• Two case studies showing the importance of Coumarin tracing blood assays to investigate acquired coagulopathies in patients with selfharm behaviour

      Ahmad, Humayun; Van Staden, Bernhard; Channa, Jawaid (2013-04)
      We have recent experience of two cases who presented with unexplained coagulopathies. Neither of them had a family or previous personal history of a bleeding tendency. They both denied the use of any medication. One case presented with unexpected menstrual bleeding after a contraceptive coil insertion. The other case presented with severe post-surgical bleeding following a gynaecological procedure for infertility. She ended up in ITU with a near fatal outcome. Both had a prolonged APTT and PT/INR which corrected with the addition of normal plasma and thus in keeping with factor deficiencies. Further factor assays revealed low levels of Factor II, VII, IX and X as one could expect with Coumarin-like drugs. With normal CTD screens and a high index of suspicion it was decided to send samples for Coumarin drug tracing/assays. With the latter, results of the first case mentioned above, showed to have Difenacoum present in the blood. Difenacoum is a rodenticide and has a significant longer half-life than Warfarin. The other case had traces of ordinary Coumadin (Warfarin) in her blood. They both responded significantly to Vitamin K therapy. Self-harm, per definition, includes self-injury and self-poisoning and is defined as the intentional, direct injuring of body tissue most often done without suicidal intentions. It is estimated that about 10% of admissions to medical wards in the UK are as a result of self-harm, the majority of which are drug overdoses. Both of the cases mentioned above had near fatal outcomes and it is important that one should consider Coumarin tracing assays as part of the work-up in patients with new acquired coagulopathies.
    • Understanding patterns of ordering common blood tests in patients admitted to hospital-an audit to evaluate number and frequency of common blood tests in admitted patients in a medium sized DGH

      Ahmad, Humayun; Proud, Rebecca; Lennerova, Tereza; McDougall, Alexandra; Spence, Chloe (2013-06)
      Blood tests play a very important part in the diagnosis and management of most diseases and pathology costs form significant proportion of the health service budget. The Independent Review of Pathology Services in the National Health Service UK by Lord Carter postulated that savings of 500 million annually are possible by reducing wastage. In cost reduction strategies most savings are predicated on economies of scale and service redesign, creating larger pathology units with Hub and Spoke models to reduce waste and improve efficiency by up-scaling automation and downscaling staffing levels etc. However, inappropriate and unnecessary blood tests also contribute significantly to waste but there is a dearth of literature or guidance on this subject. Aims: The aim was to evaluate number, frequency and appropriateness of common blood tests in adult patients admitted to the hospital in order to assess for possible wastage Methods: In our study we conducted a retrospective audit on approximately four hundred patients admitted to a medium sized District General Hospital. Obstetric and paediatric patients were excluded from this study. The remaining 309 patients were evaluated using the electronic patient records. . The purpose was to study the number and frequency of common blood tests e.g. Full Blood Count, Renal and Liver blood tests. The data on Length of stay was also evaluated. The cohort was subdivided into following subgroups for data analysis: Medicine, Care of the Elderly, Orthopaedics & Surgery. Results: Our results showed that over 50% of admitted patients were medical patients who also had a longer average length of stay than the surgical cohort. Consequently, average number of tests per patient was higher in medical patients but frequency of repeating blood tests appeared broadly similar in medical and surgical groups. The repeat ordering of blood tests did not appear to be influenced by abnormal results as similar frequency of repeat blood tests was noted in patients with normal and abnormal results. The repeat ordering appeared to follow a recurring pattern rather than being reactive to the results of the previous test. There was significant wastage as blood tests were frequently repeated even when recent results were within normal range. On the contrary in some patients repeat tests were not ordered despite abnormal results. It was also interesting to note that there was no significant difference in repeat ordering of blood tests between cases showing severe abnormalities of Full Blood Count and those with milder abnormalities. Summary / Conclusion: Although our audit had a number of limitations, it highlights the need for further studies to evaluate the pattern of ordering common blood tests in hospitalised patients with a view to identify wastage and minimise it. There is also need for developing evidence-based consensus on how to reduce unnecessary testing without compromising patient safety. Published literature on this subject is limited and much innovative research is possible.