Laboratory Professional StaffDale Andres, D.O. Medical Director, Laboratory Services

Matt Andres, D.O. Pathologist

Adam Bell, M.D. Pathologist

Clinton Crowder, M.D. Pathologist

Vijaya Dhanwada, M.D. Pathologist

Avina Kolareth, M.D. Pathologist

Carolyn Pease, M.D. Pathologist

Soraya Rodriguez, M.D. Pathologist

Ramona Thompson, M.D. Pathologist

November/December 2011 { Volume 10, Issue 12 }

MCL Newsletter

MCL Management StaffNancy Mathahs, MHA, MLSCM

(ASCP) SMCM Director, Laboratory Services

Teri Reiff, MLS (ASCP)CM Sr. Manager, Core Laboratory

Sharon Jones, MT (ASCP) Manager, Specialty Services

Mona Parekh, MHA, MLS (ASCP)CM Manager, Outreach Services

Mercy Clinical Laboratory 1111 6th Avenue Des Moines, IA 50314

www.mercydesmoines.org/mcl (515) 247-4439 or (877) 263-1622

Recommendations for Diagnosis of DiabetesBy: Teri Reiff, Sr. Manager, Core LaboratoryDiabetes is a chronic illness for which early diagnosis and on-going patient management can prevent acute and long-term complications. The American Diabetes Association (ADA) periodically reviews and revises recommendations for screening, diagnosis and treatment of this disease.

In January 2011, the ADA published the following criteria for diagnosis of diabetes:

• HBA1c≥ 6.5%, or; • Fastingplasmaglucose(FPG)≥ 126 mg/dl. Fasting is defined as no caloric intake for at least 8 hours, or; • 2-hourplasmaglucose≥200mg/dlduringanoralglucosetolerancetest(OGTT)usingaglucose load of 75 grams, or; • Inapatientwithclassicsymptomsofhyperglycemiaorhyperglycemiacrisis,arandomplasma glucose ≥ 200 mg/dl.

Unless the diagnosis is clear on clinical grounds, a test result diagnostic of diabetes should be repeated, preferably with the same test, for confirmation. If two different tests are both above the diagnosticthresholds(forexampleHBA1candFPG),thediagnosisofdiabetesisalsoconfirmed.

Recommendations for Diagnosis of Gestational Diabetes The ADA also recommends that pregnant women not known to have diabetes be screened for gestationaldiabetesmellitus(GDM)byundergoinga75gramOGTTat24-28weeksgestationwithmeasurement of plasma glucose at 1 and 2 hours. Testing should occur after an overnight fast of at least 8 hours.

ThediagnosisofGDMismadewhenanyoneofthefollowingplasmaglucosevaluesareexceeded.

• Fasting≥92 mg/dl • 1hour≥ 180 mg/dl • 2hour≥ 153 mg/dl.

Mercy Clinical Laboratory offers the following test panels to screen and diagnose diabetes in your patients.

• Glucose Tolerance Diagnostic 75 gm This is a 2-hour test using a 75 gram dose. Fasting and 2-hour samples are collected. This test should be ordered for all non-pregnant patients.

• Glucose Gestational Screen 50 gm ThistestistobeusedforscreeningpregnantwomenforGDM.A1-hoursampleiscollected.

• Glucose Tolerance 3-Hr Gestational 100 gm ThisisatestusedfordiagnosingpregnantwomenwithGDM.Thisisa3-hourtestusing a 100-gram loading dose. Fasting , 1-, 2- and 3- hour samples are collected.

• *NEW* Glucose Tolerance 2 Hr Gestational 75 gm ThistestisusedfordiagnosingpregnantwomenwithGDM.Thisisa2hourtestusing a 75 gram loading dose. Fasting , 1- and 2- hour samples are collected.

Reference: Diabetes Care, Volume 34, Jan. 2011

WelcomeDr. Soraya Rodriguez has joined Pathology Associates of Central Iowa and will be practicingatGrinnellRegionalMedical Center. She will be available for frozen sections, fine needle aspiration assessments and consultations.

Dr. Rodriguez is originally from Cuba.Heranatomicandclinicalpathologyresidencyandher cytopathology fellowship were completed at Jackson MemorialHospitalinMiami,Florida.

Sorayaandherhusband,Dr.JerryWehr,resideinGrinnell. Dr. Rodriguez has one son and a daughter-in-law, living in Florida.

Health Network CEO Honored

GordonWinkler,CEOofRinggoldCountyHospital in Mount Ayr, IA, was recently honoredbytheIowaHospitalAssociationwiththeExcellencein Leadership Award. The award is presented each year to an outstanding Iowa hospital or health system executive who shows achievement in local,

state and national health care affairs, leadership among peers and contributions to the community. Winkler has been a hospital leader for nearly 25 years.

CongratulationsBarb Anderson, Laboratory DirectoratKnoxvilleHospitaland Clinics, has been selected bytheIowaHospitalAssociationasaneliteHospitalHero.Sheisone of only 11 people selected among the 74,000 hospital employees in the state. The award is given to those who tirelessly give their time and

talents to better their patients and community. Anderson will receive the award in October at the Iowa HospitalAssociation’sannualmeetinginDesMoines.

Stool Testing Updates By: Sharon Jones, Laboratory Manager, Specialty Services

Fecal White Blood Cells The presence of white blood cells (WBCs) in the stool is indicative of intestinal inflammation and suggests certain etiologies in patients with gastrointestinal disease. Bacterial inflammatory diarrhea may be caused by Shigella, Salmonella, Campylobacter, and Clostridium difficile. Some pathogens such as Clostridium difficile produce toxins that may lyse the white cells. Therefore, with microscopic methods, white cells may not be visible even though there is severe inflammation. Noninfectious inflammatory diarrheamaybeseeninulcerativecolitisandCrohn’sdisease.Thepresenceoffecal white blood cells can be used to aid in the differentiation of Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD). Patients with IBS do not have increased fecal white blood cells, while patients with active IBD show increased presence of fecal white blood cells.

Traditional detection of fecal WBCs was reliant on microscopic methods. This test is subjective, and is negatively influenced by factors such as prolonged transportation time, collection method and temperature. Recently, Mercy Clinical Laboratory has begun using the Fecal Lactoferrin test to detect fecal WBCs. The Lactoferrin assay overcomes the problems of microscopy by utilizing immunochromotography technology. Lactoferrin is very stable (as long as 2 weeks if the specimen is refrigerated) and is not degraded by bacterial toxins.

Stools from breast fed babies cannot be tested using the Lactoferrin methodology. Those stools still need to be tested by microscopic techniques, because Lactoferrin is present in breast milk and may cause a false positive test.

Occult Blood Testing Mercy Clinical Lab (MCL) uses an immunological (IFOBT) methodology for the detection of occult blood in stools. This method has been in use at MCL for the past three years.

The IFOBT is a superior technology for several reasons, including:

1 Detects only human hemoglobin

2. No dietary or Vitamin C restrictions

3. Single sample testing, no need for three stool specimens

4. DetectsbloodfromthelowerGItract

If a stool specimen is more than four hours old, testing is done using the Guaiacmethod(theoccultbloodcard).Thecardmethodologyisableto testforupperGIbleedingandtheIFOBTmethodisspecificallyforlower GItractbleeding.TheIFOBTdetectstheintactglobinproteinportion ofhumanhemoglobin,andifthebloodisfromtheupperGIarea,thehemoglobin molecule breaks down in the stomach acid and may not be detected by IFOBT. A comment to this effect is part of each occult blood reportatMCL.IfthepatientissuspectedofhavinganupperGIbleedandtheIFOBTisnegative,youmayconsiderorderingaGuaiac-basedoccultbloodtest.

Affiliate hospital’s lab staff share their Mercy experiences

Submitted by Denise Eddy, Lab Manager at Mercy Medical Center–Centerville

Tuesday, Aug. 2, began as any other day in the lab. We were expecting a big oncology day and had several things going on. My day changed drastically at 12:56 p.m. when my husband called my office. Randy farms and raises Angus cattle on our family farm just north of Centerville. On this particular day, he was baling hay in a field not far from the hospital. When I answered the phone, he said “I need youtocomegetme,something’sthematter.”Hewasobviouslystruggling to talk and I asked him what was happening and he said “Idon’tknow,justcomegetme.”

I knew something was terribly wrong, so as I went flying out of the hospital, I stopped at the ambulance office and briefly told them something was wrong with Randy and that I needed them to follow me.

When I got there, he was in the tractor and was slumped over thesteeringwheel,whilehewasstillconscioushewasn’treallyresponding well. I got him out of the tractor and down on the ground and the paramedics arrived soon after that. As they were assessing him, I paced and finally returned to the hospital because I figured I was not helping the situation by continually yelling for themtogethimintheambulance!AfterIreturnedtotheERtheytoldmethatEMShadcalledMercyDesMoinesforthehelicopterand that the Knoxville helicopter was on its way.

WhenIlookbackonitnow,Idon’treallyknowwhatIthoughtwashappeningtohimwhenIwenttohelphim,butitdidn’toccurtomeuntil that point that he was having a heart attack. When Randy got totheER,Icouldtellbythelookonmyco-workers’facesthatthiswas very serious and I just stepped back and let these people do whattheydobest.HewasonhiswaytoMercyinlessthan45minutes.The flight crew let me ride in the helicopter and it was a fast 28- minute flight to Des Moines. When we landed, pastoral care had found myoldestdaughterShannonwaitingintheERandhadherstandingby the doorway as we entered the hospital on our way to Cath Lab.

One of the Cath Lab nurses came out as soon as we found the waiting room to tell us that Randy was already in the middle of his procedure and was doing well, and shortly after that she said that Dr.Iononnewasreadytoseeme.HesaidthathehadRandy’srightcoronary artery 100% opened within 11 minutes of arrival. This whole process had taken less than two hours since I had received the

call in my office. Randy went up to spend that night in CCU and the rest of his stay at Mercy was uneventful (thank goodness!). I encountered several familiar faces during my three days there, and Randy is telling anyone who will listen how great the care was at both Mercy Medical Center – Centerville and Mercy Des Moines!

I have just been in awe of the whole Level 1 protocol and how smoothly it went. I have said many times, if I had not been so directly involved in the event, it would have been truly amazing to watch.EverythingwentaccordingtoplanandRandyreturnedtonormal activity in early September. We received the best news of all athistwo-weekcheck-upatIowaHeart.Duetothefastresponseofeveryone involved, Randy does not have any permanent damage, and I have our Mercy family to thank for that!

Submitted by Karen Richardson, Lab Manager at Wayne County Hospital

Acute myocardial infarction. The words strike fear in everyone. It is, however, supposed to happen to “someone else” and we are the ones who are here to help. This past summer my husband Ralph was the “someone else.”

Hewaspreppingthemowerconditioneronhiswaytothehayfieldwhenthesuddenpainstruck.Therewasn’tadvancewarning.Hehadn’thadpreviouschestpainorshortnessofbreathoranyofthesymptoms that you realize later were forewarnings. Mostly, he thought he had pulled a muscle. Fortunately, the severity and unrelenting pain made him seek help.

My teenage son delivered him in a flying trip to the Wayne County ER,andtheLevel1cardiacprotocolwentintoeffect.ThecoordinationbetweenER,MercyOneandthecardiaccathlabwasimpressive.The diagnosis was determined quickly and Mercy One dispatched out of Knoxville. My husband arrived at the cardiac cath lab and was successfully reperfused with a stent and angioplasty – all within anhourofpresentingtoER.FollowingabriefstayinCICUandthen telemetry, we were able to make it home for 4th of July fireworks.

The words “fortunate” and “thankful” keep repeating themselves, but the collaboration and team effort from all were essential in such goodoutcome.Today,heisbacktofarming.Harvestisstartingandwe are gratefully healthy and active.

Upcoming Dates to RememberNovember 10, 2011

Mercy Health Network – Central Iowa Network Lab Managers Meeting Mercy Medical Center – Des Moines

January 12, 2012Mercy Health Network – Central Iowa Network Lab Managers Meeting Mercy Medical Center – Des Moines

Please use the MCL “Blue Bags” for frozen specimens only.

Our bags come preprinted with: Freeze, Refrigerate

or Room Temperature. To avoid any confusion, please use the “Blue Bags” for frozen specimens only.

C4 testing reagent informationBeckman Coulter has issued a statement to laboratories across the nation regarding concerns with the calibrator lots released for C4 testing. An internal investigation at Beckman Coulter confirmed that these calibrator lots were recovering C4 concentrations in patient and quality control samples approximately 30% lower compared to IFCC standards. Mercy Clinical Laboratory had been using these lots from November 4, 2008, through July 15, 2011. On July 15, 2011, Mercy Clinical Laboratory switched to a calibrator lot that is not affected by this issue.

During the time period of November 4, 2008 and July 15, 2011, C4 results reported by Mercy Clinical Laboratory were approximately 30% lower than the actual value. You are encouraged to review and evaluate the impact this may have had on your patients whose C4 value recovered near clinical decision points during this timeframe. Additionally, this event should also be considered when comparing future C4 values to those obtained prior to July 15, 2011, because values will appear to have increased without apparent cause.

Please direct questions or concerns to Dale F. Andres, D.O., Laboratory Medical Director at (515) 643-4517.

MCL Update