Chronic kidney disease (CKD) is a public health problem with increasing prevalence in Pakistan.1,2 Early identification of mild renal disease can delay its progression.3 Glomerular filtration rate (GFR) is the best overall index of renal function, but it is difficult to measure, so mostly clinicians rely on serum creatinine (SCr) concentration which its own limitations. On the other hand 24 hours (h) urinary creatinine clearance (CrCl) is a more sensitive marker of renal dysfunction.4,5

Objective: To determine the serum 25-hydroxycalciferol levels [25(OH)D] in adults with pre-diabetes and normoglycaemia to examine a possible association of vitamin D deficiency with pre-diabetes.Study Design: Case control study.Place and Duration of Study: Armed Forces Institute of Pathology, Rawalpindi, from November 2012 to July 2013.Methodology: A total of 272 adults including 136 pre-diabetics and 136 normoglycaemics of either gender aged 20 years and above were consecutively inducted. Patients with diabetes mellitus, pregnancy, rickets and osteomalacia, ischemic heart disease, chronic kidney disease and chronic liver disease were excluded. Fasting Plasma Glucose (FPG) was estimated with hexokinase method on Modular p800 Roche chemistry analyzer while serum 25(OH)D was measured on Diasorin Liaison immunoassay analyzer using the chemiluminescent technique. Mean 25(OH)D levels in pre-diabetic and normoglycaemic groups were compared using Mann-Whitney U test. Spearman's correlation coefficient 'r(s)' was determined between serum 25(OH)D and FPG. Odds ratio for vitamin D deficiency was also calculated.Results: Mean serum 25(OH)D level was low in pre-diabetics (23.2 nmol/L) as compared to normoglycaemics (29 nmol/L; p=0.001). Serum 25(OH)D level had inverse correlation with FPG (r(s) = -0.448, p=0.000). There was also significant association of vitamin D deficiency with pre-diabetes compared with normoglycaemia (OR: 2.21, p=0.016; 95% CI: 1.15-4.27).Conclusion: Vitamin D deficiency with pre-diabetes suggested that vitamin D may have an important role in pathogenesis of pre-diabetes.

OBJECTIVE:To evaluate the in vitro effectiveness of multiple breakpoint concentrations of newer antituberculosis agents (Linezolid and Meropenem) against Multi Drug-Resistant Tuberculosis (MDR-TB) isolates.STUDY DESIGN:A descriptive cross-sectional study.PLACE AND DURATION OF STUDY:Microbiology Department, Armed Forces Institute of Pathology (AFIP), Rawalpindi, from September 2011 to August 2013.METHODOLOGY:A total of 100 MDR-TB isolates recovered during the study period were subjected to susceptibility testing against multiple breakpoint concentrations of Linezolid (LZD) and Meropenem (MER). The breakpoint concentration used for LZD were 0.5, 1.0 and 2.0 µg/ml, while for MER were 4.0, 8.0 and 16 µg/ml. Mycobacterial Growth Indicator Tube (MGIT) 960 system was used to carry out drug susceptibility testing as per recommended protocol.RESULTS:At break point concentration of 0.5 µg/ml, 80 out of 100 (80%) MDR-TB isolates were susceptible to LZD while at breakpoint concentration of 1.0 µg/ml and 2.0 µg/ml, 96/100, (96%) of MDR-TB isolates were susceptible. For MER, at breakpoint concentrations of 4.0 µg/ml no MDR-TB isolate was susceptible, while at 8.0 µg/ml 3/100, (3%) and at 16.0 µg/ml 11/100, (11%) of MDR-TB isolates were susceptible.CONCLUSION:LZD was found to have excellent in vitro efficacy as 96% of MDR-TB isolates were susceptible at breakpoint concentration of 1.0 µg/ml or more. In case of MER it was found that in vitro susceptibility improved as the break point concentrations were increased.

OBJECTIVE:To find out the frequency of Extensively Drug Resistant (XDR) and pre-XDR tuberculosis in clinical isolates of Multi-Drug Resistant (MDR) Tuberculosis (TB) by determining the susceptibilities against Levofloxacin and Amikacin (classical second line antituberculosis drugs).STUDY DESIGN:Adescriptive cross-sectional study.PLACE AND DURATION OF STUDY:Microbiology Department, Armed Forces Institute of Pathology (AFIP), Rawalpindi, from September 2011 to August 2013.METHODOLOGY:Amikacin (AK) and Levofloxacin (LEVO) were obtained in chemically pure form from Sigma (Taufkirchen, Germany). The breakpoint concentration used for AK was 1.0 µg/ml and for LEVO 2.0 µg/ml. Mycobacterial Growth Indicator Tube (MGIT) 960 system was used to carry out drug susceptibility testing as per recommended protocol.RESULTS:A total of 3 MDR-TB isolates (3%) turned out to be XDR-TB based upon simultaneous resistance to injectable second line antituberculosis drug AK and one of the fluoro-quinolones (LEVO). A total of 24 MDR-TB isolates (24%) were found to be pre-XDR based upon resistance to LEVO alone. Treatment status record of patients with XDR and pre-XDRTB isolates revealed that majority of patients had received fluoroquinolones (FQs) during the course of treatment.CONCLUSION:XDR-TB has started to emerge in MDR-TB isolates in our set up. The worrying sign is the high frequency of pre-XDR tuberculosis. Urgent steps need to be taken to stem the tide of pre-XDR-TB in our population. It is thus recommended to develop facilities to carry out drug susceptibility testing to monitor the status of pre-XDR and XDR-TB in our population.

OBJECTIVE:To evaluate the diagnostic efficacy of two rapid methods i.e. Mycobacterium tuberculosis (MTB) Polymerase Chain Reaction (PCR) on Fine Needle Aspiration (FNA) samples by comparing with cytology of respective site sample.STUDY DESIGN:Cross-sectional comparative study.PLACE AND DURATION OF STUDY:Department of Microbiology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, Pakistan, from July 2010 through November 2013.METHODOLOGY:A total of 105 extra pulmonary lymph nodes aspirates obtained through fine needle aspiration were processed. Cytology and PCR were done on each specimen. Cytology was taken as gold standard.RESULTS:Out of the total 105 samples, 71 (67.6%) were positive for the MTB PCR while 34 (32.4%) showed negative status. According to FNA cytology (FNAC) results, 72 (68.6%) cases were positive for the disease while 33 (31.4%) were negative. Sensitivity of PCR was 90.3%, specificity 81.8%, positive predictive value (PPV) 91.5%, negative predictive value (NPV) 79.4%, with diagnostic accuracy of 87.6%. Area under the curve was 0.860 (p < 0.001).CONCLUSION:PCR is a sensitive tool for detection of MTB on FNA samples from EPTB cases. The results are available within few hours which is helpful for the clinicians to initiate therapy.

Objective: To study the immunohistochemical expression of vascular endothelial growth factors in urothelial tumours of bladder and its possible association with tumour characteristics and microvessel density.Methods: The cross-sectional descriptive study was conducted at the Histopathology Department of the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from July 2011 to December 2012, and comprised cases of non-invasive and invasive urothelial tumours of the bladder. The microvessel density and expression of vascular endothelial growth factors A, C, D were evaluated by immunohistochemistry. Specimens of transurethral bladder biopsies and surgical resection were examined. The cases were classified into non-invasive (stage pTa) and invasive groups as well as low-grade and high-grade groups. The presence of in-situ component was evaluated in each category. To assess the microvessel density, highly vascularised foci ('hot spots') after immuno-staining with CD34 were quantified for number of vessels per square millimetre and for vascular surface area density. No distinction was made between lymphatic and blood vessels. Vascular endothelial growth factor staining was scored semi-quantitatively.Results: The study examined 100 histopathology specimens, including 90(90%) transurethral bladder biopsies and 10(10%) surgical resection specimens of bladder. There were 45(45%) non-invasive (stage pTa) cases and 55(55%) invasive (stage pT1-4) cases. Besides, there were 43(43%) low-grade (grades 1 and 2) cases, and 57(57%) high-grade (grade 3) cases. Vascular endothelial growth factors A, C and D staining scores showed positive association with stage (p=0.02; p<0.01; p<0.01) and grade (p=0.007; p=0.004; p=0.002) of the tumour. Tumours with in-situ component showed association with number of vessels per square millimetre (p<0.01) and vascular surface area density (p=0.02).Conclusions: Parameters like vascular endothelial growth factor and microvessel density need to be studied further for selection of cases with potential for targeted therapy.

OBJECTIVETo assess the additional burden of the patients eligible for treatment, based on recommendations on viral load, in the light of 2009 version of AASLD guidelines, as compared to 2004 guidelines and to determine the frequency of HBeAg in chronic HBV carriers.STUDY DESIGNDescriptive cross-sectional study.PLACE AND DURATION OF STUDYVirology Department, Armed Forces Institute of Pathology, Rawalpindi, from November 2010 to January 2012.METHODOLOGYPersons with chronic HBV infection, reporting for HBV DNA PCR test, were included in the study and blood samples were collected. HBV DNA load was determined by Real Time PCR. HBsAg and HBeAg were tested by ELISA.RESULTSOut of the 801 subjects positive for HBsAg, 74 (9.24%) were positive for HBeAg. Out of them, 113 (14.1%) had HBV DNA load > 100,000 copies/ml and were eligible for treatment according to AASLD 2004 guidelines. Forty one (5.1%) had HBV load between 10,000 and 100,000 copies/ml, and were additionally eligible for treatment as per AASLD 2009 guidelines. The 5.1% of 4.5 million estimated HBV carries in Pakistan comes to 229500.CONCLUSIONThere was a low HBeAg positivity and HBV DNA positivity in our chronic HBV infected persons. Moreover, there is an increase of 229500 potential candidates for HBV treatment in Pakistan based on viral load testing, according to the AASLD 2009 guidelines when compared with 2004 guidelines. The increase in the number of candidates for treatment may require an additional expenditure of tens of billions of rupees.

OBJECTIVE:To compare the Friedewald and modified Friedewald formulae with direct homogeneous assay for serum lowdensity lipoprotein cholesterol (LDL-C) levels estimation.STUDY DESIGN:Cross-sectional study.PLACE AND DURATION OF STUDY:Armed Forces Institute of Pathology, Rawalpindi, from June to December 2011.METHODOLOGY:Healthy subjects of either gender, from Rawalpindi, aged 18-75 years were included by consecutive sampling. Patients with diabetes mellitus, chronic liver disease, chronic kidney disease, those taking lipid lowering drugs and samples with triglyceride (TG) > 4.52 mmol/l were excluded from the study. Total cholesterol, high-density lipoprotein cholesterol, TG and LDL-C were measured on Hitachi 912 chemistry analyzer (Roche). LDL-C levels were also calculated by Friedewald formula (FF) and Vujovic modified formula (VMF). Paired sample t-test and scatter plots were used for statistical analysis.RESULTS:Although both calculated methods showed good correlation with direct assay (r > 0.93) in 300 subjects, but the difference was statistically significant. The ffLDL-C were 0.12 ± 31 mmol/l (p < 0.001) lower and vmfLDL-C were 0.11 ± 26 mmol/l (p < 0.001) higher than dLDL-C. The difference was not significant between ffLDL-C and dLDL-C at TG levels < 1.70 mmol/l (p = 0.58) and between vmfLDL-C and dLDL-C at TG levels 2.26 - 4.52 mmol/l (p = 0.38). At all other TG levels, the difference between LDL-C calculated by both formulas and dLDL-C was statistically significant (p < 0.001). As compared to direct assay, 11% and 14% subjects were classified in wrong National Cholesterol Education Programm's cardiac risk categories by FF and VMF respectively.CONCLUSION:LDL-C should be measured by direct homogeneous assay in routine clinical laboratories, as the calculated methods did not have a uniform performance for LDL-C estimation at different TG levels.

BACKGROUND:In recent years inappropriate and excessive use of clinical laboratory facilities has become a cause of concern and has led to concurrent rise in the laboratory errors and the health care costs. The aim of the study was to find out the frequency of incomplete laboratory request forms, inappropriate test requests at various professional levels and the financial impact of uncollected reports at Armed Forces Institute of Pathology (AFIP) and Combined Military Hospital (CMH) Laboratory Rawalpindi.METHODS:The cross-sectional descriptive study was conducted during a three month period from April to June 2012 at AFIP and CMH Laboratory Rawalpindi. A total of 1000 laboratory request forms were collected and scrutinized for completion from AFIP (n=500) and CMH Rawalpindi laboratory (n=500). 536 request forms of costly/specialized tests from different departments of AFIP were studied to find out the professional level of test request. The total number of tests performed at AFIP during the study period and number of uncollected reports were noted. The financial impact of these uncollected reports was also calculated. Collection of data and sorting were done manually. Patient confidentiality was maintained. Microsoft excel software and SPSS-17 were used for analysis. The study was approved by the Institutional Ethical Review Committee.RESULTS:Out of a total of 1000 forms studied none was completely filled with clinical notes being present in only 2.4% and 13% of forms sent to CMH and AFIP respectively. 62% of the expensive investigations were requested by specialists while 38% were ordered by residents and general practitioners but the percentage of avoidable expensive tests ordered by the general practitioners and residents was significantly higher than the specialists(p<0.001). A total of 9026 (40%) and 5046 (22%) diagnostic test reports were not collected from the Chemical pathology and Hematology departments respectively. Financial impact of uncollected reports from all the departments at AFIP collectively amounted to Pakistani Rupees (PKR) 3338201.CONCLUSION:Processing incomplete laboratory request forms and injudicious use of laboratory facilities leads to incorrect interpretation of laboratory test results affecting outcome of the overall treatment.

OBJECTIVE:To determine the accuracy of neutrophil gelatinase-associated lipocalin (NGAL) in early detection of acute kidney injury (AKI) after cardiopulmonary bypass (CPB) surgery by comparing with serum creatinine. STUDY DESIGN:Descriptive study. PLACE AND DURATION OF STUDY:Department of Chemical Pathology and Endocrinology, AFIP in collaboration with AFIC/ NIHD, Rawalpindi, from April to December 2011. METHODOLOGY:Eighty eight patients undergoing CPB surgery in AFIC/NIHD were included by consecutive sampling. Blood samples of subjects for serum creatinine analysis were drawn pre-operatively, 4 h, 24 h and 48 h after CPB surgery. Spot urine samples for NGAL were collected at 4 h after CPB surgery. Urine samples were analyzed on Abbott ARCHITECT i2000SR analyzer whereas serum creatinine samples were measured on Beckman UniCel® DxC 600 Synchron® Clinical System. RESULTS:Out of 88 patients, 11 (13%) cases developed AKI 4 h postoperatively. Urinary NGAL increased markedly at 4 h postoperatively as compared to serum creatinine which showed rise at 24 - 48 h after cardiac surgery. Analysis of urine NGAL at a cutoff value of 87 ng/ml showed area under the curve of 0.91 [95% confidence interval (CI) 0.83 - 0.96] with sensitivity of 90.9% (95% CI 58.7 - 98.5) and specificity of 98.7% (95% CI 92.9-99.8). There was a positive correlation of 4 h urine NGAL and serum delta creatinine at 48 h, which was statistically significant (rs = 0.33, p = 0.001). CONCLUSION:The study demonstrated that levels of urine NGAL in patients suffering from AKI increased significantly at 4 h as compared to serum creatinine levels. Urine NGAL is an early predictive biomarker of AKI after CPB.

Chromium is widely used in the leather industry, and tannery workers are under constant threat of adverse health effects due to its excessive exposure. Our objective was to find out the toxic effects of chromium on tannery workers at Sialkot, Pakistan. A total of 240 males consisting of 120 workers from tanneries at Sialkot and equal number of controls were included. Blood complete counts, high-sensitive C-reactive protein, malondialdehyde and routine biochemical tests were carried out by routine procedures. Chromium levels in blood (BCr) and urine were analyzed using graphite furnace atomic absorption spectrophotometer Perkin Elmer analyst-200. Results revealed that all the workers were male with average age of 33 years and 15 (13%) had skin rashes, 14 (12%) had chronic bronchitis, 10 (8%) had gastritis and 4 (3%) conjunctivitis. The tannery workers had significantly raised median (interquartile range) of BCr 569 (377–726) nmol/L as compared to 318 (245–397) nmol/L in the control ( p < 0.001). Sixty-five (54%) workers had BCr levels above the upper limit set by Agency for Toxic Substance and Drug Registry. The urinary chromium excretion was significantly high in workers 131 (46–312) nmol/L as compared to 13 (3–26) nmol/L in controls ( p < 0.01). The workers had hematological, hepatic and renal function impairment because of oxidative stress on body systems. It is concluded that about half of the workers had excessive exposure to chromium in the tanneries at Sialkot. They had significantly raised chromium levels in their biological fluids and adverse health effects due to enhanced oxidative stress and inflammatory changes.

In this study we evaluated the performance of colorimetric nitrate reductase assay (NRA) on Middlebrook 7H11 agar instead of Lowenstein–Jensen medium for detection of isoniazid (INH) and rifampin (RIF) resistance directly on 114 smear positive sputum specimens and compared the results with direct proportion method on LJ medium. The results of both methods were in 100% agreement for detection of RIF resistance while agreement for INH was 96.4%. The average turnaround time for NRA was 18.6 days and majority of the specimens gave positive results within 21 days. Thus direct NRA testing on smear positive sputum specimens by using 7H11 agar could be used as a fast, reliable and inexpensive method in resource starved settings.

OBJECTIVE:To derive the ethnic factor and validate the modified estimated Glomerular Filtration Rate (eGFR) by Modification of Diet in Renal Disease (MDRD) equation for Chronic Kidney Disease (CKD) patients of Rawalpindi.STUDY DESIGN:Cross- sectional study.PLACE AND DURATION OF STUDY:Armed Forces Institute of Pathology (AFIP), Rawalpindi, from July 2011 to July 2012.METHODOLOGY:A total of 140 patients with CKD reporting to AFIP for GFR measurement by 99mTechnetium diethylenethiaminepenta-acetic acid (99mTc-DTPA) renal scan were consecutively inducted. Serum creatinine was measured by the Jaffe's assay on Beckman DxC 600 Analyzer prior to the renal scan. Ethnic factor for population of Rawalpindi with CKD was derived for the MDRD eGFR equation using 99mTc-DTPA renal scan by Gates method as the reference method. MDRD equation was modified by inclusion of the ethnic factor in it. Agreement between the reference GFR (rGFR) and the modified MDRD eGFR (mGFR) was assessed by applying paired samples t-test.RESULTS:Out of 140 patients of CKD, 99 (71%) were males and 41 (29%) females, with mean age of 55 ± 13.42 years. The mean values were 32.91 ± 14.96, 34.89 ± 16.45, 0.971 ± 0.20 and 33.87 ± 15.97 for rGFR, original eGFR, ethnic factor and mGFR respectively. The mGFR with new ethnic factor of 0.971 showed improved performance as compared to original eGFR and showed a significant level of correlation with rGFR (r2 = 0.817), at a p-value of 0.000.CONCLUSION:This study validates the mGFR equation by inclusion of newly derived ethnic factor of 0.971 in the population of Rawalpindi with CKD and it was found to be not significantly different from the rGFR.

Infertility affects about 15% of all couples in the world. Approximately 40% of all infertility cases could be attributed entirely to male factors. Serum inhibin B has emerged as a sensitive marker of male fertility. Analysis of serum inhibin B reflects the relationship between inhibin B, Sertoli cell function and spermatogenesis.This validation study was conducted to calculate the sensitivity, specificity, positive and negative predictive value of serum inhibin B in diagnosis of male infertility, using semen analysis as the gold standard. One hundred and sixty men were included in the study, they reported for semen analysis for evaluation of male infertility. Sperm count was done per standard procedure. Serum inhibin B level was determined by ELISA.Serum inhibin B level > or = 80 pg/ml was regarded as a normal response. The serum inhibin B test had 75% sensitivity, 93.1% specificity, 80.5% PPV and 90.7% NPV.Serum inhibin B has a positive correlation with sperm counts and could be used for evaluation of male infertility as a non-invasive predictor of spermatogenesis. The sensitivity, specificity and PPV are appropriate for clinical decision making and to avoid unnecessary testicular biopsies.

Objective: To determine the reference values of Ca++ in whole blood in our setup. Place and duration of study: The Department of Chemical Pathology & Endocrinology, Armed Forces Institute of Pathology, Rawalpindi from Jan 2008 to June 2008. Materials and Methods: Three hundred healthy individuals were included in the study after obtaining written consent. Out of these 76 individuals were excluded from the study after clinical assessment and collection of laboratory data. One hundred and fourteen were males with mean age 35±12 years and 110 were females, with mean age 28±9 years of age. Their Ca++ was estimated by ion selective electrode (ISE) method in heparinized whole blood (WB). Results: The mean and SD of whole blood Ca++ was calculated separately for the females and the males. The results showed that in our setup males have Ca++ levels of 1.12 ± 0.05 (mean ± SD) mmol/l and females have Ca++ levels of 1.12 ± 0.04 (mean ± SD) mmol/l. Conclusion: The study revealed that estimated reference range of Ca++ of the studied population was lower than the reference range published for the western population that is used by our physicians for the interpretation and comparison of results.

OBJECTIVE:To determine the frequency of adverse effects attributed to Methotrexate (MTX) toxicity and serum minimum toxic concentration with low dose MTX in Rheumatoid Arthritis (RA) patients.STUDY DESIGN:Cross-sectional observational study.PLACE AND DURATION OF STUDY:Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, from March 2010 to March 2011.METHODOLOGY:One hundred and forty adult patients of RA receiving low dose MTX (10 mg/week) for at least 3 months, ere included by consecutive sampling. Blood samples were collected 2 hours after the oral dose of MTX. Serum alanine transaminase and creatinine were analyzed on Hitachi and blood counts on Sysmex analyzer. Serum MTX concentration was measured on TDX analyzer.RESULTS:Out of one hundred and forty patients; 68 males (49%) and 72 females (51%), 38 developed MTX toxicity (27%), comprising of hepatotoxicity in 12 (8.6%), nephrotoxicity in 3 (2.1%), anaemia in 8 (5.7%), leucopenia in 2 (1.4%), thrombocytopenia in 3 (2.1%), pancytopenia in 2 (1.4%), gastrointestinal adverse effects in 5 (3.6%) and mucocutaneous problems in 3 (2.1%). Receiver operating characteristic curve revealed serum minimum toxic concentration of MTX at cutoff value of 0.71 μmol/l with a sensitivity of 71% and specificity of 76%.CONCLUSION:Adverse effects of low dose MTX were found in 27% of RA patients, mainly comprising of hepatotoxicity and haematological problems. MTX toxicity can be detected by therapeutic drug monitoring of serum concentration of 0.71 μmol/l with sensitivity of 71% and specificity of 76% in the patients on low dose MTX maintenance therapy.

BACKGROUND:The classification of ascites as 'exudative' and 'transudative' based on ascitic fluid total protein (AFTP) has been challenged in many clinical conditions like cardiac ascites, patients on prolonged diuretic therapy and malignant ascites because it had poor diagnostic efficacy. These drawbacks have led to the development of another approach to classify ascites, which is based on Serum-Ascites Albumin Gradient (SAAG) to differentiate ascitic fluid into two categories: SAAG > or = 11 g/L in ascites due to portal hypertension and SAAG < 11 g/L in ascites unrelated to portal hypertension. Objective of this study was to compare the diagnostic efficacy of serum/ascites fluid albumin gradient and ascitic fluid total protein in patients having ascites.METHODS:This Cross-sectional comparative study was conducted in the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi from 1st Jun 2007 to 30th May 2008. Ninety-three patients were included in the study by non probability convenience sampling. The patient grouped as: (Group I) 73 cases of liver cirrhosis, (Group II) 14 cases of hepatoma and 6 cases of tuberculous ascites. Ascitic fluid specimen and 3 ml blood were obtained for ascitic fluid estimation of ascitic fluid albumin, total proteins and serum albumin. Diagnostic efficacy of SAAG and AFTP was calculated by comparing the results with clinical, ultrasonographic, histopathological findings, ascitic fluid cell count/acid fast bacilli culture and other relevant investigations.RESULTS:Seventy-three cases had liver cirrhosis (group I), 14 cases had hepatoma and 6 cases had tubercular ascites (group II). Age ranged 25-80 years with mean age 56 years. Diagnostic accuracy, Sensitivity, Specificity, Positive predictive value (PPV) and Negative predictive value (NPV) of SAAG were 96%, 97%, 95%, 98.6%, and 90% respectively, whereas those of AFTP were 56%, 53%,70%, 86%, and 29% respectively.CONCLUSION:Differential diagnosis of ascites should be based on SAAG because diagnostic efficacy of SAAG was significantly higher than AFTP in work-up of ascites.

Objective: To determine the frequency of contamination of steroids in drugs prescribed by quacks, being used by patients in Rawalpindi. Study Design: Cross- sectional study. Place and duration of study: Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology Rawalpindi, from June 2010 to March 2011. Patients and Methods: One hundred and seventy eight drugs distributed by quacks in Rawalpindi were collected from the patients. Quackery formulations (QF) were analyzed by thin layer chromatography on fluorescent Aluminum silica plates by using mobile phase of methylene chloride: ether: methanol: water (77:15:8:1.2) and relative flow of spots were noted. Samples positive for steroids were confirmed by high performance liquid chromatography. Results: Out of In total of 178 samples, 125 (70.2%) were received by patients from unregistered hakeems, 29 (16.3%) unregistered homeopaths and 24 (13%) directly from nonmedical shopkeepers, prescribed for in joint pains 84 (47%), generalized weakness 43 (24%), dermatitis 28 (16%), gastrointestinal diseases 12 (7%) and respiratory diseases 11 (6%). Out of 178 samples, 38 (21%) QF were contaminated with steroids found in 18 (48%) tablets, 10 (26%) powders, 5 (13%) creams, 3 (8%) capsules and 2 (5%) syrups. Out of 38 Steroid contaminated QFs 20 (53%) countrained dexamethasone, 12 (32%) prednisolone, 4 (10%) hydrocortisone and 2 (5%) betamethasone. Conclusion: In modern era, patients are still using drugs prescribed by quacks and 21% of QF in Rawalpindi is contaminated with steroids. The steroids comprise mainly of dexamethasone and prednisolone in adulterated tablets and powders prescribed by hakeems.

BACKGROUND:Early diagnosis is the cornerstone of management of acute myocardial infarction (AMI). We aimed to compare the diagnostic accuracy of high-sensitivity troponin T (hs-cTnT) with myeloperoxidase (MPO) and pregnancy-associated plasma protein A (PAPP-A) for early diagnosis of AMI in patients at the time of presentation to the emergency department (ED).METHODS:We enrolled 289 patients who presented at the ED of the National Institute of Heart Disease (NIHD) Rawalpindi, Pakistan, within 4 hr of onset of chest pain. Clinical assessment, electrocardiography (ECG), and angiography were carried out. Blood samples were collected at 0, 3, 6, and 12 hr. Analyses of plasma hs-cTnT, MPO, and PAPP-A were carried out using commercial kits.RESULTS:Out of 289 subjects who presented to the ED, we diagnosed 180 patients with coronary heart disease as having AMI (N= 61) and 119 as without AMI (stable coronary artery disease, N=61; unstable angina, N=58). Compared to non-AMI patients, the patients with AMI had significantly higher levels (represented here as median [inter quartile range]) of plasma hs-cTnT (136 [39-370] vs. 12 [7-21] ng/L), MPO (906 [564-1,631] vs. 786 [351-1,299] pmol/L) and PAPP-A (5.78 [2.67-13.4] vs. 2.8 [1.8-4.9] mIU/L). Receiver operator characteristic curves (95% CI) for hs-cTnT (0.952 [0.909-0.978]) were significantly higher (P<0.001) than those for MPO (0.886 [0.830-0.929]) and PAPP-A (0.797 [0.730-0.854]), with AMI sensitivity and specificity percentages of 87% and 98% (hs-cTnT), 82% and 84% (MPO), and 65% and 87% (PAPP-A), respectively.CONCLUSIONS:The diagnostic performance of hs-cTnT was superior to that of MPO and PAPP-A for early triage and diagnosis of AMI among patients of coronary heart disease presenting with chest pain to the ED.