Laboratory reflex testing strategy for the early identification of primary care patients with multiple myeloma.

OBJECTIVES: Our objective was to shorten the screen for multiple myeloma (MM), through reflex testing. DESIGN AND METHODS: The clinical laboratory in the public University Hospital of San Juan (Alicante, Spain), serves 234,551 inhabitants. Through an intervention agreed with general practitioners, the Laboratory Information System (LIS) automatically registered serum immunoglobulins (Ig) when serum total proteins (STP) > 80 g/L for the first time in primary care patients. When concomitantly one Ig presented a value above and one below its reference interval, the LIS automatically registered a serum protein electrophoresis (SPEP). When a monoclonal peak in SPEP, immunofixation electrophoresis (IFE) for the typification of monoclonal bands (MB) was performed. If MB were present, a comment in the report explained the intervention. The number of additionally registered Ig, SPEP, IFE, and new diagnosis of MM were counted. The number of days elapsed from the report of elevated STP result to the final MM diagnosis was also counted as median and interquartile range (IQR), and compared to a pre intervention period. RESULTS: 2071 cases of hyperproteinemia were identified, and had 91 a monoclonal peak, confirmed by IFE. In 35 patients it was a new finding, and 9 were diagnosed with MM, 3 Waldestrom macroglobulinemia, 2 lymphoplasmacytic lymphoma and 21 monoclonal gammopathy of undetermined significance. The number of days elapsed from hyperproteinemia to diagnosis was lower in the intervention period (21.5 vs 119.4) (P < 0.01). As our results show, in addition to shortening the time to diagnosis, an increased rate of detection of plasma cell disorders was observed when using our algorithm. CONCLUSIONS: The above laboratory interventions agreed with clinicians, making use of laboratory technology resulted in early identification of MM.

Alopecia and Iron Deficiency: An Interventional Pilot Study in Primary Care to Improve the Request of Ferritin.

BACKGROUND: The aim was to study the demographic and laboratory pattern of primary care patients with alopecia undergoing laboratory testing, more specifically, the request of hemoglobin and ferritin and values showing anemia and iron deficiency, and to evaluate the effects of an intervention involving automatic ferritin registration and measurement when not requested. METHODS: Retrospective and prospective observational cross-sectional studies were conducted, as well as an intervention to automatically register and measure ferritin when not requested by the general practitioner. RESULTS: There were 343 and 1032 primary care laboratory requests prompted by alopecia in the retrospective and prospective studies. Hemoglobin was requested in almost every patient and ferritin in 88%. 5% of the cohort had anemia, and 25% had iron deficiency. The intervention registered and measured that 123 ferritin and 24 iron deficiencies were detected in patients with alopecia, all women, at a cost of 10.6€. CONCLUSION: Primary care patients with alopecia and laboratory tests request were mainly young female. Our intervention added ferritin when not requested, detecting iron deficiency in 27.9% of women, potentially avoiding the adverse effects of iron deficiency on hair loss.

Computer-assisted interventions in the clinical laboratory process improve the diagnosis and treatment of severe vitamin B12 deficiency.

BACKGROUND: Severe vitamin B12 deficiency can result in serious complications if undiagnosed or untreated. Our aim was to test the efficacy of interventions in the laboratory process to improve the detection and the treatment of severe vitamin B12 deficiency. METHODS: Quasi-experimental investigation with a retrospective 7-year pre-intervention period and 29-month post-intervention follow-up in a university hospital. Two interventions were designed to improve the detection and treatment of subjects with vitamin B12 deficiency: the laboratory information system (LIS) automatically added seru vitamin B12 (s-vitamin B12) based on certain conditions; and created a comment in the report and scheduled an appointment with the general practitioner (GP). We calculated the number of new diagnoses of severe vitamin deficiency (s-vitamin B12 <73.8 pmol/L) and the proportion of identified patients that were correctly treated in the pre- and post-intervention periods. We compared the number of tests needed to detect a new case when ordered by GPs vs. added by the strategy. Finally, we investigated the economic cost of each new case. RESULTS: The strategy added 699 s-vitamin B12 and detected 66 new cases of severe vitamin deficiency. The number of tests needed to identify a new case when s-vitamin B12 was ordered by GPs was 187, as opposed to 10 when added through the intervention (p<0.001). The intervention reagent cost was €26.7 per new case. In the post-intervention cohort, 88% of patients were correctly treated, as opposed to 52% in the pre-intervention (p<0.001). CONCLUSIONS: Interventions in the clinical laboratory process improved the diagnosis and treatment of severe vitamin B12 deficiency.

Indications for laboratory tests in primary care: assessment of the most frequent indications and requests with blank clinical information.

INTRODUCTION: The aim of this work is twofold. Firstly, to study the temporal evolution in the number of laboratory requests from primary care without clinical indication, and to analyse the number of such requests before and after the implementation of an automated requesting procedure. Secondly, to investigate what are the most frequent clinical indications that prompted laboratory testing. MATERIALS AND METHODS: This is a retrospective observational study conducted from January 2009 to December 2015. We counted the requests without clinical question, calculated the number of such requests per total number of requests and listed the most frequent indications. RESULTS: The number of tests requests with a blank clinical indication was significantly higher in 2009 when compared to 2015 (80% vs. 20%; P < 0.001). For every year in this 7-year period, dyslipidemia, essential hypertension and diabetes were the most prevalent diagnoses that prompted a laboratory test in primary care, accounting for more than 20% of all indications. CONCLUSIONS: The number of primary care requests without patient clinical question has decreased after the implementation of an automated requesting procedure. Disorders of lipid metabolism, essential hypertension and diabetes mellitus were the most prevalent diagnoses that prompted a laboratory test in primary care.

Managing inappropriate requests of laboratory tests: from detection to monitoring.

OBJECTIVES: The main objectives of this study were to show a simple approach to detect inappropriate requests of laboratory tests and to monitor success after establishing interventions. These objectives were monitored through process and outcome indicators customized according to the type and phase of the appropriateness strategy. STUDY DESIGN: Quasi-experimental design. METHODS: Based on evidence regarding laboratory test utilization differences among different geographical areas of Spain, we identified serum calcium (s-Ca) testing to be underrequested and total bilirubin (tBil) testing to be overrequested in primary care patients who undergo testing at the Public University Hospital of San Juan, in San Juan de Alicante, Alicante, Spain. Additionally, the ratio of free thyroxine (FT4) tests to thyrotropin (also called thyroid-stimulating hormone [TSH]) tests was well above the published 0.25 goal in primary care. Finally, numerous laboratory tests were overrequested in hospitalized patients due to repetitive testing. We designed and implemented a variety of strategies to correct such inappropriateness and designed different indicators to monitor the intervention success over time. RESULTS: After implementation of the different strategies, the absolute number of s-Ca tests increased. The number of tBil tests in primary care, and numerous other tests repeated too frequently in hospitalized patients, decreased. The FT4/TSH indicator goal was reached and maintained over time. Regarding the outcome indicators, the strategy of reducing tBil tests in primary care and reducing the aggregate of unnecessary tests in hospitalized patients resulted in savings of $3543.80 and $9825.50, respectively, from January 2012 to December 2014. The s-Ca strategy, from November 2011 to December 2014, detected 62 subjects' primary hyperparathyroidism at a cost of $137.80 per case. CONCLUSIONS: The study demonstrates a simple approach to detect inappropriate requests of laboratory tests, and how to assess the potential success of interventions using process and outcome indicators.

Additional technician tasks and turnaround time in the clinical Stat laboratory.

INTRODUCTION: Many additional tasks in the Stat laboratory (SL) increase the workload. It is necessary to control them because they can affect the service provided by the laboratory. Our aim is to calculate these tasks, study their evolution over a 10 year period, and compare turnaround times (TAT) in summer period to the rest of the year. MATERIALS AND METHODS: Additional tasks were classified as "additional test request" and "additional sample". We collected those incidences from the laboratory information system (LIS), and calculated their evolution over time. We also calculated the monthly TAT for troponin for Emergency department (ED) patients, as the difference between the verification and LIS registration time. A median time of 30 minutes was our indicator target. TAT results and tests workload in summer were compared to the rest of the year. RESULTS: Over a 10-year period, the technologists in the SL performed 51,385 additional tasks, a median of 475 per month. The workload was significantly higher during the summer (45,496 tests) than the rest of the year (44,555 tests) (P = 0.019). The troponin TAT did not show this variation between summer and the rest of the year, complying always with our 30 minutes indicator target. CONCLUSION: The technicians accomplished a significant number of additional tasks, and the workload kept increasing over the period of 10 years. That did not affect the TAT results.

Automatic laboratory-based strategy to improve the diagnosis of type 2 diabetes in primary care.

INTRODUCTION: To study the pre-design and success of a strategy based on the addition of hemoglobin A1c (HbA1c) in the blood samples of certain primary care patients to detect new cases of type 2 diabetes. MATERIALS AND METHODS: In a first step, we retrospectively calculated the number of HbA1c that would have been measured in one year if HbA1c would have been processed, according to the guidelines of the American Diabetes Association (ADA). Based on those results we decided to prospectively measure HbA1c in every primary care patient above 45 years, with no HbA1c in the previous 3 years, and glucose concentration between 5.6-6.9 mmol/L, during an 18 months period. We calculated the number of HbA1c that were automatically added by the LIS based on our strategy, we evaluated the medical record of such subjects to confirm whether type 2 diabetes was finally confirmed, and we calculated the cost of our intervention. RESULTS: In a first stage, according to the guidelines, Hb1Ac should have been added to the blood samples of 13,085 patients, resulting in a cost of 14,973€. In the prospective study, the laboratory added Hb1Ac to 2092 patients, leading to an expense of 2393€. 314 patients had an HbA1c value ≥ 6.5% (48 mmol/mol). 82 were finally diagnosed as type 2 diabetes; 28 thanks to our strategy, with an individual cost of 85.4€; and 54 due to the request of HbA1c by the general practitioners (GPs), with a cost of 47.5€. CONCLUSION: The automatic laboratory-based strategy detected patients with type 2 diabetes in primary care, at a cost of 85.4€ per new case.

Subacute cutaneous lupus erythematosus starting as linear lupus erythematosus.

BACKGROUND: Cutaneous lupus in childhood is usually associated with systemic lupus erythematosus (LE). Linear cutaneous LE (LCLE) is an unusual presentation mostly seen in children and young adults. METHODS: We report a rare case of cutaneous subacute LE with a segmentary pattern following the lines of Blaschko in an 18-month-old girl with a 2-month history of persistent, linear, asymptomatic, erythematous lesions along the right arm. The clinical diagnosis at presentation was lichen striatus. RESULTS: A biopsy showed an intense, band-like, inflammatory cell infiltrate with perivascular and periadnexal involvement associated with basal cell liquefactive degeneration. The lesions were treated with topical corticosteroids and healed without scarring. Two months later, new lesions manifested as multiple erythematous, edematous, polycyclic plaques. A new biopsy showed a periadnexal infiltrate, a large amount of mucin, and a thickened basement membrane. Direct immunofluorescence was negative. Our definitive diagnosis was subacute cutaneous LE starting as linear LE. The lesions responded slowly to oral corticosteroids. Six months later, only a mild livedoid skin pattern remained on the patient's legs. CONCLUSIONS: Linear cutaneous LE usually presents with erythematous, atrophic, hyperkeratotic, dyschromic circular lesions arranged in a linear pattern; the main differential diagnosis is lichen striatum. In general, LCLE can be considered as discoid lupus following Blaschko's lines, which correspond to the direction of growth in clones of cutaneous cells that arise during embryogenesis. The present patient represents the first pediatric case of subacute cutaneous LE following Blaschko's lines, with posterior progression to a generalized form of subacute LE.

Education and communication is the key for the successful management of vitamin D test requesting.

INTRODUCTION: Pre-preanalytical and post-postanalytical phases are steps where the laboratory professional may play a crucial role. Measuring the serum circulating 25 hydroxyvitamin D level (25(OH)D) is recommended to evaluate vitamin D status in patients at risk for vitamin D deficiency while 1,25 hydroxyvitamin D (1,25(OH)2D) is only recommended to monitor several particular conditions (chronic kidney disease, hereditary phosphate-losing disorders, and some other) clearly defined by the current clinical guidelines of Endocrine Society. Our research hypothesis was that through education and communication through comments in the Laboratory Information System (LIS), we could improve appropriateness in the request vitamin D tests. MATERIALS AND METHODS: A retrospective observational cross-sectional study was conducted from January 2005 to December 2014. Each 1,25(OH)2D request was reviewed individually by a member of the laboratory staff. Starting in November 2011, each inappropriate 1,25(OH)2D request was registered in LIS and 25(OH)D was measured instead of 1,25(OH)2D. We counted the overall number of 1,25(OH)2D requests and the number of inappropriate requests which then were marked with a comment. RESULTS: The request of 25(OH)D increased along years. However, 1,25(OH)2D requests increased until 2012 when demand began to diminish. CONCLUSIONS: Education and communication through comments in the LIS, corrected the inappropriate request of 1,25(OH)2D and promoted the use of 25(OH)D to study vitamin D deficiency.

Tinea capitis in schoolchildren in a rural area in southern Ethiopia.

OBJECTIVES: Skin diseases, especially tinea capitis, represent some of the most frequent causes of morbidity in developing countries. The aim of this study was to examine the prevalences of fungal infections in schoolchildren in a primary school located in a rural area in southern Ethiopia and to perform an analysis of the risk factors associated with tinea capitis. METHODS: This school-based, prospective cross-sectional study was conducted in October 2012 in Gambo School, Kore, West Arsi, Oromya Region, Ethiopia. Detailed interviews and dermatological examinations were performed. No laboratory examinations were conducted. RESULTS: A total of 647 students were interviewed and examined. The mean age of these children was 10 years (range: 4-14 years). Of the children examined, 236 had some type of dermatophytosis (prevalence: 36.5%, 95% confidence interval [CI] 32.8-40.3), which represented the most frequent type of skin problem. The prevalence of dermatophytoses was more common in males than in females (42.2% and 30.5%, respectively; P = 0.002), and among pupils aged 5-7 years (46.9%; P < 0.001). A total of 159 (prevalence: 24.6%, 95% CI 21.3-28.1) children had tinea capitis, 56 (8.7%) had tinea pedis, 50 (7.7%) had tinea corporis, and six (0.9%) had tinea unguium. In multivariate analysis, the risk factors for tinea capitis were: age (odds ratio [OR] 0.75, 95% CI 0.69-0.84; P < 0.001), and male gender (OR 2.56, 95% CI 1.69-13.39; P = 0.002). CONCLUSIONS: Fungal dermatoses, especially tinea capitis, are common in primary schoolchildren in rural areas of southern Ethiopia, especially in young boys.

Laboratory utilization improvement through a computer-aided algorithm developed with general practitioners.

BACKGROUND: One of the main duties of healthcare workers is to get an appropriate use of diagnostic and therapeutic tools. The aim of this study was to show how strategies can be designed and established in consensus with general practitioners (GPs) to reach an optimal laboratory test request. METHODS: The laboratory serves a population of approximately 235,000 inhabitants, including nine primary care centers. GPs could request every test in profiles and individually. In meetings between the laboratory and GPs our request patterns were compared to other geographic regions, and we investigated the appropriateness of test requesting. The group devised strategies that consisted of removing tests from profiles [aspartate aminotransferase (AST), γ-glutamyltranspeptidase (GGT) and phosphate], removing tests from GPs requests (iron and transferrin), substituting tests (IgA antigliadin antibody), and measuring total bilirubin (tBil) only when the icteric index value was above 34.2 mmol/L (2 mg/dL). We analyzed every test request in the post- (years 2012-2013) and pre-intervention period (years 2010-2011), and the tBil measured in the post-intervention period. We studied if AST/alanine aminotransferase (ALT) and GGT/ALT achieved indicators targets and calculated the economic savings in the post-intervention period. RESULTS: There was a significant drop in every test request in the post-intervention period. AST/ALT achieved the indicator target. GGT/ALT, never achieved the indicator goal. The strategies resulted in a savings of more than €34,000. CONCLUSIONS: The strategies designed between the laboratory and the requesting clinicians and automatically established by using our laboratory information system were successful.

Methylchloroisothiazolinone/methylisothiazolinone and methylisothiazolinone allergies can be detected by 200 ppm of methylchloroisothiazolinone/methylisothiazolinone patch test concentration.

BACKGROUND: Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and methylisothiazolinone (MI) contact allergies are rising dramatically. Moreover, 100 ppm of MCI/MI patch test might not detect an important number of MCI/MI and MI allergies. OBJECTIVES: This study aimed to present the prevalence of contact allergy to both preservatives in an area of Spain and to investigate if 100 ppm of MCI/MI is an adequate concentration for a proper diagnosis. METHODS: A prospective study was conducted from October 2011 to September 2013. All patients were patch tested with the Spanish baseline series (containing 100 ppm of MCI/MI) and with 200 ppm of MCI/MI and 2000 ppm of MI. RESULTS: A total of 490 patients were patch tested. The MCI/MI prevalence was 10% and increased from 7.8% in last term of 2011 to 14.3% in the first 9 months of 2013. The MI prevalence was 4.5% and increased from 1% to 7.7% in the same period. One hundred parts per million of MCI/MI could not diagnose 24.5% of MCI/MI allergies. All MI allergies were detected by 200 ppm of MCI/MI, whereas only 68.2% were positive to 100-ppm concentration. CONCLUSIONS: For a correct diagnosis of MCI/MI and MI contact allergies, we advocate increasing the MCI/MI patch test concentration to 200 ppm along with a temporal inclusion of MI in the North American Contact Dermatitis Group baseline series.

Secondary mucinous carcinoma of the skin.

We report a case of a woman who presented with a cystic-appearing nodule on her left nipple. After cutaneous biopsy and gynecological staging study, she was diagnosed with skin invasion of mucinous carcinoma of the breast. We describe the main features of this rare tumor and the controversies in its diagnosis because primary and metastatic mucinous carcinomas in skin are histologically indistinguishable.

Extramammary Paget disease successfully treated with topical imiquimod 5% and tazarotene.

Extramammary Paget disease (EMPD) is an intraepithelial adenocarcinoma usually localized in areas rich in apocrine sweat glands. Surgery remains the treatment of choice for EMPD. However, several nonsurgical treatments have been also described. Around 40 cases of EMPD treated with imiquimod 5% have been published; of these, only six correspond to nonresponses. We describe a recurrent vulvar EMPD with failure to respond to topical imiquimod 5% in monotherapy but a favorable response to its association with tazarotene.