Status of phlebotomy tube utilization at a major medical center. Are we using too many phlebotomy tubes?

Background and objectives: Overutilization of phlebotomy tubes at healthcare facilities leads to iatrogenic anemia, patient dissatisfaction, and increase in operational costs. In this study, we analyzed the phlebotomy tube usage data at the Zhongshan Hospital, Fudan University, to show potential inefficiencies with phlebotomy tube usage. Methods: Data of 984,078 patients with 1,408,175 orders and 4,622,349 total phlebotomy tubes were collected during years 2018-2021. Data of different patient types were compared. Furthermore, we assessed the data from subspecialty and test levels to explore the factors influencing the increase in phlebotomy tube usage. Results: We observed an overall 8% increase in both the mean number of tubes used and blood loss per order over the past 4 years. The mean blood loss per day for intensive care unit (ICU) patients was 18.7 ml (maximum 121.6 ml), which was well under the 200 ml/day threshold. However, the maximum number of tubes used reached more than 30 tubes/day. Conclusions: The 8% increase of phlebotomy tubes over 4 years should alarm laboratory managements, as tests offered are expected to increase in the future. Importantly, the whole healthcare community needs to work together to solve this problem with more creative solutions.

Evaluation of a cardiac troponin process flow at the chest pain center with the shortest turnaround time.

BACKGROUND: Early diagnosis of myocardial infarction is crucial in chest pain management and cardiac troponin (cTn) test is an important step in it. Process improvement to shorten the test turnaround time (TAT) may improve patients' outcomes. The cTn test at chest pain center (CPC) of Zhongshan Hospital had the shortest TAT ever reported, but its process flow was not fully evaluated. METHODS: We performed a stepwise evaluation of CPC cTn TAT and explored the potential factor that might cause delay. The performance of CPC cTn test was also compared with cTn test and human chorionic gonadotropin (HCG) test ordered from emergency department (ED). RESULTS: At least 95% of CPC cTn tests were completed in 60 min, while 62% in 30 min. The medians of monthly order-to-collect time, collect-to-received time, and received-to-result time were ~7 min, ~3 min, and ~13 min, respectively. The samples collected at the bedside had longer collect-to-received time than the ones collected at the blood draw site next to the laboratory. Compared to ED cTn test and ED HCG test, CPC cTn test took less time in each step. A combination of the sample type switch and the centrifugation time reduction contributed the most to the shortening of TAT, which was reflected in the received-to-result time. CONCLUSIONS: The current process flow of CPC cTn test satisfied the requirements of chest pain management, giving an example of how to implement process improvement for emergency medicine to shorten TAT of laboratory tests.

Regression-Adjusted Real-Time Quality Control.

BACKGROUND: Patient-based real-time quality control (PBRTQC) has gained increasing attention in the field of clinical laboratory management in recent years. Despite the many upsides that PBRTQC brings to the laboratory management system, it has been questioned for its performance and practical applicability for some analytes. This study introduces an extended method, regression-adjusted real-time quality control (RARTQC), to improve the performance of real-time quality control protocols. METHODS: In contrast to the PBRTQC, RARTQC has an additional regression adjustment step before using a common statistical process control algorithm, such as the moving average, to decide whether an analytical error exists. We used all patient test results of 4 analytes in 2019 from Zhongshan Hospital, Fudan University, to compare the performance of the 2 frameworks. Three types of analytical error were added in the study to compare the performance of PBRTQC and RARTQC protocols: constant, random, and proportional errors. The false alarm rate and error detection charts were used to assess the protocols. RESULTS: The study showed that RARTQC outperformed PBRTQC. RARTQC, compared with the PBRTQC, improved the trimmed average number of patients affected before detection (tANPed) at total allowable error by about 50% for both constant and proportional errors. CONCLUSIONS: The regression step in the RARTQC framework removes autocorrelation in the test results, allows researchers to add additional variables, and improves data transformation. RARTQC is a powerful framework for real-time quality control research.

Assessment of patient-based real-time quality control algorithm performance on different types of analytical error.

BACKGROUND: Patient-based real-time quality control (PBRTQC) has gained attention because of its potential to detect analytical errors in situations wherein internal quality control is less effective. Multiple PBRTQC algorithms have been proposed. However, there is a lack of comprehensive comparison of the performance of PBRTQC algorithms on different types of analytical errors. Thus, a comparative study was conducted. METHODS: The performance of six different PBRTQC algorithms was evaluated on three types of analytical errors using 906,552 test results for outpatient serum sodium, chloride, alanine aminotransferase, and creatinine at the Department of Laboratory Medicine at Zhongshan Hospital, Fudan University in 2019. The performance results were compared and assessed. RESULTS: The moving average, moving median, exponentially weighted moving average, and moving quartiles performed similarly for effectively detecting constant errors (CE) and proportional errors (PE) but not random errors (RE). The moving sum of positive patients and moving standard deviation could detect RE for serum sodium and chlorides but performed poorly on detecting the CE and PE. CONCLUSIONS: This study demonstrated the importance of assessing the potential source of error of a particular analyte and the corresponding type of analytical error before choosing a quality control algorithm for implementation.

The major causes and risk factors of total and cause-specific mortality during 5.4-year follow-up: the Shanghai Changfeng Study.

To investigate the major causes and predictive factors of death in a middle-aged and elderly Chinese population. A total of 6591 residents aged ≥ 45 years from Shanghai Changfeng community were followed up for an average of 5.4 years. The causes of death were coded according to the 10th Revision of International Classification of Diseases. The mortality rate was calculated by person-years of follow up and age-standardized according to the 2010 Chinese census data. Multivariable-adjusted Cox proportional hazards model was performed to investigate the predictors of all-cause and cause-specific mortality. During the total follow-up of 35,739 person-years, 370 deaths were documented (157 from malignant neoplasms, 70 from heart diseases, 68 from cerebrovascular diseases, 75 from other causes). The age-standardized all-cause mortality rate was 798.2 per 100,000 person-years (927.9 among men and 716.7 among women). Results from multivariable analyses showed that aging, diabetes, and osteoporosis at baseline were independent predictors of all-cause mortality, with hazard ratios (HR) of 1.11 (95% CI 1.10-1.13), 1.91 (1.51-2.42), and 1.71 (1.24-2.35), respectively. The population attributable risk percent of diabetes and osteoporosis was 19.7% and 11.7%, respectively. Cigarette smoking was associated with a higher risk of all-cause mortality in men (HR and 95%CI 1.44, 1.01-2.06). In women, diabetes and osteoporosis were related to a higher risk of cardiovascular mortality (3.27, 1.82-5.88 and 1.89, 1.04-3.46, respectively). While in men, osteoporosis was related to a higher risk of malignant neoplasms mortality (2.39, 1.07-5.33). Malignant neoplasms, heart diseases, and cerebrovascular diseases are the leading causes of death. Aging, smoking, underweight, diabetes, and osteoporosis are independent predictors of premature death among middle-aged and elderly Chinese community population. Moreover, there may have been some differences in the causes and predictors of premature death between men and women.

Sex-specific association of metabolic risk factors with brain ischemic lesions by severity and location.

BACKGROUND: Males and females exhibit significant differences in metabolism and in brain ischemic stroke and different features of brain ischemic lesions are related to different health outcomes. It is critical to understand sex differences in their associations to optimize prevention and intervention for both sexes. We aimed to investigate the sex-specific association of metabolic risk factors with brain ischemic lesions by severity and location. METHODS: Five thousand seven hundred ninety-one participants who underwent comprehensive health examinations between Jan. 1, 2017, and Dec. 31, 2017, were enrolled. Clinical and laboratory data about metabolic risk factors were obtained. Brain ischemic lesions were further categorized by severity (mild ischemic lesions or severe infarct lesions) and location (strictly lobar or deep brain/infratentorial areas) based on brain magnetic resonance imaging reports. Sex- and age-specific detected rates were calculated, and generalized linear models and multinomial logistic regression were used to analyze the associations between metabolic risk factors and the presence, severity, and location of ischemic lesions stratified by sex. RESULTS: A total of 2712 (46.8%) participants had at least one brain ischemic lesions. Age (adjusted OR, 1.10 [1.10-1.11], p < 0.001) and hypertension (adjusted OR, 1.42 [1.22-1.64], p < 0.001) were generally associated with higher risks of brain ischemia in both sexes. Metabolic syndrome was associated with greater adjusted ORs for brain ischemia with different severity and location in men (adjusted ORs between 1.23 and 1.49) but not in women. Overweight and obesity were related to lesions located strictly in lobar in men (adjusted OR, 1.23 and 1.33, respectively) and lesions located in deep brain/infratentorial areas in women (adjusted OR, 1.57 and 2.26, respectively). CONCLUSIONS: Metabolic syndrome was associated with brain ischemic lesions in men but not in women. Higher body mass index was related to ischemic lesions located in lobar in men and in deep brain/infratentorial areas in women. Its mechanisms remain to be further investigated.

Facile Synthesis of Pd Nanocubes with Assistant of Iodide and Investigation of Their Electrocatalytic Performances Towards Formic Acid Oxidation.

This article presents a facile, one-pot method using the aqueous phase for the synthesis of high-quality Pd nanocubes. In this study, Pd chloride was used as the precursor, sodium iodide as capping agent, and poly(vinylpyrrolidone) as surfactant and reducing agent. The effects of different halogens on the morphology of Pd nanocrystals were investigated. The results showed that, in this synthesis system, the selection and proper amount of sodium iodide was essential to the preparation of high-quality Pd nanocubes. When iodide was replaced by other halogens (such as bromide and chloride), Pd nanocrystals with cubic morphology could not be obtained. In addition, we have found that NaBH4 can be used to efficiently remove inorganic covers, such as iodide, from the surface of Pd nanoparticles as synthesized. The Pd nanoparticles obtained were employed as electro-catalysts for formic acid oxidation, and they exhibited excellent catalytic activity and good stability towards this reaction.

An analysis of plasma reveals proteins in the acute phase response pathway to be candidate diagnostic biomarkers for depression.

Globally, depression is one of the most serious debilitating psychiatric mental disorders. In this study, we validated the expression levels of fibrinogen alpha (FGA), fibrinogen beta (FGB), fibrinogen gamma (FGG), Complement factor B (CFB) and serpin family D member 1(SERPIND1) in the acute phase response signaling pathway in plasma samples using enzyme-linked immunosorbent assay (ELISA).Then illuminate the roles of FGA, FGB, FGG, CFB, SERPIND1 in depression using microarray data. Gene expression dataset GSE98793 was downloaded from the Gene Expression Omnibus database. There were 128 whole blood samples included 64 patients with major depressed patients and 64 healthy controls. Differentially expressed genes (DEGs) were identified, and then protein-protein interaction (PPI) network was constructed to screen crucial genes associated with FGA, FGB, FGG, CFB and SERPIND1. Moreover, gene ontology (GO) biological processes analyses was performed. The ELISA data showed that the expression levels of FGA, FGB, FGG, CFB and SERPIND1 were up-regulated in depressed patients. The enriched GO terms were predominantly associated with the biological processes including more genes were inflammation related. The PPI network was found these five genes interacted with 11 genes. FGA, FGB, FGG, CFB and SERPIND1 may be important in the pathogenesis of depression.

The prevalence of multiple non-communicable diseases among middle-aged and elderly people: the Shanghai Changfeng Study.

OBJECTIVE: We set out to study the prevalence and combination of multiple non-communicable diseases among middle-aged and elderly people in the Shanghai Changfeng community, China. METHODS: A cross-sectional survey through questionnaire, physical, and laboratory examinations, color ultrasound and DXA was performed on a typical sample of 6038 residents (ages greater than 45-years-old) from the Shanghai Changfeng community between June 2009 and December 2012. RESULTS: The prevalence of chronic diseases (rating from high to low) was as follows: hypertension (55.3%), dyslipidemia (33.5%), diabetes (21.9%), obesity (12.4%), and osteoporosis (9.3%). There were sex-specific and age-specific differences in these diseases. Just less than half (40.5%) the study population suffered from two or more chronic diseases. Hypertension patients were more likely to suffer from obesity, diabetes, dyslipidemia, and risk factors for cardiovascular diseases, but not osteoporosis. The most common combination of multiple diseases was hypertension with dyslipidemia (9.95%) or diabetes (6.61%). CONCLUSION: In the Chinese middle-aged and elderly population, the most common multiple non-communicable diseases, including hypertension, dyslipidemia, diabetes, and obesity should be controlled to prevent cardiovascular disease.

Efficacy and safety of the Chinese herbal medicine shuganjieyu with and without adjunctive repetitive transcranial magnetic stimulation (rTMS) for geriatric depression: a randomized controlled trial.

BACKGROUND: Pharmacological treatment of geriatric depression is often ineffective because patients cannot tolerate adequate doses of antidepressant medications. AIM: Examine the efficacy and safety of shuganjieyu - the first Chinese herbal medicine approved for the treatment of depression by China's drug regulatory agency -- with and without adjunctive treatment with repetitive transcranial magnetic stimulation (rTMS) in the treatment of geriatric depression. METHODS: Sixty-five inpatients 60 or older who met ICD-10 criteria for depression were randomly assigned to an experimental group (shuganjieyu + rTMS) (n=36) or a control group (shuganjieyu + sham rTMS)(n=29). All participants received 4 capsules of shuganjieyu daily for 6 weeks. rTMS (or sham rTMS) was administered 20 minutes daily, five days a week for 4 weeks. Blinded raters used the Hamilton Rating Scale for Depression (HAMD-17) and the Treatment Emergent Symptom Scale to assess clinical efficacy and safety at baseline and 1, 2, 4, and 6 weeks after starting treatment. Over the six-week trial, there was only one dropout from the experimental group and two dropouts from the control group. RESULTS: None of the patients had serious side effects, but 40% in the experimental group and 50% in the control group experienced minor side effects that all resolved spontaneously. Both groups showed substantial stepwise improvement in depressive symptoms over the 6 weeks. Repeated measures ANOVA found no differences between the two groups. After 6 weeks, 97% of the experimental group had experienced a 25% or greater drop in the level of depression, but only 20% had experience a 50% or greater drop in the level of depression; the corresponding values in the control group were 96% and 19%. There were some minor, non-significant differences in the onset of the treatment effect between the different types of depressive symptoms, but by the second week of treatment all five HAMD-17 subscale scores had improved significantly in both groups. CONCLUSION: The Chinese herbal medicine shuganjieyu is effective and safe in the treatment of geriatric depression, but only a minority of patients have greater than 50% improvement in their depressive symptoms after 6 weeks of treatment. Adjunctive use of rTMS with shuganjieyu does not improve the overall outcome and does not significantly speed up the onset of action of shuganjieyu.

[Three-year follow up of event-related potentials PPI, P50 and Color map of N400 during the rehabilitation of first episode schizophrenia patients].

OBJECTIVE: To investigate the relationship between the variations of event-related potentials (ERP) and clinical symptoms and treatment in first episode schizophrenia patients. METHODS: The ERP (P50, color map of N400 and prepulse inhibition of the startle reflex (PPI) ) were tested in 85 first episode schizophrenia (FES) patients and 78 normal controls (NC), and followed-up at 1, 2 and 3 years after treatment in FES. Positive and negative symptom scale (PANSS) was used to evaluate the psychotic symptoms of patients. RESULTS: (1) Compared with NC, FES showed decreased PPI% (41% ± 37% vs 68% ± 42%, P < 0.001), increased P50 S2/S1(87 ± 41 vs 51 ± 47, P < 0.001), prolonged N400 latency and decreased N400 amplitudes (P < 0.05 - 0.01 ). ( 2) Significant correlations were found between variations of color map of N400 latencies and general scores of PANSS (r = 0.321, P = 0.042), N400 amplitude and positive symptom scores (r = -0.437, P = 0.008) and total scores of PANSS (r = -0.392, P = 0.023), but the variations of PPI and P50 latencies and amplitudes did not show significant correlation with the positive symptom scores and total scores of PANSS. (3) The color map of N400 latencies and amplitudes in FES group showed significant difference (P < 0.05) but the major indexes of PPI and P50 did not show significant difference (P > 0.05) among the 1, 2 and 3 years' follow-up after treatment. CONCLUSION: This follow-up study suggests that the variations of PPI and P50 is probably a trait marker of FES, and the variations of color map of N400 might be a status marker of FES.

The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials.

BACKGROUND: The application of atypical antipsychotics (SGAs) for treatment of psychiatric and behavioral symptoms of dementia is controversial since their efficacy might be offset by their adverse events (AEs). OBJECTIVE: To assess the efficacy, safety, and tolerability of SGAs for treatment of psychological and behavioral symptoms of dementia. METHODS: Two researchers searched MEDLINE, PsychINFO, and the Cochrane Central Register of Controlled Trials independently for double-blind, placebo-controlled, randomized controlled trials (DB-PC-RCTs) as of June 2013, written in English. Efficacy was measured using the Brief Psychiatric Rating Scale (BPRS), Cohen-Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory (NPI), Clinical Global Impression of Change (CGI-C), and (or) Clinical Global Impression of Severity (CGI-S). Safety and tolerability were measured by frequencies of drop-outs, AEs, and death. In total, 19 treatment comparisons drawn from 16 DB-PC-RCTs were included, and 3,343 patients randomized to the antipsychotic group and 1,707 to the placebo group were assessed. RESULTS: This meta-analysis demonstrated a significant efficacy of atypical antipsychotics on BPRS (MD = -1.58, 95% CI = -2.52 - -0.65), CMAI (-1.84, -3.01 - -0.61), NPI (-2.81, -4.35 - -1.28), CGI-C (-0.32, -0.44 - -0.20), and CGI-S (-0.19, -0.30 - -0.09), compared to placebo (p < 0.01 for all). Patients receiving atypical antipsychotics showed no difference in risk for discontinuation (p > 0.05), significantly higher risks (p < 0.05 for all) for somnolence (OR = 2.95), extrapyramidal symptoms (1.74), cerebrovascular AEs (2.50), urinary tract infection (1.35), edema (1.80), gait abnormality (3.35), and death (1.52), and a lower risk for agitation (OR = 0.80, p = 0.03). CONCLUSIONS: The higher risks for AEs and mortality may offset the efficacy of atypical antipsychotics for treatment of dementia. Efficacy, safety, and tolerability thus should be carefully considered against clinical need.