Multiple myeloma masquerading as severe seropositive rheumatoid arthritis with subcutaneous nodules and mononeuritis multiplex

Multiple myeloma can rarely mimic seronegative rheumatoid arthritis (RA). We report a 55‐year‐old woman who presented with longstanding deforming polyarthritis with extensive subcutaneous nodules, tenosynovitis, anti‐cyclic citrullinated peptide positivity and mononeuritis multiplex. Even though the clinical picture was consistent with seropositive RA, the absence of bone erosion or joint space narrowing on hand and knee radiographs led us to question the diagnosis of RA. Further investigation revealed a diagnosis of multiple myeloma with cutaneous amyloid deposits, based on serum immunofixation, bone marrow aspiration and biopsy of a subcutaneous nodule. The only clue to suspect myeloma from the basic investigations and clinical examination was mild hypercalcemia. This case serves to reiterate the need to maintain a heightened suspicion for other diagnoses even when RA appears most likely.     

Cholesterol crystal embolization following plaque rupture: a systemic disease with unusual features

Cholesterol crystal embolic (CCE) syndrome is often a clinically challenging condition that has a poor prognostic implication. It is a result of plaque rupture with release of cholesterol crystals into the circulation that embolize into various tissue organs. Plaque rupture seems to be triggered by an expanding necrotic core during cholesterol crystallization forming sharp tipped crystals that perforate and tear the fibrous cap. Embolizing cholesterol crystals then initiate both local and systemic inflammation that eventually lead to vascular fibrosis and obstruction causing symptoms that can mimic other vasculitic conditions. In fact, animal studies have demonstrated that cholesterol crystals can trigger an inflammatory response via NLRP3 inflammasome similar to that seen with gout. The diagnosis of CCE syndrome often requires a high suspicion of the condition. Serum inflammation biomarkers including elevated sedimentation rate, abnormal renal function tests and eosinophilia are useful but non-specific. Common target organ involvement includes the skin, kidney, and brain. Various testing including fundoscopic eye examination and other non-invasive procedures such as trans-esophageal echocardiography and magnetic resonance imaging may be helpful in identifying the embolic source. Treatment includes aspirin and clopidogrel, high dose statin and possibly steroids. In rare cases, mechanical intervention using covered stents may help isolate the ruptured plaque. Anticoagulation with warfarin is not recommended and might even be harmful. Overall, CCE syndrome is usually a harbinger of extensive and unstable atherosclerotic disease that is often associated with acute cardiovascular events.     

Simple bedside predictors of mechanical ventilation in patients with Guillain-Barre syndrome

Objective

The objective of the study is to develop and validate a predictor score for assessing the requirement of mechanical ventilation (MV) in patients with Guillain-Barre syndrome (GBS).

Study design

The study was conducted in patients admitted with GBS in neurointensive care unit in a tertiary care hospital. The demographic, clinical factors, electrophysiological, and spirometric data of all consecutive patients were prospectively collected. The study was undertaken in 2 stages. In the first stage, data were collected for development of a predictor score. In the second stage, the score developed was validated on a separate set of patient data.

Results

The data collected were compared between the 2 groups (ventilated vs nonventilated). On univariate analysis, time taken to reach maximum deficit, neck weakness, bulbar weakness, facial weakness, single breath count (SBC), forced vital capacity, and phrenic nerve latency predicted the need for MV. On multivariate analysis, only neck weakness, bulbar weakness, SBC, and forced vital capacity were independent predictors of MV. There was a good correlation between SBC and the spirometric tests and phrenic nerve distal motor latency, as reflected in receiver operating characteristics curve. The predictor score developed using the regression coefficient of independent predictors showed that the best cutoff score for prediction of ventilation was 60 (sensitivity, 0.95; 1 – specificity, 0.065). Internal cross validation of the neck weakness, SBC, and bulbar palsy (NSB) score showed good correlation (Pearson R = 0.76; P = .00). There was no statistically significant difference between predicted and observed outcomes (sensitivity, 95%; specificity, 93%).

Conclusion

Several independent risk factors were found to predict the requirement for MV in patients with GBS at admission. However, after scoring and analyzing them, it was found that combining a few of them was more useful to predict the need for MV. A model using NSB score, developed using clinical variables, accurately predicted the requirement of MV. In addition, among the NSB score parameters, simple bedside SBC could adequately assess the adequacy of vital capacity.     

Development of U-Net Breast Density Segmentation Method for Fat-Sat MR Images Using Transfer Learning Based on Non-Fat-Sat Model

Journal of Digital Imaging - To develop a U-net deep learning method for breast tissue segmentation on fat-sat T1-weighted (T1W) MRI using transfer learning (TL) from a model developed for...     

Selective Adsorption of Potassium in Seawater by CoHCF Thin Film Electrode and Its Electrochemical Desorption/Regeneration

Cobalt Hexacyanoferrate (CoHCF) was tested for the selective uptake of K from seawater and the electrochemical method was adopted for the desorption and regeneration of the material. Powder form CoHCF could adsorb about 6.5 mmol/g of K from the seawater. For the ease of the electrochemical desorption and regeneration, CoHCF thin film was coated onto the Indium Tin Oxide (ITO) glass to obtain a CoHCF electrode. K adsorption kinetics on CoHCF thin film was found to be well fitted with the intraparticle diffusion model, which was a two-step process. Five consecutive adsorption-desorption-regeneration cycles were carried out to know the gradual decrease in the adsorption capacity owing to changes in the redox states of two metals, Co and Fe, in the material. Fourier Transform Infrared Spectroscopy (FT-IR) and Ultraviolet-Visible (UV-Vis) measurement results corresponded to the color change of CoHCF thin film, indicating the valence change of transition metals and the exchange of alkali metal cations happened on the CoHCF at different operation stages. In order to elucidate the reaction mechanism, composition of the material was analysis in the following steps: adsorption, desorption, and regeneration. It was proved that the system based on CoHCF thin film modified electrode had the potential of recovering potassium from seawater.     

Identification of Duplicates in Ginger Germplasm Collection from Odisha Using Morphological and Molecular Characterization

Proceedings of the National Academy of Sciences, India Section B: Biological Sciences - In this investigation, sixty morphologically different ginger rhizomes, collected from an active germplasm...