Pseudorenal insufficiency with isopropyl alcohol ingestion.

Isopropyl ingestion is usually a benign occurrence with little metabolic or renal abnormalities. We describe a case of a false elevation of serum creatinine due to laboratory interference in the setting of a toxic alcohol exposure that could have led to a misdiagnosis of ethylene glycol intoxication and a different treatment plan. Clinicians should be aware of this laboratory anomaly when treating suspected toxic alcohol ingestions.

Massive insulin overdose managed by monitoring daily insulin levels.

We present a case of a significant insulin overdose that was managed by monitoring daily plasma insulin levels. A 39-year-old male with poorly controlled diabetes mellitus presented to the Emergency Department via emergency medical services after an attempted suicide by insulin overdose. In the attempted suicide, he injected 800 U of insulin lispro and 3800 U of insulin glargine subcutaneously over several parts of his abdomen. The patient was conscious upon arrival to the emergency department. His vital parameters were within normal range. The abdominal examination, in particular, was nonfocal and showed no evidence of hematomas. He was awake, alert, conversant, tearful, and without any focal deficits. An infusion of 10% dextrose was begun at 100 mL/h with hourly blood glucose (BG) checks. The patient was transferred to the intensive care unit where his BG began to decrease and fluctuate between 50 and 80 mg/dL, and the rate of 10% dextrose was increased to 200 mL/h where it was maintained for the next 48 hours. The initial plasma insulin level was found to be 3712.6 uU/mL (reference range 2.6-31.1 uU/mL). At 10 hours, this had decreased to 1582.1 uU/ml. On five occasions, supplemental dextrose was needed when the BG was <70 mg/dL. Thirty-four hours after admission, the plasma insulin level was 724.8 uU/mL. Fifty-eight hours after admission, the plasma insulin level was 321.2 uU/mL, and the 10% dextrose infusion was changed to 5% dextrose solution at 200 mL/h. The plasma insulin levels continued to fall daily to 112.7 uU/mL at 80 hours and to 30.4 uU/mL at 108 hours. He was transferred to an inpatient psychiatric facility 109 hours after initial presentation. Monitoring daily plasma insulin levels and adjusting treatment on a day-to-day basis in terms of basal glucose infusions provides fewer opportunities for episodic hypoglycemia. Furthermore, it was easier to predict daily glucose requirements and eventual medical clearance based on the plasma levels.

The effect of complimentary and alternative medicine products on laboratory testing.

A multi-billion dollar industry has evolved over the last decade based on herbal product sales with an underlying belief that herbals are natural and therefore safe. The herbal product industry is essentially unregulated and producers are not required to follow good manufacturing practices (GMP). Batch to batch product variation, heavy metal and pesticide contamination, and even therapeutic drug contamination are problematic. Compounding these manufacturing issues are drug to drug and drug to herbal interactions that can cause cytochrome induction or inhibition. It is important for physicians to query their patients on herbal use and educate them on the potential adverse reactions. Herbals have been used for thousands of years and undoubtedly have demonstrated health benefits. However, more research is needed to gain an understanding of the complexity issues from mechanism of action to interference with clinical laboratory testing.

A New Era in Pathology Consultation: The MyPathologist Electronic Consultation Tool.

Pathologists and laboratory scientists provide valuable guidance on laboratory utilization, test ordering, interpretation, and quality control provided that clinical staff can easily access the laboratory team. To encourage consultation between clinicians with laboratory scientists and pathologists, we developed an easily accessible electronic tool termed "MyPathologist," placed on the homepage of our electronic health record system. Over its 2-year pilot, utilization of this consultation tool climbed as we continued to publicize it and incorporated education into housestaff onboarding and electronic health record training. Physician satisfaction with the tool was high. Additionally, this became the primary source of consults to our residency call service. Evaluation of MyPathologist questions received during its pilot period showed that more than half the questions were of significant educational value to the residents, often focusing on results interpretation, appropriate test ordering, and quality control. MyPathologist is a novel electronic tool for pathology consultation within our electronic health record and also represents an avenue for educating residents, improving utilization of the laboratory, and improving patient care.

Correlates of thrombin generation in patients with advanced prostate cancer.

Thrombin generation is increased in men with advanced prostate cancer. Thrombin has the ability to interact with, and affect the biology of, a variety of cell types including prostate cancer cell lines. We therefore looked for correlations between thrombin generation and other markers of disease activity in spot urine samples obtained from men with advanced prostate cancer. Excretion of part of the prothrombin activation peptide F(1+2) (called here iF2), interleukin-6 (IL-6), the bone turnover marker deoxypyridinoline (DpD), and vascular endothelial growth factor (VEGF) were quantitated in spot urine samples collected from 37 men with hormone-refractory prostate cancer. Following log transformation of the data, significant correlations were found by univariate analysis between the excretion of a marker of thrombin generation (iF2) and IL-6, DpD and VEGF, as well as between IL-6 and DpD or VEGF excretion. No correlation was found between any marker and serum PSA level. After multivariate analysis, a significant correlation remained between thrombin generation and IL-6 excretion. Analysis of a second urine specimen obtained from 19 of the subjects 1 to 7 months after the first also revealed a significant correlation between thrombin generation and IL-6, DpD, and VEGF excretion. These data provide evidence of a correlation between thrombin generation/coagulation system activation and IL-6 generation in patients with cancer. They provide a rationale for studying the effects of inhibitors of thrombin generation upon the biology of prostate cancer.

Seasonal vitamin D changes and the impact on health risk assessment.

OBJECTIVE: To investigate seasonal variation of vitamin D levels in 148,821 serum samples during a 2year time period in a northern-latitude city in the United States. METHODS: Total vitamin D assay testing by chemiluminescence was performed on the DiaSorin Liaison. Vitamin D results were extracted from the laboratory information system without patient identification during 2011 and 2012 and separated by season and vitamin D results: less than 10ng/mL (deficient), 10-20.0ng/mL (insufficient), 20.1-30ng/mL (borderline), 30.1-40ng/mL (sufficient), 40.1-100ng/mL, and greater than 100ng/mL. RESULTS: The seasonal winter period constituted the months of January through March; spring, April through June; summer, July through September; and fall, October through December. The data set analyzed included 36,643 samples during the winter, 38,299 in spring, 36,141 in summer, and 37,738 in fall and demonstrated an expected rise and fall in vitamin D levels. CONCLUSION: This retrospective epidemiological study demonstrates seasonal variation of vitamin D levels at clinical decision points. Although not unexpected, this variation has an impact on studies relating low vitamin D levels to higher rates of cancer, cardiovascular disease, multiple sclerosis, diabetes, autoimmune disease, and a host of other health risk assessments.