Use of a data warehouse at an academic medical center for clinical pathology quality improvement, education, and research.

BACKGROUND: Pathology data contained within the electronic health record (EHR), and laboratory information system (LIS) of hospitals represents a potentially powerful resource to improve clinical care. However, existing reporting tools within commercial EHR and LIS software may not be able to efficiently and rapidly mine data for quality improvement and research applications. MATERIALS AND METHODS: We present experience using a data warehouse produced collaboratively between an academic medical center and a private company. The data warehouse contains data from the EHR, LIS, admission/discharge/transfer system, and billing records and can be accessed using a self-service data access tool known as Starmaker. The Starmaker software allows users to use complex Boolean logic, include and exclude rules, unit conversion and reference scaling, and value aggregation using a straightforward visual interface. More complex queries can be achieved by users with experience with Structured Query Language. Queries can use biomedical ontologies such as Logical Observation Identifiers Names and Codes and Systematized Nomenclature of Medicine. RESULT: We present examples of successful searches using Starmaker, falling mostly in the realm of microbiology and clinical chemistry/toxicology. The searches were ones that were either very difficult or basically infeasible using reporting tools within the EHR and LIS used in the medical center. One of the main strengths of Starmaker searches is rapid results, with typical searches covering 5 years taking only 1-2 min. A "Run Count" feature quickly outputs the number of cases meeting criteria, allowing for refinement of searches before downloading patient-identifiable data. The Starmaker tool is available to pathology residents and fellows, with some using this tool for quality improvement and scholarly projects. CONCLUSION: A data warehouse has significant potential for improving utilization of clinical pathology testing. Software that can access data warehouse using a straightforward visual interface can be incorporated into pathology training programs.

POSITIVE TEST FOR ANTITHYROGLOBULIN ANTIBODIES DUE TO ADMINISTRATION OF IMMUNOGLOBULIN REPLACEMENT THERAPY IN A PATIENT WITH THYROID CANCER.

OBJECTIVE: Thyroglobulin (Tg) is used as a tumor marker to monitor differentiated thyroid cancer progression and recurrence. However, Tg measured by standard immunoassay (IMA) is not a reliable marker in the presence of anti-Tg antibodies (TgAbs) due to interference that may result in either false-positive or false-negative results. TgAbs levels can be high due to thyroid cancer and also exogenous immunoglobulin (Ig) administration, thus making it difficult to identify differentiated thyroid cancer recurrence. METHODS: We present an example of elevated TgAbs due to subcutaneous Ig (SCIg) administration in a patient with thyroid cancer. RESULTS: A 57-year-old male was diagnosed with stage I papillary thyroid cancer (PTC). His TgAbs were negative prior to the diagnosis of thyroid cancer and became positive after thyroidectomy and radioactive iodine administration. A detailed work-up including a whole body scan did not reveal recurrent disease. He had been diagnosed with common variable immune deficiency (CVID) and dermatomyositis at the age of 50 and was started on immunoglobulin (Ig) replacement therapy shortly after diagnosis. His Tg was negative when assessed with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Therefore, elevated TgAb titers were attributed to concomitant SCIg treatment. We also demonstrated that SCIg treatment had TgAb activity that was removed by protein A column treatment. Dilutions of SCIg medication also caused positive IgG serologies for cytomegalovirus and herpes simplex, measles, mumps, rubella, and varicella zoster viruses. CONCLUSION: An exogenous source of TgAbs from SCIg led to extensive imaging work-up to assess for PTC recurrence. LC-MS/MS is a conceptually attractive approach to overcome TgAb interference with Tg IMA measurement.

Diagnostic yield of hair and urine toxicology testing in potential child abuse cases.

Detection of drugs in a child may be the first objective finding that can be reported in cases of suspected child abuse. Hair and urine toxicology testing, when performed as part of the initial clinical evaluation for suspected child abuse or maltreatment, may serve to facilitate the identification of at-risk children. Furthermore, significant environmental exposure to a drug (considered by law to constitute child abuse in some states) may be identified by toxicology testing of unwashed hair specimens. In order to determine the clinical utility of hair and urine toxicology testing in this population we performed a retrospective chart review on all children for whom hair toxicology testing was ordered at our academic medical center between January 2004 and April 2014. The medical records of 616 children aged 0-17.5 years were reviewed for injury history, previous medication and illicit drug use by caregiver(s), urine drug screen result (if performed), hair toxicology result, medication list, and outcome of any child abuse evaluation. Hair toxicology testing was positive for at least one compound in 106 cases (17.2%), with unexplained drugs in 82 cases (13.3%). Of these, there were 48 cases in which multiple compounds (including combination of parent drugs and/or metabolites within the same drug class) were identified in the sample of one patient. The compounds most frequently identified in the hair of our study population included cocaine, benzoylecgonine, native (unmetabolized) tetrahydrocannabinol, and methamphetamine. There were 68 instances in which a parent drug was identified in the hair without any of its potential metabolites, suggesting environmental exposure. Among the 82 cases in which hair toxicology testing was positive for unexplained drugs, a change in clinical outcome was noted in 71 cases (86.5%). Urine drug screens (UDS) were performed in 457 of the 616 reviewed cases. Of these, over 95% of positive UDS results could be explained by iatrogenic drug administration. There were no cases in which a urine drug screen alone altered the outcome of a case. In summary, hair toxicology testing proved clinically useful in the evaluation of a child for suspected abuse; in contrast, urine drug testing showed low clinical yield.

Adequacy of powered vs manual bone marrow biopsy specimens: a retrospective review of sequential marrow aspirates and biopsies in 68 patients.

OBJECTIVES: To evaluate the quality and quantity of the bone marrow aspirates and biopsy specimens obtained with a powered system in comparison with the standard manual method. METHODS: The Pathology Laboratory Information System was reviewed for patients who had previously undergone bone marrow biopsies performed by both the OnControl Bone Marrow System and the manual method. A total of 136 cases (68 patients) were reviewed for adequacy and compared using an unpaired t test. RESULTS: The core biopsy specimens obtained by the OnControl system were significantly longer compared with those obtained by the manual system (16.9 vs 14.4 mm, P = .0036). However, the core biopsy specimens obtained by the manual method had on average more evaluable marrow elements (66% vs 40%, P < .0001), and the manual method was superior in 46 of the 68 cases when the length of evaluable marrow was calculated (9.7 vs 7 mm, P = .0049). CONCLUSIONS: Our findings show that longer core biopsy specimens are obtained by the OnControl Bone Marrow system but that the manual method is still superior when the percentage and length of evaluable bone marrow are analyzed.