www.themedlab.com www.biotechlab.com Revised 09/01/2009 BIOTECH LABORATORY HISTORY BIOTECH LABORATORY is a privately owned, independent clinical laboratory, serving the medical community since 1969. We take pride in the fact that we are large enough to offer a comprehensive package of services, yet small enough to offer flexibility in meeting the individual needs of our clients. We are positioned to support you in providing the best possible care to your patients. Ninety-five percent of all testing is performed in-house utilizing state of the art technology and computerized reporting of results. Our staff of highly dedicated technical, service and clerical personnel is always available to you for inquires, results, interpretation and consultation. This procedure manual has been developed to assist clients in ordering tests and in specimen collection. If you are interested in a test that is not listed in this manual, please phone the lab to obtain the necessary information. If you are interested in a profile which is not listed, please notify your customer representative. We will be happy to customize a profile to your exact specifications. MISSION STATMENT
Biotech Labs management and staff is committed to provide testing service to patients, physicians and clients at the highest possible level of excellence. Our goal is to give prompt, accurate, and understandable results on all procedures using the best technology consistent with current industry standards. Our commitment is to deal with those who we service and our fellow employees in an ethical and moral way as we come to understand it through Judeao-Christian values. Our experience is that these practices have made us successful in plans. The emphasis of our work is to contribute to the medical team which ultimately aims to restore people to health, enhance therapeutic treatment, and alleviate suffering. The continued viability, technological updating and growth of the company requires us to operate as efficiently as possible to all maximum profitability.
Biological Technology Laboratory, Inc. CORPORATE OFFICES MAIN TESTING LAB PATIENT SERVICE CENTERS
ST. LOUIS, MO SPRINGFIELD, IL TECHNICAL OPERATIONS MORTON, IL COLUMBIA, IL
Gordon Moore Regional Manager, St. Louis
EVANSVILLE, IN COLLINSVILLE, IL CLIENT SERVICE MOUNT VERNON, IL BENTON, IL
AccT Executive SO. & Central IL, & IN
Regional Manager, Springfield & Morton
BUSINESS & FINANCIAL OPERATIONS How to Contact BioTech Laboratory For Lab Draws St. Louis, Missouri Clients
Monday-Friday, 5 a.m.-5 p.m.
Monday-Friday, After 5 p.m.:
Call 314-432-5030. Leave message in STAT mailbox (this will page the on-call Phlebotomist and Technologist)
For general inquires you may dial ext. 220
Saturday, 6 a.m.-5 p.m.
Saturday, 5 p.m.-Monday 5 a.m.
Call 314-432-5030, PLEASE listen carefully to the answering system. Follow all instructions and completely answer all questions or your STAT blood draw or pickup may not be received or paged to the phlebotomist.
PLEASE NOTE
Any messages put in the Routine Draw mailbox will not be received until Monday morning.
Contacts:
Daytime Supervisor – Karen Lewis, ext. 232
Evening Supervisor – Kevin Wells, ext. 322
BioTech is closed for routine services on the following holidays:
New Years Day Memorial Day 4th of July Labor Day Thanksgiving Day Christmas How to Contact BioTech Laboratory For Lab Draws Columbia, Illinois Clients Monday-Friday, 7:30 a.m.-4 p.m. for walk-in patients STAT AFTER HOURS INFORMATION Please call our Beeper Number 618-325-7144
Contacts: How to Contact BioTech Laboratory For Lab Draws Collinsville, Illinois Clients Monday-Friday, 8 a.m.-3 p.m. for walk-in patients STAT AFTER HOURS INFORMATION Please call our Beeper Number 618-325-7144
Contacts: How to Contact BioTech Laboratory For Lab Draws Mt Vernon, Illinois Clients Monday-Friday, 7 a.m.-5 p.m. for walk-in patients
Closed for lunch between 12 Noon and 1 p.m.
STAT AFTER HOURS INFORMATION Please call our Beeper Number 618-325-3021
Contacts:
How to Contact BioTech Laboratory For Lab Draws Benton, Illinois Clients Monday-Friday, 8 a.m.-4:30 p.m. for walk-in patients
Closed for lunch between 12:30 p.m. and 1 p.m.
STAT AFTER HOURS INFORMATION Please call our Beeper Number 800-612-8191
Contacts: How to Contact BioTech Laboratory For Lab Draws Springfield, Illinois Clients Monday-Friday, 8 a.m.-4:30 p.m. for walk-in patients During the above hours, please call 217-546-4143 STAT AFTER HOURS INFORMATION
Please contact Dannielle Blue at 1-618-610-6940
How to Contact BioTech Laboratory For Lab Draws Peoria, Illinois Clients Monday-Friday, 8 a.m.-3:00 p.m. for walk-in patients During the above hours, please call 309-263-2400 STAT AFTER HOURS INFORMATION
Please contact Dannielle Blue at 1-618-610-6940
SPECIMEN COLLECTION PROCEDURES
The quality of the information derived from a
laboratory test depends to a considerable extent
on the quality of the specimen submitted for
analysis. Correct patient preparation, specimen
collection technique, and submission are
essential factors in obtaining accurate test results.
It is recommended that tubes are completely
filled (Full Tubes). This will ensure specimen
preparation and suggest ways to avoid errors.
SPECIMEN LABELING
All samples submitted for testing shall be labeled
with the patients name as it appears on the
requisition, and the date and time of collection.
If sample was collected in a red top tube, pipette the serum into a plastic
Serum is obtained from clotted blood collected in
either a serum separation tube (SST) or in a red
top tube (containing no anticoagulants or
Prolonged contact of the serum with the clot
results in alteration of many of its important
chemical constituents, especially glucose,
potassium, magnesium, alkaline phosphatase,
lactic dehydrogenase, SGOT, SGPT, lactic acid
Therefore, to ensure valid test results it is
essential to separate serum from the clot as soon
as clotting is complete (30 minutes, unless the
patient is receiving an anticoagulant drug).
Specimens should be centrifuged as soon as clotting is complete. Specimens should not be
Plasma is obtained from anticoagulated blood.
batched and centrifuged at the end of the day.
Because this blood has not clotted, it retains its
fibrinogen when separated from the cells.
Tubes used to collect plasma specimens contain
an anticoagulant, and frequently a preservative as
well. (the additive(s) in the tube are indicated by
PROCEDURE
the label on the tube.) The various tubes are not
that the tube is filled to the exhaustion
WHOLE BLOOD
Collect whole blood in the specified tube. In
most cases, this will be one containing an
anticoagulant, but a few tests require clotted
Invert the tube gently five or ten times to mix the
blood with the additives in the tube. Do not
Refrigerate the specimen until courier pickup or
mailing, unless instructed otherwise. Never
freeze whole blood unless specifically instructed
considerable during a 24-hour period. Most
random urine reference values are in the
morning. This specimen is preferred because it
has a more uniform volume and concentration,
Label the transfer vial “plasma.” If
and its lower pH helps preserve the formed
to be stored for more than one hour before courier pickup should be
RANDOM URINE PROCEDURES
1. Submit a first morning specimen when-ever
possible, especially for pregnancy testing.
FROZEN SERUM AND
(If a first morning specimen cannot be obtained, make sure that the specimen has a
PLASMA SAMPLES
Thawed samples are not suitable for analysis.
2. Specimens should be collected by the clean-
Please follow these guidelines when submitting
catch, midstream method, using a sterile
container 15 ml urine required. Refrigerate
immediately. Collect only when same-day
Submit a separate frozen specimen pickup is available.
for each test you requested; do not
3. If a frozen specimen is required, freeze
immediately after collection. Notify the
lab that you have a frozen sample to be
beverages should be consumed during this
4. Record the collection time on the label of
the container and on the Requisition Form.
The collection starts after the patient empties
his bladder. This initial voiding is not
URINE CULTURE
included in the timed collection. Note the
PROCEDURE
time and date of voiding on the label of the
1. Clean Catch. For the female patient, clean
specimen container. Collect all urine voided
during the collection period including the
specimen voided at the time the collection
period is complete. Incomplete specimens
Wash the area with soap three times, and
specimen should be collected in the clean,
labeled container provided by the laboratory.
Avoid any contact until the conclusion of
This container may contain preservatives.
Instruct the patient not to empty any powder,
For the male patient, thoroughly clean the
liquid or tablet from the container before
glans penis with soap, and completely rinse
Patient should avoid the first part of specimen
The specimen should be refrigerated during
into the toilet bowl. Secure the remainder of
the collection period. Urine is an excellent
the specimen in a sterile container. Refrigerate
medium for bacterial growth and many of its
immediately. Collect only when same-day pickup is available.
temperature. Each voiding should be added
In-Dwelling Catheter. Follow Facility
Procedure. Collect only when same-day pickup is available.
collection period on the specimen container
submitted to the laboratory and on the test
Specimens obtained from the collection bag
are NOT suitable for analysis. Foley times
Before pouring off the required aliquot,
thoroughly and gently mix the contents of the
24 HOUR URINE COLLECTION
Refrigerate the aliquot until courier pickup or
proper collection and preservation of timed
IMPORTANT NOTE:
urine specimens, patients should be carefully
instructed in correct collection procedures.
For those analyses requiring the addition of
Printed instructions are available from the
6N HCL, add the acid at the start of the
collection. Be sure to thoroughly mix the
urine before removing the aliquot of urine.
consumed during the collection period as is
The most suitable specimen is an expectorant
instructed by the physicians. No alcoholic
obtained after a deep cough, preferable early
in the morning. Collect the specimen in a
sterile, leak-proof container provided by the
anticoagulants and preservatives by inverting
the tube gently ten times, using a slow rolling
microflora indigenous to saliva or upper
respiratory tract. Refrigerate until courier
• Inadequate or delayed mixing of the blood
• Allowing a serum specimen to remain on the
CONDITIONS AFFECTING SPECIMEN INTEGRITY ORGANISM INTEGRITY TURBIDITY (Lipemia)
Turbid, cloudy or milky serum (lipemic serum) is
produced by the presence of fatty substances
culturettes provided are stable for 70 hours
(lipids) in the whole blood. A recent meal
produces transient lipemia; therefore, it is
preferable that a patient be in a basal state
HEMOLYSIS
(fasting 12-14 hours) before specimen is drawn.
surrounding red blood cells is disrupted and
Moderately lipemic specimens may be accepted
for some tests. However, lipemic specimens will
be rejected for tests measuring blood lipids or
varies in color from faint pink to bright red,
triglycerides. For true determinations, a fasting
specimen is essential for valid test results.
laboratory may reject grossly or moderately
Lipemia also distorts the results of tests for
hemolyzed specimen for testing. Even slight
albumin, bilirubin, platelet count, uric acid and
hemolysis may alter certain test results such
immunoglobulins measured by nephelometry.
as potassium, lactic dehydrogenase, SGOT
Bacterial contamination may also cause cloudy
The following actions damage the red cell
• Using a needle smaller than 22 gauge.
• Using needles, syringes or tubes that are not
• Incomplete venipuncture resulting in the tube
• Removing the needle before the tube is
completely filled, causing a rush of air into the tube.
• When using a syringe, drawing the blood
• Expressing blood from a syringe through the
needle. Always remove the needle and let the blood run down the side of the transfer tube.
• Shaking the tube containing the specimen.
Foaming or bubbling of the blood can cause
PEAK AND TROUGH LEVELS OF ANTIBIOTICS
Collection times for Peak & trough for Amikacin, Gentamicin, Tobramycin*
Trough: must be drawn within 15-30 minutes prior to dose (includes all antibiotics) PEAK: IM (intramuscular) 1 hour after dose PEAK: IV (intravenous)
infusion. Collection times for Peak & trough for Vancomycin*
Trough: must be drawn within 15-30 minutes prior to dose (includes all antibiotics) PEAK: IV *intravenous)
after infusion. (this length of time has been determined by the manufacturer and is based on the drug’s half-life) Peak & Trough Reference Values
Tobramycin Peak: RECOMMENDED PROCEDURE FOR PHLEBOTOMISTS
All contaminated materials, i.e., cotton,
wipes, materials, used for spill cleanup,
If there is an injury, spill, splatter, etc.,
the area to air-dry before inserting the
STATS and AFTER HOURS SERVICE AGREEMENT A. Turn-around Time Commitment STAT service requests shall be handled in four (4) hours or less from the time the request is received. This includes specimen collection, testing and phoning of test results. STAT service requests shall be for true medical emergencies only. It is critical that symptoms be provided on the requisition to show medical necessity for Medicare reimbursement and to minimize billings to the responsible party. B. Service to Remote Areas True STAT services are not available for customers located greater than forty (40) miles or greater than one (1) hour drive time of our testing lab in St. Louis. Should service be requested in addition to regular lab days, the lab will handle the request on the next routine route to the area, and the sample will be handled promptly upon arrival at the lab. C. Tests which are “STAT ELIGIBLE” for Testing
If a full chemistry profile is requested STAT, we will perform the chemistries listed above on a STAT basis,
and the balance of the profile will be performed the next routine run of profiles. Misc.**: Requests for “culture & sensitivity” are not considered STAT Eligible. The specimen should be collected prior to starting antibiotic therapy, then store the sample as indicated on the requisition and notify the lab that there is pickup to be made on the next regular working day. D. STAT Service Fee There is a fee of $27.00 for all STAT Service requests. E. AFTER HOURS Service Fee The regular working hours for our phlebotomy and courier staff are defined in this manual (refer to your Regional information pages 3-6). We request that service be scheduled during these regular hours. ALL requests for service that must be performed outside of those hours, and all day on Sundays and Holidays are considered STAT for billing purposes and the STAT Service Fee of $27.00 does apply. NOTIFICATION VALUES
BioTech Laboratory personnel will telephone these important lab values to the customer. The following lab values will be phoned if tests results exceed the high value or are less than the low value listed below.
CHEMISTRY LOW THERAPEUTIC DRUG LEVELS HEMATOLOGY LOW Qualitative Critical Results
Microbiology and parasitology Positive results from Gram’s stain or culture for blood, cerebrospineal fluid, or body cavity fluid; or positive India ink preparation. Positive rapid antigen detection by agglutination tests for Cryptococcus, group B streptococci, Haemophilus influenzae b, Neisseria menigitidis, or group A-B Streptococci. Salmonella, Shigella, or Campylobacter Presence of malarial parasites Clinical microscopy and urinalysis Elvated WBC count in cerebrospinal fluid Presence of malignant cells, blasts, or microorganisms in cerebrospinal fluid or body fluids. Hematology Presence of blasts on blood smear. Presence of sickle cells (or aplastic crisis). The above list of Notification Values includes only those tests for which a physician can take action which may affect the patient’s condition. This list is consistent with Notification Values used throughout the lab industry nationwide, as determined in a national survey that was published in JAMA 263: 704-707, 2003.
Patient’s Name: Medicare # (HICN): ADVANCE BENEFICIARY NOTICE (ABN) NOTE: You need to make a choice about receiving these laboratory tests.
We expect that Medicare will not pay for the laboratory test(s) that are described below. Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it. Right now, in your case, Medicare probably will not pay for the laboratory test(s) indicated below for the following reasons: Medicare does not pay for Medicare does not pay for Medicare does not pay for these tests as often as this experimental for research these tests for your condition (denied as too frequent) use tests
The purpose of this form is to help you make an informed choice about whether or not you want to receive these laboratory tests, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully.
• Ask us to explain, if you don’t understand why Medicare probably won’t pay.
• Ask us how much these laboratory tests will cost you (Estimated Cost: $_______________), in case
you have to pay for them yourself or through other insurance.
PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE.
OPTION 1. YES. I want to receive these laboratory tests I understand that Medicare will not decide whether to pay unless I receive these laboratory tests. Please submit my claim to Medicare. I understand that you may bill me for laboratory tests and that I may have to pay the bill while Medicare is making its decision. If Medicare does pay, you will refund to me any payments I made to you that are due to me. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand I can appeal Medicare’s decision. OPTION 2. NO. I have decided not to receive these laboratory tests. I will not receive these laboratory tests. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won’t pay. I will notify my doctor who ordered these laboratory tests that I did not receive them.
Date Signature of patient or person acting on patient’s behalf NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our office. If a claim is submitted to Medicare, your helath information on this form may be shared with Medicare. Your health information which Medicare sees will be kept confidential by Medicare.
OMB Approval No. 0938-0566 Form No. CMS-R-131-L
USING THE ADVANCE BENEFICIARY NOTIFICATION (ABN) IN THE PHYSICIAN OFFICE
What is an Advance What is a “Limited Coverage” Beneficiary Notification How can I know which tests How often should an ABN be have “Limited Coverage”? Does the Patient have to sign What if the ICD9 code or diagnosis is not on the list? When should the Patient be asked to read and sign the What if a Patient refuses to sign the ABN, yet demands that testing be performed? Test Code Test Name Collection Instruction PROFILES ACUTE HEPATITIS PANEL SST. Serum
IgM; B Surface Ag; C Ab ANEMIA PROFILE SST Tube & Lavender Tube BASIC METABOLIC PANEL SST. Serum.
Chloride, HCO3, BUN, Creatinine, Glucose, Calcium BODY FLUID PANEL Red Top Tube. Serum. COMPREHENSIVE METABOLIC SST. Serum. Includes: Sodium, Potassium, Chloride, HCO3, BUN, Creatinine, Glucose, Albumin, Bilirubin-Total, Calcium, Alkaline Phosphatase, Protein-Total, AST(SGOT), ALT(SGPT) ELECTROLYTES SST. Serum.
Chloride, HCO3 EPSTEIN BARR VIRUS PROFILE Red Top Tube Serum. Includes: Epstein Barr VCA (IGG),
GENERAL HEALTH PANEL SST and Lavender
Metobolic Panel (CMP), CBCP, TSH HEAVY METAL PROFILE II 2 Royal Blue Top Tubes. Test Code Test Name Collection Instruction HEPATIC FUNCTION PANEL SST. Serum. Includes: Albumin, Bilirubin-Total,
Bilirubin-Direct, Alkaline Phosphatase, Protein-Total, AST (SGOT), ALT(SGPT) LIPID PANEL SST. Serum. OBSTETRIC PANEL SST, Red Top and Lavender Tube
(D), RPR, Rubella (IgG), Antibody Screen, Hep. B Surface Antigen RAST BASIC FOOD RASTBF 2SST's Serum.
Peanut, Soybean, Beef, Scallops, Cod Fish, Clam, Shrimp, Walnut
RAST GENERAL PROFILE I RASTRAP 2SST's Serum.
(D. Farinae), Cat Epithelium, Alternaria, Dog Dander, June Kentucky Blue, Common Ragweed, Maple, Orchard, Grass, Cock Roach, Rough, Marsh, Cladosporium, Oak, Elder, Herbarum, Aspergillis Fumagatus, IGE, Total Call lab for additional information on RAST profiles. RENAL FUNCTION PANEL SST. Serum.
Chloride, HCO3, BUN, Creatinine, Glucose, Albumin, Calcium, Phosphorus
Test Code Test Name Collection Instruction INDIVIDUAL TESTS ABSOLUTE NEUTROPHIL ADRENOCORTICOTROPIC
2 Lavender Top Tubes, Prechilled. Plasma,
HORMONE (ACTH) ALDOLASE ALPHA-1-ANTITRYPSIN ALPHA-FETOPROTEIN, ALFPM SST. Serum. Indicated week of gestation, MATERNAL
age, race, weight, and if mother is diabetic, and number of fetuses. ALPHA-FETOPROTEIN, QUAD
SST. Serum. Indicated week of gestation, age, race, weight, and if mother is diabetic, and number of fetuses. ALPHA-FETOPROTEIN, TRIPLE
SST. Serum. Indicated week of gestation,
age, race, weight, and if mother is diabetic,
ALPHA-FETOPROTEIN, TUMOR ALT (SGPT) AMIKACIN AMIKACIN, PEAK
SST. Specify time of draw. See Collection
AMIKACIN, TROUGH
SST. Specify time of draw. See Collection
AMINOPHYLLINE See…THEOPHYLLINE AMIODARONE (CARDARONE) AMITRIPTYLINE (ELAVIL) Test Code Test Name Collection Instruction
plasma. Avoid hemoloysis. Keep on ice. Separate within 30 minutes. Freeze plasma immediately. Do not remove cap. Fill tube completely. Protect from light. ANAFRANIL (CLOMIPRAMINE) ANGIOTENSIN-1-CONVERTING ENZYME (ACE) ANTIBIOTIC SENSITIVITY, MINIMAL INHIBITORY
culture. Organism isolated and indentified
CONCENTRATION (MIC) with DEFINITIVE BACTERIAL INDENTIFICATION ANTIBODY SCREEN ANTI-STREPTOLYSIN O (ASO) AST (SGOT) ATIVAN (LORAZEPAM) AVENTYL See…NORTRIPTYLINE BETA-HCG See…PREGNANCY, SERUM QUANTITATIVE BETA-HCG, TUMOR MARKER BHCQTM SST. Serum from male or non-pregnant BILIRUBIN, DIRECT BILIRUBIN, PANEL Includes: Bilirubin, Total; Bilirubin,
BILIRUBIN, TOTAL BLOOD TYPE (A, B, O) BRAIN NATRIURETIC PEPTIDE (BNP) (Pro BNP) BRUCELLA ANTIBODY Test Code Test Name Collection Instruction BUN (BLOOD UREA NITROGEN) BUSPAR (BUSPIRONE)
2 Lavender Top Tubes, Prechilled. Plasma.
C. DIFFICILE TOXIN See…CLOSTRIDIUM DIFFICILE TOXIN CA 125
open tube. Draw additional tubes for any
CALCIUM, IONIZED (CALC) CALCIUM, URINE, 24 HR.
24 Hr Urine container (Preserved w/10 ml
CARBAMAZEPINE See…TEGRETOL CARBON DIOXIDE (BICARBONATE HCO3) CARCINOGENIC EMBRYONIC
SST. Serum. Refrigerate sample. Freeze if
ANTIGEN (CEA) CARDIOLIPIN ANTIBODY
2 Light Blue Top Tubes (sodium citrate).
Contact lab for further instructions. CAROTENE
Red Top Tube. Serum. Protect from light.
CATECHOLAMINES, PLASMA,
Green Top Tube. Plasma, Frozen. Transfer
TOTAL AND FRACTIONAL
immediately. Patient should avoid alcohol, coffee, tea, tobacco, and strenuous
CATECHOLAMINES, URINE,
24 Hour Urine Container (preserve w/25 ml
FRACTIONAL
6N HCL) 500 ml Aliquot of 24 Hour Urine.
CBC See…COMPLETE BLOOD COUNT W/DIFFERENTIAL CD4 (T-CELL COUNT) See LYMPHOCYTE SUBSET PANEL 5 Test Code Test Name Collection Instruction LYMPHOCYTE SUBSET PANEL CEA See…CARCINOGENIC EMBRYONIC ANTIGEN CELL COUNT BODY FLUID
Refrigerate and deliver to lab same day. CERULOPLASMIN CH50 See…COMPLEMENT- TOTAL (CH50) CHLAMYDIA AND G.C., DNA DNACOM Gen-Probe Collection Kit upon request. CHLAMYDIA, DNA PROBE DNACH Gen-Probe Collection Kit upon request. CHLORIDE CHLORIDE, 24 HR. URINE
24 Hr. Urine Container, 100 ml Aliquot of
CHLORPROMAZINE See…THORAZINE CHOLESTEROL, HDL CHOLESTEROL, LDL See…LIPID PANEL CHOLESTEROL, LDL, DIRECT CHOLESTEROL, TOTAL CITRATES, URINE, 24 HR.
24 Hour Urine Container (No Preservatives)
CLOMIPRAMINE See…ANAFRANIL CLONAZEPAM (KLONOPIN) CLOSTRIDIUM DIFFICILE TOXIN
Stool. Refrigerate Toxin. Stable 3 days. CLOZARIL (CLOZAPINE) CMV See…CYTOMEGALOVIRUS ANTIBODY COGENTIN (BENZTROPINE) Test Code Test Name Collection Instruction COLD AGGLUTINATION COMPLEMENT C3 COMPLEMENT C4 COMPLEMENT-TOTAL (CH50) COMPLETE BLOOD COUNT W/DIFF AND PLATELETS Includes: WBC, Differential, RBC, Hemoglobin, Hematocrit; Platelet
COMPLETE BLOOD COUNT W/DIFFERENTIAL Includes: WBC, Differential, RBC, Automated Hematology Hemoglobin, Hematocrit
COOMBS, DIRECT COPPER, PLASMA
Royal Blue Top Tube (EDTA). whole blood. CORTISOL, FREE, 24 HR. URINE CORTF 24 Hr. Urine Container (Preserve with 10
grams Boric Acid.) 50 ml Aliquot of 24 Hr.
CORTISOL, TOTAL C-PEPTIDE C-REACTIVE PROTEIN (CRP) C-REACTIVE PROTEIN, HIGH SENSITIVITY CREATINE KINASE (CK, CPK), CREATINE KINASE (CK, CPK), ISOENZYMES CREATININE, CLEARANCE, 24 CRCL SST and 24 Hr. Collection Container. (No
preservatives) Serum collected at any point
during the 24 hour urine collection. 50 ml Aliquot of 24 Hour Urine. Record Total
CREATININE, SERUM CREATININE, URINE, 24 HR.
24 Hr. Urine Container (No Preservatives).
Test Code Test Name Collection Instruction CREATININE, URINE, RANDOM
Sterile Specimen Container. 25 ml Urine. CULTURE, AFB (INCLUDES
87116 deep cough. First Morning specimen
incubated for 8 weeks before determined to be negative. Positive isolates are identified by conventional methods or nucleic acid hybridization. CULTURE, ANAEROBIC CULTURE, BLOOD
tube with betadine. Cleanse draw area with
incubation Biochemical Identification. CULTURE, BODY FLUIDS
Sterile Specimen Container or Culturette.
CULTURE, CHLAMYDIA CULTURE, EAR
(use one for each). Specify source right or
CULTURE, ENVIRONMENTAL CULTURE, EYE
(use one for each eye). Specify source. CULTURE, FECAL CULTURE, FUNGAL
scrapings or clippings from affected area.
CULTURE, G.C.
Jembec Kit available upon request. Store at
CULTURE, GENITAL
Culturette. Store at Room Temperature. CULTURE, HERPES
Innoculation Identification by characteristic cyopathic effect and fluorescent antibody stain. Test Code Test Name Collection Instruction CULTURE, HERPES PRENATAL
Innoculation Identification by characteristic cyopathic effect and fluorescent antibody stain. CULTURE, NASAL
(use one for each nare) & Label. CULTURE, SKIN
Scrapings. Store at Room Temperature. CULTURE, SPUTUM CULTURE, STREP ONLY CULTURE, THROAT
Culturette. Store at Room Temperature. CULTURE, TISSUE
sterile saline. Store at Room Temperature.
CULTURE, URINE CULTURE, WOUND CYSTINE, URINE, 24 HR.
24 Hr. Urine Container. 200 ml Aliquot of
24 hour urine. Freeze. Record total volume.
Age required for correct interpretation. CYTOLOGY, NON-VAGINAL NVPAP Smear on 2 slides. Spray with fixative CYTOLOGY, SPUTUM CYTOLOGY, URINE
Sterile Specimen Container. 24 ml Urine. If
alcohol to equal amount of urine. Indicate
on requisition if alcohol was added. CYTOMEGALOVIRUS
Red Top Tube. Serum. Do not use SST. ANTIBODY (IGG) CYTOMEGALOVIRUS
Red Top Tube. Serum. Do not use SST. ANTIBODY (IGM) DEPAKENE See…VALPROIC ACID Test Code Test Name Collection Instruction DESIPRAMINE (NORPRAMIN) DIASTASE See…AMYLASE DIAZEPAM See…VALIUM DIFFERENTIAL DIGOXIN (LANOXIN) DILANTIN See…PHENYTOIN DISOPYRAMIDE See…NORPACE DNA ANTIBODY (DOUBLE STRANDED) DOXEPIN (SINEQUAN) ELAVIL See…AMITRIPTYLINE ELECTROLYTES EOSINOPHILE COUNT EPSTEIN-BARR VIRUS ANTIBODY PANEL ERYTHROPOIETIN ESTRADIOL ESTROGENS, FRACTIONAL, ESTROGENS, TOTAL, SERUM ETHOSUXIMIDE (ZARONTIN) ETHOTOIN (PEGANONE) EXTRACTABLE NUCLEAR ANTIGEN ANTIBODY F.E.P (FREE ERYTHROCYTE PROTOPORPHYRIN) FACTOR VIII FUNCTIONAL
1 Blue Top Tube (sodium citrate). Separate
and freeze immediately in a plastic vail. Do
Test Code Test Name Collection Instruction FECAL FAT (Same as Total Lipids Fecal) FECAL LEUKOCYTES FERRITIN FIBRINOGEN
blood to be drawn by vacuum. Invert tube six times immediately after drawing. Allow specimen to remain at room temperature for 30 minutes before centrifuging.
FLECAINIDE (TAMBOCOR) FLUOCETINE See…PROZAC FOLIC ACID (FOLATE) FOLLICLE STIMULATING HORMONE (FSH) FTA-ABS (FLUORESCENT FTA-ABS Red Top Tube. Serum. TREPONEMAL ANTIBODY) GABAPENTIN (NEURONTIN) GAMMA GLUTAMYL TRANSFERASE (GGT) GENTAMICIN (PEAK) GENTP SST Serum. Draw peak level 60 minutes GENTAMICIN (TROUGH) GLUCOSE TOLERANCE TEST
submitted. Indicate the collection time on
both tube and sterile specimen container.
together with a single requisition. Avoid Hemolysis. Collect fasting specimens, then drink glucola. Collect specimens 1/2 hour and 1 hour after completing glucola, then in one hour increments for the desired length of testing. GLUCOSE, 1 HOUR POST PRANDIAL
Avoid Hemolysis. Draw 1 hour after meal. Test Code Test Name Collection Instruction GLUCOSE, 2 HOUR POST PRANDIAL
Avoid Hemolysis. Draw 2 hours after meal. GLUCOSE, FASTING GLUCOSE, RANDOM GLUCOSE-6-PHOSPHATE DEHYDROGENASE GLYCOHEMOGLOBIN See…HEMOGLOBIN, GLYCOSYLATED (A1C) GOLD, SERUM GONORRHEA (GC), DNA PROBE DNAGC Gen-Probe Collection Kit upon request. GRAM STAIN
Submit air-dried smears on 2 slides. Fix
with 95% alcohol or gentle flame. Specify
GROWTH HORMONE, HUMAN HALOPERIDOL (HALDOL)
Wrap in foil to protect from light or use light protected tubes. Lavender (EDTA) OR Green (Na Hep) also accepted. HAPTOGLOBIN HCO3 See…BICARBONATE HEAVY METAL PROFILE II HEMATOCRIT HEMOGLOBIN HEMOGLOBIN, ELECTROPHORESIS HEMOGLOBIN, GLYCOSYLATED, A1C HEPATITIS A ANTIBODY, TOTAL (EIA) HEPATITIS A ANTIBODY-IGM HEPATITIS B CORE ANTIBODY Test Code Test Name Collection Instruction HEPATITIS B CORE ANTIBODY- HBCAB SST. Serum. HEPATITIS B SURFACE ANTIBODY HEPATITIS B SURFACE HEPATITIS BE ANTIBODY HEPATITIS BE ANTIGEN HEPATITIS C ANTIBODY HERPES I & II HISTOPLASMA ANTIBODY HIV ANTIBODY SCREEN
identify by number, not name. Western Blot confirmation will be performed automatically if the antibody screen is
HIV ANTIBODY WESTERN BLOT
SST. Serum. Western Blot confirmation will
CONFIRMATION
be performed automatically if the antibody
Do not refrigerate or freeze. Must reach lab within 24 hours of collection. Lavender (EDTA) or Green (Na Heparin) also
HYDROXY INDOLE ACETIC
HCL.) 50 ml Aliquot of 24 Hr. Urine. Record Total Volume. Random Samples are accepted. (Reference Ranges do not
HYDROXYCORTICOSTEROIDS-
Boric Acid). 100 ml Aliquot of 24 Hr. Urine.
IGE See…IMMUNOGLOBULIN E IMIPRAMINE (TOFRANIL) IMMUNE DEFICIENCY PANEL I See LYMPHOCYTE SUBSET PANEL 1 Test Code Test Name Collection Instruction LYMPHOCYTE SUBSET PANEL IMMUNOELECTROPHORESIS, SERUM Includes: IGG, IGM, IGA IMMUNOELECTROPHORESIS,
50 ML Aliquot of a 24 Hr. Urine collection.
URINE Includes: Protein IMMUNOGLOBULIN A IMMUNOGLOBULIN E IMMUNOGLOBULIN G IMMUNOGLOBULIN M IMMUNOGLOBULINS INSULIN LEVEL
SST. Serum. Overnight fasting required. IRON BINDING CAPACITY See…IRON PROFILE IRON, TOTAL KEPPRA (LEVETIRACETAM) KETOSTEROIDS-17
Boric Acid). 50 ml Aliquot of 24 Hr. Urine.
KLONOPIN See…CLONAZEPAM KOH SMEAR FOR FUNGUS LACTIC DEHYDROGENASE (LD) LDH ISOENZYMES LDHISO Red Top Tube. Serum. Avoid Hemolysis. Test Code Test Name Collection Instruction LEAD/ZINC PROTOPORHYRIN LEUKOCYTE ALKALINE PHOSPHATE STAIN LUTEINIZING HORMONE (LH) LYME DISEASE ANTIBODY MAGNESIUM MELLARIL (THIORIDAZINE) MESORIDAZINE See…SERENTIL METANEPHRINES, 24 HR. MEXILETINE (MEXITIL) MITOCHONDRIAL ANTIBODY MONO TEST MUCIN CLOT TEST
Sterile Specimen Container. Synovial Fluid. NAVANE See…THIOTHIXENE NORPACE (DISOPYRAMIDE) NORPRAMIN See…DESIPRAMINE NORTRIPTYLINE (AVENTYL, PAMELOR) ANTI-NUCLEAR ANTIBODY OCCULT BLOOD OCCULT BLOOD SCREENING SOCBL Sterile Specimen Container. 2 g Fresh OSMOLALITY, SERUM
Red Top Tube. Serum. DO NOT USE SST. OSMOLALITY, URINE
Sterile Specimen Container. 40 ml random
Test Code Test Name Collection Instruction OVA AND PARASITES
Special Kit Upon Request or 10 g raw stool
OXALATES, URINE, 24 HR.
24 Hr. Urine Container (Preserve with 40 ml
6N HCL.) 100 ml Aliquot of 24 hour urine.
PAP SMEAR
1 Slide. Smear on 1 slide, properly fixed.
PAP SMEAR (2 slides)
2 Slide. Smear on 2 slides, properly fixed.
PAP SMEAR (AUTO CYTE)
Auto site Kit Available upon request. PAP SMEAR (THIN PREP)
Thin Prep Kit. Available upon request. PARTIAL THROMBOPLASTIN
Light Blue Top Tube. Citrated whole blood
TIME (PTT)
can be accepted within 24 hours of collection. After 24 hours citrated, frozen plasma is preferred. Draw full tube, as correct ratio of blood to citrate (9:1) is critical and mix gently. Centrifuge,
PATHOLOGY REVIEW
Peripheral Smears, with CBCP Results. PEGANONE See…ETHOTOIN PHENOBARBITAL PHENYTOIN (DILANTIN) PHENYTOIN (DILANTIN), FREE PHOSPHATASE, ACID, TOTAL PHOSPHATASE, ALKALINE PHOSPHATASE, ALKALINE, ISOENZYMES PHOSPHORUS PHOSPHORUS, URINE 24 HR. PHOSU 24 Hr. Urine Container (Preserve with 10 ml
HCL). 50 ml Aliquot of 24 Hr. Urine. Record
PINWORM PREP
Slide. Collect specimen on clear celophane
PLATELET COUNT SEMEN ANALYSIS, POST
Clean Container. Semen. Notify lab prior to
VASECTOMY
collecting specimen. Deliver specimen to
Test Code Test Name Collection Instruction POTASSIUM POTASSIUM, URINE, 24 HR.
24 Hr. Urine Container (No Preservatives).
50 ml Aliquot of 24 Hr. Urine. Record Total
POTASSIUM, URINE, RANDOM PREALBUMIN PREGNANCY, SERUM, QUALITATIVE PREGNANCY, SERUM, QUANITATIVE PREGNANCY, URINE, QUALITATIVE PRIMIDONE (MYSOLINE)
Red Top Tube. Serum. DO NOT USE SST. PROCAINAMIDE Includes: NAPA PROGESTERONE, SERUM PROLACTIN PROLIXIN (FLUPHENAZINE)
accepted. Wrap in foil to protect light. PROSTATE SPECIFIC ANTIGEN (PSA), CANCER SCREENING PROSTATE SPECIFIC ANTIGEN PROSTATE SPECIFIC ANTIGEN (PSA), FREE AND TOTAL PROTEIN, ELECTROPHORESIS, PROTEIN, ELECTROPHORESIS, ELPRU 24 Hr. Urine Container. 100 ml Aliquot of PROTEIN, TOTAL PROTEIN, URINE, 24 HR.
24 Hr. Urine Container 100 ml Aliquot of 24
PROTEIN, URINE, RANDOM PROUR Sterile Specimen Container. 24 ml Urine. Test Code Test Name Collection Instruction PROTHROMBIN TIME (PT)
plasma is preferred. Draw full tube, as correct ratio of blood to citrate (9:1) is critical and mix gently. Centrifuge, separate plasma and freeze promptly. Alternately, citrated whole blood can be accepted within
PROZAC (FLUOXETINE) PTH, C-TERMINAL (PARATHYROID HORMONE) Includes: Calcium PTH, INTACT (PARATHYROID HORMONE) Includes: Calcium PTT See…PARTIAL THROMBOPLASTIN TIME QUINIDINE RAPID STREP TEST See…STREP TEST, RAPID FOLIC ACID, RBC RBC FOLATE See.FOLIC ACID, RBC RED BLOOD CELL COUNT RETICULOCYTE COUNT Rh (D) TYPE Rh ANTIBODY SCREEN See…ANTIBODY SCREEN RHEUMATOID FACTOR (RA), QUALITATIVE RHEUMATOID FACTOR (RA), QUAL, SYNOVIAL FLUID RHEUMATOID FACTOR (RA), QUANTITATIVE
SST. Serum. If positive. MHATP performed
RUBELLA ANTIBODY (IGG) Test Code Test Name Collection Instruction RUBEOLA ANTIBODY, IGG
Red Top Tube. Serum. DO NOT USE SST. RUBEOLA ANTIBODY, IGM
Red Top Tube. Serum. DO NOT USE SST. SALICYLATES SEDIMENTATION RATE (ESR) SEMEN ANALYSIS, ROUTINE
Clean Container. Semen. Notify lab prior to
collecting specimen. Deliver specimen to
SERENTIL (MESORIDAZINE)
Draw prior to next dose. Plasma or serum.
SEROTONIN - SERUM SGOT See…AST SGPT See…ALT SICKLE CELL SMOOTH MUSCLE ANTIBODY SODIUM, URINE, 24 HR.
24 Hr. Urine Container (No Preservatives).
50 ml Aliquot of 24 Hr. Urine. Record Total
SODIUM, URINE, RANDOM
Sterile Specimen Container. 5 ml Urine. STONE ANALYSIS STREP TEST, RAPID
Rapid Strep Testing is not available at all locations. Please call your local lab for
LYMPHOCYTE SUBSET PANEL LYMPHOCYTE SUBSET PANEL LYMPHOCYTE SUBSET PANEL TEGRETOL (CARBAMAZEPINE) Test Code Test Name Collection Instruction TEGRETOL-10,11-EPOXIDE
Red Top Tube. Serum. DO NOT USE SST. TESTOSTERONE, BIOAVAILABLE (FREE & WEAKLY BOUND) TESTOSTERONE, FREE TESTOSTERONE, SERUM THEOPHYLLINE (AMINOPHYLLINE) THIORIDAZINE See…MELLARIL THIOTHIXENE (NAVANE) THORAZINE (CHLORPROMAZINE) THYROGLOBULIN THYROGLOBULIN ANTIBODY THYROID ANTIBODY PANEL ATPAN1 1 Red Top Tube. Serum. DO NOT USE T3, UPTAKE THYROID PEROXIDASE ANTIBODY (ANTI-TPO) THYROXINE BINDING THYBG Red Top Tube. Serum. GLOBULIN THYROXINE, FREE (T4) THYROXINE, TOTAL (T4) TISSUE EXAM
the volume of the specimen. For collection containers, contact lab. Specify source on
T-LYMPHOCYTE SUBSETS ASSAY See…LYMPHOCYTE SUBSET PANEL TOBRAMYCIN (PEAK) TOBRAMYCIN (RANDOM) Test Code Test Name Collection Instruction TOBRAMYCIN (TROUGH) TOFRANIL See…IMIPRAMINE TOXOPLASMA ANTIBODY, IgM TOXOPLASMA ANTIBODY, IgG TOXOG Red Top Tube. Serum. (Reflex to IGM). TP-FA (TREPONEMA MHATP SST. Serum. Performed automatically if PALLIDUM, FLUORESCENT ANTIBODY) TRANSFERRIN TRAZODONE (DESYREL) TRICHAMONAS See… WET PREP TRIGLYCERIDES T3, TOTAL TSH (THYROID STIMULATING HORMONE) URIC ACID URIC ACID, URINE, 24 HR. URACU 24 Hr. Urine Container (Preserve with 10g
Boric Acid) 50 ml Aliquot of 24 Hr. Urine.
URINALYSIS
Sterile Specimen Container. 15 ml Urine.
URINALYSIS W/CULTURE AND
Sterile Specimen Container. 15 ml Urine.
SENSITIVITY IF NECESSARY
Refrigerate. The WBC, Bacteria, Nitrites and Leukocyte esterase results from the Urinalysis will be evaluated. If 3 or 4 of these are present, a culture will be
A sensitivity will be performed if there is
VALIUM (DIAZEPAM) VALPROIC ACID (DEPAKENE) VANCOMYCIN LEVEL (PEAK)
SST. Serum. Draw peak 1.5-2.5 hours after
VANCOMYCIN LEVEL (TROUGH) Test Code Test Name Collection Instruction VARICELLA ZOSTER ANTIBODY
Red Top Tube. Serum. Fasting required. VARICELLA ZOSTER ANTIBODY
Paired sera, 2-3 weeks apart are advisable
VITAMIN B12 VITAMIN B12 AND FOLIC ACID (FOLATE) VITAMIN D (1,25 DIHYDROXY) VITAMIN D (25 HYDROXY) VMA (VANILLYMANDELIC ACID)
24 Hr. Urine Container (Preserved with 6N
HCL) 50 ml Aliquot of 24 Hr. Urine. Record
WBC See…WHITE BLOOD COUNT WESTERN BLOT CONFIRMATION (HIV) WET PREP FOR TRICHOMONAS Microscopic WHITE BLOOD CELL COUNT ZINC PROTOPORPHRYN
Lavender Top Tube. Full tube. Wrap in foil
ZINC, PLASMA
Royal Blue Top (EDTA). Send whole blood. ZOLOFT (SERTRALINE) Test Code Test Name Collection Instruction TOXICOLOGY
In this procedure manual, drug screens have been divided into two categories: "medical" and "non-medical". In general, drug screening for treatment or rehabilitation programs is considered "medical", while drug screening for employment purposes is considered "non-medical". The drug screens listed below are the most commonly ordered. However, any of the following drugs can be ordered individually or in any combination to meet specific testing requirements of the client:
Amphetamines Propoxyphene Cocaine Alcohol Methadone Cannabinoids Barbiturates Opiates Benzodiazepine Phencyclidine
1. MEDICAL DRUG SCREENS ALCOHOL, BLOOD, QUANTITATIVE 2 Grey Top Tubes of whole blood. AMPHETAMINES, BARBITURATES, Submit 25 ml. (minimum) urine for BENZODIAZEPINES, CANNABINOIDS, COCAINE, testing. METHADONE, OPIATES, PHENCYCLIDINE, PROPOXYPHENE
For drug screens listed on the left, the initial
ALCOHOL, AMPHETAMINES, BARBITURATES,
testing is performed by Immunoassay. Positive results are confirmed by alternate
BENZOIDIAZEPINES, CANNABINOIDS, COCAINE, METHADONE, OPIATES, PHENCYCLIDINE,
Immunoassay), with a quantitative result
PROPOXYPHENE AMPHETAMINES, CANNABINOIDS, COCAINE, AMPHETAMINES, CANNABINOIDS, OPIATES, PHENCYCLIDINE, COCAINE AMPHETAMINES, BARBITUREATES, BENZOIDAZEPINES, CANNABINOIDS, COCAINE, OPIATES, PHENCYCLIDINE ALCOHOL, AMPHETAMINES, BARBITURATES, BENZODIAZEPINES, CANNABINOIDS, COCAINE, OPIATES, PHENCYCLIDINE CANNABINOIDS, COCAINE, OPIATES ALCOHOL, URINE AMPHETAMINES BARBITURATES BENZODIAZEPINES CANNABINOIDS (25 ng/ml cut off) Test Code Test Name Collection Instruction METHADONE PHENCYCLIDINE PROPOXYPHENE COMPREHENSIVE DRUG SCREEN: Drugs Screened Submit 2 Grey Top Tubes or one Red Top Tube (DO NOT USE SST). DO NOT Amphetamines: Amphetamine, Methamphetamine OPEN TUBES. Analgesics: Acetaminophen, Salicylates Antidepressants: Amitriptyline, Amoxapine, Desipramine, Doxepin, Fluoxetine, Imipramine, Loxapine, Maprotiline, Nortriptyline, Protriptyline, Trazodone Antiepileptics: Carbamazepine, Phenytoin Antihistamines: Chlorpheniramine, Diphenhydramine, Doxylamine, Methapyrilene, Pyrilamine Barbiturates: Amobarbital, Butabarbital, Butalbital, Pentobarbital, Phenobarbital, Secobarbital Benzodiazepines: Chlordiazepoxide, Diazepam, Flurazepam, Nordiazepam (as A Class) Cardiacs: Lidocaine, Propranolol, Quinidine/Quinine, Verapamil/Norverapamil Miscellaneous Agents: Cimetidine, Cocaine (Benzoylecgonine), Ephedrine/Pseudoephedrine, Methocarbamal, Phencyclidine, Phenylpropanolamine, Phenytoin Sedates & Hypnotic: Ethchlorvynol, Glutethimide, Meprobamate Volatiles: Acetone, Ethanol, Isopropanol, Methanol 2. NON-MEDICAL DRUG SCREENS AMPHETAMINES, BARBITURATES, Submit 60 ml (minimum) urine in a BENZODIAZEPINES, CANNABINOIDS, COCAINE, Chain of Custody Kit. METHADONE, OPIATES, PHENCYCLIDINE, PROPOXYPHENE
For drug screens listed on the left, the initial
ALCOHOL, AMPHETAMINES, BRABITURATES,
testing is performed by immunoassay. Positive results are confirmed by GCMS
BENZODIAZEPINES, CANNABINOIDS, COCAINE, METHADONE, OPIATES, PHENCYCLIDINE,
All testing and confirmations are performed
PROPOXYPHENE AMPHETAMINES, CANNABINOIDS, COCAINE,
using cut-off levels established by NIDA/SAMSHA. OPIATES, PHENCYCLIDINE AMPHETAMINES, BARBITURATES, BENZODIAZEPINES, CANNABINOIDS, COCAINE, OPIATES, PHENCYCLIDINE AMPHETAMINES, BARBITURATES, BENZODIAZEPINES, CANNABINOIDS, COCAINE, OPIATES, PHENCYCLIDINE Test Code Test Name Collection Instruction ALCOHOL, AMPHETAMINES, BARBITURATES, BENZODIAZEPINES, CANNABINOIDS, COCAINE, OPIATES, PHENCYCLIDINE CANABINOIDS (50 ng/ml cut off) AMPHETAMINES, CANNABINOIDS, COCAINE, NIDA.DOT Test performed by NIDA certified lab. OPIATES, PHENCYCLIDINE Submit split specimens in a NIDA Chain of Custody Kit.
Stiftung zum Schutze unserer Fledermäuse in der Schweiz Foundation for Bat Conservation in Switzerland Fondation pour la protection des chauves-souris en Suisse Fondazione per la protezione dei pipistrelli della Svizzera Fundaziun per la protecziun da noss mez mieurs e mez utschels en Svizra Liste der empfohlenen und für Fledermäuse verträglichen Holzschutzmittel Empfohlen werden al
5. Using Multiple Vocabularies Catalogers of art information require multiple vocabularies because no single vocabulary provides the full set of terminology needed to catalog or index a given set of cultural heritage data; therefore, a combination of vocabularies is necessary for indexing. Furthermore, separate vocabu- laries may be required for retrieval; ideally, retrieval vocabularies are