Use Of Laboratory Services Research Articles

The effect of Covid-19 pandemic on healthcare utilization in public vs private centers in Iran: a multiple group interrupted time-series analysis

BackgroundThe outbreak of Coronavirus in late 2019 and its continuation in the following years has affected all human societies, government organizations, and health systems. Access to health services is an important issue during crises. The present study aimed to investigate the effect of the Covid-19 pandemic on the consumption of health services in the public sector compared to the private sector in Iran.MethodsThe research population consisted of all insured individuals covered by Iran Health Insurance Organization in Fars province, which amounts to approximately 2,700,000 people. The required information including the utilization of laboratory, radiology, medicine, and hospitalization services was extracted on a monthly basis from February 2019 to February 2021. The Multiple Group Interrupted Time Series Analysis (MGITSA) was used for data analysis along with STATA.15 software.ResultsAccording to the findings of MGITSA, in the short-term, the utilization of private laboratory, radiology, medication, and hospital admissions had decreased by approximately 18,066, 8210, 135,445, and 1086 times, respectively (P < 0.05). In the long-run, the use of laboratory and radiology services had increased by about 2312 and 514 times (P < 0.05), respectively. The comparison between the public and private sectors showed that in the short-term, the use of radiology services decreased by about 12,525, while the use of medication increased by about 91,471 times (P < 0.05). In the long-run, the use of laboratory services decreased by about 1514 times (P = 0.076) and no change was observed in the other services utilization (in public relative to private centers).ConclusionsUtilization of health services in the public versus private centers, except for medication and hospitalization, significantly decreased in the short-term. However the utilization of most services returned to the usual trend in the long-term. The reduction in access to health services could impose a significant burden of various diseases, at least in the short-term, and increase health costs in the coming years.

DE01 Swabs: a practical way to teach medical students about cutaneous infections

Abstract It is well established that dermatology is poorly understood among medical students and doctors of all grades. The combination of time allocated to teaching of dermatology, as well as the high impact of the hidden curriculum reinforcing dermatology as difficult and mysterious, lends itself to perpetuation of the zeitgeist. Cutaneous infections have a particularly high cognitive load due to their relatively short presentation time and wide varieties of manifestations. Investigation of cutaneous infections is also problematic with incorrect sampling undertaken for different infections. Junior doctors frequently default to black charcoal swabs for all skin infections, often getting feedback as inappropriate investigation after the patient has been discharged or are being read by different doctors altogether due to shift working. For 8 years, we have been running a practical tutorial session on skin infections at Swansea University Medical School. Old venesection prosthetic arms are decorated with simulation bacterial, fungal and viral infections. The bacterial pus is cold custard (or ‘pustard’) on swollen reddened sections. Herpetic vesicles are simulated with bubble wrap injected with Hibiscrub®. Tinea is simulated by dry polyvinyl acetate glue surrounded by red marker. The students have access to black charcoal swabs, red viral swabs, scalpels and fungal scraping cards. They also have dry universal containers and investigation forms. The 10–12 year-2 students are tasked with diagnosing each infective presentation with a short history and medical photography to back up the prosthetic representation. They then have to select the most appropriate investigative method and information to give to the microbiology department. Some students only have access to black charcoal swabs and need to improvise working out how to use the universal containers for their investigations. The knowledge is then shared at the end of the 40-min tutorial. This is conducted a day before the skin infection lecture, to reduce the cognitive load of that lecture. There has been consistently good feedback for this session, which allows students to think in real time about common clinical scenarios, making best use of laboratory services and improvising investigative techniques, where appropriate resources may not be available. The prosthetics have worked well year on year. Many of our first students are now practising doctors locally, and their dermatology knowledge is manifest in referrals. By practising the techniques in simulation, they are comfortable doing so in working life.

Integrated use of laboratory services for multiple infectious diseases in the WHO European Region during the COVID-19 pandemic and beyond.

Technical advances in diagnostic techniques have permitted the possibility of multi-disease-based approaches for diagnosis and treatment monitoring of several infectious diseases, including tuberculosis (TB), human immunodeficiency virus (HIV), viral hepatitis and sexually transmitted infections (STI). However, in many countries, diagnosis and monitoring, as well as disease response programs, still operate as vertical systems, potentially causing delay in diagnosis and burden to patients and preventing the optimal use of available resources. With countries facing both human and financial resource constraints, during the COVID-19 pandemic even more than before, it is important that available resources are used as efficiently as possible, potential synergies are leveraged to maximise benefit for patients, continued provision of essential health services is ensured. For the infectious diseases, TB, HIV, hepatitis C (HCV) and STI, sharing devices and integrated services starting with rapid, quality-assured, and complete diagnostic services is beneficial for the continued development of adequate, efficient and effective treatment strategies. Here we explore the current and future potential (as well as some concerns), importance, implications and necessary implementation steps for the use of platforms for multi-disease testing for TB, HIV, HCV, STI and potentially other infectious diseases, including emerging pathogens, using the example of the COVID-19 pandemic.

Quality microbiological diagnostics and antimicrobial susceptibility testing, an essential component of antimicrobial resistance surveillance and control efforts in Pacific island nations.

ProblemEmerging bacterial antimicrobial (antibiotic) resistance (AMR) is a global threat to human health. However, most lower income countries do not have microbiological diagnostic testing for prompt, reliable confirmation of bloodstream infection and identification of AMR.ContextClinicians in Pacific island nations are increasingly challenged by patients who have infection due to antimicrobial-resistant bacteria. Treatment of infection remains empirical because of a lack of diagnostic testing capacity and may follow guidelines that were formulated without reference to local measures of AMR prevalence. There is limited understanding among clinicians of microbiology testing and test interpretation.ActionExamine the lessons learnt from pilot laboratory development programmes in two Pacific island nations that focused on establishing standard procedures for micrological diagnostics and antimicrobial susceptibility testing (AST) and on improving the training of clinicians to increase their use of laboratory services.OutcomeThe pilot programmes addressed a range of logistical difficulties and evaluated two blood culture systems. They also examined and improved internal QC implementation and evaluated the prevalence of AMR.DiscussionContinued development of microbiological diagnostic capability in the Pacific region is paramount. Pacific Island nations need to develop the capability of at least one central laboratory to culture AMR pathogens and subject them to quality-controlled AST or arrange for suitable referral to a nearby country.DiscussionThis study demonstrated a persistently high prevalence of three major bacterial STIs across four countries in WHO’s Western Pacific Region during nearly two decades. Further strengthening of strategies to control and prevent STIs is warranted.

RATIONAL USE OF LABORATORY IN PATHOLOGY LABORATORY ROUTINE: RETROSPECTIVE EVALUATION OF TEST REQUESTS

Akılcı laboratuvar kullanımı, doğru teşhisin konulması, gereksiz tetkiklerin önlenmesi ve maliyetlerin düşürülmesi amacıyla laboratuvar hizmetlerinin akılcı olarak kullanılmasıdır. Bu çalışmanın amacı, patoloji laboratuvar rutininde, gelen tetkik istemlerinde rapor sonuç sürelerinin ve örnek istemlerinin ön tanıya uyumu açısından değerlendirilmesi ve patoloji laboratuvarlarının akılcı kullanımının sağlanmasına yönelik çözüm önerileri sunmaktır. Çalışma, 1 0cak 2017 ve 31 Aralık 2018 tarihleri arasında İstanbul’da özel bir patoloji laboratuvarına gelen 814 tiroid İİAB (İnce İğne Aspirasyon Biyopsisi) isteminin retrospektif olarak değerlendirildiği kesitsel tanımlayıcı bir çalışmadır. Patoloji sonuçlarına göre olguların %35,8’i malign (277 olgu) ve %64,2’si (497 olgu) benign olduğu belirlenmiştir. Testin duyarlılığı %78,70, özgüllüğü %75,25, pozitif kestirim değeri %63,93, negatif kestirim değeri %76,37 ve doğruluğu %76,49 olarak hesaplanmıştır. Olguların patoloji sonuçları ile ön tanı sonuçları arasında istatistiksel olarak anlamlı uyum saptanmamıştır. Başka bir ifadeyle sürecin laboratuvar tarafında, analitik ve post-analitik evrelerinde, patoloji sonuçlarını etkileyecek bir uyumsuzluk olmadığı, bununla birlikte patoloji laboratuvarlarının akılcı kullanıldığı belirlenmiştir. Patoloji laboratuvarlarının akılcı kullanımı, iş akış süreçlerindeki tüm aşamaların iyi yönetilmesine ve sorunlar karşısında çözüm yollarının iyi bilinmesine bağlıdır. Bununla birlikte, hastanın klinik sürecinden sorumlu hekimin, istem sırasında hastayla ilgili istenen bilgileri eksiksiz olarak patoloji formlarına doldurması gerektiği ve sitopatolog-klinisyen iletişiminde belli algoritmaların kullanılması gerektiği düşünülmektedir.

2034. Standardized Point Prevalence Survey on Antibiotic Use to Inform Antimicrobial Stewardship Strategies in the Caribbean

BackgroundInappropriate use of antimicrobials is one of the core contributors to antimicrobial resistance. While hospitals create high selection pressures on bacteria due to the high quantity and broader spectrum of antibiotics used, information on antimicrobial use at the patient level in the Caribbean is sparse. In response, PAHO implemented a standardized WHO methodology to engage national leaderships, build local capacity, and facilitate the use of data to inform antimicrobial stewardship programs (ASP) in the Caribbean.MethodsPoint prevalence surveys (PPS) were performed in four acute care hospitals in Barbados, Guyana and Saint Lucia between June and July 2018. Medical records of all inpatients were reviewed to collect information on antibiotic use, indications and use of laboratory services (Figure 1). A hospital questionnaire was used to assess hospital infrastructure, policy and practices, and monitoring and feedback systems (Figure 2). Training on PPS methods and electronic data collection tool in REDCap™ were provided to build local capacity and identify potential ASP leaderships. A standardized data validation, analysis and reporting system was built in R to streamline the process. Results and recommendations were disseminated to national authorities and stakeholders to support hospital and national decision-making and training for healthcare providers (Figure 3).ResultsA total of 60 physicians, nurses, pharmacists, laboratory technicians, and infection control specialists were trained and participated in the PPS. The survey collected records of 816 patients in which 442 (54%) were females and 374 (46%) were males. In total, 356 (44%) patients received 551 antibiotics. Overall, 300 (75%) of 398 indications for antibiotic use were treatment and 72 (18%) were prophylaxis. A higher use of parenteral antibiotics (79%) was observed compared with oral antibiotics (21%). Antibiotic prescribing patterns differed across hospitals. The most commonly used antibiotics were metronidazole (12%) and amoxicillin/clavulanate (11%).ConclusionThe PPS method provided a feasible and effective way to collect baseline data and identify target areas for interventions. Engaging national leaderships and building local capacity offered a sustainable way in optimizing antimicrobial use in resource-limited settings. Disclosures All authors: No reported disclosures.

South African Hypertension Society commentary on the American College of Cardiology/American Heart Association hypertension guidelines.

In late 2017, the publication of the new American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines created considerable controversy. The threshold for hypertension was redefined as > 130/80 mmHg and target blood pressure < 130/80 mmHg. The purpose of this commentary is to give clarity on the position of the Southern African Hypertension Society (SAHS). In South Africa more than 90% of hypertensives are not controlled at < 140/90 mmHg. Furthermore, by redefining hypertension to a level of 130/80 mmHg, this will significantly increase the prevalence of hypertension by 43%. The new targets will necessitate greater use of health services for increased health visits to monitor patients, greater use of antihypertensives to achieve the lower target, and increased use of laboratory services to monitor for adverse effects. It is the position of SAHS that the new definition and targets are not relevant to low- and middle-income countries such as South Africa, the threshold for hypertension remains at 140/90 mmHg, and a universal target is < 140/90 mmHg for all categories of hypertension.

Overusing laboratory tests: more advantages or drawbacks?

After decades of accumulating evidence, the inappropriate use of laboratory services has now become a well-known critical issue. An interesting survey, just recently published in JAMA Internal Medicine (1), describes some interesting aspects concerning the prescription attitudes and the overuse of inpatient laboratory testing in a large American cancer center (i.e., Memorial Sloan Kettering Cancer Center, New York, NY, USA).

Building capacity in laboratory medicine in Africa by increasing physician involvement: a laboratory medicine course for clinicians.

To describe a 4-day laboratory medicine course for clinicians given at Addis Ababa University, Ethiopia, designed to improve the use of laboratory-based diagnoses. Each day was dedicated to one of the following topics: hematology, blood bank/transfusion medicine and coagulation, chemistry, and microbiology. The course included lectures, case-based learning, laboratory tours, and interactive computer case-based homework. The same 12-question knowledge quiz was given before and after the course. Twenty-eight participants took the quiz before and 21 after completing the course. The average score was 5.28 (range, 2-10) for the initial quiz and 8.09 (range, 4-11) for the second quiz (P = .0001). Two of 12 and 8 of 12 questions were answered correctly by more than 60% of trainees on the initial and second quiz, respectively. Knowledge and awareness of the role of the laboratory increased after participation in the course. Understanding of laboratory medicine principles by clinicians will likely improve use of laboratory services and build capacity in Africa.

Flow cytometry in cerebrospinal fluid-rational use of laboratory services.

Flow cytometry in cerebrospinal fluid-rational use of laboratory services.

Demand management and test request rationalization

Demand for laboratory testing is increasing disproportionately to medical activity, and the tests involved are becoming increasingly complex. When this phenomenon is seen in parallel with declining teaching of laboratory medicine in the medical curriculum, a need emerges to manage demand to avoid unnecessary expenditure and improve the use of laboratory services: 'the right test in the right patient at the right time.' Various methods have been tried to manage demand, with success depending on the medical context, type of health service and preintervention situation. Because many factors contribute to demand, and the different settings in which these exist, it is not realistic to meta-analyse the studies and we are limited to trying to identify trends in results in particular situations. The studies suggest that education combined with facilitating interventions, such as feedback, prompts and changes to laboratory request forms are the most successful. From the perspective of a whole health service, it is important that results are not exaggerated by assessing benefits in terms of total rather than marginal cost. It would be desirable, although difficult, to include the impact on downstream clinical activity caused or avoided by the interventions. Advances in information and web technology may make the elusive goal of achieving substantial demand control more achievable.

Decision-making in general practice: the effect of financial incentives on the use of laboratory analyses

This paper examines the reaction of general practitioners (GPs) to a reform in 2004 in the remuneration system for using laboratory services in general practice. The purpose of this paper is to study whether income motivation exists regarding the use of laboratory services in general practice, and if so, the degree of income motivation among general practitioners (GPs) in Norway. We argue that the degree of income motivation is stronger when the physicians are uncertain about the utility of the laboratory service in question. We have panel data from actual physician-patient encounters in general practices in the years 2001-2004 and use discrete choice analysis and random effects models. Estimation results show that an increase in the fees will lead to a small but significant increase in use. The reform led to minor changes in the use of laboratory analyses in GPs' offices, and we argue that financial incentives were diluted because they were in conflict with medical recommendations and existing medical practice. The patient's age has the most influence and the results support the hypothesis that the impact of income increases with increasing uncertainty about diagnosis and treatment. The policy implication of our results is that financial incentives alone are not an effective tool for influencing the use of laboratory services in GPs' offices.

Utilisation of laboratory services by health workers in a district hospital in Malawi

Aims:To identify priorities for improving effective use of laboratory services in a district hospital in Malawi.Methods:A prospective observational study of clinician–patient interactions to analyse laboratory test requesting practices and utilisation...

Clinical biochemistry guidelines in Wales: their impact on laboratory services

Evidence of significant variations in clinical biochemistry practice in Wales led to the formation of the All Wales Clinical Biochemistry Audit Group (AWCBAG) in 1993, with the aim of auditing laboratory services to ensure that they are optimally used. As part of this process, clinical guidelines are produced and circulated to all clinical biochemistry departments in Wales. The current aim of the AWCBAG is to assess the extent and impact of adoption of these guidelines across Wales. Three surveys were dispatched at intervals over a decade to all clinical biochemistry departments in Wales to investigate practice in: (1) urine albumin testing to screen for diabetic nephropathy; (2) biochemical investigation of menopausal status and the monitoring of hormone replacement therapy; (3) screening for Cushing's syndrome. The results show that laboratories across Wales are generally following guideline criteria and are adapting their practice in-line with changing recommendations. The introduction of AWCBAG guidelines has been widely accepted by clinical biochemistry departments in Wales. These guidelines have led to a more efficient and effective use of laboratory services.

Is the medical undergraduate curriculum ‘fit for purpose’?

Patient safety became a fundamental priority for the National Health Service (NHS) in 2000 following the Department of Health’s publication ‘Organisation with a Memory’ and subsequent establishment of the National Patient Safety Agency in 2001. Despite this, most acutely ill patients are cared for by the most junior medical staff who have the least knowledge and experience. Moreover, their knowledge of basic science has fallen due to the practical elimination of Pathology and Laboratory Medicine from the curriculum in many medical schools. This has happened despite the recommendation from the General Medical Council (GMC). ‘Tomorrow’s Doctors’ states that medical graduates must have a knowledge and understanding of clinical and basic sciences; that they must be able to follow, safely and effectively, interpretation of results of commonly used investigations; and ‘make clinical decisions based on the evidence they have gathered’. At the present time the GMC Education Section is preparing to review that document to ensure that the guidance is fit for purpose. Formal consultation will take place in 2008. The modernization of the NHS includes a plan to reduce the heavy reliance on junior doctors out-of-hours by implementing ‘Hospital at Night’. This relies on defining competencies rather than grade of staff. It is recognized that a core function is the recognition and management of the critically ill patient. This will require inter alia competence in prescribing and maintaining intravenous fluids, necessitating a clear basic understanding of fluid balance and its assessment. The new National Institute for Clinical Excellence (NICE) Guidance ‘Acutely ill patients in hospital’ states that routine monitoring should include biochemical tests (for example, electrolytes, lactate, glucose and arterial pH). In 2006, a number of child deaths were reported to the Coroner in Northern Ireland, in which hyponatraemia had played a significant part, and mismanagement of fluid and electrolyte balance was identified as a major factor. How will our junior doctors become competent in requesting and interpreting investigations in laboratory medicine? The author’s experience of Foundation Years 1 & 2 (FY1 & FY2) doctors is that they have a very poor understanding of simple electrolyte disturbance including hyponatraemia. Moreover, they appear to have little concept of how tests should be used, and the role of positive or negative predictive values. There is very little literature to demonstrate the impact of the knowledge of basic sciences by junior doctors and its bearing on patient outcome. There is no shortage of anecdote and circumstantial evidence, but hard evidence is missing. The report by Khromova and Gray in this issue is therefore timely and confirms the concerns of our profession. Interestingly, ‘most countries assume that an increase in the doctor training rates will improve health care, but the evidence indicates that national health-care funds are better spent on promoting ‘evidence-based care’ directly’. Surely, an understanding of clinical biochemistry is pivotal to that evidence-based care. It should be appreciated that it is not only clinical biochemistry but also physiology, anatomy, therapeutics and clinical pharmacology where undergraduate training is deficient. A letter in BMA News in June 2007 described a FY2 doctor examining a patient with a broken forearm who did not know the anatomical name of the bone, but thought it began with ‘T’! The Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement are planning to incorporate teaching of management and leadership skills to undergraduates. Admirable in its way, but will it be to the further detriment of basic clinical science? If we are unable to improve the undergraduate training or even training of junior doctors, the role of clinical validation and interpretive comments will become still more crucial in protecting patients, and will need to be combined with foolproof decision support systems and effective interactive computerized physician order entry. Are junior doctors even aware the laboratories have staff who can help them, not only with interpretation, but also with advice on appropriate testing? Khromova and Gray review the sparse literature available, pointing out there is little evidence that the use of laboratory services can be improved by education. The authors‘ survey was implemented as a result of the frustration of laboratory staff who recognized the gaps in the knowledge of junior doctors when discussing significant results. This must be echoed all round the UK. Annals readers will not be surprised in the report that junior doctors felt more confident in their knowledge of when to request tests than in their ability to interpret the results. Almost 20% junior doctors felt confident enough to request tests that they were not confident in interpreting. Many of the junior doctors did not feel confident in either requesting or interpreting laboratory test such as magnesium, phosphate, parathyroid hormone, urine sodium

Postanalytical External Quality Assessment of Blood Glucose and Hemoglobin A1c: An International Survey

Diabetes mellitus (DM) is diagnosed and monitored worldwide by blood glucose (BG) and glycohemoglobin A(1c) (HbA(1c)) testing, respectively. Methods for quality assessment of clinician interpretations of changes in these laboratory results have been developed. This study uses survey responses from general practitioners (GPs) in different countries to investigate possible differences in interpretation of results, as well as the feasibility of performing international postanalytical external quality assessment surveys (P-EQAS). GPs recruited from 7 countries received questionnaires requesting interpretation of changes in a potentially diagnostic capillary BG result and an HbA(1c) value obtained during monitoring of a patient with type 2 DM. GPs were asked to estimate clinically significant differences between 2 consecutive laboratory results [critical difference (CD)/reference change value] for both BG and HbA(1c). The CDs reported by GPs were used to calculate the analytical variation (CV(a)), which was taken as the quality specification for analytical imprecision. Participants received national benchmarking feedback reports after the survey. The study included responses from 2538 GPs. CDs in BG results showed the same pattern and were comparable among countries. Calculated median CV(a) values would be possible to attain at 80% confidence but not at the conventional 95% confidence. For HbA(1c), the same pattern was shown across countries, but with lower changes considered true when HbA(1c) increased than when it decreased. Despite the consistent pattern, variations among GPs were considerable in all countries. Assessments of CDs for BG and HbA(1c) were similar internationally, and quality specifications for these analytes based on clinicians' opinions are therefore interchangeable among countries. International P-EQAS may contribute to a more rational use of laboratory services and clinical guidelines.

Socio-economic differences and health seeking behaviour for the diagnosis and treatment of malaria: a case study of four local government areas operating the Bamako initiative programme in south-east Nigeria.

BackgroundMalaria is one of the leading causes of mortality and morbidity in Nigeria. It is not known how user fees introduced under the Bamako Initiative (BI) system affect healthcare seeking among different socio-economic groups in Nigeria for diagnosis and treatment of malaria. Reliable information is needed to initiate new policy thrusts to protect the poor from the adverse effect of user fees.MethodsStructured questionnaires were used to collect information from 1594 female household primary care givers or household head on their socio-economic and demographic status and use of malaria diagnosis and treatment services. Principal components analysis was used to create a socio-economic status index which was decomposed into quartiles and chi-square for trends was used to calculate for any statistical difference.ResultsThe study showed that self diagnosis was the commonest form of diagnosis by the respondents. This was followed by diagnosis through laboratory tests, community health workers, family members and traditional healers. The initial choice of care for malaria was a visit to the patent medicine dealers for most respondents. This was followed by visit to the government hospitals, the BI health centres, traditional medicine healers, private clinics, community health workers and does nothing at home. Furthermore, the private health facilities were the initial choice of treatment for the majority with a decline among those choosing them as a second source of care and an increase in the utilization of public health facilities as a second choice of care. Self diagnosis was practiced more by the poorer households while the least poor used the patent medicine dealers and community health workers less often for diagnosis of malaria. The least poor groups had a higher probability of seeking treatment at the BI health centres (creating equity problem in BI), hospitals, and private clinics and in using laboratory procedures. The least poor also used the patent medicine dealers and community health workers less often for the treatment of malaria. The richer households complained more about poor staff attitude and lack of drugs as their reasons for not attending the BI health centres. The factors that encourage people to use services in BI health centres were availability of good services, proximity of the centres to the homes and polite health workers.ConclusionsFactors deterring people from using BI centres should be eliminated. The use of laboratory services for the diagnosis of malaria by the poor should be encouraged through appropriate information, education and communication which at the long run will be more cost effective and cost saving for them while devising means of reducing the equity gap created. This could be done by granting a properly worked out and implemented fee exemptions to the poor or completely abolishing user fees for the diagnosis and treatment of malaria in BI health centres.

Autoantibodies and specific serum proteins in the diagnosis of rheumatological disorders.

Rheumatic diseases are a major cause of morbidity and long-term disability. Approximately one-third of individuals aged over 75 years of age in the UK population has significant musculoskeletal problems.' There has been a tremendous expansion in the use of laboratory services over the past 10 years in rheumatology, and present day rheumatological practice relies heavily on serological testing. This has resulted from major advances in research in this field, particularly in the areas of immunology, the genetics of the human leucocyte antigen (HLA) system and the biochemistry of inflammation. The laboratory costs involved in providing a service for rheumatology for an average district general hospital lie between £50000 and £100000 per annum (personal communication), and many biochemistry laboratories currently perform a range of serological tests. However, the clinical significance and limitations of many of these tests may not be fully understood and appreciated by both clinical and laboratory personnel. As a result, a barrage of investigations are often requested, many of which may be unnecessary and incorrectly interpreted. The utilization of laboratory services in this way is probably not cost-effective or optimal for patient care. This review covers the use and interpretation of laboratory investigations employed in the common rheumatic diseases and highlights recent developments. The methodological aspects have been discussed in detail in a recent review.'

Laboratory Service Use in a University Health Clinic

We examined the use of laboratory services in a university health clinic. Data collected from the International Classification of Diseases Ninth Revision Clinical Modification Code and the Current Procedural Terminology Code were tabulated and analyzed from a 2-year period. Laboratory tests most frequently performed for this population were urinalyses, blood counts, wet preps, urine and gonorrhea cultures, and a variety of serologic tests used to screen for chlamydia, β streptococcus, Epstein-Barr mononucleosis, and pregnancy. The findings attest to the uniqueness of the college population when compared with the general physician office laboratory and the importance of health services and educational planning for this population.

Laboratory diagnosis of infectious diarrhea.

The microbiology laboratory, in conjunction with the medical staff, must determine a reasonable approach to the evaluation of diarrheal stools since the cost to rule out all potential pathogens is prohibitive and control of the use of laboratory services is now a major focus in all institutions. All stool cultures should be examined for Campylobacter, Salmonella, and Shigella, the most common causes of inflammatory bacterial diarrhea in the United States. Special media for other pathogens should be added only if there is high regional endemicity or significant clinical suspicion. If a child has bloody diarrhea, a search for E coli O157:H7 is indicated. For patients with a history of raw seafood ingestion or foreign travel, the laboratory should be asked to screen specimens for Vibrio and Plesiomonas species. The report from the laboratory should specifically state what enteropathogens have been excluded, for example, "No Salmonella, Shigella, or Campylobacter isolated." A report of "negative" or "no enteric pathogens" is not very useful. Diagnosis of viral and parasitic enteritis and antibiotic-associated diarrhea require a variety of additional tests. Clinicians are encouraged to discuss these issues with the pathologist or microbiologist at their local laboratory and be familiar with community microbiology practice, particularly which organisms require a special request for the laboratory to attempt identification.