Roots, development and future directions of laboratory medicine

Lab-on-a-lollipop (LoL) platform for preventing food-induced toxicity: all-in-one system for saliva sampling and electrochemical detection of vanillin

Saliva has emerged as a primary biofluid for non-invasive disease diagnostics. Saliva collection involves using kits where individuals stimulate saliva production via a chewing device like a straw, then deposit the saliva into a designated collection tube. This process may pose discomfort to patients due to the necessity of producing large volumes of saliva and transferring it to the collection vessel. This work has developed a saliva collection and analysis device where the patient operates it like a lollipop, stimulating saliva production. The lollipop-mimic device contains yarn-based microfluidic channels that sample saliva and transfer it to the sensing zone embedded in the stem of the device. We have embedded electrochemical sensors in the lollipop platform to measure vanillin levels in saliva. Vanillin is the most common food flavoring additive and is added to most desserts such as ice cream, cakes, and cookies. Overconsumption of vanillin can cause side effects such as muscle weakness, and damage to the liver, kidneys, stomach, and lungs. We detected vanillin using direct oxidation at a laser-induced graphene (LIG) electrode. We showed a dynamic range of 2.5 μM to 30 μM, covering the physiologically relevant concentration of vanillin in saliva. The lab-on-a-lollipop platform requires only 200 μL of saliva and less than 2 minutes to fill the channels and complete the measurement. This work introduces the first sensor-embedded lollipop-mimic saliva collection and measurement system.

A Clinico-Pathological Multidisciplinary Team Increases the Efficacy of Skin Biopsy and Reduces Clinical Risk in Dermatology

A clinical risk is an inherent risk in healthcare processes, including skin biopsy procedures, and may lead to misdiagnoses, increased healthcare costs and potential harm to patients. Indeed, clinical and histopathological data must be integrated if we are to reduce clinical risks and improve diagnostic accuracy in the diagnosis of dermatologic diseases. Although dermopathology services used to be part of a dermatologist's duty, the recent centralization of these laboratories has caused a loss of expertise and increased both complexity and safety issues. Some countries have implemented clinical-pathological correlation programs aimed at facilitating communication between clinicians and dermatopathologists. However, Italy has regulatory and cultural barriers that make the implementation of these programs difficult. Therefore, an internal analysis was carried out to assess the efficacy and impact that skin biopsy procedures for inflammatory and neoplastic conditions have on the quality of care in our dermatology department. As the analysis evidenced a high number of descriptive pathologic reports and discordant diagnoses, a multidisciplinary group of four dermatologists, four general pathologists and one dermatopathologist was set up. Herein, we present the results of this analysis and project and describe the structure of the multidisciplinary group. We also discuss the pros and cons, possibilities and limitations of our project, including the regulatory barriers of the Italian National Health System.

Quality in laboratory medicine and the Journal: walking together

Quality in laboratory medicine is defined as "an unfinished journey", as the more essential the laboratory information provided, the more assured its quality should be. In the past decades, the Journal Clinical Chemistry and Laboratory Medicine has provided a valuable forum for garnering new insights into the analytical and extra-analytical phases of the testing cycle, and for debating crucial aspects of quality in clinical laboratories. The impressive number of papers published in the Journal is testimony to the efforts made by laboratory professionals, national and international scientific societies and federations in the quest to continuously improve upon the pre-, intra- and post-analytical steps of the testing cycle, thus enhancing the quality of laboratory information. The paper appearing in this special issue summarizes the most important and interesting contributions published in the Journal, thus updating our knowledge on quality in laboratory medicine and offering further stimuli to identify the most valuable measures of quality in clinical laboratories.

Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model

The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.

Evaluation of direct-to-consumer low-volume lab tests in healthy adults

BACKGROUND

Clinical laboratory tests are now being prescribed and made directly available to consumers through retail outlets in the USA. Concerns with these test have been raised regarding the uncertainty of testing methods used in these venues and a lack of open, scientific validation of the technical accuracy and clinical equivalency of results obtained through these services.

METHODS

We conducted a cohort study of 60 healthy adults to compare the uncertainty and accuracy in 22 common clinical lab tests between one company offering blood tests obtained from finger prick (Theranos) and 2 major clinical testing services that require standard venipuncture draws (Quest and LabCorp). Samples were collected in Phoenix, Arizona, at an ambulatory clinic and at retail outlets with point-of-care services.

RESULTS

Theranos flagged tests outside their normal range 1.6× more often than other testing services (P < 0.0001). Of the 22 lab measurements evaluated, 15 (68%) showed significant interservice variability (P < 0.002). We found nonequivalent lipid panel test results between Theranos and other clinical services. Variability in testing services, sample collection times, and subjects markedly influenced lab results.

CONCLUSION

While laboratory practice standards exist to control this variability, the disparities between testing services we observed could potentially alter clinical interpretation and health care utilization. Greater transparency and evaluation of testing technologies would increase their utility in personalized health management.

FUNDING

This work was supported by the Icahn Institute for Genomics and Multiscale Biology, a gift from the Harris Family Charitable Foundation (to J.T. Dudley), and grants from the NIH (R01 DK098242 and U54 CA189201, to J.T. Dudley, and R01 AG046170 and U01 AI111598, to E.E. Schadt).

An alternative perspective on how laboratory medicine can contribute to solve the health care crisis: a model to save costs by acquiring excellence in diagnostic systems

The rapid escalation in health care costs has led to the idea to deliver better care at lower costs, reshaping the responsibilities of the health care system to achieve the goal of creating value for the patient. The pressure for fiscal containment and the progressive reduction in available health care resources originated very short term strategies consisting of abrupt reductions in expenditure, specifically in the provision of clinical pathology laboratory medicine services. However, the impact of laboratory test results on diagnostic and therapeutic interventions has increased enormously in the past decade, due to advances in personalized medicine and to the strictly correlated requirement to use new biomarkers with increasing sensitivity and specificity in clinical practice. In order to create savings by delivering better care there is the need to invest financial resources in purchasing high technology and new sophisticated tests and to promote the expertise of clinical pathologists and laboratory medicine professionals. This approach to creating value in patient health care is more productive and sustainable ethically, morally and economically as a long-term strategy. It can be successfully achieved by applying defined rules that make public-private cooperation clearer, skipping incompatible solutions such as transforming clinical laboratories to 'industrially productive premises', outsourcing laboratory medicine services and using central acquisition of diagnostic systems.

Ask the right question: a critical step for practicing evidence-based laboratory medicine

The purpose of laboratory medicine is to facilitate better decision making in clinical practice and healthcare delivery. Decision making implies an unresolved issue, problem or unmet need. The most important criterion for any investigation to be of value in clinical practice is that it addresses an unmet need. The different ways in which laboratory investigations are utilized in patient care can be represented in the form of questions. It is important that these questions are articulated to highlight the variables that will impact on the effectiveness of the investigation in the scenario being considered. These variables include the characteristics of the patient (or population) and clinical setting, the nature of the decision and action taken on receipt of the test result and the expected outcome. Asking a question is the first step of the evidence-based laboratory medicine (EBLM) cycle, the other steps being acquiring the evidence, critically appraising the evidence, applying the evidence and auditing use of the evidence. Getting the question right determines the quality of the whole process, thus, defines the quality in practice of laboratory medicine. Whilst the main focus of the EBLM cycle is to provide a strong evidence base for use in clinical practice, it is clear that the five steps are equally applicable in commissioning, delivery and audit (performance management) of services. Asking the right question is crucial to improving the quality of evidence, and practice, in laboratory medicine, and should be used in routine laboratory medicine practice and management throughout healthcare.

Integrated diagnostics: proceedings from the 9th biennial symposium of the International Society for Strategic Studies in Radiology

The International Society for Strategic Studies in Radiology held its 9th biennial meeting in August 2011. The focus of the programme was integrated diagnostics and massive computing. Participants discussed the opportunities, challenges, and consequences for the discipline of radiology that will likely arise from the integration of diagnostic technologies. Diagnostic technologies are increasing in scope, including advanced imaging techniques, new molecular imaging agents, and sophisticated point-of-use devices. Advanced information technology (IT), which is increasingly influencing the practice of medicine, will aid clinical communication and the development of “population images” that represent the phenotype of particular diseases, which will aid the development of diagnostic algorithms. Integrated diagnostics offer increased operational efficiency and benefits to patients through quicker and more accurate diagnoses. As physicians with the most expertise in IT, radiologists are well placed to take the lead in introducing IT solutions and cloud computing to promote integrated diagnostics. To achieve this, radiologists must adapt to include quantitative data on biomarkers in their reports. Radiologists must also increase their role as participating physicians, collaborating with other medical specialties, not only to avoid being sidelined by other specialties but also to better prepare as leaders in the selection and sequence of diagnostic procedures.

Key Points

• New diagnostic technologies are yielding unprecedented amounts of diagnostic information.

• Advanced IT/cloud computing will aid integration and analysis of diagnostic data.

• Better diagnostic algorithms will lead to faster diagnosis and more rapid treatment.