Pavai Sthaneshwar

The utility of immature reticulocyte fraction as an indicator of erythropoietic response to altitude training in elite cyclists.

Altitude training is sometimes employed by elite endurance athletes to improve their sea level performance. This improvement results from the increased red cell mass consequent upon the boost in erythropoietin (EPO) level that occurs as a response to the relatively hypoxic environment at high altitudes. We measured serum EPO levels together with various red cell and reticulocyte parameters including immature reticulocyte fraction (IRF) in eight national track‐endurance cyclists, resident at sea‐level, prior to and upon return from an altitude of approximately 1905 m. Reticulocytes and soluble transferrin receptor (sTfR) were significantly increased with reduction in ferritin levels immediately on return from high altitude indicating increased erythropoietic activity. IRF in particular showed a significant peak immediately on return but decline to sub‐baseline levels by day 9, and recovery to baseline by day 16. Our results indicate that IRF is a sensitive marker of erythropoietic status in athletes undergoing altitude training and subsequent loss of EPO stimuli on return to sea level.

Serum prohepcidin concentrations in rheumatoid arthritis

Aim: Hepcidin, a recently identified peptide, acts as a central regulator of iron metabolism. It is regarded as a factor regulating the uptake of dietary iron and its mobilisation from macrophages and hepatic stores. It is considered as a mediator of anaemia of inflammation. The aim of this study was to assess whether serum prohepcidin concentration is able to distinguish iron deficiency from anaemia of inflammation in patients with rheumatoid arthritis (RA). Method: Blood samples were obtained from 20 healthy blood donors, 30 RA patients who presented with anaemia and 30 patients who had pure iron deficiency anaemia (IDA). The samples were analysed for full blood count, iron, ferritin, transferrin, soluble transferrin receptor and prohepcidin. Results: The mean prohepcidin level in the control subjects was 256 µg/L. The prohepcidin level was significantly lower in IDA patients (100 µg/L; p < 0.0001) but not significantly different from that of control in RA patients (250 µg/L; p > 0.05). Higher serum soluble transferrin receptor (sTfR) levels were observed in IDA (p < 0.0001) but not in RA compared with that of control (p > 0.05). RA patients were divided into iron depleted and iron repleted subgroups based on the ferritin level. Prohepcidin in the iron depleted group was significantly lower than the iron repleted group and the control (p < 0.0001) and higher levels were observed in the iron repleted group (p < 0.01). sTfR levels in the iron depleted group were significantly higher than the control and the iron repleted patients (p < 0.001). In the iron repleted group, sTfR level was not statistically different from that of control (p > 0.05). Conclusion: Serum prohepcidin is clearly reduced in uncomplicated iron deficiency anaemia. The reduced prohepcidin levels in the iron depleted RA patients suggests that there may be conflicting signals regulating hepcidin production in RA patients. In RA patients who have reduced hepcidin in the iron depleted group (ferritin <60 µg/L) where sTfR levels are increased suggests that these patients are iron deficient. Further studies with a larger cohort of patients are required to substantiate this point.

Hashimoto's Thyroiditis — A Malaysian Perspective

This study was undertaken to analyze the fine needle aspiration (FNA) cytologic, functional and immunologic features in Hashimotos thyroiditis (HT) with special reference to ethnicity in Malaysian patients. 88 cases of HT retrieved from the archives of the cytology laboratory were reviewed. Ethnic, clinical, cytologic, biochemical, and immunologic features were correlated. HT was more common in Indian patients (57%). 33% of HT cases presented with nodular thyroid enlargement (47.5% were Chinese). 57.5% were euthyroid and 35% hypothyroid. Thyroglobulin antibody (TG Ab) and thyroid peroxidase antibody (TPO Ab) (tested in 29/88 cases) were elevated in 83% and 93% cases respectively. Review of cytologic smears showed Hurthle cells in 56% cases, high lymphoid to epithelial ratio in 38%, lymphoid follicles in 67%, follicular cell infiltration by lymphoid cells in 69% and lymphohistiocytic clusters in 40%. Giant cells and/or granulomas were present in 45% and plasma cells and/or immunoblasts in 40% of cases. 17% showed neutrophils and/or eosinophils infiltrating follicular epithelial cells. Follow up FNA of eight cases showed appearance of a diagnostic cytologic pattern in all and changes in clinical presentation in four. Hashimotos thyroiditis was more common among Indian women with nodular presentation seen more often in Chinese. Hurthle cell change, lymphoid follicles and follicular cell infiltration by lymphoid cells, considered histologic hallmarks of HT, were seen less frequently. 17% cases showed infiltration of follicular cells by neutrophils and eosinophils, a hitherto undescribed feature in HT. Follow up cytology was helpful in monitoring progression of disease and arriving at a definitive diagnosis.

Modification to reporting of qualitative fluorescent spot test results improves detection of glucose-6-phosphate dehydrogenase (G6PD)-deficient heterozygote female newborns

Introduction:  The glucose‐6‐phosphate dehydrogenase (G6PD) fluorescent spot test (FST) is a useful screening test for G6PD deficiency, but is unable to detect heterozygote G6PD‐deficient females. We sought to identify whether reporting intermediate fluorescence in addition to absent and bright fluorescence on FST would improve identification of mildly deficient female heterozygotes.

Serum free light chains: diagnostic and prognostic value in multiple myeloma

Abstract Background: Measurement of serum free light chains (FLCs) has recently become available for the diagnosis and monitoring of patients with plasma cell dyscrasias. The aim of this study was to investigate the performance of the serum FLC assay as a tumour marker by comparing FLC concentrations with serum protein electrophoresis (PE) results in the diagnosis of multiple myeloma (MM). In addition, we also evaluated the prognostic value of the baseline serum FLC ratio in patients with MM. Methods: We measured FLC concentrations and calculated the kappa/lambda (κ/λ) FLC ratios for three groups (control, polyclonal gammopathy and MM). Results: The FLC ratio at a cut-off threshold of 2.0 showed higher sensitivity and specificity compared with serum electrophoresis for the diagnosis of MM. We used the median FLC ratio of >57.5 and <0.04 for κ and λ secretors, respectively, for assessing survival. Survival was 30 months in patients with the κ/λ ratio of >57.5 and <0.04 compared to 47 months in patients with the ratio <57.5 and >0.04, indicating that more abnormal serum FLC ratios are associated with poorer survival (p<0.011). Conclusions: Despite the limitations of the assay, the results of our study indicate that the FLC assay in combination with serum PE has an increased sensitivity in the diagnosis of MM. Also, baseline measurement of the κ/λ ratio provides prognostic information in these same patients. Clin Chem Lab Med 2009;47:1101–7.

Limited utility of plasma m30 in discriminating non- alcoholic steatohepatitis from steatosis - a comparison with routine biochemical markers

Introduction The utility of Cytokeratin-18 fragment, namely CK18Asp396 (M30), for the diagnosis of non-alcoholic steatohepatitis (NASH) is currently uncertain. We aimed to provide further data in this area among multi-ethnic Asian subjects with NAFLD. Materials and Methods The accuracy of M30 for detecting NASH was compared with serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma glutamyl transpeptidase (GGT) levels in consecutive adult subjects with biopsy-proven non-alcoholic fatty liver disease (NAFLD). Results Data for 93 NAFLD subjects (mean age 51.0±11.1 years old and 51.6% males) and 20 healthy controls (mean age 50.2±16.4 years old and 33.3% males) were analyzed. There were 39 NASH subjects (41.9%) and 54 non-NASH subjects (58.1%) among the NAFLD subjects. Plasma M30 (349 U/L vs. 162 U/L), and serum ALT (70 IU/L vs. 26 IU/L), AST (41 IU/L vs. 20 IU/L) and GGT (75 IU/L vs. 33 IU/L) were significantly higher in NAFLD subjects than in healthy controls. Serum ALT (86 IU/L vs. 61 IU/L), AST (58 IU/L vs. 34 IU/L) and GGT (97 IU/L vs. 56 IU/L) were significantly higher in NASH subjects compared to non-NASH subjects, but no significant difference was observed with plasma M30 (435 U/L vs. 331 U/L). The accuracy of plasma M30, and serum ALT, AST and GGT was good for predicting NAFLD (AUROC 0.91, 0.95, 0.87 and 0.85, respectively) but less so for NASH (AUROC 0.59, 0.64, 0.75 and 0.68, respectively). Serum ALT and AST, but not plasma M30 showed a significant trend with increasing grades of ballooning and lobular inflammation. Conclusion The utility of M30 in the detection of NASH in clinical practice appears limited, in comparison to routine biochemical markers.

Pattern of Tissue Expression of CA-125 and HE4 in Primary Epithelial Ovarian Tumours and Correlation with Serum CA-125 Levels

The objective of this study is to assess tissue expression of CA-125 and HE4 protein in primary benign and malignant epithelial tumours of the ovary and correlate with serum CA-125 levels. A total of 100 formalin-fixed, paraffin embedded sections of ovarian tumours which included serous adenoma (11), mucinous adenoma (42), serous carcinoma (20), mucinous carcinoma (12) and endometrioid carcinoma (15), histologically diagnosed between 1st January 2004 to 31st December 2012 at the University Malaya Medical Centre, were stained for HE4 (rabbit polyclonal antibody, Abcam, UK) and CA-125 (mouse monoclonal antibody clone: OC125, Cell Marque Corporation, Rocklin, California, USA). Pre-operative serum CA-125 levels were obtained from the laboratory information system. Immunoscore (I score) for HE4 and CA-125 was given based on the intensity of staining and percentage of positive tumour cells and considered significant when it was >50 (intensity of staining multiplied by percentage of positive tumour cells). Serum CA-125 levels were compared with the I score of HE4 and CA-125 in tissues. We noted that the CA-125 levels in serum and tissues were significantly raised in malignant compared to benign ovarian tumours (p value<0.05). Tissue expression of HE4 protein was also significantly raised in malignant tumours compared to benign tumours (p value<0.05). We conclude that HE4 can be a useful tissue immunomarker in addition to CA-125.

Serum Wisteria floribunda agglutinin-positive Mac-2 binding protein in non-alcoholic fatty liver disease

Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA+-M2BP) has been suggested to be useful for the assessment of disease severity in non-alcoholic fatty liver disease (NAFLD). Consecutive adult NAFLD patients who had a liver biopsy were included. Serum WFA+-M2BP level was measured using a lectin-antibody sandwich immunoassay using a chemiluminescence enzyme immunoassay machine (HISCL-5000, Sysmex, Kobe, Japan). The measured levels were indexed using the following equation: Cut-off index (COI) = ([WFA+-M2BP]sample−[WFA+-M2BP]NC) / ([WFA+-M2BP]PC−[WFA+-M2BP]NC), where PC = positive control and NC = negative control. Histopathological examination of liver biopsy specimen was reported according to Non-Alcoholic Steatohepatitis (NASH) Clinical Research Network Scoring System. Data for 220 cases were analyzed. The AUROC of the COI for the diagnosis of NASH was 0.65. The AUROC of the COI for the diagnosis of steatosis grade ≥2 and 3 was 0.64 and 0.53, respectively. The AUROC of the COI for the diagnosis of lobular inflammation grade ≥1, ≥2 and 3 was 0.57, 0.68 and 0.59, respectively. The AUROC of the COI for the diagnosis of hepatocyte ballooning grade ≥1 and 2 was 0.64 and 0.65, respectively. The AUROC of the COI for the diagnosis of fibrosis stage ≥1, ≥2, ≥3 and 4 was 0.61, 0.71, 0.74 and 0.84, respectively. Out of the 220 cases, 152 cases were the same 76 patients who had a repeat liver biopsy after 48 weeks of intervention. The AUROC of the change in the COI to detect improvement in steatosis, lobular inflammation, hepatocyte ballooning and fibrosis was 0.57, 0.54, 0.59 and 0.52, respectively. In conclusion, serum WFA+-M2BP was most useful for the diagnosis of significant fibrosis, advanced fibrosis and cirrhosis in NAFLD patients. However, it was less useful for differentiating NASH from non-NASH, and for diagnosis and follow-up of the individual histopathological components of NASH.

Clinical and autoantibody profile in systemic sclerosis: baseline characteristics from a West Malaysian cohort

To evaluate the clinical and antibody profile of systemic sclerosis (SSc) in a Malaysian cohort.

Effect of HbE heterozygosity on the measurement of HbA1c

Aim: Measurement of HbA1c provides an excellent measure of glycaemic control for diabetic patients. However, haemoglobin (Hb) variants are known to interfere with HbA1c analysis. In our laboratory HbA1c measurement is performed by Variant II turbo 2.0. The aim of this study is to investigate the influence of HbE trait on HbA1c analysis. Methods: Haemoglobin variants were identified by HbA1c analysis in 93 of 3522 samples sent to our laboratory in a period of 1 month. Haemoglobin analysis identified HbE trait in 81 of 93 samples. To determine the influence of HbE trait on HbA1c analysis by Variant II Tubo 2.0, boronate affinity high performance liquid chromatography (HPLC) method (Primus PDQ) was used as the comparison method. Two stage linear regression analysis, Bland Altman plot and Deming regression analysis were performed to analyse whether the presence of HbE trait produced a statistically significant difference in the results. The total allowable error for HbA1c by the Royal Australasian College of Pathologists (RCPA) external quality assurance is 5%. Hence clinically significant difference is more than 5% at the medical decision level of 6% and 9%. Results: Statistically and clinically significant higher results were observed in Variant II Turbo 2.0 due to the presence of HbE trait. A positive bias of ∼10% was observed at the medical decision levels. Conclusion: Laboratories should be cautious when evaluating HbA1c results in the presence of haemoglobin variants.