Frequency of primary hyperaldosteronism in young hypertensives in a tertiary care setting of Rawalpindi

Objective: To determine the frequency of primary hyperaldosteronism in young hypertensives in hospital settings of Rawalpindi

Study Design: Cross-sectional study

Place and Duration of Study: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology [AFIP], Rawalpindi, from June 2016 to May 2017

Methodology: Two hundred and fifty patients with hypertension [blood pressure of more than 140/90 mm Hg] of both genders, with age between 17-40 years were recruited in the study. Patients on anti-hypertensive medications, renal function derangement, pregnant females and those labelled with secondary hypertension were excluded. Blood samples were taken for the analyses of plasma renin, aldosterone, electrolytes, and blood gases. Parametric quantitative variables were presented as mean + SD

Results: Eight cases, out of a total 80 subjects fulfilling the inclusion criteria, were diagnosed with primary hyperaldosteronism and 72 with essential hypertension. Mean age of patients having primary hyperaldosteronism was 29.25 +7.1 years. The mean diastolic blood pressure of all patients was 90.3 +6.5 mm of Hg, while mean systolic blood pressure was 142.7 +10.5 mm of Hg

Conclusion: Frequency of primary hyperaldosteronism was found to be 10%, emphasising on the fact that it is not very uncommon in young hypertensives

Evaluation of multiple risk factors involved in the development of diabetic Retinopathy

Objective: To determine the role of hypertension, hyperlipidemia, smoking and positive family history of diabetes and hypertension in the development of diabetic retinopathy

Methods: This prospective cohort study was conducted at the Department of Chemical Pathology, Armed Forces Institute of Pathology, Rawalpindi over 2 years period from June 2014 to June 2016. One hundred consecutive diabetic patients with no signs of diabetic retinopathy and good glycemic control [HbA1c<6.5%] were registered by non-probability convenient sampling after taking written informed consent. They were evaluated for hypertension, hyperlipidemia and smoking status. These patients were then followed 6 monthly for 2 years to look for the development of diabetic retinopathy

Results: The mean age of the patients was 50.72+/-9.29 years and there were 57 [57%] male and 43 [43%] female patients. Majority [82%] of the patients had NIDDM. The mean duration of diabetes was 8.31+/-6.83 years. 11% of the patients were smoker, 37% were hypertensive, 6% had hyperlipidaemia, 62% had family history of diabetes and 30% had family history of hypertension. At the end of follow-up, 9 [9.0%] patients had diabetic retinopathy. The frequency of diabetic retinopathy increased with increasing age of the patient; however, the difference was statistically insignificant. A comparatively higher frequency of diabetic retinopathy was also seen in patients with IDDM and those with positive family history of diabetes and hypertension yet again, the difference was statistically insignificant. Also, no significant difference was noted among male and female genders and smokers vs. non-smoker. However, the frequency of diabetic retinopathy increased significantly with increasing duration of diabetes. It was also higher among those with hypertension and hyperlipidemia

Conclusion: Higher patient age [>/=50 years], increasing duration of diabetes [>/=20 years], insulin dependent diabetes mellitus, hypertension, hyperlipidemia, and positive family history of diabetes and hypertension were found to be associated with increased frequency of diabetic retinopathy

Classical homocystinuria in a juvenile patient

Classical homocystinuria, also known as cystathionine beta synthase deficiency, is a rare disorder of methionine metabolism, leading to an abnormal accumulation of homocysteine and its metabolites in blood and urine. A young child with homocystinuria is discussed, who presented with behavioral abnormalities, involuntary movement, mental retardation, and decreased vision since birth. The diagnosis of homocystinuria was not made at initial presentation. Subtle phenotypic features with developmental delay and MRI brain finding of bilateral medially dislocated lens, eventually provided the first indication at five years of age. Laboratory screening with plasma amino acid profile by ion exchange chromatography [IEC] showed elevated homocystine and methionine, and low cystine in plasma in the absence of vitamin B12, and folate deficiency; giving the diagnosis of classical homocysteinuria

Association of metabolic risks with subclinical hypothyroidism: a cross-sectional analysis

Objective: To compare lipid parameters, HbA1c, uric acid and albumin creatinine ratio [UACR] among subjects having euthyroidism, Sub-Clinical Hypothyroidism [SCH] and overt hypothyroidism

Methods: This comparative cross-sectional analysis was carried out from Dec-2015 to Oct-2016 in collaboration between PNS HAFEEZ hospital and department of chemical pathology and endocrinology, Armed Forces Institute of Pathology, Rawalpindi. Biochemical parameters including lipid indices, HbA1c and UACR were compared between euthyroidism [TSH: 0.5 to 4.0 mIU/L, n=163], subclinical hypothyroidism [TSH: 4.0 to 10 mIU/L, n=16] and overt hypothyroidism [TSH:>/= 10.0 mIU/L, n=9]

Results: LDL-cholesterol, non-HDL-cholesterol and UACR results were as: [[Euthyroid: 2.66 +/- 0.73], [SCH: 2.68 +/- 0.51] and [Overt hypothyroidism: 3.23 +/- 0.59], p-value=0.063], [[Euthyroid: 3.49 +/- 0.64], [SCH: 3.35 +/- 0.59] and [Overt hypothyroidism: 4.01 +/- 0.30], p-value=0.033] and [[Euthyroid: 2.48 [95% CI: 1.63-3.33]], [SCH: 2.27 [95% CI: 0.37-4.90]] and [Overt hypothyroidism: 14.95 [95% CI: 10.71-19.14]], [p-value< 0.001]]. Results for total cholesterol, triglycerides and HDL-cholesterol though increased in overt hypothyroid group were not found to be statistically significant

Conclusion: LDL-cholesterol, non-HDL-cholesterol and UACR increased from euthyroid subjects to overt hypothyroidism group. However, these changes were found to be more subtle in the subclinical hypothyroid subjects than cases with overt hypothyroidism

Association of hypomagnesemia with hyperglycemia and its renal complication in outpatients

Objective: To evaluate the association of hypomagnesemia with hyperglycemia and its renal complication in outpatients

Study Design: Case control study

Place and Duration of Study: Department of chemical pathology and endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from October 2014 to July 2015

Material and Methods: Adults of either gender aged 20 years and above comprising 63 subjects with hyperglycemia and 63 controls with normoglycemia were consecutively inducted in the study. Patients with malabsorption, thyroid dysfunction or adrenal dysfunction, renal impairment, taking mineral supplement, pregnancy, lactation and any acute illness were excluded from the study. Fasting plasma glucose [FPG] and serum magnesium [Mg] level were measured on ADVIA 1800 siemens clinical chemistry auto-analyzer with hexokinase and xylidyl blue methods, respectively. Urine albumin was analyzed by Immunoturbidimetric method and urine creatinine was measured by the Jaffé kinetic assay on same analyzer. Albumin/creatinine ratio [ACR] was calculated. Pearson correlation coefficient "r" was calculated for serum Mg with FPG and ACR. Mean serum Mg levels in hyperglycemic and normoglycemic groups were compared using in dependent sample "t" test. Frequency of hypomagnesemia [serum magnesium

Results: Serum Mg has significant inverse correlation with FPG [r=-0.543, p=0.001] and ACR [r=-0.474; p=0.001].Mean serum Mg was 0.78 mmol/l in hyperglycemics and 0.88 mmol/l in normoglycemics [p=0.001]. The frequency of hypomagnesemia in subjects with type 2 Diabetes Mellitus [T2DM] was found to be 18.8% while no subject with pre-diabetes and normoglycemia had hypomagnesemia

Conclusion: Subjects with hyperglycemia had significantly lower mean serum Mg levels compared with healthy counterparts. Hypomagnesemia was also associated with poor glycemic control and diabetic nephropathy

Insulin resistance and glucose levels in subjects with subclinical hypothyroidism

Objective: To compare insulin resistance and glycemic indicators among subjects with euthyroidism and subclinical hypothyroidism

Study Design: Comparative cross-sectional study

Place and Duration of Study: Department of Pathology and Medicine, PNS Hafeez, Islamabad, in collaboration with the Department of Chemical Pathology and Endocrinology at the Armed Forces Institute of Pathology [AFIP], Rawalpindi, from December 2015 to September 2016

Methodology: Subjects referred for executive screening of apparently healthy population [without any known history of diabetes, hypertension, heart disease or other chronic ailments], were included. Subjects were grouped as euthyroidism and subclinical hypothyroidism

Results: Median [IQR] insulin resistance indices including fasting insulin and Homeostasis Model Assessment for Insulin Resistance in subjects with group-1 [n=176, 87%, Thyroid Stimulating Hormone: 0.5 - 3.5 mlU/L] and group-2 [n=26, 13%, Thyroid Stimulating Hormone: 3.51 -15 mlU/L] were 7.6 [6.70] vs. 11.4 [13.72, p=0.040] and 1.77 [1.79] vs. 2.8 [3.07, p=0.071]

The median differences for fasting plasma glucose were 5.0 [1.0] in group-1 vs. 5.0 [1.47] for Group-2 [p=0.618], and glycated hemoglobin was 5.60 [1.1] vs. 5.60 [1.7, p=0.824]. Homeostasis Model Assessment for beta sensitivity index in paradox showed slightly higher values for group-2 [median [IQR] 86.67 [92.94]] than group-1 [111.6 [189.64, p= 0.040]]

Conclusion: Measures of insulin resistance including Homeostasis Model Assessment for Insulin Resistance and fasting insulin levels were significantly different between subjects with euthyroidism and having subclinical hypothyroidism

Diagnostic accuracy of serum iron and total iron binding capacity [TIBC] in iron deficiency state

Objective: To determine the diagnostic accuracy of serum iron and total iron binding capacity [TIBC] in detection of iron deficiency

Study Design: Descriptive, analytical study

Place and Duration of Study: Department of Chemical Pathology and Endocrinology, from January 2013 to October 2015

Methodology: Data of 1,815 patients with results of serum iron, TIBC and ferritin from January 2013 to October 2015 was retrieved from Laboratory information System [LIMS] of AFIP. Diagnostic Accuracy Studies [STARD] guidelines were followed. Subjects of either gender, aged 1 - 68 years were included. Cases with raised serum ferritin levels [male > 336 ng/ml, female > 307 ng/ml] were excluded. Serum Ferritin was taken as gold standard with specificity of 99% and sensitivity of 80% at concentration of 30 ng/ml. Transferrin saturation was determined by dividing serum iron by TIBC and multiplying by 100

Results: Out of 1,815 subjects, 931 [51.29%] were males and 884 [48.71%] were females. The median age of the patients were 29.1 years [Inter-quartile range, IQR 19.1]. Taking ferritin as gold standard, the sensitivity and specificity of serum iron was 63.5% and 38.6%, respectively; while that of TIBC was 64.5 % and 42.8%, respectively. Ferritin showed poor correlation with iron, TIBC and transferrin saturation

Conclusion: Serum iron and TIBC give no additional information in the diagnosis of iron deficiency anemia and these tests are redundant for the diagnosis of iron deficiency state, if serum ferritin is available

study of ninety snake bite cases at Pakistan air force [PAF] hospital, shorkot, Pakistan

Analysis of clinicoepidemiological and laboratory findings of snake bite cases managed in PAF Hospital Shorkot. Descriptive observational study. PAF Hospital Shorkot, from July 2008 to June 2011. A total of ninety [90] cases of snake bite who reported in emergency department of the hospital were included in the study. Data of patients was recorded for type of snake [as much as possible], site of snake bite, presence of fang marks, age and sex of the person bitten, date, time and place of bite, time taken by the victim to reach hospital, presence of symptoms and signs of envenomation in victim and type of treatment received before referral. All patients were managed accordingly. Similarly type of in-hospital treatment like giving of anti-venom serum and total duration of hospital stay in each patient was also recorded. Data was then expressed in percentage. There were 70% male and 30% female patients. The age range was 7-54 years with a mean age of 27.8 +/- 10.8 years. Most of the cases of snake bite [82%] occurred between the months of April and September. A total of 60 [66.6%] patients were bitten at night. In 21 [23.3%] cases the victims brought the snakes, Among these, 4 [19.0%] snakes were scaled vipers, 3 [14.3%] snakes were kraits and 2 [9.5%] snakes were cobras, while 57.2% snakes remained unidentified. Majority [63%] had bites on lower extremities, 36% had bites on upper limbs. One [1.1%] victim was bitten on scrotum. Intravenous anti-snake venom was given to 52 [57.8%] patients. Majority of cases of snake bite occur during rainy summer season in rural areas particularly at night. Severity and pattern of envenoming varies from patient to patient. Knowledge of types of snake and risk factors and complications of snake bite is important. Early evacuation of snake bite cases to nearest hospital capable of dealing with snake bite can effectively reduce mortality and morbidity

hospital based autopsy study of 50 cases at combined military hospital [CMH], Sialkot

To analyze the pattern of deaths on autopsy carried out on armed forces personnel in CMH sialkot. Retrospective analytical study. Combined military hospital sialkot [CMH], from 2009 t0 2012. In a total of fifty [50] cases detailed postmortems were carried out and gross features on external examination and different systemic examinations were recorded. Histopathology of various organs was done in all cases. Chemical and toxicological examination of various abdominal viscera was carried out in all sudden and suspicious deaths. Ischemic heart disease [IHD] was most common cause of death [38%] followed by road traffic accidents [14%] and electrocution [8%]. Sudden adult death syndrome accounted for 4 cases of deaths. Other causes were drowning,cerebral malaria, heat stroke, gunshot wounds, myocarditis, brain hemorrhage, meningitis and diabetic ketoacidosis. Most of these cases were young soldiers [n=30] followed by non-commissioned officers [n=17]. A large number of our young soldiers dying of heart problems is an alarming situation. Awareness among the troops of various risk factors is most important. Precautionary measures against preventable causes should be taken

Malaria in Shorkot garrison- a four years experience report

To study the frequency of malaria in Shorkot Garrison, and the clinical features and laboratory findings in patients caused by various Plasmodium species. This observational study was carried out in Department of Pathology in collaboration with Department of Medicine and Department of Paediatrics, Pakistan Air Force Hospital Shorkot during the period from January 2007 to December 2010. One thousand and fifty three patients were included in the study. These subjects were having positive malarial parasite slides. Patients were admitted and their clinical features and laboratory parameters were recorded. Out of 10405 clinically suspected cases of malaria, only 1053 [10.12%] were found to be positive for malarial parasite. Eighty four percent cases were males and 16% were females. Their mean age was 25.6 +/- 12 years. Out of 1053 patients, 775 [73.5%] were having Plasmodium vivax, 226[21.5%] were P falciparum and 52 [5.0%] were with mixed infection. The high rate of infection was between May to October. The predominant symptom was fever [100%] followed by rigors and chills [93%], body aches [82%] and sweating [84%]. Hepatomegaly was found in 8.2% cases while splenomegaly in 55%. Among the haematological findings, anaemia was found in 66.3% cases of malaria, while thrombocytopenia was detected in 65.8% patients. Jaundice was found in most cases of P falciparum. No case of P malariae and P ovale infection observed in the study. Malaria Parasite index was found to be between 0.1-5.0%. The frequency of malaria was 10.12%. Anaemia and thrombocytopenia was very common in patients of malaria. It is suggested that index of suspicion for malaria should be kept high in dealing with patients with fever along with anaemia and thrombocytopaenia

Pre-operative evaluation of ovarian mass: risk of malignancy index

To evaluate the risk of malignancy index [RMI] for pre-operative diagnosis of ovarian mass. Design: Observational study. Place and Duration of Study: Department of Chemical Pathology and Endocrinology at Armed Forces Institute of Pathology [AFIP], Rawalpindi from January 2001 to January 2002. Subjects and The study consisted of 100 female patients consecutively admitted for surgical exploration of ovarian mass. Pre-operatively ultrasonic evaluation of ovarian mass, menopausal status and serum cancer-associated antigen 125 [CA 125] levels were carried out. Postoperatively histopathology of the resected ovarian mass was done to confirm the diagnosis. To increase the sensitivity and specificity of CA 125 for early detection of ovarian cancer, a combination of serum CA 125 with ultrasonography and menopausal status, designated as risk of malignancy index [RMI] for each patient, was calculated. The sensitivity and specificity of CA 125 alone for the diagnosis of ovarian cancer, at cutoff level of 35 U/ml, were 83% and 82% respectively. Using RMI, at cutoff level of 125, the sensitivity was 87%, and specificity was 88%. Receiver operating characteristic [ROC] curves reveal that RMI was a better discriminant than CA 125 alone for differentiating between benign lesions and malignant ovarian tumors. The risk of malignancy index [RMI] is a better diagnostic marker as compared to CA 125 alone because of its high specificity and sensitivity in differentiating ovarian cancer from ovarian benign lesions. It is a simple scoring system and, therefore, its application is recommended to evaluate ovarian masses in clinical practice