Iodine Deficiency in Neonates: Where Do We Stand After a Quarter Century of Initiating Iodization Programs?

An observational study was conducted at the Section of Clinical Chemistry, Department of Pathology and Laboratory Medicine, to assess the iodine status using the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), and the International Council for Control of Iodine Deficiency Disorders (ICCIDD) consensus criteria, which state that >3% prevalence of serum thyroid stimulating hormone (TSH) ≥10 mIU/L in the population is an indicator of iodine deficiency. Serum neonatal TSH was analyzed from January to December 2013. In a period of one year, a total of 11,597 neonates with the mean (25 percentile, 75 percentile value) age of 2.0 days (0.5–3.5) were tested for serum TSH. The overall mean TSH level was 3.38 mIU/L (5.63–1.96), with optimal levels (1–39 mIU/L) in 93%, <1 mIU/L in 6.3%, and ≥40 mIU/L in 0.3% neonates. Of all the neonates, 7.9% (N=916) showed TSH ≥10 mIU/L which is higher than the recommended WHO/UNICEF/ICCIDD criteria for mild endemicity for iodine deficiency in the population. These results suggest that iodine deficiency is still prevalent in our population, indicating a need for effective intervention programs and increasing awareness regarding the use of iodized salt and supplementation in all reproductive-aged women to prevent iodine deficiency in neonates.

Tailored metabolic workup for urolithiasis: the debate continues

Urolithiasis is one of the commonest afflictions of the urinary tract. Stones are of various chemical compositions, some share some common etiology; but most are specific to the structure and composition of stone. In view of highly recurrent nature of this condition, it is logical to have strategies for prevention. However, due to multiple factors most patients receive no or fragmented information on prevention. The current controversy is to the extent of metabolic workup in adult first time stone former. This requires longitudinal studies to show benefit in prevention strategies. Patients at high risk can have recurrence in weeks to years, depending upon the composition and attending risk factor. They should be targeted with concentric and tailored prevention protocols. The major urological guidelines [EAU and AUA] recommend basic stone workup for all patients. However, indication for detailed workup are less well documented, so one potential solution is to tailor metaphylaxis strategies for individual patient

High burden of subclinical lead toxicity after phase out of lead from petroleum in Pakistan

Objective: To evaluate the frequency of subclinical lead toxicity

Study Design: Cross-sectional study

Place and Duration of Study: Department of Pathology and Laboratory Medicine, The Aga Khan University Hospital, Karachi, from January 2011 to December 2014

Methodology: Analysis of laboratory data for blood lead levels [BLL] was performed. Lead was tested by atomic absorption spectrometer. For all subjects, only initial test results were included while the results of repeated testing were excluded. Exemption was sought from institutional ethical review committee. BLL of 2-10 ug/dl and 10-70 ug/dl in children and adults, respectively were taken as subclinical lead toxicity

Results: Amongst the total number of subjects tested [n=524], 26.5% [n=139] were children [<16 years] while rest were adults. Overall median BLLs was 6.4 ug/dl [20.9-3.1]. The median BLL was 4 ug/dl [6.7-2.6] in children and 8.3 ug/dl [27.9-3.4] in adults, respectively. The BLL increased with age; higher levels were observed in age range 21-30 years of subjects [median lead level 16.9 ug/dl [36.1-4]] and lower level [4.2 ug/dl [6.8-2.6]] in children with <10 years of age. Only 16% [n=22] children had desirable lead levels while most had either subclinical [76%, n=106] or toxic lead levels [8%, n=11]. In adults, [55%, n=212] subjects had desired lead levels, and 40% [n=154] and 4.99% [n=19] had subclinical and toxic lead levels

Conclusion: Presence of subclinical lead poisoning even after phasing out of lead petroleum in Pakistanis is alarming, especially in children. A national population-based study to determine the lead status and targeted intervention to identify potential sources is need of the time

Bone turnover markers for osteoporosis status assessment at baseline in postmenopausal Pakistani females

Objective: To assess bone turnover status in osteopenic and osteoporotic postmenopausal females

Study Design: Cross-sectional analytical study

Place and Duration of Study: The Aga Khan University Hospital, Karachi, from January to December 2013

Methodology: A cross-sectional study was conducted on 203 postmenopausal females undergoing bone mineral density testing [BMD] by DXA scan. Patients with clinical history of any disorder or medications affecting bone turnover were excluded. Bone turnover was assessed with osteocalcin and beta-CTx. Data was analyzed by SPSS version 19

Results: Mean age of the participants was 54 +/- 4.66 years with a mean BMI of 28.7 +/- 5.5 kg/m2. Mean beta-CTx [0.28 +/- 0.24 ng/ml] and osteocalcin [21.5 +/- 10.6 ng/ml] levels were within the normal reference range. Subjects were grouped into normal [26.6%], osteopenic [44.8%], and osteoporotic [28.6%] based on the t-scores. Serum levels of osteocalcin and beta-CTx between normal, osteopenic, and osteoporotic groups were not significantly different. beta-CTx was negatively and significantly associated with only lumber spine BMD [r = -0.13, p=0.04]. Positive association [< 0.0001] was noted between both markers in normal, osteopenic, and osteoporotic females. However, association of these markers with BMD in the 3 groups were not found. Multivariate linear regression showed a positive and significant effect of BMI on BMD [beta = 0.332, p= < 0.0001]. beta-CTx had negative but significant effect on BMD [beta = -0.155, p= 0.018] of postmenopausal women

Conclusion: Association between baseline levels of BTM and rate of bone loss is variable and site dependent. beta-CTx correlates better with BMD. However, role of osteocalcin in postmenopausal osteoporosis is uncertain and needs further investigation

Pattern of drugs of abuse identified in chemical samples

To determine the pattern of drugs of abuse in urine and blood samples processed at referral laboratory in Pakistan so that information on the type of drugs used can be identified and used for ready reference for future strategy. Observational study. Clinical Laboratory of The Aga Khan University Hospital, Karachi, from July 2006 to March 2008. Retrospective review of records were done for the common drugs that are used for screening at the Clinical Laboratory include alcohol, amphetamine, barbiturates, benzodiazepines, cannabinoids, cocaine and opiates. Alcohol was tested in blood and others were identified using urine. Percentages of tests screened positive and negative for individual drugs were computed by using SPSS 16.0. The ratio between male and female users was also established. A total of 17,714 tests were performed for drugs. The mean age of the patients whose samples were processed was 30 +/- 14.84 years. Majority used benzodiazepines 520/1317 [39.5%] among the samples tested for drug of abuse, followed by cannabinoids 423/5450 [7.8%], alcohol 75/1302 [5.8%], barbiturates 32/1148 [2.8%], opiates 137/5640 [2.4%], cocaine 5/1655 [0.3%] and amphetamine 3/1 202 [0.2%]. In all, males 15411 [87%] were tested more frequently as compared to females 2303 [13%]. Males were more frequently tested for drug abuse; however, drug abuse is increasingly seen among females. Benzodiazepines are the most frequently used. The same pattern of drugs abuse existed in different gender and age group. There is a need to explore the pattern and type of drug abuse on national scale

Work flow analysis: audit of the turn around time in chemical pathology in a tertiary care hospital

A retrospective analysis of the laboratory results was performed to explore the turnaround time [TAT] for the laboratory services. The TAT for specimens arriving at the main laboratory from wards, main laboratory and critical care areas was noted and compared with the standard set for reporting. Median TAT for results of 169 blood samples was on average 195 min [n=170], 172 min [n=169], 121 min [n=167] from main lab, wards and for STAT samples from critical care areas respectively. Median analytical time was 170 min, 105 min, and 72 min from main lab, from wards and for STAT samples respectively. This TAT is within acceptable limits according to the standard sets. However, high transport time from critical care areas [median 49 min] was noted, which can be further improved if the portering and transport arrangements of the specimens are made more effective

Comparision between bed side testing of blood glucose by glucometer vs centralized testing in a tertiary care hospital

To determine the accuracy, turnaround time and cost effectiveness of bedside monitoring of blood glucose levels by non-laboratory health care workers and centralized testing of blood glucose by automated analyzer in a tertiary care hospital. The study was conducted in Section of Chemical Pathology, Department of Pathology and Microbiology and Section of Endocrinology Department of Medicine, Aga Khan University and Hospital Karachi, from April 2005 to March 2006.One hundred and ten patients were included in the study. The blood glucose levels were analyzed on glucometer [Precision Abbott] by finger stick, using Biosensor Technology. At the same time venous blood was obtained to analyze glucose in clinical laboratory on automated analyzer [SYNCHRON CX7] by glucose oxidase method. We observed good correlation between bed side glucometer and laboratory automated analyzer for glucose values between 3.3 mmol/L [60 mg/dl] and 16.7 [300 mg/dl]. A significant difference was observed for glucose values less than 3.3 mmol/L [p=0.002] and glucose values more than 16.67 mmol/l [p=0.049]. Mean Turnaround time for glucometer and automated analyzer were 0.08 hours and 2.49 hours respectively. The cost of glucose testing with glucometer was 48.8% lower than centralized lab based testing. Bedside glucometer testing, though less expensive does not have good accuracy in acutely ill patient with either very high or very low blood glucose levels

Comparison of two methods [precipitation manual and fully automated enzymatic] for the analysis of HDL and LDL cholesterol

To compare accuracy and throughput time for the measurement of HDL and LDL cholesterol by manual precipitation and fully automated enzymatic methods. Fifty, serum samples collected over a 4 months period [February - May 2004] were analyzed for HDL and LDL cholesterol by two different methods i.e. precipitation manual and automatic enzymatic method in the section of chemical pathology, Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi Pakistan. The mean standard deviation for HDL Cholesterol by precipitation method and automated method were 43.12'8.97mg/dl and 43.86'10.34mg/dl respectively [p-value = 0.301]. The mean standard deviation for LDL cholesterol by precipitation method and automated method were 111.76'25.57mg/dl and 111.8'28.41mg/dl respectively [p-value = 0.981]. The calculated "t" and "F" value for HDL-C was 0.0172 and 0.75 respectively, and calculated "t" and "F" values for LDL-C were 0.047 and 0.809 respectively. Average time for manual method was 45 minutes and automation 20 minutes. Both the precipitation [manual] method and the automated method provide reliable, precise and accurate results. In both the methods "t" and "F" values were less than critical. Automated method provide high throughput and are less labor intensive. The choice of method can depend on laboratory facilities and workload

Correlation of serum cortisol levels and stress among medical doctors working in emergency departments

To assess and correlate serum cortisol levels and self-perceived work-related stress among medical doctors working in emergency departments in different tertiary care hospitals of Karachi. Cohort study. The study was conducted in Section of Chemical Pathology, Department of Pathology and Microbiology, AKUH, from December 2004 to August 2005. A total of 64 doctors participated from one private and two public tertiary care hospitals of Karachi. Thirtyfour doctors were from emergency departments and 30 from non-emergency departments. Serum cortisol levels were measured in the morning [between 8.00-8.30 am] and in the evening [between 8.00-8.30 pm]. Cortisol was measured by Florescence Polarization Immunoassay [FPIA] technique. Two questionnaires, modified mental Professional Stress Scale [PSS] and Aga Khan University Anxiety and Depression Scale [AKUADS] were used to assess stress levels. Emergency room physicians [ERP] were 1.2-year younger than non-emergency room physicians [NERP]. Mean evening cortisol of emergency physicians was 60.72nmol/L higher than non-emergency physicians. The difference between morning and evening cortisol was marginally significant [p = 0.051]. Morning diastolic blood pressure was 3mmHg higher in emergency physicians. Forty-one percent of emergency physicians and 20% of non-emergency physicians had AKUADS more than or equal to 20, the difference was borderline significant [p = 0.068]. Mean value of professional stress scale for emergency physicians was significantly higher than non-emergency physicians. Evening serum cortisol concentration was significantly associated with PSS [p = 0.011]. The sub-scales such as work-load [p = 0.007] and lack of resources were highly significant with evening cortisol [p = 0.005]. In this study, evening serum cortisol levels significantly correlated with work overload and lack of resources, however, there was marginally significant correlation between morning and evening serum cortisol difference. Study suggests that emergency physicians perceive more stress than non-emergency physicians. Work overload and lack of resources are major contributing factors for stress in these doctors

Frequency of hypercalcemia in patients of multiple myeloma in Karachi

To determine the frequency of hypercalcemia and skeletal abnormalities in multiple myeloma patients. Cross-sectional study. Study was conducted from January 1999 to July 2004 at the Aga Khan University Hospital [AKUH], a tertiary care hospital in Karachi, Pakistan. Medical records of all the diagnosed cases of multiple myeloma at their presentation to hospital were reviewed. The frequency of hypercalcemia and skeletal lesions was calculated. Independent sample test and chi-square test as appropriate, was applied to calculate the difference in parameters between normocalcemic and hypercalcemic patients. Sixty-seven percent patients were males and 33% were females. The mean age was 61 +/- 11 years. Of the 105 study patients, 51.2% had hypercalcemia [S.Ca >2.64 mmol/l]. Radiological survey showed different levels of skeletal involvement in 89.8% of patients. It was also found that 94.3% of hypercalcemic patients had skeletal lesions, out of which 20% had advanced [stage 3] bone lesions. Also noteworthy was the fact that 84.6% of normocalcemic patients had mild /moderate [stage 1 and 2] skeletal lesions. There was higher frequency of hypercalcemia in multiple myeloma patients in this series. Skeletal lesions were present in significant number of these patients. It is suggested that patients with multiple myeloma should be checked for serum corrected calcium and radiological surveys be included in routine workup for early detection and prevention of hypercalcemia and skeletal lesions

To compare the total cholestrol and HDL cholestrol before and after ultracentrifugation in lipemic samples

It is an everyday routine in laboratories to encounter interference in the analysis of lipids. These likely interferences [hemolysis, icterus and lipemia] are countered by asking physicians and patients to send fresh and properly collected samples. At the Aga Khan University [AKU] Laboratory, we receive 2-3 lipemic/turbid samples per day. Previously it was our departmental policy to advise these patients to go for lipoprotein electrophoresis, which though accurate was time consuming and not cost effective. We therefore studied ultra centrifugation/airfuge as an alternate method to clear lipid interference and provide accurate, reliable and cost effective results. Daily 2-3 grossly turbid samples are identified on the lipid bench, 48 samples were received in 4 months [February to May 2004]. These samples were analyzed for total cholesterol [TC] and High Density Lipoprotein -Cholesterol [HDL-C] before and after ultra centrifugation/airfuge. There was a positive correlation between the lipemia and the false high TC and HDL-C. The mean TC and HDL-C before ultra centrifugation were 263.06 mg/dl and 39.42 mg/dl respectively and after centrifugation these became 191.77 mg/ dl and 33.06 mg/dl. P value showed a significant difference in both results. This study suggests that the removal of turbidity by ultra centrifugation/airfuge is cost effective, less time consuming and provides accurate reliable results of TC and HDL-C in patients with lipemia interference

Expected ages in the patients of chronic diseases

This retrospective study was conducted to find out the expected ages in the patients of hepatic cirrhosis, chronic renal failure and heart failure. This study thus covers most of the patients of out medical wards presenting with chronic illnesses. On comparison of these expected ages it is also found that the expected age in all these three groups is not much different. So, the disease process or the mechanism of the chronic disease in the body may be different, but somehow the final out come is not much different in terms of life span