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Answering your questions on Canadian phlebotomy regulations, reporting fetal lung maturity, the Mucin Clot test, and allergy testing.

Phlebotomy regulations in Canada

Q I need to schedule some home blood draws in Canada for a research project. I have been on the Internet and on the phone for several days, but cannot find anyone who knows what the licensing/certification requirements are for phlebotomists. Can we send our people there to collect the samples?

A The regulation of phlebotomy in Canada varies from province to province. Quebec and Ontario are the only two provinces with regulations about who can perform phlebotomy.

In Quebec only members of the Odre Professionel Des Technologistes Medicaux du Quebec, licensed nurses, or physicians can draw blood. In Ontario, members of the Medical Laboratory Technologists of Ontario can draw. However, members can delegate the task to another regulated health professional, although the individual who delegates still bears responsibility. A quirk to Ontario's regulation is that an older law contravenes the current law, and allows anyone who works in a licensed lab to draw blood, even if they aren't a regulated professional.

In Saskatchewan, blood specimens may be drawn by a number of professionals, including physicians, nurses who demonstrate competency, medical technologists and technicians, and other assistants who work under the direct supervision of any of the aforementioned professionals. It is the responsibility of the employer to assure competency.

It is anticipated that new regulations will soon be approved in the province of British Columbia and will be similar to Ontario's regulations. In Alberta and Newfoundland, phlebotomy is not a restricted activity and competencies are left to be established by each facility. Restrictions in the remaining provinces are either nonexistent or are under review.

Dennis Ernst, MT(ASCP)

Director

The Center for Phlebotomy Education

Ramsey, IN

Reporting fetal lung maturity

Q We currently use the Amniostat-FLM (Irvine Scientific, Santa Ana, CA), a semi-quantitative slide test, as the only test we offer for lung maturity. Many of our OB physicians are not comfortable with only this test and request that we send negative specimens out for confirmation. All local labs use the same test kit we do. The only lab we have found that offers a different test uses the Abbott FLM II test (Abbott Laboratories, Abbott Park, IL).

Since we started doing comparisons, all tests sent out for confirmation have come back negative and have correlated with our procedure. What can we tell our providers so that they trust our results without confirming negatives with the Abbott FLM? Is confirmation of our negative results appropriate with the Abbott FLM, or should we confirm with a different procedure such as L/S ratio?

A Tests for fetal lung maturity are based on the observation that as the fetal lung develops, there is an increase in certain lipids, especially lecithin (L), sphingomyelin (S) and phosphatidyl-glycerol (PG). These lipids act as surfactants, decreasing the surface tension within the pulmonary alveoli, and preventing collapse of the alveoli when the lung is deflated. Collapse of the alveoli results in infant respiratory distress syndrome (RDS), a life-threatening condition in premature infants. The test is used to assist the obstetrician in determining whether it is safe to deliver a baby that is premature. A variety of tests have been developed to measure these components.

AmnioStat is a rapid semiquantitative screening test. It is an immunologic agglutination slide test that estimates PG. In this test, PG is incorporated into a lipid-containing reagent. After dilution, the suspension of lipid-PG particles is mixed with an antibody reagent. Agglutination indicates a PG concentration of 0.5 [micro]g/mL or greater.

The Abbott Fetal Lung Maturity II test has taken a different approach. It measures the amnionic fluid surfactants and albumin, expressing the test result as a ratio between these materials. The test is a quantitative measurement, performed on the Abbott TDx instrument, using fluorescence polarization technology. Fluorescent dyes bind directly to the surfactant particles and to albumin, without an immunologic reaction. Differences in the fluorescence polarization characteristics are used for differentiating the surfactants from albumin. This test is based on the observation that the amnionic fluid surfactants increase as the fetal lung matures, while the fluid albumin remains as a constant concentration.

Since the technologies of these two tests are different, and the Abbott test is quantitative, it is valid and useful to use the Abbott test to confirm results of the AmnioStat test. Whether confirmation is necessary should be a decision made between the medical staff and the laboratory. It depends on the clinicians' level of comfort and should be based on a careful reading of studies about the reliability of the test published in the medical literature.

Daniel M. Baer, MD

Professor Emeritus

Department of Pathology

Oregon Health and Science University

Mucin Clot

Portland, OR

Q What is the value of the Mucin Clot or Ropes Test? Current textbooks don't even address the test. In a text from 1984, a paragraph was devoted to the test, but ended with "the test should be considered obsolete" and "... the quality of the information is inferior to that of other procedures." We currently offer the test, but have not had an order since March 1999. I would like to discontinue the test, but I don't know what test should be the replacement.

A The Mucin Clot test is now considered obsolete and of historical interest. The test was described by Ropes [1] in 1953 and is done as follows [2,3]:

Several drops of synovial fluid are added to about 20mL of 5 percent acetic acid in a small beaker. Allow one minute for a "clot" to form and then shake the beaker.

(a) a "good clot" from normal or osteoarthritic fluid forms a firm mass that does not fragment on shaking.

(b) a "poor clot" like those that results from inflammatory effusions, fragments easily and forms flakes, shreds, and cloudiness in the surrounding fluid.

Certain patients with systemic lupus erythematosus and rheumatic fever may have mild inflammation and still form good mucin clots.

Good mucin reflects the normal integrity of hyalouronate. Whereas, "poor mucin" indicates destruction and dilution of hyalouronate protein. The mucin test and viscosity only gives rough clues to help differentiate inflammatory arthritic conditions from joints which do not have moderate to significant inflammation.

Today, the mucin test is not ordered or offered in many clinical laboratories. It is not a sensitive indicator of inflammation by the measurement of the integrity hyalouronate proteins in the synovial fluid.

Better indicators of inflammation are the leukocyte and white counts in the synovial fluids. In addition, the C-reactive protein (CRP), an acute phase protein, can be used to monitor the presence and course of inflammatory activity in joints as seen in patients with rheumatoid arthritis and rheumatic fever.

Robert M. Nakamura, MD

Chairman Emeritus and Senior Consultant

Department of Pathology

Scripps Clinic

References

La Jolla, CA

(1.) Ropes, M.W., and Bauer, W: Synovial vial Fluid Changes in Joint Disease, Harvard University Press, Cambridge, MA 1953.

(2.) Schumacher, H.R. Volume 1, Chap. 38: Synovial Fluid Analysis p. 598 in Textbook of Rheumatology 1st Edition, edited by Kelley, W.M, Harris, C.B. W.B. Saunders, Philadelphia, PA 1981.

(3.) Schumacher, HR. Vol. 1, Chap 36: Synovial Fluid Analysis and Synovial Biopsy, pg. 570 in Textbook of Rheumatology, 4th Edition. Edited by Kelley W.M., Harris, ED., Ruddy 5, Sledge C.B. W.B. Saunders, Philadelphia, PA. 1993.

Allergy testing

Q Is the RAST test still the only laboratory diagnostic test for identifying allergies?

A Histamine release from basophils, from allergic individuals, will occur after antigen is added to a mixed leukocyte culture, taken from that individual. The leukocytes histamine release test has been known to be an accurate way of identifying allergic antibody (usually specific IgE) for a number of years. [1]

Leukocyte histamine assays are relatively difficult to standardize and comparing one patient's leukocytes to another is only qualitative. RAST is standardized and specific in most cases, assuming that excess IgG antibody, specific for the same test antigen, does not displace IgE. The leukocyte histamine assays have been used for testing in food allergy.

Immediate skin testing (prick and intradermal) is accurate, specific and reproducible. Interference by antihistamines is the limiting variable.

Donald E. Stevenson

Senior Consultant

Division of Allergy, Asthma & Immunology

Reference

Scripps Clinic

(1.) Lichtenstein, L.M. and Osler A.G. 1964. Studies on the mechanism of hypersensitivity phenomena. Histamine release from human leukocytes by ragweed pollen antigen. J. Exp. Med 120:507

Daniel M. Baer is professor emeritus of laboratory medicine at Oregon Health Sciences University in Portland, OR, and a member of MLO's editorial advisory board.
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Author:Baer, Daniel M.
Publication:Medical Laboratory Observer
Geographic Code:1CANA
Date:Oct 1, 2001
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