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Pus alone may not reveal the etiologic agent since the PMNs may have destroyed morphological evidence of microbial invasion.

While most molecular tests have excellent sensitivity, a Mycobacterium tuberculosis NAAT test should be an adjunct to a culture and never ordered alone. No current commercial methods are FDA-cleared for intra-abdominal specimens, so laboratories must have validated the test they use.

If M. tuberculosis is present, it is usually a sign of disseminated disease that must be thoroughly investigated.

In cases of spontaneous bacterial peritonitis (SBP), the source of the invading organism(s) is unknown and the syndrome can also be seen in patients with preexisting risk factors such as cirrhosis with ascites [ 157 , 158 ]. SBP is an ascitic fluid infection without an evident intra-abdominal focus, tends to be monomicrobic, and is usually caused by aerobic organisms from the intestinal tract; therefore, anaerobic cultures are less valuable. Sufficient fluid (eg, 10–50 mL if available) should be obtained to allow for concentration by centrifugation and a cytospin Gram stain evaluation. At a minimum, at least 10 mL of peritoneal fluid (not swabs of the fluid) should be collected aseptically and transported to the laboratory prior to the administration of antimicrobial agents. Additional laboratory testing should include fluid analysis for protein, cell count and differential, lactate concentration, and pH along with 2–3 sets of blood cultures for the identification of concomitant bacteremia ( Table 29 ). Alternatively, because SBP and infections of ascites fluid tend to be monomicrobic, an aerobic blood culture bottle can be inoculated with fluid (volume dependent upon blood culture system) if the presence of a single organism is reasonably certain. A Gram stain may be used prior to broth inoculation to evaluate the morphology of any organism(s) present in the specimen. Since the differentiation between SBP and secondary peritonitis may be uncertain, it may be beneficial to submit peritoneal fluid in a sterile container for conventional culture and stain as well as to inoculate blood culture bottles at the bedside with the fluid. Mass spectrometry, sequencing, and 16S PCR can be used to identify isolates present in these specimens if these techniques are available to the laboratory. In the next few years, next-generation sequencing will be able to analyze such specimens to determine the total microbial load by species. If >1 morphologic type is noted in the Gram stain, a broth should not be inoculated. The caveat for use of blood culture bottles with fluid other than blood is that not all systems have been evaluated for this purpose. Furthermore, broth cultures do not accurately reflect the bacterial burden or the variety of organisms at the time the specimen is obtained, and the presence of a true pathogen may be obscured by the overgrowth of a more rapidly growing organism.

The same tests may be used to screen for and diagnose diabetes and to detect individuals with prediabetes. Diabetes may be identified anywhere along the spectrum of clinical scenarios: in seemingly low-risk individuals who happen to have glucose testing, in individuals tested based on diabetes risk assessment, and in symptomatic patients.

Fasting and 2-Hour Plasma Glucose

The FPG and 2-h PG may be used to diagnose diabetes ( Table 2.2 ). The concordance between the FPG and 2-h PG tests is imperfect, as is the concordance between A1C and either glucose-based test. Numerous studies have confirmed that compared with FPG and A1C cut points, the 2-h PG value diagnoses more people with diabetes.

Recommendations

The A1C test should be performed using a method that is certified by the NGSP ( Quality From China Wholesale Mino Small Wallet in Black See By Chloé Free Shipping Footlocker Pictures With Paypal Sale Online Cheap Sale Store aQavO3T7by
) and standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assay. Although point-of-care A1C assays may be NGSP certified, proficiency testing is not mandated for performing the test, so use of point-of-care assays for diagnostic purposes is not recommended but may be considered in the future if proficiency testing is performed, documented, and deemed acceptable.

The A1C has several advantages compared with the FPG and OGTT, including greater convenience (fasting not required), greater preanalytical stability, and less day-to-day perturbations during stress and illness. However, these advantages may be offset by the lower sensitivity of A1C at the designated cut point, greater cost, limited availability of A1C testing in certain regions of the developing world, and the imperfect correlation between A1C and average glucose in certain individuals. National Health and Nutrition Examination Survey (NHANES) data indicate that an A1C cut point of ≥6.5% (48 mmol/mol) identifies a prevalence of undiagnosed diabetes that is one-third of that using glucose criteria ( Buy Online Cheap Sale Classic Unisex W Base Camp Mini Flip Flops The North Face Shop For Buy Cheap Comfortable E54rF
).

When using A1C to diagnose diabetes, it is important to recognize that A1C is an indirect measure of average blood glucose levels and to take other factors into consideration that may impact hemoglobin glycation independently of glycemia including age, race/ethnicity, and anemia/hemoglobinopathies.

To avoid misdiagnosis or missed diagnosis, the A1C test should be performed using a method that is certified by the NGSP and standardized to the Diabetes Control and Complications Trial (DCCT) assay. B

Marked discordance between measured A1C and plasma glucose levels should raise the possibility of A1C assay interference due to hemoglobin variants (i.e., hemoglobinopathies) and consideration of using an assay without interference or plasma blood glucose criteria to diagnose diabetes. B

In conditions associated with increased red blood cell turnover, such as sickle cell disease, pregnancy (second and third trimesters), hemodialysis, recent blood loss or transfusion, or erythropoietin therapy, only plasma blood glucose criteria should be used to diagnose diabetes. B

Jamie, Baymard Institute December 15, 2014

Jamie, Baymard Institute

Hi Jessica,

Thanks for your comment and questions.

The key insight here is that if you don’t mark both required and optional fields, the user can’t focus on just the field they are currently filling out – they need to take the surrounding context into account. Depending on how it is done (i.e. only denoting optional fields vs only marking required ones) and the context in which it occurs (e.g. desktop vs mobile), this introduce a light-to-heavy mental tax on the user – a tax which can be avoided simply by adding a single-word ‘Optional’ / ‘Required’ tag alongside each field’s label.

Of course from a user POV it is generally preferred to have as few questions as possible asked, so yes, if some fields are deemed unnecessary, do remove them. But this is obviously a business consideration too – maybe certain customer info has great value for customer service or for marketing. Similarly, there may be certain info some customers will happy give if they are simply assured of proper usage. Phone is a great example where if you can promise it will only be used in case of delivery issues, then some users will happily give it up – yet the field should obviously remain optional. So the best solution is to remove unnecessary form fields and then add proper explanations for the few optional fields that are deemed sufficiently valuable to be included.

We’ve conducted in-lab tests of checkouts with 63 participants (in separate think-aloud and eye-tracking studies) across roughly 20 sites. Some of them are among the 9 sites which mark both, but not all of them (note: those nine sites are from our benchmark study).

Jessica Enders December 16, 2014

Hi Jamie

I am questioning whether that is in fact the key insight from the research, or whether the key insight is that challenging questions need to be marked. Totally agree with you that users are wanting to know, /at the field/ whether it is required. But my hypothesis is that they only want to know for challenging questions , not all questions in general. If that’s the case, then we can reduce visual and cognitive noise, while still having a seamless experience, if on the challenging questions we either mark “optional” or explain why information needed.

I agree completely with your second para.

Thanks for the clarification around numbers. How many sessions did you run where both were marked? And in how many of those sessions did the participant react negatively to both being marked?

Jamie, Baymard Institute December 16, 2014

Hi Jessica,

Thanks for following up, we really appreciate thoughtful dialogue – it adds immensely to the articles :)

I’m not entirely sure I understand the definition of “challenging questions”? I should point out that, as we note throughout the article, these insights are related specifically to checkouts and long account creation forms. We haven’t tested surveys etc so I can’t say if the findings hold true in that context.

However, only denoting some fields (i.e. ‘challenging questions’) with a ‘required’ label but not other fields (even though they are required too), would make for a fairly inconsistent denotation of the fields and I would therefore think this would confuse users, but we haven’t tested the approach so I obviously can’t say for sure.

I find that the visual noise introduced by adding a single-word ‘Required’ tag next to the field label is rather minimal considering the overall checkout / account creation context, so the clarity gained by doing so seems to far outweigh the downside in my analysis. (Again, other form types such as surveys may very well benefit from different denotations – we haven’t tested that so we really can’t say what works best in e.g. a survey form.)

Jessica Enders December 21, 2014

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