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II DOT PANELS 14
Cardiovascular System 14
Respirotary System 14
GI Tract and Pancreas 14
Hepatobillary Tract 14
Urogenital Tract 15
Endocrine Systems 15
Haematology 16
Acid Base Disorders 17
Autoimmune Disorders 17
Infectious Diseases 17
Mineral / Bone Disorders 22
Skeletal Muscle Disorders 22
Joint Diseases 23
Cancer 23
Prenatal and Neonatal Diagnosis 24
General 25
Introducing the First Ever,"Alchoholism Index" 26
III ENDORSEMENTS 27
Dear Friend
As you may well be aware, technology nowadays has increased the number, variety & complexity
of lab tests to such an extent that they "outstrip the ability of the physician," to keep informed
about their diagnostic utility, & more importantly their interpretation in clinical situations.
"Everytime a physician faces a medical diagnosis, he/she has to select from about 1000 tests at
any given time". Obviously then selecting the appropriate tests further applying their findings to
achieve a diagnosis can be an extremely mind boggling task !!!
At present physicians have no option but to choose from "test request lists/brochures/booklets"
which basically resemble "a la carte like menus" [whether from large hospitals; specialized
reference labs, private labs, or diagnostic centres], These test request formats in no way, help the
physician in the diagnostic process.
A brief mention regarding the "utilty of interpretive reporting". Interpretive reports by the
pathologist, give meaning & knowledge to raw lab data, thereby increasing their informative
content. Besides saving precious time & effort of the physician, interpretive reports guide the
physician, to focus on important facts. while at the same time overlook irrelevant data. The
diagnostic possibilities, suggested by the pathologist (from test values) are similar to provisional
diagnosis, conceptualised by the physician [from clinical history, signs, symptoms] & ideally
should not be ignored. However physicians have the same prerogrative of accepting or rejecting
the suggestion as for any other consultant.
Finally friends, in the next few pages, I have taken the liberty of sharing a few thoughts with you,
regarding the current scenario in lab testing. I hope the new concept of "Decision Oriented
Laboratory Testing" will in some way, change the attitudes and approach, towards clinical
diagnosis & management by lab methods. Looking forward for your support.
Regards
Dr. Deepak H. Daswani
INTRODUCTION
Whether it is major hospitals, large or small volume path labs, speciality reference labs or
diagnostic centres; the appearance of test request forms/slips are all alike. The tests are arranged
like "little ticket items" which have to be ticked off. These menus mostly contain lists of individual
tests, along with some "multitest profiles" [ex SMA 12, Pacer 22; 26: profiles [liver; kidney;
cardiac: body etc.].
“It is the content of the panel & not the concept, that has been problematic" These
"menus" are based on the fact "at tests have been traditionally segregated by the technology by
which they were performed. Hence he distinction into arbitrary categories like: Haematology;
clinical pathology; biochemistry; immunology; microbiology, histopathology; blood banking etc.
"typical of hospital menus"]. Non specific categories like Routine; Hormones; Elise: Serology;
Bacteriology are "typical of private labs".
Although for the purposes of a price list or services offered these categories would
suffice, but by no stretch of imagination, would these lists give the physician, any clue
as to selection of appropriate tests, to make a diagnosis.
It is generally assumed that, the laboratory is solely responsible, for total quality management in
diagnosis. To a large extent this is true, since technically speaking, the correct result depends on
the correct test analysis. "The Lab information Loop" (is an excellent) representation of variables
associated with lab testing. As you can see a "wrong report" could be generated due to an error at
any stage in the loop:
Faulty sampling [C]; specimen processing [D]; bad equipment or reagents[E]; poor quality control
[F]; Any of these can render report useless, despite the best management systems. "However the
bottom line is that, if the appropriate tests are not requested by physician, effective test report
[G] by pathologist is not possible, hence the whole process of lab testing is futile.
"The Lab Information Loop" Fig [1]
Of the Internationally accepted criteria for TQM; two are most relevant :-
1. "The tests requested by the physician must be appropriate to the medical problem"
[A]Effective medical diagnosis would require first of all, appropriate tests be chosen by the
physician.
Interpretive reports, close the gap between mere reporting of lab test results, viz a viz their
integration into the diagnostic & management process.
How
to effectively order lab tests "The
Diagnostic Reasoning Approach"
Effective lab test utilization, can only be understood in relation to their clinical context. This
approach provides a useful frame work for the initial confusion as to which type of tests to order.
Ordering of lab tests are usually done for primary medical reasons like:
Screening [wellness case finding]
Diagnosis
Monitoring
When the question is health v/s illness multitest screening profiles ["SMA 12; Pacer 22; Pacer 26"]
in general have not proven to be beneficial. The single most important reason is "The unexplained
abnormal test result". It is known that the probability of an abnormal result. (result above the
reference Lange); would represent a "statistical outlier" If it did not fit in with any clinical
findings.
It should be noted here, that reference values represent statistical data for 95% of the population.
"These statistical outliers" therefore may or may not represent disease. "The probability of these
unexplained abnormal results, increase with the number of tests in the screening panel" Fig [2]
What actually happens is that, with any unexplained abnormal test result, "the physician faces the
dilemma, whether to ignore the finding or follow it". In most cases, the physician follows up with
extensive investigations. This leads to the "Ulysses Syndrome" [like Ulysses the greek
mythological character, the patient has to pass through a long journey of investigations before he
is declared fit].This obviously, is traumatic to the patient in more ways than one.
A sure shot way to tackle the problem of the "unexplained abnormal result", would be to "discount
physiological variables" [age; sex; stress, exercise; pregnancy; diet etc.] as well "as preanalytical
variables" [specimen collection; effects of drugs etc]. If all of these do not explain the abnormal
result, then "repeat or serial testing at intervals", would finally decide whether test was actually
abnormal.
The most common single test abnormalities in screening panels [SMA 12; Pacer etc] are
seen with: Calcium; Alkaline Phosphatase; Albumin; Glucose; Sodium;
Profiles [ex. Liver; Kidney; Thyroid; Lipid etc] are of use only in case findings i.e. testing
individuals symptomatic for a particular organ system disease, by tests used for other organ
system. Examples are:-
Thyroid profile: For patients with Atrial fibrillation, or recently diagnosed hyperlipadaemias;
infertility in women, normocytic anaemias; elderly people admitted to hospitals.
Liver profile: For patients with coagulopathies [increased prothromobin time; PTT etc];
hyperlipidaemias; normocytic anaemia & electrolyte imbalances (Hypo/hypernatremias)
Kidney profile: For chronic diabetics; long standing hypertensives, Acid base abnormalities
(metabolic acidosis); electrolyte imbalances [hypo/hypernatremia]; Renal osteodystrophy
Normocytic anaemias.
Lipid profile: In Diabetics; chronic liver diseases (ex. obstructive jaundice), kidney disease (ex.
nephrotic syndrome; chronic uraemia); chronic alcoholism, obesity etc.
In these situations, results of profiles will provide a clue as to whether there is presence or
absence of disease.
Like "guided missiles" diagnostic tests should home onto the target (diagnosis). This can only
be achieved by a structured approach to testing. Ideally the "right mix" of diagnostic tests should
either: Confirm a diagnosis; Exclude a diagnosis; Clarify a diagnosis; Provide clues to an unclear
diagnosis.
Some important situations where diagnostic tests, coupled with interpretive reports, would be of
use are:
Anaemia
Hepatitis
Thyroid disorders
Metabolic problems [Hypercalcaemia; Hypo or hypernatremias; Acid base disorders etc.]
Autoimmune disorders
Complex haematological disorders [ex. Leukaemias; Lymphomas; Coagulopathies1]
If diagnostic tests sort out the diagnosis; monitoring tests on the other hand "piggy back" on the
diagnostic tests. If the disease has recently been diagnosed or is already known, then
monitoring tests are useful for : Monitoring course of disease; Monitoring therapy;
Staging severity of disease; Providing prognostic parameters:
Leukaemias/Lymphomas/Myelomas
Pancreatitis (Acute & chronic)
Hyperlipidaemias (primary/secondary)
Tumour markers [ex. CEA (colon cancers); CA 125 (ovarian cancers); AFP (liver & germ cell
tumors), PSA (prostate cancers) etc]
Chronic renal failure
Viral hepatitis
It is entirely possible, to categorize common & complicated medical problems (within their
respective organ systems). These problems can then be viewed in the format of so called "DOT
PANELS". The type of tests utilized in these panels, would determine whether any given panel is
ideal for either :- "screening, diagnostic or monitoring purposes".
Appropriate Tests: Not only do these panels ensure that the correct tests are requested, they
also ensure that, unnecessary or outdated tests are eliminated, while at the same time new
accurate tests are introduced.
Interpretive Reports: Test results can be communicated "in the same format" as that of request
form, hence improving the diagnostic utility of the test results.
Strategy Implementation: DOT PANEL - request forms, allow implementation of: "optimal
screening, diagnostic & monitoring strategies"
Presented below are examples of how DOT - PANELS score over the conventional profiles [note
tests have been ommited]. Only the diagnostic utility of these panels are highlighted.
Acute Renal failure Diagnostic Differentiating types Pre renal; Renal & Post renal
Presented below are "more than 400 DOT PANELS". These Span 10 organ systems & important
clinical categories like: Acid base & Electrolyte disorders; Autoimmune disorders; Infectious
diseases; Tumour markers; Prenatal (neonatal diagnosis) & inherited disorders of metabolism.
These panels coveralmost all common (& not so common) diseases in current existence.
I have deliberately omitted the tests within these panels (due to space constraints). "The intention
here, is to convey the concept of these panels in focussed diagnosis".
The right mix of tests: to guide the physician towards a fast & accurate diagnosis
Strategy Implementation: In screening, diagnosis or monitoring situations.
Multipurpose use: Can double up as request forms, as well as Interpretative reports.
DOTS PANELS
CARDIOVASCULAR SYSTEM
1. Lipid Panel – Basic
2. Coronary risk factor panel
3. Atherothrombotic Profile
5 A M I - M a r k e r s o f complications
7. CCF - Panel II
8 Hypertension Panel - I
9 Hypertension Panel - II
RESPIRATORY SYSTEM
1. Pleural fluid analysis Panel -
2. Pleural fluid analysis Panel - I
3. Acute Pharyngitis Panel
4 Acute Resp i ratory Infection Panel - 1
9 Lung Cancer
GI TRACT AND PANCREAS
1 GI Panel - I
2. Gastric Evaluation Panel - I
3 Intestinal Malabsorption Panel - I
4. Intestinal Malabsorption Panel - II
5. Acute Diarrhaea - Panel 1
6 Acute Diarrhaea - Panel II
7 Chronic Diarrhaea
9.Acute Pancreatitis
10.Chronic Pancreatitis
11.Pancreatic Carcinoma
HEPATOBILIARY TRACT
1. Liver panel - Basic
2. Acute Hepatitis
3. HBV- Acute Phase Markers
4. HBV - Chronic Phase Markers
5. HBV- Carrier Phase Markers
6. HBV- Prenatal screen 7. HDV - Panel
7. HCV - Panel 1
8. HCV Panel 11
9. Alcoholism Index
10. Fatty liver & Alcoholic Hepatitis
11. Acute Fulminant Hepatic Failure
12. Chronic Hepatitis
13. Auto Immune Hepatitis 15, Primary Billary Cirrhosis Panel -1
14. Primary Billary Cirrhosis Panel - II
15. Primary Sclerosing Cholangitis
16. Hemochromatosis
17. Cirrhosis
18. Cholestasis/Billiary obstn
19. Liver Metastatsis
20. Neonatal Hyperbillirubinemia
21. Spontaneous bacterial Peritonitis
UROGENITAL TRACT
1. Renal Profile - Basic
3. Protenuria - follow up
4. Haematuria - follow up
6. Diabetic Nephropathy
7. Nephrotic Syndrome
16. Urethritis/Cervicitis
5 Hypoglycaemia
8 Hyperthyroidism Panel -1
9 Hyperthyroidism Panel - II
10. Hypothyroidism Panel - I
11 Hypothyroidism Panels -II
12. Neonatal hypothyroidism
9. Neutrophilia/Leucocytosis
20. Lymphocytosis
3. Hyponatremia
4. Hypernatremia
5. Hypokalernia
6. Hyperkalemia Panel - I
7. Hyperkalemia Panel - II
AUTOIMMUNE DISORDERS
1. Autoimmune Panel - 1
2. Autoimmune Panel - 11
3. SLE Profile - 1
4. SLE Profile - II
5. Sjogren Syndrome
6. Scleroderma
7. Polymyositis/ Dermatomyositis
8. MCTD
9. Rheumatoid Arthritis
INFECTIOUS DISEASES
1. Bacteria Detection
2. Viral Detection -
3. Chlamydial Detection -
4. Mycoplasma Detection -
5. Fungal Detection -
6. Parasite Detection -
9. Fever Profile
B - Cellulitis
C - Wound Infectious [Including surgery/post damaged tissue ulcers/ traumatic devitalized
tissue/burn, wound etc]
II - RESPIRATORY SYSTEM
III - ENT
A - Sinusitis [acute/chronic]
B - Pharyngitis & Tonsilitis [sore throat/Epiglotitis]
C - Otitis Media [acute/ chronic; Mastoiditis/ External ear infection]
IV - GIT
A - Oesophagitis
B - Gastritis/Duodentitis [GI ulcers]
C - Enterocolitis [gastroenteritis Infectious colitis; Diahorreas]
VI – OPTHALMIC
A - Orbital Infection
B - Conjunctivitis
Vll - C N S
A - Meningitis
B - Encephalitis
C - Brain Abscess
D - Encephalopathy [Brain Infiltration/Vascular occlusion etc]
E - Neuropathy [mono or polyneuritis/periph eral neuropathy/myelopathy
IX - UROGENITAL TRACT
A - Acute Glomerulo - Nephritis [Nephrotic syndrome]
X - LYMPH NODE
A - Lymphadenitis/ Lymphadenopathy [acute/chronic/ulcerative/ lymphangitis]
XI - BLOOD
A - Bacteremia
B Vire mia
C Fungemia
D - Parasitaemia
E - Others [TB; Bartonella; Rickettsiae]
F - Haemopoetic System
• Altered WBC counts
• Anaemia
• Haemolytic Anaemia
• Bone Marrow lnfiltn
• Hematologic Malignancies
II - VIRAL INFECTIONS
A - Torch Panel
Toxoplasma Gondii
Rubella#
CM
HSV
HIV
Parvo virus B19
Enterovirus
B - Viral Infections in lmmuno Compromised [CMV; HSV; EBV; HIV]
C - Viral Disease Organ Panels [CANS; Respiratory Exanthems; Myocarditis - Pericarditis
Enterocolitis]
V .SPIROCHAETAL INFECTIONS
A - Syphillis
B - Lyme disease [Bordelia Burgdorferi]
C – Leptospirosis
MINERAL/BONE DISORDERS
SKELETAL/MUSCLE DISORDERS
Skeletal Muscle Disease Panel - Basic
Muscular Dystrophies -Panel-I
Muscular Dystrophies -Panel - II
Polymyositis
Myopathies [endocrinal & alcoholic]
Malignant Hyperthermia [Heatstroke]
Myaesthenia Gravis
JOINT DISEASES
Arthritis Panel - I
Arthritis Panel - II
Synovial Fluid testing
Infective Arthritis
Rheumatoid Arthritis Panel I
Rheumatoid Arthritis Panel II
Gout
CANCER
I GASTROINTESTINAL TRACT
A. - Oral Cavity
Tongue Carcinoma
Salivary gland carcinoma
Oral cavity & cheek tumors
C Colon
Colorectal adenocarcinoma
Familial Adenomatous Polyposis colic
Familial non polyposis colon cancer
D - Pancreas
Pancreatic Carcinoma
Glucagonoma
Insulinoma
Non islet cell Tumors
Pancreatic islet cell Tumors
E - Liver
Hepatocellular Carcinoma
Angiosarcoma liver
F - Spleen
IV - LUNG CANCER
A - Adenocarcinomas
B - BronchogenicCarcinoma
C - Mesotheliomas
D - OAT (small cell) Carcinomas
IX - VARIOUS TUMORS
A - Squamous Cell Cancers [Uterus; Cervix, lung; neck]
B - Carcinomas [general]
C - Bone Cancer [general]
D – Osteosarcoma
E - Soft Tissue Sarcoma
F - Mesothelioma
X - CNS CANCERS
A - CNS Tumors [general]
B- Astrocytoma
C - Neuroblastoma
D - Pituitary Tumors
E - Haemangioblastomas
F - Neurofibromatosis [type 1 & 11]
G -Schwannomas & Meningiomas
XI - HAEMOPOIETIC SYSTEM
A - Leukaemias (general)
B - Leukaemias - Chronic Myeloid
C - Leukaemias - Acute Lymphoid
D - Leukaemias - Acute Myeloid
ELymphomas[general]
GENERAL
E - Electrophoresis
[Monoclonal gammopathy]
F - Electrophoresis
[Unexplained Proteinuria]
G - Electrophoresis [Acute
phase response]
H - Electrophoresis
Immunodeficiencies
I - Electrophoresis
[Lymphomas: CLL]
K - Electrophoresis
Collagen diseases
II – MISCELLANEOUS DISORDERS
A- Sarcoidosis
B – Amyloidosis
C – Lead Poisoning