Challenges in HbA1c Analysis and Reporting in Patients with Variant Hemoglobins.

Hemoglobin A1c (HbA(1)c) is a well-established indicator of mean glycemia. The presence of genetic variants of hemoglobin can profoundly affect the accuracy of HbA(1)c measurements. Variants of hemoglobin especially Hemoglobin E (HbE) is prevalent in South East Asia including Bangladesh. The objective of our study is to compare the HbA(1)c values measured on high performance liquid chromatography (HPLC) and Turbidimetric Inhibition Immunoassay (TINIA) in diabetic patients with variant hemoglobins including HbE. A total of 7595 diabetic patients receiving treatment at BIRDEM General Hospital were analyzed for HbA(1)c results within a period of two months from December 2013 to January 2014. Seventy two cases out of 7595 (0.95%) had either undetectable or below normal HbA(1)c levels (males-33 and females-39; ratio = 0.82:1) by HPLC method. In 34(0.45%) cases, HbA(1)c value was undetectable by HPLC method but was in the reportable range by TINIA method. In the other 38 (0.55%) cases, HbA(1)c levels were below the reportable range (<4%) by HPLC method but were in the normal or higher range by TINIA method. TINIA method did not agree with HPLC method on Bland Altman plot in the 38 cases with below normal HbA(1)c levels, [Mean bias -5.2(-9.3 to 1.0), 95% CI] but agreed very well [mean bias -0.21 (-0.84 to 0.42), y=1.1037+0.776X; r(2)=0.30, p<0.01] in controls. In control group mean MCV was 83.80±7.48 and in study group was 73.65±10.44. Alkaline electrophoresis confirmed the variant hemoglobin to be HbE. The fasting blood sugar levels of all the 72 cases correlated strongly with TINIA method (r(2) =0.75, p<0.0001) but not with HPLC (r = 0.24, p=0.13). In our regions where populations have a high prevalence of Hb variant, proper knowledge of hemoglobin variants which affect the measurements HbA(1)c level is essential. MCV of 80fl or below may serve as a rough guide to select samples that require analysis by TINIA method. Moreover, HPLC may be a convenient and inexpensive tool for screening of hemoglobinopathies especially among diabetic population in Bangladesh. It may therefore be helpful in improving management of complications related to both anaemia and iron overload.

Value of red cell distribution width (RDW) and RBC indices in the detection of iron deficiency anemia.

Iron deficiency anemia is the common problem during pregnancy. Detection of iron deficiency early during pregnancy can reduce maternal and child mortality and morbidity. Red cell distribution width is a new routine parameter in fully automated hematology analyzer that can give the idea of early iron deficiency before other test. It gives the idea of red cell size variation which is the earliest morphologic changes in iron deficiency anemia. In prelatent and latent stage of iron deficiency MCV are normal. Whereas in latent stage Red Cell Distribution Width (RDW) would be expected to increase because of a microcytic population of cells appears in the blood. This study evaluates the role of red cell distribution width and RBC indices in determining iron deficiency early and provide reliable and useful technique. In this study 190 pregnant women were included. RDW, MCV, MCH, MCHC and iron profile were done. RDW compared with MCV, MCH and MCHC in various stages of iron deficiency. In latent stage of iron deficiency higher RDW was found significant than MCV, MCH, MCHC (p<0.05). In this study RDW had sensitivity 82.3% and specificity 97.4%. Whereas MCV, MCH and MCHC had 29.2%, 68.1% and 15% sensitivity but specificity was 98.7%, 83.1% and 96.1% in the detection of iron deficiency. Iron deficiency anaemia without other complicating disease could be screened out early by increased RDW when RBC indices were normal.

Role of red cell distribution width (RDW) in the detection of iron deficiency anaemia in pregnancy within the first 20 weeks of gestation.

Iron deficiency anemia is common problem during pregnancy. Red cell size variation (anisocytosis) is the earliest morphologic changes in iron deficiency anemia. Red cell distribution width is a quantitative measure of red cell size variation and it can give the idea of early iron deficiency before other test to become positive. 190 pregnant women were included in this study. Red cell distribution width was compared between iron deficient & non-iron deficient pregnant women. Red cell distribution width also compared with Hb level, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration and peripheral blood film in prelatent iron deficiency, latent iron deficiency, mild and moderate iron deficiency anemia. Red cell distribution width had sensitivity 82.3% and specificity 97.4%. Whereas Hb level, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration and peripheral blood film all had 56.6%, 29.2%, 68.1%, 15% and 38.9% sensitivity but specificity was 90.9%, 98.7%, 83.1%, 96.1% and 98.7% in the detection of iron deficiency. Red cell distribution width appears to be a reliable and useful parameter for detection of iron deficiency during pregnancy.

Estimation of Serum Creatinine and Uric Acid in Bangladeshi Gestational Diabetic Mother Attending in Tertiary Care Hospital.

The hyperuricaemia in Gestational diabetes mellitus has been explained to be a component of the metabolic syndrome which reflects insulin resistance and it has been shown to have a positive correlation with the creatinine levels. Gestational hyperuricaemia was found to be significantly associated with a high rate of maternal and foetal complications along with proteinuria and hypertension. Aimed of this study was to evaluate the serum creatinine and uric acid levels in Bangladeshi women with GDM in their second and third trimester of pregnancy. This descriptive cross sectional study was conducted at Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from July 2013 to June 2014. Pregnant women, in their second and third trimester, attending the outpatient department of Obstetrics and Gynecology and the Department of Endocrinology, MMCH, Mymensingh, Bangladesh were enrolled by purposive sampling technique. GDM was diagnosed on the basis of oral glucose tolerance test (OGTT) as outlined in UN agency WHO criteria 2013. Out of 172 participants, 86 had GDM (Case) and 86 were normoglycemic (control). The mean age of GDM and control groups was 28.6±3.2 and 27.3±3.1 years respectively. The BMI was 26.4±1.5 kg/m² and 26.3±1.3 kg/m². In this study we found serum creatinine levels in GDM cases were significantly (p<0.001) increased in both trimesters (1.09±0.16mg/dl and 1.07±0.11mg/dl) compared to those without GDM (0.69±0.16mg/dl and 0.64±0.15mg/dl). Serum uric acid levels in GDM and without GDM in 2nd trimester were (4.47±0.42mg/dl and 4.43±0.63mg/dl respectively) had (p>0.05) no significant difference. Serum uric acid levels in GDM cases were significantly (p<0.001) higher in third trimesters (4.48±0.41mg/dl) compared to those without GDM (3.52±0.74mg/dl). There was distinct alteration of serum creatinine and uric acid levels in GDM compared to normal pregnancy.

Estimation of Serum Zinc, Copper and Magnesium Levels in Bangladeshi women with Gestational Diabetes Mellitus Attending in a Tertiary Care Hospital.

Zinc (Zn), Copper (Cu) and Magnesium (Mg) are essential trace elements for normal embryogenesis and fetal growth. Alteration of Zn, Cu and Mg concentrations in blood has been observed in normal pregnancy as well as in gestational diabetes mellitus (GDM). Aim of this study was to evaluate the serum Zn, Cu and Mg levels in Bangladeshi women with GDM in their second and third trimester of pregnancy. This descriptive cross sectional study was conducted at Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from July 2013 to June 2014. Pregnant women, in their second and third trimester, attending the outpatient department of Obstetrics and Gynecology and the Department of Endocrinology of MMCH were enrolled by purposive sampling technique. GDM was diagnosed on the basis of oral glucose tolerance test (OGTT) as defined in WHO criteria 2013. Out of 172 participants, 86 had GDM (Case) and 86 were normoglycemic (control). The mean age of GDM and control groups was 28.6±3.2 years and 27.3±3.1 years respectively. The BMI was 26.4±1.5kg/m² and 26.3±1.3kg/m². In this study we found serum Zn levels in GDM cases were significantly (p<0.001) low in both trimesters (43.93±5.48µg/dl and 46.86±3.12µg/dl) compared to those without GDM (67.30±7.81µg/dl and 67.58±9.12µg/dl). On the contrary, serum Cu levels in GDM cases were significantly (p<0.001) higher in both trimesters (224±3.8µg/dl and 243.91±6.9µg/dl) compared to those without GDM (220.1±7.6µg/dl and 234.9±4.6µg/dl). There was significant (p<0.001) increase of serum Cu levels in 3rd trimester compared to 2nd trimester in both GDM and non GDM cases. Serum Mg level was significantly low (p<0.001) in 2nd and 3rd trimesters in GDM cases (1.39±0.26mg/dl and 0.93±0.15mg/dl) compared to control group (1.67±0.30mg/dl and 1.67±0.31mg/dl). There was distinct alteration of serum Zn, Cu and Mg levels in GDM compared to normal pregnancy.

Study of Thyroid Disorders among Type 2 Diabetic Patients Attending a Tertiary Care Hospital.

Type 2 diabetes mellitus (T2DM) and thyroid disorders (TD) are the two most common endocrine disorders in clinical practice. Unrecognized thyroid disorders may adversely affect the metabolic control and add more risk to an already predisposing type 2 diabetes mellitus. The objective of the study is to find out the percentage of hypothyroidism and hyperthyroidism in patients with type 2 diabetes mellitus and non diabetic subjects. This cross-sectional study was conducted in the department of Biochemistry and outpatient Department of Endocrinology, BIRDEM General Hospital, Dhaka, Bangladesh from July 2014 to June 2015. Total 200 patients were selected by inclusion and exclusion criteria. Among them, 115 were T2DM subjects and 85 were non diabetic subjects. Type 2 diabetes mellitus and normoglycemia were diagnosed according to WHO criteria from previous medical records. All patients were underwent thyroid function tests; free thyroxine (FT4), free tri-iodothyronine (FT3) and S. TSH (thyroid stimulating hormone). Study sample were divided 4 groups: Group 1: Type 2 diabetic subjects with thyroid disorders; Group 2: Non diabetic subjects with thyroid disorders; Group 3: Type 2 diabetic subjects without thyroid disorders; Group 4: Non diabetic without thyroid disorders. Thyroid disorders were categorized into subclinical hypothyroidism, overt hypothyroidism, subclinical hyperthyroidism and overt hyperthyroidism. Percentage of thyroid disorders in type 2 diabetes mellitus and non diabetic patients were estimated. Comparison of all demographic characteristics was done among the groups. The percentage of thyroid disorders in type 2 diabetic patients was 23.5%. The most frequent thyroid disorders in type 2 diabetic patients were subclinical hypothyroidism (10.4%) and overt hypothyroidism (6.1%). The percentage of thyroid disorders in non diabetic subjects was 12%. Here, subclinical hypothyroidism is 5.9% and overt hypothyroidism is 3.5% were significantly higher in female, overweight and obese subjects. Patients with thyroid disorders (both type 2 diabetic and non-diabetic) had strong association with family history of thyroid disorders. This study showed that the percentage of thyroid disorders in type 2 diabetes mellitus is very high. Specially hypothyroidism (both subclinical and overt) are most frequent. So it is very necessary to provide regular screening for thyroid disorders in type 2 diabetic patients as well as initiating early treatment. Early treatment thyroid disorders in type 2 diabetic patients will help us to avoid complications and reduce morbidity and mortality of diabetes mellitus and thyroid disorders.