Metastatic Breast Cancer or Multiple Myeloma? Camouflage by Lytic Lesions

We report a case of a female with stage I infiltrating ductal carcinoma who received adjuvant therapy including trastuzumab. One year later she developed lytic lesions and was retreated with trastuzumab that was held after she developed symptomatic heart failure. Lytic lesions were attributed to relapse of breast cancer, and cardiac failure attributed to prior trastuzumab therapy. After complications necessitated multiple hospitalizations, a further workup revealed that the lytic lesions were not metastatic breast cancer but multiple myeloma. Her advanced multiple myeloma was associated with systemic amyloidosis involving gut and heart, which ultimately led to her demise. This report addresses the pitfalls of overlapping symptoms and the question of which patients with suspected metastatic disease should undergo a biopsy

Treatment of Tardive Dyskinesia with High Dose Vitamin B6 Associated with Depression

Tardive dyskinesia (TD) is a movement disorder associated with dopamine receptor blocking medications. Recommended treatments for TD include discontinuing the causative agent, adding vesicular monoamine transporter 2 (VMAT2) inhibitors, or adding vitamin B6. We present a 66-year-old Caucasian male with bipolar I disorder who developed TD while on lithium and quetiapine having been euthymic on this regimen for three years. He was initially treated with 1200 mg B6 daily. This failed to improve his TD and was associated with a depressive episode. He switched to valbenazine 40 mg daily which improved his TD and concurrently his mood, but months later the TD symptoms worsened again. Our case adds to the literature by demonstrating that some patients with TD will not respond to vitamin B6. To our knowledge, ours is the first case suggesting association of high dose vitamin B6 with depression. This case also demonstrates that response to valbenazine may not last and further studies are needed

A self-lensing binary massive black hole interpretation of quasi-periodic eruptions

Binary supermassive black hole (SMBH) systems result from galaxy mergers, and will eventually coalesce due to gravitational wave (GW) emission if the binary separation can be reduced to $\lesssim 0.1$ pc by other mechanisms. Here, we explore a gravitational self-lensing binary SMBH model for the sharp (duration $\sim 1$ hr), quasi-regular X-ray flares -- dubbed quasi-periodic eruptions -- recently observed from two low mass active galactic nuclei: GSN 069 and RX J1301.9+2747. In our model, the binary is observed $\sim$edge-on, such that each SMBH gravitationally lenses light from the accretion disc surrounding the other SMBH twice per orbital period. The model can reproduce the flare spacings if the current eccentricity of RX J1301.9+2747 is $\epsilon_0 \gtrsim 0.16$, implying a merger within $\sim 1000$ yrs. However, we cannot reproduce the observed flare profiles with our current calculations. Model flares with the correct amplitude are $\sim 2/5$ the observed duration, and model flares with the correct duration are $\sim 2/5$ the observed amplitude. Our modelling yields three distinct behaviours of self-lensing binary systems that can be searched for in current and future X-ray and optical time-domain surveys: i) periodic lensing flares, ii) partial eclipses (caused by occultation of the background mini-disc by the foreground mini-disc), and iii) partial eclipses with a very sharp in-eclipse lensing flare. Discovery of such features would constitute very strong evidence for the presence of a supermassive binary, and monitoring of the flare spacings will provide a measurement of periastron precession.Comment: Accepted for publication in MNRA

White Light Flare Continuum Observations with ULTRACAM

We present sub-second, continuous-coverage photometry of three flares on the dM3.5e star, EQ Peg A, using custom continuum filters with WHT/ULTRACAM. These data provide a new view of flare continuum emission, with each flare exhibiting a very distinct light curve morphology. The spectral shape of flare emission for the two large-amplitude flares is compared with synthetic ULTRACAM measurements taken from the spectra during the large 'megaflare' event on a similar type flare star. The white light shape during the impulsive phase of the EQ Peg flares is consistent with the range of colors derived from the megaflare continuum, which is known to contain a Hydrogen recombination component and compact, blackbody-like components. Tentative evidence in the ULTRACAM photometry is found for an anti-correlation between the emission of these components.Comment: 8 pages, 3 figures. Proceedings of the 16th Workshop on Cool Stars, Stellar Systems, and the Sun (PASP conference series, in press

The acceptability and impact of a randomised controlled trial of welfare rights advice accessed via primary health care: qualitative study

BACKGROUND: Qualitative research is increasingly used alongside randomised controlled trials (RCTs) to study a range of factors including participants' experiences of a trial. The need for a sound evidence base within public health will increase the need for RCTs of non-clinical interventions. Welfare rights advice has been proposed as an intervention with potential to reduce health inequalities. This qualitative study, nested within an RCT of the impact of welfare rights advice, examined the acceptability of the intervention, the acceptability of the research process and the perceived impact of the intervention. METHODS: 25 men and women aged 60 years or over were recruited from four general practices in Newcastle upon Tyne (UK), a sub-sample of those who consented to be contacted (n = 96) during the RCT baseline interview. Semi-structured interviews were undertaken and analysed using the Framework Method. RESULTS: Participants viewed the trial positively although, despite agreeing that the information leaflet was clear, some had agreed to participate without being fully aware of what was involved. Some participants were unaware of the implications of randomisation. Most thought it fair, but a few concerns were raised about the control condition. The intervention was acceptable and made participants feel confident about applying for benefit entitlements. 14 out of 25 participants received some financial award; median weekly income gain was £57 (€84, $101). The perceived impact of additional finances was considerable and included: increased affordability of necessities and occasional expenses; increased capacity to deal with emergencies; and a reduction in stress related to financial worries. Overall, perceived independence and ability to participate in society increased. Most participants perceived benefits to their mental well-being, but no-one reported an improvement in physical health. The RCT showed little or no effect on a wide range of outcome measures. CONCLUSION: Participation in the trial and the intervention was acceptable to participants. Welfare rights advice targeted at people aged 60 years or over and accessed via primary care had a positive impact on quality of life and resulted in increased social participation. The divergence of qualitative and quantitative findings suggests that both methods make important contributions to the evaluation of complex social interventions

Musical Hallucinations Treated with Atypical Antipsychotics in a Geriatric Population – A Case Series

Musical hallucinations have been likened to the auditory equivalent of Charles Bonnet Syndrome, which involves complex visual hallucinations, most often in the context of visual impairment. Musical hallucination frequently take the form of hymns, carols, and show-tunes and are strongly associated with hearing loss, with some studies suggesting a prevalence of 2.5–3.6% in the hearing impaired. Musical hallucinations are typically treated with anticonvulsant and anticholinesterase medications, with some studies having evaluated the efficacy of sedative hypnotics, antipsychotics and antidepressants in various psychiatric and medical subpopulations suggesting a heterogeneous spectrum of causes for this disorder. We present two cases of musical hallucinations in both a 70-year-old African American female with past psychiatric history of major depressive disorder who developed hymnal auditory hallucinations during an acute medical and psychiatric admission and an 86-year-old Caucasian female, who complained of hearing gospel music with eventual onset of visual hallucinations after a fall at age 80. Our patients were successfully treated in both the inpatient and outpatient settings with atypical antipsychotics. The presented cases add to the paucity of literature regarding utilization of atypical antipsychotics for treatment of musical hallucinations and demonstrate efficacy to this effect. This study lends further validity to the use of psychopharmacologic agents for novel purposes that have yet to be fully explored

3.6 and 4.5 μm Phase Curves and Evidence for Non-equilibrium Chemistry in the Atmosphere of Extrasolar Planet HD 189733b

We present new, full-orbit observations of the infrared phase variations of the canonical hot Jupiter HD 189733b obtained in the 3.6 and 4.5 μm bands using the Spitzer Space Telescope. When combined with previous phase curve observations at 8.0 and 24 μm, these data allow us to characterize the exoplanet's emission spectrum as a function of planetary longitude and to search for local variations in its vertical thermal profile and atmospheric composition. We utilize an improved method for removing the effects of intrapixel sensitivity variations and robustly extracting phase curve signals from these data, and we calculate our best-fit parameters and uncertainties using a wavelet-based Markov Chain Monte Carlo analysis that accounts for the presence of time-correlated noise in our data. We measure a phase curve amplitude of 0.1242% ± 0.0061% in the 3.6 μm band and 0.0982% ± 0.0089% in the 4.5 μm band, corresponding to brightness temperature contrasts of 503 ± 21 K and 264 ± 24 K, respectively. We find that the times of minimum and maximum flux occur several hours earlier than predicted for an atmosphere in radiative equilibrium, consistent with the eastward advection of gas by an equatorial super-rotating jet. The locations of the flux minima in our new data differ from our previous observations at 8 μm, and we present new evidence indicating that the flux minimum observed in the 8 μm is likely caused by an overshooting effect in the 8 μm array. We obtain improved estimates for HD 189733b's dayside planet-star flux ratio of 0.1466% ± 0.0040% in the 3.6 μm band and 0.1787% ± 0.0038% in the 4.5 μm band, corresponding to brightness temperatures of 1328 ± 11 K and 1192 ± 9 K, respectively; these are the most accurate secondary eclipse depths obtained to date for an extrasolar planet. We compare our new dayside and nightside spectra for HD 189733b to the predictions of one-dimensional radiative transfer models from Burrows et al. and conclude that fits to this planet's dayside spectrum provide a reasonably accurate estimate of the amount of energy transported to the night side. Our 3.6 and 4.5 μm phase curves are generally in good agreement with the predictions of general circulation models for this planet from Showman et al., although we require either excess drag or slower rotation rates in order to match the locations of the measured maxima and minima in the 4.5, 8.0, and 24 μm bands. We find that HD 189733b's 4.5 μm nightside flux is 3.3σ smaller than predicted by these models, which assume that the chemistry is in local thermal equilibrium. We conclude that this discrepancy is best explained by vertical mixing, which should lead to an excess of CO and correspondingly enhanced 4.5 μm absorption in this region. This result is consistent with our constraints on the planet's transmission spectrum, which also suggest excess absorption in the 4.5 μm band at the day-night terminator