Inappropriate repeat testing of complete blood count (CBC) and electrolyte panels in inpatients from Alberta,Canada

IntroductionThe avoidance of repeat chemistry testing such as Complete Blood Count (CBC) and Electrolyte Panel (EP) on clinically stable patients was identified as important utilization goals by Choosing Wisely Canada. The purpose of this study was to assess the volume of overutilization of CBC and EP in an inpatient setting in Alberta, Canada, and provide an estimated cost assessment of unnecessary testing.MethodsThe total laboratory testing volumes of two common test panels were collected retrospectively for one-year from January to December 2018. Data was collected on test panels performed in an emergency room (ER) and inpatient setting from three separate Laboratory Information Systems covering the provincial population in Alberta, Canada. Total initial test panel instances, total repeated panels, repeated panels that were previously normal or abnormal, and estimated costs were examined. Cost assessment was completed based on Reference Median Cost (RMC) analysis for each of these two common test panels.ResultsDuring the study period, 2,020,467 (CBC) and 1,455,983 (EP) initial test panel instances were recorded, of which 67.7% and 73.5% were repeated for the CBC and EP, respectively. There was a higher proportion of EP repeated inappropriately (previously normal; 35.6%) compared to CBCs (5.4%). The cost to the province for inappropriately repeating CBC and EP were estimated to be RMC $0.52 million and RMC $1.90 million CAD, respectively.ConclusionResults from this study can assist policy makers in implementing utilization management initiatives and update clinical practice guidelines to reduce costs to healthcare without compromising patient care.     

Understated Cognitive Impairment Assessed with the Clock-Drawing Test in Community-Dwelling Individuals Aged ≥50 Years

ObjectivesTo estimate the prevalence of understated cognitive impairment by administering the Clock-Drawing Test (CDT) to community-dwelling individuals aged ≥50 years and to investigate the associated clinical phenotype.DesignA cross-sectional analysis of baseline data on community-dwelling individuals assessed at an outpatient clinic in the Paris region of France.Setting and ParticipantsParticipants aged ≥50 years (n = 488, median age: 62.1 years) prospectively included in the SUCCessful agEing outpatiEnt's Department survey between 2010 and 2014.MethodsA multidimensional geriatric assessment, including cognition [7-point CDT, Mini-Mental State Examination (MMSE), the 5-word screening test (5-WT), and the Frontal Assessment Battery (FAB)], gait speed in dual tasks, mood [the Geriatric Depression Scale (GDS)], balance, physical functions (gait speed and handgrip strength), nutrition, bone density, and comorbidities; major cardiovascular risk factors, and Scheltens and Fazekas scores on brain magnetic resonance imaging. Baseline characteristics were analyzed as a function of the CDT score (<7 vs 7), using age-adjusted logistic models.ResultsThe prevalence of impairment in the CDT was 23.6%; higher than the values for the MMSE (12.7%), 5-WT (2.3%), and FAB (16.6%). In age-adjusted analyses, a lower educational level (odds ratio [95% confidence interval] = 0.72 [0.58‒0.89]), diabetes (2.57 [1.14‒5.79]), metabolic syndrome (1.93 [1.05‒3.56]), lower gait speed in the cognitive dual task (1.27 [1.05‒1.53]), a poorer Geriatric Depression Scale score (1.86 [1.04‒3.32]), a poorer MMSE score (2.56 [1.35‒4.88]), a poorer FAB score (1.79 [1.01‒3.16]), impaired episodic memory in the 5-WT (4.11 [1.12‒15.02]), and a higher Scheltens score (P = .001) were significantly associated with CDT impairment.Conclusions and ImplicationsUnderstated cognitive impairment is common among young seniors and is associated with factors known to be linked to a higher risk of cognitive decline and dementia. These findings suggest that the CDT may be of value for identifying high-risk individuals who may then benefit from targeted multidomain prevention actions (diet, exercise, cognitive training, and vascular risk factor management).     

Probabilistic cost-utility analysis and expected value of perfect information for the Oncotype multigenic test: a discrete event simulation model

ObjectiveTo carry out a cost-utility analysis of the application of the Oncotype genomic test to inform the decision to use or not to use chemotherapy in the Basque Country (Spain).MethodThe cost-utility study was carried out using a discrete event simulation model representing the natural history of breast cancer. The decision of treatment with chemotherapy based on Oncotype was compared with the standard of treatment based on clinical-pathological criteria. The model included clinical data from Basque hospitals and the literature and was processed by deterministic and probabilistic analysis to calculate the incremental cost-effectiveness ratio (ICER), the cost-effectiveness plane, the acceptability curve and the expected value of perfect information. The study adopted both a health and societal perspective.ResultsFrom a health perspective, the deterministic analysis estimated an ICER for Oncotype of 17,453 euros/quality-adjusted life year (QALY), discount included, and 9,613 euros/QALY without the discount. Eighty five percent (85%) of the simulations were below the efficiency threshold for Spain. The parametric variability associated with the Oncotype results was the main uncertainty factor in the decision.ConclusionsOncotype is a cost-effective intervention from a health system perspective since each QALY gained costs less than 25,000 euros. From a societal perspective, it is dominant since it provides greater health and is accompanied by cost savings.     

Quality assurance at the point-of-care: Noninvasively detecting vaccine freezing variability using water proton NMR

Aluminum-adjuvanted vaccines are freeze-sensitive products that require attentive cold chain adherence. Freeze/thaw events can be tested using “The World Health Organization Shake Test”, a qualitative test whereby a vial from the batch suspected to have been frozen is checked to infer whether the whole batch has been frozen. In this paper, we present a noninvasive and quantitative method to detect whether a vial of liquid vaccine has experienced freeze/thaw using the water proton transverse relaxation rate by Nuclear Magnetic Resonance relaxometry (wNMR relaxometry). Importantly, wNMR relaxometry does not compromise the vial’s integrity so the analyzed vial can be used for vaccination if it meets the quality specifications. Vial-to-vial variability in freezing susceptibility within a single carton of vaccine vials was also detected, both by visual observation and concurrently by wNMR relaxometry. This variability brings into question the practice of using one or a few vials in a batch of vaccines to infer about the quality of the whole batch.     

Exploring Effective Contextual Factors for Regular Cervical Cancer Screening in Iranian Women: A Qualitative Study

Background: Adherence to regular screening programs for cervical cancer in Iranian women is not common.The aim of this study was to explore contextual factors influencing behavior and compliance with guidelines.Methods: This qualitative content analysis study was conducted in 2016-2017 in Hamadan city, Iran. Semi-structuredin-depth interviews were conducted with 31 participants who were selected purposefully on referring to health centers.Twenty-three were women with various experiences of cervical cancer screening and 8 were health care providers(4 midwives, 1 gynecologist, 1 general practitioner and 1 family health expert). Guba and Lincoln criteria were usedfor tustworthiness. MAXQDA10 software was employed for data analysis. Results: Four themes were extracted fromthe data: an opportunity maker system, opportunities to become acquainted, concerns for healthy living, and perceptionof cancer. Conclusion: The results showed sensitivity of health care providers and their appropriate performancein relation to regular screening behavior of women is very important. Women’s perception of cancer and its curabilityis another factor with a major effect on screening behavior. Opportunities for people to become acquainted with thePap smear in a variety of ways and concern for healthy living and the need to have a healthy life to ensure qualityof life were also found to be important.     

Postprandial hyperinsulinaemia, insulin resistance and inappropriately high phosphaturia are features of younger males with idiopathic calcium urolithiasis: Attenuation by ascorbic acid supplementation of a test meal

In idiopathic recurrent calcium urolithiasis (RCU) the state of insulin and carbohydrate metabolism, and relationships to minerals such as phosphate, are insufficiently understood. Therefore, in two groups of males with RCU (n = 30) and healthy controls (n = 8) the response to an oral carbohydrate- and calcium-rich test meal was studied with respect to glucose, insulin, and C-peptide in peripheral venous blood (taken before and up to 180 min post-load), and phosphate and glucose in fasting and post-load urine. In one RCU group (n = 16) the meal was supplemented with ascorbic acid (ASC; 5 mg/kg body weight). The mean age (RCU 29, RCU + ASC 30, controls 27 years) and mean body mass index [RCU 24.4, RCU + ASC 25.0, controls 24.0 kg/m²] were similar. Insulin resistance (synonymous sensitivity of peripheral organs to insulin) was calculated from insulin serum concentration, as was also integrated insulin, C-peptide, and glucose. Untreated stone patients (RCU) developed hyperinsulinaemia between 60 and 120 min post-load, increased integrated insulin, and insulin resistance (P 0.05 vs controls)., whereas the rise of C-peptide and glycaemia (absolute and integrated values) was only of borderline significance. Fasting phosphaturia was low in both RCU subgroups vs controls; however, phosphaturia in untreated RCU rose in response to the meal, contrasting sharply with a decrease in controls. ASC supplementation of the meal (in the RCU + ASC subgroup) normalized insulin, failed to normalize postload phosphaturia, but reduced post-load glucosuria and urinary pH significantly (mean pH values 5.55 vs 5.93 in untreated RCU, controls 5.50). Postprandial urinary oxalate, calcium, protein, and supersaturation products were not changed. The postprandial changes in phosphaturia and insulin sensitivity were inversely correlated (n = 38,r = -0.44,P = 0.007). It was concluded that in younger RCU males: (1) postprandial hyperinsulinaemia, the failure to reduce phosphaturia and —within limits — glucosuria, appropriately, as well as poor urine acidification are important features of the metabolism; (2) these phenomena are probably caused by insulin resistance of organs, the kidney included; and (3) the addition of a supraphysiological dose of ASC to a meal, the subsequent abolition of hyperinsulinaemia, and the restoration of normal urine acidification suggest that this antioxidant is capable of counteracting some preexisting basic abnormality of cell metabolism in RCU.     

Susceptibility of Entamoeba histolytica to oxygen intermediates

To explore the susceptibility of the extracellular protozoan, Entamoeba histolytica, to toxic oxygen intermediates, trophozoites were exposed to fluxes of O₂^?, H₂O₂, and OH · generated enzymatically by the glucose oxidase and xanthine oxidase reactions. HM-1 trophozoites were resistant to O₂^?, but were readily killed by H₂O₂ alone. OH · and ¹O₂ were not required for effective amebicidal activity. The addition of a peroxidase and halide enhanced trophozoite killing by H₂O₂. Sonicates of amebae contained virtually no catalase and little glutathione peroxidase activity which may contribute to susceptibility to H₂O₂. Coupled with our previous studies with Toxoplasma gondii and Leishmania spp. these observations indicate that there is a broad spectrum of susceptibility of intra- and extracellular pathogenic protozoa to killing by oxygen intermediates.