INTRODUCTION TO LABORATORY MEDICINE (CLINICAL LABORATORY)

DR. dr. Tinny Rasjad SpPK (K)

CLINICAL LABORATORY
CLINICAL PATHOLOGY MICROBIOLOGY PARASITOLOGY

LEARNING OBJECTIVE
1. Understand the use of laboratory tests in clinical practice.

2. Define the sensitivity, specificity, reliability, and accuracy of a laboratory test.

3. Define the predictive value of positive and negative test results and how they vary with changes in the prevalence of disease. 4. Understand the meaning of the reference interval of a test and how it is manipulated to increase the test's sensitivity and specificity. 5. Understand the principles of anticoagulation in blood collection tubes and the differences between plasma and serum. 6. Define and give examples of pre-analytical, analytical, and post-analytical variables that affect laboratory tests. 7. Understand patient factors that alter tests results such as age, sex, habits and underlying disease.

General Laboratory (General Principles of CLINICAL LABORATORY)

CLINICAL CHEMISTRY HEMATOLOGY HEMOSTASIS AND THROMBOSIS BLOOD BANK URINALYSIS AND OTHER BODY FLUIDS IMMUNOPATHOLOGY MEDICAL MICROBIOLOGY MEDICAL PARASITOLOGY MOLECULAR PATHOLOGY

Schedule:
First half semester (7 weeks)
Lab. Clinical pathology + Middle test 6 weeks lecture + seminar
Introduction Hematology Urinalysis Clinical chemistry Serology

Second half semester (7 weeks):

Microbiology & Parasitology + middle test + final test Six weeks (lecture)
4 weeks: Microbiology: Staining (Gram; BTA, etc) 2 weeks: Parasitology: Malaria, Toxoplasmosis, etc

Grouping
A (80 students) Amphy room B (80 students) Class room II ( 3rd floor of Physiology Laboratory Building) EC (English class) English class room (4th floor of new building)

Clinical Pathology Seminar

A / B groups:
Divided into 4 groups (20 students each) (KBK room no. 3.17 to 3.20) Each group to be divided into 3 sub groups (6-7 students each)

English class:
Divided into 2 groups (20-30 students each) (KBK room no. 3.15 & 3.16)

Task Group:
Submitted 3 days before seminar

The use of laboratory tests in clinical practice.

Clinical assessment
Interpretation of results

Interpretation of results

Laboratory study results

Determination of additional clinical information needs

Clinical observation

Selection of laboratory studies

Selection of laboratory studies

Cyclic structure of the use of medical studies

The role of the laboratory test

1. Screening
Detect subclinical disease Detect and quantify the risk of future disease

2. diagnoses
Establish and exclude the presence of disease in symptomatic persons ( in differential diagnosis )

3. Helpful patient management

Assess disease severity estimate prognoses Detect disease recurrent Select appropriate therapy Monitor disease progress and treatment effect

Clinical information need for lab. test

1. 2. 3. 4. 5. 6. 7. 8. Assess organ functional status Assess metabolic activity Assess macro- and micronutritional status Detect and quantity tissue injury Detect and monitor neoplastic condition Detect and identify infectious agent Detect and identify intoxicants and poisons Monitor therapeutic agents

 ALSO PLAY A LEADING ROLE IN

EDUCATION AND RESEARCH INFORMATION TECHNOLOGY DESIGN AND IMPLEMENTATION QUALITY IMPROVEMENT

Perfect Test
1). Accurate 2). Precise 3). Discriminating 4). Pain free 5). Risk free 6). Inexpensive 7). Useful

Role of lab tests

Correct diagnosis Appropriate therapy

Restoration of patient health to normal

Diagnosis
Diagnosis is most important; a test or procedure that helps detect, confirm, document or exclude a disease. Once a disease is suspected, further tests aimed to increase or decrease the diagnostic certainty of one diagnosis to the exclusion of others.

Prognosis
Prognosis can be predicted, for example, by noting the degree of test abnormality. The higher the transaminase level in hepatitis, and the higher the creatine kinase MB isomer level in acute myocardial infarction, the more serious the disease and usually the worse the prognosis.

Symptomatic Patients:
1. Non-specific complaints 2. Specific problem already identified

Non-specific Complaints

1. Battery of chemistry tests 2. CBC (Cellular Blood Count) 3. Urinalysis Problem: Solution: Positive test Repeat abnormal test false positive results

Specific problem

Defined set of differential diagnosis

Screening tests to pare down differential diagnosis (high sensitivity for a disease)

1). test negative disease excluded 2). test positive true positive false posiitive

USE TEST(S) WITH HIGH SPECIFICITY

Test characteristics
Normal : A term with many meanings, including those persons in the nondiseased population and an equivalent term for a gaussian distribution Abnormal : test result outside of reference intervals observed in people with desease or in less than good health Reference interval : the interval between including two reference limit Cut off value : limit above or below which the patient is abnormal or positive for a condition such as substance abuse Prevalence : the number of persons who have a disease in a given population at any one point in time, or more often the rate of such disease, which is also called the disease frequency

 Specificity : the probability that a laboratory test will be negative in the absence disease; defined as a true negatives divided by the sum of true negatives and false positive Sensitivity : probability that a laboratory test is positive in the presence of disease; defined as true negatives divides by the sum of true positives and false negative

 Predictive value : probability that a laboratory result accurately reflects the true presence or absence of disease Positive predictive value : probability that a lab. result outside the reference interval actually reflects the presence of disease; defined as true positive divides by the sum of true positives and false positives Negative predictive value : probability that a lab. result falling; defined as true negatives divided by the sum of true negatives and false negatives

Predictive value
Condition (e.g. Disease) As determined by "Gold" standard True False Positive Predictive Value

Positive
Test outcome Negative

True Positive

False Positive

False Negative

True Negative

Negative Predictive Value

Sensitivity

Specificity

Accuracy

Precision
Test precision is a measure of a test reproducibility when repeated on the same sample. Reproducibility within day and between day An imprecise test is one that yields widely varying result on repeated measurement

High precision but low accuracy

Accuracy
The accuracy of laboratory test is its correspondence with true value The accuracy test is maximized by calibrating laboratory equipment with reference material and by participation in external quality control program

High accuracy but low precision

High precision and accuracy

Normal Range & Interpretation of Results

The "normal range" of the mean plus or minus 2 S.D. is a purely statistical concept - by definition 2.5% of healthy individuals will have values exceeding this. In addition, in statistical terms "normal" implies a Gaussian distribution
ex. Normal plasma sodium 136 148 mmol/L

Alb (Albumin)
NORMAL RANGE
3.3-5.2 mg/dl

DEFINITION
This is the major protein in the blood, made only by the liver. It makes up the largest part of the Total Protein level. It maintains the fluid balance in your body.

EXPLANATION OF TEST RESULT

A low level liver disease

Normal Range
Reference values: urea - 10-20 mg/dl
200 mg/dl? 40 mg/dl? 25 mg/dl? could be a false positive?

* How much above normal must the test result be before an intensive chain of studies is set into motion to determine the cause of the alleged abnormality?

FACTORS AFFECTING LAB. VARIATION

PRE-ANALYTICAL ANALYTICAL POST-ANALYTICAL

PRE-ANALYTICAL VARIATION
Precollection causes of variation Cyclic biological variables Patient-related physical variables Normal variation in reference interval Blood collection causes of variation Blood collection technique Types of blood sample Error related to preservatives and anticoagulants

 Postcollection causes of variation

Sample transportation Sample processing Sample storage

Other preanalytical collection concerns

Urine collection : sources of variation Specimen collection from infants Computer-based aids for error detection Criteria for rejection of spesimens

Normal variations in reference intervals

a. b. c. d. e. f. Newborns Children Adult men Adult women Pregnant women Geriatric population

Collection of Blood
Plasma anticoagulant in the collection tube chelating agents(EDTA,citrate) or heparin(enhance antithrombin3) Centrifugation - 3 layers a. plasma b. buffy coat(WBC,platelets) c. RBCs

Serum
blood clots

no anticoagulant
centrifugation

deficient in fibrinogen prothrombin factor V factor VIII platelets

Instrumental Variation (Analytic)

Method and technique variation Analytic bias and variability To overcome: Intra & inter- laboratory quality control (precision, accuracy, coefficient variation)

QUALITY CONTROL
QUALITY CONTROL:

Assessment & Control of ANALYTICAL Variability Used in daily operations of clinical lab. assess precision over time within a single clin. Lab Quality Control : internal and external QC

INTERNAL QUALITY CONTROL

Used daily operations Primary asses precision and method during the day Type :
within run , with replicated result of single performance group together between run, with replicated result from number of different runs group together

External quality control

To assess accuracy of lab. method across of number laboratory

External QC procedure

Post-analytical Variation
Result of the measurement Report the measurement sent to the requesting physician. Interpretation laboratory result
Sensitivity & Specificity in diagnosis testing Predictive value

Post-collection Causes of Variation

Result of the measurement

Interpretation resulting Specificity,sensitivity,p redictive value