Effect of ABCA1-R219K Polymorphism in Serum Lipid Parameters in Patients under Statin Therapy Visiting Tertiary Cardiac Center of Nepal.

Introduction ATP-binding cassette transporter A1 (ABCA1) encoded by ABCA1 gene is one of the important protein involved in lipid metabolism. The effect of statin therapy on dyslipidemia varies among individuals and it may be due to different genetic polymorphism. The R219K polymorphism of ABCA1 gene is found to have a significant role in the response of statin. Objective This study was designed to evaluate the effect of R219K polymorphism in lipid-lowering action of statin in patients with dyslipidemia. Material and Methods This study was conducted in 88 patients. Blood samples were taken from patients before and at the end of 3 months of statin use and were analyzed for lipid profile. Whole blood was analyzed for R219K Polymorphism using polymerase chain reaction-restriction fragment length polymorphism. Results R219K polymorphism was associated with significant percentage reduction of serum triglyceride/high-density lipoprotein (TG/HDL) ratio and total cholesterol/high-density lipoprotein (TC/HDL) ratio in atorvastatin users. However, there was no significant association of polymorphism with change in serum TC, HDL-C, LDL-C, TG, and very low-density lipoprotein (VLDL). Among KK genotype individuals, value of TG, VLDL, TG/HDL, and TC/HDL were significantly lower than in RR genotypes. Also, TG/HDL and TC/HDL were significantly lower in RK genotype than in RR. Treatment of dyslipidemia with statin was found to be comparatively better in patients having the genotypes KK and RK. Conclusion Our study demonstrated association of R219K polymorphism with the significant reduction of TG/HDL and TC/HDL and particularly the KK genotype was associated with significant improvement of lipid parameters following atorvastatin treatment.

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.

High Burden of Vitamin B12 Deficiency among Adults and Elderly.

BACKGROUND: Deficiency of vitamin-B12 is widespread. Adults and the elderly are particularly susceptible to vitamin-B12 deficiency. This study investigated the burden of vitamin-B12 deficiency and insufficiency among adults and the elderly attending a tertiary care hospital in Nepal. METHODS: This is a retrospective chart review conducted at Dhulikhel hospital. We reviewed records of 1615 patients investigating Vitamin-B12 level (pmol/L) at the clinical biochemistry laboratory from laboratory management database MIDAS between June 2020 and December 2021. Vitamin-B12 level was measured using enzyme immunoassay in Abbott Architect i1000SR analyzer. The categorical variables are presented as frequency and percentage; and numerical variables as  means and standard deviations, or median and Interquartile range.  Pearson Chi-square test was used to determine association between categorical variables.  Mann Whitney test and Kruskal Wallis H test were used to compare Vitamin-B12 level by categories. RESULTS: There were 1454 participants of which 33.5% of the patients were deficient, 27.9% were borderline deficient, while 38.7% had adequate vitamin B12 levels. Young adults(170.4 pmol/L) had a lower median vitamin B12 level than middle-aged adults (183.7pmol/L) and the elderly population (247.9pmol/L) (P<0.001). Compared to females (186.7 pmol/L), males(171.9 pmol/L) had lower vitamin B12 level (P <0.05). CONCLUSIONS: The study revealed that a significant proportion of young adults, middle aged adults and elderly population visiting a tertiary care hospital of Nepal are having vitamin B12 deficiency and borderline deficiency of public health concern.  Keywords: Adults; deficiency; elderly, vitamin B12.

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.

Importance of Observing the Progress Curve During Enzyme Assay in an Automated Clinical Chemistry Analyzer: A Case Study.

In the case presented here the reported result for total creatine phosphokinase led to the physician calling for report confirmation. The repeated test result was in keeping with the clinical picture and thus the previous erroneous result was amended. The incorrect result from auto analyzer was identified as failure to run the sample in dilution after instrumental flagging of possible substrate exhaustion evidenced by erroneous progress curve. A frequent reason for nonlinear progress curves is the presence of excess enzyme which can be easily misinterpreted as lower enzyme activity in a provided sample. Careful inspection of progress curve and predilution of sample in anticipated cases could avoid erroneous result.

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.

HbA1c Below the Reportable Range.

This case report concerns a 71 year old female patient who had a very low glycosylated hemoglobin (HbA1c) despite having a high level of fasting blood glucose. The patient had a decreased erythrocyte count, elevated red blood cell indices, and a reticulocyte count with no evidence of hemoglobinopathy. She reported receiving hydroxychloroquine treatment for systemic lupus erythematosus. Subsequent laboratory investigations revealed hemolysis with formation of cold agglutinin. Because cold agglutinins can interfere with HbA1c assays, the specimens were reanalyzed after warming. The complete blood count results improved, but the HbA1c result did not change. In patients in whom medications and/or medical conditions may interfere with HbA1c levels, alternative measures of glycemic control, such as fructosamine, could be beneficial.

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.

C-reactive Protein to Albumin Ratio among Patients Admitted to Intensive Care Unit of a Tertiary Care Hospital: A Descriptive Crosssectional Study.

INTRODUCTION: Sepsis is the most common cause of mortality among patients admitted to intensive care unit. There is emerging evidence on the role of C-reactive protein to albumin ratio (C-reactive protein/Albumin) in predicting outcomes in patients with critical illness and sepsis, admitted to intensive care unit. We aimed to find out the median value of C-reactive protein/Albumin ratio among patients admitted to intensive care unit of a tertiary care hospital. METHODS: We conducted a descriptive cross-sectional study of 110 critically ill patients (>18 years old) admitted to intensive care unit of Dhulikhel Hospital from April, 2014 to June, 2016. The ethical approval (Reference number.51/16) was obtained from Institutional Review Committee at Kathmandu University School of Medical Sciences. C-reactive protein/albumin ratio was calculated from records of patients admitted to the intensive care unit. Convenience sampling was done. Data were entered into Microsoft Excel and analysed using Statistical Package for Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequencies and percentages for binary data. RESULTS: Among 110 patients admitted to the intensive care unit, the median value of C-reactive protein/Albumin ratio was found to be 3.4 (Interquartile range: 3.1-4.5). Out of these patients, 44 (39.5%) patients were septic and their median C-reactive protein/albumin ratio was 3.4 (Interquartile range: 3.1-4.5). CONCLUSIONS: Our study showed higher median C-reactive protein /Albumin similar to other studies. Sepsis is a common finding among patients admitted to intensive care unit. Monitoring of C-reactive protein/albumin level in a patient admitted to intensive care unit could be useful for stratifying patients with a high risk of developing sepsis.

The Detection of Postprandial Hypoglycemia with 5-Hour Oral Glucose Tolerance Test.

INTRODUCTION: Postprandial hypoglycemia (PH) is a poorly understood phenomenon. Five-hour oral glucose tolerance test (5-OGTT) is often a useful laboratory investigation to understand and establish a diagnosis of PH. The aim of this study is to present the patterns observed during 5-OGTT performed in cases with PH in a tertiary hospital in Nepal. METHODS: 5-OGTTs were performed on 52 patients who complained symptomatic postprandial neuroglycopenic symptoms, at the Nepal Medicity hospital during the period of 2 years from 2017 to 2019. The anthropometry, medical history, serum glucose; insulin and cortisol were obtained. The homeostatic model assessment score for insulin resistance (HOMA-IR) based on fasting glucose and insulin levels were calculated. Data was analyzed using SPSS (Version 20.0). RESULTS: 21 (40.4%) patients out of 52 developed hypoglycemia [blood glucose < 55mg/dl (3.1mmol/L)], among them nine patients developed hypoglycemia at 3 hours, 11 at 4 hours and one at 5 hours post glucose load. The fasting insulin level in patients who developed hypoglycemia was 12.1 ± 5.8 µU/ml compared to the insulin level analyzed at the point of hypoglycemic episode which was 6.4 ± 1.8 µU/ml, P<0.005. CONCLUSION: The level of insulin is disproportionately high in the setting of hypoglycemia where it was expected to be nearly absent. The disturbance in physiological mechanism between insulin sensitivity and insulin secretion may be the possible cause of PH.

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.

A cross sectional study to assess the sFlt-1:PlGF ratio in pregnant women with and without preeclampsia.

BACKGROUND: Preeclampsia is a multisystem disorder characterized by vascular endothelial malfunction occurring after 20 weeks of gestation. Placental soluble fms-like tyrosine kinase-1 (sFlt-1) is an antiangiogenic factor and placental growth factor (PlGF) is a potent angiogenic factor. The imbalance between these factors during placenta and fetal development has been shown to play a role in endothelial damage in preeclampsia. Preeclampsia is the leading cause of maternal mortality in Nepal. This study was designed to compare the sFlt1:PLGF ratio in pregnant women with and without preeclampsia attending Tribhuvan University Teaching Hospital (TUTH). METHOD: An observational cross-sectional study was performed in the Gynecology and Obstetrics Department of TUTH involving forty-four subjects with preeclampsia and forty-four age- and gestational-week-matched normal pregnant subjects as controls. Blood pressure, urinary protein levels, serum sFlt-1 levels, serum PlGF levels and the sFlt-1:PlGF ratio was compared in both the cases and control. The concentrations of sFlt-1 and PlGF were measured with commercially available ELISA kits. SPSS ver. 20.0 was used to analyze the data. RESULTS: There was no significant difference in age or gestational age in either study group. The ratio of the sFlt-1 and PlGF concentrations was significantly higher in women with preeclampsia (31.6 ± 9.6) than in the controls (3.2 ± 1.3). Likewise, diastolic blood pressure was significantly associated (p-value 0.000), whereas the severity of proteinuria was not associated (p-value 0.773) with the sFlt-1:PlGF ratio in women with preeclampsia. The significantly higher ratio (35.51 ± 8.1 versus 25.4 ± 8.7) was found in women with preeclampsia who developed complications than the group of women with preeclampsia who did not develop complication. CONCLUSION: The sFlt-1:PlGF ratio is significantly higher in Nepalese women with preeclampsia than in normal controls and this finding can be applied for further planned clinical trials.

A Case Study of Stevens-Johnson Syndrome-Toxic Epidermal Necrolysis (SJS-TEN) Overlap in Mycoplasma pneumoniae-Associated Tracheobronchitis.

Stevens-Johnson syndrome is a medical emergency which is characterized by skin and mucosal reaction to the use of certain drugs. Atypical Steven-Johnson syndrome can occur due to various microorganisms and Mycoplasma pneumoniae being one of them. We present a clinical course, diagnosis, and successful management of Steven-Johnson syndrome-toxic epidermal necrolysis (SJS-TEN) overlap due to Mycoplasma pneumoniae in a 17-year-old Nepalese female. In the resource-limiting country and hospitals where serology and PCR for M. pneumoniae is not easily accessible, a simple bedside cold agglutination test can be done to increase the suspicion of infectious cause (most common M. pneumoniae ) of SJS-TEN overlap. M. pneumoniae infection should be considered in all cases of mucositis, especially in patients having preceding respiratory tract infections (tracheobronchitis).

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.