Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241125EnglishN2020March7HealthcareA Study of the Determinants of Laboratory Turnaround time in Tertiary Care Teaching Hospital in Bihar English0105Manasij MitraEnglish Dipak SinhaEnglish Maitraye BasuEnglishIntroduction: The laboratory turnaround time can be commonly defined as the time from when a test is ordered until the result is reported. One of the parameters to measure performance of any laboratory is the Turnaround time (TAT). Turnaround time of laboratories is equally important as accuracy and precision of the tests performed by the laboratories when considering their quality of service. Studies have highlighted that outcomes in certain situations such as operation theatres and in emergency departments have been affected by timely reporting of laboratory test results. These parameters can directly influence clinical outcomes and patient satisfaction. Materials and Methodology: This was a cross-sectional study done in the Biochemistry department of a 600 bed tertiary care multi-speciality teaching hospital in Bihar. 2600 samples from patients admitted over a period of 6 months from 1st April 2019 to 30thOctober 2019 were analysed using descriptive statistics. Results: The average TAT from test advise by physician to report despatch is 10.68 hours(±4.16 Standard Deviation) while the average TAT from receipt of samples in the laboratory to report despatch was 7.54 hours (±2.28 Standard Deviation) Discussion: This study did a detailed analysis looking into the reasons for delay and bringing forth feasible recommendations towards rectification. This study also looked into the “Critical tests” and the “Critical results” TAT and the reasons for delay therein which was not highlighted in many studies done in Indian settings earlier. Conclusion: Pre analytical phase and post analytical phase delays contribute to delayed TAT in hospital settings. Recommendations with an aim to reduce the delays with active involvement of the management can be fruitful. EnglishTurnaround time (TAT), Critical tests, Critical results, DelayIntroduction The laboratory turnaround time can be commonly defined as the time from when a test is ordered until the result is reported.1 One of the parameters to measure performance of any laboratory is the Turnaround time (TAT). Turnaround time of laboratories is equally important as accuracy and precision of the tests performed by the laboratories when considering their quality of service. Clinicians prefer faster Turnaround times which help them arrive at the diagnosis and start treatment early which can lead to earlier patient discharge, reduced length of stay and is beneficial to the physicians, patients and the hospital management. Studies have highlighted that outcomes in certain situations such as operation theatres and in emergency departments have been affected by timely reporting of laboratory test results.These parameters can directly influence clinical outcomes and patient satisfaction.2 Clinicians and laboratory personnel define TAT differently. For laboratory personnel, TAT includes the time from the receipt of sample in laboratory to generation of report while to the clinicians TAT means the time of test requisition till the receipt of report.3 The total TAT for laboratory assays includes the entire interval from ordering of the test to the result intimation to the clinician. It takes into consideration the intervals from order requisition to specimen collection, the time required for transport to the laboratory, accessioning in the laboratory, sample processing and additional pre-analytic steps if necessary, sample analysis time, the time from completion of analysis until result verification, and the time it takes for the clinical team to be informed of the result.4 TAT may depend on various factors like thetype of test performed, priority of the test and clinical status of the patients for which the tests are ordered.5 The ultimate aim of the laboratory services is to provide accurate results to the physician at the earliest inorder to facilitate treatment.  Turnaround time being a complex interplay of factors, brings out the very important concept of critical tests and critical test results. Lundberg more than 40 years ago was one of the pioneers in this issue which has then been reiterated and refined by many international and national organizations down the years.6 The Joint Commission International (JCI), an independent not-for-profit organization endeavoured to improve patient safety and quality of health care, defines a critical test as “a test that requires immediate communication of result irrespective of whether it is normal, significantly abnormal or critical”. This definition is also used by many organizations such as the Clinical and Laboratory Standards Institute (CLSI) and the Royal College of Pathologists (RCP). A critical result on the other hand as defined by the JCI is “a test result that is significantly outside the normal range and may represent life-threatening values and thus requires immediate notification to the physician to start medical intervention”7 Communication of Critical results is now an integral part of many National and International accreditation procedures for medical laboratories like the International Organization for Standardization (ISO) 15189:2012, the Joint Commission International, 6th Edition Standards effective from 1st July 2017 and the National Accreditation Board for Testing and Calibration Laboratories Standards. Timely notification of critical results is endorsed as one of the leading quality indicators of the post-analytical phase by the Working Group “Laboratory Errors and Patient Safety” (WG-LEPS) of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). 8 Monitoring of the Turnaround time is thus of paramount importance so far as the quality parameters of a laboratory are concerned. Improving TAT is a continuous process. The causes of delayed TAT should be identified and duly addressed on a routine basis with an aim towards a holistic approach for reducing the obstacles to optimise TAT.9 The study was conducted to evaluate the delay and reasons of delay of turnaround time (TAT) of tests in the Biochemistry department of a teaching medical college in Bihar. Materials and Methodology This was a cross-sectional study done in the Biochemistry department of a 600 bed tertiary care multi-speciality teaching hospital in Bihar. 2600 samples from patients admitted over a period of 6 months from 1st April 2019 to 30thOctober 2019 were analysed using descriptive statistics. The study was approved by the Institutional Ethics Committee. We collected the date which was entered in an excel spreadsheet. The data was analysed using the statistical software SPSS (Version 21). All the routine tests having standard turnaround time and advised by the physicians of the Medical College and performed in the Biochemistry department during the said time period were considered. Rare tests which do not have standard turnaround time and are not done in the Biochemistry department or done through outsourced laboratory services were not considered. The routine tests included hematology, plasma total calcium, glucose, uric acid, cholesterol, protein, albumin, AST, ALT, ALP, total bilirubin, direct bilirubin, phosphorous, magnesium, urea, creatinine, gamma-glutamyl transferase, sodium, potassium, chloride, total CO2, amylase, lipase, lactate dehydrogenase, triglyceride, HLD cholesterol, LDL-cholesterol, C-reactive protein, CPK,CPK-MB, iron, and TIBC. In this study, the total TAT was classified into 3 phases i.e., pre-analytical phase (specimen collection, transport and processing), analytical phase (testing), and post-analytical phase (testing result interpretation to reporting). The process flow from test advice by the physician to reporting the results is depicted in Figure 1. Results There were a total of 2876 samples from 1st April 2019 to 30th October 2019 in the Sample Entry Master Register of the Department of Biochemistry of which 2600 samples (90.43%) were included in the study. 276 samples (9.57%) were not included in the study as those were rare tests or were outsourced. 1370 (52.7%) of the samples were from female patients while 1230 (47.3%) of the samples were from male patients. This is depicted in Figure 2. The average age of the patients whose samples were included in the study were 42.36 years (± 12.24 Standard Deviation) and range from 1 month to 80 years. The average TAT from test advise by physician to report despatch is 10.68 hours(±4.16 Standard Deviation) while the average TAT from receipt of samples in the laboratory to report despatch was 7.54 hours (±2.28 Standard Deviation)4 Out of 2600 samples, 2295 samples (88.27%) complied with the standard TAT while 305 samples (11.73%) did not comply with the standard TAT. This is depicted in Figure 3. Of the 305 samples which did not comply to the TAT, pre-analytical phase delay was the reason for failure to comply with the TAT in 164 (53.77%) samples, post analytical delay was the reason for failure to comply with the TAT in 122 (40.0%) samples while both pre-analytical and post analytical phase delay was the reason of failure to comply with the TAT in 19 (6.23%) samples. The same is depicted in Figure 4. The average TAT for Critical results were 24.28 mins (±2.26 Standard Deviation). Discussion One of the most discussed areas of laboratory service is how fast a test result is returned to a caregiver.10 Though studies have been done on the determination of laboratory turnaround time in tertiary care hospitals in India, there is a dearth of such studies in teaching hospitals where the reasons for delayed TAT can be different. Though the reasons for delayed TAT as highlighted in this study were similar to those highlighted in other studies, however, as depicted in other studies were did not note in delays due to instrumentation failure.11 This could be due to the stringent process of Quality control and Inventory management or attributed to the short study period of six months. Moreover, this study did a detailed analysis looking into the reasons for delay and bringing forth feasible recommendations towards rectification. This study also looked into the “Critical tests” and the “Critical results” TAT and the reasons for delay therein which was not highlighted in many studies done in Indian settings earlier. The reasons for delay were as follows: Pre-analytical phase Communication delay between the treating team and the nursing team Errors in sample collection by the nursing staff or trainee doctors mostly Delay in samples reaching the laboratory Delay in screening samples in the laboratory for feasibility of further analysis Analytical phase No noted delays Post-analytical phase Shortage of Typist specially in the peak morning hours. Delay in abnormal reports verification by Biochemists Failure by laboratory staffs to intimate “Critical tests” and “Critical results” to the treating team as per hospital protocol. Difficulty by the laboratory staffs to reach out to the treating team to intimate “Critical tests” and “Critical results” to the treating team as per hospital protocol.5 Recommendations with an aim to reduce delays in different phases: Pre-analytical phase Incorporation of the allocated staff nurse during physician rounds and starting physician handoff forms to strengthen physician communication between shift changes. To continue with the existing process of bed-side shift handover for the nursing staffs. An extra column for investigations advised by the treating team with their pending status was added in the display board in every ward. Training imparted to the staff nurses and the trainee doctors on the use of appropriate vials for sample collection and reference document made available in the work stations. The concept of ward rounds by the phlebotomists was initiated at 6 AM, 10 AM, 2 PM and 6 PM to improve on the sample collection process. A red coloured “URGENT” sticker was introduced and the staff nurses, the trainee doctors, the runner boys and the laboratory staffs were trained on the use and the implications of the sticker which needed to be processed on an urgent basis. During peak morning hours, the nursing in-charges of the respective patient care units were asked to liaison with the Housekeeping supervisors of the respective floors to ensure rapid and smooth sample transportation to the laboratory.  The hospital management took proactive steps to increase the number of sample carrier boxes with an aim towards infection control practices for carrying blood, urine and stool samples separately. 24X7 sample receiving area with appropriate manning was ensured by the hospital management and backup with adequate and trained staffs provided to ensure that technician shortage was also taken care of to reduce of the delay of screening and processing samples for run analysis. Analytical Phase No delays were reported in the analytical phase. The hospital has a good system of Internal and External Quality Control and maintains its inventory of reagents meticulously which is being monitored by the hospital management on a monthly basis. Commonly used indispensable machines have backups. Preventive Maintenance of the Machines as a part of the Comprehensive Maintenance Contract is under direct supervision of a dedicated in-house Biomedical Engineer appointed for the Laboratory equipment. Post-analytical Phase Shortage of typists were duly addressed by recruitment of a typist in the morning hours. The on call night duty roster for Post Graduate students and the faculty was enforced to ensure that there is atleast one competent authority to verify and abnormal reports even at night. The clinical and the laboratory staffs were trained on the “Critical tests” and the “Critical results” and the hospital policy on reporting the same to the treating team together. The list of “Critical tests” and “Critical results” were made available in the 6 computers in the Nursing stations and the Laboratory for ready reference of the involved staffs. Laboratory staffs were retrained on the documentation of result reporting to treating team for the “Critical tests” and the “Critical results”. The nursing staffs and the trainee doctors were trained on the hospital protocol of acting upon a “Critical test” and a “Critical result” once intimated from the laboratory. The hospital management together with active support from the Head of the Department, Biochemistry gave full support with an aim towards improving on the TAT. Last but not the least, in the second phase the proposal to introduce the Bar coding system with scanner and printer was put forth to the hospital management with an aim to reduce errors and ensure faster sample handing. The recommendation to link up the “Critical test” and the “Critical results” reporting with the Short Message Service (SMS) alert of the departmental service mobiles is also under consideration for further improvement. The study brought out the problems in the process which were affecting the TAT of the samples handled by the Biochemistry laboratory. Conclusion Pre analytical phase and post analytical phase delays contribute to delayed TAT in hospital settings. Stringent Quality Control measures can avoid analytical phase delays. Recommendations with an aim to reduce the delays with active involvement of the management can be fruitful. Limitations of the study The study looked into the Turnaround Time for the samples handled by the Biochemistry department only and rare and outsourced tests were excluded. Though the study, meticulously looked into the reasons for delayed Turnaround time of the samples handled by the Biochemistry department in detail looking into every process step, however, the short span of the study for three months could be a deterrent in unmasking other potential problem areas. Further follow-up studies are needed to analyse the effects of the interventions on the Turnaround time of the samples handled by the Biochemistry department. Conflict of Interest The authors declare that there is no conflict of interest. Special Acknowledgement The authors are deeply indebted to the Director, Dr Dilip Kumar Jaiswal, the Registrar, Dr Ichchhit Bharat and the Head of the Department, Biochemistry, Dr H N Das of MGM Medical College and LSK Hospital, Kishanganj for their support. 7 Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Englishhttp://ijcrr.com/abstract.php?article_id=2655http://ijcrr.com/article_html.php?did=26551.Hawkins RC. Laboratory turnaround time. Clin Biochem Rev. 2007;28:179-94. 2. Howanitz  J  H,  Howanitz  P J.Laboratory results. Timeliness as a quality attribute and strategy.  Am J ClinPathol 2001; 116:311–315. 3.Steindel S J, Howanitz P J. Physician satisfaction  and  emergency department  laboratory  test turnaround  time.  Arch  Pathol  Lab Med 2001; 125:863–871. 4. Kilgore ML, Steindel SJ, Smith JA. Evaluating stat testing options in an academic health center: therapeutic turnaround time and staff satisfaction. Clin Chem. 1998;44:1597-603. 5. Goswami  B,  Singh  B,  Chawla R et al.  Turaround  time  (TAT)  as  a benchmark  of  laboratory performance. Indian J ClinBiochem 2010; 25:376-379. 6.Lundberg G. When to panic over an abnormal value. Med Lab Obs 1972;4:47-54. 7.Lippi G, Mattiuzzi C. Critical laboratory values communication: summary recommendations from available guidelines. Ann Transl Med. 2016;4(20):400. Doi:10.21037/atm.2016.09.36 8. Performance criteria and quality indicators for the post-analytical phase. Sciacovelli L, Aita A, Padoan A, Pelloso M, Antonelli G, Piva E, Chiozza ML, Plebani M ClinChem Lab Med. 2016 Jul 1; 54(7):1169-76. 9. Dey, Biswajit& Bharti, Jyotsna & Chakraborty, Montosh. (2013). Laboratory turnaround time. International Journal of Health Sciences and Research. 3. 82-84. 10.Steindel SJ, Novis DA. Using outlier events to monitor test turnaround time. A college of American pathologist Q-probe study in 496 laboratories. Arch Pathol Lab Med. 1999;123:607-14. 11. Wankar AD. Study of determination of laboratory turnaround time in tertiary care hospital in India. Int J Res Med Sci 2014;2:1396-401.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241125EnglishN2020March7HealthcareIron Quantification in Deep Subcortical Nuclei and its Correlation with Extracranial Venous System in Multiple Sclerosis and Controls English0612Sheikh Hilal AhmadEnglish C. S. AgrawalEnglish Seema SudEnglish Manish MahajanEnglishBackground: Multiple sclerosis (MS) is an acquired demyelinating disease of the central nervous system presumed to be of autoimmune nature. This MRI based study was done to see iron deposition in deep subcortical nuclei and look for any abnormalities in extracranial venous drainage system and to look for any correlation with clinical parameters . Material and Methods: This case control study was done in a single large north Indian institute and had two groups of 25 cases each. One group being of consecutive MS patients and another of other neurological disease (OND). The two groups were age and sex matched. Both the groups underwent Magnetic Resonance Venography (MRV) of neck vessels and azygous system and cross sectional areas of internal jugular veins, azygous veins were measured. Iron stores in deep grey matter nuclei were quantified with Susceptibility weighted Imaging (SWI) studies. Results: The predefined cross sectional areas of internal jugular veins ( IJV) and azygous veins were comparable. On comparing the flows of right and left IJVs, there was a clear dominance of right side in both MS and OND groups. We found more iron in all the nuclei in MS group compared to OND group. But statistically significant difference between the two groups was seen in bilateral pulvinar thalami and red nuclei, right putamen, right caudate nucleus and left substantia nigra. The absence of any difference in anatomical parameters in two groups goes against any vascular hypothesis of iron deposition in deep subcortical nuclei. The iron deposition may be an epiphenomenon of underlying disease rather than having to do something with etiopathogenesis. EnglishIron quantification, Deep subcortical nuclei, Venous abnormalitiesIntroduction Multiple sclerosis (MS) is an inflammatory, demyelinating disease of the central nervous system (CNS) of unknown pathogenesis; it is considered to be of autoimmune nature.[1,2]  and continues to challenge investigators trying to understand the pathogenesis of the disease and prevent its progression. [3] Importance of iron in multiple sclerosis has been recently studied and its significance in pathogenesis of disease has generated a lot of interest. Many  opposing theories have been put forth and this is shown by the  fact that on one side  chelating therapy was tried in one study to reduce iron deposition in brain  by Levine et al; the hypothesis being to decrease free radical damage induced by iron via Fenton reaction.[4] On the converse side  iron deficiency has been postulated to increase relapse rate  and even put forth as a reason for increased incidence of MS in females.[5,6] Having said that, increased iron deposition has been demonstrated in multiple sclerosis brain in many studies mostly in deep subcortical nuclei and around demyelinating plaques. Exact process of iron deposition is not known. The presence of iron was thought to be secondary to immune response causing local accumulation of iron by disrupting the blood brain barrier and by attracting iron-rich macrophages. [7] Impaired axonal clearance of iron has also been postulated. [8] In the past decade a vascular theory for MS was proposed; with some similar insinuations made in 19th century.[9 ,10]  The theory put forth is that iron deposits in MS are a consequence of altered cerebral venous return and chronic insufficient venous drainage.[9,11] . It is shown diagrammatically Figure 1.            Moreover it was postulated that venous  hypertension and local reflux in medial venous drainage system of brain (internal cerebral veins and vein of Galen) leads to deposition of iron in  thalamus and basal ganglia.[12] Furthermore   several studies have demonstrated a greater correlation between grey matter lesions with  fatigue and deficits in cognitive than with white matter  lesions, this has suggested  that measuring iron in grey matter might be of  clinical significance.[13] The vascular theory put forth proposes structural venous abnormalities in extracranial draining veins viz; internal jugular and azygous veins in the form of stenosis and abnormal valves. This would lead to decreased flow from primary draining veins and reflux of venous blood getting transmitted to medial venous system in brain and opening of collateral channels in vertebral veins and lumbar veins. In fact pathological changes have been shown in jugular veins and absence of endothelium on defective valves shown by scanning electron microscope.[14] The venous abnormalities were looked via doppler studies initially and later on via percutaneous selective venography. MRI studies being non-invasive and with more interoperative reliability than Doppler were used to investigate this theory subsequently. However conflicting results were shown regarding both anatomical and flow dynamics in draining veins and furthermore correlation with clinical parameters of MS was not done in all. The lack of a clear explanation for iron deposition in deep subcortical nuclei has kept the vascular hypothesis in debate even though a randomised study was published to demolish the vascular hypothesis.[15] In this context our study was conceptualised to look into iron deposition in brain in context of vascular hypothesis. Material and methods It is a case control observational study. It consisted of two groups one being multiple sclerosis patient group (diagnosed as per McDonald Criteria) and another was a control group consisting of patients having other neurological disease OND. First 25 sequential patients of those who gave consent were enrolled as a case in the MS group. The study was cleared by our hospital’s ethics committee. Other neurological disease OND (Control Group): These included those patients who were suffering from other neurological disease OND and needed MRI plain and contrast for their basic disease; e.g. Headache, leucodystrophy, Dementias. Twenty five patients were enrolled as controls in this Other Neurological disease (OND) group. Exclusion criteria History of surgery in head, neck or  mediastinum . Radiation to neck or chest. Past history of cerebral venous thrombosis, History of Transient global amnesia. Thrombosis in veins of neck or any central venous catheter in the Internal Jugular Vein.  Chronic Heart or  lung disease. Budd–Chiari syndrome. An  informed consent was taken from all  patients .A  detailed history was taken and thorough  physical examination was done. Type of MS, disease duration, relapse rate, Expanded Disability Scoring Scale (EDSS) score was noted.        Non invasive evaluation for extracranial venous drainage in MS patient group as well as OND controls was done by MRI studies and this included, CEMRI Brain and spine, Contrast MRV of head, neck and azygous venous system (figure 2), Susceptibility weighted imaging of brain. The MRI studies were done on a 3T SEIMES VERIO machine and it is a left sided system.          Susceptibility weighted imaging (SWI): For doing iron quantification we acquired the susceptibility weighted images SWI images. The SWI study was done as per the protocol keeping TR= 27, TE= 20, FOV 240, Slice thickness= 4mm, Distance factor= 20, FOV phase 81.3, FA flip angle= 150o and bandwidth BW=287hz/px. In the post processing we quantified iron in sub cortical deep grey matter nuclei  viz., Caudate nucleus, Globus pallidus, putamen, red nucleus, pulvinar thalamus, red nucleus, substantia nigra. On the phase images of the MS and OND cases regions of interests (ROIs) were hand-drawn following the contour of nucleus. We used SPIN software for processing SWI phase images and it generated the number of pixels, mean, SD, maximum intensity and minimum intensity within the ROI. For converting phase values to microgram iron we took 180 units (0.276 radians) of phase to be equivalent to 480 g Fe/g/cc tissue. And for calculating total iron content following formula was used.16 Iron content = - {(φSPU -2048) × 3.14× 480× pixel # × 3.23} / (2048× 0.276× 1000) μg/cc. φSPU            =  mean phase pixel #    = number of pixels Anatomical details of draining veins: Measurement of the maximum and minimum cross sectional area (CSA) in both the internal jugular veins IJVs (right and left) in both the groups was done. Cross sectional area CSA at the bulb of internal jugular vein IJV i.e. just below its formation from the jugular sinus was also measured. This acts like a reference point as it is taken at a predetermined level in all the cases of MS or OND group. Stenosis in any IJV was defined as a CSA of less than 0.125cm2 at or above 3rd cervical vertebral level or a CSA of less than 25cm2 below 3rd cervical vertebral level.[16,17] Morphological measurements in azygous vein included measuring maximum CSA of the horizontal part of the azygous vein as it enters superior venecava. We also measured the minimum CSA of the vertical portion of the azygous vein. Results Cohort demographics: The two groups were   similar in age and sex  distribution (Table  1). The mean of relapses in previous 2 years was 2.76(SD=1.535).The relapses in previous 2 years in the multiple sclerosis cohort were; minimum 1 and   maximum 8. Of the 25 patients, 22 were having Relapsing Remitting MS (RRMS) type of multiple sclerosis; while 3 patients were having  Secondary progressive MS (SPMS). On comparing the total iron; which was calculated from mean phase, number of pixels i.e.  volume and as per equation discussed in material and methods ,in various deep subcortical nuclei between the two groups (figure 3) we found more iron in all the nuclei in MS group compared to OND group ( Table 2). statistically significant difference was seen in bilateral pulvinar thalami and red nuclei, right putamen, right caudate nucleus and left substantia nigra. Various cross sectional areas (CSA) of IJV at maximum ,minimum and at IJV bulb were comparable  in cases and controls on both sides as described in (Table 3) P value was insignificant between two groups .similarly maximum and minimum cross sectional area (CSA) of the horizontal segment of azygous vein in MS cases and OND group were again comparable (Table 3 ) The number of cases having stenosis (by definition adopted by as discussed above) in Right IJV was 2 and 5 in MS and OND groups respectively. Similarly on left side 2 and 3 cases had stenosis in MS and OND group respectively (figure 4). Discussion The anatomical parameters of draining veins in MS cases and OND controls were comparable .Similar results were shown in other studies as well. The presence of stenosis in IJV looks as normal variation in caliber of draining veins as they were present in comparable numbers in OND group as well (figure 3); we have used a definition for defining stenosis similar to most studies so as to make our results comparable. As we know well that veins have a considerable variation in their size, shape as compared to other anatomical structures in body and may depend on position of body respiratory cycle and hydration status. [18]Thus these so called “stenosis” seem to be normal anatomical variations rather than any pathological entities (figure 5). These observations go against the theory of CCSVI which proposes stenotic lesions as the basis of the etiopathogenesis of multiple sclerosis. As per CCSVI hypothesis we should have had lesser cross sectional areas and more stenosis in the MS group which we did not observe in our study. Similar findings refuting the CCSVI hypothesis and showing no evidence of more IJV stenoses/narrowing in MS patients were observed by other authors.[19,20,21,22] Iron quantification: we documented increased iron deposition in multiple sclerosis and we have quantified it as well. As has been demonstrated in other studies in multiple sclerosis, we found more iron in all the nuclei in MS group compared to OND group. statistically significant difference was seen in bilateral pulvinar thalami and red nuclei, right putamen, right caudate nucleus and left substantia nigra. Similarly iron deposition has been show in other studies.[23,24] As regarding Clinically isolated syndrome (CIS) we did not have CIS patients in our study. But there have been contradicting results in previous studies; while a study by khalil et al  revealed no iron deposition ;  other  studies showed increased iron  in CIS patients.[25,26,27] It has been shown in a previous study  that basal ganglia iron accumulation in MS occurs with advancing disease and is related to the extent of morphologic brain damage.[25] We could not find any correlation between total iron in the six deep grey matter nuclei on both sides with the various clinical parameters as EDSS, Disease duration ,Relapses in previous 2 years and whether stenosis was present or not. Lebel et al found significant correlations of disability with pulvinar iron deposition; marginally significant correlations were also observed in the thalamus and red nucleus. No significant correlations were observed with duration since index relapse.[28] The apparent lack of any correlation is not clear. The MS patients in which we could get iron quantification was only 19 which is very small sample for such a correlation. Second we had only 3 MS cases having stenosis (one having bilateral and two having unilateral stenosis), hence getting any sort of correlation was not possible. Third our cohort of patients were having relatively less disease duration with median age being 4 years only and we had no CIS patients in our study. Though we need longitudinal studies ideally to look into such a correlation, but there might be a suggestion here that iron deposition in subcortical nuclei is more of a bystander phenomenon rather than something involved in pathogenesis of disease. As regarding reason for iron deposition in these deep subcortical nuclei we feel this could be because of  impaired axonal transport of iron because of axonal injury secondary to multiple sclerosis lesions. Thus it is difficult to accept vascular theory for iron deposition .Its promoters argue that the pattern of iron deposition seen in the basal ganglia, thalamus and midbrain of most MS patients represents a backward iron accumulation and is consistent with the hypothesis of venous hypertension i.e. MS is a perivenular disease first and an inflammatory demyelinating disease second. But it is very difficult to accept that iron deposition is because of venous hypertension without first proving the basic step i.e. anatomical and physiological abnormalities of draining veins. The comparison between CIS and RRMS in another study discussed above showed significantly increased iron in RRMS and thus this iron deposition could very well be epiphenomenon of the underlying disease. [25] Strength and limitations of our study The strength of our study is that unlike other studies it is a case control study and has attempted to verify the CCSVI hypothesis critically. We have used a noninvasive MRI techniques to study the two groups and thus involved no risk whatsoever to the cases and controls unlike studies done involving conventional venography. The limitations include that; we have not taken a healthy control group as our ethics committee did not allow for contrast MRI studies in healthy controls. The sample size in our study was not large and we could do iron quantification studies in 19 out of 25 patients only due to technical reasons. We have not taken any clinically isolated syndromes (CIS). Conflict of interest:  Authors declare no conflict of interest. Funding: Grant by research department of Sir Ganga Ram Hospital. No specific directions or intervention what so ever were made by research department during or after the study. Acknowledgements: We thank MR Medical Imaging Innovations, Hyderabad, for helping in iron quantification. Conclusion: There was increased iron deposition in most of the deep subcortical grey matter nuclei in MS patients as compared to controls. This may be an epiphenomenon of underlying disease rather than having to do something with etiopathogenesis. The significance of deposition in subcortical deep grey matter needs to be studied further. We could not find evidence in support of vascular theory on doing non-invasive evaluation of MS patients and comparing with control group.  There was no significant correlation between clinical parameters of MS patients viz. Age, EDSS, Disease duration, Relapses in preceding two years  and anatomical measurements and stenosis. Thus even though CCSVI is an interesting hypothesis but we could not find any evidence in its favour in our study. But on a positive site CCSVI theory has generated a lot of interest and research into studying venous hemodynamics, venous abnormalities and iron deposition as possible mechanisms of various disease processes in CNS. Englishhttp://ijcrr.com/abstract.php?article_id=2656http://ijcrr.com/article_html.php?did=26561.Noseworthy JH, Lucchinetti C, Rodriguez M, Weinshenker BG. Multiple sclerosis. N Engl J Med 2000;343:938–52. 2.Frohman EM, Racke MK, Raine CS. Multiple sclerosis—the plaque and its pathogenesis. N Engl J Med 2006;354:942–55. 3.Noseworthy J. Progress in determining the causes and treatment of multiple sclerosis. Nature 1999;399: Suppl:A40-A47. 4.LeVine SM, Chakrabarty A  .The role of iron in the pathogenesis of experimental        allergic encephalomyelitis and multiple sclerosis. Ann N Y Acad Sci 2004;1012:252–266 5. Warren SA, Svenson LW, Warren KG  Contribution of incidence to increasing prevalence of multiple sclerosis in Alberta, Canada. Mult Scler 2008; 14:872–879 6. Susan J. van Rensburg & Maritha J. Kotze & Ronald Van Toorn. The conundrum of iron in multiple sclerosis – time for an individualised approach. Metab Brain Dis 2012 ;27:239–253.       7. Lucchinetti C, Bruck W, Parisi J, Scheithauer B, Rodriguez M, Lassmann H. Heterogeneity of multiple sclerosis lesions: implications for the pathogenesis of demyelination. Ann Neurol 2000;47:707–717. 8. Lassmann H, Bruck W, Lucchinetti CF. The immunopathology of multiple sclerosis: an overview. Brain Pathol 2007;17:210–218. 9. Zamboni P. The big idea: iron-dependent inflammation in venous disease and proposed parallels in multiple sclerosis. J R Soc Med 2006;99:589-93. 10. Putnam. Evidences of vascular occlusion in multiple sclerosis and encephalomyelitis. Arch. Neurol. Psychiatry1937; 6: 1298-1321. 11. Singh and Paolo Zamboni.   Anomalous venous blood flow and iron deposition in multiple sclerosis. Journal of Cerebral Blood Flow & Metabolism 2009; 29, 1867–1878 12. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241125EnglishN2020March7Life SciencesCorrelation of Serum Vaspin with Cardiovascular Risk Factors in T2DM English1318Priya KumariEnglish S K BansalEnglish D K SharmaEnglish Birendra Kumar YadavEnglishBackground: Vaspin is a visceral adipose tissue-derived serine protease inhibitor. Previous data suggest that vaspin may be involved in the glucose metabolism and the development of T2DM in humans. Objectives: This study is intended to compare the serum vaspin and atherogenic propensity by comparing fasting plasma glucose, post-prandial plasma glucose, lipid profile, atherogenic index and BMI with Ox-LDL level as a marker for cardiovascular risk between diabetic patients and non-diabetic subjects. Material & Methods: This study was conducted with 120 newly diagnosed type 2 diabetes mellitus (T2DM) patients with age-matched 120 non-diabetic subjects as controls. Results: We found that there is significant increase in the parameters like serum Vaspin, FPG, PPPG, lipid profile (Total Cholesterol, Triglycerides & Very low density lipoprotein), Oxidized-Low density lipoprotein level and Atherogenic index (TC/HDL). No significant differences were found between BMI, LDL & HDL parameters of T2DM patients compared to non-diabetic subjects. The results have been shown positive correlation (P?0.01) between Vaspin with BMI and LDL while negative correlation (P?0.01) was observed between Vaspin with FBS, PPBS, Ox-LDL & VLDL in T2DM patients. Conclusion: Our results indicate that circulating Vaspin and Ox-LDL are potential new independent CVD risk biomarker in T2DM. EnglishT2DM, Risk factors, Vaspin and Ox-LDLIntroduction: Vaspin (visceral adipose tissue-derived serine protease inhibitor), a novel adipocytokine, was firstly identified in obese OLETF (Otsuka Long-Evans Tokushima Fatty) rat. Vaspin belongs to the serpin super family, clade A (Serpina 12). It is composed of 415, 412, and 414 amino acids in humans, rats, and mice, respective­ly [1]. In addition to adipose tissue, vaspin gene expression has been observed in human stomach, liver and pancreas and vaspin expression has also been observed in the hypothalamic of db/db and C57BL/6 mice [2-4]. It has been suggested that vaspin has potential insulin-sensitizing effects [1]. In humans, vaspin expression in terms of mRNA was detected in human visceral and subcutaneous adipose tissue [2]. Recent studies also found that vaspin gene expression in human adipose tissue and circulating vaspin levels were positively associated with obesity-associated diseases and T2DM [5, 6]. Furthermore, it is indicated that vaspin plays a role in adipoinsular axis, and may be associated with insulin resistance in obese subjects, including patients with T2DM and polycystic ovary syndrome [7, 8]. Therefore, all these data suggest that vaspin may be involved in the glucose metabolism and the development of T2DM in human. Up to date, all studies on roles of vaspin in human metabolic diseases were cross-sectional, but it is still unclear what the real role of vaspin is in the progression of diabetes in a longitudinal process. It remains unclear whether the observed alterations in serum Vaspin and/or inflammatory parameters in T2DM are due to excess adipose tissue mass and/or directly associated with the diabetic state [9, 10].   This study is intended to compare the serum vaspin and atherogenic propensity by comparing fasting plasma sugar, post-prandial plasma glucose, lipid profile, atherogenic index and BMI with Ox-LDL level as a marker for cardiovascular risk between diabetic patients and non-diabetic subjects. The purpose of this study was to explore the correlation of serum Vaspin with lipid profile, fasting plasma glucose, and oxidized LDL level as inflammatory markers for cardiovascular risk between diabetic and non-diabetic patients and with anthropometric variables in patients with T2DM. Materials & Methods: Study participants This study was conducted with 120 newly diagnosed type 2 diabetes mellitus (T2DM) patients with age-matched 120 non-diabetic subjects as controls. Inclusion criteria were patients in the age group of 30-60 years of both males and females. Patient with newly diagnosed Type 2 DM based on fasting plasma glucose level ≥ 126 mg/dl or 2-hour postprandial plasma glucose ≥ 200 at two separate occasions after an overnight fast 8- 12 hours  (based on American Diabetic Association) [11]. Exclusion criteria were age < 30 and > 60 years, conditions that could potentially alter vaspin concentrations such as prolonged fasting, advanced chronic diseases (such as chronic liver disease, chronic kidney disease, congestive heart failure, thyroid disease, etc.), Patient on medications such as hypolipidemic drugs, hypoglycemic drugs, hormone replacement therapy, tissue plasminogen activator (tPA), anticoagulant therapy (heparin) and steroid, Known cases of Type 1 diabetes mellitus, Pregnant and lactating women. Diagnosis of diabetes was based on the criteria of American Diabetes Association [11]. The information of patients were obtained through a questionnaire consisted of the sex, age, height, weight and BMI. BMI was calculated using the following formula: BMI = weight (kg)/height (m) 2 [12]. Informed consent was obtained from all participants and the study protocol was approved by the Ethics Committee of the SGT Medical College, Gurugram, Haryana and India. Methods Assay of biochemical markers Five milliliters of venous blood samples were collected from each patients and controls subject after 12 h of overnight fast in serum separator tubes. After clot formation, samples were centrifuged at 1000 x g for 20 minutes, and then serum was separated and transported into new disposable tubes and kept at -20°C for one month. Fasting plasma glucose (FPG), Post-prandial plasma glucose [13, 14], total cholesterol (TC) [15, 16], triglycerides (TG) [17], high density lipoprotein (HDL) [18-20] and low density lipoprotein (LDL) [21-23] were assayed on fully automated analyzer (EM-200). Assay of circulating Vaspin and Ox-LDL in serum The assay was performed after bringing all reagents, diluted standards and samples to the room temperature. Vaspin was assayed using Human vaspin ELISA Kit SEA706Hu (Cloud-Clone Corp, Inc., USA) with detection range from 0.156 ng/ml to 10 ng/ml and sensitivity of 0.056 ng/ml, with no significant cross-reactivity or interference with other analogues [24]. Ox-LDL was assayed using Human Oxidized Low Density Lipoprotein (Ox LDL) ELISA Kit SEA527Hu (Cloud- Clone Corp, Inc., USA). The detection range is from 15.6 pg/ml to 1000 pg/ml with an estimated sensitivity of less than 6.2 pg/ml. Intra-assay and inter-assay precision coefficients of variation (CV%) were Englishhttp://ijcrr.com/abstract.php?article_id=2657http://ijcrr.com/article_html.php?did=2657 Hida K, Wada J, Eguchi J, Zhang H, Baba M, et al. Visceral adipose tissue-derived serine protease inhibitor: a unique insulin-sensitizing adipocytokine in obesity. Proc Natl Acad Sci USA. 2005; 102:10610–5. Kloting N, Berndt J,et al. Vaspin gene expression in human adipose tissue: association with obesity and type 2 diabetes. Biochem Biophys Res Commun. 2006; 339: 430-6. Kloting N, Kovacs P, et al. Central vaspin administration acutely reduces food intake and has sustained blood glucose-lowering effects. Diabetologia. 2011; 54(2011): 1819-23. Korner A, Neef M, et al. Vaspin is related to gender, puberty and deteriorating insulin sensitivity in children. Int J Obes (Lond). 2011; 35: 578-86. Tan BK, Heutling D, Chen J, Farhatullah S, Adya R et al. Metformin decreases the adipokine vaspin in overweight women with polycystic ovary syndrome concomitant with improvement in insulin sensitivity and a decrease in insulin resistance. Diabetes. 2008; 57:1501–7. Aktas B, Yilmaz Y, Eren F, Yonal O, Kurt R, et al. Serum levels of vaspin, obestatin, and apelin-36 in patients with nonalcoholic fatty liver disease. Metabolism. 2011; 60:544–9. Cakal E, Ustun Y, Engin-Ustun Y,et al. Serum vaspin and C-reactive protein levels in women with polycystic ovaries and polycystic ovary syndrome. Gynecol Endocrinol. 2011; 27:491–5. 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