Protocolised inpatient care of diabetes mellitus.

BACKGROUND: The prevalence of hyperglycaemia in patients with diabetes mellitus at admission is high. Prevention and treatment is important to prevent further clinical complications. We have conducted a study evaluating implementation of a new protocol to standardise inpatient care of patients with diabetes mellitus. METHODS: A retrospective study including all glucose measurements of adult patients with diabetes mellitus type 1 o r 2 , admitted to a surgery department, was performed before and after implementation of the new protocol. This protocol included direct consultation of an internist and diabetes specialist nurse at admission, who initiated a daily treatment program and adjustment scheme based on glucose measurements four times a day by the HemoCue201DM glucose point of care device. We compared the prevalence of hyperglycaemia and hypoglycaemia before and after implementation with logistic regression analyses adjusted for age and gender. RESULTS: Overall, 360 patients with diabetes mellitus type 1 or 2 with 5322 glucose measurements were included. The risk of developing hyperglycaemia was significantly reduced after implementation of the protocol (22 patients with 65 hyperglycaemias) compared with before the intervention (70 patients with 417 hyperglycaemias) (RR adjusted 0.24 (95% confidence interval 0.19; 0.32)). Overall, 45 patients experienced 95 episodes of hypoglycaemia, which did not differ significantly between the two groups. CONCLUSION: After implementation of a new protocol to standardise inpatient care of diabetes mellitus we established a decrease in the risk to develop hyperglycaemia of 76% without an increased risk of developing hypoglycaemia. Implementation of this protocol required frequent glucose measurements which are facilitated by point of care glucose measurements.

[Prospective comparison of the flow chart for laboratory investigations for anaemia from the Dutch College of General Practitioners' guideline 'Anaemia' with a self-developed, substantive and logistical alternative flow chart]. / Prospectieve vergelijking van het stroomschema voor laboratoriumonderzoek van anemie uit de NHG-standaard 'Anemie' met een eigen, inhoudelijk en logistiek alternatief stroomschema.

OBJECTIVE: To compare the flow diagram for the diagnosis of anaemia from the guideline 'Anaemia' from the Dutch College of General Practitioners (NHG) with a substantive and logistical alternative protocol. DESIGN: Prospective. METHOD: For evaluation of anaemia, 124 patients from primary care reported to the laboratories of the St. Elisabeth Hospital in Tilburg (n = 94) and the Scheper Hospital in Emmen (n = 30), the Netherlands. Two flow charts were used: the NHG's flow chart and a self-developed chart in which not mean corpuscular volume, but ferritin concentration occupies the central position. All the laboratory tests mentioned in both flow charts were carried out in every patient with, for practical reasons, the exception of Hgb electrophoresis and bone marrow investigations. General practitioners were approached and patient dossiers were consulted to obtain further clinical data. RESULTS: According to the NHG protocol, on the grounds of the laboratory investigations, 64 (52%) of patients could not be put in a specific category. The majority were patients with normocytary anaemia who did not fulfil the criteria for iron deficiency anaemia or the anaemia of chronic disease. According to the alternative chart, in 36 (29%) patients no diagnosis was made. These were patients in whom no abnormal laboratory findings were observed, other than low haemoglobin values. The majority of the patients had normocytary anaemia, in some cases this was interpreted as the anaemia of chronic disease, but more often the anaemia could not be assigned to a particular category. A large number ofpatients had a raised creatinine value. This value did not appear in the NHG protocol. In 15% of patients, more than one cause for anaemia was found. The NHG protocol did not enable these multiple diagnoses to be made. Accordingly, the NHG protocol was difficult to implement in the laboratory. CONCLUSION: Using the NHG flow diagram a large percentage of patients could not be assigned to a particular category. Using the alternative flow diagram, which procedure is easier to carry out in the laboratory, it was possible to make multiple diagnoses.

Procalcitonin as an early marker of infection in neonates and children.

A child or neonate presenting with fever is a common medical problem. To differentiate between those with a severe bacterial infection and those with a localised bacterial or a viral infection can be a challenge. This review provides an overview of neonatal and paediatric studies that assess the use of procalcitonin as an early marker of bacterial infection. Procalcitonin is an excellent marker for severe, invasive bacterial infection in children. However, the use of procalcitonin in the diagnosis of neonatal bacterial infection is complicated, but if correctly used procalcitonin results in a higher specificity than C-reactive protein. In addition, procalcitonin has been shown to correlate with severity of disease (urinary tract infections and sepsis), and can therefore be used as a prognostic marker. Procalcitonin is therefore a useful additional tool for the diagnosis of bacterial disease in neonates and children.

Measurement of pyruvate in blood by high-performance liquid chromatography with fluorescence detection.

Accurate measurement of pyruvate is particularly important in the detection of mitochondrial enzyme disorders. describe a simple high-performance liquid chromatography assay for pyruvate with derivatization and fluorescence detection. Between-run variation is below 4.5% and the method is linear between I and 1,200 micromol/L. The mean recovery is 101%. After sample pretreatment, the calculated pyruvate concentration proved to be stable for 15 days when samples were kept at -20 degrees C.

Graphical non-linear representation of multi-dimensional laboratory measurements in their clinical context.

A polygon-based graphical representation of laboratory test results using nonlinear scaling is described. It is argued that the nonlinearity of the scale and the use of colors in the representation facilitates interpretation of the test result in its relationship to the standard reference range and critical clinical decision levels. Preliminary results suggest that this representation may be fruitfully used to enhance the efficiency of the information transfer from the clinical chemistry laboratory to clinicians. Other applications, inside as well as outside the medical field, may easily be imagined.

A multi-dimensional analysis of three chemical quantities in the blood.

A three-dimensional model for the analysis of the three quantities pH, pCO2 and base excess (BE), as measured in arterial blood, is presented. Whereas the conventional analysis of these quantities relies on reference regions as established from the univariate distributions, treating the quantities as uncorrelated, the present model estimates the parameters of the three-dimensional reference region from a sample of observations, based on the assumption that the observations inside the reference region follow a multi-dimensional Gaussian distribution. For observations outside the reference region, reference directions are established, corresponding to the conventionally defined specific states of acid-base disturbances. This leads to a new classification model, the results of which are compared to those of the conventional model.

Multicentre comparison of the Novo Biolabs immunometric CK-MB assay with four established methods.

The analytical performance of a new immunometric CK-MB assay from Novo Biolabs was evaluated in three hospitals. Comparisons were made with another immunometric assay, an immune inhibition/precipitation technique, an immune inhibition method, and a column separation method. The Novo assay exhibited good precision (CV 3-7%) at all concentration levels tested (6-150 micrograms/L) and was found to be linear over the range 0-200 micrograms/L. Comparison of the Novo kit with the other methods using patients' sera showed acceptable correlation between the methods over a wide concentration range (r = 0.96-0.99). We conclude that the assay is a useful adjunct to the specific measurement of CK-MB, particularly in routine laboratories with a high throughput of such determinations.

Detection of aberrant observations in a background of an unknown multidimensional Gaussian distribution.

An exploratory iterative technique for the detection of aberrant observations on a background of a multidimensional Gaussian distribution is described. Its development was motivated by the analysis of a set of three measurements reflecting the acid-base metabolism in the blood of 2,402 intensive care patients. This new, three-dimensional treatment of such data yields a meaningful description. A technical evaluation of the method, using artificially generated data is also presented. It is shown that the model parameters of the underlying Gaussian distributions are determined with good accuracy and that the accuracy with which the contamination is estimated increases with increasing distance of the contaminating observations from the mean.

Pseudohyperkalaemia in thrombocythaemia.

Pseudohyperkalaemia in thrombocythaemia, in its primary form or associated with polycythaemia vera, can occur with platelet counts in excess of 600 X 10(9)/l, and it is not related to high leukocyte or thrombocyte counts. An increment of 0.15 mmol/l serum potassium was found for every 100 X 10(9)/l rise in platelet count with a correlation coefficient of 0.82. Potassium from platelets is not released during the aggregation phase but during the degranulation phase of the coagulation process.

Serum water determination by means of microwave evaporation.

A novel method is described for the determination of serum water using a microwave oven. The sources of experimental errors were analysed. Serum samples from two hundred patients were analysed for sodium, water and protein, and the data were used to calculate serum sodium molalities. A possible correlation was investigated between serum water content and protein concentration. The results were compared with those in the literature.

Renal stone analysis: LITHOS, an expert system for evaluation of X-ray diffractograms of urinary calculi.

An expert system for evaluation of X-ray diffraction patterns of urinary calculi is described and evaluated. The software was developed using the PERSONAL CONSULTANT expert system shell from Texas Instruments.

Alkaline phosphatase and cholestasis.

The process of cholestasis in both man and rat leads in the majority of cases to the appearance of a biliary band in the electrophoresis of alkaline phosphatase isoenzymes. In this article, the biochemical nature and mode of formation of the biliary band is discussed, with reference to its appearance in cholestasis and other hepatobiliary diseases.

Hydrophobic properties of alkaline phosphatases.

The butanol extraction method of Morton (1950), a routine step in enzyme purification, is discussed with special reference to a hydrophobic form of alkaline phosphatase from human liver tissue. This form slowly precipitates from butanol-extracted liver tissue homogenates stored at 4 degrees C. Furthermore, it is lost when acetone precipitation is applied as a purification procedure. The soluble form in liver tissue is shown to have a higher relative hydrophobicity than the serum liver/bone isoenzyme. The use of sodium cholate in the isolation of the hydrophobic form produces an artefact in isoelectric focusing, which can be abolished by dialysis prior to focusing.

Isoelectric focusing of alkaline phosphatases in agarose gel.

An isoelectric focusing technique in agarose gel is presented which is suitable for alkaline phosphatases from both serum and tissue sources. An anomaly in the literature about isoelectric focusing of serum alkaline phosphatase from liver origin is discussed and a possible explanation is proposed. The presented technique is used to demonstrate some differences in behaviour of serum liver and bone isoenzymes towards neuraminidase treatment.