– Prophylactic examinations should be performed at least once a year. This applies especially to morphology, blood glucose, urinalysis and basic inflammatory indicators, such as ESR or CRP, says Dr. Wirginia Krzystak from the Department of Medical Diagnostics of the Jagiellonian University Medical College, the patient’s laboratory diagnostician. In her opinion, in times of a pandemic, mobile collection points may be helpful in carrying out research.
- Preventive examinations are a source of valuable information about our health. We should do them at least once a year
- As we age, the number of tests needed to monitor our body increases
- Situations that require special attention on our part include: pregnancy and its planning, stress, change of diet, suspected diseases and recovery time – says Dr. Wirginia Krzystak
- In order to facilitate the performance of tests, mobile points are created that enable blood collection at the patient’s home
- You can find more such stories on the TvoiLokony home page
Adrian Dąbek, Medonet .: Why should we do preventive examinations?
Dr hab. Virginia Krzystak: Such tests provide valuable information, in particular on blood, in the case of the basic blood count, as well as provide information related to the work and function of many organs, thus giving a complete picture to the attending physician about the current clinical condition and possible need for performance. additional tests that may be necessary from time to time.
Situations in which we should definitely examine ourselves are the period of planning offspring, preventive examinations performed during pregnancy, after childbirth, during increased physical exertion, in a situation of exposure to stress, mental and physical, when changing the diet, when suspecting various diseases, such as as one of the most common among young women, iron deficiency anemia, infectious and inflammatory diseases, and to monitor the above. diseases, disorders of the coagulation system, during and after treatment of these conditions, also during convalescence to check that everything is back to normal.
In situations where we are not trying to conceive and there are no signs of disease, how often should we do such tests?
In the case of blood counts, it is recommended that these tests be performed at least once a year. However, apart from the morphology, other laboratory tests that we should monitor at least once a year include the basic indicators of inflammation, such as ESR, CRP, blood glucose, urinalysis, especially in the 30-40 age group.
If there are cardiovascular diseases in the family, we should also prophylactically assess the lipid profile, which includes measurements of total cholesterol, also its fraction: cardioprotective HDL and atherogenic fractions: LDL and non-HDL, as well as triglycerides, which are the basic diagnostic tests laboratory in terms of adequate monitoring and assessment of coronary risk.
However, in the case of people between 40 and 50 years of age, in addition to the aforementioned tests, as part of the prevention of colorectal cancer, it is worth doing a fecal occult blood test once a year and assessing the functioning of the thyroid by testing the level of hormones such as TSH and FT4.
After the age of 50, the list of recommended tests increases, and in women, the level of sex hormones in the blood is also determined in connection with the perimenopausal period. In men over 50, due to the increased risk of changes in the prostate gland, apart from the appointment of a urologist and prostate examination, the determination of the prostate-specific antigen, i.e. PSA, should be performed.
- What preventive examinations should a young mother perform?
In general, the appropriateness of performing laboratory testing is related to the initiation, termination, or modification of therapy. In individual cases, the course of the disease determines the validity of subsequent tests.
It should be noted that diagnostic laboratory tests are a very important aid in medical patient care, but these data are useful for the patient only if clinical conclusions can be drawn from them.
Research can also be used to improve lifestyle habits. For example, when it comes to reducing or completely eliminating stimulants, such as tobacco or alcohol, increasing physical activity or introducing modifications related to the diet. In some cases, the results of laboratory tests may be decisive in excluding or confirming a genetic disease, which may have an impact on further treatment.
The frequency of repeating the tests is based on international or local recommendations. Often these minimum intervals can only be determined for specific groups of patients. Recommended minimum intervals for repeating certain laboratory tests depend on the type of test. For example, the repeated measurement of glycosylated hemoglobin, which is a parameter slightly better than a single measurement of fasting glucose, because it reflects the actual glucose level over three months in diabetic patients treated with insulin, in the case of patients not treated with insulin, it is a period of six months.
- Prophylactic examinations for men. What tests are worth doing?
In the case of re-determination of the parameter, which is ferritin, which reflects iron stores in our body, the period of re-examination is two months from the commencement of supplementation with iron preparations in connection with the treatment of iron deficiency anemia. Serum ferritin is the preferred diagnostic test to monitor the effectiveness of treatment.
In the case of assessing the level of vitamin B12, the follow-up examination period is two months if a deficiency of this vitamin is suspected.
Another situation that requires re-testing is the therapeutic monitoring of some drugs, for which control measurements are performed at the beginning of treatment, after changing the dose of the drug, and also in the case of suspected change in the pharmacokinetics of the drug used due to changes in the liver or kidneys. Diseases of the liver or kidneys can modify the kinetics of drugs biotransformed by the liver or kidneys. Knowledge about the metabolism of drugs and their impact on the functions of the liver or kidneys may be the basis for changing a medical decision to adjust a specific dose of the drug in patients with impaired functioning of these organs.
More frequent monitoring of the concentration may be needed immediately after initiation of treatment, especially with drugs with different inter-individual kinetics, for example with vitamin K antagonists such as acenocoumarol for thromboembolism prophylaxis. Repeated testing is most often needed infrequently in well-controlled and stable patients undergoing maintenance treatment, therefore an average of three to six months follow-up is recommended for psychotropic medications, especially in patients without complications.
Therapeutic drug monitoring is a broad issue and requires the assessment of the work function of many organs, but their laboratory control seems to be necessary, thanks to which it becomes realistic to predict the response to the applied treatment, which is important for personalized medicine.
Is the mentioned age of 30 the moment when we should think more about preventive examinations?
Definitely yes, although the period of the pandemic should also be taken into account, in which prophylactic examinations should be performed in the group of children and adolescents due to the risk of the diseases mentioned earlier, also the risk of obesity and metabolic syndrome. Therefore, tests such as glucose and cholesterol levels in children and adolescents should be carried out at least once between the ages of 9 and 11, and again between the ages of 17 and 21. This is especially important due to the existing statistics. According to the Central Statistical Office of Poland (GUS), cardiovascular disease is the main cause of death. And despite significant progress in the field of counteracting premature mortality from this cause, it is still the cause of about 46 percent. deaths in Poland are cardiological diseases. When it comes to the matter related to the metabolic syndrome or diabetes, here international societies recommend prophylaxis related to the determination of blood glucose for type 2 diabetes in people from the age of 30. Especially in those people with additional risk factors, such as overweight or obesity. In these groups, these tests should be performed every three years, even if the results are normal.
- Preventive examinations for women of all ages. Do regularly
However, with increased cardiovascular risk or diseases such as diabetes, these tests should be performed more frequently as they can provide clinicians with information on the diagnosis and severity of cardiovascular failure, but also improve prognosis and treatment strategies.
The legitimacy of performing repeated laboratory tests, in addition to the group of patients with cardiological problems, applies to people with schizophrenia spectrum disorders, and recently also to young people under the age of 20 in the early stages of psychosis or with mood disorders, which, due to the increasing pandemic, constitute a significant problem in all over the world. The high prevalence of mental health problems among students affected by social isolation is an argument for including this social group with enhanced prevention, supervision and easier access to medical care. According to the report of the Organization for Economic Cooperation and Development, as well as the European Commission of 2020, the issue of mental health becomes an even greater priority in EU countries and there is an increased need for more frequent laboratory tests and monitoring of mental health in the youngest age groups.
Can we afford to neglect prophylaxis during a pandemic, because the circumstances are not conducive to visits to doctor’s offices or clinics?
Definitely not. When it comes to such general public concern, people have learned to live with the virus for over a year. Currently, there is no fear of leaving the house as it was a year ago, when government orders and bans were introduced, such as those related to moving. It seems to me that the current epidemic situation related to the difficult access to medical facilities has increased awareness of pro-health prophylaxis, which has resulted in a greater openness of the public to perform laboratory tests, apart from those commissioned as part of primary health care, also privately, at commercial points. Operating commercial service providers provide, among others, home blood tests, mobile points are created that enable or even facilitate the activities of patients related to the collection and transport of biological material to the laboratory for further analysis, in a way that reduces the patient’s exposure to diseases.
- Why don’t we check ourselves prophylactically? “This is partly due to our mentality and partly to ignorance”
The health care burden, not only with the existing pandemic, but with the current burdensome administrative procedures, means that doctors have limited time to care for patients. This should constitute the basis for a revision of the currently functioning procedures related to medical care. Perhaps a partial solution to the problem would be the introduction of the so-called medical secretary, as this problem is currently being solved in the health service structures in the USA.
How does it look in practice?
The need for interaction of medical personnel with patients, in conditions that are completely safe for them, such as their home, increased the demand for mobile collection and testing of biological material, e.g. blood. In a situation where the scale of the pandemic changes dramatically, remote ordering of such services and consistent laboratory tests in the collected biological material constitute a new form of patient care.
The pandemic has shown that laboratory tests and the associated stressful blood collection can provide reliable information about health in a convenient way for the patient without visiting crowded health care facilities, while maintaining the safety of both patients and healthcare professionals.
In practice, trained nurses or phlebotomists who provide mobile laboratory services come to the patient’s home. Subsequently collected biological material is transported to the laboratory, where its complete analysis is performed. If the patient is still reluctant to leave home, it is also possible to consult and discuss these results over the phone or through online contact in relation to the patient.
And how do you assess the awareness of Poles as regards the necessity of preventive examinations?
I think people’s awareness has increased a bit over the course of this year. Due to the existing pandemic, after a year, people began to pay more attention to performing preventive laboratory tests. Nevertheless, it does not change the fact that health problems related to the most common diseases, such as: cardiovascular diseases, diabetes, obesity and mental diseases, are still not decreasing, also in the youngest groups.
Recommendations regarding the frequency of laboratory tests remain. Particular care should be taken for children and adolescents, due to the prolonged social isolation with peers or the lack of exercise, which for the young generation is one of the most important factors contributing to the improvement of mental health and cognitive functions as well as the work of individual organs.
And if we get coronavirus, what should we do?
For those who have had COVID-19 infection behind them, the primary strategy to mitigate the SARS-CoV-2 pandemic pandemic is the use of laboratory diagnostic tools. These include serological tests assessing prior exposure to SARS-CoV-2 in the population, allowing the identification of highly reactive plasma donors, and allowing the determination of protective antibody titers. These tests allow us to assess the level of IgG and IgM antibodies related to the detection of past or passing SARS-CoV-2 virus infection by measuring the humoral immune response of a person in contact with the virus. Serological tests measuring antibodies against Coronavirus 2 are one method of estimating infection rates and monitoring the progress of the epidemic.
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The use of serological tests covers four situations where these tests could be of assistance.
First, in the diagnosis of acute suspicion of COVID-19 in symptomatic patients in whom the virus could not be detected, especially in molecular tests. Secondly in assessing the immune response of patients with severe disease. Situation three in turn, it concerns natural persons who are assessed for whether they have been infected with SARS-CoV-2 and are resistant. After all, these tests are of use in public health seroprevalence studies. Situation three is to study people whose symptoms have passed during the recovery period while last situation relates to the results of people’s tests at various time points, including during long-term observation. The humoral immune response associated with antibody levels is expected to be significantly higher in situation three than in situation four. This is because the levels of antibodies will be significantly higher in people who have disappearing symptoms compared to those who did not have obvious symptoms. Thus, the use of serological tests depends on the purpose they are intended to serve.
Other uses would include people who have symptoms and have not been tested, but also people who are asymptomatic as well as symptomatic people. It should be noted that there are many limitations to serological testing. The assessment of the level of antibodies required for protection against subsequent infection or the duration of this protection and the factors related to the development of a protective antibody response seems to be the key subject of research. The kinetics of the antibody response, the study of the maximum duration of neutralizing antibodies and the ability to protect against recontamination have not yet been clearly established.
There are three types of antibodies produced in response to SARS-CoV-2 infection. In serological tests, mainly IgM and IgG antibodies are used. Their increases are observed at different times after the onset of infection. IgG antibodies are used in most serological tests because they last the longest, they may reflect long-term immunity, although evidence shows that their titer persists after the last infection. In contrast, IgM antibodies usually increase rapidly with infection and fall shortly after the infection clears.
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Information that may influence general serological prescriptions is changing rapidly, especially evidence as to whether positive serological tests indicate protective immunity or reduced viral transmission in recently ill people. Currently, it seems interesting to determine whether to conduct characterization and evaluation of the performance of serological tests for the biological material of patients who have negative genetic tests and IgG positive results, in order to be able to use the indicated laboratory diagnostic tools to assess the importance of population tests as the pandemic develops and the expected reduction in the level of IgM antibodies in a greater number of people with different disease course (symptomatic patients and patients not showing symptoms of infection), who have activated the humoral response.
Serological testing is often offered as an adjunct to the diagnosis of acute COVID 19 in people who report late. For those who report between 9 and 14 days after the onset of symptoms, in addition to the recommended direct virus detection methods such as genetic testing or viral antigen detection testing, serological testing may only be used as an aid. During this time, the sensitivity of nucleic acid detection decreases. Throat swabs collected after the eighth day after the onset of the disease show a low positive percentage, especially in samples of biological material collected from patients with mild disease. Later, however, the sensitivity of serological tests increases.
Nor should a serological test alone be used to confirm the presence or absence of SARS-CoV-2 infection or reinfection. Antibodies may also be absent in people tested in the early stages of the disease, or in people who will not develop detected antibodies after infection, and those who have undergone COVID-19 have innate cellular immunity strong enough that a humoral response it is not triggered at all, which may (this is my hypothesis supported by the literature) mainly concerns young people before 30, 40 years of age without comorbidities. An example is the situation in which using the ELISpot test for the presence of interferon-γ, it was noted that about 80% of PCR-positive volunteers with undetectable antibodies showed strong resistance of T lymphocytes to the presence of SARS-CoV-2. This proves that, in addition to tests assessing humoral immunity, in the assessment of population immunity, tests assessing cellular immunity should also be taken into account, especially in people with undetectable IgG antibodies to SARS-CoV-2 whose immunity may be mediated mainly by T lymphocytes.
After the infection has passed, what should we do to see if there is any trace of COVID-19 left?
We do not know all the effects of SARS-CoV-2 infection and will not be known for a long time, but there are a number of laboratory tests that are used in clinical practice as additional biomarkers for assessing complications, such as increased D-dimers or alkaline phosphatase, increasing the risk of development of deep vein thrombosis, requiring early evaluation and decisive treatment, especially in the 60+ age group.
In the case of complications related to COVID-19 in children, manifested 4-6 weeks after infection with high fever, organ dysfunction and highly elevated markers of inflammation, it seems important to monitor basic parameters such as blood counts, including a decline in lymphocytes is a hallmark of COVID-19 in this age group. Another important factor seems to be the assessment of the dynamics of changes in the level of inflammatory markers, such as C-reactive protein (CRP) or ferritin, which often determine a prolonged disease.
- Long COVID-19. The list of ailments keeps getting longer. What do convalescents suffer from?
In the case of patients reporting neurological problems, attention should be paid to the assessment of the level of pro-inflammatory cytokines, i.e. IL6, ferritin or protein markers of neuronal dysfunction, including amyloid beta, neurogranin, total tau protein, which in all convalescents with COVID-19 with neurological problems are strongly associated with the severity of the consequences, which suggests a relationship between peripheral inflammation and neuroinflammation after COVID-19. People recovering from COVID-19 may have latent nerve damage, which seems to be important for their health, not only physically but also mentally. The SARS CoV-2 virus affects the microcirculation, causing swelling and damage to endothelial cells (endothelial inflammation), microscopic blood clots, capillary congestion and pericyte damage, which lead to disruption of capillary integrity and blood-brain barrier function. Hypoxia impairs the function of the mitochondria (which are the energy center for cells with high levels of energy metabolism, ie neurons), which thus act as reservoirs for the SARS-CoV-2 virus and its subsequent “dormant” interactions with the host. High viral loads in COVID-19 patients who report CNS complications result in neuronal impairment.
Increased levels of cytokines in the systemic circulation as a consequence lead to low levels of oxygen and high levels of cytokines in the brain tissue, which in turn affects the synthesis of neurotransmitters and mood, hence we observe an increasing group of patients with the so-called severe long-term mental and cognitive changes, including a recently identified symptom known as ‘brain fog’.
Chronic persistence or development of new symptoms associated with SARS-CoV-2 infection in the course of COVID-19 is increasingly reported by a greater proportion of patients, regardless of whether the disease is laboratory or clinical confirmed. These symptoms are just as heterogeneous as in acute COVID-19 and can be persistent, appear with varying frequency, or be masked by symptoms associated with other systems. This situation requires a holistic approach to the management of COVID-19 patients, especially in low-status countries. Many of the people reporting after long-term COVID or in the course of a prolonged disease will require more work from specialists in various fields, including laboratory medicine, clinical immunologists, geneticists, radiologists, neurologists, psychiatrists and rehabilitation doctors.
The long-term health effects of COVID-19 remain largely unclear. The priority of health care systems should be to enable the study of the consequences of health effects of people with a severe course of COVID-19, as well as people with non-classical symptoms of the disease. In particular, laboratory test packages should be available to facilitate clinical decisions, e.g. related to the assessment of the severity of the disease. This would allow for an objective (by means of laboratory tests) assessment of the work status of many organs, including the cardiovascular system (troponin), the liver (aspartate and alanine aminotransferases), the efficiency of the blood coagulation system (D-dimers, fibrinogen). These parameters allow the identification of risk factors and thus facilitate the classification of patients, which currently seems to be a key element of the diagnostic process guaranteeing rapid identification of patients with complications or with long-term COVID-19.
Finally, I will ask what we should or should not do before the research?
When it comes to individual laboratory tests, before carrying out, we should properly prepare on this subject, the information we obtain as soon as possible is at the stage of selecting laboratory tests for analysis in a given laboratory or biological material collection point. A short period of fasting before the test is usually associated with obtaining more reliable results, especially in the case of blood counts, glucose tests and triglyceride levels. The activities related to the preparation for the test, along with all the procedures before starting the laboratory tests, are part of the so-called the preanalytical phase, which accounts for the majority of laboratory errors, due to the fact that these activities are performed by persons unrelated to the laboratory itself, and therefore without the direct supervision of laboratory personnel.
Thus, the proper organization or management of the pre-analytical process of preparation for the study and taking into account the impact of confounders, as well as the adherence to the procedures for collecting blood samples themselves, are fundamental to obtaining a reliable test result, as the different steps themselves are sources of laboratory variation.
The package of preventive examinations with access to the patient’s home is available in Medonet Market in several variants to choose from
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