Ordering Patterns of Thrombophilia Testing and Its Appropriateness

Background Despite society recommendations to limit thrombophilia testing, this testing is often sent inappropriately. The results of thrombophilia testing frequently do not affect management. Additionally, interpretation of thrombophilia testing is confounded by acute thrombosis, anticoagulation (AC) therapy, and other medical comorbidities. Incorrect test selection is also a source of unnecessary testing [i.e. Factor V (FV) activity level instead of Factor V Leiden (FVL)]. The aim of our study was to assess ordering patterns for thrombophilia testing by qualifying the number of tests, identifying the requesting services, and assessing the appropriateness of testing. Methods This was a retrospective study of thrombophilia testing performed at LAC+USC Medical Center, Los Angeles, CA from January 1, 2019 to December 31, 2019. A laboratory query of thrombophilia testing was performed to identify eligible adult patients who received thrombophilia testing without a prior confirmed thrombophilia. Thrombophilia testing included: FVL and prothrombin 20210 gene mutations; activated protein C (APC) resistance; antithrombin, or protein C or S activity levels; and antiphospholipid syndrome (APS) evaluation with lupus anticoagulant, cardiolipin (CL) immunoglobulins IgM/G, and beta-2 glycoprotein (b2gp) IgM/IgG; and JAK2 V617F mutation. Homocysteine (HC) levels and methylenetetrahydrofolate reductase (MTHFR) gene mutation testing were considered to have limited clinical utility. FV activity and phosphatidylserine IgM/IgG were considered incorrect tests. The electronic medical record was reviewed for clinical history, indication for testing, requesting service, and appropriateness. The criteria for defining appropriateness were determined based on major society guidelines and literature review. The main criteria are summarized here. Testing was considered inappropriate for a provoked venous thromboembolism (VTE) or stroke/transient ischemic attack (TIA). For unprovoked VTE, testing was considered inappropriate for patients > 45 yo except for APS testing. For non-stroke arterial thrombosis, recurrent pregnancy loss or stillbirth, and diagnostic evaluation of suspected lupus, APS testing only was considered appropriate. Results 450 patients underwent thrombophilia testing with a mean age of 42 (range: 18-90); 76% were female and 81% were Hispanic. A total of 1698 thrombophilia tests were sent by 27 services. Testing was done in the following settings: inpatient (40%), outpatient (59%), and emergency department (1%). The mean tests per patient were 3.7 (range: 1-12). The most common requesting services were rheumatology (24%), obstetrics-gynecology (19%), and internal medicine/medicine-pediatrics (14%). Hematology requested 10% of tests. Common indications for testing were VTE (21%), rheumatology-related (25%), pregnancy-related (13%), ischemic stroke/TIA (9%), ocular-related (7%), non-stroke arterial thrombosis (3%), and dermatology-related (4%) (Table 1). 5% (84 tests) were sent for the evaluation of other non-thrombotic conditions. 8% (132 tests) were sent for > 1 indication, such as concurrent arterial and venous events. 840 tests (49%) were deemed inappropriate. Common reasons for inappropriate testing included provoked VTE events, stroke/TIA, APS testing after first pregnancy loss, current AC, and duplicate testing (Table 2). APS testing issues included testing for LAC while on AC, incomplete testing (both CL and b2GP not sent), incorrect tests (phosphatidylserine IgM/IgG), and repeat testing < 12 weeks from prior. Incorrect/redundant testing for FVL included: FV activity levels (36 total tests; 9 ordered in additional to FVL and 27 ordered instead of FVL) and APC resistance ordered simultaneously with FVL in 7 patients. Of note, 92 tests were sent for evaluation of non-thrombotic conditions. Conclusions Thrombophilia testing is often done inappropriately. Correct test selection is also a relatively common issue, particularly with APS and FVL testing. Given the large number of services ordering thrombophilia testing at our training hospital and this testing being sent for a variety of reasons, it is unlikely that physician education alone will lead to a substantial or sustained decrease in the number of inappropriate tests. Rather, it may be necessary to restrict at least some thrombophilia testing to certain services. Figure 1 Figure 1. Disclosures Piatek: Rigel: Consultancy, Research Funding; Alexion: Consultancy, Research Funding; Apellis: Research Funding; Dova: Consultancy, Speakers Bureau.

HIV-2 infections: a lesson in diagnostic test selection in Egypt

The first HIV-2 infection in an Egyptian national is documented in this report. Infection with HIV-2 was recognized only after a HIV-1 specific assay yielded negative results in an individual previously identified as being HIV-seropositive by a HIV-1/HIV-2 assay. This emphasizes the importance of using assays capable of detecting both HIV-1 and HIV-2 for testing blood supplies and diagnosis of HIV infections in regions where the prevalence of HIV-2 infections is extremely low.

Bridging the model-to-code abstraction gap with fuzzy logic in model-based regression test selection

Regression test selection (RTS) approaches reduce the cost of regression testing of evolving software systems. Existing RTS approaches based on UML models use behavioral diagrams or a combination of structural and behavioral diagrams. However, in practice, behavioral diagrams are incomplete or not used. In previous work, we proposed a fuzzy logic based RTS approach called FLiRTS that uses UML sequence and activity diagrams. In this work, we introduce FLiRTS 2, which drops the need for behavioral diagrams and relies on system models that only use UML class diagrams, which are the most widely used UML diagrams in practice. FLiRTS 2 addresses the unavailability of behavioral diagrams by classifying test cases using fuzzy logic after analyzing the information commonly provided in class diagrams. We evaluated FLiRTS 2 on UML class diagrams extracted from 3331 revisions of 13 open-source software systems, and compared the results with those of code-based dynamic (Ekstazi) and static (STARTS) RTS approaches. The average test suite reduction using FLiRTS 2 was 82.06%. The average safety violations of FLiRTS 2 with respect to Ekstazi and STARTS were 18.88% and 16.53%, respectively. FLiRTS 2 selected on average about 82% of the test cases that were selected by Ekstazi and STARTS. The average precision violations of FLiRTS 2 with respect to Ekstazi and STARTS were 13.27% and 9.01%, respectively. The average mutation score of the full test suites was 18.90%; the standard deviation of the reduced test suites from the average deviation of the mutation score for each subject was 1.78% for FLiRTS 2, 1.11% for Ekstazi, and 1.43% for STARTS. Our experiment demonstrated that the performance of FLiRTS 2 is close to the state-of-art tools for code-based RTS but requires less information and performs the selection in less time.

PERBANDINGAN KEMAMPUAN REGRESSION TESTING TOOL PADA REGRESSION TEST SELECTION: STARTS DAN EKSTAZI

Regression testing as an essential activity in software development that has changed requirements. In practice, regression testing requires a lot of time so that an optimal strategy is needed. One approach that can be used to speed up execution time is the Regression Test Selection (RTS) approach. Currently, practitioners and academics have started to think about developing tools to optimize the process of implementing regression testing. Among them, STARTS and Ekstazi are the most popular regression testing tools among academics in running test case selection algorithms. This article discusses the comparison of the capabilities of the STARTS and Ekstazi features by using feature parameter evaluation. Both tools were tested with the same input data in the form of System Under Test (SUT) and test cases. The parameters used in the tool comparisons are platform technology, test case selection, functionality, usability and performance efficiency, the advantages, and disadvantages of the tool. he results of the trial show the differences and similarities between the features of STARTS and Ekstazi, so that it can be used by practitioners to take advantage of tools in the implementation of regression testing that suit their needs. In addition, experimental results show that the use of Ekstazi is more precise in sorting out important test cases and is more efficient, when compared to STARTS and regression testing with retest all.

Laboratory Demand Management Strategies—An Overview

Inappropriate laboratory test selection in the form of overutilization as well as underutilization frequently occurs despite available guidelines. There is broad approval among laboratory specialists as well as clinicians that demand management strategies are useful tools to avoid this issue. Most of these tools are based on automated algorithms or other types of machine learning. This review summarizes the available demand management strategies that may be adopted to local settings. We believe that artificial intelligence may help to further improve these available tools.