Basics of laboratory statistics.

The strict monitoring of examinations and evaluation of newer methods or instruments is a daily routine in clinical laboratory. The automated analyzers accumulate an enormous amount of data from patients' examinations and quality control procedures. This laboratory data is meaningless if it does not generate the information that we can extend to the population of our interest. In an analytical work, the most important operation is the comparison of data, to quantify accuracy and precision and to generate meaningful explanation for clinician and patients queries. Most of the information needed in the regular laboratory work can be obtained with the use of simple convenient statistical tools. This article describes the basics of laboratory statistics, the knowledge of which answers about the application of quality control in laboratory, accuracy and diagnostic power of our examinations, variability in reports, comparison of different methods and derivation of a biological reference interval for an analyte.

Importance of Interpretative Comments in Clinical Biochemistry - a Practitioner's Report.

Interpretative comment (IC) from the clinical biochemist is a professional obligation. Most of the Nepalese clinical laboratories use only predefined comments on the report, while few laboratories do not provide comments at all. Apart from doctors, other healthcare professionals and sometimes patients themselves seek laboratory expert opinion in the interpretation of obtained results. The non-availability of patient's medical record or limited communication with physicians as well as insufficient professional knowledge impacts the quality of interpretative comments in Nepal. This report is intended to emphasize that the task of providing IC is becoming more important in the context of Nepal. Similarly, this report also guides those who provide interpretative comments.

Establishment of a Rapid Phone Consultation Service for COVID-19 Public Health Support in Nepal.

Background The coronavirus disease 2019 (COVID-19) pandemic strained the already weak health system of Nepal, especially during the surge of the delta variant. A telephonic consultation service was rapidly established to provide free consultations to assist those in home isolation due to severe acute respiratory syndrome coronavirus 2 infection. In this study, we describe the process of establishing the hotline and share preliminary findings. During the peak of the delta wave in Nepal, the hotline was started by a local non-profit organization. Methodology We established the hotline with help of a private telecommunication company. The hotline was advertised on social media, radio, and newspapers. Healthcare workers were recruited and trained and the service was provided for free. Patient data were recorded and de-identified for analysis, monitoring, and evaluation. Results The majority of the callers were from Kathmandu valley, which includes three districts, Kathmandu, Lalitpur, and Bhaktapur. Overall, 44% of the callers inquired about the clinical manifestations of COVID-19. On average, there were 75 calls each day between May 2021 and February 2022. The average call duration was three minutes and 42 seconds. Trained healthcare workers answered the calls for 15.5 hours a day. Conclusions Our work established the feasibility of a rapid hotline service in response to the pandemic causing high strain on the health system. Lessons learned from this experience can be useful for future disasters in Nepal and other places with similar health system strains.

Pseudo-hypertriglyceridaemia in glycerol kinase deficiency misdiagnosed and treated as true hypertriglyceridaemia.

High triglyceride in a serum sample with no apparent visible lipaemia is a confusing laboratory condition. This condition of apparent hypertriglyceridaemia might be an asymptomatic condition of pseudo-hypertriglyceridaemia which is seen in individuals with glycerol kinase deficiency. Glycerol is increased in glycerol kinase deficiency, therefore biochemical analysers that measure glycerol to estimate triglyceride report high triglyceride values. Clinicians are often unaware of this laboratory condition; as a result, patients are subjected to aggressive hypolipidaemic drugs and lifestyle changes, and these measures turn ineffective to lower triglyceride levels. In this report, a case of a 50-year-old Nepalese male is presented with an apparent hypertriglyceridaemia refractory to various hypolipidaemic drugs for the last 13 years until a correct diagnosis of his condition was made.

Variation in Laboratory Reports: Causes other than Laboratory Error.

When a sample of an individual is measured at different times at the same or different clinical laboratory, the results are always different, even the state of health of an individual is the same. This disparity in the results from clinical laboratories might confuse diagnosing, treating, and monitoring disease. Patients and healthcare professionals usually interpret these differences as laboratory errors. However, this might not always be the case, because laboratory test results are highly variable and are neither consistent nor comparable due to several reasons other than laboratory error, namely preanalytical variation, biological variation, and analytical variation.

In-House Algorithm for Reporting Discrepant HbA1c Result and Troubleshooting a Case of False Low HbA1c.

We report an unusual case of a patient having low glycosylated hemoglobin (HbA1c) below the reportable range, despite having borderline fasting blood glucose. The patient had decreased erythrocytes count and elevated reticulocyte count, with no evidence of hemoglobinopathy. He reported taking multidrug therapy for borderline lepromatous leprosy. Dapsone induced hemolysis was identified as the cause for the discordant HbA1c. Thus, it is important to be aware of medications and conditions that may lead to a falsely low HbA1c level so that incorrect treatment decisions are not made. In such situations, alternative measure of glycemic control, such as fructosamine is recommended. Further it is also recommended that clinical laboratories have standard protocol to troubleshoot any discrepant HbA1c result.

Hematological and Biochemical Parameters along with IgG Antibody against SARS-CoV-2 in Patients visiting a referral laboratory for recovery check up after COVID-19 infection in Nepal.

BACKGROUND: The laboratory abnormalities for hospitalized patients with the SARS-CoV-2 have been described in various studies. Limited data are available for the recovered patients. This study aimed to evaluate various laboratory findings in the recovered SARS-CoV-2 patients. METHODS: In this cross sectional study, the laboratory findings of various hematological and biochemical parameters along with antibody against SARS-CoV-2 of 150 patients who visited Samyak Diagnostic Pvt. Ltd for recovery check up after SARS-CoV-2 were studied from October 2020 to March 2021. RESULTS: Out of total 150 participants, 84% of SARS-CoV-2 recovered patients, who had mild or moderate illness, reported persistence of milder symptoms. Persistence of high serum inflammatory markers such as CRP, Ferritin and LDH along with abnormal cell count and morphology of leukocyte lineage was present in 45.4% of these patients. Similarly, 98.7 % had SARS-CoV-2 IgG antibody after 37 median days of recovery. CONCLUSIONS: Various laboratory abnormalities may persist after SARS-CoV-2 recovery in addition to the presence of SARS-CoV-2 IgG antibody. Follow up study is needed to determine the period up to which these abnormalities are present and the protection from antibody is conferred.

Broadening the List of Differential Diagnosis for Acute Abdomen - a Case Report from Nepal.

When a patient has an acute abdominal pain, it is important to identify if the underlying cause is life threatening. To that end, a thorough medical history and relevant investigation will be pivotal. Here we report a case of lead toxicity where the patient presented with an acute abdomen following intake of Ayurvedic medicines. The baseline blood lead level was 82.3 µg/dl. The Ayurvedic medicines when analyzed for its lead content, revealed high lead concentration. We observed that the cessation of Ayurvedic medication along with D-penicillamine therapy was beneficial in reducing the blood lead level and in alleviating abdominal pain. Our findings implicate the need of awareness program regarding the potential health hazards associated with the use Ayurvedic medicines.

Blood Lead Levels in Rag-Pickers of Kathmandu and its Association with Hematological and Biochemical Parameters.

INTRODUCTION: Lead poisoning is a common health problem in Nepal and there are a limited number of studies on blood lead levels in various population groups. Rag-pickers are those people who visit from house to house to collect the materials that can be recycled and thus earn their livelihood. The present study was designed to evaluate blood lead level (BLL) and its relationship between hematological and biochemical parameters in rag-pickers working in Kathmandu. METHODS: An observational cross-sectional study among 50 ragpickers working in the selected area of Kathmandu was done in May 2019 after obtaining ethical approval from the Nepal health research council. Capillary and venous blood was drawn from each participant after written consent to measure the BLL, aspartate aminotransferase, alanine aminotransferase, total bilirubin, creatinine, glucose and to test for a complete blood count. Whole blood was also screened for the presence of hemoglobin variants in cases with abnormal red blood cell indices. Data was analyzed using SPSS (Version 20.0). RESULT: All rag pickers were men with mean age of 32.56 ± 12.51 years. The mean BLL among ragpickers was 11.6 ± 7.23 µg/dL. High eosinophil count was found (8.27 ± 5.49 %) in 27 cases (54%) having no significant association with BLL. The mean BLL was higher (12.89 µg/dL) in a cohort of workers who pick and recycle electronic waste. Beta-Thalassemia trait was seen in four cases, all of them had high BLL. No significant association of BLL with the number of years worked by rag picker was found. Similarly, no significant association of BLL with hematological and biochemical parameters was found. CONCLUSION: Rag-pickers working in Kathmandu are at increased risk of lead toxicity. The use of protective gloves, masks, shoes and clothes along with a regular medical examination of this vulnerable group is recommended.

Fasting Blood Glucose Test in Nepal - Time for a Harmonized Definition.

There are various views in defining protocols for fasting blood glucose test currently being used by healthcare providers in Nepal. A number of modifiable factors can influence the result of an estimation of fasting blood glucose in a clinical laboratory. Variations in the results of fasting blood glucose tests are usually controlled by minimizing the discrepancies in the pretesting variables, one of which is the inconsistency in what represents fasting. In order to minimize the complications of erroneous reporting of fasting blood sugar tests, it is crucial to define the protocols for the test and adopt them in unison by all clinical laboratories of Nepal. Keywords: Clinical laboratory; fasting blood glucose; pretesting variables.

Postprandial Blood Glucose can be less than Fasting Blood Glucose and this is not a Laboratory Error.

Higher fasting blood glucose level than postprandial level can be seen in variety of conditions in both normal population and diabetics. Various modifiable factors along with underlying condition of patient behind such laboratory picture are discussed in this article. Keywords: clinical laboratory; diabetes; fasting blood glucose; postprandial blood glucose.

Breast tuberculosis, a rare entity.

Breast tuberculosis is a rare form of extra-pulmonary tuberculosis. It is rare in western countries, usually occurs in multiparous and lactating women but rare in male and older women. It has a varied clinical, radiological and pathological presentation that can be similar to that of a breast abscess or carcinoma. Constitutional symptoms are not usually present making it even harder to diagnose clinically. Here we present a case of a young Nepalese woman with tubercular mastitis who was initially misdiagnosed as breast abscess.

Acute mountain sickness in children at 4380 meters in the Himalayas.

OBJECTIVE: To determine the incidence of and risk factors for acute mountain sickness (AMS) in native Nepalese children during a pilgrimage trip to Gosaikunda Lake in the Langtang National Park Region of Nepal (elevation 4380 m). METHODS: A descriptive, noninterventional, cross-sectional study was completed on a group of children during the pilgrimage to Gosaikunda. Participants were interviewed about the symptoms of AMS using the Lake Louise Scoring System. RESULTS: Thirty-six children between 3 and 15 years of age were interviewed after a rapid ascent (over 1 to 3 days) from 1950 m to 4380 m. Acute mountain sickness was diagnosed in 17 of 36 (47.2%) children. The sickness was seen in only 5 of 20 (25%) children who took 2 or more days to ascend, compared with 12 of 16 (75%) children who spent only 1 night (reaching the study site at Gosaikunda on the second day) to complete the same ascent (P < or = .01, odds ratio [OR] = 9.0, 1.61 < OR < 57.36). No significant correlation was found between the incidence of AMS and gender, previous exposure to high altitude, or concurrent illness. CONCLUSIONS: Our results indicate that the incidence of AMS in this group of Nepalese children was high and associated with rapidity of ascent. Rapid ascent to high sleeping altitude and increased physical activity were observed as possible risk factors. We suggest organizing educational programs to make children and their parents aware of altitude-related problems and advise gradual ascent to such high-altitude pilgrimage sites.

Prevention of acute mountain sickness by acetazolamide in Nepali porters: a double-blind controlled trial.

OBJECTIVE: This study aimed to determine the efficacy, tolerability, and practicality of acetazolamide for the prevention of acute mountain sickness (AMS) in Nepali trekking porters early in the trekking season. METHODS: This study was a randomized, double-blind controlled trial with 400 male Nepali porters in the Mount Everest region of Nepal, trekking from Namche Bazaar (3440 m) to Lobuche (4930 m), the study endpoint. Participants were randomized to receive 250 mg acetazolamide daily or placebo, and AMS symptom scores (Lake Louise) were compared in highlanders vs lowlanders. RESULTS: Only 109 (27.2%) of the 400 porters completed the trial (28 highlanders, 81 lowlanders). The rest either dropped out (275/400 porters, 68.8%) or were excluded (16/400 porters, 4%). Acute mountain sickness occurred in 13 (11.9%) of 109 porters; all were lowlanders; 7 were taking acetazolamide, 6 taking placebo. Birthplace, acclimatization in the week before the trial, ascent rate, and rest days were the most important variables affecting the incidence of AMS. No highlanders, but 13 (16.1%) of 81 lowlanders had AMS (P = .016). Acclimatization in the pretrial week reduced AMS incidence (P = .013), as did a slower ascent rate (P = .0126), but rest days were the most potent prophylactic variable (P = .0001). Side effects were more frequent in porters taking acetazolamide than in the placebo group (P = .0001), but there were no serious side effects. CONCLUSIONS: Acetazolamide was tolerable, but impractical for the routine prevention of AMS in Nepali porters. A good trekking schedule and adequate acclimatization remain the most effective preventive measures. This study identified lowland porters as a high-risk group for developing AMS.