Study of non-alcoholic fatty pancreatic disease among the Egyptian population and the value of serum fatty acid binding protein-1 (FABP-1) as a non-invasive biomarker.

BACKGROUND: Non-alcoholic fatty pancreas disease (NAFPD) can be detected using various imaging techniques, but accurately measuring the amount of fat in the pancreas remains difficult. Fatty acid binding protein-1 (FABP-1) is a marker specific to certain tissues and can aid in diagnosing NAFPD. However, this study aimed to investigate the prevalence of NAFPD among obese and non-obese people with and without diabetes mellitus (DM). Additionally, it aimed to evaluate the associated risk factors for NAFPD and the utility of the FABP-1 level as a simple, non-invasive biomarker for diagnosing NAFPD. METHODS: This study is a prospective cross-sectional study. RESULTS: Ninety-five patients were enrolled in the study, comprising 35 males and 60 females, with a mean age of 44 years and a standard deviation (SD) of 11 years. However, 26.3 % were morbidly obese, 22.1 % were severely obese, 31.6 % were obese, 12.6 % were overweight, and 7.4 % were normal. Additionally, 35.8 % had diabetes mellitus, while 26.3 % of patients had hypertension. Regarding the ultrasonographic findings, 94.7 % of the patients had fatty liver, with the majority (41.1 %) classified as grade II, followed by 38.9 % classified as grade I, and 14.7 % classified as grade III fatty liver. Among these patients, 78.9 % had fatty pancreas, with 38.9 % classified as grade II, 31.6 % classified as grade I, and 8.4 % classified as grade III fatty pancreas. The median FABP-1 level among patients with fatty pancreas was 3.3 ng/ml, which exhibited a significant fair negative correlation with total bilirubin and a fair, positive correlation with alkaline phosphatase and portal vein diameter. A statistically substantial distinction was observed between the levels of AFABP-1 and the presence or grading of the fatty pancreas (p-value = 0.048 and < 0.001, respectively). Using multivariate analysis, FABP-1 was the only significant predictor of a fatty pancreas. The receiver operating characteristic (ROC) curve analysis indicated that at a cut-off point of FABP-1 of ≤ 3.7, it had a sensitivity of 58 %, specificity of 80 %, positive predictive value (PPV) of 96.6 %, negative predictive value (NPV) of 17 %, and an area under the curve (AUC) of 0.77. CONCLUSION: NAFPD is becoming an increasingly significant challenge. FABP-1 can potentially be a straightforward and non-invasive predictor of the fatty pancreas.

Beneficial role of healthy eating Index-2015 score & physical activity on COVID-19 outcomes.

BACKGROUND: Nutritional status and physical activity are essential to maintain a strong immune system. No definite pharmacological strategies for Coronavirus disease 2019 treatment are presently available, so natural enhancement of the immune system is in need. Our goal was to assess the correlation of healthy diet and physical activity on COVID-19 disease outcome. METHODS: This cohort study was conducted on 68 adult patients who contracted mild (38) or moderate [30] cases of COVID-19, recruited via a convenience sampling technique from the outpatient clinic, Kasr Al-Aini Faculty of Medicine, Cairo University Hospital. Patients' Healthy Eating Index (HEI) and degree of physical activity as measured by the Global Physical Activity Questionnaire were evaluated and linked with several inflammatory markers. RESULTS: Most of patients with mild COVID-19 patients (92.1%) were physically active, compared to only 50% of moderate COVID-19. The total Metabolic Equivalent Task-min/week was positively correlated with the lymphocyte percentage. The median total HEI score was significantly higher in the patients with mild COVID-19 than with moderate COVID. Significant positive correlations observed among the lymphocyte count and total HEI-2015. There was approximately a 64% reduction in the probability of acquiring moderate COVID-19 illness for each unit rise in The HEI. CONCLUSION: Healthier nutrition and Physical activity correlated with reduced COVID-19 disease severity. TRIAL REGISTRATION: The study was registered on clinical trial.gov maintained by the US National Library of Medicine (CinicalTrials.gov identifier = NCT04447144; https://clinicaltrials.gov/ ) (25/06/2020).

Detection of chronic toxoplasmosis in the brain of mice using loop-mediated isothermal amplification (LAMP) and conventional PCR.

BACKGROUND: Toxoplasma gondii is a common protozoan parasite that infects approximately one-third of the world's population. It is a disease with multiple manifestations. In immunocompetent individuals, symptoms are mild and flu-like, whereas, in immunocompromised patients, it often results in severe morbidity and mortality. Thus, studies for developing a simple, rapid diagnostic tool for early detection of Toxoplasma are emerging. Molecular diagnosis is highly accurate and helpful in congenitally infected and immunocompromised patients. The loop-mediated isothermal amplification (LAMP) technique was invented to improve nucleic acid amplification efficacy in terms of sensitivity and specificity. AIM OF THE STUDY: The study aimed to validate a LAMP protocol for detecting Toxoplasma DNA in the brain homogenates from mice experimentally infected with Toxoplasma's ME-49 (cyst-forming type II) strain in comparison to PCR. METHODS: In this study, the target DNA fragment was the Toxoplasma 529-bp, repeated 200-300 copies/genome. The sensitivity of both LAMP and conventional PCR techniques was estimated in brain homogenates in experimental mice at eight weeks post-infection and compared to the histopathology data. RESULTS: The LAMP reaction showed positive results in 18 of the 26 examined samples of brain homogenates. PCR showed the characteristic 529-bp band in 15 of the 26 examined samples. CONCLUSION: The LAMP showed a higher sensitivity over PCR in detecting Toxoplasma infection in brain homogenates of infected mice.

Beyond probiotic legend: ESSAP gut microbiota health score to delineate SARS-COV-2 infection severity.

COVID-19 pandemic continues to be a global health crisis. The gut microbiome critically affects the immune system, and some respiratory infections are associated with changes in the gut microbiome; here, we evaluated the role of nutritional and lifestyle habits that modulate gut microbiota on COVID-19 outcomes in a longitudinal cohort study that included 200 patients infected with COVID-19. Of these, 122 cases were mild and seventy-eight were moderate, according to WHO classification. After detailed explanation by a consultant in clinical nutrition, participants responded to a written questionnaire on daily sugar, prebiotic intake in food, sleeping hours, exercise duration and antibiotic prescription, during the past 1 year before infection. Daily consumption of prebiotic-containing foods, less sugar, regular exercise, adequate sleep and fewer antibiotic prescriptions led to a milder disease and rapid virus clearance. Additionally, data on these factors were compiled into a single score, the ESSAP score (Exercise, Sugar consumption, Sleeping hours, Antibiotics taken, and Prebiotics consumption; 0-11 points), median ESSAP score was 5 for both mild and moderate cases; however, the range was 4-8 in mild cases, but 1-6 in moderate (P = 0·001, OR: 4·2, 95 % CI 1·9, 9·1); our results showed a negative correlation between regular consumption of yogurt containing probiotics and disease severity (P = 0·007, OR: 1·6, 95 % CI 1·1, 2·1). Mild COVID-19 disease was associated with 10-20 min of daily exercise (P = 0·016), sleeping at least 8 h daily, prescribed antibiotics less than 5 times per year (P = 0·077) and ate plenty of prebiotic-containing food.

COVID-19 Disease Outcomes: Does Gastrointestinal Burden Play a Role?

BACKGROUND: The novel coronavirus disease 2019 presents an urgent threat to global health. As the epidemic grows, prognosis prediction is essential for monitoring risky patient. It is thus important to consider gastrointestinal manifestations and the duration of symptoms as predictors of prognosis. Our aim was to determine the correlation of gastrointestinal symptoms and laboratory markers with disease outcomes and whether symptom duration varies substantially between patients. We also undertook this study to determine the optimal time to predict COVID-19 outcome. PATIENTS AND METHODS: A total of 190 patients with polymerase chain reaction-confirmed COVID-19 were followed up until recovery. We proposed a correlation between gastrointestinal symptoms and disease severity (based on clinical data, and diagnostic investigations) to estimate the duration of symptoms as a predictor of COVID-19 prognosis. RESULTS: The prevalence of gastrointestinal symptoms was 49.5%, consisting mainly of diarrhea in 27.9% of patients. In addition, a longer disease duration and higher temperature were observed in patients with diarrhea. Symptom duration was variable, with a median of 12 days and a range of 1-55 days. Statistical analysis indicated that patients with a duration of symptoms ≥12 day had more severe symptoms and a worse prognosis. Patients who complained of diarrhea had 2.7 times the odds of a longer duration of symptoms, and those with a history of chronic lung disease have 7.2 times the odds of a longer duration of symptoms. CONCLUSION: GIT manifestations (mainly diarrhea) and the duration of symptoms of COVID-19 provide prognostic evidence of COVID-19 outcomes, irrespective of earlier categorization by the World Health Organization. Thus, patients with mild symptoms who present with diarrhea and a duration of symptoms longer than 12 days are expected to have a worse prognosis.

Serum Micro-RNA-122 Level as a Simple Noninvasive Marker of MAFLD Severity.

BACKGROUND: Metabolic-associated fatty liver disease (MAFLD) is a common disease worldwide. Micro-RNA-122 is known to be the most abundant micro-RNA expressed in the liver. OBJECTIVE: To evaluate the association of micro-RNA-122 and the degree of steatosis and fibrosis in obese patients with MAFLD. METHODS: The study included 120 obese Egyptian patients with MAFLD, which were diagnosed and classified according to ultra-sonographic liver findings. All patients enrolled in the study were subjected to thorough clinical examination and laboratory investigations (serum micro-RNA-122 levels by PCR, lipid profile, liver biochemistry, and functions). Fibro-scan was used to assess the level of fibrosis. RESULTS: There was a significant increase in levels of micro-RNA-122 in obese patients with MAFLD compared to controls (p<0.001). Micro-RNA-122 level was lower in patients with mild liver steatosis than patients with moderate or severe steatosis (p<0.001). It was lower in patients with a mild degree of fibrosis than those with mild or moderate fibrosis (p<0.001). Micro-RNA-122 was significantly positively correlated with low-density cholesterol and triglycerides level, and liver enzymes, and negatively correlated to high-density cholesterol (p<0.001). CONCLUSION: Serum micro-RNA-122 could be a useful predictor of assessing MAFLD severity regarding level of steatosis or fibrosis.

Serum LPS and CD163 Biomarkers Confirming the Role of Gut Dysbiosis in Overweight Patients with NASH.

BACKGROUND: Gut-microbiota alterations and bacterial translocation might attribute to hepatic inflammation. Lipopolysaccharide stimulates toll-like receptor 4 leading to the activation of Kupffer cells which express the surface receptor, CD 163. OBJECTIVE: To assess the levels of CD 163 and LPS in overweight and obese patients with different degrees of NAFLD as confirmed by liver biopsy (NAS score). METHODS: This is an observational case-control study. Sixty overweight and obese patients with NAFLD and 40 healthy controls were enrolled in the study. Liver biopsy was obtained from all participants with NAFLD. LPS and CD 163 levels were assessed using ELISA. RESULTS: The mean LPS and CD163 levels were significantly higher in patients with NAFLD when compared with healthy controls (p-value <0.001, p-value <0.001, respectively). LPS and CD163 levels were the lowest in Non-NASH (13.17 ± 3.34, 5.61 ± 2.35 ng/mL, respectively) and the highest in NASH (58.61 3± 3.81, 18.11 ± 6.84, respectively) (p-value <0.001, p-value <0.001, respectively). Statistically significant correlation was found between the levels of LPS and CD163 and NAS score (p-value <0.001, p-value < 0.001, respectively), steatosis grade (p-value <0.001, p-value <0.001, respectively), degree of inflammation (p-value 0.017, p-value <0.001, respectively) and ballooning (r= 0.663, p-value <0.001, r= 0.558, p-value <0.001, respectively). In ROC analysis, both sCD163 and LPS had high sensitivity and specificity in diagnosing NAFLD. CD163 and LPS had the high sensitivity and accuracy in discriminating NASH from Non-NASH (p-value <0.0001 in both). Moreover, the mean serum levels of LPS and sCD163 correlated positively and significantly with the BMI (r=0.329, p value<0.01; r=0.477. p value <0.001, respectively). CONCLUSION: sCD163 and LPS can be used as non-invasive tools for diagnosis and grading of NAFLD severity in overweight and obese patients, thus confirming the role of dysbiosis in fat deposition and inflammation and suggesting the potential benefits of gut-microbiota-targeted therapies in restoring the gut homeostasis.

Validation of dried blood spots in monitoring toxoplasmosis.

Due to the growing importance of toxoplasmosis worldwide, simple methods of diagnosis are important for epidemiologic studies. Dried blood spot (DBS) is a useful tool that surpasses venipuncture. DBS-Toxoplasma testing via a finger-stick could also be used in setting where phlebotomies might not be feasible, such as worldwide prenatal and newborn screening for congenital toxoplasmosis. This study included 101 study subjects were occupationally at-risk to Toxoplasma gondii infection and 33 as controls. Serum was collected from both groups for the detection of anti-Toxoplasma IgG antibodies by ELISA as a reference gold standard test. For the occupational at-risk group, capillary finger stick derived blood was blotted onto five sets of Whatman protein saver cards. Discs were stored as four sets; three sets at 4°C and eluted 1, 2 and 3 months of storage and one set at -20°C for 3 months then eluted. Additionally, one set was eluted immediately. Anti-Toxoplasma IgG antibodies were evaluated by ELISA from DBS eluted samples and compared to matched sera. DBS elutes from discs that were freshly prepared for anti-Toxoplasma IgG showed 100% sensitivity, specificity and diagnostic accuracy. Serologic testing using DBS showed very good diagnostic accuracy under all mentioned conditions of storage. Higher stability was obtained when the blood discs stored at 4°C for 1 month and up to 3 months at -20°C, with 98.18% sensitivity, 100% specificity and 99% diagnostic accuracy. DBS-Toxoplasma testing is characterized by simplicity in performance, cost-effectiveness and the ease of handling, to store and to transport, with high diagnostic accuracy.

Loop mediated isothermal amplification (LAMP) of Toxoplasma DNA from dried blood spots.

INTRODUCTION: The cosmopolitan protozoan Toxoplasma gondii is a major parasite of warm-blooded animals including man. Early and accurate diagnosis is a must for proper treatment that prevents life threatening sequels. Loop-mediated isothermal amplification (LAMP) is a novel technique that can amplify DNA with high sensitivity and specificity under isothermal conditions. AIM OF THE STUDY: To validate a LAMP-specific protocol for detection of Toxoplasma DNA using dried blood spots (DBS) from mice experimentally infected with the cystogenic Toxoplasma ME-49 strain. METHODS: In this study, the target DNA fragment was the Toxoplasma 529-bp repeat element that exists in 200-300 copies per T. gondii genome. The sensitivity of both LAMP and conventional PCR techniques was estimated in DBS samples from experimental mice at 1-week and 8-weeks post-infection. RESULTS: Out of 20 blood samples gathered on Whatman filter paper from mice at 1-week post-infection, 18 and 16 were positive by LAMP and conventional PCR, respectively. Neither techniques detected parasite DNA in blood at 8th week of infection. CONCLUSION: Dried blood spots are easy source of material for molecular studies. LAMP assay proved higher sensitivity than the conventional PCR in detecting parasitemia in early infection with the cystogenic Toxoplasma strain.

Novel Application of the Traditional Lipid Ratios as Strong Risk Predictors of NASH.

PURPOSE: Limited data are available regarding the role of triglycerides, cholesterol and lipoproteins ratios as risk factors for nonalcoholic fatty liver disease (NAFLD) progression. In the present study, the investigators aimed to investigate the value of cardiovascular risk ratios of triglycerides, cholesterol, and lipoproteins as predictors of nonalcoholic steatohepatitis (NASH) and the correlation of such ratios with disease severity. PATIENTS AND METHODS: This study included 131 overweight and obese patients with NAFLD who were divided into NASH, borderline NASH, and non-NASH fatty liver (NNFL) subgroups according to NAFLD activity score (NAS) in liver biopsy, and 60 healthy participants as a control group. Lipid profile and lipid ratios including triglycerides/HDL (TGs/HDL), low-density lipoprotein/high-density lipoprotein (LDL/HDL) and total cholesterol/HDL (TC/HDL) ratios were measured. RESULTS: Significantly higher triglycerides/HDL ratio was found in NASH and borderline NASH, while higher cholesterol/HDL ratio was found in borderline NASH in comparison to controls. There were positive correlations between TGs/HDL and steatosis, ballooning, inflammation, BMI, and NAS; between LDL/HDL and inflammation; and between cholesterol/HDL and BMI, steatosis, and NAS. The highest AUC was that of TG/HDL (0.744), at a cut-off point of 3, with 71.8% sensitivity and 76.8% specificity. CONCLUSION: Triglycerides, cholesterol and lipoprotein ratios showed higher levels in NASH and correlated with NAFLD severity, and above these cut-off ratios, we can rule in the NASH cases which confer also the cardiovascular morbidities. Structured lipid ratios could serve as markers to screen NASH progression from simple steatosis cases and clarify the link of NASH with the cardiovascular risk prediction in overweight and obese patients.

Abdominal subcutaneous fat thickness and homeostasis model assessment of insulin resistance as simple predictors of nonalcoholic steatohepatitis.

Background: Obesity, insulin resistance, and diabetes are major risk factors for nonalcoholic fatty liver disease (NAFLD). This study aims to evaluate the association between different grades of NAFLD and abdominal subcutaneous fat thickness with the homeostasis model assessment of insulin resistance (HOMA-IR). Methods: In this pilot study, 59 obese nondiabetic participants with NAFLD were enrolled. Total cholesterol, HbA1c, and HOMA-IR were measured. Abdominal subcutaneous fat thickness in the midline just below the xiphoid process in front of the left lobe of the liver (LSFT) and in the umbilical region (USFT), and the degree of hepatic steatosis, were evaluated by ultrasound scans, and their correlation with the degree of steatosis and the NAFLD Activity Score in liver biopsy was assessed. Results: Of the 59 studied participants, 15 had mild, 17 had moderate, and 27 had severe hepatic steatosis by abdominal ultrasound. The mean ± SD HOMA-IR level in NAFLD patients was 5.41±2.70. The severity of hepatic steatosis positively correlated with body mass index (P<0.001), HOMA-IR (P<0.001), serum triglycerides (P=0.001), LSFT (P<0.001), and USFT (P<0.001). Receiver operating characteristics analysis showed that LSFT at a cut-off of 3.45 cm is the most accurate predictor of severe hepatic steatosis, with 74.1% sensitivity and 84.4% specificity. The best cut-off of USFT for identifying severe hepatic steatosis is 4.55 cm, with 63% sensitivity and 81.3% specificity. Conclusion: Abdominal subcutaneous fat thicknesses in front of the left lobe of the liver and in the umbilical region, together with HOMA-IR, are reliable indicators of the severity of NAFLD in obese nondiabetic individuals.

Diabetes Mellitus, Nonalcoholic Fatty Liver Disease, and Conjugated Linoleic Acid (Omega 6): What Is the Link?

BACKGROUND AND OBJECTIVE: Type 2 DM and obesity are the coming epidemics and their association with NAFLD is well established; essential fatty acids are vital for body health yet the body cannot make them; 2 essential fatty acids are especially important: linoleic (omega-6) and alpha-linoleic (omega-3) acids; they can be considered as "bioactive lipids" and serve as functional foods. METHODS: 50 type 2 Egyptian diabetic patients controlled on oral hypoglycemic drugs together with 20 age- and sex-matched healthy participants were enrolled in the study; all were subjected to complete history taking, BMI, fasting plasma glucose, HOMA-IR, ALT, AST, GGT, urea and creatinine, total lipid profile, hepatitis markers including hepatitis B surface antigen and hepatitis C virus antibodies, conjugated linoleic fatty acid "CLA," and abdominal ultrasound for grading of NAFLD. RESULTS: Our study in Egyptian diabetics with NAFLD revealed a low level of serum CLA compared to healthy control; such deficiency was more marked with advanced grades of NAFLD; lowest levels were observed in those with severe steatosis (NASH) with definite association between CLA and obesity. CONCLUSION: Insulin resistance is the main link between NAFLD, diabetes, and obesity. Conjugated linoleic acid (CLA) has a role in fat deposition in the liver and in development and improvement of insulin resistance. Fatty food had a documented role in the pathogenesis of obesity and diabetes but it can also be the cure.

Combined Adiponectin Deficiency and Resistance in Obese Patients: Can It Solve Part of the Puzzle in Nonalcoholic Steatohepatitis.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) has become the most prevalent cause of liver disease, nonalcoholic steatohepatitis (NASH) and fibrosis in obese patients identifies the risk group with increased incidence of liver-related deaths. AIM: To clarify the role of serum adiponectin and its receptor liver gene expression in the progression of liver damage in NAFLD. METHODS: Fifty four (54) obese patients with NAFLD preliminary diagnosed by liver ultra-sound were recruited. Full medical history, anthropometric measurement, biochemical studies, serum adiponectin level, liver biopsy for histological examination and NAS score to identify NASH patients, and assessment of adiponectin receptor gene expression by RT-PCR, were conducted for each patients. Fifteen ages matched average weight healthy adult had been chosen as a control for serum adiponectin level. RESULTS: According to NAS score, patients were divided into non- NASH (8 patients), and NASH (46 patients). Serum adiponectin level was significantly lower in NAFLD patients compared to normal participants (p < 0.004). Serum adiponectin level was lower in NASH patients (4.437 ± 2.569 ng/dl in NASH vs. 5.138 ± 2.841 ng/dl in non-NASH). Adiponectin receptor liver gene expression was lower in NASH patients (0.8459 ± 0.4671 vs. 1.0688 ± 0.3965 in non-NASH). CONCLUSION: Both adiponectin deficiency and resistance had a role in progression of simple liver steatosis to severe injury in obese patients.

Serum Resistin Level and Its Receptor Gene Expression in Liver Biopsy as Predictors for the Severity of Nonalcoholic Fatty Liver Disease.

BACKGROUND: Liver histology remains the gold standard for assessing nonalcoholic fatty liver disease (NAFLD). Noninvasive serological markers have been developed to evaluate steatosis to avoid biopsy. In NAFLD patients, serum resistin was higher than those in control lean and obese patients. OBJECTIVE OF THE STUDY: To investigate serum resistin and its receptor gene expression in liver biopsy as predictors for NAFLD severity. PATIENTS AND METHODS: This study was conducted on 54 obese patients, with suspected fatty liver by ultrasound (excluding diabetic, alcoholic, hepatitis C virus antibody (HCVAb) or hepatitis B surface antigen (HBsAg) positive patients). They were subjected to anthropometric measurements, laboratory studies including serum resistin, abdominal ultrasonography (US) and liver biopsy. The 15 lean subjects were included as a control group. According to biopsy results, patients were subdivided into nonalcoholic steatohepatitis (NASH) group (46 patients) and non-NASH group (8 patients). RESULTS: Significantly higher levels of resistin were detected in NAFLD patients compared to control subjects (p = 0.0001). Also, higher levels of resistin were recorded in NASH group compared to the non-NASH group; however, the difference was not statistically significant (p = 0.584). Serum alanine aspirate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transpeptidase (GGT) were higher in NASH patients than non-NASH group (p = 0.223, p = 0.005 and p = 0.006 respectively). Abdominal US showed high sensitivity in NAFLD diagnosis (sensitivity of sonar in detecting steatosis grade compared to biopsy was 61% in grade 1, 25% in grade 2 and 75% in grade 3). CONCLUSION: Serum resistin can be combined with other noninvasive markers to predict the presence of NASH as an alternative to liver biopsy.How to cite this article: Hegazy M, Abo-Elfadl S, Mostafa A, Ibrahim M, Rashed L, Salman A. Serum Resistin Level and Its Receptor Gene Expression in Liver Biopsy as Predictors for the Severity of Nonalcoholic Fatty Liver Disease. Euroasian J Hepato-Gastroenterol 2014;4(2):59-62.

Egyptian experience of reliability of 4T's score in diagnosis of heparin induced thrombocytopenia syndrome.

To evaluate the utility of the 4Ts clinical scoring system as a pretest probability method for detection of heparin-induced thrombocytopenia (HIT). Medical and surgical inpatients and outpatients at Kasr El Eini hospital. This single-centre series of 50 HIT testing referrals assessed combination of clinical score (thrombocytopenia, timing, thrombosis, other causes of thrombocytopenia not evident; 4T's), Heparin platelet factor 4 (H-PF4) rapid particle gel immunoassay (PaGIA) and 14C serotonin release assay (SRA) to develop a practical and well tolerated diagnostic strategy for HIT. Sixteen patients (32%) had a low 4T's score, 26 (52%) had an intermediate score and only eight (16%) had a high score. A positive H-PF4 by PaGIA was seen in seven patients (14%). As might be anticipated, the likelihood of obtaining a positive H-PF4 by PaGIA increased with an increasing clinical score, with positive H-PF4 by PaGIA results in low, intermediate and high scoring patients of 6.25, 7.7 and 50%, respectively. The positive predictive value of a positive PaGIA was 92%. The negative predictive value was 100%. Five patients (10%) in our cohort had a positive SRA. All patients with a positive SRA were included in the intermediate (two of 26 patients, 7.7%) or high (three of eight patients, 37.5%) score groups. The negative predictive value of a low 4T's score was 100%, effectively ruling out HIT. A low 4Ts score supports low probability of HIT based on the results of the PaGIA and SRA. Overall, the interrater reliability of the scoring system was fair.