Clinician perspectives on characteristics and care of traumatic brain injury among asylum seekers and refugees.

PURPOSE: Traumatic brain injury (TBI) disproportionately affects asylum-seekers and refugees (ASR), although underdiagnosed and undertreated. Our study assesses clinicians' perspectives on characteristics and management of TBI among ASR, with the hope of improving TBI management in this population. MATERIALS AND METHODS: We conducted six focus groups of 16 clinicians across two academic medical centers in Boston, Massachusetts, United States. Clinicians in our sample included primary care clinicians, nurse practitioners, social workers, psychologists, neurologists, psychiatrists, and neuropsychologists. We analyzed the qualitative data following a hybrid inductive-deductive thematic analytic approach. RESULTS: Clinicians characterized TBI among ASR as mostly mild and remote, involving head strikes, perpetrated predominantly by interpersonal violence and strangulation-related brain injury, and involving symptom overlap with mental health diagnoses, challenging diagnosis. Clinicians also described inadequate screening, the importance of connecting the physical and psychological symptoms of the brain injury rather than viewing them as distinct, and addressing diagnosis-related stigma and shame. Finally, they discussed lack of TBI-specific knowledge among providers and patients alike, and resource limitations affecting the continuum of care for this population. CONCLUSION: Integrating clinicians' perspectives in caring for this population allows us to best meet their needs, including in TBI recovery.

Traumatic Brain Injury (TBI) disproportionately affects asylum-seekers and refugees (ASR).ASR predominantly sustain TBI through head strikes, but strangulation-related brain injury is under-recognized and must be assessed alongside common TBI mechanisms of injury.Current challenges in assessing TBI in ASR include mild and remote presentation of TBI, perpetration in contexts of interpersonal violence, and symptom overlap with mental health diagnoses.Rehabilitation professionals can enhance TBI-related assessment, care, and communication by enhancing education of ASR patients and clinicians who serve them. This includes implementing use of, and improving, existing screening tools.

Urticarial mycosis fungoides: A distinctive presentation with blood involvement and a peculiar immunophenotype.

Mycosis fungoides (MF) has been widely reported to mimick a considerable number of different dermatoses, including scarring alopecia, bullous dermatoses or cysts, and comedones. In atypical presentations, histopathology is essential for the diagnosis. We present two cases of MF with clinical urticarial lesions and a striking blood involvement that responded to mogamulizumab treatment. Histopathologically, both cases had classic MF features and shared a peculiar immunophenotype, with positivity for CD25 and FOXP3. Differential diagnoses included urticarial lymphomatoid drug reactions and other lymphomas, like T-cell prolymphocytic leukemia, atypical Sézary syndrome, or adult T-cell lymphocytic leukemia. A low suspicion threshold is necessary for the diagnosis of atypical presentations of MF.

Order Keepers or Immigration Agents? Latine Immigrant Views of Law Enforcement in Healthcare Settings.

BACKGROUND: Police and security presence in healthcare settings have grown. There are few studies exploring perceptions of these law enforcement agents among US Latine immigrants, who can be vulnerable to immigration enforcement actions due to past and ongoing criminalization and anti-immigrant policies. OBJECTIVE: To explore Latine immigrants' perceptions of law enforcement in healthcare settings. DESIGN: Exploratory, semi-structured qualitative interviews asked participants about their perspectives of law enforcement in healthcare settings. PARTICIPANTS: English- and Spanish-speaking adult patients (n = 19) from a Federally Qualified Health Center (FQHC) in Los Angeles, CA, serving predominantly low-income Latine immigrants. APPROACH: We used the framework method for analysis to establish a codebook and inform our thematic interpretation. KEY RESULTS: We identified three themes: (1) perceptions of safety offered by police officers are separated from the role of immigration officers; (2) perceptions of police officers are integrated into broader perceptions of the healthcare system; and (3) lived experiences, including immigration status, influenced valence response to officer uniforms and perceptions of officers. Most participants viewed police officers positively as maintaining order and safety, separating them from federal immigration enforcement actions, and reflecting on local, state, and organizational "sanctuary" or immigrant-friendly policies. Individuals with precarious immigration status more often saw officers as intimidating. Immigration enforcement remained a key concern. CONCLUSIONS: Differentiating police and security roles from immigration enforcement in healthcare could improve Latine immigrant trust and access. Future studies should explore perspectives of Latine immigrants in localities without sanctuary laws or organizational immigrant-friendly policies.

Intracranial atherosclerotic plaque enhancement and long-term risk of future strokes: A prospective, longitudinal study.

BACKGROUND AND PURPOSE: The prognostic significance of postcontrast enhancement of intracranial atheromatous plaque is uncertain. Prospective, long-term follow-up studies in Caucasians, using a multicenter design, are lacking. We aimed to evaluate whether this radiological sign predicts long-term new stroke in symptomatic and asymptomatic intracranial atherosclerotic disease (ICAD) patients. METHODS: This was a prospective, observational, longitudinal, multicenter study. We included a symptomatic and an asymptomatic cohort of ICAD patients that underwent 3T MRI including high-resolution sequences focused on the atheromatous plaque. We evaluated grade of stenosis, plaque characteristics, and gadolinium enhancement ratio (postcontrast plaque signal/postcontrast corpus callosum signal). The occurrence of new events was evaluated at 3, 6, 9, and 12 months and annually thereafter. The association between plaque characteristics and new stroke was studied using Cox multiple regression survival analysis and Kaplan-Meier curves. RESULTS: Forty-eight symptomatic and 13 asymptomatic patients were included. During 56.3 ± 16.9 months, 11 patients (18%) suffered a new event (seven ischemic, two hemorrhagic, and two transient ischemic attacks). A receiver operating characteristic curve identified an enhancement ratio of >1.77 to predict a new event. In a multivariable Cox regression, postcontrast enhancement ratio >1.77 (hazard ratio [HR]= 3.632; 95% confidence interval [CI], 1.082-12.101) and cerebral microbleeds (HR = 5.244; 95% CI, 1.476-18.629) were independent predictors of future strokes. Patients with a plaque enhancement ratio >1.77 had a lower survival free of events (p < .05). CONCLUSIONS: High intracranial postcontrast enhancement is a long-term predictor of new stroke in ICAD patients. Further studies are needed to elucidate whether postcontrast enhancement reflects inflammatory activity of intracranial atheromatous plaque.

Cerebellar metastasis of a Liposarcoma: Case report and literature review.

BACKGROUND: Liposarcoma (LPS) is a rare type of tumor; they come from the adipose tissue. It is the most common type of soft-tissue sarcoma. Every type of LPS has morphological features, immunophenotypic, and molecular pathogenesis characteristics of their own. In this case, we are going to report a cerebellar metastatic disease from a well-differentiated liposarcoma (WDL) with pleomorphic component, not found in our literature research. CASE DESCRIPTION: A 72-year-old woman with progressive pain and inflammation in the left knee with functional limitation when climbing stairs. MRI shows a tumor in the vastus medialis of the left thigh. Pathology result was pleomorphic and WDL, Stage III and negative for MDM2 and CDK4. Extension study was carried out, finding nodular lesion in the right cerebellar hemisphere with mass effect and partial obliteration of the fourth ventricle, suspicious of distant disease. CONCLUSION: Cerebellar metastasis of LPS is uncommon; there are only a few cases reports with the literature reviews describing orbital or skull base metastases, but not in the cerebellum. Our case allows us to remember that neurological symptoms, no matter how subtle, in patients diagnosed with LPS, a secondary affectation of the central nervous system must be ruled out, even though it is a rare location. The findings of distant disease in LPSs, allow planning oncological treatment options and targeted radiotherapeutic.

Cutaneous eruption with reactive endothelial atypia due to emerging targeted cancer therapies: Report of two cases with clinico-pathologic correlation.

Targeted anticancer therapy is being used with greater frequency and dermatologic toxicities are among the most frequent adverse events of these drugs. However, histopathological features of these adverse events are not yet well characterized. We present two cases of clinically different cutaneous toxicities on two patients with hematologic neoplasia. They were treated with different drugs and in both cases medications shared inhibition of PI3K as mechanism of action. The skin biopsy specimen showed endothelial cell atypia with large nuclei and mitotic figures. To the best of our knowledge, no other cases with these striking histopathologic findings have been reported with PI3K inhibitors or other anticancer targeted therapy.

Toker cell hyperplasia in Zuska disease: A tricky association.

Toker cells (TCs) are sometimes present in the nipple epidermis as oval cells with pale cytoplasm and roundish nuclei. In most cases, TCs may be easily distinguished from cancerous cells of Paget disease of the nipple (PCs). Especially in TC hyperplasia, in which mild-to-moderate atypia may be present, it may be challenging to distinguish between TCs and PCs. The combination of chronic inflammatory changes in the nipple, in the context of Zuska disease, and TC hyperplasia, may easily lead to an erroneous diagnosis of mammary Paget disease.

Three additional cases of non-neural granular cell tumor with novel immunohistochemical findings.

BACKGROUND: Non-neural granular cell tumor (NNGCT) is an uncommon neoplasm of controversial histogenesis and its histopathologic differential diagnosis includes, in addition to conventional GCT, other dermal tumors that may exhibit granular cell change. METHODS: Three patients with a diagnosis of NNGCT were identified in the authors' files. Hematoxylin and eosin-stained sections and immunohistochemical studies were performed. RESULTS: Histopathological study of the three lesions showed dermal proliferation of granular cells arranged in thick fascicles between collagen bundles. The lesions showed positivity for Factor XIIIa, CD163, CD68, NKIC3, vimentin, ALK, fascin, and cyclin D1. CONCLUSION: To our knowledge, positivity for cyclin D1 has not been reported to date in NNGCT. In borderline cases, where the diagnosis is unclear despite histopathologic and immunohistochemical findings, positivity for cyclin D1 may favor the diagnosis of NNGCT. Further investigations to assess the differentiation of this rare neoplasm are needed.

Syringocystadenoma papilliferum associated with verrucous carcinoma of the skin in the same lesion: Report of four cases.

The association of syringocystadenoma papilliferum (SCAP) with verrucous carcinoma (VC) of the skin in the same lesion is a rare, but well-documented event. Although human papillomaviruses (HPV) have been proposed to have an etiologic role in the development of the verrucous proliferations associated with SCAP, most of the immunohistochemical and molecular studies have failed to show the presence of their genomic material in these lesions. We report a series of four cases of SCAP associated with VC in anogenital lesions. In two of the cases, we demonstrated the presence of the BRAF V600E mutation by polymerase chain reaction and immunohistochemistry, both in the glandular and in the squamous component. No HPV-related histopathologic changes were found, nor could the presence of viral DNA be showed.

Acrolocalized variant of lichen sclerosus initially manifesting as degenerative collagenous plaques of the hands.

Lichen sclerosus involving the hands is very uncommon. On the other hand, degenerative collagenous plaques of the hands is a rare condition characterized by keratotic, translucent papules in linear array, on the radial border of the hands. Histopathologically, lesions of degenerative collagenous plaques of the hands show increased collagen bundles in upper half of the dermis and dermal elastosis. We describe the clinical and histopathological progression experienced by a woman who initially presented lesions with clinical and histopathological appearance of degenerative collagenous plaques of the hands, which evolved into characteristic lichen sclerosus. We propose that some cases of the so-called degenerative collagenous plaques of the hands may represent an acrolocalized lichen sclerosus at an early stage.

Langerhans cell histiocytosis and multiple reticulohistiocytomas in a patient with TAR syndrome: An association not previously described.

We describe a patient with thrombocytopenia-absent radius (TAR) syndrome, multisystemic Langerhans cell histiocytosis and multiple reticulohistiocytomas. A mutational study by massive sequencing identified the Val600Glu (V600E) BRAF mutation in the Langerhans cell histiocytosis lesions, but no molecular alterations were found in the reticulohistiocytoma lesions. The concomitant presence in the same patient of more than one type of histiocytosis from two different groups recognized in the most recent Histiocyte Society classification is an extremely rare event. Our case is the first reported case of multisystemic Langerhans cell histiocytosis and multiple reticulohistiocytomas in a patient with TAR syndrome.

Plaque-Like Pilar Sheath Acanthoma: Histopathologic and Immunohistochemical Study of 3 Unusual Cases.

Pilar sheath acanthoma is an uncommon, benign follicular neoplasm that frequently presents as a solitary lesion. This neoplasm usually appears on the skin around the upper lip of elderly patients. Histopathologically, the neoplasm usually shows a cystic configuration with epithelial lobules resembling to those of the outer root sheath of the hair follicle at the level of the isthmus emanating radially from the cyst wall. We present 3 peculiar cases of a pilar sheath acanthoma showing a plaque-like architecture because the lesions exhibited a horizontal configuration. To our knowledge, there are no previously reported examples of plaque-like pilar sheath acanthoma.

Dermal Hyperneury and Multiple Sclerotic Fibromas in Multiple Endocrine Neoplasia Type 2A Syndrome.

Importance: Multiple endocrine neoplasia type 2 (MEN 2) syndrome is an autosomal dominant, hereditary cancer disorder caused by germline mutations in the RET (formerly MEN2A, MEN2B) proto-oncogene located on chromosomal band 10q11.21. Two distinct clinical forms have been described as the following phenotypes: multiple endocrine neoplasia type 2A (MEN 2A) and multiple endocrine neoplasia type 2B (MEN 2B) syndromes. The common and necessary nexus that defines these 2 phenotypes is the presence of medullary thyroid carcinoma (MTC). The familial MTC type of MEN 2 syndrome was included within the spectrum of MEN 2A syndrome. Cutaneous manifestations of MEN 2A syndrome include macular amyloidosis, whereas MEN 2B syndrome is traditionally linked to multiple mucosal neuromas. Objectives: To describe a family with cutaneous manifestations not previously described in patients with MEN 2A syndrome and to discuss the association of this disorder with Cowden syndrome. Design, Setting, and Participants: Clinicopathologic correlation of cutaneous lesions and genetic studies in 11 members of a family with familial MTC. Interventions: Cutaneous lesions were histopathologically and immunohistochemically studied. Genetic screening for a germline mutation at the RET gene was performed in 11 family members. Main Outcomes and Measures: Identification of cutaneous lesions not previously described in patients with MEN 2A syndrome. Results: This family of 11 individuals with familial MTC type of MEN 2A syndrome demonstrated the moderate risk RET p.Val804Met (protein valine at residue 804 replaced by methionine) genetic mutation, with 2 of the relatives presenting with dermal hyperneury, cutaneous lesions classically described in MEN 2B syndrome, and 1 relative also showing multiple sclerotic fibromas, a cutaneous manifestation of PTEN (phosphatase and tensin homologue) hamartoma-tumor syndrome. Conclusions and Relevance: Dermal hyperneury and multiple sclerotic fibromas should be added to the list of cutaneous manifestations of patients with the familial MTC type of MEN 2A syndrome.

Carcinoma hemorrhagiectoides: case report of an uncommon presentation of cutaneous metastatic breast carcinoma.

In most cases, cutaneous metastases develop after the diagnosis of the primary internal malignancy has been established, but sometimes they can be discovered earlier or simultaneously. We describe a case of a 90-year-old woman who presented to the emergency room in poor general condition, with cutaneous lesions characterized by hot, infiltrated, violaceous and erythematous plaques involving the left chest wall. The clinical and histopathological findings were consistent with the recently described variant of inflammatory cutaneous metastatic carcinoma named carcinoma hemorrhagiectoides. Microscopic examination demonstrated extensive infiltration of the dermis by tumor cells as well as intralymphatic involvement by neoplastic cells. This is a very rare presentation of cutaneous metastasis from breast cancer.

Genital folliculo-sebaceous cystic hamartoma: A claim of the stroma as a clue in the diagnosis of proliferations with follicular differentiation.

Folliculo-sebaceous hamartomas comprise a series of entities whose boundaries are imprecise. We present the clinical case of a folliculo-sebaceous cystic hamartoma of genital localization where the diagnosis was established based on the epithelial proliferation, but mostly, on the characteristic stroma. Because this lesion lacked of the cystic component, we mention the most frequent differential diagnoses and review the literature of the few cases published on this infrequent localization.