AACB CURRICULUM 2007

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AACB CURRICULUM 2007

Prepared by

AACB Education Committee Chair: Dr Chris Florkowski

&

AACB Board of Examiners

Chair: Mr Paul Sheehan

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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• It was recognised that the previous AACB Syllabus was out-of-date and provided minimal guidance on appropriate topics and learning resources

• The previously published study guides were similarly largely out-of-date and too voluminous to reasonably expect anybody to try and update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

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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

1. Analytical Biochemistry

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

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2. Clinical Biochemistry

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

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3. Molecular Genetics

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

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5. Laboratory Management

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

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1. Analytical Biochemistry

(a) Specimen Collection; pre-analytical phase

• Patient preparation– biological, diurnal and patient-related physical variables^1,2,3

• Patient identification and correct labelling of samples

• Variables due to anticoagulants and preservatives^1,2,3

• Blood collection – technique, site of collection^1,2,3

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

• Analysis of the errors in laboratories⁴

• Errors due to blood collection tube components^5,6

1. Young DS, Bermes EW, Haverstick DM. Specimen Collection and Processing in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4^th 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). 4^th 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.

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(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 selection^1-4 and method requirements

1. Kricka LJ. Analytical Techniques and Instrumentation in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE.

2006. Chapter 3: 61-92.

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

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(c) Luminescence and Fluorescence

• Concepts of fluorescence, bioluminescence, chemiluminescence and electroluminescence^1,2

• Theory of luminescent reactions^1,2

• 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 PCR^1,3,4,5

• Principles, applications and advantages of chemiluminescent , enhanced chemiluminescent and electroluminescent reactions in the laboratory^1,3,6,7

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.

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(d) Flame Emission Photometry

• Principles of flame photometry^1,2

• 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 FES^2,3

• 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.

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(e) Nephelometry and Turbidimetry

• Principles^1-3of Nephelometry & Turbidimetry: antigen–antibody complexes, light scattering, antigen excess, rate nephelometry

• Nephelometer components^1-3

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

• Instrument selection: method requirements⁶, troubleshooting⁶

1. Manual of Clinical Laboratory Immunology, 6^th 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 Chemistry and Molecular Diagnostics. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE.

2006. Chapter 9: 219-44.

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

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(f) Atomic Absorption Spectrophotometry and ICP-MS

• Principles of Atomic Absorption^1,2. Line spectra.

• Components of an Atomic Absorption Spectrophotometer^1,2; hollow cathode lamp, burner, flameless atomic absorption, monochromator and detector.

• Interferences^1,2; 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. 4^th 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. 4^th 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. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 35: Pages 1371-1390.

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(g) Main analyser platforms and automation

• Concepts^1-3of random access, discrete, continuous flow, stat testing.

• Operational features of analytical platforms^1-3 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 automation^1-6; modular systems, front-end specimen processing, specimen archiving. Advantages of automation^4-6.

• History of automation^1-6e.g. drivers of automation, changes in technology.

• Impact of automation^1-6 e.g. on quality of results, throughput, labour requirements.

1. Pesce MA. Laboratory Automation in Clinical Chemistry: Theory, Analysis and Correlation. 4^th 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. 4^th 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.

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(h) Ion Selective Electrodes

• Principles of Ion Selective Electrodes^1-4; concepts of activity, potentiometry, ionophores and the Nernst equation

• Direct versus Indirect Ion Selective Electrodes^1-4

• 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. 4^th 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). 4^th 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.

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(i) Acid-Base Measurement

• pH, pO₂, pCO₂ electrodes^1,2– amperometric and potentiometric electrode and optode design and operation

• Measurement of HCO₃ using enzyme method^1,2

• Calculation of HCO3 using Henderson-Hasselbalch equation^1,2

• Calculation and measurement of oxygen saturation^1,2

• Specimen collection and preservation^1,2

• Quality Control^1,2 and Quality Assurance

• Effect of temperature and pressure on parameters^1,2

1. D’Orazio P, Meyerhoff ME. Electrochemistry and Chemical Sensors in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4^th 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). 4^th Ed. Kaplan LA, Pesce AJ, Kazmiercrak SC. Elsevier Science 2003

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(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. 4^th 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. 4^th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC. 2003.

Chapter 5. Pages 107-128.

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(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-MS^8,9

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.

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(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

Correlation. 4^th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC. 2003. Chapter 7. Pages 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.

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(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 applications^1,5

• 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. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE. Elsevier Saunders 2006. Pages 121-140.

2. Brewer JM. Electrophoresis: Theory and Practice in Clinical Chemistry: Theory, Analysis and Correlation. 4^th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC. 2003.

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.

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(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 separation^1,2

• 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. 2^nd Edition, United Kingdom: Nature Publishing group, 2001.

2. Kricka LJ. Principles of Immunochemical techniques in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE.

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

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(o) Isotopic Techniques

• Structure of the atom, fundamental particles, nomenclature^1,2

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

• Modes of decay^1,2 associated with tritium, carbon-14 and iodine-125

• Measurement of radioactivity^1,2 – gas-filled and scintillation detectors

• Applications of radio-isotopes in the clinical laboratory^1,2 - see immunoassays

• Safety considerations, waste disposal^1,2

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. 4^th 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. 4^th Ed.

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

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(p) Osmometry

• Principles of osmotic pressure and osmosis,¹ colligative properties

• Freezing point depression versus vapour pressure osmometry¹

• Osmolality versus osmolarity,¹ calculated osmolarity^1,2

• 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. 4^th 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.

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(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.

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(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 spectrometry^1,2(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. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 7: 165-190.

2. Lehrer M. Mass Spectrometry: Theory and Practice in Clinical Chemistry: Theory, Analysis and Correlation. 4^th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC. 2003.

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(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

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(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. 4^th 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.

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2. Clinical Biochemistry

(a) Water and Sodium

• Distribution of sodium and water^1,2

• Homeostatic mechanisms including renal handling, regulation by thirst, ADH, Renin- Angiotensin-Aldosterone (RAA) system and natriuretic peptides^1,2

• 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, psuedohyponatraemia^1-4

• Pathophysiology of hyponatraemia^1-4 including diuretics, renal dysfunction, SIADH, Addison’s disease liver/heart failure and other causes

• Pathophysiology of hypernatraemia;³dehydration, 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 4^th Ed. William J Marshall. Harcourt Publishers Ltd 2000. Pages 13-36.

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

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(b) Potassium

• Distribution of potassium,^1,2 homeostasis^1,2 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 hypokalaemia^1,2 including redistribution, non-renal losses, hyperaldosteronism^1,2 and inherited disorders of potassium homeostasis³ (Bartter’s, Gitelman’s syndromes)

• Pathophysiology, causes, diagnosis and clinical effects of hyperkalaemia⁴including 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, 4^th edition 2000. Harcourts Publication Limited.

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

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(c) Acid-Base Regulation

• Acid-Base parameters:^1,2 concepts of pH, pO₂, pCO₂, pK, actual bicarbonate, standard bicarbonate, dissolved CO₂, base excess

• Buffer systems^1,2 and their role in regulating pH of body fluids

• Respiratory mechanisms^1,2 in regulation of acid-base balance

• Renal mechanisms^1,2 - bicarbonate reabsorption and regeneration

• The buffer (Henderson-Hasselbalch) equation^1,2

• 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, 4^th edition 2000. Harcourts Publication Limited.

2. Burtis, Ashwood and Burns. Tietz Textbook of Clinical Chemistry and Molecular diagnosis, Chapters 27 and 46, 4^th 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

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(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

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(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 nephropathy^1,6

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

1. Sacks DB. Carbohydrates in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4^th 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.

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(f) Hypoglycaemia

• Definition, classification, adrenergic vs neuroglycopaenic symptoms^1,2

• Hypoglycaemia in context of diabetes mellitus^1,3

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

• 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 OGTT^1,2,6

• Neonatal and infant causes¹ – see paediatric section

1. Clinical Chemistry 4^th 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. 4^th 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.

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(g) Clinical Enzymology

• Clinical value of enzyme measurements – factors affecting plasma levels^1,2

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

• Aminotransferases^1,2 (AST, ALT) and GGT^1,2 – see LFTs section

• Lactate dehydrogenase^1,2 – isoenzymes and clinical significance^1,2

• Creatine kinase^1,2 – isoenzymes and clinical significance.^1,2 Macro-CK^2,3. Role in diagnosis of MI – see troponins section

• Amylase^2,4– salivary versus pancreatic. Macroamylasaemia.^2,4 Lipase and diagnosis of acute pancreatitis^2,5

• Cholinesterase – see section on Drug Metabolism & Pharmacogenetics and Poisoning

2. Panteghini M, Bais R, van Solinge WW. Enzymes in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE.

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.

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.

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(h) Proteins in Health and Disease

• Plasma proteins and their functions^1,2

• Serum protein electrophoresis – typical abnormalities seen^1,2

• Hypoalbuminaemia – differential diagnosis^1,2

• α-1 antitrypsin deficiency – diagnosis and clinical significance^1-3

• 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 chains^1,5

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

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

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(i) Gastro-Intestinal Function

• Overview of GI tract anatomy & physiology^1,2

• 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 Pancreatitis^1,2 – amylase, lipase, macro-amylase

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

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

2006. Chapter 48: 1849-1889.

3. Thomas PD, Forbes A, Green J et al. Guidelines for the investigation of chronic diarrhoea, 2^nd 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).

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(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.

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(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-betalipoproteinaemia^1,3

• 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. 4^th 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.

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(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 outcomes^1,2

• Homocysteine – recent vitamin intervention studies³

• High sensitivity CRP and other inflammatory markers – inflammatory hypothesis and critique^1,4

• 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. 4^th 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.

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(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 Syndrome^4,5

• 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.

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(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 patients^4,5

• 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

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

• Forms of calcium in plasma^1,2

• Calcium, phosphate and magnesium homeostasis^1,2

• PTH – structure, actions and secretion^1,2

• Vitamin D – structure, actions and secretion^1,2,6

• Optimal target level, replacement strategies (FAACB)

• Measurement of calcium, phosphate, magnesium and PTH²

• Clinical disorders – Hypercalemia, hypocalcemia, hyper- and hypophosphatemia, hyper- and hypomagnesaemia^1,2,7, low vitamin D

• Bone remodelling and its regulation, bone disorders^3,4

• Biochemical bone turnover markers^2,5

• Assaysfor PTH and Vitamin D

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

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

3. Willams Textbook of Endocrinology 9^th 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

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(p) Iron Studies and Haemoglobin

• Overview of iron metabolism and regulation of iron status^1,2,3

• Pathophysiology of iron deficiency; Laboratory investigation of iron deficiency^1,2 Ferritin ranges. Role of soluble transferring receptors (StFR)^1,4

• Iron overload syndromes. Investigation of genetic haemochromatosis and non-HFE hereditary iron overload syndromes^2,5

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

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(q) Pituitary Function

• Physiology – anterior and posterior pituitary function^1-3

• Clinical features of hypopituitarism and investigation^1-3

• Growth Hormone^1-3 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 investigation^2,5

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

1. Demers LM. General Endocrinology in Clinical Chemistry: Theory, Analysis and Correlation. 4^th Ed. Kaplan LA, Pesce AJ, Kazmierczak SC. 2003. Chapter 43. Pages 809-26.

2. Demers LM and Vance ML. Pituitary Function in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 50: 1967-2002.

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.

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(r) Thyroid Function

• Biochemistry and physiology of thyroid hormone production and function^1,2

• 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 diseases^2,4,5

• Interpretation of thyroid function tests in treated and non-treated thyroid disorders^2,4,5 Interpretation of thyroid function tests in pregnancy^6,7

• Effects of drugs on thyroid function and thyroid function tests^1,2,5,7

• Thyroid function test interferences^1,2,5,7

• Causes and management of discrepant thyroid function test results^1,2,5,7

• Awareness of associated assays and their use in thyroid disease including thyroglobulin, thyroid autoantibodies and TSH receptor antibodies^1,2,7

• Screening for neonatal hypothyroidism^1,6,7

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).

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(s) Adrenal Function

• Cortex versus medulla - steroid and catecholamine pathways^1-3

• Congenital adrenal hyperplasia – pathophysiology and investigation^1,2

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

• Cushing’s syndrome^1,2 – pathophysiology, differential diagnosis, screening tests and further investigation

• Hyperaldosteronism^1,2 – approach to investigation; renin and aldosterone

• Adrenal tumours^1,2 – role of DHEA-S

• Analytical methodologies for adrenocortical hormones²

• Phaeochromocytoma^1,3,4 – 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)

2. Demers J. The Adrenal Cortex. in Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4^th 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 Molecular Diagnostics. 4^th Ed. Burtis CA, Ashwood ER, Bruns DE. 2006. Chapter 29:

1033-1074.

4. Lenders JWM, Eisenhofer G, Mannelli M, Pacak K. Phaeochromocytoma. Lancet 2005; 366: 665-675.