Monoclonal gammopathy with systemic amylodosis: an evaluation of diagnostic elements

Monoclonal gammopathies result from an overproduction of a single abnormal clone of plasma cell or B lymphocyte that produce an immunologically homogenous immunoglobulin (Ig) commonly referred to as paraprotein or monoclonal (M) protein. The circulating M-protein may consist of an intact immunoglobulin, the light chain only, or (rarely) the heavy chain only. The heavy chain is from one of the five immunoglobulin classes G, A, M, D or E, while the light chain is either kappa (κ) or lambda (λ) in type. Accurate detection and quantitation of monoclonal immunoglobulins is important for the diagnosis and management of monoclonal gammopathies. We report a case of a 71 year old lady with a history of chronic gastritis and recurrent lower respiratory tract infection whereby no specific diagnosis was made until a computed tomography (CT) guided lung biopsy and orogastroduodenoscopy

Performance characteristics of anti-thyroid peroxidase and anti-thyroglobulin assays on roche cobas E411 immunoassay system

Background: Thyroid autoantibodies are measured in the evaluation of patients with thyroid diseases. The clinically important thyroid autoantibodies are anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-TG). The aim of this study was to assess the analytical performance of anti-TPO and anti-TG assays on Roche Cobas e411, an automated electrochemiluminescence immunoassay (ECLIA) system. Materials and Methods: The following parameters, imprecision, accuracy and stability were evaluated. Imprecision (within-run and between-run) and accuracy studies were performed using two levels of quality control materials. The stability of samples for anti-TPO and anti-TG measurements were evaluated by calculating the percentage recovery of serum samples stored at different temperatures (4°C, -20°C and -80°C) on day 3 and day 12 of storage. Result: The imprecisions for anti-TPO were between 2.5 to 11.3%. The percentage deviation from the true value was -4.9% and -3.6% for low and high QC, respectively. Anti-TPO showed variable recovery from 92.0% to 119.0% on day 3 and day 12 of storage. For anti-TG, the imprecisions were between 3.0 to 11.5%. The percentage deviation from the true value was 3.5% and 12.7% for low and high QC, respectively. Anti-TG showed variable recovery from 89.8% to 117.0% on day 3 and day 12 of storage. Conclusion: Roche Cobas e411 anti-TPO and anti-TG assays have demonstrated acceptable precision and accuracy. It is recommended that samples for anti-TPO and anti-TG are stored and analysed as per recommended to avoid the effects of storage

Serum soluble transferrin receptor concentration as a biomarker of erythropoietic activity: surrogate marker of adequate transfusion in adult Beta-thalassaemia intermedia patients

Management of Beta (β)-thalassaemia intermedia in contrast to β-thalassaemia major patients has no clear guidelines as to indicators of adequate transfusion. Regular blood transfusion suppresses bone marrow erythropoietic activity. Serum soluble transferrin receptor (sTfR) concentration is a marker for erythropoietic activity, with increased sTfR being associated with functional iron deficiency and increased erythropoietic activity. This study aimed to determine the use of sTfR as an indicator of adequate transfusion in adult β-thalassaemia intermedia patients. A cross-sectional study was conducted at Hospital Ampang, Malaysia, for six months. Patient group included six β-thalassaemia intermedia and 34 HbE-β-thalassaemia transfused patients. None of the patients were on regular monthly blood transfusions as in β-thalassaemia major. The control group comprised of 16 healthy subjects with normal haematological parameters. Haemoglobin (Hb) analysis, sTfR and ferritin assays were performed. Hb and HbA percentages (%) were found to be significantly lower in patients compared to the controls, while HbE%, HbF%, sTfR and ferritin were significantly higher in patients. An inverse relationship was found in the controls between HbF% with Hb (r = -0.515, p < 0.05) and HbA% (r = -0.534, p < 0.05). In patients, sTfR showed an inverse relationship with HbA% (r = -0.618, p = 0.000) and a positive correlation with HbE% (r = 0.418, p = 0.007) and HbF% (r = 0.469, p = 0.002). Multivariate analysis showed that HbA% (r = 2.875, p = 0.048), HbE% (r = 2.872, p = 0.020) and HbF% (r = 2.436, p = 0.013) best predicted sTfR independently in patients. Thus, sTfR is a useful marker for erythropoiesis. The elevate sTfR in these patients indicate that the transfusion regimen used was inadequate to suppress ineffective erythropoiesis. Hb levels may not be the best target for monitoring transfusion treatment in β-thalassaemia intermedia patients, but the use of sTfR is helpful in individualising transfusion regimens

Determination of the 99th percentile upper reference limit for highsensitivity cardiac troponin I in Malaysian population

Introduction of high-sensitivity cardiac troponin I (hscTn I) assays for routine clinical use in Malaysia requires determination of the 99th percentile upper reference limit (URL) for each assay to suit local context. Hence, this study aimed to determine the 99th percentile URL for hscTn I in the Malaysian population. A total of 250 (120 males and 130 females) healthy Malaysian blood donors aged 18 to 60 years old were recruited. Blood samples for hscTn I were measured using Abbott Diagnostics hscTn I assay on Architect i2000sr analyser. The 99th percentile was calculated using a non-parametric method and gender specific results were compared. The 99th percentile URL for hscTn I for the overall population was 23.7 ng/L, with gender specific values being 29.9 ng/L and 18.6 ng/L for male and female, respectively. Females had significantly lower hscTn I compared to males. This study confirms the use of gender specific 99th percentile URL for hscTn I for clinical use in a multi-ethnic Malaysian population

Practice of self-monitoring blood glucose among insulin-treated diabetic patients in Hospital Serdang

Introduction: Diabetes Mellitus (DM), characterised by chronic hyperglycaemia, exposes patients to acute and chronic complications, such as hypoglycaemia and vascular complications, respectively. The latter is associated with the degree of glycaemic control. Glycated haemoglobin (HbA1c) indicates long-term glycaemic control of the preceding 2-3 months. The practice of self-monitoring blood glucose (SMBG) is essential for insulin-treated diabetic patients to achieve optimum glycaemic control and prevent hypoglycaemia. Aim: The study aimed to determine the SMBG practice and frequency and its association with HbA1c and factors in insulin-treated diabetic patients. Methods: This was a cross-sectional study of insulin-treated diabetic patients attending follow-up at the diabetic clinic of Hospital Serdang from April 2015 to August 2015. Consented eligible patients completed validated self-administered questionnaires. Patients’ HbA1c results were obtained from the hospital information system. Results: Ninety-one of 137 (66%) patients practiced SMBG and 46 (34%) did not. Although 82% had seen diabetic nurses, 54% of patients did not alter their treatment accordingly. Neither the practice nor the frequency of SMBG was significantly associated with differences in HbA1c levels (p=0.334 and p=0.116 respectively). Ethnicity and household income significantly affected SMBG practice. The presence and frequency of hypoglycaemia significantly increased the likelihood of SMBG practice (p<0.001) and frequency (p<0.001). Conclusions: The prevalence of SMBG practice in diabetic patients on insulin was 66%. However, SMBG was not followed by proper treatment alteration in 54% of patients. There was no association between SMBG practice and frequency with good glycaemic control. Hypoglycaemia significantly affected the practice and frequency of SMBG

Determination of the 99th percentile upper reference limit for highsensitivity cardiac troponin I in Malaysian population

Introduction of high-sensitivity cardiac troponin I (hscTn I) assays for routine clinical use in Malaysia requires determination of the 99th percentile upper reference limit (URL) for each assay to suit local context. Hence, this study aimed to determine the 99th percentile URL for hscTn I in the Malaysian population. A total of 250 (120 males and 130 females) healthy Malaysian blood donors aged 18 to 60 years old were recruited. Blood samples for hscTn I were measured using Abbott Diagnostics hscTn I assay on Architect i2000sr analyser. The 99th percentile was calculated using a non-parametric method and gender specific results were compared. The 99th percentile URL for hscTn I for the overall population was 23.7 ng/L, with gender specific values being 29.9 ng/L and 18.6 ng/L for male and female, respectively. Females had significantly lower hscTn I compared to males. This study confirms the use of gender specific 99th percentile URL for hscTn I for clinical use in a multi-ethnic Malaysian population

Utility of copeptin in acute myocardial infarction

Copeptin, a surrogate marker for vasopressin, is increased immediately following an acute myocardial infarction (AMI). In several studies, using a single multi-marker strategy, copeptin in combination with either conventional or high-sensitive troponin drawn at presentation of patients with AMI was able to rule out AMI with high negative predictive value (NPV). Copeptin is also reviewed as a prognostic marker for predicting mortality and morbidity in AMI and allows risk stratification of patients into low, moderate and high risk patients. This review looked at past researches conducted on copeptin as either a diagnostic marker for those presenting to emergency department with chest pain, or its prognostic value

Awareness of glycosylated haemoglobin (HbA1c) among type 2 diabetes mellitus patients in Hospital Putrajaya

The glycosylated haemoglobin (HbA1c) test is the most widely accepted laboratory test for evaluating long term glycaemic control. Patient’s understanding of HbA1c can lead to better glycaemic control. This study is aimed to determine the awareness and level of understanding of HbA1c among type 2 DM patients and its association with glycaemic control. A cross-sectional descriptive study among Type 2 DM patients undergoing routine follow up in an endocrine clinic of a tertiary centre in Malaysia. Patients were invited to answer a validated questionnaire which assessed their awareness and understanding of HbA1c. Their last HbA1c results were retrieved from the laboratory information system. A total of 92 participants were recruited. Fifty-six (60.9%) were aware of the term HbA1c. Fifty percent were categorised as having good HbA1c understanding, with age, monthly income and level of education between HbA1c understanding and glycaemic control, although more patients with good HbA1c understanding had achieved the target glycaemic control compared to those with poor understanding. The level of HbA1c awareness and understanding was acceptable. Factors associated with understanding were age, income and level of education. Continuing efforts however, must be made to improve patients understanding of their disease and clinical disease biomarkers

Is J.S. Mill's Account of Free Speech Sustainable in the Age of Social Media?

In this paper, I examine whether John Stuart Mill’s account of free speech can survive three main challenges posed by social media. First, I consider the problem of social media failing to distinguish between emotive and factual language. Second, I look at the problem of algorithms creating moralism. I then turn to a potential objection to my first two challenges. The objection elucidates the benefits of social media’s emotional and algorithmic character, amplifying arguments and increasing public engagement. However, I take issue with this objection on consequentialist terms. I finally return to the third challenge, where I focus on how anonymity removes the consequences to our words; I contend that this final failure is the ultimate reason why Mill’s account cannot persist in the modern age. In conclusion, I argue that Mill’s account cannot withstand the problems posed by social media

Biochemical effects of statins on lipid parameters among newly diagnosed dyslipidaemia subjects in primary care

Introduction: Statins have several pleiotropic effects including its primary effect of lipid lowering that is important to prevent cardiovascular disease (CVD). Subjects often have heterogeneous responses to statin. This study aims to determine the biochemical effects of statins on lipid parameters among newly diagnosed dyslipidaemia subjects. Methods: This was a prospective observational study involving 118 newly diagnosed adults with dyslipidaemia from three government health clinics in Selangor, Malaysia. Biochemical analyses including fasting lipid profile [triglyceride (TG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C)] and apolipoproteins (apoA1, apoB) were taken at baseline and follow-up after a month on statin. Results: Majority of subjects (61.9%) were prescribed with lovastatin, with the rest on simvastatin. At baseline, the median values for all lipid profile parameters (TC, LDL-C, HDL-C) and non-conventional lipid parameters (LDL-C:HDL-C ratio, non-HDL-C, TC:HDL-C ratio, apoB:apoA1 ratio) were deranged except for TG and apoA1. On follow up, all parameters showed median values within the reference range except for HDL-C, non-HDL-C and TC:HDL-C ratio. There was significant difference in the effect of statins on lipid parameters including predictors of cardiovascular risk, simvastatin having better effects. Conclusions: Different statins have varying effects on lipid parameters. Simvastatin showed significantly better effects compared to lovastatin. Non-HDL value should be included in the standard lipid profile report given its ease of use and implementation as it’s both a marker of coronary artery disease (CAD) risk stratification as well as an established determinant of goal attainment during therapy