Clinical Laboratory Quotes

Burnout at its deepest level is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice. When a great ship steams across the ocean, even tiny ripples can accumulate over time, precipitating a dramatic shift in course. There are many Tertius Lydgates, male and female, inhabiting the lecture halls, laboratories, and clinics of today’s medical schools. Like latter-day Lydgates, many of them eventually find themselves expressing amazement and disgust at how far they have veered from their primary purpose.

Our own poor poets, I am afraid, have been so intimidated by our clinics and laboratories that they have abandoned the first principles of beginning, that of the festival; and the heart of the festival has always been the atmosphere of myth, of delight.

I say "despair" because it is a word that can live comfortably in a house without changing the building's purpose. It only changes the mood. "Depression" and "suicidal ideation" and "anxiety" all cast a stage or laboratory light. Even here, in this room. It shifts from paragraph to clinic. Despair recognizes its own ridiculousness, its emotional exaggeration.

Despite decades of obesity research, and billions of dollars spent in the laboratory and on clinical trials, the bedrock fundamental concept underlying all nutrition and dietary advice is that fat and lean people are effectively identical physiologically, and that our bodies respond to what we eat the same way, except that the fat people at some point in their lives ate too much and expended too little energy and so became fat, while the lean people didn’t.

Wilson-Donovan wanted to move ahead as quickly as possible to clinical trials on patients, which was why it was so important to test Vicotec’s safety now before the FDA hearings in September, which would hopefully put it on the “Fast Track.” Peter was absolutely sure that the testing being concluded by Paul-Louis Suchard, the head of the laboratory in Paris, would only confirm the good news he had just been given in Geneva.

The earliest modern attempt to test prayer’s efficacy was Sir Francis Galton’s innovative but flawed survey in 1872.16 The field languished until the 1960s, when several researchers began clinical and laboratory studies designed to answer two fundamental questions: (1) Do the prayerful, compassionate, healing intentions of humans affect biological functions in remote individuals who may be unaware of these efforts? (2) Can these effects be demonstrated in nonhuman processes, such as microbial growth, specific biochemical reactions, or the function of inanimate objects? The answer to both questions appears to be yes.

There appears to be a close connection between these skin disorders (acne and warts) and the emotions. As with virtually all of these mind-body processes, there is no laboratory proof of the causative role of emotions, but there is certainly a mountain of clinical evidence. Acne is one of the common "other things" that people with TMS have had or continue to have even while they're having back trouble. And then there's the story of the man who developed an itchy rash under his wedding band that disappeared as soon as he separated from his wife. Other gold rings did not produce a similar rash. It has been suggested that other skin disorders like eczema and psoriasis are related to the emotions. I am inclined to agree but have no evidence one way or the other. (page 195)

Yet skill in the most sophisticated applications of laboratory technology and in the use of the latest therapeutic modality alone does not make a good physician. When a patient poses challenging clinical problems, an effective physician must be able to identify the crucial elements in a complex history and physical examination; order the appropriate laboratory, imaging, and diagnostic tests; and extract the key results from densely populated computer screens to determine whether to treat or to “watch.” As the number of tests increases, so does the likelihood that some incidental finding, completely unrelated to the clinical problem at hand, will be uncovered. Deciding whether a clinical clue is worth pursuing or should be dismissed as a “red herring” and weighing whether a proposed test, preventive measure, or treatment entails a greater risk than the disease itself are essential judgments that a skilled clinician must make many times each day. This combination of medical knowledge, intuition, experience, and judgment defines the art of medicine, which is as necessary to the practice of medicine as is a sound scientific base.

In 1937, Gunda Lawrence, a teacher and homemaker from South Dakota, lay close to death from abdominal cancer. Doctors at the Mayo Clinic in Minnesota had given her three months to live. Luckily, Mrs. Lawrence had two exceptional and devoted sons—John, a gifted physician, and Ernest, one of the most brilliant physicists of the twentieth century. Ernest was head of the new Radiation Laboratory at the University of California at Berkeley and had just invented the cyclotron, a particle accelerator that generated massive amounts of radioactivity as a side effect of energizing protons. They had in effect the most powerful X-ray machine in the country at their disposal, capable of generating a million volts of energy. Without any certainty what the consequences would be—no one had ever tried anything remotely like this on humans before—the brothers aimed a deuteron beam directly into their mother’s belly. It was an agonizing experience, so painful and distressing to poor Mrs. Lawrence that she begged her sons to let her die. “At times I felt very cruel in not giving in,” John recorded later. Happily, after a few treatments, Mrs. Lawrence’s cancer went into remission and she lived another twenty-two years. More important, a new field of cancer treatment had been born.

(Notably, temporary loss of blood or oxygen or excess carbon dioxide in the blood can also cause a disruption in the temporoparietal region and induce out-of-body experiences, which may explain the prevalence of these sensations during accidents, emergencies, heart attacks, etc.) NEAR-DEATH EXPERIENCES But perhaps the most dramatic category of out-of-body experiences are the near-death stories of individuals who have been declared dead but then mysteriously regained consciousness. In fact, 6 to 12 percent of survivors of cardiac arrest report having near-death experiences. It’s as though they have cheated death itself. When interviewed, they have dramatic tales of the same experience: they left their body and drifted toward a bright light at the end of a long tunnel. The media have seized upon this, with numerous best sellers and TV documentaries devoted to these theatrical stories. Many bizarre theories have been proposed to explain near-death experiences. In a poll of two thousand people, fully 42 percent believed that near-death experiences were proof of contact with the spiritual world that lies beyond death. (Some believe that the body releases endorphins—natural narcotics—before death. This may explain the euphoria that people feel, but not the tunnel and the bright lights.) Carl Sagan even speculated that near-death experiences were a reliving of the trauma of birth. The fact that these individuals recount very similar experiences doesn’t necessarily corroborate their glimpses into the afterlife; in fact, it seems to indicate that there is some deep neurological event happening. Neurologists have looked into this phenomenon seriously and suspect that the key may be the decrease of blood flow to the brain that often accompanies near-death cases, and which also occurs in fainting. Dr. Thomas Lempert, a neurologist at the Castle Park Clinic in Berlin, conducted a series of experiments on forty-two healthy individuals, causing them to faint under controlled laboratory conditions. Sixty percent of them had visual hallucinations (e.g., bright lights and colored patches). Forty-seven percent of them felt that they were entering another world. Twenty percent claimed to have encountered a supernatural being. Seventeen percent saw a bright light. Eight percent saw a tunnel. So fainting can mimic all the sensations people have in near-death experiences

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WHY ADDICTION IS NOT A DISEASE In its present-day form, the disease model of addiction asserts that addiction is a chronic, relapsing brain disease. This disease is evidenced by changes in the brain, especially alterations in the striatum, brought about by the repeated uptake of dopamine in response to drugs and other substances. But it’s also shown by changes in the prefrontal cortex, where regions responsible for cognitive control become partially disconnected from the striatum and sometimes lose a portion of their synapses as the addiction progresses. These are big changes. They can’t be brushed aside. And the disease model is the only coherent model of addiction that actually pays attention to the brain changes reported by hundreds of labs in thousands of scientific articles. It certainly explains the neurobiology of addiction better than the “choice” model and other contenders. It may also have some real clinical utility. It makes sense of the helplessness addicts feel and encourages them to expiate their guilt and shame, by validating their belief that they are unable to get better by themselves. And it seems to account for the incredible persistence of addiction, its proneness to relapse. It even demonstrates why “choice” cannot be the whole answer, because choice is governed by motivation, which is governed by dopamine, and the dopamine system is presumably diseased. Then why should we reject the disease model? The main reason is this: Every experience that is repeated enough times because of its motivational appeal will change the wiring of the striatum (and related regions) while adjusting the flow and uptake of dopamine. Yet we wouldn’t want to call the excitement we feel when visiting Paris, meeting a lover, or cheering for our favourite team a disease. Each rewarding experience builds its own network of synapses in and around the striatum (and OFC), and those networks continue to draw dopamine from its reservoir in the midbrain. That’s true of Paris, romance, football, and heroin. As we anticipate and live through these experiences, each network of synapses is strengthened and refined, so the uptake of dopamine gets more selective as rewards are identified and habits established. Prefrontal control is not usually studied when it comes to travel arrangements and football, but we know from the laboratory and from real life that attractive goals frequently override self-restraint. We know that ego fatigue and now appeal, both natural processes, reduce coordination between prefrontal control systems and the motivational core of the brain (as I’ve called it). So even though addictive habits can be more deeply entrenched than many other habits, there is no clear dividing line between addiction and the repeated pursuit of other attractive goals, either in experience or in brain function. London just doesn’t do it for you anymore. It’s got to be Paris. Good food, sex, music . . . they no longer turn your crank. But cocaine sure does.

People v. Marx, 54 Cal. App. 3d 101 (1975), became one of the most consequential opinions in forensic science, not just forensic odontology. It began with a remarkable concession: there was “no established science of identifying persons from bite marks.” The technique had not been subjected to even the most rudimentary tenets of the scientific method. No hypotheses were tested. No laboratory experiments were conducted. No clinical research. The dentists never demonstrated their claimed ability to match teeth to bite marks. It was just an opinion.

In the weeks that followed, I frequently visited Kahn’s clinic and research laboratory, to see how lasers worked, talk with staff, try the equipment myself, and then train to use it. Kahn’s clinic, called Meditech, had a staff of forty-five people, mostly clinicians, and also a laboratory that designed the lasers. The ultimate goal of my visits was to see how lasers might influence the brain, but first I wanted to understand how lasers worked and see what serious laser treatments could do for common bodily afflictions.

You need to have a diploma from nursing school and be certified as a registered nurse.             Ideally, you should have at least two to three years of clinical experience as an outpatient nurse or as an emergency room nurse.             You should be certified in Basic Life Support and Advanced Cardiac Life Support (ACLS). Some cruise lines request Advanced Trauma Life Support (ATLS) certification as well.             You may need to have experience in dealing with laboratory procedures and basic x-ray procedures as there is not likely to be a lab tech or x-ray tech on duty.             You should have a background in general medicine and/or emergency medicine.             You should have past experience caring for patients in a trauma, cardiac care, emergency care, or internal medicine practice.             Because cruise liners travel to often to foreign lands and have people of all different cultures on board, you may need to have knowledge of other languages besides English.   As

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Table 3.2 Components of Clinical Whole Blood, Plasma, and Serum Matrices

Conversely, the release of elements or cell lysis associated with the coagulation cascade is responsible for the increase in potassium (±6%), inorganic phosphate (±11%), ammonia (±38%), and lactate (±22%) in serum compared to plasma [9]. Furthermore, anticoagulants, preservatives, and other additives that aid or inhibit coagulation may interfere with the assay, as discussed later. Also, the presence of fibrinogen may interfere with chromatic detection or binding in immunoassays or the appearance of a peak that may simulate a false monoclonal protein in the gamma region during protein electrophoresis [9,10]. Serum Versus Plasma for Clinical Laboratory Tests There are many advantages to using plasma over serum for clinical laboratory analysis. However, for some analytes, serum is preferred over plasma. These issues are addressed in this section.

S.P. is a 68-year-old retired painter who is experiencing right leg calf pain. The pain began approximately 2 years ago but has become significantly worse in the past 4 months. The pain is precipitated by exercise and is relieved with rest. Two years ago, S.P. could walk two city blocks before having to stop because of leg pain. Today, he can barely walk across the yard. S.P. has smoked two to three packs of cigarettes per day (PPD) for the past 45 years. He has a history of coronary artery disease (CAD), hypertension (HTN), peripheral vascular disease (PVD), and osteoarthritis. Surgical history includes quadruple coronary artery bypass graft (CABG × 4) 3 years ago. He has had no further symptoms of cardiopulmonary disease since that time, even though he has not been compliant with the exercise regimen his cardiologist prescribed, he continues to eat anything he wants, and continues to smoke two to three PPD. Other surgical history includes open reduction internal fixation of the right femoral fracture 20 years ago. S.P. is in the clinic today for a routine semiannual follow-up appointment with his primary care provider. As you take his vital signs, he tells you that, besides the calf pain, he is experiencing right hip pain that gets worse with exercise, the pain doesn't go away promptly with rest, some days are worse than others, and his condition is not affected by a resting position. � Chart View General Assessment Weight 261 lb Height 5 ft, 10 in. Blood pressure 163/91 mm Hg Pulse 82 beats/min Respiratory rate 16 breaths/min Temperature 98.4° F (36.9° C) Laboratory Testing (Fasting) Cholesterol 239 mg/dL Triglycerides 150 mg/dL HDL 28 mg/dL LDL 181 mg/dL Current Medications Lisinopril (Zestril) 20 mg/day Metoprolol (Lopressor) 25 mg twice a day Aspirin 325 mg/day Simvastatin (Zocor) 20 mg/day Case Study 4 Name Class/Group Date ____________________ Group Members INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several

In nature, ecosystems consist of fauna and flora, climatic characteristics, soil conditions, geologic features, and a host of other interacting influences. Similarly, the precision medicine ecosystem is made of many interacting components, including patients, clinicians, researchers, laboratory services, CDS software, genomic databases, smartphones, servers, claims data, mobile apps, biobanks to store clinical specimens, and EHRs. EHRs need to serve as gateways to this ecosystem. And for the EHR to become an effective conduit, it needs a way to organize these diverse sources in a way that lets clinicians and patients make more effective diagnostic and treatment decisions.

Throughout your administration, you have carried out a policy of scientific aid to the Kingdoms. You have given them atomic power. You have helped rebuild power plants on their territories. You have established medical clinics, chemical laboratories and factories.’ ‘Well? And your objection?’ ‘You have done this in order to keep them from attacking us. With these as bribes, you have been playing the fool in a colossal game of blackmail, in which you have allowed Terminus to be sucked dry – with the result that now we are at the mercy of these barbarians.

But laboratory, radiology, and pathology results were computerized relatively early (many hospitals and clinics did so in the 1990s), and some healthcare systems began experimenting with giving patients access to them.21 While this information was less fraught than doctors’ notes, many in the medical establishment still worried about how patients might handle seeing such results unfiltered.

create experience and control it, in the laboratory of our minds. Both experimental and clinical psychology have proved beyond a shadow of a doubt that the human nervous system cannot tell the difference between an actual experience and an experience imagined vividly and in detail.

After the active ingredients are manufactured, the additional ingredients chosen, and the principal laboratory and clinical tests conducted, the formula then moves to the manufacturing floor to see if it can be made on a commercial scale. As the manufacturing runs become larger, the processes become harder to control. If something can go wrong, it will. You can build a fortress of current good manufacturing practices around the drug-making process and still “shit happens,” as Malik liked to say. Conscientious manufacturers try to protect against past disasters and prevent new ones. But because manufacturing plants are operated by humans, the systems will break down, no matter how perfectly designed they are. For example, Johnson & Johnson’s epilepsy drug was fine until the company stacked it on wooden pallets that likely leached solvents into the medicine. At Mylan’s Morgantown plant, one lab technician left a note for another stating that he had to “rig” a hose on the equipment to get it to work properly—a word choice that easily could have shut down the plant had an FDA investigator stumbled across it and suspected fraud instead of primitive problem-solving. The only remedy for this variability is for plants to adhere scrupulously to good manufacturing practices and create real-time records of each drug-making step. The resulting data serve as a blueprint for finding and fixing the inevitable errors, a process that FDA investigators scrutinize. How well and how closely did the company investigate itself? The goal is to address a problem “in a way that it never happens again,” as Malik explained.

three associates of the William Pepper Clinical Laboratory at the University of Pennsylvania used well over a hundred children under the age of eight at the St. Vincent’s Home for Orphans, a Catholic orphanage in Philadelphia, for a series of diagnostic tests in which a tuberculin formula was placed in the test subjects’ eyes. 23

In 1963, Choh Hao Li, chairman and lone tenured faculty member in the Institute of Experimental Biology at Berkeley, announced that he had isolated and purified his sixth pituitary hormone, lipotropin. The magnitude of such a feat is clear considering that only one other person had ever purified a hormone, and that person was not coincidentally a student of Li's. The purification of lipotropin should have been a reason to celebrate; however, Li's colleagues at Berkeley acknowledged but did not rejoice in his success. As they perceived it, endocrinology was a scientific field that came out of the clinical sciences, which meant that Li's research was completely unsound, and they put enormous pressure on him to change his scientific topic. When that did not work, Wendell Stanley tried to 'promote [Li] out of the Virus Laboratory,' then later University Chancellor Clark Kerr threatened to discontinue the Institute for Experimental Biology because it did not fit with Berkeley's commitment to pure research. Things got infinitely worse for Li, of course, because he became perceived as less qualified with each professional achievement. [...] C. H. Li's travails at Berkeley are only half the story. In 1969, five years after transferring from Berkeley to UCSF, Li and his laboratory assistants assembled a highly complex synthetic version of human growth hormone (HGH) that was biologically active and could promote the growth of bones and muscle tissue. Rather than ignore or criticize the work, however, journalists waxed eloquently [sic] about Li's creation of HGH. One described it as no less than a panacea for most of the world's problems. Others clearly saw specific applications: 'it might now be . . . possible to tailor-make hormones that can inhibit breast cancer.' Li's discovery of synthetic HGH 'constituted a truly . . . great research breakthrough [that had] obvious applications,' ranging from 'human growth and development to . . . treatment of cancer and coronary artery disease.' Desperate letters poured in too; athletes wanted to know if HGH would help them become faster, bigger, stronger, and dwarfs from all over the world begged for samples of HGH or to volunteer as experimental subjects. Unlike at Berkeley, Li's discovery made him a hero at UCSF. None other than UCSF Chancellor Phillip Lee described Li's discovery as 'meticulous, painstaking, and brilliant research' and then tried to capitalize on the moment by asking the public and their political representatives to increase federal support of bioscience research. 'Research money is dwindling fast,' repeated Lee to anyone who cared to listen. 'We've proven than synthesis can be done, now all we need is the money and time to prove its tremendous value.' It is not surprising that federal and state money began to pour into Li's lab. What is shocking, however, is how quickly Li achieved scientific acclaim, not because he changed, but because the rest of the world around him changed so much.

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And like cocaine before it, the illicit painkiller trade was dominated by one state: Florida. But the similarities between cocaine and oxycodone ended there. Oxycodone wasn’t created in Colombian jungle laboratories or smuggled in suitcases or on thirty-foot “go-fast” speedboats. It was manufactured in pharmaceutical plants in St. Louis and promoted on highway billboards, and in page after page in the back of the New Times, a free weekly newspaper in South Florida. The bigger advertisements usually showed a woman holding her forehead and wincing, or a man’s torso arched in agony. The ads blared: “CHRONIC PAIN? STOP HURTING AND START LIVING!” Then, in smaller type: “Walk-Ins Welcome. Dispensing On-Site!” Some offered coupons or specials. One clinic’s ad said nothing about pain itself and simply displayed the goods: an amber prescription bottle, dozens of little blue pills tumbling out.

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