Wallach's Interpretation of Diagnostic Tests, 11th Edition
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Eleventh Edition
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Copyright © 2015 Wolters Kluwer. Copyright © 2011, 2007 Lippincott Williams & Wilkins, a Wolters Kluwer business.
Copyright © 2000 Lippincott Williams & Wilkins. Copyright © 1996, 1992, 1986 Jacques Wallach, MD.
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Contributors
M. Rabie Al-Turkmani, PhD, DABCC, FAACC
Chief Scientific Officer and Medical Director
Labtech Diagnostics
San Antonio, Texas
Vishesh Chhibber, MD
Chairperson and Laboratory Medical Director
Coney Island Hospital
Brooklyn, New York
Regional Medical Director for Transfusion Medicine
Northwell Health
Manhasset, New York
Assistant Professor of Pathology and Laboratory Medicine
Zucker School of Medicine at Hofstra/Northwell
Hempstead, New York
Marzena M. Galdzicka, PhD, MB(ASCP)CM, DABCC
Assistant Professor
Department of Pathology
University of Massachusetts Medical School
UMass Memorial Medical Center
Worcester, Massachusetts
Scientific Director, Molecular Department
Quest Diagnostics MA, LLC
Marlborough, Massachusetts
Edward I. Ginns, MD, PhD, DABCC
Professor
Department of Psychiatry, Neurology, Pediatrics and Pathology
Director, Lysosomal Disorders Treatment and Research Program
University of Massachusetts Medical School
Worcester, Massachusetts
Neurology Franchise Medical Director
Quest Diagnostics and Athena Diagnostics
Marlborough, Massachusetts
Amanda J. Jenkins, PhD, F-ABFT, D-ABC
Associate Professor (Ret)
Department of Emergency Medicine
UMass Medical School/UMass Memorial Medical Center
Worcester, Massachusetts
Scientific Director
Toxicology
Quest Diagnostics
Marlborough, Massachusetts
Charles R. Kiefer, PhD
Associate Professor
Department of Pathology
University of Massachusetts Medical School
Worcester, Massachusetts
Patricia Minehart Miron, PhD, FACMGG
Associate Professor
Department of Pathology and Pediatrics
University of Massachusetts Medical School
UMass Memorial Medical Center
Worcester, Massachusetts
Scientific Director, Cytogenetics
Quest Diagnostics MA, LLC
Marlborough, Massachusetts
Michael J. Mitchell, MD, FCAP
Associate Professor
Department of Medicine and Pathology
University of Massachusetts Medical School
UMass Memorial Medical Center
Worcester, Massachusetts
Scientific Director, Microbiology
Quest Diagnostics MA, LLC
Marlborough, Massachusetts
L. V. Rao, PhD, FAACC
Professor of Pathology
University of Massachusetts Medical School
Worcester, Massachusetts
Executive Director, Science
Quest Diagnostics, North Region
Marlborough, Massachusetts
Craig S. Smith, MD
Assistant Professor of Medicine
Medical Director, Cardiac Intensive Care
University of Massachusetts
Worcester, Massachusetts
L. Michael Snyder, MD
Professor
Department of Medicine and Pathology
University of Massachusetts Medical School
UMass Memorial Medical Center
Worcester, Massachusetts
Academic Associate
Quest Diagnostics MA, LLC
Marlborough, Massachusetts
Juliana G. Szakacs, MD, MSW
Associate Director
Physician Health Services
Massachusetts Medical Society
Waltham, Massachusetts
Neng Yu, MD
Associate Professor Department of Pathology
University of Massachusetts Medical School
Director, Histocompatibility Laboratory
UMass Memorial Medical CenterWorcester,
Massachusetts
Hongbo Yu, MD, PhD
Chief, Pathology and Laboratory Medicine Service
Director, Boston Area Consolidated Laboratories
VA Boston Healthcare System
West Roxbury, Massachusetts
Assistant Professor
Department of Pathology
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts
Mohammed Waseem Akhter, MD, FACC
Graduate Student, Duke Global Health Institute
Duke University
Durham, North Carolina
Foreword
Laboratory tests cost-effectively improve quality of patient care by objectively determining
the presence or absence and extent of the disease and aid in monitoring treatment
effectiveness. Approximately 60%–70% of all clinical decisions on patient management is
based on laboratory tests, and these tests are rapidly evolving with advances in technology
and based on clinical needs. There are three major areas that will have a positive and long-
lasting impact in laboratory medicine: (1) disruptive technologies and solutions for reducing
costs and improving quality of care, (2) consumerism in health care, and (3) artificial
intelligence (AI) in laboratory medicine.
DISRUPTIVE TECHNOLOGIES AND SOLUTIONS
FOR REDUCING COSTS AND IMPROVING
QUALITY OF CARE
Laboratory medicine plays a vital role in all health care decisions, and new technologies will
continue to disrupt health care as long as these disruptive technologies drive significant cost
reductions while improving quality of patient care. With government and commercial payers
reducing reimbursement rates, the need for higher productivity and efficiency to lower
laboratory costs will be enabled by disruptive technologies. Advanced laboratory diagnostic
tests will see the most reduction in costs as a result of disruptive technologies. In the near
future, health care will be tailored to your individual genome or your lifestyle. Physicians
will use genomic data to determine what therapies you should receive based on genetic traits
you have inherited from family, your daily habits, and where you live.
CONSUMERISM IN HEALTH CARE
As more of the health care costs are pushed to consumers, consumers are playing a decisive
role regarding diagnostics tests and have become more actively engaged in ensuring they are
getting the best value for their money. They are expecting price transparency and demanding
better health care consumer experience. The success of health care providers will depend on
their ability to meet consumers’ needs and expectations and providing educational tools and
health care data to enable consumers to make their decisions
AI IN LABORATORY MEDICINE
Laboratory medicine is a data business, and deriving actionable insights from the data is key
for preventing, predicting, diagnosing, and treating disease. In the next few years, AI will
interpret important data both at individual patient level and patient cohorts, advise on the
value of other diagnostic tests, and integrate information to guide physicians to enable early
detection and individualized treatment plans. AI will enable clinicians to spend more time
with patients, providing compassionate care while reducing time spent by health care
providers integrating and interpreting vast data. AI is here to stay, and it will be
transformational in health care.
In the eleventh edition of this text, authors include the latest advances in laboratory
testing as well as incorporate ongoing feedback from readers and health care providers.
Authors updated this gem of a text book in laboratory medicine and made it simple, effective,
and efficient in both the print text and eBook formats to meet and exceed the dynamically
changing needs in health care.
KARTHIK KUPPUSAMY, PHD
Vice President & General Manager, North Region
Quest Diagnostics, Marlboro, Massachusetts
Tribute to Jacques Wallach
Jacques Wallach, pathologist, educator, and author of this book, left us on August 10, 2010.
He was 84. Forty years before that, he wrote the first edition, widely recognized as a
necessary resource for both busy house staff and seasoned clinicians alike. It was the product
of his vast experience as a clinical pathologist, his unquenchable thirst for medical
knowledge, and his passion for teaching. He devoted tireless hours of research toward
updating this book seven times since then. Several hundreds of thousands of copies have
been distributed in numerous translations throughout the world.
As a resident in Internal Medicine in the mid-1980s, my first encounter with this book came
in the early hours before our daily morning report, as my fellow house officers scurried to
review the overnight admissions prior to presenting these cases to the Department Chief. The
ensuing hour was usually punctuated by moments when one or more of us incurred the
Chief’s wrath for failure to accurately appreciate the patient’s disorder or appropriately
intervene. In an effort to avoid a similar fate, each of us would keep a copy of the book in an
overfilled pocket of our lab coat to review quickly prior to this daily inquisition. Years later, I
witnessed many students and house officers under my supervision do same, often secretly
racing each other to the passage contained therein that would earn them the sought after
recognition of their peers.
In the years that followed, I saw the third edition of the book become the fourth, fifth,
and so on, never really appreciating the work that Jacques put into each update. Like many of
us, however, I did appreciate the place that each update had among my collection of those
clinical books, which were always kept within easy reach and never seemed to collect any
dust in my personal medical library.
When I first met Jacques, I was impressed by his dedication and commitment to medical
education. He taught pathology at Albert Einstein, Rutgers, and SUNY Downstate and
consulted for Children’s Specialized Hospital in Mountainside, South Amboy Memorial
Hospital, Kings County Hospital in Brooklyn, and for the Bronx Zoo. He also wrote
Rheumatic Heart Disease (1962) and Interpretation of Pediatric Tests (1983) as well as over
40 articles for peer review medical journals. He was a Fellow of the American College of
Physicians, the American Society of Clinical Pathologists, the College of American
Pathologists, and the New York Academy of Medicine. From 1975 to 1985, he donated his
time and expertise in pathology to laboratories around the world. His office was crammed
with countless notes he made while researching, scrolled on small pieces of paper, and filed
between the pages of dozens of medical books and journals, waiting their turn to adorn the
pages of his next book. It was like he realized that clinicians and patients around the world
depended on him to unlock the keys to their own medical mysteries, and he did not take that
responsibility lightly. More recently, Jacques asked me to join his small list of distinguished
contributors and lend some assistance in my own area of expertise. To contribute in some
small way to his labor of love was truly an honor.
As the devoted teacher, nothing was more rewarding to Jacques than being able to impart
the wisdom he had worked hard to accumulate to the pupil looking for guidance. This ninth
edition and all subsequent editions, now entitled Wallach’s Interpretation of Diagnostic Tests,
represent his legacy and his ongoing gift to physicians around the world who continue to use
his guidance everyday to care for their patients. I have no doubt that nothing would have
made him happier.
ANTHONY G. AUTERI, MD
Preface
In the eleventh edition of Wallach’s Interpretation of Diagnostic Tests, the authors continue to
modify the content and organization based on feedback from readers as well as to keep pace
with a rapidly changing health care environment. The primary focus of this book is to stress
the most accurate and efficient use of clinical lab testing. This edition is not an exhaustive
catalog of all disease states but a more practical guide.
We modified the format by bringing the individual test section to the front of the book. In
the first chapter, for convenience, we also include a tabular form of most frequently ordered
tests. This table is also provided in a perforated tear-out version at the end of the book for
clinical use. Also, we updated the genetic, molecular diagnostics, and neurology testing
chapters with the most current, cutting-edge information.
We expanded the index, thus enabling the reader to locate more efficiently subjects of
interest. Enhancements to the electronic version will now include hypertexting of tests
mentioned in the disease section, referring back to the individual test section. This book does
not cover, for the most part, references to pathophysiology, therapy, and treatment. Common
pitfalls and limitations of testing are addressed.
As in previous editions, this book is geared to primary care physicians, subspecialists,
physician assistants, nurse practitioners, and medical and nursing students. We would
appreciate continued feedback and comments about changes we have implemented.
L. V. RAO, PHD
L. MICHAEL SNYDER, MD
Preface to the First Edition
Results of laboratory tests may aid in
Discovering occult disease
Preventing irreparable damage (e.g., phenylketonuria)
Early diagnosis after onset of signs or symptoms
Differential diagnosis of various possible diseases
Determining the stage of the disease
Estimating the activity of the disease
Detecting the recurrence of disease
Monitoring the effect of therapy
Genetic counseling in familial conditions
Medicolegal problems, such as paternity suits
This book is written to help the physician achieve these purposes the least amount of
Duplication of texts
Waste of patient’s money
Overtaxing of laboratory facilities and personnel
Loss of physician’s time
Confusion caused by the increasing number, variety, and complexity of tests currently
available. Some of these tests may be unrequested but performed as part of routine surveys or
hospital admission multitest screening.
In order to provide quick reference and maximum availability and usefulness, this handy-
sized book features
Tabular and graphic style of concise presentation
Emphasis on serial time changes in laboratory findings in various stages of disease
Omission of rarely performed, irrelevant, esoteric, and outmoded laboratory tests
Exclusion of discussion of physiologic mechanisms, metabolic pathways, clinical
features, and nonlaboratory aspects of disease
Discussion of only the more important diseases that the physician encounters and should
be able to diagnose
This book is not
An encyclopedic compendium of clinical pathology
A technical manual
A substitute for good clinical judgment and basic knowledge of medicine
Deliberately omitted are
Technical procedures and directions
Photographs and illustrations of anatomic changes (e.g., blood cells, karyotypes, isotope
scans)
Discussions of quality control
Selection of a referral laboratory
Performance of laboratory tests in the clinician’s own office
Bibliographic references, except for the most general reference texts in medicine,
hematology, and clinical pathology and for some recent references to specific conditions
The usefulness and need for a book of this style, organization, and contents have been
increased by such current trends as
The frequent lack of personal assistance, advice, and consultation in large commercial
laboratories and hospital departments of clinical pathology, which are often specialized and
fragmented as well as impersonal
Greater demand for the physician’s time
The development of many new tests
Faculty and administrators still assume that this essential area of medicine can be learned
“intuitively” as it was 20 years ago and that it therefore requires little formal training. This
attitude ignores changes in the number and variety of tests now available as well as their
increased sophistication and basic value in establishing a diagnosis.
The contents of this book are organized to answer the questions most often posed by
physicians when they require assistance from the pathologist. There is no other single
adequate source of information presented in this fashion. It appears from numerous
comments I have received that this book has succeeded in meeting the needs not only of
practicing physicians and medical students but also of pathologists, technologists, and other
medical personnel. It has been adopted by many schools of nursing and of medical
technology, physician’s assistant training programs, and medical schools. Such widespread
acceptance confirms my original premise in writing this book and is most gratifying.
A perusal of the table of contents and index will quickly show the general organization of
the material by type of laboratory test or organ system or certain other categories. In order to
maintain a concise format, separate chapters have not been organized for such categories as
newborn, pediatric, and geriatric periods or for primary psychiatric or dermatologic diseases.
A complete index provides maximum access to this information.
Obviously, these data are not original but have been adapted from many sources over the
years. Only the selection, organization, manner of presentation, and emphasis are original. I
have formulated this point of view during 40 years as a clinician and pathologist, viewing
with pride the important and growing role of the laboratory but deeply regretting its
inappropriate utilization.
This book was written to improve laboratory utilization by making it simpler for the
physician to select and interpret the most useful laboratory tests for his clinical problems.
J.W.
