Gastrointestinal Amyloidosis as a Cause of Anemia: Rare and Rarely Considered.

Gastrointestinal involvement in amyloidosis is reported in 3% of cases, mostly associated with multiple myeloma. An elderly man with chronic kidney disease presented to the hospital after a large melenic bowel movement. The patient was tachycardic and anemic to 3.8 g/dL on admission and was transfused blood. Endoscopy and colonoscopy were unremarkable. Subsequently, the patient had 2 more admissions for severe anemia requiring blood transfusion. Repeat esophagoduodenoscopy with capsule endoscopy were unremarkable. The patient was diagnosed with monoclonal gammopathy of undetermined significance by hemoglobin electrophoresis, and endoscopy biopsy revealed intestinal amyloidosis in a duodenal specimen. The patient's recurrent anemia was attributed to bleeding from gastrointestinal amyloidosis, in the absence of other identifiable sources of anemia, and was managed with intravenous iron infusions.

Clinical spectrum of sarcoidosis in patients at a tertiary care hospital, Pakistan: Ten-year follow-up study.

OBJECTIVE: To identify the local patterns of manifestations, organ involvement other than lungs, diagnostic tools and treatment regimens related to patients of sarcoidosis. Methods: The retrospective study was conducted from November 1, 2019, to February 28, 2020, at the Aga Khan University Hospital, Karachi, and comprised data of sarcoidosis patients who needed hospitalisation between 2009 and 2019. The entire clinical spectrum was noted based on organ involvement. Data was analysed using SPSS 21. RESULTS: Of the 80 patients, 53(66.3%) were women. The overall mean age at diagnosis was 52.0±13.5 years. Pulmonary sarcoidosis was found in 60(75%) patients, while 13(16.3%) had extrapulmonary manifestations, and 6(8.8%) had both pulmonary and extrapulmonary involvement. None of the patients had hypercalcaemia, while antinuclear antibodies were positive in 2 (18.2%) patients. In terms of treatment, 75(93.8%) patients received corticosteroids. Acute exacerbation of interstitial lung disease was the most common reason of hospitalisation 16(20%). Mortality was the outcome in 11(14.7%) cases. CONCLUSIONS: Sarcoidosis was found to be more prevalent in women aged 50 years and above. A quarter of patients had extrapulmonary manifestation, while interstitial lung disease was the most common complication.

Community acquired versus hospital acquired acute kidney injury; causes and outcome.

OBJECTIVE: To evaluate causes of community-acquired and hospital-acquired acute kidney injury and the factors associated with increased inpatient mortality. METHODS: The observational prospective study was conducted at the Aga Khan University Hospital, Karachi, from September 2018 to March 2019, and comprised patients having acute kidney injury either at the time of admission in group A or developed it after 48 hours of hospital stay in group B. The patients were followed up for 12 weeks and outcomes were categorised as recovered, developed chronic kidney disease, died or remained dialysis-dependent. Data was analysed using SPSS 19. RESULTS: Of the 400 patients, 347(86.8%) were in group A; 190(54.8%) males and 157(45.2%) females with an overall mean age of 57.2±17.0 years. The remaining 53(13.3%) were in group B; 31(58.5%) males and 22(41.5%) females with an overall mean age of 58.5±16.3 years. Urinary tract infection 105(30.3%) was the most frequent cause in group A, followed by volume depletion 73(21%). The causes in group B were multiple, with nephrotoxic antibiotics vancomycin 21(39.6%) and polymyxin 20(37.7%) being the most common. At 12 weeks, 224(56%) patients recovered, 55(13.8%) died, 82(20.5%) and 38(9.5%) developed new onset and progressive chronic kidney disease, respectively, and 1(0.25%) patient remained dialysis-dependent. Chronic liver disease, renin angiotensin system inhibitors, infection, shock, invasive ventilation and increasing length of stay were associated with increased inpatient mortality (p<0.05). CONCLUSIONS: Acute kidney injury was largely community-acquired, and infection was the leading cause with better outcome in contrast to hospital-acquired acute kidney injury which was mostly multifactorial.

Online Medical Education and Examinations during COVID-19: Perspectives of a Teaching Associate.

The novel coronavirus disease 2019 (COVID-19) pandemic has not only challenged global health systems but also social, economic, and educational systems. In this short communication, our focus is on its impact on medical education in Pakistan. We discuss the structure of undergraduate medical education in Pakistan; and how it has evolved in the wake of COVID-19. We describe our role as teaching associates (TAs) at the Aga Khan University (AKU); and how it has enabled us to be a part of the transition to online medical education, with a specific focus on online examinations in medical schools. Key Words: Medical education, Online examinations, COVID-19, Pandemic.

Online Medical Education and Examinations during COVID-19: Perspectives of a Teaching Associate.

The novel coronavirus disease 2019 (COVID-19) pandemic has not only challenged global health systems but also social, economic, and educational systems. In this short communication, our focus is on its impact on medical education in Pakistan. We discuss the structure of undergraduate medical education in Pakistan; and how it has evolved in the wake of COVID-19. We describe our role as teaching associates (TAs) at the Aga Khan University (AKU); and how it has enabled us to be a part of the transition to online medical education, with a specific focus on online examinations in medical schools.  Key Words: Medical education, Online examinations, COVID-19, Pandemic.

Changes in vitamin E levels as a marker of female infertility.

OBJECTIVE: To study the impact of Vitamin E (VE) levels of follicular fluid (FF) on oocyte competence, embryo development and pregnancy outcome in patients after intra cytoplasmic sperm injection (ICSI). METHODS: It was a cross-sectional study conducted in Islamabad Clinic Serving Infertile Couples in which follicular fluid of 137 females booked for ICSI, was obtained during oocyte retrieval, centrifuged and stored for analysis. VE levels in FF were analyzed by enzyme linked immune sorbent assay. Receiver Operating Curve (ROC)was used to demarcate VE levels required for acquiring pregnancy. Generalized linear model using log binomial regression was applied to see the effect of VE on pregnancy, the effect of VE on oocyte and embryo parameters was assessed by linear regression; all p-values less than 0.05 were considered statistically significant. RESULTS: ROC suggested 5.49 (unit) as the cutoff value of VE in the pregnancy group, with 72.9% area under the curve. Ninety-one females comprised Group I with VE > 5.49, whereas forty six females formed Group II with VE < 5.49. Follicular fluid VE levels were significantly high in 39 (28.5%) females who compromised pregnancy group. Chances of pregnancy increased to 4% with an increase in VE levels (p-value 0.01). VE gave significant positive relationship with all oocyte (retrieved, mature and fertilized) parameters, cleavage of embryo till its differentiation to blastocysts (p<0.01). CONCLUSIONS: Adequate amount of VE in follicular fluid enhances the possibility of maturation of oocytes which resulted in better reproductive outcome after ICSI.