งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

Laboratory interpretation Lalita Norasetthada, MD Hematology Division, Department of internal medicine, CMU.

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งานนำเสนอเรื่อง: "Laboratory interpretation Lalita Norasetthada, MD Hematology Division, Department of internal medicine, CMU."— ใบสำเนางานนำเสนอ:

1 Laboratory interpretation Lalita Norasetthada, MD Hematology Division, Department of internal medicine, CMU

2 Laboratory interpretation Hematology lab ▫ CBC ▫ Coagulogram Blood chemistry ▫ Liver function ▫ Kidney function ▫ FPG and lipid profile Serologic test

3 Normal Laboratory Values 2 SD Abnormal Normal normal values = mean ± 2SD of normal population

4 CBC : Complete Blood Count

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6 ปริมาณลดลง ▫ การติดเชื้อไวรัส ▫ ยาบางชนิด ▫ โรคของไขกระดูกทำให้สร้างเม็ดเลือดขาว ลดลง ปริมาณเพิ่มขึ้น ▫ การตอบสนองของร่างกายปกติที่เกิดใน ภาวะติดเชื้อหรือการอักเสบ (< 30,000/uL) ▫ มะเร็งเม็ดเลือดขาว Normal range 4,500-10,000 cell/mm x 10 3 /uL White blood cell count

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9 WBC morphology

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12 การ ตรวจ ค่าผลการตรวจ ต่ำ สูง Hemog lobin Hemat ocrit - ภาวะเสียเลือด - ขาดสารอาหาร เช่น ธาตุเหล็ก, ขาดวิตามิน - ภาวะเม็ดเลือด แดงแตก จากการ ติดเชื้อ, สารพิษ, ยา หรือดแตกเอง ในร่างกาย - ไขกระดูกผ่อหรือ ไม่ทำงาน - มะเร็งของเม็ด เลือด - ขาดสารน้ำ - ภาวะที่มี OXYGEN ในเลือดต่ำเรื้อรัง เช่น สูบบุหรี่ - ไขกระดูกสร้างเม็ด เลือดสูงผิดปกติ

13 RBC morphology

14 Concerning values For general dental procedure ▫ Hb > 7 gm/dl Procedure under GA ▫ Hb > gm/dl

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16 การนับจำนวนเกร็ดเลือด (platelet count) Platelet count ▫ 100, ,000/mm 3 ▫ x 10 3 /uL

17 การตรวจค่าผลการตรวจ ต่ำ สูง เกร็ด เลือด - ม้ามโต - เกร็ดเลือดถูก ทำลายมากขึ้น จาก ยา, ภูมิต้านทาน - เกร็ดเลือดสร้าง ได้น้อยจากความ ผิดปกติของไข กระดูก ไขกระดูกฝ่อ หรือทำงาน ผิดปกติ ไขกระดูกถูก แทรกซึมจาก การติดเชื้อหรือ มะเร็ง โรคมะเร็งเม็ด เลือด - การอักเสบหรือการ ติดเชื้อเรื้อรัง - มะเร็งของอวัยวะอื่น - โรคไขกระดูกสร้าง เม็ดเลือดเพิ่มมาก ผิดปกติ - มะเร็งเม็ดเลือดขาว เรื้อรัง

18 Platelet morphology

19 Increased risk of bleeding when Platelet count ▫ <50,000/mm 3 or < 50 x 10 3 /uL ▫ > 1,000,000/mm 3 or > 1,000 x 10 3 /uL In mild thrombocytopenia, all dental procedure can be done safely (50, ,000/mm 3)

20 Coagulation test

21 Primary hemostasis

22 Secondary Hemostasis In vivo In vitro

23 Coagulation test PT : prothrombin time ▫ Range 8-11 seccods aPTT : activated partial thromblastin time ▫ Range seconds

24 Isolated PT Prolongation Inherited FVII deficiency Acquired Vitamin K deficiency Liver disease Warfarin administration Inhibitor of FVII

25 Isolated PTT prolongation Inherited Deficiency of F VIII, IX, XI Deficiency of FXII, prekallikrein, HMW kininogen VWD Acquired Lupus anticoagulant Inhibitor to FVIII, IX, XI, XII Heparin administration

26 Combined PT and PTT prolongation Inherited Deficiency of FV, X, fibrinogen, prothrombin Acquired Liver disease DIC Supratherapeutic dose of warfarin and heparin Inhibitor of FV, X, fibrinogen, prothrombin Primary amyloidosis associated FX deficiency

27 Bleeding risk Increased risk of bleeding after invasive procedure when ▫ Either PT or aPTT increases > 1.5 folds above mid normal range ▫ Ex.  PT 24 secs (8-12), INR 2.5  PTT 40 secs (28-32)

28 Bleeding disorder in the setting of normal screening test Platelet dysfunction ▫ Drug : aspirin, NSAID, clopidrogrel ▫ Chronic disease : liver/kidney failure ▫ Hereditary disorder Impaired fibrin crosslink and fibrinolytic disorder

29 Blood Chemistry BUN Cr Albumin / Globulin GOT / GPT Alk. Phosphatase Cholesterol Bilirubin Cholesterol Triglyceride HDL LDL Plasma glucose Kidney function Liver function test Lipid Profile

30 Kidney function test

31 Laboratory test to evaluate kidney function Glomerular filtration rate (GFR) Plasma creatinine Plasma urea Urine volume Urine electrolytes, protein, urea, osmolality

32 Glomerular filtration rate Value always adapted to the BSA!! Ideal BSA in adults is 1.73m 2 Schwartz equation : GFR= v x P cr (umol/L) How to assess easy if plasma creatinine is OK

33 Creatinine and Urea Plasma Concentration- hyperbolic correlation GFR 50% pCr,pUrea 140 mL/min (100%) 0 mL/min (0%) Lower limit 90 ml/Min./1.73 m 2 Normal range->

34 Plasma urea (BUN) BUN (blood urea nitrogen) mg/dl Urea: product of protein catabolism Synthesized by liver, excreted by kidney, partially reabsorbed in tubuli Plasma concentration increases with decreased GFR

35 BUN in patients with kidney diseases Useful test but must be interpreted with great care ▫ urea plasma level is more than creatinine dependent on protein intake Most useful when considered along with creatinine ▫ High in high protein intake, UGI bleeding ▫ Low in severe liver dysfunction

36 Creatine Creatinine (Waste product) H2O Creatine : main storage compound of high energy phosphate needed for muscle metabolism Creatinine: anhydride of creatine Creatinine is freely filtered by the glomerulii and is not reabsorbed Plasma creatinine and renal function

37 Plasma creatinine Male mg/dL, Female mg/dL Pre-renal disorder ▫ BUN:Cr ratio >20 Renal and postrenal disorders ▫ BUN: Cr both elevated Analytic method

38 Liver function test

39 Liver Function Test Liver chemistry testClinical implication of abnormality ALTHepatocellular damage ASTHepatocellular damage BilirubinCholestasis, impair conjugation, or biliary obstruction ALPCholestasis, infiltrative disease, or biliary obstruction PTSynthetic function AlbuminSynthetic function GGTCholestasis or biliary obstruction Bile acidsCholestasis or biliary obstruction 5`-nucleotidaseCholestasis or biliary obstruction LDHHepatocellular damage, not specific

40 Normal values

41 Advantages Sensitive, noninvasive method of screening liver dysfunction Pattern of laboratory test abnormalities to recognize type of liver disorder Assess severity of liver dysfunction Follow cause of liver disease Disadvantages Not specific for liver dysfunction Seldom lead to specific diagnosis Liver Function Test

42 Liver function test

43 Classified in 3 groups Synthetic function : albumin, prothrombin time (PT) Hepatocyte injury : AST, ALT Cholestasis : bilirubin, ALP, GGT PT, albumin, bilirubin : most common tests used as prognostic factors Liver Function Test

44 Liver function test

45 Albumin Depending on nutrition, volume status, vascular integrity, catabolism, hormone, loss in stool and urine Not specific for liver disease T1/ D

46 Globulin Produced by stimulated B-lymphocyte Elevation in chronic liver disease chronic inflammation and malignant disease

47 Hypoalbuminemia globulinchol/TGHb 1.decrease synthesis -protein malnutrition -chronic liver disease -chronic inflammation 2.increase loss -Protein loosing enteropathy -NS 3.increase Vd (ascites, overhydration)

48 Metabolic Syndrome

49 Abnormal Lipid Metabolism LDL  ApoB  HDL  Trigly.  Abnormal Lipid Metabolism LDL  ApoB  HDL  Trigly.  Cardiometabolic Risk Global Diabetes / CVD Risk Overweight / Obesity Inflammation Hypercoagulation Hypertension Smoking Physical Inactivity Unhealthy Eating Smoking Physical Inactivity Unhealthy Eating Age, Race, Gender, Family History  Glucose  BP  Lipids Age Genetics Insulin Resistance Insulin Resistance Syndrome Insulin Resistance Syndrome Cardiometabolic Risk - Graphic

50 Interpreting Blood Glucose Levels Fasting glucose : No caloric intake > 8 hours ▫ Healthy BG FPG < 100 mg/dL ▫ Pre-diabetes FPG 100–125 mg/dL (Impaired fasting glucose) ▫ Diabetes FPG ≥126 mg/dL Random plasma glucose ▫ PG > 200 mg/dl Fasting glucose : No caloric intake > 8 hours ▫ Healthy BG FPG < 100 mg/dL ▫ Pre-diabetes FPG 100–125 mg/dL (Impaired fasting glucose) ▫ Diabetes FPG ≥126 mg/dL Random plasma glucose ▫ PG > 200 mg/dl

51 Total Cholesterol Goals34 Desirable — Less than 200 mg/dL Borderline high risk — 200–239 mg/dL High risk — 240 mg/dL and over Desirable — Less than 200 mg/dL Borderline high risk — 200–239 mg/dL High risk — 240 mg/dL and over American Diabetes Association. Understanding Cardiometabolic Risk: Broadening Risk Assessment and Management, Dyslipidemia Richard M Bergenstal, MD International Diabetes Center

52 Lipid profile No caloric intake > 12 H Lipid profle ▫ Total choleterol ▫ LDL ▫ HDL ▫ TG

53 Cholesterol Management Category of riskLDL-C Goal 0-1 risk factor*< 160 mg/dL or lower Multiple (2+) risk factors*< 130 mg/dL or lower People with coronary heart disease or risk equivalent (e.g., diabetes) < 100 mg/dL or lower Known CAD and DM < 70 mg/dL or lower may be ideal LDL-C-lowering

54 Serologic tests

55 Test and window period Virusmarker window period meanrange HBVHBsAg HCVanti-HCV HIVanti-HIV-1/ HTLVanti-HTLV-I NAT yield in Thailand : The National Blood Centre Thai Red Cross Society HIV 1:97,000 HCV 1:490,000, HBV 1:2,800

56 Viral hepatits Acute ▫ AntiHAV ▫ HBsAg Chronic ▫ HBsAg ▫ AntiHCV

57 Main Ways to Get Hepatitis A Fecal-oral route

58 Viral hepatitis A

59 Having sex without condoms with someone who has hepatitis B Main Ways to Get Hepatitis B Sharing needles and syringes Being born to a mother who has hepatitis B Receiving blood component from HBV infected donor

60 Natural history of HBV - related infection Acute hepatitis Contamination ResolutionChronic infection 95% Chronic hepatitis 5% Inactive carriage HCC Cirrhosis 3-5% yearly Asymptomatic 30% Fulminant hepatitis 1% 66% 33% 10-20%

61 Viral hepatitis B

62 If you have never had hepatitis B, you can get 3 shots and get long lasting protection. 321 Hepatitis B can be prevented!

63 Main Ways to Get Hepatitis C Sharing needles and syringes Receiving blood component from HCV infected donor

64 Hepatitis C Virus (HCV) HCV Infection -Acute infection -Mild symptoms % of affected patients develop chronic hepatitis -20% of affected patients develop cirrhosis or hepatocellular carcinoma

65 Viral hepatitis C

66 HIV infection AIDs situation in Thailand, March 2011 Prevalence 0.6% ▫ Total HIV infected cases 372,874 persons ▫ Already died 98,153 persons

67 Having sex without condoms with HIV infected persons Main Ways to HIV Sharing needles and syringes Being born to a mother who has HIV Receiving blood component from HBV infected donor

68 Strauss JM & Strauss EG,2002 HIV

69 Who to Test for HIV High risk groups include ▫ MSM ▫ Injection drug users or history injection drugs ▫ Heterosexual partners of those listed above ▫ Those interested in HIV testing ▫ People presenting with an opportunistic infection or recurrent/severe infections that can not otherwise be explained

70 HIV Testing EIA- standard serologic screening test ▫ Needs to be repeatedly positive ▫ Should not give the patient this test result until confirmed Western Blot-confirmatory test. ▫ 2 bands of the following: p24, gp41 or gp120/160  Antibodies to p24 and p55 appear earliest but decrease or become undetectable.  Antibodies to gp31, gp41, gp120, and gp160 appear later but are present throughout all stages of the disease ▫ EIA and Western Blot >99.9% sensitive and specific

71 Window period in HIV infection

72 HIV Testing 4-20% of test results are indeterminate with WB assays with positive bands for HIV-1 proteins Causes of indeterminate tests include ▫ Patients in the process of seroconversion ▫ HIV-2 infection ▫ Cross-reacting nonspecific antibodies ▫ Testing should be repeated at 6-8 weeks, 3, and 6 months

73 HIV Testing Rapid testing ▫ Two tests FDA approved, SUDS and Oraquick ▫ Oraquick much easier and very accurate ▫ Sensitivity and Specificity is 99.5% ▫ Positives still need confirmation ▫ Similar to performing a pregnancy test

74 The End


ดาวน์โหลด ppt Laboratory interpretation Lalita Norasetthada, MD Hematology Division, Department of internal medicine, CMU.

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