Conversion of autoimmune hypothyroidism to hyperthyroidism

Background: Graves\u27 disease and Hashimoto\u27s thyroiditis are the two autoimmune spectrum of thyroid disease. Cases of conversion from hyperthyroidism to hypothyroidism have been reported but conversion from hypothyroidism to hyperthyroidism is very rare. Although such cases have been reported rarely in the past we are now seeing such conversions from hypothyroidism to hyperthyroidism more frequently in clinical practice. Case Presentation: We are reporting three cases of middle aged Asian females who presented with classical symptoms of hypothyroidism and the investigations showed elevated thyroid stimulating hormone with positive thyroid antibodies. Diagnosis of autoimmune hypothyroidism was made and thyroxine replacement therapy was initiated. Patients became asymptomatic with normalization of thyroid stimulating hormone level. After few years they developed symptoms of hyperthyroidism with suppressed thyroid stimulating hormone level. Over replacement of thyroxine was considered and the dose of thyroxine was decreased, but they remain symptomatic. After gradual decrease in the dose of thyroxine it was stopped finally. Even after few months of stopping thyroxine, the symptoms of hyperthyroidism did not improve and the biochemical and imaging modalities confirmed that the patients have developed hyperthyroidism. Anti-thyroid treatment was then started and the patients became symptom free. Conclusion: High index of suspicion should be there for possible conversion of hypothyroidism to hyperthyroidism if a patient with primary hypothyroidism develops persistent symptoms of hyperthyroidism. Otherwise it can be missed easily considering it as an over replacement with thyroid hormone

Personal Remittance, A Reagent of Macroeconomic Stability in the Perspective of Pakistan (2005-2017)

Pakistan is a semi-industrialized economy, which mainly comprehends fabrics, chemicals, food dispensation, cultivation and other activities. Economy of Pakistan is at very stirring phase in structural and financial point of view such as unfavorable balance of payments and high debt profile. To disrupt these unfavorable economic balances many peripheral economic factors act as a source of income or core factor of advantageous balances such as FDI, Remittances, Exports, Foreign aids etc. So this study is aimed to detect pros and cons of personal remittances along with correlation with macroeconomic volatilities. Data is collected from secondary sources during time span of 2005-2017. The period is chosen for study is 2002 to 2017 and numerical data is used for validity. Data is evaluated through statistical software EVIEWS. Standardized criteria is assumed to accept or reject the hypothesis. On the basis of inferences, policies and implication are given in the shape of recommendation for curative measures. Keywords: Personal Remittances, Current account balance, Unemployment, Inflation DOI: 10.7176/JESD/10-6-10 Publication date:March 31st 201

Hyponatraemia: etiology, management and outcome

OBJECTIVE: To determine the etiology of hyponatraemia, the treatment instituted and the outcome of treatment in a tertiary care hospital setting. STUDY DESIGN: Case series.PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, between January and June 2004. METHODOLOGY: Case records of 220 patients admitted to the medical service were identified through computerized hospital patients\u27 data. All patients (3) 15 years with a sodium level on admission of (2) 130 mmol/litre were included. The records of those patients were reviewed for relevant demographic, clinical and laboratory data, in addition to the diagnosis, treatment and outcome of hospitalization. The data was analyzed through SPSS software version 11.0. RESULTS: Over a 6-month period, 220 patients were admitted with hyponatraemia (serum sodium (2) 130 mmol/L). Of those 127 females and 93 males, the mean age was 65 + 13.29 years. Neurological symptoms were the presenting feature in 25% patients. The mean serum sodium level on admission was 119.46 mmol/L. The rate of correction was \u3e10 mmol/L/ 24 hours in 17% patients. The average duration of stay was 4 days. The mortality was 6.8%. Medicines accounted for 30% cases of hyponatraemia, of which diuretics, angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blockers (ARBs) were top of the list. Other causes were gastrointestinal in 25%, chest infection in 11% patients, depletional hyponatraemia in 10% patients, SIADH (Syndrome of Inappropriate Antidiuretic Hormone) in 6% patients, congestive cardiac failure and malignancy in 5% each and chronic liver disease in 3.6% patients. CONCLUSION: Hyponatraemia was seen more commonly in the elderly, major causes being gastrointestinal losses and use of drugs. Serum sodium correction should be less than 10 mmol/L/24 hours. The treatment plan be directed to correction of the underlying cause. Diagnosis of SIADH should be sought with appropriate investigation

A Management of forgotten double J Ureteric stent in a young male: A Case Report

Urologic devices called Double-J stents (DJSs) are frequently used to treat urinary tract blockage. Advancement in endourology in last few decades has led to an increase in use of ureteric stents and so its related complications. Herein, we report a case of a 17 years old male patient of poor socioeconomic background from a remote village of Afghanistan, presented to our out-patient department with abdominal pain at the right flank. He had history of double J stent placement during right open pyelolithotomy 6 year before. However, no further details were available

Vitamin B12 deficiency common in primary hypothyroidism

OBJECTIVE: To assess the prevalence and clinical features of B12 deficiency in hypothyroid patients and to evaluate clinical response in symptoms to B12 replacement therapy. METHODS: One hundred and sixteen hypothyroid patients from our endocrine clinic were evaluated for signs and symptoms of vitamin B12 deficiency. Laboratory parameters including Haemoglobin (Hb), MCV, Vitamin B12 levels and presence of anti thyroid antibodies were analyzed. Patients with low B12 levels were treated with parenteral intramuscular vitamin B12 monthly, and monitored for improvement of symptoms. RESULTS: A total of 116 patients (95 females and 21 males) were evaluated. Forty six (39.6%) hypothyroid patients had low vitamin B12 levels. Males and females had the same prevalence of B12 deficiency. Generalized weakness, impaired memory, depression, numbness and decreased reflexes were more frequently noted in B12 deficient patients, but failed to achieve statistical significance when compared with B12 sufficient patients. The mean Hb in B12 deficient group was 11.9 +/- 1.6 mg/dl and 12.4 +/- 1.7 mg/dl in the B12 sufficient group, however the mean MCV did not differ in the two groups. Patients with B12 deficiency did not have a higher prevalence of anaemia. Thyroid antibodies were checked in half the patients and 67% had positive titers for anti thyroid antibodies. Prevalence of vitamin B12 deficiency did not differ in patients with positive antibodies (43.2%) compared to those with negative antibodies (38.9%) (p= 0.759). Twenty four hypothyroid patients with B12 deficiency received intramuscular vitamin B12 injections monthly and improvement in symptoms was noted in 58.3% of these subjects. Additionally, 21 subjects complained of symptoms consistent with B12 deficiency but who had normal range B12, levels and were prescribed monthly B12 injections and 8 (40%) had good subjective clinical response at 6 months. CONCLUSIONS: There is a high (approx 40%) prevalence of B12 deficiency in hypothyroid patients. Traditional symptoms are not a good guide to determining presence of B12 deficiency. Screening for vitamin B12 levels should be undertaken in all hypothyroid patients, irrespective of their thyroid antibody status. Replacement of B12 leads to improvement in symptoms, although a placebo effect cannot be excluded, as a number of patients without B12 deficiency also appeared to respond to B12, administration

End-to-end communication modelling for large scale vehicular networks using AADL

Nowadays novel embedded computing devices enable nodes to form large scale mobile peer-to-peer networks with high communication and computational demands. Inter-vehicular communication is an example of such a large scale flow intensive system where vehicles assist each other to improve the driving experience. Currently, network simulators are being used as a cost effective means to experiment with different inter-vehicle flows of traffic related information, but lack a more analytical approach to identify trade-offs. Architecture Analysis and Design Language (AADL) is a modelling formalism that supports architectural based modelling and analysis of functional and non-functional requirements of embedded systems. In our paper, we perform an analysis using AADL for large scale flow intensive vehicular networks. In order to better analyze the trade-off points and optimize the communication in vehicular networks we model end-to-end (EtE) flows with different levels of various in-flows using AADL. Our results show that with the help of AADL flow models, we analyzed the EtE flows in a flow intensive system like large scale vehicular networks at multiple levels of abstraction which is a significant advantage unlike in simulations and also optimize the information dissemination by fine-tuning for the vehicular network quality attributes of interest.status: publishe

Effects of peripartal glucose precursor supplementation on lactation performance and metabolic health of primiparous and multiparous dairy cows

Objective Hyperketonemia remains a major metabolic issue of serious milk production and a major health concern in early lactation cows. Oral supplementation of glucose precursors (GP) can be used to prevent hyperketonemia in dairy cows. The objective of this study was to compare the beneficial effects of orally supplementing a mixture of GP on metabolic health indicators and milk production status of primiparous (PP) and multiparous (MP) dairy cows. Methods Twenty-eight Holstein cows were blocked by expected date of parturition, previous lactation yield, and parity. The cows were randomly allocated to one of the four treatment groups (n = 7 cows/group) based on their parity and GP supplementation: i) PP cows fed basal diet only (PP-CON), ii) PP cows with oral supplementation of GP (PP-GP), iii) MP cows fed basal diet only (MP-CON), and iv) MP cows with oral supplementation of GP (MP-GP). Glucose precursor (glycoline liquid) was orally drenched (300 mL/d) in GP cows from 7 days prepartum through 7 days postpartum. Other than GP supplementation, all cows were fed similar pre- and postpartum basal diets. Results In both pre- and postpartum periods, serum glucose concentration was increased, whereas β-hydroxybutyrate and free fatty acids were decreased in GP cows compared with the CON cows. Milk yield and milk components were statistically not different between GP and CON cows over the first 9 week of lactation. The yield of actual milk, energy-corrected milk, 63-days cumulative milk, colostrum yield, and calf birth weight remained higher in MP cows compared with PP cows. Conclusion Oral drenching of GP around calving can be recommended to successfully improve the metabolic health and reduce the negative effects of hyperketonemia not only in MP but also in PP dairy cows

Prognostically significant fusion oncogenes in Pakistani patients with adult acute lymphoblastic leukemia and their association with disease biology and outcome

Background and objectives: Chromosomal abnormalities play an important role in genesis of acute lymphoblastic leukemia (ALL) and have prognostic implications. Five major risk stratifying fusion genes in ALL are BCR-ABL, MLL-AF4, ETV6-RUNX11, E2A-PBX1 and SIL-TAL1. This work aimed to detect common chromosomal translocations and associated fusion oncogenes in adult ALL patients and study their relationship with clinical features and treatment outcome. Methods: We studied fusion oncogenes in 104 adult ALL patients using RT-PCR and interphase-FISH at diagnosis and their association with clinical characteristics and treatment outcome. Results: Five most common fusion genes i.e. BCR-ABL (t 9; 22), TCF3-PBX1 (t 1; 19), ETV6-RUNX1 (t 12; 21), MLL-AF4 (t 4; 11) and SIL-TAL1 (Del 1p32) were found in 82/104 (79%) patients. TCF3-PBX1 fusion gene was associated with lymphadenopathy, SIL-TAL1 positive patients had frequent organomegaly and usually presented with a platelets count of less than . Survival of patients with fusion gene ETV6-RUNX1 was better when compared to patients harboring other genes. MLL-AF4 and BCR-ABL positivity characterized a subset of adult ALL patients with aggressive clinical behaviour and a poor outcome. Conclusions: This is the first study from Pakistan which investigated the frequency of5 fusion oncogenes in adult ALL patients, and their association with clinical features, treatment response and outcome. Frequencies of some of the oncogenes were different from those reported elsewhere and they appear to be associated with distinct clinical characteristics and treatment outcome. This information will help in the prognostic stratification and risk adapted management of adult ALL patients.Noreen Sabir, Zafar Iqbal, Aamer Aleem, Tashfeen Awan, Tahir Naeem, Sultan Asad, Ammara H Tahir, Muhammad Absar, Rana MW Hasanato, Sulman Basit, Muhammad Azhar Chishti, Muhammad Faiyaz Ul-Haque, Ahmad Muktar Khalid, Muhammad Farooq Sabar, Mahmood Rasool, Sajjad Karim, Mahwish Khan, Baila Samreen, Muhammad Hassan Siddiqi, Saba Shahzadi, Sana Shahbaz, Agha Shabbir Ali, Amer Mahmood, Muhammad Akram, Tariq Saeed, Arsalan Saleem, Danish Mohsin, Ijaz Hussain Shah, Muhammad Khalid, Muhammad Asif, Mudassar Iqbal, Tanveer Akhta