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.

Case Report of a Missed Small Bowel Adenocarcinoma on an Upper Endoscopy-A Review of Small Bowel Diagnostic Modalities.

Background: Small bowel neoplasms (SBN) are rare but pose a significant diagnostic challenge. The routine upper endoscopy delays the diagnosis, and most cases require multiple investigations increasing the health care burden. Case summary: A 74-year-old man presented with two months of progressively worsening postprandial bilious emesis and epigastric abdominal pain. He underwent outpatient evaluation with upper endoscopy and a computed tomographic enterography. The first endoscopy did not enable us to recognize the small bowel mass, leading to a diagnostic delay of two months. He subsequently developed a complete intestinal obstruction. A Second look upper endoscopy done with a push enteroscopy showed an apple core-like mass suggestive of a possible malignant neoplasm at the distal duodenum/proximal jejunum. Conclusion: Therefore, more sensitive, and specific diagnostic modalities like push enteroscopy, capsule endoscopy, and deep enteroscopy should be considered in case upper endoscopy is not conclusive.

Risk of Gastrointestinal Bleeding in Patients with End-Stage Renal Disease: The Link between Gut, Heart, and Kidneys.

Patients with end-stage renal disease (ESRD) have a five times higher risk of gastrointestinal bleed (GIB) and mortality than the general population. Aortic stenosis (AS) has been associated with GIB from intestinal angiodysplasia. In this retrospective analysis, we obtained data from the 2012 and 2019 National Inpatient Sample. The primary outcome of interest was all-cause in-hospital mortality and risk factors of mortality in patients with ESRD with GIB with aortic valve disorders especially AS. We identified all patients (≥18 years of age) with ESRD (n = 1,707,452) and analyzed based on discharge diagnosis of valvular heart disease (n = 6521) in patients with GIB compared with those without GIB (n = 116,560). Survey statistical methods accounting for strata and weighted data were used for analysis using survey packages in R (version 4.0). Baseline categorical data were compared using Rao-Scott chi square test, and continuous data were compared using Student's t-test. Covariates were assessed using univariate regression analysis, and factors with p value less than 0.1 in the univariate analysis were entered in the final model. The univariate and multivariable associations of presumed risk factors of mortality in ESRD with GIB patients were performed by Cox proportional hazards model censored at length of stay. Propensity score matching was done using MatchIt package in R (version 4.3.0). 1 : 1 nearest neighbour matching was done with propensity scores estimated through logistic regression, in which occurrence of GIB, valvular lesions, and AS was regressed according to other patient characteristics. Among patients with ESRD with valvular heart diseases, AS was found to be associated with increased risk of GIB (adj.OR = 1.005; 95% CI 1.003-1.008; p < 0.01). ESRD patients with AS showed increased risk of lower GIB (OR = 1.04; 95% CI 1.01-1.06; p = 0.02), colonic angiodysplasia (OR = 1.03; 95% CI 1.01-1.05; p < 0.01), stomach and duodenal angiodysplasia (OR = 1.03; 95% CI 1.02-1.06; p < 0.01), need for blood transfusion add pressors as compared to those without AS. However, there was no increased risk of mortality (OR = 0.97; 95% CI 0.95-0.99; p < 0.01).

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.

Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan.

BACKGROUND: The utilization of ambulances in low- and middle-income countries is limited. The aim of this study was to ascertain frequency of ambulance use and characteristics of patients brought into emergency departments (EDs) through ambulance and non-ambulance modes of transportation. METHODS: The Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a pilot active surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan between November 2010 and March 2011. Univariate and multivariate logistic regression was performed to investigate the factors associated with ambulance use. RESULTS: Out of 274,436 patients enrolled in Pak-NEDS, the mode of arrival to the ED was documented for 94. 9% (n = 260,378) patients, of which 4.1% (n = 10,546) came to EDs via ambulances. The mean age of patients in the ambulance group was significantly higher compared to the mean age of the non-ambulance group (38 ± 18.4 years versus 32.8 ± 14.9 years, p-value < 0.001). The most common presenting complaint in the ambulance group was head injury (12%) while among non-ambulance users it was fever (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001) adjusted for gender, cities, hospital type, presenting complaint group and disposition. The adjusted odds ratio of utilizing ambulances for those with injuries was 3.5 times higher than those with non-injury complaints (p-value < 0.001). Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients after adjustment for other variables in the model. CONCLUSION: Utilization of ambulances is very low in Pakistan. Ambulance use was found to be more among the elderly and those presenting with injuries. Patients presenting via ambulances were more likely to die in the ED.

Emergency and trauma care in Pakistan: a cross-sectional study of healthcare levels.

BACKGROUND: The importance of emergency medical care for the successful functioning of health systems has been increasingly recognised. This study aimed to evaluate emergency and trauma care facilities in four districts of the province of Sindh, Pakistan. METHOD: We conducted a cross-sectional health facility survey in four districts of the province of Sindh in Pakistan using a modified version of WHO's Guidelines for essential trauma care. 93 public health facilities (81 primary care facilities, nine secondary care hospitals, three tertiary hospitals) and 12 large private hospitals were surveyed. Interviews of healthcare providers and visual inspections of essential equipment and supplies as per guidelines were performed. A total of 141 physicians providing various levels of care were tested for their knowledge of basic emergency care using a validated instrument. RESULTS: Only 4 (44%) public secondary, 3 (25%) private secondary hospitals and all three tertiary care hospitals had designated emergency rooms. The majority of primary care health facilities had less than 60% of all essential equipments overall. Most of the secondary level public hospitals (78%) had less than 60% of essential equipments, and none had 80% or more. A fourth of private secondary care facilities and all tertiary care hospitals (n=3; 100%) had 80% or more essential equipments. The average percentage score on the physician knowledge test was 30%. None of the physicians scored above 60% correct responses. CONCLUSIONS: The study findings demonstrated a gap in both essential equipment and provider knowledge necessary for effective emergency and trauma care.

Undergraduate clerkship in emergency medicine: experience from Pakistan.

Although Emergency Medicine (EM) is an integral part of undergraduate medical curriculum in many countries, it has not been included formally in the MBBS curriculum in Pakistan. Medical graduates are supposed to be able to handle common as well as life threatening emergencies but little has been done to ensure the process to achieve this competence. The development of an undergraduate EM curriculum is important but challenging task. Implementation of standard curriculum will ensure that medical graduates have gained competence in assessing and managing acutely ill patients and dealing with common emergencies. This paper shares the features of an undergraduate EM clerkship which can be used as a template by other medical institutions.