An Unusual Presentation of Multiple Myeloma.

Multiple myeloma commonly presents as anemia, renal failure, bone pain, and infections. Presentation with epistaxis is extremely rare, and hence myeloma as the etiologic factor is seldom considered. We report the case of a patient who initially presented with recurrent epistaxis and then with myasthenia. It was only when he developed acute kidney injury 4 months after the initial presentation with epistaxis that a diagnosis of multiple myeloma was made.

Evidence of the Effectiveness of Pictorial Health Warnings on Cigarette Packaging in Nepal.

BACKGROUND: Tobacco Control Act of 2010 mandates government to implement at least 75% pictorial health warnings (PHWs) on tobacco packaging that was enforced in 2013. The purpose of the study was to assess the effectiveness of PHWs and its impact to the policy change. METHODS: A cross-sectional study was conducted in 9 cities between September 2014 and March 2015. Direct interviews were made among 2250 randomly selected individuals. The effectiveness of PHWs were measured as perceived: i) scariness; ii) quit motivation iii) convincing youth not to start smoking; iv) encouraging ex-smokers to remain as quitters; v) building public awareness. Logistic regression analysis was used to determine the factors associated with the effectiveness of PHWs. RESULTS: Of the 2250 participants, 29.8% (670) were current smokers, 8.6% (193) were ex-smokers and 97.6% believed that smoking was addictive. PHWs made 83% of the participants scared. Participants believed that PHWs would be effective in motivating smokers to quit (80.2%), in convincing youth not to start smoking (86.8%), in encouraging ex-smokers to remain as quitters (89.1%) and in building public awareness on the dangers of smoking (94%). PHWs made 58% of the current smokers intended to quit smoking and reduced their daily intake of cigarettes from 11 to 5 on average.  Current smokers preferred to purchase loose cigarettes rather than a pack. The covariates significantly associated with the effectiveness of PHWs were current smokers, ex-smokers and addiction. CONCLUSION: PHWs were found important to motivate smokers to quit smoking, to reduce consumption of cigarettes and to prevent relapse in ex-smokers. Evidence from the study had triggered policy changes which included enlargement of the size of PHW to 90% and the release of a notification to ban selling of loose cigarettes. Thus, the warning messages with pictures are required to be improved and rotated.

Burden and predictors of hypertension in India: results of SEEK (Screening and Early Evaluation of Kidney Disease) study.

BACKGROUND: Hypertension (HTN) is one of the major causes of cardiovascular morbidity and mortality. The objective of the study was to investigate the burden and predictors of HTN in India. METHODS: 6120 subjects participated in the Screening and Early Evaluation of Kidney disease (SEEK), a community-based screening program in 53 camps in 13 representative geographic locations in India. Of these, 5929 had recorded blood pressure (BP) measurements. Potential predictors of HTN were collected using a structured questionnaire for SEEK study. RESULTS: HTN was observed in 43.5% of our cohort. After adjusting for center variation (p < 0.0001), predictors of a higher prevalence of HTN were older age ≥ 40 years (p < 0.0001), BMI of ≥ 23 Kg/M2 (p < 0.0004), larger waist circumference (p < 0.0001), working in sedentary occupation (p < 0.0001), having diabetes mellitus (p < 0.0001), having proteinuria (p < 0.0016), and increased serum creatinine (p < 0.0001). High school/some college education (p = 0.0016), versus less than 9th grade education, was related with lower prevalence of HTN. Of note, proteinuria and CKD were observed in 19% and 23.5% of HTN subjects. About half (54%) of the hypertensive subjects were aware of their hypertension status. CONCLUSIONS: HTN was common in this cohort from India. Older age, BMI ≥ 23 Kg/M2, waist circumference, sedentary occupation, education less, diabetes mellitus, presence of proteinuria, and raised serum creatinine were significant predictors of hypertension. Our data suggest that HTN is a major public health problem in India with low awareness, and requires aggressive community-based screening and education to improve health.

Recurrent hyponatremia in an elderly patient with a cystic pituitary gland.

A 71-year-old male with a long history of diabetes and hypertension was admitted with mild azotemia and recurrent hyponatremia. He was diagnosed with a pituitary gland cystic tumor. On careful evaluation, his hyponatremia was found to be due to cerebral salt wasting. The patient made a full recovery following treatment for cerebral salt wasting.

Mycophenolate induced diarrhoea.

Mycophenolate (MMF) has arisen as an important addition in the immunosuppression armamentarium. GI disturbances (diarrhea) and bone marrow suppression are its main side effects requiring dose reduction or even withdrawal. The mechanism of diarrhoea is unknown, although some theories have been postulated. We evaluated three of our patients on MMF who came to us with chronic diarhoea. Their evaluation consisted of CBC, stool routine examination, stool culture, endoscopy and biopsy. Histopathologic examination in all three cases showed villous atrophy. All of them improved with discontinuation of MMF and addition of folic acid suggesting that diarrhoea was related to MMF. Since this complication is seen in only a few cases, we can hypothesize that it may be due to lower levels of the enzyme inosine monophosphate dehydrogenase (IMPDH)--the site of action of MMF.

Squamous cell carcinoma of tongue in a renal transplant recipient.

The overall incidence of malignancies in post renal transplant recipients is reported to be approximately 5 to 6%. Malignancies are significant complications after transplantation. Common malignancies include malignancies of the skin and post-transplant lymphoproliferative disorder (PTLD). Squamous cell carcinoma of the tongue is very rare. We present a case of squamous cell carcinoma of the tongue developing nine years after renal transplantation, in a 30-year-old man. He underwent left hemiglossectomy initially and then modified neck dissection. His graft function continues to remain stable.