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I think that it just shows that a "tweet" is not really a suitable format for an interpretive scheme (no offence meant to organisers!) I'll put my hand up to scoring zero on one case - even though from what I put in my tweet (always prefaced by "ring me" as I don't interpret or comment on numbers) I identified what was probably the real clinical risk for the patient, Likewise I stand by my answer, but my response was to say - I'll participate again when subjectivity is gone Comment please in context of Path QA Review! dj From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Jonathan Kay Sent: 15 October 2015 13:24 To: [log in to unmask] Subject: Re: Canvassing your opinions What fraction of your workload on adult patients has a plasma sodium of 144 mmol/L or greater and a plasma potassium of 3.6 mmol/L or lower? (Bonus marks for anyone offering Bonferroni correction for all other combinations of analytes... ) Thanks Jonathan On 15 Oct 2015, at 13:04, Barlow Ian (NORTHERN LINCOLNSHIRE AND GOOLE NHS FOUNDATION TRUST) <[log in to unmask]<mailto:[log in to unmask]>> wrote: Dear all, Many thanks to everyone who sent me their opinions on this set of results. Most responses quite rightly commented that in most labs the results would be auto-validated and not be seen by laboratory staff. Most respondents also quite rightly pointed out that in the absence of additional clinical information, detailed interpretation was difficult. So .......................to the reason for my posting:- Background These results were part of the UKNEQAS clinical case, Assessment of Clinical Interpretation case number 377 (thank you to NEQAS for giving me permission to share the case with you all). Members of the scheme were invited to comment on the full case (I just gave you part of it) as follows:- A 54 year old man presented to his Family Doctor. The clinical details on the request card were 'jaundice' Serum results are as follows: Sodium 144 mmol/L (134 - 145); Potassium 3.6 mmol/L (3.6 - 5.3); Urea 5.0 mmol/L (2.8 - 7.0) Creatinine 87ìmol/L (62 - 133); Albumin 41 g/L (35 - 49); Adjusted calcium 2.38 (2 .15 - 2.60) Bilirubin 140 ìmol/L (3 - 21); Alkaline phosphatase 58 IU/L (38 - 126); ALT 35 IU/L (7 - 56); Gamma GT 35 IU/L (15 - 73) The full blood count showed that haemoglobin was within normal limits with a slightly decreased red cell count. Participants were asked to type the comment that you would append to this report. I obviously commented on the possibility of a haemolytic episode and also suggested that tumour markers MIGHT be helpful if there was any weight loss. However, I also suggested that given the pattern of the U/E results Conns/Cushings should be considered IF there were any relevant features. I was given a very disappointing minus 0.6 marks by the assessors of this case for my comments, and have since appealed to NEQAS. For the benefit of non-members of the scheme, the maximum score is 3.0 and very few participants are given negative scores. In their reply to my appeal, NEQAS state that I was the only respondent (out of approx. 200 participants) that mentioned the possibility of Cushings/Conns; which totally astounded me. I suggested those diagnostic possibilities because as we all know (or should know), the classical presentation of an elevated sodium with low potassium is not that common in these cases. Subtle electrolytes changes are often seen in these disorders - particularly in primary hyperaldosteronism (which is underdiagnosed yet accounts for between 5-13% of patients with hypertension). Bear in mind also that "normality" is very hard to define and these borderline results could actually be quite "abnormal" for this particular individual. The on-going ALT discussion covers some of this too. One other important reason that I mentioned these diagnostic possibilities was that this sample was from a GP - therefore there is a high possibility of this being "pseudonormo-kalaemia" (which 3 respondents also highlighted too). Summary of your results So,..................... to the results of the "opinion survey". I had 33 responses to the posting - pretty good I thought. Many thanks indeed to you all that responded. Of these 33, 18 respondents (55%) said the results were NOT SIGNIFICANT. Eleven respondents (33%) suggested, as I did, the possibility of Cushings/Conns/Steroid excess, especially in the context of hypertension (which we were not told of course) or an exam situation; which this, arguably, is. Two respondents suggested the possibility of vomiting and might consider adding Cl, HCO3, Mg One respondent suggested Addisons as the cause One respondent suggested loop diuretics as the cause Discussion Even though NEQAS gave me my lowest ever score I still fully stand by my comments - even more so now that 33% of you also agreed with me. In fact if these results were part of an FRCPath exam, I would consider it to "biochemist suicide" if candidates did not mention the diagnostic possibilities of Cushings/Conns (with any relevant features of course). However, it remains to be seen whether UKNEQAS reconsider my appeal or not. I doubt if they will, but not withstanding that, this has been a fun and interesting educational exercise - which is what it is all about really! ONE FINAL QUESTION THOUGH:- TO THOSE 18 RESPONDENTS THAT SAID THAT THESE RESULTS WERE NOT SIGNIFICANT - WOULD YOU NOW CHANGE YOUR MIND IF THESE RESULTS CAME ACROSS YOUR DESK? I will summarise the responses if I get any. Many thanks to you all. Have a great day Best wishes Ian From: Barlow Ian (NORTHERN LINCOLNSHIRE AND GOOLE NHS FOUNDATION TRUST) Sent: 14 October 2015 13:18 To: Clinical biochemistry discussion list Subject: Canvassing your opinions Dear all, This is not a trick question, but I would be interested to hear whether you consider the results shown below to be of significance or not. Could I please ask you the following:- 1. Do you consider the results to be significant (YES/NO) 2. If you do consider them to be significant what are the most likely cause/s? 3. What follow up tests, if any, would you advise? I am happy to collate/publish the opinions:- A 54 year old man went to his GP who then sent us a blood sample for U/E. No clinical details were provided. Serum results are as follows: Sodium 144 mmol/L (134 - 145); Potassium 3.6 mmol/L (3.6 - 5.3); Urea 5.0 mmol/L (2.8 - 7.0) Creatinine 87ìmol/L (62 - 133); Albumin 41 g/L (35 - 49); Adjusted calcium 2.38 (2 .15 - 2.60). ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk Green Laboratories Work http://www.laboratorymedicine.nhs.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/ This message contains confidential information and is intended only for the individual named. If you are not the named addressee you should not disseminate, distribute or copy this e-mail. Please notify the sender immediately by e-mail if you have received this e-mail in error and delete this e-mail from your system. If you are not the intended recipient you are notified that disclosing, copying, distributing or taking any action in reliance on the contents of this information is strictly prohibited. ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk Green Laboratories Work http://www.laboratorymedicine.nhs.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/