Role of δ-tocotrienol and resveratrol supplementation in the regulation of micro RNAs in patients with metabolic syndrome: A randomized controlled trial.

OBJECTIVE: To determine the effect of δ-tocotrienol and resveratrol mixture (TRM) supplementation in comparison to placebo for 24 weeks, on the relative expression of miRNAs (miRNA-130b-5p, miRNA-221-5p, miR-15b-5p, miRNA-122-5p, and miRNA-376b-5p) in patients with Metabolic syndrome (MetS). DESIGN: This randomized placebo-controlled trial was conducted at the tertiary care institute of the NUMS, Rawalpindi, Pakistan. A total of 82 adult MetS patients were enrolled and randomly grouped into the TRM group (n = 41) and the Placebo group (n = 41). Patients in the TRM group were given 400 mg capsules (δ-tocotrienol 250 mg; Resveratrol 150 mg) and placebo received (cellulose 400 mg capsule) twice daily for 24 weeks. RESULTS: The TRM supplementation revealed a significant (p < 0.001) upregulation of 3.05-fold in miRNA-130b-5p and 2.45-fold in miRNA-221-5p while miRNA-122-5p was downregulated by 2.22-fold as compared to placebo. No significant difference was observed in miRNA-15b-5p and miRNA-376b-5p. Moreover, TRM group participants with reverted MetS had significantly (p < 0.05) upregulated miRNA-130b-5p, miRNA-221-5p, and downregulated miRNA-122-5p relative to non-reverted patients with MetS. CONCLUSION: Daily TRM supplementation may improve metabolic syndrome by upregulated miR-130b-5p, which is involved in central obesity and inflammation, as well as miR-221-5p, which is involved in insulin resistance. Additionally, TRM downregulate of miRNA 122, which improved dyslipidemia.

Publication dynamics: what can be done to eliminate barriers to publishing full manuscripts by the postgraduate trainees of a low-middle income country?

OBJECTIVES: This study aimed to determine the publication rate of free paper abstracts presented by the postgraduate (PG) trainees and determine the reasons for non-publication. A mixed methods study was conducted. PG trainees presenting free papers at the at the Pakistan Society of Chemical Pathologist conferences from 2012 to 2018 were included. Three databases were searched to identify if the abstracts were published or not. The PG trainee authors of abstracts not published as full manuscript, were surveyed to determine the barriers and challenges in publishing a manuscript. RESULTS: The average rate of full manuscript publication was 51.8% (n = 93/177) for the abstracts presented by the PG trainees. Publication rate was higher for oral (n = 73/119, 61.3%) compared to poster presentation (n = 20/58, 34.5%). Most of the manuscripts were published after two years of abstract presentation. The survey showed that the main challenges to publishing an abstract were lack of time, limited scientific writing or submission skills, lack of funding for publication fee, and negative or statistically non-significant results. This reflects a need to arrange workshops/symposia for the PG trainees of low-middle income country (LMIC) to enhance their writing and time management skills and improve the full manuscript publication rate from LMICs.

B-type natriuretic peptide as diagnostic and prognostic marker in various forms of acute coronary syndrome.

Objectives: This study was conducted to evaluate the diagnostic and prognostic value of B-type natriuretic peptide (BNP) in different categories of acute coronary syndrome (ACS) patients on arrival. Methods: This cohort study included 197 patients admitted in Coronary Care Unit (CCU) of Rehman Medical Institute (RMI) Peshawar from January 2020 to June 2020. Patients were categorized in two subgroups. Subgroup-I with BNP below 100pg/mL. Subgroup-II having BNP above 100pg/mL. Samples were obtained on admission from these patients for Cardiac Troponin I (Trop-i), BNP and serum creatinine. BNP samples were analyzed on Cobas® using chemiluminescence method. Descriptive statistics were derived for age; gender and cardiac biomarkers. Receiver-operating characteristic curves (ROC) were generated. Diagnostic accuracy parameters were determined for Non ST- segment elevation myocardial infarction (STEMI), ST- segment elevation myocardial infarction (STEMI) and unstable angina (UA). Result: One hundred fourteen patients (58.2%) were males and 82 were females (41.8%).Our of this 89 patients were NSTEMI in group II. Mean BNP was 1438±1463.Age distribution shows 120 individuals were over 55 years (61.2%). Hypertension, diabetes, smoking and previous infarcts were the risk factors for ACS. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive value (NPV), likelihood ratios, and overall accuracy of BNP at admission for the entire sub categories in ACS (cut-off value 100 pg/mL) were determined by using Trop-i the gold standard. ROC curve showed AUC = 0.557, (95% confidence interval: 0.476-0.638). When Pearson correlation was applied, BNP was found to be a noteworthy independent predictor. Conclusion: BNP can be a useful Biomarker along with standard cardiac biomarkers in various categories of patients with ACS.

Development of a virtual classroom for pre-analytical phase of laboratory medicine for undergraduate medical students using the Delphi technique.

BACKGROUND: Amongst the pre-analytical, analytical, and post-analytical phase of laboratory testing, pre-analytical phase is the most error-prone. Knowledge gaps in understanding of pre-analytical factors are identified in the clinical years amongst undergraduate students due to lack of formal teaching modules on the pre-analytical phase. This study was conducted to seek experts' consensus in Clinical Chemistry on learning objectives and contents using the Delphi technique with an aim to develop an asynchronous virtual classroom for teaching pre-analytical factors of laboratory testing. METHODS: A mixed method study was conducted at the Aga Khan University. A questionnaire comprising of 16 learning objectives and their associated triggers was developed on Google Docs for developing the case vignettes. A four-point Likert Scale, which included strongly agree, agree, disagree and strongly disagree, was utilized for the learning objectives. An open-ended question was included for experts to suggest new items for inclusion. A cut off of at least 75% agreement was set to establish consensus on each item. A total of 17 Chemical Pathology faculty from 13 institutions across Pakistan were invited to participate in the first round of Delphi. Similar method of response was used in round two to establish consensus on the newly identified items suggested by the faculty in round 1. Later, the agreed-upon objectives and triggers were used to develop interactive scenarios over Moodle to concurrently test and teach medical students in a nonchalant manner. RESULTS: A total of 17 responses were received in Round 1 of the Delphi process (response rate = 100%), while 12 responses were received in Round 2 (response rate = 71%). In round 1, all 16 learning objectives reached the required consensus (≥ 75%) with no additional learning objectives suggested by the experts. Out of 75 triggers in round 1, 61 (81.3%) reached the consensus to be included while 39 were additionally suggested. In 2nd round, 17 out of 39 newly suggested triggers met the desired consensus. 14 triggers did not reach the consensus after two rounds, and were therefore eliminated. The virtual classroom developed using the agreed-upon learning objectives and triggers consisted of 20 items with a total score of 31 marks. The questions included multiple choice questions, fill in the blanks, drag and drop sequences and read-and-answer comprehensions. Specific learning points were included after each item and graphs and pictures were included for a vibrant experience. CONCLUSION: We developed an effective and interactive virtual session with expert consensus on the pre-analytical phase of laboratory testing for undergraduate medical students which can be used for medical technologist, graduate students and fellows in Chemical Pathology.

Hepato-Protective Effects of Delta-Tocotrienol and Alpha-Tocopherol in Patients with Non-Alcoholic Fatty Liver Disease: Regulation of Circulating MicroRNA Expression.

MicroRNAs (miRNAs) play a key role in the regulation of genes for normal metabolism in the liver. Dysregulation of miRNAs is involved in the development and progression of non-alcoholic fatty liver disease (NAFLD). We aimed to explore changes in circulating miRNA expression in response to delta-tocotrienol (δT3) and alpha-tocopherol (αTF) supplementation and correlate them with relevant biochemical markers in patients with NAFLD. In total, 100 patients with NAFLD were randomized to either receive δT3 (n = 50) 300 mg or αTF (n = 50) 268 mg twice/day for 48 weeks. Plasma expression of miRNA-122, -21, -103a-2, -421, -375 and -34a were determined at baseline, 24 and 48 weeks of intervention using RT-qPCR. Both δT3 and αTF significantly downregulated expression of miRNA-122, -21, -103a-2, -421, -375 and -34a. Moreover, δT3 was more effective than αTF in reducing expression of miRNA-375 and -34a. A significant correlation was observed between miRNA expression and biochemical markers of hepatic steatosis, insulin resistance (IR), oxidative stress (OS), inflammation and apoptosis. δT3 and αTF exert hepato-protective effects by downregulating miRNAs involved in hepatic steatosis, IR, OS, inflammation and apoptosis in patients with NAFLD. Furthermore, δT3 has more pronounced effects than αTF in reducing miR-375 and miR-34a, which are linked to regulation of inflammation and apoptosis.

Trace metal profiling in patients with depression in Pakistani population.

OBJECTIVE: To determine level of trace metals in patients with depression in order to explore any association between the two. METHODS: The case-control study was conducted at the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology and Armed Forces Institute of Mental Health, Rawalpindi, Pakistan, from January to December 2017, and comprised diagnosed cases of depression with equal number of age- and gender-matched controls. Depression was diagnosed by a consultant psychiatrist as per the International Classification of Diseases version 10 / Diagnostic and Statistical Manual of Mental Disorders -IV criteria and a self-reported depression screening through Siddiqui-Shah Depression Scale. Blood samples were collected from each subject for the measurement of metals like zinc, chromium and copper. Data was analysed using SPSS 24. RESULTS: Of the 370 subjects, there were 185(50%) in each of the two groups. There were 82(44.3%) males and 103(55.7%) females among the cases with an overall mean age of 37.75±11.49 years, and 65(35.1%) males and 120(64.9%) females with an overall mean age of 39.38±12.56 years among the controls. Mean levels of zinc and copper were significantly different between the groups (p<0.05), while the difference was non-significant for chromium (p>0.05). Equivocal prevalence of depression was present between males and females (p=0.04) without any significant age group association (p=1.92). CONCLUSIONS: Blood level of serum zinc and copper were found to be associated with depression.

Evaluation of blood lead levels by atomic absorption spectrometry in school going children of northern areas of Pakistan.

OBJECTIVE: To evaluate blood lead levels and assess their correlation with academic performance in school children. 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, 2017, and comprised school children in Rawalpindi, Pakistan, and Hajira, Azad Jammu and Kashmir. About 5 ml of venous blood was collected in potassium-ethylenediaminetetraacetic acid tubes for lead levels, haemoglobin and plasma ferritin. The preceding three years' academic performance, rated as excellent, good, fair and poor, of the subjects was categorised on a specifically-designed proforma. Data was analysed using SPSS 24. RESULTS: Of the 400 subjects, 205 (50.25%) were females. The overall mean age was 9.15±2.8 years. Mean level of lead was 4.3±2.6 µg/dL, and difference in values was significant between children of Hajira and Rawalpindi (p<0.05). Mean haemoglobin was 12.9±0.919g/dL and mean ferritin was 49.17±16.0ng/ml. Of the total, 85(21.3%) showed excellent school performance, 162(40.5%) good, 113(28.3%) fair and 40(10%) showed poor performance. Significant negative association was found between school performance and mean blood lead level (p>0.05). No significant difference was found in terms of gender and age with school performance of both regions. CONCLUSIONS: Majority of school going children in northern Pakistan were found to have lead levels ≤ 5µg/dL which is a level of concern as it is inversely related to academic performance.

Determination of high sensitive cardiac troponin I 99th percentile upper reference limits in a healthy Pakistani population.

OBJECTIVE: This study aims to establish the 99th percentile upper reference limits of high sensitive cardiac troponin I in a healthy Pakistani population. METHODS: It was an Observational cohort study carried out in Department of Chemical Pathology and Endocrinology Rehman Medical Institute Peshawar, over the period of one year (January 2019- December 2019). Total 299 cardio-healthy males and females were interviewed and taken past medical history. Based on history, clinical examination, echocardiogram and laboratory data including results of estimated glomerular filtration rate (eGFR) and N-terminal pro-B-type natriureteric peptide (NT-proBNP), subjects with possible subclinical diseases were excluded. High Sensitive Cardiac Troponin I (hs-cTtrop I) was analysed on Abbot ARCHITECT STAT ci8200 using chemiluminescent immunoassay technique. The 99th percentile upper reference limit (URL) of hs-cTtrop I was determined using a non-parametric statistic, while gender specific results were compared. RESULTS: In this study, 178 males (59.5%) and 121 females (40.5%) were included. The median Interquartile ranges (IQR) of age was 57 (11.6) for males and 56 (13) for females. The 99th percentile URL hs-cTtrop I was found to be 33.9 ng/L, while gender specific values were 38.41ng/L and 15.73ng/L for males and females, respectively (p= 0.0045). CONCLUSION: High sensitivity cardiac troponin I 99th percentile URL in our study population was found to be 33.9 ng/L with gender specific values being 38.41 ng/L and 15.73ng/L for males and females respectively. Troponin I in males was substantially high in comparison with females.

Delta-tocotrienol supplementation improves biochemical markers of hepatocellular injury and steatosis in patients with nonalcoholic fatty liver disease: A randomized, placebo-controlled trial.

OBJECTIVE: The aim of this study was to examine the effects of delta-tocotrienol (δ-tocotrienol) supplementation on biochemical markers of hepatocellular injury and steatosis in patients with nonalcoholic fatty liver disease (NAFLD). DESIGN: The study design was a two-group, randomized, double-blind, placebo-controlled trial. The patients with NAFLD were randomly assigned to receive δ-tocotrienol 300 mg twice daily or placebo for 24 weeks. ENDPOINTS: The primary endpoints were change from baseline in fatty liver index (FLI) and homeostasis model of insulin resistance (HOMA-IR) after 24 weeks. Secondary endpoints included change from baseline in high sensitivity C-reactive protein (hs-CRP), malondialdehyde (MDA), alanine transaminase (ALT), aspartate transaminase (AST) and grading of hepatic steatosis on ultrasound. Between-group differences were tested for significance using ANCOVA. Mean differences (MD) with 95 % CIs are reported. RESULTS: A total of 71 patients (tocotrienol=35, placebo=36) were randomized and included in the intention to treat analysis. Compared with placebo, δ-tocotrienol significantly reduced (MD [95 % CI]) FLI (-8.52 [-10.7, -6.3]; p < 0.001); HOMA-IR (-0.37 [-0.53, -0.21]; p < 0.001), hs-CRP (-0.61[-0.81, -0.42]; p < 0.001), MDA (-0.91 [-1.20, -0.63]; p < 0.001), ALT (-8.86 [-11.5, -6.2]; p < 0.001) and AST (-6.6 [-10.0, -3.08]; p < 0.001). Hepatic steatosis was also reduced by a significantly greater extent with tocotrienol than with placebo (p =0.047). No adverse events were reported. CONCLUSION: δ-tocotrienol effectively improved biochemical markers of hepatocellular injury and steatosis in patients with NAFLD. δ-tocotrienol supplementation might be considered as a therapeutic option in the management of patients with NAFLD. TRIAL REGISTRATION: Sri Lankan Clinical Trials Registry (SLCTR/2015/023, 2015-10-03).

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.

Biochemical spectrum of parathyroid disorders diagnosed at a tertiary care setting.

OBJECTIVE: To determine the clinical and biochemical pattern of parathyroid disorders in a tertiary care setting.. METHODS: The cross-sectional study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from September 2017 to February 2018, and comprised patients with suspected parathyroid disorders. A panel of biochemical tests were used for diagnosis of parathyroid disorders, which included parathyroid hormone levels, total calcium, ionized calcium, inorganic phosphorus, alkaline phosphatase, magnesium, total vitamin D and urinary calcium-to-creatinine ratio. SPSS 24 was used for data analysis. RESULTS: Of the 384 subjects, 248(65%) were male and 136(35%) were female. Overall mean age was 48±19years. Of the total, 302(786%) had parathyroid issues, with 244(81%) having secondary hyperparathyroidism. Mean serum total calcium, phosphorus, ionized calcium, magnesium and total vitamin D were 8.98±1.52 mg/dl, 4.0±1.30 mg/dl, 4.65±0.52 mg/dl, 2.11±0.27 mg/dl and 20.5±8.52 ngml respectively. Of the patients diagnosed with secondary hyperparathyroidism, 72.2% patients had chronic kidney disease and 20.2% had isolated vitamin D deficiency. CONCLUSIONS: Parathyroid disorders had significant impact on bone health. Moreover, secondary hyperparathyroidism was seen to be emerging as a major endocrine problem, especially in chronic kidney disease patients and vitamin D-deficient individuals.

Diagnosis of inherited metabolic disorders by selective metabolite testing: three years' experience at a tertiary care center in Rawalpindi.

OBJECTIVE: To determine the pattern of various inherited metabolic disorders specifically through plasma amino acid and urine organic acid testing in high-risk paediatric population.. METHODS: The cross-sectional retrospective study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, and comprised data from April 2015 to March 2018 of children referred to the Department of Chemical Pathology and Endocrinology for work-up of suspected inherited metabolic disorders. Complete clinical history, baseline biochemical investigations, plasma amino acid and urine organic acid profiles, where indicated, were collected. Quantitative plasma amino acid and analysis was carried out by Ion Exchange Chromatography on Biochrome 30+ amino acid analyser, and urine organic acid analysis by Gas Chromatography-Mass Spectrometry. Findings were linked to the identified disorders. SPSS 21 was used for data analysis. RESULTS: Of the 805 cases reviewed, 49(6%) had an inherited metabolic disorder. Male:Female ratio of the cases was 1.5:1, and the median age was 240 days (interquartile range: 1-15695 days). The most common presenting symptom was seizures 316(39.3%) followed by lethargy 283(35.2%). Of the diagnosed cases, aminoacidopathies were 28(57%) and in them, non-ketotic hyperglycaemia accounted for 7(25%.). There were 12(24.5%) cases of organic acidurias followed by 9(18.4%) that were other than the two diagnoses. CONCLUSIONS: The cases of inherited metabolic disorder detected indicated significant prevalence. Non-ketotic hyperglycinemia was the commonest disorder diagnosed.

Diagnostic accuracy of cannabinoid testing by liquid chromatography-tandem mass spectrometry in human hair.

OBJECTIVE: To determine the diagnostic accuracy of Cannabinoids testing by LC-MS/MS in human hair and compare it with urine in civil heavy vehicle drivers. METHODS: Current study was a diagnostic accuracy study done in "Armed Forces Institute of Pathology Rawalpindi, Pakistan" from February to November 2017. Urine and hair samples were collected by non-probability convenient sampling technique from 151 heavy vehicle drivers from Punjab. Hair and urine samples were collected from each subject. Separation of compounds was performed on Agilent Poroshell and analyzed using 6460 Triple Quadrapole LC-MS along-with software Mass hunter ©. RESULTS: Study population (151 civil heavy vehicle drivers) was divided into three main divisions There were 69 (46%) truck drivers,43 (28.5%) twenty-wheeler drivers and 39 (26%) bus drivers. Mean age of study participants was 36±10.82 years. Paired t-test was applied to check mean difference between the two tests' concentration (i.e urine and hair analysis for cannabis) which showed significant difference at p<0.001. Among the different factors of diagnostic accuracy in hair and urine specimens were: Sensitivity (96% and 62%), Specificity (93% and 95%) Positive Predictive Value (88% and 87%), Negative Predictive Value (97% and 82%) respectively. Overall diagnostic accuracy of Cannabinoids detection in hair was 94% while in urine it was 83%. ROC curve showed area under curve of 0.79 and 0.96 for urine and hair samples respectively. CONCLUSIONS: Current study signified hair as a substitute matrix owing to its non-invasive specimen collection, better diagnostic yield and wider detection period compared to urine.

Comparison of Various Abdominal Obesity Measures for Predicting Metabolic Syndrome, Diabetes, Nephropathy, and Dyslipidemia.

OBJECTIVE: To evaluate abdominal volume index (AVI), body roundness index (BRI), body adiposity index (BAI), a body shape index (ABSI) and conicity index (C-Index) for differences in subjects with or without metabolic syndrome, diabetes, nephropathy, and dyslipidemia; and secondly, to evaluate the diagnostic performance through measuring area under curve (AUC) by ROC curve analysis for new and conventional obesity measures in diagnosing metabolic syndrome. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: PNS Hafeez Hospital, Islamabad, from January 2016 to December 2018. METHODOLOGY: Baseline anthropometric measures including BMI, WHpR, WHtR, AVI, BRI, BAI, ABSI and C-Index were measured for 232 subjects along with measurement of various biochemical parameters. Differences among subjects with and without metabolic syndrome, diabetes, nephropathy, and groups based upon insulin resistance were noted. ROC curve analysis was utilised to measure AUC for all anthropometric measures for diagnosing metabolic syndrome. RESULTS: Pearson's correlation between obesity measures and lipid indices suggested highest correlation for AVI for most lipid indices followed by WHpR and WHtR. Mean AUC for obesity measures were greater than 0.80 for WHtR and AVI, followed by other parameters. The least AUC i.e. 0.320, was observed for ABSI. The differences between various anthropometric measures for groups based upon metabolic syndrome, diabetes, nephropathy, and insulin resistance remain variable indicating that each anthropometric index may depict a different aspect of the metabolic risk. CONCLUSION: WHtR and AVI showed the highest AUC to diagnose metabolic syndrome and were better associated with metabolic diseases.

Subclinical-Hypothyroidism: A Pathology in Evolution.

Subclinical-hypothyroidism is identified as suboptimal thyroid hormonal production associated with mild TSH (thyroid stimulating hormone) elevation. Though several non-thyroidal illness in the later stages, medications and dietary supplements may resemble SCH (subclinical-hypothyroidism), but mild persistent subnormal thyroidal pathologies are usually termed as SCH. This review briefly describes the various cardiovascular risk associations with subclinicalhypothyroidism and attempts to provide an insight into the risk and benefit association, which a patient faces once treated for SCH.

Determination of reference intervals of thyroid markers during pregnancy in Urban area of District Rawalpindi Pakistan.

OBJECTIVE: To determine the reference values for thyroid stimulating hormone, free tetra-iodothyronine and total tri-iodothyronine for healthy pregnant women. METHODS: This cross sectional study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from January 2016 to June 2017. Pregnant women with normal, single intrauterine, uncomplicated pregnancy were recruited from the local population. Blood sample was taken to analyse thyroid stimulating hormone, free tetra-iodothyronine and total tri-iodothyronine using chemiluminescence immunoassay. For thyroid hormone levels during each trimester 5th and 95th percentiles were calculated as reference intervals. Data was analysed using SPSS 24. RESULTS: Out of 384 subjects, 188(48.95%) were in their first trimester and 196(51.04 %) females were in their second trimester. There were 109(57.97%) primigravida in the first trimester and 137(69.9%) in the second trimester. Mean age of subjects presenting in the first and second trimester was 25.37±3.78 years and 26.54±4.65 years respectively. Reference intervals for those in the first trimester for thyroid stimulating hormone was 0.05-2.8uIU/ml, for free tetra-iodothyronine14.4-22.7pmol/l and total tri-iodothyronine1.5-3.3nmol/l. For those in second trimester the corresponding values were 0.16-3.3 uIU/ml, 14.2-24.6.0 pmol/l and 1.6-3.1nmol/l. CONCLUSIONS: Laboratories should adopt trimester-specific reference intervals for thyroid function tests in pregnancy..

A Novel Clinico-Biochemical Score for Screening of Inherited Metabolic Diseases in Children.

OBJECTIVE: To evaluate a novel clinico-biochemical score for screening of inherited metabolic diseases (IMDs) in children in our setup. STUDY DESIGN: Descriptive analytical study. PLACE AND DURATION OF STUDY: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from August 2016 to August 2017. METHODOLOGY: Clinical data, preliminary biochemical investigations, plasma amino acid (PAA) and organic acid profiles (where indicated) of 354 children, aged <1 year to 12 years, referred to the study place for evaluation of suspected inherited metabolic diseases, was collected and evaluated. A clinico-biochemical score card named Rawalpindi Inherited Metabolic Diseases Score (RISc) was devised, on a scale from 1 to 10, incorporating 5 clinical and 5 important biochemical findings, and each variable was assigned a score, based on its relative frequency/risk. Each case was then assigned the RISc score and evaluated for presence or absence of any inherited metabolic disease, based on the score. This score was validated keeping plasma amino acids and organic acid profiles (in selected cases) as reference standard. RESULTS: Patients were divided into three groups, based on RISc score as low RISc (0.5-2.5), medium RISc (3.0-5.5) and high RISc (6-10). A total of 354 cases reported in 2016 and 2017 and 33 (9.3%) were diagnosed to be having IMDs. One (3.0%) patient from low RISc, four (12.1%) from medium RISc, and 28 (84.8%) from high RISc group were found to test positive for any one IMD. High RISc group had a statistically significant higher IMD rate than the other two groups (p<0.001). Specificity, sensitivity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value and accuracy were 93%, 85%, 11.8, 0.16, 55%, 98% and 90%, respectively. CONCLUSION: The cost effective RISc, based on clinical data and preliminary biochemical investigations, is highly accurate in diagnosing IMDs in cost restrained setups. It is strongly suggested that the initial screening for suspected IMDs and decision for advanced laboratory testing be carried out, based on the RISc card presented in the study.

Bilirubin Interference in Plasma Amino Acid Analysis by Ion Exchange Chromatography.

OBJECTIVE: To evaluate the effect of bilirubin interference on plasma amino acid analysis by Ion Exchange Chromatography (IEC). STUDY DESIGN: Cross-sectional (method validation) study. PLACE AND DURATION OF STUDY: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi from August 2016 to July 2017. METHODOLOGY: Twenty non-icteric samples from paediatric patients were collected in lithium heparin tubes and analysed for amino acids on IEC-based Biochrome® 30+ Analyzer (Harvard Biosciences UK). Baseline bilirubin levels were noted. Samples were spiked with neonatal bilirubin standard with concentration of 488.4 mol/L (Spinreact®-Spain) at final concentrations of 50, 150 and 230 mol/L and re-analysed for amino acids at these three concentrations. RESULTS: Among the 20 selected patients with normal amino acid profiles, 12 (60%) were males. Majority (55%) were in age group of 1-5 years. Significant difference was observed for Arginine (p = 0.01), Histidine (p = 0.001), Isoleucine (p = 0.01), Leucine (p = 0.007), Lysine (p = 0.005), Ornithine (p = 0.03) and Phenylalanine (p = 0.02). Mean rank of these amino acids showed decreasing trend with the increase of bilirubin concentration, and pronounced interference was identified at bilirubin level of 50 mol/L. No difference was observed for alanine, citrulline, glutamic acid, glycine, methionine, proline, threonine, tyrosine, asparagine, aspartic acid, cystine, valine and tryptophan. CONCLUSION: Bilirubin significantly interferes with certain amino acid levels when analysis is carried out by ion exchange chromatography. A close follow-up of such patients with other biochemical tests and a repeat amino acid analysis, after jaundice is settled, is recommended to confidently rule out any possible inherited metabolic disorder in these patients.

Spectrum of renin angiotensin aldosterone system disorders in young hypertensives.

OBJECTIVE: To analyse the spectrum of renin angiotensin aldosterone system disorders in young hypertensive patients in hospital settings. METHODS: This 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. It comprised hypertensive subjects aged 17-40 years of either gender presenting in the outpatient department. All subjects were having blood pressure more than 140/90mmHg and were not on any anti-hypertensive medicine. Blood sample was taken from each patient to analyse arterial blood gases, plasma renin, serum aldosterone and electrolytes. Association of qualitative variables like age, systolic and diastolic blood pressure with essential hypertension and primary hyperaldosteronism was explored. RESULTS: Of the 80 patients, 72(90%) were diagnosed with essential hypertension and 8(10%) with primary hyperaldosteronism. None of the patients had Liddle syndrome, apparent mineralocorticoid excess or Gordon syndrome. Mean age of patients having essential hypertension was 30.97±7.1 years, whereas, for those with primary hyperaldosteronism it was 29.25±7.1 years. Systolic blood pressure was significantly higher (p = 0.000) among all patients. No statistically significant association was found between age, systolic and diastolic blood pressure (p<0.05). CONCLUSIONS: Primary hyperaldosteronism as compared to other renin angiotensin aldosterone system disorders was found to be the leading cause of hypertension in young population.

Cost-effectiveness of Screening and Confirmatory Tests for Multiple Myeloma in Pakistani Population: An Audit Report.

OBJECTIVE: To find out the use of screening and confirmatory tests for diagnosis of multiple myeloma as ordered by clinicians. STUDY DESIGN: An Audit. PLACE AND DURATION OF STUDY: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from January 2012 to January 2017. METHODOLOGY: Data retrieved from Laboratory Information Management system (LIMs) by selecting serum protein electrophoresis (SPE) as screening test and immunoelectophoresis (IE) and immunofixation (IF) as confirmatory tests. RESULTS: There were 3,108 tests of serum protein electrophoesis and 1,329 tests of immunoelectophoresis had been performed in last five year. Cost-effective clinical audit of SPE tests showed that only 17.1% tests of SPE were either used for proper diagnosis of multiple myeloma (totally justified tests 13%) or useful for diagnosis of other important diseases whose early diagnosis were helpful for patients management (partially justified tests 4.1%). The cost related to these tests were justified while 82.8% tests of SPE were either normal (total unjustified tests 24.4%), or diagnosed irrevalent and nonspecific diseases (partially unjustified 58.4%). IE and IF audit revealed that only 26.6% tests were properly utilised for diagnosis and differentiation of multiple myeloma and its subtypes and cost attributable to these tests were justified while 73.4% of these confirmatory tests were normal and cost related to them was not justified. CONCLUSION: Overutilisation of laboratory tests for diagnosis of multiple myeloma can be minimised by proper clinical scrutiny of request forms.