Multiple gastric involvement by myeloid antigen CD13-positive non-secretory plasma cell leukaemia

Gastrointestinal tract involvement is a rare complication of plasma cell neoplasia. We present a case of non-secretory type primary plasma cell leukaemia (PCL) with multiple gastric involvement. Dual surface antigen analysis of bone marrow cells revealed that atypical plasma cells coexpressed CD38 and myeloid antigen CD13. Upper gastrointestinal endoscopy disclosed multiple submucosal masses in the body of the stomach. Endoscopic biopsy specimens showed marked infiltration of atypical plasma cells consistent with a diagnosis of gastric involvement by PCL. Since CD13 antigen is identical to aminopeptidase N, a membrane-bound glycoprotein thought to be involved in the process of tumour invasion, CD13 expression on neoplastic plasma cells may be related to the gastric involvement in this patient.     

Coronary Atherosclerosis,Cardiac Troponin,and Interleukin-6 in Patients With Chest Pain: The PROMISE Trial Results

BackgroundIncreased inflammation and myocardial injury can be observed in the absence of myocardial infarction or obstructive coronary artery disease (CAD).ObjectivesThe authors determined whether biomarkers of inflammation and myocardial injury—interleukin (IL)-6 and high-sensitivity cardiac troponin (hs-cTn)—were associated with the presence and extent of CAD and were independent predictors of major adverse cardiovascular events (MACEs) in stable chest pain.MethodsUsing participants from the PROMISE trial, the authors measured hs-cTn I and IL-6 concentrations and analyzed computed tomography angiography (CTA) images in the core laboratory for CAD characteristics: significant stenosis (≥70%), high-risk plaque (HRP), Coronary Artery Disease Reporting and Data System (CAD-RADS) categories, segment involvement score (SIS), and coronary artery calcium (CAC) score. The primary endpoint was a composite MACE (death, myocardial infarction, or unstable angina).ResultsThe authors included 1,796 participants (age 60.2 ± 8.0 years; 47.5% men, median follow-up 25 months). In multivariable linear regression adjusted for atherosclerotic cardiovascular disease (ASCVD) risk, hs-cTn was associated with HRP, stenosis, CAD-RADS, and SIS. IL-6 was only associated with stenosis and CAD-RADS. hs-cTn above median (1.5 ng/L) was associated with MACEs in univariable analysis (HR: 2.1 [95% CI: 1.3-3.6]; P = 0.006), but not in multivariable analysis adjusted for ASCVD and CAD. IL-6 above median (1.8 ng/L) was associated with MACEs in multivariable analysis adjusted for ASCVD and HRP (HR: 1.9 [95% CI: 1.1-3.3]; P = 0.03), CAC (HR: 1.9 [95% CI: 1.0-3.4]; P = 0.04), and SIS (HR: 1.8 [95% CI: 1.0-3.2]; P = 0.04), but not for stenosis or CAD-RADS. In participants with nonobstructive CAD (stenosis 1%-69%), the presence of both hs-cTn and IL-6 above median was strongly associated with MACEs (HR: 2.5-2.7 after adjustment for CAD characteristics).ConclusionsConcentrations of hs-cTn and IL-6 were associated with CAD characteristics and MACEs, indicating that myocardial injury and inflammation may each contribute to pathways in CAD pathophysiology. This association was most pronounced among participants with nonobstructive CAD representing an opportunity to tailor treatment in this at-risk group. (PROspective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550)     

Instruments for measuring mental health recovery: A systematic review

Persons in recovery, providers, and policymakers alike are advocating for recovery-oriented mental health care, with the promotion of recovery becoming a prominent feature of mental health policy in the United States and internationally. One step toward creating a recovery-oriented system of care is to use recovery-oriented outcome measures. Numerous instruments have been developed to assess progress towards mental health recovery. This review identifies instruments of mental health recovery and evaluates the appropriateness of their use including their psychometric properties, ease of administration, and service-user involvement in their development. A literature search using the Medline and Psych-INFO databases was conducted, identifying 21 instruments for potential inclusion in this review, of which thirteen met inclusion criteria. Results suggest only three instruments (25%) have had their psychometric properties assessed in three or more unique samples of participants. Ease of administration varied between instruments, and for the majority of instruments, development included service user involvement. This review updates and expands previous reviews of instruments to assess mental health recovery. As mental health care continues to transform to a recovery-oriented model of service delivery, this review may facilitate selection of appropriate assessments of mental health recovery for systems to use in evaluating and improving the care they provide.     

Toward resolution of the debate regarding purported crypto-Jews in a Spanish-American population: Evidence from the Y chromosome

Background: The ethnic heritage of northernmost New Spain, including present-day northern New Mexico and southernmost Colorado, USA, is intensely debated. Local Spanish-American folkways and anecdotal narratives led to claims that the region was colonized primarily by secret- or crypto-Jews. Despite ethnographic criticisms, the notion of substantial crypto-Jewish ancestry among Spanish-Americans persists. Aim: We tested the null hypothesis that Spanish-Americans of northern New Mexico carry essentially the same profile of paternally inherited DNA variation as the peoples of Iberia, and the relevant alternative hypothesis that the sampled Spanish-Americans possess inherited DNA variation that reflects Jewish ancestry significantly greater than that in present-day Iberia. Subjects and Methods: We report frequencies of 19 Y-chromosome unique event polymorphism (UEP) biallelic markers for 139 men from across northern New Mexico and southern Colorado, USA, who self-identify as ‘Spanish-American’. We used three different statistical tests of differentiation to compare frequencies of major UEP-defined clades or haplogroups with published data for Iberians, Jews, and other Mediterranean populations. We also report frequencies of derived UEP markers within each major haplogroup, compared with published data for relevant populations. Results: All tests of differentiation showed that, for frequencies of the major UEP-defined clades, Spanish-Americans and Iberians are statistically indistinguishable. All other pairwise comparisons, including between Spanish-Americans and Jews, and Iberians and Jews, revealed highly significant differences in UEP frequencies. Conclusion: Our results indicate that paternal genetic inheritance of Spanish-Americans is indistinguishable from that of Iberians and refute the popular and widely publicized scenario of significant crypto-Jewish ancestry of the Spanish-American population.

Résumé. Arrière plan:?L’héritage ethnique de la partie la plus septentrionale de la Nouvelle Espagne, incluant aux USA l’actuel nord du Nouveau-Mexique et le sud du Colorado, est intensément discuté. Des traditions hispano-américaines locales et des anecdotes tendent à proclamer que cette région a été colonisée primitivement par des crypto-juifs. En dépit de critiques ethnographiques, la notion d’ancestralité substantielle crypto-juive persiste chez les hispano-américains.

But:?Tester l‘hypothèse nulle que les hispano-américains du Nouveau-Mexique septentrional présentent essentiellement le même profil de variation d’ADN paternel que les populations de la péninsule ibérique et l’hypothèse alternative que les hispano-américains échantillonnés possèdent une variation d’ADN qui reflète significativement plus l’ancestralité juive que l’ibérique.

Sujets et méthodes:?On reporte les fréquences de 19 polymorphismes uniques du chromosome Y (PU-Y) de marqueurs bi-alléliques chez 139 hommes du nord du Nouveau-Mexique et du sud du Colorado qui s’auto-identifient comme hispano-américains. On utilise trois tests statistiques de différenciation afin de comparer les fréquences des clades ou haplogroupes de PU-Y majeurs, ainsi que les fréquences des marqueurs PU-Y singularisés à l’intérieur de chaque haplogroupe majeur, avec les données publiées pour les espagnols, les juifs et d’autres populations méditerranéennes.

Résultats:?Tous les tests de différenciation montrent que les hispano-américains et les ibères sont statistiquement indistincts pour les fréquences des clades majeurs à définition PU-Y. Toutes les autres comparaisons deux à deux incluant hispano-américains et juifs et ibères et juifs, montrent des différences hautement significatives des fréquences PU-Y.

Conclusion: Nos résultats indiquent que l’hérédité paternel des hispano-américains ne peut être distinguée de celle des ibères et réfute le scénario populaire et largement diffusé, de l’existence d’une origine significative crypto-juive de la population hispano-américaine.

Zusammenfassung. Hintergrund:?Das ethnische Erbe des nördlichsten Teils von Neuspanien, einschliess;lich des heutigen New Mexico und des südlichen Colorado, USA, unterliegt intensiven Diskussionen. Lokale spanisch-amerikanische Traditionen und Anekdoten haben zu Behauptungen beigetragen, dass diese Region hauptsächlich von Geheimjuden beziehungsweise sogenannten crypto-jews kolonialisiert worden war. Trotz ethnographischer Kritik an dieser Theorie, hält sich die Vorstellung, dass ein bedeutender Anteil der heutigen in dieser Region lebenden Spanisch-Amerikaner von crypto-Jewish Vorfahren abstammen.

Ziel:?Wir untersuchen die Nullhypothese, die besagt, dass die Spanisch-Amerikaner des nördlichen New Mexico im Wesentlichen dasselbe Profil väterlich vererbter DNS-Variationen zeigen wie die Bevälkerung der Iberischen Halbinsel, und die entsprechende Alternativhypothese, die besagt, dass die getesteten Spanisch-Amerikaner DNS-Variationen besitzen, die ein signifikant höheres Mass; an jüdischer Herkunft widerspiegelen als die, die heute auf der Iberischen Halbinsel vorgefunden werden.

Probanden und Methoden:?Für 139 Männer aus dem nördlichen New Mexico und südlichen Colorado, USA, die sich selbst als, Spanisch-Amerikaner“ bezeichnen, wurde eine Genotypisierung auf dem Y-Chromosom anhand von 19 verschiedenen biallelischen Markern (unique event polymorphism, UEP) vorgenommen. Drei verschiedene statistische Tests wurden ausgeführt, um mögliche Unterschiede bei den Häufigkeiten der wesentlichen UEP-definierten Stämme oder Haplogruppen mit denen von bisher veröffentlichten Daten von Bewohnern der Iberischen Halbinsel, Juden sowie anderen mediterranen Völkern vergleichen zu können. Auss;erdem berichten wir die Häufigkeiten von abgeleiteten UEP-Markern innerhalb einer jeden Haupt-Haplogruppe und vergleichen diese mit publizierten Daten für die entsprechenden Populationen.

Ergebnisse:?Alle Untersuchungen auf Unterschiede zeigten für die Häufigkeiten der wesentlichen UEP-definierten Stämme, dass sich die der Spanisch-Amerikaner und der Bewohner der Iberischen Halbinsel statistisch nicht unterscheiden. Alle anderen paarweisen Vergleiche, einschliess;lich derer zwischen zum einen Spanisch-Amerikanern und Juden und zum anderen Bewohnern der Iberischen Halbinsel und Juden, zeigten signifikante Unterschiede in den jeweiligen UEP-Häufigkeiten.

Zusammenfassung:?Unsere Ergebnisse legen nahe, dass die väterliche genetische Vererbung bei Spanisch-Amerikanern nicht von der der iberischen Bevölkerung zu unterscheiden ist. Das populäre und oft publizierte Szenario einer signifikanten crypto-Jewish Abstammung, unter der heutigen spanisch-amerikanischen Bevölkerung wird damit widerlegt.

Resumen. Antecedentes:?La herencia étnica de la Nueva España situada más al norte, que incluye el norte del actual Nuevo México y el sur de Colorado, E.E.U.U., es objeto de un intenso debate. El modo de vida y las narraciones anecdóticas locales hispanoamericanas conducen a afirmar que la región fue colonizada inicialmente por judíos secretos o cripto-judíos. A pesar de las críticas etnográficas, persiste aún la noción de una ascendencia cripto-judía substancial entre los hispanoamericanos.

Objetivo:?Comprobamos la hipótesis nula de que los hispano-americanos del norte de Nuevo México portan esencialmente el mismo perfil de variación de ADN heredada por vía paterna que los pueblos de la Península Ibérica, así como la hipótesis alternativa relevante de que los hispanoamericanos estudiados poseen una variación de ADN heredada que refleja su ascendencia judía de forma mucho más perceptible que en la actual Península Ibérica.

Sujetos y métodos:?Presentamos las frecuencias de 19 marcadores bialélicos de polimorfismo de evento único (UEP) del cromosoma Y, de 139 varones procedentes de la zona situada entre el norte de Nuevo México y el sur de Colorado (E.E.U.U.), quienes se identifican a sí mismos como “hispanoamericanos”. Utilizamos tres pruebas estadísticas distintas de diferenciación para comparar las frecuencias de los principales clados o haplogrupos de UEP, definidos mediante datos publicados sobre ibéricos, judíos y otras poblaciones mediterráneas. También presentamos las frecuencias derivadas de los marcadores UEP dentro de cada haplogrupo principal, comparadas con los datos publicados sobre poblaciones relevantes.

Resultados:?todos los tests de diferenciación mostraron que, para las frecuencias de los principales clados de UEP definidos, hispanoamericanos e ibéricos son estadísticamente indistinguibles. El resto de pares comparados, incluyendo hispanoamericanos y judíos, e ibéricos y judíos, revelaron diferencias altamente significativas en las frecuencias de los UEP.

Conclusión:?nuestros resultados indican que la herencia genética paterna de los hispanoamericanos es indistinguible de la de los ibéricos y refuta el escenario popular y ampliamente publicitado de una significativa ascendencia cripto-judía de la población hispanoamericana.     

Renal Manifestations in 2007 Korean Patients with Beh?et's Disease

Purpose

Behçet''s disease (BD) theoretically affects all sizes and types of blood vessels and results in multi-organ involvement. However, renal BD has not been fully characterized, though the kidneys are histologically rich in blood vessels.

Materials and Methods

A total of 2007 patients who fulfilled the diagnostic criteria for BD were enrolled in this study. We reviewed the medical records and test results of the BD patients and used univariate and multivariate logistic regression analyses to determine the clinical significance of renal involvement in BD.

Results

Among the 2007 BD patients, we noted hematuria in 412 (20.5%) and proteinuria in 29 (1.4%). Univariate analysis showed that the BD patients with hematuria were predominantly female and older, had higher erythrocyte sedimentation rates (ESRs), and more frequently presented with genital ulcerations. BD patients with proteinuria had higher ESR levels compared to BD patients without proteinuria. In the multivariate analysis, age, sex, and ESR were found to be significantly associated with hematuria in BD patients, whereas only ESR was associated with proteinuria in BD patients. We also found that IgA nephropathy was the most common pathologic diagnosis in 12 renal BD patients who underwent renal biopsies.

Conclusion

We suggest that routine urinalysis and serum renal function tests be performed for the early detection of renal BD, especially in older female BD patients with recurrent hematuria, high ESR levels, and frequent genital ulcers, as well as in BD patients with proteinuria and high ESR levels.     

Option Grids: Shared decision making made easier

Objective

To describe the exploratory use of short decision support tools for patients, called Option Grids. Option Grids are summary tables, using one side of paper to enable rapid comparisons of options, using questions that patients frequently ask (FAQs) and designed for face-to-face clinical encounters. To date, most evidence about ‘patient decision aids’ has been based on tools with high content levels, designed for patients to use independently, either before or after visits.

Methods

We studied the use of Option Grids in a quality improvement project, collecting field notes and conducting interviews with clinical teams.

Results

In the ‘Making Good Decisions in Collaboration’ (MAGIC) program, clinicians found that using Option Grids made it easier to explain the existence of options and reported a ‘handover’ effect, where patient involvement in decision making was enhanced.

Conclusion

Option Grids made options more visible and clinicians found it easier to undertake shared decision making when these tools were available. Used in a collaborative way, they enhance patients’ confidence and voice, increasing their involvement in collaborative dialogs.

Practice implications

Further work to confirm these preliminary findings is required, to measure processes and to assess whether these tools have similar impact in other clinical settings.     

Using a ‘talk’ model of shared decision making to propose an observation-based measure: Observer OPTION

Objective

To propose a revised Observer OPTION measure of shared decision making.

Methods

We analyzed published models to identify the core components of a parsimonious conceptual framework of shared decision making. By using this framework, we developed a revised measure combining data from an observational study of clinical practice in Canada with our experience of using Observer OPTION^{12 Item}.

Results

Our conceptual framework for shared decision making composed of justifying deliberative work, followed by the steps of describing options, information exchange, preference elicitation, and preference integration. By excluding items in Observer OPTION^{12 Item} that were seldom observed or not aligned to a robust construct, we propose Observer OPTION^{5 Item}.

Conclusion

Although widely used, Observer OPTION^{12 Item} did not give sufficient attention to preference elicitation and integration, and included items that were not specific to a core construct of shared decision making. We attempted to remedy these shortcomings by proposing a shorter, more focused measure.

Practice implications

Observer OPTION^{5 Item} requires evaluation; we hope that it will be useful as both a research tool and as a formative measure of clinical practice.     

Is there shared decision making when the provider makes a recommendation?

Objective

To compare the amount of shared decision making in breast cancer surgery interactions when providers do and do not make a treatment recommendation.

Methods

We surveyed breast cancer survivors who were eligible for mastectomy and lumpectomy. Patients reported whether the provider made a recommendation and the recommendation given. They completed items about their interaction including discussion of options, pros, cons, and treatment preference. A total involvement score was calculated with higher scores indicating more shared decision making.

Results

Most patients (85%) reported that their provider made a recommendation. Patients who did not receive a recommendation had higher involvement scores compared to those who did (52% vs. 39.1%, p = 0.004). Type of recommendation was associated with involvement. Patients given different recommendations had the highest total involvement scores followed by those who received mastectomy and lumpectomy recommendations (65.5% vs. 42.5% vs. 33.2%, respectively, p < 0.001).

Conclusion

Providers were less likely to present a balanced view of the options when they gave a recommendation for surgery. Patients who received a recommendation for lumpectomy had the lowest involvement score.

Practice implications

Providers need to discuss both mastectomy and lumpectomy and elicit patients’ goals and treatment preferences regardless of whether or not a recommendation is given.     

The perception of shared medical decision making of expert and lay people: Effects of observing a movie clip depicting a medical consultation

Objective

To test for differences between experts and lay people in assessment of the degree to which a doctor engaged in a shared decision making (SDM) with a patient using the OPTION scale and a movie clip as stimulus material.

Methods

A segment of the movie ‘Wit’, depicting the communication of the diagnosis and the therapy proposed of a cancer, was shown to (a) university students with no knowledge about doctor–patient communication; (b) nurses working in medicine departments; (c) advanced medical students; (d) hospital physicians. The participants were asked to complete the OPTION scale which measures the extent to which physicians involve patients in medical decisions. An analysis of variance was used to compare OPTION scores across the four groups and to compare males and females.

Results

Being female [F_(1,190) = 11.9; p < .001] and being familiar with medical issues [F_(3,190) = 11.09; p < .001] were both significantly associated with a negative evaluations of the doctor's ability to involve the patient in the SDM.

Conclusion

Lay people and males (including male experts), are less demanding regarding SDM abilities.

Practice implications

A more systematic use of videos and the OPTION scale as validated outcome measure could be helpful educational strategy for the teaching of SDM.