Seth D. Force, MD

• Associate Professor of Surgery
• Division of Cardiothoracic Surgery
• Emory University
• Atlanta, Georgia

Diagnosis and disease severity/dynamics are fundamental for treatment decisions and to predict prognosis medicine rheumatoid arthritis cheap lamictal 100 mg online. A patient is asymptomatic but presents with chance finding on chest radiography or computed tomography xanthine medications lamictal 200mg on-line. A patient is asymptomatic but presents with chance finding on a pulmonary functioning test symptoms 0f pneumonia purchase cheap lamictal on-line. There are four main questions to be answered: (1) When did respiratory symptoms start In addition medicine world lamictal 50mg fast delivery, all available radiographs of the lung should be reviewed to characterize the nature and development of the radiologic pattern treatment 02 binh trusted lamictal 200 mg. Differential diagnoses include complications such as infections or pulmonary embolism symptoms 8 days after conception purchase 200mg lamictal with visa. Alternatively, infections, lung cancer, and pulmonary embolism have to be considered. Because history taking is a very complex and time-consuming task, it is often helpful to use a standardized questionnaire, such as that available from the American College of Chest Physicians. Routine laboratory testing should include a complete blood cell count; leukocyte differential; platelet count; erythrocyte sedimentation rate; determination of serum electrolyte levels, including calcium, serum urea nitrogen, and creatinine; liver function tests; and urinary sediment. To further evaluate the presence of connective tissue disease, systemic disease. Intraindividual changes of serum angiotensin-converting enzyme activity or of serum concentration of the soluble interleukin-2 receptor are to some extent helpful in monitoring disease activity in sarcoidosis. Calculated lung function indices may also be helpful to objectify the course and prognosis of the disease. The pattern and distribution of radiologic appearances contribute to initial diagnostic considerations as summarized in Table 7. It is associated with significant morbidity and mortality and should be reserved for those patients in whom the management and treatment could change depending on the result of biopsy. British Thoracic Society Interstitial Lung Disease Guideline Group, British Thoracic Society Standard of Care Committee; Thoracic Society of Australia; New Zealand Thoracic Society; Irish Thoracic Society. Predicting survival in idiopathic pulmonary fibrosis: scoring system and survival model. Obviously, there is an interaction between the underlying diagnosis and the prevalence of one or another pattern of disease behavior. Nonetheless, it seems very helpful to select the broad treatment approach in an individual patient by applying the patterns of disease behavior characterized in Table 7. Idiopathic pulmonary fibrosis: a composite physiologic index derived from disease extent observed by computed tomography. The goals of palliative care are to provide symptom management, prevent and relieve suffering, and support the best possible quality of life, regardless of stage of the disease or need for other therapies. Chronic illness, a permanently altered health state, results from a nonreversible pathologic condition. These medications slow the rate of deterioration of lung function, but have no proven impact on ultimate survival or quality of life. These symptoms are distressing to patients and family caregivers and present a challenge in maintaining quality of life as the disease relentlessly progresses. Clinical Practice Guidelines for Quality Palliative Care On behalf of the National Consensus Project for Quality Palliative Care Task Force. Patients receive emotional and spiritual support focused on enabling them to live better with the consequences of an incurable illness. In this setting, referral has the additional benefit of providing support to family caregivers who are asked to serve as surrogate decision-makers. Palliative Care Versus Hospice In 1967, Dame Cicely Saunders (who trained as a nurse, a social worker, and a physician) founded the St. Prior to the conference, the nurse telephoned the patient and carer to identify current concerns and goals for the visit. A mutual action plan was developed with telephone follow-up at 2 weeks, 1 month, and 2 months, and as needed. Patients reported that the sessions improved their ability to manage their symptoms and quality of life, demonstrating this type of intervention can improve patient care. The intervention focused on using clinical visits to identify changes in health status and functional activity, patient understanding of symptoms, interventions to improve symptoms, coping strategies, and caregiver roles. Three important areas for improvement were identified: (1) including a focus on supportive interventions and symptom self-management in discussion during clinic visits, (2) recognition of importance of family caregivers, and (3) appreciation of differences in patients and caregivers regarding need for information and change in needs over time. Findings revealed that patients initially had a clear understanding of their prognosis, but were uncertain about how their disease would progress and be managed. To elicit perspectives of patients and family caregivers, Lindell conducted focus groups consisting of patients currently living with the disease, caregivers for patients living with the disease, and caregivers of a deceased family member. Participants also verbalized hesitance to engage in advance care planning, which was recognized as a need, but avoided because it was perceived as loss of hope. Caregivers of the patients living with the disease were vocal about "only wanting positive options," including research participation opportunities. Bajwah and colleagues reported findings from a survey of 124 general practitioners that attempted to elicit barriers to implementation. Health professionals had varied knowledge and confidence in managing these concerns and tended to underestimate patient concerns. In testing a disease management intervention that included a session on advance care planning, Lindell20 found the content reduced perceived stress among caregivers who participated in the study. Therefore, it is advisable to introduce the potential of evaluation for transplant early following diagnosis. Barriers include fear that referral will signal abandonment by the transplant team and concern over opioid use. While concerns about adverse impact are not supported by evidence, perceptions on the part of clinicians, patients, and family caregivers can be extremely difficult to change. Hospice and palliative medicine is now recognized as a medical subspecialty by the American Board of Medical Subspecialties, as well as in Canada, England, Ireland, Australia, and New Zealand. Empiric practice, therefore, is borrowed from strategies found effective in other types of lung diseases. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study. Sertraline for chronic obstructive pulmonary disease and comorbid anxiety and mood disorders. Treatment Summary Abernethy: Benefits found with low-dose opiates Jennings: Patients were started on a very-low-dose oral morphine and given a weekly set titration protocol; of the 32 patients enrolled, 20 ended the trial on long-acting doses of oral morphine, and of the remaining patients 9 continued to take immediate-release morphine. Thalidomide for the treatment of cough in idiopathic pulmonary fibrosis: a randomized trial. Treatment Summary Roth: Benzodiazepine receptor agonists such as zolpidem are found to be effective Davis: Opioids are most effective when treating cough; cough suppressants, mucolytics, and nebulizer can also be used Chung: Morphine extended-release has been reported to be helpful for refractory cough. Supplemental oxygen may be beneficial, but comes with its own burden16 because of the equipment required and its impact on body image. As the prescription of oxygen increases, diligence should be paid to the delivery devices to ensure that the patient is able to receive the accurate dose of oxygen, and humidification should be added to the inspired oxygen to avoid excessive drying of the nasal mucosa. All of these delivery systems have "the potential to improve quality of life, improve pain and symptom management, and deliver goal-directed care to patients with cancer and other serious illnesses. Studies have reported that even when patients and their caregivers understood the terminal nature of the disease, they did not appreciate that symptoms could escalate rapidly, resulting in death. Idiopathic pulmonary fibrosis: a disease with similarities and links to cancer biology. Follow-up and nonpharmacological management of the idiopathic pulmonary fibrosis patient. Impact of a disease-management program on symptom burden and health-related quality of life in patients with idiopathic pulmonary fibrosis and their care partners. Clinical Practice Guidelines for Quality Palliative Care on behalf of the National Consensus Project for Quality Palliative Care Task Force. He completed the evaluation process and was deemed too well for transplant at that time. He participated in a clinical trial, and his symptoms remained stable over an 18-month period. He was seen in follow-up by his pulmonologist, who referred him back for lung transplant evaluation. Consequently he was seen and deemed to be "too sick" at this time and declined as a transplant candidate. The patient and his wife became very angry and he said, "I did everything you asked me to . It also provided the ability for him and his wife to acclimate to this decline and vent their frustration. Both the patient and wife were surprised and relieved with improvement in dyspnea. Be honest and help me prepare for the future: what people with interstitial lung disease want from education in pulmonary rehabilitation. Part 2: pharmacologic and nonpharmacologic management of dyspnea and other symptoms. Redefining the "planning" in advance care planning: preparing for end-of-life decision making. Clinical Practice Guidelines for Quality Palliative Care On behalf of the National Consensus Project for Quality Palliative Care Task Force; 2013. The national agenda for quality palliative care: the national consensus project and the national quality forum. The costs of waiting implications of the timing of palliative care consultation among a cohort of decedents at a comprehensive care center. Understanding breathlessness: cross-sectional comparison of symptom burden and palliative care needs in chronic obstructive pulmonary disease and cancer. Palliative care in advanced lung disease: the challenge of integrating palliation into everyday care. Referral to Palliative Care Infrequent in Patients with Idiopathic Pulmonary Fibrosis Admitted to an Intensive Care Unit. Cultural difference in palliative care in patients with idiopathic pulmonary fibrosis. Invited correspondence to european experience of location of death for patients with idiopathic pulmonary fibrosis. The palliative care needs of patients with idiopathic pulmonary fibrosis: a qualitative study of patients and family caregivers [in review]. The palliative care needs for fibrotic interstitial lung disease: a qualitative study of patients, informal caregivers and health professionals. The care needs of patients with idiopathic pulmonary fibrosis and their carers (CaNoPy): results of a qualitative study. Predictors and consequences of perceived lack of choice in becoming an informal caregiver. Patient-focused, family-centered end-of-life medical care: views of the guidelines and bereaved family members. Outcomes of lung transplant candidates referred for co-management by palliative care: a retrospective case series. Physician practices for communicating with patients with cystic fibrosis about the use of noninvasive and invasive mechanical ventilation. Perceptions of palliative care among patients with advanced cancer and their caregivers. Pilot testing of a question prompt sheet to encourage family caregivers of cancer patients and physicians to discuss end-of-life issues. Effectiveness of an interdisciplinary palliative care intervention for family caregivers in lung cancer. The use of mechanical ventilation in patients with idiopathic pulmonary fibrosis in the United States: a nationwide retrospective cohort analysis. Noninvasive ventilation in the event of acute respiratory failure in patients with idiopathic pulmonary fibrosis. Lung transplantation remains a complex medical intervention that requires a dedicated recipient and a medical team. The first human lung transplantation was performed in 1963 at the University of Mississippi by Dr. The advent of cyclosporine A began a new era, and Reitz and Shumway performed the first successful heart and lung transplant at Stanford University in 1981. Together these three diseases account for over 75% of all lung transplants performed. Once the change occurred, over 35%13 of the recipients between 2005 and 2012 had advanced lung disease 107 108 Interstitial Lung Disease learn about the entire process, from the surgery to the complex medical management one must adhere to after transplantation. The decision to actively list for transplant, alternatively, is based on organ allocation for a particular region, estimated risks and benefits based on the expertise of the individual transplant center, and the personal assessments of the transplant recipient. This increase in the number of transplants differs with trends for idiopathic pulmonary arterial hypertension. With the advance of successful therapies for the treatment of pulmonary arterial hypertension, the number of transplants for this condition has significantly declined, now accounting for 2% of all transplants in 2014 compared with 13% of transplants performed in 1990. Choice of Procedure There are three potential procedures for the interstitial lung disease recipient.

During the next 7 to 12 days medications jejunostomy tube purchase generic lamictal pills, additional growth and replication occur medications safe while breastfeeding order generic lamictal line, and the initial bodies develop into mature inclusions treatment magazine discount lamictal online master card, which appear by light microscopy as mulberry (morular) forms symptoms vitamin b12 deficiency discount lamictal 50mg online. This organism is a cause of potentially fatal human illness in North and South America and is transmitted to human beings by the bite of infected tick species medicine effexor generic 200 mg lamictal overnight delivery. In the United States these include the American dog tick (Dermacentor variabilis) medications 1 order lamictal uk, Rocky Mountain wood tick (Dermacentor andersoni), and brown dog tick (Rhipicephalus sanguineus). For example, the American dog tick is found in the eastern, central, and Pacific coastal United States; the Rocky Mountain wood tick resides in the western United States. The first sample should be taken as early in the disease as possible, preferably in the first week of symptoms, and the second sample should be taken 2 to 4 weeks later. IgM antibodies usually rise at the same time as IgG near the end of the first week of illness and remain elevated for months or even years. Also, IgM antibodies are less specific than IgG antibodies and more likely to yield a false-positive result. For these reasons, physicians requesting IgM serologic titers should also request a concurrent IgG titer. Both IgM and IgG levels may remain elevated for months or longer after the disease has resolved or may be detected in persons who were previously exposed to antigenically related organisms. Up to 10% of currently healthy people in some areas may have elevated antibody titers because of past exposure to R. Doxycycline is the first-line treatment for adults and children of all ages and is most effective if started before the fifth day of symptoms. Symptoms can include fever, rash (occurs 2 to 5 days after fever; may be absent in some cases), headache, nausea, and vomiting. Becoming nationally notifiable is an important step toward monitoring disease occurrence. Babesiosis is a preventable but sometimes life-threatening, tickborne, parasitic disease. In New England and the eastern United States, the disease is caused by Babesia microti; in California, it is caused by Babesia equi. Diagnostic Evaluation In symptomatic people, babesiosis usually is diagnosed by examining blood specimens under a microscope and observing Babesia parasites inside red blood cells. The gold standard for their identification is the visualization of the intraerythrocytic organisms in thick or thin blood films. In some infections with intraerythrocytic parasites, the morphologic characteristics observed on microscopic examination of blood smears do not allow an unambiguous differentiation between Babesia and Plasmodium organisms. In addition, molecular approaches are valuable for the investigation of new Babesia variants (or species) observed in recent human infections in the United States and Europe. Babesia canis has been found to be responsible for several cases in Mexico and France. When larvae develop into nymphs and adults, they feed on the white-tailed deer (Odocoileus virginianus), but they may also choose a human host. Babesiosis is most common in older individuals, splenectomized patients, or immunocompromised patients. In the 1970s, cases were primarily reported during the spring, summer, and fall in coastal areas in the northeastern United States, especially Nantucket Island off the coast of Massachusetts and on Long Island in New York. Most (95%) of the cases were reported by seven states-Connecticut, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, and Wisconsin-as well as in some European countries. The organism has also been transmitted via blood transfusion from asymptomatic donors. Between 1979 and 2009, 159 cases of transfusion-related babesiosis were identified. Treatment and Prevention Standardized treatments for babesiosis have not been developed. However, some drugs used for the treatment of malaria have been found to be effective in some patients with babesiosis. Antimicrobial therapy is recommended for splenectomized or immunodeficient patients, older patients, and patients with severe infections. Exchange transfusion has been effective for patients with a high level of parasites (>10%), severe disease, or massive hemolysis. Prevention requires vigilance when in tick-infested areas (see earlier discussion of Lyme disease prevention). The clinical presentation is variable, ranging from asymptomatic to rapidly progressive and sometimes fatal. The disease can cause fever, fatigue, and hemolytic anemia lasting several days to several months. Chikungunya virus is most often spread to people by Aedes aegypti and Aedes albopictus mosquitoes. In late 2013, the virus was found for the first time in the Americas on islands in the Caribbean (U. As of December 16, 2015, 653 travel-related cases of chikungunya virus disease had been reported from 44 U. Signs and Symptoms Symptoms usually begin 3 to 7 days after being bitten by an infected mosquito. Diagnostic Evaluation Chikungunya IgM and IgG antibody testing can be performed by reference laboratories. In addition to testing an acute serum specimen, parallel testing of an acute specimen and a convalescent specimen obtained within 30 days should be tested together. Treatment and Prevention Treatment to relieve fever and pain is the only available medication. Dengue is transmitted between people by the mosquitoes Aedes aegypti and Aedes albopictus, which are found throughout the world. Epidemiology Dengue is endemic in at least 100 countries in Asia, the Pacific, the Americas, Africa, and the Caribbean. Nearly all dengue cases reported in the 48 continental states were acquired elsewhere by travelers or immigrants. Symptoms of infection usually begin 4 to 7 days after the mosquito bite and typically last 3 to 10 days. In fatal cases, nucleic acid amplification, histopathology with immunohistochemistry, and virus culture of autopsy tissues can also be useful. However, cross-protective (heterotypic) immunity against dengue is short lived, with estimated durations of 1 to 3 years. In dengue endemic areas where infection pressure is high, rarely individuals have been shown to have sequential episodes of dengue with two different infecting serotypes. In patients with milder disease, symptoms resolve over time, although even healthy people have been sick for several weeks. Treatment and Prevention Treatment is consistent with the classification of the dengue infection. There are not yet any vaccines to prevent infection with dengue virus, and the most effective protective measures are those that prevent mosquito bites. Typically, these mosquitoes lay eggs in and near standing water in objects such as flower pots. Mosquitoes that spread chikungunya, dengue, and Zika are aggressive daytime biters, but they can also bite at night. Mosquitoes become infected when they feed on a human being already infected with the virus. Infected mosquitoes can then spread the virus to other human beings through bites. In addition to direct infection by an infected mosquito, three other modes of transmission exist. A pregnant woman already infected with Zika virus can transmit the Zika virus to her fetus during the pregnancy or around the time of birth. To date, there are no reports of infants getting Zika virus through breastfeeding. In addition, Zika can be transmitted through sexual contact, even if the infected person does not have symptoms at the time. To date, there have not been any confirmed blood transfusion transmission cases in the United States, but there have been multiple reports in Brazil of transmission of Zika by blood transfusion. Epidemiology the virus has been in the United States since at least the summer of 1999. Signs and Symptoms West Nile virus infection is characterized by fever, headache, fatigue, aches, and sometimes a rash. Diagnostic Evaluation Historically, flavivirus infections have been diagnosed by serologic tests or virus isolation. IgM antibody is evident in most infected patients 7 to 8 days after the onset of symptoms. IgM antibody has been shown to persist for longer than 500 days Epidemiology Zika virus is named after the Zika Forest in Uganda, Africa. Because the symptoms of Zika are similar to those of many other diseases, many cases may not have been recognized. Although outbreaks of Zika have been reported in tropical Africa, Southeast Asia, and the Pacific Islands sporadically, the first major increase in infection was noted in 2007. Since that time, Zika has appeared in South America, initially in Brazil and was recognized as a major health problem in the U. Locally acquired mosquito-borne cases were next prevalent in incidence at 139 cases, followed by 34 sexually transmitted cases. Signs and Symptoms Zika infection during pregnancy can cause the birth defect microcephaly, which is caused by incomplete brain development and other severe fetal brain defects. Eye defects, hearing deficits, and impaired growth have resulted from fetal infection. In areas with active Zika virus transmission, asymptomatic pregnant women should undergo IgM testing as part of routine obstetric care in the first and second trimester. The best way to prevent diseases spread by mosquitoes is to provide protection from mosquito bites. Her company annually sponsored a Memorial Day weekend golf outing at a Long Island club. The spot was about 2 inches wide in the bright red area with an overall diameter of about 6 inches, including the surrounding pale area. During this interval, she experienced fever, malaise, arthromyalgias, headache, and a stiff neck but recovered completely. In the fall, the woman noticed insidiously progressive fatigue, malaise, memory deficits, irritability, and inattentiveness to the demands of her job. She visited a physician, but no abnormalities were noted, and she was referred to a Manhattan neurologist. IgM levels are variable but generally are positive starting near day 4 after the onset of symptoms and continuing for 12 weeks. Is it important to determine whether one or both infections are present in the same host Over the last several months, he had become seriously dysfunctional at work and home. His residence and travel history revealed a week-long vacation on Cape Cod the previous summer. A laboratory test yielded a positive result, and a 4-week course of doxycycline was initiated. Two weeks later, he noted significant improvement in symptoms, but 3 months later his previous symptoms recurred. Two months after the second course of antibiotic, his Lyme test result was still positive, and the patient was given 2 weeks of infusion therapy with ceftriaxone. The Western Blot procedure is more definitive in the stage of Lyme disease. Why did the patient demonstrate a positive laboratory result, even though the usual treatment regimen was unsuccessful On returning to his home in Boston after Labor Day, he began to feel unusually tired and had difficulty breathing. He also reported that his urine had become dark brown several days after returning home. On physical examination, the patient was found to be jaundiced, and he had an enlarged spleen. His total white blood cell count was normal, but he had an increased percentage of segmented neutrophils. His hemoglobin and hematocrit values and platelet count were all below the normal reference range. The patient was treated with quinine and the antibiotics clindamycin and doxycycline. If Babesia cannot be observed by microscopic examination of a peripheral blood smear from a patient who is ill but has no travel history to a malaria-endemic area, an acute infection with Babesia can be diagnosed by: a. Testing acute and convalescent patient sera for a rise in the IgG antibody titer c. A fever and myalgia began after the patient removed a small tick from his left thigh while on vacation in an area in which B.

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Stimulate T-cell proliferation the characteristic associated with tumor necrosis factor is: a medications covered by medicare order lamictal without prescription. This voluntary system integrates a number of surveillance systems and provides data on devices treatment refractory buy 50mg lamictal with amex, patients symptoms 8-10 dpo purchase lamictal 100mg online, and staff medications medicaid covers purchase lamictal 25 mg visa. Many hospitals have reorganized the physical layout of handwashing stations (see later medicine 219 buy lamictal cheap, "Handwashing") to prevent the spread of pathogens medications known to cause tinnitus purchase 200 mg lamictal free shipping. Adherence to general safety practices will reduce the risk of inadvertent contamination with blood or body fluids, as follows: 1. Staff must wear laboratory coats and be additionally protected from contamination by infectious agents. Food and drinks should not be consumed in work areas or stored in the same area as specimens. Containers, refrigerators, or freezers used for specimens should be marked as containing a biohazard. Specimens needing centrifugation are capped and placed into a centrifuge with a sealed dome. A gauze square is used when opening rubber-stoppered test tubes to minimize aerosol production (introduction of substances into the air). This manual should contain a comprehensive listing of approved policies, acceptable practices, and precautions, including Standard Blood and Body Fluid Precautions. In the immunology-serology laboratory, precautions must be taken to prevent accidental exposure to infectious diseases and other laboratory hazards. Clinical laboratory personnel are routinely exposed to potential hazards in their daily activities. The importance of safety and correct first aid procedures cannot be overemphasized. Many accidents do not just happen; they are caused by carelessness or lack of proper communication. For this reason, the practice of safety should be uppermost in the mind of any worker in a clinical laboratory. This article presents safety issues that contribute to quality in laboratory testing and are applicable to patient outcomes and the immunology-serology laboratory staff. To ensure that workers have safe and healthful working conditions, the federal government passed the Occupational Safety and Health Act of 1970 and, in 1988, expanded the Hazard Communication Standard to apply to hospital staff. Occupational Safety and Health Act regulations apply to all businesses with one or more employees and are administered by the U. The programs deal with many aspects of safety and health protection, including compliance arrangements, inspection procedures, penalties for noncompliance, complaint procedures, duties and responsibilities for administration and operation of the system, and how the standards are set. Responsibility for compliance is placed on the administration of the institution and the employee. The desired outcome is that increased collaboration, including the ordering of appropriate tests, analysis and interpretation, reporting, and communicating of results, enhance clinical decision making. Specific regulations in regard to the handling of blood and body fluids from patients suspected or known to be infected with a bloodborne pathogen were originally issued in 1983. Viral transmission can result from contact with inanimate objects, such as work surfaces or equipment contaminated with infected blood or certain body fluids. If the virus is transferred to the skin or mucous membranes by hand contact between a contaminated surface and nonintact skin or mucous membranes, it can produce viral exposure. The number of cases of acute hepatitis among health care workers because of occupational exposure has sharply declined since hepatitis B vaccine became available in 1982. If these aerosol products are infectious and come into direct contact with mucous membranes or nonintact skin, direct transmission of virus can result. It eliminates the need for separate isolation procedures for patients known or suspected to be infectious. The application of Standard Precautions also eliminates the need for warning labels on specimens. Standard Precautions are intended to supplement rather than replace handwashing recommendations for routine infection control. Garments should be changed immediately if grossly contaminated with blood or body fluids to prevent seepage through to street clothes or skin. Contaminated coats or gowns should be placed in an appropriately designated biohazard bag for laundering. Disposable plastic aprons are recommended if blood or certain body fluids may be splashed. There are no reported differences in barrier effectiveness between intact latex and intact vinyl gloves. Tactile differences have been observed between the two types of gloves, with latex gloves providing more tactile sensitivity; however, either type is usually satisfactory for phlebotomy and as a protective barrier during technical procedures. Latex-free gloves should be available for personnel with sensitivity to usual glove material. General guidelines related to the selection and use of gloves include the following: 1. Use sterile gloves for procedures involving contact with normally sterile areas of the body or during procedures in which sterility has been established and must be maintained. Use nonsterile examination gloves for procedures that do not require the use of sterile gloves. The National Institute of Occupational Safety and Health mandates the use of gloves for phlebotomy. Wear gloves when processing blood specimens, reagents, or blood products, including reagent red blood cells. Gloves should be changed frequently and immediately if they become visibly contaminated with blood or certain body fluids or if physical damage occurs. Washing with detergents may cause increased penetration of liquids through undetected holes in the gloves. Rubber gloves may be decontaminated and reused, but disinfectants may cause deterioration. Rubber gloves should be discarded if they have punctures, tears, or evidence of deterioration or if they peel, crack, or become discolored. It is faster, more effective, and better tolerated by your hands than washing with soap and water. Wash your hands with soap and water when hands are visibly dirty or visibly soiled with blood or other body fluids or after using the toilet. If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks of Clostridium difficile, handwashing with soap and water is the preferred means. Alternatively, frequent handwashing should be performed after contact with patients and laboratory specimens (Box 6. The efficacy of handwashing in reducing the transmission of microbial organisms has been demonstrated. Many hospitals have reorganized the physical layout of handwashing stations to prevent the spread of pathogens. The Association for Professionals in Infection Control and Epidemiology has reported that extreme variability exists in the quality of gloves, with leakage in 4% to 63% of vinyl gloves and in 3% to 52% of latex gloves. Before eating, drinking, applying makeup, and changing contact lenses and before and after using the bathroom. Before all activities that involve hand contact with mucous membranes or breaks in the skin. If the contact occurs through breaks in gloves, the gloves should be removed immediately and the hands thoroughly washed. The bleach or alcohol is left on the skin for at least 1 minute before final washing with liquid soap and water. Facial Barrier Protection and Occlusive Bandages Facial barrier protection should be used if there is a potential for splashing or spraying of blood or certain body fluids. Masks and facial protection should be worn if mucous membrane contact with blood or body fluids is anticipated. All disruptions of exposed skin, including defects on the arms, face, and neck, should be covered with a water-impermeable occlusive bandage. Touch only a restricted surface of the glove corresponding to the wrist (at the top edge of the cuff). To avoid touching the skin of the hand and touch only a restricted surface forearm with the gloved hand, turn of glove corresponding to the wrist. Once gloved, hands should not touch anything else that is not defined by indications and conditions for glove use. Pinch one glove at the wrist level to remove it, without touching the skin of the forearm, and peel away from the hand, thus allowing the glove to turn inside out. Remove the second glove by rolling it down the hand and fold into the first glove. Then, perform hand hygiene by rubbing with an alcohol-based handrub or by washing with soap and water. Protective gloves should always be worn for handling any type of biological specimen. Substances can become airborne when the stopper (cap) is popped off a blood-collecting container, a serum sample is poured from one tube to another, or a serum tube is centrifuged. When the cap is being removed from a specimen tube or a blood collection tube, the top should be covered with a disposable gauze pad or special protective pad. Gauze pads with an impermeable plastic coating on one side can reduce contamination of gloves. The tube should be held away from the body and the cap gently twisted to remove it. When not in place on the tube, the cap should still be kept in the gauze and not placed directly on the work surface or countertop. Specially constructed plastic splash shields are used in many laboratories for the processing of blood specimens. The tube caps are removed behind or under the shield, which acts as a barrier between the worker and specimen tube. Laboratory safety boxes are commercially available and can be used for unstoppering tubes or doing other procedures that might cause spattering. When specimens are being centrifuged, the tube caps should always be kept on the tubes. The centrifuge should be allowed to stop by itself and should not be manually stopped by the worker. Another step to lessen the hazard from aerosols is to exercise caution in handling pipettes and other equipment used to transfer human specimens, especially pathogenic materials. If an adequate volume of an alcohol-based handrub is used, it should take 15 to 25 seconds for hands to dry. Longer nails do not fit into gloves properly and can cause problems with blood collection and analysis. In addition to biological hazards, other hazards in the clinical laboratory include open flames, electrical equipment, glassware, chemicals of varying reactivity, flammable solvents, and toxic fumes. In addition to the safety practices common to all laboratory situations, certain procedures are mandatory in a medical laboratory. Proper procedures for the handling and disposal of toxic, radioactive, and potentially carcinogenic materials must be included in the safety manual. Information regarding the hazards of particular substances must be included as a safety practice and to comply with the legal right of workers to know about the hazards associated with these substances. Concentrations of 1:10 to 1:100 free chlorine are effective, depending on the amount of organic material present on the surface to be cleaned and disinfected. When unregistered products are used for surface disinfection, users do so at their own risk. While wearing gloves, all work surfaces should be cleaned and sanitized at the beginning and end of the shift with a 1:10 dilution of household bleach. Instruments such as scissors or centrifuge carriages should be sanitized daily with a diluted solution of bleach. It is equally important to clean and disinfect work areas frequently during the workday and before and after each shift. Disposable materials contaminated with blood must be placed in containers marked "Biohazard" and properly discarded. However, an area contaminated by blood or body fluids needs to be treated as potentially hazardous and requires prompt removal and surface disinfection. Strategies differ for decontaminating spills of blood and other body fluids, based on the setting. The cleanup procedure depends on the porosity of the surface and volume of the spill. The following protocol is recommended for managing spills in a clinical laboratory: 1. Bleach solutions are less effective in the presence of high concentrations of protein. Using a diluted bleach (1:10) solution, clean the spill site of all visible blood. Place all disposable materials used for decontamination into a biohazard container.

Discuss the principles of classic latex pregnancy testing symptoms diabetes type 2 cheap lamictal generic, including sources of error 97140 treatment code cheap lamictal 50 mg. Precipitation is the combination of soluble antigen with soluble antibody to produce a visible insoluble complex medicine 2015 buy lamictal 50mg on-line. Furthermore treatment yeast infection nipples breastfeeding lamictal 50mg without prescription, IgM classes are almost exclusively used as reagents medications you cant take with grapefruit order lamictal, and this class of antibodies is the one that is most commonly detected in patients as an analyte medicine 3604 pill buy lamictal 50mg cheap, for example, rheumatoid factor. Immunofixation electrophoresis (see Chapter 11) Allow antiserum and antigens in gel wells across from one another. Draw a standard curve using D2 for Fahey or Marcini, or use semilog paper with D versus concentration on the y-axis. A method of separating macromolecules such as proteins on the basis of their net electrical charge and size (molecular weight). Serum electrophoresis is a technique for separating ionic molecules, principally proteins, into five fractions on a medium such as paper, cellulose acetate, or gel. The separation is based on the rate of migration, depending on size and ionic charge of the individual components in an electrical field. Oppositely charged antigen and antibody are propelled toward each other by an electrical field. This allows detection of concentrations of antigens and antibodies 10 times smaller than the lowest concentrations measurable by immunodiffusion or double diffusion. Immunofixation electrophoresis: A procedure in which specific antibodies help produce sensitive and specific qualitative visual identification of paraproteins by electrophoretic position. Soluble phase Nephelometry Turbidometry Precipitation Assays A precipitation reaction involves the diffusion of soluble antigen and antibody. Precipitation reactions in gel are not as commonly performed in the clinical laboratory today. Immune precipitation methods in gel can be classified as passive methods or those using electrophoresis (Table 10. Flocculation tests used for antibody detection are based on the interaction of soluble antigen with antibody, which results in the formation of a precipitate of fine particles. The size and position of precipitin bands provide information regarding equivalence or antibody excess. Proteins are differentiated not only by their electrophoretic mobility, but also by their diffusion coefficient and antibody specificity. In this technique, cylindrical wells are cut out of agarose gel and spaced appropriately in a Petri dish. The antigen and antibody molecule in solution diffuse out of the wells and through the porous agar. If antibody specific for the antigen is present, the antigen and antibody combine at a point of optimal concentration called the zone of equivalence and produce a visible precipitin band or line of precipitation. A pattern of identity confirms the presence of the antibody in an unknown specimen. This procedure is used for looking at immune responses (antibodies) produced in patients in response to various diseases, especially fungal. The antigen passively diffuses through the agar and, at the zone of equivalence with the antibody, forms a precipitate. The diameter of the zone of precipitation is directly proportional to the concentration of the antigen. Cells unrelated to the antigen, such as erythrocytes coated with antigen in a constant amount, can be used as biological carriers. Whole bacterial cells can contain an antigen that will bind with antibodies produced in response to that antigen when it is introduced into the host (Table 10. It is important to note that quality results are dependent on the proper training of the person performing the assay and adherence to strict quality control regulations. Many antibody molecules can be bound to each latex particle, increasing the potential number of exposed antigen-binding sites. The antigen and antibody molecules in the solution diffuse from the wells and through the porous agarose. If the unknown serum contains antibody to the known antigen, a precipitin band forms at a point of optimal concentration of each component. In the presence of serum antibodies, these particles agglutinate into large visible clumps. Procedures based on latex agglutination must be performed under standardized conditions. A variety of conditions can produce false-positive or false-negative reactions in agglutination testing (Table 10. Coagglutination uses antibodies bound to a particle to enhance the visibility of agglutination. It is a highly specific method but may not be as sensitive as latex agglutination for detecting small quantities of antigen. This glycoprotein hormone consists of two noncovalently linked subunits, alpha and beta. Technical Sources of Error Reagents should never be expired; latex reagent must be well shaken, and agglutination should be read within 3 minutes to avoid erroneous results caused by evaporation. Chorioepithelioma, hydatidiform mole, or excessive ingestion of aspirin may give false-positive results. In men, a test identical to that used for pregnancy may be performed to detect the presence of a testicular tumor. Another variation is a one-step chromatographic color-labeled immunoassay for use with urine or serum. Store equipment and reagent in clean, dust-free environment, and handle with care. Autoagglutination Use a control with saline and no antibody as a negative control. Delay in reading slide reactions results Follow procedural directions and read in drying out of mixture. Overcentrifugation causes cells or Calibrate centrifuge to proper speed particles to clump too tightly. Delay in reading slide reactions Undercentrifugation Prozone phenomenon Using antibodies made against the subunit will cut down on cross-reactivity with the other three hormones. Flocculation tests for antibody detection are based on the interaction of soluble antigen with antibody, which results in the formation of a precipitate of fine particles. These particles are macroscopically or microscopically visible only because the precipitated product is forced to remain in a confined space. The most basic tests measure the antibody produced by the host to antigen determinants on the surface of a bacterial agent in response to infection with that bacterium. In a thick suspension of the bacteria, the binding of specific antibodies to surface antigens of the bacteria causes the bacteria to clump together in visible aggregates. The formation of aggregates in solution is influenced by electrostatic and other forces; therefore certain conditions are usually necessary for satisfactory results. The use of sterile physiologic saline with free positive ions in the agglutination procedure enhances the aggregation of bacteria because most bacterial surfaces exhibit a negative charge that causes them to repel each other. The small volume of liquid used in slide testing requires rapid reading before the liquid evaporates. Chemicals such as chromic chloride, tannic acid, and glutaraldehyde can be used to cross-link antigens to the cells. Mechanisms of Agglutination Agglutination is the clumping of particles that have antigens on their surface, such as erythrocytes, by antibody molecules that form bridges between the antigenic determinants. Agglutination is influenced by a number of factors and is believed to occur in two stages: sensitization and lattice formation. If a sufficient concentration of antibody is present, the erythrocytes are cross-linked and agglutinated. If nonreacting antibody or an insufficient quantity of antibody is present, the erythrocytes will fail to agglutinate. Sensitization the first phase of agglutination, sensitization, represents the physical attachment of antibody molecules to antigens on the erythrocyte membrane. Altering the physical conditions can result in the release of antibody from the antigen-binding site. The amount of antibody that will react is affected by the equilibrium constant, or affinity constant, of the antibody. Difference in electrostatic potential between net charge at cell membrane and charge at surface of shear. The concentration of salt in the reaction medium has an effect on antibody uptake by the membranebound erythrocyte antigens. Immunoglobulin M (IgM) antibodies are more efficient at agglutination because their large size and multivalency permit more effective bridging of the space between cells caused by zeta potential. Under conditions of antibody excess, there is a surplus of molecular antigen-combining sites not bound to antigenic determinants. Precipitation reactions depend on a zone of equivalence, the zone in which optimum precipitation occurs, because the number of multivalent sites of antigens and antibodies are approximately equal. For a precipitation reaction to be detectable, the reaction must occur in the zone of equivalence. In this zone, each antibody or antigen binds to more than one antigen or antibody, respectively, forming a stable lattice or network (see later). This lattice hypothesis is based on the assumptions that each antibody molecule must have at least two binding sites and that an antigen must be multivalent. On either side of the zone of equivalence, precipitation is prevented because of an excess of antigen or antibody. If excessive antibody concentration is present, the phenomenon known as the prozone phenomenon (Table 10. In this case antigen combines with only one or two antibody molecules and no cross-linkages are formed. This phenomenon can be overcome by serially diluting the antibody-containing serum until optimum amounts of antigen and antibody are present in the test system. If an excess of antigen occurs, the postzone phenomenon occurs, in which small aggregates (clumps) are surrounded by excess antigen and no lattice formation is established. To correct the postzone phenomenon, a repeat blood specimen should be collected 1 or more weeks later. If an active antibody reaction is occurring in vivo, the titer of antibody will increase and should be detectable. Repeated negative results generally suggest that the patient has the specific antibody being tested for by the procedure. If the number of antigenic sites is small or if the antigenic sites are buried deeply in the cell membranes, antibodies will be unable physically to contact antigenic sites. Steric hindrance is an important physiochemical effect that influences antibody uptake by cell surface antigens. The effect of this competition can be mutual blocking, or steric hindrance, and neither antibody type will be bound to its respective antigenic determinant. Steric hindrance can occur whenever there is a conformational change in the relationship of an antigenic receptor site to the outside surface. In addition to antibody competition, competition with bound complement, other protein molecules, or the action of agents that interfere with the structural integrity of the cell surface can produce steric hindrance. The pH of the medium used for testing should be near physiologic conditions, or an optimum pH of 6. At a neutral pH, high electrolyte concentrations act to neutralize the net negative charge of particles. The duration of incubation required to achieve maximum results depends on the rate of association and dissociation of each specific antibody. The optimum time of incubation varies, depending on the class of immunoglobulin and how tightly an antibody attaches to its specific antigen. Centrifugation attempts to overcome the problem of distance by subjecting sensitized cells to a high gravitational force that counteracts the repulsive effect and physically forces the cells together. Enzyme treatment alters the zeta potential or dielectric constant to enhance the chances of demonstrable agglutination.