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The object of our study was to determine if any association exists between low serum cholesterol (< 4.14 mmol/l) and adverse outcomes in elderly patients > 60 years. Patients with low serum cholesterol were compared to a patient population with high serum cholesterol (> 6.22 mmol/l) and normal cholesterol (> or = 4.14 to < or = 6.22 mmol/l). Only hospitalized patients > 60 years, who were not on cholesterol lowering drugs, and did not have cardiovascular or liver disease were included in this study. The study group was 157 patients (79 with low, 78 with high, and 23 with normal cholesterol concentrations). Using the Kruskal-Wallis tests, the low cholesterol group was found to have statistically (p < 0.05) longer length of stay (average difference of > 11.1 days), higher hospital re-admission rate over a 1-year period (average difference of > 0.4 re-admissions), greater use of acute care services (average difference of > 0.6 days), and more emergency room (ER) visits over 1 year (average difference of > 0.5 admissions).

The improvement of quality in clinical care can greatly benefit form continuous benchmarking with information based on laboratory data. To be most effective, the information is best provided in the form of real-time disease management decision support. Such an approach requires advances in the implementation of hospital information systems. This article describes ground-breaking work at LDS Hospital in Salt Lake City, Utah that provides examples of major well-documented impacts of the "intelligent laboratory report" on patient outcomes.

In clinical practice, the measurement of urinary free cortisol (UFC) provides the most sensitive and specific diagnostic information for excess adrenal production of cortisol. The existing methodologies (RIA and HPLC) are time consuming, costly, involve tedious extractions, derivatizations and problems with non-specific interactions with cortisol metabolites in urine. In the present study, we describe the development of an SPE-CE method for the rapid analysis of UFC. UFC was concentrated using SPE C18 cartridges (3M Empore) under a vacuum and eluted with acetonitrile-SDS. The use of 10% acetone to wash cartridges before final elution with acetonitrile-SDS showed significant improvements in the free cortisol recovery. The complete extraction was accomplished in 10-15 min with a recovery of 89-94%. CE analysis was done on a Beckman P/ACE 5010 with detection at 254 nm using a neutral capillary. Detection limits of free cortisol in urine was improved to 10 microg/l with SPE compared to 500 microg/l without SPE. No interferences either from BSA or other urinary cortisol metabolites affected the free cortisol determinations. The results showed the feasibility of a rapid UFC detection with improved sample handling capacity.

From the clinical perspective, steroids have always held a great deal of interest, since they are highly specific in their function. They do not have a general or systemic effect, but instead regulate specific physiological functions, such as sex differentiation, fetus implantation and growth, electrolyte balance, menstrual cycles, and muscle and bone development. Many disorders have been identified as being caused by under- or oversecretion of steroids, i.e., Addison's disease, Cushing's syndrome, hirsutism and virilism, adenomas, congenital adrenal hyperplasia, acromegaly, Liddle's syndrome, hypertension, and so on (1). Diseases resulting from steroid imbalance usually result from the cumulative effect of one or more steroids. To get a better understanding of the patho-physiology resulting from steroid imbalances, the measurement of a profile of steroids is potentially more beneficial than measuring a single steroid. Fiet et al. (2), who used a profile of eight steroids to gain a better understanding of hirsutism and acne in women, demonstrated a good example of this type of study.

The dynamism of change in the evolution of integrated health-care systems is driving change in the skills and competencies required to manage diagnostic services. Formal educational preparation and practical experience in a wider array of disciplines will be essential to the backgrounds of those who will be chosen for these new and ever more complex roles. Curricular elements relevant to this educational challenge are outlined herein. This article is intended to expand on the position of CLMA as reflected in the position paper "New Path for Health-Care Leadership: Clinical Systems Management," issued in August 1997 (1).

How does the laboratorian influence patient outcome, and how is this influence measured? The clinical laboratory gives vital support to decisions about diagnosis, treatment, and management. Outcome assessment must include a structured approach to performance improvement, proper test utilization, and defining best practices.

Ethical values and beliefs will shape the decisions that shape the future of health care. This can be exemplified by reviewing some of the issues related to developing genetic testing. A good leader recognizes the ethical issues and addresses them explicitly.

With the arrival of managed care, increased pressure is being placed on the health-care system to reduce the use of laboratory services. When evaluating less expensive methods to measure CK-MB to help reduce costs of triaging patients suspected of having myocardial infarction (MI), we also had an opportunity to evaluate the ordering pattern of LDH isoenzymes for these same patients. We found that LDH isoenzymes were continuously ordered as a routine test at least 14% of the time. We worked with the Division of Cardiology to reduce the use of LDH isoenzymes in two ways: 1) by changing the protocol of triaging suspected MI patients and 2) by reporting the test result only after director approval. This article summarizes our approach to reducing the use of LDH isoenzymes, an expensive test in terms of reagent cost and technician time.

V.W. is a day-shift phlebotomist at Sunny View Cancer Hospital, located in a mid-sized southern city. She is a high-school graduate from an underprivileged background who has had no exposure to the hospital environment and has been recently trained "on the job" for her current position. She has been extremely troubled recently and has been unable to report to work because of stress-related symptoms. All of this began when, on a routine phlebotomy sweep one day, an extremely cachectic cancer patient looked her in the eyes and asked her why his blood had to be drawn again, saying that he did not expect to live through the night. What should V.W. do? What should V.W.'s manager do?

Multiple factors in the past encouraged physicians to order laboratory tests excessively and perhaps even abusively. The shift in the financing of health care to managed care and capitation will create an environment where physicians will be more receptive to laboratory efforts to influence their test ordering behavior toward cost-effectiveness. Various strategies to modify physicians' test-ordering behavior have met with only mixed success due to lack of data to support the desired result: reducing laboratory tests that are not specifically indicated for a particular patient. The current dynamics in the health care industry in general and in the clinical laboratory in particular place increasing value on information about the overall process of health-care delivery. This information can be derived from data from what were formerly considered discrete, transactional events, i.e., specific publications. Combining data from articles dealing with the same subject (meta-analysis) is increasingly being used to assess the value of the overall process of delivery (the outcome). Although considered ¿arm chair¿ research, meta-analysis is an important tool in evaluating the worth of a method in patient care. We chose to evaluate, given the current literature, which laboratory test--lecithin/ sphingomyelin ratio, surfactant/albumin ratio, lamellar bodies, or phosphatidylglycerol--is the best and most cost effective method to screen for fetal lung maturity. We identified all pertinent literature from 1966 to the present using a search of Medline.