4th week

hello! i've been posted to Histopathology. Honestly, i feel that it has been an intriguing month. i feel blessed to be embarking on this mirthful journey with Ernest and Ying Chee. Being part of the Histopathology Lab has helped paint a picture of what Histopathology is all about. Htech finally makes more sense now. Since i am in a routine lab, i shall focus more about embedding for this week. However these are the events in Histopathology Lab:

1. Specimens from a surgery are sent to the Specimens Receiving room. These specimens are kept in containers filled with formalin. Each specimen is allocated a biopsy number.

2. Specimens are transported into the trimming room. The larger specimens such as breast, colon, liver, lungs are trimmed by pathologists. On the other hand, the smaller specimens are handled by the medical technologists as they do not require trimming of any sort. The medical technologists have to solely place the small tissues into filter papers and subsequently into cassettes. This is to ensure that they are not lost when placed into the tissue processor. The area of interest of the larger specimens are trimmed and placed into cassettes. For example, for a breast specimen, one of the most important area is the lymph nodes. Hence the lymph nodes are extremely sort after by the pathologists. The pathologists will practically be frisking for the lymph nodes as they are rather minute. The cassettes are then shut and placed into a container of formalin. This is done by the medical technologist assisting the pathologist. Also, biopsy number is written on each cassette containing any tissue by the med tech. The med tech must also record the name of the pathologist performing the trim and the number of cassettes used for the case.

3. The container of formalin filled with cassettes will be placed into the tissue processor for 9.5 hours.

4. The tissues are then ready for embedding. This is the part which i would like to discuss in my entry. This is because i have been observing how embedding is done for about a week and ulteriorly i was given the chance to embed the specimens myself. With close supervision, for sure.

a) Depending on the size of the tissue, a suitable mold is chosen.Retrieved July 19, 2008, from,

http://www.leitzmicro.com/website/products.nsf?open&language=english&path=/website/products.nsf/(allids)/77de5e12c4f02672c1256a72004c1348

b) The mold is partially filled with wax. The mold is placed on the cold plate and the tissue is orientated in the mold. This has to be done simultaneously to ensure that the wax does not cool down completely before the tissues are properly orientated. If that happens, the position of tissue in the cooled wax will be uneven and this will hinder smooth-sailing sectioning during microtomy later. The mold is placed on the cold plate to provide a "third hand". When the wax is partially cooled, the tissue will not be floating around. By the way, the tissue is picked up from the cassette and into the mold using an electrically heated forceps. As it is hot, the chances of tiny tissues getting stuck on the forceps are arguably zilch. Henceforth, using those forceps hinders contamination.

Retrieved July 19, 2008, from,

http://www.leitzmicro.com/website/products.nsf?open&language=english&path=/website/products.nsf/(allids)/0215b39eb7698a5641256ab60036fc0f


Even the way tissues are orientated is crucial. Take cyst for example, the cyst wall is the part of interest. Therefore, when embedding, the cyst wall must be at the base of the mold. The senior med tech termed is as "block standing". When embedding, i believe the most important reminder to note is, to ensure that the tissues are pressed flat down. Of course, this has to be performed gently to prevent any smashed tissues as a result. The cover of the cassette is discarded while the base of the cassette is placed on top on the mold. Wax is dispensed for the second time above the cassette.

c) The mold is then placed on the cold plate until the wax is fully cooled. When the wax has wholly cooled down, the tissue block can be removed from the mold easily.




5) The tissue block is sectioned using the microtome.

6) The tissue is placed in the waterbath for fishing.

7) The slide is dried on the hot plate.

8) The slide is loaded into the H&E autostainer.

9) Slides are sent for sorting to be sent to the various pathologists for examination.



Nurathirah
0606561I
Tg01

3rd week of SIP

Name: Hardina Bte Hamzah

Topic: Histology
There are many processes that take place in Histopathology Laboratory.
Firstly, specimens will be sent by the portal assistant. There are steps to follow when receiving the specimens. We need to check the information on the requisition form against specimen bags or bottles to ensure it tallies. The specimens will then be given specific numbers as identification. We must ensure that the specimen bottles or bags are labeled properly to ensure accuracy. Formalin is present in each packaging to preserve the specimens.

The specimen will be inspected by the medical technologist or assistant pathologist after receiving. The gross description of the specimen is recorded. The specific parts of the specimen will be taken and placed in cassettes to be processed. Specimens that have been placed in cassettes will be loaded into a tissue processor. All the reagents needed are present in the tissue processor. For example, reagents like formalin, alcohol, xylene and wax. The specimens will undergo dehydration to remove water and immerse in xylene to remove excess alcohol. Then they will be exposed to hot liquid paraffin turning soft, moist tissues into a sample miscible with paraffin. This process will only be done at the end of the day as it takes 14 hours to finish.
When the tissue processing is done, drain out all the excess wax present in the chamber before taking out the specimens. Embedding is done after tissue processing. Wax is half-filled into embedding mould and the tissue is placed inside. The tissue is pressed down so that all the parts of the tissue will be exposed when it is cut into thin sections. Then, the base of the cassette is placed on top of it and more wax is added. The mould will be put on ice to cool is faster. After it cools, the paraffin block is removed from the mould. After embedding is done, the baskets will be loaded into the tissue processor and flushing will occur. This process will remove the excess wax and clean the baskets.

The paraffin block is cut into thin sections (3µm) by using microtome. We must be very careful when using microtome as the blade is sharp and can injure our fingers. After sectioning, the section is placed into a water bath with the temperature between 43-50°C to allow the section to expand. Then, fishing is done by orienting section properly onto slide. We must maintain the water bath at the correct temperature and free of debris to prevent contamination. The work area has to be cleaned daily to ensure cleanliness.

The slides with the tissue on them will be placed in the oven of temperature between 85-90°C to melt the wax and fix the tissues on the slides. Then, the slides are loaded into the autostainer to undergo H&E staining. Firstly, it will hydrate the tissues (1. Xylene: to remove wax, 2. Alcohol: to clear xylene) and stain with haematoxylin. Then, wash the slides to remove excess haematoxylin. The tissues are then stained with eosin and later undergo dehydration (1. Alcohol: to remove water, 2. Xylene: to clear alcohol). Depex are then placed on the tissues followed by coverslips. This is done by a machine. This process is mainly automated.
These slides are then labeled and re-checked against paraffin blocks to ensure no mistake is done before sending them to pathologist.

Topic: Cytology
Conventional Pap Smear
Pap smear is the smearing of cells from the cervix and staining it with Pap stain. The pathologist will then observe the slides to see if there are any cancerous cells or infection.
Firstly, I will explain on how to obtain the sample and make a smear.
1. Insert a broom-like device into the vagina.
2. Ensure that it comes into contact with the ectocervix.
3. Gently push the device and rotate clockwise for 5 times to ensure that enough cells are collected.
4. The doctor will then smear the cells onto a glass slide thoroughly and spray-fixed the smear before sending to the lab.

However, several problems have been discovered when using the conventional Pap smear.
After the cervical sample has been collected using the broom-like device, the cells will be smeared onto the slide. However, over 80% of collected sample is discarded and higher chances that the cancer cells will not be smeared onto the slide. After staining the slide, it will then be observed under the microscope. Due to the smearing technique, the cells tend to clump together and will have difficulties to identify cells. In addition, as 80% of collected sample is discarded, there will be missing cells which restrict from producing an accurate diagnosis. It will not reflect the patient’s actual condition.
Therefore, a new method is introduced.

Liquid- based Cytology (LBC)
After cervical sample is collected using the broom-like device, the device will be rinsed into a vial containing preservatives. This ensures that 100% of collected sample is present in the vial and no cells are left on the device. This sample will then be processed using a processor. This process is automated. The processor will stir the solution in the vial to disperse the cells. Cell will be collected onto a filter by suction. Cells will then be transferred onto a slide by making the filter come into contact with the slide. This will produce a thin layer of cells and minimize the clumping of cells. With this, it will allow the pathologist to detect any abnormalities.

2nd week of SIP

Name: Nurdyana Abdul Rahman
Topic: CELL-DYN RUBY

Picture taken from: http://www.abbottdiagnostics.com/Products/Instruments_by_Platform/default.cfm?system=cell-dyn&suffix=ruby

HEY people!How's your SIP?I hope its going great aite. As for me, I was attached to the Haematology Lab for the first 2 weeks. Most of the tests there are done by analysers which makes the job of a Medical Technologist much easier. However, Medical Technologist is still responsible for the proper sorting out of the samples and maintaining the machinery so that the result obtain would be accurate. Here is one of the analyser that I use to perform Full Blood Count(FBC).

CELL-DYN RUBY

The CELL-DYN RUBY is use to perform full blood count and retics. It uses the optical technology which is Multi-Angle-Polarized Scatter Separation (MAPSS). It helps to differentiate the different white blood cells and at the same time also measure the full blood count such as MCT, MCV, Hb, WBC, RBC and etc.

Upon receiving EDTA blood sample, checking of clot in the blood is done manually before the EDTA sample is placed into the CELL-DYN RUBY. EDTA sample is checked to see if clot is present because in presence of clot, it will affect the overall full blood count. If blood is found to be clotted, the sample is rejected and a request for a new EDTA blood sample is done. Sometimes, blood are clotted in EDTA tube because it has not been mixed thoroughly. Wherelse for sample that are not clotted, they are placed into a rack which will then enter the CELL-DYN RUBY. Results will directly be uploaded into the LISS.

As for retics, the amount of reticulocytes are counted. The test is slightly different from FBC. It requires prior preparation before loading it in the analyser. 20microlitres of the sample is added to the reticulocyte reagent tube and mixed well. It is then incubated before it is run. Incubation should be between the range of 15minutes to 2hours.

In the laboratory that I am attach to, there are two of the same analysers. Which means there are 2 CELL-DYN RUBY. Two analysers are use together at the same time so to ensure that the turnaround time is shorter. Maintainence of analyser are done once a week. Since there are two analysers running at the same time, correlation is done twice daily. Once in the morning and the other in the evening. Correlation is done by using the same EDTA sample and running it in both machine. Since it is the same EDTA sample, both machine will have to produce similar results to indicate that they are working properly and according to standards. This is also part of the maintainence of the machine. Autovalidation is also done. Every 10 samples, a random sample is collected and result of that random sample is printed form LISS. Peripheral blood film is done and stained. It is then viewed under microscope to manually count and observe the cells. This is to ensure that the analyser is working well.

I hope with this information you guys have learnt and now know another brilliantly invented analyser that makes life of a Medical Technologist easier. Good Luck for your coming weeks!!!

Peace,
Dyana.

SIP

Subject Title: Microbiology
Name of Test: VDRL

Hello guys! Hope all of you are enjoying your SIP =)


For the first three days, I was attached to the Microbiology lab. I will be sharing with you about VDRL test which I was allowed to perform on urgent and routine specimens over the three days.

Test: Venereal Disease Research Laboratory (VDRL)


Principle:

• VDRL is a screening test for syphilis which is a Sexually-Transmitted Disease.
• Syphilis is caused by Treponema pallidum which is from the spirochetes group which consists of the spiral and motile bacteria.
• Reagin antibodies are produced when one is infected with syphilis. Reagin antibody is a mixture of IgM and IgG antibodies.
• This test uses nontreponemal antigens which are extracted from normal mammalian tissues. Lecithin and cholesterol are usually added to enhance the reaction.
• The reagent contains carbon particle cardiolipin antigens (extracted from beef heart) which will bind to the reagin antibodies causing visible clumping.
  

Materials:

1. Cards with 10 circles measuring 18mm






Retrieved June 29,2008, from http://www.bd.com/ds/productCenter/DT-MacroVueComponents.asp





2. Plastic dispensing tubes (Dispenstirs)







Retrieved June 29, 2008, from http://www.bd.com/ds/productCenter/DT-MacroVueComponents.asp

3. Reagent
4. Patient's Serum
5. Rotator











Retrieved June 29, 2008, from http://www.bd.com/ds/productCenter/DT-MacroVueComponents.asp






Method:




1. Using the dispensing tubes, dispense 1 drop of patient's serum onto the one of the 18mm circles. Since there are 10 such circles on one card, the test can be done on 10 patients' serum at one go.

2. Spread the patient's serum using the flat part of the tubes as shown in the picture, making sure the serum does not flow out of the circle.



3. Dispense 1 free falling drop of reagent onto the serum.



4. Bend the card downwards using both of your hands to prevent the serum from entering into another circle when the card is being rotated.


5. Place the card on the rotator which rotates at 100 rpm for 8 minutes.


6. Read the results macroscopically by rotating and tilting the card 3-4 times in a to-and-fro motions





Results:








Retrieved 29 June, 2008 from http://www.bmb.leeds.ac.uk/mbiology/ug/ugteach/dental/tutorials/std/vdrlexplain.html

Upper left circle: results are reported as non-reactive as there is no clumping
Upper and lower right circles: results are reported as reactive as there is visible clumping

Note:

• Once, when the supervisor was performing the test, he got a reactive specimen. After which, he did serial dilution to determine the antibody titre.
• Both positive and negative control must be carried out using the control solutions which are available with the kit. This is to confirm that the reagent is working.

Reference:

1. http://www.bd.com/ds/technicalCenter/clsi/clsi-RPR.pdf

2.http://www.bmb.leeds.ac.uk/mbiology/ug/ugteach/dental/tutorials/std/vdrlexplain.html

3.http://www.bd.com/ds/productCenter/DT-MacroVueComponents.asp

2. Geo. F. Brooks., Karen C. Carroll., Janet S. Butel., & Stephen A. Morse. (2007). Medical Microbiology. USA: The McGraw-Hill Companies,Inc.

Name: Nur Farhana Binte Ramlan

Admin No: 0604834B

Laboratory Management and Quality Assurance

Name: Sutiana Bte Kamis

Subject Title: Laboratory Management and Quality Assurance

Topic: Organization or regulatory bodies that regulate the operations of clinical laboratories in Singapore

SPRING Singapore is the national standard authority that is responsible for the standardization of Singapore’s industry activities. The organization is the member body of the International Organisation of Standardization (ISO).1, 2

SPRING Singapore helps to align Singapore standards with international standards.They are guided by the national Standard Council which oversees the nation standardization programme in key industry sectors including medical technology.1,3

Semi-automated and automated instruments are widely used in clinical laboratories especially in Clinical Chemistry. Hence the use of ISO ensures the accuracy of the laboratories operations thus lead to good quality results.

1. National Standard Body (2007). Retrieved 16 June, 2008, from Spring Singapore. Website: http://www.spring.gov.sg/Content/WebPageleft.aspx?id=e6ff85fa-
58ad-4dd3-b307-92efe370d03c

2. International Standards Bodies/Regional Standards & Conformance Fora (2007). Retrieved 16 June, 2008, from Spring Singapore. Website: http://www.standards.org.sg/AboutUs.cfm?id=AU1001

3. The Singapore Standard Programme (2007). Retrieved 16 June, 2008, from Spring Singapore. Website: http://www.standards.org.sg/

Laboratory Management and Quality Assurance

Name: Nurdyana Binte Abdul Rahman

Subject Title: Laboratory Management and Quality Assurance

Topic: Organization or regulatory bodies that regulate the operations of clinical laboratories in Singapore

Ministry of Health(MOH) is one of the regulatory bodies operations of clinical laboratories in Singapore. It had come up with more than 20 Acts which regulate public health and safety1. This would include the healthcare profession, healthcare practices or establishment as well as charges if terms and conditions are violated1. For instance, the Private Hospitals and Medical Clinics Act serves in providing for the control, licensing and inspection of private hospitals, medical clinics, clinical laboratories and healthcare establishments, and for purposes connected with any form of medical practices2. An example would be the Department of Laboratory Medicine of Tan Tock Seng hospital is licensed under MOH and CAP3.

1. Legislation. (2007). Retrieved 16 June, 2008, from: http://www.moh.gov.sg/mohcorp/legislations.aspx?id=214

2. Private Hospitals and Medical Clinics Act. (2008). Retrieved 16 June, 2008, from: http://statutes.agc.gov.sg/non_version/cgi-bin/cgi_retrieve.pl?actno=REVED-248&doctitle=PRIVATE+HOSPITALS+AND+MEDICAL+CLINICS+ACT%0A&date=latest&method=part&sl=1

3. Clinical Specialties. (2006). Retrieved 16 June, 2008, from: http://www.ttsh.com.sg/new/clinicalspecial/laboratory.php

Laboratory Management and Quality Assurance

Name: Nurathirah Md Sharoni

Subject Title: Laboratory Management and Quality Assurance

Topic: Organization or regulatory bodies that regulate the operations of clinical laboratories in Singapore

• WSH (Workplace Safety and Health) Council collaborates with MOM. It is accountable for; enhancing capabilities of industry to improve WSH, encouraging safety and health at work, acknowledge companies with good WSH records, and setting acceptable WSH practices. 1

• It ensures that workers are aware about safety and health hazards in labs. Subsequently, appropriate actions are made to reduce the risks. 2

• It provides health and environmental surveillance as exposure to toxic substances could lead to occupational diseases. 3

• It ensures that reports of incidents are made when there are workplace accidents, dangerous occurrence (eg. explosion in lab) or occupational diseases (eg. toxic hepatitis). 4

1. About WSHCouncil. (2008). Retrieved June 13, 2008, from: http://www.wshc.gov.sg/about_us.html

2. Risk Management (2008). Retrieved June 14, 2008, from: http://www.mom.gov.sg/publish/momportal/en/communities/workplace_safety_and_health/maintaining_a_safe_workplace/occupation_safety/risk_management.html#reg

3. Safety and Health Management. (2008). Retrieved June 15, 2008, from: http://www.mom.gov.sg/publish/momportal/en/communities/workplace_safety_and_health/maintaining_a_safe_workplace/health_and_environmental.html

4. Incident Report. (2008) Retrieved June 15, 2008, from: http://www.mom.gov.sg/publish/momportal/en/communities/workplace_safety_and_health/maintaining_a_safe_workplace/report_incident/What_is_an_Incident_Report.html