Utility and Necessity of Repeat Testing of Critical Values in the Clinical Chemistry Laboratory

Context

Routine repeat testing of critical values is a long-standing practice in many clinical laboratories; however, its usefulness and necessity remain to be empirically established and no regulatory requirements yet exist for verification of the critical value results obtained by repeat analysis.

Objective

To determine whether repeat testing of critical values is useful and necessary in a clinical chemistry laboratory.

Methods

A total of 601 chemistry critical values (potassium, n = 255; sodium, n = 132; calcium, n = 108; glucose, n = 106) obtained from 72,259 routine clinical chemistry specimens were repeat tested. The absolute value and the percentage of difference between the two testing runs were calculated for each of the four critical values and then compared with the allowable error limit put forth in the College of American Pathologists (CAP).

Results

Among the repeat data for the 601 critical values, a total of 24 showed large differences between the initial result and the repeated result which exceeded the CAP limits for allowable error. The number and rates (%) of large differences for within and outside the analytical measurement range (AMR) were 12 (2.1%) and 12 (41.4%), respectively. For the 572 critical values within the AMR for each test category, the mean absolute difference (mmol/L) and difference(%) between the two testing runs were: potassium, 0.1 mmol/L (2.7%); sodium, 2.1 mmol/L (1.7%); calcium, 0.05 mmol/L (3.0%); glucose, 0.18 mmol/L (2.6%).

Conclusions

When the initial chemistry critical values are within the AMR, repeated testing does not improve accuracy and is therefore unnecessary. When the initial chemistry critical values are outside the AMR, however, the benefit of repeated testing justifies its performance and makes it necessary. Performing repeat clinical testing on a case-by-case, rather than routine, basis can improve patient care by delivering critical values more rapidly while providing savings on reagent costs associated with unnecessary repeat testing.     

某三级综合医院专病门诊诊疗工作分析

目的 了解某三级综合医院专病门诊的诊疗工作现状,分析专病门诊患者需求及管理模式的特点。方法 对2008—2011年某三级综合医院专病门诊量进行描述性分析、线性回归分析及相关性分析。结果 加强专病门诊管理有利于提高医疗质量和水平,简化门诊流程,实施疾病全程式规范化管理与治疗,提高门诊医疗服务效率。结论 近年来专病门诊已逐渐成为门诊工作的增长点,为适应学科发展及患者需求,需不断规范对专病门诊的管理与建设。     

全国三级医院临床工程部门人员发展现状分析

目的 掌握我国临床工程部门人员发展现状,为临床工程部门发展提供建议。方法 采用问卷调查法,向全国282家三级医院临床工程部门发放调查问卷282份,对其基本发展情况进行调查,问卷回收率100%。结果 三级医院临床工程人员存在职称结构不合理、整体素质偏低、科研能力不足和继续教育项目内容过于单一等问题。结论 三级医院应当加强临床工程部门人员学历教育、鼓励开展科研、畅通职称晋升渠道、加强与国外临床工程学术交流,推动临床工程更好发展。     

Evaluation of the Short-Term Effects of Antimicrobial Stewardship in the Intensive Care Unit at a Tertiary Hospital in China

Antibiotic abuse can lead to antibiotic resistance, which is a severe problem in China. The purpose of this study is to evaluate the short-term effects of antimicrobial stewardship strategies, including formulary restriction, preauthorization, perioperative quinolone restriction, and control of total antibiotic consumption in the ICU at a tertiary hospital in China. After implementation of antimicrobial stewardship, the total antibiotic consumption in the ICU significantly decreased. The defined daily doses (DDDs) per 100 patient-days decreased from 197.65 to 143.41; however, the consumption of cephalosporins increased from 53.65 to 63.17 DDDs. Significant improvements in resistance to amikacin, gentamicin, ciprofloxacin, ofloxacin, ceftriaxone, ceftazidime, and piperacillin in Enterobacteriaceae and resistance to ceftazidime, imipenem, and meropenem in non-fermenting Gram-negative rods were observed. In addition, the initial use of no antibiotics or of a single antibiotic significantly increased (P<0.001) and the use of two antibiotics in combination significantly decreased (P<0.001). Our results demonstrate that implementation of antimicrobial stewardship in a short period in the ICU dramatically reduced antibiotic consumption and significantly improved antibiotic resistance, which leads to more reasonable antibiotic selections by ICU physicians.     

Candidemia in Adults at a Tertiary Hospital in China: Clinical Characteristics,Species Distribution,Resistance, and Outcomes

Background

Candidemia is one of the most common nosocomial bloodstream infections. Early diagnosis and antifungal treatment improve clinical outcomes in some studies but not all, with diverse data reported from different institutions. Similarly, antifungal resistance is more common in the USA than in Europe, but there is little data regarding the microbiology and clinical course of candidemia in adult patients in Asia.

Aims

(1) To capture species distribution and drug resistance rates among Candida bloodstream isolates, (2) to describe clinical features of candidemia, and (3) to identify factors associated with all-cause mortality, with emphasis on early initiation of antifungal treatment, at a large tertiary University Hospital in China.

Methods

In this single-center retrospective study, we identified all patients with candidemia, between 2008 and 2014. Demographic and clinical characteristics, microbiological information, details of antifungal therapy and clinical outcomes were collected.

Results

We studied 166 patients. 71 (42.8%) had cancer. Candida albicans was the most frequent species (37.3%), followed by C. parapsilosis (24.1%), C. tropicalis (22.8%), and C. glabrata (14.5%). Antifungal resistance was more frequent in non-albicans strains and especially C. glabrata. Twenty patients received inappropriate treatment with all-cause mortality of 35%. The remaining 146 patients had significantly lower mortality (21.9%, P?=?0.045). Among patients who received antifungal treatment, mortality rate increased with time to appropriate antifungal therapy (AAT): 13.7%, for?<?24 h, 21.1% for 24–48 h, 23.1% for?>?48 h, and 32.4% among patients who received no AT (χ² for trend P?=?0.039). Initiating AAT more than 24 h after blood culture collection was an independent risk factor for mortality, after adjustment for other confounders (OR 7.1, 95% CI 1.3–39.4, P?=?0.024).

Conclusions

Candida albicans was the most frequent cause of candidemia at a large tertiary hospital in China, but antifungal resistance is a growing concern among non-albicans Candida species. The mortality rate of patients treated with ineffective antifungal agents based on in vitro susceptibilities was similar to that of patients who received no treatment at all, and delayed initiation of antifungal treatment was associated with increased risk of death.

     

Consistency of Thyroid Imaging Reporting and Data System Reporting in Community-Based Imaging Centers Versus a Large Tertiary Hospital

ObjectiveIn our country, thyroid nodules are sonographically evaluated in health maintenance organization (HMO) imaging centers, and patients are referred to tertiary hospitals for ultrasound-guided fine-needle aspiration (FNA) biopsy when indicated. We evaluated the concordance in Thyroid Imaging Reporting and Data System (TI-RADS) classification reporting between these sites.MethodsWe conducted a retrospective cohort study reviewing the sonographic features of thyroid nodules evaluated both at the HMO and a large tertiary center between January 2018 and December 2019. The primary outcome was concordance between the TI-RADS classification at both sites. Additional endpoints included correlation of TI-RADS to the Bethesda category following FNA and correlation of TI-RADS with malignancy on final pathology at each site.ResultsThe records of 336 patients with 370 nodules were reviewed. The level of concordance was poor (19.8%), with 277 (74.8%) nodules demonstrating higher TI-RADS and 20 (5.4%) lower TI-RADS at the HMO compared to the hospital (P < .001; weighted κ = 0.120). FNA results were available for 236 (63.8%) nodules. The Bethesda category strongly correlated with the hospital TI-RADS (P < .001), yet not with HMO TI-RADS (P = .123). In the surgically removed 57 nodules, a strong correlation was identified between the malignancy on final pathology and TI-RADS documented at the hospital (P < .001), yet not at the HMO (P = .259).ConclusionsThere is poor agreement between TI-RADS classification on ultrasound performed in the HMO compared to a tertiary hospital. The hospital’s TI-RADS strongly correlated with the Bethesda category and the final risk of malignancy, unlike the HMO.     

Molecular Epidemiology of Clostridium difficile Infection in a Large Teaching Hospital in Thailand

Clostridium difficile infection (CDI) is a leading cause of healthcare-associated morbidity and mortality worldwide. In Thailand, CDI exhibits low recurrence and mortality and its molecular epidemiology is unknown. CDI surveillance was conducted in a tertiary facility (Siriraj Hospital, Bangkok). A total of 53 toxigenic C. difficile strains from Thai patients were analyzed by multi-locus sequence typing (MLST), PCR ribotyping, and pulse-field gel electrophoresis (PFGE). The mean age of the cohort was 64 years and 62.3% were female; 37.7% of patients were exposed to > two antibiotics prior to a diagnosis of CDI, with beta-lactams the most commonly used drug (56.3%). Metronidazole was used most commonly (77.5%; success rate 83.9%), and non-responders were treated with vancomycin (success rate 100%). None of the isolates carried binary toxin genes. Most isolates (98.2–100%) were susceptible to metronidazole, vancomycin, tigecycline and daptomycin. There were 11 sequence types (STs), 13 ribotypes (RTs) and four PFGE types. Six previously identified STs (ST12, ST13, ST14, ST33, ST41 and ST45) and five novel STs unique to Thailand (ST66, ST67, ST68, ST69 and ST70) were identified. PCR RTs UK 017 (ST45) (45.3%) and UK 014/020 (ST33) (24.5%) were the most common. High concordance was observed between the MLST and ribotyping results (p<0.001). C. difficile isolates from Thai patients were highly susceptible to standard antimicrobial agents. In conclusion, the five STs indicate the high genetic diversity and unique polymorphisms in Thailand. Moreover, the emergence of antimicrobial resistance to vancomycin warranted continuous surveillance to prevent further spread of the toxigenic C. difficile isolates.     

Prevalence of Dermatomycosis in a Brazilian Tertiary Care Hospital

A total of 233 specimens obtained from suspected cases of dermatomycosis from 189 patients were examined for causative fungi from December 2009 to May 2010 in a tertiary care hospital in the city of Belo Horizonte, state of Minas Gerais, southeastern Brazil. Yeast and fungal isolates obtained from specimens were regarded as conclusive diagnosis of mycoses in 82 cases (35.19?%), with the exception of two patients with pityriasis versicolor (2.4?%), in which the diagnosis was made only by direct examination plus clinical diagnostics of individuals. Forty-four subjects (23.28?%) were infected in more than one anatomical site. There was a higher occurrence on female patients (146, 77.2?%) than male (43, 22.8?%). Most of the infected patients were aged between 41 and 70?years (68.29?%). There were no statistically significant differences between occurrence of fungal infection and gender, presence of secondary disease and contact with animals. The largest number of examined material occurred in samples from toenails, which resulted in 50?% of positive cultures. Candida species were the most frequent group causing dermatomycosis in many anatomical sites, mainly in toenails and fingernails. Candida parapsilosis was the most representative (40.24?%) among all agents causing dermatomycosis of toenails and fingernails, followed by Candida tropicalis (20.73?%) and Trichophyton rubrum (10.98?%). Among the dermatophytes, Trichophyton genus represented over 80?% of the isolates, with T. rubrum representing 64.29?%, T. interdigitale (T. mentagrophytes) (21.43?%) and Microsporum gypseum (14.29?%).     

Epidemiology and Microbiology of Nosocomial Pediatric Candidemia at a Northern Indian Tertiary Care Hospital

The availability and aggressive use of chemotherapeutic and immunosuppressive agents as well as broad-spectrum antibacterial agents have created a large population of patients who are at increased risk of acquiring infections with fungal organisms, especially Candida species. Present work was undertaken to study the epidemiology and microbiology of candidemia and Candida colonization in hospitalized children. A total of 323 suspected cases of septicemia were enrolled, of which blood culture from 7.4% subjects was positive for Candida species. In total, 57.3% subjects were colonized by Candida species at least at one of the tested sites. Of 337 isolates, 24.3, 71.5, 2.9, 0.59, and 0.59% were Candida albicans, Candida tropicalis, Candida krusei, Candida kefyr, and Candida lusitaniae, respectively. Antifungal susceptibility results show that fluconazole, itraconazole, and amphotericin B resistance is prevalent in 18.2, 2.4, and 3.6% of C. albicans isolates, and 21.1, 4.6, and 0.04% of C. tropicalis isolates, respectively. In a large number of cases, source of blood infection was patient’s own colonizers, as shown by genetic matching. It was also noted that some strain types are circulating within the ward. High prevalence of non-albicans candidemia with high resistance to fluconazole is prevalent in North Indian hospitalized children.     

临床实验室危急值及其相关制度沿革历程与策略探讨

系统阐述了危急值的特点及其制度建立、评估与完善的策略,剖析了我国危急值制度的现状及存在的问题并提出了有针对性的建议,最后对危急值制度的未来发展趋势作出展望。通过对制度的多角度解读和分析,能够促进危急值相关制度的临床规范化应用,最大限度地实现保障患者安全的核心目标。

     

Sickle Cell Disease in Pregnancy: Trend and Pregnancy Outcomes at a Tertiary Hospital in Tanzania

SCD in pregnancy is associated with increased adverse fetal and maternal outcomes. In Tanzania where the frequency of sickle cell trait is 13% there has been scanty data on SCD in pregnancy. With progressive improvement in childhood survival the burden of SCD in pregnancy will increase. We analyzed all deliveries at Muhimbili National Hospital (MNH) from 1999 to 2011. Fetal and maternal outcomes of SCD deliveries were compared with non-SCD. Data were analyzed using IBM SPSS statistics version 19. Chi square and Fisher Exact tests were used to compare proportions and the independent t-test for continuous data. To predict risks of adverse effects, odds ratios were determined using multivariate logistic regression. A p-value<0.05 was considered significant. In total, 157,473 deliveries occurred at MNH during the study period, of which 149 were SCD (incidence of 95 SCD per 100,000 deliveries). The incidence of SCD had increased from 76 per 100,000 deliveries in the 1999–2002 period to over 100 per 100, 000 deliveries in recent years. The mean maternal age at delivery was lower in SCD (24.0±5.5 years) than in non-SCD deliveries (26.2±6.0 years), p<0.001. Compared with non-SCD (2.9±0.7 Kg), SCD deliveries had less mean birth-weight (2.6±0.6 Kg), p<0.001. SCD were more likely than non-SCD to deliver low APGAR score at 5 minutes (34.5% Vs 15.0%, OR = 3.0, 95%CI: 2.1–4.2), stillbirths (25.7% Vs 7.5%, OR = 4.0, 95%CI: 2.8–5.8). There was excessive risk of maternal deaths in SCD compared to non-SCD (11.4% Vs 0.4%, OR = 29, 95%CI: 17.3–48.1). The leading cause of deaths in SCD was infections in wholly 82% in contrast to only 32% in non-SCD. In conclusion SCD in pregnancy is an emerging problem at MNH with increased adverse fetal outcomes and excessive maternal mortality mainly due to infections.     

某三级甲等综合医院430例医疗纠纷数据分析

采用回顾性分析的方法,收集黑龙江省某三级甲等综合医院2010—2013年医疗纠纷共430例,按照发生医疗纠纷的科室分布、责任人分布、产生原因分析及纠纷处理情况进行分析。结果显示： 4年间,医疗纠纷发生比率分别为0.78‰、0.67‰、0.64‰、0.63‰,呈逐年降低趋势。纠纷发生科室分布以外科为主;医疗纠纷责任人分布情况以主治医师为主;纠纷发生的主要原因为缺乏医疗知识对并发症及医疗效果不满意,医疗纠纷的处理情况以“无过错”为主。     

Photostatic Reporting in a Hospital Bacteriology Laboratory

A method of reporting results of tests performed in a hospital bacteriological laboratory is described in which a modified commercially available electrostatic copier is used. This device was designed for a hispital system in which more than one report per specimen is issued and in which rubber stamps are widely used and frequently changed. It has been working satisfactorily for more than six months. It increases accuracy and saves time and money. Attention to the clarity of reproduction is necessary. It is suggested that this system could be modified for other laboratory reporting systems.     

上海某市级医院行政管理组织诊断结果分析

目的 通过对上海市某市级医院行政管理组织诊断分析,评价该医院行政管理的组织构架和岗位职责现状及特征,了解组织诊断方法的应用方式。方法 选取上海某三级甲等综合性医院,对行政管理人员采用问卷调查法、主管人员分析法及访谈法等,收集分析有关组织结构、行为评价、工作满意度、工作期望等信息和数据。结果 管理人员努力做好工作的意愿比较强烈,工作行为还是比较积极的,在管理工作中整体上较少产生生理退行行为,整体上缺乏比较强烈的进步期望,管理上存在一些不足。结论 该医院应就某些管理的组织构架、管理流程、分工及责权予以调整,以有利于管理工作的顺畅高效实施。     

某三甲医院主治医师查房质量考核情况分析

?????? 目的 通过主治医师查房质量考核,调查目前主治医师查房过程中存在的问题,以督促主治医师不断提高查房水平,进而持续改进医疗质量。方法 采用评分及专家点评相结合的方法收集资料,运用统计软件进行分析。结果 被考核主治医师分布在27个监床科室,共计199名,全院主治医师查房质量考核分数为93.8分;考核发现,主治医师查房考核过程中存在带教意识不强、查房流程不清晰等问题。结论 应提高主治医师对查房的重视程度,通过进行示范查房培训,提高主治医师带教能力。     

我国三级综合医院医疗质量安全核心制度演化进程

通过系统回顾医疗质量安全核心制度相关的政策文件,整理分析我国三级综合医院医疗质量核心制度的演化进程,总结三级综合医院执行医疗质量安全核心制度的政策依据及原则;分析医院在落实医疗质量安全核心制度中存在的问题,有利于为我国医院持续改进医疗质量提供理论支持。     

Spectrums of Opportunistic Infections and Malignancies in HIV-Infected Patients in Tertiary Care Hospital,China

Background

HIV-related opportunistic infections (OIs) and malignancies continued to cause morbidity and mortality in Chinese HIV-infected individuals. The objective for this study is to elucidate the prevalence and spectrums of OIs and malignancies in HIV-infected patients in the Beijing Ditan Hospital.

Methods

The evaluation of the prevalence and spectrums of OIs and malignancies was conducted by using the clinical data of 834 HIV-infected patients admitted in the Beijing Ditan hospital from January 1, 2009, to November 30, 2012.

Results

The prevalence and spectrums of OIs and malignancies varied contingent on geographic region, transmission routes, and CD4 levels. We found that tuberculosis was most common OI and prevalence was 32.5%, followed by candidiasis(29.3%), Pneumocystis pneumonia(PCP)(22.4%), cytomegalovirus(CMV) infection(21.7%), other fungal infections(16.2%), mycobacterium avium complex(MAC)(11.3%), cryptococcosis(8.0%), progressive multifocal leukoencephalopathy(PML)(4.4%), Cerebral Toxoplasmosis(3.5%) and Penicillium marneffei infection(1.4%); while Lymphoma(2.9%), Kaposi’s sarcoma(0.8%) and cervix carcinoma(0.3%) were emerged as common AIDS-defining malignancies. Pulmonary OI infections were the most prevalent morbidity and mortality in patients in the AIDS stage including pulmonary tuberculosis (26.6%) and PCP (22.4%). CMV infection(21.7%) was most common viral infection; Fungal OIs were one of most prevalent morbidity in patients in the AIDS stage, including oral candidiasis (29.3%), other fungal infection (16.2%), Cryptococcosis (8.0%) and Penicillium marneffei infection (1.4%). We found the low prevalence of AIDS-defining illnesses in central neural system in this study, including progressive multifocal leukoencephalopathy (4.4%), cerebral toxoplasmosis (3.5%), tuberculosis meningitis (3.2%), cryptococcal meningitis (2.4%) and CMV encephalitis (1.1%). In-hospital mortality rate was 4.3 per 100 person-years due to severe OIs, malignancies, and medical cost constraints.

Conclusions

The prevalence and spectrums of OIs, malignancies and co-infections were discussed in this study. It would help increase the awareness for physicians to make a diagnosis and empirical treatment sooner and plan good management strategies, especially in resource limited regions.     

Low Birth Weight at Term and Its Determinants in a Tertiary Hospital of Nepal: A Case-Control Study

Birth weight of a child is an important indicator of its vulnerability for childhood illness and chances of survival. A large number of infant deaths can be averted by appropriate management of low birth weight babies and prevention of factors associated with low birth weight. The prevalence of low birth weight babies in Nepal is estimated to be about 12-32%.Our study aimed at identifying major determinants of low birth weight among term babies in Nepal. A hospital-based retrospective case control study was conducted in maternity ward of Tribhuvan University Teaching Hospital from February to July 2011. A total of 155 LBW babies and 310 controls were included in the study. Mothers admitted to maternity ward during the study period were interviewed, medical records were assessed and anthropometric measurements were done. Risk factors, broadly classified into proximal and distal factors, were assessed for any association with birth of low-birth weight babies. Regression analysis revealed that a history of premature delivery (adjusted odds ratio; aOR5.24, CI 1.05-26.28), hard physical work during pregnancy (aOR1.48, CI 0.97-2.26), younger age of mother (aOR1.98, CI 1.15-3.41), mothers with haemoglobin level less than 11gm/dl (aOR0.51, CI0.24-1.07) and lack of consumption of nutritious food during pregnancy (aOR1.99, CI 1.28-3.10) were significantly associated with the birth of LBW babies. These factors should be addressed with appropriate measures so as to decrease the prevalence of low birth weight among term babies in Nepal.