First report of paracoccidioidomycosis reactivation as a complication of immunosuppressive therapy for acute severe colitis in a caving enthusiast.

Treatment for ulcerative colitis often requires the administration of immunosuppressive therapy. Shortly after rescue therapy with infliximab for acute severe colitis, a patient who was also taking corticosteroids, azathioprine and adalimumab became rapidly unwell with atypical pneumonia, which did not respond to conventional antimicrobials. Re-examining the travel history revealed a prior caving trip to Costa Rica. Dimorphic fungal serology was thus tested and a diagnosis of paracoccidioidomycosis was made. After a lengthy intensive care unit admission, the patient made a recovery after the administration of appropriate antifungal therapy and was discharged home on long-term oral antifungals.

Rituximab to the rescue: novel therapy for chronic gastrointestinal bleeding due to angiodysplasia and acquired von Willebrand syndrome.

Identification of acquired von Willebrand syndrome (AVWS) was key to treating a patient with chronic gastrointestinal (GI) bleeding due to angiodysplasia. After exhausting endoscopic and pharmacological options, the patient was successfully treated with rituximab. A 78-year-old man developed chronic GI bleeding from caecal and jejunal angiodysplasia. Red cell transfusion was required weekly despite argon plasma coagulation. A diagnosis of AVWS was made from analysis of clotting factors. Therapies including von Willebrand factor concentrate, thalidomide and tranexamic acid were unsuccessful. With failed endoscopic therapy and no viable surgical option, the patient was given intravenous immunoglobulins (IVIGs). Haemoglobin remained stable from this point. The impact on the patient and hospital of attending for IVIG every 3 weeks necessitated consideration to longer-term therapy. After a single course of rituximab, no further blood products, IVIG or rituximab were required. This case is the first to describe the use of rituximab in AVWS-associated angiodysplasia.

Extending landscape of volatile metabolites as novel diagnostic biomarkers of inflammatory bowel disease - a review.

The diagnosis of inflammatory bowel disease (IBD) remains a challenging task despite significant increase in the understanding of the disease aetiology and pathogenesis. Recent decade has seen a massive interest in the non-invasive diagnostic biomarkers of IBD, consequently a number of studies have explored a variety of potential biomarkers to diagnose the disease and monitor the disease activity. Volatile metabolites are the chemicals, which emanate from biological fluids and can reflect the status of health and disease of an individual. Recent advances in the analytical techniques have enabled the detection and interpretation of the changes in volatile metabolites in breath, urine, faeces and blood of an individual in correlation with various gastrointestinal (GI) disorders including IBD. This can provide a simple, fast and reproducible diagnosis at the point of care. This review focuses on the current and future novel approaches for detecting and the monitoring gut inflammation in IBD by using volatile organic metabolites.

Value of baseline serum thyrotropin as a predictor of hypothyroidism in patients with diabetes mellitus.

OBJECTIVE: To determine whether serum thyrotropin measurement performed at diagnosis of diabetes mellitus or at initial patient contact predicts subsequent development of hypothyroidism. METHODS: We retrospectively reviewed the computerized records of patients attending annual visits between January 2008 and December 2008 at a hospital diabetes mellitus clinic. Serum free thyroxine and thyrotropin at current and baseline annual visits were documented. A Cox regression model was used to analyze the relationship between development of thyroid dysfunction and patient characteristics including age, sex, type of diabetes, and baseline serum thyrotropin concentration. Kaplan-Meier survival curves were generated for predictors of hypothyroidism. RESULTS: Clinical records of 1101 patients were reviewed (595 men [54%] and 506 women [46%]). Mean age was 60.0 ± 17 years. Two hundred twenty-three patients (20.3%) had type 1 DM and 878 (79.7%) had type 2 diabetes. Thyroid dysfunction was present in 136 patients (12.4%) at baseline and developed in 71 patients (6.4%) at follow-up (median duration, 37 months). Overt and subclinical hypothyroidism developed in 28 (2.5%) and 38 (3.5%) patients, respectively. Incident hypothyroidism was associated with baseline thyrotropin concentration greater than 2.2 mIU/L (relative risk, 10.4; confidence interval, 5.6-19.6; P<.001) and female sex (relative risk, 1.8; confidence interval, 1.1-2.9; P = .007). The predictive influence of sex was abolished in patients with a thyrotropin value greater than 2.2 mIU/L. This TSH threshold yielded an optimal sensitivity and specificity of 83% and 72%, respectively, for predicting hypothyroidism. CONCLUSIONS: Baseline serum thyrotropin predicted hypothyroidism in patients with diabetes mellitus even at thyrotropin concentrations within the reference range. Selective annual thyroid screening in diabetic patients with baseline thyrotropin concentrations greater than 2.2 mIU/L may be more cost-effective than universal screening.

An audit of patients' satisfaction after adult day-case surgery at Ayub Teaching Hospital, Abbottabad.

BACKGROUND: Day-case surgery has become an important component in the provision of surgical care in the Western countries. This study was done to introduce the concept of day-case surgery and assess the patients' satisfaction after day case general surgery in our set up with vast rural communities lacking medical facilities and no day-case surgery units in the hospitals. METHODS: All those patients suitable for day-case surgery and who accepted day-case surgery for general surgical procedures in General Surgical 'A' unit of Ayub Teaching Hospital, Abbottabad were interviewed after the operation on follow up visits. Questions were asked about their satisfaction with day-case surgery. If they were not satisfied, the reasons for dissatisfaction were noted. Direct admissions and re-admissions after day-case surgery were recorded. Any complications in the postoperative period were also noted. The patient's preference for a similar procedure as day-case in future was also recorded. RESULTS: There were 122 patients in this study. 60(49%) were operated under general anesthesia and 62(51%) under local anesthesia. Fourty Nine (40%) patients were satisfied while 73(60%) were not satisfied with day-case surgery. Six (5%) patients were admitted directly after day-case surgery while 7(5.7%) patients were admitted after discharge. Complications occurred in 41(33.6%) patients at home. Wound complications and pain were the most common morbidity encountered by the patients. Twenty eight (23%) patients contacted a hospital or a doctor in the early postoperative period. Sixty two (51%) patients would prefer operation as in-patient while 74 (60.6 %) would prefer an overnight stay after the operation next time. CONCLUSIONS: Patients' satisfaction with day-case surgery in Ayub Teaching Hospital is not high. Short-stay surgery would be more appropriate in our set up.