By Cat Troiano

Calcium is one of the seven macrominerals found in the human body. All minerals are crucial for carrying out a variety of functions to sustain human life. Calcium is not produced in the body, and so this important micronutrient must be consumed through diet. Calcium is the building block for bone and tooth formation. Bones contain 99 percent of the body’s calcium. The remaining small percentage carries out additional critical functions, including:

• Works together with vitamin K to aid in blood coagulation
• Regulates heartbeat rhythms
• Enables vasoconstriction and vasodilation to stabilize blood pressure
• Maintains permeability and stability of cell membranes to enable cellular communication
• Aids in neurotransmission
• Enables the binding of muscle fiber proteins to facilitate muscle contraction

That’s a lot of jobs for only one percent! If there is an insufficient amount of calcium on board to carry out these vital roles, then the parathyroid glands come to the rescue. These four glands that neighbor the thyroid gland release an increased amount of parathyroid hormone (PTH) when low blood calcium levels are detected, prompting the bones to release calcium into the blood. PTH also stimulates the production of calcitriol, an inactive form of vitamin D, to facilitate increased dietary calcium absorption in the gastrointestinal tract. PTH also acts on the kidneys to prevent the filtration of calcium for elimination and instead encourage reabsorption of calcium back into the blood.

Conversely, when blood calcium levels are too high, the parathyroid gland produces a lower amount of PTH, and the thyroid gland kicks in to release calcitonin, a hormone that reduces blood calcium levels by reducing the breakdown of bone. Throughout life, bone continuously breaks down and rebuilds, a normal process called remodeling. The human skeleton is almost entirely rebuilt over the course of every 10 years. Remodeling enables the removal of calcium from bone when blood calcium levels are deficient or when the need for increased blood calcium arises, such as during pregnancy and lactation. PTH stimulates specialized bone cells called osteoblasts to build bone tissue. PTH, as well as calcitonin, can also inhibit osteoclasts, the bone cells that break down bone tissue.

Maintaining an ideal calcium level for optimal physiological function is a balancing act that the body must perform. Testing blood calcium levels is essential so that abnormal levels can be addressed to restore proper function.

Calcium Tests

There are two presentations of calcium in the blood. Free calcium, also called ionized calcium, is calcium which is not bound to organic molecules. Bound calcium is that which is bound to molecules, predominantly to the protein albumin and, in smaller proportions, to immunoglobulins and to phosphorus.

The body’s ability to utilize a mineral depends on the mineral’s bioavailability. Once a mineral is bound, it is no longer bioavailable. Free calcium is the more active form of calcium with a higher bioavailability, and bound calcium accounts for roughly 40 percent of blood calcium. Therefore, total calcium is considered to be a mineral that is of medium bioavailability.

Tests that evaluate blood calcium levels include the following:

Total calcium test – evaluates levels of both free and bound calcium. The normal reference range for an adult is a total blood calcium level of 8.5 to 10.3 mg/dL.

Ioniozed calcium test– evaluates the blood calcium level of free calcium only. The normal reference range for an adult is an ionized calcium level greater than 4.6 mg/dL.

Total calcium levels are also typically included in both the comprehensive metabolic panel and the basic metabolic panel.

When the body has an excess surplus of calcium, some of that excess is eliminated through urination. The urinary Ca+2 test evaluates the amount of calcium that has been passed in all of a patient’s urine that has been excreted over 24 hours. The normal reference range for urinary Ca+2 is 100 to 300 mg per 24 hours.

Fasting is not necessary for calcium level testing, but patients should be instructed to refrain from taking any medications or supplements that can affect calcium levels, including anticonvulsant drugs, diuretics, bisphosphonates, corticosteroids, lithium, estrogen, calcium supplements and vitamin D supplements.

Patients for whom calcium level testing should be ordered include those with:

• Kidney disease
• Thyroid disease
• Osteoporosis
• Neurological deficits
• Liver disease
• Pancreatitis
• Malabsorption
• Abnormal EKG

Ionized calcium levels should be monitored in patients who have cancer, who are critically ill and receiving intravenous fluid therapy, who are receiving blood transfusions and who have abnormal albumin levels on their metabolic panels.

What Does a Low Calcium Level Indicate?

Hypocalcemia is defined as an abnormally low calcium level. This can result when too much calcium is eliminated through urination or when an insufficient amount of calcium is released from bone into the blood. Causes of hypocalcemia include the following:

• Underactive parathyroid gland
• Low blood protein levels
• Low magnesium levels
• Low vitamin D level
• High phosphorus level
• Kidney failure
• Pancreatitis
• Dietary calcium deficiency
• Use of certain drugs, including bisphosphonates, corticosteroids, calcitonin, anticonvulsants, such as phenobarbitol, and certain antibiotics, such as plicamysin and rifampin
• Dietary calcium deficiency                

Initially, patients with moderately low calcium levels may be asymptomatic. Severely low or prolonged low calcium levels can result in symptoms that include arrhythmias, tingling in the hands or feet, muscle spasms, muscle cramping, confusion, memory loss, hallucinations and seizure activity.

Hypocalcemia can usually be corrected with the use of calcium supplements, and vitamin D supplementation may be recommended as well. Treatment for the underlying cause of low calcium levels must also be recommended.

What Does an Elevated Calcium Level Indicate?

Hypercalcemia, the opposite of hypocalcemia, is defined as an abnormally high calcium level. Causes of hypercalcemia include the following:

• Overactive parathyroid glands
• Hyperthyroidism
• Cancer, including lung cancer, breast cancer, blood cancers and cancers that have metastasized to the bones
• Tuberculosis
• HIV/AIDS
• Sarcoidosis
• Paget disease
• Certain drugs, including lithium prescribed for the treatment of bipolar disorder, diuretics prescribed for the treatment of hypertension and heart failure, and antacids
• Excessive intake of calcium and/or vitamin D supplements over an extended duration
• Extreme dehydration
• Patient inactivity

As in the case of hypocalcemia, mild hypercalcemia may present no apparent symptoms. Patients with more severe or advanced cases of hypercalcemia experience increases in water intake and urinary output, kidney stones, nausea, vomiting, constipation, abdominal pain, decreased appetite, bone pain, muscle weakness, fatigue, depression, syncope, arrhythmia and coma.

Drug therapy is typically the course of treatment for hypercalcemia. The drugs that are prescribed are dependent on the cause of the high calcium levels. Commonly used drugs include biphosphonates, calcitonin and corticosteroids.

Depending on the abnormal calcium level test result, additional screenings may be ordered, such as thoracic diagnostic imaging, thyroid and parathyroid hormone levels, phosphorus level, vitamin D level and a renal function panel.

How Much Calcium Should Be Taken In?

Since calcium must be consumed, patients should be educated as to how much calcium they should be taking in. Female patients are especially concerned, knowing that as their age advances and their estrogen hormone levels decline sharply during menopause, the body’s bone formation capability is less able to keep up with the breaking down of bone, resulting in lower bone mass density. This condition, known as osteoporosis, results in brittle bones than fracture easily and can render a patient physically impaired, threatening their independence and quality of life.

According to the National Osteoporosis Foundation, healthy adults should strive to take in 1,000 mg of calcium daily. That amount should be increased to 1,200 mg daily for women older than 50 and for men older than 70 years of age. Foods that contain calcium include, but are not limited to, milk, yogurt, cheese, egg yolks, almonds, soybeans, edamame, tofu, sardines and leafy greens, such as spinach, kale and bok choy.

Remember that calcium cannot be absorbed without the help of vitamin D. Only three vitamins can be produced by the human body, and although vitamin D is one of the three, in addition to vitamin K and biotin, it is only produced when a patient’s skin receives adequate sunlight exposure. Healthy adults should take in 5µg of vitamin D daily. Wild-caught tuna and salmon are among the few foods that naturally contain vitamin D, but many cereals, dairy products and orange juices are fortified with vitamin D and, in some cases, with calcium as well.

As described above, you can have too much of a good thing. All patients should have their calcium levels checked and their overall metabolic health evaluated prior to consulting with their physicians about calcium supplementation.

By Cat Troiano

It’s that time of year. Schools, office buildings and other crowded public spaces are teeming with pathogens, from the common cold and influenza viruses to bacterial pneumonia and strep throat. Testing select patients who present with a sore throat provides the definitive diagnosis of strep throat so that effective treatment can be prescribed.

Sore Throat Is Not Always Strep Throat

The symptom of a sore throat can arise from irritants in the environment, inhalant allergies, acid reflux, postnasal drip, a fungal infection, a cold or a bacterial infection. A typical sore throat that often accompanies the onset of a cold is not the same as streptococcal pharyngitis, which is better known as strep throat. Strep throat is an infection caused by group A streptococci bacterium. A patient who has a cold-related sore throat typically experiences other upper respiratory symptoms as well, such as coughing, nasal congestion, chest congestion and a runny nose. These symptoms do not accompany strep throat. Symptoms that do commonly go hand in hand with strep throat include the following:

• High fever, typically 101 degrees Fahrenheit or greater
• Chills
• Headache
• Redness of the throat and on the hard and/or soft palate
• Dark red spots in the mouth, on the palate or on the throat
• White or yellow patches on the tonsils
• Swollen tonsils
• Swollen lymph nodes in the neck
• Pain or difficulty when swallowing
• Loss of appetite
• Nausea
• Muscle aches
• Lethargy
• Sandpaper-like skin rash that is pink in color

Children and teens aged 5 to 15 are the most typically affected, with nearly 30 percent of patients of this age group presenting with sore throats being diagnosed cases of strep throat, compared to only an average of 10 percent of adults with sore throats. Kids are taught to share, and they aren’t shy about sharing germs! However, adults who are frequently exposed to children, such as day care workers and schoolteachers, as well as parents of children who have the infection, are also at risk. Strep throat is contagious, and the incubation period is two to five days post exposure. Strep infection is rare in children less than three years of age.

Any patient who presents with a sore throat that began quickly and persists for a week, or with a sore throat combined with a fever along with any of the additional symptoms that may be indicative of strep throat, should be tested so that proper treatment can be initiated.

Swab for Strep

There are two ways to test for group A streptococci. One test, the rapid streptococci screening test, yields results quickly. This immunoassay test identifies the presence of group A streptococci antigen in a sample of mucous that has been taken from a pharyngeal swab, and it generates a positive or negative result in approximately 5 to 10 minutes. A positive result can facilitate confident on-site diagnosis and prompt initiation of effective treatment.

The second way to test for strep is the traditional microbial culture method. Like the rapid strep test, the culture test requires a sample that has been swabbed from the back of the throat. Although culturing a sample has a high level of accuracy due to high sensitivity and specificity, the test can take 48 hours to generate results. Since a culture can generate more accurate results than the rapid strep testing, this method is recommended to confirm negative rapid strep test results from symptomatic patients as well as to rule out other infections. In addition to group A streptococci, the throat culture test also detects the presence of pathogens that cause such conditions as bacterial pneumonia, meningitis and pertussis.

It is important to note that patient use of antiseptic mouthwash products as well as recent antibiotic therapy can alter the results of rapid strep tests and throat culture tests.

Some patients may be carriers of group A streptococci, which simply means that such individuals may harbor the bacteria without having an active infection. Carriers will have positive results on their tests, even if their sore throats are caused by other pathogens. Patients who are otherwise asymptomatic and test positive for strep throat typically do not require treatment, as carriers are much less likely to develop complications that can arise from failure to treat strep infections, and their probability of spreading the bacteria to others is lower.

Treatment and Prevention

While sore throats that present with viral infections, which do not respond to antibiotic drugs, typically resolve without treatment, it is essential to treat strep throat promptly. Failure to treat a strep infection places the patient at risk for serious complications. One such complication is rheumatic fever, a life-threatening inflammatory condition that affects the joints and can also ultimately result in congestive heart failure. Another potential complication is poststreptococcal glomerulonephritis, which is an inflammation of the glomeruli – the filtration structures of the kidneys – that can lead to kidney disease and renal failure. Other complications include ear infections, sinus infections, abscesses on the tonsils, scarlet fever and mastoiditis, which is an inflammation of the mastoid process, which is the lower portion of the temporal bone of the skull.

Once the rapid strep test issues a positive result, antibiotic therapy is prescribed for a period of 5 to 14 days, depending on which antibiotic drug is used. Patients should stay home from school or work until at least 24 hours after the antibiotic treatment has begun and the fever is gone. It is imperative that patients complete the entire prescribed course of antibiotic treatment, even once symptoms improve, in order to ensure that the infection is completely resolved. Antibiotic treatment will prevent the aforementioned complications that can arise from an untreated strep infection, decrease the symptoms, shorten the duration of illness and reduce the spread of infection to others.

Group A streptococci is spread through contact with droplets from infected patients who sneeze or cough. When someone touches a contaminated surface and proceeds to touch his or her eyes, nose or mouth, he or she can contract the infection. Patients should cover their mouth with a tissue if they sneeze, and everyone should refrain from sharing drinking glasses, cups and bottles as well as dining utensils. Everyone should also be extra diligent with washing their hands frequently throughout the school year, which also tends to coincide with the flu season.

Since some of the symptoms of strep throat and those of the influenza virus are similar, a rapid influenza test may be ordered along with the rapid strep test for a more thorough and definitive diagnosis. Testing is a crucial part of ensuring a proper diagnosis so that ineffective treatments can be avoided and the development of patient antibiotic resistances can thus be prevented.

By Cat Troiano

This year’s flu season is well underway, normally peaking during the months of December through February. Over the course of the 2017-2018 season, there were 185 influenza-related pediatric deaths, and more than 30,000 individuals in the United States were hospitalized due to influenza. A number of diagnostic tests are now available for helping to diagnose influenza patients, and some of these tests can achieve an earlier diagnosis for more prompt initiation of treatment. This, in turn, can help to reduce the mortality rate and the number of hospitalizations that result when complications of the virus set in.

A Few Flu Facts

Influenza, commonly referred to as the flu, is a contagious and potentially serious viral respiratory infection that is transmitted through aerosolized droplets and surface contact.
While there is some overlap in many of the symptoms of the flu and those of a cold, one distinction between the two is the sudden onset of the flu when it strikes, unlike a cold’s gradual presentation. Another distinction is that most, but not all, patients who have the flu will run a fever and experience chills. Other symptoms of the flu include:

• Muscle aches
• Headaches
• Cough
• Chest discomfort
• Lethargy
• Sore throat
• Nasal congestion or nasal discharge

Vomiting and diarrhea can also present in some influenza cases, especially in pediatric patients.

While the majority of patients recover from the flu without additional misery, the illness can pose further complications to some individuals, including:

• Pediatric patients under the age of five years
• Senior patients aged 65 years or older
• Pregnant women
• Residents of long-term care facilities
• Patients with obesity
• Patients with compromised immune systems, such as those with cancer, HIV or AIDS
• Patients who suffer from any of a number of chronic conditions, including asthma, diabetes, coronary artery disease or cardiorespiratory disease

Some of the complications that can result from influenza include sinus infections, bronchitis and pneumonia, which can be fatal in these high-risk patients.

A Virus by Any Other Name

There are two types of flu viruses, which are known as influenza A and influenza B, that are the common culprits for flu outbreaks among the human population each season. However, there are numerous subtypes of influenza A, each identified by its specific protein makeup. Two proteins that are analyzed to identify these subtypes are hemagglutinin and neuraminidase. To date, subtypes H1 through H18 as well as N1 through N11 have been identified. H1N1 and H3N2 are the most prevalent subtypes of influenza A that are currently affecting human patients.

There are also influenza types C and D. Influenza C typically causes a much milder respiratory infection and is not believed to lead to an epidemic. Influenza D is infects cattle and is not known to pose a health threat to humans.

Influenza A and B viruses mutate into new strains through processes known as antigenic drift, which is a slower and more gradual process, and antigenic shift, which takes place more abruptly. In both antigenic drifts and antigenic shifts, the genetic material of the virus undergoes changes when the virus replicates. It is the evaluation influenza antigenic properties that enables the identification of presently circulating flu virus strains and then guides in the formulation of influenza vaccine to be administered for combating the flu during the following season. The results of influenza testing can also provide this valuable data.

Timely Influenza Tests

If a patient presents with the aforementioned flu symptoms, performing an influenza test can serve four purposes:

• Rule out other illnesses than may be causing the symptoms
• Enable the proper flu treatment sooner if the test is positive or avoid unnecessary drug therapy if the patient is negative
• Guide the physician toward the safest course of recommended treatment for patients who are high-risk individuals for developing complications
• Keep tabs on the potential for localized outbreaks of a flu virus in order to prompt recommendations for preventative measures

There are several influenza tests available. Traditional culturing and other tests can take hours to days to generate results. However, there are two tests that can be performed onsite which generate results in minutes.

The rapid influenza diagnostic test is an antigen detection test. The test is able to screen for influenza in a specimen taken from a nasopharyngeal, nasal or throat swab or aspirate. The rapid influenza detection test provides positive or negative results in as little as 15 minutes. Depending upon the specific test that is used, some rapid influenza diagnostic tests can detect both influenza types A and B.

The rapid molecular assay test detects the presence of influenza RNA, or nucleic acid. This test analyzes a specimen from a nasopharyngeal or nasal swab for influenza types A and B, providing a positive or negative result in 15 to 30 minutes.

One drawback of the rapid influenza diagnostic test is a high incidence (30 to 50%) of false-negative results. However, if a symptomatic patient’s test generates a negative result and his or her primary care physician strongly suspects influenza as the cause of the symptoms, the Center for Disease Control and Prevention (CDC) advises initiating flu treatment while pursuing a second test, either through the more sensitive and specific rapid molecular assay test or a viral culture test, for confirmation of the illness.

It should be noted that a patient who received the live attenuated influenza vaccine within the previous seven days are likely to receive a positive result on a rapid influenza diagnostic test, even if they are not contagious with the influenza virus. Depending on which rapid influenza diagnostic test is used, some will detect the vaccine strains for even longer than seven days.

For the most accurate results, patients should be tested within three to four days of the onset of their symptoms. Patients who can be treated for the flu with anti-viral drug therapy will gain the greatest benefits, including a shorter duration of the illness, a reduction in the severity of their symptoms and a reduced chance of developing complications, when treatment is begun early in their illness.

Prevention Through Vaccination

The first proactive step toward flu prevention is for patients to be vaccinated against the seasonal flu virus. The CDC recommends that every individual six months of age and older should receive the influenza vaccine. Several variations of the vaccine are available to accommodate different age groups and patient health needs for maximum safety and efficacy. Influenza vaccines are tailored each year to combat recent active strains of the illness. Therefore, everyone must be inoculated annually. Pregnant women are more prone to serious illness as a result of contracting the flu virus, and the flu places their unborn baby at risk for premature labor and delivery. The flu vaccine offers protection for the pregnant women and for their developing fetuses.

Additional Preventative Measures

In addition to vaccination, physicians should advise patients to practice the following habits to enhance their immune system’s ability to fight off the flu virus:

• Wash hands often and thoroughly.
• Refrain from close personal contact with anyone who has the flu.
• Avoid interacting with someone who has the flu as much as possible.
• Continue to eat a nutritionally balanced diet, and engage in regular physical fitness routines.
• Keep stress levels to a minimum, and get plenty of sleep.

Reduce the Spread

Anyone who contracts the influenza virus should stay home from work or school to avoid spreading the illness to others. These additional measures should be followed to reduce contamination and spread:

• Patients should cover their nose and mouth with tissues when they cough and sneeze.
• Patients should refrain from close personal contact with others.
• Patients should avoid touching their nose, mouth or eyes. Doing so and then touching other surfaces spreads the germs.
• To reduce the viability of aerosolized flu viruses, maintain a relative humidity level of 40 percent or higher in the home. The higher the air humidity is, the lower the chances are that the flu virus will thrive. This is why flu season peaks during the colder months of low climatic humidity and increased dryness in the air that results from indoor heating systems.
• Use a disinfectant that has been approved by the Environmental Protection Agency as being effective at killing the influenza virus to wipe down countertops and frequently handled objects, including doorknobs, remote controls, keys and key fobs, faucet handles, toilet flush handles, light switches, tablets, phones, door handles, desktop computer keyboards and control panels on refrigerators, microwaves and coffee machines, etc.

According to the CDC, the influenza virus infects 5 to 20 percent of the United States population each season, and up to 200,000 individuals are admitted annually to hospitals as a result of its complications. A combination of preventative measures and early testing of symptomatic patients can reduce that number of hospitalizations as well as the flu’s severity and duration.

By Cat Troiano

According to the Centers for Disease Control and Prevention (CDC), approximately 1.1 million Americans are living with human immunodeficiency virus (HIV), but one out of every seven of these individuals is unaware that he or she has the illness. When isolating those in the 13 to 24 year age group, the proportion of those who do not know that they have HIV jumps to more than 50 percent. The CDC also estimates that 50,000 new cases of HIV are diagnosed each year. By adhering to testing recommendations, a diagnosis of HIV is no longer considered a death sentence as it was during the 1980s. Today, once HIV is detected, available treatment can effectively manage the disease and empower many patients to live full and productive lives.

What Is HIV?

HIV is a virus that attacks the T-cells of the body’s immune system. T-cells are a type of white blood cell known as lymphocytes. The primary function of T-cells is to seek out and destroy pathogens as well as unhealthy cells, such as cancer cells. When the virus invades a T-cell, it replicates within the cell and destroys it. As HIV continues its attack, more and more of these T-cells are destroyed, resulting in a weakened immune system that can no longer fight off infections and certain cancers. By that point, once the T-cell count has dropped lower than 200 cells per millimeter, the disease has led to acquired immunodeficiency syndrome, or AIDS, which is the third and final stage in the HIV progression.

HIV Testing Guidelines

Although some patients who contract HIV may experience bouts of generalized symptoms similar to those of influenza, others remain asymptomatic during the earlier two stages of the disease. The only way to make a definitive diagnosis of HIV is through laboratory testing. The CDC currently advises routine HIV testing for every patient at least once between the ages of 13 and 64 years as well as for all pregnant women.

All patients should also be assessed for risk factors, which include the following:

• Having male to male sexual relations
• Having sexual relations with an HIV-positive partner
• Having sexual relations with someone without knowing that individual’s sexual history or HIV status
• Use of intravenous drugs, especially if sharing needles and other supplies with other individuals
• Previously diagnosed with a sexually-transmitted disease, hepatitis B, hepatitis C or tuberculosis
• Being a healthcare worker who may potentially have direct exposure to the blood of an HIV-positive patient
• Receiving a blood transfusion prior to 1985

Patients who carry any of these risk factors should be tested at least once annually.

HIV Antigen/Antibody Test

The HIV antigen/antibody test is the preferred laboratory test for initial HIV screening. When a patient is exposed to a bacteria or virus, which is known as an antigen, his or her immune system generates antibodies, also known as immunoglobulin, to neutralize the invading pathogen. The HIV antigen is known as p24. The HIV antigen/antibody test detects the level of p24 as well as two HIV antibodies, which are HIV-1 and HIV-2, the former of which is the more prevalent HIV antibody in the United States. Due to the test’s ability to detect p24, HIV can be detected in its earliest stage, as early as two to six weeks post patient exposure.

HIV Antibody Test

Any HIV antibody test that is performed in the United States is able to detect the presence of HIV-1 antibodies. This test can detect HIV as early as three to twelve weeks post patient exposure. Performance of any HIV screening test too soon after patient exposure can produce false-negative results. Once a patient tests positive on an HIV antigen/antibody test, the CDC recommends a follow up test with an HIV antibody test to confirm diagnosis. If both tests yield positive results, then the patient is considered HIV-positive, and treatment options will be presented by the patient’s physician. If the two test results do not concur, then ordering an HIV nucleic acid test is advised.

HIV Nucleic Acid Test (NAT)

The HIV nucleic acid test, which is also referred to as an HIV RNA quantitative test, screens for the actual virus in a blood sample by evaluating the level of HIV genetic RNA material. If the HIV antigen/antibody and the HIV antibody test results do not both yield positive results, this test can verify a patient’s HIV status.

Once a patient is diagnosed with HIV, the HIV NAT can be ordered to establish a baseline value of the individual’s viral load. The HIV NAT test is a useful method for monitoring that patient’s viral load levels periodically to determine the efficacy of their treatment protocol. The result of an HIV NAT is expressed as the quantity of HIV copies per milliliter of blood. When a patient’s treatment is effective, the number of copies/ml declines. Once that number drops lower than 200 copies/ml on a consistent basis, then the virus is said to be suppressed. This does not mean that the patient is cured of HIV. Rather, it indicates that the HIV viral load has reduced to undetectable levels, and the disease progression has been dramatically slowed.

Treatment Options

There is still no vaccine available to prevent HIV infection. However, those who are at significantly high risk for HIV have the option of taking a daily medication that has been shown to be effective at reducing their chances of HIV infection. This preventative treatment is known as pre-exposure prophylaxis, or PrEP.

Preventative treatment can also be administered on an emergency basis to individuals who suspect that they were exposed to HIV within the previous 72 hours. For example, if a victim of sexual assault begins taking the medication as soon as possible within 72 hours of the incident for 28 days, the risk of HIV infection declines. Such preventative treatment is known as post-exposure prophylaxis, or PEP.

There is no cure for HIV, but the disease can be controlled through antiretroviral therapy (ART). When positive test results confirm an HIV diagnosis in its earlier stage, patients who undergo this method of treatment and monitor their condition closely under their physicians’ recommendations can reduce their viral load to undetectable levels. This retards the progression of the disease, staving off the development of AIDS and enabling patients to live normally for years.

According to the World Health Organization, the rate of HIV and AIDS-related deaths worldwide has been reduced by more than half that of 2004 when the rate peaked. Screening patients for HIV enables earlier treatment with ART, which ultimately saves lives.

By Cat Troiano

Diabetes is a prevalent chronic metabolic disease, and according to the American Diabetes Association, nearly 10 percent of the American population has this condition. Roughly 1.5 million new cases of diabetes are diagnosed in the United States each year, but 7.2 million American adults who have diabetes are undiagnosed. Understanding which patients should be tested for diabetes and which tests to order can be a proactive step toward reducing the number of undiagnosed cases and saving more lives.

Types and Risk Factors of Diabetes

Diabetes refers to a group of metabolic diseases in which the body is unable to produce or respond to insulin, which is needed for maintaining proper blood glucose levels.

Insulin is a hormone that is produced by beta cells in the pancreas. In a healthy individual, once dietary sugar from carbohydrates is metabolized, insulin is responsible for transporting the glucose from the blood to the body’s muscles and other tissues for use as energy. Any extra glucose gets stored in the liver for a future energy source. In an individual who has diabetes, glucose ends up accumulating in the bloodstream, resulting in hyperglycemia.

Type 1 diabetes, also known as diabetes insipidus, is characterized by the pancreas’ inability to produce insulin. The cause of type 1 diabetes is still unconfirmed, but it is believed to be an autoimmune disorder, and the incurable condition is typically diagnosed early in life. Patients with type 1 diabetes require lifelong treatment with insulin medication.

Type 2 diabetes, also known as diabetes mellitus, is the most prevalent form of diabetes and is characterized by insulin resistance. This means that although the pancreas does produce insulin, the body does not utilize the insulin efficiently to keep blood glucose levels within normal parameters. While type 2 diabetes was once primarily diagnosed in adult patients, the recent trend in rising childhood obesity rates has resulted in an increased rate of diagnosis in children.

Gestational diabetes is a form of diabetes that occurs during pregnancy. It is usually diagnosed in expectant mothers during the third trimester, and once the baby is born, the blood sugar level usually returns to normal.

Prediabetes is the condition that precedes type 2 diabetes in which the blood glucose level is abnormally high, but it is not yet high enough to confirm a diagnosis of diabetes.
According to the Centers for Disease Control and Prevention, one in three Americans has prediabetes. Failure to detect prediabetes and intervene to reverse its course will most likely result in diabetes. Unlike type 1 diabetes, which acts as an autoimmune disorder, type 2 diabetes, which is considered a lifestyle disease, can be prevented. Risk factors for type 2 diabetes include:

• Obesity
• Excess abdominal fat, indicated by a waist circumference measurement that is greater than 100 centimeters in men or greater than 88 centimeters in women
• Triglyceride level that exceeds 150 mg/dL
• HDL cholesterol level that is lower than 40 mg/dL
• Hypertension
• Sedentary lifestyle
• Prediabetes, indicated by a fasting glucose level that is greater than 100
• Family history of diabetes
• Previous history of gestational diabetes
• History of giving birth to a baby whose birth weight exceeded nine pounds
• Being 45 years of age or older
• Being of African-American, Native-American, Hispanic-American or Asian-American ethnicity

Patients who possess any of these risk factors must be screened for diabetes to enable early detection before the disease’s damaging complications occur.

Random Blood Glucose Level

For an immediate blood test result in patients who present with symptoms of diabetes, a blood test that does not require fasting can be performed at any time. Symptoms of diabetes include:

• Increased water intake and urinary output
• Unexplained weight loss
• Persistent hunger
• Blurred vision
• Slow healing time for wounds and lacerations
• Frequent infections

A result of 200 mg/dL or higher on a random blood glucose level test is indicative of diabetes.
Fasting Blood Glucose Level

This test reveals a patient’s blood glucose level after fasting overnight. Diabetic patients typically check their own fasting blood glucose level on a daily basis by using a glucometer, which analyzes a drop of blood. Whenever a physician orders a comprehensive metabolic profile, the panel includes the blood glucose level. When patients are directed to fast prior to testing, as is typical when the panel includes a lipid profile, then the blood glucose level result is a fasting level. Fasting blood glucose levels are interpreted as:

Normal Range: 99 mg/dL or lower
Prediabetes Range: 100 to 125 mg/dL
Diabetes Range: 126 mg/dL or higher

When two different tests are performed on two different days and the fasting blood glucose level results on both tests fall within the prediabetic range, then steps must be taken, such as dietary changes and exercise routine implementation, to try to reduce the patient’s risk of his or her prediabetic status advancing to diabetes. There are also additional tests that can be ordered to better assess the patient’s blood glucose level trends.

HbA1c

The hemoglobin A1c (HbA1c) test, for which fasting is not required, is a blood test that reveals a patient’s average blood glucose level for the two to three-month timespan prior to testing. This test evaluates the percentage of glycated, or glucose-coated, hemoglobin in the blood. HbA1c test results are interpreted as:

Normal Range: 5.6 percent or lower
Prediabetic Range: 5.7 to 6.4 percent
Diabetic Range: 6.5 percent or higher

The HbA1c test can be performed to establish a baseline blood glucose level average, and it is also used to monitor diabetic management and progression. The HbA1c test should be ordered annually for patients who have prediabetes. The test may be ordered more often for patients with types 1 or 2 diabetes.

Since the HbA1c test assesses a two to three-month average blood glucose level, pregnancy and certain medical conditions in which the lifespan of a patient’s blood cells is shorter in duration than the typical 120 days, such as hemolytic anemia, can reduce the accuracy of the test.

Fructosamine Test

Like the HbA1c test, the fructosamine test also measures the glycated protein, in this case albumin, in the blood. The two tests differ in that the fructosamine test provides an average blood glucose level for the past two to three weeks instead of the HbA1c test’s result of a two to three-month average. The fructosamine test can be used to provide an earlier assessment of the patient’s glycemic control once dietary and other lifestyle changes are made and insulin therapy has begun.

Normal reference range for fructosamine: 200 to 285 mcmol/L

The higher the fructosamine test result is above 285, the less effective a patient’s current diabetic treatment protocol is in achieving glycemic control.

Oral Glucose Tolerance Test

The glucose tolerance test evaluates blood glucose levels over a two-hour duration, which offers a glimpse into how efficiently a patient’s body processes glucose. After an overnight fast, the first blood sample is drawn for a fasting blood glucose test. The patient is then required to drink a sugary solution, and then an additional blood sample is taken two hours later, for an additional blood glucose level reading. That reading that is taken at the two-hour mark is interpreted as:

Normal Range: 139 mg/dL or lower
Prediabetic Range: 140 to 199 mg/dL
Diabetic Range: 200 mg/dL or higher

The glucose tolerance test is extended to a three-hour duration with a third blood sample drawn when used to screen for gestational diabetes in pregnant women. If at least two of the three sample results are 200 mg/dL or higher, then gestational diabetes is diagnosed.

Ketones in the Urine
When the body does not have a sufficient amount of insulin available to utilize glucose for energy, body fat is burned for energy instead. When this occurs, a byproduct called ketones is produced and expelled from the body through urine. Ketones can be found in the urine and in the blood, and the presence of ketones is known as ketosis. Results for ketones in urine testing are interpreted as follows:

Negative: normal
Small: Less than 20 mg/dL
Moderate: 30 to 40 mg/dL
Large: Greater than 80 mg/dL

Having ketones in the urine can be indicative of diabetes. Diabetes is not only cause of ketosis, however. Other causes include anorexia, hyperthyroidism, long durations of vomiting, severe infections, high fevers, excess alcohol consumption and the currently popular ketogenic diet. When a diabetic patient’s ketone levels accumulate to moderate or large numbers and blood glucose levels are also high, the patient is then at risk for a potentially life-threatening condition called diabetic ketoacidosis.

Diabetes is the seventh leading cause of mortality, but with the availability of several different laboratory tests that can be called upon to diagnose and monitor diabetes, patients today have an excellent chance of controlling their condition, enabling them to live a normal life for a full lifespan.