………………………………………………………….                                73
Gastro-intestinal tract …………………………………………………….                      25
Genital ulcers ……………………………………………………………..                           108
Giardia Lambia …………………………………………………………...                           112
Glucose ( Fasting ) ………………………………………………………..                        43
Glucose (Random ) ……………………………………………………….                           43
Glucose 6-Phosphate Dehydrogenase (Quantitative) …………………….         44
Glucose 6-Phosphate Dehydrogenase (Screen) …………………………..            44
Glucose Tolerance Test …………………………………………………...                      43
Glycosylated Hemoglobin ……………………………………………….                        45
Growth Hormone …………………………………………………………                              74
Ham's Test ………………………………………………………………..                              91


                                                                         151
Haptoglobulin, Serum ……………………………………………………                126
Hb Electrophoresis ……………………………………………………….                84
Heinz Body ……………………………………………………………….                     84
Helminths …………………………………………………………………                      116
Hemoflagellates …………………………………………………………..                 115
Hepaclot ………………………………………………………………….                      88
Heparin Test ……………………………………………………………....                 88
Hepatitis A Antibody, IgM ……………………………………………….            126
Hepatitis B Core Antibody ……………………………………………….            126
Hepatitis B Core Antibody –IgM …………………………………………          127
Hepatitis B Surface Antibody …………………………………………….          128
Hepatitis B Surface Antigen ……………………………………………...         128
Hepatitis Be Antibody ……………………………………………………               127
Hepatitis Be Antigen ……………………………………………………..              127
Hepatitis C Serology ……………………………………………………..              128
Herpes Simplex Antibody ………………………………………………..             128
High Density Lipoprotein Cholesterol …………………………………...    45
HLA-B27 …………………………………………………………………                        128
Homocystine ……………………………………………………………..                    74
Hospital Autopsies ………………………………………………………..               29
Immunoglobulin A ……………………………………………………….                  128
Immunoglobulin G ……………………………………………………….                  129
Immunoglobulin M ………………………………………………………                   129
Immunoglobulin E ……………………………………………………….                  74
Infectious Mononucleosis Screening Test ………………………………..   129
Inhibitor (Anticoagulant ) Screen ………………………………………..      87
Insulin …………………………………………………………………….                      74
Intestinal Nematodes ……………………………………………………..              113
Intestinal Protozoa ………………………………………………………..              113
Iron and Total Iron Binding Capacity …………………………………….     46
Ketone Bodies ( BLOOD ) ……………………………………………….              46
Kidney Biopsy ……………………………………………………………                    20
Kleihauer Test …………………………………………………………….                  84
Lactate Dehydrogenase …………………………………………………..              46
Lactic Acid ……………………………………………………………….                    46
Lead ………………………………………………………………………                         47
Leishmania Donovani …………………………………………………….                113
Leishmania Tropica ………………………………………………………                 113
Lipase …………………………………………………………………….                       47
Lipid Profile ………………………………………………………………                   47
Lithium ……………………………………………………………………                       62
Low Density Lipoprotein Cholesterol ……………………………………       47


                                                               152
Luteinizing Hormone …………………………………………………….                   75
Lymph Node Biopsy ……………………………………………………...                   18
Lymphocyte Subset Enumeration …………………………………………              129
Magnesium ………………………………………………………………..                        48
Malaria - Blood film for Malaria …………………………………………           83
Malarial Parasites (Plasmodium) …………………………………………            113
Mastigophoral Parasites ………………………………………………….                115
Medico-Legal Autopsies …………………………………………………                  29
Metanephrines ( Total ) …………………………………………………..               48
Methemoglobin ………………………………………………………….                       48
Methotrexate II ……………………………………………………………                     75
Microalbuminuria …………………………………………………………                     49
Miscellaneous ……………………Cytology……………………………...                26
Miscellaneous chemistry tests …………….………………………………            65
Mucopolysaccharidoses ………………………………………………….                  49
Muscle Biopsies …………………………………………………………..                    19
Mycoplasma Serology ……………………………………………………                    130
Myeloperoxidase Reaction ……………………………………………….                92
Myoglobin ( Qualitative ) ………………………………………………...             49
Nasal swab ………………………………………………………………..                       106
Nasopharyngeal swab / pernasal swab ……………………………………          106
Nematodes ………………………………………………………………...                       117
Neutrophil Alkaline Phosphatase …………………………………………            93
Nitroblue Tetrazolium (NBT) Test ……………………………………….           93
Non-Specific Esterase …………………………………………………….                 92
Osmolality ………………………………………………………………...                      50
Osmolality ( Calculated ) …………………………………………………               49
Osmotic Fragility …………………………………………………………                    85
Oxalate ……………………………………………………………………                          50
Packed Red Cells Transfusion …………………………………………...            141
Parasite Screen ……………………………………………………………                     130
Parathyroid Hormone (Intact ) …………………………………………..            75
Parietal Cell Antibody ……………………………………………………                 130
Peripheral blood ………………………….Cytogenetics…………………             97
Peripheral Smear ………………………………………………………….                    82
Perl's Test for Iron (Prussian Blue Reaction) ……………………………   91
Phenobarbital ……………………………………………………………..                     63
Phenylalanine Test ………………………………………………………..                  50
Phenytoin …………………………………………………………………                         63
Phosphorus ……………………………………………………………….                        50
Placentas ………………………………………………………………….                        19
Platelet aggregation ………………………………………………………                  90


                                                                  153
Platelet Concentrate ………………………………………………………                 142
Porphobilinogen ( Qualitative ) …………………………………………..         51
Porphobilinogen ( Quantitative ) …………………………………………          51
Potassium …………………………………………………………………                        51
Pregnancy Test ……………………………………………………………                     131
Product of Conception and Fetuses ………………………………………          19
Progesterone ……………………………………………………………...                    75
Prolactin ………………………………………………………………….                       76
Prostate Specific Antigen ….……………………………………………..            76
Prostatitis (prostatic secretion) ……………………………………………        108
Protein ( Total ) …………………………………………………………...                52
Protein (Quantitative ), Urine …………………………………………….          52
Protein C, Protein S and Free Protein S …………………………………..    131
Protein Electrophoresis …………………………………………………...             52
Prothrombin Time (PT) …….…………………………………………….                85
Protozoan Parasites ……………………………………………………….                 114
Pseudocholinesterase ……………………………………………………..                52
Pyruvate …………………………………………………………………..                       53
Pyruvate Kinase …………………………………………………………..                   53
Red Cell Antigen typing …………………………………………………                141
Renin ……………………………………………………………………..                         76
Reptilase Time ……………………………………………………………                     88
Respiratory Syncytial Virus Antigen …………………………………….        131
Respiratory system ……………………………………………………….                  25
Reticulocyte Count ……………………………………………………….                  82
Rheumatoid Factor ……………………………………………………….                   131
RPR ……………………………………………………………………….                           132
Rubella Serology ………………………………………………………….                   132
Salmonella Titer …………………………………………………………..                  133
Scrapings (skin, nail, hair, nasal) …………………………………………       106
Semen Analysis …………………………………………………………...                   26
Seminal fluid ……………………………………………………………...                   108
Seminal vesiculitis & epididymitis ……………………………………….        109
Serum bactericidal activity ……………………………………………….            102
Sickling Test ………………………………………………………………                     83
Skeletal Alkaline Phosphatase (SALP) ……………………………………        77
Smooth Muscle Antibody …………………………………………………                 133
Sodium ……………………………………………………………………                          53
Solubility test for factor XIII activity …………………………………….   87
Somatomedin - C …………………………………………………………                     77
Specific esterase ………………………………………………………….                  92
Sporozoal Parasites ……………………………………………………….                 115


                                                                 154
Sputum ……………………………………………………………………                       107
Stone Analysis ……………………………………………………………                  65
Stool specimen ……………………………………………………………                  111
Sudden Infant Death Syndrome (SIDS) ………………………………….      29
Synovial fluid …………………………………………………………….                 105
Syphilis-IgG ………………………………………………………………                   132
Tacrolimus II (FK506) ……………………………………………………              77
Testosterone ………………………………………………………………                   77
The blood + tissue nematodes of man ……………………………………      118
The intestinal flukes ………………………………………………………             116
The liver flukes ……………………………………………………………                116
The lung flukes ……………………………………………………………                 116
The tapeworm (cestoda) ………………………………………………….             117
Theophylline ……………………………………………………………...                 64
Therapeutic Drug Monitoring & Toxicology …………………………….   59
Throat swab ……………………………………………………………….                   107
Thrombin Time (TT) ……………………………………………………...              86
Thyroid Antimicrosomal antibody ………………………………………..       133
Thyroid Antithyroglobulin Antibody ……………………………………..     134
Thyroid Stimulating Hormone ……………………………………………           77
Tissue and biopsies ……………………. Microbiology…………………..     105
Tissue Typing - Cross Matching ………………………………………….        134
Tissue Typing for HLA Class I & II ……………………………………...    134
Toxoplasmosis Serology ………………………………………………….             135
Tri-Iodothyronine …………………………………………………………                77
Trichomonas Vaginalis ……………………………………………………              113
Triglycerides ……………………………………………………………...                53
Troponin T ………………………………………………………………..                   54
Tuberculous And Fungal Cases …………………………………………..         18
Urea Nitrogen …………………………………………………………….                  54
Urethral swab …………………………………………………………….                  109
Uric Acid …………………………………………………………………                     54
Urinary system ……………………………………………………………                  25
Urine Cortisol …………………………………………………………….                 78
Urone Aldosterone ……………………………………………………….                78
Vaginal and endocervical swabs ………………………………………….        109
Valproic Acid …………………………………………………………….                  64
Vanillylmandelic Acid ……………………………………………………              54
VDRL ……………………………………………………………………..                       135
Vitamin B-12 …………………………………………………………….                   78
Widal test …………………………………………………………………                    133
Wound swab ……………………………………………………………...                   105


                                                              155
Zinc ………………………………………………………………………. 55




                                       156
                     Departmental Telephone Directory

Chairman                                           2463

Secretary                                          2591, 2202, 1289
Conference Room                                    2201

Fax :    392183

GENERAL SERVICES

Supervisor                                         2828

Specimen Collection                                2040
Reports Control                                    2030
Male OPD Lab.                                      2693
Female OPD Lab.                                    2698
Pediatric OPD Lab.                                 1114
OPD Annex Lab.                                     442333 Ext. 229
PEC Lab.                                           2974
Women Hospital OPD Lab.3721
Rumaillah Hospital Lab. (Phlebotomy)               3143, Lab-3664

DIVISION OF CHEMICAL PATHOLOGY

Sections :   Clinical Chemistry, Endocrionology

Head                 2033

Clinical Chemistry          Clerk                  2592
                            Technical Incharge /   2593
                            Supervisor
                            Consultant             2033
                            Stat Lab.              2039, 2282
                            Urine Chemistry        2045
                            Special Chemistry      2350

Endocrinology               Clerk                  3416
                            Supervisor             3070
                            Lab                    3071




                                                                      157
DIVISION OF ANATOMIC PATHOLOGY

Sections :   Histopathology, Cytopathology, Forensic Pathology

Head                 1031
Supervisor           2017

Histopathology              Clerk                      2047, 2046
                            Technical Incharge / Lab   2048
                            Consultant                 2041
                            Consultant                 2044
                            Reporting Room             2061

Cytopathology               Clerk                      3032
                            Technical Incharge / Lab   3061
                            Consultant                 3031
                            Consultant                 2042


Forensic Pathology          Mortuary                   2594
                            PM Room                    2043


DIVISION OF MICROBIOLOGY

Sections :   Immunology, Bacteriology / Parasitology

Head                 2031

Immunology                  Clerk                      2004
                            Supervisor                 1282
                            Technical Incharge / Lab   2283
                            Head of Section            2037

Bacteriology /              Clerk                      2038, 2871
Parasitology                Supervisor                 2796
                            Technical Incharge / Lab   2351
                            TB Lab                     2598




                                                                    158
DIVISION OF HEMATOLOGY & CYTOGENETICS

Sections :   Hematology, Cytogenetics

Head               2035

Hematology                Clerk                      2364
                          Supervisor                 2029
                          Routine Lab.               2365
                          Stat                       2366
                          Coagulation                2363
                          Special Hematology         2362

Cytogenetics              Clerk                      3847
                          Supervisor                 3062
                          Lab                        3030


DIVISION OF TRANSFUSION MEDICINE

Sections :   Blood Bank, Donor Unit

Head               2035

Blood Bank                Clerk                      2032
                          Supervisor                 2034
                          Lab.                       2027

Donor Unit                1081
                          4432129
                          4352713




We welcome your comments, remarks, complaints or suggestions. Please contact
any one of the above numbers related to respective queries.




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