Upper Limit Of Normal Level Research Articles

Elevation in Liver Enzymes as a Predictor for COVID-19 Severity

Abstract Background The coronavirus disease 2019 (COVID-19) started in December of 2019 as a cluster of pneumonia cases of unclear etiology in Wuhan city of Hubei province in China. Later, it was found to be caused by a coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease rapidly spread throughout the world, becoming a pandemic, and as of April, 2022, there were more than 500 million cases worldwide with more than 6 million deaths. It is postulated that the virus enters the human body by binding to the angiotensin-converting enzyme receptor-2 (ACE-2) with the help of spike protein on its cell membrane. Aim of the Work To compare the serum liver chemistries such as hepatic transaminases to evaluate whether they can predict severity and mortality in COVID-19. Patients and Methods A comparative cross-sectional study for 6 months in Ain-Shams University hospitals, we studied 100 hospitalized patients with confirmed COVID-19 by RT- PCR for SARS- CoV-2. They included 70 patients with non-severe COVID-19 and 30 patients with severe COVID- 19 on hospital admission. This classification was based on the quick COVID-19 severity index (qCSI) and CT- severity index. Results The results of our study showed that levels of inflammatory markers such as CRP, serum ferritin, d-dimer, and procalcitonin were significantly higher in the severe group when compared to the non-severe group. This could be an indicator of a more intense inflammatory state in patients with severe COVID- 19 admitted to ICU. Our study showed that 40% of the severe group admitted to the ICU passed away. In our study, the median levels for ALT, AST at admission were 51 and 46 U/L, respectively, which are considered higher than the upper limit of normal levels. Our study showed that during hospitalization, the group of patients with severe COVID-19 who were admitted to ICU had significantly higher prevalence of abnormal ALT levels when compared to the non- severe group (86% versus 32%, respectively). Conclusion Our study showed that patients with severe COVID-19 have significantly higher levels of AST and ALT and that, on admission, patients with abnormal ALT and AST levels have significantly higher odds for developing severe COVID-19 compared to patients with normal levels. We confirm the importance of monitoring liver enzymes in hospitalized patients with COVID-19 as patients with abnormally elevated AST and ALT are more expected to progress to severe COVID- 19 which have prognostic implications in the COVID-19 disease course.

Resistance to first-generation somatostatin receptor ligands does not impair the results of gamma knife radiosurgery in acromegaly.

Gamma knife radiosurgery (GKRS) has proven to be an effective adjuvant treatment for patients with acromegaly. We performed the present study to investigate, which would be the outcome of GKRS, independently on the response to somatostatin receptor ligand (SRL). Retrospective, observational study. Ninety-six patients with active acromegaly were included. The cumulative probability of normalisation of insulin-like growth factor 1 (IGF-1) levels after GKRS was assessed by the Kaplan-Meier method. The association of several clinical characteristics with GKRS outcomes was explored with the use of a Cox proportional-hazard model with the relative hazard ratioand 95% confidence interval (CI). Resistance to SRLoccurred in 39 of the 96 patients (40.6%). After GKRS, patients resistant to SRL had a 5- and 10-year probability of remission of 40.7% (95% CI: 23.7%-57.7%) and 75.9% (95% CI: 57.9%-93.9%), respectively. Patients responding to SRL had a 5- and 10-year probability of remission of 46.8% (95% CI: 32.2%-61.4%) and 58.1% (95% CI: 41.5%-74.7%), respectively. The difference was not significant (p = .48 by the log-rank test). Multivariate Cox analysis confirmed that the only independent variables associated with GKRS outcome were basal growth hormone (GH; p = .001) and IGF-1 multiple of the upper limit of normal levels before GKRS (p = .013). We demonstrate for the first time that the responsiveness to SRL has no effect on the probability to obtain remission of acromegaly after GKRS. The remission of disease occurred more frequently in patients who had lower GH and IGF-1 levels before GKRS.

Efficacy of Per Rectal Non-Steroidal Anti-inflammatory Drugs to Prevent Post Endoscopic Retrograde Cholangiopancrea-tography Pancreatitis: A Comparative Study

Background and aims: Acute pancreatitis is the most common major post-ERCP complication ranging as high as 10% to 40%. Rectal NSAIDS (Indomethacin or Diclofenac) seem to be the most promising drugs to prevent post ERCP pancreatitis. We performed a trial to investigate the efficacy of indomethacin or diclofenac.
 Methods: A prospective randomized comparative trial was performed at Dhaka from January 2013 to June 2019. Patients undergoing ERCP were randomly selected to group-A and group-B. Diclofenac 50mg suppository was given to group-A patients and Indomethacin 100mg suppository was given to group-B patients during or just after ERCP. The primary outcome was acute pancreatitis following the procedure which was defined by new upper abdominal pain, elevation of pancreatic lipase to at least 3 times the upper limit of normal level 24 hours after ERCP and hospitalization for 02 nights. Retrospective analysis of data of 122 patients who had undergone ERCP in 2012 but had no history of rectal NSAIDS (group C) was done.
 Results: Total 613 patients were included in this study and followed up. Post ERCP pancreatitis developed in 21(8.5%) patients of group-A (n=247), in 19(7.78%) patients of group-B (n=244) and in 20(17.85%) patients of group-C (n=122)(p=0.02). Moderate to severe pancreatitis was found in 08(3.23%) patients of group-A, in 06(2.45%) patients of group-B and in 12(9.83%) patients of group-C(p= 0.01). Administration of these NSAIDS showed clear benefit to reduce occurrence of Post ERCP pancreatitis when compared with no drug group (P=0.01). The efficacy of indomethacin compared with diclofenac was similar (P=0.874).
 Conclusions: Prophylactic use of rectal indomethacin or diclofenac during or just after ERCP significantly reduces the incidence of post ERCP pancreatitis. These NSAIDs are inexpensive, safe and should be used routinely in each patient undergoing ERCP.
 Bangladesh J Medicine July 2021; 32(2) : 99-106

COMPARISON BETWEEN RHABDOMYOLYSIS INDUCED AND SEPTIC ACUTE KIDNEY INJURY IN CENTRAL NEPAL

Background: Acute kidney injury (AKI) is one of the most serious complications of rhabdomyolysis (RM). We studied the clinical manifestations and prognosis of rhabdomyolysis induced AKI and compared it with septic AKI among hospitalized patients.
 Methods: A prospective study was conducted at Chitwan Medical College between January 2017 to June 2018 to compare AKI secondary to rhabdomyolysis (RM-AKI) and sepsis (SA-AKI). AKI was diagnosed as per Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines. Rhabdomyolysis was diagnosed if serum creatinine phosphokinase raised >5 times the upper limit of normal level and sepsis as an increase of two or more points in the Sequential Organ failure Assessment (SOFA) score with the evidence of infection.
 Results: A total of 145 patients with AKI (21 with RM and 124 with sepsis) were included in the study. Mean age of the patients was 43.7 years with majority (54%) being males. Wasp bite and bee sting combined together (47.6%) were the most common causes for RM-AKI whereas pneumonia accounted for 46.6% of the septic AKI. Serum creatinine (SCr) at admission and at discharge were 3.8 and 1.4 mg/dL respectively in RM-AKI group; and 2.4 and 1.6 mg/dL in septic AKI group. Duration of stays in the hospital (9.2 versus 6.4 days) and ICU (4.2 versus 3.7 days) were longer in RM than in septic AKI. In hospital mortality was 4.8% in RM and 8.9% in septic AKI.
 Conclusions: This study has found that, despite a longer duration of hospital stay, RM-AKI had a lower in-hospital mortality than septic AKI.

Extracorporeal Membrane Oxygenation Therapy for Critically Ill Coronavirus Disease 2019 Patients in Wuhan, China: A Retrospective Multicenter Cohort Study

SummaryCurrently, little in-depth evidence is known about the application of extracorporeal membrane oxygenation (ECMO) therapy in coronavirus disease 2019 (COVID-19) patients. This retrospective multicenter cohort study included patients with COVID-19 at 7 designated hospitals in Wuhan, China. The patients were followed up until June 30, 2020. Univariate and multivariate logistic regression analyses were performed to identify the risk factors associated with unsuccessful ECMO weaning. Propensity score matching was used to match patients who received veno-venous ECMO with those who received invasive mechanical ventilation (IMV)-only therapy. Of 88 patients receiving ECMO therapy, 27 and 61 patients were and were not successfully weaned from ECMO, respectively. Additionally, 15, 15, and 65 patients were further weaned from IMV, discharged from hospital, or died during hospitalization, respectively. In the multivariate logistic regression analysis, a lymphocyte count ≤0.5×109/L and D-dimer concentration >4× the upper limit of normal level at ICU admission, a peak PaCO2 >60 mmHg at 24 h before ECMO initiation, and no tracheotomy performed during the ICU stay were independently associated with lower odds of ECMO weaning. In the propensity score-matched analysis, a mixed-effect Cox model detected a lower hazard ratio for 120-day all-cause mortality after ICU admission during hospitalization in the ECMO group. The presence of lymphocytopenia, higher D-dimer concentrations at ICU admission and hypercapnia before ECMO initiation could help to identify patients with a poor prognosis. Tracheotomy could facilitate weaning from ECMO. ECMO relative to IMV-only therapy was associated with improved outcomes in critically ill COVID-19 patients.

A STUDY ON LEVELS OF CHOLINESTERASE IN PLEURAL FLUIDS OF DIVERSE ETIOLOGIES

Introduction: Acetylcholinesterase , also known as true, specific, type I cholinesterase or RBC cholinesterase: It is found in nervous tissue, erythrocytes, lungs, spleen and grey matter. It is decreased in pernicious anaemia and after antimalarial therapy. Methodology: Patients participating in the study were explained about the procedure, technique and complications of pleural fluid aspiration. Pleural fluid aspiration was performed under strict aseptic precautions after analysing the fluid levels by percussion and chest x-rays. In few of the cases, ultrasonography-guided pleural fluid aspiration was performed. Results: The mean values of pleural fluid cholinesterase levels were 806.26 + 516.28 U/L in the transudates group and 3476.11 + 1250.17 U/L in the exudates group. The normal levels of cholinesterase varies between laboratories. The cut-off value is 1/10th of the upper limit of normal level of cholinesterase in the respective laboratory. Conclusion: In this study Light’s criteria had a sensitivity of 91.9% and specificity of 87.3% in comparison to pleural fluid to serum cholinesterase ratio that had a sensitivity of 96.8% and specificity of 95.2%.

SUN-173 COMPARISON BETWEEN RHABDOMYOLYSIS INDUCED AND SEPTIC ACUTE KIDNEY INJURY

Acute kidney injury (AKI) is one of the most serious complications of rhabdomyolysis (RM). AKI occurs in 13 to 50% of all cases of rhabdomyolysis, where mortality rates might rise up to 59% in critically ill patients. We studied the etiologies, severity, biochemical changes, clinical course and prognosis of rhabdomyolysis induced AKI (RM-AKI) and compared it with septic AKI among hospitalized patients. A prospective study with comparison between AKI secondary to rhabdomyolysis and sepsis was conducted in a tertiary hospital in central Nepal. AKI was diagnosed as per KDIGO guidelines. Rhabdomyolysis was diagnosed if serum creatinine phosphokinase (CK) raised more than five times the upper limit of normal level and sepsis as an increase of two or more points in the SOFA score with the evidence of infection. Simple descriptive analysis was performed to compare the outcome between two groups. A total of 145 patients with AKI (21 with RM and 124 with sepsis) were included in the study. Mean age of the patients was 43.7 years and majority (54.5%) aged between 30 to 49 years. Fifty-four percentage of patients were males. Wasp bite and bee sting combined together (47.6%) were the most common causes for RM-AKI whereas pneumonia accounted for 46.6% of the septic AKI. Among patients with RM-AKI, mean level of CK was 31644 mcg/L at presentation and 148.5 mcg/L at discharge. Serum creatinine (sCr) at admission and at discharge were 3.8 and 1.4 mg/dL respectively in RM-AKI group; and 2.4 and 1.6 mg/dL in septic AKI group. Stage 3 AKI was seen 52.4% in RM group and 33.9% in septic AKI group with indication of hemodialysis for 28.6% and 21.8% of patients in two groups respectively. Duration of stays in the hospital (9.2 versus 6.4 days) and ICU (4.2 versus 3.7 days) were longer in RM than in septic AKI. In hospital mortality was 4.8% in RM and 8.9% in septic AKI. Achievement of complete recovery, defined as the latest sCr returned to normal range (<1.2 mg/dL) or within 20% of baseline sCR, was better in septic AKI (51.6% versus 47.6%). This first ever study done in Nepal has found that, despite a longer duration of hospital stay, RM-AKI had a lower in-hospital mortality than septic AKI.

Comparison between Rhabdomyolysis Induced and Septic Acute Kidney Injury in Central Nepal

Background: Acute kidney injury (AKI) is one of the most serious complica­tions of rhabdomyolysis (RM). We studied the clinical manifestations and prognosis of rhabdomyolysis induced AKI and compared it with septic AKI among hospitalized patients.&#x0D; Methods: A prospective study was conducted at Chitwan Medical College between January 2017 to June 2018 to compare AKI secondary to rhabdo­myolysis (RM-AKI) and sepsis (SA-AKI). AKI was diagnosed as per Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines. Rhabdomy­olysis was diagnosed if serum creatinine phosphokinase raised &gt;5 times the upper limit of normal level and sepsis as an increase of two or more points in the Sequential Organ failure Assessment (SOFA) score with the evidence of infection.&#x0D; Results: A total of 145 patients with AKI (21 with RM and 124 with sepsis) were included in the study. Mean age of the patients was 43.7 years with majority (54%) being males. Wasp bite and bee sting combined together (47.6%) were the most common causes for RM-AKI whereas pneumonia accounted for 46.6% of the septic AKI. Serum creatinine (SCr) at admission and at discharge were 3.8 and 1.4 mg/dL respectively in RM-AKI group; and 2.4 and 1.6 mg/dL in septic AKI group. Duration of stays in the hospital (9.2 versus 6.4 days) and ICU (4.2 versus 3.7 days) were longer in RM than in septic AKI. In hospital mortality was 4.8% in RM and 8.9% in septic AKI.&#x0D; Conclusions: This study has found that, despite a longer duration of hospi­tal stay, RM-AKI had a lower in-hospital mortality than septic AKI.

Glutathione S-transferase M1 and T1 polymorphisms and the risk of mild hepatotoxicity induced by carbamazepine in a tunisian population study

BackgroundThe aim of this study was to evaluate whether the glutathione S-transferase M1 (GSTM1) and T1 (GSTT1) null alleles may contribute to carbamazepine-induced hepatotoxicity.MethodsA cross-sectional prospective study was conducted to identify the frequency distribution of GSTM1 and GSTT1 alleles in 129 Tunisian epileptic patients treated with carbamazepine. Null alleles were determined using a Polymerase Chain Reaction. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were measured by standard methods.ResultsOur results showed that the frequencies of GSTM1 (−) null allele and GSTT1 null (−) allele were 74.4 and 17.8% respectively. The ALT and AST levels were elevated in 46 (35.7%) and 33 (25.6%) cases. The mean values of ALT and AST were approximately 1.32 and 3.61 times higher than the upper limit of normal levels, respectively. The values of ALT and AST were significantly higher in GSTM1 (−) allele than in GSTM1 (+) (p = 10−3.and 0.004, respectively).The level of ALT was significantly higher in combination of GSTM1 (−)/T1(−) than in combined GSTM1(−)/T1(+) and combined GSTM1(+)/T1(+) (p = 0.2 and 0.03, respectively), and that of AST was significantly higher in combination of GSTM1(−)/T1(−) and in combination of GSTM1(+)/T1(−) than in combination of GSTM1(+)/T1(+) (p = 10−3 and 10−3, respectively).ConclusionsOur findings suggest that the GSTM1 (−) allele may be considered as a key factor for the development of carbamazepine-induced hepatotoxicity. Results related to GSTT (−) allele and elevation in AST levels should be considered with caution as AST may be elevated in other pathophysiological conditions.

The study of association of serum parathyroid hormone level with obesity in subjects admitted to a tertiary care centre

Objectives: Obesity has become an ever growing problem of epidemic proportions. Recent researches in this field suggested a possible association of high serum parathyroid hormone level and low vitamin D level with obesity and metabolic syndrome. This study was conducted in Mysore Medical College, Mysore to evaluate association of obesity with high serum PTH level in obese individuals. Methods: The study was conducted on 100 obese subjects admitted to medical wards who met the required criteria. Subjects were divided into different categories based on anthropometric measurements. Serum parathyroid hormone level was estimated in each group based on early morning sample drawn. Results: Among 100 subjects studied, 52 were females and 48 were males. Subjects with grade 1 obesity had mean S.PTH value of 54.5pg/ml which was within normal population limit (8.9-82.4). Mean serum PTH in subjects of grade 2 obesity was 77.305, towards the upper limit of normal level (fourth quartile). Among patients with grade 3 obesity, serum PTH level was high with a mean value of 116.42 pg/ml. Pearson’s coefficient of analysis for association of S.PTH with waist circumference was 0.652 (less than 1). There was significant positive correlation for level of S.PTH with waist hip ratio (coefficient of correlation 0.530) These findings were statistically significant with a P value < 0.001. Conclusion: The study shows that there is a significant association of high serum parathyroid hormone level with BMI. This association was most significant among subjects with morbid obesity. Analysis based on waist circumference and waist hip ratio also showed a positive correlation.

Tardus parvus waveforms in Doppler ultrasonography for hepatic artery stenosis after liver transplantation: can a new cut-off value guide the next step?

PurposeConsidering the high false-positive diagnosis of the tardus parvus waveform (TPW) in Doppler ultrasonography (DUS) for hepatic artery stenosis (HAS) after liver transplantation (LT), this study aimed to determine clinical features and new cut-off values to help guide treatment.Materials and methodsThis retrospective study was approved by an Institutional Review Board. A total of 171 LT recipients were included and underwent DUS and either computed tomography angiography or digital subtraction angiography with an interval < 4 weeks at least 1 month post-LT. The DUS of 69 patients exhibited TPW [defined as resistive index (RI) < 0.5 and systolic acceleration time (SAT) > 0.08 s]. A multilevel likelihood ratio (LR) analysis was used to explore new cut-off values for DUS. In addition, abnormal liver function was considered additional evidence (defined as any liver enzyme > 3-fold of the upper limit of normal level or 2-fold increased). The results were stratified into three categories, category 1 (subjects with traditional TPW), category 2 (subjects with traditional TPW and abnormal liver function), and category 3 (subjects with traditional TPW and abnormal liver function, or with new cut-off values), and the diagnostic performance of each category was analyzed.ResultsThe LR analysis revealed new cut-off values of RI < 0.4 (LR = 10.58) or SAT > 0.12 s (LR = 16.46). The false-positive rates for categories 2 and 3 were significantly lower (7.6% vs. 18.1%, P = 0.038; 1.9% vs. 18.1%, P < 0.001, respectively) than those for category 1, while the sensitivity for category 2 was significantly lower (41.8% vs. 74.6%, P < 0.001; 41.8% vs. 61.2%, P = 0.038, respectively) than that for categories 1 and 3.ConclusionUsing either (1) RI < 0.4 or SAT > 0.12 s, or (2) traditional TPW (RI < 0.5 and SAT > 0.08 s) in the presence of abnormal liver functions as the DUS criteria for HAS will significantly decrease the false-positive rate compared to traditional TPW without a significant increase in the false-negative rate.

The value of serum chromogranin A as a predictor of tumor burden, therapeutic response, and nomogram-based survival in well-moderate nonfunctional pancreatic neuroendocrine tumors with liver metastases.

To investigate the usefulness of serum chromogranin A (CgA) for the prediction of tumor burden, therapeutic response, and nomogram-based survival in well-moderate nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) with liver metastases (LMs). This prospective study included 51 NF-PNETs of LMs patients, 134 other neuroendocrine tumors, and 125 controls. Serum CgA levels were determined by enzyme-linked immunosorbent assay at baseline and after treatment. LMs tumor burden was computed simultaneously from computed tomography/MRI scan with thin slices using a semiquantitative three-dimensional reconstruction approach. Predictive CgA for therapeutic response was assessed using the response evaluation criteria in solid tumors criteria. A nomogram to predict the prognostic value of CgA with variables selected in the multivariate Cox proportional hazards model was constructed; the accuracy of the nomogram was quantified by the (concordance index) C-index and a calibration plot. Considering NF-PNETs, CgA correlated with the tumor grade and differentiation (P<0.05). There was a nonlinear exponential regression between LMs tumor burden and CgA levels (P<0.001). The alteration in CgA correlated with therapeutic response (P<0.001). Increased CgA presented significantly lower progression-free survival than the stable/decreased CgA subgroup (P<0.001). For overall survival, a baseline CgA increase greater than 2.5 upper limit of normal level was predictive of a poor prognosis (P<0.001). Baseline CgA level, LMs tumor burden, and Ki-67 were selected as independent factors for the nomogram to predict overall survival; the nomogram showed fitting calibration with a C-index of 0.87 (95% confidence interval, 0.82-0.92). Serum CgA could be used to reflect tumor burden, evaluate the therapeutic response, and predict the survival outcomes for NF-PNETs with LMs. An effective nomogram including CgA was proposed for prediction.

Incidence and risk factors of skin rashes and hepatotoxicity in HIV-infected patients receiving nevirapine-containing combination antiretroviral therapy in Taiwan

To retrospectively investigate the incidence of and factors associated with skin rashes and hepatotoxicity in HIV-infected patients who initiated combination antiretroviral therapy (cART) containing nevirapine plus two nucleos(t)ide reverse-transcriptase inhibitors. The medical records of HIV-infected adult patients who started nevirapine-containing cART and continued follow-up for ≥4 weeks were reviewed at two hospitals in Taiwan between 2000 and 2012. Clinical data obtained at baseline and during follow-up were collected and analyzed. Of the 338 patients included in the analysis, 13.0% tested positive for hepatitis B virus surface antigen and 7.9% tested positive for anti-hepatitis C virus antibody. The incidence of rashes was 21.6% and of hepatotoxicity was 25.5%. On multiple logistic regression analysis, a two-fold or greater increase from the upper limit of normal levels of aminotransferases at baseline was associated with rashes (adjusted odds ratio (aOR) 3.74, 95% confidence interval (CI) 1.56-8.96); higher CD4 counts (aOR for per 50 cells/μl increase 1.51, 95% CI 1.12-2.03) and the concurrent use of trimethoprim/sulfamethoxazole (aOR 14.01, 95% CI 1.98-98.95) were associated with hepatotoxicity. Abnormal liver function at baseline was significantly associated with skin rashes, while a higher CD4 count and the concurrent use of trimethoprim/sulfamethoxazole were associated with hepatotoxicity after the initiation of nevirapine-containing cART in HIV-infected Taiwanese patients.

Sa1323 Frequency of Celiac Disease Among Women With Reproductive Disorders

AIM. To assess the frequency and clinical presentation of celiac disease (CD) among women with reproductive disorders (RD) and to estimate the efficiency of influence of GFD in CD women with RD. MATERIALS AND METHODS: At the period from 2002 to 2011 we examined 217 women from gynecological-obstetrics departments. Age ranged from 16 to 72 years, the average age was 30,5± 5,8 years. The first stage of examination determined anti-TTG and main classes of immunoglobulin. The second stage women with high level of anti-TTG were undergone endoscopy examination with biopsy. The great attention was paid to careful data collection of gastroenterological symptoms in women with RD. CD diagnosis was based on duodenal biopsy. Results of intestinal biopsy were classified according to revised Marsh criteria 1999. The control group consisted of 15 healthy women. RESULTS: The majority of the patients (87,3%) had spontaneous abortions in anamnesis, infertility in 12.7% cases. The great attention was paid to careful data collection of gastrointestinal symptoms in women with RD. Established that the majority of patients had normal stool once or twice a day (89,8%), however, 18,5 % of the patients had diarrhea, 29,7%-constipation, 40,5% had bloating, 40%-weakness. The anti-tTG level ranged from 1 to 280 while 16 of them exceeded upper limit of normal level and averaged 50,2± 19.4. The anti-tTG level in patients of control group ranged from 0 to 10 and the average level 4,4 ±1,5. We compared gastroenterological symptoms in women with high level of anti-tTG and women with normal level of anti-tTG.Women with increased level of anti-tTG suffered from bloating75%(p<0,001), weakness-56,2%( p<0,001), diarrhea-68,7%( p<0,001). Therefore, these patients had every reason to diagnose CD. Biopsy was performed in 14 women with increased level of anti-tTG. We proved the CD diagnose by biopsy in 7 women (Marsh criteria 1999). Normal structure of the mucosa was revealed in 7 women. CD diagnosed in 7 women. Two women with miscarriages in anamnesis were pregnant. The anti-tTG level was 21,9 and 15,9. They were not offered esophagogastroscopy, however to avoid complications they were suggested to keep to GFD. After strict keeping to GFD they felt better, their gastrointestinal complaints disappeared, antibody level normalized. As a result they gave birth to healthy, full-term newborns. Three women did not strictly keep GFD, 2 women did not plan pregnancy. Two women after 8-12 months of strict keeping to GFD gave birth to healthy, full-term newborns. CONCLUSION. The frequency of CD among women with RD was 3,2%. Therefore celiac disease diagnostic procedures (serological screening) could be routinely performed in women with RD as a potential useful strategy to treat the same disorders and to allow for an early diagnosis of those all too often unrecognized cases of celiac disease.

Changes of thyroid function in thyroid cancer after total or subtotal thyroidectomy

Objective To investigate the change of thyroid function after total or subtotal thyroidectomy.Methods During January 2009 to April 2011,88 cases of thyroid cancer undergoing total or subtotal thyroidectomy were enrolled to detect thyroid function before surgery (0 d),postoperative day 1 (1 d),3 (3 d) and 5 (5 d),including T3,T4,FT3,FT4 and TSH,and their changing patterns were analyzed.Results FT3 and T3 expressed a downward trend,the changes were statistically significant (FT3:F =47.752,P ＜ 0.01; T3:F =15.317,P ＜ 0.01 ),and both of the values on 3 d were close to the lower limit of normal level; FT4 and T4 levels were increased after 1 d,then decreased gradually.Changes of FT4 on 0 d,1 d and 5 d had no significant difference (P ＞ 0.05),those of T4 on 0 d and 1 d had no statistically significant difference (P ＞ 0.05),and those at the remaining time points had statistically significant difference (P ＜ 0.05).TSH level was declined on 1 d,but gradually increased on 3 d and 5 d.TSH level on 0 d and 1 d had no statistically significant difference ( P ＞ 0.05 ),and those on the remaining time points had statistically significant difference ( P ＜ 0.05 ).TSH level on 3 d was close to the upper limit of normal level,and greater than that on 5 d.Conclusion Thyroid function after total or subtotal thyroidectomy does not decrease or decrease mildly on 1 d after surgery.There is no need to test thyroid function or supply thyroid hormone at this time.Thyroid function after surgery is significantly decreased from 3 d,thyroid function should be monitored,and according to the level of thyroid function,proper thyroid hormone should be given. Key words: Thyroid cancer; Subtotal thyroidectomy; Thyroid function

Prognostic value of CA 19-9 level in resectable pancreatic adenocarcinoma.

The prognosis in patients with pancreatic cancer is poor and some authors describe it as a lethal disease. At the time of diagnosis only 14% of patients could be surgically treated and up to 30% of them die within 12 months. Therefore, further clinical investigations on preoperative patient qualification are needed. A total of 81 patients were included into the study. The CA 19-9 concentration was measured before surgery by an automated, commercially available enzyme immunoassay in Axsym analyzer (Abott Diagnostics Laboratory). A value of 37 U/ml was used as the upper limit of normal levels. Tumors were staged according to the Union Against Cancer (UICC) of 2004 and graded during the histological evaluation according to the G0-G4 scale. All patients were monitored every three month via outpatient clinic visits. In the case of missing visit we contacted the families to establish the cause. We assessed perioperative, 12 month, 2 year and 5 year survival. Twelve moth, 2 year and 5 year survival were assessed in the whole studied population and in the group of patients with the exception of these who died during the perioperative period. The total five year survival was 6%. The median time of survival was 467 days (range: 163 - 586 days). The perioperative period was survived by 91.4% patients, 12 months were survived by 71.6% patients, 2 years were survived by 35.8% patients, 5 years were survived by 6.2% patients. The serum Ca 19-9 level was above the normal limit in 80.5% patients. ROC curve analysis revealed that CA 19-9 level of more than 106 U/ml was linked to 2 year survival with 79.3% sensitivity and 74.5% specificity. Preoperative level of CA 19-9 below 106U/ml represents a predictive factor of 2- and 5-year survival, independent of other factors, such as lower size of the tumor, absence of metastases to lymph nodes, female gender of patients. After exclusion of the patients who died in the perioperative period, no relationship could have been disclosed between preoperative CA 19-9 levels and one year survival. The observation points to the chance that patients with higher levels of CA 19-9 harbour micrometastases, the development of which is sufficiently slow to allow for a one-year survival of the patients but which increase the risk of death after two and five years.

GlutathioneS-Transferase M1 Null Genotype as a Risk Factor for Carbamazepine-Induced Mild Hepatotoxicity

The aim of this study is to verify whether the combination of glutathione S-transferase (GST) M1 null and GSTT1 null genotypes, which is a candidate genetic risk factor for troglitazone-induced liver failure, is common to that for the carbamazepine-induced mild hepatotoxicity. The genotypes of GSTM1 and GSTT1, and microsomal epoxide hydrolase-3 and -4, were determined in 192 Japanese epileptics treated with carbamazepine. The GSTM1 null (GSTM1-) and GSTT1 null (GSTT1-) genotypes in the subjects were 55.7 and 39.6%, respectively. The alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were elevated in 46 (24.0%) and 62 (32.3%) cases, and the mean values were approximately 2.3- and 1.8-times higher than the upper limit of normal levels, respectively. The levels of ALT and AST were significantly higher in GSTM1- than in GSTM1 present (GSTM1+) genotypes (p = 0.007 and 0.004, respectively). The level of ALT was significantly higher in GSTM1-/T1- than in GSTM1+/T1- and GSTM1+/T1+ (p = 0.01 and 0.01, respectively), and that of AST was significantly higher in GSTM1-/T1- and GSTM1-/T1+ than in GSTM1+/T1+ (p = 0.02 and 0.003, respectively). The microsomal epoxide hydrolase genotype did not influence the hepatotoxicity. These findings suggested that GSTM1- rather than GSTM1-/T1- was a risk factor for carbamazepine-induced mild hepatotoxicity.

Predictors of Single-Gland vs Multigland Parathyroid Disease in Primary Hyperparathyroidism

Preoperative clinical, biochemical, and imaging studies could be used to reliably select patients with single-gland primary hyperparathyroidism who could undergo minimally invasive parathyroidectomy and to determine whether additional perioperative testing is necessary. Retrospective analysis. Tertiary referral center. A total of 238 patients who underwent neck surgical exploration and parathyroidectomy for primary hyperparathyroidism from January 7, 2002, to December 23, 2004. Demographic, clinical, biochemical, and imaging factors that predict single-gland vs multigland parathyroid disease, and biochemical cure. Of the 238 patients, 75.2% had a single adenoma, 21.4% had asymmetric 4-gland hyperplasia, and 3.4% had double adenomas. A biochemical cure was achieved in 99.2% of the patients. Preoperative calcium and intact parathyroid hormone levels were significantly higher (P = .03 and .04, respectively) and ultrasound and sestamibi scan results were more likely to be positive (both P<.001) in single-gland primary hyperparathyroidism. A dichotomous scoring model based on preoperative total calcium level (>/=3 mmol/L [>/=12 mg/dL]), intact parathyroid hormone level (>/=2 times the upper limit of normal levels), positive ultrasound and sestamibi scan results for 1 enlarged gland, and concordant ultrasound and sestamibi scan findings reliably distinguished single-gland vs multigland cases (P<.001). The positive predictive value of this scoring model to correctly predict single-gland disease was 100% for a total score of 3 or higher. Preoperative biochemical and imaging study results reliably distinguished single-gland vs multigland parathyroid disease in primary hyperparathyroidism. Our findings suggest that patients with a score of 3 or higher can undergo a minimally invasive parathyroidectomy without the routine use of intraoperative parathyroid hormone or additional imaging studies, and those with a score of less than 3 should have additional testing to ensure that multigland disease is not overlooked.

Renal osteodystrophy in dialysis patients: diagnosis and treatment.

This article reviews the clinical, biological, radiological, and pathological procedures and their respective indications for the practical diagnosis of the following various histological patterns of renal osteodystrophy: osteitis fibrosa due to parathyroid hormone (PTH) hypersecretion: osteomalacia or rickets due to native vitamin D deficiency and/or aluminum overload; and adynamic bone disease (ABD) due to aluminum overload and/or PTH secretion oversuppression. Our advice regarding bone biopsy is to restrict it to patients with symptoms and hypercalcemia, especially those who have been previously exposed to aluminum. In other cases, we propose relying merely on the determination of the plasma concentrations of calcium, protide, phosphate, bicarbonate, intact PTH, aluminum, 25(OH)D3, and alkaline phosphatase (total and bony if hepatic disease is associated) to choose the appropriate treatment. Because of the danger of the desferrioxamine treatment necessary to chelate and remove aluminum, the suspicion of aluminic bone disease (osteomalacia or ABD) will always be confirmed by a bone biopsy. In the case of nonaluminic osteomalacia, correction of the vitamin D deficiency by native vitamin D or 25(OH)D3, and of the calcium deficiency and acidosis by alkaline salts of calcium and if necessary sodium bicarbonate are sufficient to cure the disease. In the case of nonaluminic ABD, the stimulation of PTH secretion by the discontinuation of 1alpha hydroxylated vitamin D and the induction of a negative calcium balance during dialysis by decreasing the calcium concentration in the dialysate will allow an increase of the CaCO3 dose to correct for hyperphosphatemia without inducing hypercalcemia. For hyperparathyroidism, i.e., plasma intact PTH levels greater than two- or four-fold the upper limit of normal levels (according to the absence or presence of previous aluminum exposure), the treatment will consist in increasing the CaCO3 dose to correct for hyperphosphatemia together with a decrease of the calcium concentration in the dialysate if the dose of CaCO3 is so high that it induces hypercalcemia. When the hyperphosphatemia has been corrected and there is still a low or normal corrected plasma calcium level, 1alpha(OH)D3 in an oral bolus 2 or 3 times a week should be given at the minimal dose of 1 microg. When the PTH level stays above 400 pg while hypercalcemia occurs and hyperphosphatemia persists, surgical subtotal parathyroidectomy is recommended or the injection of calcitriol into the big nodular hyperplastic parathyroid glands under sonography control in high surgical risk patients. Special recommendations are given for children.

An industrial toxicological study on workers who synthesize aminophenol and anisidine from chloronitrobenzene

Aromatic nitro- and amino-compounds (ANA) are notorious methemoglobin forming substances. From 1987 to 1993, the author surveyed the exposure level to ANA and health status of workers in a chemical industry where they synthetize nitrophenol and anisidine from chloro-nitrobenzene. The ANA exposure indicator was the diazo-reaction positive substance in the worker's urine (Dz) and the biological effect of ANA was monitored through the methemoglobin concentration in the blood (MHb). The following results were obtained from the survey. 1. Both the Dz and MHb values tended to become lower between 1987 and 1993. 2. The MHb levels of the workers were a little higher than the control levels, and the difference between the values was statistically significant (p < 0.01); both levels were, however, within the normal range. 3. The MHb value was estimable from a mathematical model: MHb = (k1-k2/a) x DU x CH, where k1 and k2 were constants and a, DU and CH indicated the activity of glutathione S transferase in erythrocytes (GST), DZ in urine and blood hemoglobin concentration, respectively. The correlation coefficient of the multiple regression was statistically significant (R2 = 0.263, p < 0.01). This model suggests that the biotransformed fraction of ANA in the pulmonary uptake site, the lung, could not penetrate into erythrocytes or act as an MHb former. The model seemed to be consistent and valid when urinary DZ values were less than 1.0 (mg/mg creatinine) and MHb values were less than 2.0 (mg/ml blood). Thus, the upper limit of normal levels for MHb can be considered to be 2.0 (mg/ml blood), or 12-1.6% of total hemoglobin in blood. 4. The significance of the uptake sites, i.e., lung, skin etc., was discussed with reference to the evidence obtained from the longshoremen cases, who were percutaneously exposed to chloronitrobenzene in 1984. 5. Hemolysate solutions from the blood of workers were applied to isoelectric focusing electrophoresis (IEF), and Hb species of different valencies were separated; intermediate MHbs, where the heme iron in one of the components of Hb, i.e., in the alpha or beta chain was oxidized and MHb where both the alpha and beta chain heme iron oxidized and Hb X and Y, were separated and easily discernible. The correlation matrix was calculated using the data relevant to IEF and other indicators; MHb estimated spectrophotometrically, GST activity of erythrocytes, Hb and urinary DZ vale. The statistical procedure of principal component analysis was applied to the matrix, and two major principal components were extracted from the calculation.(ABSTRACT TRUNCATED AT 400 WORDS)