The cost of inappropriateness of coagulation testing [I costi dell'inappropriatezza in coagulazione]

Background. Laboratory utilization has steadily increased with a corresponding increase in overall costs; several authors have attempted to measure the impact of inappropriateness on clinical outcomes but data are insufficient. The aim of the study is to assess the cost of inappropriateness of test-ordering behaviour for second-level coagulation tests (hemorrhagic diathesisand thrombophilia). Methods. We reviewed all second-level coagulation testrequests received by our department during a six months period. Clinicians must fill out a specific order form for these kind of tests, containing all informations deemed necessary for the laboratory specialist to evaluatethe appropriateness of the request. We identified all inappropriate requests and counted the numbers and types of all coagulation tests that were not performed during the period. An analysis of the laboratory activity costs was done in order to calculate the global costof each test in our department and to estimate the savings achieved. Results. On a total of 1664 second-level coagulationtest requests, we estimated 150 as completely inappropriate. We found an overall of 295 inappropriate testswhich were not performed. This resulted in an economic saving of 20.000 euro in 6 months. Conclusions. The analysis of cost of our intervention shows the urgent need for a definite and sustained reduction in inappropriate requests of second-level coagulation tests. Even though we estimated only the economic aspect of inappropriate testing, this is also associated with the overuse of diagnostic tests which entailsthe risk of generating erroneous results with potentialnegative consequences on patients' health.

Patients with AIDS-defining cancers are not universally screened for HIV: a 10-year retrospective analysis of HIV-testing practices in a Swiss university hospital.

OBJECTIVES: Kaposi's sarcoma (KS), invasive cervical carcinoma (ICC) and non-Hodgkin lymphoma (NHL) have been listed as AIDS-defining cancers (ADCs) by the Centers for Disease Control and Prevention since 1993. Despite this, HIV screening is not universally mentioned in ADC treatment guidelines. We examined screening practices at a tertiary centre serving a population where HIV seroprevalence is 0.4%. METHODS: Patients with KS, ICC, NHL and Hodgkin lymphoma (HL), treated at Lausanne University Hospital between January 2002 and July 2012, were studied retrospectively. HIV testing was considered part of the oncology work-up if performed between 90 days before and 90 days after the cancer diagnosis date. RESULTS: A total of 880 patients were examined: 10 with KS, 58 with ICC, 672 with NHL and 140 with HL. HIV testing rates were 100, 11, 60 and 59%, and HIV seroprevalence was 60, 1.7, 3.4 and 5%, respectively. Thirty-seven patients (4.2%) were HIV-positive, of whom eight (22%) were diagnosed at oncology work-up. All newly diagnosed patients had CD4 counts < 200 cells/μL and six (75%) had presented to a physician 12-236 weeks previously with conditions warranting HIV testing. CONCLUSIONS: In our institution, only patients with KS were universally screened. Screening rates for other cancers ranged from 11 to 60%. HIV seroprevalence was at least fourfold higher than the population average. As HIV-positive status impacts on cancer patient medical management, HIV screening should be included in oncology guidelines. Further, we recommend that opt-out screening should be adopted in all patients with ADCs and HL.

Non-invasive RF built-in testing using on-chip temperature sensors

This poster shows how to efficiently observe high-frequency figures of merit in RF circuits by measuring DC temperature with CMOS-compatible built-in sensors.

Recent developments in the use of isotope ratio mass spectrometry in sports drug testing.

According to the annual report of the World Anti-Doping Agency, steroids are the most frequently detected class of doping agents. Detecting the misuse of endogenously occurring steroids, i.e. steroids such as testosterone that are produced naturally by humans, is one of the most challenging issues in doping control analysis. The established thresholds for urinary concentrations or concentration ratios such as the testosterone/epitestosterone quotient are sometimes inconclusive owing to the large biological variation in these parameters.For more than 15 years, doping control laboratories focused on the carbon isotope ratios of endogenous steroids to distinguish between naturally elevated steroid profile parameters and illicit administration of steroids. A variety of different methods has been developed throughout the last decade and the number of different steroids under investigation by isotope ratio mass spectrometry has recently grown considerably. Besides norandrosterone, boldenone was found to occur endogenously in rare cases and the misuse of corticosteroids or epitestosterone can now be detected with the aid of carbon isotope ratios as well. In addition, steroids excreted as sulfoconjugates were investigated, and the first results regarding hydrogen isotope ratios recently became available.All of these will be presented in detail within this review together with some considerations on validation issues and on identification of parameters influencing steroidal isotope ratios in urine.

Spare non-occupational HIV post-exposure prophylaxis by active contacting and testing of the source person.

OBJECTIVE: HIV-1 post-exposure prophylaxis (PEP) is frequently prescribed after exposure to source persons with an undetermined HIV serostatus. To reduce unnecessary use of PEP, we implemented a policy including active contacting of source persons and the availability of free, anonymous HIV testing ('PEP policy'). METHODS: All consultations for potential non-occupational HIV exposures i.e. outside the medical environment) were prospectively recorded. The impact of the PEP policy on PEP prescription and costs was analysed and modelled. RESULTS: Among 146 putative exposures, 47 involved a source person already known to be HIV positive and 23 had no indication for PEP. The remaining 76 exposures involved a source person of unknown HIV serostatus. Of 33 (43.4%) exposures for which the source person could be contacted and tested, PEP was avoided in 24 (72.7%), initiated and discontinued in seven (21.2%), and prescribed and completed in two (6.1%). In contrast, of 43 (56.6%) exposures for which the source person could not be tested, PEP was prescribed in 35 (81.4%), P &lt; 0.001. Upon modelling, the PEP policy allowed a 31% reduction of cost for management of exposures to source persons of unknown HIV serostatus. The policy was cost-saving for HIV prevalence of up to 70% in the source population. The availability of all the source persons for testing would have reduced cost by 64%. CONCLUSION: In the management of non-occupational HIV exposures, active contacting and free, anonymous testing of source persons proved feasible. This policy resulted in a decrease in prescription of PEP, proved to be cost-saving, and presumably helped to avoid unnecessary toxicity and psychological stress.

Acceptance of inflammatory bowel disease treatment recommendations based on appropriateness ratings : do practicing gastroenterologists agree with experts?

BACKGROUND: Appropriateness criteria for the treatment of Crohn's disease (CD) and ulcerative colitis (UC) have been developed by experts' panels. Little is known about the acceptance of such recommendations by care providers. The aim was to explore how treatment decisions of practicing gastroenterologists differ from experts using a vignette case study and a focus group. METHODS: Seventeen clinical vignettes were drawn from clinical indications evaluated by the expert panel. A vignette case questionnaire asking for treatment options in 9-10 clinical situations was submitted to 26 practicing gastroenterologists. For each vignette case, practitioners' answers on treatments deemed appropriate were compared to panel decisions. Qualitative analysis was made based on focus group discussion to explore acceptance and divergence reasons. RESULTS: 239 clinical vignettes were completed, 98 for CD and 141 for UC. Divergence between proposed treatments and results from panels was more frequent for CD (34%) than for UC (27%). Among UC clinical vignettes, the main divergences with the panel were linked to 5-ASA failure assessment and to situations where stopping treatment was the main decision. For CD, the care provider propositions diverged with the panel in mild-to-moderate active disease, where practitioners were more prone to an accelerated step up than the panel's recommendations. CONCLUSIONS: In about one third of vignettes cases, IBD treatment propositions made by practicing gastroenterologists diverged as compared to expert recommendations. Practicing gastroenterologists may experience difficulties in applying recommendations in daily practice.

Jackson County Sanitary Disposal Agency independent auditor's reports, basic financial statements and required supplementary information, schedule of findings, June 30, 2009

Audit report on the Jackson County Sanitary Disposal Agency for the year ended June 30, 2009

Mutational and computational analysis of the alpha(1b)-adrenergic receptor. Involvement of basic and hydrophobic residues in receptor activation and G protein coupling.

To investigate their role in receptor coupling to G(q), we mutated all basic amino acids and some conserved hydrophobic residues of the cytosolic surface of the alpha(1b)-adrenergic receptor (AR). The wild type and mutated receptors were expressed in COS-7 cells and characterized for their ligand binding properties and ability to increase inositol phosphate accumulation. The experimental results have been interpreted in the context of both an ab initio model of the alpha(1b)-AR and of a new homology model built on the recently solved crystal structure of rhodopsin. Among the twenty-three basic amino acids mutated only mutations of three, Arg(254) and Lys(258) in the third intracellular loop and Lys(291) at the cytosolic extension of helix 6, markedly impaired the receptor-mediated inositol phosphate production. Additionally, mutations of two conserved hydrophobic residues, Val(147) and Leu(151) in the second intracellular loop had significant effects on receptor function. The functional analysis of the receptor mutants in conjunction with the predictions of molecular modeling supports the hypothesis that Arg(254), Lys(258), as well as Leu(151) are directly involved in receptor-G protein interaction and/or receptor-mediated activation of the G protein. In contrast, the residues belonging to the cytosolic extensions of helices 3 and 6 play a predominant role in the activation process of the alpha(1b)-AR. These findings contribute to the delineation of the molecular determinants of the alpha(1b)-AR/G(q) interface.

Queen acceptance in a socially polymorphic ant

A central question in social evolution is what processes regulate the number of breeders in each social group. Here, we tested whether differences in the rate of acceptance of new queens by resident workers could be a proximate cause explaining the coexistence of single- and multiple-queen colonies in an ant population. We found that Formica selysi workers discriminated against foreign (non-nestmate) queens, which contributes to maintaining the genetic integrity of the social group essential to kin selection. All the young and newly mated foreign queens introduced into experimental groups of workers died within 48 h. In contrast, workers frequently accepted young newly mated nestmate queens. The survival of nestmate queens was not significantly lower in groups of workers originating from single- queen colonies than in groups of workers originating from multiple-queen colonies. Finally, virgin queens had significantly higher survival than mated queens. Together, these results show that the maintenance of single-queen and multiple-queen colonies in the same population is unlikely to be caused by strong differences between the two types of colonies in their rate of acceptance of new queens by workers. They also suggest that the discrimination of queens by resident workers restricts the dispersal of foreign queens among colonies, but not the acceptance of additional nestmate queens.

Wireless E911 Emergency Communications Fund Iowa Homeland Security and Emergency Management Division of the Iowa Department of Public Defense independent auditor's reports, basic financial statements and supplementary information, June 30, 2009.

Audit report on the Wireless E911 Emergency Communication Fund of the Iowa Homeland Security and Emergency Management Division of the Iowa Department of Public Defense for the year ended June 30, 2009