ASCP Recalls as of August 2013

1.How is Calcium measured in ISE?

Ionized Calcium
2.Know the picture of:
E. coli:

E. nana:

E. histolytica:

3.Maximum interval which a recipient sample maybe used for crossmatching

if the patient has been recently transfused, has been pregnant? 3 days
4. Refrigeration of blood samples what is affected?
inc potassium, dec glucose , dec enzymes
tryglicerides not affected

5.Rgt strip (-), Ictotest (+), What does this mean?

- Difference in sensitivity levels
- Rgt strip can detect 0.5 mg /dl of bilirubin while Ictotest from 0.05
-0.1 mg/ dl.
- Ictotest is a tablet test based on diazotization; (+) blue or purple
color in 60 seconds
6.What is affected in lactic acidosis?
- a form of metabolic acidosis
- dec PH, inc Lactate, dec Oxygen
- deep and rapid breathing , vomiting, and abdominal pain
- caused by diabetic ketoacidosis, liver or kidney diseases,
medication ( phenformin), HIV
drugs ( antiretrovirals) , arsenic poisoning
7.Procedure for Lactic Acid test
- used as an indirect assessment of oxygen level in tissues and to
determine the cause of
lactic acidosis
8. Culture media for Legionella
- buffered charcoal-yeast extract (BCYE) agar media
9. CPT blood was drawn @ 10 Am, pooled @ 11:30 am. Patient has xray @ 2
pm, what will you do with the product?
- transfuse the blood before xray
10. Enzymes:

Destroy = M N S Duffy
Enhance = Rh Lewis I Kidd
Cold Antibodies:
Lewis S
Warm Antibodies :

RH Kell

Pi

Duffy Kidd

11.False (+) for RPR ( Rapid Plasma Reagin ) Non treponemal test for
Rickettsia
-

LE
RF
IM
Infectious Hepatitis
Leprosy
Malaria
Pregnancy
Aging process
Pneumococcal pneumonia

12. Read about PCR

13. Read about RIA radioimmunoassay

14. Study ANA test Pattern with picture:

Feedback
This is an example of a mix of homogeneous and speckled ANA patterns.
In this sample notice the speckled ANA is the dominant pattern in the interphase
cells (a) and some speckling in the area outside of the chromosomal area of the
mitotics (b).
Also notice the smooth staining of the chromosomal area of the metaphase mitotic
cells (c). This represents the presence of a homogeneous ANA pattern.

a. Peripheral (rim) the central protein of the nucleus is only slightly stained
or not stained at all , but nuclear margins fluoresce strongly and appear to
extend into the cytoplasm
- i.e. anti DNA
- associated with SLE in the active stage of the dis. and in Sjogrens dis.
b.

Homogenous ( diffuse) the whole nuicleus fluoresces evenly

- i.e. anti DNA
anti Histone
anti DNP

typically seen in Rheumatoid disorders

Inc. titres are suggestive of SLE
Dec. titres maybe found in SLE, RA, Sjogrens syndrome and Mixed
Connective Tissue Dis. ( MCTD)

c. Speckled - a grainy pattern with numerous round dots of nuclear

fluorescence, without staining of the nucleoli
- i.e. anti RNP
anti Sm . Specific for SLE
- occurs in the presence of antibody to any extractable nuclear antigen
devoid of DNA or histone
- the antibody is detected against the saline extractable nuclear antigens
- antiobodies to Sm antigens is highly specific for SLE and as a marker
antibody.

d. Nucleolar - a few round, smooth nucleoli that vary in size will fluoresce
when examined with UV.
- i.e. anti- nucleolar
- present in 50% with Scleroderma, Sjogrens syndrome, SLE

e. Anti centromere - discrete and speckled

- Highly selective for CREST
-

Primary Billiary Cirrhosis

In order to understand the ANA test (antinuclear antibody test), it is first important to
understand different types of antibodies.

Antibodies are proteins, produced by white blood cells, which normally circulate in

the blood to defend against foreign invaders such as bacteria, viruses, and toxins.
Autoantibodies, instead of acting against foreign invaders, attack the body's own

cells. This is an abnormality.

Antinuclear antibodies are a unique group of autoantibodies that have the ability to
attack structures in the nucleus of cells. The nucleus of a cell contains genetic material
referred to as DNA (deoxyribonucleic acid).

An ANA test (antinuclear antibody test) can be performed on a patient's blood sample as
part of the diagnostic process for certain autoimmune diseases.
How the Test Is Performed
To perform the ANA test, sometimes called FANA (fluorescent antinuclear antibody test), a
blood sample is drawn from the patient and sent to the lab for testing. Serum from the
patient's blood specimen is added to microscope slides which have commercially prepared
cells on the slide surface. If the patient's serum contains antinuclear antibodies, they bind to
the cells (specifically the nuclei of the cells) on the slide.
A second antibody, commercially tagged with a fluorescent dye, is added to the mix of
patient's serum and commercially prepared cells on the slide. The second (fluorescent)
antibody attaches to the serum antibodies and cells which have bound together. When the

slide is viewed under an ultraviolet microscope, antinuclear antibodies appear as fluorescent

cells.

If fluorescent cells are observed, the ANA test is considered positive.

If fluorescent cells are not observed, the ANA test is considered negative.

ANA Titer
A titer is determined by repeating the positive test with serial dilutions until the test yields a
negative result. The last dilution which yields a positive result (fluorescence observed under
the microscope) is the titer which gets reported. Here is an example:
1:10 positive
1:20 positive
1:40 positive
1:80 positive
1:160 positive (reported titer)
1:320 negative
Parts of an ANA Report
An ANA report has three parts:

Positive or negative

If positive, a titer is determined and reported

The pattern of fluorescence is reported

Significance of ANA Pattern

ANA titers and patterns can vary between laboratory testing sites, perhaps because of
variation in methodology used. These are the commonly recognized patterns:

Homogeneous - total nuclear fluorescence due to antibody directed against

nucleoprotein. Common in systemic lupus erthematosus (SLE).

Peripheral - fluorescence occurs at edges of nucleus in a shaggy appearance. Anti-

DNA antibodies cause this pattern. Also common in SLE.

Speckled - results from antibody directed against different nuclear antigens.

Nucleolar - results from antibody directed against a specific RNA configuration of the
nucleolus or antibody specific for proteins necessary for maturation of nucleolar RNA.
Seen in patients with systemic sclerosis (scleroderma).

Positive ANA Test Result Explained

Antinuclear antibodies are found in patients who have various autoimmune diseases, but
not only in autoimmune diseases. Antinuclear antibodies can be found also in patients with
infections, cancer, lung diseases, gastrointestinal diseases, hormonal diseases, blood
diseases, skin diseases, and in elderly people or people with a family history of rheumatic
disease. Antinuclear antibodies are actually found in about 5% of the normal population,
too.
ANA test results are just one factor considered when a diagnosis is being formulated. A
patient's clinical symptoms and other diagnostic tests must also be considered by the
doctor. Medical history is also significant because some prescription drugs can cause "druginduced antinuclear antibodies".
Incidence of ANA in Various Diseases
Statistically-speaking, the incidence of positive ANA test results (in percent per condition)
is:

Systemic lupus erythematosus (lupus or SLE) - over 95%

Progressive systemic sclerosis (scleroderma) - 60-90%

Rheumatoid arthritis - 25-30%

Sjogren's syndrome - 40-70%

Felty's syndrome - 100%

Juvenile arthritis - 15-30%

Subsets of the ANA tests are sometimes used to determine the specific autoimmune
disease. For this purpose, a doctor may order anti-dsDNA, anti-Sm, Sjogren's syndrome
antigens(SSA, SSB), Scl-70 antibodies, anti-centromere, anti-histone, and anti-RN.
The ANA test is complex, but the results (positive or negative, titer, pattern) and possible
subset test results can give physicians valuable diagnostic information.

Several different serum tests are used to detect autoimmunity. These are conditions where the
immune system acts directly against the bodys own tissues. One test, the ANA, or anti-nuclear
antibody test, detects antibodies that are directed against various components of the nucleus of
the cell. These include antibodies that have been formed against double-stranded or singlestranded DNA (two ways in which the cells DNA can be found in the serum after being released
from old and dying cells). Other components of the nucleus such as histones are also released
from old cells and can also become targets of the immune response. When they appear they
may be markers for excess or inappropriate immune responses directed against ones own
tissues. Physicians in our group test for various autoantibodies in order to characterize patients
as those who might have a tendency for autoimmune responses. Those who test positive have
been found to have a higher risk for recurrent pregnancy loss and are more likely to benefit from
therapeutic interventions (see diagram).

Consequences
-Antinuclear Antibody (ANA) positive, speckled pattern.
-Autoantibody to DNA leads to inflammation in the placenta.
-Autoimmune disease screening in the woman is negative (No evidence of lupus or rheumatoid
arthritis).
A blood test determines the presence of antibodies to polynucleotides, histones and DNA. This
process involves running 27 different tests on a sample of blood.
The presence of antibodies is also tested for by doing the ANA test. This is a less sensitive test
but one that many doctors have already done on their patients before we ever see them.
The test is reported as a titer and a pattern. Any titer above 1:40 is significant. The titers can get
into the thousands such as 1:2,500. This simply means that the test is positive when the blood
serum is diluted many times.
The pattern is reported as homogeneous, nucleolar or speckled:
-Homogeneous: the antibody is to the ss DNA or ds DNA.
-Nucleolar: the antibody is directed to the polynucleotides.
-Speckled: the antibody is directed against the histones.
Some women demonstrate a mixed pattern of speckled/homogeneous. These same antibodies
appear positive in women with lupus, rheumatoid arthritis, Crohn's disease and other
autoimmune diseases. They are usually in high titers. Pregnancy losses, infertility and IVF
failures cause the titers to be much lower and a low positive titer does not mean that you have
or are getting an autoimmune disease; however, this is ruled out during the testing.
In women with autoimmune diseases these antibodies cause inflammation in joints and organs.
In women with no autoimmune diseases but a positive antibody, the antibody causes
inflammation around the embryo at the time of implantation or in the placenta after implantation.
This inflammation is exactly the same as occurs if you get a splinter under your fingernail. The
tissue around the splinter gets hot, red and swollen and it happens quickly.

15. Read about MIC for susceptibility test to report in microbiology

16. Epstein Barr Virus, How to detect? Know the procedure.

- infectious mononucleosis
- test to detect:
a) Mono spot
b) CBC
c) EBV serology
- can help detect if an individual has an infection due to
EBV, and if they are prone
to future infections due to dormant virus.
- VCA-IgM
VA-IgG Tests ---------- help to identify current infection
EA-D
EBNA Test -------------- help to dx future infection due to
an existing dormant virus.
d) throat culture
e) Liver profile
17.HgA1c 5, blood gluscose 200 gm/dl. What does this mean?
- Glucose normal for the past month, currently high.
18. Know how to answer acid /gas case study.
Know the Normal Value to be able to answer case study.
PH
=
7.35 - 7.45
PCO2 =
35 - 45
HCO3 =
22 - 26
19. 10% sodium hypochlorite for cleaning surfaces
20. Know how to identify pictures of Leukemias
ALL
AML
CLL
CML
21. Identify ABO discrepancy case study
- what to do next

-what is causing the discrepancy

22. Identify Enterobacteria organism.: Use the flash card
EKE

ESCP

KES

E. coli
KES
Shigella
Salmonella
Edwardsiella

I
+
+
+

PMP

PMPK

M
+
+
+
+

C:
+
+
-

V
+
+
-

SKY

YESC

KEEPS

23. Identify picture of microorganism.

Gram (+) or gram (-)
24.

Bilirubin
Pre hepatic
Hepatic
Post Hepatic

inc

Urobilinogen
dec

25. Effect of exposure of blood to air

- C02 dec, PCO2 dec,
PH inc
- dec Ca, dec acid phosphatase, dec glucose, dec bilirubin
26. 17 ketosteoid is produced in
- Adrenal gland
27. Read on Weil Felix Reaction
-

test for Rickettsia------ Typhus fever

this test involves testing of certain strains of Proteus vulgaris

28. Read on Syphilis

- Treponema pallidum
- Reagin - non treponemal antibodies
- Darkfield Microscopy - test of choice for patient with SY
- Non Treponemal Method: - a flocculation ( or agglutination )
test
1)
VDRL - can be used to test for CSF
2)
RPR - contains charcoal ; cant be used for CSF ;
Causes of False (+)
- LE

RF
IM
Infectious Hepatitis
Leprosy
Malaria
Pregnancy
Aging process
Pneumococcal pneumonia

29. Steps in agglutination

-

Sensitization
= 1st step in agglutination
= physical attachments of antibody molecules to antigens on the
RBC membranes

Lattice Formation
= establishments of cross links between sensitized particles and
antibodies resulting in aggregation (clumping), is a much slower
process thant the sensitization phase

30. Dilution:
1st tube
6th tube
1.1 Serum
0.9 diluent

2nd tube

3rd tube

1:320

31. What causes synovial fluid turbidity?

Choices:
a)
Fibrinogen
b) crystals
immunoglobulins
d) fibrinogen III

5th tube

0.5 serum
0.5 diluent

What is the dilution in the 6th tube?

4th tube

c)

SF --- Increase content of hyaluronic acid ( mucin)

Mucin clot test --- precipitation of SF with weak acetic acid
Immunoglobulins , immune complexes, complement -----produced by cells in the imflamed joints
Normal SF does not clot , viscous, and clear
SF that clots suggests the presence of synovitis and is
cause by fibrinogen

32. Green top tube , blood is collected and refrigerated for 3 hours. Should
you not accept?
My answer: plasma should be separated before refrigeration

33. Malabsoption test?

Fecal fat

34. Fungus picture? My answer penicillium

35.Group of organism for HACEK
- Haemohilus ( H . parainfluenza, aphrophilus, paraphrophilus )
- Actinobacillus ( actinomycetemcomitans )
- Cardiobacterium hominis
- Eikenelle corrodens
- Kingella ( K. kingae)
36. Prevents replication of virus?
Interferon
37. Result of hemodilution?
- low serum electrolytes
38. As a result of hemolysis
-

freezing canm cause hemolysis

dec K, dec LDH, dec AST, normal uric acid

38. automaterd method for measuring Chloride which generates silver ions
in the reaction.
- cystic fibrosis
- Coulometry
39. Purpose of documentation log.
40. Diagnosis of a case study:
Glomerulonephritis
Pyelonephritis
Cystitis
41. Fetal lung maturity
42. Which of the following methods is MOST reliable for determining the appropriate
dosage of Rh immune globulin to give to an identified Rh immune globulin
candidate after delivery?

Flow cytometry is the most reliable method of those listed. It is a quantitative

method, whereas Keihauer-Betke and the rosette test are very subjective tests.

43. Hemoglobin electrophoresis uses an electric field to separate hemoglobin

molecules based on differences in net electrical charge. The rate of electrophoretic
migration is also dependent on the ionic radius of the molecule, the viscosity of the
solution through which it is migrating, the electrical field strength, temperature, and
the type of supporting medium used.
44. Thin-layer chromatography is particularly useful as a tool in the identification
of:
- Drugs
45. Know Blood Panel
46. Know Paternity Testing
47. Study Weak D in Blood Banking
48. Machines set @ 150 wavelenght, then wavelength @ 0 when used. What is the
problem?

49. Release of results to whom?

My answer :
Dentist
50. Read on immunoassay
51. B lactam Test ------

grm (-)

52. Study Anion Gap

53.Troponin enzyme in MI elevated the longest
54. Study MI enzymes

55. Liver Disease : study other

My answer:
ALT
AST
56. Study Ferritin and transferring levels in :
Hemochromatosis
Iron deficiency anemia

Anemia of chronic diseases

Thalassemia
57. Monoclonal graph . What to do next?
- multiple myeloma
- presence of Bence jones protein in the urine
- monoclonal gammopathy

Bone marrow cytology in a dog with multiple myeloma. There are large numbers of plasma cells (*) in the
aspirate, some of which are binucleate. Hematopoietic cells (both myeloid [M] and erythroid [E]) are found
in normal numbers and maturation sequence.

1. Myeloma Cells
I.

with rouleax cells

Labs: Findings
A. Serum Protein Electrophoresis and Urine Protein electrophoresis for
Monoclonal Peak
1. M Protein in either serum or urine: 97% of patients
2. Serum M Protein by electophoresis (82%) or immunofixation
(93%)
3. Urine M Protein by electrophoresis: 75%
B. Chemistry panel with Serum Calcium
1. Hypercalcemia
a. Serum Calcium >11 mg/dl (present in 13% of patients)
2 Renal Insufficiency
a. Serum Creatinine >2 mg/dl (present in 23% of patients)
B. Complete Blood Count with platelets
1 Normochromic Normocytic Anemia

a. Hemoglobin <12 grams/dl (present in 65% of patients)

B. Bone Marrow Aspiration and biopsy

C. Peripheral Smear
1 Myeloma Cells
2 Rouleaux of Red Blood Cells
D. Erythrocyte Sedimentation Rate (ESR)
1 Increased >50 mm/hour in most cases (except bence-jones
Myeloma)
E. Serum Viscosity
F. Urinalysis
1 Bence-Jones Protein
2. Rouleaux of Red Blood Cells

Suggested sequence of immunologic testing :

electrophoresis

M spike on serum protein

Serum:

-Immunoelectrophoresis
-Immunofixation
-Quantitation of immunoglobulins by radial immunodiffusion or nephelometry
- Screening for croglobulins
- Determination of serum viscosity of IgM, IgA, or IgG , or signs and
symptoms suggestive of
Hyperviscosity

Urine:
Screening of urine for increased protein, e.g. sulfosalicylic acid
Total protein assay of a 24 hour urine specimen
Urinary protein electrophorsis
Urinary immunoelectrophoresis
Immunofixation

58. Salmonella in the diarrhea. Know how to ID.

59. Providencia organism
60. Proteus Vulgaris organism

61. Culture media for Legionella?

63. Hematology:
Target Cells
DIC
CLL
PAS (+) and SUDAN (+) is what?
Smudge cells
Big Platelet
64.

Inc. ESR causes: Study othe causes

My answer ; Inc Paltelet

65. Rouleaux formation due to ?

Choose:
a)
Slow or fast smearing
b)
Angle of the smear
c)
d)

66. Ferritin :
Increase Ferritin , Normal TIBC
67. Hereditary Chromatosis;
C282Y
H63D
S65C

-------- inflammatory process

DNA analysis of the following

68. Know the cases for Deferral of blood donors:

My answer:

Pt with CMV

69. Tests affected by blood hemolysis?

- Increase:
K, LD, AST, Plasma Hgb
- Decrease :
T4
- Falsely Elevated: Phosphorus, Total protein, Albumin, Magnesium,
Calcium, Acid
Phosphatase
70. Affected by exposure of lights to blood:
- Decrease : Vitamin A and B6, Beta-carotene, Phorphyrins, Bilirubin
Should be wrapped in aluminum foil immediately after collection.