Establishment of a CSF bank.

A bank of well-characterized CSF has been established by collecting and storing (-70 degrees C) CSF samples remaining after completion of routine clinical studies. Over 1,700 individual patient samples were collected during a 12-month period. A database derived largely from information down-loaded from existing hospital-based systems includes the results of individual CSF laboratory studies, in addition to the patient age, primary diagnoses, and details of any malignancy. CSF control material is used to verify storage conditions. The CSF bank supplies investigators with CSF handled in a standardized manner for more precise investigation of CNS disease.

Cerebrospinal fluid (CSF) TRAP. A method to improve CSF laboratory efficiency.

Establishment of a procedure termed cerebrospinal fluid (CSF) TRAP ("Transport and Rapid Accessioning for Additional Procedures") allows clinicians to appropriately store, at -75 degrees C, and rapidly access CSF specimens. The CSF TRAP enhances patient care by decreasing the need for repeat lumbar punctures and providing reserve fluid for the following: (1) further CSF testing; (2) repeating questionable test results; and (3) laboratory accidents. The CSF TRAP has been approved for third-party payment because it promotes efficient laboratory utilization by encouraging clinicians to review initial CSF findings before ordering low-yield CSF assays such as the venereal disease research laboratory (VDRL) and cryptococcal antigen latex agglutination tests. Currently, CSF TRAP samples are being obtained with 40% of all CSF acquisitions at the Duke University Medical Center. The availability of the CSF TRAP was associated with a significant decrease in the ordering of CSF VDRL and cryptococcal antigen assays (P less than 0.05); however, there was no significant change in the proportion of those studies being performed on normal CSF. The CSF TRAP procedure provides the framework for an overall restructuring of CSF testing that is being investigated.

Issues in cerebrospinal fluid management. Acid-fast bacillus smear and culture.

Meningeal tuberculosis is an uncommon disease in the United States with an annual incidence of fewer than 200 cases. This study evaluates three approaches to improving the use of the cerebrospinal (CSF) acid-fast bacillus (AFB) smear and culture procedure: (1) education alone; (2) optional screening by which physicians can select to have the AFB analysis stopped if the initial CSF findings are unremarkable; and (3) mandatory screening before the performance of all CSF AFB analyses. With education alone, the CSF AFB culture rate decreased from 20.6% of all CSF acquisitions to 15.7% (P less than 0.001); however, the effect may have been related to a decrease in all types of AFB testing. Optional screening had no impact on the AFB testing rate. Mandatory screening significantly decreased the CSF AFB rate to 6.7% (P less than 0.001), unrelated to changes in other types of AFB testing. Laboratories that employ mandatory screening should report the screening results immediately and have a mechanism whereby physicians can bypass the screen, providing CSF AFB analysis on unremarkable fluid from high-risk patients.

A system's architecture which dissociates management of shared data and end-user function.

An architecture for providing an institutional systems infrastructure is proposed. The architecture permits distributed applications while maintaining an integrated patient database.