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`Lab Updates
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`Important announcements regarding tests, procedures and results are reported approximately once per
`month on this Web page:
`
`May 2010
`Laboratory Testing/Reporting of Antibody to Hepatitis C Virus (HCV) | Specimen Handling | JAK2
`Exons 12 and 13 Sequencing Testing
`
`April 2010
`Genetic Testing | Changes in Specimen Labeling Requirements | Changes in BNP and ACTH
`Specimen Collection Requirements
`
`March 2010
`Quad Maternal Screen Test (QUAD) | Hemoglobin A1C for the Diagnosis of Diabetes | HIV
`(OHIV) Serology Testing | Featured Patient Service Center
`
`February 2010
`UMass Memorial Laboratories - Health Alliance | Involuntary Weight Loss | Featured Patient
`Service Centers
`
`January 2010
`Celiac Disease | Patient Service Center Locations | Featured Patient Service Center
`
`December 2009
`Drugs of Abuse [DOA] Testing in Urine | DNA Sequence analysis for Ellis-van Creveld Syndrome
`and Weyers Acrofacial Dysostosis | Arthritis | Highlights of the Educational Symposium
`
`November 2009
`Specific Immunoglobulin E (IgE) Allergen Tests | Spurious Hyperbilirubinemia Caused by
`Naproxen | Change in Cytomegalovirus Quantitative Testing | Sequencing Assay for Detecting
`Pompe Disease Mutations | HBV Quantitation by PCR (COBAS TaqMan) | Enterovirus Detection
`Assay by Real Time PCR | Featured patient Service Center
`
`September/October 2009
`Proteinuria | Evaluation of Pleural Effusions | Insert: Educational Symposium | Featured patient
`Service Center
`
`August 2009
`Changes in Syphilis Testing | Antinuclear Antibody (ANA) Testing Update | Featured patient
`Service Center
`
`July 2009
`Specific Ummunoglobulin E (IgE) Allergen Tests | Spurious Hyperbilirubinemia Caused by
`Naproxen
`
`June 2009
`Fatigue | Genomic Microarray Analysis | Featured Patient Service Center
`
`May 2009
`Changes in Epstein-Barr Virus (EBV) and Lyme Serology Test Reports | Sexually Transmitted
`Diseases
`
`April 2009
`The Anemias | Use of Creatinine Output as a Check on the Completeness of 24 Hour Urine
`Collections | HIV-1 Quantitation and Hepatitis C Virus Quantitation by PCR (COBAS TaqMan) |
`Changes in Dilute Russell Viper Venom Time | RVP Panel Stability | QuantiFERON-TB Gold in
`Tube Assay Now Available | Laboratory Supply Distribution Center Updates | New Vacuette
`Coagulation Tube Labels
`
`March 2009
`Thyroid Function Tests | Estimated Average Blood Glucose (eAG): A new way to talk to patients
`about diabetes management | Laboratory Supply Distribution Center Updates | | Featured
`Patient Service Center
`
`February 2009
`Laboratory Confirmation of Pertussis Infection | Specimen Validity and Drug Testing | New
`Respiratory Viral Panel Test | Addendum to Changes in Free Testosterone and Bioavailable
`Testosterone Testing | Special Coagulation Requirements | Changes in H.Pylori, HSV-1 and
`HSV-2 IgG Serology Test Reports
`
`January 2009
`Serum Protein Electrophoresis and Immunofixation | Hypercalcemia | Lab Test Collection Alerts |
`Featured Patient Service Center
`
`https://www.ummlabs.org/ClientNews.asp
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`December 2008
`Anti-Neutrophil Cytoplasmic Antibody (ANCA) Testing | Changes in IgG Antibodies to Glomerular
`Basement Membrance (GBM) Testing | Non-Invasive Test for the Diagnosis of Heliobacter Pylori
`(H. Pylori) Infection (UBT) | Changes in Measles, Mumps, Rubella and Varicella IgG Serology
`Test Reports | Changes in Free Testosterone and Bioavailable Testosterone Testing |
`Comprehensive HLA Testing | Labeling Guides for Blood Specimens | Featured Patient Service
`Center
`
`November 2008
`Lab Evaluation for the Jaundiced Patient | Quantitative Urine Chemistry Tests: 24 Hr vs.
`Random Urine | Patient Service Center Locations in New England | Featured Patient Service
`Center
`
`October 2008
`New Immunoassay Based Fecal Occult Blood Test (FIT) | Sample Preparation for Uric Acid
`Testing in Patients Receiving Rasburicase (ELITEK) Therapy | New IgG Cased ELISA Assay for
`Diagnosis of Heparin-induced Thrombocytopenia | Methicillin-Resistant Stahpylococcus aureus
`Detection - Two Choices | Tips for a Successful Coagulation Blod Draw | Featured Patient
`Service Center
`
`September 2008
`UMass Memorial Medical Center Accreditation | VKORC1 Sequencing | Sequencing Assay for
`Detecting Fabry Disease Mutations | Molecular UGT1A1 DNA Assay | Lab Start Award for "Lab
`Values/Mission" | Featured Patient Server Center
`
`August 2008
`Optimal Level of Vitamin D | Varicella IgG (VARG) Test Tange Changes | Hemoglobin Evaluation
`(HGBSCR) Test Changes | Lupus Screen Changes | Patient Service Centers in Central
`Massachusetts | New Patient Service Center - Worcester, MA
`
`July 2008
`Laboratory Document Control Center | Malaria Update | Featured Patient Service Center -
`Enfield, CT
`
`June 2008
`Streptococcal Antibody Tests | Changes in CA 27.29 Testing | Reference Range Changes |
`Featured Patient Service Center - Hartford, CT
`
`April 2008
`Human Cardiolipin Antibodies, IgG, IgM and IgA by Enzyme Immunoassay | Reference Range
`Changes | Phosphorous Assay Interference Alert | New Procedure for Detection of Cytogenetic
`Aberrations in Plasma Cell Dyscrasia | Rapid Prenatal Flourescence in Situ Hybridization |
`Specimen Requirement Changes | New Patient Service Center - Westerly, RI
`
`March 2008
`Creatinine Standardization | Changes in Lamotrigene (Lamictal) Testing | Updates to the Lab
`Test Directory | Special Coagulation Assays | JAK2 Qualitative Assay for Bone Marrows |
`Hepatitis B Quantitative Testing | Specimen Requirement Changes/Clarifications | Featured
`Patient Service Center - Marlboro Lakeview
`
`January 2008
`Direct Group A Streptococcus Detection, Gen-Probe | Full Throat Culture Screens | Supplies
`Contact Information | Changes in urine Opiate Confirmation and Quantitation Testing | Updates
`to the Lab Test Directory | Featured Patient Service Center - Worcester
`
`November 2007
`Noninvasive Tests for the Diagnosis of Heliobactor Pylori (H.Pylori) Infection | Changes in
`Triglyceride Testing | Laboratory Confirmation of Pertussis Infecion | New Patient Service Center
`- Marlboro | Specimen Submission Form
`
`October 2007
`Directly Measured LDL vs. Calculated LDL | Change in Cyclic Citrullinated Peptide (CCP) Antibody
`Testing | New Test: Hemoglobin S Quantitative | Changes in Oxcarbazepine (Trileptal)
`Metabolite Testing| Change in C. Difficile Testing | Change in 10-OH Progesterone Testing |
`Update on Special Coagulation Assays | New Patient Service Center - Attleboro
`
`August 2007
`Fractional Excretion of Sodium (FENa) | Changes in Epstein-Barr Virus (EBV) Serology Testing|
`Changes in Lyme Serology Testing | Testing for Shellfish Allergy | Changes in Varicella-Zoster
`Serology Testing | Changes in C-Peptide Testing | Update on DVT D-Dimer Assay | New Patient
`Service Center Opens in Cumberland, Rhode Island
`
`June/July 2007
`Change in Cytomegalovirus Quantitative Virus | Consent and History Form Reminders | General
`Reminders | New Patient Service Center Opens in Raynham | Sample Forms
`
`May 2007
`Patient Height Information is Required for Warfarin Dose Guideline Calculation when Requesting
`the Anti-Coagulation Pharmacogenetic Panel | Examination of Fecal Specimens for Giardia,
`Cryptosporidium and other Parasites | New Test: Oxycodone and Oxymorphone | Reference
`Range Changes for Coagulation Testing | Patient Service Center (PSC) Locations | New Patient
`Service Center Opens
`
`April 2007
`Non-HDL Cholesterol as a Predictor of Cardiovascular Disease in Patients with Diabetes |
`Changes in Therapeutic Drugs Testing Specimen Requirements; RED TOP (No Gel) vs SST (GEL)
`Tubes | Changes in HIV Serology Testing | New Patient Service Center Opens | Patient Service
`Center (PSC) Locations
`
`https://www.ummlabs.org/ClientNews.asp
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`February 2007
`Measurement of Ammonia in Blood| Changes in Serum Ketone (ACE or BHY) Testing| Changes
`in Zinc Protoporphyrin (ZPP) Testing | Clarification Regarding the Anticoagulation
`Pharmacogenetic Panel
`
`December 2006 - January 2007
`Changes in Antinuclear Antibody (ANA) Testing | Recommendations for Ordering D-Dimer Assay
`| Reference Range Changes | Patient Service Center (PSC) Locations
`
`November 2006
`Changes in HCV Genotype Testing | Reference Range Changes | Laboratory Confirmation of
`Pertussis Infection
`
`October 2006
`Changes in Testosterone and Free Testosterone Testing | Changes in Ferritin Testing | Changes
`in C_Reactive Protein (CRP) Testing | Changes in Measles, Mumps and Rubella IgG Test
`Reference Changes | Changes in Cytomegalovirus Quantitative Testing | Sample Submission
`Change for Stone Risk Testing | Changes in Urine Toxicology Screening | Additional Testing
`Changes | Patient Service Center Move
`
`September 2006
`Changes in Maternal Serum Screening | Changes in Testing for PNH| Changes in Performing the
`Ristocetin Cofactor Assay | Changes in Reporting of i-STAT Potassium | Critical Value Changes
`
`August 2006
`Changes in Maternal Serum Screening | Recommendations for Use of Molecular Diagnostic
`Requisition and Genetic Consent Form | Changes in Adrenocorticotropic Hormone Test (ACTH) |
`Changes in 17 Alpha-Hydroxy Progesterone Resulting | Changes in Hepatitis B Surface Antibody
`Testing | Chlamydia and Neisseria Gonorrhea Urine Collection | Reference Range Changes |
`Tube Recall
`
`July 2006
`Sputum Culture Specimen Collection | New Test: Protein-Creatinine Ratio | Changes in
`Lipoprotein-a Testing | Recommendations for Specimen Collection and Processing | Workup for a
`Patient with Suspected Hemostatic Diathesis | Sedimentation Rate Methodology Change |
`Reference Range Changes | Critical Value Changes
`
`June 2006
`Lyme Disease Testing| Changes in High Sensitivity CRP (hsCRP) Reporting Units | Changes in
`Alpha-FeteoProtein (AFP) Reporting Units | Changes in Urine Cannabinoids Confirmation Testing
`| Reference Range Changes | Specimen Requirements Change: LDL Subclasses | New Test:
`Osmolal Gap | Changes to Platelet Aggregation Studies | Molecular Testing for Genetic Diseases
`| Hereditary Cancer Risk Assessment and Genetic Testing | Genetic Testing Support Services |
`Phone System Upgrade Notification | | New Patient Service Center Locations | New Laboratory
`Report Format
`
`April 2006
`Cell Counts on Body Fluids | Absolute CD4+ T Cell Counts by Flow Cytometry | JAK-2 (Janus
`Kinase-2) Gene Testing | Carrier Screening for Cystic Fibrosis DNA Mutations | New Patient
`Service Center Locations
`
`March 2006
`Changes in Erythropoietin (EPO) Testing | Specimen Requirement and Testing Changes |
`Quantitative BCR/ABL Replaces Ultraquant® Assay for Bone Marrow Specimens | Therapeutic
`Drug Monitoring (TDM): Optimal Specimen Collection Times in Relation to Drug Dosing
`
`January/February 2006
`Changes in Thyroid Testing Hormone | Change in CA19-9 Testing | Renin Testing Availability |
`Osmotic Fragility Testing Availability | Paroxysmal Nocturnal Hemoglobinuria (PNH) | Monitoring
`Minimal Residual Disease (MRD) in Treated CLL Patients | Carrier Screening for Cystic Fibrosis |
`Cytokines and Growth Factor Assays | Reference Range Changes
`
`December 2005
`Urinalysis Methodology Change | Lead Testing Methodology Change | 17-α-
`Hydroxyprogesterone (17-α-OHP) | Fecal Occult Blood (Guaiac) Testing | Schistocyte Reporting
`on Peripheral Smears | CPT Code Changes for 2006
`
`October/November 2005
`Quantitative BCR/ABL Assay Replaces Ultraquant Assay | Division of Anatomic Pathology Has
`Moved | New Patient Service Center | Molecular Genetics Test Ordering Changes | Stool Culture
`Billing Modification | Changes in Drugs of Abuse (DOA) Tests in Urine | Changes in Urine
`Amylase Testing | Changes in Vitamin B12 Reference Range | New Test: Corticotropin Releasing
`Hormone (CRH) Stimulation Test | New Test: Growth Hormone Stimulation Test
`
`©UMass Memorial Laboratories | Biotech One, 365 Plantation Street, Worcester MA 01605
`Directions | Careers | Contact Us | Disclaimer | UMass Memorial Medical Center
`
`https://www.ummlabs.org/ClientNews.asp
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`UMass Memorial Medical Center
`One Biotech Park, Suite 200
`365 Plantation Street
`Worcester, MA 01605-2376
`Tel: 508-334-2863 or
` 800-476-4431
`Fax: 508-334-4210
`Email: LabsCS@ummhc.org
`
`L. Michael Snyder, MD
`Chairman
`
`Guy M. Vallaro, Ph.D.
`Vice President
`Clinical Laboratories
`An archive of Lab Updates is posted on Our Net or external web site: http://www.ummlabs.org
`
`
`
` February 2007
`
`
`
`MEASUREMENT OF AMMONIA IN BLOOD
`
`
`The measurement and interpretation of ammonia, a normal constituent of all body fluids, is challenging.
`An elevated ammonia level in blood is an indicator of an abnormality in nitrogen homeostasis, most
`commonly related to liver dysfunction. In excess, ammonia is a potent toxin, principally of central nervous
`system function. In both acute and chronic settings, the prompt measurement of the plasma ammonia
`level is very important, but the clinical status of a patient’s brain function should outweigh the importance
`of these test results. This is because ammonia levels may not directly correlate with clinical status. When
`the ammonia level is low, patients seem to be particularly sensitive to small increases in the level. When
`the ammonia level is elevated, patients seem to exhibit a tolerance to the high level with fewer
`symptoms. This could explain why symptoms may precede significant rises in ammonia levels and high
`ammonia plasma levels can still be present when the patient is clearly getting better. In most instances
`clearly aberrant values cannot be explained, although preanalytical artifacts are believed to account for
`many of these spurious results.
`
`The major limitations of conventional in vitro blood ammonia measurements are the complexity involved
`in the proper drawing and handling of the sample and the time allowed between drawing and assaying.
`Most methods recommend collecting a sample from patients who have fasted for at least 6 hours.
`Plasma ammonia levels are known to increase with exercise, smoking, GI bleeding, blood transfusions,
`high protein intake and some medications. Squeezing a ball in the hand for a few minutes has the effect
`of raising blood ammonia levels to as high as 150 µmol/L. Heparin is the preferred anticoagulant,
`because it has been shown to reduce red blood cell ammonia production. The patient’s arm should be
`as relaxed as possible, because muscle exertion may increase venous ammonia levels. The blood
`sample should be drawn into a chilled, sodium heparinized vacuum tube that is immediately
`placed on ice. The sample should then be centrifuged and the plasma removed within 15 minutes
`of draw. It is crucial to keep blood samples cold after collection, because the ammonia
`concentration of standing blood and plasma increases spontaneously. Most of this increase has
`been attributed to the generation and release of ammonia from red blood cells and the deamination of
`amino acids, particularly glutamine. The use of capillary blood should be avoided, because platelet
`aggregation and clotting lead to elevated ammonia levels. Measurements should be taken at the same
`time of day and under the same circumstances, because there is a diurnal variation in blood ammonia
`levels. The best way to confirm a raised ammonia level is not an artifact is by repeating the measurement
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`with another blood sample and carefully following the guidelines on the collection, handling, and storage
`of samples.
`
`Plasma ammonia levels in whole blood samples maintained at 4oC are stable for <1 hour. When
`promptly separated from blood, plasma ammonia levels are stable at 4oC for 4 hours. We do not
`recommend, freezing specimens at –200 C. Our internal validation studies showed significant variations
`in ammonia levels when frozen.
`
`For inpatient and outpatient testing: The required specimen is plasma from a dark green-top (sodium
`heparin) tube. The specimen should be mixed gently by inversion and placed on ice. The specimen
`should be transported immediately to the laboratory on ice.
`
`For specimens collected off site: The required specimen is plasma from a dark green-top (sodium
`heparin) tube. The specimen should be mixed gently by inversion and centrifuged immediately (within 15
`minutes) to obtain plasma. The plasma should be transferred to a separate vial and placed on ice. The
`specimen should be transported on ice. DO NOT FREEZE. You must call for a STAT pickup by
`contacting Customer Service at 508-334-2863. Samples must arrive at laboratory within 3 hours after
`collection.
`
`Do not use block ice or dry ice, as this will freeze the specimen. Hemolyzed specimens and specimens
`received at ambient temperatures, will not be analyzed, as falsely increased ammonia concentrations
`may result. Unspun tubes will not be accepted from outside the hospital. If you do not have a centrifuge
`you must refer the patient to a UMass Memorial Laboratories Patient Service Center. Call Customer
`Services at 508-334-2863 for the nearest location.
`
`1. Laboratory Medicine Practice Guidelines, NACB, 2000.
`2. Barsotti RJ. (2001). The Journal of Pediatrics, 138: S11-S20.
`
`If you require further information or have comment or concerns, please contact:
`Dr. L.V. Rao, Director, at 508-334-7593 or via email at RaoL@ummhc.org
`Ms. Judy Rennell, Manager, at 508-334-3803 or via email at Rennellj@ummhc.org
`
`CHANGES IN SERUM KETONE (ACE or BHY) TESTING
`
`
`Serum Ketone testing is generally done with nitroprusside (Acetest) tablets. A 4+ reaction with serum
`diluted 1:1 is strongly suggestive of ketoacidosis. The nitroprusside method only measures acetoacetic
`acid and acetone. However, beta-hydroxybutyrate (BHB), the strongest and most prevalent acid in
`diabetic ketoacidosis (DKA), is not measured by the nitroprusside method.
`
`Direct measurement of BHB in the blood is the preferred method for monitoring DKA1. During therapy,
`BHB is converted to acetoacetic acid, which may lead the clinician to believe that ketosis has worsened.
`Therefore, assessments of serum ketone levels by the nitroprusside method should not be used as an
`indicator of response to therapy.
`
`Effective March 12, 2007, serum ketone testing will be performed by BHB testing only. There are no
`changes in specimen collection requirements (One SST/ Serum). The normal range < 2 mmol/L.
`
` Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM. Hyperglycemic
`crises in diabetes. Diabetes Care 2004 Jan;27(Suppl 1):S94-102
`
`If you require further information or have comment or concerns, please contact:
`Dr. L.V. Rao, Director, at 508-334-7593 or via email at RaoL@ummhc.org
`Ms. Judy Rennell, Manager, at 508-334-3803 or via email at Rennellj@ummhc.org
`
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`CHANGES IN ZINC PROTOPORPHYRIN (ZPP) TESTING
`
`ZPP is ordered primarily in the general adult population along with a lead level, as part of a screen for
`chronic lead exposure. In an industrial setting, the Occupational Safety & Health Administration (OSHA)
`mandates the use of ZPP and strongly recommends that a ZPP test be ordered every time that a lead
`level is ordered to monitor an employee’s exposure to lead. Both are necessary because ZPP will not
`reflect recent or acute lead exposure, and it does not change quickly when a patient is removed from
`lead exposure. ZPP levels are reflective of a person’s average exposure to lead over the last 3-4 months.
`Values for ZPP rise more slowly than blood lead concentration following exposure, and they take longer
`to drop after exposure to lead has ceased. ZPP may be elevated in inflammatory conditions, infections,
`and several blood-related diseases, but it is not generally used to monitor or diagnose these conditions.
`Falsely low values may occur if the sample is not protected from light before testing.
`
`Effective March 12, 2007, ZPP testing will be performed using the ZP Hematofluorometer. There are no
`changes in specimen collection requirements and or reference ranges.
`
`If you require further information or have comments or concerns please contact:
`Dr. L.V. Rao, Director, at 508-334-7593 or via email at RaoL@ummhc.org
`Ms. Rachel Ambacher, Manager, at 508-334-7316 or via email at Ambacher@ummhc.org.
`
`
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`
`
`CLARIFICATION REGARDING THE ANTICOAGULATION PHARMACOGENETIC PANEL
`
`Please note the following correction to the January 2007 publication of Lab Updates. Our Anti-
`coagulation Pharmacogenetic Panel will test the Cytochrome P450 (CYP2C9) and vitamin K epoxide
`reductase complex subunit 1 (VKORC1) DNA variants. Specifically, the Anticoagulation
`Pharmacogenetic Panel will include testing for CYP2C9 (*1,*2,*3) and VKORC1.
`
`If you require further information or have comment or concerns, please contact:
`Dr. Edward Ginns at 508-856-8134 or via email at Edward.Ginns@umassmed.edu
`Dr. Marzena Galdzicka at 508-856-4384 or via email at Marzena.Galdzicka@umassmed.edu
`
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