MODULO di RICHIESTA di BIOPSIA NERVO /
MUSCOLO
Neuromuscolare Clinica Laboratorio: Alan Pestronk, M.D., Director
Washington University School of Medicine – Neurology Department
CAP# 19233-16 : CLIA ID# 26D0652044 : Medicare Provider # 26-8235
Internet Home Page
http://www.neuro.wustl.edu/neuromuscolare
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Referring institution
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paziente name
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Requesting physician
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Sex
Età
DOB |
Send report to
NAME
ADDRESS
CITY, STATE, ZIP
PHONE e FAX #
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Date Biopsia received
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Bill charges to
Labs diverse dalle Washington University: Se we sono
billing paziente, please provide insurance authorization numero.
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Diagnosi clinica e Storia
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Specimens e Site biopsied
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Surgeon
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Istruzioni
Hand carried fresh tissue: Wrap in moist (saline) gauze; Do non
immerse in saline o fissativi
Mailed tissue: NOTES - Laboratorio only open Monday attraverso le Friday;
Send by overnight mail for early next day delivery
Metodo A. Congelamento one piece of tissue in isopentano cooled
con azoto liquido; Fissazione a 2a piece, o
Metodo B. Wrap Biopsia specimens in moist (saline) gauze; Place
in sealed plastic container
TESTS RICHIESTE:
HistoChimici e immunocitochimiche colorazioni sono
condotti on frozen, unfixed tissue.
Routine Istochimica:
Performato on tutti biopsies
[ ] MUSCLE: H&E X 2, NADH, GT,
ATPasi X 3, VvG, Congo Rossa, Sudan Black, Alkaline e Acid Phosphatase, Esterasi
Periodic Acid Schiff, Cytochrome Oxidase, Succinic deidrogenasi, Amylo-fosforilasi,
AMPDA
[ ] NERVI Frozen
sezioni: H&E, GT, Congo Rossa, Alkaline e Acid Phosphatase, VvG
Plastic sezioni: Blu di toluidina
NEUROPATHOLOGY reports aggiunta information covering the biopsia nervosa in a
separate report.
Dystrophies
(Immunocitochimica (IHC) e#177; Western blot (WB)): [ ]
Distrofia-correlate proteina panel
[ ] Distrofina (IHC); [ ] Distrofina
(WB); [ ] Sarcoglicani (α, β, δ, γ) (IHC); [ ] Sarcoglicani (WB); [ ] Dysferlin
(IHC e WB); [ ] Calpain 3 (WB);
[ ] Emerin (IHC e WB); [ ] Desmin (IHC);
[ ] Caveolina (IHC e WB); [ ] α-distroglicano (IHC); [ ] Laminina α2 e B (IHC);
[ ] VCP (IHC)
Immune miopatia panel:
[ ] MHC Class I; Capillary morfologia (Ulex); C5b-9
(MAC); CD4; CD20; CD68; Decorin; IgM deposition
BIOCHEMISTRY
Performato at WU Neuromuscolare Laboratorio EXTRA SPECIMEN
solitamente required (> 0.5 cm3, 100 mg)
[ ] Ossidativi (Mitocondriali) enzimi;
[ ] Glicogeno; [ ] Maltasi acida
Requirements for tissue to be forwarded dalla NM lab
to other labs for further esaminazione
Extra specimen (minimum 0.5 cm3,
200 a 500 mg); Clinica information; Billing information e approval #; Requisiti
ALTRE_______________________________;
For questions, please page the neuromuscolare fellow
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SHIPPING ADDRESSES
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Frozen specimens
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Fresh tissue -- HAND DELIVERY!!
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SHIPPING/MAILING ADDRESS:
ALAN PESTRONK, M.D.
Washington University - Neurology, Box 8111
660 S. Euclid Ave.
St. Louis, MO 63110
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STREET LOCATION:
NEUROMUSCULAR LABORATORIO
Irene Walter Johnson Institute
509 S. Euclid, Room 404
St. Louis, MO 63110
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Phone: 314-362-6981 (Office); 314-362-2406 (Laboratorio); FAX: 314-362-3752;
Turn around time: ~3 wks
Revised 7/8/2004 GJP/AP
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Traduzione di Natale
Marzari