Dutch trial register-ID: NTR4236. URL http://www.trialregister.nl/trialreg/admin/rctsearch.asp?Term=mistral.

After 5 years of therapy with enalapril, compared with placebo, normotensive subjects with type 2 diabetes experienced significantly less progression of microalbuminuria to clinical albuminuria, reduced AER, and preserved GFR.

Pulmonary vein thrombosis (PVT) is rather an uncommon condition which presents nonspecifically and is usually associated with lung malignancy and major pulmonary surgery. Rarely could no cause be found. It causes increased pulmonary venous pressure leading to pulmonary arterial vasoconstriction and subsequent pulmonary arterial hypertension and subsequently can cause cor pulmonale if not addressed in timely fashion. Other associated complications like peripheral embolization and stroke have also been reported. This case emphasizes the importance of maintaining high index of clinical suspicion especially when CT pulmonary angiogram is negative for pulmonary embolism.

Background and purposeIn developing countries like Pakistan the cost effectiveness and patient convenience in any treatment modality is a question of major concern. The purpose of this study was two-fold; first to report our experience with a high-dose rate Iridium-192 surface mould brachytherapy of keloid scars after surgical excision, using different radiation treatment regimen and second to establish the most convenient and cost effective treatment protocol having no compromise on the treatment outcomes.Materials and methodsFrom January 2012 to April 2015 a total 51 patients with 65 keloid lesions underwent postoperative Iridium-192 high-dose rate surface mould brachytherapy. The dose regimen used was: 8 Gy in a single fraction, 10 Gy in a single fraction, 15 Gy in three fractions and 18 Gy in three fractions. The median follow-up period was 33 months (range 15–53 months).ResultsThe success rates were 57·2, 89·5, 85 and 89·5% for the treatment regimen of 8 Gy/F×1, 10 Gy/F×1, 5 Gy/F×3 and 6 Gy/F×3, respectively. Grade 2 or above radiation induced toxicity was not observed.FindingsThe results of this study show that a dose regimen of 10 Gy (biological effective dose=20 Gy) in a single fraction have comparable results with a dose regimen of 15 Gy in three fractions or 18 Gy in three fractions. 10 Gy in a single fraction is therefore the most convenient and cost effective dose regimen for the management of keloid scars in developing countries like Pakistan, while 8 Gy in a single fraction is considered suboptimal and discouraged in practice.

A 38-year-old gentleman presented with thyroid storm with multiorgan involvement in the form of heart failure (thyrotoxic cardiomyopathy), respiratory failure (respiratory muscle fatigue), hepatic dysfunction, fast atrial fibrillation, pulmonary embolism, and disseminated intravascular coagulation (DIC). His Graves’ disease (GD) remained undiagnosed for nearly 8 months because apart from weight loss, he has not had any other symptoms of thyrotoxicosis. The presentation of thyroid storm was atypical (apathetic thyroid storm) with features of depression and extreme lethargy without any fever, anxiety, agitation, or seizure. There were no identifiable triggers for the thyroid storm. Apart from mechanical ventilation and continuous veno-venous renal replacement therapy in the intensive care unit, he received propylthiouracil (PTU), esmolol, and corticosteroids, which were later switched to carbimazole and propranolol with steroids being tapered down. He was diagnosed with thyrotoxic myopathy which, like GD, remained undiagnosed for long (fatigability). A high index of suspicion and a multidisciplinary care are essential for good outcome in these patients.

Retroperitoneal haemorrhage (or retroperitoneal haematoma) refers to an accumulation of blood found in the retroperitoneal space. It is a rare clinical entity with variable aetiology including anticoagulation, ruptured aortic aneurysm, acute pancreatitis, malignancy, and bleeding from renal aneurysm. Diagnosis of retroperitoneal bleed is sometimes missed or delayed as presentation is often nonspecific. Multislice CT and arteriography are important for diagnosis. There is no consensus about the best management plan for patients with retroperitoneal haematoma. Stable patients can be managed with fluid resuscitation, correction of coagulopathy if any, and blood transfusion. Endovascular options involving selective intra-arterial embolisation or stent-grafts are clearly getting more and more popularity. Open repair is usually reserved for cases when there is failure of conservative or endovascular measures to control the bleeding or expertise is unavailable and in cases where the patient is unstable. Mortality of patients with retroperitoneal haematoma remains high if appropriate and timely measures are not taken. Haemorrhage from a benign renal tumour is a rarer entity which is described in this case report which emphasizes that physicians should have a wide index of suspicion when dealing with patients presenting with significant groin, flank, abdominal, or back pain, or haemodynamic instability of unclear cause. Our patient presented with features of acute abdomen and, being pregnant, was thought of having a ruptured ectopic pregnancy.

The goal of radiotherapy is to deliver prescribed dose to the target volume and simultaneously minimize the dose to the healthy organs. The purpose of this work was to verify the accuracy of calculations carried out with a treatment planning system (TPS). Measurements carried out with thermoluminescence detectors (TLDs) were compared with doses calculated with TPS. Doses were measured and calculated both in the open beam’s region and under individual blocks. Measurements were performed in the Randophantom. The work was carried out for photon beams generated in the Varian CLINAC 2100C accelerator. The maximum / minimum percentage differences between measured and calculated doses were 4.9/0.6%, 2.6/0%, and 3.5%/0.5% in open, shielded and partially shielded points, respectively. Differences between the measured and calculated doses were within acceptable limits.

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