Pulmonary Haemosiderosis Secondary to Hereditary Haemochromatosis; a Case Report

Introduction: Hereditary haemochromatosis (HH) is an autosomal recessive disease of increased intestinal absorption of iron, leading to accumulation in tissues which may progress to organ damage, most commonly in the liver. Iron deposition in the liver can lead to cirrhosis and hepatocellular carcinoma. Other common manifestations of haemochromatosis include diabetes, bronzing of the skin, arthropathy and cardiomyopathy. Here, we describe a case of pulmonary haemosiderosis secondary to HH. Case Description: A 49-year-old male with no medical history or family history of iron overload presented with fatigue, shortness of breath and chest pain after a recent finding of elevated ferritin. The patient was found to have biallelic C282Y mutations of the human homeostatic iron regulator protein (HFE) protein and after further workup with laboratory tests and imaging was diagnosed with HH with secondary pulmonary haemosiderosis. The patient is receiving twice weekly phlebotomies and has had an overall improvement in his symptoms. Practical Implications: The presentation of haemochromatosis can vary widely depending on the severity of iron overload and the presence of conditions that predispose organ dysfunction. Pulmonary haemosiderosis is a very rare manifestation of HH. This report illustrates the various manifestations of this disease and provides insight into this rare presentation to improve the diagnosis of this disease.&nbsp

Evaluation of Impact of Prescribing Safety Assessment Workshop on Medical Doctors Using Kirkpatrick Model

Background Clinical pharmacology training is a prerequisite for all medical graduates. Prescription writing errors are not infrequent at primary health care level leading to threat to patient safety. Prescribers lacks uniform structured training and assessment which is one of the major factors for this situation across the country. In lots of institutions despite proper curriculum, learners lack interest because the subject importance is insignificant. Hence to bring more interest in pharmacology for prescribers there is a dire need for innovative and interesting methods of teaching and assessment, one of which is prescribing safety assessment (PSA). Objectives To assess if the PSA is superior method of training prescription writing than CPW To evaluate the workshop on prescription writing using guidelines of Kirkpatrick Model   Methods It was an experimental study. 44 medical doctors participated; a pre-test was taken 01 week before the workshop. Afterwards, they were randomized into 02 groups, group A went through PSA and group B followed conventional prescription writing (CPW) 01-day workshop. At the end, post-test was taken from both groups. The qualitative data was also collected from participants on feedback proforma consisting of few closed ended questions on Likert scale. Results The independent t-test was used to compare the data as it was in normal distribution. Posttest performance of PSA group significantly increased P ˂ 0.001 as compared to CPW. Reaction  to closed ended 13 questions on Likert scale showed high satisfaction from 4.32 to 4.84 on 5 points  Likert scale on workshop satisfaction. Conclusion PSA is an effective teaching and assessment strategy for learning clinical pharmacology. The study objectively proves its effectiveness in comparison to CPW and provides a guideline to implement this innovative and useful tool for teaching and assessment. Keywords Prescribing safety assessment, conventional prescription writing, Faculty development, Workshop, Impact, Kirkpatrick model

Dengue outbreak 2013: Clinical profile of patients presenting at DHQ Burner and THQ Shangla, Khyber Pakhtunkhwa, Pakistan

We evaluated the clinical features, disease severity, laboratory findings and outcome of serologically confirmed cases of Dengue fever in Patients during the recent outbreak in two districts (Buner & Shangla) in 2013, Khyber Pkhtunkhwa, Pakistan. We encountered 320 cases of Dengue fever during 5 months period (July to November, 2013). The dengue infection rate in females (180: 56%.2) was higher as compared to males (140: 43.8%). The dengue infections were more frequently seen in the post-monsoon season than in the monsoon period. The death ratio in the overall weighted prevalence was 0%. All the patients suffered from fever but no specific pattern could be identified, degree was variable ranging from low to high grade. Abdominal pain was the next most common symptom followed by vomiting and diarrhea. Only (45%) patients complained of body aches and pains, (30%) patients had hemorrhagic manifestations in the form of gum bleed, and (05%) patients had melena while (15%) patient’s complained of skin rashes. The most common clinical sign was the Enlarged liver that was present in (75%) patients. There is critical need for molecular and entomological surveillance of dengue among the dengue epidemics-prone areas to eliminate the disease

Pancreatic Adenocarcinoma with Stomach Wall Invasion: Can it be Foreseen?

Introduction: The association of adenocarcinoma found in the pancreas and stomach wall is a relatively rare condition as is any metastasis from the pancreas to the stomach.  Pancreatic carcinoma associated with additional gastric cancer is also relatively uncommon.  The most frequent sites of metastasis reported for pancreatic adenocarcinoma are the lymph nodes, lung, liver, adrenal glands, kidney, and bone.  We report a case of adenocarcinoma of the pancreas associated with a separate adenocarcinoma of the stomach wall.  Not enough research has been placed on properly distinguishing these two forms of malignancies.Presentation of Case: In this case report we discuss the presentation of an 87 year old female who presented with abdominal pain and was found to have multiple sites of metastasis of Adenocarcinoma of pancreatic origin with direct spread to the stomach wall.Conclusion: The characteristics of this combination of gastric and pancreatic adenocarcinoma, whether there is a direct correlation or through local metastasis, needs to be further investigated to shed light on this condition

Skin Mass as a Presenting Feature of Renal Cell Carcinoma: Need for High Index of Suspicion

Introduction: Renal cell carcinoma is the most common form of malignant renal tumor. Clinical presentation of Sarcomatoid Renal Cell Carcinoma (sRCC) varies widely and is dependent on the stage at which the diagnosis has been reached. At the time of diagnosis, about one-third of patients develop metastasis affecting the lung, lymphatic, liver, bone, contralateral kidney, adrenal glands, and brain. Case Report: A 46 year old Hispanic female with no significant past medical history presents to the Emergency department with recurrent episodes of dizziness, difficulty breathing, dry mouth, weakness, and productive cough without blood. She initially presents with a rare initial dermatological finding related to her current condition.Conclusion: Sarcomatoid Renal Cell Carcinoma is a rare variant of RCC with stage-dependent outcomes. Initial presentations may not be very obvious in suspicion of sRCC. However, in this particular case, the external findings happened to be the initial presentation, prompting further evaluation of the patient. Delving into the features of sRCC and maintaining all possibilities may allow future workup of the more common variants of RCC to be included in the investigation of sentinel lesions seen in the more rare variants

Myelodysplastic Syndrome with Transfusion Dependence Treated with Venetoclax

Myelodysplastic syndromes are characterized by ineffective hematopoiesis in one or more lineages of the bone marrow. They are a group of heterogeneous clonal stem cell malignancies with a high risk to progress to acute myeloid leukemia. Currently, there are no curative FDA-approved medications for myelodysplastic syndromes. Hematopoietic cell transplantation is potentially the only curative option; however, treatment is often unavailable due to age and comorbidities. Hypomethylating agents, azacitidine and decitabine, and the immunomodulatory agent, lenalidomide, are the only FDA approved medications for the treatment of MDS, all of which are noncurative. Venetoclax, an inhibitor of the antiapoptotic protein BCL-2 used to treat chronic lymphocytic leukemia, is currently being evaluated in clinical trials as a monotherapy in high-risk myelodysplastic syndromes/acute myeloid leukemia. We present a patient with transfusion-dependent myelodysplastic syndromes refractory to the current standard of care treatment not a candidate for hematopoietic cell transplantation who responded well to monotherapy treatment with venetoclax and has since remained transfusion-independent

KARAKTERIZACIJA VODONOSNIKA I FIZIČKO-KEMIJSKA ANALIZA PODRUČJA DERA GHAZI KHAN, PUNJAB, PAKISTAN

The study area is located in the arid section of Punjab province, Pakistan. The accessibility of freshwater is the main problem in this area. The area is mainly flat and alluvial deposits are present down to 800 m. The groundwater is not fit for drinking because of its salinity. Hence, it is essential to mark the transition between fresh water and saltwater. Resistivity models were used to locate freshwater areas. The saltwater areas are between 10 and 30 m deep. Salt flats and clayrich deposits are visible on resistivity maps and were identified by low resistance values. After linking resistivity data and maps, it is determined that the south portion of the area has a freshwater aquifer, especially at a depth of 200 m. At this depth, the quality of water is very good, regardless of its mild salinity in some areas. The margin between salty and freshwater is set to no degree. This is dependent upon the recharge and usage of an aquifer. Groundwater pollution poses a severe threat to the city’s residents. Results from the physio-chemical analysis of the water samples confirm the presence of arsenic in excessive amounts in water samples and are outside the limits set by the WHO and NDWQS. Just two out of 10 samples are within the limits for safe drinking water. The results of this research are valued for groundwater management and the installation of tubular wells in freshwater areas for households and irrigation purposes.Istraživano područje smješteno je u pustinjskome dijelu provincije Punjab u Pakistanu, obilježenome nedostatkom pitke vode. Područje je najvećim dijelom zaravnjeno i prekriveno aluvijem koji mjestimice može dosegnuti i 800 m debljine. Podzemna voda nije pogodna za piće zbog slanosti. Stoga je iznimno važno prepoznati prijelaznu zonu između slatke i slane vode. Za lociranje slatkovodnih područja korišteni su modeli otpornosti. Područja slane vode duboka su između 10 i 30 m. Taložine soli i gline opažaju se na kartama otpornosti niskim vrijednostima otpora. Uočeno je kako se na jugu područja javljaju vodonosnici slatke vode, čak na dubini od 200 m, s vrlo dobrom kvalitetom vode, uz rijetku pojavu bočatosti. Granicu između slatke i slane vode nije moguće jednoznačno odrediti, a ovisi o dotoku i uporabi vodonosnika. Njihovo zagađenje može biti ozbiljan problem, poglavito za gradska područja. Rezultati fizičko-kemijske analize pokazali su nazočnost prevelikih količina arsena, tj. u granicama iznad dopuštenih klasifikacijama WHO-a i NDWQS-a. Od 10 samo su 2 uzorka bila u granicama koje određuju pitku vodu. Rezultati su vrijedan doprinos za gospodarenje tom podzemnom vodom te projektiranje bušotina kojima bi se pitka/slatka voda dovodila kućanstvima ili koristila za navodnjavanje

Pericardial Metastasis Induced Tamponade from Urothelial Carcinoma: A Rare Entity

Urothelial carcinoma in a few cases may result in cardiac metastasis. A rare presentation of this condition is its diagnosis as a result of cardiac tamponade. Tamponade is an unusual entity as a result of urothelial carcinoma and has only been reported in four cases. There have also been only a total of fifteen cases of cardiac metastasis from this form of malignancy. It is through this discussion that we emphasize the importance of early detection and monitoring of cardiac symptoms with the implementation of echocardiogram imaging. Although not feasible in all patients it may be considered in those presenting with cardiac and pulmonary symptoms. In this case we discuss the presentation of a 71-year-old gentleman with a history of urothelial carcinoma after cystectomy and while on chemotherapy presented with new onset atrial fibrillation and later was diagnosed with cardiac tamponade as a result of malignant metastasis

Multivessel Spontaneous Coronary Artery Dissection in an Unlikely Patient

When approaching the symptom of acute onset chest pain in a previously healthy 26-year-old male, anchoring heuristic presents a challenge to healthcare workers. This diagnostic error is the healthcare professional’s tendency to rely on a previous diagnosis, and, in situations where a set of symptoms might mask a rare and deadly condition, this error can prove fatal for the patient. One such condition, Spontaneous Coronary Artery Dissection (SCAD), is an uncommon and malefic presentation of coronary artery disease that can lead to myocardial infarction and sudden death. We present a case of SCAD in an otherwise healthy 26 year-old male who had been experiencing chest pain during and after sports activity. In the young, athletic male with SCAD, the danger of diagnostic error was a reality due to the broad symptomatology and the betraying demographics