An educational intervention to increase awareness reduces unnecessary laboratory testing in an internal medicine resident-run clinic.

At our resident-run clinic in an underserved community, laboratory test costs in 2013 exceeded the government subsidy by $400 000. To optimize limited resources and improve patient care, an education program to reduce testing was implemented. Between November 2014 and January 2015, residents attended lectures on utilization of laboratory testing, focusing on standard practice guidelines, and analyses of unnecessary tests. Multivariate nonparametric statistical methods and subgroup analysis were used to evaluate cost reduction. There were 453 clinic visits during the intervention period and 471 visits during the control period. Lectures were independently associated with a significant laboratory cost reduction. Median laboratory cost per visit decreased from $106.00 to $74.00. Total cost in the study period decreased from $79 403 to $51 463. There were similar reductions of laboratory costs in two subgroups: age groups of <50 years and ≥50 years, new encounters, and follow-up visits . In the analysis of individual tests, the cost of TSH and Vitamin D tests had the greatest reduction ($8176 and $5088 respectively). An appropriate physician education program can reduce laboratory tests and costs. Screening tests with inadequate evidence support were reduced most, whereas those with proven benefits did not decrease significantly.

Calciphylaxis leading to penile necrosis.

Penile gangrene is a rare disease. It represents a poor prognostic sign in end stage renal disease (ESRD) patients and an indicator of metastatic vascular calcification. Pathogenesis of this life threatening condition is not clearly understood and treatment is also controversial. We describe the case of a 61-year-old man known to have diabetes mellitus, chronic renal failure on haemodialysis, who was complaining of worsening groin pain for 4 weeks. On examination dry gangrene of glans penis was noted. Cultures from the penis showed multiple organisms. Computed tomography (CT) showed diffuse calcification of external and internal iliac arteries. Later, he developed caciphylaxis of right anterior thigh. His overall condition did not improve in spite of adequate antibiotics and he was shifted to intensive care unit (ICU) where he required high doses of vasopressors. Clinically he kept deteriorating and passed away due to septic shock.