Characterization of add-on testing before and after automation at a core laboratory.

Objectives: Add-on testing refers to the process that occurs in clinical laboratories when clinicians request that additional tests be performed on a previously analysed specimen. This is a common but inefficient procedure, highly time-consuming, especially at core laboratories and could be optimised by automating these procedures. The aims of this study are: 1) To describe patterns of add-on testing at a core laboratory at a tertiary hospital, 2) To evaluate turnaround time (TAT) before and after automation of the pre-, post- and analytical phases. Methods: Retrospective, observational study conducted at the biochemistry area of a core laboratory of all add-on orders received in two different months (pre-automation and post-automation). Results: A total of 2464 add-on orders were analysed, representing around 5 % of total requests. Most orders were for either one (>50 %) or two (≈20 %) tests. Most orders were received during the week (from Monday to Friday), particularly during the morning shift (>50 %). More than 50 % of requests were made by the Emergency Department. The two most common add-on parameters were C-reactive protein and N-terminal pro-brain natriuretic peptide. After automation, the median TAT decreased by 42.3 % (from 52 to 22 min). The largest decreases in TAT were observed for routine samples (58.89 %) and fully automated analyses (56.86 %). Conclusions: Automation of our core laboratory substantially reduced turnaround time for add-on testing, indicating an increase in efficiency. Automation eliminated several manual steps in the process, leading to a mean reduction of 15 work hours per day (more than 2 full-time equivalents).

Management of postanalytical processes in the clinical laboratory according to ISO 15189:2012 Standard requirements: considerations on the review, reporting and release of results.

The objective of this paper is to share some considerations about the management of postanalytical processes in relation to the review, reporting and release of test results in accordance with UNE-EN ISO 15189:2013 Standard requirements. The scope of this paper includes postanalytical activities and the personnel involved (laboratory management and staff). We describe the criteria and information required to review and validate analytical results and ensure that clear reports are sent to requesters. These criteria also guarantee that results are transcribed in a reliable way and that all necessary information is provided for the correct interpretation of results. Likewise, the requirements for the correct release of laboratory results are described, with special emphasis on the release of alarming or critical results. In some European countries, clinical laboratories are required to hold partial or full ISO 15189 accreditation, which is a global trend. Therefore, understanding ISO 15189 requirements is imperative for a progressive and more effective implementation of the Standard.

Management of post-analytical processes in the clinical laboratory according to ISO 15189:2012. Considerations about the management of clinical samples, ensuring quality of post-analytical processes, and laboratory information management.

ISO 15189:2012 establishes the requirements for clinical sample management, ensuring quality of process and laboratory information management. The accreditation authority, ENAC in Spain, established the requirements for the authorized use of the label in reports issued by accredited laboratories. These recommendations are applicable to the postanalytical processes and the professionals involved. The Standard requires laboratories to define and document the duration and conditions of sample retention. Laboratories are also required to design an internal quality control scheme to verify whether postanalytical activities attain the expected standards. Information management requirements are also established and laboratories are required to design a contingency plan to ensure the communication of laboratory results. Instructions are finally provided about the correct use of the accreditation label in laboratory reports. A range of nations and scientific societies support that clinical laboratories should be required to obtain accreditation. With ISO 15189 being the most specific standard for demonstrating technical performance, a clear understanding of its requirements is essential for proper implementation.

Infección necrotizante de tejidos blandos: experiencia durante 15 años en un hospital pediátrico / Necrotizing soft tissue infections: experience over 15 years in a pediatric hospital

INTRODUCCIÓN: La Infección Necrotizante de tejidos blandos (INTB) tiene una elevada morbimortalidad. El objetivo de este trabajo es describir del manejo perioperatorio de menores de 15 años que cursaron con INTB durante 15 años en un Hospital pediátrico. MATERIAL Y MÉTODOS: serie de pacientes identificados INTB entre 2000 y 2015 en el Hospital Roberto del Río. Se describen variables demográficas, clínicas, vacuna, tratamiento, cirugías, complicaciones, microorganismos, seguimiento, y fallecimientos. RESULTADOS: 22 pacientes, con mediana de 2 años y 9 meses de edad. 50% estaban cursando con una varicela. Dos fallecieron. Ninguno era previamente vacunado contra el virus varicela zoster. La localización fue tronco (14), extremidades (7), cuello (1). Los pacientes conscientes presentaron hiperestesia cutánea. Se realizó aseo quirúrgico con una mediana de 6,8 horas desde el inicio de la hiperestesia y 2 horas desde la sospecha diagnóstica. Los microorganismos fueron: S. pyogenes (38%) y E. coli (31%). Los antibióticos más frecuentes fueron penicilina más clindamicina. La herida se manejó con cierre primario, injertos y/o colgajos. Cinco evolucionaron con secuelas que necesitaron tratamiento. CONCLUSIÓN: Se identificó que la INTB puede presentarse con varicela. Debe sospecharse en lesiones cutáneas e hiperestesia desproporcionada. Resección amplia y precoz son fundamentales para el tratamiento.

INTRODUCTION: Necrotizing soft tissue infection (NSTI) has a high morbidity and mortality. The objective of this study is to describe the perioperative management of children under 15 years of age who have had this condition for 15 years in a pediatric hospital. MATERIAL AND METHODS: cases series of patients identified by Pathological Anatomy with NSTI during 2000 and 2015 at the Dr. Roberto del Río Hospital. Demographic variables, treatment, antecedents of vaccination, surgeries, complications, microorganisms, follow-up, and deaths are described. RESULTS: 22 patients were identified, with a median of 2 years 9 months of age (interquartile range: 13 months to 5 years y 10 months). 50% of the cases were associated to chickenpox. Two died. No patient was previously vaccinated against varicella zoster virus. The location was trunk (14), extremities (7) and neck (1). All conscious patients presented cutaneous hyperesthesia. Surgical debridement was performed with a median of 6.8 hours from the onset of hyperesthesia and 2 hours from diagnostic suspicion. The most frequent microorganisms were: Streptococcus pyogenes (38%) and Escherichia coli (31%). The most frequent antibiotics used were penicillin plus clindamycin. The wound was handled with primary closure, grafts and / or flaps. Five patients evolved with sequelae that needed treatment. CONCLUSION: It was identified that STNI in children is associated with chickenpox. It should be suspected in cutaneous lesions and disproportionate hyperesthesia. Aggressive resection is essential for treatment

Abordaje del dolor crónico no oncológico / Management of chronic non-malignant pain

El dolor crónico no oncológico es una patología importante e incapacitante, con elevado coste sanitario. El abordaje debe estar centrado en el paciente, debiendo realizar un diagnóstico etiológico del dolor, identificación del tipo de dolor (nociceptivo, neuropático o mixto), utilización de escalas para valoración de la intensidad del dolor y de la calidad de vida, que nos ayudarán a ir viendo la evolución. Realizaremos un plan de tratamiento integral que incluya unos objetivos claros y realistas, junto a la toma optimizada de medicación y siempre teniendo en consideración la opinión y preferencias del paciente. No podemos olvidar la mejora de la capacidad funcional, la realización de actividad física adecuada y los cambios en el estilo de vida. Usaremos los fármacos a la menor dosis efectiva y durante el menor tiempo posible. Debemos reevaluar al paciente de forma programada, sobre todo en aquellos que tratamos con opioides potentes

Chronic non-malignant pain is an important and disabling pathology, with high healthcare costs. Its managementshould be focused on the patient, requiring an etiological diagnosis of pain, identification of the type of pain (nociceptive, neuropathic, or mixed), use of scales to assess pain intensity and quality of life, which will help us to see the evolution. We will carry out a comprehensive treatment plan that includes clear and realistic objectives, together with the optimized taking of medication, and always taking into consideration the opinion and preferences of the patient. We must not forget the improvement of functional capacity, adequate physical activity and changes in lifestyle. We will use drugs in the lowest effective doses and for the shortest periods of time possible. We must reevaluate the patient on a scheduled basis, especially those treated with potent opioids

Asociación de diabetes respecto a variables sociodemográficas, hipertensión, hipercolesterolemia y enfermedad periodontal / Association diabetes between sociodemographic variables, hypertension, hypercholesterolemia and periodontal disease

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Comparación de la ecuación CKD-EPI respecto a MDRD-IDMS en la derivación de pacientes a Nefrología / Comparison of CKD-EPI and MDRD-IDMS equations and referrals to specialized care

Introducción: Las Guías KDIGO 2012 recomiendan la ecuación CKD-EPI como una estimación más exacta del filtrado glomerular (FG). Realizamos un análisis retrospectivo para evaluar la concordancia entre CKD-EPI y MDRD-IDMS y para calcular el diferencial de derivaciones a Nefrología. Participantes y métodos: Para el estudio de concordancia se analizó una muestra de 16.720 solicitudes de pacientes visitados en Atención Primaria en el área de influencia del Hospital Universitario Joan XXIII de Tarragona durante un año. Para el cálculo del diferencial de derivaciones se seleccionaron 8.478 pacientes. Solo se tuvieron en cuenta parámetros de laboratorio (FG y albuminuria). Se siguieron las recomendaciones del documento de consenso sobre enfermedad renal crónica (ERC) del 2012 y se compararon con los resultados obtenidos al aplicar el documento de consenso del 2008. Resultados: Las ecuaciones mostraron una buena concordancia a nivel global (kappa = 0,94; p < 0,001). Con la aplicación del nuevo documento de consenso, CKD-EPI supuso un incremento de 9 derivaciones (12,7%) respecto a MDRD-IDMS, siendo 7 (9,9%) atribuibles al grupo de pacientes de edad superior a 80 años. Con la aplicación del antiguo documento de consenso, CKD-EPI hubiese supuesto un aumento de 28 derivaciones (7,4%) respecto a MDRD-IDMS. Conclusiones: La ecuación CKD-EPI conduce a una reclasificación de la ERC que afecta a la práctica clínica, al paciente y a la economía. En los pacientes de mayor edad se observa un aumento de las derivaciones, indicando la necesidad de aplicar en algunos casos ecuaciones de estimación del FG más exactas en este grupo de edad (AU)

Introduction: The new KDIGO 2012 Guidelines recommend CKD-EPI equation as a more accurate estimation of glomerular filtration rate (GFR). A retrospective analysis was performed in order to evaluate the correlation between CKD-EPI and MDRD-IDMS and to calculate the difference in referrals to Specialized Care using both equations. Participants and methods: A concordance study was performed comparing CKD-EPI equation to MDRD-IDMS. The sample consisted of 16,720 requests of patients seen in Primary Care in the referral area of the University Hospital Joan XXIII in Tarragona within a one year period. To calculate the difference in referrals between both equations 8,478 patients were selected from the initial sample. Only laboratory parameters were taken into account (GFR and urine albumin). The analysis used the recommendations from the current chronic kidney disease (CKD) consensus document. The results were also calculated applying the referral criteria from 2008. Results: The study showed a good correlation between both equations (kappa = 0.94, P < .001). The new consensus document involved an increase of 9 referrals (12.7%) using CKD-EPI in comparison to MDRD-IDMS, of which 7 (9.9%) were due to the group of patients older than 80 years. With the application of the old consensus document, using CKD-EPI would have had an increase of 28 referrals (7.4%) compared to using MDRD-IDMS. Conclusions: The CKD-EPI equation leads to a re-classification of CKD affecting clinical practice, the patient and the economy. An increase in the referrals of older patient was observed. In some cases, this reveals the need for applying more accurate equations to estimate GFR for this age group (AU)

Hemólisis masiva en un caso de sepsis por Clostridium perfringens / Fatal hemolysis due to Clostridium perfringens sepsis

Presentamos un caso de hemólisis masiva fulminante a causa de una sepsis por Clostridium perfringens en un paciente diabético que acude a un hospital comarcal manifestando dolor abdominal. Mostramos las imágenes de la sangre periférica obtenida antes de la muerte del paciente, que tuvo lugar 22 h después de su ingreso hospitalario (AU)

We report a case of fulminant massive hemolysis due to Clostridium perfringens sepsis in a diabetic patient who was seen in a local hospital complaining of abdominal pain. The patient died 22 h after hospital admission. We present images of peripheral blood taken before death (AU)

Prevalencia de Violencia de Género en mujeres que acuden a consultas de Atención Primaria / Prevalence of gender violence in women who attend primary care centres

Objetivos. Conocer qué proporción de las mujeres que consultan en atención primaria sufren situaciones de violencia doméstica, así como las características clínicas y sociodemográficas asoiadas. Diseño. Estudio observacional, descriptivo, transversal. Emplazamiento. Consultas de atención primaria rurales y urbanas. Participantes. Muestreo consecutivo de mujeres de 18 o más años, con pareja sentimental actual o que hubiesen tenido pareja en el pasado. Mediciones y resultados principales. Se diseñó un cuestionario que incluía variables sociodemográficas, antecedentes patológicos y de consumo de tóxicos, respuesta a la versión abreviada del Woman Abuse Screening Tool (WAST), asi como un cuestionario autoadministrable sobre situaciones de abuso. Un 26,2% (IC 95%: 21,7-31,1%) presentó un resultado positivo del WAST y 25,9 % (IC95%: 21,3-30,9%) admitió situaciones de abuso, físico, emocional o sexual, actual (11,7%)o pasado (17,4%). La concordancia en las respuestas a ambos cuestionarios fue baja(Kappa: 0,53).Mediante análisis de regresión logística se encontró que el modelo que mejor predice la existencia de abuso incluye las variables etnia (OR: 0,14 -IC 95%: 0,06-0,34- para las “caucásicas españolas”) y estado civil (OR: 0,10 -IC95%: 0,04-0,24- y OR: 0,09 -IC95%: 0,04-0,21- para solteras/viudas y casadas/pareja estable, respectivamente, comparado con el grupo de separadas/divorciadas).Conclusiones: Una elevada proporción de mujeres que consultan en atención primaria han sufrido situaciones de violencia en el ámbito doméstico. Además de la sospecha clínica, es necesario disponer de algún instrumento de cribado o detección precoz para el diagnóstico de violencia contra la mujer (AU)

Objectives. To determine what percentage of women who attend primary care clinics suffer domestic violence and the women’s associated clinical and socio-demographic characteristics. Design. Cross-sectional, observational, descriptive study. Setting. Rural and urban primary care centers. Participants. Consecutive sample of woman aged 18 years or over, who has a partner or had a partner in the past. Meaurements and main results. A questionnaire was designed that included socio-demographic variables, disease history and history of substance abuse. The short version of the Woman Abuse Screening Tool (WAST), and a self-administered questionnaire on abuse situations were also used. Twenty six point two percent (95% CI: 21.7-31.1%) had a positive WAST result and 25.9 %(95% CI: 21.3-30.9%) admitted to physical, emotional and sexual abuse by their partner at the present time (11.7%) or in the past (17.4%) The concordance of the responses to the two questionnaires was low (Kappa: 0.53).Logistic regression analysis revealed that the model that best predicts the existence of abuse included ethnic variables (OR: 0.14 -95%CI: 0.06-0.34- for “Spanish Caucasian women”)and marital status (OR: 0.10 -95%CI: 0.04-0.24- and OR: 0.09 -95%CI: 0.04-0.21- for single women/widows and married women/stable partner, respectively, compared with the separated/divorced group).Conclusions: A high percentage of women who attend primary care centres have suffered domestic violence. In addition to clinical suspicion a screening or early detection tool is needed in order to diagnose domestic violence (AU)

El arte de curar: estudio sobre vías de administración. Diferencias entre medio rural y urbano / The art of curing: difference in administration routes in rural and urban settings

Objetivo. Conocer las preferencias de vías de administración de medicamentos de los pacientes y las diferencias según sea medio urbano o medio rural. Diseño. Estudio observacional, descriptivo, transversal. Participantes. Pacientes de atención primaria cuyo motivo de consulta fue dolor y éste precisó tratamiento analgésico. Mediciones principales. Escala visual del dolor para la variable intensidad del dolor. Otras variables: sociodemográficas (sexo, edad, lugar de residencia y nivel de estudios), preferencias de vía de administración de tratamiento y eficacia de vía de administración. Resultados. Se realizaron 400 encuestas (33% hombres y 66% mujeres, con edad media de 58años). Habitaban en ciudad un 59% y un 41% en medio rural. El 44.6% calificó su dolor como moderado, el 42% como intenso, el 4.2% leve y el 4.2% insoportable. El 48% prefería tratamiento parenteral, el 50% oral y el 1.8% tratamiento tópico. Preguntados sobre eficacia a igual dosis, el 74%se inclinó por tratamiento parenteral, el 8.9% por tratamiento oral y el 19.6% igual. Las personas más jóvenes y con estudios universitarios prefieren el tratamiento oral. En el medio rural la preferencia por los tratamientos parenterales es mayor que en el medio urbano, aunque la diferencia no es estadísticamente significativa. Conclusiones. Las preferencias por los tratamientos parenterales son superiores en el medio ruraly en las personas mayores de 65 años, debido principalmente a que creen que es más potente. Los jóvenes, los que poseen estudios universitarios y los que residen en el medio urbano prefieren tratamiento oral, principalmente por ser más cómodo. La vía de administración del medicamento debe ser consensuado con el paciente, puesto que la predisposición de éste puede ayudar al efecto terapéutico de dicho medicamento (AU)

Objective. To determine patient preference as regards administration route and the differences between urban and rural settings. Design. Observational, descriptive, cross-sectional study Participants. Patients who visited their primary care doctor due to pain and who needed analgesic treatment. Principal measurements. Visual pain scale for the pain intensity variable. Other variables: sociodemographic (sex, age, place of residence, educational level), administration route preference and administration route efficacy. Results. A total of 400 subjects (33% men and 66% women with a mean age of 58 years) were surveyed. 59% lived in an urban setting and 41% in a rural setting. 44.6% classified their pain as moderate,42% as severe, 4.2% as mild and 4.2% as unbearable. 48% preferred parenteral, treatment,50% oral treatment and 1.8% topical treatment. When asked about the efficacy at equal doses, 74%preferred parenteral treatment, 8.9% oral treatment and 19.6% thought it was the same for both. Younger persons with a university education preferred oral treatment. Preference for parenteral route was higher in the rural setting than in the urban setting. although the difference was not statistically significant. Conclusions. Preference for parenteral administration is greater in the rural setting and in persons over 65 years, mainly because they consider this route more effective. Younger persons, those with a university education and those who live in an urban setting prefer oral treatment, mainly because it is more convenient. The administration route should be decided on with the patient because the patient’s willingness to be treated may assist in the therapeutic effect of the medication (AU)