Biological Oxygen Demand (BOD)
It is also known as Biochemical Oxygen Demand (BOD). It is defined as the amount of oxygen consumed during the process of degradation and eventual stabilization of unstable organic substances by the biochemical activities of aerobic and other microbes. This degradation of the chemical complex is a desirable process and the final product is called stabilized wastewater. The aerobic bacteria consume oxygen during the process of oxidization of the organic and other oxidizable inorganic substances. The immensity of biochemical degradation depends on the population of bacteria. An actively growing population of bacteria will consume more oxygen to quickly decompose unstable complexes. Biological/Biochemical Oxygen Demand (BOD) is reduced with the decrease in the quantity of these complexes in the wastewater. Therefore, it can be surmised that BOD is directly proportional to the level of degradable chemical complexes; high concentration of chemical substances will result in the high BOD.
The BOD is a very useful measure of the efficiency of methods of wastewater treatment. A method in which amount of BOD reduced quickly is considered as most effective and efficient method. Therefore, exactly stabilized effluent, when discharge in the body of water, does not cause reduction of oxygen in the water.
Wastewater Disposal Methods
It is a well-known fact that the wastewater should be treated properly and effectively before its disposal into receiving water bodies. Disposal of wastewater may be accomplished with or without treatment.
Disposal of Wastewater by Treatment Methods
There are different methods available for the removal of microorganisms and stabilized the putrescible organic and inorganic chemicals in the wastewater. These methods are known as wastewater treatment methods. It is a very interesting fact that usually microorganisms are used to reduce the large burden of wastewater, which is organic matter. With few exceptions, wastewater treatment plants are integrated with physical, chemical and microbiological methods to concern with the different problems related to wastewater.
According to distinct types of treatment, they are divided into four types. Each type of treatment process has a special purpose, targeting the removal of all sources of materials and reducing the burden of microorganisms from the wastewater.
Primary Treatment of Wastewater
This process is mainly designed to remove the total solids from the wastewater by sedimentation and render it adequately free from pathogenic bacteria by chlorination. Initially, large objects are removed by bar screens from the wastewater flow. It removes a significant amount of particulate matter. The collected objects are then put into the grinder and released back into the wastewater flow.
The wastewater is then allowed to flow to a series of large primary settling compartments in which most of the organic matters and dense inorganic particles such as grit and sands are removed. Usually, there are two types of settling compartment, (a) grit compartment and (b) sedimentation tank or quiescent settling compartment. In grit compartment, wastewater flows very slow which permits large and heavy particulate matter to settle out. In the next step, the municipal and industrial wastes (particulate organic matters) in wastewater are removed in the sedimentation tank. In sedimentation tank, wastewater is allowed to stay for 1 to 3 hours during which most of the suspended organic matter settles out. The sedimented material is in the form of a semi-solid mass called sludge. The efficiency of sludge formation can be increased by the addition of various chemicals to coagulate the suspended particles which enhanced the sedimentation rate. The sludge is not allowed to remain in the bottom of sedimentation tank for a long period because of anaerobic bacteria produce gases during metabolism that tend to resuspend the settled material and increased the odor. Therefore, the sedimentation tank is equipped with scrapper mechanisms that occasionally removes the bottom sludge to a collection hopper. The underflow sludge becomes a waste product of the process. The remaining liquid portion of the wastewater which leaves the tank is called effluent.
To be continue...
There are certain bacteria which cannot be stained by Gram's method. In 1882, Paul Ehrlich developed a method of staining such type of bacteria. This method was named, and still known as acid-fast staining and the bacteria were named as acid-fast bacteria. In the same year, Ehrlich's method was improved by Zehil and Neelsen. Nowadays, Ziehl-Neelsen method is believed as most important differential staining procedure used for the identification of acid-fast species of Mycobacterium, Actinomyces, and Nocardia. There are many acid-fast bacteria which are pathogenic, such as M. tuberculosis (tuberculosis), A. israelii (actinomycosis), M. leprae (leprosis), and N. asteroides (nocardiosis).
Acid-fast bacteria may be defined as those cells which keep the color of the primary dye (carbol fuchsin) even after the process of decolorization by the acid-alcohol solution. Those bacteria which fail to do so are known as non-acid-fast bacteria.
Acid-fast bacteria are coated with a thick waxy material, mycolic acid, which makes the bacterial cells highly resistant to the penetration of dyes. The penetration of dye is promoted by using heat as mordant. The heat invades the dye through the waxy coat and into the cytoplasm.
- Differentiation between acid-fast and non-acid-fast bacteria.
- Diagnosis of pulmonary tuberculosis from sputum smear. See also: Examination of Sputum
- Carbol fuchsin
- Acid-alcohol solution
- Methylene blue
- Bunsen burner
- Wire loop
- Glass Slide
- Spirit lamp
Acid-Fast staining by Ziehl-Neelsen method
- Take a clean glass slide and prepare a thin smear from the specimen using sterile technique. The smear should be extremely thin covering a large area of the slide.
- Dry the smear is air and then fix the slide by passing the slide through the flame.
- Cover the slide with carbol fuchsin. Keep it for 5 minutes over a spirit lamp with constant heating but not boiling. Do not allow the stain to dry over the slide.
- When the slide is cooled, wash it with tap water.
- Flood the slide with acid-alcohol and leave it for 3 minutes. Wash the slide with tap water and drain.
- Counterstain with methylene blue for 2 minutes.
- Wash the slide with tap water and keep it for dry.
- Observe the slide under oil immersion objective.
Microscopic examination reveals acid-fast tubercle bacilli as short, straight or slightly curved bright red rods. Non-acid-fast cells appear blue.
Acid-Fast Staining by Mobin Method
In 1985, a Pakistani microbiologist, Abdul Mobin Khan developed a method for the staining of acid-fast bacteria. In this method, heating of flooded primary dye on smear is not required. However, initial fixing of the smear over the flame is necessary in order to increase the permeability of the cell wall and promote the newly formulated primary dye to penetrate the cell.
Sputum, body fluid, pus, or swab of cells taken from the location of an infection; a sample of bacteria grown and isolated in culture.
- Mobin stain
- 1% H2SO4
- Crystal violet
- Wire loop
- Bunsen burner
- Glass slides
- Using sterile technique, prepare a thin smear from the specimen covering a large area of the glass slide.
- Dry the smear in the air and then fix it by passing the slide 20 times through the flame.
- Place the smear on the staining rack and cover it with Mobin stain. Keep it for 10 minutes.
- Pour off the stain and wash the slide with tap water.
- Decolorize the smear by 1% H2SO4 solution till it is light pink.
- Wash the slide with tap water and keep it for dry.
- Observer the slide under oil immersion objective.
Microscopic examination reveals acid-fast tubercle bacilli as short, straight or slightly curved red rods while non-acid-fast bacteria as blue.
In 1883 (originally published in 1884), Dr. Hans Christian Gram (1853-1938) developed a technique for the classification of bacteria into two broad groups, Gram-positive and Gram-negative. It is the most important staining technique for the classification and differentiation of bacteria.
The Gram stain consist of four reagents; crystal violet (use as a primary dye), Gram's iodine (use as a mordant), ethyl alcohol (use as a decolorizer), and safranin (use as a counterstain). The Gram-negative, on the other hand, lose the primary dye (crystal violet) when decolorized and, thus, take the color of counterstain (safranin).
The Gram-reaction rely upon the chemical nature of the bacterial cell wall, especially the lipids which comprise 11-22% in Gram-negative cell wall and 1-4% in the Gram-positive cell wall. In the Gram-negative cell wall, the amount of lipids is very high, when the cell is dissolved in alcohol, it leads to the formation of large pores in the cell wall. The dehydrating result of alcohol cannot fill these pores which cause the liberate of primary stain making the cell colorless. Such cells take the color or counterstain (safranin). On the contrary, the amount of lipid is very low in the Gram-positive cell wall and easily dissolved by in ethyl alcohol, causing the formation of very small pores. These pores are further closed by the dehydrating effect of alcohol which does not permit the primary dye (crystal violet) to leave the cell.
Identification, differentiation, and classification of the bacteria.
- Crystal violet
- Gram iodine
- Ethyl alcohol (95%)
- Ceder wood oil
- Bunsen burner
- Wire loop
- Glass slides
- Prepare a smear of the specimen, dry in air and then fix it in low flame.
- Flood the smear with crystal violet, and keep it for 1 minute. Wash the smear with running tap water.
- Pour Gram's iodine on smear and after 1 minute, wash it with tap water.
- Pour alcohol on the smear until the purple color no longer comes from the smear.
- Pour safranin on the smear and after 45 seconds, wash it with tap water and keep the smear dry in air.
- Observe the stained smear under oil immersion lens and note down the arrangement, shape, and Gram-reaction of the cells.
The Gram-positive bacteria appear in purple color and Gram-negative bacteria appear in pink color.
We are all guilty of pushing ourselves too hard and burning the candle on both ends. But while blaming being tired on a too-hectic lifestyle is commonplace, there is a difference between feeling sleepy and being continuously exhausted.
Maintaining a consistent sleeping routine is essential for your well-being and for bringing about all aspects of a healthy life. Your sleep cycle can make or break your life, which is why it can be frustrating when the pattern is off.
If you are one of the many people who find it challenging to wake up in the morning and then spend the rest of the day feeling exhausted, you may also find it impossible to shut down and sleep soundly in the evening.
How do you fix this seemingly endless, unhealthy and unhappy cycle? Here are some possible reasons for your exhaustion and ways for you to get your energy right.
Reasons for Exhaustion
There are a variety of reasons why you may be suffering from exhaustion, and the causes are going to be varied for every person. However, here are six common reasons.
- A crazy work schedule
Certain work schedules severely disrupt sleep cycles. If you work in a bar, or have overnight or rotating shifts, then there is a high chance your sleeping routine is non-existent. However, working long days or being severely stressed can also disrupt your ability to shut off at night.
- Lifestyle hours that disturb your sleep cycle
If you are a new parent or are overseeing a busy social life, then you probably don't have a set "going to bed" time. Burning the midnight oil over the weekend and then sleeping in will lead to a struggle to fall asleep on a Sunday night, which then directs you to a sleep-deprived Monday morning.
- Constant travel
Traveling is exhausting and is a sure way to say "bye" to any semblance of a routine. Jet lag can wreak havoc on your body and can cause tiredness for a long time after the flight has touched the ground.
- Medical reasons/illnesses
There are several medical-related reasons that you may be suffering from constant exhaustion. Problems such as anemia, thyroid disease, diabetes, depression, and sleep apnea all affect someone's ability to sleep.
- Stimulants like drugs, alcohol, coffee, etc.
Consuming too many stimulants or digesting them at the wrong time are guaranteed means to ruin your sleeping schedule. Don't drink coffee six hours before bedtime, and stop sipping alcohol three to four hours before you try to snooze.
The truth is that you are going to have to be honest with yourself about your lifestyle and the causes of your exhaustion. Only you know how you spend your days, what you consume, and the lifestyle you are living. Being honest with yourself is the first step to tackling the problem.
Fixes for Exhaustion
While you may think that exercising is the last thing you want to do when you are exhausted, it actually is a beneficial way to maintain a sleep schedule and will help you to feel less tired in the long run. Even if you only do a daily 30-minute walk, you will have an energy boost, and then will be more likely to be able to fall asleep at night.
- Natural caffeine
A natural caffeine supplement not only battles exhaustion but also gives you improved cognitive functions, helps with blood sugar and weight management, and encourages healthy aging.
- LIfestyle and environmental changes
Stop checking your phone while in bed, cut down on your alcohol consumption, reduce stress, and eat regular meals. Make sure your bedroom is tidy, purchase some soothing candles and pillow sprays, and implement a night-time routine to help you wind down and relax.
How do you deal with exhaustion? What lifestyle changes have helped you get better quality sleep? Let us know your tips and tricks in the comments below.
- 18 May 2018
Waste products discharged from the digestive tract are composed of up to 75% water, food which is digested but not absorbed, indigestible residue, undigested food, epithelial cells, bile, bacteria, secretion from the digestive tract and inorganic bacteria. Normally an adult human excretes 100-200 grams of feces in a day.
Examination of stool is very helpful in the diagnosis of disease of the gastrointestinal tract as listed below.
Detection of parasites
Stool examination is performed for the detection and identification of worms (adult worms, larvae, segments of worms, ova) and protozoa (cyst or trophozoites). See also: Microscopic Examination of Feces
Stool culture is performed for the evaluation of bacterial infection such as Clostridium difficile, Yersinia, Salmonella, Shigella or Vibrio. Bacterial toxins (such as those released by Clostridium difficile or Clostridium botulinum) can also be identified. See also: Microscopic Examination of Feces
Evaluation of chronic diarrhea
Chronic diarrhea defined as a passage of three or more liquid or loose stools in a day lasting for more than four weeks. Acute diarrhea refers to the passing of three or more liquid or loose stools in a day for less than four weeks. In diarrhea, stool examination is very important part of laboratory investigations. Depending on the nature of the investigation, either a random stool sample or 72- sample or 48-hour sample is collected. A random stool sample is used for the tests of occult blood, pH, fat, white blood cells, microscopy, or culture. A 72- or 48-hour sample is collected and examined for the weight, carbohydrate, fat content, osmolality, or chymotrypsin activity. Causes of chronic and acute diarrhea are listed in Table 988.1 and Figure 988.1 respectively.
1. Watery diarrhea
2. Inflammatory diarrhea
3. Fatty diarrhea
Evaluation of dysentery
Identification of Rotavirus
In infants and young children, Rotavirus is the most common cause of diarrhea. Rotavirus can be identified by the electron microscopic examination of stool. Other techniques, such as latex agglutination, immunofluorescence, or enzyme-linked immunosorbent assay (ELISA) are also used for the detection of Rotavirus in stool.
Chemical tests can be applied on feces to detect excess fat excretion (malabsorption syndrome), occult blood (in ulcerated lesions of the gastrointestinal tract, especially occult carcinoma of the colon) and presence or absence of urobilinogen (obstructive jaundice). See also: Chemical Examination of Feces
Differentiating infection by invasive bacteria (like Salmonella or Shigella) from that due to toxin-producing bacteria (like Vibrio cholerae or Escherichia coli)
Feces is examined for the presence of white blood cells. Increased numbers of polymorphonuclear neutrophils (identified by methylene blue stain from the presence of granules in their cytoplasm) are seen as shown in Figure 988.2. See also: Causes, symptoms, diagnosis, and treatment of Cholera
What is acute leukemia?
It is defined as malignant clonal hematopoietic stem cell disorders characterized by the rapid increase in the number of blast cells in the bone marrow and rapidly progressive fatal course if untreated. Acute leukemia (AL) are primary disorders of the bone marrow, also known as blood cancer.
Classification of acute leukemias
The most widely used classification of acute leukemias is French-American-British (FAB) Co-operative Group classification. The FAB rule for the classification of acute leukemias was originally proposed in 1976. On the basis of the morphology and cytochemistry, they are classified into two major types.
- Acute myeloid leukemia (AML)
- Acute lymphoblastic leukemia (ALL)
Each type is further subclassified. See table 883.1
|Acute myeloid leukemia (AML)|
|M0: Acute myeloid leukemia, minimally differentiated|
|M1: Acute myeloid leukemia without maturation|
|M2: Acute myeloid leukemia, with maturation|
|M3: Acute promyelocytic leukemia M3v: Hypo- or microgranular promyelocytic leukemia|
|M4: Acute myelomonocytic leukemia M4Eo: Acute myelomonocytic leukemia with bone marrow eosinophilia|
M5: Acute monocytic leukemia
|M6: Acute erythroleukemia|
|M7: Acute megakaryocytic leukemia|
|Acute lymphoblastic leukemia (ALL)|
|L1: Lymphoblasts with constant, rounded nuclei, and adequate cytoplasm. Nucleoli are not prominent.|
|L2: More irregular lymphoblast and cytoplasm is available in large quantity. Nucleoli are large and may see one or more nucleoli.|
|L3: Large cells with moderate amount of deeply basophilic cytoplasm; prominent cytoplasmic vacuoles; regular nuclear membrane; 1-2 prominent nucleoli|
In contrast to French-American-British (FAB) classification, World Health Organization (WHO) classification recognizes AML with recurrent cytogenetic abnormalities, AML with multilineage dysplasia, and therapy-related AML as distinct entities.
Patients with clonal, recurrent cytogenetic abnormalities listed in Table 883.2 are considered to have AML irrespective of the percentage of blasts in blood or bone marrow. These patients have characteristic clinical and morphological features and a favorable response to therapy.
1. Acute myeloid leukemia with recurrent genetic abnormalities
2. Acute myeloid leukemia with multilineage dysplasia
3. AML and MDS, therapy related
4. AML, not otherwise categorized
Difference between Acute Myelocytic Leukemia (AML) and Acute Lymphocytic Leukemia (ALL)
|Characteristic Features||Acute Myelocytic Leukemia||Acute Lymphocytic Leukemia|
|Origin of cells||Myeloid series cells||Lymphoid series cells|
|Characteristics of blast cells||Cell is large in size with moderate cytoplasm. Chromatin patterns are fine and lacy. Nucleoli are prominent and are more than two.||Cell is small with scanty cytoplasm. Chromatin patterns are dense. Nucleoli are indistinct and are less than two.|
|Bone marrow||Mixed population of blast and myeloid cells.||Mainly blast cells and very few WBCs or RBCs|
|Sudan black and peroxidase||Positive||Negative|
|Periodic Acid-Schiff (PAS)||Positive in Erythroblast in M6 leukemia||Positive (block patterns) in L1 and L2, and negative in L3|
|Leukocyte Alkaline phosphatase (ALP)||Positive (It is used to differentiate CML from the leukemoid reaction)||Negative|
- Weakness and fatigue
- Low-grade fever
- Bone pain
- Bruising and mild bleeding from gums
- It appears suddenly
Diagnosis of acute leukemia
- This disease is most common in younger age group and more frequent in the children. Mostly found before the age of 20.
- Rapid development of anemia is most common with normocytic and normochromic red cells. You may see some nucleated red cells in the peripheral blood smear.
- Leucocytes (WBCs) count is variable. Mostly leucocytes count is less than 100000/μl.
- Thrombocytopenia (See also Morphology of Platelets)
• Petechiae and purpura may be seen in the skin and mucous membranes.
Laboratory findings in acute myelocytic leukemia (AML)
- Total leucocyte count (TLC) is variable. It is recorded that in 25% of patient's total leucocyte count is < 5000/μl, 25% of the patient has > 50000/μl and 5% to 10% has total leucocyte count between 5000 to 10000/μl.
- Abnormal and immature WBCs are present.
- In 50% of cases, the value of uric acid is raised.
- In bone marrow examination, > 20% blast cells are present. Promyelocytes are numerous especially in M3 (acute promyelocytic leukemia). See table 883.1
- Cytochemical stains, Sudan black, and peroxidase show the positive reaction.
- Auer rods can be seen in the cytoplasm of the cells.
- Nucleated red blood cells may be seen.
- PT, PTT and Thrombin time are elevated.
- Thrombocytopenia may be present and may see the platelets count between 30,000 to 100,000/μl.
Laboratory findings in acute lymphocytic leukemia (ALL)
- Total leucocyte count is variable from low to very high.
- Anemia and thrombocytopenia
- Bone marrow:
It is difficult to find normal RBCs and WBCs.
Very few WBCs are seen.
Characteristically there are blast cells.
Sudan black and peroxidase show the negative reaction.
Auer rods are absent.
Test value for the layman
Examination of peripheral blood smear and bone marrow is advised:
- If the patient has high TLC.
- If the patient has Anemia.
- If the patient has enlarged lymph nodes.
- If the patient has weakness and fever.
Activated Partial Thromboplastin Time (APTT), Partial Thromboplastin Time (PTT), Prothrombin Time (PT) and INR
- 01 May 2018
Why are these tests performed?
- These tests are performed for the diagnosis of bleeding disorders.
- APTT is performed to distinguished the functionality of the clotting factors I, II, V, VII, IX, X, XI, and XII.
- APTT is used to check the treatment of the patient taking heparin or other medicine for blood thinning.
Collection of Sample
Venous blood sample is collected from antecubital fossa in a test tube containing trisodium citrate (3.2%), with the anticoagulant to blood proportion being 1:9. See also: Prothrombin time (PT): Collection of Specimen.
- Sample handling is very sensitive, false and raised values are obtained if the ratio of blood and anticoagulant is not correct.
- Plasma is stable for one hour if kept at 4º C.
- Plasma can be preserved for 28 days if frozen.
Plasma is incubated with an activator (which initiates intrinsic pathway of coagulation by contact activation). Phospholipid (also called as partial thromboplastin) and calcium are then added and clotting time is measured.
Partial Thromboplastin Time (PTT)
It is one stage test. It distinguishes the functionality of the clotting factors I, II, V, VIII, X, XI, and XII. Both Activated Partial Thromboplastin Time (APTT) and Partial Thromboplastin Time (PTT) have the same clinical significance but Activated Partial Thromboplastin Time (APTT) is more reliable as compare to Partial Thromboplastin Time (PTT) due to its sensitivity.
Tissue thromboplastin and calcium are added to plasma and clotting time is determined. The test determines the overall efficiency of extrinsic and common pathways.
International Sensitivity Index (ISI) and International Normalized Ratio (INR)
International Sensitivity Index (ISI) of a particular tissue thromboplastin is derived (by its manufacturer) by comparing it with a reference thromboplastin of known ISI. For standardization and to obtain comparable results, it is recommended to report PT (in persons on oral anticoagulants) in the form of an International Normalized Ratio (INR).
International Normalized Ratio (INR) is calculated by the following formula.
Purpose of INR: The INR is calculated to evaluate the following conditions.
- Atrial fibrillation
- Prosthesis (Replacement of heart valve)
- Venous thromboembolism
- Antiphospholipid syndrome
Technique of APTT, PTT, and PT is different in different laboratories therefore normal values varies with the lab to lab. A normal control is always run with the patient's sample. In general, normal values are below.
- APTT: 30-40 seconds
- PTT: 60-70 seconds
- PT: 11-16 seconds
- INR: 1-1.5
|Disease||Required INR Value|
|Deep vein thrombosis prophylaxis||1.5 to 2.0|
|Deep vein thrombosis||2.0 to 3.0|
|Atrial fibrillation||2.0 to 3.0|
|Orthopedic surgery||2.0 to 3.0|
|Pulmonary embolism||2.5 to 3.5|
|Prosthetic valve prophylaxis||3.0 to 4.0|
- APTT: > 70 seconds (Usually it is considered as panic value. If APTT is greater then 100 seconds, spontaneous bleeding may occur.)
- INR: > 5.0 (In Deep Vein Thrombosis (DVT) patient on warfarin treatment, an expected value of INR is between 2.0 to 3.0.)
Reasons for the high results
- Disseminated intravascular coagulopathy (DIC )
- Factor XII deficiency
- Hemophilia A and B
- Von Willebrand’s disease
- Vitamin K deficiency
- Fibrin breakdown products
- All congenital deficiencies of Intrinsic system coagulation factors
The significance of APTT, PTT, PT, and INR test for the layman
- Patients, taking medication for blood thinning or on heparin treatment, are advised for these laboratory investigations.
- 28 Apr 2018
Why is this test performed?
- This hormone test is evaluated in different conditions, such as Adrenal insufficiency, in Acromegaly and Cushing Syndrome.
- In Addison's disease, the level of Adrenocorticotropic hormone (ACTH) is noted more than 1000 pg/ml.
- In Adrenal carcinoma, Adenoma, and Adrenocortical insufficiency, the level of Adrenocorticotropic hormone (ACTH) decreases.
Collection of Sample
For the estimation of Adrenocorticotropic hormone (ACTH), patient’s plasma is needed. Blood is collected in a chilled plastic test tube containing EDTA or heparin and blood is placed in cold ice-water.
The sample is centrifuged at 4º C, plasma is separated and stored at -20º C immediately within 15 minutes of the blood collection.
Note: For the diagnosis of Cushing Syndrome, the blood sample is collected in between 6 PM to 11 PM.
- Collect the blood sample in a chilled plastic test tube containing EDTA or heparin.
- Avoid high carbohydrates diet, take the low-carb diet.
- Avoid physical activity for 12 hours before the collection of the blood sample.
- Stop medication such as corticosteroids, 48 hours before the collection of blood sample.
- An anxious collection of the blood sample may increase the level of Adrenocorticotropic hormone (ACTH).
- 6 to 8 AM: < 80 pg/ml or < 18 pmol/L (SI units)
6 to 11 MP: < 50 pg/ml or < 11 pmol/L (SI units)
or less than 120 pg/ml
- According to another references:
8 AM: < 120 pg/mL
4 to 8 PM: < 85 pg/mL
Cord blood: 50 to 570 pg/mL
Newborn: 10 to 185 pg/mL
|Disease||ACTH Value||Cortisol Value|
|Ectopic ACTH (Lung cancer)||Raised||Raised|
|ACTH- producing Pituitary tumor||Raised||Raised|
|Adrenal gland failure ( Infarction, Haemorrhage)||Raised||Low|
|Congenital adrenal hyperplasia||Raised||Low|
Reasons for the increased level of ACTH
- Cushing syndrome
- Addison's disease
- Ectopic ACTH syndrome
Reasons for the decreased level of ACTH
- Secondary adrenal insufficiency
- Exogenous steroid administration
- Adrenal adenoma or carcinoma
The significance of Adrenocorticotropic hormone (ACTH) test for the layman
- This test is advised in abnormal metabolism of lipids.
- This test is advised to the patients of Diabetes Mellitus (DM).
- This test is performed for the diagnosis of Cushing syndrome.
- This test is advised if there are truncal obesity and thin extremity.
Why is this test performed?
- The test is performed for the diagnosis of prostatic carcinoma by the estimation of total acid phosphatase (TAP) and the prostatic component.
- The test is also performed for the examination for the presence of semen in medicolegal cases by a vaginal swab. Due to the high level of acid phosphatase in semen, its presence indicates recent sexual intercourse. Level of ≥50 U/sample is considered as positive evidence of semen.
Collection of Sample
For the test of total acid phosphatase (TAP) and the prostatic acid phosphatase (PAP), morning sample is preferred. About 3 to 5 ml blood is collected in a vacutainer and blood is allowed to clot. Then blood is centrifuged for 10 minutes at 4500 rpm in order to get the clear serum. The test is performed immediately. However, the sample can be preserved for 24 hours if kept at 2-8º C.
- The sample has very poor stability in the whole blood, therefore serum is separated immediately and the test is performed within an hour.
- The sample is unstable for the test of ACP if the pH is more then 7.0.
- The sample is unstable for the test of ACP at room temperature (> 37º C).
- Hemolyzed serum causes the false-positive result. Increased values can be observed in hemolyzed serum.
- Total acid phosphatase (TAP)
2.5 to 3.7 ng /mL
or < 3.0 mg /L
- Prostatic acid phosphatase (PAP)
< 2.5 ng/mL (0 to 0.6 U/L)
- Other references
Adult: 0.13 to 0.63 units/L at 37° C or 2.2 to 10.5 units/L (SI units)
Child: 8.6 to 12.0 units/mL at 30° C
Newborn:10.4 to 16.4 units /mL at 30°C
Reasons for the increased level
- Prostatic carcinoma
- Benign prostatic hyperplasia
- Metastatic carcinoma of the prostate
- Metastases to the bones
Moderately raised level seen in, other than prostatic carcinoma
- Niemann-Pick disease
- Sickle cell anemia
- Prostatitis and Benign prostatic hyperplasia ( BPH )
- Any cancer that has given metastasis to the bones.
- Urinary retention
- Multiple myelomas
- Myeloid Leukemia
- Paget disease
- Liver diseases like cirrhosis
- Renal diseases
- Gaucher’s disease
The significance of acid phosphatase test in medicolegal cases
Due to the high level of acid phosphatase in semen, its measurement is very important in rape cases. For the collection of a sample from the victim's body, following methods are applied.
- Direct aspiration or saline lavage
- Vaginal swab is obtained from the victim's vagina, and the sample is placed in 2.5% broth and can preserve at 4° C.
The significance of acid phosphatase test for the layman
- The test is performed for the diagnosis of prostatic carcinoma.
- This is carried out in cases of alleged rape or sexual assault.
- 21 Apr 2018
Purpose of the test
How to collect the urine sample for the 17-ketosteroids test?
- For the test of 17-ketosteroids in urine, 24 hours urine sample is required. Urine is collected in a container, containing one gram boric acid or 6 ml hydrochloric acid (HCl).
- The first urine sample is discarded and then collected the all urine sample for 24 hours.
- The 24 hours urine sample is transferred to the pathology laboratory for laboratory findings.
Why is boric acid used for the collection of the urine sample?
Boric acid converts the urine into a bacteriostatic medium, which inhibits the growth of bacteria in urine and preserves the urine for its bacteriological examination.
Some medicines like aspirin, diuretics, antibiotics, birth control medication and hormones therapy (e.g. Estrogen) may interfere with laboratory findings, so avoid such types of medicine before preparing yourself for the laboratory test.
- Males: 8-20 mg/24-hour
- Females: 6-15 mg/24-hour
- Elderly males > 70 years: 3-12 mg/24-hour
- Elderly females > 70 years: 3-13 mg/24-hour
- Infants: < 1 mg/24-hour
- 1 to 5 years: < 5 mg/24-hour
Reasons for the increased level of 17-ketosteroids in the 24-hour urine sample
- Stein-Leventhal syndrome
- Ectopic ACTH-secreting tumors
- Administration of ACTH
- Cushing’s syndrome
- Congenital adrenal hyperplasia
- Testosterone secreting or androgen-secreting tumors of:
(1) Ectopic ACTH-secreting tumors
Reasons for the decreased level of 17-ketosteroids in the 24-hour urine sample
- Severe infections
- Klinefelter's syndrome
- Addison’s disease
- Severe stress
- Debilitating diseases
- Chronic diseases
- Drugs that can decrease the level of 17-ketosteroids include:
(d) Thiazide diuretics
(e) Salicylates (prolonged use)
(f) Birth control pills
The significance of 17-ketosteroids for the layman
- The test is advised if the females has hairs on her face.
- The test is performed to elaborate any abnormality or disorders of the adrenal gland.
Anal sex refers to the activity in which penis is inserted into the anus. Some people found anal sex more joyful, but the fact is that the practice has the downside and it contains so many health risks.
It is prohibited in various cultures especially with regard to religious prohibition. It is a criminal offense in some countries and punishable by corporal or capital punishments. By disparity, people regard it a valid and natural form of sexual activity.
Is Anal Sex Safe?
There are so many health risks associated with the anal sex and anal intercourse, for both partners. Some of the health risks which may affect both homosexual and heterosexual couples are listed below.
Risk of bacterial infection: E. coli is a Gram-negative, facultative anaerobic bacteria, that is commonly found in the lower intestine. Anal sex increases the risk of transmission of E. coli bacteria from anal to your penis, which may cause a severe type of urinary tract infection.
E. coli may cause many bacterial infections, including, urinary tract infection (UTI), meningitis, cholecystitis, cholangitis, bacteremia, and pneumonia.
Hepatitis C Virus (HCV): It may be transmitted through the anal intercourse. Hepatitis C Virus is the cause of fetal liver chronic disease. It is a life-threatening virus and may lead to death.
Human Papilloma Virus (HPV): It may be transmitted through the anal intercourse and may cause to the anal wart. A research showed that some of the strain of HPV have carcinogenic potential. Some strains of HPV cause cancer of the cervix in women and also cause cancer of the throat.
Human immunodeficiency virus (HIV): There is a greater risk of transmission of HIV through anal intercourse. It is a life-threatening virus and leads to death.
Weakening of the anal sphincter: The anal anus is enclosed by the ring-like muscle, called the anal sphincter. The main function of anal sphincter is to hold the feces until you get to the toilet. After the excretion of feces, it tightens. Penetration of something like a penis inside the anal can be difficult and painful. Anal intercourse may lead to the weakening of the sphincter muscles, and make it hard to hold the feces.
Lack of natural lubrication: Naturally, the anal is not made for sex. The anal has lack of lubricant as vagina have, which makes the penetration harder and painful. Penetration can tear the tissues inside the anal and cause the wound, allowing viruses and bacteria to easily enter the bloodstream. Somehow, usage of oil or other lubricants can help in preventing the tearing of tissues inside the anal but doesn't completely.
A research showed that risk of transmission of HIV and HPV is much higher in anal sex and compared to the vaginal sex.
How to Prevent Anal Sex Problems
There is no way to completely eliminate the risk factors of anal sex until you avoid the anal sex. However, you can reduce the risk by the following tips.
- Always use a condom during anal sex.
- Do not enter penis into the mouth after inserting it into the anal.
- Use a sufficient amount of lubricants when penetrating into the anal to reduce the risk of tissue tear. Always use water-based lubricants with condoms.
- Do not lick the anal as it may cause the transmission of bacteria and viruses.
- Take a warm bath before anal sex.
- Lying on your stomach will make the insertion easier.
- Stop if you feel so much pain during anal sex.
- Stop if you experience bleeding or discharge coming from it, go to the hospital as soon as possible.
- Infants aged less than nine months. But if the infants live in the endemic area, they are required to be vaccinated.
- Pregnant woman except during outbreak of disease.
- People with severe allergies to egg protein.
- People with low immunity due to HIV/AIDs and thymus disorder
- 30 Mar 2018
The medical term for an infection in the vagina is vaginitis. The infection caused by any pathogenic organism such as streptococcus, staphylococcus, Trichomonasvaginalis or maybe Candida. It can happen in a child of age one to five years old, adults and old women.
But How Do You Get Infected?
The organism can transmit from a child or adult by hands or clothes. Sometimes a foreign body such as a pin is inserted by the child into the vagina can cause infection. Wiping your butt from your anus to vagina may transfer organism to the vagina.
A child with a near infection or tonsillitis can transmit bacteria by hand to her genital area as she is touching it.
Sexual abuse is leading to any sexually transmitted disease as gonorrhea.
Or nylon underclothes and harsh soap may cause the infection in your vagina.
So What Are The Symptoms Of Vagina Infection?
- Vaginal discharge. Purulent (pus discharge), blood stained if there is a foreign body or cervical polyp (growth that appear on the cervix look like bulbs on thin stems).
- Irritation, pain, and soreness due to discharge.
- Severe itching of the skin area around genital.
- Pain during peeing like burning sensation and the frequency of peeing is an increase.
How Does Your Genital Look Like If Infected?
The vulva is inflamed, red, tender, sometimes oedematous and bathed in discharge. The labia minora might stick together but can be separated apart leaving inflamed red surfaces.
What Treatment Will You Get?
You need to get proper treatment in the hospital to avoid further infection.
A specific antibiotic is given according to the nature of the organism. For non-specific vaginitis, estrogen cream is applied to the vulva each night for about two weeks. It increases local resistance to infection and relieves soreness.
Any foreign body must be removed. Local washes with warm water and boiling of the underclothes which should be cotton. If one of your child infected, you must isolate from other children to prevent cross infection.
Take extra precaution in sexual activity to avoid sexually transmitted disease which can cause infection to your vagina.
Monitor your daughter during her play time or any changes happen to her. Since prevention is better than cure isn’t it?.
- 28 Mar 2018
Menopause is a phase when you stop getting your period. It marks the end of your menstrual cycles. You stop getting your period for at least six months or one year and confirm with your gynecologist. Woman between 40s to 50s is the age of getting menopause, but in the United States, the average age is 51 years old.
Which Types of Menopause You Could Get?
- Normal or Natural menopause: occurring between the age of 40 and 55 with an average of 50 years
- Premature menopause: Period stop before you hit 40. About 1% of women have menopause below the age of 40
- Delayed menopause: you still have your period until the age of 55
- Artificial menopause: caused by surgical removal of both ovaries or destruction of ovaries by exposure to irradiation
How Menopause Started?
Maybe preceded by the infrequent period, scanty or decrease the amount of your usual period (less than 30ml). Or the length of your period becomes less to two days. A period of dysfunctional uterine bleeding or suddenly your period stop and never return. About 10% of women suddenly their period stop.
What Changes Happen To You During Menopause?
- Your breast might become smaller due to tissue in your breast atrophied or larger due to increase fat deposition
- Your appetite may be decreased or increase which leading to obesity. Constipation and gases accumulate (Fart! Fart! Fart!)
- The tendency to develop menstrual hypertension as the amount of estrogen decrease. Oestrogen can protect you from atherosclerosis
- You gradually have a high risk of coronary heart disease because the level of cholesterol and triglycerides is increased
- Liability to osteoporosis (bone disease which resulted in bone become weak easy to break)
- Mild hirsutism (increase amount of hair in the manly pattern, e.g., in an area where men typically grow hair)
- Psychological changes for examples headaches, irritability and depression
- The pubic hair becomes scanty, grey or white
- The vagina becomes narrow, and the pH becomes neutral or alkaline. This condition will predispose to infection
- The uterus becomes small and atrophic. Senile endometritis may occur (inflammation of uterus)
- The ovaries become small, fibrotic (excess fibrous of connective tissue) and containing no follicles (no egg)
- Bladder becomes small. The condition may lead to going to the bathroom a lot (you pee a lot), inflammation of your bladder and urethra
Symptoms You Might Get With Menopause
Palpitation, hot flushes (sensation of heat felt in the chest, neck, face, head or spread to all over body) and night sweats. About 75% of postmenopausal women have hot flushes. Usually, hot flushes disappear after one or two years even without treatment from a doctor.
The hot flush lasts for seconds, minutes, and rarely for one hour but usually 3 minutes. One or two in 24 hours to one every 15-30 minutes in a day.
However, about 25% of cases will continue to have hot flushes for more than five years.
Lack of concentration, poor memory and insomnia (difficult in sleeping/staying asleep). Insomnia is usually the result of night sweats
Joint pain and backache due to loose ligament and muscle become weak
What Can You Do With Menopause?
Well, menopause is a change in life and not the end of life. You can avoid factors which can cause hot flushes as hot weather, hot bath, nervousness, excessive intake of coffee or tea, excessive blanket and covering during sleep.
Control of diet with less fat to avoid obesity. Increase intake of calcium, i.e., dairy product, green leafy vegetables, nuts or fish where you eat the bones-sardine and pilchards.
There are some treatment or therapy to help you in menopause.
Treatment for symptoms such as depression and palpitation
Estrogen therapy: for a woman without a uterus
Given to women if the symptoms such as hot flushes, senile vaginitis (inflammation of vagina), increase the frequency of peeing and psychological disturbances. Treatment is given for at least one year to prevent recurrence of symptoms
This therapy also is given to premature menopause as this condition predisposes to osteoporosis (bone break easily). Treatment is given at least until the age of 50 years. The treatment reduces the risk of osteoporosis by 50% to 60%
Combined estrogen-progesterone therapy: for a woman with a uterus
To protect against endometrial hyperplasia (womb cancer).
Progesterone alone is given to control hot flushes. Although progesterone less effective than estrogen but it causes a less side effect.
Menopause happens to every woman on earth. It differs in every woman of how it started, the changes in your body, the symptom might present in you and the suitable treatment you can do. Consult your gynecologist for explanation and reassurance of the changes in your life.
Medically reviewed by Dr. Nida Hayat Khan
Editor @ BioScience.pk
- 04 Mar 2018
Have you ever listened about the “Second Brain”?
Yes, you have! whenever you are told to trust your gut instinct. This brain and gut connection is not just metaphorical. An extraordinarily extensive network of neurons (more than 100 million neurons) lines our gut that scientists have named it the Second Brain.
What about the inhabitants of gut including good and bad microbial flora?
Gut microbiota weighs up to 2kg containing trillions of micro-organisms. One-third of these microbiotas is common to all people while others are specific to every individual’s gut depending on the type of diet they take in and their lifestyle.
“Gut flora is a complex community of organisms that inhabit human and animal digestive system”. Relation between humans and gut flora is mutualistic. Bacteria in the digestive system assist in nutrient metabolism, vitamin production, and waste processing. They also aid in the host's immune system response to pathogenic bacteria.
Healthy Microbiota & Healthy Brain
The gut has a bidirectional relationship with the central nervous system referred to as the “gut-brain axis”. Introduction of good bacterial strain reduces anxiety and stress level. Gut-brain axis is used by bacteria to affect the brain function. The most significant factor related to the health of microbiome -- thus, brain – is healthy food. Following are the positive influencing microbiota Lactobacillus that produce lactic acid are found in yogurt. Taking in yogurt will boost mental capacity and relieve stress, it also aids in digestion and relieves constipation. But make sure yogurt is live culture (probiotic). Bifidobacteria feast on chocolate and ferment it causing positive effects on our health and body. Dark chocolate is also very beneficial for the heart because bacteria (Bifidobacterium, LAB, yeast) ferment it into healthful anti-oxidants. Prebiotic foods including raw garlic, raw, and cooked onions allow the healthy microbiota to grow and thrive while inhibits the growth of non-healthy microbiota. Environmental toxins can disturb microbiome and have adverse effects on brain health to save ourselves from these effects, use of home filtered water should be made compulsory. Such filters should be used that remove harmful toxins like chlorine. Fermented foods like pickles, kefir, kimchi etc. are the source of Lactobacillus lactis species and defend against leaky gut. These were some healthy microbial flora and their sources having a positive effect on your body and brain.
Non-Healthy Microbiota & Whacky Gut
There are bidirectional links between stress and microbiota. Irritable Bowel Syndrome (IBS) and Chronic Fatigue Syndrome (CSF) are also related to the gut microbiota. In CSF patients there is an alteration in normal microbiota resulting in symptoms as depression, neurocognitive impairment, pain and sleep disturbance. While IBS is considered as a gut-brain disorder which is worsened by stress. Researchers are investigating whether these unhealthy microbiota resulting in IBS are also the cause of mood disorders. No bacteria can be inherited as bad, when our body is out of balance it takes advantage and proliferates. Some bacteria having a bad reputation are given below Microbial imbalance as a high level of Lactobacillus can also cause mood disturbance and sleep disturbances. Staphylococcus can cause food poisoning, it can be found in unpasteurized milk and can affect when hygiene is poor. Higher levels of the bad clostridium bacteria can cause fatigue by using bidirectional gut-brain axis. By eating junk food firmicutes and bifidobacteria level falls and there is a rise in the level of bacteroidetes causing the lethargic behavior to upshot and immunity problems set in.
Healthy Gut of a Baby
It is believed that when babies are born their guts are sterile, as soon as they encounter the genitourinary tract and mother’s skin, they are exposed to microbial flora. Microbial flora is important to develop in infants or babies for normal functioning. This healthy microbial flora to a baby is also provided by mother through breastfeeding. Milk is a cocktail of healthy microbiota and immunoglobulins causing development and growth of microbial flora in infant’s gut. So it is necessary for mothers to take healthy balanced diets rich in probiotic, prebiotic and fermented foods.
Due to the increased demand for fruits and vegetables, portals like Selly.pk offer a much feasible way of shopping. It takes a lot less effort to buy fruits and vegetables online.
Selly.pk is a welcome initiative if you ask me because the streets and roads are already piling up with fruit & vegetable vendors. More people should realize similar ideas. However, this can be depressing for those conventional vendors if the people start buying online sabzi in Lahore. The status quo always works against change but because this is a good change, we should all work together to make it a successful prospect.
Selly.pk Doing Business with Morals
Fruit market Lahore receives new rates of fruits & veggies daily. In order to comply with a standardized rate, Selly.pk is in touch with fruit officials who know this industry on fingertips. This only gives it an upper hand over the common vendors who are more interested in earning high profits rather than being civil and selling products at a decent price.
In the fruit & vegetable market, the Jin of inflation is still under control but as soon as those items reach private vendors in different localities, the price starts touching the skies. Fruit price in Pakistan should have checks & balances so the vendors can’t get greedy.
Your Online Partner
Selly.pk is one of a kind online fruit shop in Lahore. There are not many online fruit shops in Pakistan, therefore, this is a healthy and productive initiative. Where to order fresh vegetables online? How many of us haven’t thought about this question? It is time, a serious response came through and it has in the form of Selly.pk.
Price Comparable to the Average Market Price
It is a pioneering name regarding online fruit and vegetable shopping. Moreover, one would think the price would be higher because it is online. No, not at all. I do most of my shopping from Selly.pk and the online vegetable rates are lower than most vendors out there.
Every household has a need for a fresh supply of fruits and vegetables daily. Online vegetable shopping is much more time-saving because lives are getting busier every day. It is not easy to stop the car on your way back home from work and buy fruits or vegetables.
Fixed Reasonable Rates – Bargaining Not Required
There is no need to overexert yourself anymore with Selly.pk in town. Online vegetable shopping is simpler rather than spending your brains in bargaining with the vendor at the end of the street. Moreover, the call representatives taking your call are very well-behaved, often stating the list of items to make the selection process easier for you. As soon as you place an order for fresh vegetables online, the processing starts and they promise you to reach within 45 minutes. In my case, they have always been on time. They have met my expectations so far delivering high-quality fruits and vegetables to my doorstep.
Call at your Convenience
Some of us may have trouble ordering through the website due to the fact some of us aren’t technical enough. But you can always call on 0304-111-7355 to place your order.
How Can We Pay?
Cash on delivery is encouraged because we can’t pay by debit or credit cards on the website. Neither is there a card reader with the rider to swipe those cards. These two procedures are something that is lacking in the current order of things.
The riders delivering the goods speak to you in a polite tone without being aggressive or suddenly getting rude.
They have openly declared their return policy. We can instantly return stale fruits or vegetables at the time of delivery and no questions, whatsoever, will be asked.
Fruit and vegetable grocery list – it doesn’t matter how long the list is, Selly.pk is always up for the task delivering them on time. Fresh fruit for sale online, especially in winters is more like a blessing because it’s too cold to go out for shopping anyway. Buy vegetables online easily through Selly.pk because the website is superb. Just keep on tapping the items you want to buy and keep adding them to cart until you are ready to check out.
Fresh vegetables for sale at this website are packed in a luxurious way, unlike those cheap plastic bags we normally see at shops, with a symbol or monogram of Selly.pk attached to each packet.
The Gist of the Matter
Selly.pk provides fresh vegetables near you if you are in Lahore. However, one can consider it as a fresh vegetable market nearby with so many choices to choose from. You only need a working smartphone with an active Wi-Fi connection or mobile data connection. Type in Selly.pk in your browser and you are good to go. Fresh fruits and vegetables delivered to your doorstep in a matter of minutes. Shopping was never so convenient before!
- 11 Feb 2018
- In Archaeogastropods, the Acmaea, the torsion takes place by muscles contraction alone.
- The rotation of 180° is completed in two stages, the first movement takes place by the contraction of larval retractor muscle and second rotation is slower by different growth. It is very common as in Patella, Haliotis etc.
- The rotation of 180° takes place by only differential growth processes like Vivapara.
- Rotation by differential growth processes, with anus coming to a position appropriate to the adult state like Aplysia.
- Torsion is no longer recognizable as a movement of viscera-pallium, the organs in the post-torsional position from their first appearance as in Adalaria.
- Displacement of mantle cavity: The mantle cavity was primarily present on the posterior side. The elongation of the ventral foot which was primarily very small. After torsion, the mantle cavity opens just behind the head and its associated parts are shifted forwards.
- Changes in relative position: Before torsion, the anus, ctenidia and excretory opening were placed on the posterior side and the auricles were placed behind the ventricle but after torsion the anus, ctenidia and excretory opening become anterior and the auricles lie in front of the ventricle. The original posterior face of the visceral sac becomes the anterior face so that the visceral organs morphologically of the original right side change into the left side.
- Looping of alimentary canal: The alimentary canal which was originally straight from mouth to anus, after torsion, it changes into a loop.
- Chiastoneury: The long, uncoiled pleuro-visceral nerve connectives become a figure of "8" after twisting. The right connective with its ganglion passes over the intestine to form the supra-intestinal connective, while the next connective pass under the intestine to form the infra-intestinal connective.
- Endogastric coil: The coil of visceral sac and shell, which was primarily dorsal or exogastric become ventral and endogastric after torsion.
- Loss of Symmetry of Atrophy: The anus changes their original position towards the right side of the pallial cavity so that the original symmetrical condition disturbed.
- 06 Feb 2018
Pearl is secreted by the mantle as a means of protection against a small external particle. When an external particle or body, such as a grain of sand or a small parasite invades in between the mantle and the shell it becomes enclosed in a sac of mantle epithelium which produces irritation. The irritation stimulates the mantle epithelium to secrete thin concentric layers of mother of pearl around the foreign body. The amount of deposition is in direct proportion to the degree of irritation. After several years, a pearl will be formed, usually, it requires 3 to 4 years to produce a pearl of considerable size but a large pearl requires about 7 years. The foreign particles in the pearl are called nucleus whereas the thin nacre layers are concentric and called the mother of pearl.
- 30 Jan 2018
- Towel or soft cloth
- Blackhead removal strips or pads
- Salicylic acid (C7H6O3)
|DISTILLED WATER||REVERSE OSMOSIS (RO) WATER||DEIONIZED (DI) WATER|
|Distillation is employed in the main in laboratories and factories, wherever it's required. Reverse diffusion is widely employed in water treatment plants, each reception and for the manufacture of assorted drinks, drinking water, etc.||
||DI water is as pure because the water or maybe purer|
- 17 Jan 2018
- 28 Sep 2017
- Hyperthyroidism: Elevation of both T4 and T3 values along with decrease of TSH are indicative of primary hyperthyroidism.
- Increased thyroxine-binding globulin: If concentration of TBG increases, free hormone level falls, release of TSH from pituitary is stimulated, and free hormone concentration is restored to normal. Reverse occurs if concentration of binding proteins falls. In either case, level of free hormones remains normal, while concentration of total hormone is altered. Therefore, estimation of only total T4 concentration can cause misinterpretation of results in situations that alter concentration of TBG.
- Factitious hyperthyroidism
- Pituitary TSH-secreting tumor.
- Primary hypothyroidism: The combination of decreased T4 and elevated TSH are indicative of primary hypothyroidism.
- Secondary or pituitary hypothyroidism
- Tertiary or hypothalamic hypothyroidism
- Hypoproteinaemia, e.g. nephrotic syndrome
- Drugs: oestrogen, danazol
- Severe non-thyroidal illness.
- Diagnosis of T3 thyrotoxicosis: Hyperthyroidism with low TSH and elevated T3, and normal T4/FT4 is termed T3 thyrotoxicosis.
- Early diagnosis of hyperthyroidism: In early stage of hyperthyroidism, total T4 and free T4 levels are normal, but T3 is elevated.
- Confirmation of diagnosis of secondary hypothyroidism
- Evaluation of suspected hypothalamic disease
- Suspected hyperthyroidism
- A baseline blood sample is collected for estimation of basal serum TSH level.
- TRH is injected intravenously (200 or 500 μg) followed by measurement of serum TSH at 20 and 60 minutes.
- Normal response: A rise of TSH > 2 mU/L at 20 minutes, and a small decline at 60 minutes.
- Exaggerated response: A further significant rise in already elevated TSH level at 20 minutes followed by a slight decrease at 60 minutes; occurs in primary hypothyroidism.
- Flat response: There is no response; occurs in secondary (pituitary) hypothyroidism.
- Delayed response: TSH is higher at 60 minutes as compared to its level at 20 minutes; seen in tertiary (hypothalamic) hypothyroidism.
Box 864.1 Thyroid autoantibodies
- Hyperthyroidism due to Graves’ disease, toxic multinodular goiter, toxic adenoma, TSH-secreting tumor.
- Hyperthyroidism due to administration of thyroid hormone, factitious hyperthyroidism, subacute thyroiditis.
- Differential diagnosis of high RAIU thyrotoxicosis:
– Graves’ disease: Uniform or diffuse increase in uptake
– Toxic multinodular goiter: Multiple discrete areas of increased uptake
– Adenoma: Single area of increased uptake
- Evaluation of a solitary thyroid nodule:
– ‘Hot’ nodule: Hyperfunctioning
– ‘Cold’ nodule: Non-functioning; about 20% cases are malignant.
|1. TSH Normal, FT4 Normal||Euthyroid|
|2. Low TSH, Low FT4||Secondary hypothyroidism|
|3. High TSH, Normal FT4||Subclinical hypothyroidism|
|4. High TSH, Low FT4||Primary hypothyroidism|
|5. Low TSH, Normal FT4, Normal FT3||Subclinical hyperthyroidism|
|6. Low TSH, Normal FT4, High FT3||T3 toxicosis|
|7. Low TSH, High FT4||Primary hyperthyroidism|
- 28 Sep 2017
|Box 863.1 Terminology in thyroid disorders
|Box 863.2 Thyroid function tests in hyperthyroidism
|Parameter||Primary hyperthyroidism||Secondary hyperthyroidism|
|1. Serum TSH||Low||Normal or high|
|2. Serum free thyroxine||High||High|
|3. TSH receptor antibodies||May be positive||Negative|
|4. Causes||Graves’ disease, toxic multinodular goiter, toxic adenoma||Pituitary adenoma|
|Parameter||Primary hypothyroidism||Secondary hypothyroidism|
|1. Cause||Hashimoto’s thyroiditis||Pituitary disease|
|2. Serum TSH||High||Low|
|3. Thyrotropin releasing hormone stimulation test||Exaggerated response||No response|
|4. Antimicrosomal antibodies||Present||Absent|
Box 863.3 Thyroid function tests in hypothyroidism
- 22 Sep 2017
1. Hypothalamic-pituitary dysfunction:
2. Ovarian dysfunction:
|3. Dysfunction in passages:|
|4. Dysfunction of sexual act: Dyspareunia|
- Regular cycles, mastalgia, and laparoscopic direct visualization of corpus luteum indicate ovulatory cycles. Anovulatory cycles are clinically characterized by amenorrhea, oligomenorrhea, or irregular menstruation. However, apparently regular cycles may be associated with anovulation.
- Endometrial biopsy: Endometrial biopsy is done during premenstrual period (21st-23rd day of the cycle). The secretory endometrium during the later half of the cycle is an evidence of ovulation.
- Ultrasonography (USG): Serial ultrasonography is done from 10th day of the cycle and the size of the dominant follicle is measured. Size >18 mm is indicative of imminent ovulation. Collapse of the follicle with presence of few ml of fluid in the pouch of Douglas is suggestive of ovulation. USG also is helpful for treatment (i.e. timing of coitus or of intrauterine insemination) and diagnosis of luteinized unruptured follicle (absence of collapse of dominant follicle). Transvaginal USG is more sensitive than abdominal USG.
- Basal body temperature (BBT): Patient takes her oral temperature at the same time every morning before arising. BBT falls by about 0.5°F at the time of ovulation. During the second (progestational) half of the cycle, temperature is slightly raised above the preovulatory level (rise of 0.5° to 1°F). This is due to the slight pyrogenic action of progesterone and is therefore presumptive evidence of functional corpus luteum.
- Cervical mucus study:
• Fern test: During estrogenic phase, a characteristic pattern of fern formation is seen when cervical mucus is spread on a glass slide (Figure 862.4). This ferning disappears after the 21st day of the cycle. If previously observed, its disappearance is presumptive evidence of corpus luteum activity.
• Spinnbarkeit test: Cervical mucus is elastic and withstands stretching upto a distance of over 10 cm. This phenomenon is called Spinnbarkeit or the thread test for the estrogen activity. During the secretory phase, viscosity of the cervical mucus increases and it gets fractured when stretched. This change in cervical mucus is evidence of ovulation.
- Vaginal cytology: Karyopyknotic index (KI) is high during estrogenic phase, while it becomes low in secretory phase. This refers to percentage of super-ficial squamous cells with pyknotic nuclei to all mature squamous cells in a lateral vaginal wall smear. Usually minimum of 300 cells are evaluated. The peak KI usually corresponds with time of ovulation and may reach upto 50 to 85.
- Estimation of progesterone in mid-luteal phase (day 21 or 7 days before expected menstruation): Progesterone level > 10 nmol/L is a reliable evidence of ovulation if cycles are regular (Figure 862.5). A mistimed sample is a common cause of abnormal result.
- Measurement of LH, FSH, and estradiol during days 2 to 6: All values are low in hypogonadotropic hypogonadism (hypothalamic or pituitary failure).
- Measurement of TSH, prolactin, and testosterone if cycles are irregular or absent:
Increased TSH: Hypothyroidism
Increased prolactin: Pituitary adenoma
Increased testosterone: Polycystic ovarian disease (PCOD), congenital adrenal hyperplasia (To differentiate PCOD from congenital adrenal hyperplasia, ultrasound and estimation of dihydroepiandrosterone or DHEA are done).
- Transvaginal ultrasonography: This is done for detection of PCOD.
- Infectious disease: These tests include endometrial biopsy for tuberculosis and test for chlamydial IgG antibodies for tubal factor in infertility.
- Hysterosalpingography (HSG): HSG is a radiological contrast study for investigation of the shape of the uterine cavity and for blockage of fallopian tubes (Figure 862.6). A catheter is introduced into the cervical canal and a radiocontrast dye is injected into the uterine cavity. A real time X-ray imaging is carried out to observe the flow of the dye into the uterine cavity, tubes, and spillage into the uterine cavity.
- Hysterosalpingo-contrast sonography: A catheter is introduced into the cervical canal and an echocontrast fluid is introduced into the uterine cavity. Shape of the uterine cavity, filling of fallopian tubes, and spillage of contrast fluid are noted. In addition, ultrasound scan of the pelvis provides information about any fibroids or polycystic ovarian disease.
- Laparoscopy and dye hydrotubation test with hysteroscopy: In this test, a cannula is inserted into the cervix and methylene blue dye is introduced into the uterine cavity. If tubes are patent, spillage of the dye is observed from the ends of both tubes. This technique also allows visualization of pelvic organs, endometriosis, and pelvic adhesions. If required, endometriosis and tubal blockage can be treated during the procedure.
- 22 Sep 2017
2. Hypothalamic-pituitary dysfunction (hypogonadotropic hypogonadism)
3. Testicular dysfunction:
4. Dysfunction of passages and accessory sex glands:
5. Dysfunction of sexual act:
- History: This includes type of lifestyle (heavy smoking, alcoholism), sexual practice, erectile dysfunction, ejaculation, sexually transmitted diseases, surgery in genital area, drugs, and any systemic illness.
- Physical examination: Examination of reproductive system should includes testicular size, undescended testes, hypospadias, scrotal abnormalities (like varicocele), body hair, and facial hair. Varicocele can occur bilaterally and is the most common surgically removable abnormality causing male infertility.
- Semen analysis: See article Semen Analysis. Evaluation of azoospermia is shown in Figure 861.3. Evaluation of low semen volume is shown in Figure 861.4.
- Chromosomal analysis: This can reveal Klinefelter’s syndrome (e.g. XXY karyotype) (Figure 861.5), deletion in Y chromosome, and autosomal Robertsonian translocation. It is necessary to screen for cystic fibrosis carrier state if bilateral congenital absence of vas deferens is present.
- Hormonal studies: This includes measurement of FSH, LH, and testosterone to detect hormonal abnormalities causing testicular failure (Table 861.2).
- Testicular biopsy: Testicular biopsy is indicated when differentiation between obstructive and non-obstructive azoospermia is not evident (i.e. normal FSH and normal testicular volume).
|Follicle stimulating hormone||Luteinizing hormone||Testosterone||Interpretation|
|Low||Low||Low||Hypogonadotropic hypogonadism (Hypothalamic or pituitary disorder)|
|High||High||Low||Hypergonadotropic hypogonadism (Testicular disorder)|
|Normal||Normal||Normal||Obstruction of passages, dysfunction of accessory glands|
- 08 Sep 2017
- Cephalic or neurogenic phase: This phase is initiated by the sight, smell, taste, or thought of food that causes stimulation of vagal nuclei in the brain. Vagus nerve directly stimulates parietal cells to secrete acid; in addition, it also stimulates antral G cells to secrete gastrin in blood (which is also a potent stimulus for gastric acid secretion) (Figure 859.2). Cephalic phase is abolished by vagotomy.
- Gastric phase: Entry of swallowed food into the stomach causes gastric distension and induces gastric phase. Distension of antrum and increase in pH due to neutralization of acid by food stimulate antral G cells to secrete gastrin into the circulation. Gastrin, in turn, causes release of hydrochloric acid from parietal cells.
- Intestinal phase: Entry of digested proteins into the duodenum causes an increase in acid output from the stomach. It is thought that certain hormones and absorbed amino acids stimulate parietal cells to secrete acid.
- Hydrochloric acid (HCl): This is secreted by the parietal cells of the fundus and the body of the stomach. HCl provides the high acidic pH necessary for activation of pepsinogen to pepsin. Gastric acid secretion is stimulated by histamine, acetylcholine, and gastrin (Figure 859.2). HCl kills most microorganisms entering the stomach and also denatures proteins (breaks hydrogen bonds making polypeptide chains to unfold). Its secretion is inhibited by somatostatin (secreted by D cells in pancreas and by mucosa of intestine), gastric inhibitory peptide (secreted by K cells in duodenum and jejunum), prostaglandin, and secretin (secreted by S cells in duodenum).
- Pepsin: Pepsin is secreted by chief cells in stomach. Pepsin causes partial digestion of proteins leading to the formation of large polypeptide molecules (optimal function at pH 1.0 to 3.0). Its secretion is enhanced by vagal stimulation.
- Intrinsic factor (IF): IF is necessary for absorption of vitamin B12 in the terminal ileum. It is secreted by parietal cells of stomach.
- 07 Sep 2017
- Gastric intubation for gastric analysis is contraindicated in esophageal stricture or varices, active nasopharyngeal disease, diverticula, malignancy, recent history of severe gastric hemorrhage, hypertension, aortic aneurysm, cardiac arrhythmias, congestive cardiac failure, or non-cooperative patient.
- Pyloric stenosis: Obstruction of gastric outlet can elevate gastric acid output due to raised gastrin (following antral distension).
- Pentagastrin stimulation is contraindicated in cases with allergy to pentagastrin, and recent severe gastric hemorrhge due to peptic ulcer disease.
- It is an invasive and cumbersome technique that is traumatic and unpleasant for the patient.
- Information obtained is not diagnostic in itself.
- Availability of better tests for diagnosis such as endoscopy and radiology (for suspected peptic ulcer or malignancy); serum gastrin estimation (for ZE syndrome); vitamin assays, Schilling test, and antiparietal cell antibodies (for pernicious anemia); and tests for Helicobacter pylori infection (in duodenal or gastric ulcer).
- Availability of better medical line of treatment that obviates need for surgery in many patients.
- 07 Sep 2017
- Hollander’s test (Insulin hypoglycemia test): In the past, this test was used for confirmation of completeness of vagotomy (done for duodenal ulcer).
Hypoglycemia is a potent stimulus for gastric acid secretion and is mediated by vagus nerve. This response is abolished by vagotomy.
In this test, after determining BAO, insulin is administered intravenously (0.15-0.2 units/kg) and acid output is estimated every 15 minutes for 2 hours (8 post-stimulation samples). Vagotomy is considered as complete if, after insulin-induced hypoglycemia (blood glucose < 45 mg/dl), no acid output is observed within 45 minutres.
The test gives reliable results only if blood glucose level falls below 50 mg/dl at some time following insulin injection. It is best carried out after 3-6 months of vagotomy.
The test is no longer recommended because of the risk associated with hypoglycemia. Myocardial infarction, shock, and death have also been reported.
- Fractional test meal: In the past, test meals (e.g. oat meal gruel, alcohol) were administered orally to stimulate gastric secretion and determine MAO or PAO. Currently, parenteral pentagastrin is the gastric stimulant of choice.
- Tubeless gastric analysis: This is an indirect and rapid method for determining output of free hydrochloric acid in gastric juice. In this test, a cationexchange resin tagged to a dye (azure A) is orally administered. In the stomach, the dye is displaced from the resin by the free hydrogen ions of the hydrochloric acid. The displaced azure A is absorbed in the small intestine, enters the bloodstream, and is excreted in urine. Urinary concentration of the dye is measured photometrically or by visual comparison with known color standards. The quantity of the dye excreted is proportional to the gastric acid output. However, if kidney or liver function is impaired, false results may be obtained. The test is no longer in use.
- Spot check of gastric pH: According to some investigators, spot determination of pH of fasting gastric juice (obtained by nasogastric intubation) can detect the presence of hypochlorhydria (if pH>5.0 in men or >7.0 in women).
- Congo red test during esophagogastroduodenoscopy: This test is done to determine the completeness of vagotomy. Congo red dye is sprayed into the stomach during esophagogastroduodenoscopy; if it turns red, it indicates presence of functional parietal cells in stomach with capacity of producing acid.
- Volume of gastric juice: 20-100 ml
- Appearance: Clear
- pH: 1.5 to 3.5
- Basal acid output: Up to 5 mEq/hour
- Peak acid output: 1 to 20 mEq/hour
- Ratio of basal acid output to peak acid output: <0.20 or < 20%
- 07 Sep 2017
- To determine the cause of recurrent peptic ulcer disease:
• To detect Zollinger-Ellison (ZE) syndrome: ZE syndrome is a rare disorder in which multiple mucosal ulcers develop in the stomach, duodenum, and upper jejunum due to gross hypersecretion of acid in the stomach. The cause of excess secretion of acid is a gastrin-producing tumor of pancreas. Gastric analysis is done to detect markedly increased basal and pentagastrinstimulated gastric acid output for diagnosis of ZE syndrome (and also to determine response to acidsuppressant therapy). However, a more sensitive and specific test for diagnosis of ZE syndrome is measurement of serum gastrin (fasting and secretin-stimulated).
• To decide about completeness of vagotomy following surgery for peptic ulcer disease: See Hollander’s test.
- To determine the cause of raised fasting serum gastrin level: Hypergastrinemia can occur in achlorhydria, Zollinger-Ellison syndrome, and antral G cell hyperplasia.
- To support the diagnosis of pernicious anemia (PA): Pernicious anemia is caused by defective absorption of vitamin B12 due to failure of synthesis of intrinsic factor secondary to gastric mucosal atrophy. There is also absence of hydrochloric acid in the gastric juice (achlorhydria). Gastric analysis is done for demonstration of achlorhydria if facilities for vitamin assays and Schilling’s test are not available (Achlorhydria by itself is insufficient for diagnosis of PA).
- To distinguish between benign and malignant ulcer: Hypersecretion of acid is a feature of duodenal peptic ulcer, while failure of acid secretion (achlorhydria) occurs in gastric carcinoma. However, anacidity occurs only in a small proportion of cases with advanced gastric cancer. Also, not all patients with duodenal ulcer show increased acid output.
- To measure the amount of acid secreted in a patient with symptoms of peptic ulcer dyspepsia but normal X-ray findings: Excess acid secretion in such cases is indicative of duodenal ulcer. However, hypersecretion of acid does not always occur in duodenal ulcer.
- To decide the type of surgery to be performed in a patient with peptic ulcer: Raised basal as well as peak acid outputs indicate increased parietal cell mass and need for gastrectomy. Raised basal acid output with normal peak output is an indication for vagotomy.