Laboratory Safety Climate Assessment and its Correlation with Safety Procedures Amongst Staff of a Reference Clinical Laboratory.

OBJECTIVE: To compare and correlate safety climate standards and safety practices among different subspecialities of pathology. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: The study was conducted at Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from February to November 2022. METHODOLOGY: Responses of 199 participants were recorded according to the validated Nordic Safety Climate Questionnaire (NOSACQ-50) and Lab Safety Survey form. The safety climate presented as seven dimensions according to the validated questionnaire was compared among different workgroups, based on subspeciality and job designation, using one-way ANOVA and independent sample t-test, respectively. Pearson's correlation was used to assess the relationship between the safety climate and safety practices. RESULTS: Among the safety climate dimensions, safety communication, trust in co-workers' safety competence (M=3.02) and workers trust in efficacy of safety systems (M=3.00) were the most positively perceived aspects followed by management's safety priority (M=2.98). Comparison of subspecialities showed significant differences in management safety empowerment, management safety justice, workers' safety commitment, safety communication, and trust in efficiency of safety systems (p<0.001 for all 5 factors). Chemical pathology workers and technical staff were workgroups with lower safety climate scores. A statistically significant positive correlation (r=0.97) was observed between the safety procedures and safety climate at an organisational level. CONCLUSION: The results demonstrated the existence of a good safety climate within the participating laboratories of the institute. It successfully identified areas that need further safety improvements. The study will help increase awareness about occupational safety and safety culture among healthcare workers in general and clinical laboratory setups in particular. KEY WORDS: Laboratory safety climate, Occupational health, Safe laboratory practices.

Fifth Generation Quality Control of Immunoassay Parameters by Six Sigma Value.

OBJECTIVE: To determine the sigma value of immunoassay parameters which are within the 2Z score on external quality control (EQC). STUDY DESIGN: A cross-sectional study. Place and Duration of the Study: Department of Chemical Pathology and Endocrinology (AFIP),non-ability ity consecutive  from June to November 2022. METHODOLOGY: Ten immunoassay parameters were selected on the basis of the internal quality control (IQC) and external quality control (EQC) programs. The Clinical Laboratory Improvement Amendments (CLIA) is used for Total Allowable Error (TEa). Sigma value was calculated from coefficient of variation (CV) and bias, which was determined by IQC and EQC, observed for 6 subsequent months. If the sigma values are ≥6, between 3 and 5, and <3, they are classified as good, acceptable or unacceptable, respectively. RESULTS: T4, prolactin, Vitamin B12 at >3 ó at IQC level 1. TSH, T3, T4, and Vitamin B12 showed that on level 2 IQC at >3 ó T3, Vitamin D at 4-5 ó level, Prolactin, FSH, and LH at 6 ó level in level 2 IQC. In the EQC program, the sigma level calculated for ten assays found that almost all parameters were at sigma >3 ó level except TSH which was at 5.8 Ï­ level during June to August 2022. From September to November 2022, all parameters at >3 ó level except for TSH, growth hormone, FSH, LH, and Vitamin b12 which showed at 4.4 ó level. CONCLUSION: Most of the immunoassay parameters show good performance in the EQC program and at both levels of IQC level with sigma value 4-5. KEY WORDS: Bias, Six sigma, Key performance indicators, External quality control.

Correlation of Serum Erythropoietin Levels with Different Stages of Diabetic Retinopathy.

OBJECTIVE: To determine the correlation of serum erythropoietin concentration with diabetic retinopathy in patients with type 2 diabetes mellitus. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, from July to December 2021. METHODOLOGY: A total of 180 individuals were enrolled in the study and placed in 2 groups as group 1 have 90 cases of type 2 diabetes mellitus and group 2 having 90 age-matched healthy controls. Group 1 was further subclassified into proliferative diabetic retinopathy (PDR) and non-proliferative diabetic retinopathy (NPDR) subgroups by an expert ophthalmologist. Serum erythropoietin, creatinine, blood HbA1c, and haemoglobin were analysed. Correlation between stages of proliferation and serum erythropoietin, creatinine, blood HbA1c, and haemoglobin were analysed. An independent-sample student t-test was applied to compare mean Serum erythropoietin between PDR and NPDR groups. Pearson's correlation was applied among disease severity, and type of retinopathy. A p-value of ≤0.05 was considered significant. RESULTS: The average age of participants in groups 1 and 2 was 45.88±8.6 and 56.6±10.23 years, respectively. More males (n=60, 66.7%) were noted in cases compared to controls (n=42, 46.7%). serum erythropoietin concentration observed in cases (8.4±1.87 IU/L) was higher than controls (6.50±0.9). The mean serum erythropoietin concentration in PDR (9.35±1.74 IU/L) was significantly greater than that in NPDR (7.3±1.38 IU/L, p <0.001). The serum concentration of erythropoietin in group 1 increased linearly with the severity of the disease (r=0.103). CONCLUSION: Serum erythropoietin concentrations increased in uncontrolled type 2 diabetics more so in proliferative retinopathy cases, and increased with disease severity. KEY WORDS: Erythropoietin, Diabetic retinopathy, Proliferative diabetic retinopathy.

Evaluation of hypomagnesaemia in diabetic patients with nephropathy in a reference clinical laboratory: A comparative cross sectional study.

Serum Magnesium plays a significant role in different diabetic complications. This comparative cross sectional study was conducted to evaluate serum magnesium levels in patients with Type 2 Diabetes Mellitus (T2DM) with and without nephropathy. A total of 182 diabetic patients (91 with nephropathy and 91 without nephropathy) were included. Odds ratio were calculated and Mann Whitney U test was used to compare quantitative variables; p<0.05 was considered significant. The results showed that 64/91 (70.3%) patients with nephropathy had hypomagnesaemia as compared to 21/91 (23.07%) patients without nephropathy. The risk of hypomagnesaemia was higher in patients with nephropathy than without nephropathy (Odds ratio 2.7 vs 0.34). Median magnesium levels (1.73 mg/dl) were lower in patients with nephropathy as compared to patients without nephropathy (2.09 mg/dl), p<0.01. It is concluded that magnesium levels were significantly lower in patients with diabetic nephropathy as compared to without nephropathy.

Etiological study of short stature in children and role of insulin like growth factor-1 and insulin like growth factor binding protein-3 as screening markers for growth hormone deficiency.

OBJECTIVE: To determine aetiological factors in children with short stature, and to evaluate the role of insulin like growth factor-1 and insulin like growth factor binding protein-3 as screening markers for growth hormone deficiency. METHODS: The cross-sectional study was conducted at the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from August 2020 to July 2021, and comprised children with short stature. Evaluation protocol included complete history and examination, baseline laboratory investigations, X-ray for bone age and karyotyping. Growth hormone status was assessed using growth hormone stimulation tests, and serum insulin like growth factor-1 and insulin like growth factor binding protein-3 levels were also assessed. Data was analysed using SPSS 25. RESULTS: Of the 649 children, 422(65.9%) were boys and 227(34.9%) were girls. The overall median age was 11 years (interquartile range: 11 years). Of the total, 116(17.9%) children had growth hormone deficiency. Familial short stature was present in 130(20%) children and constitutional delay in growth and puberty in 104(16.1%). There was no significant difference in levels of serum insulin like growth factor-1 and insulin like growth factor binding protein-3 in children who had growth hormone deficiency and those who had other causes of short stature (p>0.05). CONCLUSIONS: Physiological variants of short stature were found to be more common in the population followed by growth hormone deficiency. Serum insulin like growth factor-1 and insulin like growth factor binding protein-3 levels alone should not be used to screen children with short stature for growth hormone deficiency.

A Rare Case of Propionic Acidemia in a Six Months Female Child.

Propionic Acidemia (PA) is a rare metabolic disorder caused by the defect in enzyme (propionyl-coenzyme A (CoA) carboxylase) leading to the abnormal accumulation of metabolites of branched-chain amino acid catabolism in blood and urine. We describe the first ever diagnosed case in our setup of early onset PA in a 06 months old baby girl who presented with the complaints of decreased feed intake, lethargy, vomiting, failure to thrive, and intermittent seizures. The basic laboratory investigations showed pancytopenia along with high anion gap metabolic acidosis, urine dipstick positive for ketones, and hyperammonemia. Plasma amino acid analysis by ion exchange chromatography (IEC) showed elevated plasma glycine and lysine levels. Finally, urine organic acid analysis by gas chromatography-mass spectrometry (GCMS) showed marked elevation of 3-hydroxy propionate, methyl citrate, and 3-hydroxy, 2 methylbutyric acid with moderate rise in 3-hydroxy butyric acid without an elevation of methylmalonate in urine, thus giving the diagnosis of PA. Key Words: Propionic acidemia, Propionyl-CoA Carboxylase deficiency, Gas chromatography-mass spectrometry.

Early Diagnosis of Coronary Artery Disease by Inflammatory Biomarkers of Atherosclerosis in Patients with Angina.

Early diagnosis of coronary artery disease (CAD) in patients with chest pain is a challenge. Currently diagnosis of CAD is confirmed by coronary angiography, which is invasive and not easily available in developing countries. Therefore, it is imperative to establish noninvasive biomarker for early diagnosis of CAD in patients with angina and determine the diagnostic accuracy of inflammatory biomarkers of atherosclerosis in comparison to angiography and correlate with severity of CAD in patients with angina. Diagnostic accuracy study was carried out in tertiary care hospitals, Rawalpindi, Pakistan. Total of 58 patients aged 55.24 ± 11.61 years, with chest pain and troponin-I -ve, having coronary artery stenosis ≥50% were included as cases of CAD and 55 subjects having stenosis <50% were included as controls. Nuclear factor kappa-B (NF-κB), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and high-sensitivity C-reactive protein (hs-CRP) were analyzed on immunoassay analyzers. The receiver operating characteristic curve analysis revealed significant (P < 0.05) high area under curve (95% confidence interval) with sensitivity and specificity of NF-κB 0.76 (0.65-0.85), 73% and 65%; TNF-α 0.72 (0.61-0.81), 71% and 69%; IL-6 0.62 (0.52-0.71), 64% and 53% and hs-CRP 0.62 (0.52-0.71), and 53% and 56% in CAD patients compared to controls. There was significant positive correlation between NF-κB (r = 0.44), TNF-α (r = 0.37), IL-6 (r = 0.23), and hs-CRP (r = 0.23) with severity of CAD by Gensini score. The inflammatory biomarkers, especially NF-κB and TNF-α, have highest diagnostic accuracy and indicate severity of atherosclerosis in patients with angina. These markers may be used as noninvasive biomarkers to exclude healthy individuals before undergoing angiography.

Clinical parameters and treatment outcome in patients of acromegaly: A retrospective analysis of 51 patients.

The aim of the study was to analyze the pattern of clinical presentation and management outcome in patients of acromegaly. It is a cross-sectional study based on the clinical records of 51 patients of Acromegaly. All the recorded clinical data was analyzed to see the pattern of clinical presentation and management outcome. IBM SPSS statistics version 22 was used for statistical analysis. The median age was 32 years. Twenty-seven patients underwent surgery and 6 (22.2%) achieved remission. With pharmacological management, 35.8% patients achieved control of the disease with Octreotide LAR and 7.1% with cabergoline. Eighteen patients were treated with External Beam Radiation (EBR) and Stereotactic Radiosurgery (SRS). Remission rate has been 88.9% with SRS and 33.3% with EBR. The study shows higher prevalence of Growth Hormone (GH) secreting tumour in younger people and men. Remission rate was highest in patients treated with radiotherapy after partial response to TSS.

Establishing biotinidase reference interval: A foundation stone for newborn screening of biotinidase deficiency in Pakistan.

OBJECTIVE: To determine the reference interval of biotinidase activity in healthy neonates. METHODS: The cross-sectional study was conducted at the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from May to November 2019, and comprised blood samples collected from healthy neonates aged 2-6 days. The samples were collected on filter paper and analysed on genetic screening processor based on dissociation-enhanced lanthanide flouroimmunoassay. Data was analysed using SPSS 21. RESULTS: Of the 120 dried blood spot specimens, 81(67.5%) were from male babies and 39(32.5%) from female babies. Reference interval for biotinidase activity, based on 2.5th and 97.5th percentiles, was from 3.0 to 11.0 nmol/ml/min. CONCLUSIONS: Screening of newborns for biotinidase deficiency is crucial to prevent irreversible neurological damage.

Procalcitonin as a biomarker of bacterial infection in critically ill patients admitted with suspected Sepsis in Intensive Care Unit of a tertiary care hospital.

OBJECTIVE: To compare the diagnostic accuracy of procalcitonin (PCT), C- reactive protein (CRP), total leukocyte count (TLC) and lactate in critically ill patients admitted with suspicion of sepsis. METHODS: It was a cross sectional study conducted at the department of Chemical Pathology and Endocrinology AFIP, Rawalpindi, in collaboration with Medical and surgical intensive care units (ICU) of CMH Rawalpindi from January 2019 to December 2019. A total of 126 patients of both genders with age above 18 years and fulfilling the inclusion criteria of systemic inflammatory response syndrome (SIRS) were inducted in the study. RESULTS: Out of 126 patients 82 (65%) patients have positive blood culture results. Male predominance was noted in patients with positive blood culture. Out of 82 patients with positive blood culture results 69(84%) patients have positive PCT results as well whereas 13(15%) patients with positive blood culture results have negative PCT values. 57(69%) patients had Gram negative bacterial infection and 25(30%) patients had Gram positive bacterial infection. Significant difference was noted between the medians of PCT in blood culture positive and blood culture negative group (p value< 0.05) whereas no significant difference was found between medians of CRP, TLC and lactate between blood culture positive and blood culture negative patients (p value > 0.05). ROC curve analysis of PCT, CRP and TLC were done, keeping blood culture as reference standard, PCT showed largest area under the curve (AUC) and clearly outperformed TLC and CRP. PCT showed AUC of 0.781 as compared to CRP and TLC, which was 0.568 and 0.617 respectively. PCT showed sensitivity of 93.9%, specificity of 47.7%, positive predictive value (PPV) of 77% and negative predictive value (NPV) of 80.8%. CONCLUSION: Higher NPV makes it a reliable marker for screening out sepsis in suspected cases.

A Young Man with a Rare Case of Adrenal Incidentaloma.

Adrenal incidentalomas (AIs) are adrenal masses discovered as incidental finding, often on imaging studies, unrelated to adrenal disorders. Sometimes, they are discovered as part of work-up for adrenal pathology. AIs are mostly nonfunctional (hormonally silent), but can also be functional (hormonally active). The differential diagnosis includes many primary, metastatic, benign and malignant conditions. The current case is a young male, who went to a peripheral health facility with complaints of dysuria and burning micturition. His laboratory and radiological investigations suggested a urinary tract infection with an incidental finding of adrenal mass. After referral, his detailed work-up was done at Endocrine Clinic of Armed Forces Institute of Pathology (AFIP), Rawalpindi, which revealed history of episodic headaches and palpitations with paroxysmal spikes of high blood pressure up to 200/120 mmHg. Adrenalectomy was performed by laparoscopic surgery. Histopathological examination confirmed the diagnosis of pheochromocytoma with PASS score of 5/20. This is one of the rare cases of adrenal incidentaloma, often an autopsy finding. Pheochromocytoma needs to be investigated in all cases of AIs. Key Words: Adrenal incidentaloma, Pheochromocytoma, Urinary tract infection.

Effect of Temperature and Preservative on Neo-ethanol Formation in Postmortem Whole Blood Samples.

OBJECTIVE: To determine the association of temperature, time duration, and preservatives with ethanol neo-genesis in postmortem whole blood samples. STUDY DESIGN: Observational cross-sectional study. PLACE AND DURATION OF STUDY: Department of Chemical Pathology and Toxicology, Armed Forces Institute of Pathology, Rawalpindi, in collaboration with Combined Military Hospital, Rawalpindi from August 2020 to January 2021. METHODOLOGY: Whole blood samples were obtained from cardiac chamber of an autopsy case with aseptic measures and were drawn into six tubes (3 x EDTA tubes and 3 x NaF tubes). These six tubes were stored at 4˚C, 25˚C, and 37˚C. All samples were analysed along with internal standard, on head space gas-chromatography on Day-0, Day-07, Day-14, Day-21, and Day-28 of sampling. RESULTS: A total of 60 samples out of 10 autopsies, were analysed. Blood alcohol concentrations of all samples were negative on 1st day (Day-0) of analysis. Samples stored at 4˚C did not produce any ethanol at any day of analysis, regardless of preservatives used. Neo-ethanol levels of blood samples stored in EDTA preservative were significantly raised (p <0.001) as compared to samples stored in NaF preservative. Samples stored at 37˚C showed significant increase in neo-ethanol concentration (p <0.001) in comparison with samples stored at 4˚C and 25˚C. Neo-ethanol levels increased with duration of storage till 14th day of analysis. CONCLUSION: Sodium fluoride (NaF) should be used as preservative to avoid ethanol neo-genesis during storage and transportation of blood samples for alcohol analysis. Cold chain maintenance is of pivotal importance to exclude false positive blood alcohol results. Key Words: Neo-ethanol, Neo-genesis, Ethylenediaminetetra acetic acid (EDTA), Sodium fluoride (NaF).

Diagnostic Accuracy of Markers of Insulin Resistance (HOMA-IR) and Insulin Sensitivity (QUICKI) in Gestational Diabetes.

OBJECTIVES: To determine the diagnostic accuracy of HOMA-IR, and QUICKI in diagnosing gestational diabetes mellitus (GDM) considering oral glucose tolerance test (OGTT) as gold standard. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Department of Chemical Pathology, Armed Forces Institute of Pathology, Rawalpindi from September 2020 to February 2021. METHODOLOGY: Pregnant women with gestational age between 24 to 28 weeks, who reported to Endocrine Clinic of AFIP for OGTT, were included in the study. OGTT was performed by following ADA guidelines. Sample for fasting insulin was collected along with first fasting sample of OGTT. HOMA-IR and QUICKI were calculated simultaneously. Percentage was used for qualitative variable while median (IQR 25th-75th) was applied for quantitative variables. OGTT was used as gold standard for calculation of diagnostic accuracy of HOMA-IR and QUICKI. RESULTS: Out of 182 patients, 74 (40.6%) were found to have GDM on OGTT while 108 (59.4%) had normal OGTT. Women with GDM (n=74) had median values of fasting insulin 15.9 (IQR 11.2-17.77), HOMA-IR 3.5 (IQR 2.6-4.1) and QUICKI 0.31 (IQR 0.30-0.33) as compared to median values of fasting insulin 8.0 (IQR 5.9-10.3), HOMA-IR 1.60 (IQR 1.12-2.03) and QUICKI 0.35 (IQR 0.34-0.37) in patients (n=108) with normal response to OGTT, (p <0.001). On logistic regression analysis, there was a strong association of HOMA-IR and QUICKI with gestational diabetes mellitus (p <0.001, accuracy 84.6%). HOMA-IR at cutoff of ≤2 had 94.5% sensitivity, 72.2% specificity, 70% PPV, 95.1% NPV, and 81.31% overall diagnostic accuracy with 0.913 AUC. QUICKI at cutoff of 0.34 had 86.4% sensitivity, 83.3% specificity, 78.0% PPV, 90.0% NPV, and 84.61% overall diagnostic accuracy with 0.905 AUC. CONCLUSION: Fasting insulin and HOMA-IR were significantly higher while QUICKI was lower in patients of GDM as compared to non-GDM pregnant patients at 24 to 28 weeks of gestation. Being more convenient for patients, it has the potential to be used as screening tool for gestational diabetes. Key Words: HOMA IR, QUICKI, Gestational diabetes mellitus, Insulin.

Association of Therapeutic Dose of Valproic Acid and Plasma Glycine Levels in Epileptic Patients.

OBJECTIVES: To determine the frequency of hyperglycinemia in epileptic patients taking valproic acid (VPA); and the correlation between therapeutic dose of valproic acid and plasma glycine levels in epileptic patients. STUDY DESIGN: Observational, cross-sectional study. PLACE AND DURATION OF STUDY: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology Rawalpindi, in collaboration with Combined Military Hospital, Rawalpindi, from August 2020 to January 2021. METHODOLOGY: Plasma glycine levels were analysed on ion exchange chromatography (IEC)-based instrument, Biochrome 30+ of epileptic patients undergoing treatment with anti-epileptic agents. Therapeutic doses of valproic acid were taken as serum trough levels of valproic acid and analysed on chemiluminescence-based Abbott Architect Plus i1000 SR. Mann-Whitney U-test was applied to compare plasma glycine levels in epileptic patients on valproic acid and those on multiple anti-epileptic agents. Spearman's correlation was used to correlate plasma glycine levels in epileptic patients with trough levels of valproic acid, duration of treatment and frequency of fits/year. RESULTS: A total of 77 participants, upto 15 years of age, were enrolled. Plasma glycine levels were significantly raised (p <0.001) in those epileptics who were on valproic acid (monodrug therapy), in comparison with those on multiple anti-epileptic agents. There were significant positive correlations between glycine levels and trough valproic acid levels (r = 0.830), duration of treatment (r = 0.525) and frequency of seizures (r = 0.326). CONCLUSION: Epileptic patients treated with valproic acid (VPA) had raised plasma glycine levels, that increased with therapeutic dose of valproic acid and duration of treatment and was associated with increased frequency of fits in those patients. Key Words: Epilepsy, Seizure, Glycine, Valproic acid.

Association of Serum Hyaluronic Acid and Laminin with Polymerase Chain Reaction Findings in Hepatitis C Patients.

OBJECTIVES: To find the association of serum hyaluronic acid and laminin levels with polymerase chain reaction (PCR) results in hepatitis C sero-positive patients; and the correlation among viral load, serum hyaluronic acid, and serum laminin levels. STUDY DESIGN: Cross-sectional descriptive study. PLACE AND DURATION OF STUDY: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, Pakistan from December 2019 to July 2020. METHODOLOGY: One hundred and eighty diagnosed cases of hepatitis C patients were included in this study. To find association, cross tabulation was done after dividing into two groups according to their median by applying Chi-square test. Correlation of viral load, duration of disease, serum hyaluronic acid and laminin levels were calculated using Spearman's correlation. RESULTS: There were 124 (68.9%) males and 56 (31.1%) females. Median (IQR) age was 36 (32.3 - 45.0) years; while median duration of disease was 12 (8 - 18) months. There was a strong association between PCR positive cases with hyaluronic acid (p <0.001) and serum laminin levels (p <0.001). A strong relationship was found between viral load and serum hyaluronic acid (r =0.889, p <0.001), as well as with serum laminin (r =0.889, p <0.001). CONCLUSION: Current study established a strong significant association between PCR results and disease duration with levels of serum laminin and hyaluronic acid. The levels of serum laminin and serum hyaluronic acid also correlate well with viral load and duration of disease. Key Words: Hepatitis C, Hepatic fibrosis, Hyaluronic acid, Laminin.

Comparison of Estimated Glomerular Filtration Rate with Both Serum Creatinine and Cystatin C (eGFRcr-cys) versus Single Analyte (eGFRcr or eGFRcys) Using CKD-EPI and MDRD Equations in Tertiary Care Hospital Settings.

OBJECTIVES: To assess and compare the glomerular filtration rate (eGFR) estimated through MDRD and CKD-EPIcr equations in early and late stages of chronic kidney disease on biochemical marker creatinine (eGFRcr), cystatin C (eGFRcys); and combined (eGFRcr-cys), using CKD-EPI equation. STUDY DESIGN: Observational, comparative cross-sectional study. PLACE AND DURATION OF STUDY: Chemical Pathology and Endocrinology Department, Armed Forces Institute of Pathology (AFIP), Rawalpindi in collaboration with Armed Forces Institute of Urology (AFIU), Rawalpindi from October 2019 to March 2020. METHODOLOGY: GFR was assessed on the basis of creatinine clearance taking serum and 24-hour urinary specimens. MDRD and CKD-EPI equations were applied to calculate eGFR by serum creatinine (eGFRcr), cystatin C (eGFRcys), and combined (eGFRcr-cys). Pearson correlation technique was used to compare eGFR calculated by different equations with creatinine clearance in different stages of CKD. Performance of equations was evaluated and compared in different stage of CKD. RESULTS: A total of 181 subjects were enrolled. Median age was 57 years (IQR, 25). Median (IQR) GFR (ml/min/1.73m2) calculated by CrCl, MDRD, CKD-EPIcr, CKD-EPIcys and CKD-EPIcr-cys equations were 45.1 (41.5), 50.6 (23.8), 52.0 (28.0), 43.0 (65.0) and 45 (47), respectively. eGFR calculated by CKD-EPIcr had positive and slightly higher correlation (r=0.880) than MDRD study equation (r=0.867). While comparing the markers, it was observed that CKD-EPIcys had better correlation in early stages of CKD (r=0.889); whereas, CKD-EPIcr performed better in late stages (r=0.896). CKD-EPIcr-cys had the highest correlation (r=0.984) at all stages of CKD. CONCLUSION: eGFR calculated by CKD-EPI equation considered as better diagnostic efficient response than MDRD equation in diagnosis and staging of chronic kidney disease. While applying CKD-EPI equation for measurement of eGFR, eGFRcr-cys performs better than any of eGFRcr or eGFRcys at all stages of CKD. Key Words: Estimated glomerular filtration rate (eGFR), Cystatin C (Cys), Creatinine (Cr), Creatinine clearance (CrCl), CKD-EPI equation, MDRD equation.

Comparison of Turbidimetric Inhibition Immunoassay, High-Performance Liquid Chromatography, and Capillary Electrophoresis Methods for Glycated Hemoglobin Determination.

OBJECTIVE: The purpose of this study was to compare the performances of and evaluate the agreement among glycated hemoglobin values analyzed by using National Glycohemoglobin Standardization Program-certified and International Federation of Clinical Chemistry-standardized analyzers. THIS CROSS-SECTIONAL STUDY WAS CONDUCTED AT THE: Armed Forces Institute of Pathology, Department of Chemical Pathology from March 2019 to May 2019. METHODS: Glycated hemoglobin (HbA1c) was measured in the blood specimens from 100 patients on an ADVIA 1800 by a turbidimetric inhibitory immunoassay (TINIA), Sebia instrument by electrophoresis, and Bio-Rad Variant II Turbo system by high-performance liquid chromatography (HPLC). Quantitative variables were calculated as the mean ±â€…standard deviation (SD). Precision and method comparisons were carried out according to Clinical and Laboratory Standards Institute recommendations. The results obtained from each analyzer were compared by correlation analysis. Method comparison was done by linear regression and Bland-Altman plots using the SPSS software version 24. RESULTS: The mean ±â€…SD HbA1c values from TINIA, electrophoresis, and HPLC were 7.188% ±â€…1.89%, 7.164% ±â€…1.866%, and 7.160% ±â€…1.85%, respectively. The between-run coefficients of variation for TINIA, electrophoresis, and HPLC were 0.64%, 0.61%, and 0.60%, respectively. All 3 showed good correlation (TINIA, R2 = .994, P = .00; electrophoresis, R2 = .992, P = 0.00; and HPLC, R2 = .994, P = 0.00). CONCLUSION: The good clinical agreements of HbA1c and strong correlations between analyzers indicate that these analyzers can be used interchangeably.

Diagnostic accuracy of human chorionic gonadotropins (HCG) stimulation test in XY-disorders of sex development (XY-DSD) presented in Armed Forces Institute of Pathology.

OBJECTIVE: To determine diagnostic accuracy of human chorionic gonadotropins stimulation test in differentiating androgen insensitivity syndrome and 5-alpha reductase deficiency, keeping testosterone to dihydrotestosterone ratio as the gold standard. METHODS: The cross-sectional study was conducted at the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from January to December, 2016, and comprised patients aged 01 day to 20 years having XY chromosomes on karyotyping and with a spectrum of phenotypes. Blood samples were collected from each subject for basal serum testosterone, serum luteinizing hormone and serum follicular stimulating hormone level. Human chorionic gonadotropins stimulation test was performed in every subject as per the protocol. Sandwich chemiluminescence immunoassay technique was used to analyse serum samples. Serum dihydrotestosterone level was also detected to determine testosterone and dihydrotestosterone ratio. Data was analysed using SPSS 24. . RESULTS: Of the 104 subjects with a mean age of 1.78}0.95 years,96(92.3%) were diagnosed as cases of androgen insensitivity syndrome on the basis of human chorionic gonadotropins stimulation response level, which was 2-9 times of basal serum testosterone level. Also, 8(7.7%) subjects were diagnosed to have 5-alpha reductase deficiency syndrome. In such subjects, post-human chorionic gonadotropins response level of serum testosterone was more than 10 times of the basal level. CONCLUSIONS: The human chorionic gonadotropins stimulation test was found to be comparable to testosterone-to dihydrotestosterone ratio in differentiating between case of androgen insensitivity syndrome and 5-alpha reductase deficiency.

Gitelman Syndrome.

Gitelman syndrome (GS) is the most frequently inherited renal salt-wasting tubulointerstitial disease. It follows variable but usually asymptomatic benign course. We present a rare case of GS that remained clinical enigma. A 22-year male presented with severe episodic fatigue involving all limbs associated with episodes of sinking, palpitations, salt craving, increased thirst and frequent micturition hampering his routine daily activities. Laboratory workup revealed serum potassium, 2.7 mmol/L, serum magnesium, 0.69 mmol/L and metabolic alkalosis. Urine analysis showed surprising results, i.e. urine potassium 49.5 mmol/L, urine spot potassium creatinine ratio 5.1, chloride 93 mmol/L and low 24 hours urinary calcium excretion (1.19 mmol/day). Plasma active renin concentration was 135 mlU/L while plasma aldosterone was 1090 pmol/L, depicting secondary hyperreninemic hyperaldosteronism. Based on typical findings, a diagnosis of GS was made. Patient responded well to potassium and magnesium supplementation, 100 mg daily tablet aldactone® and liberal salt intake. The aim of this report is to revisit clinical approach to persistent hypokalemia with special emphasis to remember rare entities like GS in the differential diagnosis.

Diagnostic Accuracy of Serum Iron and Total Iron Binding Capacity (TIBC) in Iron Deficiency State.

OBJECTIVE: To determine the diagnostic accuracy of serum iron and total iron binding capacity (TIBC) in detection of iron deficiency. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Department of Chemical Pathology and Endocrinology, from January 2013 to October 2015. METHODOLOGY: Data of 1,815 patients with results of serum iron, TIBC and ferritin from January 2013 to October 2015 was retrieved from Laboratory information System (LIMS) of AFIP. Diagnostic Accuracy Studies (STARD) guidelines were followed. Subjects of either gender, aged 1 - 68 years were included. Cases with raised serum ferritin levels (male > 336 ng/ml, female > 307 ng/ml) were excluded. Serum Ferritin was taken as gold standard with specificity of 99% and sensitivity of 80% at concentration of 30 ng/ml. Transferrin saturation was determined by dividing serum iron by TIBC and multiplying by 100. RESULTS: Out of 1,815 subjects, 931 (51.29%) were males and 884 (48.71%) were females. The median age of the patients were 29.1 years (Inter-quartile range, IQR 19.1). Taking ferritin as gold standard, the sensitivity and specificity of serum iron was 63.5% and 38.6%, respectively; while that of TIBC was 64.5 % and 42.8%, respectively. Ferritin showed poor correlation with iron, TIBC and transferrin saturation. CONCLUSION: Serum iron and TIBC give no additional information in the diagnosis of iron deficiency anemia and these tests are redundant for the diagnosis of iron deficiency state, if serum ferritin is available.