Antiphospholipid (Hughes) syndrome: beyond pregnancy morbidity and thrombosis

The antiphospholipid syndrome is an autoimmune disease characterised by recurrent arterial or venous thrombosis, pregnancy morbidity and the persistence of positive antiphospholipid antibodies. Many other clinical manifestations may occur including heart valve disease, livedo reticularis, thrombocytopenia and neurological manifestations such as migraine and seizures. We review a number of other manfestations including stenotic lesions, coronary artery disease and accelerated atherosclerosis, skeletal disorders and the concept of seronegative antiphospholipid syndrome

Collision tumor of the thyroid: follicular variant of papillary carcinoma and squamous carcinoma

BACKGROUND: Collision tumors of the thyroid gland are a rare entity. We present a case of a follicular variant of papillary carcinoma and squamous carcinoma in the thyroid. To the best of our knowledge, this is the first documentation of a collision tumor with a papillary carcinoma and a squamous carcinoma within the thyroid gland. The clinicopathological features and immunohistochemical profile are reported. The theories of origin, epidemiology and management are discussed with a literature review. CASE PRESENTATION: A 65 year old woman presented with a large thyroid swelling of 10 years duration and with swellings on the back and scalp which were diagnosed to be a follicular variant of papillary thyroid carcinoma with metastasis. Clinical examination, radiology and endoscopy ruled out any other abnormality of the upper aerodigestive tract. The patient was treated surgically with a total thyroidectomy with central compartment clearance and bilateral selective neck dissections. The histopathology revealed a collision tumor with components of both a follicular variant of papillary carcinoma and a squamous carcinoma. Immunohistochemical analysis confirmed the independent origin of these two primary tumors. Adjuvant radio iodine therapy directed toward the follicular derived component of the thyroid tumor and external beam radiotherapy for the squamous component was planned. CONCLUSION: Collision tumors of the thyroid gland pose a diagnostic as well as therapeutic challenge. Metastasis from distant organs and contiguous primary tumors should be excluded. The origins of squamous cancer in the thyroid gland must be established to support the true evolution of a collision tumor and to plan treatment. Treatment for collision tumors depends upon the combination of primary tumors involved and each component of the combination should be treated like an independent primary. The reporting of similar cases with longer follow-up will help define the epidemiology, biology and establish standardized protocols for treatment of these extremely rare tumors

Humble Machines: Attending to the Underappreciated Costs of Misplaced Distrust

It is curious that AI increasingly outperforms human decision makers, yet much of the public distrusts AI to make decisions affecting their lives. In this paper we explore a novel theory that may explain one reason for this. We propose that public distrust of AI is a moral consequence of designing systems that prioritize reduction of costs of false positives over less tangible costs of false negatives. We show that such systems, which we characterize as 'distrustful', are more likely to miscategorize trustworthy individuals, with cascading consequences to both those individuals and the overall human-AI trust relationship. Ultimately, we argue that public distrust of AI stems from well-founded concern about the potential of being miscategorized. We propose that restoring public trust in AI will require that systems are designed to embody a stance of 'humble trust', whereby the moral costs of the misplaced distrust associated with false negatives is weighted appropriately during development and use

The ubiquitous nature of the Horizontal Branch second U-jump: A link with the Blue Hook scenario?

In a previous paper we reported on a discontinuity in the extreme horizontal branch (EHB) of the Galactic globular cluster NGC6752, which we called the second U-jump. This feature was attributed to a combination of post zero-age horizontal branch evolution and diffusion effects. In this follow-up study we analyze other EHB clusters and show that the second U-jump is a common feature among EHB clusters reaching T_{eff}\ge 23,000K, and that its onset in different clusters converges around T_{eff}\sim 21,000\pm3,000K. We also present near-ultraviolet diagrams of \omega Cen and NGC2808, the only two objects with spectroscopically confirmed ``blue hook'' stars (T_{eff}\ge 35,000K). We confirm predictions of a photometric discontinuity separating late from early-helium flashers. Moreover, we present empirical evidence that the second U-jump population might be mainly composed by early-helium flashers. Lastly, we revisit the discussion on the ubiquitous nature of the gaps and jumps so far identified in the blue HB tails, suggesting a possible discrete nature of the distribution in temperature of the HB stars.Comment: 15 pages, 8 figures. Higher resolution version available via ftp at ftp://ftp.pd.astro.it/pub/momany/momany.tar A&A accepte

A unique RET EXON 11 (G691S) polymorphism in an Indian patient with a collision tumor of the thyroid

BACKGROUND: Collision tumors of the thyroid are rare, with occasional reports dealing with their genetic analysis. CASE PRESENTATION: A 59 year old lady presented with a neck mass, associated with hoarseness of voice of 5 years duration. Radiological examination revealed nodular masses in the left lobe of her thyroid, along with one in the isthmus, extending into the right lobe and associated with enlarged neck nodes. FNAC from the left thyroid showed features of medullary carcinoma. On total thyroidectomy, 2 distinct tumor nodules were identified in the left lobe with another in the isthmus, showing features of medullary carcinoma (MTC), papillary carcinoma and follicular variant of papillary carcinoma, respectively, accompanied with nodal metastasis. Subsequently, she underwent radioablation. RET gene analysis of the patient, her 2 daughters and a grandson revealed a unique G691S polymorphism on Exon 11. CONCLUSION: This unique case of a collision tumor of thyroid, including component of an MTC deals with the value of RET gene analysis and therapeutic implications in the index case and in family members

J08069+1527: A newly discovered high amplitude, hybrid subdwarf B pulsator

We present our discovery of a new hybrid pulsating subdwarf B star, J08069+1527. The effective temperature and surface gravity of 28,500$\pm$400\,K and 5.37$\pm$0.04\,dex, respectively, place this object inside the instability strip and also among other pulsating hot subdwarfs of a hybrid nature, right next to another fascinating star: Balloon\,090100001. From this proximity, we anticipated this star could pulsate in both high and low frequency modes. Indeed, our analysis of photometric data confirmed our prediction. We detected two peaks in the high frequency region and two other peaks at low frequencies. In addition, the amplitude of the dominant mode is very high and comparable to the dominant peaks in other hybrid subdwarf B stars. Since this star is bright, we performed time-series low resolution spectroscopy. Despite a low signal-to-noise (S/N) ratio, we were able to detect the main peak from these data. All our results strongly indicate that J08069+1527 is a high amplitude pulsating hot subdwarf B star of hybrid nature. By analogy to the other pulsating sdB star, we judge that the dominant mode we detected here has radial nature. Future stellar modeling should provide us with quite good constrains as p- and g-modes presented in this star are driven in different parts of its interior.Comment: 7 pages, 10 figures, accepted for publication in MNRA

Delayed-onset disseminated BCG disease causing a multi-system illness with fatal mycotic aortic aneurysm

CASE: We report a case of disseminated BCG infection, diagnosed two years after BCG infusion for bladder cancer. Our patient, a 74-year-old male, was referred with an 18-month history of fevers, weight loss and intermittent confusion. Prior to referral, the patient had multiple hospital admissions for evaluation of fever of unknown origin, confusion, and fatigue. He was treated for several acute infections, whilst extensive investigations did not identify a focal cause of the persistent fever. During this period two aneurysms, iliac and aortic, were found and stented. Both were presumed mycotic, but no positive microbiology arose from either. He presented again with fever and confusion and was found to have a left sided pleural effusion, which was drained, and broad-spectrum antibiotics started, but his fever and inflammatory markers did not settle. Mycobacterium tuberculosis PCR on a pleural fluid sample returned a positive result, and later cultures from the same fluid grew Mycobacterium species which whole genome sequencing identified as Mycobacterium Bacillus Calmette-Guérin (BCG). Despite a number of adverse events with anti-BCG medications, the patient was established on four medications (rifampicin/isoniazid/ethambutol/levofloxacin) with symptomatic improvement. He re-presented four months later with abdominal pain and was found to have an inoperable leaking thoracic aortic sac from deterioration of his mycotic aneurysm. Following discussion with the patient and his family he was managed palliatively and died two days later. DISCUSSION: The learning points from this case are to consider disseminated BCG in patients presenting with pyrexia of unknown origin following reported intravesical BCG treatment for bladder malignancy in the years prior to presentation. Mycotic aneurysms are a rare but serious complication of disseminated BCG with a high mortality

Medication decision-making and adherence in lupus: patient–physician discordance and the impact of previous ‘adverse medical experiences’

OBJECTIVES: Medication adherence is critical in the successful management of lupus. There is very limited existing literature on reasons why non-adherence is not reported. This study explores the impact of current and previous medical experiences on patient satisfaction, adherence and reporting of non-adherence. METHODS: Mixed methodology involved thematic analysis of in-depth interviews (N = 23) to further explore the statistically analysed quantitative survey findings (N = 186). RESULTS: This study identified five themes: 1) physician-patient discordance and a 'hierarchy of evidence' in medication decisions, 2) the association of adherence with satisfaction with care, 3) the persisting impact of past Adverse Medical Experiences (AMEs), 4) the dynamic balance of patient-physician control, and 5) holistic care - beyond a purely medication- based focus. Improving quality of life (43% of participants) and a supportive medical relationship (24%) were the main reasons for adherence. Patient-priorities and self-reported symptoms were perceived as less important to physicians than organ-protection and blood results. Non-reporters of non-adherence, non-adherers and those with past AMEs (e.g. psychosomatic misdiagnoses) had statistically significant lower satisfaction with care. The importance of listening to patients was a key component of every theme, and associated with patient satisfaction and adherence. The mean rating for rheumatologist's listening skills was 2.88 for non-adherers compared to 3.53 for other participants (mean difference 0.65, P = 0.003). CONCLUSION: Patients would like more weight and discussion given to self-reported symptoms and quality of life in medication decisions. Greater understanding and interventions are required to alleviate the persisting impact of past AMEs on some patients' wellbeing, behaviour and current medical relationships