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UAB’s staff of medical detectives—pathologists, medical technologists, cytotechnologists, and others—perform more than 4.5 million tests per year in the university’s clinical labs. With clues provided by surgeons and clinicians, this cadre of highly-trained personnel works around the clock to make accurate, rapid diagnoses that support patient care. From performing routine assessments to solving unusual cases, UAB’s clinical lab staff makes sure that doctors have the right information to treat their patients and keep them well.

It’s in the Blood

No two patients who arrive at UAB Hospital are the same, but they all have very specific health needs that can be tricky to identify. For example, patients who are at risk for blood clots, heart attacks, or strokes—or those who have clotting disorders that put them at risk for hemorrhage—need particular treatment protocols. A physician may know or suspect these conditions based on a physical exam or patient history, but a workup of a blood sample will confirm the diagnosis and its severity. UAB pathologist Marisa B. Marques, M.D., an expert in coagulation and transfusion medicine, notes that clinical lab staff must understand both the biology of disease and the technicalities of analysis in order to solve sometimes quite complicated diagnostic puzzles.

“In the coagulation lab, we must mimic what happens in the blood vessel in a test tube,” she says. From a typical blood sample, the clinical lab staff prepare plasma and mix it with reagents that induce clotting. By measuring the clotting time relative to normal reference ranges, Marques and her staff can begin to pinpoint any defects. “In some cases, a patient’s history is so characteristic that it practically tells you which tests will confirm your suspicions,” she says. “However, numerous drugs affect rates of clotting, making it a challenge to understand the results in light of everything that may be happening in the patient’s system.”

As a hematopathologist, Vishnu Reddy, M.D., analyzes blood, bone marrow, tissue biopsies, and lymph nodes in cases where cancers or other blood abnormalities are suspected. Reddy notes that the analysis of blood has both quantitative and qualitative aspects. Clues come from the blood morphology—what the cells look like—and the relative numbers of various blood cells, such as red and white blood cells and platelets. “These two strategies give us information about whether or not the patient’s condition is benign, and also which additional tests we should perform,” Reddy says. For example, in cases where leukemias are suspected, Reddy uses flow cytometry with markers that identify specific types of cells. “If we know whether the aberrant cells are lymphoid or myeloid cells, then we can diagnose the type of cancer and recommend certain treatment modalities.”

However, Reddy sees his share of cases that defy conventional diagnosis. “Our goal is to make a reasonable diagnosis using a minimal number of tests,” he says. Standard panels of tests will answer 80 to 90 percent of the questions, but transient conditions—such as fever, vitamin deficiencies, or infections, and conditions such as Down’s syndrome that mimic aspects of leukemia—add a fair share of twists and turns to Reddy’s job. “We really have to stay current on the latest developments in technology and the understanding of disease,” he says, noting that a missed clue on his part could delay patients’ receiving their proper diagnoses. “Being able to make the distinctions on those ‘outside consult cases’ makes the difference in terms of whether the patients receive the correct treatment.”

Invaders and Malignancies

Pathologist Ken Waites, M.D., knows all too well the challenges of diagnosis in the clinical care setting. As director of the Diagnostic Mycoplasma Laboratory and head of the Section of Clinical Microbiology, Waites oversees the diagnosis of bacterial, fungal, and parasitic infections. “Any time an infectious process is suspected in an admitted patient, the diagnostic microbiologists are called,” he says. In practice, that means analyzing samples that are as diverse as the underlying conditions themselves; a kidney infection requires a urine sample, whereas a suspected case of meningitis must be tested in cerebrospinal fluid.

Each specimen type must also be handled uniquely in order to learn its secrets. Waites says that in some cases, such as bacterial infections, the microorganisms can be isolated and identified from a culture. However, in viral infections such as hepatitis or HIV, where microorganisms aren’t detectable by culture, the immunology lab may be called to test for the presence of an immune response. Waites notes that the diagnosis of infectious diseases has implications beyond those for the individual patient. “Some of these diseases could be transmitted to hospital staff or other patients,” he says. “To ensure safety and quality control in the hospital setting, we must identify infections rapidly and accurately.”

“Accurate diagnosis in real time is the ultimate challenge for clinical services staff,” notes pathologist Michael Klein, M.D. As head of the Section of Surgical Pathology, Klein oversees the analysis of samples from UAB’s operating rooms, from cosmetic procedures to removal of cancerous tumors. For biopsies, Klein’s staff embed tissue samples in paraffin and fix them to a slide, where they are stained and their cellular components examined. The staff then provide a written diagnosis for almost all biopsy samples within 24 hours.

However, certain surgeries require that the surgeon have an answer during the course of the operation. In a laboratory located within the operating-room suite, Klein and his staff perform frozen sections to provide surgeons with real-time diagnoses, often within 10 minutes of an operative biopsy. “We are each involved in diagnosing 3,000 to 5,000 specimens per year,” he says. “It’s quite rewarding to affect the disease management of so many patients.”

Keeping Current

Considering the number of diagnostic tests ordered for patients in UAB Hospital alone, the growing need for qualified clinical laboratory professionals is clear. Those who assume positions in clinical labs undergo thorough training in programs such as UAB’s bachelor’s degree program in medical technology and master’s degree program in clinical laboratory sciences.

Victor Skrinska, Ph.D., chair of the Department of Diagnostic and Therapeutic Sciences, directs both programs. “Our graduates take a registry exam to become credentialed professionals trained to work in immunology, clinical chemistry, microbiology, and blood bank labs,” he says. Candidates for the bachelor’s degree spend two years in focused professional courses after completing two years of undergraduate courses. The master’s program offers courses in management, education, and advanced specialty courses.

Because of ever-changing technology and technical requirements, Skrinska and other faculty members must keep abreast of evolving accreditation requirements. “Our graduates work in a variety of settings, from community hospitals to academic medical centers. Because we provide students with a clinical internship opportunity in which they use the latest technology firsthand, our faculty must actively continue their own educations.”

Perhaps in no other field is continuing education more critical than in diagnostic medicine. From moment to moment, clinical laboratory specialists are making decisions that determine how a patient will be treated, in cases from strep throat to cancer. “Physicians must have absolute trust in the clinical laboratory,” Waites says. “There is no room for mistakes in what we do. We have a responsibility to the physician, the patient, and the hospital.”

Adds Marques, “The clinical lab is a liaison between the technical and clinical worlds. Our goal is to help physicians help their patients.”