Office Laboratory Procedures Research Articles

Vaginitis: Diagnosis and Management

Vaginitis is one of the most common ambulatory problems to occur in women. It is a disorder responsible for > 10% of visits made to providers of women's health care. Although vaginal infections are the most common cause, other considerations include cervicitis, a normal vaginal discharge, foreign-body vaginitis, contact vaginitis, atrophic vaginitis, and desquamative inflammatory vaginitis. The medical history and examination are an important source of clues to the underlying diagnosis. However, making a definitive diagnosis requires skillful performance of office laboratory procedures, including the vaginal pool wet mount examination, determination of the vaginal pH, and the whiff test. Vaginal and cervical cultures, nucleic acid tests, and point-of-care tests are available and may be required in selected patients. Once a specific diagnosis is made, effective therapy can be prescribed. Candida vaginitis is generally treated with either the vaginal administration of an imidazole or triazole antifungal agent or the prescription of oral fluconazole. Oral nitroimidazole agents, metronidazole or tinidazole, are the only effective treatments for trichomoniasis in the United States. Bacterial vaginosis, which has been linked to important gynecologic and pregnancy complications, can be treated with an available oral or topical agent containing either a nitroimidazole or clindamycin.

Evaluation of vaginal complaints.

Vaginal symptoms are one of the most common reasons for gynecological consultation. Clinicians have traditionally diagnosed vaginal candidiasis, bacterial vaginosis, and vaginal trichomoniasis using some combination of physical examination, pH, the wet mount, and the whiff test. To evaluate the role of the clinical examination and determine the positive and negative likelihood ratios (LRs) for the diagnosis of vaginal candidiasis, bacterial vaginosis, and vaginal trichomoniasis. Using a structured literature review, we abstracted information on sensitivity and specificity for symptoms, signs, and office laboratory procedures. We chose published (1966 to April 2003) articles that appeared in the MEDLINE database and were indexed under the combined search terms of diagnosis with vaginitis, vaginal discharge, candidiasis, bacterial vaginosis, and trichomoniasis. Included studies of symptomatic premenopausal women seen in primary care settings. Tests were evaluated only if they would provide diagnostic information during the office visit and were compared with an acceptable criterion standard. All 3 authors extracted the data and computed sensitivity and specificity from each article independently. The absence of standard definitions for symptoms and signs made it impossible to combine results across studies. Symptoms alone do not allow clinicians to distinguish confidently between the causes of vaginitis. However, a patient's lack of itching makes candidiasis less likely (range of LRs, 0.18 [95% confidence interval [CI], 0.05-0.70] to 0.79 [95% CI, 0.72-0.87]) and lack of perceived odor makes bacterial vaginosis unlikely (LR, 0.07 [95% CI, 0.01-0.51]). Similarly, physical examination signs are limited in their diagnostic power. The presence of inflammatory signs is associated with candidiasis (range of LRs, 2.1 [95% CI, 1.5-2.8] to 8.4 [95% CI, 2.3-31]). Presence of a "high cheese" odor on examination is predictive of bacterial vaginosis (LR, 3.2 [95% CI, 2.1-4.7]) while lack of odor is associated with candidiasis (LR, 2.9 [95% CI, 2.4-5.0]). Office laboratory tests, particularly microscopy of vaginal discharge, are the most useful way of diagnosing these 3 conditions. The cause of vaginal complaints may be easily diagnosed when typical findings appear in microscopy. However, the poor performance of individual symptoms, signs, and office laboratory tests often makes it problematic to identify the cause of vaginal symptoms.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection.

Four areas of pediatric office practice are again reviewed: office laboratory procedures, office economics, parenting and parent education, and urinary tract infection. Screening for celiac disease and the use of rapid antigen testing for extrapharyngeal group A Streptococcus infections are included in office laboratory procedures. Utilization of health care among patients with public insurance, electronic medical records, billing among pediatric residents, and satisfaction surveys are reviewed in office economics. Challenges related to breastfeeding, obesity management and timely immunizations are covered within parenting and parent education. Finally, the use of an augmented urinalysis and a discussion of imaging for first febrile urinary tract infections are included in the area of urinary tract infection.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection

We once again review four areas of interest to office-based pediatricians: office laboratory procedures, office economics, parenting and patient education, and urinary tract infections. Sean Elliott reviews the current status of the Clinical Laboratories Improvement Amendments (CLIA) and their continuing impact on physician office laboratories. Eve Shapiro reviews office economics, this year focusing on managed care, the physician workforce, practice management, and health care financing for the uninsured. Anna Binkiewicz provides an update on parenting and parent education, with recent reports on nutrition and childhood immunizations. Richard Wahl again reviews recent research on urinary tract infection, discussing voiding physiology, dysfunctional voiding patterns, acute urinary retention, urine collection techniques, diagnosis in young infants, and antibiotic prophylaxis.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection.

We again review four areas of interest to office-based pediatricians: office laboratory procedures, office economics, parenting and patient education, and urinary tract infections. Sean Elliott provides an update on the Clinical Laboratories Improvement Amendments (CLIA) and their impact of office practice. Eve Shapiro reviews office economics, focusing on measuring quality of care, use of performance data, costs of new technologies, and the impact of managed care on the medical marketplace. John Walter offers an update on parenting and parent education, with approaches to counseling families about overuse of antibiotics, teen pregnancy, hyperactivity, violence, and asthma. Richard Wahl reviews the recent research on urinary tract infection, with special attention paid to office diagnosis and management, longitudinal studies of children with urinary tract infections, and the controversy surrounding the American Academy of Pediatrics Task Force on Circumcision report.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection.

These authors review four areas of office pediatric practice: office laboratory procedures, office economics, parenting and parent education, and urinary tract infections. Thomas Ball reviews the literature published this past year on physician office laboratories, with updates on the Clinical Laboratories Improvement Amendments, laboratory utilization, and office diagnosis of infectious mononucleosis. Eve Shapiro offers an update on office economics, discussing physician organizations and managed care, and a medical ethics evaluation of medical economics. Burris Duncan provides an update on parenting and parent education, with emphasis on defining "the best interests of the child." Richard Wahl summarizes the past year's publications on pediatric urinary tract infections, reviewing the circumcision debate, dysfunctional voiding, vesicoureteral reflux, and the diagnosis and follow-up of acute pyelonephritis.

Office laboratory procedures, office economics, patient and parent education, and urinary tract infection.

This review provides an update on four areas of office practice: office laboratory procedures, office economics, patient and parent education, and urinary tract infection. Thomas Ball reviews physician office laboratories, with updates on the Clinical Laboratory Improvement Amendments, office proficiency testing, and office testing for streptococcal pharyngitis and Helicobacter pylori. Eve Shapiro reports on office economics, focusing on the influence of managed care on pediatric practice. Burris Duncan provides a review of the new National Institutes of Health asthma guidelines, and challenges us to become more involved in patient education. Richard Wahl reviews urinary tract infections, vesicoureteral reflux, dysfunctional voiding, and appropriate imaging studies. Our approach is to provide pediatricians with useful and practical information for their office practices.

Office laboratory procedures, office economics, patient and parent education, and urinary tract infection.

This review provides an update on four important areas in office pediatrics: office laboratory procedures, office economics, patient and parent education, and urinary tract infection. Ball reviews new information about physician office laboratories, with updates on the Clinical Laboratory Improvement Amendments, streptococcal pharyngitis, urinalyses, office stool examination, and information on Helicobacter pylori serology. Shapiro reports on office economics, highlighting new office technologies, physician operated networks, managed care, recent legislation, and the "cost versus quality" debate. Duncan provides a very thought provoking essay on parent and patient education, focusing on improving parenting skills. Wahl reviews the recent literature on urinary tract infections, with emphasis on host-bacteria interactions, diagnostic evaluations, pyelonephritis, renal cortical scarring, and long term follow-up of vesicoureteral reflux. We hope we have provided pediatricians with useful and practical information for their office practices.

Office laboratory procedures, office economics, patient and parent education, and urinary tract infection.

This review updates our readers on four important areas of office practice: office laboratory procedures, office economics, patient and parent education, and urinary tract infection. Michael Aldous reviews the recent literature on office laboratory procedures, which includes a report on the ongoing heated discussion of the Clinical Laboratory Improvement Amendments, an update of recent studies on new and better rapid streptococcal tests, and improved methods for urinalysis. Rickey Williams provides a report on office economics that includes a discussion of the effects of capitation, how preventive care can be cost effective, and the future prospects for greatly expanded office computerization. Burris Duncan discusses patient and parent education with an in-depth review of the potential economic value of a full implementation of the American Academy of Pediatrics' The Injury Prevention Program, and in addition he chronicles the rapid growth and development of school-based health centers. John Ey reviews the recent literature on urinary tract infections in children, including how we can make the diagnosis, methods for preventing recurrent urinary tract infections, the most effective studies for evaluating the urinary system, and what follow-up is necessary. We hope this review will provide the pediatrician with important information to help in the care of their patients.

Office laboratory procedures, economics of practice, patient and parent education, and urinary tract infection.

This review highlights recent advances in four major areas that are relevant to office practice: office laboratory procedures, economics of practice, adolescent risk-taking behavior in terms of sexually transmitted diseases, and urinary tract infections. Who should be screened for diseases and where these screening tests should be done are addressed, keeping the practicing pediatrician in mind. Next we review current office economics, including whether professional courtesy should be continued, how our practices are going to be increasingly influenced by guidelines developed by the American Academy of Pediatrics, the Clinical Laboratory Improvement Amendments, and the new Clinton Health Plan if it survives Congress, and finally how all of these issues will affect our expected income in the years ahead. As pediatricians strive to retain adolescent patients in their practices, they will need to find appropriate ways of counseling these patients concerning risk behaviors that could result in sexually transmitted diseases or HIV infections. Should we leave the comfortable confines of our offices to participate in these counseling programs for adolescents, and are there lessons from existing successful International Health Programs that we can use? Finally, urinary tract infections (UTIs) continue to be a common cause of childhood infections with possible serious long-term sequelae. Can we do a better job of diagnosing UTIs, has improved treatment become available, and is prevention of recurrences possible? Once the diagnosis has been made, how can we best evaluate these children with UTIs for underlying urologic abnormalities? It is our hope that the practicing pediatrician will be better prepared to face these issues having read this review.

Patient and parent education, office laboratory procedures, and urinary tract infections.

This review of patient and parent education, office laboratory procedures, and urinary tract infections is written by three pediatricians in a group practice in Pittsburgh, Pennsylvania. The patient and parent education section covers the goals of child rearing and history taking (with emphasis on the "vulnerable child"), and reviews discipline, sleep problems, fever, smoking, and injury prevention. The office laboratory procedures section reviews the recent Clinical Laboratory Improvement Act of 1988. The urinary tract infections section reviews recent advances in diagnosis, treatments, prevention (the issue of circumcision), and radiologic studies.

782 RESIDENT LABORATORY CURRICULUM

Office Laboratory procedures are an important aspect of primary care. Effective laboratory skills programs are difficult to implement during residency training. Selected components of a previously reported, successful curriculum in laboratory medicine were implemented in two residencies (SA & OK). To determine which components of the curriculum were necessary for success, a prospective comparison of acquisition of knowledge & skills between these residents was completed. Residents in SA (N=8) & OK (N=16) had the same video-taped lectures, standardized test-teach sessions & the option to use a small office lab in their continuity clinic. In SA the lab was staffed by a technician who provided teaching, service & coordinated a 1 month laboratory rotation. Based on a blindly scored 51 item cognitive written and 50 item lab performance exam, residents in SA & OK showed marked deficits at the start of the PL-1 year in microbiology, hematology & quality control. Using covariate analysis to adjust for differences in pretest scores, SA PL-2's received higher scores on all written subtests with significant differences in 6/10 areas (p=.01 to .002). In only 3 of 8 skill subtests did both groups improve. Scores decreased for both groups in 3 subtests. Only in the performance of white cell counts were SA scores significantly (p.007) improved over OK. Thus, (the availability of) an on site lab technician enhanced resident cognitive learning but did not improve performance skills.

The Office Laboratory in Pediatric Practice

Shifts of major populations to urban and suburban communities, decline in the numbers of family practitioners, and rapid increase in the total child population and parental expectations for quality health care have contributed to an increased emphasis on group practice. Paralleling these changes in organization has been the emergence of simple, relatively inexpensive methods for performing office laboratory procedures at an increasingly more sophisticated level. Present data relating to office laboratory methods are summarized, and procedures are related to current concepts of pediatric well child care and management of patients with acute illness and the more commonly encountered chronic illnesses.

Office Laboratory Procedures in Pediatric Practice

The rewards of an in-office laboratory are many: greater selectivity in testing, lower cost to the patient, better care and follow-up. With the many prepared reagents, diagnostic kits, culture materials, and disposable equipment now available, the space and staff requirements of a laboratory in which a wide variety of basic tests can be performed are minimal. Details are given on the organization of such a laboratory.