Association Between Triglyceride-Glucose Index and Homeostasis Model Assessment for Insulin Resistance with Estimated Glucose Disposal Rate.

This cross-sectional study was aimed to compare insulin resistance, Triglyceride- Glucose (TyG) index, fatty liver index (FLI) and hepatic steatosis index (HSI), glycaemic and lipids among groups/quartiles based upon estimated Glucose Disposal Rate (eGDR) from August 2022 to December 2022 among 249 male participants. The eGDR results in (mg/kg/min) were divided into four quartiles as: Group-I: {<6.88, n = 62}, Group-II: {<6.88-9.45, n = 63}, Group-III: {9.46-10.39, n = 62}, and Group-IV: {>10.39, n = 62}. Fasting plasma glucose (FPG), HbA1c, low density lipoprotein (LDL), homeostasis model assessment for insulin-resistance (HOMAIR), and TyG index demonstrated significant worsening increase from high to low eGDR groups. Receiver operating curve (ROC) analysis to calculate area under curve (AUC) for diagnostic efficiency candidate indices for eGDR demonstrated highest AUC for FLI as AUC: 0.736 (95% CI: 0.669-0.803), p < 0.001, followed by FPG: AUC: 0.682 (95% CI: 0.606-0.757), HOMAIR: AUC: 0.670 (95% CI: 0.602-0.739), HSI: AUC: 0.660 (95% CI: 0.589-0.731), TyG index: 0.658 (95% CI: 0.583-0.732), and HbA1c: 0.639 (95% CI: 0.583-0.732). Glycaemic measures, lipid indices, insulin resistance and TyG index deteriorated with declining eGDR. Diagnostic performance as evaluated by AUC for eGDR was highest for FLI, followed by FPG, HOMAIR, HSI, TyG index, HbA1c, and triglycerides. Key Words: Triglyceride, Insulin, Glucose, Diabetes.

Differences Between Conventional and Newer Anthropometric Measures Among Individuals with and without Fatty Liver Disease.

A cross-sectional analysis was conducted to compare conventional and emerging anthropometric measures among male participants with and without fatty liver disease (FLD). The objective was to assess differences and diagnostic efficiency of anthropometric-parameters using receiver operating curve (ROC) analysis at Combined Military Hospital Multan, NUMS from April to October 2022. Comparison for anthropometric measurements between non-FLD (n=164) vs. FLD (n=85) indicated significant differences in weight (74.01 + 11.96 vs. 85.91 + 14.07 kg, p<0.001), waist circumference (9.38 + 9.82 vs. 101.35 + 10.74 cm, p<0.001), BMI (24.81 + 4.0 vs. 29.21 + 4.38 kg/m2, p<0.001), waist-to-hip ratio (WHpR) (0.924 + 0.054 vs. 0.971 + 0.054, p<0.001), waist-to-height ratio (WHtR) (0.508 + 0.054 vs. 0.578 + 0.062, p<0.001), and abdominal volume index (AVI) (16.17 + 3.56 vs. 20.77 + 4.61, p<0.001). Fatty liver index (FLI) also showed significant difference between non-FLD vs. FLD groups (38.35 + 27.12 vs. 72.01 + 21.31, p<0.001). AUCs for various significant anthropometric measurements from highest to lowest as 0.821 (95% CI: 0.767-0.874) for FLI, 0.815 (95% CI: 0.761-0.869) for WHtR, 0.809 (95% CI: 0.754-0.863) for AVI, and 0.808 (95% CI: 0.754-0.863) for waist circumference with lowest recorded AUC for height as 0.422 (95% CI: 0.347-0.497). Key Words: Fatty liver disease (FLD), Body mass index (BMI), A body shape index (ABSI), C-index, Abdominal volume index (AVI), Body roundness index (BRI).

Diagnostic Accuracy of Immature Platelet Fraction (IPF) to Differentiate Between Thrombocytopenia due to Peripheral Destruction versus Bone Marrow Failure.

OBJECTIVE: To analyse the predictive value of immature platelet fraction (IPF) as an independent diagnostic marker to differentiate between hyperdestructive and hypoproductive thrombocytopenia. STUDY DESIGN: Cross-sectional observational study. Place and Duration of the Study: Armed Forces Institute of Pathology Rawalpindi, from February to July 2022. METHODOLOGY: A total of 164 samples were included in the study by non-probability consecutive sampling. Among these, 80 were obtained from normal individuals serving as control; 43 were obtained from patients having hyperdestructive thrombocytopenia (idiopathic thrombocytopenia, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation); and 41 were obtained from those hypoproductive thrombocytopenia (acute leukaemia, aplastic anaemia, chemotherapy). Sysmex automated haematology analyzer, XN-3000 was used to determine the immature platelet fraction (IPF) of the patients. ROC curves analysis was done to ascertain area under curve. RESULTS: Immature platelet fraction (IPF %) was significantly higher in consumptive / hyperdestructive thrombocytopenia group i.e. median (IQR), 21% (14.4-26.2) as compared to 6.5% (4.6-8.9) in hypoproductive thrombocytopenia, and 2.6% (1.3-4.1) in normal control group (p <0.001). Cut-off value with the highest sensitivity and specificity for IPF vs. normal population was 7.95% with sensitivity of 97.7% and specificity of 86%. CONCLUSION: Immature platelet fraction (IPF of 7.95%) possesses high diagnostic accuracy, sensitivity and specificity for differentiation between hyperdestructive vs. hypoproductive thrombocytopenia. It can be used as a reliable marker to differentiate between the two entities. KEY WORDS: Immature platelet fraction, Thrombocytopenia, Bone marrow failure, Peripheral destruction.

HLA-DQ2 and HLA-DQ8 Alleles in Celiac Disease Patients and Healthy Controls.

OBJECTIVE: To compare HLA-DQ2 and HLA-DQ8 alleles between celiac disease patients and healthy control group. STUDY DESIGN: Observational cross-sectional study. PLACE AND DURATION OF STUDY: Department of Immunology, Armed Forces Institute of Pathology (AFIP), from April to December 2018. METHODOLOGY: Subjects were included: 100 celiac disease patients selected by non-probability consecutive sampling, and 100 healthy subjects. After collecting peripheral blood in EDTA tubes, chromosomal DNA was extracted and amplified, using sequence specific primers. Post-amplification electrophoresis was performed on two per cent agarose gel, followed by ethidium bromide staining; and specific band patterns were recorded under ultraviolet illumination to determine the HLA-DQ alleles. The subtypes of HLA-DQ2, i.e. HLA-DQ2.5 and HLA-DQ2.2 were also assessed. Frequency, percentage, mean and SD were calculated. Post-stratification Chi-square test was applied. RESULTS: The mean age of celiac disease group and healthy subjects was 14.79 ± 5.32 years and 14.71 ± 5.21 years, respectively. The frequency of HLA-DQ2 and HLA-DQ8 among celiac disease patients was 93% and 4%, respectively. Among HLA-DQ2 positive, HLA-DQ2.5 and HLA-DQ2.2 were found in 92% and 8%, respectively. Statistically significant difference (p <0.05) was observed between the celiac disease patients and healthy group. There was no significant difference observed among different age groups and gender (p >0.05). CONCLUSION: HLA-DQ2 detection reliably diagnoses celiac disease among all age groups and either gender. It can be used as an effective marker for early diagnosis of celiac disease instead of invasive procedures such as intestinal biopsy. The diagnosis can be pin-pointed by presence of HLA-DQ2.5. Key Words: Celiac disease, HLA-DQ2, HLA-DQ8, HLA-DQ2.5, HLA-DQ2.2.

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).

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.

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.