Hilary OD Critchley BSc MBChB MD FRCOG FRANZCOG FFRSH

• FMedSci
• Professor of Reproductive Medicine, Honorary Consultant
• Obstetrician and Gynaecologist, University of Edinburgh,
• Centre for Reproductive Biology, Edinburgh

Jaundice Jaundice (from the French word jaune medicine 44291 buy 800 mg nootropil free shipping, which means yellow) medications management cheap nootropil master card, also called icterus treatment management system order nootropil 800mg on line, is a condition characterized by increased bilirubin in the blood medicine during pregnancy purchase nootropil 800mg otc. The abnormal color can interfere with chemistry tests based on color reactions medications such as seasonale are designed to discount 800mg nootropil mastercard, including reagent-strip analyses on urine medicine x topol 2015 buy cheap nootropil 800mg on-line. Position Body position before and during blood collection can influence specimen composition. Going from supine (lying down on the back) to an upright sitting or standing position causes blood fluids to filter into the tissues, decreasing plasma volume in an adult up to 10%. Only protein-free fluids can pass through the capillaries; consequently, the blood concentration of components that are protein in nature or bound to protein-such as aldosterone, bilirubin, blood cells, calcium, cholesterol, iron, protein, and renin-increases. In most cases, the concentration of freely diffusible blood components is not affected by postural changes. Nevertheless, a significant increase in potassium (K+) levels occurs within 30 minutes of standing; this has been attributed to the release of intracellular potassium from muscle. Patients with congestive heart failure and hepatic disorders may exhibit even more pronounced positional effects. Key Point: the National Cholesterol Education Program recommends that lipid profiles be collected in a consistent manner after the patient has been either lying down or sitting quietly for a minimum of five minutes. In fact, the normal physiologic response to a change in position from standing to lying down can cause a condition called postural pseudoanemia (posture-related false anemia), a substantial decrease in hematocrit values due to an increase in plasma that could be mistaken for blood loss or acute anemia. Values return to normal when the patient has been sitting up for a while, as blood fluid moves back into the tissues. For proper interpretation of test results for analytes affected by positional changes, all test specimens for that analyte should be collected with the patient in the same position. Analytes most affected by positional changes typically have a recommended position for specimen collection, based upon the one used when their reference ranges were established. Key Point: Calling outpatients into the drawing area and having them sit in the drawing chair while paperwork related to the draw is readied can help minimize effects of postural changes on some analytes. Consequently, results of some laboratory tests must be compared with reference ranges established for pregnant populations. Smoking Some blood components are affected by the nicotine absorbed through smoking. The extent of these effects depends upon the amount of nicotine in the bloodstream at the time, which is directly influenced by the number of cigarettes smoked. Glucose levels in patients with diabetes are especially affected by smoking; in fact, studies have shown that nicotine is the primary cause of elevated glucose levels in smokers who are diabetic. Key Point: Skin-puncture specimens may be difficult to obtain from smokers because of impaired circulation in the fingertips. Environmental Factors Environmental factors such as temperature and humidity can affect test values by influencing the composition of body fluids. Acute heat exposure causes interstitial fluid to move into the blood vessels, increasing plasma volume and influencing its composition. Extensive sweating without fluid replacement, on the other hand, can cause hemoconcentration. Environmental factors associated with geographic location are generally accounted for when reference values are established. In addition, specimens being transported from off-site locations require protection from temperature extremes to preserve specimen integrity. Healed burn sites and other areas with extensive scarring may have impaired circulation that could lead to erroneous test results. Freshly tattooed areas may have an undetected infection or be more susceptible to infection. In addition, tattoos may mask problem areas and impair the ability to detect bruising, rashes, and other reactions to phlebotomy. Lastly, because of the value patients place in their tattoos, most do not want to have scarring or bruising anywhere near them. Key Point: If you have no choice but to draw in an area with a tattoo, try to insert the needle in a spot that does not contain dye. These veins may be sclerosed (hardened) or thrombosed (clotted) from the effects of inflammation, disease, or chemotherapy drugs. Damaged veins are difficult to puncture, may yield erroneous (invalid) test results because of impaired blood flow, and should be avoided. Key Point: Use another site, if possible, or draw below (distal to) damaged veins. Edema Edema is swelling caused by the abnormal accumulation of fluid in the tissues. Specimens collected from edematous areas may yield inaccurate test results owing to contamination with tissue fluid or altered blood composition caused by the swelling. In addition, veins are harder to locate, the stretched tissue is often fragile and more easily injured by tourniquet and antiseptic application, and healing may be prolonged in these areas. Hematoma A hematoma is a swelling or mass of blood (often clotted) that can be caused by blood leaking from a blood vessel during or following venipuncture. If the draw is difficult, there is also the possibility that hemolyzed blood from the hematoma could be drawn into the tube or syringe, resulting in a specimen that is unsuitable for testing. In addition, it is thought that obstruction of blood flow by the hematoma and the effects of the coagulation process could lead to inaccurate test results on the specimen. Examples of bruising resulting from hematomas that formed during or immediately following venipuncture. If there is no alternative site, perform the venipuncture distal to (below) the hematoma to ensure the collection of free-flowing blood. Mastectomy Never draw blood from an arm on the same side as a mastectomy (surgical breast removal). Lymph node removal, which is typically part of the procedure, may cause lymphostasis (obstruction or stoppage of normal lymph flow). Impaired lymph flow makes the arm susceptible to swelling, called lymphedema, and to infection. Lymphedema can cause range-of-motion limitations as well as pain, weakness, and/or stiffness in the affected extremity. It has also been suggested that the effects of lymphostasis could change blood composition and lead to inaccurate test results. Obesity Obese (extremely overweight) patients often present a challenge to the phlebotomist. Proper tourniquet selection and application is the first step to a successful venipuncture. Typical strap tourniquets, which are normally around 18 in long, may be too short to fit around large arms without rolling and twisting, and being uncomfortably tight. Bariatric tourniquets (longer tourniquets designed for the obese) should be available. Although "bariatric" means "pertaining to the treatment of obesity," it is used as a euphemism to refer to individuals and items for individuals who are extremely overweight even if they are not actually being treated for obesity. Obese patients often have a double crease in the antecubital area with an easily palpable median cubital vein in the area (somewhat like a valley) between the two creases. If no vein is easily visible or palpable on tourniquet application, ask the patient what sites have been successful for past blood draws. If the patient has never had blood drawn before or does not remember, another site to try is the cephalic vein. In this position, the weight of excess tissue often pulls downward, making the cephalic vein easier to feel and penetrate with a needle. Paralysis can be temporary or permanent, and it can be localized in one area of the body or widespread. An arm that has lost muscle function has also lost the muscle action that helps return blood to the heart. This can result in stagnation of blood flow and increase the chance of vein thrombosis. This chance is magnified because venipuncture disrupts the lining of the vein, which also increases the chance of thrombosis. If sensation is also lacking in that arm, there can be an inability to detect an adverse reaction such as nerve injury. If you have no choice but to draw from a paralyzed arm, follow strict venipuncture procedures. They are most commonly used for administration of medications, fluids, blood products, and sometimes blood collection. However, the phlebotomist typically assists by supplying the appropriate tubes, and if a syringe is used, transferring the blood to the tubes using a syringe transfer device. If both arms are unavailable for venipuncture, some specimens can be collected by capillary puncture (see Chapter 10). The cap or stopcock has a diaphragm (thin, rubber-like cover) that provides access for administering medication or drawing blood. A lock is often placed in a vein in the lower arm above the back of the wrist and can be left in place for up to 48 hours. To keep it from clotting, the device is filled and flushed with saline and sometimes heparin. Risks associated with using heparin and its higher cost have resulted in the saline lock becoming the type most commonly used. Description Heparin readily adheres to surfaces; therefore, it is difficult to remove all traces of it. Consequently, a 5-mL discard tube should be drawn first when blood specimens are collected from a heparin lock or from a saline lock that has been flushed with heparin. Drawing coagulation specimens from them is also not recommended because traces of heparin or dilution with saline can negatively affect test results. It may also be used to collect blood gas and other blood specimens and for the administration of drugs such as dopamine. A shunt created for dialysis use commonly joins the radial artery and cephalic vein above the wrist on the underside of the arm. When palpated, a shunt has a distinctive buzzing sensation called a "thrill" that is the result of the pressure of the arterial blood flow meeting the passive flow of the vein. Never perform venipuncture or apply a blood pressure cuff or tourniquet on an arm with any type of shunt. These devices are said to reduce the chance of infection, prevent needlesticks, and minimize waste associated with line draws. To help ensure that the specimen is not contaminated with the flush solution, a small amount of blood must be drawn from the line and discarded before a blood specimen can be collected. The exit end is surgically tunneled under the skin to a site several inches away in the chest. Patient Complications and Conditions A phlebotomist must be aware of any previous complications. The phlebotomist must also be prepared for unexpected reactions before, during, or after the draw. Allergies to Equipment and Supplies Occasionally phlebotomists will encounter patients who are allergic to one or more of the supplies or equipment used in blood collection. Examples include the following: Adhesive Allergy Some patients are allergic to the glue used in adhesive bandages. Do not wrap it too tightly, and be certain to instruct the patient to remove it in 15 minutes. If the patient is alert, mentally competent, and willing, another alternative is to instruct him or her to hold pressure over the site for five minutes in lieu of applying a bandage. Antiseptic Allergy Occasionally, a patient is allergic to the antiseptic used in skin preparation prior to blood collection. Latex Allergy Latex allergy involves a reaction to certain substances in natural rubber latex. Some latex allergies are seemingly minor and involve irritation or rashes from physical contact with latex products. Other allergies are so severe that being in the same room where latex materials are used can set off a life-threatening reaction. There should be a warning sign on the door to the room of any patient known to have a severe latex allergy, and it is vital that no items made of latex be brought into the room whether collecting blood from the patient or a roommate. Fortunately, manufacturers have come up with latex-free alternatives to many items commonly used in healthcare such as gloves, bandages, and tourniquets. The result is most healthcare facilities have abandoned the use of latex items where possible. However, there may be other medical items that still contain latex or latex parts and many nonmedical items such as balloons, rubber bands, and even the soles of some shoes that contain latex. Key Point: Patients with known allergies often wear special armbands or have allergy-specific warning signs posted in their hospital rooms. Excessive Bleeding Normally, a patient will stop bleeding from the venipuncture site within a few minutes. Some patients, particularly those on aspirin or anticoagulant therapy, may take longer to stop bleeding. Memory Jogger: To remember that syncope means fainting, look for the word cope in syncope. Some patients become faint at just the thought or sight of their blood being drawn, especially if they are ill or have been fasting for an extended period. Other contributing factors include anemia, dehydration, emotional problems, fatigue, hypoglycemia, hyperventilation, medications, nausea, needle phobia, and poor or compromised breathing. Description Key Point: Sudden faintness or loss of consciousness caused by a nervous system response to abrupt pain, stress, or trauma is a type of reflex syncope called vasovagal (relating to vagus nerve action on blood vessels) syncope. Before beginning a venipuncture, routinely ask patients if they have ever had a problem with a venipuncture. If the patient has felt faint or fainted on a prior venipuncture, he or she will usually offer this information.

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Examining the site is necessary to verify Note: Do not apply a bandage to the that bleeding has stopped medicine woman purchase nootropil pills in toronto. Do not apply a bandage because it can come loose and become a choking hazard or tear the skin when removed medicine 1920s cheap nootropil online american express. Remove gloves aseptically and wash hands or use a hand sanitizer as an infection control precaution treatment jellyfish sting discount 800mg nootropil fast delivery. Air-drying in an elevated horizontal position away from heat or sunlight is required for newborn screening specimens symptoms 3 weeks into pregnancy order genuine nootropil line. They must not be hung to dry or stacked with other specimens before medications 5 songs discount nootropil 800 mg on line, during medications order nootropil in india, or after the drying process. Hanging or storage at a slant causes blood to migrate to the low end of the filter paper and leads to erroneous test results. Thank the patient, remove gloves, sanitize the hands, and transport specimen to the lab. When dry, the sample-containing requisition is normally placed in a special envelope and sent to the appropriate laboratory for testing. Routine Blood Film/Smear Preparation A blood film/smear (a drop of blood spread thin on a microscope slide) is required to perform a manual differential (Diff), a test in which the number, type, and characteristics of blood cells are determined by examining a stained blood smear under a microscope. A manual differential is not a routine test, though one may be performed to confirm abnormal results of a machine-generated differential or platelet count. Although a common practice in the past, today blood smears are rarely made at the bedside. When collected with other skin puncture specimens, blood smears should be collected first to avoid effects of platelet clumping. Blood smear preparation from a capillary puncture is illustrated in Procedure 10-5. Explanation/Rationale Blood to make the slide can be obtained by normal finger or heel puncture, following applicable capillary puncture steps 1 through 11 until this point. Wiping the first drop removes excess tissue fluid and alcohol residue that could distort cell morphology. The drop should be 1 to 2 mm in diameter and centered on the slide adjacent to the frosted end or 1/2 to 1 in from one end of a plain slide. Hold the blood drop slide between the thumb and forefinger of the nondominant hand or between the thumb and index finger pointing away from you. With the other hand, rest the second slide in front of the drop at an angle of approximately 30 degrees. The second slide is called the pusher or spreader slide and is held at one end, between the thumb and index finger in either a vertical or horizontal position. If blood is of normal thickness, a 30-degree angle will create a smear that covers approximately three-fourths of the remaining area of the slide. Pull the spreader slide back to the edge the blood must spread the width of the of the blood drop. Stop it as soon as it pusher slide or a bullet-shaped film will touches the drop, and allow the blood to result. Push the spreader slide away from the drop in one smooth motion, carrying it the entire length and off the end of the blood drop slide. Let the weight of the spreader slide carry the blood and create the film or smear. Do not push down on the spreader slide because this creates lines and ridges and an unacceptable blood film. Place the drop of blood for the second this way, two smears can be made using smear on the spreader slide. A conscious, mentally alert patient can apply pressure; otherwise, the phlebotomist must apply pressure. Label frosted blood slides by writing the Do not use ink because it may dissolve patient information in pencil on the during the staining process. Allow the blood films to air-dry, and Never blow on a slide to dry it because red place them in a secondary container for blood cell distortion may result. Be aware that unfixed slides are capable of transmitting disease and handle accordingly. Do not apply a bandage to an infant because it can come loose and become a choking hazard or tear the skin when removed. Prompt delivery to the lab is necessary to protect integrity of the slides before they are fixed and stained. Thank the patient, remove gloves, sanitize the hands, and transport the slides to the lab. A plain capillary tube or pipet is then used to dispense a drop of blood from the specimen tube onto the slide. The device is inserted through the rubber stopper of the specimen tube and then pressed against the slide to deliver a uniform drop of blood. Improperly made blood smears may not contain a normal, even distribution of blood cells and can produce erroneous results. An acceptable smear covers about one-half to three-fourths of the surface of the slide and has no holes, lines, or jagged edges. The thinnest area of a properly made smear, often referred to as the feather, is one cell thick and is the most important area because that is where a differential is performed. The length and thickness of the smear can usually be controlled by adjusting the size of the drop or the angle of the spreader slide. Dirt, fingerprints, or powder on the slide, or fat globules and lipids in the specimen can result in holes in the smear. A chipped pusher slide, a blood drop that has started to dry out, or uneven pressure as the smear is made can cause the smear to have ragged edges. Common Problems Associated With Routine Blood Smear Preparation Problem Absence of feather Holes in the smear Probable Cause Spreader slide lifted before the smear was completed Dirty slide Fat globules in the blood Ridges or uneven thickness Smear is too thick Smear is too short Smear is too long Smear is too thin Streaks or tails in feathered edge Blood contaminated with glove powder Too much pressure applied to spreader slide Blood drop too large Spreader slide angle too steep Patient has high red blood cell count Blood drop too small Spreader slide angle too steep Spreader slide pushed too quickly Patient has high red blood cell count Blood drop too large Spreader slide angle too shallow Spreader slide pushed too slowly Patient has a low hemoglobin Blood drop too small Spreader slide angle too shallow Patient has a low hemoglobin Blood drop started to dry out Edge of spreader slide dirty or chipped Spreader slide pushed through blood drop Uneven pressure applied to spreader slide Thick Blood Smear Preparation Thick blood smears are most often requested to detect the presence of malaria, a disorder caused by four species of parasitic sporozoan (types of protozoa) organisms called plasmodia. These organisms are transmitted to humans by the bite of infected female anopheles mosquitoes. Symptoms of malaria include serial bouts of fever and chills at regular intervals, related to the multiplication of certain forms of the organism within the red blood cells and the consequent rupture of those cells. The progressive destruction of red blood cells in certain types of malaria causes severe anemia. Presence of the organism is observed most frequently in a thick smear; however, identification of the species requires evaluation of a regular blood smear. To prepare a thick smear, a very large drop of blood is placed in the center of a glass slide and spread with the corner of another slide or cover slip until it is the size of a dime. The smear must be allowed to dry for a minimum of two hours before staining with fresh diluted Giemsa stain, a water-based stain that lyses the red blood cells and makes the organism easier to see. The concentration of which substance is higher in capillary blood than in venous blood When making a routine blood smear, the "pusher slide" is normally used at an angle of how many degrees Which test cannot be collected by capillary puncture and taken to the laboratory for processing and testing Strong repetitive pressure, such as squeezing or milking a site during capillary specimen collection a. The right arm has no palpable veins so the phlebotomist decides to perform capillary puncture on the middle finger of the right hand. How might the circumstances of collection have contributed to the platelet clumping in the specimen What effect could his forgetfulness have when the results of the electrolytes and glucose are reported One of the specimens is compromised even if the problem addressed by the first question had not happened. Describe patient identification and specimen labeling procedures required for blood bank tests, and identify the types of specimens typically required. Demonstrate basic knowledge of special collection procedures, define the associated terminology, and understand importance for special labeling, equipment, collection, timing, and handling of each procedure. Describe sterile technique in blood culture collection, explain why it is important, and list the reasons why a physician might order blood cultures. Collecting specimens for some blood tests requires additional knowledge and may involve different equipment, preparation, and/or collection and handling procedures than routine blood specimens. Special Collections Most laboratory tests require blood specimens that are collected by routine venipuncture or capillary puncture procedures. Collecting specimens for these tests may require special preparation, equipment, handling, or timing. Blood Bank Specimens Blood bank specimens yield information that determines which blood products can be transfused safely into a patient. Precise and consistent attention to protocol in collecting blood bank specimens is crucial to safe transfusions. Identification and Labeling Requirements Blood bank specimens require strict patient identification and specimen labeling procedures. Specimens that have labeling errors of any kind or are unlabeled will not be accepted for testing. This pertains to specimens drawn in the emergency room and operating rooms as well. When someone other than laboratory personnel collects the specimen, the full name of that person or their assigned mnemonic, whether it is a physician or nurse, must be on the label. An error in specimen identification or labeling requires recollection of the specimen and causes a delay in patient treatment. An undetected error can result in administration of an incompatible blood product and the possibility of a fatal transfusion reaction. Before the healthcare provider physically starts the transfusion, a second nurse validation may be required. Once all verification is complete, the unit is ready to be physically transfused by the clinician. Upon completion of the transfusion, the nurse updates the identification system, which in turn updates the blood bank system to reflect that the unit has been administered and logs the date and time of completion. This method helps to increase patient safety and provides accurate records for the blood administration workflow process. Blood Donor Collection Blood donor collection involves screening and collecting blood to be used for transfusion purposes rather than for diagnostic testing. Facilities that provide blood products for transfusion purposes are called Blood Donor Centers. Key Point: All potential blood donors must be interviewed to determine their eligibility to donate blood and to obtain information for records that must be kept on all blood donors. Donor Eligibility Eligibility rules for donating blood help protect the health and safety of the donor and the recipient. According to the American Red Cross, people who wish to donate blood must feel well and be in good general health. If allowed by state law, a 16-year-old may donate with written parental permission. Adults over the age of 66 may be allowed to donate at the discretion of the blood center physician. This information is collected each time a person donates, no matter how many times a person has donated before. In addition, the donor must give written permission for the blood bank to use his or her blood. If the unit only partially fills and the procedure must be repeated, an entire new unit must be used. A phosphate compound stabilizes the pH, and dextrose provides energy to the cells and helps keep them viable. All components of the unit must be traceable to the donor for a federally required lookback program, and this requires meticulous record keeping. Lookback is the tracing and testing of blood donors and recipients when a blood product has been determined to be potentially contaminated with a bloodborne pathogen. Lookback can only occur when the blood service is made aware of the possibility of a transfusion-related infection. At that time, notification to all blood recipients is required, and verification for all blood components previously collected and currently in inventory is retrieved. Autologous Donation Despite advances in blood bank procedures and identification processes, transfusions are risky; consequently, many patients choose to take the safer route of autologous donations. Autologous donation is the process by which a person donates blood for his or her own use. This is done preoperatively for elective surgeries when it is anticipated that a transfusion may be needed. Although blood is normally collected several weeks prior to the scheduled surgery, the minimum time between donation and surgery must be more than 72 hours. To be eligible to make an autologous donation, a person must have a written order from a physician and have a hemoglobin of at least 11 g/dL or a hematocrit equal to or greater than 33%. If the blood is not used during surgery, it is discarded because rules for autologous donation are less strict, and therefore the blood does not meet safety standards required for blood that is used for other patients. Cell Salvaging Cell salvaging is a medical procedure designed to recover blood lost during surgery to reinfuse it back into the patient. Prior to reinfusion, it is recommended that the salvaged blood be tested for residual-free hemoglobin. A high free hemoglobin level indicates that too many red cells were destroyed during the salvage process and renal dysfunction can result if the blood is reinfused. However, bacteria or other microorganisms may enter the circulatory system from extravascular sites via lymph vessels. However, if microorganisms multiply faster than the body can remove them, a blood infection results.

The second lavender top fails to fill with blood treatment for pink eye discount nootropil 800mg, so he makes several needle adjustments to try to establish blood flow symptoms blood clot leg order nootropil line. After completing the draw treatment herniated disc buy nootropil online, he labels his tubes osteoporosis treatment cheap nootropil 800mg overnight delivery, putting the hematology label on the lavender top he collected first symptoms nasal polyps purchase cheap nootropil on-line. He finishes up with the client symptoms ketosis order nootropil 800 mg line, delivers the specimens to the laboratory, and goes to lunch. How might the problem with the second lavender top have contributed to the clotting of the first one Would the problem with the second lavender top have been an issue if Chi had handled the first lavender top properly After completing the draw, he takes the specimens straight to the laboratory to be processed immediately. How could Jake have avoided the problem without drawing blood from the patient twice Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. Validation and Verification of Tubes for Venous and Capillary Blood Specimen Collection. Reducing the potential for phlebotomy tourniquets to act as a reservoir for methicillin-resistant Staphylococcus aureus. Quantifying patient bacterial exposure risk from reusable phlebotomy tourniquets in a New Zealand secondary level hospital. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Discard tubes are not necessary when drawing samples for specialized coagulation testing. Demonstrate knowledge of each venipuncture step from the time the test request is received until the specimen is delivered to the lab, and define associated terminology. Identify challenges and unique aspects associated with collecting specimens from pediatric and geriatric patients. Describe why a patient would require dialysis and how it is performed, and exhibit an awareness of the type of care provided for long-term care, home care, and hospice patients. Overview Venipuncture is the process of collecting or "drawing" blood from a vein. It is the most common way to collect blood specimens for laboratory testing and the most frequent procedure performed by a phlebotomist. This article covers venipuncture procedures from the time the patient is registered with the facility and testing is requested until delivery of the specimen to the laboratory. This article addresses how to correctly identify all types of patients and how to safely obtain highquality blood specimens from them. This article also addresses challenges and unique issues associated with pediatric, geriatric, dialysis, long-term care, home care, and hospice patients. Patient Registration A patient must be registered with the healthcare facility or specimen collection center before specimen collection can take place. Registration is a routine process during which data are collected that creates a patient record for the specific individual who is being admitted to the facility, or has arrived for testing at the specimen collection center. The process typically involves assignment of a patientspecific identifier which will appear on all test requests and specimen labels for that patient. Key Point: A patient-specific identifier is a number such as a medical record number or other set of characters that is unique to the patient. This type of identifier helps eliminate mistakes caused by confusing patients with the same or similar names or even the same name and date of birth. Requests for Testing Typically, a physician or other qualified healthcare professional requests laboratory testing; the exceptions are certain rapid tests that can be purchased and performed at home by consumers and blood specimens requested by law enforcement officials that are used for evidence. The Test Requisition the form on which test orders are entered is called a requisition. With increased use of computer systems, the use of manual requisitions is declining. In addition to patient identification and test status information, many indicate the type of tube needed for the specimen and some indicate additional patient information such as "potential bleeder" or "no venipuncture right arm. Description Key Point: When a computer-generated label is used, the phlebotomist is typically required to write the time of collection and his or her initials on the label after collecting the specimen. Barcode Requisitions Either type of requisition may contain a one-dimensional or twodimensional barcode. Two-dimensional barcodes use rectangles, dots, and other geometric patterns in two dimensions to represent patient information. With both types of barcodes, the patterns represent information such as patient names, identification numbers, or laboratory tests. Manual requisitions with barcodes normally contain copies of the barcode that can be peeled off and placed on the specimens. Barcode information can be scanned into a computer using a special light or laser to identify the information represented. Barcode systems allow for fast, accurate processing, and their use has been shown to decrease laboratory errors associated with clerical mistakes. Key Point: With any type of requisition, it is essential for the information to be transcribed or entered correctly. Venipuncture Steps Blood specimen collection by venipuncture requires a series of steps that must be performed to assure that the specimen is collected from the correct patient in a timely manner under the required conditions and in a professional manner that is safe for both the patient and the phlebotomist. Step 1: Receive, Review, and Accession Test Request Blood collection procedures legally begin with the test request. This is the first step for the laboratory in the preexamination or preanalytical (before analysis) phase of the testing process. Outpatients are either given laboratory requisitions or prescription slips with test orders written on them by their physicians and are responsible for taking them to a blood collection site, or the orders are electronically sent to the collection site. Description Reviewing the Requisition A thorough review of the test requisition must be made to avoid duplication of orders and ensure that the specimen is collected at the right time under the proper conditions and that any special equipment that may be required is identified and available. Status designations (Table 8-1) and collection priorities are set by the healthcare facility and must be strictly followed. Timed specimens are the next priority and must be collected as close to the specified time as possible. Routine same-day requests for hospitalized patients will usually be put with specimens scheduled for the next "sweep" (collection rounds scheduled at regular intervals throughout the day). As part of the review process, the inpatient requisitions are sorted according to collection priority, date and time of collection, and patient location. Accessioning the Test Request the definition of accession is "the process of recording in the order received. When a test request is accessioned, it is assigned a unique number used to identify the specimen and all associated processes and paperwork and connect them to the patient. This helps to ensure prompt and accurate processing from receipt of the order to reporting of test results. Step 2: Approach, Greet, and Identify the Patient Being organized and efficient plays a role in a positive and productive collection experience. Try to clear your mind of distractions and focus on the task at hand before calling an outpatient into the drawing area or proceeding to an inpatient room. Keep the outpatient specimen collection area clean and well-stocked with supplies to set the stage for a positive patient encounter. When you summon an outpatient into the drawing area, lead them to the drawing station, and make certain they are safely situated in the phlebotomy chair with the arm rest down. Before proceeding to inpatient rooms, arrange the test requisitions according to priority and review them to see that necessary equipment is on the blood collecting tray or cart. Except for service dogs, it is generally best to request that pets be put in a room away from where you are going to collect the specimen. Never enter a home without permission unless the patient, guardian, or caregiver tells you to ahead of time. Looking for Signs Looking for signs containing information concerning the patient is an important part of the approach to an inpatient. Other commonly encountered signs may identify limits to the number of visitors allowed in the room at one time, indicate that "fall" precautions are to be observed for the patient, or warn that the patient has a severe allergy. A code uses numbers or words to convey information needed by healthcare personnel to respond to certain situations. If the door is closed, knock lightly, open the door slowly, and say something like "good morning" before proceeding into the room. Even if the door is open, it is a good idea to knock lightly to make occupants aware that you are about to enter. Curtains are often pulled closed when nurses are working with patients or when patients are using bedpans or urinals. Note the availability and location of sharps containers and hand hygiene facilities. Identify any obstacles that might prevent access to the patient or prevent proper arm positioning. If that is the only patient, wait outside the room for a few minutes or go back to the lab and draw the specimen on the next sweep. Handling Family and Visitors Often there are family members or visitors with the patient. Most will prefer to do so; however, some family members will insist on staying in the room. It is generally acceptable to let a willing family member help steady the arm or hold pressure over the site (if the patient is unable to do so), while you label tubes. Finding the Patient Unavailable If the patient cannot be located, is unavailable, or you are unable to obtain the specimen for any other reason, it is the policy of most laboratories that you enter this information into the computer system or fill out a form stating that you were unable to obtain the specimen at the requested time and the reason why. Bedside Manner the behavior of a healthcare provider toward or as perceived by a patient is called bedside manner. The way you approach and interact with the patient sets the stage for whether the patient perceives you as a professional. If you display confidence, you will most likely convey that confidence to patients and help them feel at ease. Greeting the Patient and Identifying Yourself Greet the patient in a cheerful, friendly manner and identify yourself by stating your name, your title, and why you are there. If you are a student, let the patient know this, and ask permission to do the blood draw. The patient has the right to refuse to have blood drawn by a student or anyone else. Follow facility policy on whether to use your full name when identifying yourself. Key Point: A cheerful, pleasant manner and an exchange of small talk will help put a patient at ease as well as divert attention from any discomfort associated with the procedure. Consequently, misidentifying a patient or specimen can be grounds for dismissal and can even lead to a malpractice lawsuit if the patient is injured as a result. Identification protocol may vary slightly from one healthcare institution to another. For instance, occasionally a room number will differ because the patient has been moved. The name of the ordering physician may be different, since it is not unusual for a patient to be under the care of several different physicians at the same time. Some facilities also show the labeled specimen to the patient and ask for verification that the correct name is on the label. For example, it is not unusual to have patients with the same or similar names in the hospital at the same time. There are instances when two unrelated patients share the same full name and birth date. If you are in a hurry or are in an urgent situation and assume a patient is the right one because the name or even the name and date of birth are correct, and fail to check the patient-specific identifier, misidentification can happen. Two patients may have the same name, but they will not have the same identifier. Sleeping Patients Obviously, proper identification and informed consent cannot occur if the patient is asleep. If you encounter a sleeping patient, as is often the case in hospitals and nursing homes, wake the person gently. Unconscious Patients Unconscious patients are often encountered in emergency rooms and intensive care units. Unconscious patients can often hear what is going on around them even though they are unresponsive. Caution: An unconscious patient may be able to feel pain and move when you insert the needle, so it may be necessary to have someone assist you by holding the arm during the blood draw. The third part is used if the patient needs a transfusion, and it is attached to the unit of blood. Description Caution: Never collect a specimen without some way to positively connect that specimen to the patient. Document the name (and title if a healthcare professional) of the person providing the information. The name and relationship of a relative or guardian or the name and title of a nurse who identifies the child should be recorded on the requisition. Some labs supply requisition forms to physicians who use their services, so some outpatients arrive at the collection site with lab requisitions that are already filled out. An anxious or hard-of-hearing patient may think that his or her name has been called when in fact a similar name was called. Always ask an outpatient to state his or her full name and date of birth, and spell the first and last names. Description Step 3: Explain the Procedure and Obtain Consent the patient must be told that you are going to collect a blood specimen and must consent to the procedure.

Diseases

• X chromosome, monosomy Xq28
• Albers Schonberg disease
• Chondrodysplasia punctata, Sheffield type
• Mercury poisoning (Mercurialism)
• Ceroid lipofuscinois, neuronal 4, adult type
• Taurodontism
• Kuskokwim disease
• Egg shaped pupils

The epithelium lining the papillary projections is bilayered with inner cuboidal cells and outer columnar cells medicine 657 nootropil 800 mg with visa. Capsular dissection without formal parotidectomy is a reasonable alternative in selected cases due to the benign symptoms multiple myeloma buy discount nootropil, non-recurrent nature of the tumor [54] medications 2016 cheap nootropil 800mg otc. Human oral defensins antimicrobial peptides: a future promising antimicrobial drug treatment xerostomia cheap generic nootropil canada. Morphological analysis and differential diagnosis of a rare disease of the salivary glands medicine 1975 nootropil 800 mg on line. Plasmacytoid cells in salivary-gland pleomorphic adenomas: evidence of luminal cell differentiation symptoms 2 dpo discount nootropil 800mg. Intraoral, mucinous, minor salivary gland lesions presenting clinically as tumors. Giant sialoliths of Wharton duct: report of two rare cases and review of literature. Striated duct adenoma presenting with intra-tumoral hematoma and papillary thyroid carcinoma-like histology. Canalicular adenoma: a clinicopathologic and immunohistochemical analysis of 67 cases with a review of the literature. Intercalated duct lesions of salivary gland: a morphologic spectrum from hyperplasia to adenoma. Work-up diagnostico nella patologia ostruttiva e infiammatoria delle ghiandole salivari. Surgical techniques in the treatment of pleomorphic adenoma of the parotid gland: our experience and review of literature. Sustained response of carcinoma ex pleomorphic adenoma treated with trastuzumab and capecitabine. Tobacco Tobacco smoke constituents can inhibit aromatase [7] and shift estradiol metabolism toward less potent forms of estrogen [8,9]. Conversely, components of cigarette smoke may also exert estrogen-related effects on the uterus that could promote cell proliferation [10]. However, more recent case-control [16,17] and prospective cohort studies [18,19] have found no such association. They have been widely used in food packaging, medical devices and medications, toys and building materials, as well as cosmetics and personal-care products such as perfume, lotion and nail polish [29]. There is increasing concern that exposure to phthalates may have adverse effects on reproductive health. Environmental Chemicals and Risk of Uterine Leiomyomata Exposure to phthalates is typically quantified by measuring concentrations of diester phthalate molecules in urine (or blood) that were synthesized for commercial use ("parent" molecules), or of monoester metabolites that are formed from hydrolysis or oxidation of diesters after entering living systems (Table 2. Monoester metabolites are rare in the environment because they arise only from biotransformation, and thus they are the preferred exposure measure. All of these studies were retrospective in design (cross-sectional [44,47] or case-control [45,46,48]). The fact that phthalates do not bioaccumulate and are rapidly excreted creates major challenges for the study of phthalates and health. A large interval between the etiologically relevant exposure window and the measured exposure window is a form of measurement error that may attenuate associations. Unless exposures are constant over time, measurements taken at a single point in time are less reliable indicators of typical exposures than multiple measurements. To optimize exposure assessment, measurement of urinary phthalates at multiple time points is critical. Another phenol, nonylphenol, was significantly higher in cases than controls [85], a finding that has since been replicated [86]. In a 2011 study of Chinese women, cases were divided into three groups (mild, moderate and severe) according to tumor size. It remains unclear whether the fatty acids themselves or persistent environmental pollutants. Trace Elements Several trace elements have been shown to have endocrinedisrupting properties, with the ability to interfere with the hypothalamic-pituitary-gonadal axis, and bind to and activate the estrogen receptor. Current and former cigarette smoking were associated with higher cadmium and lead levels in uterine tissues (see Tobacco section) [108,109]. However, after adjusting for age, race/ethnicity, use of oral contraceptives prior to diagnosis and smoking status at diagnosis, the association was 0. Cadmium Primary sources of cadmium exposure in humans are cigarette smoke, air pollution and contaminated food [117]. Cadmium has been shown to have estrogen-disrupting effects on reproductive development in rodents [118]. Sprague-Dawley rats exposed to cadmium 3 weeks after ovariectomy had increased uterine wet weight, promoted growth and development of the mammary glands, and induced hormone-regulated genes [119]. In the uterus, the increase in wet weight coincided with proliferation of the endometrium and induction of progesterone receptor (PgR) and complement component C3. Data suggest that lead exposure interferes with ovarian steroid stimulation of the endometrium [107,115]. In a study of rats exposed to lead acetate in drinking water in utero, prepubertally or postpubertally, the most severe effects were observed in the group exposed in utero, with disrupted estrous cycling [116]. These effects suggest direct effects of lead on the hypothalamic pituitary axis and on gonadal steroid biosynthesis. Analysis of Chemical Mixtures Given that many chemicals travel together in the environment and are correlated with each other, there has been growing interest in developing novel biostatistical approaches to evaluate mixtures of chemicals, not merely individual chemicals. Although little consensus has been reached about which methods work best, several methods are being implemented and tested. Finally, random forest analysis is a novel method that produces single measures of importance for each predictor variable and takes into account interactions among variables without requiring model specification. The advantages of random forest analysis over multivariable regression models are that this approach allows for complicated interactions among constituents and does not assume a linear exposure-outcome relationship. Random forests analyses can be run using the RandomForest package in the R statistical software package [139]. Cobalt Primary sources of exposure to cobalt are soil, water, plants and animals (natural sources) and fossil fuel and waste combustion, vehicular and aircraft exhausts, processing of cobalt and cobaltcontaining alloys, artificial hip and knee joints, use of cobalt chemicals and fertilizers derived from phosphate rocks (anthropogenic sources) [121]. Cobalt is an essential element and has an important role in female reproduction, but at high concentrations, it is toxic [122]. Animal studies have found an increase in the length of the estrous cycle in female mice exposed to 11. Mercury Humans may be exposed to mercury via fish intake, air pollution and dental amalgams [126]. Limited data are available from epidemiological studies on the relation between mercury and female reproductive function. Environmental Chemicals and Risk of Uterine Leiomyomata outcome misclassification. Chemicals that are more persistent in the environment and biologically can be assessed with fewer measurements will save on costs. The analysis of mixtures of chemicals within and across chemical classes can help address the problem of correlation among chemicals and answer questions about whether or not a particular chemical or a group of chemicals is of concern health-wise. Comprehensive questionnaire data were collected at baseline, and participants are being followed for 5 years. Amelia Wesselink, Jennifer Weuve, and Birgit Claus Henn on various aspects of this work. Calculating summary statistics for population chemical biomonitoring in women of childbearing age with adjustment for age-specific natality. Increased 2-hydroxylation of estradiol as a possible mechanism for the anti-estrogenic effect of cigarette smoking. Modulation of oestrogen receptor signalling by association with the activated dioxin receptor. Risk factors for uterine fibroids: Reduced risk associated with oral contraceptives. Lumbiganon P, Rugpao S, Phandhu-fung S, Laopaiboon M, Vudhikamraksa N, and Werawatakul Y. Protective effect of depot-medroxyprogesterone acetate on surgically treated uterine leiomyomas: A multicentre case-control study. Risk of uterine leiomyomata among premenopausal women in relation to body size and cigarette smoking. Association of intrauterine and early life factors with uterine leiomyomata in black women. Identification of uterine leiomyoma genes developmentally reprogrammed by neonatal exposure to diethylstilbestrol. Prenatal diethylstilbestrol exposure and reproductive hormones in premenopausal women. Cellular and molecular effects of developmental exposure to diethylstilbestrol: Implications for other environmental estrogens. Risk of benign gynecologic tumors in relation to prenatal diethylstilbestrol exposure. Association of intrauterine and early-life exposures with diagnosis of uterine leiomyomata by 35 years of age in the Sister Study. Steroidogenic assessment using ovary culture in cycling rats: Effects of bis(2-diethylhexyl)phthalate on ovarian steroid production. Oral toxicity of bis(2ethylhexyl) phthalate during pregnancy and suckling in the Long-Evans rat. Mono-(2-ethylhexyl) phthalate suppresses aromatase transcript levels and estradiol production in cultured rat granulosa cells. Estrogenic activity and metabolism of n-butyl benzyl phthalate in vitro: Identification of the active molecule(s). Fourth Report on Human Exposure to Environmental Chemicals, Updated Tables, (September 2013). Department of Health and Human Services, Centers for Disease Control and Prevention; 2013. Department of Health and Human Services, Centers for Disease Control and Prevention; 2009. Low serum concentrations of di-(2-ethylhexyl)phthalate in women with uterine fibromatosis. Association between phthalate exposure and glutathione S-transferase M1 polymorphism in adenomyosis, leiomyoma and endometriosis. Bisphenol A, benzophenone-type ultraviolet filters, and phthalates in relation to uterine leiomyoma. Increased urinary phthalate levels in women with uterine leiomyoma: A case-control study. Quantitative detection of nine phthalate metabolites in human serum using reversed-phase high-performance liquid chromatography-electrospray ionization-tandem mass spectrometry. Characterization of phthalate exposure among pregnant women assessed by repeat air and urine samples. Withinperson variability in urinary phthalate metabolite concentrations: Measurements from specimens after long-term frozen storage. Temporal variability of urinary phthalate metabolite levels in men of reproductive age. Temporal variability in urinary concentrations of phthalate metabolites, phytoestrogens and phenols among minority children in the United States. Assessment of human contamination of estrogenic endocrine-disrupting chemicals and their risk for human reproduction. Early-life exposures and early onset uterine Leiomyomata in black women in the Sister Study. Bisphenol-A induces cell cycle delay and alters centrosome and spindle microtubular organization in oocytes during meiosis. Estrogen and bisphenol A disrupt spontaneous [Ca(2+)](i) oscillations in mouse oocytes. Alterations in steroid hormone production by porcine ovarian granulosa cells caused by bisphenol A and bisphenol A dimethacrylate. The effects of selected phenol and phthalate derivatives on steroid hormone production by cultured porcine granulosa cells. Bisphenol A alters early oogenesis and follicle formation in the fetal ovary of the rhesus monkey. Exposure of mouse oocytes to bisphenol A causes meiotic arrest but not aneuploidy. Continuous exposure to bisphenol A during in vitro follicular development induces meiotic abnormalities. Effects of selected endocrine disruptors on meiotic maturation, cumulus expansion, synthesis of hyaluronan and progesterone by porcine oocyte-cumulus complexes. Inhibition of testicular steroidogenesis by the xenoestrogen bisphenol A is associated with reduced pituitary luteinizing hormone secretion and decreased steroidogenic enzyme gene expression in rat Leydig cells. Steroidogenesis-disrupting compounds can be effectively studied for major fertility-related endpoints using in vitro cultured mouse follicles.

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