Marys Medicine

Sa pathology newsletter

Reference interval changes 2 Significance of ANCA 4 Type 1 diabetes 6 INSIDe Clinical Utility of Bone Turnover Markers 8 Ulysses Syndrome – is it the liver? 10 Test ordering standardisation 11 Order of Draw Quick Guide 12 HbA1cFor our patients and our population

transport improvement, will enable us to Complement method change From the Executive Director meet future challenges and maintain To improve turnaround times for our hard earned reputation.
complement C3 and C4 results, As part of a highly regarded health system SA Pathology changed the method that provides outstanding patient care, and analyser platform to the integrated research and teaching activities ADVIA 2400 on 26 August 2013. we aim to continually improve the depth Results for both C3 and C4 using the and breadth of our services whilst returning new method are approximately value for money to South Australian 10% higher than those of the old method. The reference interval has changed to reflect this shift and a As a clinical support service SA Pathology paediatric range is included.
recognises that it needs to positively IMVS IS headed by ProfeSSor ruth SaloM a MedIcal graduate respond to the changing clinical landscape who haS SPecIalISed aS a in order to meet the needs of hospitals, clinicians and the community. We also recognise the need to manage demand and budget pressures, while ensuring our plans are consistent with the major developments MR KEN BARR IS EXECUTIVE that are occurring within the health system, DIRECTOR OF SA PATHOLOGY including the new Royal Adelaide Hospital and the South Australian Health and Medical Research Institute (SAHMRI), plus the major research and teaching goals >10 years and of the three universities. i am delighted to present this edition of the SA Pathology Newsletter (formerly SA Pathology will be explicitly moving the IMVS Newsletter). SA Pathology away from the ‘one hospital, one is proud to be the public provider of laboratory' model as advances in analytical, pathology services within South Australia transport and IT technology provide to ensure all our population, communities new opportunities for us to build a more DGA reference interval change and patients have 24/7 access to a flexible, efficient and effective state-wide comprehensive range of services, pathology network.
SA Pathology changed the irrespective of their income and location. Deaminated Gliadin Antibody (DGA) Be assured that our services will continue method and analyser platform on The priorities and direction contained to be clinically led, and that patient safety 9 December 2013. Whilst the new within our 2013-16 strategic plan and improving health outcomes remains method is clinically identical to the outline our clear intention to build on our primary goal. We look forward to current method the results will be a longstanding record of quality and working with you so that we can continue considerably different. excellence as a regulated and accredited to provide the very best pathology service pathology service across all disciplines to support our patients and our population.
New reference interval and our expanding Point of Care Testing The new reference interval for DGA network. Our plans for service, IT and will be: <11 U/mL. If you have any questions SA Pathology Newsletter Published by SA Pathology regarding these changes Editorial Committee please contact the John Bahnisch, Mark Fitz-Gerald, Ming Qiao, SA Pathology Photo and Imaging Immunology Consultant Dianne Zurcher and David Johnston via SA Pathology enquiries on (08) 8222 3000 cover: Ulysses and the Sirens ISSN 2203 – 2339 Print by John William Waterhouse 1891 ISSN 2203 – 2347 Online See page 10 for Ulysses syndrome SA Pathology Newsletter > 1 – 2013

Red Blood Cell Folate (RCF) What do I need to do SA Pathology has moved from serum folate to Red Blood Cell Folate (RCF) You will need to collect an Citrate Blood Tubes testing as the standard measurement EDTA specimen (purple top).
to assess folate nutritional status.
When collecting blood into Can I specifically request citrate tubes (blue tops) you Due to the 120 day average lifespan serum folate testing? must fill to the indicator line. of the red cell, RCF folate is less Yes. Serum folate levels will susceptible to rapid changes in diet A: continue to be available on compared with serum folate, and will provide more reliable and accurate results. In practice this change will: Can I request tests to n identify an additional 5% of differentiate between B12 patients with folate deficiency with and folate deficiencies? spuriously high serum levels Yes. Specific tests to identify n more accurately reflect and differentiate between the patient's folate status over the B12 and folate deficiencies, preceding 2 to 3 months.
such as homocysteine and methylmalonic acid levels, will continue to be performed. For B12 and RCF please collect both serum (white top) and whole blood (purple top).
> Mandatory folate The reason is that the ratio of fortification of flour blood to anticoagulant is critical has been in place since for clotting tests. 2009 in Australia. An under-filled tube will have too much citrate making results Clinically related questions invalid; similarly, overfilling Please contact Professor Luen Bik To, Haematology Clinical Director on the tube dilutes the citrate (08) 8222 3633 or Dr Penelope Coates, Chemical Pathology Clinical Director concentration invalidating the on (08) 8222 3391.
Collection by vacuum is the method preferred as this takes Warfarin reversal guidelines To aid decision making in this patient the correct amount of blood. group the recently updated Warfarin However if the tubes are old the In-patients receiving warfarin and Reversal Guidelines are now available vacuum may be reduced resulting experiencing bleeding is a relatively on the SA Pathology internet site. in under filling; please replace old common event, with approximately From the Home page go to: For or defective tubes.
2-3% of such individuals having a Clinicians Quick Guide for Clinicians major complication each year. Over or under filled samples will Emergency Information.
be rejected and a new sample will Patients on warfarin will also often Further advice can be obtained be required. This applies to all have high INR values without from the duty haematologist on-call clinically evident bleeding. Guidelines through the RAH switch board, for the management of both bleeding For additional information please phone (08) 8222 4000.
and non-bleeding patients with call the Haemostasis Reference an elevated INR result have been Laboratory on (08) 8222 3918.
developed by the Australian Society of Haemostasis and Thrombosis.
SA Pathology Newsletter > 1 – 2013 Dr TATjAnA BAnovic – CONsULTANT pATHOLOGIsT – ImmUNOLOGY Anti neutrophil cytoplasmic antibodies (ANCA) are associated with a spectrum of systemic vasculitic conditions affecting small and medium vessels throughout the body.
The syndromes of small vessel False positive results have been vasculitides (SVV) systemic reported in a variety of disorders vasculitides are characterised by: including infections, drug-induced vasculitis, other autoimmune diseases, n overlapping clinical and histological malignancies and inflammatory bowel features with frequent involvement disease (IBD). Conversely, negative results have been reported in patients n the need for aggressive with biopsy proven vasculitides. immunosuppressive treatment Results therefore should always be n serious morbidity and a significant evaluated in the context of other laboratory and clinical findings and should not be used as the principal The management of these vasculitides indication for treatment. often requires critical and timely decision making to prevent the There are three major patterns consequences of disease and the associated with a positive ANCA the aNca group of autoantibodies are directed hazards of mistreatment. The against cytoplasmic components in human importance of understanding the 1 Cytoplasmic or cANCA tests for ANCA used in the diagnosis cannot be overemphasised.
2 Perinuclear or pANCA 3 Atypical-ANCA pattern There are many different antigen specificities in the ANCA group The limits of ANCA testing need The atypical ANCA pattern has of autoantibodies but only two to be understood. To maximise the been reported in IBD, cystic fibrosis, have proven clinical associations, predictive value of ANCA screening autoimmune liver disease, drug- anti proteinase 3 (PR3) and anti it should only be performed on induced ANCA and rheumatic myeloperoxidase (MPO) antibodies. appropriately selected patients. diseases. In rheumatoid arthritis the Tests for other ANCA specificities The clinical indications of suspected prevalence of atypical-ANCA has been are not currently clinically useful ANCA-associated vasculitis include: detected in 20 – 70% of patients and and none have been proven specific been associated with more severe or diagnostically important for any n glomerulonephritis and long-standing disease. particular disease. Therefore all n pulmonary haemorrhage positive ANCA screens must have n cutaneous vasculitis, especially their identity confirmed to PR3 and with systemic features n multiple lung nodules n chronic destructive disease of Results should be evaluated the upper airways; long standing sinusitis or otitis in context of other laboratory n subglottic tracheal stenosis and clinical findings n retro-orbital mass.
SA Pathology Newsletter > 1 – 2013 What is ANCA?ANCA is a group of autoantibodies directed against cytoplasmic components in human neutrophils, the two main antigenic targets being proteinase-3 (PR3) and myeloperoxidase (MPO). Clinical studies done at SA Pathology have found the combination of an ANCA screen and confirmation tests yield the best diagnostic information.
If an ANCA screen on initial sensitivity around 60% for Other factors besides diagnostic presentation is positive but negative microscopic polyangiitis and 50% tests need to be considered before for both PR3 and MPO antibodies it for Churg Strauss syndrome. About deciding to administer toxic is more likely to be related to other 25% of patients with Wagner's immunosuppressive therapy, they diseases than ANCA associated Granulomatosis are also anti MPO vasculitides. However results must positive. Anti MPO levels do not n probability of improvement be interpreted in context with appear to reflect the disease activity and potential side effects with clinical findings as it may represent of patients with primary vasculitides additional biopsy investigations a limited form of disease. Patients and the effects of treatment are not for whom there is a high index of well documented.
n consequences and costs of suspicion should be monitored with mistreating nonvasculitic disorders PR3 and MPO antibodies, which may Anti MPO antibody is occasionally n consequences and costs of delaying become detectable as the disease found in other forms of or missing the diagnosis.
glomerulonephritis. It is present in about 30 – 40% of patients with anti In the appropriate clinical setting for Clinical associations glomerular basement membrane those patients with renal findings (GBM) disease, and these patients suggestive of vasculitis, initiation of To date only PR3 and MPO antibodies appear to have a better prognosis immunosuppression based on ANCA have been shown to be of value in the than those with GBM antibodies results alone without renal biopsy diagnosis of vasculitides. alone. Antibodies also occur in drug- appears justified.
induced lupus and occasionally The strongest disease association in certain other connective tissue In other clinical settings, a positive is between anti PR3 antibody and ANCA screen and MPO/PR3 Wagner's granulomatosis, which has antibodies are not sufficient for been reported in about 80% of active In general, anti MPO and anti PR3 diagnostic decisions on patient cases, however sensitivity varies do not occur in the same patient treatment. Positive ANCA results according to disease activity and in these settings must be confirmed extent. The more limited forms have with biopsy investigation.
sensitivities in the order of 67%, while generalised forms are nearly In a successfully treated vasculitis 100% of patients. Systemic necrotising vasculitides patient ANCA levels should disappear are serious life threatening or decrease significantly. If this is PR3 antibody levels appear to diseases, fatal if untreated. Since not the case, or the levels reappear, parallel disease activity. In general the introduction of combination a clinical exacerbation is likely to high levels of anti-PR3 antibodies corticosteroid and cyclophosphamide occur within the next few weeks or indicate active vasculitis and a sharp therapy clinical outcomes have rise in levels signifies disease flare. improved dramatically. The current Monitoring ANCA levels may be useful treatment schemes also include in discriminating between a disease aggressive immunosuppressive flare and non-specific infections in patients with SVV. Treatment should be started early The presence of anti MPO antibody as there is good evidence that the strongly suggests necrotising extent of organ involvement at onset vasculitis. It has a reported determines the ultimate prognosis, hence prompt diagnosis is critical. SA Pathology Newsletter > 1 – 2013 diabetes: diagnosis Drs jessicA PhiliPs, jenny couPer, jAn FAirchilD, AlexiA PeñA AnD elAine ThAm – pAEDIATRIC; ENDOCRINOLOGY WOmEN's AND CHILDREN's HOspITAL Every day in Australia two children will be diagnosed with type 1 diabetes. Currently Australia has the world's sixth highest rate for new diagnoses of type 1 diabetes. The incidence is highest amongst teenagers, with a second smaller peak amongst 5-9 year olds, but it can occur at any age, including infancy.
A combination of genetic and ketoacidosis (DKA), a life threatening environmental factors is thought complication and the leading cause of to precipitate the autoimmune death in children with type 1 diabetes. Children with type 1 diabetes usually destruction of the pancreas which Recognising the symptoms and signs present with a 2-6 week history of leads to Type 1 diabetes. Despite of the disease and starting insulin polyuria, polydipsia, and weight loss. years of research, improvements in early can prevent morbidity and Bedwetting is also common. insulin and insulin delivery devices These symptoms are often attributed a cure remains elusive. The following case study illustrates to urinary tract infections or Over 30% of children with type 1 the importance of early diagnosis and psychogenic polydipsia. If these diabetes still present in diabetic early symptoms are not recognised and ketoacidosis develops, vomiting, abdominal pain, dehydration, reduced consciousness and hyperventilation will ensue, and can be mistaken for gastroenteritis, acute abdominal pain, Mia is 4 years old. Her mother takes her to the GP as she is concerned Mia asthma or pneumonia. might have a bladder infection. She has been going to the toilet frequently and has started wetting the bed again after being mostly dry overnight for over a year. Today Mia complained of a sore tummy. She has had no fever Once suspected, type 1 diabetes can be or vomiting, but has been quite thirsty. easily diagnosed with a blood glucose Mia has no significant past medical Because of the glucosuria, her meter. The diagnosis is made if the history. Her grandfather has type 2 BGL is checked and is 14mmol/L. blood glucose level (BGL) is elevated: Her GP thinks Mia may have type n fasting BGL ≥7mmol/L or 1 diabetes and asks them to return n random BGL ≥11.1mmol/L Her GP agrees a urinary tract in the morning for a fasting blood infection is likely, though is A fasting BGL, oral glucose tolerance wondering about type 1 diabetes. test (OGTT) or an HbA1c are not Overnight Mia starts vomiting and required for diagnosis. Waiting for the Her urinalysis results are: the abdominal pain worsens. Her results of extra tests will only delay mother takes her to the emergency the diagnosis and management. department. Her BGL on arrival is 18mmol/L with blood ketones of Testing blood or urine ketones will 3.7mmol/L. A blood gas shows a help determine if ketoacidosis is likely.
metabolic acidosis with a pH of Children diagnosed with type 1 7.15 and bicarbonate of 10mmol/L. diabetes require immediate referral Mia is admitted to the paediatric to a hospital with paediatric services intensive care unit and an insulin to commence insulin and organise infusion started. multidisciplinary education and management.
SA Pathology Newsletter > 1 – 2013 Leading Light Award Children with diabetes can deteriorate Polyuria, polydipsia, bedwetting and quickly, and it is not uncommon for weight loss are usual early symptoms.
a child to present in severe DKA whilst waiting to have a fasting BGL.
A random blood glucose level >11.1mmol/L, in a symptomatic child The fasting BGL is not necessary is enough to make the diagnosis. associate Professor Susan branford for a symptomatic patient with elevated random BGL. Very early on Fasting blood glucose, OGTT or Associate Professor Susan Branford in the disease post-prandial BGLs HbA1c are not necessary to make the of the Leukaemia Unit, Department are the first to rise and fasting BGLs diagnosis and can delay treatment.
of Molecular and Genetic Pathology, Centre for Cancer Biology at Early diagnosis and immediate SA Pathology won the Australian referral to a doctor experienced in Society for Medical Research (ASMR) the management of type 1 diabetes SA Leading Light Award in September Type 1 diabetes can occur at any age, in children can prevent diabetic and is easily diagnosed if suspected. This prestigious award recognises the exceptional research output by mid-career researchers who have pursued their own research direction, Children with diabetes can and highlights the outstanding work being undertaken by up and coming deteriorate quickly researchers in South Australia. The award was presented by Professor Ian Frazer.
Young Investigator world diabetes day Raising awareness within the community KNOW THE DIABETES WARNING SIGNS!
about the four common signs of diabetes – weight loss, increased thirst, increasing urination and fatigue, reduces the number of children diagnosed late as in Mia's case. dr Julia Kuliwaba A recent Australian Excessive
study demonstrated that SA Pathology's Dr Julia Kuliwaba, a population awareness a researcher in surgical pathology, is campaign was effective the recipient of an International Bone If your child shows these signs,
in reducing the number and Mineral Society (IBMS) 2013 Sun seek immediate medical attention.
of children who present Valley Young Investigator Award – the in DKA by 64%. ¥ Alice L. Jee Award – for her research investigating the pathophysiology of Diabetes can affect children at any age. If left untreated, diabetes is deadly.
The award was presented at the 43rd International Sun Valley Workshop on Musculoskeletal Biology, Sun Valley, Idaho, in August 2013.
SA Pathology Newsletter > 1 – 2013 Dr DevikA ThomAs Osteoporosis is a major public health issue. Diagnosis relies on a bone mineral density (BMD) measurement, using dual energy X ray absorptiometry, and is defined as a bone density more than 2.5 standard deviations below the young normal (peak bone) values at the lumbar spine or the hip. Bone turnover markers (BTM) can be used as a complement to BMD in monitoring treatment response as well as fracture prediction in patients with osteoporosis.
Bone Turnover Markers serum. Total alkaline phosphatase may be used in place of bone specific Fasting morning serum CTX and BTM are products of bone formation alkaline phosphate in the absence of P1NP are convenient measures of and resorption. Bone is dynamic liver disease.
bone turnover. Diurnal variations and tissue with formation and resorption effects of food intake affect marker occurring concurrently at many levels, and serial collections for multi-cellular bone remodelling units, Products of osteoclasts and terminal monitoring should be collected under hence the measurement of BTM telopeptides of mature type 1 the same conditions, at the same reflects bone turnover and rates of collagen (like serum crosslaps – time of day and analysed by the same formation and resorption. CTX) are bone resorption markers. laboratory to minimise biological and Currently CTX is the most widely used bone resorption marker having Products of osteoblasts (osteocalcin, replaced the urine-based crosslinks Who to test and when? bone specific alkaline phosphatase) test. Products of osteoclasts are not and type 1 procollagen extension BTM testing is not a screen for routinely measured in clinical products (P1NP) are markers of bone osteoporosis and has not been formation that can be measured in validated as a diagnostic test, which still requires bone density measurement. However, BTM testing is useful for monitoring the treatment response to antiresorptive agents in patients with osteoporosis, and in the early recognition of non responders. This is an important indication because alternative treatment may be offered to non responders. BTM testing may be requested prior to commencement of treatment. Following initiation of anti-resorptive therapy it is useful to measure BTM again at three to six months to ensure adequate response, followed by re-assessment once or twice a year while treatment continues.
SA Pathology Newsletter > 1 – 2013 Follow up with BTM testing is still When monitoring treatment response useful even without a baseline value, the target would be a 30% fall in bone if the blood samples are collected resorption markers within weeks of n There is no consensus on the under recommended conditions commencing therapy. The desirable use and interpretation of BTM (ie: morning fasting samples) and limit for P1NP in postmenopausal and no recommendations in analysed by the same laboratory to women is <75 ug/L.
clinical guidelines. n Reference intervals and desirable Table 1 p1Np reference range limits vary between laboratories.
n The baseline BTM level cannot be BTM are not specific to a disease used for diagnosis of osteoporosis, and therefore cannot be used for it does not direct treatment choice diagnosis, however raised bone nor will it predict treatment resorption as reflected by raised CTX may suggest bone loss and loss of n Only a fall in BTM greater than bone microarchitecture not captured the least significant change by bone density measurements. (30% for serum markers) may be Therefore changes in BTM precede regarded as a response to treatment and proof of compliance.
BTM are raised in Paget's n It is not known to what extent disease, osteoporosis and other BTM should fall to optimise anti- conditions where bone turnover fracture efficacy.
is high, such as rheumatoid n Bone markers may be higher in arthritis, hyperparathyroidism and BTM are also useful in recognising patients with renal failure and hyperthyroidism. They are also non compliance and sometimes, dialysis dependent patients due generally higher in patients with renal helps identify those who may take to accumulation over time, and impairment due to low clearance. the medication incorrectly (i.e. taking may not directly reflect bone bisphosphonate tablets with food or turnover rate.
Monitoring therapy calcium tablets).
There is no consensus on a BTM target with as many as 50% of women Fracture prediction with osteoporosis having a BTM in There is clear and convincing evidence BTM can be used to identify patients the premenopausal range. The aim from epidemiological studies that with high bone turnover who may be of treatment would be to return BTM BTM are an independent predictor at greater risk of fragility fracture. to premenopausal levels. In patients of fractures, particularly of the spine Comparison between baseline and treated with anti-resorptive agents, and hip. Elevated CTX levels are subsequent BTM levels can be used levels of serum CTX of <400ng/L or associated with significantly increased to monitor treatment response and at least 30% reduction from baseline risk of fragility fractures. However patient compliance. In patients treated level should be the therapeutic target. there is no evidence to support BTM with anti-resorptive agents, at least for predicting fractures in individual 30% reduction from baseline level P1NP has been shown to convincingly patients and fracture calculators do should be the therapeutic target. ¥ and significantly rise after treatment not incorporate BTM as yet.
with teriparatide. When treated with anti resorptive agents such as bisphosphonates, strontium ranelate and denosumab, BTM fall significantly compared to baseline values. SA Pathology Newsletter > 1 – 2013 – is it the liver? Dr DevikA ThomAs This interesting case highlights the value of clinical history when interpreting test results, particularly those like liver enzymes with significant non-specificity. It reminds us that context is crucial to unravelling the complex web of influences that produce any set of test results. For more on the liver function tests refer to IMVS Newsletter 57.
DiscussionLiver enzyme patterns are used A 20 year old football player was admitted to the emergency Department to classify liver disease into two with a fractured mandible. Routine biochemistry tests revealed elevated broad categories – cholestatic AST, ALT and LD with normal GGT, ALP and bilirubin. There were no clinical disease (biliary obstruction) or or historical findings to explain the elevated Liver Function Test (LFT) results. hepatocellular disease. GGT and ALP Following surgical repair of the mandible the patient's GP was informed of are mainly located on cell membranes the results and requested follow up. Repeat results by the GP revealed and particularly line the biliary the following.
cannaliculi, therefore they are raised in any obstructive biliary disease anti mitochondrial, anti LKM and (cholestasis, metastatic lesions). anti smooth muscle – all negative They may also be induced by alcohol n Ceruloplasmin, alpha 1 and a variety of medications, anti- antitrypsin, haptoglobin, serum convulsants being the most common.
protein electrophoresis and coagulation studies were normal Transaminases (ALT and AST are intracellular enzymes that are n Iron studies showed normal iron released due to cellular injury, and are elevated in viral hepatitis and n Chest, abdominal and pelvic in cell destruction due to toxins CT scans – normal and medications such as high dose n Liver biopsy revealed normal paracetamol. Levels may rise 2 to The GP organised a liver and biliary hepatic and biliary tree histology 100 fold. Other causes of raised ultrasound which was normal. The Repeat liver function tests confirmed transaminases are non alcoholic patient was then referred to the liver ALT, AST and LD remained elevated steatohepatitis, haemochromatosis clinic. Subsequent investigations while GGT, ALP and bilirubin were and autoimmune liver disease.
AST and LD are also found in red n ALT and AST had risen to The patient was referred to a blood cells and muscle cells including 220 and 684 U/L respectively haematologist but no haematological cardiac cells. Intravascular haemolysis n Hepatitis A IgG, Hepatitis B cause was found for the abnormal or haemolysis of the sample after surface antigen and Hepatitis C results. Following consultation collection often raises LD and AST. In antibody tests were negative with a chemical pathologist, and some haematological diseases LD may n CMV and EBV IgM serology tests considering the patient's routine of be markedly elevated (myelodysplasia playing football most days, a CK level and pernicious anaemia). n Autoantibody tests including was requested, which was 2605 U/L If cardiac causes are suspected then ANCA, ANA, ENA, dsDNA, a troponin T assay is recommended SA Pathology Newsletter > 1 – 2013 ‘Ulysses syndrome' is the term used to describe an unnecessary complication of the diagnostic decision Test ordering standardisation where false-positive results or clinical decisions trigger a Historically ordering an MBA panel If you request an LFT plus an complex diagnostic has been something of a ‘movable additional chemistry test from work-up to elucidate feast'. Everyone seems to have their the MBA suite then you will receive the nature of what is, own interpretation on what should a full MBA report.
in fact, not a disease.
be reported with an MBA. To clarify this situation SA Pathology named after Classical has implemented consistent panel Greek hero Ulysses, who fought in definitions for the basic chemistry the Trojan War (1194 to 1184 BC) and subsequently took 20 years to return home to Greece; however If you request an MBA, or any of all his harrowing diversions proved the test panels listed below, you will receive the tests as listed.
along with an ECG and clinical history. AST and LD are abundant in skeletal muscle. Although ALT is regarded as a liver specific transaminase, it is also present in skeletal muscle and with persistent SA Pathology has also now muscle injury ALT may also be standardised on ECU as the renal function panel. Note that glucose is not included in the ECU panel and should be separately requested, and a grey top sample collected. A good history would have given The grey top provides a more stable the clue to severe muscular exertion collection environment for glucose as a potential cause. In this case, and hence results are more persistent exertions in the form of severe exercise lead to the consistently elevated AST, ALT, LD and CK from skeletal muscle. (The half life of ALT is up to 57 hours while that of AST and CK are less than 24 hours.) The differential diagnosis could have been supported by requesting the Total Cholesterol patient to have a repeat blood test after a few days rest to confirm that the cause was indeed exertion. Calculated Ionised n For more information The ‘health dollar' is a premium please speak to a SA Pathology commodity, and in this case it's easy Marketing representative to see how much time effort and money could have been saved by including a good history with the request. multiple Biochemical Analysis Liver Function Test > for list of acronyms Renal Function Test Electrolytes, Creatinine, Urea SA Pathology Newsletter > 1 – 2013 Vacuum Blood Collection System
Quick Guide Surgery Draw – Quick Guide
The volume of blood taken should be age appropriate and minimal. Please c Order of D
equency of collec The SA Pathology Order of Draw Quick Guide has recently been updated. Whilst many of the Blood Cultures (pair tests and tubes remain the same there have Anaerobic (purple) been a number of significant updates including the introduction of the ‘yellow top' for tissue INR, APTT, PT, Fibrinogen, D typing and platelet clumping.
PSA, Tumour Markers, Iron S For comprehensive information on all the (Serum - Fast Clotting) tests SA Pathology provides please visit our oponin, Lithium, o antibody tests, Viscosity web site at or Cholinesterase, Lymphoc simply scan the QR code with your xiline, T Cell subsets smartphone to go direct to the Pathology Collection Guide page.
tion, Antibody Screen 4ml: CBE, ESR, Haemoglobin, H
thy/Thalassaemia S 9ml: Blood borne
Homocysteine, Ammonia, PTH Tissue Typing, Platelet ‘Clumping' Fluoride
thology Collection G Allergy Test Requests The test information sheet, ‘Allergen Testing Guidelines' contains Liver Function Tests Epstein Barr Virus recommendations related to ordering. You can read or print the guidelines on the SA Pathology web site. Gamma Glutamyl Transferase Anti Neutrophil Cytoplasmic Antigen From the home page go to: For Clinicians Pathology Collection Guide Alkaline phosphatase Anti Nuclear Antibody and type ‘allergy' into the search box; click on the More Info link.
Alanine Aminotransferase Extractable Nuclear Antigen Antibody For clinical questions please phone SA Pathology Enquiries on Aspartate Amino Transferase Double stranded DNA antibody (08) 8222 3000 and ask for the Immunopathology Registrar or on Lactate Dehydrogenase Liver-Kidney microsomal Antibody The SA Pathology Allergy Test X-ray Computed Tomography Request form has been discontinued. SA Pathology enquiries > Metropolitan 8222 3000 > Regional and Country 1800 188 077 SA Pathology Newsletter > 1 – 2013


Die wahrscheinlichkeit, dass katzen mit husten an einer atemwegserkrankung leiden, ist bei weitem größer als die wahrscheinlic

Wenn die Mieze hustet Ein Überblick über feline Atemwegserkrankungen Husten bei einer Katze sollte man nicht auf die leichte Schulter nehmen. Katzen erkälten sich nicht so leicht wie wir Menschen, Husten gehört bei ihnen nicht zum „Alltäglichen". Daher sollte eine Katze, die wiederholt hustet (ohne dabei etwas hervorzuwürgen, z. B. Haarballen) dem Tierarzt vorgestellt werden.Erste Asthma-Anzeichen zeigen sich oft im Alter von 1 – 3 Jahren, können aber auch früher oder später auftreten. Bei manchen Katzen tritt parallel Niesen und / oder Augenausfluss auf.Wenn eine Katze schwere Atemnot hat (mit geöffnetem Maul und sichtlicher Anstrengung atmet, dabei die Ellbogen evtl. etwas nach aussen dreht), muss sie unverzüglich in tierärztliche Behandlung – dieser Zustand ist lebensbedrohlich! Auch wenn es mitten in der Nacht geschehen sollte – warten Sie lieber nicht bis zum Morgen, sondern rufen Sie den tierärztlichen Notdienst oder bringen Sie Ihre Katze ins nächste Tierspital.

Insect repellents

West Nile VirusInsect Repellents and DEET Tips:Deciding on Their Use Chemical repellents are effective at reducing bites from insects that can transmit disease. But their useis not without risk of health effects, especially if repellents are applied in large amounts or improperly.This information will help you decide when and if a repellent is right for you.