Single monoclonal spike characterized as double monoclonal gammopathy in a patient with multiple myeloma: A rare finding.

Multiple myeloma (MM) is associated with the secretion of a unique monoclonal protein (M-protein) due to overproduction of immunoglobulin (Ig) by a clone of abnormally proliferating plasma cells. However, in 4% of the cases more than one M-protein can be found. This category of gammopathies is called "double monoclonal gammopathies." Here, we present a rare case of MM with double monoclonal gammopathy, where the presence of both M-proteins was observed in the single sharp peak on capillary zone electrophoresis (CZE). Further the interference of Hook effect is also discussed. Double monoclonal gammopathies need to be identified to increase diagnostic accuracy and reliability, and to get a better understanding of the disease pathogenesis and progression.

Comparison of traditional essay questions versus case based modified essay questions in biochemistry.

Adult learning involves the analysis and synthesis of knowledge to become competent, which cannot be assessed only by traditional assessment tool and didactic learning methods. Stimulation of higher domains of cognitive learning needs to be inculcated to reach a better understanding of the subject rather than traditional assessment tools that relies primarily on rote learning. So, there is need for an alternative assessment tool. Hence, we conducted a study where we used case-based examination methodology. This study was conducted on 226 Ist year MBBS students in Maulana Azad Medical College, New Delhi (India). Based on their compiled internal assessment marks according to monthly formative assessment, students were categorized into 3 groups (I: 0-7; II: 8-14; III: 15-20) marks out of 20 marks respectively. Two sets of question papers were set by three examiners, on the same topics carrying 50 marks each. The first set was based on traditional assessment tool (Paper-A) with recall questions and second set on case-based assessment method (Paper-B). Out of 226 students, 146 were males and 80 were females. For all groups, marks (mean ± SD) in Paper B were found to be higher (18.40 ± 4.29, 30.01 ± 4.12, and 40.33 ± 1.15) as compared to paper A (10.88 ± 4.34, 21.96 ± 7.34, and 31.50 ± 6.94) respectively. However, we found that there was significant (p < 0.001) difference in group I & II, whereas with group III, difference was found to be insignificant. Hence, we concluded that students performed better in case-based assessment rather than traditional method due to their direct involvement. Thus, for better memory and deeper learning the subjects can be assessed by case-based assessment method.

Comparison of Serum Holotranscobalamin with Serum Vitamin B12 in Population Prone to Megaloblastic Anemia and their Correlation with Nerve Conduction Study.

Early detection of megaloblastic anemia and associated neurological complications is crucial for management. This study was conducted to compare serum holotranscobalamin level with serum vitamin B12 level as early biomarker in people prone to megaloblastic anemia and to evaluate co-relation between these biomarkers and nerve conduction study in study patients. 83 adult patients (Hb > 12 gm/dl) prone to megaloblastic anemia were studied for basic haematological investigations, random blood sugar, thyroid function test, liver function test, kidney function test, serum vitamin B12, serum holotranscobalamin and serum folic acid levels. 45 patients among them underwent nerve conduction studies. All study patients were classified in 6 groups on the basis of risk factors for megaloblastic anemia. 29 patients (34.9%) were on antiepileptic drugs, 26 (31.3%) were chronic alcoholic, 10 patients (12%) each, had malabsorption and ileal tuberculosis, 6 (7.22%) had chronic pancreatitis and 2 (2.4%) had ileal resection. 30 patients (36.14%) had low serum holotranscobalamin, including 7 patients (8.43%) with low serum vitamin B12 level also, unmasking vitamin B12 deficiency in 23 patients (27.7%). 7 patients (8.43%) had mean corpuscular volume (MCV) > 100fL and 8 patients (9.63%) had vitamin B12 deficiency related changes on peripheral smear. Serum vitamin B12 and holotranscobalamin levels were significantly low in patients with peripheral smear changes, with p value 0.039 and 0.041 respectively, while no such association seen with MCV. Subclinical peripheral neuropathy was detected in 18 (40%) out of 45 patients on nerve conduction study. Serum holotranscobalamin levels were significantly lower (p = 0.031) than serum vitamin B12 levels (p = 0.2) in patients with neuropathic changes. Rest investigations and serum folic acid levels were normal in all patients. Holotranscobalamin levels can be considered early and reliable marker for vitamin B12 deficiency and deficiency associated peripheral neuropathy, even in patients who are prone to megaloblastic anemia, and not yet anemic or symptomatic for neuropathy.

Menopause and its Effect on Voice.

Abstract: This study was designed to study the impact of menopause on voice quality. Cross-sectional Observational study with a total of 100 subjects. All subjects underwent biochemical analysis which included thyroid function tests, estrogen levels, progesterone levels and underwent voice analysis using the VAUGHMI voice analyser software. 50 postmenopausal females as cases and 50 premenopausal females as controls were taken for the study. The females were of the age group 35-55 yrs in order to remove age as confounding factor. The primary outcome measure was Total score, calculated based on harshness, hoarseness and breathiness. The postmenopausal females had a poorer voice quality than the premenopausal females (Total score 1.62 vs 2.48, p < 0.001). There was a significant difference between the fundamental frequency and pitch and perturbation in frequency of the postmenopausal females as compared to premenopausal females. The difference in the perturbation in the intensity of the voice was not significant. No linear correlation could be established between the voice quality and oestrogen or progesterone levels but the intergroup variation of the two parameters was significant. The premenopausal females have better voice quality than postmenopausal females. The relationship between hormonal level and voice quality couldn't be established. Further studies are required to assess the relation of hormone levels & voice quality with the possibility of exploring voice cosmesis. Level of Evidence: Level 3.

Hyperinsulinemia and Hypoadiponectinemia are Associated with Increased Risk for Occurrence of Ovarian Cancer in Non-diabetic Women of North Indian Population.

Ovarian cancer has been emerged as a most common and lethal gynecological malignancy in India. High serum insulin and low adiponectin have been associated with increased risk of ovarian cancer. But their role in development of ovarian cancer is conflicting and little evidence is available. We aimed to evaluate blood levels of insulin and adiponectin in epithelial ovarian cancer (EOC) patients and their association with the risk to develop EOC. The study included following three groups; Group 1: fifty cases of cytohistopathologically confirmed cases of EOC, Group 2: fifty age matched cases of benign ovarian conditions and Group 3: fifty ages matched healthy controls with no evidence of any benign or malignant ovarian pathology as ruled out by clinical examination and relevant investigations. Cytohistopathologically confirmed and newly diagnosed cases of EOC and benign ovarian cancer were included in this study. The median value of fasting serum insulin was significantly high (15.0 µlU/ml, P = 0.02) and adiponectin were significantly low (5.1 µg/ml, P < 0.001) in ovarian cancer patients compared to benign ovarian tumors and healthy controls group. A significant increase risk of ovarian cancer was found in high tertile (≥ 18.7 µlU/ml) of serum insulin level (OR = 2.7; 95% CI = 1.00-6.67, P = 0.04) and lower tertile (≤ 5.45 µg/ml) of adiponectin level (OR = 3.2; 95% CI = 1.10-9.71, P = 0.03). High serum insulin level and low adiponectin levels were significantly associated with increased risk for development of ovarian cancer.

Hypothyroidism in Children with Chronic Kidney Disease Attending a Tertiary Care Center.

Primary hypothyroidism is observed in adult patients with chronic kidney disease (CKD) though described scantily in the pediatric population. The primary objective of this study was to detect the prevalence of hypothyroidism in children (1-18 years) with CKD as assessed by thyroid profile. This cross-sectional study was conducted in the department of pediatrics of a tertiary care teaching hospital between January 2016 and January 2017. Clinical examination and biochemical investigations were performed for children with CKD aged 1 -18 years. Sixty-five children (51 boys, 43 CKD Stages 1-3) with a mean [standard deviation (SD)] age of 7.9 (3.2) years were enrolled. Overall, 17 (26.2%) had thyroid dysfunction; nine (13.8%) had subclinical hypothyroidism, three (4.6%) overt hypothyroidism, and five (7.7%) had isolated low T3 levels. The prevalence of hypothyroidism increased from 20.9% in CKD Stages 1-3 to 40.9% in Stages 4-5 of CKD; P = 0.09. The mean (SD) height SD scores were lower in those with hypothyroidism than with normal thyroid function [-1.02 (1.69) and -1.89 (1.12), P = 0.003, respectively], lowest at -2.79 (0.65) in overt hypothyroidism. A significant proportion of children with CKD manifest with hypothyroidism who have more profound growth failure. It may be prudent to screen CKD patients for thyroid dysfunction.

Role of Serum Melatonin and Oxidative Stress in Childhood Atopic Dermatitis: A Prospective Study.

BACKGROUND: Many factors have been implicated in the pathogenesis of atopic dermatitis (AD) and recently the role of oxidative damage has been postulated. OBJECTIVES: To study the levels of oxidants and antioxidants including melatonin in the blood of children with AD and their association with the severity of AD. METHODS: Thirty patients with atopic dermatitis, aged 6 months to 12 years, and equal number of age and sex-matched controls were included. Clinical characteristics and baseline severity assessment using SCORAD (scoring atopic dermatitis) severity index were noted. Blood superoxide dismutase, blood glutathione peroxidase, serum malondialdehyde, and serum melatonin levels were measured in cases and controls and results were compared. RESULTS: The serum levels of malondialdehyde and melatonin were significantly higher among the cases compared to controls. The blood levels of superoxide dismutase and glutathione peroxidase were higher in cases but the difference with controls was not statistically significant. There was no significant correlation between these markers and the severity of the disease. CONCLUSIONS: Oxidative stress was increased in cases of childhood AD compared to the control group in this study. No correlation between oxidative stress and the severity of the disease was found. Larger studies are warranted.

Multibranched endovascular aortic aneurysm repair in patients with and without chronic aortic dissections.

OBJECTIVE: The objective of this study was to compare multibranched endovascular aneurysm repair (MBEVAR) of postdissection thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs) with MBEVAR of degenerative TAAAs and PRAAs and to assess the role played by the preoperative correction of potential complicating factors, such as true lumen compression and false lumen origin of vital branches, using adjunctive maneuvers. METHODS: From July 2005 to July 2017, there were 162 patients who underwent elective MBEVAR of TAAAs and PRAAs. Data on demographics, procedural details, and outcomes were collected prospectively. RESULTS: The mean age was 73 ± 8 years, and 119 of 162 (74%) were men; 19 of 162 (12%) had prior aortic dissections. Patients with dissections were younger (65 ± 11 years vs 74 ± 7 years; P = .002) and were less likely to have smoked (13/19 [68%] vs 135/143 [94%]; P = .002) or to have peripheral artery disease (0/19 [0%] vs 35/143 [24%]; P = .01) compared with those without dissections. Patients with prior dissections were more likely to have Crawford type II (10/19 [53%] vs 22/143 [15%]; P = .001) and type III (6/19 [32%] vs 16/143 [11%]; P = .03) TAAAs and were more likely to require at least one pre-MBEVAR adjunctive procedure (14/19 [74%] vs 55/143 [38%]; P = .006) compared with those without dissection. There was no difference in perioperative death, stroke, or paraplegia rates between the two groups. Median follow-up was 2.4 years (interquartile range, 0.8-4.7) and did not differ significantly between the two groups. There were no significant differences in branch vessel occlusion, endoleak rate, or aneurysm-related death between the two groups. CONCLUSIONS: Patients with chronic type B aortic dissection are more likely to have extensive aneurysms and more likely to require adjunctive procedures to provide the appropriate anatomic substrate for MBEVAR, but this does not appear to affect the conduct of MBEVAR or its outcomes.

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms.

OBJECTIVE: The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications. METHODS: There were 146 patients who underwent endovascular TAAA repair using a stent graft, with a total of 538 caudally oriented self-expanding branches. Four patients died in the perioperative period and were excluded, leaving 142 patients (mean age, 73 ± 8 years; 35 [24.7%] women). Follow-up included clinical examination and computed tomography angiography at 1 month, 6 months, and 12 months and yearly thereafter. RESULTS: Mean aneurysm diameter was 67 ± 9 mm. Sixty-seven TAAAs (47.2%) were Crawford type I, II, III, or V; 75 (52.8%) were type IV or pararenal. Three patients (2.1%) died >30 days after operation from perioperative complications. During a mean follow-up of 36 months (±28 months), there were four additional aneurysm-related deaths: one (0.7%) as a result of aneurysm rupture in the presence of untreatable type I endoleak, one (0.7%) after conversion to open repair for stent graft infection, one (0.7%) after occlusion of superior mesenteric artery and celiac branches, and one (0.7%) due to bilateral renal branch occlusion. There was one additional open conversion for stent graft infection (0.7%). Nineteen patients (13.3%) underwent 20 reinterventions for late-occurring complications, including 11 (7.7%) for renal branch occlusion or stenosis, 1 (0.7%) for mesenteric branch stenosis, 4 (2.8%) for graft limb occlusion, 1 (0.7%) for type IB endoleak (distal stent graft migration), and 1 (0.7%) for type III endoleak (fabric erosion); 2 (1.4%) open conversions were performed for stent graft infection. There were no late type IA endoleaks. By Kaplan-Meier analysis, freedom from aneurysm-related death was 91.1% and freedom from aneurysm-related death or reintervention was 76.8% at 5 years. The 5-year overall survival rate of 49.1% reflects the high rate of cardiopulmonary comorbidity. Although renal branch occlusion (23 occlusions of 256 renal branches [8.9%]) was the most common late complication, only five patients required permanent dialysis. CONCLUSIONS: Total endovascular repair of TAAAs and pararenal aortic aneurysms using axially oriented cuffs is safe, effective, and durable in the long term.

The impact of prior aortic surgery on outcomes after multibranched endovascular aortic aneurysm repair.

OBJECTIVE: The purpose of this study was to evaluate the impact of prior aortic surgery on outcomes after multibranched endovascular aneurysm repair (MBEVAR) of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs). METHODS: From July 2005 to October 2016, there were 153 patients who underwent elective endovascular repair of TAAA and PRAA using multibranched stent grafts. Data on demographics, procedural details, and outcomes were collected prospectively. RESULTS: The mean age was 73 ± 8 years, and 113 of 153 (74%) were men. Mean aneurysm diameter was 67 ± 9 mm. Before MBEVAR, 68 of 153 (44%) patients had undergone a prior aortic surgery; 49 of 68 (72%) had prior open aortic surgery, 15 of 68 (22%) had prior endovascular aortic surgery, and 4 of 68 (6%) had both. There were no significant differences in age, sex, preoperative aneurysm diameter, or medical comorbidities (coronary artery disease, lung disease, diabetes mellitus, or hypertension) in patients with previous aortic surgery compared with those without. Patients with previous aortic surgery had higher fluoroscopy times (131 ± 59 vs 118 ± 54 minutes; P = .18) and procedural times (370 ± 101 vs 345 ± 118 minutes; P = .27) during MBEVAR, but these differences did not reach statistical significance. Patients without previous aortic intervention had higher rates of postoperative paraplegia (9/85 [11%]) vs (0/68 [0%]; P = .005) compared with those with previous aortic surgery. Of 153 patients, 3 (2%) had a postoperative stroke, and this was not different between the two groups. Median follow-up time was 2.5 years (interquartile range, 1.0-4.5 years) and did not differ between those with and those without previous aortic surgery. Kaplan-Meier estimated 5-year freedom from aneurysm-related mortality and overall mortality was 90% and 48%, respectively, and did not differ between the two groups. There was also no difference in branch vessel occlusion between the two groups. CONCLUSIONS: A high proportion of patients undergoing MBEVAR for TAAA or PRAA have already undergone prior open or endovascular aortic procedures, but this does not appear to increase the complication rate or affect midterm clinical outcomes. Patients with prior aortic surgery who undergo MBEVAR have lower rates of paraplegia compared with those without prior surgery, which may be due to effective recruitment of collateral circulation.

Role of oxidative stress in melasma: a prospective study on serum and blood markers of oxidative stress in melasma patients.

BACKGROUND: Melasma is a common pigmentary disorder presenting in the dermatological clinic. Many factors have been implicated in the pathogenesis, however, the cause still remains elusive. Recently the effect of oxidative damage has been proposed in the etiopathogenesis of melasma. This study was undertaken to evaluate the role of oxidative stress in patients with melasma. MATERIAL AND METHODS: Fifty patients with melasma, age 18 years of age and older, and an equal number of age and sex-matched controls were included in the study. Baseline severity assessment using the modified Melasma Area and Severity Index (modified MASI score) was done in all patients. Serum malondialdehyde, blood superoxide dismutase, and blood glutathione peroxidase levels were measured in cases and controls group and results were compared. RESULT: The serum levels of malondialdehyde, superoxide dismutase, and blood glutathione were significantly higher among the cases compared to controls. The difference in the serum concentrations was significant between the two groups (P < 0.01). A positive correlation was found between these enzyme levels and severity of melasma (modified MASI score); however, this correlation was statistically significant with serum malondialdehyde only. The level of oxidative stress among the male and female melasma patients was not statistically different. CONCLUSION: Oxidative stress was found to be increased in cases of melasma compared to the control group in this study. This substantiates the role of oxidative stress in etiopathogenesis of melasma; however, further studies are required to reach a definitive conclusion.

Role of serum interleukin-6 in deciding therapy for multidrug resistant oral lichen planus.

BACKGROUND: Oral lichen planus (OLP) is a T cell mediated immune response. T cells locally present in the involved tissues release cytokines like interleukin-6 (IL-6), which contributes to pathogenesis of OLP. Also IL-6 has been associated with multidrug resistance protein (MRP) expression by keratinocytes. Correspondingly, upregulation of MRP was found in OLP. We conducted this study to evaluate the effects of various drugs on serum IL-6 in OLP; and correlation of these effects with the nature of clinical response and resistance pattern seen in OLP lesions with various therapeutic modalities. Thus we evaluated the role of serum IL-6 in deciding therapy for multidrug resistant OLP. MATERIAL AND METHODS: Serum IL-6 was evaluated in 42 erosive OLP (EOLP) patients and 10 normal mucosa and 10 oral squamous cell carcinoma cases using ELISA technique. OLP patients were randomly divided into 3 groups of 14 patients each and were subjected to Pimecrolimus local application, oral Mycophenolate Mofetil (MMF) and Methotrexate (MTX) alongwith Pimecrolimus local application. IL-6 levels were evaluated before and after treatment. RESULTS: Serum IL-6 levels were raised above 3pg/ml in 26.19% erosive OLP (EOLP) cases (mean- 3.72±8.14). EOLP (5%) cases with IL-6 levels above 5pg/ml were resistant in MTX group. However significant decrease in serum IL-6 corresponding with the clinical resolution was seen in MMF group. CONCLUSIONS: Significantly raised IL-6 levels in EOLP reflect the chronic inflammatory nature of the disease. As serum IL-6 levels significantly decreased in MMF group, correspondingly no resistance to treatment was noted. However with MTX there was no significant decrease in IL-6 and resistance to treatment was noted in some, especially plaque type lesions. Thus IL-6 can be a possible biomarker in deciding the best possible therapy for treatment resistant OLP. KEY WORDS: Lichen planus, biological markers, cytokines, enzyme-linked immunosorbent assay, immunosuppressive agents.

Serum neutrophil gelatinase associated lipocalin (NGAL) and cystatin C as early predictors of contrast-induced acute kidney injury in patients undergoing percutaneous coronary intervention.

BACKGROUND: Contrast-induced acute kidney injury (AKI) is diagnosed by estimating serum creatinine at 48-72h after diagnostic or interventional coronary angiography. It is too late for an early intervention. Neutrophil gelatinase associated lipocalin (NGAL) and cystatin C are novel markers of AKI. We determined the optimum cut-off level of NGAL and cystatin C in early diagnosis and prediction of AKI in patients undergoing coronary angiography followed by angioplasty. METHODS: In a nested case control study, serum NGAL, cystatin C by ELISA and serum creatinine by Jaffe's kinetic method were estimated at 0, 4, 24 and 48h of coronary angiography followed by angioplasty in 30 cases who developed contrast-induced AKI and 30 subjects who did not develop AKI. eGFR was estimated for both cases and controls by the MDRD equation. ROC was used to determine the optimum cut-off. RESULTS: Serum NGAL increased sharply at 4h after the procedure and then gradually declined to near normal level at 48h in AKI cases. The rise in cystatin C peaked at 24h and then declined but remained high till 48h. In controls, they remained static. The optimum cut-off of serum NGAL and cystatin C was 155.2ng/ml and 0.517mg/l respectively at 4h and 89.5ng/ml and 0.99mg/l respectively at 24h of angiography. Odds ratio for hypertensives to develop AKI was 3.57 (CI: 1.2-11.1, p=0.03). CONCLUSION: Serum NGAL and cystatin C may act as early markers of contrast-induced AKI in patients undergoing percutaneous coronary intervention. Patients with hypertension are susceptible to develop contrast-induced AKI.

A Case of Light Chain Deposition Disease (LCDD) in a Young Patient.

Light chain disease is a variant of multiple myeloma in which the malignant population of marrow cells produces free monoclonal light chains but no heavy chain or complete immunoglobulin. The monoclonal light chains are small enough to be freely filtered by the kidneys and become Bence-Jones protein. Light chain disease comprises about 18% of multiple myeloma patients. Here we present a case report of a 38-year-old man who initially presented with complaints of pain in back and low grade fever off and on. He was found to have collapse of D9 and D12 vertebrae along with ascites and right pleural effusion and massive proteinuria. Multiple myeloma was considered as a differential diagnosis based on the investigations but eventually the patient was lost to follow up. This case is reported here as the light chain variant of multiple myeloma leading to deposition disease is less commonly reported and presents considerable difficulties in diagnosis.