LIVING THE LAB LIFE
A BLOG FOR ASCLS REGION V
Greeting from Duluth!
We kicked off the 2017 CLC with a keynote address by ASCLS Executive Vice President Jim Flanigan. Jim’s talk, titled “Disruptive Beliefs, Memes, Mission, and Myths of the Slimy Salesman” is a call to action for all laboratory professionals. As a group, we acknowledge that we do not receive that credit that we deserve for the life-saving care we provide. Additionally, we see, day in and day out, how many errors that occur in the ordering, collecting, and interpretation of laboratory testing. Medical errors like than can be costly. As many as 100,000 people die each year in the United States because of medical errors. Jim’s talk challenges laboratory professionals to be the salespeople of their trade, not only for our sake but for the sake of patient safety. In every encounter with other members of the healthcare team, we need to make the conversation about what we can do for them and for their patients. Patient lives depend on it.
The first breakout session that I attended was given by Dr. Qia Ding, MD, PhD from Ortho Diagnostics. Dr. Ding’s presentation focused on Acute Kidney Injury (AKI) and how current technologies and protocols fall short. Currently, diagnosing and staging of AKI depends on assessing serum creatinine levels and urine volume output. In many patients, this means that diagnosis (and therefore treatment) doesn’t happen until 48 hours after the event triggering the AKI. This has a major effective on patient outcomes, hospital expense, length of stay, readmission rates, etc. It is estimated that about half of all cases of AKI are either misdiagnosed, diagnosed too late, or missed all together. Dr. Ding presented to us a new test available through Ortho Diagnostics, the Nephrocheck, which can diagnose patients with AKI far more rapidly. This test recognized two urinary biomarkers, TIM-2 and IGFBP-7, associated with cellular stress in the renal tubular epithelial cells of the kidneys. A positive result indicates a patient has AKI. The test is supposed to be used within twelve hours of whatever event triggers the AKI (major surgery, nephrotoxic drugs, sepsis, circulatory shock, radiographic dyes). There is clearly an opportunity to influence better patient outcomes with more prompt diagnosis of AKI; I am very interested in seeing what more assay come out in the future to address this issue.
The second session I attended, titled “Genetic Testing 101: Navigating the world of 65,000 Different Genetic Tests,” gave an overview of the market for genetic testing and how us laboratorians can use our knowledge to help keep costs under control. The speaker, Dr. Michelle (Shellie) Keike, PhD, MS, CGC, is a genetic counselor who works in the laboratory at Region Hospital in St. Paul. Her role is to assist providers in ordering appropriate genetic testing. This is no small task, as she estimates that ten new molecular tests are added to the market EACH DAY. The work of her and her team has helped to save $700,000 in unnecessary lab testing in just two years, wow! Dr. Keike gave a few great resources for genetic testing that she recommended consulting in the event you work in a facility that doesn’t have a genetic counselor based in the laboratory (so most of us). I have listed them below:
Concert Genetics is a free search engine used to find genetic tests.
The Genetic Science Learning Center is a website curated by the University of Utah that gives general information about genetics.
Genetics Home Reference (NIH) features patient-friendly genetics information, as it related to human conditions.
GeneReviews (NIH) features genetics information related to human conditions, but caters more to healthcare and genetic professionals.
And, as always, PubMed (NIH) is a great resource for primary research, literature, and reviews.
The third session of the day addressed the opiate crisis in the United States. Dr. Brian Konowalchuk, MD, MPH, chair of the Opiate Response Team within the Essentia Health System in northern Minnesota, presented on this topic. Dr. Konowalchuk talked about the roots of this epidemic: how an initiative on the part of health care practitioners to focus on eliminating pain met with the release and (very successful) marketing of the new opiate drug Oxycontin, touted as an effective pain killer with no risk of addiction (now know to be a false claim) to create this epidemic. 80% of all opiate drugs used worldwide are used in the U.S. This has led to an unquantifiable financial expense, millions of addicts, and thousands of deaths. Opiate deaths have now surpassed motor vehicle accident deaths in the U.S. Unfortunately, despite the 249 million opiate prescriptions written the U.S. each year, we have not reduced pain, at all, according to the CDC. Dr. Konowalchuk and his colleagues at as Essentia Health have focused their efforts on reducing unnecessary prescribing. They have also tracked patient compliance with medication, through urine drug screening and pill counting, to halt prescribing to patients who are not using the drug they are prescribed but instead sell it for profit. This had led to a substantial drop in prescriptions. Obviously, this a fight that healthcare is just starting, but one that needs to be battled for the sake of the health of our patients.
The final session of the day, “Lipid Testing for CV Risk: Some Old and Some New,” was given by Dr. Leslie Donato, PhD DABCC, Co-director of the Cardiovascular Lab and Point of Care at Mayo Clinic. Dr. Donato’s talk focus on primary prevention of cardiac events (how to assess risk of cardiovascular events in patients who have never had a cardiovascular event). The famous Framingham study generated a set of risk factors for cardiovascular events: increased age, gender (sorry guys), poor diet, smoking, hypertension, hypercholesterolemia, and low HDL-C. Using a simple risk assessment—there is an app for that called the Cardiac Risk Assist—providers can calculate a risk level (both ten-year and lifetime) for their patients, using just their total cholesterol and HDL-C values. Using total cholesterol and HDL-C is great, because much research has demonstrated that these values are not impacted when a patient is non-fasting (unlike triglycerides and to a slight degree LDL), which makes things simpler for the patient. Patients who score low on the risk assessment don’t need additional intervention, patient who score high will likely need statin therapy. The tricky population to deal with are those who have an intermediate risk, how do we know if they really require intervention? Many other biomarkers can be tested to determine true risk in these patients. Dr. Donato focused on three other lipid biomarkers that can be used: LDL particles, Lipoprotein(a), and Ceramides. All three of these biomarkers are involved with plaque formation and inflammatory activity that leads to atherosclerosis. With LDL particles, laboratory analysis measures the number of LDL particles present in a patient sample. This information is then used in conjunction with the patient’s cholesterol level to determine if those particles are cholesterol-rich or cholesterol-poor (example: if two patients have the same cholesterol level, but one has a much higher number of particles, they would be considered cholesterol-poor, the patient with fewer particles is considered cholesterol-rich). Falling into the cholesterol-poor category are at a higher risk of future cardiovascular event. Lipoprotein(a) is a lipid that not all people express (genetically inherited trait). For those who have a lot of Lipoprotein(a), their risk is increased. Ceramides are the newest of the bunch. At Mayo, they measure three different ceramide molecules (and a fourth normal molecule that serves as a standard). The higher each abnormal ceramide level is, the higher the overall risk for that patient.
It was a great day of continuing education. Now off to the social event at Canal Park Brewery!