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http://slph.state.nc.us/ I N S I D E t h i s i s s u e PAGES 2-4 Newborn Screening A list of disorders PAGES 5-6 LaCrosse Encephalitis in Western NC PAGE 7 Blood glucose PAGE 8 Microscope Tips How to properly clean your microscope PAGE 9 QA Clinical Sample Submissions PAGE 10 / EDITORIAL Needle Points Patient Misidentification From the Director’s Chair We hope that you enjoyed the revival of the quarterly newsletter LabOratory. I wanted to take the opportunity to highlight some of the recent and ongoing activities in which the North Carolina State Laboratory of Public Health has been involved. Celebrating National Laboratory Week: We always look forward to this week in April! For the last two years, we have had outstanding committees plan activities, door prizes, and other morale-boosting events to celebrate the important work all our staff do every day. New Laboratory Information Management System: We are excited to begin the lengthy process of adopt-ing and confi guring a new commercial LIMS product. Th e new LIMS system will not only enhance work fl ow, quality control and quality assessment activities within the laboratory, but will also improve customer service. Social Security Number Issues: We continue to work with local health departments on a case-by-case basis as issues arise. Th e primary challenge is temporary numbers, and we are working to ensure consistency in accepting and utilizing these numbers. Lab-Oratory, June 2006 Number 84 Cont. on page 2 Leslie A. Wolf, PhD, HCLD (ABB) Acting Laboratory Director Th e State Laboratory of Public Health provides certain medical and environmental laboratory services (testing, consultation and training) to public and private health provider organizations responsible for the promotion, protection and assurance of the health of North Carolina citizens. M I S S I O N statement Lab-Oratory / June 2006 2 Local Health Department Accreditation: Our Regional Laboratory Improvement Consultants and other staff have been at-tending meetings and providing the ten local health departments with information and any documentation required during this important process. Phlebotomy Initiative: Trainings continue to be held throughout the state, and the response has been overwhelmingly positive. We are pleased to help address such a dire need in the laboratory community. Incident Command Training (ICS): As part of the State of North Carolina’s commitment to preparedness for public health emergencies, all our staff has been completing ICS 100, 200 and 700 courses. Several members of the laboratory management team have taken ICS 300 and 400 courses, as well, to ensure coverage at the Public Health Command Center in Raleigh. Regional Response Laboratories (Buncombe, Mecklenburg, Pitt counties): Th e Bioterrorism and Emerging Pathogens (BTEP) Unit has been working tirelessly for three years to bring the regional laboratories on-line. Th e primary mission of the Regional Response Laboratories is to perform analyses on suspicious samples using the national Laboratory Response Network (LRN) protocols. Secondarily, they will be performing testing to assist in specifi c outbreak situations as time allows. We look forward to the return of Dr. Lou Turner on July 1, 2006, when she resumes her role as Laboratory Director. Enjoy the rest of the spring season and have a safe summer! Leslie A. Wolf, PhD, HCLD (ABB) Acting Laboratory Director Director’s Chair cont. from page 1 Newborn Screening: Making a Difference When visiting a hospital, most people enjoy peering through the window of the newborn nursery and watching the activi-ties of the tiny occupants. Most of these babies are healthy and will go home to thrive and grow normally. However, there are some health problems that are not easily discovered by the routine examination that the newborn receives in the hospital. Th ese conditions are detected by the newborn screen-ing that is done when the baby’s heel is pricked 48-72 hours after birth, and the sample is sent to the North Carolina State Laboratory of Public Health. Th e dried blood spots that are submitted allow the laboratory to test for more than 30 abnormal conditions, many of which are life-threatening and can cause serious long term health eff ects if not treated early. Although most of these disorders are inher-ited, the family may not be aware that the po-tential for the condition exists if the parents are only carriers for the disease. Individuals in carrier states are usually healthy, but can have an aff ected child when the defective gene is acquired from both parents. Early detection and treatment with a special diet or other medical intervention can prevent mental retardation, physical disabilities or even death. Th e following is a list of the newborn disorders screened for by the N.C. State Laboratory of Public Health: Disorders detected by tandem mass spectrometry (MS/MS) Amino Acid disorders – Th ese disorders result from a lack of enzymes needed to break down amino acids, which are the building blocks of protein. Other enzyme defi ciencies create an inability of the body to rid itself of the nitrogen incorporated in amino acid molecules. Toxic levels of amino acids or ammonia build up in the body, causing varying degrees of symptoms and even death when untreated. Treatment involves dietary restrictions and supplements. NCSLPH tests for the following disorders in this category: Argininosuccinic aciduria (ASA) Citrullinemia (CIT I) Homocystinuria (cystathionine beta synthase) (HCY) Cont. on page 3 Lab-Oratory / June 2006 3 Cont. on page 4 Maple syrup urine disease/Branched-chain ketoacid dehydrogenase (MSUD) Phenylketonuria /Hyperphenylalaninemia (PKU) Tyrosinemia type II (TYR-II) Tyrosinemia type III (TYR-III) Organic Acid Disorders – Th ese diseases are also a result of loss of enzyme activity involved in the breakdown of amino acids as well as other substances such as lipids, sugars and steroids. Toxic acids build up in the body and may result in coma and death. Treatment involves dietary protein restriction and dietary supplements. Th e following conditions are currently detectable in this category: Glutaric acidemia type I (GA-I) Multiple carboxylase defi ciency (MCD) 3-Hydroxy-3-methylglutaryl-CoA lyase defi ciency (HMG) Isobutyryl-CoA dehydrogenase defi ciency (IBD) Isovaleric acidemia/Isovaleryl-CoA dehydrogenase defi ciency (IVA) Beta-ketothiolase (BKT)/Short-chain keto acylthiolase defi ciency (SKAT) Methylmalonic aciduria (MMA) 2-Methylbutyryl-CoA dehydrogenase defi ciency (2-MBD) 3-Methylcrotonyl-CoA carboxylase defi ciency (3-MCC) Propionic acidemia (PPA, PROP) Fatty Acid Disorders – Th ese conditions result from defects in enzymes needed to convert fat into energy. When the body’s supply of glucose is depleted, it breaks down fat to aid in the production of alternate fuels. When this pathway is blocked due to the defective enzymes, cells suff er an energy crisis when they run out of glucose. Individuals with these types of disorders must ensure that they consume meals on a regular basis and engage in a low-fat diet. NCSLPH screens for the fatty acid disorders listed below: Carnitine/acylcarnitine translocase defi ciency (CAT) Carnitine palmitoyltransferase II defi ciency (CPT II) Medium-chain acyl-CoA dehydrogenase defi ciency (MCAD) Multiple acyl-CoA dehydrogenase defi ciency (GA-II) Long-chain 3-hydroxyacyl-CoA dehydrogenase defi ciency (LCHAD) Short-chain acyl-CoA dehydrogenase defi ciency (SCAD) Tri functional protein defi ciency (TFP) Very long-chain acyl-CoA dehydrogenase defi ciency (VLCAD) Disorders detected by biochemical and other technologies Biotinidase Defi ciency (BIO) – Lack of this enzyme aff ects the body’s ability to process biotin, a common vitamin found in many foods. Th is disorder may result in skin rash, hair loss, hearing loss, seizures, mental retardation, and even death. Biotinidase defi ciency is treated with free biotin that is not bound to protein or other molecules. Congenital Adrenal Hyperplasia (CAH) – Th is is a group of disorders characterized by abnormal production of the hormones produced by the adrenal glands. Th ese hormones play an important role in sexual development, sometimes resulting in ambiguous genitalia when there is a defect in production. A salt-wasting form of CAH in newborns can produce symptoms of weakness, vomiting, dehydration and shock. Treatment with hormone replacements allows infants to have normal growth and development. Galactosemia (GAL) – Th is condition prevents the body from using a sugar called galactose that is found in milk. Early symptoms include vomiting, liver damage and even death. Th e infant is treated by switching from breast milk or formula to a galactose-free (soy-based) formula. Congenital Hypothyroidism (primary) (CH) – Th is disorder occurs when infants are unable to produce suffi cient amounts of thyroid hormone, which is necessary for normal metabolism, growth and brain development. Treatment with thyroid hor-mone medication prevents these symptoms. Hemoglobinopathies – Common hemo-globin abnormalities include Sickle Cell Disease, Hemoglobin C Disease, Hemoglo-bin E Disease, Sickle/Hemoglobin C Disease and Sickle/Hemoglobin E Disease. Th ese disorders are caused by genetic variations that result in structural defects of the hemoglobin molecule. Sickle Cell Disease is the most common hemoglobin disorder and is characterized by hemolytic anemia, pain episodes, serious infections and damage to vital organs. Early detection and treat-ment of infants with prophylactic penicillin signifi cantly reduces morbidity and mortal-ity from pneumococcal infections. Blood transfusions and administration of hydroxy-urea can be eff ective treatments to prevent the Newborn cont. from page 2 Lab-Oratory / June 2006 4 Newborn cont. from page 3 sickling of red blood cells that causes a pain crisis. Although a Newborn Screening form requires only a very small amount of sample to be submitted, a wealth of information can be obtained from the laboratory testing that is performed. With early detection, treatment and proper follow-up care, infants with these disorders may avoid serious health problems and even death. Th at is why it is import-ant that samples be properly collected and submitted promptly, with forms that are accurately fi lled out. For more information on the collection of Newborn Screening fi lter form specimens, check out the new educational Power Point presentation at the State Laboratory of Public Health website (http://slph.state.nc.us/) and locate “Form Training” under Newborn Screening. Any additional questions may be directed to the Newborn Screening/Clinical Chemistry Unit at (919) 733-3937. Article Submitted by: Patty Atwood, BSMT (ASCP) Supervisor, Hemoglobinopathy Laboratory Lab-Oratory / June 2006 5 LaCrosse Encephalitis in Western North Carolina, 2005 Originally published in Epi Notes LAC is a disease that resides in eastern chipmunks, gray squirrels, and possibly red foxes. Th ese animals produce high amounts of virus within their bodies. A mosquito bites (feeds on) an infected chipmunk or squirrel. During this time, the mosquito is extracting blood from the animal, which could contain LAC virus or other arboviruses. When the mosquito bites a human, virus particles are allowed to enter the human body and infect cells. Th e virus takes over the infected cells, and causes the cells to start making more virus particles that infect additional cells throughout the body. Th is causes an infection that can result in disease. Th e virus is not usually transferred human to human. Th e mosquitoes that transmit LAC are formally named Aedes triseriatus, but often are called the “treehole” mosquito. Th ey earned the nickname because they require standing water in man-made containers or natu-ral treeholes to reproduce and mature. By eliminating these water sources, the number of mosquitoes available to transmit infection will decrease. LAC infection can present itself with various symptoms. According to the Centers for Disease Control and North Carolina has a wide variety of terrains. From the Atlantic Ocean on the east to the Appalachian Mountains and Tennessee border in the west, the state has a varied geography and ecology. Th is diverse ecology supports many arthropod vectors, birds and mammals. In 2005, our state witnessed a dramatic increase in human LaCrosse Encephalitis (LAC) infections. LAC is an arbovirus that is transmitted by arthropod vectors such as mosquitoes. Th ere are hundreds of arboviruses found throughout the world, and many arboviruses can infect humans and cause mild to severe disease. Th e most familiar arboviruses found in North Carolina are West Nile Virus (WNV), LaCrosse Encephalitis (LAC), and Eastern Equine Encephalitis (EEE). Th ese diseases are usually ter-ritorial, meaning that they are usually localized to certain parts of the state. WNV and EEE tend to be found in the eastern part of the North Carolina, and LAC is usually confi ned to the western part of the state. Travel within the state is common; thus these viruses have been detected in humans in areas outside of the normal regions. Th e map below illustrates the county of residence of humans infected by LAC in 2005 (32 cases illustrated). Prevention (CDC), 80%-90% of children with LAC infection develop a mild febrile illness that includes fever, headache and vomiting. Symptomatic children have seizures in about 50% of cases and develop encephalitis and men-ingitis similar to enteroviral infection. LAC infection can produce lethargy and behavioral changes within three to four days post-infection, with sei-zures progressing to coma in 8-24 hours post-infection. Seizures can occur for up to eight years post-infection in a few cases. N.C. Public Health epidemiologists re-quested assistance from the CDC in September 2005 to help investigate the LAC outbreak in western North Carolina. From this work, the state was able to gain important informa-tion and begin to understand the causes of the increased number of infections over the previous years. Of note, North Cont. on page 6 Lab-Oratory / June 2006 6 Carolina had 32 of the 70 cases (46%) detected in the entire United States in 2005. In 2005, eight adult infections and 24 child LAC infections were detected. Th e symptoms ranged from headache, fever and other fl u-like symptoms to central nervous system defi - ciencies such as encephalitis and meningitis. Th is disease caused more severe symptoms in children than in adults. In 2005, 22 of 32 LAC infections occurred in humans under 15 years old, and seven of 32 were older than 60 years old. Th e remaining three human LAC infections were in humans 20-42 years old. Since 2000, North Carolina has seen a steady increase in human cases (Table 1). Overall, North Carolina has had a 457% increase in the number of cases in the past fi ve years. Th is fi nding has resulted in heightened surveillance and has increased public health concern. While the cause of the increase is not completely understood, raising awareness of public understanding regarding how and why the disease is trans-mitted may help decrease the number of infections. Since the discovery of WNV in the United States, arbovirus surveillance has increased in most states, and due to media attention, reporting of other arboviral infections such as LAC has increased. In 2005, the enhanced surveillance activities incorporated N.C. entomolo-gists who performed mosquito habitat evaluations, mosquito trapping, and small mammal evaluations at residences of LAC-infected individuals. Th is was an attempt to determine where the virus was most prevalent and what had contributed to the infections in the area. Decreasing the mosquito vectors is one way to decrease future infections and gather important data. Th e information gathered in 2005 and the enhanced surveillance suggests that LAC infections in North Carolina continue to be a serious problem that aff ects many people, especially children, in the western part of our state. Considerable time and resources on the local, state, and federal levels have been devoted to raising awareness of the potential for arboviral infections and to determining the cause and prevention of infection and the proper diagnosis of the disease. Th e key public health message is to help prevent infection in and around residential areas by eliminating mosquito habitat, wearing insect repellants, and avoiding outdoor areas at dusk and dawn if at all possible. In 2006, public health surveillance will continue and arboviral testing will be conducted at the N.C. State Laboratory of Public Health. For more information on protection from mosquito bites and decreasing mosquito habitat, visit the Public Health Pest Management Website at: http://www.deh.enr.state.nc.us/phpm/html/mosquitoes.html. Submitted by: Joey Johnson, Medical Laboratory Supervisor II, Special Serology March 16, 2006 Photographs appear courtesty of a CDC training presentation. Calendar Year Number of Cases 2000 7 2001 14 2002 20 2003 24 2004 14 2005 32 Table 1. Increase in LAC cases in North Carolina. LaCrosse cont. from page 5 Lab-Oratory / June 2006 7 In addition, there are non-pathological reasons for increased blood glucose. Th ese could include stress, IV fl uids, pregnancy, and medications such as antidepressants, beta-adrenergic blocking agents, corti-costeroids, dextrothyroxine, diazoxide, diuretics, epinephrine, estrogens, gluca-gons, isoniazid, lithium, phenothiazines, phenytoin, salicylates and triamterene. Certain drugs, such as acetaminophen, alcohol, anabolic steroids, clofi brate, disopyramide, gemfi brozil, insulin mono-amine oxidase inhibitors, pentamidine, propranolol, tolazamide and tolbutamide, may cause a decrease in glucose level. References Kaplan LA, Pesce AJ. Clinical Chemistry: Th eory, Analysis, and Correlation. 3rd ed. St. Louis: Mosby, Inc; 1996. Pagana KD, Pagana TJ. Diagnostic and Laboratory Test Reference. 4th ed. St. Louis: Mosby, Inc; 1999. Submitted by: Jennifer Anderson, BS, MT (ASCP)CM Consultant, Laboratory Improvement Lab Test of the Quarter Blood Glucose (Also known as Blood Sugar) Blood glucose is a very common laboratory test that measures the amount of glucose in the blood. Glucose (C6H12O6), a six-carbon polyhydroxyl aldehyde, is metabolized in cells to form ad-enosine triphosphate (ATP) which is the energy source for all biological functions. When we consume carbo-hydrates, they are broken down into smaller sugars, one of which is glucose. Part of the glucose is directly absorbed into the blood stream for immediate energy production. Th e hormone insu-lin causes the body to store any excess glucose in the form of glycogen, fats and proteins for times of glucose shortage (hypoglycemia.) If the glucose levels in the body become too low, these storage molecules are hydrolyzed (broken down) into glucose and released into the blood stream. Th is is an essential process, be-cause glucose is necessary for our survival. Th e human brain could not survive with-out a constant supply of glucose, its pri-mary source of energy. Likewise, it’s dan-gerous to have too much glucose in the blood stream (hyperglycemia) because it can be both a symptom and a cause of-diabetes. Specimen Type: Blood (venous or capillary) Normal Ranges: Premature Infant: 20-60 mg/dl Neonate: 30-60 mg/dl Infant: 40-90 mg/dl Child <2 years: 60-100 mg/dl Child >2 years-adult: 70-105 mg/dl Elderly: increase in normal range after age 50 years Critical Values (may vary slightly by facility) Newborn: <30 and >300 mg/dl Infant: <40 mg/dl Adult Female: <40 and >400 mg/dl Adult Male: <50 and >400 mg/dl When evaluating a patient’s blood glu-cose level it is important to be aware of the fasting status of the patient. For instance, a glucose level of 150 mg/dl is an expected value in a person who ate just one hour ago, but would be considered abnormal if a person had been fasting for eight hours. Th ere are several diff erent diseases state that cause abnormal blood glucose results (see Table 1). Increased Levels Decreased Levels (Hyperglycemia) -Diuretic therapy (Hypoglycemia) -Diabetes mellitus -Corticosteroid therapy -Insulinoma -Acute stress response -Acromegaly -Hypothyroidism -Cushing’s syndrome -Hypopituitarism -Pheochromocytoma -Addison’s disease -Chronic renal failure -Extensive liver disease -Glucagonoma -Insulin overdose -Acute pancreatitis -Starvation Table 1 Lab-Oratory / June 2006 8 Microscope Tips Cleaning the Brightfield Microscope detergent, rinse thoroughly and dry before reusing. 4. Moisten lens paper or cotton swab with lens cleaner and gently wipe all outer optical surfaces. Start from the center and work toward the edge with a rolling and lifting motion. Repeat the process, using a clean area of the paper or a clean swab until all dirt and smudges are removed. 5. Remove each objective from the nosepiece, one at a time, to clean as instructed in step 4. Return the clean objective to its original location before continuing to the next. CAUTION: Do NOT clean the interior of the eyepieces or objectives or the bottom of the condenser. Never take the eyepieces or objectives apart. 6. Clean the mechanical stage and other body parts (non-glass) with Kimwipes or a cloth dampened with detergent or lens cleaner. Remove the stage clips to clean the underside, and dry before returning the clips to the stage. CAUTION: If a corrosive liquid, such as urine or KOH, spills on the stage, immediately disassemble the stage clips and clean the surface. 7. Cover the clean microscope with a non-linty material to prevent dust from settling on clean surfaces. Plastic bags are acceptable replacements for damaged or lost microscope covers. Periodically inspect the power cords and plugs for safety; frayed cords are a potential shock hazard. Always keep a replacement bulb available. Never interchange bulbs between microscopes that are diff erent makes and models. Treat your microscope with the care that a precision instrument deserves. Keep a daily log to record the microscope maintenance as you would for any other laboratory instrument. Watch for Koehler Illumination instructions in the next publication. Submitted by: Colleen Miller, BS MT(ASCP) Laboratory Improvement Consultant Is the microscope in your laboratory dirty and dusty? Has it been neglected and often abused? Th e condition of a microscope’s body is often an indication of its optical and mechanical performance. Unfortu-nately, too often, the microscope gets overlooked for routine care and maintenance. Microscopes are expected to provide many years of reliable service despite continuous neglect. Good preventive maintenance will improve the performance of a microscope and extend its years of service. Preventive maintenance includes regular cleaning, setting for Koehler Illumination, and annual service by a professional. Clean the microscope daily to remove dust, grease and grime which can damage the optics, erode the surfaces, and interfere with correct use. Take particular care when cleaning the optics as they are easily scratched. Th e instructions that follow will guide you as you perform an important laboratory task. 1. Assemble the following supplies: • Squirrel or camel hair brush (such as an artist brush) • Lens cleaner (formulated for microscope or camera optics) • Lens paper • Cotton swabs • Air bulb • Detergent (mild) and Kimwipes for cleaning stage and stand 2. Unplug the microscope and wash your hands before starting. 3. Remove dust from the microscope, starting at the top and working down. Use the air bulb and brush to remove dust from the optical glass surfaces, i.e., eyepieces, objectives, condenser lens and fi lters. CAUTION: Never use a dirty brush. Clean a soiled brush with Lab-Oratory / June 2006 9 Quality Assessment Updates Clinical sample submissions Accompanying each sample is a requisition that contains the necessary information for performing a test. It is essential that all the information be completed accurately and as neatly as possible. Some facilities use labels, which are easier to read than handwritten information. Patient and facility informa-tion that is unreadable or smudged on the requisition or samples can cause a delayed turnaround time for that sample. Th e Clinical Laboratory Improve-ment Amendments (CLIA ’88 and ’03), 42CFR493, Subpart K, lists the minimum requirements for the clinical sample requisition: • Name and address of submitted, including EIN number • Patient’s name or unique identifi er • Sex and date of birth or age • Tests to be performed • Source of specimen, if appropriate • Date of collection and time, if appropriate • For Pap smears, the patient’s last menstrual period, an indication of whether the patient had a previous abnormal report, treatment or biopsy. • Any additional information relevant to testing • Other additional information required on State Laboratory requisitions: o Social Security Number (Patient number) o Medicaid Number, if applicable o Race/Ethnicity o County of residency Th e sample itself needs two identifi ers (State Laboratory requirement): • Patient name or unique identifi er and • Either date of birth or Social Security number (SSN) • Source of specimen, if appropriate Th e use of the patient’s Social Secu-rity number on sample requisitions has recently raised questions. After legal review, it was determined that “collection of SSNs from patients will be impera-tive to the performance of several legally prescribed duties, including:…..sub-mission of specimens to the state public health laboratory…” (Hoke & Moore memo, November 30, 2005, p.2). It is necessary that the patient’s SSN be submitted. Occasionally, a patient may present to the facility without a SSN. A temporary SSN may be constructed and used until a permanent SSN is obtained. Directions for creating a temporary SSN have been provided to all the local health departments. It is imperative that the local facilities are consistent in the creation of this temporary SSN; hyphenated names present a chal-lenge for a temporary SSN. Some facilities have developed policies to address Hispanic names. Th is is an excellent step because it provides a standard that can be applied across the facility. Being consistent in creating a temporary number at the local level will always provide the same temporary num-ber on specimens submitted to the State Laboratory. Questions about sample submission may be addressed to the Quality Assessment Unit, 919-807-8750. Article submitted by: Vickie Whitaker, BA, MT (ASCP) Quality Assurance Manager Lab-Oratory / June 2006 10 the wrong patient. Tragically, patient identfi ca-tion errors often mark the beginnings of a journey leading to patient mismanagement, misdiagnosis, and even death. Th at is why the Clinical and Laboratory Standards Institute (CLSI) recommends the following steps for outpatient identifi cation: • Ask outpatients to give their full name, address, identifi cation number, and/or birth date. • Compare the information with the information on the test request form. • Report any discrepancy, however minor, to a responsible party and have the patient identifi ed by name and identifi cation number before collecting any specimen. Document according to facility policy. For outpatients who are too young, mentally incompetent, or do not speak the language, the collector should: • Ask the nurse, a relative, or a friend to identify the patient by name, address, and identifi cation number and/or birth date. If unable to identify the patient, then contact the nurse or physician. Interpreter services should be accessible for non-English speaking patients who present to the laboratory without a relative or friend who can interpret for them. So, what assumptions lead to patient misidentifi cation? • Assuming errors in patient orders never occur, so that you never verify the information presented. • Assuming that any minor discrepancy noted in the identifi cation process is not worth pursuing. • Assuming the correct patient is in your phlebotomy chair simply because he/she responded when you called their name, without regard for patients who may have misunderstood you because they are hard of hearing or do not fl uently speak English. • Assuming that under certain circumstances, it’s okay to deviate from your agency’s patient identifi cation policy (i.e., during staffi ng shortages, when dealing with a backlog of patients, etc.). I eventually made it home that fi rst day of second grade, thanks to a compassionate bus driver. But make assumptions about the identity of your patients and the results that follow may not be nearly as forgiving. Patient misidentifi cation: It’s an unintended journey you don’t have to take. Patient Misidentification: An Unintended Journey Some of my most vivid childhood memories are of the fi rst day of school. Th e fi rst day meant my mom would drive me to school rather than having to ride the bus, and together we would carefully check the class rosters for my name. I distinctly recall the fi rst day of second grade. Until that day, I hadn’t known who my teacher would be or the classmates who shared a similar fate. However, I was sure about one thing; I knew which school bus would take me home. After all, I had ridden Bus 78 all of fi rst grade. When class dismissed for the day, I headed across the parking lot toward the bus that had taken me home every school day the year before. As I climbed aboard, the children were abuzz with conversa-tions I quickly joined. It was not until minutes later that I realized Bus 78 was heading down a diff erent road in the opposite direction of my house. My realization soon turned to panic and ultimately into sobs as the landscape outside the bus window became more foreign. So on that fi rst day of second grade, I learned an important lesson about making assumptions. Just like reassigned school buses, assumptions can take you on an unintended journey. With regard to patient identifi cation, making an assumption about one’s identity rather than consistently adhering to patient identifi cation protocols can set into motion unintended con-sequences for the patient, the employee, and the employer. Patient identifi cation is the fi rst and most critical step in blood specimen collection. No amount of technological advancement or sophisticated equipment can produce an accurate result from a specimen drawn on Needle Points By Lisa O. Ballance, BSMT (ASCP) EDITORIAL Lab-Oratory / June 2006 11 The Safety Corner Exposure Control Plan Series-Exposure Determination According to OSHA’s Bloodborne Pathogen Regulation, each employer who has an employee(s) with occupa-tional exposure shall prepare an expo-sure determination. An occupational exposure is any reasonably anticipated skin, eye, mucous membrane, or parenter-al contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties. An exposure determination is a listing of all job classifi cations in which employees will be exposed—such as laboratorians—or may occasionally be exposed—such as custodians—to po-tentially infectious materials on the job. Each supervisor should identify, evalu-ate and classify each task performed within the facility. Th is should be done without regard to the use of personal pro-tective equipment. In order to classify, a supervisor and employee must: • Identify the body fl uids that are likely to be contaminated with HIV, HBV and other viruses. • Determine the amount of body fl uids that the employee is likely to encounter as a result of performing the procedure. • Determine the probability of the employee being exposed to contaminated body fl uids as a result of performing the procedure. • Identify the ways HIV, HBV or HCV could enter the employee’s body as a result of performing the procedure. • Identify the engineering controls that should be used while performing the procedure. • Identify the work practice controls that are necessary to perform the procedure. Once the exposure determination has been completed and all engineering and work practice controls are in place, proper personal protective equipment may be added to ensure a safe work environment. Look for the next installment of the Exposure Control Plan series in the Fall Lab-Oratory, when employee education and training will be discussed! Article submitted by Kristy O’Briant, BS, Laboratory Improvement Consultant, NCSLPH Upcoming Event: North Carolina Clinical Laboratory Day Americans, causing debilitating complica-tions such as coronary artery disease, renal failure, adult-onset blindness, stroke and neuropathy. Th e conference is designed for health-care professionals, including physicians, medical technologists/technicians, nurses, educators and others involved in the diagnosis, care and management of patients with diabetes. Exciting lec-tures are scheduled throughout the day. Exhibitors will provide free samples and information on tests for diagnosis and management of diabetes. For more infor-mation, call the Laboratory Improvement Mark your calendar for an exciting edu-cational event on Friday, August 4, 2006 at Wake Technical Community Col-lege. Th e focus of the 2nd annual North Carolina Clinical Laboratory Day is “Th e Diabetes Challenge: Diagnosis, Education, and Management.” Th e Texas Health Foundation, the North Carolina State Laboratory of Public Health, and the North Carolina Diabetes Prevention and Control Branch will cohost the con-ference. Participants will fi nd the forum an opportunity to learn about the disease that is the sixth-leading cause of death in the United States. Diabetes has become a major public health threat to millions of offi ce at 919/733-7186, or visit http://slph.state.nc.us/LabImprovement (after June 12th). Submitted by: Colleen Miller, BS MT(ASCP) Laboratory Improvement Consultant Lab-Oratory / June 2006 12 “Dear Lab-bey” While this clinician’s concern for patient discomfort is admirable, it is not advisable to use anything other than sterile non-bacteriostatic saline to reduce discomfort when collecting a male urethral smear. According to Cami Hartley, State Lab Microbiology Supervisor, Neisseria gonorrhoeae is very sensitive and can be killed very easily. Xylocaine would defi nitely kill the organism and any oil-based substance will inhibit or prevent growth. Th e Sexually Transmitted Disease Assessment, Prevention, and Treatment Protocols, published by the N.C. HIV/ STD Prevention and Care Branch, lists the following steps for collecting the male urethral specimen for gram stain and gonorrhea culture: “Use a Calgiswab to collect a sample of the discharge. If discharge is not apparent, penis should be milked from base to tip to express discharge for collection. Insert the tip of the swab one to two centimeters into the meatal opening and gently rotate for three to fi ve seconds. Th e swab may be moistened with sterile non-bacteriostatic saline to reduce discomfort. - For gram stain, roll the swab along the glass slide. - For gonorrhea culture, roll the same swab in Z pattern on the gonorrhea culture plate and cross streak.” Every health department should have a copy of this valuable reference. If you do not, please contact the HIV/STD Prevention and Care Branch at (919)733-2030. One of our clinicians would like to use xylocaine or KY jelly on the urethral swab for GC culture to reduce discomfort. Will this interfere with the growth of the GC? “Dear Lab-bey…” If you have a technical laboratory question that you would like to have answered please submit it to: Jennifer.A.Anderson@ncmail.net. The answer to your question may be featured in the next edition of Lab-Oratory. Lab-Oratory / June 2006 13 North Carolina Public Health Phlebotomy Initiative A new and innovative phlebotomy competency assessment program, especially designed for North Carolina local health department laboratories and other interested public health agencies, was introduced in March by the Laboratory Improvement Unit. From March through May, eight half-day North Carolina Public Health Phlebotomy Initiative training sessions were held at various locations spanning the state. A total of 125 N.C. Public Health employees attended. Th e goal of Session 1: Assessing Competency was to deliver current continuing education to participants, along with guidance for establishing standardized and comprehensive phlebotomy assessment programs in their own facilities. Th is was accomplished using a combination of educational videos, question and answer sessions, and formal lecture. Also provided to attendees were competency assessment tools and a model blood collection procedure, all based on the current standard of care for phlebotomy. As a prerequisite, participants—including supervisors, laboratory profession-als, phlebotomists, nurses, and other healthcare staff —were required to possess at least one year of phlebotomy experience. Attendees who scored 80% or higher on the fi nal examination were awarded a certifi cate of completion for the course. Th e benefi ts of implementing a phlebotomy competency assessment program include reducing to the lowest possible degree the risk of patient and/or employee injuries associated with blood specimen collection and thus reducing the employer’s potential for legal liability. In addition, regular evaluation of blood collection policies and procedures, as well as of the staff who perform these duties, is key to ensuring that consistently high-quality specimens are obtained and submitted for patient testing. Laboratory Improvement strives to provide comprehensive and relevant training designed to meet the ongoing needs of the laboratory community it serves. Th e North Carolina Public Health Phlebotomy Initiative is just one example of the Unit’s creative approach to meeting an identifi ed need with a new course topic, unique format, and local delivery. Due to the overwhelming positive response to this initial course off ering, we look forward to developing additional sessions for this series. Article submitted by: Lisa O. Ballance, BSMT(ASCP) Regional Laboratory Improvement Consultant, Course Director Fayetteville Regional Offi ce, NCSLPH Lab-Oratory / June 2006 14 Who’s New in Public Health? We have a few more newcomers to North Carolina’s Public Health arena. We would like to extend a warm welcome to you all. As always, we hope you will continue to stay with us and will fi nd your job both enjoyable and fulfi lling as you serve the citizens of North Carolina. Johnston County welcomes Ree Wiley. She will begin at Johnston County on June 12, 2006. --------------------------------------------------------------------------- Moore County welcomes Nicole Cooley, MLT (ASCP.) Nicole started at Moore County in January 2006. --------------------------------------------------------------------------- Onslow County welcomes Loretta Lloyd. --------------------------------------------------------------------------- Pitt County would like to welcome Fashikie Smith and Latrica Hodges as new employees. --------------------------------------------------------------------------- Person County would like to welcome Jessica Walker. Jessica is an MLT I and joined Person County on March 13, 2006. --------------------------------------------------------------------------- Richmond County welcomes Jo Ann Meany. --------------------------------------------------------------------------- Here at the State Lab in Raleigh, we would like to recognize the following individuals: Virology welcomes Jamie Batchelor and Delshawn McLean. Special Serology welcomes Kalpana Patel, Medical Laboratory Technologist I. Microbiology welcomes Lara Godwin, Debra Springer, and Kemmy Ajisebutu. Cyto Prep welcomes Rebecca Sheppard, a Peace College student. Laboratory Improvement welcomes Janice West, Medical Laboratory Technologist I. Lab-Oratory / June 2006 15 Kudos! In the spring of 2005, the NCSLPH began naming a State Lab Employee of the Month. Employees are encouraged to nominate co-workers who demonstrate great work ethics and always lend a helping hand. In March, Cora Gibson in Lab Improvement was honored, and Juanita Harris of Virology/Serology was the April recipient of the award. Th e May recipient was Laurent Th ibault from our Laboratory Preparedness branch. Congratulations to all of our winners and thank you for your contributions to the NCSLPH! Congratulation also goes out to Claudette Bass from the Pitt County Health Department on her retirement! Good luck, Claudette, and enjoy! Xinhua Song and Natalie Sonin from Cancer Cytology have taken and passed the Specialist in Cytology exam given by the American Society for Clinical Pathology. Th is is the highest designation of Cytotechnologist recognized by the ASCP. Susie Lavender, Supervisor-Cancer Cytology and Chris O’Connell, Head Cytotechnologist are also recognized as Specialists. Great job! Please contact Kristy O’Briant at (919) 733-7186 or kristy.obriant@ncmail.net if you would like to recognize a co-worker at your facility. Each year, our Bath Building employees are honored with service awards. In September, we will honor many employees who have served the people of North Carolina from 5 to as long as 35 years! Please join us in thanking all of these employees for their hard work and dedication to the state of North Carolina! 5 years Alisa Alston (Feb) Joy Chiavacci (Jun) Graciela Reynoso(Jun) Deborah Campbell (Jul) Julie Kase (Jul) Holly Lee (Jul) Kate Sperry (Jul) Wayne Maynard(Aug) Crystal Poppler (Aug) Larry Th omas (Oct) Yolande Williams (Dec) 10 years Earl Hazelton (Mar) Peggy Brantley (Apr) Gloria Silber (May) Shirley Jordan (Jun) Roger Brown (Aug) Colleen Miller (Dec) 20 years Denise Givens (Jan) Mark Minzer (Mar) Mary Noel Dodd (Aug) Cynthia Currie (Nov) 25 years William Glenn (Jan) Samuel Merritt (Apr) Nancy Jones (Jun) Joy Hayes (Sept) Terry Hogg (Sept) Robert King (Sept) Vickie Whitaker (Nov) 30 years Georgena Millar (Jan) Sallie Szymcyk (Jan) James Harris (Aug) 35 years Linda Wall (Sept) Lab-Oratory / June 2006 16 Newborn Screening E R V Y P U V K R F A E M T J M R E H G S H U R M S I S B H T D E T E C T I O N G D D O T E Y N P S A E E R E D R O S I D D I C A O N I M A A O W Y I E J L V N U T E X V Q R X R I L Z X L O I E D I L S M U W Y Z E T A X C B O B C A P T R T E S D N O I K Z H L K L A N T S R N S H S H E A S Y Q I R B D D B S K Z K N W O M S D Y I Y C D A L Q B G A A L R A J E S H D O Z I E M H Y D R T L X O A Y S T L F U S T C Z E B K V T N S L A D D L L N P Q X E E U C A O H I M Y L R W N T T Q O I G I Y G F C M C K T X N F I M T E X E R E D Y N O C N F D R H X E P T R U C Y A V D O Z R O V M M A G A C I Y P I L N D L R I T S X F D L H S V E C I R U Y P Z C H K E S H I K U S Z J A E F W H I R A C Y O T M D B C W U G A B S S Q T M J C V D F T P R T E X T O X I B U O Q W Q P N Z G F C D N M L X H Q O I G A D S O U N G P M E R I R F I O Q G L Y M N F D Z M F Y R W X M Z M C C M A S P R W B R C L T U C P L R Y N Q W C U Z T B L O O D S P O T S P E C I M E N G T N V S R D O A R E I H A I M E S O T C A L A G L Q B D L Q O M D J P W B D Q U F D C N Z J E G F V S H M Z G U E Y Y P A I I T U X M A A S E V X C Z Z J L I F R T B F F S Y W Z T F W D D C K X Y I E I R F K E X R O N M O M V W H K D Z E M F M V C C I T E N E G Y R D Q O W B V J I E D W E C F B F AMINO ACID DISORDER BLOOD SPOT SPECIMEN DEATH DETECTION FATTY ACID DISORDER GALACTOSEMIA GENETIC HEALTHY HEMOGLOBIN HYPOTHYROIDISM MENTAL RETARDATION METABOLISM NEWBORN ORGANIC ACID DISORDER PHENYLKETONURIA PKU PREVENTION SICKLE CELL DISEASE TANDEM MASS SPECTOMETRY TREATMENT Created by Puzzlemaker at DiscoverySchool.com Lab-Oratory / June 2006 17 Brain Exercise Test your laboratory knowledge. Select the best answer(s). 1. What arbovirus causes the highest incidence of disease in the western part of the state and has the greatest eff ect on children? (West Nile, Eastern Equine Encephalitis, Rocky Mountain Spotted Fever or LaCrosse Encephalitis) 2. Generally speaking, what is/are the preferred sample(s) to diagnose a current or recent infection in Serology? (CSF only, Acute serum only, or Acute and Convalescent serum, or Convalescent Serum only) 3. For serology testing at the CDC, where should the submitting lab send the sample? (CDC directly, Private lab for referral or State Lab/with request for testing at CDC) 4. What form(s) is/are required for samples that need to be sent to the CDC for serology testing? (NC Serology form DHHS #3445, CDC DASH 50.34 form, both, or neither) 5. What serological method is used for Brucella testing at the N.C. State Lab? (Tube Agglutination, Immunofl uorescent Assay, Enzyme Immunoassay, or Latex Agglutination) 6. In what year was West Nile Virus fi rst detected in N.C.? (2000, 2001, 2002, or 2003) 7. What does the RPR test detect? (only syphilis antibodies, only anti-treponemal antibodies, or only reagin antibodies) 8. Why is it important to check the needle drop volume when performing RPR testing? (assure no restrictions in needle bore, assure proper antigen/antibody ratio, or assure proper antibody volume) 9. Who is responsible for assuring that all reagents and supplies have proper dating? (supervisor, health director or testing personnel) 10. What type of specimen is needed for follow-up testing of abnormal hemoglobins at the N.C. State Lab? (dried blood spots, serum, or EDTA blood) 11. At the N.C. State Lab (Blood Group/Antibody Screen Lab), what test(s) otherthan blood grouping and typing, is/are performed on prenatal patients? (antibody screening, antibody identifi cation, and/or weak D (Du) typing) 12. What type of specimen is acceptable for blood lead testing at the N.C. State Lab? (serum or EDTA blood) Questions submitted by: Pat Th ompson, BS MT(ASCP) Lab Manager Wilson County Health Department Joey Johnson, Supervisor Special Serology NC State Lab of Public Health Lab-Oratory / June 2006 18 Th e Th ird Annual Epi Teams Conference was held on May 17, 2006 at the Sheraton Imperial Hotel in the Research Triangle Park in Durham. North Carolina Public Health Preparedness and Response sponsored the event, partnering with the Division of Pub-lic Health, the Division of Environmental Health, the State Laboratory of Public Health, General Communicable Disease Control, and the Institute for Public Health. Th is free event included the following topics: • Teamwork for Successful Public Health Investigations • Legionellosis Outbreak Associated with a Rental Cottage in the Outer Banks in May 2005 • Cluster of LaCrosse Encephalitis Cases in Western North Carolina in July and August 2005 • ICS for Disease Outbreaks • Planning and Executing a Drive-Th rough Infl uenza Vaccination Clinic Using ICS in Catawba County in December 2005 Third Annual Epidemiology Teams Conference: LEADING THE INVESTIGATION • Mercury Incident in a School in Granville County in 2005 • An explanation of the HIV/ STD Rapid Intervention Outbreak Team • Epi Team Standard Operating Procedures Committee Report • Summary of the Intra-uterine Fetal Demise Investigation done in Alamance County in December 2005 • Investigation to determine Community Acquired Pneumonia or Bird Flu • Hospital Surveillance for Community-Associated Methicillin-Resistant Staphylococcus aureus • Communicable Disease Surveillance Reports: A Tool for Local Health Departments. Th e topics were relevant and up-to-date, and the conference allowed participants to hear the background stories behind the headlines from the individuals who had experienced them fi rst-hand. It also provided the opportunity to meet and network with other public health workers. Most importantly, the conference provided participants from all over the state the opportunity to learn from each other and gather information that may be useful should a similar event occur in other regions. Submitted by: Crystal Poppler Lab Manager, Laboratory Improvement Learning On-Line Due to rapid advances in medical technology, continuing education is vital to laboratorians. It is important to review information previously learned to maintain current skills, and continuously learn new information in order to provide the best possible care for patients. Often, employers require a certain number of hours of continuing education each year as well. With budgetary and staffi ng constraints, this is sometimes diffi cult to achieve. Fortunately, there are many sources of laboratory continuing education, many of them FREE or very inexpensive, on the Internet. We will be sharing some of our favorites each quarter in the Lab-Oratory. Two such sites are www.merckservices.com/portal/site/merckservices/index.jspzQzmenuItemzEzMedi-calzUz20EducationzUz20Sites www.ascp.org/education/default.aspx We have provided the links to these sites because they have information that may be of interest to our readers. Th e State of North Carolina and the N.C. State Laboratory of Public Health do not necessarily endorse the views expressed or the facts presented on these sites. Further, the State of North Carolina and the N.C. State Labora-tory of Public Health do not endorse any commercial products or information that may be presented on or could be advertised on these sites. Submitted by Jennifer Anderson, BS, MT(ASCP)CM Consultant, Laboratory Improvement Lab-Oratory / June 2006 19 UPCOMING EVENTS . . . June 20-23, 2006 Bacteriologic Methods in the Analysis of Drinking Water* July 13, 2006 Packaging and Shipping Workshop* July 18, 2006 PHTIN: Group B Strep presented by Melissa Miller, PhD of UNC Hospitals, and Sheila Cromer of Women’s and Children’s Health (More information to follow) July 21, 2006 State Lab Orientation* August 4, 2006 2nd Annual Clinical Lab Day “Th e Diabetes Challenge: Diagnosis, Education, and Management” August 8-9, 2006 Basic Microscopy: Viewing and Reviewing* August 10, 2006 Wet Mount Workshop* August 15-18, 2006 Process Control Chemistry Workshop* August 24, 2006 Bioterrorism Workshop* September 6-7, 2006 Advanced Urinalysis Workshop* September 12, 2006 Packaging and Shipping Workshop* September 13-14, 2006 Lab Methods in the Diagnosis of Gonorrhea* September 27, 2006 Diabetes Training Workshop—CANCELLED (Please Refer to Clinical Lab Day) September 29, 2006 State Lab Orientation* October 11, 2006 Advanced Microscopy: Viewing and Reviewing * October 12, 2006 Wet Mount Workshop* October 25, 2006 Basic Microbiology and Gram Staining Workshop* November 1-2, 2006 Lab Methods in the Diagnosis of Gonorrhea* November 8, 2006 Policy and Procedure Writing* November 14-17, 2006 Bacteriologic Methods in the Analysis of Drinking Water* November 30, 2006 Bioterrorism Workshop* *Additional information for laboratory improvement workshops and applications can be found on the SLPH web site at http://slph.state.nc.us/LabImprovement/default.asp. Lab-Oratory can also be found on the web at http://slph.state.nc.us/ under “Lab Improvement”. Laboratory Improvement P.O. Box 28047 Raleigh, NC 27611 State of North Carolina • Michael F. Easley, Governor Department of Health and Human Services • Carmen Hooker Odom, Secretary Division of Public Health • www.dhhs.state.nc.us N.C. DHHS is an equal opportunity employer and provider. 600 copies of this public document were printed at a cost of $448.91 or $0.75 per copy. 06/06 Holly Lee, Virology/ Serology; Patty Atwood, NBS/CC; Susie Lavender, Cytology; Brenda Webber, Cytology Jennifer Anderson, Lab Improvement; Kristy O’Briant, Lab Improvement; Colleen Miller, Lab Improvement Crystal Poppler, Lab Improvement; Janice West, Lab Improvement; Tony Ivosic, QA; Debra Springer, Microbiology E D I T O R I A L b o a r d Brain Exercise Answers: 1. LaCrosse Encephalitis; 2. Acute and Convalescent Serum; 3. State Lab/with request for testing at CDC; 4. both; 5.Tube Agglutination; 6. 2000; 7. only reagin antibodies; 8. assure proper antigen/antibody ratio; 9. testing personnel; 10. EDTA blood; 11. antibody screening and weak D (Du) typing; 12. EDTA blood
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Title | North Carolina lab-oratory |
Date | 2006-06 |
Description | June 2006 (Number 84) |
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Full Text | http://slph.state.nc.us/ I N S I D E t h i s i s s u e PAGES 2-4 Newborn Screening A list of disorders PAGES 5-6 LaCrosse Encephalitis in Western NC PAGE 7 Blood glucose PAGE 8 Microscope Tips How to properly clean your microscope PAGE 9 QA Clinical Sample Submissions PAGE 10 / EDITORIAL Needle Points Patient Misidentification From the Director’s Chair We hope that you enjoyed the revival of the quarterly newsletter LabOratory. I wanted to take the opportunity to highlight some of the recent and ongoing activities in which the North Carolina State Laboratory of Public Health has been involved. Celebrating National Laboratory Week: We always look forward to this week in April! For the last two years, we have had outstanding committees plan activities, door prizes, and other morale-boosting events to celebrate the important work all our staff do every day. New Laboratory Information Management System: We are excited to begin the lengthy process of adopt-ing and confi guring a new commercial LIMS product. Th e new LIMS system will not only enhance work fl ow, quality control and quality assessment activities within the laboratory, but will also improve customer service. Social Security Number Issues: We continue to work with local health departments on a case-by-case basis as issues arise. Th e primary challenge is temporary numbers, and we are working to ensure consistency in accepting and utilizing these numbers. Lab-Oratory, June 2006 Number 84 Cont. on page 2 Leslie A. Wolf, PhD, HCLD (ABB) Acting Laboratory Director Th e State Laboratory of Public Health provides certain medical and environmental laboratory services (testing, consultation and training) to public and private health provider organizations responsible for the promotion, protection and assurance of the health of North Carolina citizens. M I S S I O N statement Lab-Oratory / June 2006 2 Local Health Department Accreditation: Our Regional Laboratory Improvement Consultants and other staff have been at-tending meetings and providing the ten local health departments with information and any documentation required during this important process. Phlebotomy Initiative: Trainings continue to be held throughout the state, and the response has been overwhelmingly positive. We are pleased to help address such a dire need in the laboratory community. Incident Command Training (ICS): As part of the State of North Carolina’s commitment to preparedness for public health emergencies, all our staff has been completing ICS 100, 200 and 700 courses. Several members of the laboratory management team have taken ICS 300 and 400 courses, as well, to ensure coverage at the Public Health Command Center in Raleigh. Regional Response Laboratories (Buncombe, Mecklenburg, Pitt counties): Th e Bioterrorism and Emerging Pathogens (BTEP) Unit has been working tirelessly for three years to bring the regional laboratories on-line. Th e primary mission of the Regional Response Laboratories is to perform analyses on suspicious samples using the national Laboratory Response Network (LRN) protocols. Secondarily, they will be performing testing to assist in specifi c outbreak situations as time allows. We look forward to the return of Dr. Lou Turner on July 1, 2006, when she resumes her role as Laboratory Director. Enjoy the rest of the spring season and have a safe summer! Leslie A. Wolf, PhD, HCLD (ABB) Acting Laboratory Director Director’s Chair cont. from page 1 Newborn Screening: Making a Difference When visiting a hospital, most people enjoy peering through the window of the newborn nursery and watching the activi-ties of the tiny occupants. Most of these babies are healthy and will go home to thrive and grow normally. However, there are some health problems that are not easily discovered by the routine examination that the newborn receives in the hospital. Th ese conditions are detected by the newborn screen-ing that is done when the baby’s heel is pricked 48-72 hours after birth, and the sample is sent to the North Carolina State Laboratory of Public Health. Th e dried blood spots that are submitted allow the laboratory to test for more than 30 abnormal conditions, many of which are life-threatening and can cause serious long term health eff ects if not treated early. Although most of these disorders are inher-ited, the family may not be aware that the po-tential for the condition exists if the parents are only carriers for the disease. Individuals in carrier states are usually healthy, but can have an aff ected child when the defective gene is acquired from both parents. Early detection and treatment with a special diet or other medical intervention can prevent mental retardation, physical disabilities or even death. Th e following is a list of the newborn disorders screened for by the N.C. State Laboratory of Public Health: Disorders detected by tandem mass spectrometry (MS/MS) Amino Acid disorders – Th ese disorders result from a lack of enzymes needed to break down amino acids, which are the building blocks of protein. Other enzyme defi ciencies create an inability of the body to rid itself of the nitrogen incorporated in amino acid molecules. Toxic levels of amino acids or ammonia build up in the body, causing varying degrees of symptoms and even death when untreated. Treatment involves dietary restrictions and supplements. NCSLPH tests for the following disorders in this category: Argininosuccinic aciduria (ASA) Citrullinemia (CIT I) Homocystinuria (cystathionine beta synthase) (HCY) Cont. on page 3 Lab-Oratory / June 2006 3 Cont. on page 4 Maple syrup urine disease/Branched-chain ketoacid dehydrogenase (MSUD) Phenylketonuria /Hyperphenylalaninemia (PKU) Tyrosinemia type II (TYR-II) Tyrosinemia type III (TYR-III) Organic Acid Disorders – Th ese diseases are also a result of loss of enzyme activity involved in the breakdown of amino acids as well as other substances such as lipids, sugars and steroids. Toxic acids build up in the body and may result in coma and death. Treatment involves dietary protein restriction and dietary supplements. Th e following conditions are currently detectable in this category: Glutaric acidemia type I (GA-I) Multiple carboxylase defi ciency (MCD) 3-Hydroxy-3-methylglutaryl-CoA lyase defi ciency (HMG) Isobutyryl-CoA dehydrogenase defi ciency (IBD) Isovaleric acidemia/Isovaleryl-CoA dehydrogenase defi ciency (IVA) Beta-ketothiolase (BKT)/Short-chain keto acylthiolase defi ciency (SKAT) Methylmalonic aciduria (MMA) 2-Methylbutyryl-CoA dehydrogenase defi ciency (2-MBD) 3-Methylcrotonyl-CoA carboxylase defi ciency (3-MCC) Propionic acidemia (PPA, PROP) Fatty Acid Disorders – Th ese conditions result from defects in enzymes needed to convert fat into energy. When the body’s supply of glucose is depleted, it breaks down fat to aid in the production of alternate fuels. When this pathway is blocked due to the defective enzymes, cells suff er an energy crisis when they run out of glucose. Individuals with these types of disorders must ensure that they consume meals on a regular basis and engage in a low-fat diet. NCSLPH screens for the fatty acid disorders listed below: Carnitine/acylcarnitine translocase defi ciency (CAT) Carnitine palmitoyltransferase II defi ciency (CPT II) Medium-chain acyl-CoA dehydrogenase defi ciency (MCAD) Multiple acyl-CoA dehydrogenase defi ciency (GA-II) Long-chain 3-hydroxyacyl-CoA dehydrogenase defi ciency (LCHAD) Short-chain acyl-CoA dehydrogenase defi ciency (SCAD) Tri functional protein defi ciency (TFP) Very long-chain acyl-CoA dehydrogenase defi ciency (VLCAD) Disorders detected by biochemical and other technologies Biotinidase Defi ciency (BIO) – Lack of this enzyme aff ects the body’s ability to process biotin, a common vitamin found in many foods. Th is disorder may result in skin rash, hair loss, hearing loss, seizures, mental retardation, and even death. Biotinidase defi ciency is treated with free biotin that is not bound to protein or other molecules. Congenital Adrenal Hyperplasia (CAH) – Th is is a group of disorders characterized by abnormal production of the hormones produced by the adrenal glands. Th ese hormones play an important role in sexual development, sometimes resulting in ambiguous genitalia when there is a defect in production. A salt-wasting form of CAH in newborns can produce symptoms of weakness, vomiting, dehydration and shock. Treatment with hormone replacements allows infants to have normal growth and development. Galactosemia (GAL) – Th is condition prevents the body from using a sugar called galactose that is found in milk. Early symptoms include vomiting, liver damage and even death. Th e infant is treated by switching from breast milk or formula to a galactose-free (soy-based) formula. Congenital Hypothyroidism (primary) (CH) – Th is disorder occurs when infants are unable to produce suffi cient amounts of thyroid hormone, which is necessary for normal metabolism, growth and brain development. Treatment with thyroid hor-mone medication prevents these symptoms. Hemoglobinopathies – Common hemo-globin abnormalities include Sickle Cell Disease, Hemoglobin C Disease, Hemoglo-bin E Disease, Sickle/Hemoglobin C Disease and Sickle/Hemoglobin E Disease. Th ese disorders are caused by genetic variations that result in structural defects of the hemoglobin molecule. Sickle Cell Disease is the most common hemoglobin disorder and is characterized by hemolytic anemia, pain episodes, serious infections and damage to vital organs. Early detection and treat-ment of infants with prophylactic penicillin signifi cantly reduces morbidity and mortal-ity from pneumococcal infections. Blood transfusions and administration of hydroxy-urea can be eff ective treatments to prevent the Newborn cont. from page 2 Lab-Oratory / June 2006 4 Newborn cont. from page 3 sickling of red blood cells that causes a pain crisis. Although a Newborn Screening form requires only a very small amount of sample to be submitted, a wealth of information can be obtained from the laboratory testing that is performed. With early detection, treatment and proper follow-up care, infants with these disorders may avoid serious health problems and even death. Th at is why it is import-ant that samples be properly collected and submitted promptly, with forms that are accurately fi lled out. For more information on the collection of Newborn Screening fi lter form specimens, check out the new educational Power Point presentation at the State Laboratory of Public Health website (http://slph.state.nc.us/) and locate “Form Training” under Newborn Screening. Any additional questions may be directed to the Newborn Screening/Clinical Chemistry Unit at (919) 733-3937. Article Submitted by: Patty Atwood, BSMT (ASCP) Supervisor, Hemoglobinopathy Laboratory Lab-Oratory / June 2006 5 LaCrosse Encephalitis in Western North Carolina, 2005 Originally published in Epi Notes LAC is a disease that resides in eastern chipmunks, gray squirrels, and possibly red foxes. Th ese animals produce high amounts of virus within their bodies. A mosquito bites (feeds on) an infected chipmunk or squirrel. During this time, the mosquito is extracting blood from the animal, which could contain LAC virus or other arboviruses. When the mosquito bites a human, virus particles are allowed to enter the human body and infect cells. Th e virus takes over the infected cells, and causes the cells to start making more virus particles that infect additional cells throughout the body. Th is causes an infection that can result in disease. Th e virus is not usually transferred human to human. Th e mosquitoes that transmit LAC are formally named Aedes triseriatus, but often are called the “treehole” mosquito. Th ey earned the nickname because they require standing water in man-made containers or natu-ral treeholes to reproduce and mature. By eliminating these water sources, the number of mosquitoes available to transmit infection will decrease. LAC infection can present itself with various symptoms. According to the Centers for Disease Control and North Carolina has a wide variety of terrains. From the Atlantic Ocean on the east to the Appalachian Mountains and Tennessee border in the west, the state has a varied geography and ecology. Th is diverse ecology supports many arthropod vectors, birds and mammals. In 2005, our state witnessed a dramatic increase in human LaCrosse Encephalitis (LAC) infections. LAC is an arbovirus that is transmitted by arthropod vectors such as mosquitoes. Th ere are hundreds of arboviruses found throughout the world, and many arboviruses can infect humans and cause mild to severe disease. Th e most familiar arboviruses found in North Carolina are West Nile Virus (WNV), LaCrosse Encephalitis (LAC), and Eastern Equine Encephalitis (EEE). Th ese diseases are usually ter-ritorial, meaning that they are usually localized to certain parts of the state. WNV and EEE tend to be found in the eastern part of the North Carolina, and LAC is usually confi ned to the western part of the state. Travel within the state is common; thus these viruses have been detected in humans in areas outside of the normal regions. Th e map below illustrates the county of residence of humans infected by LAC in 2005 (32 cases illustrated). Prevention (CDC), 80%-90% of children with LAC infection develop a mild febrile illness that includes fever, headache and vomiting. Symptomatic children have seizures in about 50% of cases and develop encephalitis and men-ingitis similar to enteroviral infection. LAC infection can produce lethargy and behavioral changes within three to four days post-infection, with sei-zures progressing to coma in 8-24 hours post-infection. Seizures can occur for up to eight years post-infection in a few cases. N.C. Public Health epidemiologists re-quested assistance from the CDC in September 2005 to help investigate the LAC outbreak in western North Carolina. From this work, the state was able to gain important informa-tion and begin to understand the causes of the increased number of infections over the previous years. Of note, North Cont. on page 6 Lab-Oratory / June 2006 6 Carolina had 32 of the 70 cases (46%) detected in the entire United States in 2005. In 2005, eight adult infections and 24 child LAC infections were detected. Th e symptoms ranged from headache, fever and other fl u-like symptoms to central nervous system defi - ciencies such as encephalitis and meningitis. Th is disease caused more severe symptoms in children than in adults. In 2005, 22 of 32 LAC infections occurred in humans under 15 years old, and seven of 32 were older than 60 years old. Th e remaining three human LAC infections were in humans 20-42 years old. Since 2000, North Carolina has seen a steady increase in human cases (Table 1). Overall, North Carolina has had a 457% increase in the number of cases in the past fi ve years. Th is fi nding has resulted in heightened surveillance and has increased public health concern. While the cause of the increase is not completely understood, raising awareness of public understanding regarding how and why the disease is trans-mitted may help decrease the number of infections. Since the discovery of WNV in the United States, arbovirus surveillance has increased in most states, and due to media attention, reporting of other arboviral infections such as LAC has increased. In 2005, the enhanced surveillance activities incorporated N.C. entomolo-gists who performed mosquito habitat evaluations, mosquito trapping, and small mammal evaluations at residences of LAC-infected individuals. Th is was an attempt to determine where the virus was most prevalent and what had contributed to the infections in the area. Decreasing the mosquito vectors is one way to decrease future infections and gather important data. Th e information gathered in 2005 and the enhanced surveillance suggests that LAC infections in North Carolina continue to be a serious problem that aff ects many people, especially children, in the western part of our state. Considerable time and resources on the local, state, and federal levels have been devoted to raising awareness of the potential for arboviral infections and to determining the cause and prevention of infection and the proper diagnosis of the disease. Th e key public health message is to help prevent infection in and around residential areas by eliminating mosquito habitat, wearing insect repellants, and avoiding outdoor areas at dusk and dawn if at all possible. In 2006, public health surveillance will continue and arboviral testing will be conducted at the N.C. State Laboratory of Public Health. For more information on protection from mosquito bites and decreasing mosquito habitat, visit the Public Health Pest Management Website at: http://www.deh.enr.state.nc.us/phpm/html/mosquitoes.html. Submitted by: Joey Johnson, Medical Laboratory Supervisor II, Special Serology March 16, 2006 Photographs appear courtesty of a CDC training presentation. Calendar Year Number of Cases 2000 7 2001 14 2002 20 2003 24 2004 14 2005 32 Table 1. Increase in LAC cases in North Carolina. LaCrosse cont. from page 5 Lab-Oratory / June 2006 7 In addition, there are non-pathological reasons for increased blood glucose. Th ese could include stress, IV fl uids, pregnancy, and medications such as antidepressants, beta-adrenergic blocking agents, corti-costeroids, dextrothyroxine, diazoxide, diuretics, epinephrine, estrogens, gluca-gons, isoniazid, lithium, phenothiazines, phenytoin, salicylates and triamterene. Certain drugs, such as acetaminophen, alcohol, anabolic steroids, clofi brate, disopyramide, gemfi brozil, insulin mono-amine oxidase inhibitors, pentamidine, propranolol, tolazamide and tolbutamide, may cause a decrease in glucose level. References Kaplan LA, Pesce AJ. Clinical Chemistry: Th eory, Analysis, and Correlation. 3rd ed. St. Louis: Mosby, Inc; 1996. Pagana KD, Pagana TJ. Diagnostic and Laboratory Test Reference. 4th ed. St. Louis: Mosby, Inc; 1999. Submitted by: Jennifer Anderson, BS, MT (ASCP)CM Consultant, Laboratory Improvement Lab Test of the Quarter Blood Glucose (Also known as Blood Sugar) Blood glucose is a very common laboratory test that measures the amount of glucose in the blood. Glucose (C6H12O6), a six-carbon polyhydroxyl aldehyde, is metabolized in cells to form ad-enosine triphosphate (ATP) which is the energy source for all biological functions. When we consume carbo-hydrates, they are broken down into smaller sugars, one of which is glucose. Part of the glucose is directly absorbed into the blood stream for immediate energy production. Th e hormone insu-lin causes the body to store any excess glucose in the form of glycogen, fats and proteins for times of glucose shortage (hypoglycemia.) If the glucose levels in the body become too low, these storage molecules are hydrolyzed (broken down) into glucose and released into the blood stream. Th is is an essential process, be-cause glucose is necessary for our survival. Th e human brain could not survive with-out a constant supply of glucose, its pri-mary source of energy. Likewise, it’s dan-gerous to have too much glucose in the blood stream (hyperglycemia) because it can be both a symptom and a cause of-diabetes. Specimen Type: Blood (venous or capillary) Normal Ranges: Premature Infant: 20-60 mg/dl Neonate: 30-60 mg/dl Infant: 40-90 mg/dl Child <2 years: 60-100 mg/dl Child >2 years-adult: 70-105 mg/dl Elderly: increase in normal range after age 50 years Critical Values (may vary slightly by facility) Newborn: <30 and >300 mg/dl Infant: <40 mg/dl Adult Female: <40 and >400 mg/dl Adult Male: <50 and >400 mg/dl When evaluating a patient’s blood glu-cose level it is important to be aware of the fasting status of the patient. For instance, a glucose level of 150 mg/dl is an expected value in a person who ate just one hour ago, but would be considered abnormal if a person had been fasting for eight hours. Th ere are several diff erent diseases state that cause abnormal blood glucose results (see Table 1). Increased Levels Decreased Levels (Hyperglycemia) -Diuretic therapy (Hypoglycemia) -Diabetes mellitus -Corticosteroid therapy -Insulinoma -Acute stress response -Acromegaly -Hypothyroidism -Cushing’s syndrome -Hypopituitarism -Pheochromocytoma -Addison’s disease -Chronic renal failure -Extensive liver disease -Glucagonoma -Insulin overdose -Acute pancreatitis -Starvation Table 1 Lab-Oratory / June 2006 8 Microscope Tips Cleaning the Brightfield Microscope detergent, rinse thoroughly and dry before reusing. 4. Moisten lens paper or cotton swab with lens cleaner and gently wipe all outer optical surfaces. Start from the center and work toward the edge with a rolling and lifting motion. Repeat the process, using a clean area of the paper or a clean swab until all dirt and smudges are removed. 5. Remove each objective from the nosepiece, one at a time, to clean as instructed in step 4. Return the clean objective to its original location before continuing to the next. CAUTION: Do NOT clean the interior of the eyepieces or objectives or the bottom of the condenser. Never take the eyepieces or objectives apart. 6. Clean the mechanical stage and other body parts (non-glass) with Kimwipes or a cloth dampened with detergent or lens cleaner. Remove the stage clips to clean the underside, and dry before returning the clips to the stage. CAUTION: If a corrosive liquid, such as urine or KOH, spills on the stage, immediately disassemble the stage clips and clean the surface. 7. Cover the clean microscope with a non-linty material to prevent dust from settling on clean surfaces. Plastic bags are acceptable replacements for damaged or lost microscope covers. Periodically inspect the power cords and plugs for safety; frayed cords are a potential shock hazard. Always keep a replacement bulb available. Never interchange bulbs between microscopes that are diff erent makes and models. Treat your microscope with the care that a precision instrument deserves. Keep a daily log to record the microscope maintenance as you would for any other laboratory instrument. Watch for Koehler Illumination instructions in the next publication. Submitted by: Colleen Miller, BS MT(ASCP) Laboratory Improvement Consultant Is the microscope in your laboratory dirty and dusty? Has it been neglected and often abused? Th e condition of a microscope’s body is often an indication of its optical and mechanical performance. Unfortu-nately, too often, the microscope gets overlooked for routine care and maintenance. Microscopes are expected to provide many years of reliable service despite continuous neglect. Good preventive maintenance will improve the performance of a microscope and extend its years of service. Preventive maintenance includes regular cleaning, setting for Koehler Illumination, and annual service by a professional. Clean the microscope daily to remove dust, grease and grime which can damage the optics, erode the surfaces, and interfere with correct use. Take particular care when cleaning the optics as they are easily scratched. Th e instructions that follow will guide you as you perform an important laboratory task. 1. Assemble the following supplies: • Squirrel or camel hair brush (such as an artist brush) • Lens cleaner (formulated for microscope or camera optics) • Lens paper • Cotton swabs • Air bulb • Detergent (mild) and Kimwipes for cleaning stage and stand 2. Unplug the microscope and wash your hands before starting. 3. Remove dust from the microscope, starting at the top and working down. Use the air bulb and brush to remove dust from the optical glass surfaces, i.e., eyepieces, objectives, condenser lens and fi lters. CAUTION: Never use a dirty brush. Clean a soiled brush with Lab-Oratory / June 2006 9 Quality Assessment Updates Clinical sample submissions Accompanying each sample is a requisition that contains the necessary information for performing a test. It is essential that all the information be completed accurately and as neatly as possible. Some facilities use labels, which are easier to read than handwritten information. Patient and facility informa-tion that is unreadable or smudged on the requisition or samples can cause a delayed turnaround time for that sample. Th e Clinical Laboratory Improve-ment Amendments (CLIA ’88 and ’03), 42CFR493, Subpart K, lists the minimum requirements for the clinical sample requisition: • Name and address of submitted, including EIN number • Patient’s name or unique identifi er • Sex and date of birth or age • Tests to be performed • Source of specimen, if appropriate • Date of collection and time, if appropriate • For Pap smears, the patient’s last menstrual period, an indication of whether the patient had a previous abnormal report, treatment or biopsy. • Any additional information relevant to testing • Other additional information required on State Laboratory requisitions: o Social Security Number (Patient number) o Medicaid Number, if applicable o Race/Ethnicity o County of residency Th e sample itself needs two identifi ers (State Laboratory requirement): • Patient name or unique identifi er and • Either date of birth or Social Security number (SSN) • Source of specimen, if appropriate Th e use of the patient’s Social Secu-rity number on sample requisitions has recently raised questions. After legal review, it was determined that “collection of SSNs from patients will be impera-tive to the performance of several legally prescribed duties, including:…..sub-mission of specimens to the state public health laboratory…” (Hoke & Moore memo, November 30, 2005, p.2). It is necessary that the patient’s SSN be submitted. Occasionally, a patient may present to the facility without a SSN. A temporary SSN may be constructed and used until a permanent SSN is obtained. Directions for creating a temporary SSN have been provided to all the local health departments. It is imperative that the local facilities are consistent in the creation of this temporary SSN; hyphenated names present a chal-lenge for a temporary SSN. Some facilities have developed policies to address Hispanic names. Th is is an excellent step because it provides a standard that can be applied across the facility. Being consistent in creating a temporary number at the local level will always provide the same temporary num-ber on specimens submitted to the State Laboratory. Questions about sample submission may be addressed to the Quality Assessment Unit, 919-807-8750. Article submitted by: Vickie Whitaker, BA, MT (ASCP) Quality Assurance Manager Lab-Oratory / June 2006 10 the wrong patient. Tragically, patient identfi ca-tion errors often mark the beginnings of a journey leading to patient mismanagement, misdiagnosis, and even death. Th at is why the Clinical and Laboratory Standards Institute (CLSI) recommends the following steps for outpatient identifi cation: • Ask outpatients to give their full name, address, identifi cation number, and/or birth date. • Compare the information with the information on the test request form. • Report any discrepancy, however minor, to a responsible party and have the patient identifi ed by name and identifi cation number before collecting any specimen. Document according to facility policy. For outpatients who are too young, mentally incompetent, or do not speak the language, the collector should: • Ask the nurse, a relative, or a friend to identify the patient by name, address, and identifi cation number and/or birth date. If unable to identify the patient, then contact the nurse or physician. Interpreter services should be accessible for non-English speaking patients who present to the laboratory without a relative or friend who can interpret for them. So, what assumptions lead to patient misidentifi cation? • Assuming errors in patient orders never occur, so that you never verify the information presented. • Assuming that any minor discrepancy noted in the identifi cation process is not worth pursuing. • Assuming the correct patient is in your phlebotomy chair simply because he/she responded when you called their name, without regard for patients who may have misunderstood you because they are hard of hearing or do not fl uently speak English. • Assuming that under certain circumstances, it’s okay to deviate from your agency’s patient identifi cation policy (i.e., during staffi ng shortages, when dealing with a backlog of patients, etc.). I eventually made it home that fi rst day of second grade, thanks to a compassionate bus driver. But make assumptions about the identity of your patients and the results that follow may not be nearly as forgiving. Patient misidentifi cation: It’s an unintended journey you don’t have to take. Patient Misidentification: An Unintended Journey Some of my most vivid childhood memories are of the fi rst day of school. Th e fi rst day meant my mom would drive me to school rather than having to ride the bus, and together we would carefully check the class rosters for my name. I distinctly recall the fi rst day of second grade. Until that day, I hadn’t known who my teacher would be or the classmates who shared a similar fate. However, I was sure about one thing; I knew which school bus would take me home. After all, I had ridden Bus 78 all of fi rst grade. When class dismissed for the day, I headed across the parking lot toward the bus that had taken me home every school day the year before. As I climbed aboard, the children were abuzz with conversa-tions I quickly joined. It was not until minutes later that I realized Bus 78 was heading down a diff erent road in the opposite direction of my house. My realization soon turned to panic and ultimately into sobs as the landscape outside the bus window became more foreign. So on that fi rst day of second grade, I learned an important lesson about making assumptions. Just like reassigned school buses, assumptions can take you on an unintended journey. With regard to patient identifi cation, making an assumption about one’s identity rather than consistently adhering to patient identifi cation protocols can set into motion unintended con-sequences for the patient, the employee, and the employer. Patient identifi cation is the fi rst and most critical step in blood specimen collection. No amount of technological advancement or sophisticated equipment can produce an accurate result from a specimen drawn on Needle Points By Lisa O. Ballance, BSMT (ASCP) EDITORIAL Lab-Oratory / June 2006 11 The Safety Corner Exposure Control Plan Series-Exposure Determination According to OSHA’s Bloodborne Pathogen Regulation, each employer who has an employee(s) with occupa-tional exposure shall prepare an expo-sure determination. An occupational exposure is any reasonably anticipated skin, eye, mucous membrane, or parenter-al contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties. An exposure determination is a listing of all job classifi cations in which employees will be exposed—such as laboratorians—or may occasionally be exposed—such as custodians—to po-tentially infectious materials on the job. Each supervisor should identify, evalu-ate and classify each task performed within the facility. Th is should be done without regard to the use of personal pro-tective equipment. In order to classify, a supervisor and employee must: • Identify the body fl uids that are likely to be contaminated with HIV, HBV and other viruses. • Determine the amount of body fl uids that the employee is likely to encounter as a result of performing the procedure. • Determine the probability of the employee being exposed to contaminated body fl uids as a result of performing the procedure. • Identify the ways HIV, HBV or HCV could enter the employee’s body as a result of performing the procedure. • Identify the engineering controls that should be used while performing the procedure. • Identify the work practice controls that are necessary to perform the procedure. Once the exposure determination has been completed and all engineering and work practice controls are in place, proper personal protective equipment may be added to ensure a safe work environment. Look for the next installment of the Exposure Control Plan series in the Fall Lab-Oratory, when employee education and training will be discussed! Article submitted by Kristy O’Briant, BS, Laboratory Improvement Consultant, NCSLPH Upcoming Event: North Carolina Clinical Laboratory Day Americans, causing debilitating complica-tions such as coronary artery disease, renal failure, adult-onset blindness, stroke and neuropathy. Th e conference is designed for health-care professionals, including physicians, medical technologists/technicians, nurses, educators and others involved in the diagnosis, care and management of patients with diabetes. Exciting lec-tures are scheduled throughout the day. Exhibitors will provide free samples and information on tests for diagnosis and management of diabetes. For more infor-mation, call the Laboratory Improvement Mark your calendar for an exciting edu-cational event on Friday, August 4, 2006 at Wake Technical Community Col-lege. Th e focus of the 2nd annual North Carolina Clinical Laboratory Day is “Th e Diabetes Challenge: Diagnosis, Education, and Management.” Th e Texas Health Foundation, the North Carolina State Laboratory of Public Health, and the North Carolina Diabetes Prevention and Control Branch will cohost the con-ference. Participants will fi nd the forum an opportunity to learn about the disease that is the sixth-leading cause of death in the United States. Diabetes has become a major public health threat to millions of offi ce at 919/733-7186, or visit http://slph.state.nc.us/LabImprovement (after June 12th). Submitted by: Colleen Miller, BS MT(ASCP) Laboratory Improvement Consultant Lab-Oratory / June 2006 12 “Dear Lab-bey” While this clinician’s concern for patient discomfort is admirable, it is not advisable to use anything other than sterile non-bacteriostatic saline to reduce discomfort when collecting a male urethral smear. According to Cami Hartley, State Lab Microbiology Supervisor, Neisseria gonorrhoeae is very sensitive and can be killed very easily. Xylocaine would defi nitely kill the organism and any oil-based substance will inhibit or prevent growth. Th e Sexually Transmitted Disease Assessment, Prevention, and Treatment Protocols, published by the N.C. HIV/ STD Prevention and Care Branch, lists the following steps for collecting the male urethral specimen for gram stain and gonorrhea culture: “Use a Calgiswab to collect a sample of the discharge. If discharge is not apparent, penis should be milked from base to tip to express discharge for collection. Insert the tip of the swab one to two centimeters into the meatal opening and gently rotate for three to fi ve seconds. Th e swab may be moistened with sterile non-bacteriostatic saline to reduce discomfort. - For gram stain, roll the swab along the glass slide. - For gonorrhea culture, roll the same swab in Z pattern on the gonorrhea culture plate and cross streak.” Every health department should have a copy of this valuable reference. If you do not, please contact the HIV/STD Prevention and Care Branch at (919)733-2030. One of our clinicians would like to use xylocaine or KY jelly on the urethral swab for GC culture to reduce discomfort. Will this interfere with the growth of the GC? “Dear Lab-bey…” If you have a technical laboratory question that you would like to have answered please submit it to: Jennifer.A.Anderson@ncmail.net. The answer to your question may be featured in the next edition of Lab-Oratory. Lab-Oratory / June 2006 13 North Carolina Public Health Phlebotomy Initiative A new and innovative phlebotomy competency assessment program, especially designed for North Carolina local health department laboratories and other interested public health agencies, was introduced in March by the Laboratory Improvement Unit. From March through May, eight half-day North Carolina Public Health Phlebotomy Initiative training sessions were held at various locations spanning the state. A total of 125 N.C. Public Health employees attended. Th e goal of Session 1: Assessing Competency was to deliver current continuing education to participants, along with guidance for establishing standardized and comprehensive phlebotomy assessment programs in their own facilities. Th is was accomplished using a combination of educational videos, question and answer sessions, and formal lecture. Also provided to attendees were competency assessment tools and a model blood collection procedure, all based on the current standard of care for phlebotomy. As a prerequisite, participants—including supervisors, laboratory profession-als, phlebotomists, nurses, and other healthcare staff —were required to possess at least one year of phlebotomy experience. Attendees who scored 80% or higher on the fi nal examination were awarded a certifi cate of completion for the course. Th e benefi ts of implementing a phlebotomy competency assessment program include reducing to the lowest possible degree the risk of patient and/or employee injuries associated with blood specimen collection and thus reducing the employer’s potential for legal liability. In addition, regular evaluation of blood collection policies and procedures, as well as of the staff who perform these duties, is key to ensuring that consistently high-quality specimens are obtained and submitted for patient testing. Laboratory Improvement strives to provide comprehensive and relevant training designed to meet the ongoing needs of the laboratory community it serves. Th e North Carolina Public Health Phlebotomy Initiative is just one example of the Unit’s creative approach to meeting an identifi ed need with a new course topic, unique format, and local delivery. Due to the overwhelming positive response to this initial course off ering, we look forward to developing additional sessions for this series. Article submitted by: Lisa O. Ballance, BSMT(ASCP) Regional Laboratory Improvement Consultant, Course Director Fayetteville Regional Offi ce, NCSLPH Lab-Oratory / June 2006 14 Who’s New in Public Health? We have a few more newcomers to North Carolina’s Public Health arena. We would like to extend a warm welcome to you all. As always, we hope you will continue to stay with us and will fi nd your job both enjoyable and fulfi lling as you serve the citizens of North Carolina. Johnston County welcomes Ree Wiley. She will begin at Johnston County on June 12, 2006. --------------------------------------------------------------------------- Moore County welcomes Nicole Cooley, MLT (ASCP.) Nicole started at Moore County in January 2006. --------------------------------------------------------------------------- Onslow County welcomes Loretta Lloyd. --------------------------------------------------------------------------- Pitt County would like to welcome Fashikie Smith and Latrica Hodges as new employees. --------------------------------------------------------------------------- Person County would like to welcome Jessica Walker. Jessica is an MLT I and joined Person County on March 13, 2006. --------------------------------------------------------------------------- Richmond County welcomes Jo Ann Meany. --------------------------------------------------------------------------- Here at the State Lab in Raleigh, we would like to recognize the following individuals: Virology welcomes Jamie Batchelor and Delshawn McLean. Special Serology welcomes Kalpana Patel, Medical Laboratory Technologist I. Microbiology welcomes Lara Godwin, Debra Springer, and Kemmy Ajisebutu. Cyto Prep welcomes Rebecca Sheppard, a Peace College student. Laboratory Improvement welcomes Janice West, Medical Laboratory Technologist I. Lab-Oratory / June 2006 15 Kudos! In the spring of 2005, the NCSLPH began naming a State Lab Employee of the Month. Employees are encouraged to nominate co-workers who demonstrate great work ethics and always lend a helping hand. In March, Cora Gibson in Lab Improvement was honored, and Juanita Harris of Virology/Serology was the April recipient of the award. Th e May recipient was Laurent Th ibault from our Laboratory Preparedness branch. Congratulations to all of our winners and thank you for your contributions to the NCSLPH! Congratulation also goes out to Claudette Bass from the Pitt County Health Department on her retirement! Good luck, Claudette, and enjoy! Xinhua Song and Natalie Sonin from Cancer Cytology have taken and passed the Specialist in Cytology exam given by the American Society for Clinical Pathology. Th is is the highest designation of Cytotechnologist recognized by the ASCP. Susie Lavender, Supervisor-Cancer Cytology and Chris O’Connell, Head Cytotechnologist are also recognized as Specialists. Great job! Please contact Kristy O’Briant at (919) 733-7186 or kristy.obriant@ncmail.net if you would like to recognize a co-worker at your facility. Each year, our Bath Building employees are honored with service awards. In September, we will honor many employees who have served the people of North Carolina from 5 to as long as 35 years! Please join us in thanking all of these employees for their hard work and dedication to the state of North Carolina! 5 years Alisa Alston (Feb) Joy Chiavacci (Jun) Graciela Reynoso(Jun) Deborah Campbell (Jul) Julie Kase (Jul) Holly Lee (Jul) Kate Sperry (Jul) Wayne Maynard(Aug) Crystal Poppler (Aug) Larry Th omas (Oct) Yolande Williams (Dec) 10 years Earl Hazelton (Mar) Peggy Brantley (Apr) Gloria Silber (May) Shirley Jordan (Jun) Roger Brown (Aug) Colleen Miller (Dec) 20 years Denise Givens (Jan) Mark Minzer (Mar) Mary Noel Dodd (Aug) Cynthia Currie (Nov) 25 years William Glenn (Jan) Samuel Merritt (Apr) Nancy Jones (Jun) Joy Hayes (Sept) Terry Hogg (Sept) Robert King (Sept) Vickie Whitaker (Nov) 30 years Georgena Millar (Jan) Sallie Szymcyk (Jan) James Harris (Aug) 35 years Linda Wall (Sept) Lab-Oratory / June 2006 16 Newborn Screening E R V Y P U V K R F A E M T J M R E H G S H U R M S I S B H T D E T E C T I O N G D D O T E Y N P S A E E R E D R O S I D D I C A O N I M A A O W Y I E J L V N U T E X V Q R X R I L Z X L O I E D I L S M U W Y Z E T A X C B O B C A P T R T E S D N O I K Z H L K L A N T S R N S H S H E A S Y Q I R B D D B S K Z K N W O M S D Y I Y C D A L Q B G A A L R A J E S H D O Z I E M H Y D R T L X O A Y S T L F U S T C Z E B K V T N S L A D D L L N P Q X E E U C A O H I M Y L R W N T T Q O I G I Y G F C M C K T X N F I M T E X E R E D Y N O C N F D R H X E P T R U C Y A V D O Z R O V M M A G A C I Y P I L N D L R I T S X F D L H S V E C I R U Y P Z C H K E S H I K U S Z J A E F W H I R A C Y O T M D B C W U G A B S S Q T M J C V D F T P R T E X T O X I B U O Q W Q P N Z G F C D N M L X H Q O I G A D S O U N G P M E R I R F I O Q G L Y M N F D Z M F Y R W X M Z M C C M A S P R W B R C L T U C P L R Y N Q W C U Z T B L O O D S P O T S P E C I M E N G T N V S R D O A R E I H A I M E S O T C A L A G L Q B D L Q O M D J P W B D Q U F D C N Z J E G F V S H M Z G U E Y Y P A I I T U X M A A S E V X C Z Z J L I F R T B F F S Y W Z T F W D D C K X Y I E I R F K E X R O N M O M V W H K D Z E M F M V C C I T E N E G Y R D Q O W B V J I E D W E C F B F AMINO ACID DISORDER BLOOD SPOT SPECIMEN DEATH DETECTION FATTY ACID DISORDER GALACTOSEMIA GENETIC HEALTHY HEMOGLOBIN HYPOTHYROIDISM MENTAL RETARDATION METABOLISM NEWBORN ORGANIC ACID DISORDER PHENYLKETONURIA PKU PREVENTION SICKLE CELL DISEASE TANDEM MASS SPECTOMETRY TREATMENT Created by Puzzlemaker at DiscoverySchool.com Lab-Oratory / June 2006 17 Brain Exercise Test your laboratory knowledge. Select the best answer(s). 1. What arbovirus causes the highest incidence of disease in the western part of the state and has the greatest eff ect on children? (West Nile, Eastern Equine Encephalitis, Rocky Mountain Spotted Fever or LaCrosse Encephalitis) 2. Generally speaking, what is/are the preferred sample(s) to diagnose a current or recent infection in Serology? (CSF only, Acute serum only, or Acute and Convalescent serum, or Convalescent Serum only) 3. For serology testing at the CDC, where should the submitting lab send the sample? (CDC directly, Private lab for referral or State Lab/with request for testing at CDC) 4. What form(s) is/are required for samples that need to be sent to the CDC for serology testing? (NC Serology form DHHS #3445, CDC DASH 50.34 form, both, or neither) 5. What serological method is used for Brucella testing at the N.C. State Lab? (Tube Agglutination, Immunofl uorescent Assay, Enzyme Immunoassay, or Latex Agglutination) 6. In what year was West Nile Virus fi rst detected in N.C.? (2000, 2001, 2002, or 2003) 7. What does the RPR test detect? (only syphilis antibodies, only anti-treponemal antibodies, or only reagin antibodies) 8. Why is it important to check the needle drop volume when performing RPR testing? (assure no restrictions in needle bore, assure proper antigen/antibody ratio, or assure proper antibody volume) 9. Who is responsible for assuring that all reagents and supplies have proper dating? (supervisor, health director or testing personnel) 10. What type of specimen is needed for follow-up testing of abnormal hemoglobins at the N.C. State Lab? (dried blood spots, serum, or EDTA blood) 11. At the N.C. State Lab (Blood Group/Antibody Screen Lab), what test(s) otherthan blood grouping and typing, is/are performed on prenatal patients? (antibody screening, antibody identifi cation, and/or weak D (Du) typing) 12. What type of specimen is acceptable for blood lead testing at the N.C. State Lab? (serum or EDTA blood) Questions submitted by: Pat Th ompson, BS MT(ASCP) Lab Manager Wilson County Health Department Joey Johnson, Supervisor Special Serology NC State Lab of Public Health Lab-Oratory / June 2006 18 Th e Th ird Annual Epi Teams Conference was held on May 17, 2006 at the Sheraton Imperial Hotel in the Research Triangle Park in Durham. North Carolina Public Health Preparedness and Response sponsored the event, partnering with the Division of Pub-lic Health, the Division of Environmental Health, the State Laboratory of Public Health, General Communicable Disease Control, and the Institute for Public Health. Th is free event included the following topics: • Teamwork for Successful Public Health Investigations • Legionellosis Outbreak Associated with a Rental Cottage in the Outer Banks in May 2005 • Cluster of LaCrosse Encephalitis Cases in Western North Carolina in July and August 2005 • ICS for Disease Outbreaks • Planning and Executing a Drive-Th rough Infl uenza Vaccination Clinic Using ICS in Catawba County in December 2005 Third Annual Epidemiology Teams Conference: LEADING THE INVESTIGATION • Mercury Incident in a School in Granville County in 2005 • An explanation of the HIV/ STD Rapid Intervention Outbreak Team • Epi Team Standard Operating Procedures Committee Report • Summary of the Intra-uterine Fetal Demise Investigation done in Alamance County in December 2005 • Investigation to determine Community Acquired Pneumonia or Bird Flu • Hospital Surveillance for Community-Associated Methicillin-Resistant Staphylococcus aureus • Communicable Disease Surveillance Reports: A Tool for Local Health Departments. Th e topics were relevant and up-to-date, and the conference allowed participants to hear the background stories behind the headlines from the individuals who had experienced them fi rst-hand. It also provided the opportunity to meet and network with other public health workers. Most importantly, the conference provided participants from all over the state the opportunity to learn from each other and gather information that may be useful should a similar event occur in other regions. Submitted by: Crystal Poppler Lab Manager, Laboratory Improvement Learning On-Line Due to rapid advances in medical technology, continuing education is vital to laboratorians. It is important to review information previously learned to maintain current skills, and continuously learn new information in order to provide the best possible care for patients. Often, employers require a certain number of hours of continuing education each year as well. With budgetary and staffi ng constraints, this is sometimes diffi cult to achieve. Fortunately, there are many sources of laboratory continuing education, many of them FREE or very inexpensive, on the Internet. We will be sharing some of our favorites each quarter in the Lab-Oratory. Two such sites are www.merckservices.com/portal/site/merckservices/index.jspzQzmenuItemzEzMedi-calzUz20EducationzUz20Sites www.ascp.org/education/default.aspx We have provided the links to these sites because they have information that may be of interest to our readers. Th e State of North Carolina and the N.C. State Laboratory of Public Health do not necessarily endorse the views expressed or the facts presented on these sites. Further, the State of North Carolina and the N.C. State Labora-tory of Public Health do not endorse any commercial products or information that may be presented on or could be advertised on these sites. Submitted by Jennifer Anderson, BS, MT(ASCP)CM Consultant, Laboratory Improvement Lab-Oratory / June 2006 19 UPCOMING EVENTS . . . June 20-23, 2006 Bacteriologic Methods in the Analysis of Drinking Water* July 13, 2006 Packaging and Shipping Workshop* July 18, 2006 PHTIN: Group B Strep presented by Melissa Miller, PhD of UNC Hospitals, and Sheila Cromer of Women’s and Children’s Health (More information to follow) July 21, 2006 State Lab Orientation* August 4, 2006 2nd Annual Clinical Lab Day “Th e Diabetes Challenge: Diagnosis, Education, and Management” August 8-9, 2006 Basic Microscopy: Viewing and Reviewing* August 10, 2006 Wet Mount Workshop* August 15-18, 2006 Process Control Chemistry Workshop* August 24, 2006 Bioterrorism Workshop* September 6-7, 2006 Advanced Urinalysis Workshop* September 12, 2006 Packaging and Shipping Workshop* September 13-14, 2006 Lab Methods in the Diagnosis of Gonorrhea* September 27, 2006 Diabetes Training Workshop—CANCELLED (Please Refer to Clinical Lab Day) September 29, 2006 State Lab Orientation* October 11, 2006 Advanced Microscopy: Viewing and Reviewing * October 12, 2006 Wet Mount Workshop* October 25, 2006 Basic Microbiology and Gram Staining Workshop* November 1-2, 2006 Lab Methods in the Diagnosis of Gonorrhea* November 8, 2006 Policy and Procedure Writing* November 14-17, 2006 Bacteriologic Methods in the Analysis of Drinking Water* November 30, 2006 Bioterrorism Workshop* *Additional information for laboratory improvement workshops and applications can be found on the SLPH web site at http://slph.state.nc.us/LabImprovement/default.asp. Lab-Oratory can also be found on the web at http://slph.state.nc.us/ under “Lab Improvement”. Laboratory Improvement P.O. Box 28047 Raleigh, NC 27611 State of North Carolina • Michael F. Easley, Governor Department of Health and Human Services • Carmen Hooker Odom, Secretary Division of Public Health • www.dhhs.state.nc.us N.C. DHHS is an equal opportunity employer and provider. 600 copies of this public document were printed at a cost of $448.91 or $0.75 per copy. 06/06 Holly Lee, Virology/ Serology; Patty Atwood, NBS/CC; Susie Lavender, Cytology; Brenda Webber, Cytology Jennifer Anderson, Lab Improvement; Kristy O’Briant, Lab Improvement; Colleen Miller, Lab Improvement Crystal Poppler, Lab Improvement; Janice West, Lab Improvement; Tony Ivosic, QA; Debra Springer, Microbiology E D I T O R I A L b o a r d Brain Exercise Answers: 1. LaCrosse Encephalitis; 2. Acute and Convalescent Serum; 3. State Lab/with request for testing at CDC; 4. both; 5.Tube Agglutination; 6. 2000; 7. only reagin antibodies; 8. assure proper antigen/antibody ratio; 9. testing personnel; 10. EDTA blood; 11. antibody screening and weak D (Du) typing; 12. EDTA blood |
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