UA/BF/CHEM

anti-cyclic citrullinated peptide (CCP)

A new biomarker for RA has recently emerged. The presence of autoantibodies against cyclic citrullinated peptide (anti-CCP) present in serum has been shown to be approximately 95% specific for the diagnosis of RA. Testing for both RF and anti-CCP may be beneficial when excluding the diagnosis of RA.

Which of the following statements is true regarding the normal viscosity of semen?

A normal sample leaves the pipette in small drops with very little trailing thread. A semen sample that is abnormally viscous will form a thread more than 2 cm long. A specimen that is more viscous than normal after liquefaction may have reduced sperm motility.

Antinuclear antibody (ANA)

Autoantibodies to nuclear antigens (ANAs) are a diverse group of antibodies that react against nuclear, nucleolar, or perinuclear antigens. These antigens represent cellular components such as nucleic acid, histone, chromatin, nuclear and ribonuclear proteins. Testing for ANA is commonly performed to help diagnose many autoimmune diseases.

Which of the following statements is TRUE regarding the reagent strip test procedure?

Urine should be well mixed prior to dipping the reagent strip. Urine should NOT be centrifuged prior to dipping the reagent strip. Not all reagent strip tests can be read immediately after dipping the reagent strip into the urine specimen; the manufacturer's read-times must be followed.

Wick Flow

Wick flow is caused by the movement of the buffer into the support medium. Moisture evaporation from the gel from heat generation during electrophoresis causes movement of the buffer into the gel. Gel absorption of buffer to replace the lost moisture affects the migration of sample molecules. Using a lid or cover during electrophoresis can prevent some of this evaporation. Methods that generate excessive heat utilize a cooling system during electrophoresis to prevent wick flow and other damage to sample solutes.

The expression of receptors on the surface of cells facilitates the binding and uptake of the compound of interest. The receptors to be discussed in greater detail include:

Estrogen and progesterone receptors (ER/PR) Human epidermal growth factor receptor 2 (HER2/neu)

__________is the study of how variations in the human genome affect a given individual's response to medications. It refers to how administered drugs will affect specific patients, given their genetic makeup. Since there are many different genetic mutations and polymorphisms that can affect genes transcribing drug-metabolizing enzymes, different people often respond to the same drug differently.

Pharmacogenomics (usually abbreviated PGx)

Poor sample application technique during the serum protein electrophoresis procedure can result in wick flow in the separated bands upon analysis.

Wick flow is caused by excess heat during electrophoresis and can cause distorted bands. Poor sample application can tear the gel and also cause distorted bands.

Automated electrophoresis systems only include automated reagent addition, electrophoresis of sample, staining of separated fragments, and detection of separated bands.

False Most automated electrophoresis instruments also apply the sample to the medium. Automated sample application prevents many electrophoresis problems associated with applying the sample manually (see pg. 20, Automation).

Agarose gel is made of __________

Polyacrimalide from Seaweed

What causes polyacrylamide gels to have greater resolution of proteins than agarose gels?

Polyacrylamide gels are composed of layers of polyacrylamides and each layer can be created with a different pore size. These varying pore sizes result in more separated bands after electrophoresis.

Polymyositis (PM)

Polymyositis is a rather uncommon chronic inflammatory disease that produces muscle weakness. The condition is characterized by chronic muscle inflammation accompanied by muscle weakness and affects skeletal muscles on both sides of the body. PM can make it difficult to climb stairs, rise from a seated position, lift objects, or reach overhead. It is considered to be an autoimmune disease that is typically observed in adults between the ages of 31 and 60, and is more common in blacks than in whites, with women affected more than men. The condition is relatively rare with an incidence in the United States of approximately 0.5-8.4 cases per million people.

Proteins in a buffer with the pH set at 8.6 will become anions and move to the positively charged electrode.

This statement is true. At pH 8.6, the protein sample is above the pI of most proteins. Therefore, at pH 8.6, proteins will take on a negative charge (become anions) and migrate to the anode, the positively charged electrode (see pg. 10, Roles of Buffers and pg. 11, Buffers and pH).

Below are the laboratory results on a 20-year-old male. His waist circumference is 41 inches and blood pressure is 140/90. Fasting Blood Glucose: 90 mg/dL Triglycerides: 180 mg/dL HDL: 45 mg/dL Which of these results would lead to a diagnosis of metabolic syndrome?

Three of the five criteria that are needed to diagnose metabolic syndrome are met: waist circumference >40 inches high blood pressure elevated triglycerides.

Sperm count

To determine the sperm count, sperm concentration is multiplied by the total sample volume submitted. The lower reference limit for sperm count is 39 x 106 spermatozoa per ejaculate.

Which of these triglyceride values would be considered a risk factor for metabolic syndrome?

Triglycerides greater than 150 mg/dL is considered one of the risk factors for metabolic syndrome. High triglycerides in combination with at least two other risk factors would lead to a diagnosis of metabolic syndrome.

Every drug has a sub-clinical concentration (a concentration at which effective therapy won't be achieved) and a toxic concentration (a concentration at which the drug will be harmful to the patient.)

True

TDM and genotyping should be considered complementary and can be used in tandem to predict and then verify appropriate serum drug levels.

True

There is no cure for SARDS

True

Adipokines can be pro-inflammatory or anti-inflammatory.

True Adipokines modulate inflammation and insulin resistance. Obesity-induced insulin resistance may result, at least in part, from an imbalance in the expression of pro- and anti-inflammatory adipokines.

In insulin resistance, plasma glucose and non-esterified fatty acids (NEFAs) increase.

True In insulin resistance, insulin action is inhibited. Lipolysis increases and glycolysis and glucogenesis are decreased. This increases blood glucose and NEFAs.

Following a complete removal of the thyroid gland due to an advanced malignancy, one must be concerned with the level of _____________ as the ___________________ may also be removed or damaged secondary to this surgical procedure.

parathyroid hormone (PTH) ; parathyroid glands

Which statement is TRUE concerning C-reactive protein (CRP)?

CRP and hs-CRP assays are measuring the same protein. A patient with a high CRP will also have a high hs-CRP. Therefore, patients with high CRP cannot be assessed for cardiovascular risk using the hs-CRP assay. hs-CRP is still used to assess risk, despite its limitations.

When the glucose result on a urine specimen from an infant is negative on the urine reagent strip, it can be assumed that the specimen is also negative for other reducing substances such as galactose.

This statement is false. The method used with the urine chemical reagent strip is specific for glucose.

Urine should be at room temperature prior to testing with the reagent strip method.

This statement is true. Urine should be at room temperature prior to testing with the reagent strip method. Urine strip reactivity can increase with increased urine temperature, so the optimum temperature is 22-26o C, or room temperature.

All of the following are abnormal crystals that can be found in urine except:

Triple phosphate crystals are found in normal, alkaline urine. If the crystals are from solutes that are not normally in the urine, they are considered "abnormal." Abnormal crystals may indicate an abnormal metabolic process. These include tyrosine, leucine, and cystine.

The minimum acceptable sweat yield for a valid sweat test using 2x2 inch gauze is 75 mg. What is the minimum acceptable sweat yield for a valid test collected in 30 minutes using the Macroduct® coil method?

The minimum acceptable sweat yield in 30 minutes collection using Macroduct® coil is 15 µL.

One of the ADA's options for the diagnosis of diabetes is the use of a 2 hour plasma glucose (PG) ≥ 200 mg/dL during 75 g oral glucose tolerance test (OGTT).

True Of the 4 options for screening and diagnosing diabetes, one option is the use of the 2-hour plasma glucose (during 75 g OGTT) with plasma glucose result of ≥ 200 mg/dL.

According to the 2022 ADA guidelines, a Hb A1C result ≥ 6.5% can be used to diagnose diabetes.

True The ADA's latest guidelines (2022) indicate that one of the criteria for screening to help diagnose diabetes is a Hb A1C level of ≥ 6.5%. Moreover, the ADA indicates that the glycemic target for nonpregnant adults with diabetes is < 7.0% and lowering A1C below or around 7.0% has been shown to reduce microvascular complications and macrovascular disease. Therefore, a Hb A1C level that is < 7.0% indicates glycemic control for most adults with diabetes.

Which of the following tests included on a urine chemical reagent strip would never be reported out as negative?

Urobilinogen is reported as normal, not negative. A normal urobilinogen result is approximately 0.2-1.0 Ehr U/dL

What is the MINIMUM number of sperm that should be counted to achieve the greatest accuracy when performing a sperm count using an improved Neubauer hemocytometer?

A minimum of 200 sperm/side should be counted to achieve a low sampling error.

Which one of the following is the correct definition of isoelectric point (pI)?

A molecule that has both negatively charged groups and positively charged groups is described as amphoteric. These charges can be changed by changing the pH of the solution. The pH where there is an equal number of positive and negative charges is the isoelectric point, that is the molecule has a net charge of zero.

Speckled pattern (IFA)

Associated with SLE, Sjögren's syndrome, scleroderma, polymyositis, RA, and mixed connective tissue disease.

Increased numbers of the cells indicated by the arrows are associated with which of these conditions?

The cells that are indicated by the blue arrows are normal mature lymphocytes. A pleocytosis (increased number) of lymphocytes, including reactive forms (as indicated by the red arrows), is associated with viral meningitis.

Given what you have learned thus far, which of the following statements below is true?

The concentration of a drug in the body is a result of many variables and can be hard to predict. So far we have learned that many factors (protein binding, lipophilicity, bioavailability, elimination, etc.) affect a drug's disposition in the body. Because we usually cannot safely predict how a drug will be tolerated in a person, we use therapeutic drug monitoring (TDM) to verify that a drug is present at an appropriate concentration.

primary hormone

The hormone source is considered primary if the endocrine tissue that normally produces the hormone, produces a hormone in excess

What is the identification of these crystals seen in urine with an alkaline pH?

The identification of the crystals depicted in this image are triple phosphate crystals. Triple phosphate crystals may be normal but are usually associated with alkaline urine. These colorless crystals have a characteristic "coffin lid" appearance.

The initial laboratory evaluation for autoimmune diseases often involves which tests?

The initial laboratory evaluation for autoimmune disease can involve performing: CBC, chemistry metabolic panel, coagulation testing, and a urinalysis. When autoimmune disease is suspected, common laboratory evaluation will serve as an initial red flag to pursue further testing.

Proteins in a buffer that sets the pH at 8.6 will become ___________ charged and migrate to the ____________.

The isoelectric point (pI) of most proteins is between pH 4.0 and 7.5. A molecule in a solution above its pI will take on a negative charge. Negatively charged molecules in an electric field will migrate to the positive electrode, the anode.

Type II Hypersensitivity

The mechanism of Type II autoimmune hypersensitivities is a cytotoxic one in which class IgM or IgG antibodies attach directly to self tissues and can destroy those tissues by either triggering the complement cascade, or by triggering antibody dependent cell-mediated cytotoxicity (ADCC) which leads to activation of natural killer cells (NK cells) or CD8 T cells. These antibodies can also sometimes directly interfere with cell function. A few examples of autoimmune diseases caused by this mechanism are Goodpasture's syndrome, Autoimmune Hemolytic Anemia, and Grave's Disease, among others.

Type IV Hypersensitivity

The mechanism of this type of autoimmunity is cell mediated by pre-sensitized CD4 and CD8 T cells. Some autoimmune diseases have both a type II or III autoantibody component plus a type IV cell mediated component, such as Type I Diabetes, Rheumatoid Arthritis, and others.

Sperm concentration

The number of sperm/mL in a sample is typically determined by counting sperm in a counting chamber. According to the WHO 5th edition, the lower reference limit for sperm concentration is 15 x 106 spermatozoa/mL.

Centromere (peripheral) pattern (IFA)

Associated with scleroderma and CREST (Calcinosis, Raynaud syndrome, esophageal dysmotility, sclerodactyly, telangiectasia).

Nucleolar pattern (IFA)

Associated with scleroderma and polymyositis.

Which of the following represents the lower reference limit for semen volume?

1.5mL

An automated EP is able to separate _________ samples simultaneously

10-100 samples

Northern Blot

(not named after an inventor but by analogy to Southern blotting) separates RNA. RNA molecules are shorter and have defined lengths; cutting by restriction enzymes is not required. Denaturing conditions are required because of RNA secondary structures. After membrane blotting, the separated types of RNA are visualized with staining or labeled probes.

Which statement would NOT fit the definition of a tumor marker?

"The substance that would ordinarily be produced in healthy tissue, but is absent due to tumor overgrowth or suppression" does NOT meet the definition of a tumor marker. A tumor marker is generally classified as the presence of a substance produced by an actively growing tumor, or by the host in response to the presence of a tumor. A tumor marker can be defined as a detectable or measurable substance, or biomarker, produced by the cells of a tumor or by the host in response to the tumor, that provides utility in differentiating the tumor from normally dividing tissue. Some products produced by tumors may include functional compounds, such as hormones (see pg. 2, Tumor Marker, pg. 5, Cancer Predispositions, and pg. 6, Early Detection is Crucial). The following statements MEET the definition of a tumor marker: A substance that actively growing cells within a malignant tumor produce in abundant quantities. A substance that the surrounding healthy tissues produce in response to active tumor growth. A functional hormone that is produced in excess by a malignant tumor.

A sample of cerebrospinal fluid is diluted 1:100; the standard 9 squares of a hemocytometer are counted on each side for a total of 18 large squares. Side 1-- 186 nucleated cells counted Side 2-- 184 nucleated cells counted total nucleated cells = 370 Using the standard hemocytometer formula shown on the right, what is the nucleated cell count per microliter (µL)?

(186+184) x 100/18 x 0.1= 20,556= 2.06 x 10^4

Western Blot

(again not named after an inventor but by analogy to Southern blotting) does not separate nucleic acids; it separates proteins in a mixture. The proteins are usually separated with PAGE, transferred to the membrane and visualized with a labeled antibody against the proteins of interest.

Southern Blot

(named after Edward Southern) restriction enzymes cut fragments of DNA are separated by AGE or PAGE, transferred to a membrane or blot, and visualized by hybridization with labeled probes.

What is the recommended MINIMUM number of spermatozoa that should be counted on each side of the hemocytometer when a manual sperm count is performed using an improved Neubauer hemocytometer?

200

Moderate albuminuria

30-300 mg/g

normal/mild albuminuria

<30 mg/g

Severe albuminuria

>300 mg/g

Sweat testing for the diagnosis of cystic fibrosis (CF) would be appropriate for which one of the following patients?

A 4-day-old infant with a positive newborn screening test result who is not acutely ill A patient who undergoes sweat testing should be at least 48 hours of age and not acutely ill. There may be a transient elevation in sweat chloride concentration if the newborn is less than 48 hours old. A patient with gastroenteritis may be vomiting or have diarrhea, which would result in dehydration that will affect the ability to collect a sufficient volume of sweat and/or accurately interpret the test results. A sweat test cannot be performed over an area of inflammation, such as in eczema, because serous fluid from the lesions may falsely affect the sweat chloride result.

A physician is evaluating a 45-year-old obese male for diabetes and orders a plasma glucose at time of evaluation and a Hb A1C one week later. The patient has a family history of diabetes and currently exhibits symptoms of diabetes. What would be the best course of action if these are the blood glucose results? Casual blood glucose: 208 mg/dL Hb A1C one week later: 7.2%

A casual blood glucose ≥ 200 mg/dL on a patient with symptoms and an A1C≥ 6.5% meet diagnostic criteria for diabetes.

For the ANA test to be positive, what must be present in the nucleus of the interphase cell?

A clearly discernible pattern The strength of the reaction doesn't matter, only that it is clearly discernible. Centromere and dsDNA are just some of the many different antigens; however, without the corresponding (cognate) antibodies from the patient sample there is no ANA pattern. Remember, to be ANA positive there must be a clearly discernible pattern in the nucleus of the interphase cells.

Which statement relative to the treatment and management of diabetes is FALSE?

A combination of insulin injections and anti-diabetic drugs should not be used together. For type 1 diabetes, and more severe type 2 diabetes, medication may be required to control blood glucose levels. Some patients may require insulin injections, while others may take anti-diabetic drugs such as metformin and sulfonylureas. Others may require a combination of insulin and anti-diabetic drugs. Improvements in blood sugar levels can often result from weight reduction, increase in exercise, and a more balanced diet.

What crystal is captured in the image below?

A cystine crystal is depicted in this image. Cystine crystals are present in acidic urine, are typically colorless, and have a characteristic hexagonal shape (also described as appearing similar to a benzene ring). These crystals are associated with cystinuria.

A drug that is administered through which of the following routes will reach peak level the quickest?

A drug that is administered IV will reach peak level the quickest (15 - 30 minutes after injection/infusion). A drug that is injected IM will reach peak level at 30 minutes to one hour after injection; a drug that is taken orally will reach peak level approximately one hour after the drug is taken (if the half-life is > two hours).

What does the presence of an estrogen receptor (ER) in the tissue sampling of a breast cancer biopsy indicate?

A higher degree of treatment success using hormonal therapy Breast cancers in which estrogen receptors (ER) or progesterone receptors (PR) are present are indicated for hormonal therapies. Those tumors that are negative for ER or PR are better suited for chemotherapy, as they lack the steroid receptors for effective hormonal therapy.

A person who is classified as an ultrarapid metabolizer (UM) would need __________ of a drug metabolized by that enzyme.

A higher dose A person classified as an ultrarapid metabolizer (UM) has a polymorphism that enhances the catabolic activity of the enzyme. This means that a UM would need more of the drug to achieve a 'normal' level since he/she is rapidly metabolizing the drug.

Congestive heart failure

A left ventricular dysfunction resulting from aging, hypertension, atherosclerosis or muscle damage from an AMI or repeated AMIs.

Which statement is correct for a protein with an isoelectric point (pI) of 7.0?

A protein's isoelectric point (pI) is the pH where the net charge is zero. This means the protein has an equal number of groups with positive and negative charges. Charged particles in an electrical field will migrate to the electrode of the opposite charge. Because the net charge is zero, this protein will not migrate in an electrical field (see pg. 4, Isoelectric Point (pI)).

Which of the following tests is appropriate to confirm the diagnosis of cystic fibrosis (CF)?

A quantitative sweat chloride test is appropriate to confirm the diagnosis of CF. A sweat conductivity test is a screening test. Direct application chloride electrodes have documented problems with evaporation, making them inappropriate for clinical use. The method is not accurate and is not acceptable for diagnosis. Blood immunoreactive trypsinogen (IRT), a pancreatic enzyme, is measured as a primary screening test for NBS.

Semen viscosity can be estimated by aspirating the sample into a wide-bore plastic disposable pipette, allowing the semen to drop by gravity, and observing the length of the thread that is formed. A semen sample with normal viscosity will produce a thread more than 2 cm long.

A semen sample that is abnormally viscous will form a thread more than 2 cm long. A normal sample leaves the pipette in small drops with very little trailing thread. A specimen that is more viscous than normal after liquefaction may have reduced sperm motility. During sexual intercourse, hyperviscosity can prevent the sperm from reaching the cervix.

What effect may bacterial contamination have on urine pH?

A urine pH above 8.0 may indicate that a specimen has been held unpreserved too long, which allows multiplication of urea-splitting bacteria with resultant increase in pH

Alpha Fetoprotein (AFP)

AFP is normally produced by the yolk sac and the liver during fetal development.2 AFP is the most prevalent protein found in the blood of the human fetus and is believed to play a role similar to serum albumin, which is to transport protein of hormones and micronutrients. Normally, AFP decreases steadily during the first year or life. During pregnancy, AFP levels will rise in the blood, urine, and amniotic fluid of mothers in response to fetal development. Very high levels of AFP during pregnancy are associated with fetal malformations. As a tumor marker, AFP analysis is used in the post-treatment phase of previously diagnosed cancers, as well as in early surveillance of cancer survivors, where the rate of decrease of AFP has diagnostic and prognostic value. Malignant conditions associated with elevated levels of AFP in the blood include: Hepatocellular carcinoma Germ cell and yolk sac tumors Metastatic carcinomas of the liver

Which statement is FALSE when describing the ANA test?

ANA Assay is the primary lab test for RA. RA is the most prevalent disease in SARDs group; however, the ANA assay is NOT the primary laboratory test for RA. Instead, the test for RA looks for the presence of rheumatoid factor (RF) or cyclic citrullinated peptide antibodies (anti-CCP). The remaining answer choices are true. The two common tests used for detecting and quantifying ANAs are IFA and ELISA. The results of the ANA test alone are not diagnostic for the SARD. The patient must also have clinical evidence of the disease as well. Because the early clinical presentation for many of the SARDs are nonspecific, the results of the ANA test and subsequent follow-up testing are key pieces to making the correct diagnosis. The utility of the ANA test is to detect the antibodies early in the disease process. The ANA results in conjunction with clinical presentation give the clinician solid evidence to intervene with an appropriate treatment. Studies have shown that once treatment is started the formation of new antibodies slows or even halts.A

Reporting IFA results includes________________

ANA dilution titer and a description of the fluorescence pattern Example "Positive at 1:320 dilution with a homogenous pattern." When assessing the test results, the clinician must consider the following: The ANA test results can be positive in people without any known autoimmune disease and thus need to be evaluated carefully in conjunction with an individual's signs and symptoms. An ANA test may become positive before signs and symptoms of an autoimmune disease develop; therefore, it may take time to interpret the significance of a positive ANA test in a person who does not have symptoms. Some medications can stimulate the production of ANAs, including procainamide, hydralazine, and phenytoin ANAs that are stimulated by medication are referred to as drug-induced ANAs. Ultimately, the ANA result must be interpreted in the specific context of an individual patient's symptoms, underlying medical conditions, and other test results. It may or may not be significant, even if positive, in a given individual.

Abnormal Sperm morphology

Abnormal heads can include enlarged head, double head, round head, constricted head, amorphous head, pinhead, and acute tapering forms. There are also heads with abnormal numbers of vacuoles (>2 in the acrosomal region and/or vacuoles in the post-acrosomal region are abnormal). Midpiece abnormalities include distended and thin midpiece regions. Abnormal tails include short tails, double, triple, or multiple tails, coiled tail, broken tail, or absent tail. Cytoplasmic droplets are also seen in some specimens. These are large cytoplasm regions just below the head, assumed to represent a failure of complete sperm maturation or a sign of either toxicity or oxidation. There have also been reports that cytoplasmic droplets may be artifacts from the fixation and staining for morphology analysis.

What is the lower reference limit for sperm concentration according to World Health Organization, WHO Laboratory Manual for the Examination and Processing of Human Semen, 5th edition?

According to WHO 5th edition, the lower reference limit for sperm concentration is 15 x 106 spermatozoa/mL.

What patient symptom does NOT point to acute hepatitis?

Acute hepatitis can exhibit several typical symptoms, clear urine is not one of them. The following symptoms are associated with acute hepatitis: Fever Fatigue Loss of appetite Nausea Vomiting Abdominal pain Dark urine Diarrhea Clay-colored bowel movements Joint pain Jaundice

Chronic HBV is least likely to develop in what patient group?

Adults The chances of an HBV infection becoming chronic in an individual is highest among young children. Around 90% of infants and 25% to 50% of children 1 to 5 years old infected with HBV will develop chronic HBV. These rates are lower with adults. Only 5% of adults who contract HBV will develop a chronic infection.

Densitometry

After electrophoresis, a stained gel is passed through the optical system of a densitometer to create an electropherogram, a visual diagram or graph of the separated bands. A densitometer is a special spectrophotometer that measures light transmitted through a solid sample such as a cleared or transparent but stained gel. Using the optical density measurements, the densitometer represents the bands as peaks. These peaks compose the graph or electropherogram and are printed on a recorder chart or computer display. Absorbance and/or fluorescence can be measured with densitometry.

A mutation in a CYP450 enzyme that causes increased enzyme activity would:

All of the above answers are true. A normal (wild-type) allele of a CYP450 gene displays normal metabolic activity, whereas some of the variant forms have enhanced or diminished activity. If the variation of the gene (allele) affects at least 1% of the population, it is considered a polymorphism. If a patient has a mutation in a CYP450 enzyme that causes increased enzyme activity, he/she will probably need a higher dose than the standard dose of any drug that is metabolized by this enzyme. If standard doses are given to a patient that has increased enzyme activity, the drug will probably not achieve the desired effect.

Occasionally, tumor cells develop that begin to produce these proteins that are associated with fetal development, referred to as oncofetal antigens. The most widely studied oncofetal antigens are:

Alpha fetoprotein (AFP) Carcinoembryonic antigen (CEA) During fetal development, certain proteins are produced by the developing embryonic tissues that support the function, growth, and development of the organism. These proteins are later replaced by the proteins that play specific structural or transport roles throughout the adult life of the organism or individual.

Which of the following are genetic indicators of an increased risk of developing breast or ovarian cancer?

Although not true tumor markers in the sense that they do not diagnose active malignancies, BRCA1 and BRCA2 are genetic indicators of a predisposition of developing breast or ovarian cancer at some point in life.

What is the identification of this crystal seen in urine with an alkaline pH?

Ammonium biurate crystals commonly occur in the form of "thorny apples," as shown here, or in polyhedral shapes. They are deeply colored from dark yellow to brown.

Which of the following are considered among the classic symptoms of hyperthyroidism?

Among the classic symptoms of hyperthyroidism are: Weight loss Exophthalmos (bulging eyes) Heat intolerance Nervousness Anxiety Feeling jittery

Immunofixation Electrophoresis (IFE)

An agarose gel electrophoresis first separates the proteins in a serum sample. Antiserum against the protein of interest is spread directly on the gel. The protein of interest precipitates in the gel matrix. After a wash step to remove other proteins, the precipitated protein is stained. This method is qualitative and is used to identify proteins found in multiple myeloma.

Infarction

An area of tissue death that occurs due to lack of oxygen.

Ischemia

An inadequate blood supply that decreases availability of oxygen

A CYP2D6 ultrarapid metabolizer (UM) would require ___________ dose of a drug that is metabolized by CYP2D6 than a CYP2D6 extensive metabolizer (EM).

An ultrarapid metabolizer (UM) would require a higher dose of a drug than an EM (a person with normal enzyme activity) since the UM eliminates the drug more quickly.

Examples of Drugs monitored by TDM

Antibiotics Anticonvulsants Immunosuppressants Cardiac medications There are other drugs monitored by TDM that are not included in any of the above classifications, but the vast majority of TDM testing is performed for drugs that are included in one of these four categories.

anticonvuslants

Anticonvulsants (also known as anti-epileptic or anti-seizure medications) typically have narrow therapeutic windows. When levels are too low, the risk for seizure is present. Drug levels that are too high can depress the central nervous system and can lead to coma. Examples of anticonvulsants that are monitored by TDM include: Carbamazepine (Tegretol) Valproic acid (valproate, Depakote) Phenytoin (Dilantin) Phenobarbital Primidone (Mysoline) Levetiracetam (Keppra) Lamotrigine (Lamicital)

Which of the following statements are TRUE with regard to autoimmune diseases?

Approximately 75% with autoimmune disease are women. Autoimmune diseases are a group of disorders where the body's immune system malfunctions and attacks its own tissues. It is possible for more than one autoimmune disease to be present at same time. Current treatment for these diseases focuses on relieving symptoms, because there is no curative therapy.

A physician needs to prescribe a drug to a patient but the drug has a narrow therapeutic window. He is concerned about possible toxic effects. To assess the upper concentration of such a drug, which time for drawing the specimen do you think makes the most sense?

Approximately one hour after an oral dose The drug should be measured at a time corresponding to the peak concentration (not the trough). One to 2 hours after an oral dose is usually sufficient time for a drug to be absorbed and should correspond to peak concentration. A drug measurement that is taken 2 to 4 hours after an IV injection of the drug will not represent the peak value. A drug that is given via IV enters the circulation immediately, and the peak concentration of the drug would be measured 15 to 30 minutes after the IV injection. A measurement that is taken just before the next dose is given represents the trough value of the drug.

Which assay is performed to diagnose congestive heart failure (CHF)?

BNP is elevated in CHF patients. Cardiac troponins are measured to diagnose an AMI and homocysteine, hs-CRP, and ischemia modified albumin are markers of risk for cardiac disease.

In isoelectric focusing, the basis of separation of solutes is different than the other types of electrophoresis. Which statement below correctly describes this feature of isoelectric focusing?

Because ampholytes are a mixture of polyaminocarboxylic acids, their separation on a gel creates a pH gradient across the gel. This gradient is stronger than the ionic cloud of the ions created by the pH set by the buffer and its migration when power is applied to the field. In isoelectric focusing, the solutes do not migrate to the electrode of their opposite charge but to the pH zone in the gradient across the gel that matches their pI. This separation results in more fragments or bands than routine electrophoresis (see pg. 29, Isoelectric Focusing (IEF)).

Which cardiac protein is part of the myocyte contraction mechanism?

Both cTnI and cTnT are components of the regulation of myocyte contraction.

Roles of Buffers

Buffers are used in electrophoresis to create the pH and conduct the current. The buffer ions will carry the current during electrophoresis. The pH set by the buffer determines the net charge on the solutes. The pH ionizes these solutes, and the resulting net charge determines which electrode the solutes migrate toward. Besides setting the pH, the buffer also maintains the pH throughout the electrophoresis of the sample.

The most common mucin tumor markers:

CA 125 CA 15-3 CA 549 CA 27.29 Mucins are high molecular weight glycoproteins that are produced by specialized epithelial cells and serve as protectants and lubricants of the epithelial surface.

CA125 tumor marker

CA 125 falls short of being an ideal tumor marker in that it lacks the specificity required to be used as an effective screening tool. CA 125 is a mucin tumor marker that is produced primarily by ovarian and endothelial cells. Because CA 125 is sometimes produced by non-cancerous endothelial cells of the uterine endothelium, it is not recommended as a screening test for ovarian cancer in non-symptomatic women. CA 125 is also produced by some non-ovarian carcinomas of the pancreas, lung, breast, and colon. CA 125 is produced with an incidence of over 90% in cases of advanced ovarian cancer, and thus has been used to assist in the diagnosis of ovarian cancer in symptomatic women.6 Persistently elevated levels of CA 125 after chemotherapy are indicative of a poor prognosis. CA 125 is also used to monitor the effectiveness of ovarian cancer treatments, to assess the prognosis of a patient, and to determine recurrence or relapse from a state of remission.7

Which statements below are associated with electroendosmosis?

Electroendosmosis is the tension created by oppositely moving ionic clouds in electrophoresis. The ionized sample creates such a cloud. If buffer ions are attracted to the gel, an ionic cloud of the opposite charge forms (see pg. 47, Electroendosmosis). This tension will affect protein migration; some proteins can be slowed, others can become immobile on the gel, and others pushed to the opposite electrode.

Interference, when present, is often due to suppression or inadvertent consumption of produced peroxide reporter molecules (H2O2).

Enzymatic

CA15-3 tumor marker

CA 15-3 is a mucin tumor marker that is found in certain breast carcinomas. CA 15-3 is produced by healthy tissues of the liver and breast, but to lesser degrees than typically associated with malignancies. At a cut off level of 25 kU/L, CA 15-3 has been found to be elevated in 92% of breast carcinomas.2 CA 15-3 is also elevated in other malignancies, including the colon, ovaries, and liver. CA 15-3 is not recommended as a primary diagnostic tool for primary breast cancer, because the frequency of elevation is low and the specificity falls short of being ideal. CA 15-3 is useful in monitoring the effectiveness of therapy. CA 15-3 has been used effectively in monitoring disease progression in metastatic breast cancer.8

The most widely used and best-characterized blood group antigen-related tumor markers include:

CA 19-9 CA 50 CA 72-4 CA 242 Each of the above tumor markers has been used with limited success in identifying tumor growth in cancers of the gastrointestinal tract and digestive system, namely colorectal and pancreatic carcinomas. Among these markers, CA 19-9 has been successfully developed into commercially available immunoassays.

Which of the following has utility as a tumor marker for pancreatic cancer, especially in assessing therapeutic success?

CA 19-9 is approved for use in monitoring pancreatic cancer patients. CA 19-9 levels correlate with pancreatic cancer staging, recurrence, and are used to assess therapeutic success. CA 27.29 is a mucin antigen that is a marker for breast carcinoma. As a tumor marker, CEA is associated with colon cancer, in which CEA measurement is mainly used to monitor colorectal carcinoma treatment, to identify recurrences after surgical resection, and for staging to determine the degree of metastasis. Malignant conditions associated with elevated levels of AFP in the blood include hepatocellular carcinoma, germ cell and yolk sac tumors, and metastatic carcinomas of the liver.

CA27.29 Tumor Marker

CA 27.29 is a mucin antigen that is a marker for breast carcinoma. CA 27.29 is similar to CA 15-3 in sensitivity and specificity, and thus is not effective as a screening tool for early tumor growth. The CA 27.29 marker appears more readily in the ascitic fluid of patients with metastatic breast cancer. CA 27.29 is used to detect recurrence or metastasis of breast cancer following successful eradication of a tumor.10

CA549 tumor marker

CA 549 is a mucin antigen that also serves as a marker for breast and ovarian carcinoma. CA 549 lacks the sensitivity and specificity to serve as an effective screening tool. CA 549 is also elevated in some pregnancies, in benign breast disease, and in liver disease. Some ovarian, lung, and even prostate cancers may elevate CA 549 levels. Similar to CA 15-3, CA 549 has limited utility in detecting early breast carcinoma, due to the low prevalence of individuals with elevated CA 549 during the early stages of breast cancer.9 CA 549 has strong utility as an indicator of recurrence of breast cancer after previous successful treatment to reduce tumor growth. An increasing level of CA 549 after previous successful attempts to decrease or stabilize tumor growth parallels the redevelopment or increasing growth of a breast carcinoma.9

Carcinoembryonic Antigen (CEA)

CEA is normally produced in the developing gastrointestinal tract of the human fetus. Production stops shortly after birth and is normally found in very low concentrations in the blood of adults. Serum levels of CEA may be elevated in heavy smokers. As a tumor marker, CEA is associated with colon cancer, in which CEA measurement is mainly used to monitor colorectal carcinoma treatment, identify recurrences after surgical resection, and for staging to determine the degree of metastasis.2 CEA may also be elevated in malignancies of other tissues, including the stomach, pancreas, breast, lung, and thyroid. Because of this relatively low specificity for a tissue or organ system, it is not recommended for use as a screening tool.

CKD is more prevalent in:

CKD prevalence is linked to numerous factors, to include sex, race, and socioeconomics. The disease is: More common in women than men (16% vs 13%) More common in non-Hispanic blacks than non-Hispanic whites (18% vs 13%) More common in Hispanics than non-Hispanic whites (15% vs 13%)

The genes involved in warfarin metabolism are__________

CYP2C9 and vitamin K epoxide reductase complex subunit 1 (VKOR). Warfarin owes its anticoagulant action to its inhibition of VKOR. This enzyme recycles vitamin K, a critical element for the clotting factors II, VII, IX, and X, as well as for proteins C, S, and Z. There are six CYP2C9 alleles that are known to cause prolonged metabolism of warfarin: CYP2C9 *2, *3, *4, *5, *6, and *11 (polymorphisms in CYP450 genes are denoted with asterisks.)One-third of the patients who receive warfarin metabolize it differently than expected and experience a higher risk of bleeding. Genetic testing for the two most common polymorphisms (CYP2C9*2 and *3) as well as for VKOR may be able to reduce the variability associated with warfarin dosing response.Labs performing PGx testing can provide general warfarin dosing recommendations based on the patient's genotype analysis. The lab report will indicate whether a patient has a normal, mild, moderate, high, or very high sensitivity to warfarin. Online calculators or handy paper charts can then help physicians calculate an appropriate starting and maintenance dose given the phenotype of a particular person.For example, a patient who has one CYP2C9 normal wild-type allele (CYP2C9 *1), one polymorphism (CYP2C9*3), and also a VKOR polymorphism is predicted to have a moderate sensitivity to warfarin. This patient should have frequent INR monitoring and possible warfarin dose reduction.It is important to recognize that knowing a genotype does not necessarily guarantee accurate dose prediction; other drugs and/or environmental or disease factors can also alter CYP2C9 activity. Therefore, monitoring the INR is still very important.

________ assays are often based on coupled enzymatic reactions involving creatinase.

Enzymatic

Capillary Electrophoresis

Capillary electrophoresis (CE) combines electrophoresis and high-performance liquid chromatography. CE takes place in a very thin, fused silica capillary tube with polyacrylamide or agarose gel (Polyacrylamide is the most commonly used gel). The ends of the capillary tube are placed in two buffer reservoirs, with the anode in one and the cathode in the other. A high-voltage power supply and cooling system are included. Separated solutes are detected with this method as migration and separation occur instead of detection after separation is completed. An optical detector attached to the capillary detects solutes after separation while still in the capillary. The detector is linked to data collection and storage.

In DNA sequencing, multiple fluorescence labeled nucleotides are separated using capillary electrophoresis.

Capillary electrophoresis is used in DNA sequencing and several other molecular diagnostic procedures.

CA19-9

Carbohydrate antigen (CA) 19-9 is a tetrasaccharide-rich marker that is a modification of a Lewis(a) blood group antigen. CA 19-9 has been detected at increased concentrations in the blood of patients with colon cancer and pancreatic cancer. CA 19-9 is also known to be elevated in esophageal cancer and hepatocellular carcinoma. Many non-malignant conditions are known to elevate CA 19-9 in the blood, including cirrhosis, pancreatitis, and diseases of the bile duct. Because CA 19-9 is not tissue-specific and may also be elevated in non-malignant states, its utility is not as a cancer screening tool in asymptomatic individuals, but rather as a management tool in pancreatic cancers. When treating individuals who have been diagnosed with a pancreatic tumor, a baseline level of CA 19-9 may be determined. Following treatment, follow-up testing regimens are used to assess the success of the treatment, as levels of CA 19-9 should decrease in response to the treatment.11 Likewise, subsequent increases or recurrence of elevated levels of CA 19-9 in the blood following a period of remission would be a likely indication of tumor regrowth or metastasis.

Which of these tetrasaccharide-rich tumor markers is derived from a blood group antigen?

Carbohydrate antigen (CA) 19-9 is derived from a blood group antigen and has utility as a tumor marker for colorectal and pancreatic carcinoma.

These assays use antibodies that are conjugated to enzymes, such as peroxidase or alkaline phosphatase. These enzymes, when mixed with chemiluminescent substrates, produce light in the visible spectrum.

Chemiluminescence A direct relationship exists between the amount of drug that is present in the sample and the light units that are produced. This is measured by a luminometer in the instrument. Assays that use chemiluminescence are more sensitive than immunoassays that rely on the generation of a colored product.

Angina

Chest pain caused by inadequate supply of oxygen to heart myocardium.

If the HBsAg is positive, and the HBc IgM is negative, what form of hepatitis does the patient have?

Chronic HBV

Dermatomyositis (DM)

Dermatomyositis is an uncommon inflammatory disease marked by muscle weakness and a distinctive skin rash. The condition is similar to PM in that it produces inflammation of the muscles and may also affect the joints. It produces inflammation of the skin and the underlying muscle tissue typically involving degeneration of collagen, discoloration and swelling. The skin rash appears patchy with purple or red discolorations and typically develops on the eyelids and on the muscles used to extend or straighten joints. The rash can also appear on other areas of the body. DM affects adults and children alike. In adults, DM usually occurs from the late 40s to early 60s. In children, the disease most often appears between 5 and 15 years of age. DM affects more females than males. The incidence of DM is approximately 9 cases per million population in the US.

The antinuclear antibody (ANA) is used to screen for the presence of autoantibodies that are directed toward components in the nucleus of the cell. Which of the following choices are true regarding the ANA test? (Select all that apply.)

Clinicians use the ANA test to assess the likelihood that a given patient has a SARD. The results of the ANA test alone are not diagnostic for the SARD. The patient must also have clinical evidence of the disease. Because the early clinical presentation for many of the SARDs are nonspecific, the results of the ANA test and subsequent follow-up testing are key pieces to making the correct diagnosis. The utility of the ANA test is to detect the antibodies early in the disease process. The ANA results in conjunction with clinical presentation give the clinician solid evidence to intervene with an appropriate treatment. Studies have shown that once treatment is started, the formation of new antibodies slows or even halts. Rheumatoid arthritis (RA) is the most prevalent disease in this group; however, the ANA assay is not the primary laboratory test for RA. Instead, the test for RA looks for the presence of rheumatoid factor (RF) or more recently, cyclic citrullinated peptide antibodies (anti-CCP). More recently, a cell line called HEp-2000® has become popular for ANA detection. HEp-2000® is a HEp-2 cell line that has been transfected with the cDNA for overexpression of the SSA/Ro antigen. This results is a substrate with all of the original advantages of HEp-2 plus an added advantage of increased sensitivity for detection of antibodies directed to the SSA/Ro antigen and the ability to identify these clinically significant antibodies during the screening process.

Which of the following procedures should be followed when performing a manual urine reagent strip test? (choose all that apply)

Compare strip to color chart to check for correlating color and handling strips at the end away from the test area are the two correct answers. It is incorrect to leave the reagent strip bottle cap off until testing is completed as moisture from the air can alter the test pads on the chemical reagent strips.

HDL cholesterol plays a vital role in the transport of excess cholesterol to the liver, which decreases total plasma cholesterol. Which of the following statements is true regarding HDL concentration in the blood?

Concentration of HDL cholesterol is decreased by triglyceride-rich VLDL in the blood.

Which of these is NOT correct?

Decreases in serum creatinine are associated with higher levels of kidney function.

What is the result of the defective cystic fibrosis transmembrane conductance regulator (CFTR) protein on chloride reabsorption in the sweat ducts and chloride concentration in sweat?

Defective CFTR causes decreased chloride reabsorption in the ducts, which results in increased chloride concentration in sweat.

denaturing polyacrylamide gel electrophoresis

Denaturing chemicals can be added to the acrylamides during formation of polyacrylamide gels. These additives keep the solutes or molecules in a denatured state during separation. Urea denatures double-stranded DNA to single-stranded DNA. A detergent, sodium dodecyl sulfate (SDS), denatures proteins. Adding SDS with heat denatures proteins to small, similar shaped particles and coats each so that protein structures are not reformed. SDS is usually added to the gel and the protein sample. The mixture of protein-coated fragments then moves through polyacrylamide gel pores with speeds similar to a mixture of DNA fragments.

Cells present in semen include

Epithelial cells, RBCs (blue), WBCs & Spermatids (red) Increased WBCs may indicate inflammation of the accessory glands Round cells are either Spermatids or WBCs differentiated using 1000x

Which statement about diabetes is FALSE?

Diabetes can produce weight loss as a result of the excess buildup and storage of protein. Weight loss from diabetes results from increased utilization of proteins and fats for energy. Diabetes is considered a metabolic disorder that results when insulin concentrations are absent or reduced, or when insulin action is impaired (referred to as insulin resistance). Without cellular uptake of blood glucose for energy, the balance of metabolizing carbohydrates, fats, and proteins for energy is lost. This results in hyperglycemia and the excess use of fats and proteins for energy production. Polydipsia (increased thirst), polyuria (increased volume of urine), and unexplained weight loss are symptoms of diabetes. Polydipsia and polyuria occur as the body tries to lower blood glucose concentrations with increased urinary excretion of glucose. Weight loss results from increased utilization of proteins and fats for energy.

Which of these is the leading associative cause of CKD?

Diabetes is associated with greater than 37% of cases of CKD hypertension is associated with approximately 27%. Other factors associated with CKD include: Genetics and family history Gender, ethnicity, age, birth weight Socioeconomic status Obesity, smoking Exposure to nephrotoxins Prior acute kidney injury

What type of medication is used to cure the majority of cases of chronic HCV?

Direct-acting antiviral (DAA) medications are prescribed.They are oral medications and are specific to certain viral genotypes. It is possible to be infected with more than one strain. Medications are taken for 8 to 12 weeks.

immunosuppressant

Drugs used to inhibit the immune system are standard treatment after transplant surgeries. Unfortunately, these life-saving drugs also cause hepatotoxicity and nephrotoxicity at high concentrations. The reason drug monitoring is used for immunosuppressants is to ensure that concentrations are adequate to suppress the immune response and prevent rejection yet not high enough to cause liver failure or severe immunodeficiency. Examples of immunosuppressants that are monitored by TDM include: Cyclosporine Methotrexate (this drug is also used as an anti-neoplastic drug) Tacrolimus Sirolimus

What is the definition of dyslipidemia?

Dyslipidemia is elevation of plasma cholesterol, triglycerides, or both, or a low high-density lipoprotein (HDL); it is one of the factors that can lead to a diagnosis of metabolic syndrome.

Specked Pattern Follow-Up Testing

ENA ENA testing is most frequently done by ELISA method.

Prostate Specific Antigen (PSA)

Early detection of prostate cancer Staging of prostate cancer Monitoring effectiveness of treatment Monitoring for recurrence PSA is known to have an enzymatic function as a serine protease. It is produced exclusively by the epithelial cells of the acini and ducts of the prostate gland. It is released into the lumina of the prostatic duct (see image on the right), where it acts to liquefy the seminal coagulum. PSA is produced in adult males by normal, benign, hyperplastic, and malignant prostate tissue but not in any other human tissues. Following its production from the acini and ducts, a small amount of PSA is taken by the capillary-rich prostate into the blood circulation, where it remains in circulation with a half-life of 3.2 days.2 The entire 240 amino acid residue sequence of PSA has been confirmed, along with its three-dimensional structure.2 Because its structure is so well characterized, specific antibodies against several of its antigenic epitopes have been developed, which has led to several specific immunoassays to detect its presence and quantitate its concentration in biological samples. Despite the high degree of specificity for prostatic tissue, PSA testing by itself is not highly effective as a screening tool for prostate cancer. PSA is also elevated in benign prostatic hyperplasia, which occurs with high frequency in men over the age of 50. PSA is used in conjunction with a digital rectal examination and followed by a transrectal ultrasound to provide a more sensitive and accurate diagnosis.3

Which statements below are correct descriptions of visualization and detection methods used in electrophoresis?

Ethidium Bromide and SyBr green are special stains visualizing separated DNA and RNA fragments. Ponceau S and Coomassie Brilliant Blue are used to detect separated protein bands (see pg. 39, Stains and Dyes). Minute-size fragments are often detected with labeled probes; the probe generates a signal when it is bound to the target. Densitometry is a special spectrophotometer that creates a graph of peaks; each peak represents a separated band. The concentration of each peak can be determined with the information gathered.

Which one of the stains below is used to detect separated nucleic acids?

Ethidium bromide, SyBr green, and silver are common stains for separated nucleic acids.

In the thyroid hormone feedback mechanism, what is the normal effect of T4 on thyroid-stimulating hormone (TSH) production?

Excessive T4 provides a negative feedback mechanism with the pituitary and production of TSH, meaning that increased production of T4 should normally cause the pituitary to produce less TSH.

Cancer has been attributed to preventable factors such as:

Exposure to toxins and chemicals, or carcinogens: Cigarette smoke and tobacco products Industrial pollutants and pesticides Heavy alcohol consumption Exposure to infectious agents: Hepatitis B virus (HBV) and hepatitis C virus (HCV) Human papilloma virus (HPV) Human immunodeficiency virus (HIV) Helicobacter pylori Exposure to harmful ultraviolet rays: Prolonged sunlight exposure Tanning beds Obesity: Lack of physical exercise Poor nutrition

Depending on the laboratory and specific method used, an ANA titer is typically considered negative when the titer is equal to or less than 1:80.

FALSE ANA titer is typically considered negative when it is less than or equal to 1:40. A titer equal to or less than 1:80 is often considered borderline, while a titer greater than 1:80 is considered positive.

When identifying the Midbody pattern, only cells in interphase and metaphase are useful.

FALSE All stages of mitosis are useful when identifying the Midbody pattern. In this pattern there is no staining in the early interphase cells. By late interphase fine speckling is present. In metaphase, the speckling is located in the chromosomal area and is very similar to centromere staining. As the cells progress into anaphase and telophase, staining is seen in the intercellular bridge.

Cytoplasmic patterns are interesting to look at but have no clinical significance and should NOT be reported.

FALSE Autoantibodies to the nucleus of the cell are not the only antibodies with clinical significance. Autoantibodies to components of the cytoplasm can be very important pieces in solving the diagnostic puzzle for some patients and should be reported. Cytoplasmic patterns can be key pieces of information for the clinician. For example, when making the diagnosis for some diseases such as Primary biliary cirrhosis (PBC), an anti-mitochondrial pattern in the cytoplasm is exactly what the clinician is expecting.

Chronic Kidney Disease is defined as abnormalities of kidney structure and/or function that have implications for long-term health. To be diagnosed, abnormalities must be present for greater than 1 month.

FALSE. For diagnosis, abnormalities must be present for greater than 3 months.

A reactive HBc IgM assay is selective for chronic HBV.

FALSE. Hepatitis B core IgM Ab (HBc IgM) appears at the onset of symptoms in acute hepatitis B. It is detectable at the time symptoms appear but becomes undetectable after six to nine months. After this period, Hepatitis B core IgG Ab is developed. So, this assay is selective for acute HBV.

All drugs benefit from TDM

False

EIA has better specificity and better positive predictive values than CIA, leading to EIA methodology being more widely used, particularly in high-volume clinical laboratories.

False EIA assays have a history of false-positive results due to the lack of specificity. This is due to the potential for other substances in the patient's serum to bind to the antibody of the assay.

Microalbumin is the preferred and recommended term to describe the presence of increased urine albumin.

False Microalbumin and microalbuminuria are historical terms used to describe the presence of "small" amounts of urine albumin. The terms urine albumin and albuminuria are recommended by the KDIGO and National Kidney Foundation.

The detection of an immunoglobulin clone, such as IgM, is ALWAYS associated with a malignant condition, such as a multiple myeloma.

False While detection of monoclonal paraproteins is highly associated with a malignant plasma cell tumor, the appearance on non-malignant monoclonal bands increases with age, and may approach a prevalence of 5% in those over age 75. Non-malignant monoclonal bands are typically lower in concentration than in malignant cases (see pg. 22, Specific Proteins as Tumor Markers - Monoclonal Immunoglobulins).

Electroendosmosis is the movement of buffer into the medium due to heat generation and ensuing drying of that medium.

False Wick flow is caused by the movement of buffer into the medium due to heat generation and ensuing drying of that medium. The bands of separated proteins where wick flow occurs will be distorted and atypical in appearance.

Which of the following blood tests would aid in the diagnosis of metabolic syndrome?

Fasting blood glucose, triglycerides, HDL-C along with waist circumference and blood pressure are the measurements used in the diagnosis of metabolic syndrome.

One or more of the following markers may be elevated in acute or chronic inflammation, but are not specific to autoimmune disorders

Ferritin Ceruloplasmin Haptoglobin Albumin Fibrinogen

When is TDM not useful?

For drugs which act intracellularly, or that need to be converted to active forms (like AZT). (The serum level wouldn't reflect the active intracellular drug level) For drugs in which the effects last much longer than the serum concentrations of the drugs; examples include antineoplastics (cancer chemotherapies) and warfarin. For narcotic pain medications in which continued use leads to tolerance such that the levels needed for pain relief in one person would be toxic to another person.

Peak and Trough Sampling Times

For oral medications, one hour after drug is taken is usually adequate (this assumes a half-life of > two hours). For IV medications, sample 15-30 minutes after injection/infusion. For Intramuscular (IM) injections, sample 30 minutes to one hour after injection.

Which type of electrophoresis is used to separate larger DNA fragments (>50 kb)?

Fragments of DNA > 50 kb will not separate in most types of electrophoresis due to their large size. Special techniques are required; pulsed field electrophoresis is one type of electrophoresis that will separate these larger fragments.

Historical methods for determining the free thyroxine index (FTI) have been largely replaced with more sensitive and automated immunoassay methods for determining which hormone?

Free T4 (FT4) Only the unbound fractions of thyroid hormones have biologic activity, and as such should be measured directly to determine their available concentrations in circulation. FT4 is routinely measured using sensitive immunoassay methods, thus eliminating the need for estimation using the FTI.

Which of these factors are associated with CKD? More than one option may be correct.

Genetics Socioeconomic status Obesity All of these are risk factors for development of CKD. In addition, family history, gender, ethnicity, age, birth weight, smoking status, exposure to nephrotoxins, and prior acute kidney injury may be associated with development of the disease.

Which of the following is true of genotype screening in pharmacogenomics?

Genotyping does not take into account drug interactions which can affect metabolism. Genotyping, while more robust and definitive, cannot factor in environmental or health variables that could affect drug metabolism. Probe drug analysis does factor in these variables, but it is more complex and tedious. Genotyping typically involves measuring many polymorphisms. For example, a laboratory that offers CYP2D6 profiling may measure twelve of the most common and significant mutation sites on this enzyme.

Which of the following statements related to Graves' disease is TRUE?

Graves' disease is an autoimmune condition where the body produces increased amounts of thyroid hormone. Graves' disease is an autoimmune condition where the body produces an autoantibody called thyroid stimulating immunoglbulin, which has an effect similar to that of TSH on stimulating the thyroid to produce excessive T4 and T3. Graves' disease is more common in women than men, and most commonly occurs in adults over the age of 60 years.

Which hepatitis virus is typically spread by the fecal-oral route?

HAV is stable under normal environmental conditions and can contaminate food or water. It is through the fecal-oral route that it is usually spread. HAV does not result in chronic infection, instead is self-limited and usually resolves within two months of infection.

Which hepatitis virus is most prevalent in the US?

HCV 2016 data estimate the number of chronic HBV infections at 862,000. Meanwhile, the number of chronic HCV infections is estimated to be around 2.4 million. This is partially due to the lack of a vaccine against HCV, and a higher rate of chronic HCV infections compared to HBV. As illicit opiate drug use skyrockets, more HepC infections are expected.

Human Epidermal Growth Factor Receptor 2 (HER2/neu)

HER2/neu is found amplified in breast, ovarian, and tumors of the gastrointestinal tract. Increased amplification of the HER2/neu oncogene correlates with decreased response to hormonal and monoclonal antibody therapy in breast cancer. HER2/neu has strong prognostic value in breast cancer, and correlates with increased tumor size, positivity in adjacent lymph nodes, and higher grading scores with likelihood of metastases. HER2/neu analysis may be performed on suspicious or representative tissue samples using immunohistochemical (IHC) techniques. HER2/neu is also released into the blood, and as such, may be identified and quantified in plasma samples using commercially available immunoassay methods.2

Typically, ___________ are used as a substrate to detect the antibodies in human serum.

HEp-2 cells Microscope slides are coated with HEp-2 cells, and the serum is incubated with the cells. If antibodies are present, they will bind to the antigens on the cells, and, in the case of ANAs, the antibodies will typically bind to the nucleus. The binding is visualized by adding a fluorescent tagged anti-human antibody that binds to the Fc portion of the patient's antibodies.

Which of these is NOT considered one of the systemic autoimmune rheumatic diseases (SARDs)?

Hashimoto disease of the thyroid is not a systemic autoimmune disease; it is an organ-specific autoimmune disease. That is, the autoantibodies are directed at a single target organ (in this case, the thyroid). SLE, SSc, and RA are all considered SARDs because they can affect multiple systems in the body (systemic), including the joints, muscles, and bones (rheumatic).

Which of the following statements best describe Hb A1C?

Hb A1C is the nonenzymatic addition of a glucose molecule to Hb A. After a rearrangement, the addition is irreversible. The concentration of Hb A1C relates to the individual's average glucose concentration over two to three months.

A cerebrospinal fluid (CSF) sample for hematologic evaluation should be tested within how long of collection?

Hematologic analysis of CSF samples should be performed within one hour of fluid aspiration. Both red blood cells (RBCs) and white blood cells (WBCs) have limited stability in CSF because CSF is hypotonic and cells can rapidly lyse.

All of the following viruses are part of the acute hepatitis panel, EXCEPT?

Hepatitis E (HEV) The viruses tested for in the acute hepatitis panel are Hepatitis A (HAV), Hepatitis B (HBV), and Hepatitis C (HCV).

High Resolution EP (HRE)

High-resolution electrophoresis (HRE) is routine electrophoresis using a high voltage. Serum samples separated with HRE may yield approximately fifteen distinct protein bands. Other HRE applications are the separation of CSF proteins for the diagnosis of multiple sclerosis and light chains in urine for early detection of lymphoproliferative disorders such as multiple myeloma. Both of these specimen separations require more resolution of proteins than routine protein electrophoresis can provide. Increasing the voltage will increase the heat that is generated. A cooling system is included in HRE instrumentation to prevent the denaturation of proteins and drying out of gels and other system components.

What is the most common combination of ANA patterns?

Homogeneous and speckled is correct. In some labs this combination of patterns is the most frequent of all positive ANAs. Remember, however, any other combination is possible, and the other combinations listed above are not uncommon.

What is the epidermal growth factor receptor that appears on the surface of some breast cancer cells that predicts the success of hormonal and monoclonal antibody therapies?

Human epidermal growth factor 2, or HER2/neu biomarker and target therapy using specific hormonal and monoclonal antibody therapies.

Which of the following are considered among the classic symptoms of hypothyroidism?

Hypothyroidism presents with the classic symptoms of fatigue, weight gain, and cold intolerance.

If a drug is given at intervals that are the same as its half-life, approximately how long will it take the drug to reach steady state?

If a drug is given at intervals that are the same as its half-life, it will take about 5 half-lives to reach steady state.

A semen sample is received in the laboratory for evaluation of fertility. No sperm are observed upon initial microscopic examination of the sample. How should you proceed?

If no sperm are seen on initial microscopic examination, a concentrating technique, such as centrifugation, should be used. Mix the original specimen, centrifuge an aliquot, and evaluate again.

The pI of a protein is 9.2. This protein is placed in an electrical field where a buffer sets the pH at 10.0. Select the correct statement regarding the electrophoretic migration of this protein.

If the pH for electrophoresis is above the pI of a protein, the protein will have a net negative charge. Negative ions, anions, will migrate to the positively charged electrode, the anode (see pg. 4, Isoelectric Point (pI)).

Which of the following statements is FALSE when describing indirect immunofluorescence assays (IFAs)?

If the sample is negative for ANA, the nucleus will show NO clearly discernible pattern of nuclear fluorescence. The remaining statements are true. The FITC is conjugated to a secondary antibody and, when bound to sites in the nucleus, will produce a fluorescence which is measured under a microscope. Hep-2 is the most commonly used substrate for IFA detection of ANA. In 5% of healthy individuals, positive titers of 1:160 or higher can be found.

Following the surgical removal of the thyroid in thyroid carcinoma, which of the following proteins may be used as an indicator of cancerous regrowth of thyroid tissue?

If using an assay with a high degree of sensitivity, Tg may be used as a tumor marker to detect thyroid cancer recurrence.

The most common monoclonal immunoglobulin in multiple myelomas is____________

IgG Paraprotein

Which of the following is the most common technique that is used by clinical laboratories for therapeutic drug monitoring?

Immunoassay is the most common technique that is used by clinical laboratories for therapeutic drug monitoring. Most of the drugs commonly assessed with TDM can be measured on analytical platforms which utilize antibodies (in some form) for detection. Antibodies can be developed that recognize drugs. Although most drugs are much too small to evoke an immune response, scientists can conjugate drugs to immunogenic proteins to produce antibodies that recognize drug-specific epitopes.

_____________are the most common technique used by clinical laboratories for therapeutic drug monitoring.

Immunoassays Antibodies that recognize specific drugs have been developed. Although most drugs are much too small to evoke an immune response, scientists can conjugate drugs to immunogenic proteins to produce antibodies that recognize drug-specific epitopes. There are several methods that utilize the principles of immunoassay for the detection and quantification of therapeutic drugs in serum. Some of these methods are: Particle-enhanced turbidimetric inhibition immunoassay (PETINIA) Cloned enzyme donor immunoassay (CEDIA) Fluorescence Polarization Immunoassay (FPIA) Chemiluminescent assays (EMIT)

Albuterol is a fast-acting bronchodilator used acutely during asthma attacks. Which of the reasons below would best explain why TDM for albuterol is not available or common?

It is not a chronically used drug so toxicity is less likely. The half-life is short, and the drug is cleared quickly. It has a wide therapeutic window. Compliance is not an issue with albuterol.

In recent years, the American Diabetes Association (ADA) recommended reporting which of these values to correlate with Hb A1C as a further indicator of glycemic control?

In 2008, the ADA recommended calculating and reporting the estimated average glucose (eAG) with Hb A1C measurement results. eAG is a glucose concentration level calculated from a patient's Hb A1C result. The eAG is essentially a health tool to help clinicians set glucose level targets in patients, especially useful in cases where the patient is not entirely compliant and where patients don't check their blood glucose frequently enough to keep proper track through self-monitoring of blood glucose. The ADA introduced the term to help translate the A1C results into numbers that are closer to every day readings on glucose meters.

Electrophoresis equiptment

In addition to the specimen sample, support medium, and buffer for electrophoresis, a power supply, positive and negative electrodes, chamber, and identification or detection method are needed.

How many white blood cells (WBCs) would be considered normal for adult cerebrospinal fluid?

In an adult, 0 - 5 WBC/µL is considered normal. Children will have slightly higher cell counts. Up to 30 WBC/µL is within normal limits for newborns. Lymphocytes account for 60 - 100% of these cells.

Which statement best describes small dense LDL particles that can occur in atherogenic dyslipidemia?

In excess triglycerides, the triglycerides reduce the amount of cholesterol in LDL particles producing small dense LDL molecules. Because of size and density, these molecules more easily enter damaged endothelium and vessel walls and are more easily incorporated as plaque is formed.

Which electrophoresis method first creates a pH gradient across the gel before migration of proteins?

In isoelectric focusing, the ampholytes migrate first and create a pH gradient across the gel. Then the proteins migrate to the pH area that matches their isoelectric point.

Which oncofetal antigen is a tumor marker for hepatocellular carcinoma and is believed to normally serve the role of serum albumin in the developing human fetus?

In the developing human fetus, AFP is the most prevalent protein and most likely plays a similar role as serum albumin in transporting hormones and micronutrients.

Which statement best describes ketones and their involvement in ketoacidosis?

Increased ketones can result in a metabolic acidosis referred to as ketosis, ketoacidosis or diabetic acidosis. Type 1 diabetic patients are especially at risk for ketoacidosis. Ketones are produced when glucose is not available to supply the body's cells with energy. This can occur when insulin levels are insufficient or lacking. To make energy, the body then begins breaking down fat into acetyl CoA. The acetyl CoA produced is converted to acetone, acetoacetate, and beta-hydroxybutyrate. These are acids that when dissolved in body fluids in excess, lower the blood pH.

Which one of the following will slow down the migration of solutes in electrophoresis?

Increasing the ionic strength of the buffer increases the buffer ions in the buffer ionic cloud that forms during electrophoresis. As the buffer ionic cloud becomes larger, this slows down the movement of the ionic cloud of the sample ions and causes the sample to decrease its rate of movement. Increasing the viscosity of the medium or gel the sample is placed on would make sample mobility more difficult (see pg. 6, Rate of Migration).

Both direct measurement and indirect estimates of GFR can be performed. Which one of these is more common?

Indirect estimates are by far more common. Then are relatively non-invasive (a simple blood draw only) and simple to perform in contrast to methods of direct measurement.

Which of the following hormones inhibits gluconeogenesis, the formation of glucose from noncarbohydrate sources such as amino acids, glycerol, and fatty acids?

Insulin Gluconeogenesis is the formation of glucose from noncarbohydrates when carbohydrate intake is absent (a fasting state). The hormones cortisol, along with glucagon and epinephrine, all stimulate this metabolic pathway. Insulin, however, inhibits this pathway and is therefore the correct answer.

Which two stages of cell division are the most important for reading ANAs?

Interphase and Metaphase is the correct answer. While it is necessary to recognize all stages of cell division, the two most important are interphase and metaphase. In order for the ANA to be positive, there must be a clearly discernible pattern in the nucleus of the interphase cells. Metaphase mitotic cells are used to assist in identification of the ANA pattern.

Proliferating Cell Nuclear Antigen (PCNA)

Interphase cells: 30-50% of interphase cells stain Coarse to fine speckling in the nucleus Nucleoli do not stain Metaphase mitotic cells: No staining at this stage of the cell cycle. Follow-up testing to confirm antibodies to PCNA is recommended. Anti-PCNA antibodies are specific for SLE. This pattern is reported as ANA positive, Speckled, possible PCNA; titering is necessary. Proliferating Cell Nuclear Antigen (PCNA) Cell cycle dependent pattern Antigen not expressed in all growth stages.

Nuclear Membrane ANA Pattern

Interphase cells: Smooth staining of entire nucleus Brighter staining at the periphery of the nucleus May notice wrinkles in nuclear envelope Metaphase mitotic cells: No staining in the chromosome region Region outside of the chromosome area will stain with variable intensity Follow-up testing is not required for this pattern. Possible antigens include nuclear lamins A, B or C, nuclear pore complex and gp210. These antibodies are generally seen in autoimmune liver diseases. This pattern is reported as "ANA positive, Nuclear Membrane; titering is necessary." Unusual Homogeneous - Nuclear Membrane (Envelope)

homogeneous ANA pattern

Interphase cells: Smooth staining of entire nucleus Nucleoli may or may not stain Metaphase mitotic cells: Smooth staining of the chromosomal region No staining outside of the chromosomal area Follow-up testing for anti- dsDNA, histone or chromatin antibodies is recommended. These antibodies are primarily seen in patients with systemic lupus erythematosus (SLE). This pattern is reported as "ANA positive, Homogeneous; titering is necessary."

Speckled ANA Pattern

Interphase cells: Speckled staining in nucleus May be coarse, fine or mixture of both Nucleoli do not stain Metaphase mitotic cells: No staining in the chromosome region Region outside of the chromosome area will stain with variable intensity Follow-up testing for antibodies to the extractable nuclear antigens (ENAs) such as Sm, U1-RNP, SSA/Ro, SSB/LA and Scl-70 is recommended. These antibodies are seen in a variety of patients, including those with SLE (Sm, SM/RNP, SSA/Ro, and SSB/La), Sjögren's syndrome (SSA/Ro and SSB/La), and systemic sclerosis (Scl-70). This pattern is reported as "ANA positive, Speckled; titering is necessary."

Nucleolar ANA Pattern

Interphase cells: Staining only of the nucleoli Clumpy Smooth Speckled Metaphase mitotic cells: Can demonstrate variable staining depending on the antigen involved Follow-up testing for anti-nucleolar antibodies is very limited and, in most cases, not done. There are assays for identification of anti-RNP polymerase antibodies. Anti-nucleolar antibodies are primarily seen in patients with systemic sclerosis. This pattern is reported as "ANA positive, Nucleolar; titering is necessary."

Centromere ANA Pattern

Interphase cells: Usually 46 discrete speckled Evenly distributed in the nucleus Metaphase mitotic cells: Discrete speckles align in the chromosomal region of the mitotics No staining outside of the chromosomal area The presence of anti-centromere antibodies can be determined by the staining pattern alone. No specific follow-up testing is necessary. Anti-centromere antibodies are most often seen in patients with the limited form of systemic sclerosis called the CREST syndrome. CREST is an acronym for the clinical features: Calcinosis cutis Raynaud's phenomenon Esophageal dysfunction Sclerodactyly Telangiectasia Anti-centromere antibodies have been detected years prior to the onset of symptoms. Finding these antibodies in patients with Raynaud's phenomenon or other risk factors is an important indicator for the potential development of systemic sclerosis. This pattern is reported as "ANA positive Centromere; titering is necessary."

Isoelectric focusing

Isoelectric focusing is a type of separation where the solutes migrate based on a different principle. The separation takes place on a gel where a pH gradient has been created using ampholytes. Ampholytes are mixtures of amphoteric polyaminocarboxylic acids. This mixture possesses a range of pIs, a high buffering capacity at each pH, and is used to create pH gradients. When ampholytes undergo electrophoresis, each ampholyte migrates to its own region, an area that matches its pI. After the migration of ampholytes, the gel has stable pH zones of increasing pH or a pH gradient. The solutes in the specimen do not migrate to the electrode of the opposite charge but to the zone or area that matches their pI. IEF is performed on a gel in a capillary tube, strip, or plate. Gels used are most commonly polyacrylamide gels, but agarose and cellulose acetate can also be used.

A semen sample for semen analysis should generally be received at the testing site within what period of time?

It is recommended that a semen analysis sample be delivered within one hour to ensure accurate testing results. The semen specimen is examined under a microscope to determine the concentration, motility (movement), and morphology (appearance and shape) of the sperm. Since it is important to observe the sperm while they are still active, samples must be received for analysis within an hour.

_________ reaction is an alkaline-picrate reaction that forms a yellow/orange/red complex with creatinine.

Jaffe (alkaline-picrate)

cross-reaction with other metabolites and the presence of background color (e.g., high bilirubin due to liver disease) can lead to interference.

Jaffe (alkaline-picrate)

Match the following urine chemical reagent strip test pads to the disease or disorder that would most likely cause a positive test result.

Ketones- Diabetes mellitus Blood- Renal calculi Bilirubin- Hepatitis/cirrhosis Nitrite- Urinary tract infection

Pulsed field electrophoresis

Larger fragments of DNA, > 50 kilobases (kb), cannot be separated with AGE or PAGE in routine electrophoresis systems; the gel pore sizes are too small for their migration. Fragment separation can be achieved by alternately applying the power to different pairs of electrodes. The most common method alternates the positive and negative electrodes in cycles during electrophoresis. The DNA fragments must reorient to a new field direction in each cycle. These changing pulses and reorientations separate the large size DNA fragments. Sample runs require longer time periods, some 24 hours or more, special gel boxes, different electrodes, and controls for switching the electric fields during electrophoresis.

Which one of the following adipose tissue hormones (adipokines) inhibits appetite and stimulates metabolism?

Leptin inhibits appetite and stimulates metabolism. Resistin increases insulin resistance and enhances adhesion molecules present on endothelial cells. Adiponectin increases fatty acid oxidation.

Lower reference limits for a normal semen analysis.

Liquefaction: ≤30 minutes (no greater than 1 hour) Volume: >1.5 mL pH: ≥7.2 Sperm concentration: ≥15 x 106 / mL Motility: Progressive motility 32%. The lower reference limit for total motility (progressive + non-progressive) 40%. WHO 5th edition: ≥4% normal forms

Systemic lupus erythematosus (SLE) and other subsets of lupus

Lupus is a chronic inflammatory autoimmune disorder in which the immune system produces autoantibodies to different cellular components such as DNA, histones, etc. The disorder may affect the skin, joints, blood vessels, and internal organs, especially the kidneys, heart, lungs, and brain. There are several types of lupus, but the most common is systemic lupus erythematosus (SLE), which affects many areas of the body. Lupus is much more common in women and is more common in persons of African, Asian, Hispanic, and Native American descent. SLE is most frequently seen in people between the ages of 15 and 45, although younger children and older adults can also have the disorder.

Where does most cerebrospinal fluid (CSF) originate?

Most CSF originates in the choroid plexus. The choroid plexus is composed of a mass of tiny blood vessels that are located in the third lateral and fourth ventricles. The remaining CSF, about 30%, is formed in other sites such as the subarachnoid space and the ependymal lining of the ventricles.

Metabolic syndrome ___________ the risk of developing type 2 diabetes.

Metabolic syndrome increases the risk of developing type 2 diabetes. The insulin resistance state impairs carbohydrate metabolism and elevates blood glucose levels. However, diabetes is often diagnosed before a patient is evaluated for metabolic syndrome.

Below are the laboratory results and chief clinical findings in a 58 year-old woman. Laboratory Results: Thyroid-stimulating hormone (TSH): 4.21µIU/mL (ref range 0.4 - 4.12 µIU/mL) Free T3 (FT3): 2.5 pg/mL (ref range 2.5 - 3.9 pg/mL) Free T4(FT4): 1.0 ng/dL (ref range 0.6 - 1.3 ng/dL) Thyroperoxidase antibody (TPOAb): <1.0 IU/mL (ref range <9.0 IU/mL) Thyroglobulin antibody (TgAb): <0.5 IU/mL (ref range <4.0 IU/mL) Clinical Findings: Inability to lose weight Constipation Of the options below, what is the most likely diagnosis of this patient?

Mildly symptomatic patients found to have slightly elevated TSH levels, with FT3 and FT4 levels within expected limits, and the absence of detectable thyroid antibodies meet the criteria of subclinical hypothyroidism.

Polyacrilamide gel electrophoresis (PAGE)

More separations can be achieved with layers of polyacrylamide gels, each with a different pore size. The gels can be horizontal or vertical slabs or incorporated into vertical cylinders or rods. DNA of 100 base pairs (bp) or less can be separated. Common applications of PAGE are the separation of proteins and nucleic acids. Polyacrylamide gels are also used as the medium in several other types of electrophoresis described in this section.

Protein Binding

Most drugs are bound to proteins when they circulate in the body. This makes sense when considering the general solubility rules of chemistry. If a drug is very simple chemically, eg, an elemental salt such as lithium, it will easily dissolve into the aqueous environment of the blood and widely distribute through the circulation. However most drugs are not that simple, they are usually complex organic molecules with variable solubility in water. For drugs that are not highly soluble in an aqueous environment, some carrier protein will be needed to solubilize that drug into blood. Serum contains a myriad of proteins. Although these proteins themselves are water-soluble (since they are found dissolved in blood) they often contain lipophilic regions on them, which can bind non-polar drugs and thus carry these drugs through the circulation. Albumin is the major drug-binding protein in serum. Albumin is an alkaline protein, so acidic and neutral drugs primarily bind to it. If albumin binding sites become saturated, acidic and neutral drugs can bind to lipoproteins. Alkaline drugs tend to bind to globulins, particularly to a globulin called alpha-1 acid glycoprotein. Only free, unbound drugs are able to bind drug receptors on cells and have therapeutic effects. An equilibrium will exist in the body between free and protein-bound drug and between free and receptor-bound drug.

Bence Jones (Kappa & Lambda) protein are often indicative of _________________

Multiple Myeloma

Which two of the following biomarkers are not specific to cardiac muscle and may be elevated in patients with injury to muscle other than cardiac muscle?

Myoglobin and CK-MB are present in skeletal muscle and can be elevated in injury to these cells. Other causes of increased myoglobin and CK-MB levels include: Severe injury to skeletal muscle Strenuous exercise Extremely difficult breathing (increased use of chest muscles) Kidneys failure Chronic muscle disease Alcohol abuse Troponin T and I tests are much more specific to cardiac muscle than myoglobin and CK-MB assays.

Which of these organizations is responsible for the formal definition of CKD developed in 2002?

NKF-K/DOQI developed the original defition in 2002. KDIGO is responsible for the most recent guidelines developed in 2013.

amphoteric molecule

Negatively or positively charged. Changing the pH using buffers will alter the charge and magnitude of the charge. Ph 5.5 A molecule with this amphoteric ability is sometimes referred to as an ampholyte or, by the older term, zwitterion. Proteins with their ionizable amino and carboxyl groups are amphoteric. Nucleic acids (deoxyribonucleic acid or DNA and ribonucleic acid or RNA) are charged and thus are amphoteric.

The mobility or rate of migration of ions in electrophoresis is dependent upon the following factors:

Net charge of the molecules Size and shape of the molecules Support medium properties Strength of the electrical field Ionic strength of the buffer Temperature The net charge of a molecule is the most important factor affecting the mobility of that molecule. The greater the net charge, the greater the mobility or the more quickly the molecule migrates. The net charge of a particular compound depends upon the buffer and the resultant pH set by that buffer. The size and shape of a molecule also influence the rate of migration in that the larger the size, the slower the molecule will move in electrophoresis. The viscosity and the pore size in the support media or gels used for electrophoresis influence the rate of migration. Increased viscosity slows the migration, and increasing pore size speeds up the migration. Increasing the strength of the electrical field by raising the voltage and increasing the temperature used for the electrophoresis will increase the mobility and rate of migration. When increasing these factors that affect mobility, caution is necessary. An increase in temperature could denature the sample and alter the characteristics of the support medium. The ionic strength of the buffer and its effect on mobility is more complicated. The ionic strength of the buffer affects the thickness of the ionic cloud, the rate of migration, and the sharpness of the separated solutes. In electrophoresis, a cloud of ions forms over the medium and is composed of buffer ions, sample ions, and other nonbuffer ions. Increasing the buffer ionic strength increases the buffer ions in the cloud, slows the movement of solutes, and creates sharper bands. However, this also increases heat production.

Negative IFA

No discernible pattern in interphase cells Mitotics may be hard to find Do not confuse intensity with positive Do not stare so long you talk yourself into a positive Be consistent

Following a radical prostatectomy (the removal of the prostate in men with prostate cancer), what should the patient's PSA level be?

Non-detectable, since only the prostate gland produces PSA. Since only the prostate gland produces PSA, the complete removal of the prostate should result in the absence of PSA or the inability to detect PSA using immunoassay methods. Any PSA that remains in the blood circulation is likely indicative of a metastatic condition, where a prostatic carcinoma in a remote location (such as the bone marrow or liver) is producing PSA, indicating a poor prognosis.

Which of these tumor markers is recommended as a cancer screening test in non-symptomatic individuals?

None of these markers are recommended as screening tests for cancer in asymptomatic individuals. (CA 15-3, CA 125 & CA 19-9) While each of these tumor markers has utility in assessing success of treatment and the recurrence of cancer, all lack the required specificity required to be used as a cancer screening test in asymptomatic individuals.

Which of the following describes normal semen pH?

Normal semen pH is slightly alkaline (around 7.2).

Excessive carbohydrate loss that may occur due to vomiting or rapid weight loss may result in the presence of which of following substances not normally contained in the urine?

Normal urine specimens usually yield negative results for the presence of ketones. Low levels of ketones may be detected in the urine during conditions of physiological stress such as fasting, rapid weight loss, frequent strenuous exercise or prolonged vomiting. The presence of ketones in these situations is due to either inadequate intake of carbohydrates or increased loss of carbohydrates.

Blotting Techniques are used to separate _________ Fragments of DNA/RNA

Nucleic Acid

Which statement about samples or specimens for electrophoresis is correct?

Nucleic acids need to be isolated from cells in a specimen and purified before electrophoresis. The protein concentrations in plasma and serum are high enough for good separation. Cerebrospinal fluid and urine samples require concentration before electrophoresis because the proteins are in low concentrations in these specimens. As far as protein electrophoresis, serum, plasma, urine, and cerebrospinal fluids are more often used than peritoneal or pericardial fluids.

Which of the following patients is MOST at risk for hyperosmolar nonketotic coma?

Ordinarily, ketones are negative in a type 2 diabetic patient. Because the elderly often have reduced renal excretion and impaired cardiac function, a type 2 elderly diabetic is at risk for developing a hyperosmolar nonketotic coma.

Stains used for semen include

Papanicolaou (PAP) stain Differential Quik Stain Kit (Modified Giemsa) Shorr stain

Which of the following macroscopic findings is most consistent with the microscopic finding of oval fat bodies?

Positive protein is reported with the presence of oval fat bodies. Damage to the glomerular membrane in the nephrotic syndrome allows passage of proteins and lipids from the blood into the urinary filtrate.

Identify this cell

Presumptive malignant cell

Which of these is a function of the kidney?

Primary functions of the kidneys include: Regulating water/electrolyte content Contributing to acid-base balance through retention or excretion of acids Removing and excretion of metabolic waste products and xenobiotics Regulating arterial pressure through production and release of renin Regulating red blood cell production through production of erythropoietin Participating in calcium/phosphorus metabolism through production of 1,25-dihydroxyvitamin D

Most commonly used tumor markers________________________________________

Prostate-specific antigen (PSA) Prostatic acid phosphatase (PAP) Alkaline phosphatase Neuron-specific enolase PAP is also associated with cancers of the bone and bone marrow and benign conditions of the prostate, bones, and parathyroid. Although it lacks specificity as a tumor marker, PAP does have utility in staging prostate cancer. Among these most common enzymatic tumor markers, only PSA is specific or sensitive enough to identify specific organ involvement related to cancer.

Chemiluminescent immunoassays (CIA) utilize an immobilized capture ______ that attaches to the target serological marker in the patient's serum.

Protein Chemiluminescent immunoassay involves an immobilized capture protein that attaches to the target serological marker in the patient's serum. This process involves presenting the corresponding antibody to the patient's serum. Chemiluminescent immunoassays (CIAs) also exploit the very strong and specific binding between an antibody and the epitope binding site on an antigen. Like EIAs, a CIA will have an immobilized capture protein (either an antigen or an antibody). The assay steps are then very similar to an EIA with the exception that instead of color production, or a change in fluorescence, the CIA uses reporter enzymes that produce light. The detection and quantitation for a CIA are performed using a luminometer (a component that measures photons) rather than a spectrophotometer or fluorometer (that measures absorbance or fluorescence respectively). CIAs are much more sensitive than EIAs. CIAs can detect concentrations of analytes with 1000Xs more sensitivity than traditional EIAs. For this reason, most high-volume serology tests are now performed using instruments that perform CIAs.

Alternatives to TDM Include:

Prothrombin Time (PT) --> Warfarin

After reviewing the information on specimen samples for electrophoresis, select the one correct statement.

The protein content in urine and CSF are normally in low concentrations. Because of this, concentration of these proteins is required before electrophoresis. Due to high protein content, serum and plasma samples do not require concentration prior to electrophoresis (see pg. 13, Specimens).

Rheumatoid factor (RF)

RF is an autoantibody that reacts to the Fc portion of polyclonal IgG and to other classes of immunoglobulin (most assays detect the IgM rheumatoid factor). RF is helpful in evaluating patients who may have rheumatoid arthritis (RA), although it is absent in about 15% of patients with rheumatoid arthritis. RF positive patients are more likely to have progressive, erosive arthritis with loss of joint mobility and also extraarticular manifestations, including rheumatoid nodules and vasculitis. On the other hand, RF can be present in other autoimmune disorders.

Which of the following are considered potential treatment options for patients with CKD? Choose all that apply.

Reducing blood pressure Improving lifestyle choices associated with poor health Controlling diabetes Kidney transplant

Which of the following is NOT a function of CSF?

Regulating body metabolism is NOT a function of CSF. Cerebrospinal fluid has three main functions: Protect brain and spinal cord from trauma. Supply nutrients to nervous system tissue. Remove waste products from cerebral metabolism.

Rheumatoid arthritis (RA)

Rheumatoid arthritis (RA) is a chronic autoimmune disease that produces stiffness, pain, loss of mobility, inflammation, and erosion of the joints. The disease typically affects multiple joints symmetrically and can produce other symptoms including fatigue, fever, the development of nodules under the skin, and malaise. In addition, individuals with RA may develop anemia and other systemic complications. Although RA can affect anyone at any age, it tends to develop between the ages of 40 and 60, with over 70% of those affected being women. Over 1.3 million people in the United States have RA, and if left untreated the disease can shorten a person's lifespan and can leave many of those affected too disabled to work. The course of RA and its prognosis vary and may progress slowly or rapidly. Moreover, It may go into remission in some people and, in a few, it may disappear.

________ is the most prevalent of the SARDS.

Rheumatoid arthritis (RA) is the most prevalent disease in this group. However, the ANA assay is not the primary laboratory test for RA. Instead, the test for RA looks for the presence of rheumatoid factor (RF) or cyclic citrullinated peptide antibodies (anti-CCP).

Routine EP

Routine electrophoresis (also known as zone electrophoresis) is performed on a rectangular slab gel. Several patient specimens and control(s) can be placed on one gel, and solutes separated in one run. Routine electrophoresis is mostly used for the separation of proteins. A serum sample with normal plasma proteins yields five zones or bands of separated proteins: albumin, alpha-1-globulins, alpha-2-globulins, beta-globulins, and gamma-globulins. CSF and urine proteins can also be separated with routine electrophoresis. Other applications include the separation of isoenzymes, hemoglobins, and fragments of DNA and RNA. A manual agarose gel electrophoresis of eight serum samples is pictured. After electrophoresis, the gel was stained with Ponceau S.

SS-A/Ro ANA Pattern

SS-A/Ro (HEp-2000® only) Interphase: Seen with about 89% of samples containing anti-SS-A/Ro antibodies Hyperexpressing interphase cells 10-15% hyperexpress the SS-A/Ro antigen Stronger nucleolar staining Stronger speckled staining Non-hyperexpressing interphase cells May or may not stain SS-A/Ro (HEp-2000® only) Metaphase: Metaphase mitotic cells No staining in the chromosome region Region outside of the chromosome area will stain with variable intensity Some mitotics may also demonstrate brighter staining The presence of anti-SSA/Ro antibodies is confirmed by the unique staining pattern. Follow-up testing for antibodies to other extractable nuclear antigens (ENAs) is recommended. These antibodies are seen in patients with SLE, Sjögren's syndrome and low frequency in other diseases. This pattern is reported as ANA positive, SSA/Ro pattern, anti-SSA/Ro antibodies present. Most labs will titer these samples. However, because the significance is that the anti-SSA antibodies are present regardless of the titer endpoint, some labs do not titer the SSA/Ro pattern.

For successful gel electrophoresis, care must be taken with each of the following:

Sample application Buffers Support medium Stains Electroendosmosis and wick flow are technical considerations. When irregular, distorted, and atypical bands result, possible causes are investigated.

You are performing a sweat test using the Macroduct® system. At the end of 30 minutes, you observe that the patient is not producing very much sweat in the Macroduct® coil. Visually, you estimate it is between 5-10 µL. What should you do?

Samples collected in Macroduct® coils that are less than 15 µL should not be analyzed and should be reported as "QNS." Sweat should only be collected for 30 minutes; extending the time increases the opportunity for evaporation. In general, it does not yield more sweat and invalidates the minimum sweat rate based on 30 minutes collection time. Reagent volumes should not be adjusted, and samples collected from different sites should never be combined to bring the total volume up to 15 µL

Which of the following describe type 2 diabetes?

Selections 1,2 and 4 are correct: Type 2 diabetes was previously referred to as non-insulin-dependent diabetes or adult-onset diabetes. Most, but not all, type 2 diabetes are obese. Insulin resistance is probably the primary dysfunction in type 2 diabetes. The hyperglycemia can result from insulin resistance, insulin deficiency, or a defect in insulin secretion.Selection 3 is incorrect: Instead, type 2 diabetes accounts for approximatley 90% of all diabetes.

Sjogren's syndrome (SjS)

Sjögren's syndrome is an autoimmune disorder in which the body's immune system mistakenly attacks tissue in glands that produce moisture, such as tear and salivary glands. The disorder is a chronic inflammatory disease that often progresses to a more complex, systemic disorder affecting other tissues and organs. Sjögren's syndrome is characterized by an unusual infiltration of lymphocytes in glands such as tear and salivary glands. Although Sjögren's syndrome can affect anyone at any age, the majority of those afflicted are older than 40, and women are nine times more likely than men to have the disorder.

In which autoimmune disorder (and a form of SARDs) does the body's immune system mistakenly attack tissue in glands that produce moisture, such as tear and salivary glands?

Sjögren's syndrome, a form of SARDs, is an autoimmune disorder in which the body's immune system mistakenly attacks tissue in glands that produce moisture, such as tear and salivary glands. The disorder is a chronic inflammatory disease that often progresses to a more complex, systemic disorder, affecting other tissues and organs in the body. Sjögren's syndrome is characterized by an unusual infiltration of lymphocytes in glands such as tear and salivary glands. Celiac sprue is a reaction to gluten (found in wheat, rye, and barley) that causes damage to the lining of the small intestine. SSc (scleroderma) is a complex, multisystem, inflammatory autoimmune disease that often progressively affects the skin, blood vessels, lungs, gastrointestinal tract, kidneys, heart, and musculoskeletal tissues. Individuals with scleroderma overproduce collagen, a fibrous protein that makes up connective tissue including skin, resulting in symptoms that range from cosmetic problems to tissue damage to life-threatening organ dysfunction. Graves' disease is an autoimmune disorder that affects the thyroid, causing the overproduction of thyroid hormones (hyperthyroidism).

Sperm Morphology

Smear evaluation General (Head, Neck, Midpiece & Tail) Headstaining characteristics Tailstaining characteristics

round cells may either be _______

Spermatids or WBCs

A patient has a sweat conductivity result of 60 mmol/L. What would be the estimated corresponding sweat chloride concentration?

Sweat conductivity is approximately 15 mmol/L higher than sweat chloride due to the presence of other ions. Therefore, a conductivity of 60 mmol/L would roughly correspond to a sweat chloride concentration of 45 mmol/L.

Half Life

The amount of time it takes for a drug concentration in the body to decrease by 50% is called the drug's half-life (abbreviated t1/2). The longer a drug's t1/2, the slower it is removed from the body. Most drugs are eliminated from the body in 1 to 3 days, but some drugs with longer half-lives can still be detected in the body for weeks after the initial dose. The figure below illustrates a typical kinetic pattern for an oral drug. After 5 half-lives 94% of a drug will be gone. After 6 half-lives, a drug can be considered eliminated.

Systemic sclerosis (SSc)/Scleroderma

Systemic sclerosis, also known as scleroderma, is a complex, multisystem, inflammatory autoimmune disease that often progressively affects the skin, blood vessels, lungs, gastrointestinal tract, kidneys, heart, and musculoskeletal tissues. Individuals with scleroderma overproduce collagen, a fibrous protein that makes up connective tissue including skin, resulting in symptoms that range from cosmetic problems to tissue damage to life-threatening organ dysfunction. Although SSc is relatively rare and its prevalence difficult to determine. the condition is estimated to affect as many as 250 out of every million American adults. Scleroderma can affect anyone at any age, including children, but most cases are observed in individuals age 30 to 50 with women being affected four times more often than men. The condition may be more common in certain Native Americans, European descendants, and women of African descent.

Decreases in GFR may be caused by both benign and pathologic conditions.

TRUE. Both benign and pathologic conditions may result in a decreased GFR. Many benign conditions may not effect true disease in affected patients

The nephron is considered the functional unit of the kidney.

TRUE. The nephron is the major functional component of the kidney where plasma filtration takes place.

The American Thyroid Association (ATA) recommends the use of which laboratory test in screening all adults for thyroid disease, starting at age 35?

The ATA recommends using TSH to screen for thyroid in all adults over the age of 35 years, and every five years thereafter.

The currently recommended equation to estimate the GFR is the:

The CKD-EPI equation is currently recommended by KDIGO for use to estimate GFR due to its superior performance in contrast to the other options presented.

Which statement accurately describes the Colorzyme® system?

The Colorzyme® ANA test does, in fact, utilize the indirect enzyme antibody technique. The Colorzyme® system: Uses horseradish peroxidase, rather than FITC, as the marker on the secondary antibody. Offers the same advantages as the IFA procedure, but also has the added benefits of being more photo-stable and not requiring a fluorescent microscope. Shows a bright bluish purple staining in the cell nuclei of positive samples, with a pattern characteristic of the particular nuclear antigen distribution within the cells.

Which statement is FALSE when describing the diagnosis of autoimmune diseases?

The ESR test may be a better reflection of current inflammation than CRP because changes in serum ESR concentration occur more quickly than CRP. Changes in serum CRP concentration occur more quickly than ESR and therefore CRP may be a better reflection of current inflammation. Unlike the ESR, CRP is a fairly stable serum protein whose measurement is not time-sensitive and is not affected by other serum components. In addition, the magnitude of inflammation directly relates to the concentration of CRP. More recently, the use of high sensitivity CRP has been utilized and may better quantify lower levels of inflammation. The ESR typically is elevated in inflammation. While the ESR is not a diagnostic test, it can be used to monitor disease activity and treatment response and signal that inflammatory or infectious stress is present. Since autoimmune diseases can affect multiple organs and produce highly variable signs and symptoms that can change in severity over time, the recognition and diagnosis of autoimmune diseases can definitely be difficult. Signs and symptoms, when present, can be vague and slow to present and can cause incorrect diagnosis. Blood tests that indicate the presence of inflammation are usually performed to help diagnose an autoimmune disorder. Characteristic findings on a CBC can include a normochromic, normocytic anemia indicating the chronicity or severity of diseases and can also include an elevated or decreased platelet count and/or white blood cell count. Leukopenia and thrombocytopenia are common in patients with systemic lupus erythematosus (SLE).

Approximately 47% of individuals with cystic fibrosis are homozygous for the F508del mutation of cystic fibrosis transmembrane conductance regulator (CFTR). How does this mutation affect CFTR?

The F508del mutation results in a block in processing. This mutation is associated with a lack of amino acid, phenylalanine (Phe or F), at position 508 ( F508del). The lack of phenylalanine affects the folding of the protein, and it is trapped in the endoplasmic reticulum and degraded in the Golgi, never making it to the cell membrane.

Sulfosalicylic acid is a secondary method that can be used to determine the presence of which one of the following substances in the urine, if color interference prevents the accurate reading of a urine chemical reagent strip?

The SSA reaction is used to detect protein in the urine. It is sometimes used as a secondary method if interfering urine color makes it difficult to read the color reaction on the urine reagent strip

A patient is taking cimetidine for a stomach ulcer. This drug inhibits CYP2D6. The patient is now prescribed amphetamine for narcolepsy. Amphetamine is metabolized by CYP2D6. What would you predict?

The amphetamine dose may need to be adjusted down. Since cimetidine inhibits CYP2D6, less amphetamine will probably need to be given since it will not be able to be metabolized as readily. Most drug interactions are like this: one drug inhibits or competes with the same CYP450 as another drug. The end result is that higher concentrations of one, or both, drugs are present, leading to potential toxicity.

What is the optimal time to begin initial microscopic examination of a semen specimen, assuming liquefaction is complete?

The analysis should begin at 30 minutes (if liquefaction is complete) but no longer than one hour after ejaculation. Occasionally a specimen does not liquify. If this occurs, mechanical mixing or enzyme treatment may be necessary in order for the sperm count, motility analysis, and other microscopic aspects of a semen analysis to be performed.

These tubes of cerebrospinal fluid (CSF) arrive in the laboratory for evaluation. The tubes were numbered in the order in which they were obtained, with #1 being the first tube collected and #3 being the last tube collected. What may be indicated by the macroscopic appearance of the CSF?

The appearance of the CSF suggests a traumatic tap. This is indicated by the fact that there is decreasing amounts of blood in the sequentially collected tubes; tube #1 contains visible red blood cells, but the amount of blood decreases in the other tubes. Normal CSF is clear and colorless. If the blood was the result of a subarachnoid hemorrhage, all three tubes would contain blood and the amount of blood in each tube would be consistent (unless a traumatic tap also occurred during collection of the sample).

The image is a Wright-Giemsa stained smear (1000x) of cerebrospinal fluid (CSF). The arrows point to cells that may indicate which of the following conditions?

The arrows point to immature cells, probably blasts, which may indicate leukemia with CNS involvement. Blasts are not associated with allergic reactions, bacterial meningitis, or viral meningitis.

Organ specific autoimmune disease

The autoantibodies attack a specific organ. Example: Hashimoto thyroiditis where autoantibodies damage the thyroid gland.

Non-organ specific/systemic autoimmune disease

The autoantibodies attack multiple organ systems. Example: Systemic lupus erythematosus (SLE) where the autoantibodies may attack any organ in the body.

Bioavailability of an oral drug refers to the:

The bioavailability of an oral drug is the fraction of the drug that is absorbed into systemic circulation. The bioavailability of a drug is calculated by comparing the area under the plasma concentration-time curve of an equivalent dose of the intravenous form and the oral form of the drug. For oral drugs to be effective, bioavailability typically should be greater than 70%.

Which component of an electrophoresis system sets the pH?

The buffer used in electrophoresis sets the pH in that system.

Inotropics (drugs used to increase the pumping ability of the heart) and antiarrhythmics may need TDM. (Cardiac Medication)

The cardiac glycoside inotropics digoxin and digitoxin have narrow therapeutic windows. Overdose can cause vomiting, diarrhea, confusion, visual disturbances, and cardiac arrhythmias. An interesting conundrum regarding these medications is that an overdose will produce the same symptoms that the drug is used to treat. For example, procainamide is used for arrhythmyia, but an overdose of procainamide can produce an arrhythmia. Thus, without TDM the physician will not know whether to give more drug or less drug, since both states can lead to the same presentation. Examples of cardiac medications that are monitored by TDM include: Digoxin Digitoxin Procainamide N-acetylprocainamide (NAPA) -the metabolite of procainamide Quinidine Continue to the next page

Identify the cells that are indicated by the arrow.

The cells depicted in this image are transitional epithelial cells. These cells originate from the renal pelvis, ureters, bladder, and/or urethra and are usually round or polygonal. They are smaller and smoother in outline than squamous cells but larger than a white blood cell (WBC).

A 3-week-old female with no signs or symptoms of cystic fibrosis (CF) has a positive newborn screening (NBS) test result for CF. The NBS is based on genotyping. The baby is then referred for sweat chloride testing. The sweat chloride result is 15 mmol/L, which is in the normal range. What do these results most likely indicate?

The patient is most likely a carrier of CF. Carriers for CF have no clinical manifestations of the disorder. The positive NBS indicates at least one mutated copy of CFTR (assuming no sample mix up). However, the patient is most likely heterozygous for CF, as demonstrated by the positive NBS and a normal sweat chloride result.

If a disease or disorder causes serum binding proteins (such as albumin) to decrease, what may occur if the dose of a highly protein-bound drug with a narrow therapeutic window is not adjusted?

The patient may experience toxic effects (high free drug fraction). If serum protein levels fall, as can occur in liver failure or nephrotic syndrome, less protein (specifically albumin) will be available for drug binding; a subsequent dose may produce a toxic concentration of free drug. Doses of drugs that are highly protein-bound may need to be adjusted in patients with lower drug-binding protein levels.

A 70-year-old type 2 diabetic patient is comatose and in the emergency department. STAT blood glucose and serum ketones are ordered. Blood glucose is 650 mg/dL Serum ketones are negative What is the best conclusion?

The patient may have hyperosmolar nonketotic coma and should be further evaluated. The blood glucose value is critical and with negative ketones is consistent with type 2 diabetes. The elderly type 2 diabetic is at risk for a hyperosmolar nonketotic coma. The patient becomes dehydrated due to increased urine excretion to lower the blood glucose. If reduced renal or cardiac function is also present, glucose excretion is impaired and blood glucose concentrations can become extremely high. Ketones are not produced in excess; thus, the patient remains nonketotic. Insufficient hydration, elevated blood glucose, and decreased renal excretion of waste products result in an increased osmolality and total concentration of all plasma components A measurement of urine glucose would not be useful at this point.

Which of the following factors would not affect an orally-administered drug's absorption and/or distribution in the body?

The position of the patient when the drug is taken (sitting vs. standing) Regional blood flow will affect drug distribution because the drug is transported in the blood. Reduced area blood flow can be seen in diabetics, and enhanced blood flow can be seen in tumors. Drug kinetics and dispositions change throughout life. In general, metabolism of drugs is reduced in the elderly. In the diseased gut, an orally-administered drug may not be absorbed as expected.

Lymphocyte pleocytosis refers to...

The presence of a greater than normal number of lymphocytes in the spinal fluid is considered lymphocyte pleocytosis.

There are several different types of media that can be used in electrophoresis. Most methods today use a gel (cellulose acetate, agarose, or polyacrylamide). Which one of the following statements is true regarding these gels?

The presoaking and clearing steps required with cellulose gel makes using this gel more time-consuming. Polyacrylamide gels and agarose gel are more often used. Polyacrylamide gels are composed of layers of acrylamides with varying pore size. The ability to vary the pore size in each layer and use layers of more than one pore size increases the separations achieved with polyacrylamide gel electrophoresis. Acrylamides are carcinogenic and therefore extra care must be taken in their use (see pg. 16, Agarose Gel and pg. 17, Polyacrylamide Gels).

What causes the hormones produced by malignant endocrine tissues to be highly elevated in the blood circulation?

The rapid and uncontrolled growth of malignant endocrine tissues paired with the lack of an effective negative feedback mechanism. Malignant endocrine tumors producing functional hormones are not only rapidly dividing, they often lack functional receptors for the products being produced by the target tissues or organs, which serves as a negative feedback mechanism designed to stop further hormone production. Thus, hormone levels in cases of malignant endocrine tumors are typically elevated to several times the upper reference limit and serve as tumor markers.

A Hb A1C result for a diabetic patient is 6.0%. What conclusion can be made regarding this patient's carbohydrate management?

The results demonstrate compliance with diet and medication. The Hb A1C result is < 7.0%, indicating glycemic control for most adults with diabetes.

What form of triiodothyronine (T3) is formed in circulation under the influence of high stress in conjunction with elevated levels of cortisol?

The stress hormone cortisol influences deiodinases to remove iodine residues from the inner ring of the T4 prohormone to produce an inactive form of T3, known as reverse T3 (RT3).

Which of the following is directly involved in the production of semen?

The structures involved in producing semen include the prostate, the seminal vesicles, the bulbourethral gland, and the testes and epididymis. Semen is produced as a combination of secretions from the different regions of the male reproductive tract. Each fraction differs in chemical composition and function. Spermatozoa are produced in the testes. They mature in the epididymis. The testes also produce testosterone and inhibin. Fluid from the seminal vesicles accounts for approximately 70% of semen volume. The seminal vesicles are the source of fructose in semen. Spermatozoa use fructose as an energy source. The prostate gland supplies about 20% of the volume of semen. Its fluids include acid phosphatase and proteolytic enzymes that lead to coagulation and subsequent liquefaction of semen. The prostate also contains most of the IgA found in semen. The bulbourethral gland produces mucoproteins that makeup about 5% of the volume of semen. The pituitary gland is not directly involved in producing semen; instead, hormones are released which stimulate the production of sperm. The urethra is not involved in the production of semen.

Which statements are TRUE regarding the testing and diagnosis of gestational diabetes (GDM)?

The testing and diagnosis of GDM is typically accomplished during a woman's first prenatal visit in those individuals with risk factors. In pregnant women not previously known to have diabetes, testing for GDM is usually done at 24-28 weeks of gestation. In addition, women with GDM are typically screened for persistent diabetes at 4-12 weeks postpartum. Moreover, women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years. A 2013 NIH panel recommended the two-step approach of screening with a 1-hour, 50-g glucose load test (GLT) followed by a 3-h 100-g oral glucose tolerance test (OGTT) for those who screen positive.

Liquefaction of a semen specimen always occurs immediately after ejaculation.

This statement is false. Liquefaction, or the resolution of the gel-like consistency, is expected within 15 minutes at room temperature. If liquefaction does not occur within 60 minutes, you should note this on the report sheet. Normal liquefied semen may contain jelly-like granules (gelatinous bodies) that do not liquefy.

The reagent strip method for protein primarily tests for which type of protein?

The urine reagent strip method for protein primarily indicates increased albumin, although other proteins may also produce a positive result if greatly elevated.

______________is a branch of clinical chemistry that specializes in the measurement of medication levels in serum. TDM requires that the laboratory make quantitative measurements of drugs and/or their metabolites.

Therapeutic drug monitoring (TDM) TDM should be contrasted with urine drug testing. While both measure drugs in patient specimens, urine drug testing is performed to detect drug abuse or confirm patient compliance when a patient is prescribed a drug with high abuse potential. Determining actual drug concentrations is less important when it comes to urine drug screening. TDM, on the other hand, must provide accurate, quantitative, serum concentrations for therapeutic drugs. Serum concentrations provided with TDM allow clinicians to adjust medication dosages as well as assess a patient's drug metabolism response and their compliance or dosing regimen.

Which statements are TRUE when describing autoimmune diseases?

There are as many as 80 types of autoimmune diseases. Many of them have similar symptoms, which makes them very difficult to diagnose. It's also possible to have more than one at the same time. Autoimmune diseases are a group of disorders where the body's immune system malfunctions and attacks its own tissues. As a result, the immune system attacks healthy cells and, depending on the type, an autoimmune disease can affect one or many different types of body tissue. Autoimmune diseases usually fluctuate between periods of remission (little or no symptoms) and flare-ups (worsening symptoms). African Americans, Hispanics, and Native Americans tend to have an increased risk of developing an autoimmune disease. Approximately 75% of those individuals affected with autoimmune disease are women

Why are ANA positive samples titered? (Select all that apply.)

There are two main reasons for titering ANA samples: to determine the amount of antibody present and to look for multiple ANA patterns. Often one ANA pattern will mask over, or hide, another pattern. Titering can also facilitate the detection of multiple patterns, alerting the clinician to possible disease associations and relevant follow-up testing. ANA titering does not reflect disease severity. The higher the titer, the more likely the patient has one of the systemic autoimmune rheumatic diseases (SARDs); however, titer levels do not necessarily change with disease activity or severity.

CYP2D6

There has been a significant amount of research over the years to characterize CYP450 enzymes and uncover any polymorphisms that have clinical significance. This course will not discuss CYP450s at length (for more see the course on Drug Metabolism) but we will consider CYP2D6 as one example: It is estimated that about 25% of common drugs are metabolized by CYP2D6. CYP2D6 accounts for only about 1% of all CYP450 enzymes, but it is important in the metabolism of about 100 drugs. There are more than 80 genetic variants that have been described in the CYP2D6 gene. The normal, wild-type allele displays normal metabolic activity whereas some of the variant forms have enhanced or diminished activity. The variants can be grouped generally according to the resulting alterations in protein function. The groupings correlate with four major enzyme metabolic capacities (phenotypes):poor metabolizersintermediate metabolizersextensive (normal) metabolizersultra-rapid metabolizers

Between HAV, HBV, and HCV; which one of these does NOT have a vaccine?

There is no vaccine for hepatitis C available. However, there is currently research being performed for the development of one.

What are the microscopic elements that are indicated by arrows in this image?

These are bacteria. The presence of white blood cells supports this identification rather than an "artifact" because white blood cells (WBCs) are usually present with bacteria during a urinary tract infection (UTI). The presence of bacteria with the absence of WBCs is usually an indication of an old specimen that wasn't refrigerated or tested within 2 hours after collection.

Type III Hypersensitivity

These autoimmune reactions are mediated by class IgG antibodies forming antigen/antibody complexes which then deposit out in various tissues in the body. They can then go on to trigger the complement system or attract neutrophils, leading to inflammation. An example of this mechanism is Systemic Lupus Erythmatosus (SLE).

Which of the following statements is true regarding CYP450 enzymes?

They are able to make compounds more water-soluble and therefore enhance excretion. CYP450s are the primary, but not the only, hepatic enzymes involved in drug metabolism. There are many CYP450s (at least 18 with possible isoenzymes of each). CYP450s are found primarily in the liver. They accept a variety of substrates and so are able to metabolize diverse compounds. Each CYP450 can metabolize several different drugs, making the CYP450 family versatile and able to address the wide range of chemical substances encountered by an individual.

A person with normal enzyme activity is referred to as 'wild type' or as an extensive metabolizer (EM)

This person should respond to standard dosages of a drug. Most people are EMs. This is the population in which most dosing regimens have been worked out in clinical trials.

A drug that is readily cleared and has a wide therapeutic window, such as ampicillin, should always be monitored by TDM.

This statement is false. For some drugs, such as ampicillin, the range between the minimum effective concentration and the toxic concentration is large. These drugs are thus relatively safe. Drugs that have a very narrow therapeutic window need to be monitored by TDM.

Insulin is the main regulatory hormone produced and secreted by the pancreatic beta cells. It stimulates the uptake of glucose and the movement of glucose from the blood to cells for energy production.

True Insulin is the main regulatory hormone produced and secreted by the pancreatic beta cells. It stimulates the uptake of glucose and the movement of glucose from blood to cells for energy production. Insulin also stimulates glycogenesis, inhibits glycogenolysis, and regulates protein synthesis.

Positive ANA test is seldom useful if other clinical or laboratory data supporting a diagnosis are not present.

True It is important to stress that autoantibody screening is useful in the diagnosis of autoimmune disorders and monitoring levels helps to predict the progression of disease. The levels of antibodies are analyzed by performing dilutions on the serum sample and reported as a titer. This is the highest dilution of the serum at which autoantibodies are still detectable. Depending on the laboratory and specific method used, an ANA titer is typically considered negative when it is less than or equal to 1:40. A titer equal to or less than 1:80 is often considered borderline, while a titer greater than 1:80 is considered positive. Higher titers are more clinically significant, whereas low positives (≤1:160) may be found in up to 20% of healthy individuals (especially the elderly). Although positive titers of 1:160 or higher are strongly associated with autoimmune disorders, they are also found in 5% of healthy individuals.

HBsAg is used to make the HBV vaccine.

True The vaccine uses HBsAg to induce the body to make anti-HBs. If levels of anti-HBs are ≥ 10 mIU/mL, then the patient is considered protected. The vaccine is given in three or two rounds, depending on the manufacturer.

A gender and genetic predisposition is usually the first step toward the development of an autoimmune reaction. The second step is the occurrence of a "triggering event" that leads to a break in tolerance.

True A current hypothesis suggests that the first two steps for the initiation of an autoimmune reaction are (1) gender and genetic predisposition toward the development of an autoimmune reaction and (2) the occurrence of a triggering event that leads to a break in tolerance.

Wick flow is caused by movement of the buffer ions into the medium when there has been a loss of moisture in the medium due to heat generation.

True Heat generated during electrophoresis can dry the gel medium. The drying gel will absorb some of the buffer to rehydrate, and the bands achieved can be irregular, distorted, or atypical in shape. This interaction between the gel and buffer is different than the gel and buffer interaction in electroendosmosis. In electroendosmosis, the gel attracts positive ions from the buffer, and in the electric field, an ionic cloud forms. The first movement is a physical change; the latter is a chemical change that changes the electrophoretic movement of the proteins (see pg. 48, Wick Flow).

Sodium dodecyl sulfate is added to polyacrylamide gels to denature the proteins in the sample and enhance their separation.

True Sodium dodecyl sulfate is a detergent that denatures proteins, that is, causes them to lose their protein folding and become smaller sized. The electrophoresis results in more separations because of the smaller-sized proteins and their migration in the small pores of the polyacrylamide gel (see pg. 26, Denaturing Polyacrylamide Gels).

The utility of the ANA test is to detect the antibodies early in the disease process

True The ANA results, in conjunction with clinical presentation, give the clinician solid evidence to intervene with an appropriate treatment. Studies have shown that once treatment is started, the formation of new antibodies slows or even halts.

Some molecular diagnostics utilizes blotting techniques to separate nucleic acids; northern blotting separates RNA.

True The first step in a blotting technique is electrophoresis of the sample. In molecular diagnostics, Southern blotting is detection of DNA, northern blotting is detection of RNA, and western blotting is a special separation of proteins.

Ideally, for a tumor marker to be considered as a screening tool, it should be consistently elevated at early stages of disease so that the diagnostic sensitivity is near 100%, and elevated only when the cancer of interest is present so that the diagnostic specificity is near 100%.

True While most tumor markers fall short of providing both 100% sensitivity and specificity and thus are not recommended for routine screening, ideally these are the desired characteristics of a tumor marker (see pg. 8, The Ideal Tumor Marker Would Have 100% Specificity and pg. 9, The Ideal Tumor Marker Would Have 100% Sensitivity).

Antibiotics may have nephrotoxic/ototoxic effects

True concentrations of these antibiotics need to be monitored. Serum concentrations that are too low or too high must be avoided. Examples of antibiotics that are monitored by TDM include: Amikacin Gentamicin Tobramycin Vancomycin Antifungals (voriconazole, posaconazole, fluconazole, flucytosine) Antibiotics such as ampicillin that are readily cleared and have a wide therapeutic window are not usually monitored by TDM.

Match the tumor marker with its respective category:

Tumor markers are often classified by their primary components or properties. The properties and components of tumor markers lead directly to how the analytical methods are developed to permit their detection and quantification. The correct category for each tumor marker is listed below: CEA is an oncofetal antigen PTH is a hormone CA 15-3 is a mucin-rich carbohydrate HER2/neu is a receptor IgM is a specific protein

Which of the following statements regarding semen analysis are TRUE?

Two or three semen samples are recommended to be obtained and evaluated to provide more information for an accurate interpretation of fertility status. In addition to determining male fertility status, a semen analysis can be used to assess the success of vasectomy and vasectomy reversal.

Two Dimensional Electrophoresis

Two-dimensional electrophresis is separating the same sample with two distinct separation techniques or two different electrophoresis separations. The separated bands from one electrophoresis are resolved more with the second electrophoresis. IEF followed by PAGE or AGE is the most frequent two-dimensional electrophoresis. The gel from the IEF capillary is removed and placed across the PAGE or AGE gel slab at right angles for the second electrophoresis. If PAGE is used for the second electrophoresis, it is often PAGE with SDS. Two-dimensional electrophoresis can also be a single sample run on either agarose or polyacrylamide gels. The gel is then turned 90 degrees and the same type electrophoresis is run on the separated solutes to separate each band from the first run into more bands.

Type I Hypersensitivity

Type I reactions are primarily due to the class IgE antibodies. This group is not responsible for autoimmunity; it involves mainly reactions to environmental antigens such as occurs in allergy.

Homogenous (diffuse) pattern (IFA)

Typically associated with SLE, mixed connective tissue disease, and drug-induced lupus.

While many laboratory tests are employed in diagnosis and monitoring of CKD, which two are the primary ones used to diagnose, risk stratify, and monitor the disease (select two)?

Urine albumin (as a creatinine ratio) and creatinine (to calculate GFR) are the most common tests used to diagnose, risk stratify, and monitor CKD.

Semen analysis includes

Volume Viscosity Concentration Total # (Viability) Motility - just keep swimming # of normal and defective Coagulation Fructose pH - 7.2-8.0 (alkaline) # of immature sperm WBCs, bacteria, parasites (infection)

ectopic hormone

When a hormone is produced at a distant site by non-endocrine tissue, the production is considered ectopic.

In regards to hormone production, what is the term that is associated with the production of a hormone at a distant site by non-endocrine tissue?

When a hormone is produced at a distant site by non-endocrine tissue, the production is considered ectopic. The hormone source is considered primary if the endocrine tissue that normally produces the hormone produces hormone in excess (see pg. 17, Primary and Ectopic Hormones).

A patient suspected of a urinary tract infection has a negative nitrite test, but bacteria are present upon microscopic examination. What may have caused this discrepant result? (Choose ALL correct answers)

When a urine sample shows a negative nitrite test, but bacteria are present upon microscopic examination, the false-negative result could be caused by two possibilities listed in the choices above: The bacteria that is present is not a nitrate-reducer OR the urine was in the bladder for an insufficient amount of time for nitrate to be reduced to nitrite.

What marker is important to measure in conjunction with determining thyroglobulin (Tg) levels with an immunoassay?

When determining levels of Tg using any immunoassay principle, it is essential to also determine if TgAb levels are elevated, as such antibodies may bind to circulating Tg molecules and lead to analytical inaccuracy.

Whole blood glucose values are ____________ plasma glucose values.

Whole blood glucose values are lower than plasma glucose values. For this reason, point-of-care whole blood glucose meters are programmed to correct the value before presenting the result; therefore, the whole blood glucose meter result correlates to serum or plasma results.

Electroendosomosis

With a pH of 8.0-9.0 used for protein electrophoresis, proteins take on a negative charge, that is, a negative ion cloud forms. As the negative ion cloud migrates to the anode, the proteins are pulled to the anode. Several gels used routinely for protein electrophoresis attract positive ions from the buffer and form a positive ion cloud. This ion cloud moves in the opposite direction to the cathode. This phenomenon is called electroendosmosis or endosmosis. The tension created by these oppositely moving ion clouds can affect the movement of sample macromolecules. The migration of some proteins can be slowed, some proteins can become immobile, and other proteins are pushed toward the cathode.

What are the microscopic elements that are indicated by arrows in this image?

Yeast can appear as single cells or in budding form. The most common yeast found in urine is Candida albicans, which typically demonstrates budding forms. The presence of budding forms helps to distinguish yeast from RBCs when urine sediment is viewed microscopically.

polymorphism

a variation in a specific gene (allele) that affects at least 1% of the population. It is essentially a mutation that occurs relatively frequently in the population.

If both HBsAg and HBc IgM are positive

acute HBV

Phase I reactions

alter a drug's chemical structure by oxidation, reduction, or hydrolysis.

Homogenous Pattern Follow Up Testing

antibodies to dsDNA is appropriate Most labs using a fluorescent slide method (CLIF) or ELISA.

If no sperm are seen on the concentrated sample, a report of "no sperm seen on a concentrated sample" can be made. The absence of sperm suggests a diagnosis of___

azoospermia

Theophylline

bronchodilator for the treatment of moderate to severe asthma and chronic obstructive pulmonary disease (COPD). TDM is needed for theophylline because the kinetics of the drug are highly variable. It has a narrow therapeutic window, and overdose can result in elevated heart rate, arrhythmia, and CNS excitability. Clearance of the drug is increased in children, smokers, persons with cystic fibrosis, and persons with hyperthyroidism. Elimination is slowed in congestive heart failure and in the elderly.

Identify this cell

choroidal cell

Phase ll reactions

conjugate drugs with other molecules to create products that are water-soluble.

A sperm concentration of 25 x 106 spermatozoa/ mL would be considered an abnormally low concentration, according to the WHO 5th edition.

false, According to WHO 5th edition, the lower reference limit for sperm concentration is 15 x 106 spermatozoa per ml.

CYP450

family of enzymes found predominantly in the liver. CYP450 enzymes work on a variety of substrates (in this case, drugs), altering their chemical structures to facilitate excretion in the urine and feces. Many polymorphisms occur in the protein sequences of CYP450 enzymes. Recall that earlier we stated that the liver has enzymes that will attach chemical groups onto drug molecules to make them more water-soluble, to facilitate their excretion. These are the reactions that the CYP450 enzymes facilitate.

polyacrimide gel

gel formed by polymerizing and cross-linking acrylamides. These gels are stronger than agarose gels and also thermostable and transparent. The matrix created by cross-linking the polymer chains is more regular, and the pore sizes are more uniform in an individual gel. The pore size can be changed by changing the concentrations of the acrylamides used. In addition to separating fragments by charge and mass, PAGE also separates solutes by molecular size. When using PAGE, the gel allows more fractions of smaller size to be detected than the traditional agarose gel methods creating greater resolution or separation of solutes. Care is required in polyacrylamide gel preparation and use because acrylamides are carcinogenic.

intermediate metabolizer (IM)

has one wild-type (normal) copy of the gene and one absent or dysfunctional copy. The IM group is very heterogeneous.

Components produced by cancer cells includes________________________________

hormones, specific proteins, enzymes, carbohydrates, mucins, blood group antigens, target receptors, and oncofetal antigens.

poor metabolizer (PM)

is a person who lacks a fully-functional enzyme or has reduced expression of the enzyme and therefore exhibits decreased metabolism of the drug(s) that are substrates for that CYP enzyme. This person would require lower doses of drug. A PM who receives a standard dose is more likely to experience unwanted side effects or toxicity. A PM can also experience diminished effects with pro-drugs. Pro-drugs are compounds that need to be metabolized into active compounds before they are effective.

Identify this cell

lymphocyte

Electrophoresis is________

migration or separation of charged particles or solutes of a liquid solution in an electrical field. Charged particles under the influence of a liquid media placed in an electric field will migrate to the electrode of the opposite charge. Positive ions (cations) will migrate to the cathode, the negative electrode. Negative ions (anions) will migrate to the anode, the positive electrode.

Identify this cell

monomacrophages

If both HBsAg and HBc IgM are negative

negative for HBV

Estrogen receptors (ER) and progesterone receptors (PR):

normally found in the tissues where their respective target hormones play a regulatory role, such as the uterus, pituitary gland, hypothalamus, and breast. Upon hormone binding, the respective receptors form a large protein complex that activates transcription. As these receptors are tissue-based, the determination of their presence or absence requires a representative tissue sampling. Both ER and PR are used in breast cancer as indicators for hormonal therapy. Those positive for ER and PR will typically respond to hormonal treatment, while those with negative receptors will require other treatment modalities, such as chemotherapy.2 Patients with positive ER and PR typically are associated with a better prognosis and higher survival rate.

Liquifaction of sperm

occurs after >30min

Most protein electrophoresis is performed at________

pH 8.6 Buffers most commonly used are barbital or tris-boric acid-EDTA buffers. They fix the pH at 8.6, leading to sharper bands and good separations. The isoelectric point of most proteins is between pH 4.0 and 7.5. In pH 8-9, proteins will take on a negative charge and migrate to the anode.

The isoelectric point (pI)

pH where the net charge of a molecule is zero. At its pI, a molecule will not move in an electrical field because it does not have a charge. Ph 6.0 An amphoteric molecule, such as a protein in a pH below its pI, will have a net positive charge (as shown). If the pH is above the pI, a protein will have a net negative charge.

ultrarapid metabolizer (UM)

require a higher dose than usual since he/she has a polymorphism (mutation) that codes for a more efficient enzyme or more expression of an enzyme. They will eliminate the drug more quickly. A UM may be resistant to standard treatments, and it may take some time to adjust the dosage before therapy is achieved.

The antinuclear antibody test (ANA) is used to________________

screen for the presence of autoantibodies that are directed toward components in the nucleus of the cell. Clinicians use the ANA test to assess the likelihood that a given patient has a SARD. The results of the ANA test alone are not diagnostic for the SARD. The patient must also have clinical evidence of the disease as well. Because the early clinical presentation for many of the SARDs are nonspecific, the results of the ANA test and subsequent follow-up testing are key pieces to making the correct diagnosis.

Breast cancer type 1 (BRCA1) and breast cancer type 2 (BRCA2)

susceptibility proteins normally expressed in breast tissue, where they help repair damaged DNA or destroy cells if the damaged DNA cannot be repaired. Those with genetic defects or mutations of the BRCA1 or BRCA2 genes are predisposed to developing breast or ovarian cancer. Studies have shown that carriers of the BRCA1 gene have as high as an 85% risk of developing breast cancer and a 45% risk of developing ovarian cancer by age 85.2 BRCA determination is typically performed on blood or saliva samples, which contain the DNA necessary to perform the genetic analysis. Detection of positive mutations creates dilemmas for patients, as decisions must be made about the course for prevention. In some cases, especially where family history prevails, preventive mastectomy or oophorectomy are performed to reduce the risk of developing cancers in the target organs or tissues. While not a TRUE tumor marker in the sense that BRCA is NOT detecting the growth of a malignant tumor, it has been included here since it has been used as a screening tool to assess those at risk for developing specific cancers.

The most common condition associated with a positive ANA test is___________

systemic lupus erythematosus (SLE) About 95% of those with SLE have a positive ANA test result. Other conditions in which a positive ANA test result may occur include: Drug-induced lupus: A number of medications may trigger this condition, which is associated with SLE symptoms. Cessation of the drug typically stops the symptoms, which usually go away. Although many medications have been reported to cause drug-induced lupus, those most closely associated with this syndrome include hydralazine, isoniazid, procainamide, and several anticonvulsants. Sjögren's syndrome: About 40-70% of those with this condition have a positive ANA test result. While this finding supports the diagnosis, a negative result does not rule it out. About 90% or more of individuals with Sjögren's syndrome have autoantibodies to SSA. Scleroderma (systemic sclerosis): About 60-90% of those with scleroderma have a positive ANA. In people who may have this condition, ANA subset tests can help distinguish certain forms of the disease. Other less common conditions: Less commonly, ANAs may occur in people with Raynaud syndrome, arthritis, dermatomyositis or polymyositis, mixed connective tissue disease, and other autoimmune conditions.

Bioavailability

the amount of drug absorbed relative to the amount given. This is calculated as the ratio of drug exposure after equivalent doses of oral and intravenous forms of a drug are administered (to the same subjects). Exposure is measured on a kinetic graph and is easy to calculate. It is the area under the curve (AUC) of the drug level (in serum) over time. This is illustrated in the accompanying figure. The fraction of oral drug that makes it to the circulatory system will always be less than the amount of drug achieved with IV infusion. The percentage of drug that reaches the serum from an oral dose would be the "oral bioavailability" for that drug. For IV drugs, the bioavailability is 100% since all of the drug is available instantly. For oral medications, the bioavailability will be less than 100%, due in part to any of these reasons:Oral drugs have slower absorption and distribution than IV drugs.The amount of drug that is absorbed can depend on the status of the GI tract (stomach pH, presence of food, integrity/health of the intestines, speed of the GI tract, etc.)Oral drugs may be broken down by enzymes that are present anywhere along the GI tract. If bioavailability is low then the oral dose needed has to be increased so that a given dose achieves the appropriate serum concentration. Since the absorption of an oral drug is slower than an IV drug and the drug takes longer to enter the circulation, clearing the drug will also take a longer time.

In ANA positive samples________________

the cell nuclei will show a bright apple-green fluorescence with a staining pattern characteristic of the particular nuclear antigen distribution within the cells. If the sample is negative for ANA, the nucleus will show no clearly discernible pattern of nuclear fluorescence. The cytoplasm may demonstrate weak staining, while the non-chromosome region of mitotic cells demonstrates brighter staining.

Pharmacokinetics

the study of drug disposition in the body, including how and when drugs enter the circulation, how long they remain in the blood, and how they are ultimately eliminated from the body. TDM is the clinical assessment of a drug's pharmacokinetic properties. Physicians and pharmacists need to establish whether or not a given drug is present at a clinically-effective concentration in a patient. This ensures that the drug concentration does not reach a toxic level.

If only the HBc IgM is positive

the test is inconclusive, probably patient is recovering from acute HBV

To be considered ANA positive_________

there must be a clearly discernible pattern staining the nucleus of the interphase cell. When a pattern is present in the nucleus of the interphase cell, then the metaphase mitotic cells are examined to assist in identifying the pattern(s). If there is no staining in the nucleus of the cell but there is a discernible pattern in the cytoplasm of the cell, the sample is reported as ANA negative. However, the presence of a cytoplasmic pattern should be noted.

Epithelial cells are frequently found in semen

true

Mucus strands may increase liquification time to >60min

true

_______________________is a detectable or measurable substance produced by the cells of a tumor or by the host in response to the tumor. It can be used to differentiate the tumor from normally dividing tissue. Such measurable substances may be found in blood, urine, other body fluids, tissue samplings, or cellular cultures.

tumor marker (Biomarker)

In order for drugs to be eliminated from the body, the body has to make them__________

water-soluble. Only when after drugs are made soluble in the blood can they be filtered out of the body by the kidneys and excreted into urine. The liver plays the major role in converting lipophilic, nonpolar molecules to more polar, water-soluble forms. It does this through a series of enzymatic reactions. Drug molecules can be modified by either phase I or phase II reactions. These reactions are carried out by several important classes of enzymes.

Mrs. Jones, a diabetic, is admitted to the hospital on November 25th. It appears that she has had an AMI but did not feel the severe chest pain because of diabetic neuropathy. She has not felt well since November 20th and her physician believes she possibly had an AMI on November 20th.Assuming that the infarct was uncomplicated, which of the following cardiac biomarkers would most likely still be elevated and would assist in an AMI diagnosis?

Cardiac troponin, either cTnI or cTnT, remains elevated after an AMI for 10-14 days. Myoglobin returns to normal range in 24-36 hours and CK-MB is back to normal range in 48-72 hours.

A technologist decides to make a 1:20 dilution of cerebrospinal fluid (CSF) after briefly evaluating a portion of the sample microscopically. After making the dilution and charging the chambers, the number of cells that are observed in each of the large squares of the hemocytometer is >100. What should the technologist do to obtain the most accurate count?

The best choice would be to make a larger dilution before performing the cell count. This will provide the most accurate results.

Atherosclerosis is a hardening of an artery specifically due to which of the following?

Atherosclerosis is a hardening of an artery specifically due to the buildup of plaque. The risk to patients with significant atherosclerosis is that eventually a narrowing of the artery (stenosis) can cause a reduction in oxygen delivery to tissues and plaque rupture can lead to an acute coronary event.

Which of the following organs synthesizes and secretes b-type natriuretic peptide (BNP)?

BNP is secreted by the heart and acts as an indicator of the heart's relative functionality. A higher BNP level signifies worsening symptoms of heart failure, as the left ventrical myocardium releases BNP in response to ventricular wall stress or tension, which occur in chronic heart failure.

What is the function of BNP?

BNP promotes diuresis in order to decrease intravascular volume and lower blood pressure. It is a marker of volume overload.

Common crystals which can be found in acidic urine include:

Calcium oxalate crystals can be found in acidic urine. Amorphous phosphates, triple phosphate, and calcium carbonate are all found in alkaline urine.

A 32-year-old teacher is seeing her internist for her yearly physical. Because of a family history of heart disease, she is concerned about her risk for cardiac disease. She is not a smoker nor hypertensive, and is not overweight. She is physically active and maintains a good diet and nutrition. Her physician ordered a lipid panel and hs-CRP to evaluate her cardiac disease risk.

Cholesterol 189 mg/dL< 200 mg/dL Triglyceride 140 mg/dL< 150 mg/dL LDL- cholesterol 98 mg/dL< 100 mg/dL (optimal) HDL-cholesterol 60 mg/dL≥ 59 mg/dL (optimal) hs-CRP 0.9 mg/dL< 1 mg/L (low risk) The individual would be at low risk for cardiac disease. She does not have any risk factors, her lipid levels are in the recommended ranges, and her hs-CRP is in low risk range.

Which of the following is a disadvantage of using the Hb A1C test over blood glucose measurement for diabetes screening?

Conditions that shorten RBC survival (eg, hemolytic anemia, homozygous sickle cell trait, pregnancy, or recent significant blood loss) will reduce exposure of the RBCs to glucose, thereby lowering the Hb A1C test value. Other disadvantages of utilization of Hb A1C over blood glucose measurement include: Cost per test is higher than blood glucose. Specimens with >10% fetal hemoglobin (HbF) may have a falsely decreased Hb A1C test result. If onset of diabetes is rapid, blood glucose levels will more correctly reflect glycemia than Hb A1C levels. Advantages of utilization of Hb A1C over blood glucose measurement include: Fasting is not required Greater specimen stability Less fluctuations in day-to-day levels caused by stress and illness

Six months ago, a 55-year-old female had a fasting plasma glucose (FPG) greater than 200 mg/dL on two occasions. She was diagnosed as having type 2 diabetes and treatment was started. Along with routine FPG, which of the following tests would most likely be used to monitor glycemic control?

FPG is performed to monitor diabetes, often weekly or even daily. The ADA also recommends that a Hb A1Cbe tested at least two times each year in patients who are meeting treatment targets and have stable glycemic control.

A patient who has a primarily vegetarian diet will most likely have an acid urine pH

False

A characteristic of a good cardiac biomarker is that it is normally present in a HIGH concentration in the peripheral blood.

False A biomarker that is a good indicator of cardiac damage is normally in low concentrations in peripheral blood.

Gestational diabetes is diagnosed with the same testing and criteria used for the diagnosis of diabetes for a nonpregnant adult.

False There are different screening tests for gestational diabetes and an oral glucose tolerance test (OGTT) is used to confirm diagnosis. An NIH panel recommended the two-step approach of screening with a 1 hour, 50 g glucose load test (GLT), followed by a 3 hour, 100 g OGTT for those who screen positive.

These 3 tubes of cerebrospinal fluid (CSF) are delivered to the laboratory for analysis. The tube labeled #1 was the first tube collected. Which one of the tubes should be used by the hematology department for cell count and differential?

Hematology analysis is typically performed on the last tube collected to ensure that any peripheral blood that may have contaminated the sample during the lumbar puncture has cleared. In this case, only 3 tubes were collected. Therefore, tube #3 should be used for cell count and differential. The first tube collected should not be used for hematology analysis because of possible blood contamination from the lumbar puncture.

What common thyroid condition is associated with the production of the highest levels of thyroperoxidase antibody (TPOAb)?

Highly elevated levels of TPOAb are associated most prevalently in Hashimoto's thyroiditis. TPOAb may also be encountered in Graves' disease and in sera of type I insulin-dependent diabetics.

Patients who are homozygous for the F508del mutation of cystic fibrosis transmembrane conductance regulator (CFTR) exhibit which of the following characteristics?

Patients with F508del tend to be pancreatic insufficient and have more severe pulmonary disease. High blood pressure is not a clinical manifestation of CF. Patients who are homozygous for F508del are said to have "classical CF."

Below are the laboratory results and chief clinical findings in a 31 year-old woman. Laboratory Results: Thyroid-stimulating hormone (TSH): 0.02 µIU/mL (ref range 0.4 - 4.12 µIU/mL) Free T3 (FT3): 6.8 pg/mL (ref range 2.5 - 3.9 pg/mL) Free T4 (FT4):1.6 ng/dL (ref range 0.6 - 1.3 ng/dL) Thyroperoxidase antibody (TPOAb): 10.4 IU/mL (ref range <9.0 IU/mL) Thyroglobulin antibody (TgAb): 5.5 IU/mL (ref range <4.0 IU/mL) Clinical Findings: Bulging eyes Hand tremors Extreme weight loss Accelerated heartbeat Which of the options below is most likely the diagnosis of this patient?

Hyperthyroidism, possibly due to Graves' disease In Graves' disease, a hyperthyroid state results from the stimulation of the thyroid gland to produce hormone, absent the direct stimulation of TSH from the pituitary. In this case, there is evidence of an autoimmune process with TPOAb elevated, which although not diagnostic in itself for Graves' disease, indicates that anti-thyroid antibodies may be contributing to the findings of increased FT3 and highly decreased TSH.

Why is it important to screen expectant mothers for thyroid disorders early in pregnancy?

It is important to screen expectant mothers for thyroid insufficiency, as undetected deficiencies of maternal thyroid could cause mental disabilities and decreased cognitive skills in her newborn.

Select the true statement regarding lipids and heart disease.

It is now known that atherosclerosis formation is primarily an inflammatory process but lipids do play a role in the process. Increased blood levels of LDL-C indicates a greater risk for atherosclerosis. An increased level of HDL-C is not associated with an increased risk for cardiovascular disease. In fact, the HDL lipoprotein plays a role in reducing lipid levels in the blood."

What condition can be described as the occurrence of blood glucose levels that are higher than normal, but not high enough to diagnose diabetes and suggests an individual at an increased risk for developing type 2 diabetes?

Prediabetes usually occurs when blood glucose levels are higher than normal, but not high enough to diagnose diabetes. The condition suggests an individual is at an increased risk for developing type 2 diabetes. Many people with prediabetes develop type 2 diabetes within 10 years. However, modest weight loss and moderate physical activity may often help people with prediabetes delay or even prevent type 2 diabetes. In the US approximately 1 in 3 adults have prediabetes.

The 2022 American Diabetes Association (ADA) updated guidelines include which of the following recommendations for prediabetes and diabetes screening in asymptomatic adults?

Selections 2, 3 and 4 are correct. The 2022 ADA guidelines recommendations for screening for prediabetes and diabetes in asymptomatic adults indicate that if test results are normal, testing should be repeated at a minimum of 3-year intervals.. Also, patients with prediabetes (A1C ≥5.7% or impaired glucose tolerance or impaired fasting glucose) should be tested yearly and women who were diagnosed with GDM should have lifelong testing at least every 3 years. Selection 1 is incorrect: The ADA now recommends that adults who do not have diabetes symptoms should be screened for prediabetes and type 2 diabetes starting at age 35.

What is the identity of the cells indicated by the arrow in this image?

The cells in this image are squamous epithelial cells. A squamous epithelial cell is a large flattened cell with abundant cytoplasm and a small round central nucleus. These cells are some of the largest cells found in the urine and are not usually pathologic. Squamous epithelial cells originate from the skin or urethra (lower urethra in males).

What is the goal of physiotherapy with inhaled medications in the treatment of CF?

The goal of the therapy is to improve lung function and decrease lung infections by clearing the airways and loosening mucus secretions. Medications such as bronchodilators and Pulmozyme® (DNase) are used in nebulizers before chest physiotherapy to open the airways and help degrade the DNA found in mucus from white blood cells. Following percussive therapy and postural drainage, inhaled antibiotics like tobramycin and aztreonam are used. In addition to these medications, some patients use inhaled hypertonic saline to aid in airway clearance and some use ibuprofen to decrease pulmonary inflammation. These medications treat the symptoms of CF but not the underlying molecular defect of CFTR. There is currently no cure for CF, and CF patients will continue to require the use of drugs to treat the symptoms.

What is the element indicated by the arrow in this image?

The image below depicts a granular cast. Granular casts are usually indicative of renal disease. These casts are composed of a protein matrix with degraded cellular material.

Which of the following white blood cells would NOT produce a positive leukocytes test on the urine reagent strip?

The presence of lymphocytes will not produce a positive leukocytes test since lymphocytes do not contain leukocyte esterase. Detection of leukocyte esterase is the basis of the leukocytes reagent strip test. Granulocytes (neutrophils, eosinophils, and basophils) contain leukocyte esterase and would be detected by the reagent strip test.

The sediment from a freshly collected urine specimen is examined microscopically. In addition to bacteria, what other finding from the list below would further indicate the presence of a urinary tract infection (UTI)?

The presence of white blood cells, especially in large quantities as in this case, is very indicative of urinary tract infections as the white cells are migrating to the urinary tract to fight the bacterial infection.

Which of the following urine chemical reagent strip tests is based on the Ehrlich-aldehyde reaction?

The urobilinogen urine chemical reagent strip test is based on the Ehrlich-aldehyde reaction. In this test, a pink-red color forms in proportion to the amount of urobilinogen present.

What crystals are captured below?

These are cholesterol crystals. These crystals look like plates of glass, sometimes with a notch out of one corner (top image).

A voided urine specimen is delivered from the women's clinic to the laboratory six hours after collection. The following results are reported: Clarity: cloudy Nitrite: positive Sp. Gravity: 1.020 pH: 9.0

These results indicate that the urine may have remained too long at room temperature and bacterial contaminants have affected the nitrite and pH results. Unpreserved urine samples should be refrigerated if they cannot be analyzed within two hours.

Identify the crystals that are seen in this image.

This image shows leucine crystals. These crystals are round to oval with radiating bands going from a center point out to the periphery, often referred to as a "wagon wheel."

A patient has a fasting plasma glucose (FPG) performed at an outpatient laboratory. He has fasted as instructed. The result of the FPG is 135 mg/dL. What does this result indicate and what, if any, further action is recommended by the ADA?

This is considered an elevated plasma glucose level, however in the absence of unequivocal hyperglycemia, the patient needs further testing. The ADA considers a FPG of ≥ 126 mg/dL as elevated. However, in the absence of unequivocal hyperglycemia, the results should be confirmed using repeat testing. (Diagnosis requires two abnormal results on same sample or in separate sample)

What cells are present in this image of urine sediment that is observed using brightfield microscopy?

This slide shows red blood cells (RBCs).

Which element is essential for the production of thyroid hormone?

Thyroid hormones are produced by incorporating iodine moieties into tyrosine residues found in the thyroglobulin protein.

Upon centrifugation, a cerebrospinal fluid (CSF) sample supernatant exhibited xanthochromia. The image is a Wright-Giemsa stained smear that was made from that CSF sample. What condition is probably related to these macroscopic and microscopic findings?

Xanthochromia may be an indication of previous subarachnoid hemorrhage (SAH). The presence of dark, granular, iron-laden hemosiderin deposits, indicated by the blue arrows, and yellow, crystalline, iron-free hemotoidin crystals (red arrows) in macrophages, point to an SAH several hours to days prior to CSF analysis. Macrophages begin to appear in CSF approximately two hours after bleeding occurs into the central nervous system. The macrophages start to phagocytize red blood cells (RBCs). As the RBCs degenerate further, the breakdown products are seen in the phagocytic cells as hemosiderin deposits or hematoidin crystals. The appearance of hemosiderin and hematoidin crystals occurs approximately 18 hours following an SAH and may be present in the CSF for several months. If a CSF sample from a traumatic tap is centrifuged, the supernatant would be clear rather than xanthochromic, if the sample was analyzed within one hour of sample collection. Many RBCs would be present, but hemosiderin deposits and hemotoidin crystals would not be present. These findings are also not associated with leukemia or meningitis.