Guidelines
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 Laboratory
Practice
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Laboratory Guidelines 2012 Edition Page 7 Specimen Retention Hematology Chemistry Microbiology Cytopathology Surgical Pathology Peripheral Blood Smear -7days Peripheral Blood Smear re

GENERAL

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2012
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RETENTION GUIDELINE

Laboratories vary in size, facility and extent of services provided Clinical laboratories must maintain thorough, accessible records that can demonstrate an acceptable standard of care and compliance with the accreditation requirements

The Laboratory Quality Assurance Program of the College of Physicians and Surgeons urges laboratories to retain records, materials, or both for a longer period of time than specified for educational and quality improvement needs

Laboratories must establish policies that meet or exceed the following minimum requirements for retention of documents and specimens as established by professional and/or regulatory organizations

References include: CSTM, CSCC, CAP, CSA, ISO, CPSS

Record Retention Storage Time

Hematology Biochemistry Microbiology Cyto-

pathology

Surgical Pathology

Paper copy of patient reports 3 months 3 months 3 months indefinite indefinite Quality control/PT documents 2 years 2 years 2 years 2 years 2 years

plus 2 years

Method /instrument evaluation 2 years after the method has been discontinued

Technologist ID & initials

log/computer

Laboratory Information Systems

Records

- Validation records, including

transmission of results and

Biomedical Waste Manifests must be retained for a minimum of 1 year

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Specimen Retention Hematology Chemistry Microbiology Cytopathology Surgical

Pathology

Peripheral Blood Smear

-7days Peripheral Blood Smear reviewed by a pathologist -1 yr Semen smears

- 3 months Bone Marrow Slides/Reports

- 20 yrs (adults)

- 50 yrs (children) Whole blood/Plasma

- 24 hrs after report has been finalized Body fluids

- 48 hrs after report has been finalized Urine

- 24 hrs after report has been finalized

Whole blood, serum &

plasma

- 48 hrs after report has been finalized Body fluids

- 48 hrs after report has been finalized Urine - routine

- 24 hrs after report has been finalized 24hr Urines

- samples discarded 48 hrs after report has been finalized

Swabs or specimens

- 24 hrs after report has been finalized Positive Blood Culture

- 5 days after reporting Gram Stain

- one week or until final report

is sent Ova & Parasite slides

- one month

Slides neg/unsatisfactory

- 5 years Slides suspicious/pos

- 20 years Fine-needle aspiration slides

- 20 years Cytology Consultation/

Requisition

- Indefinitely Male fertility slides

- 1 year Cytology paraffin blocks

- 20 years

Blocks & slides

- 20 yrs (adults)

- 50 yrs (children) Autopsy

- 20 yrs Gross specimen

- min 8 weeks after issue of report Wet Autopsy Tissue

- 8 weeks after issue of report Bone Marrow Slides/ Reports

- 20 yrs (adults)

- 50 yrs (children) Photographic Transparencies – indexed and kept indefinitely

REFERENCE TEXTBOOK LIST

1) Circular of Information, Canadian Blood Services (most recent version)

2) Canadian Standards Association Blood and Blood Component Z902 (most recent version) 3) Canadian Society for Transfusion Medicine (most recent version)

4) Modern Blood Banking and Transfusion Practices 5th Edition; Harmening, Denise M

5) Canadian Medical Association Journal Guidelines for Red Blood Cell and Plasma

Transfusion for Adults and Children; supplement to CAN MED ASSOC J 1997;

156 (11)

6) American Association of Blood Banks Technical Manual - most recent edition

7) Bloody Easy 3: Blood Transfusions, Blood Alternatives and Transfusion Reactions 3rd

Edition; Ontario Regional Blood Coordinating Network

3) Hematology: Clinical Principles and Applications 3rd Edition; Rodak, Fritsma, Doig

4) Clinical Hematology Atlas 3rd Edition; Carr/Rodak

Chemistry

1) Tietz Fundamentals of Clinical Chemistry 6th Edition, W B Saunders Company; Burtis, Ashwood, Bruns

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2) Clinical Chemistry – Principles, Procedures, Correlations 6th Edition; Bishop

Urinalysis

1) Graff’s Textbook of Urinalysis and Body Fluids 2nd Edition; Mundt, Shanahan

Anatomic Pathology

1) Histotechnology: A Self Instructional Text 3rd Edition; Carson & Hladik

2) Principles of Anatomy & Physiology 13th Edition; Tortora & Grabowski

Safety

1) Transportation of Dangerous Goods Act and Regulations

Supplement Canada Gazette, Part II [www.tc.gc.ca/eng/tdg/clear-tofc-211.htm]

2) CSMLS Guidelines – Laboratory Safety, 6th Edition

A NATOMIC

PATHOLOGY

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SPECIMENS EXEMPT FROM ALL GROSS &/OR MICROSCOPIC

PATHOLOGY LABORATORIES

Irrespective of the exemptions listed below, gross &/or microscopic examinations will be performed whenever the attending physician requests it, or at the discretion of the pathologist when indicated by gross findings

MICROSCOPIC

Bone or cartilage removed from the arthritic

joints during joint replacement surgery



Bone segments removed as part of corrective

orthopedic procedures (for example: rotator

cuff, synostosis repair, spinal fusion)



Calculi (renal bladder etc.), are sent for

chemical analysis and description

(By Chemistry Dept.)

Extraocular muscle from corrective surgical

procedures (strabismus repair)



Femoral head removed for prosthesis (if

straight forward)



Foreign bodies, such as bullets or

medicoloegal evidence that is given directly

to law enforcement personnel



Intrauterine contraceptive devices without

attached soft tissue



Medical devices such as catheters,

gastrostomy tubes, myringotomy tubes,

stents and sutures that have not contributed

to patient illness, injury or death



Nasal bone and cartilage from rhinoplasty or

septoplasty



Orthopedic hardware and other radioopaque

mechanical devices provided there is an

alternative policy for documentation



SPECIMEN TYPE DISCRETIONARY GROSS &/OR

MICROSCOPIC Placentas which do not meet the criteria for

examination



Prosthetic cardiac without attached tissue 

Rib segments or other tissue removed only

for the purpose of gaining surgical access

from patients who do no have a history of

malignancy



Saphenous vein segments harvested for

coronary artery bypass



Skin or other normal tissue removed during

cosmetic or reconstructive procedures

(blepharoplasty, cleft palate repair,

abdominoplasty, rhinectomy or syndactyly

repair) that is not contiguous with a lesion

and that is taken from a patient who does not

have a history of malignancy



Tonsils and adenoids if clinically not

suspicious

(under 10 yrs old)

(over 10 yrs)

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SURGICAL PATHOLOGY REPORTS

Timeliness of reports is critical to providing quality of care Guidelines for surgical pathology reporting include:

(i) Routine Surgical Pathology reports

 Complete within 2 working days

 Where additional procedures are being performed, an extension of 24 hours is appropriate

(ii) Autopsy Reports

 Written initial reports of gross pathological findings within 72 hours

 Final Report – 30 days for routine cases, 90 days for complicated cases

REMOVAL OF TISSUE, BLOCKS OR SLIDES FROM THE ORIGINAL HOSPITAL SITE

Anatomic Pathologists are charged with the responsibility of keeping and guarding the integrity

of the ever-growing number of tissue containing paraffin blocks and slides derived from surgical, cytological and autopsy diagnostic services Documentation and maintenance (tracking) of the continuous care shall ensure quality practice These specimens must be maintained in orderly files to ensure ready access There are inevitably increasing demands for slides, blocks or tissues

to be retrieved from the original site

*A release form must be provided and retained on file at the original institution for permanent release

Summary

 Follow HIPA guidelines

 Ensure there is sufficient material for further work-up

 Indicate reason for request

 Return all material as soon as possible

 The lab is the custodian of tissue, blocks or slides collected

 The source of material remains the property of the patient

These are the various suggested categories to be considered:

In-Province Consultation

• Request may be initiated by the primary physician, surgeon or oncologist for review by local

or out-of-district pathologist

• Request may be initiated by the original signing out pathologist who is responsible for

maintaining records and assuring return of the material

Note: The return of materials to the original site must be documented and a consult report sent

to the original pathologist as well as the requesting pathologist

Out-of-Province (recommended slides only)

• Request from an originating pathologist to seek out-of-province consultation for diagnostic

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Research

• Regulations require pathologists to obtain patient authorization and/or an Institutional Review Board (Ethics Committee) waiver of informed consent when using any identifiable patient health information for research purposes

• Requests must ensure the integrity of the patient material

• All materials that have critical diagnostic, prognostic or medical-legal implication may be retained at the discretion of the releasing institution

• Return all materials as soon as possible

References:

Guardians of the Wax…and the Patient Editorial.; American Journal of Clinical Pathology 1995 104 p 356-7

Use of Human Tissue Blocks for research Association of Directors of Anatomic and Surgical Pathology Human Pathology 1996.27 p 519-520

PERFORMANCE OF NON-GYNECOLOGICAL CYTOLOGY

Non-gynecological cytology comprises of fine needle aspiration biopsies (FNAB) of organs/tissues such as lungs and other visceral lesions, effusion cytology of pleural, peritoneal, pericardial fluids, cytology of urine, CSF, sputum, broncho-alveolar lavage (BAL) and brush biopsies of endoscopic procedures, (gastrointestinal tract, etc) Scrapings of open lesions and nipple discharges may also be included along with cytology of transplant organs to test for rejection (kidneys), or for cyclosporin toxicity BAL and transplant cytology is usually done in specialized centers as it requires specific interpretation and often special tests Most of the other samples can be handled and processed in a routine surgical pathology/cytology lab equipped with basic facilities including a biological safety cabinet (fume hood), cyto-centrifuge and staining capability for H & E and PAP stains

In contrast to gynecological cytology, non-gynecological cytology (NGC) does not necessarily require a screening step If adequate diagnostic material is present the focus is on diagnosis of and interpretive correlation with the clinical setting If cell block or cytospin samples are available, further testing with special procedures could be performed

Some aspects of NGC require a rapid turnaround time such as FNAB performed under CT-scan

or ultrasound guidance and intra-operative cytology requests

It is important for institutions with CT scanner facilities to be able to provide cytology service in house However, it is acceptable, if the lab does not have a cytology department, the technologists in the histology lab are trained in processing the specimens Such training is easily obtained and can be provided by short courses provided on site and documented

Most NGC procedures are performed on patients who are in-patient residents in a hospital/health care institution or are required to come in for a day procedure/ambulatory care Due to the time factor involved in patients’ institution stay; a rapid turnaround time becomes a key factor in availability of the service On the other hand, the patient in an acute care setting may have an infectious process or malignancy requiring rapid diagnosis and treatment

The final interpretation and reporting of non-gynecological cytology shall be made by a pathologist

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FOLLOW-UP REPORTS FOR GYNECOLOGICAL CYTOLOGY

To ensure a quality cytology service, a follow-up mechanism must be in place to provide reports

to the primary and/or consulting physician

In an attempt to eliminate the potential for “LOST – TO FOLLOW” reporting situations, the following require follow-up letters to the primary and/or consulting physician:

1 A repeat smear was requested at the time of reporting and 3 months have lapsed since the

date of request

2 A diagnosis is rendered requiring follow-up and none has occurred For example:

 HSIL required follow-up a.s.a.p and if this has not occurred within 3 months, a letter

is required

 LSIL (ASCUS, AGUS) within 6 months requires a letter in 9 months

 A malignant diagnosis with no apparent followup

3 A follow-up letter has been previously issued with no reply These letters should be

automatically generated by the computer system and then replies must be recorded and reviewed quarterly

4 A minimum laboratory requirement of a computer system used to report gynecological

cytology shall have the ability to generate automatic follow-up letters that are linked to diagnostic codes

FOLLOW-UP PROGRAM FOR CYTOLOGY

A follow-up mechanism shall be in place to ensure that actions appropriate for abnormal findings are implemented

a) All patients who are reported to have a significant abnormality should be followed up by

the laboratory or other agency to which this task may be delegated, to obtain final clinical

or preferably tissue confirmation of the diagnosis

b) Statistical data should be maintained which would include the number of cases screened

annually in each category, and all correlative follow-up data available Discrepancies, if any, should be included with this information

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CHEMISTRY

ESTIMATED GLOMERULAR FILTRATION RATE - eGFR

Evidence-based clinical practice guidelines suggest that an estimate of GFR (eGFR) provides the best clinical tool to gauge kidney function The Canadian Society of Nephrology has recommended that laboratories report eGFR routinely for adult patients, in order to detect chronic kidney disease

Serum creatinine results can vary significantly and tend to be ineffective in general practice as an early marker 24 hr collection for creatinine clearance is impractical and prone to error eGFR should be reported on outpatients over the age of 18 years eGFR has not been validated for use

in hospitalized patients and therefore, is not recommended for reporting on inpatients

eGFR is less reliable in,

• patients with near normal eGFR

• unstable serum creantinine

• acute illness

• extremes of body composition (eg obesity, cachexia)

• unusual muscle mass (eg marked muscularity, muscle disease, amputation)

• pregnancy

• age under 18 years or over 70 years

• drugs with significant renal toxicity or clearance

• drugs affecting creatinine metabolism or clearance

• unusual dietary intake (eg vegetarians)

• other serious comorbid conditions

• eGFR is frequently used for DRUG DOSING using the Cockroft-Gault equation eGFR-MDRD has not been validated for this purpose

• eGFR-MDRD assumes “steady state” For rapidly changing kidney function, monitor serum creatinine (MDRD: Modification of Diet in Renal Disease)

• The reported eGFR shall be multiplied by 1.21 for patients of African descent

NOTE: This information is intended for clinicians, patients and allied health professionals

References: www.jasn.org, www.csnscn.ca, www.kidney.org, www.renal.org

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CHOLESTEROL / TRIGLYCERIDE / LIPID TESTING

Cholesterol results are based on optimal performance of testing Considerations to be included: a) treatment/preparation of the patient

b) the emergent or non-emergent nature of the test

c) appropriate technical equipment

d) adequate quality control

The accomplishment of treatment goals also demands accurate cholesterol measurements This requires standardization of all cholesterol measurement for accuracy to minimize the method-specific biases This can be achieved ONLY by standardizing the cholesterol measurements and ensuring accuracy that is traceable to the National Reference System for Cholesterol (NRS/CHOL), National Cholesterol Education Program

Clinical protocols are well established and should be followed by all testing sites

Laboratories testing for lipids shall be capable of performing the entire profile, to include: Cholesterol, Triglycerides, HDL and LDL, for diagnosis and assessment All lipid measurements should be performed by the same methodology

Only instrumentation capable of maintaining intralaboratory precision that is less than or equal to

3 % (C.V.); and can demonstrate an accuracy bias of less than 3 % from the true value may be used for cholesterol analysis

Report quantitative results in SI units

REPORTING SPERM IN URINE

Sperm are not normally present in urine and if presence is detected, it is usually considered a contaminant

When sperm appear in a microscopic exam, they shall be reported as present However, prior to reporting, results should be discussed with the attending physician, in order to avoid errors (ie mislabelling, etc.)

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QUALITY CONTROL (QC)

The purpose of QC is to detect the problems early enough to prevent their consequences

QC emphasizes statistical control procedures, but may also include non-statistical check procedures, such as linearity checks, reagent and calibration checks, etc

Two or three different materials should be selected to provide concentrations that monitor performance at different levels of medical decision-making

For quantitative tests, the use of two levels of control material shall be run each day of use, as a minimum

For qualitative tests that include built-in controls, a positive and negative control shall be performed a minimum of once per month and upon initiation of a new lot number and shipment For those that do not include a built-in control, known positive and negative external controls shall be tested each day of use

PERFORMANCE OF WHOLE BLOOD GLUCOSE TESTING

Glucose meters are a convenient, quick and simple means for clinicians and their patients to obtain a blood glucose estimation Glucose meters are not designed to diagnose diabetes and should not be used to monitor seriously ill patients The results from a properly used glucose meter are accurate enough to determine insulin dosage and dietary compliance Glucose meters allow for frequent and rapid blood glucose estimations thereby improving the overall control of the diabetic state Glucose meter testing is intended to supplement rather than substitute for clinical laboratory testing

The basic requirements for whole blood glucose testing shall include proper training to ensure consistent operating techniques and a quality control surveillance program to ensure proficiency The Clinical and Laboratory Standards Institute (CLSI) serves as the reference for this document All glucose meter testing, performed outside the traditional laboratory, excluding patients performing glucose in his place of residence is required to meet the criteria of quality assurance

to ensure acceptable performance The glucose meter is appropriate for monitoring treatment, but not suitable for diagnostic testing (i.e GTT) The components of glucose monitoring by glucose meters will include, but not restricted to the following:

1 Choosing the meter

Personnel at sites where glucose testing is performed by glucose meter will consider the following components when determining which meter to use:

 evaluations by pathologist-supervised laboratories to include:

analytical proficiency, user satisfaction, cost,

ease of use

 review proficiency testing results to assess performance on that meter

 review the number of users for that instrument

 technical limitations of the meter to include:

hi/lo range, technical service support

It is recommended that only one type of testing meter be used in a program This is because of potentially confusing differences among the various systems for testing and quality control procedures

CAUTION: very high hematocrits in newborns interfere with results, so specific instruments shall be recommended for glucose estimations in newborns

2 Internal QC

Daily controls ensure accurate performance of the meter This may include:

- running controls once per day of use for each machine; alternating high and low levels

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- meter-laboratory comparison of that meter

- performing visual inspection

- comparison to package insert chart

- daily maintenance

3 Proficiency testing

Proficiency testing is an important aspect of quality assurance and requires participation in the recognized proficiency testing program designated/approved by the Accreditation Program

4 Training/Certification of Users

Training of personnel to perform glucose meter testing is critical to a successful program and the following components are required:

 establishment of a training/inservice program

 initial certification on all meters in use (standardization of meters is highly recommended)

 training program of users with on-going evaluation as established by an inservice program

5 Responsibility for Internal/External QC and certification/supervision of users

It is the responsibility of the applicant to designate an affiliation with a reference laboratory for training, certification, supervision and overseeing the internal and external QC program

of whole blood glucose testing

A qualified professional shall supervise training

6 Glucose Tolerance Testing

 Glucose tolerance tests, including the gestational diabetic screen, shall not be performed using a glucose meter

DIAGNOSIS AND MONITORING OF THYROID DISEASE

Thyroid function tests are among the most commonly ordered laboratory tests in the province In the past, investigations of thyroid disease required more than one test Sensitive thyroid stimulating hormone (TSH) is the initial test in the diagnosis of hypothyroidism (TSH elevated

or above normal) and hyperthyroidism (TSH is suppressed or below normal) Free T4 (FT4) is preferred over total T4 (TT4) measurement to confirm the diagnosis of hypothyroidism or hyperthyroidism FT4 is 0.02 – 0.04% of total T4 FT4 is the metabolically active form of TT4and is a better indicator of thyroid status than TT4 because it is unaffected by protein binding

abnormalities such as pregnancy and oral contraceptives Free T3 (FT3) is mainly of value in diagnosing T3 toxicosis, in determining the T3 response to therapy, and clarifying protein binding abnormalities It can also be of use in the early progression of subclinical hyperthyroidism to overt thyrotoxicosis when FT4 is normal and TSH is suppressed FT3 is often the first to be increased FT3 is approximately 0.2 – 0.5% of total T3

American Association of Clinical Endocrinologists (AACE) recommends that the TSH reference range run from 0.3 - 3.0, versus the old range of 0.5 - 5.5 Keep in mind that there is disagreement among practitioners

Limitations:

1 These guidelines do not apply to neonates

2 TSH is not reliable in the investigation of hypothalamic or pituitary disease

3 TSH may be an unreliable indicator of thyroid status in patients with acute severe thyroidal illness (e.g CCU and ICU patients) and the test is only recommended when there are clinical indicators of possible pre-existing thyroid disease

non-4 Medications such as lithium, amiodarone, glucocorticoids, and dopamine affect TSH and may also affect the individual’s thyroid status

Clinical Aspects of Testing:

1 Screening asymptomatic, apparently healthy patients for thyroid disease is not considered indicated at this time

2 Testing is indicated in the presence of symptoms or signs that are suggestive of thyroid disease especially in high risk populations

3 High-risk groups include women over 50, the ambulatory elderly, postpartum, individuals with a strong family history of thyroid disease and other autoimmune diseases such as Type I diabetes

Symptoms and Signs of Hypothyroidism: Cold intolerance, lethargy, depression, constipation, menstrual disorders, dry skin, weight gain There will be slow growth in children

Symptoms and Signs of Hyperthyroidism: Palpitations, fatigue, weakness, increased appetite, heat intolerance, usually enlarged thyroid, weight loss, warm moist skin, tremor and tachycardia Restlessness, sleep disturbances, difficulty maintaining attention and concentration occur in children

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Recommended Testing Algorithm

If TSH screen is abnormal, a FT4 will be done on the same sample reducing the need to call back the patient for subsequent testing If the TSH is less than 0.3mU/L a FT4 and FT3 will be done

on the same sample Free T3 is a better indicator of the degree of thyrotoxicosis in most patients

Further Testing Recommendations:

1 Follow-up for Primary hypothyroidism or replacement therapy: TSH should be performed 6 – 8 weeks after start of therapy or dosage adjustment After normal results have been achieved, TSH should be done annually, unless the clinical condition changes or unless the clinical condition warrants re-testing In children under one year of age the TSH and FT4should be measured every 3 months and every 6 months for children under six years of age Also rapidly growing adolescents should have a TSH checked once every 6 months

2 After Radioactive iodine treatment: A FT4 should be done at 4-6 weeks interval for the first 6 months or until normal At 6 months and then annually a TSH should be done to detect hypothyroidism In most children and young people following thyroid ablation the FT3 is a better indicator of control

3 Antithyroid drugs for Hyperthyroidism: Patients should be monitored by means of FT4monthly until controlled and then at least every 3 months while on medication If clinical signs and symptoms are present a FT3 may be indicated In cases of T3 toxicosis a FT3should be ordered In patients with thyrotoxicosis the TSH may not recover for quite some time after euthyroidism has been achieved and sometimes requires a period of hypothyroidism before recovery

4 Suppressive doses of thyroxine: Designed to support a neoplasm or goiter TSH and FT4every 2 months until TSH has reached a level of suppression acceptable to the clinician

5 Subclinical hypothyroidism: Borderline results are fairly common in elderly patients and individuals with an autoimmune mechanism are more likely to progress to a hypothyroid state Observation and monitoring by TSH at 6-12 month intervals is recommended

TSH

is high for secondary hypothyroidsm order FT4 as initial test

Primary

hypothyroidism hyperthyroidism FTsuspicion is high 3 if clinical

6 Subclinical hyperthyroidism: Patients with low or suppressed TSH but thyroid hormones in the normal levels with minimal or no symptoms are followed by FT4 and/or FT3 at 6 –12 months to gauge the progression of their condition

References:

1 HSURC guidelines Nov 1992

2 Ontario Association of Medical Laboratories Guidelines for the use of serum tests to detect thyroid dysfunction May 1987

3 Ontario Association of Medical Laboratories Guidelines for the use of serum testing in the management of primary hypothyroidism June 1998

4 Alberta Medical Association Laboratory Testing Guidelines for Investigation of Thyroid Dysfunction May 1999

5 Protocol Steering Committee B.C for the use of Thyroid function tests in the diagnosis and monitoring of patients with thyroid disease Aug 1997

6 The College of Physicians and Surgeons of Manitoba Investigation of Thyroid Disease February 1995

7 National Academy of Clinical Biochemistry Laboratory Support for the Diagnosis and Monitoring of Thyroid Disease November 2000

8 Vanderpump MPJ, Ahlquist JAO, Franklyn JA et al 1996 Consensus statement of good practice and audit measures in the management of hypothyroidism and hyperthyroidism BMJ 313: 539-44

9 Singer PA, Cooper DS, Lewy EG et al 1995 Treatment guidelines for patients with hyperthyroidism and hypothyroidism JAMA 273: 808-12

10 Ladenson PW, Singer PA, Ain KB et al 2000 American Thyroid Association Guidelines for detection of thyroid dysfunction Arch Intern Med 160: 1573-5

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PRESENCE OF SMALL AMOUNTS OF ALBUMBIN

Presence of small amounts of albumin in urine is considered an early predictor of the development of glomerular damage in the absence of overt nephropathy Patients with diabetes and hypertension are the primary risk groups

The Canadian Diabetes Association recommends testing for small amounts of albumin once/year after the onset of diabetes

The presence of small amounts of albumin in urine is detectable by dipstick methodologies, and

is approved as a screen for renal damage in the known diabetes patient

All positive results must be confirmed by quantitative analysis

PERFORMING THE SAME TEST PROCEDURE

 Proficiency testing registration is mandatory for each analytical ‘test’

 Rotating proficiency testing result submission between analyzers is not a requirement, but is suggested where appropriate (e.g Blood Gases)

 Where there are multiple analyzers performing the same test procedure in larger facilities, it may be more appropriate for proficiency testing submission to be consistently submitted from the same analyzer for tracking purposes

 An internal cross-check/validation protocol is required to ensure that there is correlation between all analyzers providing the same test result

in the same facility

 If this protocol is not followed, then each analyzer must be registered in the external proficiency testing program as mandated by LQAP

 This procedure is recommended every six months

Chemistry/Hematology High Volume Analyzers (e.g Electrolytes/CBC) Validation/Crosscheck

Frequency/Data Points:

Patient correlation  Regularly scheduled intervals

 Whenever criteria for recalibration/validation is met:

- change of manufacturer for reagents or equivalent

- after maintenance or service as per manufacturers recommendations

- as required for purposes of troubleshooting /validation of reagent lot # changes or as indicated

by quality control data

 Minimum of 20 patient specimens/2 times per year or equivalent

(i.e 10 patient specimens/4 times per year or on-going data collection as appropriate)

 As necessary per recalibration/validation event

Chemistry/Hematology Low Volume Analyzers (e.g Fibrinogen) Validation/Crosscheck

Patient correlation  Regularly scheduled intervals

 Whenever criteria for recalibration/validation is met:

- change of manufacturer for reagents or equivalent

- after maintenance or service as per manufacturers recommendations

- as required for purposes of troubleshooting /validation of reagent lot # changes or as indicated

by quality control data

 Minimum of 5-10 patient specimens/2 times per year or equivalent

 As necessary per recalibration/validation event

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Work-up guidelines and definitions (change in method/instrument):

Between run – 20 results from 20 separate runs on 2 levels over a 10-day minimum time period using appropriate QC material

40 data points are recommended with a minimum of 20 having 50% of the data points outside the reference intervals, if possible Correlations should involve comparison with an acceptable reference method or laboratory

n=20

√

n=40

√

3 Linearity (IFCC) The range of concentration or other quantity in the specimen

over which the method is applicable without modification (CLIS) when analytical results are plotted against expected concentrations;

the degree to which the plot curve conforms to a straight line is a measure of the system linearity

4 data points each in duplicate as a minimum requirement, but 5 data points are preferred (over reportable range) Linearity studies are expected on an initial method work-up and further studies as defined by the College guidelines (i.e

The minimum requirement is 20 data points for confirmation of an established reference range and 120 for the establishment of a new reference range

√

5 Accuracy Closeness of the agreement between the result of a measurement and

the accepted reference value (true value of the analyte)

3 data points using acceptable reference material (i.e CEQAL or CAP) 1 data point may be acceptable for haematology accuracy studies if related to sample stability

√

6 Sensitivity Measure of the ability of an analytical method to detect small

quantities of the measured component When concern is performance

at a very low concentration it is useful to determine the detection limit as influenced by imprecision

Sensitive studies are only required for those methods which have clinical relevance at values close to “0” (i.e TSH)

√ When clinically relevant

√ When clinically relevant

√ Storage and transportation

√ Storage and transportation

8 Interference The effect of any component of the sample on the accuracy of the

measurement of the desired analyte

Document the manufacturer’s interference information The method should include a disclaimer or a process for dealing with a lipemic, icteric or hemolyzed sample

√ Methods with known interferences

√ Methods with known interferences

9 Recovery A recovery procedure involves the addition of a known amount of

analyte to an aliquot of sample Recovery is defined as the ratio of the amount of the analyte recovered to amount added and is given as percentage

Recovery studies should only be necessary for those methods or analytes where organic extractions or equivalent are required as part of the methodology (i.e

Toxicology)

√ Method specific/organic extraction

Work-up requirements when an instrument is moved from site “A” to site “B”: (It is assumed that the instrument has been in recent use with acceptable performance)

1 Imprecision studies, QC only As above

2 Patient correlation 10 data points, where feasible

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HEMATOLOGY

PRINCIPLES FOR HEMATOLOGY PRACTICE

Hematology incorporates leading edge technology to help decipher and treat troubling diseases

As hematology has evolved, there are some generic principles that must be simply stated for quality patient care

Quality management practices are essential to ensuring quality care Some of the core principles include:

1) Hemoglobin, the single most common complex organic molecule (Hb) shall be determined

by spectrophotometric methodology

2) WBC and platelet counts shall be tested by automated methodology as part of a CBC on whole blood specimens If necessary, WBC and platelet counts may be estimated on the peripheral smear

3) Manual PT (INR)/APTT testing shall be discontinued Please refer to CLSI H21-A4 for reference on collection and storage

4) Reticulocyte Count shall be performed by automated methodology Manual counts may used

as a QC method for automated analyzers

5) All differential leukocyte counts shall be reported in absolute values Reporting percentages

is optional, and would be in addition to absolute values

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HEMATOLOGY FILMS/LABELLING OF SLIDES

Unequivocal patient identification is the first step to ensuring a quality hematology slide

With no formal standards in place for labelling slides, the basic principles require:

 Unique identification of the patient (at least two identifiers)

 Written instructions for labelling

 Labels shall be clear and legible

MORPHOLOGY OF LYMPHOCYTES

Benign versus Malignant

A variety of diseases and disorders may produce changes from the normal in numbers and/or morphology and functions of one or more of the leukocytes The most important feature of variant lymphocyte morphology is the recognition of its benign nature The pertinent fact is that these lymphocytes are normal cells that have been altered as the result of a normal response to stimulus When changes in WBC’s are produced by non-malignant disorders (e.g infections), the cells formerly called atypical, are now referred to as reactive lymphocytes When changes are suspicious of being produced by malignant disorders (leukemias, lymphomas, gammopathies) and additional investigations may be required, the cells are often referred to as atypical and/or abnormal

In non-malignant disorders, the variant lymphocytes, reactive lymphocytes, atypical lymphocytes, virocytes, stress lymphocytes, Downey cells, transformed lymphocytes, transitional lymphocytes, and glandular fever cells, among others, are normal cells reacting to a stimulus, whether it be viral or other The designation of reactive lymphocytes is preferred

In Chronic Lymphocytic Leukemia, the lymphocytes are somewhat larger than normal, have nuclei with clumped or condensed chromatin, and may have prominent nucleoli The cytoplasm may be abundant, nongranular and moderately basophilic, or it may be relatively scant

In Prolymphocytic Leukemia, the prolymphocyte is a relatively large mononuclear lymphoid cell with an oval to round nucleus, coarse-appearing chromatin strands and one or two large vesicular nucleoli with perinuclear condensations of chromatin The cytoplasm is abundant and usually granular and is basophilic with Romanowsky stains

In Waldenström’s Macroglobulinemia, the abnormal B-lymphocytes involved are transitional cells They have the ability to differentiate into large plasmacytoid lymphocytes and plasma cells These malignant cells circulate in the peripheral blood only in the terminal stages

In Lymphomas, peripheral blood involvement (i.e., abnormal circulating cells) is seen late in the disease Lymphoma cells can exhibit a variety of appearances and the cellular morphology is variable and depends on the underlying type of lymphoma These cells can exhibit variable size, shape, nuclear, and cytoplasmic characteristics Lymphoma cells are usually round to oval, and

can be irregular Cell size ranges from 8 to 30 µm and the N-C ratio varies from 7:1 to 3:1 In

diffuse small lymphocytic lymphoma (the tissue equivalent of chronic lymphocytic leukemia), the cells are generally small with round to oval nuclei, compact and coarse chromatin, and have a scant amount of basophilic cytoplasm They may be the same size as normal lymphocytes or may be slightly larger Occasionally, the nuclei exhibit an angulated appearance with slightly more open chromatin A small nuclear indentation may be present Nucleoli are not seen Scattered prolymphocytes, which are larger cells with a centrally placed nucleus, a prominent single nucleolus, and moderate basophilic cytoplasm, often are seen In the small-cleaved cell lymphomas, the cells are slightly larger than normal lymphocytes and have an angulated

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appearance The majority of nuclei have clefts, indentations, folds, convolutions, and may even

be lobulated The chromatin is moderately coarse and one or more nucleoli may be prominent Their cytoplasm is scant to moderate and basophilic The cells in small noncleaved lymphomas (Burkitt’s lymphoma) appear similar to L3 lymphoblasts These cells are generally moderate in size (10 to 25 µm) and have a round to oval nucleus with moderately coarse chromatin, and one

or more prominent nucleoli The cytoplasm is moderate, stains dark blue, and may contain numerous small vacuoles Large cell lymphomas and immunoblastic lymphomas may exhibit some of the most blast-like and abnormal morphology These cells are large (20 to 30 µm) and have scant to moderate amounts of deeply basophilic cytoplasm The nuclei are generally round

to oval, but may be angulated, folded, indented, or convoluted Nucleoli are prominent and may

be single or multiple Vacuoles can occasionally be seen in the cytoplasm These cells can be easily confused with blasts T cell lymphomas can exhibit similar morphology to any of the above types of lymphomas The typical appearance is a moderate-size cell with a markedly convoluted nucleus giving a cerebriform or grooved pattern Their chromatin is moderately coarse and nucleoli are not apparent The cytoplasm is generally scant and blue

In Hairy Cell Leukemia, the abnormal lymphocytes (Hairy Cells) have scant to abundant, agranular, light grayish-blue cytoplasm The plasma membrane appears irregular with hair-like

or ruffled projections, which are seen more easily with phase microscopy These cells often have

a round or oval nucleus; sometimes, the nucleus appears folded or bilobed The chromatin is loose and lacy, and one or two nucleoli are commonly seen

In Sézary Syndrome, the abnormal lymphocyte is larger than normal with scanty cytoplasm, and the nucleus is large with clefting Nuclear folding can be so extensive as to suggest an image of the brain, and these nuclei are thus described as cerebriform The nuclear chromatin is fine with little condensation There may or may not be visible nucleoli

Note: Performance of manual differentials is required when abnormalities/unexpected results are found in the WBC

References:

McTaggart Bill, SAIT Hematology Updating Correspondence Course, 5th Edition, 1993 pp 10

Stiene-Martin, 1998, pp 355-356, 484-485, 490, 507-508 College of American Pathologists, Surveys, Hematology Glossary,

2001

DIFFERENTIAL PERFORMANCE AND REFERRAL PRACTICE GUIDELINE

Blood Film Reference Range Perform a Differential or Scan

on First Occurrence or Significant Change

Referral Unexpected or Unexplained WBC Count – adults 4.0 - 11.0 x 10 9 /L

Lower referral range <1.5 x 10 9 /L (all age groups) <1.0 x 10 9 /L (all age groups)

children (2-14 years) 5.0 – 15.0 x 10 9 /L

children (90 days – 2

yrs)

5.0 – 20.0 x 10 9 /L newborn (0 – 90 days) 7.0 – 20.0 x 10 9 /L

Absolute Neutrophils 1.5 – 7.5 x 109 /L <1.5 x 10 9 /L (all age groups) <1.0 x 10 9 /L (all age groups)

Absolute

Granulocytes

1.5 – 7.5 x 10 9 /L <1.5 x 10 9 /L (all age groups) <1.0 x 10 9 /L (all age groups)

Absolute Eosinophils 0.0 – 0.6 x 109 /L >1.0 x 10 9 /L (all age groups) >2.0 x 10 9 /L (all age groups)

Absolute Basophils 0.0 – 0.2 x 10 9 /L >0.3 x 10 9 /L (all age groups) >0.5 x 10 9 /L (all age groups)

(Combined with MCV <70 fL)

<100 g/L (Combined with MCV <70 fL) Upper referral range

0 – 3 months 98 – 114 fL <97 fL

(Combined with HGB <135 g/L)

<90 fL (Combined with HGB <135 g/L)

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Blood Film Reference Range Perform a Differential or Scan

on First Occurrence or Significant Change

Referral Unexpected or Unexplained

Platelet Count 150 – 400 x 109/L

WBC Morphology > 10% Reactive Lymphs

Pelger-Huet anomaly Hypogranulated neutrophils Hairy Cells

Blasts/Immature Cells

RBC Morphology RBC inclusions: Pappenheimer,

Howell-Jolly or Heinz Body, basophilic stippling

Presence of schistocytes, echinocytes, bite cells, sickle cells, rouleaux,

autoagglutination, significant polychromasia, oval or round macrocytes, target cells, tear drops, spherocytes, elliptocytes, acanthocytes, stomatocytes Dimorphic picture

Technologist initiated Technologist initiated – if

suspicious cells are present, refer

to a pathologist