Addressing Syndemics and Self-care in Individuals with Uncontrolled HIV: An Open Trial of a Transdiagnostic Treatment.

Interventions addressing syndemics and ART adherence are needed for individuals with uncontrolled HIV and psychosocial problems. Twenty-seven participants with detectable HIV plasma viral load (PVL) or recent STI participated in an open trial of transdiagnostic adherence counseling and cognitive behavioral therapy. Outcomes were collected at baseline, 4-, and 8-months. Log PVL improved from baseline to 4-month (γ = - 1.13, 95% CI - 1.72, - 0.55, p < 0.001) and 8-month (γ = - 0.93, 95% CI - 1.57, - 0.30, p = 0.006), with more participants suppressed at 4- (χ2(1) = 9.09, p = 0.001) and 8-month (χ2(1) = 5.14, p = 0.016). Self-reported adherence improved across major assessments (γ = 0.87, 95% CI 0.28, 1.46, p = .005); Wisepill adherence did not. Negative affect declined during treatment (γ = - 0.28, 95% CI - 0.40, - 0.16, p < 0.001), with improvement at 4- (γ = - 4.34, 95% CI - 6.99, - 1.69, p = 0.002) but not 8-month. Positive affect trended positively during treatment and from baseline to 4-month, with significant 8-month improvement (γ = 3.84, 95% CI 0.33, 7.44, p = 0.04). Depressive symptoms did not change. In a complicated sample of participants selected for uncontrolled HIV, the intervention yielded improved PVL and self-reported adherence. Efforts to end HIV should improve upon strategies such as these, addressing syndemics. Registration: clinicaltrial.gov: NCT02696681.

Detecting Depression in People Living with HIV in South Africa: The Factor Structure and Convergent Validity of the South African Depression Scale (SADS).

Screening measures for depression developed in high-income countries have not always demonstrated strong psychometric properties in South Africa and with people living with HIV (PLWH). The present study explored the psychometric properties of the 16-item South African Depression Scale (SADS) comprised of idioms of distress specific to isiXhosa culture in PLWH. The SADS was administered to 137 Xhosa-speaking PLWH who met diagnostic criteria for major depressive disorder (MDD) together with the Hamilton Depression Scale (HAM-D) and the Center for Epidemiological Studies Depression Scale (CES-D). We conducted exploratory factor analysis, correlation, and reliability statistics. Four factors of the SADS emerged: Sadness, lethargy/burdened, anhedonia/withdrawal, and cognitive/somatic. All factors correlated significantly with the HAM-D and CES-D. Internal consistency of the overall measure was high (α = .89). The SADS promises to be a robust measure of depression in isiXhosa-speaking PLWH in South Africa likely due to the inclusion of local idioms of distress.

'I went back to being myself': acceptability of a culturally adapted task-shifted cognitive-behavioural therapy (CBT) treatment for depression (Ziphamandla) for South African HIV care settings.

There is a need for a culturally adapted, evidence-based, psychotherapy treatment that is effective, acceptable, and feasible for integration into primary care in South Africa. This qualitative study used exit interviews to examine participants' experiences of an adapted cognitive-behavioural therapy treatment for adherence and depression, task-shifted and delivered by nurses in two peri-urban HIV clinics near Cape Town. Nine semi-structured exit interviews were conducted with isiXhosa-speaking females and analysed using thematic analysis. Overall, participants responded positively to the treatment, viewing it as acceptable and beneficial and as a catalyst to returning to normalcy. Results indicated that participants viewed the treatment as being effective in ameliorating their depressive symptoms and improving their adherence to ART . Additional benefits described included improvements in subjective wellbeing and social and occupational functioning. Several began or resumed employment, an important behavioural indicator of the treatment's capacity to facilitate positive change and cost saving. Recommendations to improve the treatment included using video material and educating others about depression. These findings have positive implications regarding the acceptability and cultural applicability of the treatment for use in South Africa.

Adaptation of community health worker-delivered behavioral activation for torture survivors in Kurdistan, Iraq.

BACKGROUND: Growing evidence supports the use of Western therapies for the treatment of depression, trauma, and stress delivered by community health workers (CHWs) in conflict-affected, resource-limited countries. A recent randomized controlled trial (Bolton et al. 2014a) supported the efficacy of two CHW-delivered interventions, cognitive processing therapy (CPT) and brief behavioral activation treatment for depression (BATD), for reducing depressive symptoms and functional impairment among torture survivors in the Kurdish region of Iraq. METHODS: This study describes the adaptation of the CHW-delivered BATD approach delivered in this trial (Bolton et al.2014a), informed by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing (ADAPT-ITT) framework for intervention adaptation (Wingood & DiClemente, 2008). Cultural modifications, adaptations for low-literacy, and tailored training and supervision for non-specialist CHWs are presented, along with two clinical case examples to illustrate delivery of the adapted intervention in this setting. RESULTS: Eleven CHWs, a study psychiatrist, and the CHW clinical supervisor were trained in BATD. The adaptation process followed the ADAPT-ITT framework and was iterative with significant input from the on-site supervisor and CHWs. Modifications were made to fit Kurdish culture, including culturally relevant analogies, use of stickers for behavior monitoring, cultural modifications to behavioral contracts, and including telephone-delivered sessions to enhance feasibility. CONCLUSIONS: BATD was delivered by CHWs in a resource-poor, conflict-affected area in Kurdistan, Iraq, with some important modifications, including low-literacy adaptations, increased cultural relevancy of clinical materials, and tailored training and supervision for CHWs. Barriers to implementation, lessons learned, and recommendations for future efforts to adapt behavioral therapies for resource-limited, conflict-affected areas are discussed.

Long-term survivor characteristics in HER2-positive metastatic breast cancer from registHER.

BACKGROUND: Data characterising long-term survivors (LTS) with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) are limited. This analysis describes LTS using registHER observational study data. METHODS: A latent class modelling (LCM) approach was used to identify distinct homogenous patient groups (or classes) based on progression-free survival (PFS), overall survival, and complete response. Demographics, clinicopathologic factors, first-line treatment patterns, and clinical outcomes were described for each class. Class-associated factors were evaluated using logistic regression analysis. RESULTS: LCM identified two survivor groups labelled as LTS (n=244) and short-term survivors (STS; n=757). Baseline characteristics were similar between groups, although LTS were more likely to be white (83.6% vs 77.8%) with oestrogen receptor-positive (ER+) or progesterone receptor-positive (PgR+) disease (59.4% vs 50.9%). Median PFS in LTS was 37.2 (95% confidence interval (CI): 32.9-40.5) vs 7.3 months (95% CI: 6.8-8.0) in STS. Factors associated with long-term survival included ER+ or PgR+ disease, metastasis to node/local sites, first-line trastuzumab use, and first-line taxane use. CONCLUSIONS: Prognostic variables identified by LCM define a HER2-positive MBC patient profile and therapies that may be associated with more favourable long-term outcomes, enabling treatment selection appropriate to the patient's disease characteristics.

Addressing narcissistic personality features in the context of medical care: integrating diverse perspectives to inform clinical practice.

Narcissistic personality disorder (NPD) is characterized by an unrealistic need for admiration, lack of empathy toward others, and feelings of superiority. NPD presents a unique and significant challenge in clinical practice, particularly in medical settings with limited provider contact time, as health professionals treat individuals who often require excessive admiration and have competing treatment needs. This practice review highlights real case examples across three distinct medically oriented clinical settings (inpatient and outpatient behavioral medicine and a Level I trauma center) to demonstrate the difficult and compromising situations that providers face when treating patients with general medical conditions and comorbid narcissistic personality features. The main goal of this article is to discuss the various challenges and obstacles associated with these cases in medical settings and discuss some strategies that may prove successful. A second goal is to bridge diverse conceptualizations of narcissism/NPD through the discussion of theoretical and empirical perspectives that can inform understanding of the clinical examples. Despite differing perspectives regarding the underlying motivation of narcissistic behavior, this practice review highlights that these paradigms can be integrated when sharing the same ultimate goal: to improve delivery of care across medically oriented clinical settings for patients with narcissistic features.

Gamma probe-directed lymphatic mapping and sentinel lymphadenectomy in primary melanoma: Reliability of the procedure and analysis of failures after long-term follow-up.

BACKGROUND AND OBJECTIVES: Some patients presenting with cutaneous malignant melanoma without palpable adenopathy have regional metastatic disease. The results of a prospective clinical study of gamma probe-directed sentinel lymph node (SLN) biopsy are presented. METHODS: Over a 3-year period, 103 patients with a diagnosis of invasive primary cutaneous malignant melanoma (Breslow > 0.12 mm or > Clark level II) underwent preoperative lymphoscintigraphy with technetium sulfur colloid followed by gamma-probe-guided sentinel lymphadenectomy. There were 46 women and 57 men with a mean age of 55.7 years (range, 19-91). RESULTS: Mean Breslow thickness was 2.3 mm (range, 0.12-10 mm). Primary locations were head and neck in 12, trunk 46, upper extremity 19, and lower extremity in 26. One hundred sixteen lymph node basins were mapped in 103 patients. Axillary, inguinal, and cervical nodal basins comprised 55, 34, and 11% of the total basins evaluated, respectively. Sixty-eight patients (66%) underwent lymphatic mapping of one regional nodal basin, 27 patients (26%) underwent synchronous lymphatic mapping of 2 regional nodal basins, 6 patients (6%) underwent synchronous lymphatic mapping of 3 regional nodal basins, and 2 patients (2%) underwent synchronous lymphatic mapping of 4 regional nodal basins. Seroma or infection did not occur in any patients. Micrometastatic disease was identified in 15 sentinel lymph node biopsy sites in 13 (10%) patients. Of 10 patients undergoing lymph node dissection, 9(90%) had no additional pathological lymph node involvement. We achieved 99% success rate, 1% rate of failed sentinel node procedure, and 8% false-negative rate after median follow-up for 2 years. CONCLUSIONS: We concluded that gamma probe-directed sentinel lymph node biopsy is a straightforward procedure which can be done in the outpatient setting and facilitates management of patients with cutaneous malignant melanoma. It allows the surgeon to identify all basins at risk for metastatic disease and the location of the sentinel node(s) in relation to the basin.

Increased proteasome degradation of cyclin-dependent kinase inhibitor p27 is associated with a decreased overall survival in mantle cell lymphoma.

Mantle cell lymphoma (MCL) is an aggressive neoplasm characterized by the deregulated expression of cyclin D1 by t(11;14). The molecular mechanisms responsible for MCL's clinical behavior remain unclear. The authors have investigated the expression of p53, E2F-1, and the CDK inhibitors p27 and p21 in 110 MCLs, relating their expression to proliferative activity (Ki-67). For comparison, they have similarly analyzed low-grade (12 MALT, 16 CLL/SLL) and high-grade (19 DLCL) lymphomas. p53 was detected more frequently in large-cell MCL (l-MCL; 5 of 7) than in classical MCL (s-MCL; 13 of 103) and DLCL (8 of 19). In MCL and DLCL, the percentage of E2F-1+ nuclei was high, correlating with high Ki-67 expression. Most MCLs (91 of 112) and DLCLs (12 of 19) showed a loss of p27; MALT and CLL/SLL, however, were p27 positive. Reverse transcription-polymerase chain reaction and in vitro protein degradation assays demonstrated that MCLs have normal p27 mRNA expression but increased p27 protein degradation activity via the proteasome pathway. Correlation of MCL p53 and p27 expression with clinical data showed an association between reduced overall survival rates and the overexpression of p53 (P =.001), the loss of p27 (P =. 002), or both. Loss of p27 identified patients with a worse clinical outcome among p53 negative cases (P =.002). These findings demonstrated that MCL has a distinct cell cycle protein expression similar to that of high-grade lymphoma. The loss of p27 and the overexpression of p53 in MCL are prognostic markers that identify patients at high risk. The demonstration that low levels of p27 in MCL result from enhanced proteasome-mediated degradation should encourage additional clinical trials. (Blood. 2000;95:619-626) (Blood. 2000;95:619-626)

Surgical intervention for the aging face. Combination of mini-face-lifting and superficial carbon dioxide laser resurfacing.

BACKGROUND: Patients seeking facial rejuvenation often would benefit from a combination of face-lifting and laser resurfacing. Fear of skin slough has prevented the study of this issue. OBJECTIVE: We report our experience utilizing a combination of simultaneous cervicofacial rhytidectomy and carbon dioxide (CO2) laser resurfacing, and summarize the results of a survey completed by each patient. METHODS: Forty patients underwent the combination treatment. Patients were followed and asked to respond to a questionnaire 12 months postprocedure regarding their surgical experience. RESULTS: Our survey revealed an overall degree of satisfaction. Reported complications included transient swelling, redness, pigmentary alteration, and numbness. One patient experienced minimal slough in a nonresurfaced site. CONCLUSIONS: The control of depth of thermal damage with the CO2 UltraPulse laser allows for precision in its combined application along with face-lifting. In the area of the flap, one pass at low power settings is safe in our experience and results in an improved cosmetic result.

Extracorporeal photochemotherapy in a patient with Ki-1-positive anaplastic large-cell lymphoma.

A 57-year-old man with Ki-1 anaplastic large-cell lymphoma treated with extracorporeal photochemotherapy is described.

Silicone granuloma in acral skin in a patient with silicone-gel breast implants and systemic sclerosis.

A 68-year-old white woman was referred to us by her rheumatologist for possible participation in a clinical study of photopheresis for scleroderma. In February 1993, she noticed edema of her distal phalanges, Raynaud's phenomenon in both hands, flu-like symptoms, fatigue, intermittent diarrhea, abdominal pain, tearing in both eyes, dyspnea on exertion, dysphagia, and odynophagia. Bilateral silicone-gel breast implants had been placed 12 years before; 2 months before her present evaluation, they were removed and found to be ruptured. Physical examination revealed edema, limited to the fingers and hands bilaterally, and slight induration of the skin on the dorsum of both hands and distal forearms. The remainder of the physical examination was normal. According to our study protocol, a skin biopsy specimen from the dorsum of the right hand was taken, but all other laboratory investigations were refused. Histopathologic examination revealed multiple clear spaces of varying sizes in the dermis and multinucleated macrophages containing small refractile particles, characteristic of silicone granuloma (Figs. 1 and 2); however, the specimen showed no evidence of scleroderma. X-ray energy dispersive analysis by scanning electron-microscopy confirmed the presence of elemental silicon in the small refractile particles. The patient did not receive any treatment after her diagnosis and shortly thereafter, she was lost to follow-up.

Treating nevoid basal cell carcinoma syndrome.

More than 100 anomalies are associated with this syndrome. In this case, a cyst removed from a 15-year-old male was diagnosed as an odontogenic keratocyst. The long history of this syndrome with its associated problems is described.

Change in presentation of breast cancer in a community hospital.

An aggressive mammographic screening program under the auspices of a community hospital resulted in a significantly earlier detection of breast cancer at presentation in 1990 as compared to 1980. It is anticipated that further followup will show a reduction in cancer mortality as a result of this earlier detection.

Granulomatous prostatitis: a hypoechoic lesion of the prostate.

Numerous benign and malignant entities can disrupt the normal prostatic parenchymal architecture producing hypoechoic lesions in the peripheral zone. We report two cases of granulomatous prostatitis mimicking carcinoma. The differential diagnosis of hypoechoic lesions and the etiologies of granulomatous prostatitis are discussed. All hypoechoic lesions in the peripheral zones of the prostate require biopsy for histologic diagnosis.

Bilateral temporal bone involvement with eosinophilic granuloma.

We present an unusual case of bilateral temporal bone destruction due to eosinophilic granuloma in a young child. The patient initially presented with otitis media, with subsequent rapidly developing bilaterally symmetric masses in the mastoid region. Computed tomography demonstrated extensive bony destruction which, after a course of vinblastine chemotherapy, improved dramatically on follow-up scans.

Immunoperoxidase study of lymphomas. Comparison of a one-step frozen section technic with indirect methods on paraffin sections.

Fifty cases of non-Hodgkin's lymphoma (15 nodular and 35 diffuse) were studied to determine the sensitivity, specificity, and ease of several different immunoperoxidase methods. The methods included a rapid, simple one-step immunoperoxidase procedure on frozen sections compared with indirect immunoperoxidase technics on paraffin sections. The frozen-section immunoperoxidase technic stained 15 of 15 nodular lymphomas and 24 of 35 diffuse lymphomas for monoclonal light chain. The majority of the diffuse lymphomas that did not stain for light chains were morphologically and immunohistochemically consistent with T-cell lymphomas. The indirect method on B-5 and formalin-fixed tissues only rarely displayed monoclonal staining for nonplasmacytoid small cell lymphomas but did stain some large cell lymphomas and a majority of plasmacytoid lymphomas for monoclonal light chain. The frozen section technic presented in this report is sufficiently sensitive and reliable to detect immunoglobulins in any morphologic subtype of B-cell lymphoma, whereas paraffin-embedded tissues have only limited application.

Gastrointestinal lymphomas. Immunohistochemical studies on the cell of origin.

The classification of primary malignant lymphomas of the gastrointestinal tract by their cell of origin has been a subject of great controversy in recent years, with the proportion of histologic subtypes varying substantially in different published series. Much of this controversy was initially due to the widely recognized inherent difficulty of classifying lymphomas based on routine histologic sections alone. However, the advent of immunohistochemical techniques has also yielded disparate results. Particularly contentious has been the notion of true histiocytic lymphomas, which some investigators have claimed to be relatively frequent in the gastrointestinal tract, whereas others doubt whether they exist at all. We present here a classification of 25 gastrointestinal lymphomas seen in the surgical pathology services of UCLA Hospital and Stanford University Medical Center. Unlike all previously reported series, we have utilized frozen tissue sections for the performance of immunohistochemical studies, which we and others have found to be far more reliable than the use of formalin-fixed, paraffin-embedded tissues, particularly in detecting monoclonal surface staining of immunoglobulin light- and heavy-chain markers. We find that this technique lessens the likelihood of overinterpreting the stains for histiocyte markers (alpha 1-antitrypsin and lysozyme), which are often difficult to read owing to strong positive staining of benign reactive histiocytes within the tumor. Utilizing these techniques, we have been able to classify definitely 21 of our 25 lymphomas (84%) as of B-cell origin, whereas none appeared to be histiocytic. We conclude that true histiocytic lymphomas of the gastrointestinal tract must be very rare, and we recommend the routine use of frozen tissue sections for more accurate classification of these interesting lesions.

Teratomas of the head and neck in childhood.

Teratomas are tumors consisting of tissue arising from all three embryonic germ layers. Their occurrence in the head and neck region is rare. Three patients with this lesion are presented. Although exhibiting progressive uncoordinated growth, histologic evidence of malignancy in the head and neck form of this tumor is distinctly uncommon. Mortality associated with teratomas is most often secondary to respiratory compromise. Complete surgical extirpation is the treatment of choice to lower mortality and recurrences. The use of fine needle aspiration in the management of neck masses in children is discussed.

Pulmonary nodular amyloidosis presenting as Sjögren's syndrome.

A case of nodular pulmonary amyloidosis with Sjögren's syndrome is presented. A search of the literature failed to reveal any such case in which pulmonary nodules progressively calcify.

A case of probable benign pulmonary "metastases" or implants arising from a giant cell tumor of bone.

Several large pulmonary lesions were found in a 45-year-old woman after therapy for a typical tibial giant cell tumor. The pulmonary lesions were incidentally found during a routine chest examination four years after the original bone tumor had been found. Removal of the lung lesions showed ordinary giant cell tumor identical to the primary bone tumor, with no evidence of sarcomatous transformation. After an analysis of 12 other well-documented cases in the world literature, we postulate that the lung lesions in this case probably represent benign "metastases;" i.e., benign tumor implants compatable with a good long-term prognosis, rather than the usual lethal course associated with the vast majority of metastatic malignancies.