Joseph Rudolf

Cholesterol, Lipoproteins, High-sensitivity C-reactive Protein, and Other Risk Factors for Atherosclerosis

Coronary heart disease is a common and costly epidemic in the Western world. Intensive study has led to a deeper understanding of the pathogenesis of coronary disease and risk stratification. Traditional risk factor assessment has focused on parameters derived from the Framingham Heart Study (age, hypertension, cholesterol, family history, and cigarette smoking). New emerging risk factors, both biological and genetic, are reshaping the understanding of heart disease and the approach to risk stratification. As these emerging assays become more standardized, automated, and inexpensive to perform, they are becoming increasingly important tools in the assessment and treatment of coronary heart disease.

Total and ionized magnesium testing in the surgical intensive care unit – Opportunities for improved laboratory and pharmacy utilization

Purpose: Ionized fraction (iMg) is the physiologically active form of magnesium (Mg); total Mg may not accurately reflect iMg status. Erroneously “low” Mg levels may result in unnecessary repetitive testing. Materials and methods: From 11/2015 to 01/2016, patients ordered for Mg from a pilot ICU also had iMg tested. Weighted kappa statistic was used to assess agreement between Mg categories (low, normal, high). Predictors of unnecessary repeated Mg testing and repletion using data were explored through logistic regression models using GEE techniques to account for repeated measurements in both bivariate and multivariable analyses. Results: There were 470 Mg/iMg paired measurements from 173 patients. The weighted kappa statistic was 0.35 (95%CI 0.27–0.43) indicating poor agreement in assessment of magnesium status. Of the 34 Mg samples reported as “low”, only 6 (18%) were considered “low” using concurrent iMg testing. In the multivariable models, history of atrial fibrillation (aOR = 1.61, 95%CI 1.16–2.21, p = 0.004) and concomitant metoclopramide (aOR = 1.71, 95%CI 1.03–2.81, p = 0.036) were significant predictors of unnecessary repeat Mg testing. Conclusions: In the surgical ICU, categorical agreement (low, normal, high) was poor between Mg and iMg. Over 80% of “low” total Mg values are erroneous and may result in unnecessary additional measurements and repletion. HighlightsCategory agreement between total Mg and ionized Mg (iMg) is poor.Only 18% of “low” total Mg values are actually low on iMg measurement.Atrial fibrillation and concomitant metoclopramide predict unnecessary Mg testing.

Evaluation of the i-STAT point-of-care capillary whole blood hematocrit and hemoglobin: Comparison to the Siemens RAPIDLab 1200, Sysmex XE5000, and manual spun hematocrit

BACKGROUND Conductivity based point-of-care hematocrit with calculated hemoglobin devices serves an important role in clinical scenarios where time sensitive transfusion decisions are necessary. However, questions about the appropriateness of conductivity based assays in certain patient populations (patients on cardiopulmonary bypass and those receiving high volumes of intravenous fluids or autologous blood transfusions) have been raised. The clinical suitability of POC devices for these applications necessitates that they be accurate and that the results are interchangeable with central laboratory methods. METHODS We performed hematocrit and hemoglobin analysis on 225 clinical samples using the i-STAT instrument, a standard reference method for hematocrit (manual spun) and other common methods on both cardiopulmonary bypass and non-cardiopulmonary bypass patients. RESULTS The i-STAT hematocrit and hemoglobin showed close agreement to comparison methods with minimal bias. Median test results were not clinically or statistically different between those measured on the i-STAT and those measured using the manual spun hematocrit reference method (p=0.4085, Wilcoxon signed rank test) or the Sysmex photometric hemoglobin method (p=0.2728, Wilcoxon signed rank test). The results on the i-STAT were statistically different from those obtained on the Sysmex for hematocrit (p<0.0001) and the Siemens RAPIDLab co-oximeter for hemoglobin (p<0.0001). CONCLUSION The i-STAT hematocrit and hemoglobin performs well when compared to the hematocrit reference method and other common methods for both hematocrit and hemoglobin. Some differences between non-reference methods may be observed, but these were not considered clinically significant.

ST2 Predicts Mortality and Length of Stay in a Critically Ill Noncardiac Intensive Care Unit Population.

OBJECTIVES The biomarker suppression of tumorigenicity 2 (ST2) is a well-established clinical biomarker of cardiac strain and is frequently elevated in a variety of cardiac conditions. Here, we sought to evaluate the prognostic value of ST2 in critically ill medical intensive care unit (MICU) patients without primary cardiac illness. METHODS We measured ST2 and high-sensitivity troponin T (hsTnT) on plasma specimens collected on 441 patients following admission to a noncardiac MICU and evaluated the prognostic power of ST2 both alone and in multivariate models. RESULTS Of these critically ill patients, 96% exhibited ST2 concentrations above the reference interval. ST2 concentrations were highly predictive of intensive care unit and hospital length of stay, as well as in-hospital mortality, with high concentrations predicting a poor prognosis. Rates of in-hospital mortality were more than four times higher in patients with ST2 concentrations in the highest compared with the lowest quartile. In multivariate analysis, ST2 remained an important predictor of death after adjustment for age, hsTnT, and common diagnoses. CONCLUSIONS ST2 is increased and predictive of prognosis in critically ill patients without primary cardiac disease, suggesting that critically ill patients may often have unrecognized cardiac injury. Clinical decision support algorithms incorporating ST2 and hsTnT results may be useful in patient risk stratification.

Career paths of pathology informatics fellowship alumni

Background: The alumni of todays Pathology Informatics and Clinical Informatics fellowships fill diverse roles in academia, large health systems, and industry. The evolving training tracks and curriculum of Pathology Informatics fellowships have been well documented. However, less attention has been given to the posttraining experiences of graduates from informatics training programs. Here, we examine the career paths of subspecialty fellowship-trained pathology informaticians. Methods: Alumni from four Pathology Informatics fellowship training programs were contacted for their voluntary participation in the study. We analyzed various components of training, and the subsequent career paths of Pathology Informatics fellowship alumni using data extracted from alumni provided curriculum vitae. Results: Twenty-three out of twenty-seven alumni contacted contributed to the study. A majority had completed undergraduate study in science, technology, engineering, and math fields and combined track training in anatomic and clinical pathology. Approximately 30% (7/23) completed residency in a program with an in-house Pathology Informatics fellowship. Most completed additional fellowships (15/23) and many also completed advanced degrees (10/23). Common primary posttraining appointments included chief medical informatics officer (3/23), director of Pathology Informatics (10/23), informatics program director (2/23), and various roles in industry (3/23). Many alumni also provide clinical care in addition to their informatics roles (14/23). Pathology Informatics alumni serve on a variety of institutional committees, participate in national informatics organizations, contribute widely to scientific literature, and more than half (13/23) have obtained subspecialty certification in Clinical Informatics to date. Conclusions: Our analysis highlights several interesting phenomena related to the training and career trajectory of Pathology Informatics fellowship alumni. We note the long training track alumni complete in preparation for their careers. We believe flexible training pathways combining informatics and clinical training may help to alleviate the burden. We highlight the importance of in-house Pathology Informatics fellowships in promoting interest in informatics among residents. We also observe the many important leadership roles in academia, large community health systems, and industry available to early career alumni and believe this reflects a strong market for formally trained informaticians. We hope this analysis will be useful as we continue to develop the informatics fellowships to meet the future needs of our trainees and discipline.

Creation and Use of an Electronic Health Record Reporting Database to Improve a Laboratory Test Utilization Program

OBJECTIVES Laboratory-based utilization management programs typically rely primarily on data derived from the laboratory information system to analyze testing volumes for trends and utilization concerns. We wished to examine the ability of an electronic health record (EHR) laboratory orders database to improve a laboratory utilization program. METHODS We obtained a daily file from our EHR containing data related to laboratory test ordering. We then used an automated process to import this file into a database to facilitate self-service queries and analysis. RESULTS The EHR laboratory orders database has proven to be an important addition to our utilization management program. We provide three representative examples of how the EHR laboratory orders database has been used to address common utilization issues. We demonstrate that analysis of EHR laboratory orders data has been able to provide unique insights that cannot be obtained by review of laboratory information system data alone. Further, we provide recommendations on key EHR data fields of importance to laboratory utilization efforts. CONCLUSION We demonstrate that an EHR laboratory orders database may be a useful tool in the monitoring and optimization of laboratory testing. We recommend that health care systems develop and maintain a database of EHR laboratory orders data and integrate this data with their laboratory utilization programs.

Laboratory Testing for Tick-Borne Infections in a Large Northeastern Academic Medical Center

Objectives We evaluated changes in the testing menu, volume, and positivity rates for tick-borne illnesses in a New England medical center over an 11-year time frame. Methods Testing data were obtained by a retrospective review utilizing searchable data from a laboratory information system archive. Results Testing for tick-borne infections (TBI) increased 5.3-fold over an 11-year time period and the number of positive test results increased threefold. Annual rates for Lyme serology positivity varied from 14% to 29% and for western blot confirmation from 26% to 48%. Test volumes and the number of positive results increased for all TBI endemic to our region. Conclusions Our results confirm national trends suggesting increasing rates of TBI and substantially increased testing. This may reflect a greater incidence of TBI in our region and/or increased awareness of these infections.

Development of a Commercial Reference Laboratory Elective Rotation for Residents in Clinical Pathology

Objectives To develop a curriculum for a commercial reference laboratory clinical pathology training elective. Methods A 4-day elective at Quest Diagnostics was developed. The elective included 32 sessions composed of interactive didactic sessions and laboratory tours/demonstrations. Ten residents who attended the elective completed a written evaluation and scored each component of the curriculum. Results Written comments were very positive and demonstrated the goals of the elective were achieved. Laboratory tours and one-on-one sessions with the medical directors were especially well received. Most of the residents stated that the rotation gave them exposure to an area of laboratory medicine that they were not familiar with. Conclusions The elective provided a resident training experience that was highly regarded and exposed residents to an area of laboratory medicine not encountered in most pathology training programs. Our curriculum could serve as a model for establishing a similar elective in other training programs.

Utilization Management in the Routine Hematology Laboratory

The modern hematology laboratory is a highly automated operation, performing a variety of tests including blood and fluid cell counts, routine coagulation tests, and in many cases urinalysis. Despite its automated nature, the hematology laboratory also performs labor-intensive testing including microscopic review of blood and urine samples. Effective utilization management in the hematology laboratory involves initiatives to improve appropriate test ordering (reducing routine daily orders, discouraging preoperative orders in healthy patients, banning obsolete tests) and within laboratory strategies to reduce the volume of manual testing (validated instrument flagging rules). There are also new automated morphological technologies that are improving hematology workflow and efficiency. Successful implantation of these initiatives and technologies involves collaboration with clinicians on the test menu, physician education, and the implementation of decision support tools.

Analysis of Daily Laboratory Orders at a Large Urban Academic Center

Objectives We sought to address concerns regarding recurring inpatient laboratory test order practices (daily laboratory tests) through a multifaceted approach to changing ordering patterns. Methods We engaged in an interdepartmental collaboration to foster mindful test ordering through clinical policy creation, electronic clinical decision support, and continuous auditing and feedback. Results Annualized daily order volumes decreased from approximately 25,000 to 10,000 during a 33-month postintervention review. This represented a significant change from preintervention order volumes (95% confidence interval, 0.61-0.64; P < 10-16). Total inpatient test volumes were not affected. Conclusions Durable changes to inpatient order practices can be achieved through a collaborative approach to utilization management that includes shared responsibility for establishing clinical guidelines and electronic decision support. Our experience suggests auditing and continued feedback are additional crucial components to changing ordering behavior. Curtailing daily orders alone may not be a sufficient strategy to reduce in-laboratory costs.