Adrian Park, MD, chair of the Department of Surgery, and Igor Belyansky, MD, director of the Abdominal Wall Reconstruction Program, led the surgical symposium “Advanced Hernia in General Surgery” on June 26 and 27. The event, which attracted general surgeons from all over the East Cost, was held in the Simulation to Advance Innovation and Learning (SAIL) Center. It provided surgeons the opportunity to learn or further refine their knowledge of hernia repair and soft tissue repair techniques.
News and Updates
The AAMC Laboratory Utilization Committee has identified an approximately 70% duplicate test order rate for CRP and ESR. This is clearly too high. While there are certain clinical indications for ordering both tests, in most instances the CRP is the test of choice. We will continue to monitor duplicate test ordering rates with a goal of reduction to under 20%. We plan to selectively interview physicians who continue the practice of duplicate ordering to get mutual feedback about the clinical utility of this practice. As a reference guide please refer to the table shown below that was published by the bpac nz better medicine organization from New Zealand. See the full article here, which has some excellent information about ESR and CRP. Thanks to Dr. Jack Lichtenstein for consulting on this problem.
What is the best test to use in different situations?
There are few studies that compare the use of ESR and CRP, hence there are only a few conditions for which there are clear recommendations. As a result, the best approach is to consider the various clinical questions that may be posed during the course of the consultation, refer to Table 1.
Table 1: Choosing CRP or ESR
AAMC practice guideline for universal screening of new colorectal cancer patients with molecular testing for Lynch Syndrome (LS)by Medical Staff Office on July 29, 2014
The AAMC Laboratory Utilization Committee, after consultation with representatives from gastroenterology, hematology/oncology, colorectal surgery, and our genetic counselor, endorses a policy of universal molecular tumor testing for Lynch Syndrome in newly diagnosed colorectal cancer patients under 70 years of age. After reviewing literature on this topic, the most reasonable and cost-effective strategy seems to be screening for mismatch repair genes using immunohistochemistry with reflex testing for BRAF V600E mutation if MLH1 is absent. Loss of expression in any of the MMR genes (in the absence of a BRAF mutation) should prompt consultation with a genetic counselor for consideration of additional testing. This screening strategy should detect approximately 97% of cases. Furthermore, it is recommended that testing be obtained at the time of diagnostic biopsy so the information is available prior to surgery, as a diagnosis of LS may change surgical options (hysterectomy in females and extended colectomy in males). We recommend gastroenterologists adopt these guidelines when they have a new colorectal cancer diagnosis in their endoscopy center. Any new diagnoses of colonic adenocarcinoma made at AAMC in patients less than 70 years of age will automatically be sent for MMR profile with reflex to BRAF if MLH-1 is borderline or lost. This policy is meant to serve as a practice guideline. Other testing approaches at the time of initial diagnosis may be equally reasonable at the discretion of the gastroenterologist or surgeon. Thanks to Drs. Steve Proshan, Barry Cukor, and John Neuman along with Ashley Allenby, genetic counselor for their review and input.
As we increasingly focus on ways to provide safer, higher-quality care to patients, we are finding ways to reduce waste in healthcare resources. A Laboratory Utilization Committee has been gathering since February 2014 and is tasked with providing our clinicians with evidence-based recommendations for optimal clinical laboratory utilization. This work is being done in collaboration with Choosing Wisely®, a national initiative of the ABIM Foundation and with the American Society for Clinical Pathology.
Below you will find the first in a series of recommendations and guidelines from the committee regarding the RBC folate test. Expect periodic updates regarding changes to our lab test menu as we work toward our goal of developing an evidence-based formulary approach to lab test ordering. For more information or to recommend tests as good candidates for utilization review or elimination, please contact Sanford Robbins, MD, chief of pathology, at 443-481-4252 or srobbins@AAHS.org.
RBC Folate Test No Longer Indicated
The Lab Utilization Committee has identified RBC folate as a test that is no longer indicated. Based on studies carried out at Mayo Medical Laboratories, we believe there is sufficient equivalence between RBC and serum folate testing to support this decision. Effective immediately, all requests for RBC folate will be converted to an order for serum folate.
A 10-year retrospective study of RBC and serum folate testing, performed by Mayo Medical laboratories, concludes that there is no evidence to support routine ordering of RBC or serum folate, and that serum folate concentrations provide equivalent clinical information to RBC folate in the assessment and diagnosis of folate deficiency. The following is a quote from a Mayo Medical Laboratories’ “Hot topics in laboratory medicine”:
“True folate deficiency in the current era of FDA-mandated folic acid supplementation is exceedingly rare. There is no evidence to support routine ordering of RBC or serum folate, but serum folate concentrations provide equivalent clinical information to RBC folate in the assessment and diagnosis of folate deficiency. Based on these statistics, and because serum folate provides equivalent results to RBC folate in almost all clinical scenarios, routine ordering of RBC folate is no longer warranted. Furthermore, investigation of megaloblastic anemia should preferentially be initiated with vitamin B12 testing instead of folate due to the low incidence of modern folate deficiency. In the absence of B12 deficiency, it is more cost effective to simply supplement with folic acid rather than routinely test and monitor a patient’s folate status, similar to other nutritional deficiencies such as vitamin D.”
Please use the link shown below for additional information from the Mayo Hot Topics presentation given November, 2010.
The entire article can be found here.
This policy change was approved by a multidisciplinary committee of AAMC physicians that included representatives from hematology/oncology. Please direct any questions or comments to Suzanne Leshinskie, laboratory director, or Sanford Robbins, MD, Chief of Pathology.
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MDICS is Maryland’s largest, private hospitalist group of physicians, nurse practitioners and physician assistants dedicated to providing comprehensive, cost-effective, high-quality medical care to patients in hospitals, skilled nursing and rehabilitation centers, assisted living communities and continuing care retirement communities.
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“We are extremely proud that we’ve been selected as one of The Washington Post Top Workplaces,” said Dr. Douglas Mitchell, CEO and Co-Founder of MDICS. “We value our employees and strive to attain our Core Values, which includes achieving quality metrics for healthcare systems, teamwork with our providers and clients, a willingness to accomplish what our clients request (‘Yes’ culture), and maintaining connections with our employees, providers, and valued customers.”
Click here to read the article, “Cancer Pain and Current Theory for Pain Control.”
Please welcome the following new medical staff members:
- Bryan Ambro, MD – Annapolis Ear, Nose, Throat & Allergy Associates
- Clifford Andrew, MD – Private Practice, Neurology
- Susan Berger, MD – Joining Annapolis Rheumatology
- Madelaine Binner, CRNP – Joining Anne Arundel Oncology Center
- John Choi, MD – Joining Chesapeake Retina Centers
- Myra DeLuca, CNM – Joining Special Beginnings Birth and Women’s Center
- Bridgette Gourley, CRNP – AAMC Community Clinics
- Donna Greenfield, CNM – Joining Special Beginnings Birth and Women’s Center
- Cescili Hopkins, MD – Joining AAMC OB/Gyn Hospitalist Program
- Lianrui Li, CRNP – Joining AAMC Fast Care at Bowie
- Ellen McInerney, MD – Joining Maryland Inpatient Care Specialists, LLC
- Maureen O’Brien, PA-C – Joining AAMC Breast Center
- Tiffany Owens, MD – Joining Anesthesia Company, LLC
- Samir Patel, MD – Joining Anesthesia Company, LLC
- Valerie Sinady, MD – Joining AAMC Fast Care at Bowie
- Teresa Stanfill, CRNP – AAMC Community Clinics
- Sophie Thibodeau, CRNP – Joining Women Ob/Gyn, PA
Twelve college students began an eight-week program at AAMC on June 2. Working closely with a physician or nurse leader, the interns assist with clinical research and performance improvement projects toward a goal of presentation or publication. They are also learning research tactics in a classroom setting, and will present initial outcomes of their research to their cohorts, mentors and executives. In addition to research, students “shadow” mentors in clinics, on inpatient floors and operating rooms. Mentor clinicians include: Stephen Cattaneo, MD; Raymond Hoffman, MD; Alex Katcheves, MD; Paul King, MD; Cathaleen Ley, RN; Will Maxted, MD; Barry Meisenberg, MD; Joe Moser, MD; Lorraine Tafra, MD; David Weng, MD; and Aimee Yu, MD.