Physicians' Newsletter Volume 11 Issue 5

Thursday, 01 October 2009

In this issue

1. Pilot Project - my ehealth
2. Laboratory testing for the antiphospholipid antibody syndrome - Anti-β2 glycoprotein 1
3. Investigation of Iron Deficiency
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Pilot Project - my ehealth

Excelleris is launching a new service called my ehealth to provide British Columbian patients with the same secure internet access to their lab results that is currently provided to more than 5,600 BC physicians.
More and more of your patients are requesting hard copies of their test results — in fact, BC Biomedical mails more than 9,500 paper copies of results to patients each month. my ehealth is designed to provide a more expedient and secure method to deliver results to patients. Stringent security and encryption processes have been developed for my ehealth and privacy and confidentiality of patient information are assured. Excelleris consulted with the BCMA, the BC College of Physicians and Surgeons, a physician focus group, the Office of the Information and Privacy Commissioner for BC and other stakeholders in the design of my ehealth. BC Biomedical Laboratories is participating in a pilot of this new service beginning in November 2009 at two of our Patient Service Centres:

1. Morgan Creek Corporate Centre, South Surrey
2. Kensington Square, Burnaby

This pilot project will only include results generated by BC Biomedical Laboratories and LifeLabs. Results from other laboratories will not be available at the pilot stage of the project. In the pilot stage, only patients 16 years of age and older with a BC CareCard will be able to register for my ehealth. Patients who request copies of lab results in these two Patient Service Centres will be offered my ehealth as an alternative or as an addition to hard copies sent by Canada Post. The purpose of the pilot project is to provide some logistical feedback from patients, physicians and Medical Office Assistants before it is made more widely available early next year.

What this means to you:

• Patients will have access to results as they are released from the testing laboratory, which may mean that patients have the results before you do if you are not an Excelleris subscriber or if you have not yet accessed your Excelleris inbox.
• Please note, BC Biomedical will continue to telephone significantly abnormal values, critical values or results ordered STAT according to our current protocols. my ehealth will not be a replacement for this service.
• Also, physicians are reminded that they are still responsible for following up of any abnormal lab results with their patients.
• Patients may present reports to you which they have printed from my ehealth. These should always be confirmed by accessing the Excelleris records or your own hard copy reports, as corrected or supplementary reports may have been issued.
• Your office may receive fewer telephone calls from patients enquiring about lab results, especially for those
  results which are still pending.

Please visit www.myehealth.ca for more information. If you have any questions, comments or suggestions, please contact Lindsay Allan, President, Excelleris at 604-658-2103 or at This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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Laboratory testing for the antiphospholipid antibody syndrome - Anti-β2 glycoprotein¹

The antiphospholipid antibody syndrome (APS) is defined by a combination of clinical features and the presence of antiphospholipid antibodies. In 2006, revised clinical and laboratory criteria for APS were published¹ which required at least one of the clinical criteria and one of the laboratory criteria to be met before assigning
this diagnosis: Clinical Criteria (at least one clinical criterion is required for diagnosis of APS):

1. Vascular thrombosis One or more clinical episodes of arterial, venous or small vessel thrombosis in any tissue or organ. Must be confirmed by objective validated criteria.
2. Pregnancy morbidity
   1. One or more unexplained deaths of a morphologically
      normal fetus at or beyond the 10th week of gestation, with normal fetal morphology documented by ultrasound or by direct examination of the fetus or
   2. One or more premature births of a morphologically normal neonate before the 34th week of gestation because of eclampsia or severe pre-eclampsia, defined according to standard definitions or recognized features of placental insufficiency or
   3. Three or more unexplained consecutive spontaneous abortions before the 10th week of gestation with no evidence of maternal anatomic, hormonal or paternal/maternal chromosome abnormalities

Laboratory Criteria (One positive test is sufficient for diagnosis of APS):

1. Lupus anticoagulant or
2. Anticardiolipin antibody (IgG and/or IgM isotype) or
3. Anti-β2 glycoprotein 1 antibody (IgG and/or IgM isotype)
   Note: a positive laboratory test must be present on at least two occasions, at least 12 weeks apart

BC Biomedical Laboratories currently offers tests for lupus anticoagulant and anticardiolipin antibodies.
Effective October 19th, 2009 we are pleased to offer anti-β2 glycoprotein 1 antibody testing as an additional laboratory test to aid in the diagnosis of the APS.

Indications for antiphospholipid antibody investigations should be limited to the clinical scenarios listed above.
Please direct any enquiries or concerns to any member of the Hematopathology Group at 604-507-5000.

¹ Miyakis S et al: International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thrombosis and Haemostasis 2006; 4:295-306.

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Investigation of Iron Deficiency

We continue to receive orders for iron, total iron binding capacity (TIBC) and % transferrin saturation together with a serum ferritin.

Please be reminded that the serum ferritin is the best diagnostic test for iron deficiency.

The following is an excerpt from the BCMA/MSP Guidelines and Protocols Committee on Investigation and Management of Iron Deficiency (Revised 2004). The full guideline can be accessed at http://www.bcguidelines.ca/gpac/.

Recommendation 3: Assessment of possible iron deficiency

Clinical assessment: Identification of patients at risk of iron deficiency should be based upon a directed history (dietary, social, demographic, cultural, physiological factors as well as other conditions like neoplasms, medications, GI disease etc – see Appendix 2 of Guideline for common causes), review of symptoms, and physical examination.

Diagnosis of iron deficiency: Laboratory investigation of iron deficiency should be based on clinical suspicion, not on presence of anemia. In the early stages, iron deficiency can exist without overt anemia, but with non-hematological symptoms (see Rationale section of Guideline).

• Serum ferritin is the best diagnostic test for iron deficiency. A ferritin concentration below 15 μg/L for adults and 12 μg/L for children indicates iron deficiency. These cutoffs include most cases of iron deficiency, however, deficiencies can occur in the low normal range.
• Ferritin measurements may be unreliable in patients with concurrent acute or chronic inflammation, malignancy, hepatic or kidney disease. Patients with persistently elevated serum ferritin levels, without chronic inflammatory disorder should be tested for iron overload (See separate guideline: Investigation and Management of Iron Overload).
• Serum iron and transferrin saturation (iron and iron binding capacity) should only be measured when the ferritin values are reported as normal or high in the face of clinically suspicious iron deficiency, or in patients with kidney failure.
• A hematology profile can suggest iron deficiency. It is not the diagnostic test of choice, but is required to assess the severity of anemia. A constellation of the following findings is highly suggestive of iron deficiency: microcytic, hypochromic anemia and mild thrombocytosis.
• Monitored trial of iron: In patients with anemia, likely resulting from iron deficiency due to an obvious cause, a monitored trial of iron therapy may be both diagnostic and therapeutic. Oral iron preparations are given at a dose of 180 mg elemental iron per day for adults and 6 mg elemental iron per kg per day for children. A rise in hemoglobin of 10-20 g/L in two to four weeks supports the diagnosis of iron deficiency.
  Please direct any questions to any member of the Hematopathology or Medical Biochemistry Groups at 604-507-5000.

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