Band 34, Heft 5

Inflammatory disorders of the heart can be classified as myocarditis, pericarditis or endocarditis. Myocarditis is an acute or chronic inflammation affecting the myocardium. Next to viral infections bacterial pathogens represent the most important cause of myocarditis in Europe and North America. Different bacterial, fungal and parasite agents also play an important role in the pathophysiology of inflammatory heart disorders. In addition to infectious agents, a wide variety of toxins and drugs (e.g., cocaine…) and some chronic autoimmune diseases (lupus) also have the ability to cause myocarditis. Clinical features of acute or chronic myocarditis are often non-specific, ranging from mild to life-threatening symptoms (sudden cardiac death, chronic heart failure…). In 25% of cases, myocarditis is associated with a pericardial infection. Many isolated pericarditis cases are seen during disseminated purulent bacterial infections and tuberculosis.

Viral infections are the most common cause of myocarditis in Europe. Although the symptoms of pericarditis are often non-ambiguous, the diagnosis of “myocarditis” can be difficult in terms of clinical presentation and different testing methods used for confirmation. Immunohistochemical techniques for characterization and quantification of inflammatory heart tissue reactions as well as molecular methods for viral genome detection are applied. The viral testing methods are described and their advantages and limitations are discussed.

A variety of factors are known to influence qualitative and quantitative serological assays. Here, we discuss such pitfalls in serology emerging in a case of influenza A/H1N1v-hemagglutination inhibition test (H1N1-HHT) subsequent to hyposensitization and vaccinations. Assuming that hyposensitization and vaccinations are frequently provided services, their potential interference with serological assays should be considered.

The dual platelet inhibition therapy with a P2Y 12 -inhibitor and with acetylsalicylic acid is standard of care in patients with acute coronary syndrome or after implantation of coronary stents. Clopidogrel is the most often used P2Y 12 -inhibitor and prasugrel has recently been approved. Clopidogrel dosing is very complex because of highly heterogeneous inter-individual pharmacokinetics due to genetic polymorphisms and interactions with concomitant medication. Optimization of platelet inhibition therapy is pivotal because platelet inhibitors are one of the most frequently used drugs and overdosing as well as underdosing has enormous consequences. For optimization, pharmacogenetic tests as well as platelet function tests have been developed. Wide arrays of platelet function tests are available with very different complexity and different results. With appropriate point-of-care-tests, dosing can be adjusted immediately. However, pharmacogenetic tests as well as platelet function tests have not yet demonstrated their benefit in prospective studies.

Although the costs for laboratory medication are only very minor compared to the total expenditures in the healthcare system, cost-cutting is frequently focused on hospital laboratories. Only 7.3% of German hospitals have a laboratory headed by a laboratory physician. To discontinue this trend it is mandatory that the hospital is not considered as a cost centre any longer but should be transformed into a profit and competence centre. To achieve this goal, the laboratory needs to show that it adds to the value of patient care and that it is an essential link in the value chain of the total hospital enterprise. The hospital laboratory should be a workflow management system. In particular, microbiology can serve as an example to demonstrate the economic advantage of a local hospital laboratory. The competence of the medical laboratory and its staff has to be offered to the hospital and its medical disciplines around the clock. However, in the future it will also be necessary to provide laboratory competence and excellence to outpatients. To achieve this, hospital laboratories have to consolidate and cooperate in regional networks.

In the hospital medical laboratory processes can be improved by use of Lean and Six sigma principles. A precondition for this approach is a process orientated viewpoint and an analysis of the laboratory-internal processes in connection with processes outside of the laboratory. Characteristics of a Lean Production are the understanding of customer requirements regarding product quality and product value, the avoidance of waste, the tuning of the individual process steps for a continuous work flow with small variability. In addition to Lean, Six sigma introduces statistical procedures for detecting, measuring and reducing errors, and a strictly structured procedure for continuous quality improvement. By several examples, it is shown that the use of Lean and Six sigma principles in the hospital laboratory results in a clear improvement of processes and cost savings simultaneously.

Accounting services of a medical laboratory are important for an organisation to be profitable. Increasingly complex structures of an organisation need to be considered. Many medical laboratories use laboratory information systems (LISs) that have to support accounting. Here, we describe the current state of accounting in medical laboratories. We focus on special situations in laboratory medicine and on relevant differences between accounting with LISs and accounting with third party or patient administration systems. Accounting with a patient administration system seems to be the simplest method, but special circumstances need to be considered. The more complex the requesting structure is, the more accounting with LISs is recommended. A checklist will provide the reader with the opportunity to choose a matching method of accounting for each individual situation of the laboratory in question. In particular, the “Kassenärztliche Vereinigungen”, responsible for accounting with compulsory health insurances, is currently undergoing large-scale changes. In the near future more changes are to be expected, particularly with the new medical fee regulation.