In message <[log in to unmask]>, Gerald. Maguire
<[log in to unmask]> writes
>Following the introduction of a new analyser for the measurement of
>specific proteins in June 1997, we reviewed our service and now only offer
>it for the detection of paraproteins. It had previously been our practice
>to perform serum protein electrophoresis(SPE) on all requests for
>immunoglobulin measurement. However we came to the conclusion that SPE is
>only of limited value except for the detection of paraprotein bands and the
>diagnosis of myeloma. After discussion with our principal users, we stopped
>automatically performing SPE on all requests for immunoglobulins but
>selected for SPE only those samples with abnormal (elevated or depressed)
>Igs for which the cause of the abnormal Igs was not known from previous
>requests or from the clinical details supplied.
>For patients specifically being investigated for myeloma we offer a test
>profile called "paraprotein studies". For patients with known myeloma this
>test profile comprises serum paraprotein quantitation and Ig measurement
>and urine investigation for BJP. For patients being investigated for
>suspected myeloma, the test profile comprises of serum and urine
>electrophoresis and serum immunoglobulin measurement. If no serum
>paraprotein or urine BJP is detected, there are no further investigations..
>Any serum paraprotein is typed by immunofixation and quantitated and any
>urine BJP is typed.
>
>We have encountered no problems with this policy which was introduced after
>extensive discussion with our users.
>
>Gerald A Maguire
>Dept of Clinical Biochemistry and Clinical Immunology
>Addenbrooke's Hospital
>Cambridge
>UK
>CB2 2QR
>UK
>Tel 44 (0) 1223 217159
>fax 44 (0) 1223 216862
Happy New Year everyone.
Perhaps I could add my two penn'orth to the debate. It all depends on
the question being asked. We do a lot of serum electrophoresis, which
has not been requested specifically, as a screen for non-specific rises
in the globulins (as calculated by Total protein minus albumin). Whilst
acknowledging all the inaccuracies that are involved in this, we have
found a lot of monoclonal gammopathy with a reasonable pick up of
myeloma by screening at a level of 35 g globulin per litre - as well as
when indicated for other reasons (e.g. Clinical Case 70). We used to
have a higher limit (40 g/L) but found we were missing some cases which
were picked up later, and on the basis that early warning is better than
being detected when complications ensue, have accepted the increased
workload. However, once we have found the monoclones, we ensure
personally that results are communicated to a senior clinician involved
with the patient and then liaise with our haematological colleagues
(immediately) for assessment and follow up. The serum is also sent to
immunology for a more detailed estimation. From the cases that have
turned up again later, apparently unrecognised, we have found that the
most important element is not the laboratory diagnosis but making sure
that the clinicians appreciate the significance of the finding. Hence
the personal attention to detail in communicating the result both to the
clinicians and the haematologists to ensure that clinical follow up is
undertaken.
In immunology, (a separate department) all immunoglobulin estimations
have an SPE run on them, but their referral pattern is heavily biased
towards the follow up of myeloma patients so this informs their
practice.
As in all laboratory procedures, individual practice depends on an
appropriate professional response to the question being asked - which
also involves trying to educate clinicians to ask the right questions
and to respond appropriately to the results provided.
>
>
Trevor
--
Trevor Gray
Dept. of Clinical Chemistry,
Northern General Hospital,
Sheffield S5 7AU
0114 271 4309
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