Letters to the editor.

[C-urea.sup.13] breath test for H. pylori 

I read with great interest the short response on Helicobacter pylori written by Dr. David Sewell for "Tips from the clinical experts" in the May 1999 issue of MLO (p. 8). While I agree with the statement that the [C-urea.sup.13] breath test is sensitive, specific, and becoming the test of choice, I disagree with the comment that it is slower and requires a larger test dose. We recently published results from a study we conducted on this test, based on a pediatric population, and the test proved to be extremely sensitive and specific. [1] The analysis was performed on as little as 90 mL of expired air after a 50-mg dose of [C-urea.sup.13]. The test took 30 minutes, and [C.sup.13] analysis was performed in less than 2 minutes. Further, the test can easily be performed in a physician's office, and the expired air car be sent by regular mail (no liquids, no radioactivity) to a central lab.

Edgard E. Delvin, PhD)

Head, Department of Clinical Biochemistry

Ste Justine Hospital

Montreal, Quebec

Reference

(1.) Delvin EE, Brazier JL, Deslandres C, Alvarez F, Russo P, Seidman E. Accuracy of the [C-urea.sup.13] breath test in diagnosing Helicobacter pylori gastritis in pediatric patients. J Pediatr Gastroenterol Nutr. 1999;28:59-62.

Reporting "alert values"

I read with interest the question on reporting "alert values" in the "Tips from the clinical experts" column in the May 1999 issue of MLO (p. 8). While I agree with the lab's practice of flagging low hematocrits on samples received for tests other than hematology and with Dr. John Koepke's affirmation, I recently had a much different response from a physician in a similar situation.

In our noncomputerized lab, we found it convenient to report the entire hemogram printout from our analyzer's ticket printer even though the order might only be for a hemoglobin and hematocrit. We would charge, however, only for the tests specifically ordered. We were recently called to task by a physician who received results showing a markedly elevated white blood cell count as well as the H&H results he had ordered. He said it was not ethical for us to provide the extra test results bemuse it placed him in the position of having to act on the results even though he didn't order the test.

We have since revised our practice and manually write in only the counts requested rather than letting the ticket printer print them all. In our presently regulated environment, perhaps, good judgement on the part of technologists must bow to the authority of compliance regulations and the philosophy of "don't ask, don't tell."

Janet Hugg

Director, Laboratory Services

St Joseph's Memorial Hospital

Hillsboro, WI

Dr. Koepke responds

The Tip on reporting "alert values" published in the May 1999 issue of MLO was in response to a specific problem associated with a patient receiving anticoagulant therapy. He/she apparently had internal bleeding and was developing an anemia that was discovered on the blood specimen drawn for anticoagulation monitoring. However, your question is a much broader one related to abnormalities that might be found on panels of tests such as complete blood counts, in which the specific test that is found to be abnormal has not been requested by the patient's physician. I cannot agree with the last sentence in your letter that promotes a "don't ask, don't tell" mentality for handling laboratory results on unordered tests.

We in laboratory medicine must have the patient's welfare as our primary responsibility. Our job is to perform accurate laboratory testing with good turnaround times. When we inadvertently find some significant abnormality that may affect the patient's well being, we should report it to the patient's physician-I feel we would be delinquent in our duties if we failed to do so. A malpractice attorney would have little problem convincing a jury that it was not acceptable to suppress a report of a possible leukemia, for example, if the test had not been specifically ordered but the laboratory still had knowledge of such a possibility.

How do you formulate a policy that guarantees good medical practice? The medical director of the laboratory should discuss which tests and what levels of "alert values" to report with the medical staff as well as how they should be reported. Guidelines for hematology studies can be found in a number of sources, one of which is noted below.

Reference

(1.) National Committee for Clinical Laboratory Standards. Calibration and quality control of automated hematology analyzers. Proposed Standard H38-P. Wayne, PA: National Committee for Clinical Laboratory Standards; 1999.

E-mail etiquette

I enjoyed Dr. Chris Frings' reply in the "Management Q & A" column in the May 1999 issue of MLO (p.14) about what to include in e-mail training. As the list owner of Medlab-L and someone involved in teaching e-mail and mailing-list etiquette to students and laboratory professionals, I have developed 2 on-line resources that MLO readers may find useful:

1. E-netiquette:http://www.ualberta.ca/http://www.ualberta.ca/pletendr/e -neiquetted.html

2. List-netiquette: http://www.ualberta.ca/pletendr/list-net.html

Pat Letendre, BSc, RT(CSMLS), MEd

Medical Laboratory Science,

University of Alberta

Edmonton, Alberta, Canada