Pakistan Journal of Pathology

Complete Issue 2024; Vol 35: No 1 January - March

2024-03-29UTCUTC88

Glycated hemoglobin (HbA1c) in diagnosis of gestational diabetes mellitus

2024-02-07UTCUTC37

Objective: To evaluate the diagnostic accuracy of glycated hemoglobin for diagnosing gestational diabetes mellitus.

Material and Methodology: This cross-sectional comparative study was conducted at the Department of Chemical Pathology and Endocrinology, Reference Laboratory, Rawalpindi from June 2023 to October 2023. The study included women having gestational amenorrhea between 24th to 28^th weeks, who gave informed written consent for a 75-gram oral glucose tolerance test (OGTT) at Reference Laboratory Rawalpindi. Women with diabetes, hypertension, hemoglobin< 10g/dl, on steroid treatment, with gastrointestinal or thyroid diseases were excluded. The medical history and anthropometric measurement (height, weight, body mass index (BMI) and blood pressure were recorded on a predesigned proforma. Blood sample for glucose was taken in sodium fluoride tubes and HbA1c in potassium EDTA tubes. American Diabetes Association criteria 2023 was used to diagnose gestational diabetes mellitus (GDM). Study participants were divided into two groups on basis of 75g- OGTT results; Group 1 included GDM and Group 2 Normal Glucose Tolerance (NGT).

Results: A total of 100 pregnant ladies were enrolled whose ages ranged from 15-45 (mean & SD 29±5 & 31±6 years in groups 1& 2 respectively). Mean fasting plasma glucose (FPG) was 5.11±0.6 mmol/l & 4.57±0.4mmol/l, and HbA1c was 6.12%±1 & 5.26% ±0.48 in groups 1& 2 respectively. GDM was found in 19 (group 1) of 100 patients, while 81 responded normally. HbA1c at 5.6% has 84.2% sensitivity, 87.6% specificity, 61.5% PPV, 95.9% NPV and 87% diagnostic accuracy. FPG, 1hr glucose and HbA1c exhibited an Area Under Curve (AUC) by Receiver Operating Characteristic (ROC) Curve of 0.762, 0.801 & 0.894 respectively.

Conclusion: HbA1c has shown higher diagnostic yield for gestational diabetes mellitus and can be used as a screening test.

Keywords: Glycated hemoglobin, Oral glucose tolerance test, Gestational diabetes mellitus

Unveiling colistin resistance in extensively drug-resistant microorganisms among ICU patients of tertiary care hospital Karachi, Pakistan

2024-02-02UTCUTC32

Objective: To determine the prevalence of extensively drug-resistant (XDR) microorganisms in the intensive care unit (ICU) of a tertiary care hospital in Karachi and to identify the presence of colistin resistance (CLR) among these XDR isolates.

Material and Methods: A cross sectional study was carried out in the ICU of a tertiary care hospital from August 2022 to February 2023 and various clinical samples of XDR Gram negative bacilli (GNB) were collected from ICU. These specimens were processed by following the guidelines established by the Clinical and Laboratory Standards Institute (CLSI), Agar and broth microdilution methods were used to assess the colistin susceptibility of XDR isolates.

Results: The study focused on 100 extensively drug-resistant (XDR) specimens. K. Pneumoniae dominated (32%), followed by E. coli (23). Among the 100 XDR, 89% were colistin susceptible, and 11% were resistant, tested by agar and broth microdilution. Of the 11% CLR, P. aeruginosa was most common, with the highest resistance in urine specimens. Colistin resistance was highest for P. aeruginosa (45%), followed by A. baumannii (18%), E. coli (18%), K. Pneumoniae (9%), and K. oxytoca (9%). CLR isolates were mainly (27%) from urine.

Conclusion: Prolonged hospital stays and antibiotic pressure can lead to CLR development. Labs should monitor XDR closely, implementing measures to minimize antibiotic resistance. Controlling colistin resistance through stewardship is crucial.

Keywords: Extensively drug resistant, Colistin resistant, Minimum inhibitory concentration, Nasobronchial lavage

The clinical significance of CRP and IL-6 in early recognition of neonatal sepsis

2024-01-22UTCUTC21

Objective: The aim of this study was to determine serum CRP and IL-6 levels in confirmed and clinically suspected groups of neonatal sepsis and these biochemical parameters are being compared with blood culture of neonates with clinical signs and symptoms of sepsis.

Material and Methods: The samples of 180 suspected cases of neonatal sepsis were sent to pathology department. Out of them 92 were proven positive for blood culture and were considered as confirmed septic group while rests were included in clinically suspected group. Blood culture was performed on BACT/ALERT® 3D. Serum CRP was performed by immunoturidimetric method on AU 680 Beckman Coulter and IL-6 measurement was done on Access 2.

Results: The serum CRP and IL-6 levels were higher in confirmed sepsis group and their levels were in correspondence to severity of infection. At cut off values of >10mg/L, CRP showed sensitivity of 94%, and specificity of 74% while at cut off of >35ng/L, IL-6 had sensitivity and specificity of 70% and 88% respectively.

Conclusion: The results of this study suggested that CRP was a highly sensitive marker and IL-6 was a more specific for detection of neonatal sepsis.

Keywords: neonatal sepsis, CRP, IL-6

Frequency of loss of calretinin expression in clinically susceptible cases of Hirschprung disease in rectal biopsies

2024-02-07UTCUTC37

Objective: To determine the frequency of loss of calretinin expression in clinically susceptible cases of Hirschprung disease in rectal biopsies.

Material and Methods: This descriptive, cross-sectional study was conducted at Department of Histopathology, Combined Military Hospital, Multan for a period of 6 months (17^th Oct 2021 to 16^th April 2022). A total 93 suspected cases of Hirschprung disease were taken. Specimens received in 10 % buffered formalin and fulfilling inclusion criteria were included in the study. The cases diagnosed as Hirschprung disease were taken and calretinin immunohistochemical stain was applied and result recorded after evaluation by consultant histopathologist. Data was analyzed using (Statistical Software for Social Sciences (SPSS) version 19).

Results: Out of 93 cases, 67 (72.0%) were male patients, whereas 26 (28.0%) were female patients. The average age of the study participants was 7.95 months, with a minimum age of 1 month and a maximum age of 12 months. Twenty-eight (30.1%) of the 93 study cases were from rural areas, while 65 (69.9%) were from metropolitan areas. Twenty-five families (26.9%) reported monthly incomes of up to Rs. 35000, while 68 families (73.1%) reported incomes of over Rs. 35,000. Of these 93 study cases, failure to pass meconium was noted in 24 (25.8%) patients, constipation was noted in 75 (80.6%) and abdominal distension was noted in 62 (66.7%) patients. Loss of calretinin expression was noted in 34 (36.6%) of our study cases.

Conclusion: According to the findings of our investigation, calretinin is very helpful in identifying suspicious cases of Hirschsprung disease. When acetylcholinesterase enzyme histochemistry is not accessible, it can be a helpful, cost-effective diagnostic assistance in centers with limited resources. It is a reliable and efficient diagnostic tool for early diagnosis of the illness. Loss of Calretinin expression was significantly associated with age and residential status.

Keywords: Calretinin expression, Frequency, Hirschsprung disease, Immunohistochemistry

Phlebotomy- A gateway to laboratory diagnostics

2024-03-21UTCUTC80

Objective: To assess the knowledge, practice and attitude about venipuncture amongst Nursing staff of a tertiary care hospital.

Material and Methods: This questionnaire-based survey was done at Rawal General and dental hospital, Islamabad, from January to April 2022. The Questionnaire was developed as per the CLSI H3-A6 and WHO‘s venipuncture guidelines. It was distributed to nursing staff by hand. Most were filled inside the classes in front of the teacher.

Results: The frequency of correct responses in the knowledge section varied from 4(4.6%) about the number of tube inversions to 79(90.8%) about wearing of gloves before taking a sample while 47(54%) selected the correct option of identifying a patient. Regarding the standard phlebotomy protocols, the response was quite low which was 26(29.9%), 18(20.7%) and 8(9.2%) about the correct angle of needle insertion, what to inspect of the supplies and the location of applying the tourniquet respectively. Recapping with two hands is still done by 13% and 79% still put the sample by holding tube in the other hand. In spite of all this 66% still think that one can learn venipuncture by practicing the techniques without going through a proper course.

Conclusion: Nursing staff in Rawal General and dental hospital is not fully aware about basic laboratory protocols and their importance. This unawareness can lead to generation of erroneous lab reports. Formal education, training with summative assessments should be a part of the curriculum of nursing courses followed by rigorous implementation monitoring.

Keywords: Awareness, Nurses, Phlebotomy, Venipuncture, Sample

Correlation of nucleated red blood cell counts by Sysmex XN-1000 with conventional microscopy

2023-11-23UTCUTC326

Objective: To correlate the results of manual microscopy with that of Sysmex XN-1000 analyzers and to determine its diagnostic accuracy, taking microscopy as gold standard.

Material and Methods: The study was conducted at Chughtai Institute of Pathology from July 1^st -December 31^st, 2022. Nucleated Red Blood Cells (nRBCs) were manually enumerated against 100 White Blood Cells (WBCs) on peripheral smears and 511 such positive cases were included. 500 samples negative for nRBCs by manual microscopy were also included. These positive and negative samples were run on two Sysmex XN-1000 analyzers. A result of 0.3 and above nRBCs/100 WBCs on Sysmex XN-1000 was considered positive and less than 0.3 as negative. Mean values of both manual and automated methods were correlated.

Results: Our study mentioned nRBCs ranging from 0 to 1330 nRBCs/100WBCs by manual count. Compared with Sysmex XN-1000 analysis, the Deming regression analysis showed the mean difference between the two methods was 0.055 (95%CI: −0.015 to +0.124) (p>0.05 no proportional bias between two methods). The Sysmex XN produced an area under the curve, by ROC analysis, at 0.894 (P < .001). The overall sensitivity was (90.56%) (CI 87.56-92.98%), with few false-negative results. The overall specificity is (88.30%) (CI 85.20%-90.96%) due to few false positivity. Positive predictive value and negative predictive value were 88.26% (CI 88.54-90.52%) and 90.6% (CI 87.99-92.69%) respectively. Accuracy was 89.42% (CI87.35-91.25%).

Conclusion: Sysmex XN1000 analyzer is a highly sensitive and accurate instrument which can replace nRBCs enumeration using manual counting by conventional microscopy.

Keywords: Nucleated red blood cells, Hematology analyzer, Sysmex XN 1000, Manual microscopy

Pattern and burden of thrombocytopenia in chronic hepatitis C virus patients at a tertiary care hospital

2024-02-23UTCUTC53

Objective: To determine the frequency of thrombocytopenia in chronic Hepatitis C virus infection.

Material and Methods: This Descriptive cross-sectional study was conducted at department of Hematology, King Edward Medical University, Lahore from February 2023 to October 2023. A total of 143 patients of either gender with chronic Hepatitis C virus infection were included in the study. For every patient, a fresh 3 ml blood sample was collected by syringe using aseptic technique in a vacutainer containing EDTA. A complete blood count was carried out using Automated Hematology Analyzer and peripheral blood smear was prepared using Wright Giemsa stain to establish whether thrombocytopenia was present or not. Thrombocytopenia was assessed by Neubauer chamber.

Results: Age range in this study was from 18 to 65 years with mean age of 44.132±7.34 years, mean duration of HCV 12.685±4.53 months and mean platelet count was 238076.923 ± 100165.08/µL. Thrombocytopenia was seen in 37.1% patients.

Conclusion: Our results show that chronic hepatitis C infection is related to high frequency of thrombocytopenia. The higher the duration of disease process, higher is the risk of thrombocytopenia in these patients. This study highlights that identification by screening, timely diagnosis and treatment of Hepatitis C infection can prevent thrombocytopenia and its complications. Serial hematological follow up can play a pivotal role in such patients.

Keywords: Chronic hepatitis, Hepatitis C virus, Thrombocytopenia

Hematological disorders on bone marrow examination in a tertiary care Centre

2024-01-02UTCUTC1

Objective: The aims of this study were to understand the range of different blood-related disorders diagnosed through bone marrow examination and to explore the connection between the age groups and genders of our patients with the subtypes of acute leukemia.

Material and Methods: This was a cross-sectional study carried over a period of one year from January 2022 to December 2022, in the department of Pathology, Pakistan Institute of Medical Sciences (PIMS), Islamabad. Analysis of bone marrow was conducted on patients referred with suspected blood-related disorders, and a total of 254 cases were incorporated into the study. We divided age into groups as 0-12 years (paediatric age group) and >12 years (adults) for comparison with subtypes of acute leukemias. Pearson chi-square test was applied. P value of <0.05 was considered statistically significant.

Results: The age range was from 05 months - 91 years with male: female ratio of 1.2:1. The prevalent non-malignant conditions identified during bone marrow examination were peripheral destruction/consumption of platelets (24.8%) followed by anemias (22%) and infection- related changes (9.4%). Among hematological malignancies, acute leukemias were the most frequent (22.8%), with chronic leukemias following at 7.1%. We also observed that Acute Lymphoblastic Leukemia was more common in Paediatric age group, while Acute Myeloid Leukemia was more frequent type of acute leukemia in adults (p <0.001).

Conclusion: The examination of bone marrow specimens is a key procedure for swiftly obtaining a confirmatory diagnosis for numerous hematological disorders, including hematologic malignancies.

Keywords: Anemia, Bone Marrow Trephine Biopsy, Bone marrow aspiration, Leukemia, Megaloblastic anemia