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.

Improving diagnosis and treatment of hypomagnesemia

Magnesium is one of the most abundant cations in the body and acts as a cofactor in more than 600 biochemical reactions. Hypomagnesemia is a highly prevalent condition, especially in subjects with comorbid conditions, but has received less attention than other electrolyte disturbances. This review will discuss magnesium physiology, absorption, storage, distribution across the body, and kidney excretion. After reviewing the regulation of magnesium homeostasis, we will focus on the etiology and clinical presentation of hypomagnesemia. The role of laboratory medicine in hypomagnesemia will be the main purpose of this review, and we will discuss the laboratory tests and different samples and methods for its measurement. Although free magnesium is physiologically active, total serum magnesium is the most commonly used measurement in laboratory medicine and is apt for clinical purposes; however, it is not appropriately used, and many patients with hypomagnesemia remain undiagnosed and not treated. Using information technologies, laboratory medicine can largely improve the diagnosis and treatment of hypomagnesemia through the design and establishment of automatic demand management and result management interventions by acting in the first and last steps of the laboratory cycle, test requests, and actions taken after test results, to unmask patients with hypomagnesemia and improve the number of patients undergoing treatment.

Double positivity for rheumatoid factor and anti-CCP autoantibodies: improving referral from primary care of patients suspected of having rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic progressive autoimmune inflammatory disease with significant morbidity and mortality. The course of the disease can be modified if diagnosis is early and treatment appropriate.

AIM

In this study, we aimed to evaluate a new strategy for early identification of RA patients in primary care settings (the 'diagnostic bottleneck') based on serological biomarkers and to manage inappropriate rheumatoid factor (RF) laboratory test requests.

METHOD

A two-arm study was carried out. The first arm corresponded to a retrospective observational descriptive study of patients referred for RF testing from primary care using the current laboratory workflow. The second arm included the following prospective interventions: cancelation of RF requests corresponding to patients with previous negative results for RF over a one-year period; and automatic reflex testing antibodies against cyclic citrullinated proteins (anti-CCP) for patients displaying RF values >30 IU/ml. Outcomes from both arms were then compared.

FINDINGS

As double positivity for RF and anti-CCP notably increases the positive likelihood ratio of RA. The intervention enabled a reduction of 2813 tests in 22 months. Moreover, the frequency of unnecessary referrals was reduced from 22% to 8.2%, while that of missed patients decreased slightly (from 21% to 16%), with the number of patients diagnosed per RF request remaining unchanged. In terms of costs, we saved 19.4 RF tests per anti-CCP test added.We developed a simple and cost-effective strategy for reducing the time to diagnosis of RA that can improve patients' quality of life. This approach was supported by primary and specialised care.

Reporting age-adjusted D-dimer cut-off values reduces radiology overuse in emergency department patients with suspected deep venous thrombosis

INTRODUCTION

Venous thromboembolism (VTE) is a leading cause of death, associated with substantial morbidity in the absence of treatment. Our aim was, first, to compare the diagnostic performance of D-dimer for the diagnosis of VTE in the emergency department (ED), when reporting conventional cut-off point versus when additionally reporting age-adjusted values. Second, we explored the ordering pattern of Doppler ultrasound (US) and computerized tomographic pulmonary angiogram (CTPA), before and after reporting of the aforementioned age-adjusted cut-off value.

MATERIALS AND METHODS

We conducted a cross-sectional study to compare the diagnostic performance of D-dimer as a screening for VTE when reporting the conventional cut-off value versus when additionally including the age-adjusted metrics, and a quasi-experimental study to explore the ordering of Doppler US and CTPA before the age-specific metrics were shared in the report in ED patients between 50 and 100 years-old with D-dimer ordering.

RESULTS

The cross-sectional study included 392 patients, 25 with VTE. The specificity using an age-adjusted cut-off value was significantly higher (0.51) compared to a single absolute cut-off (0.42), and the negative likelihood ratio was lower as well (0.08 vs. 0.19), but again not statistically significant. In the quasi-experimental study, there was a decrease in the rate of use of both CTPA and Doppler US (P < 0.05).

CONCLUSION

The intervention improved the use of the D-dimer result in the ED and helped improve the request for imaging tests.

Laboratory Strategies to Improve Allergy First-Line Screening in Primary Care

BACKGROUND

There are nonestablished protocols in use for first-line allergy screening based on IgE testing. These protocols attempt to address an unmet need for sustainability of clinical laboratories, at a time when demand is increasing.

OBJECTIVE

To present a novel protocol for first-line allergy screening and to evaluate the implementation benefits for patients, the health care system, and payers.

METHODS

We carried out an observational retrospective study analyzing 4359 interventions on primary care testing requests. Interventions included overriding redundant serum IgE (sIgE) testing for allergen mixes, extracts included in mixes, low-prevalence extracts, and milk and egg molecular components without previous positive results when exposed to extracts. We also added prevalent allergen testing.

RESULTS

The strategy saved 683 tests from being performed unnecessarily. Test volume decline was primarily driven by the cancelation of 2186 egg and milk components tests; 561 tests were added for mixes, together with 942 allergen extracts tests.

DISCUSSION

The results of this study show how the allergy laboratory plays a key role in actively managing demand for sIgE testing, leading to optimized diagnosis.

Early Brain Amyloid Accumulation at PET in Military Instructors Exposed to Subconcussive Blast Injuries

Background Traumatic brain injury (TBI) is the leading cause of disability in young adults. Recurrent TBI is associated with a range of neurologic sequelae, but the contributing factors behind the development of such chronic encephalopathy are poorly understood. Purpose To quantify early amyloid β deposition in the brain of otherwise healthy adult men exposed to repeated subconcussive blast injury using amyloid PET. Materials and Methods In this prospective study from January 2020 to December 2021, military instructors who were routinely exposed to repeated blast events were evaluated at two different points: baseline (before blast exposure from breacher or grenade) and approximately 5 months after baseline (after blast exposure). Age-matched healthy control participants not exposed to blasts and without a history of brain injury were evaluated at similar two points. Neurocognitive evaluation was performed with standard neuropsychologic testing in both groups. Analysis of PET data consisted of standardized uptake value measurements in six relevant brain regions and a whole-brain voxel-based statistical approach. Results Participants were men (nine control participants [median age, 33 years; IQR, 32-36 years] and nine blast-exposed participants [median age, 33 years; IQR, 30-34 years]; P = .82). In the blast-exposed participants, four brain regions showed significantly increased amyloid deposition after blast exposure: inferomedial frontal lobe (P = .004), precuneus (P = .02), anterior cingulum (P = .002), and superior parietal lobule (P = .003). No amyloid deposition was observed in the control participants. Discriminant analysis on the basis of regional changes of amyloid accumulation correctly classified the nine healthy control participants as healthy control participants (100%), and seven of the nine blast-exposed participants (78%) were correctly classified as blast exposed. Based on the voxel-based analysis, whole-brain parametric maps of early abnormal early amyloid uptake were obtained. Conclusion Early brain amyloid accumulation was identified and quantified at PET in otherwise healthy adult men exposed to repetitive subconcussive traumatic events. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Haller in this issue.

Unusually High Prevalence of Stroke and Cerebral Vasculopathy in Hemoglobin SC Disease: A Retrospective Single Institution Study

INTRODUCTION

Unlike homozygous hemoglobin SS (HbSS) disease, stroke is a rare complication in hemoglobin SC (HbSC) disease. However, recent studies have demonstrated a high prevalence of silent stroke in HbSC disease. The factors associated with stroke and cerebral vasculopathy in the HbSC population are unknown.

METHODS

We conducted a retrospective study of all patients with sickle cell disease treated at the University of Missouri, Columbia, over an 18-year period (2000-2018). The goal of the study was to characterize the silent, overt stroke, and cerebral vasculopathy in HbSC patients and compare them to patients with HbSS and HbS/β thalassemia1 (thal) in this cohort. We also analyzed the laboratory and clinical factors associated with stroke and cerebral vasculopathy in the HbSC population.

RESULTS

Of the 34 HbSC individuals, we found that the overall prevalence of stroke and cerebral vasculopathy was 17.7%. Only females had evidence of stroke or cerebral vasculopathy in our HbSC cohort (33.3%, p = 0.019). Time-averaged means of maximum velocities were lower in the HbSC group than the HbSS group and did not correlate with stroke outcome. Among HbSC individuals, those with stroke and cerebral vasculopathy had a marginally higher serum creatinine than those without these complications (0.77 mg/dL vs. 0.88 mg/dL, p = 0.08). Stroke outcome was associated with recurrent vaso-occlusive pain crises (Rec VOCs) (75 vs. 25%, p = 0.003) in HbSC patients. The predominant cerebrovascular lesions in HbSC included microhemorrhages and leukoencephalopathy.

CONCLUSION

There is a distinct subset of individuals with HbSC who developed overt, silent stroke, and cerebral vasculopathy. A female predominance and association with Rec VOCs were identified in our cohort; however, larger clinical trials are needed to identify and confirm specific clinical and laboratory markers associated with stroke and vasculopathy in HbSC disease.

Stat Laboratory Interventions to Improve Patient Management in the Emergency Department and Resource Expenditure: A 10-Year Study

OBJECTIVE

To illustrate the changes in stat laboratory procedures over a 10 year period.

MATERIALS AND METHODS

We implemented 5 different interventions: reporting total bilirubin through the icteric index, replacing total proteins for albumin, reporting albumin-adjusted calcium in hyper- or hypocalcemia, using lipase as a first marker and amylase-selected scenario, and measuring magnesium in hypocalcemia, hypokalemia, or high lipase values.

RESULTS

Only 9.9% of total bilirubin that was requested was measured, which resulted in savings of $22,492.83. There were 30,036 albumin tests measured, and $15,625.18 was saved replacing total protein. There was $41,374.38 spent to measure lipase and amylase; the difference in costs from the lipase establishment was $16,929.62. Finally, $382.30 was spent for magnesium: 717 magnesium levels were measured given hypocalcemia or hypokalemia (42.8% hypomagnesemia), and 123 tests were added because of high lipase (35% hypomagnesemia). Overall, $53,374.15 was saved.

CONCLUSION

Progressive changes in stat laboratory procedures resulted in more efficient resources expenditures.

Dealing with redundant gamma glutamyl transpeptidase in primary care, when requested along with alkaline phosphatase

The use of gamma glutamyl transpeptidase (GGT) levels as screening test for liver function is controversial. The GGT main utility is in cases in which alkaline phosphatase (ALP) is elevated. We aimed to investigate the request over time for alanine amino transferase (ALT), ALP and GGT, study the effect of a new demand management (DM) intervention for optimal GGT measurement in primary care. Our descriptive study was conducted from January 2010 to December 2020. The intervention was established in November 2019 and consisted of the laboratory information system would automatically remove GGT, if the test had been ordered simultaneously with ALP and there was no prior pathological result on record. We counted the absolute number of measured ALT, ALP and GGT, and calculated the ratios for each of the three markers related to creatinine, and GGT related to ALT in a monthly basis. The number of measured GGT increased slightly and progressively along the study until October 2019, when a decrease was observed. The ALT and ALP request from primary care also increased slightly along years. However, the GGT/ALT ratio never reached the 0.2 goal. Out of the 57,614 GGT requested in primary care patients, 38,167 (66.2%) were not measured. 7633.4€ were saved in reagent. The DM intervention to reduce the measurement of GGT when requested redundantly with ALP in primary care was successful, and the results have been maintained over time as observed by monitoring the GGT/CREA and GGT/ALT indicator results.

The clinical laboratory: a decision maker hub

OBJECTIVES

We aimed to share a new laboratory model based on laboratory knowledge, meaningful use of information technology, and partnership with clinicians, to lead the appropriate use of laboratory testing and clinical decision making in the diagnosis of as-yet-undiagnosed disease. More specifically, we evaluate the role of eight different opportunistic interventions to diagnose certain asymptomatic disorders, by means of the automatic registration of appropriate laboratory testing according to different scenarios.

METHODS

This is a retrospective longitudinal study to evaluate the impact of laboratory interventions on the diagnosis of different diseases and on patient care, including data from January 2012 to September 2020.

RESULTS

Overall, the above strategies have so far identified 2063 patients with clinically relevant as-yet-undiagnosed disorders who would have otherwise remained occult, such as for instance, primary hyperparathyroidism, diabetes, and hypomagnesemia.

CONCLUSIONS

We are facing a new laboratory model, a leading laboratory rather than a passive traditional laboratory, not just to intervene in clinical decision-making, but to make the clinical decision, through the identification of patients with occult disease.

Multi-parametric magnetic resonance imaging evaluation of cerebral amyloid angiopathy related inflammation: Case series and review of literature

Cerebral amyloid angiopathy related inflammation is a rare disorder in the spectrum of cerebral amyloid angiopathy which is characterized by vascular and/or perivascular inflammation related to Aβ deposits. Clinically, the patient typically presents with acute to subacute encephalitis-like symptoms with focal neurological deficits, rapidly cognitive decline, and/or seizures. Typical magnetic resonance imaging findings include asymmetric mass-like non-enhancing white matter hyperintensity with scattered microhemorrhages. Additionally, in these cases diffusion weighted imaging, perfusion weighted imaging and magnetic resonance spectroscopy help to exclude neoplastic processes and could determine the correct diagnosis.

Current Practice and Regional Variability in Recommendations for Patient Preparation for Laboratory Testing in Primary Care

BACKGROUND

Preparation of the patient for laboratory tests is crucial. Our aim was to investigate the current practice and regional variability of recommendations regarding patient preparation for laboratory testing.

METHODS

A call for data was posted by email. Spanish laboratories were invited to fill out and submit a survey.

RESULTS

Sixty-eight laboratories participated in the study. In 73% of those laboratories, fasting was always recommended regardless of the requested tests. Only one-third of the laboratories systematically recommended a 12-hour fast before the tests. In 71% of the laboratories, water intake was allowed without restrictions during the fasting period. In 57% of the laboratories, computerized order entry offered the possibility to print customized recommendations automatically in the primary care doctor's office according to the requested tests. Seventy-two percent of the laboratories agreed with the proposed recommendation.

CONCLUSIONS

There was high variability in patient preparation for laboratory testing. A significant proportion of centers did not follow international guidelines.

Multi-modality imaging evaluation of the dorsal arachnoid web

PURPOSE

Dorsal arachnoid web (DAW) is a rare intradural abnormality which is associated with progressive myelopathy. Our objective was to review multi-modality imaging techniques demonstrating the scalpel sign appearance in evaluation of DAW.

METHODS

We retrospectively reviewed various imaging modalities of patients found to have DAW at our institution during January 2015 to February 2020. Five patients underwent surgical decompression with pathological correlation. The remaining patients were presumptively diagnosed based on the characteristic finding of scalpel sign. Clinical data were evaluated and correlated to imaging findings. All imaging modalities demonstrated the characteristic scalpel sign.

RESULTS

Sixteen patients (10 females, and six males) with multi-imaging modalities were evaluated. Their mean age was 52 year (range 23-74 years). Fifteen patients underwent conventional spine MRI. Further high-resolution MR imaging techniques, e.g. 3D T2 myelographic sequence, were utilized with two patients. MRI spine CSF flow study was performed to evaluate the flow dynamic across the arachnoid web in one patient. Eight patients were evaluated with CT myelogram. Syrinx formation was discovered in seven (44%) patients; five (71%) of them underwent surgical resection and decompression. Two patients underwent successful catheter-directed fenestration of the web with clinical improvement. We found a statically significant positive correlation between the degree of cord displacement and compression with syrinx formation (r = 0.55 and 0.65 with p-value of 0.03 and 0.009, respectively).

CONCLUSION

DAW has characteristic scalpel sign independent of imaging modality. Multi-modality imaging evaluation of DAW is helpful for evaluation and surgical planning.

Laboratory parameters in patients with COVID-19 on first emergency admission is different in non-survivors: albumin and lactate dehydrogenase as risk factors

Prompt identification of the clinical status and severity of COVID-19 can be a challenge in the emergency department (ED), as the clinical severity of the disease is variable, real-time reverse-transcription PCR (RT-PCR) results may not be immediately available, and imaging findings appear approximately 10 days after the onset of symptoms. There is currently no set of simple, readily available and fast battery of tests that can be used in the ED as prognostic factors. The purpose was to study laboratory test results in patients with COVID-19 at hospital emergency admission and to evaluate the results in non-survivors and their potential prognostic value. A profile of laboratory markers was agreed with the ED providers based on the International Federation of Clinical Chemistry and Laboratory Medicine recommendation of its usefulness, which was made in 218 patients with COVID-19. Non-survivors were significantly older, and the percentage of patients with pathological values of creatinine, albumin, lactate dehydrogenase (LDH), C reactive protein, prothrombin time, D-dimer, and arterial blood gas, PaO₂/FIO₂ and satO2/FIO₂ indices were significantly higher among the patients with COVID-19 who died than those who survived. Patients who died also presented higher neutrophil counts. Among all studied tests, albumin and LDH were independent prognostic factors for death. The results of the study show pathology in nine laboratory markers in patients with COVID-19 admitted in the ED, valuable findings to take into consideration for its prompt identification when there is no immediate availability of RT-PCR results.

Spotlight on the pediatric eye: a pictorial review of orbital anatomy and congenital orbital pathologies

Orbital lesions in the pediatric population vary from adults in terms of their presentation, unique pathology, and imaging characteristics. The prompt and accurate diagnosis of these lesions is imperative to prevent serious consequences in terms of visual impairment and disfigurement. Along with dedicated ophthalmologic examination, imaging is instrumental in characterizing these lesions, both for accurate diagnosis and subsequent management. In our pictorial essay, we provide a basic review of orbital embryology, anatomy, and congenital orbital pathologies, with emphasis on radiological findings.

CONUT: a tool to assess nutritional status. First application in a primary care population

OBJECTIVES

Malnutrition is an unfavorable prognostic factor associated with an increase in mortality, hospital stays, readmissions and resources consumption. The aim was to screen primary care patients for risk of malnutrition by using the control nutritional (CONUT) score, calculated through total lymphocytes count, serum albumin and total cholesterol, when the three markers were requested, and to compare results between primary care centers (PCC).

METHODS

The clinical laboratory located in a 370-bed suburban University Community Hospital serves the Health Department inhabitants (2,34,551), attended in nine PCC. The laboratory information system (LIS) automatically calculated the CONUT score in every primary care patient over 18 years old, when all three laboratory markers were ordered by the General Practitioner. For all primary care patients, we collected demographic data, CONUT index and PCC. We classified results by PCC, and compared them.

RESULTS

The clinical laboratory received 74,743 requests from primary care. The CONUT score was calculated in 7,155 (12.28%) patients. Nine hundred seventy-six (13.6%) were at risk of malnutrition according to the CONUT score, mainly male (p<0.01) and over 65 (p<0.01). Detected cases of malnutrition were all mild, except 48 patients (4.9%) with moderate, and one (0.1%) with severe risk. The percentage of patients at risk of malnutrition was not significantly different among PCC, with the exception of one with patients at lower malnutrition risk.

CONCLUSIONS

It is possible to use CONUT score as a front-line population-wide laboratory marker to screen for the risk for malnutrition in primary care patients that was lower in one PCC.

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.

Less is more: Two automated interventions to increase vitamin B12 measurement when long-term proton pump inhibitor and decrease redundant testing

INTRODUCTION

To test the efficacy of two interventions to promote the measurement of serum vitamin B₁₂ (s- vitamin B₁₂) in patients with long-term proton pump inhibitor (PPI) use and to decrease inadequate s-vitamin B₁₂ measurement by implementing a minimum retest interval.

MATERIAL AND METHODS

The Laboratory Information System (LIS) automatically registered s-vitamin B₁₂ when not ordered by General Practitioners to all requests patients with long term (>3years) PPI treatment, and with no s-vitamin B₁₂ testing in the previous year. Through the second intervention, the LIS reported the previous s-vitamin B₁₂ result through an explanatory comment in the report, when the test had been requested in the previous three months. We calculated the new diagnoses of vitamin deficiency (s-vitamin B₁₂ < 200 pg/mL), examined the number of tests needed to detect a new case and investigated the economic cost of each one identified by the intervention. Additionally, we counted the s-vitamin B₁₂ that were requested but not measured, and calculated the savings in reagent.

RESULTS

The strategy added 548 s-vitamin B₁₂ and identified 47 new cases of vitamin B₁₂ deficit. The number of added s-vitamin B₁₂ needed to identify a new case by means of the intervention was 12. The total intervention reagent cost was 1446€, with a cost of 30.7€ per new case. The second intervention avoided unnecessary measurement of 611 tests, with 1613€ savings.

CONCLUSIONS

Through the two automated interventions we improved the diagnosis of vitamin B₁₂ deficiency, and decreased inadequate redundant s-vitamin B₁₂ measurement, cutting unnecessary laboratory costs.

From "Time is Brain" to "Imaging is Brain": A Paradigm Shift in the Management of Acute Ischemic Stroke

Arterial recanalization to restore the blood supply and limit the brain damage is the primary goal in the management of acute ischemic stroke (AIS). Since the publication of pivotal randomized clinical trials in 2015, endovascular thrombectomy has become part of the standard of care in selected cases of AIS from large-vessel occlusions up to 6 hours after the onset of symptoms. However, the association between endovascular reperfusion and improved functional outcome is not strictly time dependent. Rather than on rigid time windows, candidates should be selected based on vascular and physiologic information. This approach places imaging data at the center of treatment decisions. Advances in imaging-based management of AIS provide crucial information about vessel occlusion, infarct core, ischemic penumbra, and degree of collaterals. This information is invaluable in identifying patients who are likely to benefit from reperfusion therapies and excluding those who are unlikely to benefit or are at risk of adverse effects. The approach to reperfusion therapies continues to evolve, and imaging is acquiring a greater role in the diagnostic work-up and treatment decisions as shown in recent clinical trials with extended time window. The 2018 American Heart Association/American Stroke Association guidelines reflect a paradigm shift in the management of AIS from "Time is Brain" to "Imaging is Brain." This review discusses the essential role of multimodal imaging developing from recent trials on therapy for AIS.

High frequency of anti-parietal cell antibody (APCA) and intrinsic factor blocking antibody (IFBA) in individuals with severe vitamin B12 deficiency – an observational study in primary care patients

Background

Vitamin B12 deficiency is common worldwide and is also linked to several diseases including autoimmune atrophic gastritis (AAG). The presence of anti-parietal cell antibodies (APCA) and/or intrinsic factor blocking antibodies (IFBA) is indicative of AAG that may develop into pernicious anemia. Both conditions are known to be associated with an increased risk of gastric carcinoma. The aim of this study was to estimate the frequency of individuals positive for APCA and IFBA antibodies in primary care patients with severe vitamin B12 deficiency.

Methods

An observational study was designed and 5468 consecutive patients from primary care with a request for vitamin B12 status were included and add-on testing for APCA and IFBA that were automatically registered if severe vitamin B12 deficiency was identified (<73.8 pmol/L). For patients included in the intervention, study demographic data, mean corpuscular volume (MCV) and hemoglobin values were collected.

Results

Seventy-seven patients with severe vitamin B12 deficiency were identified and out of these 44 (57%) presented with antibodies to APCA and 11 (14%) to IFBA, 25 (32.5%) had anemia, and 25 (32.5%) had macrocytosis. The majority of APCA and/or IFBA positive patients were found in the age group >70 years. Both anemia and macrocytosis were more common among APCA positive patients but the association was not statistically significant, neither was the correlation between IFBA status and anemia and/or macrocytosis. Among the patients with anemia, 10 (39%) had macrocytosis, although the rate of macrocytosis among patients with or without anemia did not differ significantly.

Conclusions

The automated analysis strategy of measuring antibodies to APCA and IFBA in patients with severe vitamin B12 deficiency, efficiently detected positivity in more than 60% the patients. The result point to the presence of a high rate of otherwise undetected AAG and the potential clinical utility of APCA and IFBA as markers in primary care.

Laboratory Computer-Based Interventions for Better Adherence to Guidelines in the Diagnosis and Monitoring of Type 2 Diabetes

INTRODUCTION

The aim was to present two automated laboratory strategies designed to detect new cases of type 2 diabetes and prediabetes and improve their monitoring.

METHODS

To improve diabetes diagnosis, we automatically registered the glycated hemoglobin (HbA1c) levels of every primary care patient between 25 and 46 years old in case of abnormal lipid testing when an HbA1c test had not been requested in the current order or during the previous year and when fasting glucose was > 100 mg/dl. We counted the number of detected cases of diabetes and prediabetes and calculated the cost per identified patient. To improve diabetes monitoring, the levels of HbA1c, total cholesterol, high- and low-density lipoprotein cholesterol and triglycerides and the spot urinary albumin-to-creatinine ratios (ACRs) were automatically registered in patients with diabetes when not ordered according to guidelines. We calculated the total economic costs according to the total number of additional registered tests and reagent cost.

RESULTS

Of 103,425 requests, 224 (0.22%) met the inclusion criteria. Seventeen (7.6%) patients were identified as having new cases of diabetes and 149 (66.5%) of prediabetes, at a cost of €15.2 and €2.3, respectively, per case detected. From 13,874 requests in patients with diabetes, 91 HbA1c and 708 lipid tests and 862 ACRs were automatically registered to comply with guidelines, resulting in expenses of €1948.90.

CONCLUSIONS

Making use of laboratory technology, it is possible to detect new cases of type 2 diabetes and prediabetes and to improve disease monitoring.

Predicting Motor Outcome in Acute Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Predicting motor outcome following intracerebral hemorrhage is challenging. We tested whether the combination of clinical scores and DTI-based assessment of corticospinal tract damage within the first 12 hours of symptom onset after intracerebral hemorrhage predicts motor outcome at 3 months.

MATERIALS AND METHODS

We prospectively studied patients with motor deficits secondary to primary intracerebral hemorrhage within the first 12 hours of symptom onset. Patients underwent multimodal MR imaging including DTI. We assessed intracerebral hemorrhage and perihematomal edema location and volume, and corticospinal tract involvement. The corticospinal tract was considered affected when the tractogram passed through the intracerebral hemorrhage or/and the perihematomal edema. We also calculated affected corticospinal tract-to-unaffected corticospinal tract ratios for fractional anisotropy, mean diffusivity, and axial and radial diffusivities. Motor impairment was graded by the motor subindex scores of the modified NIHSS. Motor outcome at 3 months was classified as good (modified NIHSS 0-3) or poor (modified NIHSS 4-8).

RESULTS

Of 62 patients, 43 were included. At admission, the median NIHSS score was 13 (interquartile range = 8-17), and the median modified NIHSS score was 5 (interquartile range = 2-8). At 3 months, 13 (30.23%) had poor motor outcome. Significant independent predictors of motor outcome were NIHSS and modified NIHSS at admission, posterior limb of the internal capsule involvement by intracerebral hemorrhage at admission, intracerebral hemorrhage volume at admission, 72-hour NIHSS, and 72-hour modified NIHSS. The sensitivity, specificity, and positive and negative predictive values for poor motor outcome at 3 months by a combined modified NIHSS of >6 and posterior limb of the internal capsule involvement in the first 12 hours from symptom onset were 84%, 79%, 65%, and 92%, respectively (area under the curve = 0.89; 95% CI, 0.78-1).

CONCLUSIONS

Combined assessment of motor function and posterior limb of the internal capsule damage during acute intracerebral hemorrhage accurately predicts motor outcome.

Automated Requests for Thyroid-Stimulating Hormone and Ferretin Tests in Young Primary Care Patients with Anorexia as an Intervention to Improve Detection of Underlying Conditions

Objective

To improve clinical laboratory contribution to the treatment of primary care patients with anorexia through automated computerized strategies.

Methods

We recorded the number of laboratory requests due to anorexia; the demographic data, laboratory values, and presence of pathological values for the applicable patients. In a prospective study, the laboratory information management system (LIMS) automatically added thyroid-stimulating hormone (TSH) and/or ferritin testing when it was not requested by general practitioners for all primary care patients with anorexia who were younger than 16 years.

Results

A total of 3562 patients underwent laboratory testing due to anorexia, of whom 47% were younger than 16 years. The tests in which the results most frequently were abnormal were hemoglobin, ferritin, and TSH. TSH results were abnormal in 20% of patients younger than 16 years. Through the intervention, we detected 3 low ferritin values and 7 cases of pathological TSH levels.

Conclusions

The LIMS required TSH and ferritin testing in young patients even when not requested, potentially avoiding the adverse effects of iron deficiency and thyroid disorders on neurological development and cognition in those patients.

Urinary albumin strip assay as a screening test to replace quantitative technology in certain conditions

Background The clinical laboratory plays a crucial role in the diagnosis and monitoring of chronic kidney disease. The quantitative measurement of urine albumin in a spot sample, expressed as ratio per creatinine (ACR) is the most frequently used biomarker for such a purpose. Our aim was to evaluate the diagnostic performances of a strip for measuring ACR for differentiating patients who are candidates for subsequent albumin quantification, and to evaluate the economic effects of its implementation. Methods We systematically measured strip analysis when quantitative urinary albumin was requested. Semiquantitative urinary albumin was measured using a UC-3500 (Sysmex, Kobe, Japan), based on the protein error of a pH indicator. We collected and reviewed all the values of quantified urinary albumin and their corresponding results in ACR strip tests. We calculated the diagnostic indicators for ACR at different albumin and creatinine values using the quantitative ACR measurement as a "gold standard". We also studied the economic effects based on both tests prices (€1.31 for quantitative albumin plus creatinine, and €0.04 for an albumin strip). Results The study included 9148 patients (mean age 63, 46.3% men). The results at different albumin and creatinine cutoffs showed the best performance when 10 mg/L and above 50 mg/dL, respectively. Based on our results, we would have saved 3506 urine albumin and creatinine tests in the study period, corresponding to €4226.94. Conclusions The present study supports the use of the ACR strip test to identify pathological albuminuria values to be measured through quantitative methods. Considerable economic savings are possible.

Soft-tissue vascular malformations and tumors. Part 2: low-flow lesions

Vascular malformations and tumors, also known as "vascular anomalies", comprise an extensive variety of lesions involving all parts of the body. Due to a lack of a complete understanding of the origin and histopathology of such lesions, this field has been traditionally obscured by the use of an unclear nomenclature. Knowledge of the classification and clinical and imaging characteristics of this group of lesions is paramount when managing these patients. The objective of this series of two articles is to review the current classification of vascular anomalies, to describe the role of imaging in their diagnosis, to summarize their distinctive histopathologic, clinical and imaging features, and to discuss the treatment options. High-flow lesions were discussed in the first article of this series. In this second article, we will focus on low-flow lesions, including complex syndromes with associated low-flow malformations.

Vitamin B12 deficiency and clinical laboratory: Lessons revisited and clarified in seven questions

The objective of this review article is to address the most frequently asked questions that pathologists and primary care physicians might face when dealing with a patient with suspicion of vitamin B12 deficiency. More specifically, the article mainly discusses the importance and prevalence of the deficit, how to recognize it, and the important role of a prompt diagnosis confirmation based on laboratory biomarkers for efficient replacement therapy.

Uncritical Request of Thyroid Laboratory Tests May Result in a Major Societal Economic Burden: Results from a Large Population Study in Spain

BACKGROUND

Our aim is to study the regional variability in the request of thyroid laboratory tests from primary care facilities in Spain and to investigate a potential inappropriate request and its economic societal impact.

METHODS

Spain is divided into 17 autonomous communities (AACCs) which are in turn divided in Health Departments that cover a geographic area and its population and a laboratory that attends the needs of every inhabitant. Each participating laboratory was required to report the number of thyroid tests requested from primary care during year 2014 and to provide organizational data. The request of every test per 1000 inhabitants and ratio of related tests (free thyroxine (FT4)/thyrotropin (TSH), triiodothironine (FT3)/TSH, antithyroglobulin antibody (ATG)/antiperoxidase antibody (TPO)) were calculated and compared in different AACCs with more than 4 participants. The economic costs taking into account reagent cost were calculated.

RESULTS

110 laboratories participated (27,798,262 inhabitants). Close to 6 million TSH tests were requested, representing an expense of more than 10 million euros. That corresponds to 18 million euros when extrapolating for the whole Spanish population, only in reagent cost. The number of TSH requests per 1000 inhabitants in the different AACCs ranged from 198 to 289. FT4 was ordered more than twice as frequently in some regions compared to others. TPO request per 1000 inhabitants ranged from 0.2 to 11.2.

CONCLUSIONS

There was a significant over-request and regional variability of thyroid laboratory tests in primary care in Spain, resulting in a high economic impact on society.

[Application of a continual improvement approach to selecting diagnostic markers for acute pancreatitis in an emergency department]

OBJECTIVES

To apply a continual improvement model to develop an algorithm for ordering laboratory tests to diagnose acute pancreatitis in a hospital emergency department.

MATERIAL AND METHODS

Quasi-experimental study using the continual improvement model (plan, do, check, adjust cycles) in 2 consecutive phases in emergency patients: amylase and lipase results were used to diagnose acute pancreatitis in the first phase; in the second, only lipase level was first determined; amylase testing was then ordered only if the lipase level fell within a certain range. We collected demographic data, number amylase and lipase tests ordered and the findings, final diagnosis, and the results of a questionnaire to evaluate satisfaction with emergency care.

RESULTS

The first phase included 517 patients, of whom 20 had acute pancreatitis. For amylase testing sensitivity was 0.70; specificity, 0.85; positive predictive value (PPV), 17; and negative predictive value (NPV), 0.31. For lipase testing these values were sensitivity, 0.85; specificity, 0.96; PPV, 21, and NPV, 0.16. When both tests were done, sensitivity was 0.85; specificity 0.99; PPV, 85; and NPV, 0.15. The second phase included data for 4815 patients, 118 of whom had acute pancreatitis. The measures of diagnostic yield for the new algorithm were sensitivity, 0.92; specificity, 0.98; PPV, 46; and NPV, 0.08].

CONCLUSION

This study demonstrates a process for developing a protocol to guide laboratory testing in acute pancreatitis in the hospital emergency department. The proposed sequence of testing for pancreatic enzyme levels can be effective for diagnosing acute pancreatitis in patients with abdominal pain.

Request Pattern, Pre-Analytical and Analytical Conditions of Urinalysis in Primary Care: Lessons from a One-Year Large-Scale Multicenter Study

BACKGROUND

To study the urinalysis request, pre-analytical sample conditions, and analytical procedures.

METHODS

Laboratories were asked to provide the number of primary care urinalyses requested, and to fill out a questionnaire regarding pre-analytical conditions and analytical procedures.

RESULTS

110 laboratories participated in the study. 232.5 urinalyses/1,000 inhabitants were reported. 75.4% used the first morning urine. The sample reached the laboratory in less than 2 hours in 18.8%, between 2 - 4 hours in 78.3%, and between 4 - 6 hours in the remaining 2.9%. 92.5% combined the use of test strip and particle analysis, and only 7.5% used the strip exclusively. All participants except one performed automated particle analysis depending on strip results; in 16.2% the procedure was only manual.

CONCLUSIONS

Urinalysis was highly requested. There was a lack of compliance with guidelines regarding time between micturition and analysis that usually involved the combination of strip followed by particle analysis.

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.

Large-Scale Analysis Evaluating Regional Variability in the Request of Laboratory Tests in Primary Care and its Potential Economic Impact

Objective

To compare the ratios of requests of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) and urea to creatinine (Crea); to investigate the variability among regions and to calculate the potential savings if a target is reached.

Methods

Laboratories were invited to fill out a registration form on the number of AST, ALT, Urea and Crea requested in 2014, and to provide the reagent price of urea and AST. AST:ALT and Urea:Crea were calculated and compared; also compared were potential savings if each laboratory would have reached the target. Results: A significant difference was found among regions in Urea:Crea. Twenty-one laboratories reached the goal in AST:ALT, and 6 in Urea:Crea. The potential savings if each indicator would have reached the target would have been $553,827 and $745,184, respectively.

Conclusion

Variability was found in AST:ALT and Urea:Crea, which resulted in a significant unnecessary financial burden and suggests the need to promote the optimal requesting rate.

Serum Uric Acid Laboratory Test Request Patterns in Primary Care: How Panels May Contribute to Overutilization and Treatment of Asymptomatic Patients

Background

To study the variability in the request of serum uric acid (SUA) in primary care.

Method

A cross-sectional study was designed and conducted at a main core laboratory. Spanish laboratories were invited to report their number of serum glucose (SG) and SUA tests requested from primary care during 2014. A survey was sent to every participant in November 2016 regarding the inclusion of SUA in order profiles/panels. The ratio of SUA/SG requests (SUA/SG) was calculated and compared between regions, and laboratories depending on whether SUA was included or not in a health check profile.

Results

110 laboratories participated in the study (59.8% Spanish population). The median SUA/SG ratio was 0.82 (IQR: 0.25), and 41 laboratories had a ratio over 0.9. There was a significant regional variability (P = .008). Laboratories where SUA was not included in the "health check profile" had lower SUA/SG indicators (P = .003).

Conclusion

There was significant regional variability in the request of SUA, and an overall over-request. Different regional customs or habits and the inclusion of SUA in the health check profile were probable causes behind the observed over-request.

Big differences in primary care celiac disease serological markers request in Spain

Introduction

Celiac disease (CD) prevalence is increasing but the disorder remains undiagnosed. The study compares CD serology markers requested by General Practitioners (GPs) over time and geographical areas. The aim of the current research is to assess the inter-practice and temporal variability in the request of CD serology markers by GPs in Spain, and the differences between regions.

Materials and methods

A cross-sectional study was conducted enrolling Spanish clinical laboratories. Primary care CD serology markers request in 2010, 2012 and 2014 from 15 autonomous communities (AACC), with more participants was reported. Test-utilization rates were calculated (tissue transglutaminase IgA antibodies (tTG-IgA) and deaminated peptide gliadine IgA antibodies (DGP-IgA) per 1000 inhabitants), and also the ratio of both tests request (DGP-IgA /tTG-IgA).

Results

The request of tTG-IgA per 1000 inhabitants increased significantly along years (from 3.99 to 5.90 (P < 0.001)). The demand of DGP-IgA per 1000 inhabitants was maintained in 2010 and 2012 (0.68 and 0.6), and decreased in 2014 (0.35) (P = 0.927). DGP-IgA /tTG-IgA diminished over time (from 0.16 to 0.06 (P = 0.548)), and in the 2014 edition, there was a significant regional difference, ranging from 0.01 to 0.57 (P < 0.001).

Conclusions

The variability in the request in CD serology markers emphasizes the need of inter-regional cooperation to develop strategies to optimize the use of laboratory tests.

Clinical and Imaging Characteristics of Arteriopathy Subtypes in Children with Arterial Ischemic Stroke: Results of the VIPS Study

BACKGROUND AND PURPOSE

Childhood arteriopathies are rare but heterogenous, and difficult to diagnose and classify, especially by nonexperts. We quantified clinical and imaging characteristics associated with childhood arteriopathy subtypes to facilitate their diagnosis and classification in research and clinical settings.

MATERIALS AND METHODS

The Vascular Effects of Infection in Pediatric Stroke (VIPS) study prospectively enrolled 355 children with arterial ischemic stroke (2010-2014). A central team of experts reviewed all data to diagnose childhood arteriopathy and classify subtypes, including arterial dissection and focal cerebral arteriopathy-inflammatory type, which includes transient cerebral arteriopathy, Moyamoya disease, and diffuse/multifocal vasculitis. Only children whose stroke etiology could be conclusively diagnosed were included in these analyses. We constructed logistic regression models to identify characteristics associated with each arteriopathy subtype.

RESULTS

Among 127 children with definite arteriopathy, the arteriopathy subtype could not be classified in 18 (14%). Moyamoya disease (n = 34) occurred mostly in children younger than 8 years of age; focal cerebral arteriopathy-inflammatory type (n = 25), in children 8-15 years of age; and dissection (n = 26), at all ages. Vertigo at stroke presentation was common in dissection. Dissection affected the cervical arteries, while Moyamoya disease involved the supraclinoid internal carotid arteries. A banded appearance of the M1 segment of the middle cerebral artery was pathognomonic of focal cerebral arteriopathy-inflammatory type but was present in <25% of patients with focal cerebral arteriopathy-inflammatory type; a small lenticulostriate distribution infarct was a more common predictor of focal cerebral arteriopathy-inflammatory type, present in 76%. It remained difficult to distinguish focal cerebral arteriopathy-inflammatory type from intracranial dissection of the anterior circulation. We observed only secondary forms of diffuse/multifocal vasculitis, mostly due to meningitis.

CONCLUSIONS

Childhood arteriopathy subtypes have some typical features that aid diagnosis. Better imaging methods, including vessel wall imaging, are needed for improved classification of focal cerebral arteriopathy of childhood.

Glycated hemoglobin: A powerful tool not used enough in primary care

BACKGROUND

Glycated haemoglobin (HbA1c) is one of the most useful and relevant laboratory tests currently available. The aim of the actual research was to study the variability and appropriateness in the request of HbA1c in primary care, and differences between regions, to assess if there would be an opportunity to improve the request.

METHODS

A cross-sectional study was conducted enrolling clinical Spanish laboratories. The number of HbA1c requested in 2014 by all general practitioners was reported by each participant. Test-utilization rate was expressed as tests per 1000 inhabitants. The index of variability was calculated, as the top decile divided by the bottom decile. HbA1c per 1000 inhabitants was compared between the different regions. To investigate whether HbA1c was appropriately requested to manage patients with diabetes, the real request was compared to the theoretically ideal number, according to prevalence of known diabetes mellitus in Spain and guideline recommendations.

RESULTS

A total of 110 laboratories participated in the study, corresponding to a catchment area of 27 798 262 inhabitants (59.8% of the Spanish population) from 15 different autonomous communities (AACCs). 2 655 547 HbA1c were requested, a median of 93.9 (interquartile range (IQR): 33.4) per 1000 inhabitants. The variability index was 1.97. The HbA1c/1000 inhabitants was significantly different among the AACCs, ranging from 73.4 to 126.3. A total of 4 336 529 additional HbA1c would have been necessary to manage patients with diabetes according to guidelines, and 3 861 769 for diagnosis in asymptomatic patients.

CONCLUSIONS

There was a high variability and significant differences between Spanish AACCs. Also a significant under-request of HbA1c was observed in Primary Care in Spain.

Urinary albumin: a risk marker under-requested in primary care in Spain

Background

To study the inter-practice regional variation in the request of urinary albumin by general practitioners and compare to guideline recommendations.

Methods

A cross-sectional study enrolled laboratories from different Spanish autonomous communities. Laboratories were invited to report the number of urinary albumin requested by general practitioners during 2012 and 2014. Urinary albumin requested per 1000 inhabitants and the index of variability (90th centile/10th centile) was calculated, and compared between autonomous communities and time periods. To investigate potential inappropriate requesting in the management of diabetes and arterial hypertension, the actual number of requests was compared to the theoretical, based on prevalence and guideline recommendations.

Results

Urinary albumin requested per 1000 inhabitants was similar for years 2012 and 2014 (78.2 (60.1) to 85.4 (55.4); P = 0.235), as was the variability index (4.6 for both). There were significant differences between autonomous communities, with the indicator ranging from 46.0 (33.1) to 125.8 (64.3) ( P < 0.05). The theoretical cut-off ratios of urinary albumin per 1000 inhabitants to manage patients with diabetes and arterial hypertension were, respectively, 78 and 159; no laboratory reached both values.

Conclusions

Requesting of urinary albumin showed a significant regional variability in primary care in Spain, and was insufficient to correctly monitor patients with diabetes and arterial hypertension.

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.

Primary care requests for anaemia chemistry tests in Spain: potential iron, transferrin and folate over-requesting

Aim

To study the regional variability of requests for anaemia chemistry tests in primary care in Spain and the associated economic costs of potential over-requesting.

Methods

Requests for anaemia tests were examined in a cross-sectional study. Clinical laboratories from different autonomous communities (AACCs) were invited to report on primary care anaemia chemistry tests requested during 2014. Demand for iron, ferritin, vitamin B12 and folate tests per 1000 inhabitants and the ratios of the folate/vitamin B12 and transferrin/ferritin requests were compared between AACCs. We also calculated reagent costs and the number of iron, transferrin and folate tests and the economic saving if every AACC had obtained the results achieved by the AACC with best practice.

Results

110 laboratories participated (59.8% of the Spanish population). More than 12 million tests were requested, resulting in reagent costs exceeding €16.5 million. The serum iron test was the most often requested, and the ferritin test was the most costly (over €7 million). Close to €4.5 million could potentially have been saved if iron, transferrin and folate had been appropriately requested (€6 million when extrapolated to the whole Spanish population).

Conclusions

The demand for and expenditure on anaemia chemistry tests in primary care in Spain is high, with significant regional differences between different AACCs.

Abstract 169: Clinical and Imaging Biomarkers of Childhood Arteriopathy: Results of the Vascular effects of Infection in Pediatric Stroke (VIPS) Study

Introduction: Childhood cerebral arteriopathies are heterogeneous and difficult to classify. Our goal was to identify clinical and imaging biomarkers associated with subtypes of childhood arteriopathy in order to facilitate their diagnosis and classification in both research and clinical settings.

Methods: From 2009-2014, the VIPS study enrolled 355 children (age 29d-18y) with arterial ischemic stroke. A neuroradiologist and pediatric vascular neurologist independently reviewed vascular imaging and clinical data to diagnose arteriopathy (none, possible, definite), and then classify arteriopathy subtype: arterial dissection, transient cerebral arteriopathy (TCA), moyamoya, and secondary vasculitis. Disagreements were resolved through discussion by a panel of two neuroradiologists and two pediatric vascular neurologists. We constructed multivariable logistic regression models to identify characteristics independently associated with each subtype.

Results: Of 127 cases with definite arteriopathy, 109 received a single arteriopathy subtype diagnosis (26 dissection, 25 TCA, 34 moyamoya, 15 secondary vasculitis, and 9 “other”), while 18 were of indeterminate subtype. There were no cases of primary vasculitis. Independent predictors of arteriopathy subtype are shown (Table). The association between black race and moyamoya is explained by sickle cell anemia. A banding pattern on the vascular imaging was pathognomonic of TCA. Moyamoya and vasculitis secondary to meningitis had similar distal internal carotid artery abnormalities, but lenticulostriate collaterals suggested moyamoya, and a decreased level of consciousness predicted secondary vasculitis.

Conclusions: The different subtypes of childhood arteriopathies are associated with typical clinical, parenchymal and vascular imaging features that can help narrow the differential diagnosis in pediatric stroke patients with vascular abnormalities.