AACB CURRICULUM 2007 - Univerzita Karlovakocna/edu/AACB Curriculum 2007.pdfAACB Curriculum 2007 11 (e) Nephelometry and Turbidimetry • Principles1-3 of Nephelometry & Turbidimetry:

AACB CURRICULUM 2007

Prepared by

AACB Education Committee Chair: Dr Chris Florkowski

& AACB Board of Examiners Chair: Mr Paul Sheehan

Copyright © 2007 Australasian Association of Clinical Biochemists Inc.

AACB Curriculum 2007 2

AACB – Learning Objectives and Resources

Background and Rationale

• It was recognised that the previous AACB Syllabus was out-of-date and provided

minimal guidance on appropriate topics and learning resources

• The previously published study guides were similarly largely out-of-date and too

voluminous to reasonably expect anybody to try and update

• At the AACB Education Committee meeting in Christchurch (2006), it was agreed that

a new Curriculum would be formulated as a “middle-ground” option by listing more

explicit learning objectives with links to key resources

• A model was agreed between the Chairs of the Education Committee and the Board

of Examiners by providing a hierarchy of topic headings with the objective of listing a

few bulleted learning objectives and key links for each

• Resources include published materials, websites and other links. These are intended

to be pertinent, accessible and user-friendly, though not necessarily definitive or

exhaustive. Otherwise out-dated references are used where considered to be

particularly helpful. It is expected that these initial links will lead to other resources for

more in-depth coverage where required

• The Curriculum is intended to be a broad guide to the spectrum of Laboratory

Medicine. Some headings have been highlighted as more pertinent areas for study

and also topics where more depth of insight may be expected at FAACB (as opposed

to MAACB) level

• Members are encouraged to give feedback through their Branch Education

representatives with a view to the Curriculum being updated in perpetuity

The AACB is grateful to the Education Committee and Board of Examiners who have had input to the preparation of the new Curriculum, along with a broad cross section of our membership, including members of Working Parties and other niche experts from across the Region. May 2007

DISCLAIMER: The AACB accepts no responsibility for the accuracy or currency of the information contained in this document.


AACB – Learning Objectives and Resources

Principal Topic Headings:

1. Analytical Biochemistry

2. Clinical Biochemistry

3. Molecular Genetics

4. Therapeutic Drug Monitoring and Toxicology

5. Laboratory Management


a. Specimen Collection; pre-analytical phase

b. Spectrophotometry

c. Luminescence and Fluorescence

d. Flame Emission Photometry

e. Nephelometry and Turbidimetry

f. Atomic Absorption Spectrophotometry and ICP-MS

g. Main analyser platforms and automation.

h. Ion Selective Electrodes – eg Na+, K+, Ca++

i. Acid-Base Measurement

j. Principles of Chromatography

k. High-Performance Liquid Chromatography

l. Gas Chromatography

m. Electrophoresis

n. Immunoassay and detection systems

o. Isotopic Techniques

p. Osmometry

q. Enzymology

r. Mass-Spectrometry

s. Emerging Technologies, eg NMR

t. Quantities and Units



a. Water and sodium

b. Potassium

c. Acid-Base regulation

d. Renal Function

e. Diabetes Mellitus

f. Hypoglycaemia

g. Clinical Enzymology

h. Proteins in Health and Disease

i. Gastro-Intestinal Function

j. Liver Function

k. Lipids

l. Cardiac Risk Factors

m. Troponins

n. Natriuretic Peptides

o. Calcium, Phosphate, Magnesium, PTH and Bone Markers

p. Iron Studies and Haemoglobin

q. Pituitary Function

r. Thyroid Function

s. Adrenal Function

t. Fertility, Menopause and PCOS

u. Pregnancy

v. Nutrition

w. General Paediatric Clinical Chemistry

x. Inborn Errors of Metabolism

y. Porphyria

z. Urine Analysis – Na, alb, protein, calcium, uric acid

aa. CSF Analysis

bb. Amniotic Fluid Analysis and prenatal diagnosis

cc. Pleural Fluid Analysis

dd. Tumour Markers

ee. Serology and Autoimmunity

ff. Renal Calculi



a. Nucleic Acid Extraction; Strategies for Mutation Detection

b. Mutational Analysis for Specific Disorders

c. Mitochondrial Genome and its Role in Investigation

d. Genetics and Molecular Oncology

e. Cytogenetics

f. Ethical, Legal and Social Issues (ELSI)

4. Therapeutic Drug Monitoring (TDM) and Toxicology

a. Pharmacokinetic and Pharmacodynamic Concepts

b. Drug-metabolism and Pharmacogenetics

c. Rationale and Service Provision for TDM

d. TDM, with specific consideration of:

i. Digoxin

ii. Cyclosporin and immuno-suppressant drugs

iii. Lithium

iv. Anticonvulsant drugs

e. Initial Management and Evaluation of the Poisoned Patient

f. Toxicological Profiles and Interventions for Specific Poisons

g. Drugs of Abuse Testing (including workplace drug testing)

h. Occupational Health Monitoring; solvents, trace metals



a. Organisation of a Clinical Laboratory

b. Laboratory Safety and Hazard Management

c. Laboratory Accreditation; ISO

d. Internal Quality Control

e. External Quality Assurance

f. Laboratory Statistics

g. Method Comparison

h. Reference Intervals

i. Evidence Based Laboratory Medicine (EBLM)

j. Information Technology and the Laboratory

k. Selection and Evaluation of Methods and Equipment

l. Scope of Point of Care Testing (POCT) and Accreditation Issues

m. Evidence Based Medicine and POCT



(a) Specimen Collection; pre-analytical phase

• Patient preparation– biological, diurnal and patient-related physical variables1,2,3

• Patient identification and correct labelling of samples

• Variables due to anticoagulants and preservatives1,2,3

• Blood collection – technique, site of collection1,2,3

• Specimen processing (storage, transport, centrifugation) 1,2,3

• Analysis of the errors in laboratories4

• Errors due to blood collection tube components5,6

1. Young DS, Bermes EW, Haverstick DM. Specimen Collection and Processing in Tietz

Textbook of Clinical Chemistry and Molecular Diagnostics. 4th Ed. Burtis CA,

Ashwood ER, Bruns DE. Elsevier Saunders 2006. Chapter 2; Pages 41-60.

2. Dufour DR. Sources and Control of Preanalytical Variation in Clinical Chemistry

(Theory, Analysis, Correlation). 4th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC.

Elsevier Science 2003; Chapter 3: Pages 64-82.

3. Preventing pre-analytical errors, Center for Phlebotomy Education Inc.

www.phlebotomy.com

4. Plebani M. Errors in clinical laboratories or errors in laboratory medicine?

Clin Chem Lab Med. 2006;44(6):750-9. Review.

5. Bowen AR, Chen Y, Ruddel ME, Hortin GL, Csako G, Demosky SJ, et al.

Immunoassay interference by a commonly used blood collection tube additive, the

organosilicone surfactant Silwet L-720. Clin Chem 2005;51:1874-1882.

6. Dimeski G, Carter A. Magnesium contamination from Terumo blood collection tubes.

Clin Chem 2006;52:1612-1614.

http://www.phlebotomy.com/


(b) Spectrophotometry

• Principles of spectrophotometry;1-4 principles of light transmittance and absorbance,

Beer-Lambert law

• Spectrophotometer components,1,2 function, double beam, scanning

• Assessment of Performance,1-4 calibration, quality assurance, interference, detection

limits

• Instrument selection1-4 and method requirements

1. Kricka LJ. Analytical Techniques and Instrumentation in Tietz Textbook of Clinical

Chemistry and Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE.

2006. Chapter 3: 61-92.

2. Henry’s Clinical Diagnosis and Management by Laboratory Methods, 21st Ed. Richard

A McPherson and Matthew R Pincus. Part 1-Principles of Instrumentation.

3. Taulier A, Levillain P, and Lemonnier A. ‘Determining Methemoglobin in Blood by

Zero-crossing-point first-derivative Spectrophotometry’. Clinical Chemistry 1987;

33(10): 1767-1770.

4. Vink KLJ, Schuurman W and van Gansewinkel R. Use of the caffeine reagent in direct

spectrophotometry of Bilirubin. Clinical Chemistry 1986; 32(7): 1389-1393.

Useful website:

www.ibms.org/pdf/pdf_science/principles_spectrophotometry.pdf

Riddle P: ‘Principles of spectrophotometry’, The Biomedical Scientist, February 2005.

Background reading:

http://www.iupac.org/publications/pac/1980/index.html

Malmstadt HV. Analytical Instrumentation for the 1980’s. Pure & Applied Chemistry 1980;

52(11), 2495-2507

http://www.ibms.org/pdf/pdf_science/principles_spectrophotometry.pdf

http://www.iupac.org/publications/pac/1980/index.html


(c) Luminescence and Fluorescence

• Concepts of fluorescence, bioluminescence, chemiluminescence and

electroluminescence1,2

• Theory of luminescent reactions1,2

• Principles of luminescent measurement1

• Design of spectrofluorimeters and the function of component parts1

• Limitations of fluorescence measurement (inner filter effect, concentration quenching,

light scattering etc)

• Application of fluorescent measurement in the laboratory including FPIA, FIA, time

resolved fluorescence, flow cytometry and real-time PCR1,3,4,5

• Principles, applications and advantages of chemiluminescent , enhanced

chemiluminescent and electroluminescent reactions in the laboratory1,3,6,7

1. Kricka L. Optical Techniques. In Tietz. Textbook of Clinical Chemistry and Molecular

Diagnostics. Fourth Edition. Chapter 3: pages 61-91.

2. Kaplan and Pesce. Clinical Chemistry. Theory, Analysis and Correlation. Second or

higher editions.

3. Williams and Marks. Principles of Clinical Biochemistry. Second Edition.

4. Jolley M E, Stoupe K, Schwenzer KS, Wang CJ, Lu-Steffes M, Hill HD et al.

Fluorescence Polarisation Immunoassay. An automated system for therapeutic drug

determination. Clin Chem 1981;27:1575-1579.

5. Hemmila L. Fluoroimmunoassays and Immunofluorometric Assays. Clin Chem

1985;31:359-370.

6. Weeks I, Beheshti I, McCapra F, Campbell AK, Woodhead JS. Acridinium esters as

high-specific activity labels in Immunoassay. Clin Chem 1983;29:1474-1479

7. Henry. Clinical Diagnosis and Management by Laboratory Methods. Twentieth

Edition.


(d) Flame Emission Photometry

• Principles of flame photometry1,2

• Typical components of a flame photometer and their function3

• Practical aspects1 including the importance of sample atomization, factors limiting the

sensitivity of FES and differences between FES and AAS3, composition of calibrators

(viscosity, wetting agent), problem of “mutual excitation” and “self-absorption”,

function of internal standard in FES2,3

• Comparison of FES with Ion Selective Electrodes (ISE)1

• The application of the technique in routine laboratory medicine

Comment: Flame photometry has declined in popularity and has been replaced in

many laboratories by ISE technology. Many recent textbooks do not cover this topic

in any detail; hence a previous edition of Tietz (reference 1) and other older texts may

give more detail.

1. Caraway WT. Photometry. In Tietz. Fundamentals of Clinical Chemistry. 3rd Ed.

Tietz NW. 1987. Pages 61-3 and 618-9.

2. Kaplan and Pesce. Clinical Chemistry. Theory, Analysis and Correlation. Second

Edition.

3. Williams and Marks. Principles of Clinical Biochemistry. Second Edition.


(e) Nephelometry and Turbidimetry

• Principles1-3 of Nephelometry & Turbidimetry: antigen–antibody complexes, light

scattering, antigen excess, rate nephelometry

• Nephelometer components1-3

• Performance,4 calibration, quality assurance, interference,5 detection limits

• Instrument selection: method requirements6, troubleshooting6

1. Manual of Clinical Laboratory Immunology, 6th edition. By Noel R. Rose, Robert G.

Hamilton and Barbara Detrick; Chapter 2.

2. Kricka LJ. Principles of Immunochemical techniques in Tietz Textbook of Clinical


2006. Chapter 9: 219-44.

3. Henry’s Clinical Diagnosis and Management by Laboratory Methods, 21st edition By

Richard A McPherson and Matthew R Pincus. Part 1-Principles of Instrumentation.

4. Stowe H. Lawrence D. Newman DJ. Lamb EJ. Analytical performance of a particle-

enhanced nephelometric immunoassay for serum cystatin C using rate analysis.

Clinical Chemistry. 2001: 47(8):1482-5.

5. Bossuyt X. Blanckaert N. Evaluation of interferences in rate and fixed-time

nephelometric assays of specific serum proteins. Clinical Chemistry, 1999. 45(1):62-7.

6. http://www.dadebehring.com

This site has an interactive online training program.

Register user name and password; Support → Online Training→Plasma Proteins

Choose: My BN ProSpec or My BN11.

http://www.dadebehring.com/


(f) Atomic Absorption Spectrophotometry and ICP-MS

• Principles of Atomic Absorption1,2. Line spectra.

• Components of an Atomic Absorption Spectrophotometer1,2; hollow cathode lamp,

burner, flameless atomic absorption, monochromator and detector.

• Interferences1,2; chemical, ionisation, matrix, emission. Zeeman correction2.

• Applications of Atomic Absorption Spectrophotometry – trace metal analysis3.

• Principles of Inductively coupled plasma mass spectrometry (ICP-MS)

http://www.missouri.edu/~murrwww/pages/ac_icpms1.shtml

http://ewr.cee.vt.edu/environmental/teach/smprimer/icpms/icpms.htm

• Applications of ICP-MS – trace metal analysis3.

1. Pesce AJ, Frings CS, Gauldie J. Spectral Techniques: Theory and Practice in Clinical

Chemistry: Theory, Analysis and Correlation. 4th Ed. Kaplan LA, Pesce AJ,

Kazmierczak SC. 2003. Chapter 4. Pages 83-106.

2. Kricka LJ. Optical Techniques in Tietz Textbook of Clinical Chemistry and Molecular

Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 3: Pages 61-

91.

3. Moyer TP, Burritt MF, Butz J. Toxic Metals in Tietz Textbook of Clinical Chemistry

and Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter

35: Pages 1371-1390.

http://www.missouri.edu/%7Emurrwww/pages/ac_icpms1.shtml

http://ewr.cee.vt.edu/environmental/teach/smprimer/icpms/icpms.htm


(g) Main analyser platforms and automation

• Concepts1-3 of random access, discrete, continuous flow, stat testing.

• Operational features of analytical platforms1-3 e.g throughput, cycle times, interfacing,

reflex testing, auto dilutions, closed tube sampling, reagents (ready-made,

concentrated, lyophilised), combined chemistry and immunoassay platforms,

expandability, connectivity to LIS, connectivity to other analysers, modular and task-

targeted automation.

• Concepts of automation1-6; modular systems, front-end specimen processing,

specimen archiving. Advantages of automation4-6.

• History of automation1-6e.g. drivers of automation, changes in technology.

• Impact of automation1-6 e.g. on quality of results, throughput, labour requirements.

1. Pesce MA. Laboratory Automation in Clinical Chemistry: Theory, Analysis and

Correlation. 4th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC. 2003. Chapter 16. Pages

287-302.

2. Anderson, S. C. and Cockayne, S. Clinical Chemistry: Concepts and Applications.

3. Boyd JC, Hawker CD. Automation in the Clinical Laboratory in Tietz Textbook of

Clinical Chemistry and Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns

DE. 2006. Chapter 11: 265-298.

4. Middleton, SR. Developing an automation concept that is right for your laboratory.

Clin Chem 2000;46:757-763.

5. Boyd, JC, Felder, RA & Savory, J. Robotics and the changing face of the clinical

laboratory. Clin Chem 1996;42:1901-1910.

6. Dadoun, R. Impact on human resources: core laboratory versus laboratory

automation system versus modular robotics. Clin Lab Manage Rev 1998;12:248-255.

Look at www.clinchem.org and journals such as the Journal of the Assoc for

Laboratory Automation for examples of different analytical platforms.


(h) Ion Selective Electrodes

• Principles of Ion Selective Electrodes1-4; concepts of activity, potentiometry,

ionophores and the Nernst equation

• Direct versus Indirect Ion Selective Electrodes1-4

• Effects of proteins5 and lipids6 on indirect ion selective electrodes

• Effects of haemolysis on potassium7

1. D’Orazio P, Meyerhoff ME. Electrochemistry and Chemical Sensors in Tietz Textbook

of Clinical Chemistry and Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER,

Bruns DE. Elsevier Saunders 2006. Chapter 4, pages 93-119.

2. Heinemann WR, Kirchhoff JR, Wheeler JF, Lunte CE, Jenkins SH. Electrochemistry:

Principles and Measurements in Clinical Chemistry (Theory, Analysis, Correlation). 4th

Ed. Kaplan LA, Pesce AJ, Kazmiercrak SC. Elsevier Science 2003.

3. D’Orazio P. Electrochemical sensors: a review of techniques and applications in point

of care testing. Point of Care 2004;3:49-59.

4. Burnett RW, Covington AK, Fogh-Andersen N, Kulpmann WR, Lewenstam A, Maas

AH, Muller-Plathe O, VanKessel AL, Zijlstra WG. Use of ion-selective electrodes for

blood-electrolyte analysis. Recommendations for nomenclature, definitions and

conventions. International Federation of Clinical Chemistry and Laboratory Medicine

(IFCC). Scientific Division Working Group on Selective Electrodes. Clin Chem Lab

Med. 2000 Apr;38(4):363-70.

5. Dimeski G, Barnett RJ. Effects of total plasma protein concentration on plasma sodium,

potassium, and chloride measurements by an indirect ion selective electrode measuring

system. Crit Care and Resus 2005;7:12-15.

6. Dimeski G, Mollee P, Carter A. Effects of hyperlipidaemia on plasma sodium,

potassium and chloride measurements by an indirect ion selective (ISE) measuring

system. Clin Chem 2006;52:155-6.

7. Dimeski G, Clague AE, Hickman PE. Correcting and reporting of potassium results in

haemolysed samples. Ann Clin Biochem 2005; 42:119-123.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10928658&query_hl=11&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10928658&query_hl=11&itool=pubmed_docsum


(i) Acid-Base Measurement

• pH, pO2, pCO2 electrodes1,2 – amperometric and potentiometric electrode and optode

design and operation

• Measurement of HCO3 using enzyme method1,2

• Calculation of HCO3 using Henderson-Hasselbalch equation1,2

• Calculation and measurement of oxygen saturation1,2

• Specimen collection and preservation1,2

• Quality Control1,2 and Quality Assurance

• Effect of temperature and pressure on parameters1,2

1. D’Orazio P, Meyerhoff ME. Electrochemistry and Chemical Sensors in Tietz Textbook


Bruns DE. Elsevier Saunders 2006. Chapter 4, pages 93-119.

2. Heinemann WR, Kirchhoff JR, Wheeler JF, Lunte CE, Jenkins SH. Electrochemistry:

Principles and Measurements in Clinical Chemistry (Theory, Analysis, Correlation). 4th

Ed. Kaplan LA, Pesce AJ, Kazmiercrak SC. Elsevier Science 2003


(j) Principles of Chromatography

• Branches of Chromatography and General Principles,1,2 adsorption, partition,

resolution, retention, theoretical plates, selectivity, derivatisation, polarity, solvents

http://ull.chemistry.uakron.edu/chemsep/chrom_theory/

• Separation mechanisms:1,2 ion-exchange, partition, adsorption, affinity, gel-filtration

chromatographies

1. Ullman MD, Burtis CA. Chromatography in Tietz Textbook of Clinical Chemistry and

Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 6:

141-163.

2. Tabor MW. Chromatography: Theory and Practice in Clinical Chemistry: Theory,

Analysis and Correlation. 4th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC. 2003.

Chapter 5. Pages 107-128.

http://ull.chemistry.uakron.edu/chemsep/chrom_theory/


(k) High Performance Liquid Chromatography (HPLC)

• Analytical Principles,1,2,3 components of HPLC system; pumps, columns, solvents,

types of detectors. Resolution, retention, efficiency, Height Equivalent to Theoretical

Plate (HETP)

• Applications of HPLC; including drug analysis,1 biogenic amines,1,4,5 vitamins,6

porphyrins7

• Derivatives of HPLC: HPLC-MS8,9

1. HPLC in the Clinical Laboratory, The Clinical Biochemist Monograph. Ed Sampson

DC, Pub AACB Sydney, November 1986.

2. http://www.waters.com and follow the links to Liquid Chromatography, Library, How to

guides and HPLC primer.



141-163.

4. Weinkove C, acp Broadsheet No. 127, Measurement of catecholamines and their

metabolites in urine. J. Clin Pathol.,1991, 44: 269-275.

5. Pillai D, Earl JW, Duncan MW, Sampson DC, Potezny N, Crawford GA, Gallery EDM.

Biogenic Amines: Significance, Measurement and Clinical Applications, Clin Biochem

Revs 1991; 12: 14-21.

6. Catignani GL. Simultaneous determination of retinol and α tocopherol in serum and

plasma by liquid chromatograph. Clin Chem 1983; 29 (4): 708-712.

7. Lim CK, Peters TJ. Urine and faecal porphyrin profiles by reversed phase HPLC in

the porphyrias. Clinica Chemica Acta 1984; 139: 55-63.

8. Vogeser M. Liquid chromatography-tandem mass spectrometry: Application in the

clinical laboratory. Clin Chem Lab Med 2003; 41(2): 117-126.

9. Ho CS, Lam CWK, Cheung RCK, Law LK, Lit LCW, Ng KF, Suen MWM, Tai HL.

Electrospray Ionisation Mass Spectrometry: Principles and Clinical Applications. Clin

Biochem Rev 2003; 24: 3-12.

http://www.waters.com/


(l) Gas Chromatography (GC)

• Analytical Principles,1,2 components of GC system; instrumentation, columns, carrier

gases, injector, temperature control, types of detectors (flame-ionisation, thermal

conductivity, electron capture)

http://teaching.shu.ac.uk/hwb/chemistry/tutorials/chrom/gaschrm.htm

• Molecules that can be separated by GC,1,2 partitioning, column performance, Height

Equivalent to Theoretical Plate (HETP)

• Applications of GC (and derivatives, eg GC-MS); including toxicology3 and inborn

errors of metabolism4



141-163.

2. Poklis A. Gas Chromatography in Clinical Chemistry: Theory, Analysis and


154-170.

3. Kalasinsky KS, Levine B, Smith ML. Feasibility of using GC/FTIR for drug analysis in

the forensic toxicology laboratory. J Anal Toxicol 1991; 16: 332.

4. Forman DT. Role of the laboratory in diagnosis of organic acidurias. Ann Clin Lab Sci

1991; 21: 85.

http://teaching.shu.ac.uk/hwb/chemistry/tutorials/chrom/gaschrm.htm


(m) Electrophoresis

• Principles of electrophoresis,1-3 practical aspects including supporting media, buffers,

stains, concept of endosmosis. Applications to serum,1-4 urine, CSF4

• Immunofixation electrophoresis and identification of monoclonal bands1

• Immunoelectrophoresis - principles and applications

• Isoelectric focusing (IEF) – principles and applications1,5

• Principles and applications of Polyacrylamide Gel Electrophoresis (PAGE)1,2

• Capillary Gel Electrophoresis2 – technical aspects, applications and comparison with

other methodologies, including HPLC

1. Karcher A, Landers JP. Electrophoresis. In Tietz Textbook of Clinical Chemistry and

Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. Elsevier Saunders

2006. Pages 121-140.

2. Brewer JM. Electrophoresis: Theory and Practice in Clinical Chemistry: Theory,



3. Jeppson JO, Laurell CB, Franzen B. Agaraose gel electrophoresis. Clin Chem 1979;

25: 629-38.

4. Laurell CB. Composition and variation of the gel electrophoretic fractions of plasma

and cerebrospinal fluid. Scand J Clin Invest 1972; 29 (Suppl 124): 71-82.

5. Jeppson JO, Franzen B. Typing of genetic variants of A1At by electrofocusing. Clin

Chem 1982; 28: 219-25.


(n) Immunoassay and detection systems

• Requirements:1,2 antibody, standard, signal (linked to analyte or antibody), separation

technique, signal generation and detection/measurement

• Characteristics of antibodies,1,2 haptens, specificity, polyclonal, monoclonal, affinity,

avidity, scatchard analysis

• Competitive vs non-competitive formats,1,2 antibody concentration, affinity of tracer

and analyte, optimum antibody concentration. 1 site, 2-site immunometric.

Standards, matrix effects

• Labels and Signals:1 radioisotopes, enzymes (ALP, peroxidase), luminescence

(chemi, electro), fluorescence and time resolved fluorescence

• Homogeneous vs heterogeneous immunoassay,1,2 methods for separation1,2

• Elements of assay performance:1 cross reactivity, interference, recovery, precision,

analytical sensitivity, functional sensitivity

• Interferences,1-3 analyte autoantibodies, heterophilic antibodies, cross reacting

substances, rheumatoid factor, high dose hook effect, endogenous binding proteins,

anticoagulants

• Automated immunoassay:1,2,5 instrument technology, consumable technology,

separation system, labelled component, generation of signal, detection of signal

1. Wild D Editor The Immunoassay Handbook. 2nd Edition, United Kingdom: Nature

Publishing group, 2001.

2. Kricka LJ. Principles of Immunochemical techniques in Tietz Textbook of Clinical


2006. Chapter 9: 219-44.

3. Tate JR and Ward G. Interferences in Immunoassay. Clin Biochem Rev 2004;25:105-

120.

4. Selby C. Interference in immunoassay. Ann Clin Biochem 1999;36:704-721

5. Wheeler MJ. Automated immunoassay analysers. Ann Clin Biochem 2001;38:217-

229.


(o) Isotopic Techniques

• Structure of the atom, fundamental particles, nomenclature1,2

• Principles of radioactivity,1,2 modes of decay, units, half life

• Modes of decay1,2 associated with tritium, carbon-14 and iodine-125

• Measurement of radioactivity1,2 – gas-filled and scintillation detectors

• Applications of radio-isotopes in the clinical laboratory1,2 - see immunoassays

• Safety considerations, waste disposal1,2

http://www.ncrponline.org/ (National Council on Radiation Protection)

1. Chen I-W. Radioisotopes in Clinical Chemistry: Theory and Practice in Clinical

Chemistry: Theory, Analysis and Correlation. 4th Ed. Kaplan LA, Pesce AJ,

Kazmierczak SC. 2003. Chapter 9. Pages 187-200.

2. Bermes EW, Kahn SE, Young DS. Introduction to Principles of Laboratory Analyses

and Safety in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th Ed.

Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 1: Pages 3-39.

http://www.ncrponline.org/


(p) Osmometry

• Principles of osmotic pressure and osmosis,1 colligative properties

• Freezing point depression versus vapour pressure osmometry1

• Osmolality versus osmolarity,1 calculated osmolarity1,2

• Osmolar Gap2 - see initial management and evaluation of the poisoned patient

• Interpretations of plasma and urine osmolality – see sodium and water balance

section

1. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th Ed. Burtis CA,

Ashwood ER, Bruns DE. Elsevier Saunders 2006.

2. Osypiw JC, Watson ID, Gill G. What is the best formula for predicting osmolar gap?

Ann Clin Biochem. 1997; 34: 692-3.


(q) Enzymology

• Enzyme catalysis

• Enzyme kinetics and factors governing rate of reaction

• Enzyme co-factors

• Measurement of reaction rate

• Km and Vmax of enzyme reactions

• Monitoring of enzyme reactions and substrate depletion

• Enzyme as reagents, including use of enzymes in EIA

• Application of immobilised enzymes

• Standardisation of enzyme assays

1. Tietz. Textbook of Clinical Biochemistry and Molecular Diagnostics. 4th Edition. Bais

R, Panteghini M. Chapter 8.


(r) Mass Spectrometry (MS)

• Basic principles;1,2 mass-to-charge (m/z) ratios, mass spectra

• Components of a Mass Spectrometer;1,2 ionization sources (electron, chemical, laser

desorption), mass filter (quadrupole, magnetic), detectors

• Use of Mass Spectrometer;1,2 full-scan analysis, selected ion monitoring, quantitation

• Separation techniques;1,2 GC-MS, HPLC-MS. http://www.ionsource.com (Mass

spectrometry resource)

• Time-of-flight MS1 (TOF), MALDI-TOF, SELDI-TOF

• Principles of Tandem mass spectrometry1,2 (MS/MS)

• Applications of MS based techniques – see sections on Drugs of Abuse testing and

Inborn Errors of Metabolism

http://www.asms.org (American Society for Mass Spectrometry)

1. Annesley T, Rockwood AL, Sherman NE. Mass Spectrometry in Tietz Textbook of

Clinical Chemistry and Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns

DE. 2006. Chapter 7: 165-190.

2. Lehrer M. Mass Spectrometry: Theory and Practice in Clinical Chemistry: Theory,



http://www.ionsource.com/

http://www.asms.org/


(s) Emerging Technologies

• Nuclear Magnetic Resonance (NMR) Spectroscopy; theory and applications

http://teaching.shu.ac.uk/hwb/chemistry/tutorials/molspec/nmr1.htm

http://www.cem.msu.edu/~reusch/VirtualText/Spectrpy/nmr/nmr1.htm

• Infrared Spectroscopy; theory and applications

http://www.cem.msu.edu/~reusch/VirtualText/Spectrpy/InfraRed/infrared.htm

http://teaching.shu.ac.uk/hwb/chemistry/tutorials/molspec/irspec1.htm

http://teaching.shu.ac.uk/hwb/chemistry/tutorials/molspec/nmr1.htm

http://www.cem.msu.edu/%7Ereusch/VirtualText/Spectrpy/nmr/nmr1.htm

http://www.cem.msu.edu/%7Ereusch/VirtualText/Spectrpy/InfraRed/infrared.htm

http://teaching.shu.ac.uk/hwb/chemistry/tutorials/molspec/irspec1.htm


(t) Quantities and Units

• Hierarchy of methodologies; definitive, reference and routine methods.1,2 Networks of

primary and secondary reference laboratories1

http://www.iso.org/iso/en/ISOOnline.frontpage

• Implications – eg for HbA1c testing (see heading under Diabetes Mellitus)

• Other examples of method standardisation – see HCG and troponins

• Traceability of reference materials http://www.bipm.fr/en/committees/jc/jctlm/

• Système internationale (SI) – units http://www.bipm.fr/en/si/

• Molar versus mass units – effect on interpretation3

1. Tietz NW. A model for a comprehensive measurement system in clinical chemistry.

Clin Chem 1979; 35: 833-9.

2. Westgard JO, Klee GG. Quality Management. In Tietz Textbook of Clinical Chemistry

and Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. Elsevier

Saunders 2006. Chapter 19: pages 485-529.

3. Simpson D. Units for reporting the results of toxicological measurements. Annals of

Clinical Biochemistry 1980 Nov;17(6):328-31.

http://www.iso.org/iso/en/ISOOnline.frontpage

http://www.bipm.fr/en/committees/jc/jctlm/

http://www.bipm.fr/en/si/



(a) Water and Sodium

• Distribution of sodium and water1,2

• Homeostatic mechanisms including renal handling, regulation by thirst, ADH, Renin-

Angiotensin-Aldosterone (RAA) system and natriuretic peptides1,2

• Concepts of molality vs molarity, electrolyte exclusion effect2 - methods of measuring

sodium and osmolality; osmolar gap - see analytical section

• Preanalytical and analytical factors influencing results including specimen collection,

sample requirements, psuedohyponatraemia1-4

• Pathophysiology of hyponatraemia1-4 including diuretics, renal dysfunction, SIADH,

Addison’s disease liver/heart failure and other causes

• Pathophysiology of hypernatraemia;3 dehydration, and salt poisoning5

• Differential diagnosis and investigation of polyuria and polydipsia;1 Cranial vs

Nephrogenic Diabetes Insipidus;3 role of water deprivation test ± DDAVP

• Algorithms for investigation;3,6 hyponatraemia, hypernatraemia, polyuria

1. Clinical Chemistry 4th Ed. William J Marshall. Harcourt Publishers Ltd 2000. Pages

13-36.


Ashwood ER, Bruns DE. 2006. Chapters 27 (pages 983-1018) and 46 (pages 1747-

1776).

3. Kumar S, Berl T. Electrolyte quintet: Sodium, Lancet 1998; 352:220-228.

4. Oh MS. Pathogenesis and diagnosis of hyponatraemia, Nephron 2002;92 (suppl 1):

2-8.

5. Coulthard MG, Haycock GB. Distinguishing between salt poisoning and

hypernatraemic dehydration in children, BMJ 2003;326:157-160.

6. Biochemical Investigations in Laboratory Medicine. Barth JH, Butler GE, Hammond P.

Eds Hooper J, Sherwood R, Marshall W. ACB Venture Publications 2001. Pages52-8.


(b) Potassium

• Distribution of potassium,1,2 homeostasis1,2 and regulation by RAA system2

• Analytical aspects of potassium measurement - see analytical section

• Preanalytical and analytical factors;2 artefactual results related to specimen collection,

handling, haemolysis and potassium leakage from cells

• Pathophysiology, causes, diagnosis and clinical effects of hypokalaemia1,2 including

redistribution, non-renal losses, hyperaldosteronism1,2 and inherited disorders of

potassium homeostasis3 (Bartter’s, Gitelman’s syndromes)

• Pathophysiology, causes, diagnosis and clinical effects of hyperkalaemia4 including

drug induced Hyperkalaemia,5 redistribution, impaired renal excretion of potassium,

and pseudohyperkalaemia6

• Investigation algorithms for hypokalaemia and hyperkalaemia7

1. Marshall W J. Clinical Chemistry, Chapter 2, Water, Sodium and Potassium, 4th

edition 2000. Harcourts Publication Limited.


Ashwood ER, Bruns DE. 2006. Chapters 27 (pages 983-1018) and 46 (pages 1747-

1776).

3. Kamel KS, Oh MS, Halperin ML. Bartter’s, Gitelman’s and Gordon’s Syndromes,

Nephron 2002;92(suppl 1):18-27.

4. Hollander-Rodriguez J C, Calvert JFJr. Hyperkalaemia, American Family Physician

2006; 73(2): 283-290.

5. Palmer BF. Managing Hyperkalaemia Caused by Inhibitors of the Renin-Angiotensin-

Aldosterone System, NEJM 2004;351(6):585-592.

6. Sugimoto et al. Familial Psuedohyperkalaemia: A Rare cause of Hyperkalaemia,

Internal Medicine 2005; 44(8): 875-878.

7. Biochemical Investigations in Laboratory Medicine. Barth JH, Butler GE, Hammond P.

Eds Hooper J, Sherwood R, Marshall W. ACB Venture Publications 2001. Pages 59-

62.


(c) Acid-Base Regulation

• Acid-Base parameters:1,2 concepts of pH, pO2, pCO2, pK, actual bicarbonate,

standard bicarbonate, dissolved CO2, base excess

• Buffer systems1,2 and their role in regulating pH of body fluids

• Respiratory mechanisms1,2 in regulation of acid-base balance

• Renal mechanisms1,2 - bicarbonate reabsorption and regeneration

• The buffer (Henderson-Hasselbalch) equation1,2

• Analytical aspects of blood gases – see analytical section

• Acid-base disorders:1-3 pathophysiology (with clinical examples) of metabolic and

respiratory acidosis and alkalosis, compensated and mixed acid-base disturbances

• Derivation of Anion Gap4 and its utility. Examples of high and normal anion gap

acidoses3

• Pathophysiology of renal tubular acidosis3

• Strong Ion Difference: an alternative approach to interpretation5

1. Marshall W J. Clinical Chemistry, Chapter 3, H+ ion homeostasis and blood gases, 4th

edition 2000. Harcourts Publication Limited.

2. Burtis, Ashwood and Burns. Tietz Textbook of Clinical Chemistry and Molecular

diagnosis, Chapters 27 and 46, 4th edition 2006. Elsevier Saunders.

3. Gluck S L. Electrolyte quintet: Acid-base, The Lancet 1998; 352:474-480.

4. Moe OW and Fuster D. Clinical Acid-base Pathophysiology: Disorders of Plasma

Anion Gap, Best Pract Res Clin Endocrinol Metab 2003; 17: 559-574

5. Lloyd P. Stron Ion Calculator – A practical Bedside Application of Modern

Quantitative Acid-Base Physiology, Critical Care & Resuscitation 2004; 6: 285-294


(d) Renal (Glomerular) Function

• Renal pathophysiology – creatinine versus GFR1

• Cockcroft & Gault,2 MDRD3 equations -use and limitations

• Operational use of e-GFR – Australasian Position Statement4

• Laboratory implementation issues for e-GFR

www.aacb.asn.au/files/File/eGFR%20Laboratory%20Guidelines.pdf

• Stages of chronic kidney disease5

• Cystatin-C:6 an alternative marker of renal function

• Spot urine biochemistry and diagnosis of acute tubular necrosis1

• Biochemical changes in acute and chronic renal failure1

1. Marshall WJ. The kidneys, renal function and renal failure. In Clinical Biochemistry.

Metabolic and Clinical Aspects. Eds Marshall WJ & Bangert SK. Churchill

Livingstone 1995.

2. Cockcroft, DW, Gault MH. Prediction of creatinine clearance from serum creatinine.

Nephron, 1976. 16(1): p. 31-41.

3. Levey, AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth DA. A more accurate

method to estimate glomerular filtration rate from serum creatinine: a new prediction

equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med, 1999.

130(6): p. 461-70.

4. Chronic Kidney Disease and automatic reporting of estimated glomerular filtration

rate: a position statement. Med J Aust 2005; 183(3): 138-141.

5. Levey AS, Coresh J, Balle E. National Kidney Foundation Practice Guidelines for

Chronic Kidney Disease: Evaluation, Classification and Stratification. Ann Intern Med

2003; 139: 137-47.

6. Filler G, Bokenkamp A, Hofmann W, Le Bricon T, Martinez-Bru C, Grubb A. Cystatin

C as a marker of GFR – history, indications and future research. Clinical

Biochemistry 2005; 38: 1-8.

http://www.aacb.asn.au/files/File/eGFR%20Laboratory%20Guidelines.pdf


(e) Diabetes Mellitus

• Overview of carbohydrate metabolism and glucose regulation1

• Classification;1 Type 1 vs type 2, MODY,2 gestational3

• Oral Glucose Tolerance testing (OGTT) – diagnostic criteria4

• HbA1c methodologies; IFCC standardisation initiatives.5 Fructosamine1

• Patho-physiology of ketoacidosis.1 Measurement of ketones1

• Predisposition to type 1 diabetes; predictive value of ICA, anti-GAD1

• Complications screening; microalbuminuria and nephropathy1,6

• Glucose methods.1 Quality standards for laboratory testing in diabetes7

1. Sacks DB. Carbohydrates in Tietz Textbook of Clinical Chemistry and Molecular

Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 25: 837-901.

2. Fajans SS, Bell GI, Polonsky KS. Molecular mechanisms and clinical

pathophysiology of maturity-onset diabetes of the young. N Engl J Med 2001;

3. Hoffman L, Nolan C, Wilson JD, et al. Gestational diabetes mellitus — management

guidelines. The Australasian Diabetes in Pregnancy Society. Med J Aust 1998; 169:

93-97.45(13): 971-80.

4. Position statement from the ADS, NZSSD, RCPA and AACB. New classification and

criteria for the diagnosis of diabetes mellitus. Med J Australia 1999; 170: 375-8.

5. Goodall I. HbA1c standardisation destination--global IFCC Standardisation. How,

why, where and when--a tortuous pathway from kit manufacturers, via inter-laboratory

lyophilized and whole blood comparisons to designated national comparison

schemes. Clin Biochem Rev 2005; 26(1): 5-19.

6. American Diabetes Association. Diabetic Nephropathy. Diabetes Care 2003; 26

Suppl 1: S94-98.

7. Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, Parrott M.

Guidelines and recommendations for laboratory analysis in the diagnosis and

management of diabetes mellitus. Clin Chem 2002; 48(3): 436-72.


(f) Hypoglycaemia

• Definition, classification, adrenergic vs neuroglycopaenic symptoms1,2

• Hypoglycaemia in context of diabetes mellitus1,3

• Insulinoma – diagnosis and investigation.1,2 Factitious hypoglycaemia1,2,4

• Non-islet cell tumour hypoglycaemia.1,2 Role of IGF-22

• Endocrine causes of hypoglycaemia.1,2 Insulin auto-immune syndrome5

• Post-prandial hypoglycaemia – role of extended OGTT1,2,6

• Neonatal and infant causes1 – see paediatric section

1. Clinical Chemistry 4th Ed. William J Marshall. Harcourt Publishers Ltd 2000. Chapter

11 – Disorders of carbohydrate metabolism: Pages 175-98.

2. Service FJ. Hypoglycaemic disorders. N Engl J Med. 1995; 332(17):1144-52.

3. Sacks DB. Carbohydrates. In Tietz Textbook of Clinical Chemistry and Molecular

Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 25: 837-901.

4. Marks V. Hypoglycaemia – Real and Unreal, Lawful and Unlawful: The 1994 Banting

Lecture. Diabetic Medicine 1995; 12: 850-64.

5. Redmon JB, Nuttall FQ. Autoimmune Hypoglycaemia. Endocrinology & Metabolism

Clinics of North America 1999; 28(3): 603-18.

6. Charles MA, Hofeldt F, Shackleford A et al. Comparison of Oral Glucose Tolerance

Tests and Mixed Meals in Patients with Apparent Idiopathic Postabsorptive

Hypoglycaemia: Absence of Hypoglycaemia After Meals. Diabetes 1981; 30: 465-70.


(g) Clinical Enzymology

• Clinical value of enzyme measurements – factors affecting plasma levels1,2

• Alkaline Phosphatase – bone versus liver.1,2 Isoenzyme determination1,2

• Aminotransferases1,2 (AST, ALT) and GGT1,2 – see LFTs section

• Lactate dehydrogenase1,2 – isoenzymes and clinical significance1,2

• Creatine kinase1,2 – isoenzymes and clinical significance.1,2 Macro-CK2,3. Role in

diagnosis of MI – see troponins section

• Amylase2,4 – salivary versus pancreatic. Macroamylasaemia.2,4 Lipase and diagnosis

of acute pancreatitis2,5

• Cholinesterase – see section on Drug Metabolism & Pharmacogenetics and

Poisoning


225-30.

2. Panteghini M, Bais R, van Solinge WW. Enzymes in Tietz Textbook of Clinical


2006. Chapter 21: 597-643.

3. Lee KN, Csako G, Bernhardt P, Elin RJ. Relevance of macro creatine kinase type 1

and type 2 isoenzymes: laboratory and clinical data. Clin Chem 1994; 40(7): 1278-3.


97-99.

5. Clave P, Guillaumes S, Blanco I et al. Amylase, Lipase, Pancreatic Isoamylase, and

Phospholipase A in Diagnosis of Acute Pancreatitis. Clin Chem 1995; 41(8): 1129-

34.


(h) Proteins in Health and Disease

• Plasma proteins and their functions1,2

• Serum protein electrophoresis – typical abnormalities seen1,2

• Hypoalbuminaemia – differential diagnosis1,2

• α-1 antitrypsin deficiency – diagnosis and clinical significance1-3

• Acute phase response – effects on proteins.1 Inflammation – CRP, cytokines1 and

other markers, including procalcitonin4

• Immunoglobulins – structure, function, classes.1 Differential diagnosis of

hypogammaglobulinaemia and hypergammaglobulinaemia1

• Paraproteins – MGUS vs multiple myeloma.1 Waldenstrom’s macroglobulinaemia and

hyperviscosity.1 Role of serum free light chains1,5

• Awareness of heavy chain disease.1 Amyloidosis – pathology and diagnosis1

• Oligoclonal banding – detection and role in diagnosis of multiple sclerosis2

• Tau-transferrin and identification of fluid as Cerebrospinal fluid (CSF)6

• Transudates versus exudates – see section on pleural fluid analysis

1. Clinical Chemistry 4th Ed. William J Marshall. Harcourt Publishers Ltd 2000. Chapter

13 – Proteins and Enzymes: Pages 215-224.

2. Johnson AM. Amino Acids, Peptides and Proteins. in Tietz Textbook of Clinical


2006. Chapter 21: 533-95.

3. Liver Disease & Laboratory Medicine. McFarlane I, Bomford A, Sherwood R. Eds

McGreanor G & Marshall W. ACB Venture Publications 2000. p71-4.

4. Uzzan B, Cohen R, Nicolas P, Cucherat M, Perret GY. Procalcitonin as a diagnostic

test for sepsis in critically ill adults and after surgery or trauma: a systematic review

and meta-analysis. Crit Care Med. 2006; 34(7):1996-2003.

5. Rajkumar SV, Kyle RA, Therneau TM et al. Serum free light chain ratio is an

independent risk factor for progression in monoclonal gammopathy of undetermined

significance. Blood 2005; 106(3): 812-7.

6. Papadea C, Schlosser RJ. Rapid method for beta2-transferrin in cerebrospinal fluid

leakage using an automated immunofixation electrophoresis system. Clin Chem

2005; 51(2): 464-70.


(i) Gastro-Intestinal Function

• Overview of GI tract anatomy & physiology1,2

• Tests for H. pylori – including urease, serology, 13C-urea breath test1

• Lactose intolerance1 - investigation including hydrogen breath test1

• Coeliac disease; serology.1 Malabsorption; faecal fat.1-3 Bacterial overgrowth1

• Anti-saccharomyces antibodies

• Exocrine pancreatic function – dynamic function tests.1,2 Elastase1

• Acute Pancreatitis1,2 – amylase, lipase, macro-amylase

• Investigation of chronic diarrhoea.1,3 Faecal osmotic gap – interpretation1,3

• Neuroendocrine tumours ;1-3 carcinoid syndrome & 5-HIAA; VIP, gastrinomas

• Colorectal Cancer (CRC) Screening – faecal occult blood screening.4

http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-

1lp . CEA - see tumour markers section

• Faecal calprotectin – role in inflammatory bowel disease5

1. Hill PG. Gastric, Pancreatic and Intestinal Function. in Tietz Textbook of Clinical


2006. Chapter 48: 1849-1889.


95-108.

3. Thomas PD, Forbes A, Green J et al. Guidelines for the investigation of chronic

diarrhoea, 2nd edition. Gut 2003; 52 (Suppl V): v1-v15.

4. Towler B, Irwig L, Glasziou P, Kewenter J, Weller D, Silagy C. A systematic review of

the effects of screening for colorectal cancer using the faecal occult blood test,

Hemoccult. British Medical Journal 1998; 317: 559-65.

5. Gearry R, Barclay M, Florkowski C, George P, Walmsley T. Faecal calprotectin: the

case for a novel non-invasive way of assessing intestinal inflammation. N Z Med J.

2005; 118(1214):U1444. (May 6).

http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-1lp

http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-1lp


(j) Liver Function Tests (LFTs)

• Patterns of LFT abnormalities;1-3 hepatocellular, obstructive, mixed, increased GGT,

isolated increased bilirubin

• Differential diagnosis of viral hepatitis: hepatitis A,B,C, EBV, CMV, others1

http://www.healthservices.gov.bc.ca/msp/protoguides/gps/vihep.pdf

• Alcohol,1 drug-hepatotoxity,1,4 non-alcoholic fatty liver disease (NAFLD),1,5

haemochromatosis (see iron studies section), Wilson’s disease, alpha-1-antitrypsin

deficiency, autoimmune hepatitis,1 ischaemic hepatitis

• Non-hepatic causes of LFT abnormalities:1 eg - bone pathology

• Bilirubin conjugation defects – Gilbert’s syndrome and genetic testing6

• Differential diagnosis of cholestatic jaundice;1-3 liver metastases, primary biliary

cirrhosis

• Algorithmic approach to investigating LFT abnormalities1

1. McFarlane I, Bomford A & Sherwood R. Liver Disease & Laboratory Medicine. Eds

McCreanor G, Marshall W. ACB Venture Publications 2000.

2. Green RM, Flamm S. AGA Technical Review on the Evaluation of Liver Chemistry

Tests. Gastroenterology 2002;123:1367-84.

3. Pratt DS. Approach to the patient with abnormal liver function tests UpToDate 2002

www.uptodate.com

4. Lee WM. Drug-Induced Hepatotoxicity. NEJM 2003,349:474-85

5. Sanjal AJ. American Gastroenterological Association. AGA technical review on

nonalcoholic fatty liver. Gastroenterology 2002;123:1705-25.

6. Harraway JR, George PM. Use of fully denaturing HPLC for UGT1A1 genotyping in

Gilbert syndrome. Clin Chem 2005; 51(11):2183-5.

http://www.healthservices.gov.bc.ca/msp/protoguides/gps/vihep.pdf

http://www.uptodate.com/


(k) Lipids

• Lipoprotein metabolism;1 Friedewald equation, Apo-proteins

• Methodologies of lipid and apolipoprotein measurement1

• Pathophysiology of hyperlipidaemia:1 Type III hyperlipidaemia & apo-E genotyping.1

Familial Combined Hyperlipidaemia.1 Low HDL-C.1 Secondary hyperlipidaemia.1

Hypertriglyceridaemia and lipoprotein lipase deficiency1

• Familial Hypercholesterolaemia; LDL receptor genotyping.2 Defective apo-B1

• Low cholesterol – abetalipoproteinaemia versus hypo-betalipoproteinaemia1,3

• Role and mechanism of action of lipid-lowering drugs including statins, fibrates and

bile-acid sequestrant resins4

• Awareness of landmark lipid lowering trials – eg Heart Protection Study5

• Cardiovascular Risk Assessment and Management:

http://www.heartfoundation.com.au/downloads/Lipids_HLCPosStatementFINAL_2005

.pdf (Australian Guidelines)

• http://www.nzgg.org.nz/guidelines/0035/CVD_Risk_Full.pdf (NZ Guidelines)

1. Rifai N, Warnick GR. Lipids, Lipoproteins, Apolipoproteins and Other Cardiovascular

Risk Factors. In Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th

Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 26: 903-81.

2. Laurie AD, Scott RS, George PM. Genetic screening of patients with familial

hypercholesterolaemia (FH): a New Zealand perspective. Atherosclerosis

Supplements 2004; 5(5): 13-15.

3. Rader DJ, Brewer B. Abetalipoproteinaemia; New Insights into Lipoprotein Assembly

and Vitamin E Metabolism from a Rare Genetic Disease. JAMA 1993; 270(7): 865-9.

4. Stocks N, Allan J, Mansfield PR. Management of hyperlipidaemia. Aust Family

Physician 2005; 34(6): 447-53.

5. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536

high-risk individuals: a randomised placebo-controlled trial.

Lancet 2002; 360(9326): 7-22.

http://www.heartfoundation.com.au/downloads/Lipids_HLCPosStatementFINAL_2005.pdf

http://www.heartfoundation.com.au/downloads/Lipids_HLCPosStatementFINAL_2005.pdf

http://www.nzgg.org.nz/guidelines/0035/CVD_Risk_Full.pdf


(l) (Other) Cardiovascular Risk Factors

• Cardiovascular Risk Assessment – see lipids

• Lipoprotein (a) – biology and role in atherogenic risk1

• Homocysteine – pathophysiology and link to adverse vascular outcomes1,2

• Homocysteine – recent vitamin intervention studies3

• High sensitivity CRP and other inflammatory markers – inflammatory hypothesis and

critique1,4

• Apoprotein B and LDL particle size5

1. Rifai N, Warnick GR. Lipids, Lipoproteins, Apolipoproteins and Other Cardiovascular

Risk Factors. In Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th

Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 26: 903-81.

2. Stein JH, McBride PE. Hyperhomocysteinaemia and Atherosclerotic Vascular

Disease. Arch Intern Med 1998; 158: 1301-6.

3. Loscalzo J. Homocysteine Trials – Clear Outcomes for Complex Reasons. N Engl J

Med 2006; 354: 1629-32 (Editorial on related articles).

4. Sattar N, Lowe GD. High sensitivity C-reactive protein and cardiovascular disease:

an association built on unstable foundations? Ann Clin Biochem 2006; 43: 252-6.

5. Griffin BA, Furlonger N, Iversen A. Plasma apolipoprotein(b) to LDL cholesterol ratio

as a marker of small, dense, LDL. Ann Clin Biochem 2000; 37: 537-9.


(m) Troponins

• Circulating troponin forms. Troponin I and T-differences1

• Assay formats, standardisation and harmonisation2

• Time course of troponin elevation1

• Assay imprecision, cut-off levels and definition of acute Myocardial Infarction3

• Risk of marginally elevated troponin levels4

• Troponins in renal failure4

• Causes of troponin elevation other than Acute Coronary Syndrome4,5

• Performance evaluation, heterophilic antibodies and false results6

• Awareness of alternative markers: ischaemia-modified albumin, H-FABP7

1. Naidoo D. Biochemical markers of coronary heart disease. Pathology 2001; 33: 329-

37.

2. Panteghini M. Current concepts in standardization of cardiac marker immunoassays.

Clin Chem Lab Med 2004; 42(1): 3-8.

3. The Joint European Society of Cardiology/American College of Cardiology

Committee. Myocardial infarction redefined – a consensus document: Eur Heart J

2000; 36: 959-69.

4. Korff S, Katus HA, Giannitsis E. Differential diagnosis of elevated troponins. Heart

2006; 92: 987-993.

5. Ammann P, Pfisterer M, Fehr T, Rickli H. Raised cardiac troponins. Causes extend

beyond acute coronary syndromes. BMJ 2004; 328: 1028-9.

6. Lam Q, Black M, Youdell O, Spilsbury H, Schneider Hg. Performance evaluation and

subsequent clinical experience with the Abbott Automated Architect STAT Troponin-I

assay. Clin Chem 2006; 52(2): 298-300.

7. Apple FS, Wu AH, Mair J et al. Future biomarkers for detection of ischaemia and risk

stratification in acute coronary syndrome. Clin Chem 2005; 51(5): 810-24.


(n) Natriuretic Peptides

• Circulating forms of natriuretic peptides; ANP, BNP, NT-BNP, CNP1

• Synthesis, physiology and metabolism of natriuretic peptides1

• Assays for natriuretic peptides and quality specifications2

• Circulating levels of BNP, NT-BNP; effects of age, renal function3

• Natriuretic peptides in the differential diagnosis of dyspnoeic patients4,5

• Natriuretic peptides and monitoring of anti heart-failure therapy6

• Biological variation of natriuretic peptides and implications for clinical use7

1. Yandle TG, Nichollls MG, Richards AM. Brain Natriuretic Peptide – its function and

diagnostic application. Clin Biochemist Rev 2002; 23: 3-20.

2. Apple FS, Panteghini M, Ravkilde J et al. Quality specifications for B-type natriuretic

peptide assays. Clin Chem 2005; 51(7): 1307-9.

3. Richards M, Nicholls MG, Espiner EA et al. Comparison of B-Type Natriuretic

Peptides for Assessment of Cardiac Function and Prognosis in Stable Ischemic Heart

Disease. Journal Am College Cardiology 2006; 47: 52-60.

4. Mueller C, Scholer A, Laule-Kilian K et al. Use of B-type natriuretic peptide in the

evaluation and management of acute dyspnoea. New England Journal of Medicine

2004; 350: 647-54.

5. Wright SP, Dought RN, Pearl A et al. Plasma amino-terminal pro-brain natriuretic

peptide and accuracy of heart-failure diagnosis in primary care: a randomized,

controlled trial. J Am Coll Cardiol. 2003 Nov 19;42(10):1793-800.

6. Troughton RW, Frampton C, Yandle TG, Espiner EA, Nicholls MG, Richards AM.

Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide

(N-BNP) concentrations. Lancet 2000; 355: 1126-30.

7. Bruins S, Fokkema MR, Romer JWP et al. High intraindividual variation of B-type

natriuretic peptide (BNP) and amino-terminal pro-BNP in patients with stable chronic

heart failure. Clin Chem 2004; 50(11): 2052-58.


(o) Calcium, Phosphate, Magnesium, PTH and Bone Markers

• Forms of calcium in plasma1,2

• Calcium, phosphate and magnesium homeostasis1,2

• PTH – structure, actions and secretion1,2 • Vitamin D – structure, actions and secretion1,2,6

• Optimal target level, replacement strategies (FAACB)

• Measurement of calcium, phosphate, magnesium and PTH2

• Clinical disorders – Hypercalemia, hypocalcemia, hyper- and hypophosphatemia,

hyper- and hypomagnesaemia1,2,7, low vitamin D

• Bone remodelling and its regulation, bone disorders3,4

• Biochemical bone turnover markers2,5

• Assays for PTH and Vitamin D

1. Willams Textbook of Endocrinology 9th or later edition. Chapter 24: Mineral

metabolism.

2. Tietz Textbook of Clinical Chemistry 3rd or later edition. Chapter 39: Mineral and bone

metabolism.

3. Willams Textbook of Endocrinology 9th or later edition. Chapter 25: Metabolic bone

disease.

4. Khosla S. The OPG/RANK/RANKL system (review). Endocrinology 2001;142:5050-5.

5. Rosen HN. Biochemical markers of bone turnover: clinical utility. Curr Opin

Endocrinol Diabetes 2003; 10:387-93.

6. Hickey & Gordon. Vitamin D deficiency: new perspectives on an old disease. Curr

Opin Endocrinol Diabetes 2004; 11:18-25

7. Gaasbeek A and Meinders AE. Hypophosphatemia: an update on its etiology and

treatment. Am J Med 2005; 118:1094-1101


(p) Iron Studies and Haemoglobin

• Overview of iron metabolism and regulation of iron status1,2,3

• Pathophysiology of iron deficiency; Laboratory investigation of iron deficiency1,2

Ferritin ranges. Role of soluble transferring receptors (StFR)1,4

• Iron overload syndromes. Investigation of genetic haemochromatosis and non-HFE

hereditary iron overload syndromes2,5

• Pathophysiology and diagnosis of Thalassaemia, Sickle cell Disease.2 Awareness of

other Haemoglobinopathies and strategy for investigation (FAACB)

1. Siah CW, Ombiga J, Adams LA, Trinder D, Olynk JK. Normal Iron Metabolism and

the Pathophysiology of Iron Overload Disorders. Clin Biochem Revs 2006; 27(i): 5-

16.

2. Higgins T, Beutler E, Doumas BT. Hemoglobin, Iron and Bilirubin. In Tietz Textbook


Bruns DE. 2006. Chapter 31: 1165-1208.

3. Fleming RE, Bacon BR. Orchestration of Iron Homeostasis. N Engl J Med 2005;

352(17): 1741-4.

4. Beguin Y. Soluble transferrin receptor for the evaluation of erythropoiesis and iron

status. Clinica Chimica Acta 2003; 329: 9-22.

5. Pietrangelo A. Non-HFE hemochromatosis. Hepatology 2004; 39(1): 21-9.


(q) Pituitary Function

• Physiology – anterior and posterior pituitary function1-3

• Clinical features of hypopituitarism and investigation1-3

• Growth Hormone1-3 excess and deficiency in children and adults. Protocols for

investigation of Growth Hormone deficiency.2 Insulin-like growth factors2

• Growth Hormone assays, units and standardisation4

• Hyperprolactinaemia and infertility – see infertility section

• Macroprolactinaemia – significance and investigation2,5

• ADH deficiency and diabetes insipidus – see salt and water balance section

1. Demers LM. General Endocrinology in Clinical Chemistry: Theory, Analysis and


809-26.

2. Demers LM and Vance ML. Pituitary Function in Tietz Textbook of Clinical Chemistry

and Molecular Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter

50: 1967-2002.


225-30.

4. Wood P. Growth hormone: its measurement and the need for assay harmonization.

Ann Clin Biochem 2001; 38: 471-82.

5. Sadideen H, Swaminathan R. Macroprolactin: what is it and what is its importance?

Int J Clin Pract. 2006 Apr;60(4):457-61.


(r) Thyroid Function

• Biochemistry and physiology of thyroid hormone production and function1,2

• Measurement of thyroid hormones (including rationale of free thyroid hormone

measurement) and thyroid stimulating hormone (TSH)2,3

• Pathology and treatment of primary and secondary thyroid gland diseases2,4,5

• Interpretation of thyroid function tests in treated and non-treated thyroid disorders2,4,5

Interpretation of thyroid function tests in pregnancy6,7

• Effects of drugs on thyroid function and thyroid function tests1,2,5,7

• Thyroid function test interferences1,2,5,7

• Causes and management of discrepant thyroid function test results1,2,5,7

• Awareness of associated assays and their use in thyroid disease including

thyroglobulin, thyroid autoantibodies and TSH receptor antibodies1,2,7

• Screening for neonatal hypothyroidism1,6,7

1. National Academy of Clinical Biochemistry. Laboratory medicine practice guidelines.

Laboratory support for the diagnosis of thyroid disease Thyroid 2003; 13;1-126 and

www.nacb.org/lmpg/thyroid

2. Stockigt J. Assessment of thyroid function: Towards an integrated Laboratory –

Clinical Approach. Clin Biochem Rev 2003; 24;109-122.

3. Midgley JE. Direct and Indirect Free Thyroxine Assay Methods: Theory and Practice.

Clinical Chemistry 2001; 47(8): 1353–1363.

4. Pearce E. Diagnosis and management of thyrotoxicosis BMJ 2006;332;1369-73.

5. Dayan C. Interpretation of thyroid function tests. Lancet 2001; 357: 619–24.

6. Haddow JE et al, Maternal thyroid deficiency during pregnancy and subsequent

neuropsychological development of the child. N Engl J Med 1999; 341: 549-55.

7. http://www.thyroidmanager.org/

(Very comprehensive site with detailed clinical and laboratory information).

http://www.nacb.org/lmpg/thyroid

http://www.thyroidmanager.org/


(s) Adrenal Function

• Cortex versus medulla - steroid and catecholamine pathways1-3

• Congenital adrenal hyperplasia – pathophysiology and investigation1,2

• Adreno-cortical hypofunction (“Addison’s disease”)1,2

• Cushing’s syndrome1,2 – pathophysiology, differential diagnosis, screening tests and

further investigation

• Hyperaldosteronism1,2 – approach to investigation; renin and aldosterone

• Adrenal tumours1,2 – role of DHEA-S

• Analytical methodologies for adrenocortical hormones2

• Phaeochromocytoma1,3,4 – clinical features, investigation, including role of urine

catecholamines, plasma metanephrines. Suppression tests

• Hereditary phaeochromocytoma syndromes and role of genetic testing – eg von

Hippel-Lindau, MEN2 (FAACB)


129-46.

2. Demers J. The Adrenal Cortex. in Tietz Textbook of Clinical Chemistry and Molecular

Diagnostics. 4th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 51: 2003-

2052.

3. Rosano T, Eisenhofer G, Whitley RJ in Tietz Textbook of Clinical Chemistry and


1033-1074.

4. Lenders JWM, Eisenhofer G, Mannelli M, Pacak K. Phaeochromocytoma. Lancet

2005; 366: 665-675.


(t) Fertility, Menopause and Polycystic Ovary Syndrome (PCOS)

• Menstrual cycle1 – day-21 progesterone1,2 and ovulation prediction

• Definition3 and strategy for investigation of infertility1,4

• Amenorrhoea;1,2 Hypothalamic and pituitary causes of infertility, investigation of

hyperprolactinaemia, primary ovarian failure

• Hypogonadism in the male5

• Delayed puberty (FAACB)

• Polycystic Ovary Syndrome (PCOS)6 – definition, investigation and differential

diagnosis from other causes of hyperandrogenism

• Problems with testosterone measurement in the female7,8

• Clinical Chemistry of the Menopause – role of FSH measurement9

• Gynaecomastia – differential diagnosis and investigation10 (FAACB)


109-27 and 161-73.

2. Hamilton-Fairley D, Taylor A. ABC of subfertility. Anovulation. BMJ 2003; 327: 546-9.

3. Taylor A. ABC of subfertility. Extent of the problem. BMJ 2003; 327: 434-6.

4. Taylor A. ABC of subfertility. Making a diagnosis. BMJ 2003; 327: 494-7.

5. Hirsh A. ABC of subfertility. Male subfertility. BMJ 2003; 327: 669-72.

6. Fraser IS, Kovacs G. Current recommendations for the diagnostic evaluation and

follow-up of patients presenting with symptomatic polycystic ovary syndrome. Best

Practice & Research Clinical Obstetrics & Gynaecology 2004; 18(5): 813-23.

7. Herold DA, Fitzgerald RL. Immunoassays for testosterone in women: better than a

guess? Clin Chem 2003; 49(8): 1250-1.

8. Kane J, Middle J, Cawood M. Measurement of serum testosterone in women; what

should we do.? Ann Clin Biochem 2007;44:5-15.

9. Gow SE, Turner EI, Glasier A. The clinical biochemistry of the menopause and

hormone replacement therapy. Ann Clin Biochem 1994; 31(6): 509-28.

10. Ismail AA, Barth JH. Endocrinology of gynaecomastia. Ann Clin Biochem 2001; 38(6):

596-607.


(u) Pregnancy

• HCG and diagnosis of pregnancy1 - methodological aspects, recognition and

management of false positives.1 Gestational Trophoblastic Neoplasia

http://www.hcglab.com/sources.htm

• Awareness of altered reference ranges in pregnancy2 – eg albumin, ALP, lipids,

TBG/CBG/SHBG, Cortisol, PTH, prolactin, DHEAS, oestrogens, LH/FSH

• Glucose intolerance in pregnancy & gestational diabetes – see Diabetes Mellitus

• LFTs in pregnancy – HELLP,2,3 Obstetric Cholestasis and role of bile acids2,4,5

(FAACB)

• Thyroid hormone changes and thyroid disease in pregnancy.6

www.thyroidmanager.org Iodine deficiency7

• Antenatal serum screening for Down syndrome and neural tube defects – hCG, alpha

fetoprotein, unconjugated oestriol, PAPP-A8

• Fetal fibronectin and role in the detection of premature labour9 (FAACB)

1. Davies S, Byrn F, Cole LA. Human chorionic gonadotropin testing for early pregnancy

viability and complications. Clin Lab Med 2003; 23(2):257-64.

2. Ashwood ER, Knight GJ. Clinical Chemistry of Pregnancy in Tietz textbook of Clinical

Chemistry and Molecular Diagnostics. Burtis CA, Ashwood ER, Bruns DE (Eds).

Elsevier Saunders, Missouri, 2006; Chapter 54; Pages 2153-2206.

3. Geary M. The Hellp syndrome. B J Obst Gynaecol. 1997; 104: 887-91.

4. Riely CA. Hepatic Disease in Pregnancy. Am J Med 1994; 96(1A): 18S-22S.

5. Walker IA et al. Role of bile acid measurement in pregnancy. Ann Clin Biochem 2002;

39: 105-13.

6. Alexander EK et al. Timing and magnitude of increases in levothyroxine requirements

during pregnancy in women with hypothyroidism. N Engl J Med 2004; 351: 241-9.

7. Laurberg P, Nohr SB. Iodine intake and prevention of thyroid disorders (Edit). Med J

Austr; 176: 306-7.

8. Holding S, Current state of screening for Down’s syndrome. Ann Clin Biochem 2002;

39: 1-11.

9. Honest H et al. Accuracy of cervical vaginal fetal fibronectin test in predicting risk of

spontaneous preterm birth: systematic review. BMJ 2002; 325: 301.

http://www.hcglab.com/sources.htm

http://www.thyroidmanager.org/


(v) Nutrition

• Digestion & absorption;2,3 macronutrients; proteins, carbohydrates, lipids2,3

• Essential trace elements and vitamins.2 Syndromes of deficiency and excess1,2,4

• Biochemistry of malnutrition and starvation.1,3,4,8 Malnutrition as a risk factor in

disease.8,9 Prevalence of malnutrition in community and hospital patients6,9 (FAACB)

• Nutritional aspects of disease4,8 – renal failure, COPD, liver disease, burns, stroke,

cancers, surgery, inflammatory bowel disease, short bowel, sepsis (FAACB)

• Nutritional Support4,5,8 – indications, complications, role of the laboratory

• Assessment of nutritional status1,8,9 – biochemical markers1,8

• Clinical and biochemical features of the refeeding syndrome8

• Nutritional aspects of diabetes mellitus and lipid disorders7

• Obesity – risks, complications of, investigation, management10

1. Clinical Biochemistry – Metabolic and clinical aspects (1995). Marshall WJ and

Bangert SK eds. Churchill Livingstone, New York.

2. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics 4th ed. (2006) Burtis

CA, Ashwood ER and Bruns DE eds. Elsevier Saunders, St Louis.

3. Review of Medical Physiology 20th ed. (2001) Ganong WF McGraw Hill, New York.

4. Oxford Textbook of Medicine 3rd ed. Vol. 1 (1996) Weatherall DJ, Ledingham JGG

and Warrell DA eds. Oxford University Press, Oxford.

5. Total parenteral nutrition: potion or poison? Jeejeebhoy KN. Am J Clin Nutr 2001

74(2):160-3.

6. Incidence and recognition of malnutrition in hospital. McWhirter JP, Pennington CR.

BMJ 1994;308:945-948 (9 April)

7. The Assessment and Management of Cardiovascular Risk. New Zealand Guideline

Group (2003).

8. Artificial Nutrition Support in Clinical Practice 2nd ed. (2001). Payne-James J, Grimble

GK and Silk DBA eds. Cambridge University Press, Cambridge.

9. Malnutrition: etiology, consequences, and assessment of a patient at risk. Alberda C,

Graf A and, McCargar L. Best Pract Res Clin Gastroenterol. 2006;20(3):419-39 +

other reviews in this series.

10. Clinical Obesity (1999) Kopelman PG and Stock MJ eds. Blackwell Science Oxford.


(w) General Paediatric Clinical Chemistry

• Sample requirements.1 Paediatric reference ranges2

• Neonatal jaundice – differential diagnosis and investigation3

• Genital ambiguity,4 congenital adrenal hyperplasia5

• Precocious puberty6 (FAACB)

• Performance of sweat test, interpretation and diagnosis of cystic fibrosis7

http://www.aacb.asn.au/files/File/Guidelines_for_sweat.test_2006.pdf

• Investigation of neuroblastoma – role of VMA, HVA8

• Growth retardation and growth hormone deficiency9

• Delayed puberty6 (FAACB)

• Differential diagnosis of proteinuria in childhood – see urine chemistry section

• Differential diagnosis and investigation of hypoglycaemia in children10

• Disorders of calcium metabolism in childhood11 - also see calcium section

1. Soldin SJ, Rifai N, Hicks JMB. Biochemical Basis of Pediatric Disease, 2nd Ed, 1995.

AACC Press, USA.

2. Soldin SJ, Brugnara C, Wong EC. Pediatric Reference Intervals, 5th Ed, 2005. AACC

Press, USA.

3. Denny PA, Seidman DS, Stevenson OK. Neonatal hyperbilirubinaemia. New Engl J

Med 2001: 344; 581-90.

4. McLaughlin DT, Donahoe PK. Sex Determination and Differentiation. N Engl J Med

2004; 350: 367-78.

5. Merke DP, Bornstein SR. Congenital Adrenal Hyperplasia. Lancet 2205; 365: 2125-

36.

6. Traggiai C, Stanhope R. Disorders of pubertal development. Best Practice &

Research Clinical Obstetrics and Gynaecology 2003: 17; 41-56.

7. Stern RC. The diagnosis of cystic fibrosis. N Engl J Med 1997; 336: 487-91.

8. Brodeur GM et al. Biology and genetics of human neuroblastomas. J Pediatr Hematol

Oncol 1997; 19: 93-101.

9. Dattani M, Preece M. Growth hormone deficiency and related disorders: insights into

causation, diagnosis and treatment. Lancet 2004: 363; 1977-87.

10. Neonatology & Laboratory Medicine. Green A, Morgan I, Gray J. ACB Venture

Publications 2003. Eds Harris B, Marshall W.

11. Singh J et al. The investigation of hypocalcaemia and rickets. Arch Dis Child 2003;

88: 403-7.

http://www.aacb.asn.au/files/File/Guidelines_for_sweat.test_2006.pdf


(x) Inborn Errors of Metabolism (IEM)

• Scope of IEM, classification and general approach to diagnosis1

• Neonatal screening programmes (www.moh.govt.nz/nationalscreeningunit) –

rationale and efficacy2,3

• PKU, Galactosaemia, Maple Syrup Urine Disease, MCAD deficiency, Urea Cycle

Disorders, Cystic Fibrosis, Congenital Hypothyroidism, Glycogen Storage Diseases

(MAACB)

• Distinction between, and investigation of aminoacidopathies, organic acidopathies,

keto-lactate acidosis, fatty acid oxidation and carnitine cycle disorders, carbohydrate

and glycosylation disorders, urea cycle disorders (with investigation of

hyperammonaemia), lysosomal storage disorders, peroxisomal disorders and

respiratory chain disorders1,4-6 (It is appropriate to know the different classes of

disease and how they are discriminated, without knowing individual diseases)

(FAACB)

• IEM – methodological aspects:6 urine and plasma aminoacid chromatography, urine

organic acid GC-MS, tandem MS (especially of blood spots), MPS and

oligosaccharide electrophoresis, transferrin isoelectric focusing, enzyme analysis,

mutation analysis (see analytical chemistry sections for more detail)



2. Chase DH et al. Use of tandem mass spectrometry for multianalyte screening of dried

blood specimens from newborns. Clin Chem 2003; 49: 1797-1817.

3. Wilcken B et al. Screening newborns for inborn errors of metabolism by tandem mass

spectrometry. N Engl J Med 2003; 348: 2304-12.

4. Fernandes J, Saudubray J-M, Van den Burghe G (Eds). Inborn Metabolic Diseases

(3rd Ed) 2000; Springer: Berlin.

5. Scriver CR, Beaudet AL, Sly WS, Valle D (Eds). The Metabolic and Molecular Basis

of Inherited Disease. McGraw Hill Companies Inc, New York; 2001. (definitive

reference for coverage of specific disorders)

6. Rinaldo P, Hahn S, Matern D. Inborn Errors of Amino Acid, Organic Acid and fatty

Acid Metabolism in Tietz textbook of Clinical Chemistry and Molecular Diagnostics.

Burtis CA, Ashwood ER, Bruns DE (Eds). Elsevier Saunders, Missouri, 2006.

Chapter 55; Pages 2207-2247.


(y) Porphyria

• Haem metabolism and concepts of pathway1-3

• Pathophysiology of AIP, VP, HCP, EPP, PCT1-3

• Clinical scenarios and strategies for investigation1-3

• Urine PBG, urine and faecal porphyrins. HPLC profiling1-3

• Differential diagnosis of porphyrinuria1-3

• Differential diagnosis of elevated blood porphyrins1-3

• Role of fluorescence emission scanning of plasma1-4

• Mutational analysis and its place in family screening1,2,5 (FAACB)

1. Deacon AC, Whatley SD, Elder GH. Porphyrins and Disorders of Porphyrin

Metabolism in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th Ed.

Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 32: 1209-35.

2. Sies C, Florkowski C, George P, Potter H. Clinical indications for the investigation of

porphyria: case examples and evolving laboratory approaches to its diagnosis in New

Zealand. New Zealand Medical Journal 2005; 118: 1222 (September 16 2005).

3. Ratnaike S, Blake D. The diagnosis and follow up of porphyria. Pathology 1995; 27:

142-53.

4. Hift RJ, Davidson BP, van der Hooft C, et al. Plasma fluorescence scanning and fecal

porphyrin analysis for the diagnosis of variegate porphyria: precise determination of

sensitivity and specificity with detection of protoporphyrinogen oxidase mutations as

standard. Clin Chem. 2004;50:915–23.

5. Whatley SD, Puy H, Morgan RR, et al. Variegate porphyria in Western Europe:

identification of PPOX gene mutations in 104 families, extent of allelic heterogeneity,

and absence of correlation between phenotype and type of mutation. A J Hum Genet.

1999;65:984–94.


(z) Urine Analysis

• Renal function; mechanisms of proteinuria - glomerular vs tubular1,2

• Analytical methods for urine protein measurement2,3 and quality standards4

• Reagent-strip measurement – principles, false positives and negatives5

http://www.diaglab.vet.cornell.edu/clinpath/modules/ua-rout/protstix.htm

• Pathogenesis and differential diagnosis of proteinuria2,6

• Microalbuminuria;3,7 prediction of diabetic nephropathy – see diabetes section

• Pre-eclampsia and albumin/creatinine ratio8

• Urinary electrolytes & osmolality: interpretation in context of hyponatraemia,

hypokalaemia and acid-base disorders - see other clinical sections

• Calcium, uric acid

• Bence-Jones Proteins; electrophoresis, urinary concentration devices, multiple

myeloma, MGUS - see section on proteins in health and disease

1. Marshall W J. Clinical Chemistry, Chapter 4, The kidneys, 4th edition 2000. Harcourts

Publication Limited.

2. Burtis, Ashwood and Bruns. Tietz Textbook of Clinical Chemistry and Molecular

diagnosis, Chapters 24, 45 and 20, 4th edition 2006. Elsevier Saunders.

3. Peters T. How should we measure the Albumin in Urine? Clin Chem 2006; 52(4):

555-6.

4. Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, Parrott M.

Guidelines and recommendations for laboratory analysis in the diagnosis and

management of diabetes mellitus. Clin Chem 2002; 48(3): 436-72.

5. Simerville JA, Maxted WC, Pahira J. Urinalysis: A Comprehensive Review. American

Family Physician 2005;71:1153-62.

6. Carroll MF, Temte JL. Proteinuria in Adults: A Diagnostic Approach. American Family

Physician 2000;762:1333-40.

7. Ruggenebti P, Remuzzi G. Time to abandon microalbuminuria? Kidney International

2006;70:1214-22.

8. Price C P, Newall RG and Boyd J C. Use of Creatinine:Protein Ratio Measurements

on Random Urine samples for Prediction of Significant Proteinuria: A Systematic

Review. Clin Chem 2005;51(9):1577-86.

http://www.diaglab.vet.cornell.edu/clinpath/modules/ua-rout/protstix.htm


(aa) Cerebrospinal Fluid (CSF) Analysis

• Formation and circulation of CSF1

• CSF glucose, protein and lactate analysis1

• Awareness of other CSF analytes; eg neopterin, NSE1

• Subarachnoid haemorrhage – clinical features and diagnosis2

• Scanning spectrophotometry and interpretation3

• CSF bilirubin as an alternative to spectrophotometry4

1. Watson MA, Scott MG. Clinical utility of analysis of cerebrospinal fluid. Clin Chem

1995; 41(3): 343-60.

2. Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid

haemorrhage. NEJM 2000; 342(1): 29-36.

3. UK National External Quality Assessment Scheme for Immunochemistry Working

Group. National guidelines for analysis of cerebrospinal fluid for bilirubin in

suspected subarachnoid haemorrhage. Ann Clin Biochem 2003; 40: 481-8.

4. Ungerer JPJ, Southby SJ, Florkowski CM, George PM. Measurement of

Cerebrospinal Fluid Bilirubin in Suspected Subarachnoid Hemorrhage. Clinical

Chemistry 2004; 50(10): 1854-6.


(bb) Amniotic Fluid Analysis

• Formation and composition of amniotic fluid1

• ΔA 450 and amniotic fluid bilirubin1,2 – rhesus isoimmunization

• Amniocentesis:1 risks and benefits, applications of analyses – AFP, cholinesterase,

amniocyte culture/prenatal diagnosis

• Amniocentesis versus chorionic villus sampling1 - see pre-natal diagnosis section

• Awareness of evaluation of fetal lung maturity - L/S ratio1,2

1. Ashwood ER, Knight GJ. Clinical Chemistry of Pregnancy in Tietz textbook of Clinical

Chemistry and Molecular Diagnostics. Burtis CA, Ashwood ER, Bruns DE (Eds).

Elsevier Saunders, Missouri, 2006; Chapter 54; Pages 2153-2206.




(cc) Pleural Fluid Analysis

• Pleural fluid formation1

• Transudate versus exudate.1 Light’s criteria2

• Triglycerides. Recognition of chylous effusion1

• Value of other analytes: amylase, tumour markers1

1. Tarn AC, Lapworth R. Biochemical analysis of pleural fluid: what should we measure?

Ann Clin Biochem 2001; 38: 311-322.

2. Light RW, MacGregor MI, Luchsinger PC, Ball WC. Pleural effusions: the diagnostic

separation of transudates and exudates. Ann Intern med 1972; 77: 507-13.


(dd) Tumour Markers

• Nature of tumour markers – relation to tumour biology, ideal properties and

appropriate use in detection and monitoring of malignancy1-7

• Measurement and clinical utility of specific tumour markers;1-7 AFP, CEA, CA 19-9,

CA-125, CA 15-3, HCG. CA15-3 and breast cancer.7 AFP and hepatocellular

carcinoma.9 CA-125 and screening for ovarian cancer10

• 5-HT, 5-HIAA, chromogranin A and carcinoid syndrome1,8

• PSA including interpretation; free PSA, age-specific ranges, screening.

http://www.moh.govt.nz/moh.nsf/wpg_index/About-National+Screening+Unit+-

+Prostate+Cancer 1,11,12

• HER-2, prognosis and guiding of therapy in breast cancer1

• Phaeochromocytoma – see Adrenal Gland

• Multiple myeloma – see section on Proteins in health and Disease

• Neuroblastoma and VMA – see General Paediatric Clinical Chemistry

• Susceptibility genes and monitoring – see Genetics and Molecular Oncology

1. Chan DW, Booth RA, Diamandis EP. Tumor Markers. In Tietz Textbook of Clinical


Elsevier Saunders 2006. Chapter 23: pages 745-795.

2. Duffy MJ. Evidence for the clinical use of tumour markers. Ann Clin Biochem 2004;

41(5):370-7.

3. Pannall P, Kotasek D. Cancer & Clinical Biochemistry. Eds McCreanor G, Marshall

W. ACB Venture Publications 1997.

4. McGinley PJ, Kilpatrick ES. Tumour markers: their use and misuse by clinicians. Ann

Clin Biochem 2003; 40(6):643-7.

5. Bast RC, Ravdin P, Hayes DF et al. 2000 Update of recommendations for the use of

tumor markers in breast and colorectal cancer: Clinical practice guidelines of the

American Society of Clinical Oncology. J Clin Oncology 2001; 19: 1865-1878.

6. Barratt A. Cancer screening. Benefits, harms and making an informed choice. Aust

Fam Physician 2006; 35: 39-42.

7. Duffy MJ. Ca15-3 and related mucins as circulating markers in breast cancer. Ann

Clin Biochem 1999; 36: 579-586.

8. Lips CJM, Lentjes EGWM, Hoppener JWM. The spectrum of carcinoid tumours and

carcinoid syndromes. Ann Clin Biochem 2003; 40: 612-27.

http://www.moh.govt.nz/moh.nsf/wpg_index/About-National+Screening+Unit+-+Prostate+Cancer

http://www.moh.govt.nz/moh.nsf/wpg_index/About-National+Screening+Unit+-+Prostate+Cancer


9. Gupta S, Bent S, Kohlwes J. Test characteristics of alpha-fetoprotein for detecting

hepatocellular in patients with hepatitis C. Ann Int Med 2003; 139: 46-50.

10. Quinn MA. Screening for ovarian cancer. Aust Fam Physician 2001; 30: 530-534.

11. Sikaris KA. Prostate specific antigen. Clin Biochem Rev 1996; 17: 50-68.

12. Hernandez J, Thompson IM. Prostate specific antigen: A review of the validation of

the most commonly used cancer biomarker. Cancer 2004; 101: 894-904.


(ee) Serology and Autoimmunity

• The immune response;1 antibody classes and complement2

• Acute hepatitis – serological changes and interpretation2,3 - see LFTs

• Antinuclear factor, rheumatoid factor, anti-CCP and autoantibodies4,8

• Anaphylaxis – mast cell tryptase5 and C1 esterase inhibitor deficiency6 (FAACB)

• Classification and investigation of Immunodeficiency7 see Proteins section (FAACB)

• Islet cell antibodies, anti-GAD and diabetes – see Diabetes Mellitus section

• Anti-gliadin, TTG, EMA and coeliac disease – see Gastro-Intestinal section

1. Chaplin D D. Overview of the immune response J Allergy Clin Immunol.

2006:117(2):S430-S435

2. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. Chapter 47. 4th Ed.

Burtis CA, Ashwood ER, Bruns DE. 2006.

3. Dufour, Lott, Nolte et el. NACB: Laboratory guidelines for Screening, Diagnosis and

Monitoring of Hepatic Injury. 2000. http://www.aacc.org/NR/rdonlyres/AFC5E191-

9354-409B-99B2-3FA1EEB675E6/0/3_hepatic_Hepatitis.pdf

4. Miles J, Charles P, Riches P. A review of methods available for the identification of

both organ-specific and non-organ-specific autoantibodies. Ann Clin Biochem 1998;

35: 19-47

5. Payne V and Kam P C A. Mast cell tryptase: a review of its pathology and clinical

significance. Anaesthesia, 2004; 59:695-703

6. Gompels M M, Lock J R, Abinun M et al. C1 inhibitor deficiency: consensus

document. Clinical and Experimental Immunology, 2005; 139:379-394

7. Etzioni A. Immunodeficiency and Autoimmunity. Autoimmunity Reviews 2003; 2:364-

369

http://www.aacc.org/NR/rdonlyres/AFC5E191-9354-409B-99B2-3FA1EEB675E6/0/3_hepatic_Hepatitis.pdf

http://www.aacc.org/NR/rdonlyres/AFC5E191-9354-409B-99B2-3FA1EEB675E6/0/3_hepatic_Hepatitis.pdf


(ff) Renal Calculi

• Epidemiology1

• Composition of stones1,2

• Theories of stone formation1,3,4

• Types of renal stone1

• Evaluation and prophylaxis5

• Analysis of renal calculi6

1. Moe OW. Kidney stones: pathophysiology and medical management. Lancet

2006;367:333-343.

2. Teichman JMH. Acute renal colic from ureteral calculus. NEJM 2004;350:684-693.

3. Ryall RL. The formation and investigation of urinary calculi. Clin Biochem Rev

1989;10:149-157.

4. Pak CYC. Kidney Stones. Lancet 1998;351:1797-801.

5. Wilkinson H. Clinical investigation and management of patients with renal stones.

Ann Clin Biochem 2001;38:180-187.

6. Kasidas GP, Samuell CT, Weir TB. Renal stone analysis: why and how? Ann Clin

Biochem 2004;41:91-97.



(a) Nucleic Acid Extraction; Strategies for Mutation Detection

• DNA and RNA extraction and purification.1 Principles of PCR2

• Spectrum of genetic variation.1,2 Mutations versus polymorphisms.2 Nomenclature

and variants: http://www.hgvs.org/mutnomen/ (Human Genome Variation Society)

• Restriction enzyme analysis and RFLPs2,3 ARMS, OLA, ASO hybridisation assays,

DGGE, DHPLC and other strategies2,3 (FAACB)

• Homogenous assays:3 5’ fluorogenic nuclease (TaqMan); principles and applications

of melting curve analysis2-4

• Principles of dideoxy-sequencing (Sanger) and applications2

• Applications of plasma DNA analysis5

• Genomics, Proteomics, Microarray technology (FAACB)

• Epigenetics2 (FAACB)

1. Lo YMD, Chiu RWK. Principles of Molecular Biology and Approaches to Nucleic Acid

Isolation. In Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th Ed.

Burtis CA, Ashwood ER, Bruns DE. Elsevier Saunders 2006. Chapter 36: pages

1393-1406.

2. Wittwer CT, Kusukawa N. Nucleic Acid Techniques. In Tietz Textbook of Clinical


Elsevier Saunders 2006. Chapter 37: pages 1407-1449.

3. Mamotte CDS. Genotyping of Single Nucleotide Substitutions. Clin Biochem Revs

2006; 27: 63-75.

4. Reed GH, Wittwer CT. Sensitivity and specificity of single-nucleotide polymorphism

scanning by high-resolution melting analysis. Clin Chem 2004; 50(1): 1748-54.

5. Lui YYN, Lo YMD. Circulating DNA in Plasma and Serum: Biological and Clinical

Implications. Clin Biochem Revs 2002; 23: 52-62.

http://www.hgvs.org/mutnomen/


(b) Mutational analysis for specific disorders

• Clinical value of genotyping1-3 indications and testing strategies - for any specific

disorder: http://www.genetests.org/

• Single gene disorders. Patterns of inheritance1,2 - implications for genetic counselling.

Genetics of complex disorders1,2

• Cystic Fibrosis testing

• HFE (and non-HFE) testing for iron overload – see Iron Studies section

• Trinucleotide repeat disorders: Fragile X, Huntington’s Disease, Myotonic Dystrophy,

Friedrich’s Ataxia

• Database of human mutations: http://www.hgmd.cf.ac.uk/ac/index.php

• See section on Ethical, Legal and Social Implications (ELSI)

1. Vnencak-Jones CL. Inherited Diseases. In Tietz Textbook of Clinical Chemistry and


2006. Chapter 40: pages 1483-1538.

2. Thompson & Thompson. Genetics in Medicine, 6th Ed. Nussbaum RL, McInnes RR,

Willard HF. W B Saunders Co, 2004.

3. Scriver CR, Beaudet AL, Sly WS, Valle D (Eds). The Metabolic and Molecular Basis

of Inherited Disease. McGraw Hill Companies Inc, New York; 2001. (Comprehensive

reference for specific disorders).

http://www.genetests.org/

http://www.hgmd.cf.ac.uk/ac/index.php


(c) Mitochondrial Genome and its Role in Investigation

• Properties of mitochondrial genome; concepts of maternal inheritance, heteroplasmy

and threshold effect1-3

• Disorders1-3 (and common mutations eg A3243G) associated with alterations of

mitochondrial genome sequence including Leber’s Hereditary Optic Neuropathy

(LHON), Mitochondrial Encephalomyopathy Lactic Acidosis and Stroke (MELAS),

Myoclonic Epilepsy and Ragged Red Fibres (MERRF) and maternally inherited

diabetes with deafness http://www.mitomap.org/

• http://www.oxfordancestors.com/

• Role (versus enzyme analysis and histopathology) in diagnosis of mitochondrial

respiratory chain disorders4 (FAACB)



2006. Chapter 40: pages 1483-1538.

2. Maasen JA. Mitochondrial Diabetes: Pathophysiology, Clinical Presentation and

Genetic Analysis. American Journal of Medical Genetics (Semin Med Genet) 2002;

115: 66-70.



4. Thorburn DR, Sugiana C, Salemi R et al. Biochemical and Molecular Diagnosis of

Mitochondrial Respiratory Chain Disorders. Bichim Biophys Acta 2004; 1659: 121-8.

http://www.mitomap.org/

http://www.oxfordancestors.com/


(d) Genetics and Molecular Oncology

• Cell cycle biology and genes involved in human cancers.1 Oncogenes, Tumour

Suppressor Genes, DNA Repair Genes (FAACB)

• Familial Cancer Syndromes and susceptibility to malignancy1-3 – eg BRCA, FAP,

HNPCC, MEN 1 and 2, retinoblastoma (FAACB)

• BCR-ABL and role in diagnosis and monitoring of CML3,4 (FAACB)

• Tumour Markers – see section in Clinical Biochemistry

1. Pannall P, Kotasek D. Cancer & Clinical Biochemistry. Eds McCreanor G, Marshall

W. ACB Venture Publications 1997.



2006. Chapter 40: pages 1483-1538.



4. Elenitoba-Johnson KSJ. Molecular Genetics and Diagnosis of hematopoietic

Neoplasms. In Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th

Ed. Burtis CA, Ashwood ER, Bruns DE. Elsevier Saunders 2006. Chapter 39: pages

1457-82.


(e) Cytogenetics

• Principles of clinical Cytogenetics.1 Chromosome number and identification.1 FISH.1

Indications for cytogenetic analysis1

• Concepts of aneuploidy, deletions, duplications, translocations, mosaicism,

imprinting.1 Implications for genetic counselling1

• Trisomy 21, Turner’s and Klinefelter’s syndromes1

http://members.aol.com/chrominfo/geninfo.htm (basic cytogenetics)

• Mendelian disorders with cytogenetic effects1



http://members.aol.com/chrominfo/geninfo.htm


(f) Ethical, Legal and Social Issues (ELSI)

• Scope and implications of genetic testing;1 role in diagnosis, prognosis, prediction,

pre-symptomatic, pre-natal, pre-implantation testing

• Ethical issues:1 identification, consent, confidentiality, testing of children, duty to

inform. Storage and access to data

• Laboratory issues;1 NPAAC guidelines.2 Access to tests, level 1 vs level 2 tests,

professional genetic counselling, laboratory reports (FAACB)

• Genetic tests and population screening – ethical issues3,4

1. Barlow-Stewart K, Burnett L. Ethical Considerations in the Use of DNA for the

Diagnosis of Disease. Clin Biochem Revs 2006; 27(i): 53-61.

2. National Pathology Accreditation Advisory Council (NPAAC) Laboratory Accreditation

Standards and Guidelines for Nucleic Acid Detection and Analysis, Draft 6.1, 17

November 2004.

http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-npaac-

publication.htm/$FILE/NADGuidelines.pdf.

3. Barlow-Stewart K, Burnett L, Proos A, et al. A genetics screening program for Tay-

Sachs disease and cystic fibrosis for Australian Jewish High Schools Students. J Med

Genet 2003;40:e45. http://www.jmedgenet.com/cgi/content/full/40/4/e45

4. Massie RJ, Delatycki MB, Bankier A. Screening couples for cystic fibrosis carrier

status: why are we waiting? Med J Aust 2005;183:501-2.

http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-npaac-publication.htm/$FILE/NADGuidelines.pdf

http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-npaac-publication.htm/$FILE/NADGuidelines.pdf

http://www.jmedgenet.com/cgi/content/full/40/4/e45


4. Therapeutic Drug Monitoring (TDM) and Toxicology

(a) Pharmacokinetic and Pharmacodynamic Concepts

• Pharmacokinetics versus pharmacodynamics1,2

• Concepts of bioavailability, volume of distribution, clearance, half-life, steady state

concentration.1,2 Determination of loading versus maintenance dose1,2

• Zero order versus first order elimination1,2

• Effects of pH, protein binding and drug metabolism1,2

• Drug dosing in disease states, the elderly, children and pregnant women1

• Awareness of p-glycoprotein pathway1

1. Instant Clinical Pharmacology. Evan J Begg. Blackwell Publishing, 2003.

2. Therapeutic Drug Monitoring & Clinical Biochemistry. Hallworth M & Capps N. ACB

Venture Publications, UK 1997. Pages 5-13 and 120-72.


(b) Drug Metabolism and Pharmacogenetics

• Biotransformation and cytochrome P450 metabolism1

• Poor versus rapid metabolism – acetylator status, 2D6, 2C9, 2C19: Rationale and

role of pharmacogenetics2

• Thiopurine methyltransferase (TPMT) – pathway, toxicity of thiopurine drugs,

phenotyping versus genotyping prior to dose initiation.3 6-TGN monitoring3

• Cholinesterase activity (dibucaine & fluoride numbers) and muscle relaxant drugs4

1. Instant Clinical Pharmacology. Evan J Begg. Blackwell Publishing, 2003.

2. Pillans PI. Increasing relevance of pharmacogenetics of drug metabolism in clinical

practice. Intern Med J. 2001; 31(8):476-8.

3. Gearry RB, Barclay MI, Roberts RL et al. Thiopurine methyltransferase and 6-

thioguanine nucleotide measurement: early experience of use in clinical practice.

Intern Med J. 2005; 35(10):580-5.

4. Pantuck EJ. Plasma cholinesterase: genes and variations. Anesth Analg 1993; 77:

380-6.


(c) Rationale and Service Provision for Therapeutic Drug Monitoring

• Criteria for valid TDM – which drugs?1,2

• Essentials for an effective TDM service; practical considerations – request, specimen,

analytical considerations, staffing, near-patient testing2

• Drugs for which TDM is of established value (see separate topic headings) versus

those for which the case for TDM is less established

• Awareness of TDM issues for drugs not listed under separate topic headings;

Gentamicin, Tobramycin, Vancomycin, Methotrexate, Theophyline, Amiodarone2

1. Instant Clinical Pharmacology. Evan J Begg. Blackwell Publishing, 2003. Pages 60-3

2. Therapeutic Drug Monitoring & Clinical Biochemistry. Hallworth M & Capps N. ACB

Venture Publications, UK 1997. Pages 13-27 and 95-117.


(d) (i) Digoxin – Therapeutic Drug Monitoring

• Indications for therapeutic drug monitoring of digoxin1,2

• Pharmacokinetics (including p-glycoprotein handling), distribution and appropriate

sampling time1,2

• Drug interactions for digoxin1,2

• Factors affecting tissue sensitivity to digoxin1,2

• Role of digoxin and appropriate therapeutic ranges3,4

• Awareness of digoxin-like immuno-reactive substances (DLIS)1

• Analytical interferences and methodological considerations5

• Digoxin toxicity and use of Digibind. Impact of Digibind on assay results

1. Barclay M, Begg E. The practice of digoxin therapeutic drug monitoring. New

Zealand Medical Journal 2003; 11: 1187 (12 December 2003).

2. Hallworth M, Capps N. Therapeutic Drug Monitoring and Clinical Biochemistry. Eds

Freedman DB & Marshall WJ. ACB Venture Publications 1993. Pages 54-9.

3. Campbell TJ, MacDonald PS. Digoxin in heart failure and cardiac arrhythmias.

Medical Journal of Australia 2003; 179: 98-102.

4. Rathore SS, Curtis JP, Wang Y, Bristow MR, Krumholz HM. Association of serum

digoxin concentration and outcomes in patients with heart failure. JAMA 2003; 289:

871-8.

5. Steimer W, Muller W, Eber B. Digoxin assays: frequent, substantial and potentially

dangerous interference by spironolactone, canrenone and other steroids. Clinical

Chemistry 2002; 48(3): 507-16.


(d) (ii) Cyclosporin and immunosuppressants – Therapeutic Drug Monitoring

• Rationale for therapeutic drug monitoring of cyclosporin1,2,3

• Rationale of C2 versus C0 monitoring for cyclosporin1,2

• Parent drug versus metabolite – analytical considerations1,3

• Drug interactions and cyclosporin sparing strategies1

• Induction versus maintenance ranges and transplant types3

• Tacrolimus and sirolimus – rationale and methodologies for TDM4

• Mycophenolic acid - rationale and methodologies for TDM5

1. Morris RG. Cyclosporin Therapeutic Drug Monitoring – an Established Service

Revisited. Clin Biochem Rev 2003; 24: 33-46.

2. Levy GA. C2 Monitoring Strategy for Optimising Cyclosporin Immunosuppression

from the Neoral Formulation. BioDrugs 2001; 15(5): 279-90.

3. Oellerich M, Armstrong VW, Kahan B et al. Lake Louise Consensus Conference on

Cyclosporin Monitoring in Organ Transplantation: Report of the Consensus panel.

Therapeutic Drug Monitoring 1995; 17: 642-54.

4. Ting LS, Villeneuve E, Ensom MH. Beyond cyclosporine: a systematic review of

limited sampling strategies for other immunosuppressants. Ther Drug Monit.

2006;28(3):419-30.

5. Holt DW. Monitoring mycophenolic acid. Annals of Clinical Biochemistry 2002; 39(3):

173-83.


(d) (iii) Lithium – Therapeutic Drug Monitoring

• Clinical use and pharmacokinetics of lithium; rationale for TDM1,2

• Toxic effects of lithium1,2

• Monitoring of lithium therapy – prophylaxis versus acute mania1,2

• Measurement of lithium in the laboratory



2. Aronson JK, Reynolds DJM. ABC of monitoring drug therapy: Lithium. British

Medical Journal 1992; 305: 1273-76.


(d) (iv) Anticonvulsant drugs – Therapeutic Drug Monitoring

• Clinical use and pharmacokinetics of phenytoin, with reference to saturation kinetics;

rationale for TDM1

• Toxic effects and monitoring of phenytoin1

• Clinical use and pharmacokinetics of sodium valproate, with reference to

concentration-dependent protein binding; rationale for TDM2

• Toxic effects and monitoring of sodium valproate2

• Clinical use and pharmacokinetics of carbamazepine, with reference to drug

metabolism and drug interactions; rationale for TDM3

• Toxic effects and monitoring of carbamazepine3

• Awareness of lamotrigine – rationale for TDM4

• Assays for measurement of these drugs










(e) Initial Management and Evaluation of the Poisoned Patient

• Types of Poisoning – intentional, occupational & environmental1,2

• Clinical features of poisoning – awareness of Glasgow Coma Scale1

• Biochemical effects of poisoning – acid-base disturbances, effects on electrolytes,

anion gap and osmolar gap1

• Laboratory investigation – analytes (poisons) with need for 24/7 availability1,3

• Analytical considerations – role of immunoassays, thin-layer chromatography, HPLC,

GC-MS1

• Quality Assurance of Toxicological analyses (AUSTOX)

http://www.austox.com/about_austox.cfm

• Treatment options1,2– resuscitation, roles of gastric lavage, charcoal, forced diuresis,

manipulation of urine pH, dialysis and haemoperfusion

• Specific antidotes (see separate toxicological profiles)

• Forensic toxicology – chain of custody and other requirements1

1. Poisoning & Laboratory Medicine. Watson I & Proudfoot A. ACB Venture

Publications 2002. Pages 1-49 and 161-6.

2. Greene SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a

nutshell. Postgraduate Medical Journal 2005; 81: 204-16.

3. Laboratory analyses for poisoned patients: joint position paper. National Poisons

Information Service and Association of Clinical Biochemists. Annals of Clinical

Biochemistry 2002; 39(4): 328-39.

http://www.austox.com/about_austox.cfm


(f) Toxicological Profiles and Interventions for Specific Poisons

• Paracetamol – mechanisms of toxicity.1 Timing, enzyme induction and determinants

of indication for N-acetylcysteine or other antidotes1,2

• Salicylates1,2 – mechanisms of toxicity. Rationale of forced alkaline diuresis1

• Tricyclic antidepressants – clinical features and supportive management1,2

• Methanol and Ethylene Glycol – metabolism and interventions (including 4-

methylpyrazole)1,3

• Carbon Monoxide – carboxyhaemoglobin and hyperbaric oxygen therapy1,4

• Organophosphate – clinical features, mechanisms and antidotes1,5

• Awareness of toxicity and interventions for other substances,1 including cyanide, iron,

lithium, lead (see occupational health monitoring), paraquat, volatile substances,

opioids, cocaine, benzodiazepines1,2 (including indications for flumazenil)

1. Poisoning & Laboratory Medicine. Watson I & Proudfoot A. ACB Venture

Publications 2002. Pages 51-160.

2. Greene SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a

nutshell. Postgraduate Medical Journal 2005; 81: 204-16.

3. Brent J, McMartin K, Phillips S et al. Fomepizole for the treatment of ethylene glycol

poisoning. N Engl J Med 1999; 340: 832-8.

4. Weaver LK. Hyperbaric oxygen in carbon monoxide poisoning. British Medical

Journal 1999; 319: 1083-4.

5. Wagner SL. Diagnosis and treatment of organophosphate and carbamate

intoxication. Occup Med (Philadelphia) 1997; 12: 239-49.


(g) Drugs of Abuse Testing (including workplace drug testing)

• Recognition of adulteration of samples to avoid drug detection1

• Analytical approaches – immunoassay,2 thin-layer chromatography and GC-MS

confirmation. Near-patient testing devices – advantages and limitations3

• Cut-offs and duration of positivity in urine for cannabis, opiates, benzodiazepines,

GHB, methadone, cocaine, barbiturates, amphetamine, MDMA and

metamphetamine4

• Salivary compared with urine testing for drugs of abuse2

• “Herbal highs” – the advent of benzylpiperazine (BZP)5

• AS/NZS 4308 standards – for drugs of abuse in urine testing, including procedures

for workplace drug testing (eg chain-of custody)6

1. Lafolie P, Beck O, Blennow G et al. Importance of Creatinine Analyses of urine When

Screening for Abused Drugs. Clin Chem 1991; 37(11): 1927-31.

2. Luzzi VI, Saunders AlN, Koenig JW et al. Analytic Performance of Immunoassay for

Drugs of Abuse Below Established Cutoff Values. Clinical Chemistry 2004; 50(4):

717-22.

3. George S, Braithwaite RA. Use of On-Site Testing for Drugs of Abuse. Clinical

Chemistry 2002; 48(10): 1639-46.

4. Verstraete AG. Detection Times of Drugs of Abuse in Blood, Urine and Oral Fluid.

Therapeutic Drug Monitoring 2004; 26(2): 200-5.

5. Gee P, Richardson S, Woltersdorf W, Moore G. Toxic effects of BZP-based herbal

party pills in humans: a prospective study in Christchurch, New Zealand. NZ Medical

Journal 2005 Dec 16;118(1227):U1784.

6. AS/NZS 4308:2001 : Procedures for the collection, detection and quantitation of

drugs of abuse in urine. Published by Standards Australia International Ltd, GPO

Box 5420, Sydney, NSW 2001 and Standards New Zealand, Private Bag 2439,

Wellington 6020.


(h) Occupational health Monitoring; solvents, trace metals (FAACB)

• Context of Occupational Health Monitoring – Workplace Exposure Standards and

Biological Exposure Index. www.osh.dol.govt.nz

• Sampling requirements – preanalytical considerations (eg end of shift)

• Solvent analytes1,2,3 – eg hexane, toluene, styrene, perchloroethylene, acetone

• Gas Chromatography (for solvents) – see Analytical Biochemistry

• Trace elements1,2 – eg lead, mercury, cadmium, chromium, arsenic; awareness of

settings of industrial exposure and features of clinical toxicity1

• Methodologies for trace elements; eg Atomic Absorption, ICP-MS – see Analytical

Biochemistry

• Scope of Occupational Medicine

http://www.anzsom.org.au/html/s01_home/home.asp?dsb=27

1. Hunter’s Diseases of Occupations. 8th Ed. Eds Raffle PAB, Adams PH, Baxter PJ,

Lee WR. Edward Arnold Publishers 1994.

2. Biological Monitoring Methods for Industrial Chemicals. 2nd Ed. Randall C. Baselt.

PSG Publishing Co Inc 1988.

3. Industrial Chemical Exposure: Guidelines for Biological Monitoring. 2nd Edn. Robert

R. Lauwery, Perrine Hoet. Lewis Publishers 1993.

http://www.osh.dol.govt.nz/

http://www.anzsom.org.au/html/s01_home/home.asp?dsb=27



(a) Organisation of a Clinical Laboratory (FAACB)

• Hospital Management Structure and the Clinical Laboratory1,2

• Personnel management;1 staff recruitment and retention, job descriptions, rostering,

performance appraisal

http://www.apsc.gov.au/publications02/performancemanagement.htm

• Requirements for continuing education and professional development

http://www.aims.org.au/c/index.php?page=apace (AIMS-APACE)

http://www.nzimls.org.nz/53.html (NZIMLS CPD)

• Resource and Financial management;1 budgeting, capital expenditure, cost

accounting and reimbursement

• Information management; productivity, test utilisation – see Information Technology

and the Laboratory

• Key Performance Indicators;3 turnaround times, error rates

• LEAN and Six-Sigma principles. Quality Management Systems4

http://www.westgard.com/guest30.htm

1. Crolla LJ, Reninger L, Stiffler PW. Laboratory Management in Clinical Chemistry:

Theory, Analysis and Correlation. 4th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC.

2003. Chapter 2. Pages 45-63.

2. Truchaud A, Le Neel T, Brochard H, Malvaux S, Moyon M, and Cazaubiel M.

Organisation of a Clinical Laboratory – New tools for laboratory design and

management. Clin Chem 1997; 43(9): 1709 – 1715

3. Heatherley SS. Key performance indicators to assess laboratory operations.

Benchmarking with the best. Clin Lab Mange Rev 1997; 11(6): 396-401.

4. Burnett D. Understanding Accreditation in Laboratory Medicine. Eds McCreanor G,

Sherwood RA, Sweetman J. ACB Venture Publications 1996.

http://www.apsc.gov.au/publications02/performancemanagement.htm

http://www.aims.org.au/c/index.php?page=apace

http://www.nzimls.org.nz/53.html

http://www.westgard.com/guest30.htm


(b) Laboratory Safety and Hazard Management

• Health and Safety Policy1. Role of the Health and Safety Officer2

• Risk assessment and hazard management, accident and Incident reporting,

education and training requirements2 http://www.osh.govt.nz • Radiation safety issues, waste disposal considerations2


Sherwood RA, Sweetman J. ACB Venture Publications 1996. Chapter 8; pages 140-

157.

2. Bermes EW, Kahn SE, Young DS. Introduction to Principles of Laboratory Analyses

and Safety. In Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th Ed.

Burtis CA, Ashwood ER, Bruns DE. Elsevier Saunders 2006. Chapter 1: pages 3-39.

http://www.osh.govt.nz/


(c) Laboratory Accreditation; ISO

• Scope and definitions of Laboratory Accreditation1

• Standards and Guidelines. ISO 15189 and other standards http://www.iso.org

• Aspects of Accreditation:1 Policies, procedures and manuals. Organisation and

management (see Organisation of a Clinical Laboratory section). Staffing, facilities

and equipment. Quality assurance and evaluation (see EQA section). Preparing for

an Inspection. Role of the Quality Manager

• Special considerations - eg Molecular Diagnostics Laboratory2 (FAACB)

• National Association of Testing Authorities (NATA) http://www.nata.asn.au/

• International Accreditation, New Zealand (IANZ) http://www.ianz.govt.nz/


Sherwood RA, Sweetman J. ACB Venture Publications 1996.

2. Killeen AA. Design and Operation of the Molecular Diagnostics Laboratory. In Tietz

Textbook of Clinical Chemistry and Molecular Diagnostics. 4th Ed. Burtis CA,

Ashwood ER, Bruns DE. Elsevier Saunders 2006. Chapter 38: pages 1451-6.

http://www.iso.org/

http://www.nata.asn.au/

http://www.ianz.govt.nz/


(d) Internal Quality Control (QC)

• Quality Management; definition of internal QC versus EQA1

• Setting in context of Laboratory Error and Six Sigma Process2

• Control materials, control charts,2 Levey-Jennings plots2 and power functions.2

Process for selecting QC procedures2

• Westgard (acceptance) rules and Internal QC2

• Internal QC and laboratory accreditation requirements3

www.nata.asn.au (NATA) www.ianz.govt.nz (IANZ)




2. Westgard QC website. See essays and lessons in the “Archives” section.

In particular the following essays and lessons are recommended:

• Myths of Quality. www.westgard.com/essay2.htm

• QC- Back To Basics. www.westgard.com/essay13.htm

• Six Sigma Quality Management and Desirable Laboratory Precision.

www.westgard.com/essay35.htm

• Power Function Graphs. www.westgard.com/lesson4.htm

• QC - The Chances of Rejection. www.westgard.com/lesson15.htm

• QC - The Out-of-Control Problem. www.westgard.com/lesson17.htm

3. ISO 15189:2003 Medical Laboratories – Particular requirements for quality and

competence. (Also published as AS 4533-2004)



http://www.westgard.com/essay2.htm



http://www.westgard.com/lesson4.htm




(e) External Quality Assurance (EQA)

• Quality Management; definition and objectives of EQA vs internal QC1,2,3

• Operation of an EQA scheme:3,4 samples – matrix, design, stability, frequency

• Analytical goals3-5 – method classification system, central reference value, acceptable

range

• Reports – interpretation of interim, end-of-cycle and subgroup reports5

• Key performance indicators (KPIs)5

• EQA and laboratory accreditation requirements2,6,7





Sherwood RA, Sweetman J. ACB Venture Publications 1996, Chapter 11, pages 218-

247.

3. www.rcpaqap.com.au/chempath/educationalresources/talks

4. www.ukneqas.org.uk (UK, NEQAS website)

5. www.rcpaqap.com.au/chempath/reports

6. National Association of Testing Authorities (NATA) www.nata.asn.au

7. International Accreditation, New Zealand (IANZ). www.ianz.govt.nz

http://www.rcpaqap.com.au/chempath/educationalresources/talks

http://www.ukneqas.org.uk/

http://www.rcpaqap.com.au/chempath/reports




(f) Laboratory Statistics (excluding method comparison)

• Sensitivity, Specificity, Predictive Value.1,2 Effect of Prevalence1,2

• Likelihood Ratios (and their utility3), Odds Ratios – Fagan’s nomogram2

• Receiver Operating Characteristic (ROC) Curve analysis2

• Normal distribution.2,4 Parametric versus non-parametric statistics2,4

• Student’s t test.2,4 Wilcoxon signed rank test.2,4 Pearson’s correlation coefficient2,4

• Confidence Intervals,2,4 Chi-Squared test,2,4 meaning of significance,2,4 sample size

and power calculations2,4

• Univariate versus Multivariate analysis4

• Biological Variation. Changes in serial results - critical difference5

• Imprecision and coefficient of variation.2 Uncertainty of Measurement in context of

overall interpretation of laboratory results. Combining uncertainties (Anion Gap,

Creatinine Clearance etc.)

http://www.aacb.asn.au/files/File/Uncertainty%20of%20measurement.pdf

• Absolute and relative risk reduction. Numbers needed to treat (NNT). Ability to

interpret data from clinical intervention studies2 (see Lipids section).

1. Galen RS, Gambino SR: Beyond normality: the predictive value and efficiency of

medical diagnosis. New York, John Wiley & Sons, 1975.

2. Clinical Investigation and Statistics in Laboratory Medicine. Jones RG & Payne RB.

ACB Venture Publications, UK 1997.

3. Steurer J, Fischer JE, Bachmann LM, Koller M, ter Riet G. Communicating accuracy

of tests to general practitioners: a controlled study. British Medical Journal 2002; 324:

824-6.

4. Primer of Biostatistics 5th Ed. Stanton A Glantz. McGraw-Hill Medical Publishing

Division, 2002.

5. Biological Variation: from principles to practice. Callum G Fraser. AACC Press,

Washington DC 2001.

http://www.aacb.asn.au/files/File/Uncertainty%20of%20measurement.pdf


(g) Method Comparison

• Linear regression analysis - slope and intercept1,2

• Weighted and unweighted Deming regression analysis1,2

• Passing and Bablok analysis1,2

• Bland-Altman difference plots3 – bias, limits of agreement1-3

• Method comparison software – www.medcalc.be

• Requirements of a method comparison study4,5


1. Hollis S. Analysis of method comparison studies. Ann Clin Biochem 1996; 33: 1-4.

2. Clinical Investigation and Statistics in Laboratory Medicine. Jones RG & Payne RB.

ACB Venture Publications, UK 1997.

3. Bland JM, Altman DG. Statistical methods for assessing agreement between two

methods of clinical measurement. Lancet 1986; i: 307-10.

4. NCCLS EP9-A: Method comparison and bias estimation using patient samples.

National Committee for Clinical Laboratory Standards, Wayne, PA, 1995.

5. Hyltoft Petersen P, Stockl D, Blaaberg O et al. Graphical interpretation of analytical

data from a comparison of a field method with a reference method by use of

difference plots. Clin Chem 1997;43: 2039-46.

http://www.medcalc.be/



(h) Reference Intervals

• Approaches to setting of Reference Intervals:1-3 numbers needed, distribution of data,

parametric vs non-parametric analysis, criteria for partitioning of data3

• Paediatric reference intervals4

• Common Reference Intervals5,6

• “Data-mining”: the Bhattacharya approach7

1. National Committee for Clinical Laboratory Standards. How to define and determine

reference intervals in the clinical laboratory: Approved guideline - second edition.

NCCLS document C28-A. Wayne USA, 2000, NCCLS.

2. Solberg HE. Establishment and use of reference values. Tietz Textbook of Clinical

Chemistry, Burtis and Ashwood eds.

3. Biological Variation: from principles to practice. Callum G Fraser. AACC Press,

Washington DC 2001.

4. Paediatric Reference Ranges. Soldin SJ and Hicks JM eds. AACC Press.

5. Jones GRD, Barker A, Tate J, Lim C-F, Robertson K. The case for Common

Reference Intervals. Clin Biochem Rev 2004; 25: 99-104.

6. Nordic Reference Intervals Project (www.furst.no/norip).

7. Bhattacharya CG. A simple method of resolution of a distribution into Gaussian

components. J Biometric Soc 1967;23:115-35.


(i) Evidence Based Laboratory Medicine (EBLM) FAACB

• Definition and background to EBLM1,2

• Setting the Question (“PICO” format)

http://www.cebm.net/focus_quest.asp

• Searching the Evidence (see online tutorial including “diagnostic” filters)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

• Study design: STARD criteria3. Appraisal instruments; eg STEP

http://www.health.usyd.edu.au/step/about/appraisal.htm

• Sources of bias in studies of diagnostic accuracy4

• Statistical exercises (see Laboratory Statistics section)

• Systematic Reviews,5 Meta-analysis; Cochrane Collaboration

http://www.cochrane.org

• Guideline development, levels of evidence and appraisal

http://www.agreecollaboration.org/

• Laboratory Medicine and Outcomes; Applying the Evidence2

1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based

medicine: what it is and what it isn't. BMJ. 1996;312:71-2.

2. Evidence Based Laboratory Medicine. From Principles to Outcomes. Ed Price CP &

Christenson RH. AACC Press, Washington DC 2003.

3. Bossuyt PM, Reitsma JB, Bruns DE et al. Towards complete and accurate reporting

of studies of diagnostic accuracy: the STARD initiative. Standards for Reporting of

Diagnostic Accuracy. Clin Chem. 2003; 49(1):1-6.

4. Lijmer JG, Mol BW, Heisterkamp S et al. Empirical Evidence of Design-Related Bias

in Studies of Diagnostic Tests. JAMA 1999; 282: 1061-6.

5. Horvath AR, Pewsner D. Systematic reviews in laboratory medicine: principles,

processes and practical considerations. Clin Chim Acta 2004; 342: 23-9.

http://www.cebm.net/focus_quest.asp

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

http://www.health.usyd.edu.au/step/about/appraisal.htm

http://www.cochrane.org/

http://www.agreecollaboration.org/


(j) Information Technology and the Laboratory

• Basic computing essentials:1,2 hardware, software, operating systems, networks,

storage, Internet

• Core functions of laboratory information systems (LIS)1,2

• Laboratory processes:1,5,8 for managing security, data integrity, privacy

• Regulatory requirements for information management and communication of

laboratory data1,5,8

• Data standards and encoding1,3

• Current technologies for results transmission and delivery1,3,8

• Autoverification, autovalidation and automated commenting3,4,7

• Laboratory applications of artificial intelligence and expert systems3,7 (FAACB)

• Computerised request order entry systems.1,6 Middleware1,4

1. Cowan D. (Ed.) Informatics for the Clinical Laboratory - A Practical Guide for the

Pathologist, Springer 2005.

2. Spackman K. Clinical Laboratory Informatics in: Tietz Textbook of Clinical Chemistry

and Molecular Diagnostics 4th Edition Elsevier 2006.

3. Jones R. and O’Connor J. Information Management and Informatics: need for a

modern pathology service. Ann Clin Biochem 2004;41:183-191.

4. Teal J, D’Agostino J. The Rise and Rise of Middleware. Clin Biochem News

2006;162:10-14

5. National Pathology Accreditation Advisory Council (NPAAC) Requirements for

Information Communication (Draft Document for Public Consultation) 2006

http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-npaac-

publication.htm.

6. Georgiou A. and Westbrook J. Computerised Order Entry Systems and Pathology

Services – A Synthesis of the Evidence. Clin Biochem Revs 2006;27(2):79-87.

7. Edwards G. Putting the “Clinical” Back in Biochemistry – Lessons from the

Informatics Coalface. Clin Biochem News 2006;162:16-26.

8. Ward-Cook K et al (Eds) Clinical Diagnostic Technology-The Total Testing Process,

Volume 3: The Postanalytical Phase. AACC Press 2006.

http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-npaac-publication.htm

http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-npaac-publication.htm


(k) Selection and Evaluation of Methods and Equipment

• Equipment requirements e.g. laboratory goals, throughput, specimen types, on-board

methodologies, range of analytes tested, space limitations, connectivity to LIS and/or

other equipment such as pre-analytical units or automation, physical environment,

financial constraints, labour goals

• Suitability and safety of on-board methods

• Basic attributes of relevant on-board methodologies e.g. Precision, linearity,

accuracy, interferences (documented), recovery

• Requirement, availability and suitability of third-party methodologies

• Compare candidate equipment using available manufacturer’s specifications

• Compare candidate equipment using available customer feedback

• On-site comparison of candidate equipment. i.e. have a written protocol to enable

identical comparison of different equipment

• Statistical tools e.g. MS Excel and others, F test, T-test, linear regression

• Make evaluation and recommendation based on the above criteria

• Impact on existing reference intervals

• Impact of re-training requirements on laboratory workflow, staffing and finances

• Consider lean and six sigma approaches to laboratory reorganisation

1. Linnet K, Boyd JC. Selection and Analytical Evaluation of Methods – With Statistical

Techniques in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th Ed.

Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 14: 353-408.

2. Anderson SC and Cockayne S. Clinical Chemistry: Concepts and Applications.

Chapter 5, p 65+.

3. Garber CC, Carey RN. Evaluation of Methods in Clinical Chemistry: Theory, Analysis

and Correlation. 4th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC. 2003. Chapter 22.

Pages 402-26.


(l) Scope of Point of Care Testing and Accreditation Issues

• Scope and definitions of POCT.1,2 For definition, see ISO22870 Standard

http://www.iso.org.

• Awareness of range of analytical methodologies – e.g., reflectance photometry, -

Clinitek 50 urine reflectance meter, Roche Cardiac reader; electrochemical devices,

blood gas analysers, glucose meters, PR/INR analysers; spectrophotometry, e.g.,

Hemocue haemoglobin monitors

• Issues for POCT implementation – equipment evaluation, inventory and maintenance,

health and safety, user training and competency records, connectivity, quality

assurance, interpretation. Ongoing competency and retraining of staff are key issues3

• Role of the Point-of-Care Coordinator4

• Accreditation Standards and POCT: ISO 15189 and ISO 22870. http://www.iso.org.

ISO 22870 is now its own Standard; this interprets POCT in light of ISO 15189, the

International Standard for Medical Laboratories5

1. Marks V. Clinical Biochemistry nearer the patient. BMJ 1983; 286: 116-7.

2. Freedman DB. Clinical governance: implications for point-of-care testing. Ann Clin

Biochem 2002; 39: 421-423.

3. Hagerman P. Schweiz Runsch Med Prax. Shortfalls in Laboratory Medicine 1999 Aug

26;88(35):1396-400 PMID: 10489484.

4. Gerald J. Kost, MD, PhD. Preventing Medical Errors in Point-of-Care Testing.

Archives of Pathology and Laboratory Medicine: Vol. 125, No. 10, pp. 1307–1315.

5. Kenny, Desmond. The new ISO and CEN standards for quality and accreditation of

medical laboratories. Jugoslovenska medicinska biohemija 2004(23) Issue: 3 Pages:

305-310.

http://www.iso.org/

http://www.iso.org/


(m) Evidence Based Medicine and POCT

• Outcomes of relevance for laboratory tests, including POCT1

• Examples of evidence base for POCT including HbA1c testing,2 studies in the

emergency department,3,4 operating theatres,5 self-monitoring of blood glucose6 and

INR testing in the home7

• POCT troponin testing and rural health in Australia8 http://www.icarnet.org/

• POCT testing and diabetes management in Aboriginal communities9

• Ongoing Trial of POCT in Australian General Practice

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pathology-

poctt-index.htm-copy2

1. St John A, Price CP. Measures of Outcome. In Evidence Based Laboratory Medicine.

From Principles to Outcomes. Ed Price CP & Christenson RH. AACC Press,

Washington DC 2003; pages 55-74.

2. Winter WE. Does Availability of Hemoglobin A1c Results at the Point of Care Make a

Difference in the Clinical Care or Outcome of the Patient with Diabetes? Point of Care

2006; 5: 58-61

3. Kendall J, Reeves B, Clancy M. Point of care testing: randomised controlled trial of

clinical outcome. Br Med J 1998; 316: 1052-7.

4. Murray RP, Leroux M, Sabga E, Palatnick W, Ludwig L. Effect of point of care testing

on length of stay in an adult emergency department. J Emerg Med 1999; 17: 811-4.

5. Chen H, Mack E, Starling JR. Chen H, Mack E, Starling JR. A comprehensive

evaluation of perioperative adjuncts during minimally invasive parathyroidectomy:

which is most reliable? Ann Surg 2005;242:375-80.

6. Coster S, Gulliford MC, Seed PT, Powrie JK, Swaminathan R. Self-monitoring in

Type 2 diabetes mellitus: a meta-analysis. Diabet Med. 2000;17:755-61.

7. Murray ET, Fitzmaurice DA, McCahon D. Point of care testing for INR monitoring:

where are we now? Br J Haematol. 2004 Nov;127:373-8

8. Tirimacco R, Tideman P. Using Point of care Troponin T testing to deliver Evidence

Based Cardiac Care in Rural South Australia. Clinical Biochemist Reviews

Supplement 2004; S18.

9. Shephard MDS. Cultural and Clinical Effectiveness of the ‘QAAMS’ Point-of-Care Testing Model for Diabetes Management in Australian Aboriginal

Medical Services. Clin Biochem Rev 2006; 27(iii):169-170

http://www.icarnet.org/

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pathology-poctt-index.htm-copy2

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pathology-poctt-index.htm-copy2

Documents

AACB CURRICULUM 2007 - Univerzita Karlovakocna/edu/AACB Curriculum 2007.pdfAACB Curriculum 2007 11 (e) Nephelometry and Turbidimetry • Principles1-3 of Nephelometry & Turbidimetry: