Review of labs and … some - PowerPoint Presentation

1. Review of labs and … someTESTS I WISH YOU’D NEVER ORDEREDChristopher Fink, DODuke Primary Care Medical Director for Clinical Laboratory PracticeAssistant Professor of Medicine, Duke University School of Medicine

2. Labs that should not be collected outside main labAmmoniaSemen analysisIonized CalciumGenetic Testing( patients should be referred to Genetic clinic $$$)(depending on the clinic)blood culturesBlood film- Special HemeSputum/Bronchial samplesBlood GasesStool samples – Can be brought into the lab but not collected in house (preferably)

3. HEPATITIS CGoal is to screen all Americans and treat now that cure with treatment is near 100%. If we can screen and treat we will be able to mostly eradicate this disease in the US. **Hep C Antibody with Reflex to PCR LAB9369

4. Metabolic Panels2 types: BMP and CMPWhen to order each? Make sure you have a reason for the lab you order.BMP: Na, K, CO2,CL, BUN/Cr, Ca, GlucoseCMP: The above and Bilirubin, AST, ALT, ALK Phosphorus, Albumin and Total Protein.

5. STD Screening recommendations from UptoDate

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8. Point of Care – A1c (why is it off?)Not uncommon to get erroneous results. (Should not happen but does)Why? Usually due to sampling error. Need to make sure cleansing of the finger is done with alcohol swab. Do not wipe away. AFTER dry use the lancet and collect the sample. If needed repeat sample or send in a lab draw. If still looks erroneous please place and ERS and let us know.MAKE SURE THAT PATIENTS ALWAYS HAVE A BANDAID PLACED AFTER ANY NEEDLE STICKS. WHETHER THEY WANT IT OR NOT. WE DON’T LIKE BLOOD ON THE DOOR HANDLES OR FURNITURE!

9. Urine Culture and mixed floraSteps to decrease Mixed Flora1. Provider education 2.Patient instructions Verbal and in Print3.Educators looked instructions over and adapt the language to a 5th grade level. Provide instructions in Spanish. 4.Now working on poster/cartoon instructions.5.Draw off Ucx first on all UAs, even if not ordered. Ideally within 15 minutes of urine dropping6.Observe processes

10. When should we not order a Urine Culture?Healthy non pregnant young women with typical of non-febrile cystitis who have no risk factors of resistant infection.When the UA shows no nitrites, blood or leukocytes (unless <2yo)AND DUH!! When the patient doesn’t have any symptoms!!!Always remember, bacteriuria does not indicate a need for antibiotics in an asymptomatic patient.

11. D Dimer and PED-dimer is a degradation product of cross-linked fibrin. It is elevated in nearly all patients with an acute DVT (very sensitive)…BUT very nonspecific since elevated levels are found in other conditions (malignancy, sepsis, recent surgery, trauma, pregnancy, renal failure)

12. OVER-use of D-dimerUnnecessary cost of D-Dimer testUnnecessary delays in investigation, management or dispositionUnnecessary further imagingRadiation exposureContrast nephropathyUNDER-use of D-dimerUnnecessary further imaging (if negative D-dimer would have precluded further investigation)Radiation exposure Contrast nephropathyMissed diag of VTE resulting in morbidity and mortality

13. PERC (Pulmonary Embolism Rule Out Criteria)The Eight-factor PERC rule was developed in 2004.A clinical decision rule that gives a 99% clinical probability of no PE, allowing the physician to avoid workup (e.g., D-dimer test, CT). The PERC rule has better sensitivity than the Wells Criteria for ruling out PE.

14. PERC (Pulmonary Embolism Rule Out Criteria)Is the patient > 49Is the pulse rate > 99 bpmIs pulse ox <95% on room air? Does the patient have current hemoptysis?Is the patient taking exogenous estrogen?Does the patient have a history of venous thromboembolism?Has the patient had surgery or trauma requiring hospitalization in the last 4 weeks?Does the patient have unilateral leg swelling?IF ALL NEGATIVE THEN NO D-DIMER AND NO CT

15. Wells Criteria/Modified Wells CriteriaWells was developed to decide if a patient was low, moderate or high probability of PE.Modified Wells further delineates as either PE likely or unlikely.

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19. FIT testingThis test reacts to a protein component of human hemoglobin (globin); guaiac tests are less sensitive as they react to the heme portion.No dietary or medication restrictions. Keep taking ASA, Direct oral anticoagulants (DOACs),warfarinDo not collect sample 3 days before, during or 3 days after menstruation. Do not collect while you have bleeding hemorrhoids, blood in your urine or cuts on your hands/fingers. Do not collect if you have strained during a BMThese are home kits. Should not be done in the officeSample stability is listed as 14 days. Quicker is better. Samples degrade faster in heat. Do not mail if > 86 degrees. And don’t leave in car.

20. FIT cost effectivenessVery cost effective for colon cancer screeningMarkov model found FIT or Colonoscopy to be more effective and less costly than Multitarget stool DNA (1) aka CologuardNon invasive strategies (FOBT,FIT) tended to be cost saving and outperform invasive strategies (colonoscopy/sigmoidoscopy) for both Medicare and Private Insurance.No large head to head trialsCologuard false positive 10% due to the fact that DNA normally undergoes methylation as we age. (insurance may or may not pay for Cologuard)1. (Ladabaum U, MannalitharaA. Comparative Effectiveness and Cost Effectiveness of a Multitarget Stool DNA Test to Screen for Colorectal Neoplasia. Gastroenterology. 2016 Sep; 151(3):427-439 e6.)

21. Colorectal Cancer Screening for the Average-Risk Adults: 2018 Guideline Update From the American Cancer Society, they have a figure that shows that mt-sDNA only save 93% of the lives that FIT saves.

22. Who should you not offer FIT to?Those with genetic predisposition for colon cancers (FAP, HPNCC)Those who have inflammatory bowel disease (UC, Crohn’s)Those with a personal history of colon cancers, serrated polyps, or high risk adenomasThose with a first degree relative with colon cancer

23. H pylori testingH.pylori is a Gram neg that causes chronic inflammation in the stomach associated with: Peptic Ulcers Chronic Gastritis Gastric Cancer Gastric Mucosa Associated Lymphoid Tissue (MALT) lymphoma (Crowe, 2018)

24. 45 yo F comes in with gradual onset dyspepsia. You want to order an H. pylori test. Which one do you order?A. H. pylori breath testB. H. pylori stool antigenC. H. pylori serologyD. Tell them to suck it up and stop drinking coffee and alcohol!

25. A. Urease Breath test (Was around $450-500)-Sensitivity high as 97%, Specificity high as 100%. -pts should be off of PPIs, bismuth, abxs x2wk.-pts off H2 blockers x 2 days-not accurate with bleeding peptic ulcer-NPO for 1 hr (breath into bag, drink a liquid and wait 15 min then breath into 2nd bag)-approved for pediatrics down to age 3yo. (but need to do calculations. See Website)-Often considered Gold Standard! But not right now!

26. B. Stool Antigen (Was around $100-120)-sensitivity of 0.94 and specificity of 0.97-immunoassay that detects antigens in stool-Pts to be off abxs for 4 wks and PPIs for 1-2 wks.-Not accurate with a bleeding peptic ulcer

27. C. Serology (was around $90)-sensitivity of 0.85 and Specificity of 0.79 for the test at the Core Lab-Sensitivity of 0.50 and Specificity of 0.79 for in office monoclonal test.-Serology does not distinguish between active and past infection. IgG: once positive, always positive.

28. Answer: H. Pylori stool Antigen.If COVID wasn’t here we could also use the breath test. (right answer if you are stuck in 2019.)

29. Do you need to follow up test for H.Pylori?A. No the abxs should take care of thingsB. Re-test with the breath test or stool antigen the day after finishing abxs.C. Re-test with serology 4-6 wks laterD. Re-test with the breath test or stool antigen 4-6 wks later

30. Re-testing H.pyloriApproximately 20% failure rate of treatment.Should retest at least 4 wks after treatment.If Positive then need to treat with second line of therapy. (See uptodate – this is another lecture)

31. H.Pylori in pediatricsShould be diagnosed by biopsy. But breath test or stool antigen may be used for confirmation of eradication.

32. Well Child LabsUnless you have a specific reason, do not order:UA – false positive rate is 84%. Choosing Wisely Campaign, “With consideration of the currently available evidence, we recommend limiting screening UA in patients who are at high risk for chronic kidney disease (CKD), including but not necessarily limited to patients with a personal history of CKD, acute kidney injury (AKI), congenital anomalies of the urinary tract, acute nephritis, hypertension (HTN), active systemic disease, prematurity, intrauterine growth retardation, or a family history of genetic renal disease, to improve the cost-benefit ratio

33. Well Child LabsYou should orderLead: 12 mo, 24 mo“All children enrolled in Medicaid, regardless of whether coverage is funded through title XIX or XXI, are required to receive blood lead screening tests at ages 12 months and 24 months. In addition, any child between 24 and 72 months with no record of a previous blood lead screening test must receive one. Completion of a risk assessment questionnaire does not meet the Medicaid requirement. The Medicaid requirement is met only when the two blood lead screening tests identified above (or a catch-up blood lead screening test) are conducted.” -Medicaid.gov accessed 8/30/19

34. Well Child LabsYou should orderPOC Hgb: Iron deficiency is the most common nutritional deficiency and is seen most frequently in young children and pregnant womenThe Centers for Disease Control and Prevention recommends screening for iron deficiency anemia at 9 to 12 months of age, again at 15 to 18 months, and then yearly until 5 years of age.Likewise, the Institute of Medicine recommends screening infants at 9 months of age who are breastfed or not receiving iron-fortified formula.Medicaid requires screening at 12 mo and risk assessment at other wccsUSPSTF Recommendation Statement concludes that “the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in children ages 6–24 months.”

35. Well Child LabsYou should orderPOC Hgb ifAdolescent Males: Screen only those with known risk factors (e.g., low iron intake, special health care needs, previous diagnosis of iron-deficiency anemia).Adolescent Females: Screen annually those with known risk factors (e.g., extensive menstrual or other blood loss, low iron intake, a previous diagnosis of iron-deficiency anemia). Screen every 5 to 10 years during routine health examinations.

36. Well Child LabsYou should orderChlamydia females: We suggest chlamydia screening for all sexually active women <25 years and sexually active women ≥25 years with risk factors (eg, a history of prior chlamydial or other sexually transmitted infection, new or multiple sex partners, sex partner with concurrent partners, sex partner with a sexually transmitted infection, or exchanging sex for drugs or money). Chlamydia males: high-risk populations (men attending clinics for sexually transmitted infections, men who have sex with men or men in correctional facilities).

37. Well Child LabsYou should orderHIV: The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Grade A

38. Labs for physicals, >18 yoUnless you have a specific reason, Do not order a UADo not order a CBCDo not order a BMP, CMP

39. Labs for physicals, >18 yoScreen for HIV at least onceScreen for Hep C at least onceChlamdyia and Gonorrhea if sexually active for females age 24 and younger and in older women at risk for infection(grade B)

40. Labs for physicals, >18 yoScreening glucose (not A1c): Adults 40 to 70 years of age who are overweight or obese, and repeating testing every three years if results are normal. Individuals at higher risk should be considered for earlier and more frequent screening. The American Diabetes Association recommends screening for type 2 diabetes annually in patients 45 years and older, or in patients younger than 45 years with major risk factors. *USPTF is revising their statement

41. Labs for physicals, >18 yoScreening lipids: Screening men: The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men 35 years and older for lipid disorders. A recommendation.The USPSTF recommends screening men 20 to 35 years of age for lipid disorders if they are at increased risk of coronary heart disease (CHD). B recommendation.Screening women at increased risk: The USPSTF strongly recommends screening women 45 years and older for lipid disorders if they are at increased risk of CHD. A recommendation.The USPSTF recommends screening women 20 to 45 years of age for lipid disorders if they are at increased risk of CHD. B recommendation.Screening young men and all women not at increased risk: The USPSTF makes no recommendation for or against routine screening for lipid disorders in men 20 to 35 years of age, or in women 20 years and older who are not at increased risk of CHD. C recommendation.

42. COVID, FLU, RSV and Strep. Using IDNOW

43. COVID, FLU, RSV and Strep. Using IDNOWMost will be done through drive through clinic.If done in clinic the COVID, FLU and RSV need to be collected on nasopharyngeal swap. STREP is a throat swab.STREP sensitivity is so good that you will not need to collect a throat culture.Each test will need to be run separately.FLU and RSV can be done off the same swab (but run separately)COVID needs a dedicated swab.

44. COVID IDNOW 85-90% sensitive. (Lab RT-PCR 90-95% sensitive)Time for Negative test around 15 min. Positive test comes back sooner

45. FLU/RSV IDNOW70-90% Sensitivity (Lab RT-PCR 93-99%)Time to negative 15 min or lessMany patients tested for COVID do not need FLU/RSVLimit testing to periods of local activity and symptomatic patients with ≥1of the followingNew moderate to severe resp symptomsHigh risk for influenza complications and/or RSV severe diseaseNeeding specific antiviral treatmentHigh risk family memberFront-line healthcare workers/essential workers and their children when flu testing impacts ability to return to work/school/childcare.

46. Point of Care / rapid assay Use only when < 2hr result is required for patient management

47. Extended Respiratory PanelRestricted to specific scenarios and high-risk patients (ED/inpatients)Does NOT detect SARS-CoV-2 Can be done on same sample used for SARS-CoV-2 PCR