laboratory testing: its role in diagnosing and …€¦ · phase ii trial al-46383a...
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LABORATORY TESTING: ITS ROLE IN DIAGNOSING AND MANAGING OCULAR
DISEASE
Tammy Pifer Than, MS, OD, FAAO
UAB School of Optometry
Birmingham, AL
Nothing to Disclose
Getting the Job Done...
External Lab TestingPCP
External laboratory
In-office samplingis it ok?
Before You Order Tests...
good case hx
narrow ddx
avoid “shot gun” approach
comprehensive ocular exam
If You Order Tests...
interpretLaboratory Tests and Diagnostic Procedures
6th edition – 12/2012Chernecky and Berger
– includes Herbal interactions
communicate treat refer
Getting the Job Done...
In Office Lab TestingPoint-of-Care
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CLIA Clinical Laboratory Improvement Act regulates all lab tests performed on
humans in US ensures quality laboratory testing “materials derived from the human
body… for the diagnosis, prevention or treatment…”
www.cms.hhs.gov/clia
CLIA
Classification FDA CertificatesCertificate of Waiver
~60% of 225,000 labs
Certificate of ComplianceCertificate of Accreditation
2 year renewals
CLIA can file for “Waived Status”Approximately 80 tests
random blood glucose
ESR
urine pregnancy test
RPS AdenoPlus
TearLab Osmolarity System
CLIA Certificate of Waiver
must meet criteria:enroll in CLIA programpay fee biennially ($150 for waived)follow manufacturers’ test instructions Good Laboratory Practices
“Educational” Visits2%/yearannounced
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Technology
• A rapid, point‐of‐care test that detects all known serotypes of Adenovirus
Test Components
Sterile Sample Collector
Test Cassette Buffer Vial
Survey – AAO 2013n = 340
Adenoviral Conjunctivitis
povidone-iodine ophthalmic solution (Betadine) (85:15)off-labeled use5% ophthalmic solution
Zirgan?
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Combined results from 7 eye care meetings held in 2013n = 649
In the works…
FST-100Foresight Biotherapeutics
0.1% dexamethasone and 0.4% povidone-iodine
Phase II trial
AL-46383A (N-chlorotaurine)Aganocide compound
Phase II trial
Doxovir
What’s Up and Coming?
www.clinicaltrials.govThe Food and Drug Administration
Amendments Act of 2007 (FDAAA or US Public Law 110-85) was passed on September 27, 2007
The law requires mandatory registration and results reporting for certain clinical trials of drugs, biologics, and devices
Dry Eye Disease and MMP‐9
Matrix metalloproteinases (MMP) are proteolyticenzymes that are produced by stressed epithelial cells on the ocular surface1
MMP‐9 in Tears
Non‐specific inflammatory marker
Normal range between 3‐41 ng/ml
More sensitive diagnostic marker than clinical signs1
Correlates with clinical exam findings1
Ocular surface disease (dry eye) demonstrates elevated levels of MMP‐9 in tears1
[1] Chotiakavanich S, de Paiva CS, Li de Quan, et al. Invest Ophthalmol Vis Sci 2009; 50(7): 3203‐3209.
Dry Eye Disease and MMP‐9
Increased concentrations of MMP‐9 can be found in other diseases or conditions, including:
Ocular rosacea
Meibomian gland disease
Sjögren’s syndrome
Corneal ulcers
Corneal erosions
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InflammaDry® Limit of Detection
Normal levels of MMP‐9 in human tears ranges from 3‐41 ng/ml
NEGATIVE TEST RESULTMMP‐9 < 40 ng/ml
POSITIVE TEST RESULTMMP‐9 ≥ 40 ng/ml
InflammaDry 4‐Step Process
* Release the lid after every 2‐3 dabs. Allow the sampling fleece to rest along the conjunctiva for 5 seconds.
*
Reimbursement Strategy
CPT Code 83516 – Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
$15.46
CLIA Waived Status
2/27/2014
Traditional Understanding of Sjögren’s
Sjögren’s is a chronic, systemic, progressive autoimmune inflammatory disease
Characterized by the immune‐mediated (lymphocytic) destruction of the lacrimal and salivary glands
Early hallmark symptoms include dry eyes and dry mouth
Recent evidence suggests that all layers of tear film can be affected
Traditional Understanding of Sjögren’s
Primary Sjögren’s
Disease presents alone
• Secondary Sjögren’s
Subsequent to another autoimmune condition (e.g. rheumatoid arthritis)
It currently takes 4.7 years to receive an accurate diagnosis
Systemic effects are seen in 30‐70% of patients
Myths of Sjögren’s
“All Sjögren’s patients are identified and diagnosed”
“There are only a few patients in my practice”
“Nothing can be done for the patients if they are diagnosed”
“Sjögren’s Syndrome does not have serious long‐term consequences, it is just a nuisance”
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Sjögren’s Syndrome and Non‐Hodgkin’s Lymphoma
Solans‐Laque R, et al, Seminars Arthritis Rheum, 2011
Lymphoma risk
~10% at 15 years
Risk with time
Ioinnidis et al, Arthritis Rheum, 2002
Primary SS
20% deaths due to lymphoma
Mortality in pSS
Ioinnidis et al, Arthritis Rheum, 2002
723 patients studied in Greece
1 in 5 deaths of pSS patients due to lymphoma
Early detection is key!
Markers for Sjögren’s
• The classical serological markers for Sjögren’s are anti‐Ro/SS‐A and anti‐La/SS‐B antibodies• Other antinuclear antibodies (ANA) and rheumatoid factors (RF) are also included as the more common serological markers detected
• The combined serology sensitivity and specificity of the classical markers is around 40‐60%• None of the currently recommended serology tests diagnose Sjögren’s early in the disease progression
• In approximately 20‐30 % of cases no classic Sjögren’santibodies are found
New Markers
Salivary Gland Protein 1 (SP‐1) Submandibular and lacrimal glands
Carbonic Anhydrase 6 (CA6) Involved in buffering capacity of saliva
Submandibular and parotid glands
Parotid Secretory Protein (PSP) Involved with binding and helping to clear various infections
The Specifics
No CLIA waiver
Saturate at least 3 of 5
CPT 36416Collection of blood by capillary blood
specimen (e.g. finger, heel, ear stick)
Insurance Info
Call FedEx
IMMCO Lab Only
OR…
Microbiology
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Cultures and Sensitivities
specimen preparation is important no anesthetic – if possible sterile swab plate onto culture media culturette media:Thioglycolate brothBlood agarChocolate agarSaboraud’s agar
Transport Media
Amies media without charcoalHigher yield than other media
Comparable to plates
Subconjunctival Hemorrhage
Historyfrequency
medications
activity
Examination
Subconjunctival Hemorrhage
Idiopathic Valsalva maneuver HTN, DM Von Willebrand’s Disease 1-2%
Severe hepatic disease Leukemia Vitamin K deficiency AIDs
Subconjunctival Hemorrhage
Blood pressure CBC with differential PT (prothrombin time) PTT (partial thromboplastin time) INR (international normalized ratio)
Prothrombin Time (PT)
prothrombin:vitamin-K dependent glycoprotein produced
by liverneeded for firm fibrin clot formation
PT – measures time for clot formationreagent tissue thromboplastin and calcium
are added to citrate plasma
avoid coffee and alcohol for 24 hours before test ↓ time
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Prothrombin Time (PT)
each lab has normal value normal range is 2 secs Adult 12-14 sec International Normalized Ratio (INR)standardizes PT resultsINR = (Patient’s PT in seconds)ISI
Mean normal PT in secondsISI = international sensitivity indexNormal 0.9 – 1.3Coumadin therapy
Partial Thromboplastin Time (PTT) evaluates how well coagulation
sequence is functioning time for recalcified, citrate plasma takes
to clot after partial thromboplastin is added
Activated PTTcommercial activating materials used to
standardize the testcurrent method of the test
Standardized times reported by each lab< 35 seconds
Coagulation Studies
recurrent subconjunctivalhemorrhages
non-traumatic hyphema
± artery or vein occlusion
pre-op ocular surgery
To Treat or not to Treat.
34 YOWF
CC: HAs, double vision, dizzy
OHx: no trauma, LEE – long time ago
MHx: Voltaren, Zantac
Magnetic Resonance Venography(MRV)
Emerging imaging toolVeins of abdomen, pelvis, thorax and
extremities
Duplex sonography hindered by acoustic access
DVTNew gold standard
Cerebral Venous Sinus Thrombosis
Causes increased intracranial pressure
Can be life-threatening
Should be a DDX for every case of IIH
CVST9-26% of patients
Reference Lin A, Foroozan R, et al, Occurrence of cerebral venous
sinus thrombosis in patients with presumed idiopathic intracranial hypertension. Ophthalmology 1996; 113(12);2281-84.
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Management
weight loss
acetazolamideDiamox Sequels
steroids??
ON sheath decompression
LP shunt
Before you prescribe Diamox
baseline electrolytes
CBC with differentialR/O blood dyscrasias
monitor every 6 months
Electrolytes Na+
135.0 – 145.0 mmol/L
K+
3.50 – 5.3 mmol/LPanic Level: <2.5 or >6.6
Cl-
97 – 107 mmol/LPanic Level: <80 or >115
CO2 total content blood
21.0 – 31.0 mmol/L Increasedalcoholismairway obstructionpneumoniadrugs (e.g. antacids)
Decreaseddehydrationacetazolamide
measures compliance - < 20 mEq/L
tetracyclines
SMA-6
Sequential multiple analyzer (SMA) automated system that analyzes multiple
blood values from one tube of blood SMA-6Carbon dioxideChlorideCreatininePotassiumSodiumUrea nitrogen
SMA-7
Carbon dioxide
Chloride
Creatinine
Glucose
Potassium
Sodium
Urea nitrogen
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SMA-12AlbuminAlkaline phosphataseAspartate aminotransferaseBilirubinCalciumCholesterolGlucoseLactate dehydrogenasePhosphorusProteinUrea nitrogenUric acid
Glad you looked!
58 year old female
CC: SpRx broken
OHx: unremarkable
MHx: unremarkable, no meds
20/20 OD; 20/20 OS
Random Blood Glucose
note when patient ate laste.g. 220 mg/dL pp 3 hours
pp = post-prandial
diabetic if: 200 mg/dL with symptoms
can do in-office
encourage patients to do this!
± reimbursed (CPT code – 82962)
Fasting Plasma Glucose
no food or drink for 8-12 hours
diabetes if 126 mg/dLmust repeat if asymptomatic
IFG = 100 – 125 mg/dL
also increased with:steroids
stress
diuretics
Oral Glucose Tolerance Test (OGTT)
75 g oral glucose
check urine and blood at intervals
non-diabetic BS will return to fasting levels in 3 hours
diabetic if 200 mg/dL at 2 hours
impaired GT if 140 and < 200 mg/dL at 2 hours
not needed if FBS > 200 mg/dL
Glycosylated Hemoglobin HbA1c
checks long-term control glycosylated HgB stays with RBC for its
entire life normal = 4.3-6.1%Diabetic if 6.5%
diabetic goal < 7.0% ask patients! A1C Now InView multitest system CPT 83036QW
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A1C Now InView CLIA waived
$129.00 for 10 tests
Medicare Coverage$13.56
Private insurance$18.00
Glycoslyated HemoglobinA1C Blood Glucose Levels
12% 345 mg/dL
11 310
10 275
9 240
8 205
7 170
6 135
5 100
4 65
1% A1C = 30 mg/dL
eAG
estimated Average GlucoseA1C-derived average glucose study
Diabetes Care 2008 31(8);1704-7.
Linear relationship
Recommended by ADA
eAG = 28.7 * A1C – 46.7
Pre-Diabetes
IFG or IGT OR A1C 5.7-6.4% Weight loss of 7% of body weight 150 minutes/week of moderate activity
www.diabetes.org
Executive Summary – Standards of Medical Care in Diabetes - 2014
ESR
erythrocyte sedimentation rate
nonspecific test for inflammation
mm/hr
M: age/2
F: (age+10)/2
usually > 60 mm/hr in GCANormal in 7-20%!!!
C-Reactive Protein (CRP) abnormal serum glycoprotein produced by
liver during acute inflammation disappears rapidly once inflammation
subsides 4 hour fast from food/fluids alternative to ESR more informativeESR high in most elderlyno cross interference
normal: Qualitative – negative; Quantitative – 0-10 mg/L
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The Observant Patient..
52 YOWM
CC: “inferior vision OS is dim”
MHx: diabetic x 20 years; poorcontrol
VAs: OD 20/20 OS 20/20-2
LEE: 6 month priortwo dot hemorrhages OD
?????
Causes of Optic Nerve Edema
Arteritic Ischemic Optic Neuropathy Nonarteritic Ischemic Optic Neuropathy Central Retinal Vein Occlusion Compressive Optic Nerve Head Tumor Diabetic Papillopathy Infiltration of Optic Nerve Head Malignant Hypertension Papilledema Papillitis Papillophlebitis Thyroid Ophthalmopathy
Thyroid Testing
Sensitive Thyroid Stimulating Hormone0.3 – 3 μU/L
↓ - hyperthyroidism
↑ - hypothyroidism
Also if:Proptosis
SLK
Etc.
Lipid Panel
12 hour fast
total cholesterol
LDL
HDL
triglycerides
risk for CAD
ratio total cholesterol / HDL
Cholesterol
over half of adults in US have cholesterol > 200 mg/dL
desirable: 160-200 mg/dL borderline: 200-239 mg/dL high 240 mg/dL Outside US cholesterol x 0.0259 mmoles/L (international
units)200 mg/dL = 5.18 mmol/L
More Numbers…
HDLgood 35 mg/dL
women probably 45 mg/dL
1 mg/mL risk of HD 2-3%Helsinki Heart Study (gemfibrizol in men )
LDLgood < 130 mg/dLhigh 190 mg/dL
Ratio (Total / HDL) 5:1
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Triglycerides
normal < 200 mg/dLwomen probably < 150
borderline 200-400
high 400-1000
very high > 1000
Vertical Auto Profile (VAP) Test
More detailed info
Beginning to replace lipid profile
Only test to meet ADA and American College of Cholesterol Guidelines
Subclasses of lipoproteins
Some additional lipids measured
VAP
Total VLDL
HDL + LDL + VLDL (sum total cholesterol)
LDL + VLDL (total non-HDL)
Total apoB100 (apolipoprotein B100)
Lp(a) cholesterolInherited risk factor for atherosclerosis
IDL – intermediate density lipoprotein↑ in FHx of diabetes
VAP
LDL-RCLDL bound to C-reactive protein
Found at site of atherosclerotic plaques
Lp(a)+IDL+LDL (sum total LDL-C)
LDL size patternA
A/B
B – 4X greater risk of heart disease than A
VAP
HDL-2Particularly protective
HDL-3
VLDL-3Proposed that if ↑, more likely to develop
diabetes
Additional Testing…
ImagingMRI – imaging of choice
Gadolinium– Nephrogenic Systemic Fibrosis
CT – caution if ordering contrast
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CT Contrast
Iodineenhances visibility of vascular lesions
Administered IV (or intrathecal)
1:40,000 incident of AE
BUN and Creatinine
NPO
Good medication hxd/c Metformin (Glucophage) prior to
procedure
CI if shellfish allergy
BUN (Blood Urea Nitrogen)
actually performed on serum or plasma12% higher than blood
nitrogen portion of urea urea is formed in liver from protein
breakdown filtered through renal glomerulismall amount reabsorbed in the tubulesremainder excreted in urine
azotemia – elevated BUNnonspecific prerenal, renal, or postrenal
BUN (Blood Urea Nitrogen)
must be compared over time or evaluated with other testsrenal function – also assess creatinine levels
fasting not required Adult 5-20 mg/dL >60 8-21 mg/dL increased BUNmany conditions and many drugs
decreased BUNalcohol abuse, diet lacking protein, liver
destruction, late pregnancy
CREATININE
product of anaerobic energy-producing creatine-phosphate metabolism in skeletal muscle
excreted by kidneysincreased levels indicative of decreased
glomerular filtration rate
Avoid excessive exercise for 8 hours and avoid excessive red meat for 24 hours before testing
CREATININE
Normalfemales 0.5 – 1.1 mg/dLmales 0.6 –1.2 mg/dLelderly – may be lower
Creatinine clearance, urine24 hour collection
Creatinine clearance, serum - urine6, 12, or 24 hour collectionblood sample collected anytime during urine
collection period Creatinine with eGFR
Diabetic Papillopathy
0.4 – 2% of diabetics
characteristicssectoral or total ON edema
± peripapillary hemorrhages
± nerve fiber layer infarcts
± macular edema
unilateral or bilateralasymmetric
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Diabetic Papillopathy
retinopathy does not need to be present
small optic nerve cupping 0.3/0.3
prognosis:significant or complete recovery in several
months
may have residual pallor and VF defect
pathophysiology is unclear
Laboratory Testing for Uveitis
ACE
angiotensin converting enzyme
produced by a variety of cells including granulomatous cells
best for patients > 20 YO
helps confirm dx of sarcoidosisACE elevated in 60%
12 hour fast
Sarcoidosis
Laboratory TestingChest X-Ray
Serum Angiotensin Converting Enzyme (ACE)
Conjunctival or lacrimal gland biopsy
Serum lysozyme
Serum calcium
Gallium scanNuclear medicine test
Radioactive gallium citrate is injected
Hot spots at site of inflammation
ANA
antinuclear antibody
evaluates immune system
8 hour fast
screening test for SLE
sensitive but not specific
Non-specific testRheumatoid arthritis
Scleroderma (60-90%)
Sjögren syndrome
ANA
Look at staining patternHomogenous (SLE)
Speckled (SLE, Sjögren syndrome, scleroderma, etc.)
Peripheral or rim (SLE)
Nucleolar (Sjögren syndrome, scleroderma)
normal: nonreactiveTiter <1:20
results in 4-5 days
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ANA - Sensitivity
SLE- 95 %
Scleroderma- 60-90%
Rheumatoid arthritis- 41%
Sjőgren syndrome- 48%
JIA with uveitis – 80%
HLA-B27
Human Leukocyte AntigenSurface of WBC
Immune function
HLA B-27 present in up to 8% of population50-60% with acute anterior uveitis
Normal: negative
HLA-B27
Order if acute, recurrent, unilateral anterior uveitis50-80% are seronegative spondyloarthropathies
Ankylosing spondylitis
Reactive arthritis (FKA Reiter’s syndrome)
Inflammatory bowel disease
Psoriatic arthritis
p-ANCA perinuclear-Antineutrophil Cytoplasmic
Antibody
Autoimmune antibodies directed against the lysosomal enzymes in neutrophil granules
p-ANCAAntibodies found near the nucleus
(perinuclear)SLE, Rheumatoid arthritis, ulcerative colitis
Elevated in Crohn’s disease
C-ANCA c-ANCA (classical)Antibodies found scattered in the cytoplasm of
neutrophils
Only test available for the diagnosis of vasculitis
Granulomatosis with polyangiitis(Wegener’s)
Normal: negative; titer <1:40
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Rheumatoid Factor
Positive titers in numerous collagen vascular diseases
(+) in 70-80% of patients with Rheumatoid Arthritis
Also (+) with:SLE, Sjogren, TB, sarcoid, viral infection
Negative finding most useful (<1:20)JIA
Rheumatoid Arthritis
Rheumatoid Factor
Anti-cyclic citrullinated peptide antibodyanti-CCP
Auto-antibody frequently seen in RA
Allows early dx
Syphilis: Ever Had It?
FTA-ABSfluorescent treponemal antibody absorption
test
ordered more frequently
positive even after treatment
MHA-TPmicrohemagglutination treponemal pallidum
test
Syphilis: Do you have it now?
RPRrapid plasma reagin test
VDRLvenereal disease research laboratory test
EIAEnzyme immunoassay
Other Testing in AU
PPDCheck in 48-72 hours
Positive for active and inactive TB
Lyme titers
Etc.