Navigating HER2-Low Testing in Invasive Breast Cancer: Update Recommendations for Pathologists.

The article discusses the importance of accurately distinguishing HER2-low from HER2-negative breast cancer, as novel ADCs have demonstrated activity in a large population of patients with HER2-low-expressing BC. While current guidelines recommend a dichotomous classification of HER2 as either positive or negative, the emergence of the HER2-low concept calls for standardization of HER2 testing in breast cancer, using currently available assays to better discriminate HER2 levels. This review covers the evolution and latest updates of the ASCO/CAP guidelines relevant to this important biomarker in breast cancer, including still-evolving concepts such as HER2 low, HER2 heterogeneity, and HER2 evolution. Our group presents the latest Mexican recommendations for HER2 status evaluation in breast cancer, considering the ASCO/CAP guidelines and introducing the HER2-low concept. In the era of personalized medicine, accurate HER2 status assessment remains one of the most important biomarkers in breast cancer, and the commitment of Mexican pathologists to theragnostic biomarker quality is crucial for providing the most efficient care in oncology.

"Where have you been in this world?" a qualitative study of clients' curiosity about their psychotherapists.

Curiosity is widely seen as a basic human drive, important to the development of relationships as well as to the process of change in psychotherapy. Less attention, however, has been directed toward examining curiosity in the client-therapist relationship. In particular, we lack a comprehensive understanding of what occurs for clients when they become curious about their therapists. As a result, we aimed to explore clients' experiences of curiosity about their therapists. Using a consensual qualitative research approach, we analyzed data from ten current and former adult psychotherapy clients. Results were organized in six domains that captured different facets of participants' experiences of curiosity about their therapists: the content of the curiosity, motivation(s) for the curiosity, triggers of the curiosity, expressions of curiosity, influences on the curiosity, and consequences of the curiosity. More specifically, results revealed participants experienced curiosity that (a) concerned the therapist's professional and personal life, (b) was motivated by concerns over the therapist's ability to understand or relate, and (c) was triggered by therapist behavior (e.g., disclosures). For some participants, having a positive therapeutic relationship led to greater curiosity; by the same token, participants' desire for professional boundaries at times quelled this curiosity. Moreover, although some participants described positive relational outcomes, others disclosed feelings of shame or discomfort resulting from their curiosity. Several cultural factors were also found to influence participants' curiosity. Implications for research and practice are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

High expression of both desmoplastic stroma and epithelial to mesenchymal transition markers associate with shorter survival in pancreatic ductal adenocarcinoma.

Desmoplastic stroma (DS) and the epithelial-to-mesenchymal transition (EMT) play a key role in pancreatic ductal adenocarcinoma (PDAC) progression. To date, however, the combined expression of DS and EMT markers, and their association with variations in survival within each clinical stage and degree of tumor differentiation is unknown. The purpose of this study was to investigate the association between expression of DS and EMT markers and survival variability in patients diagnosed with PDAC. We examined the expression levels of DS markers alpha smooth muscle actin (α-SMA), fibronectin, and vimentin, and the EMT markers epithelial cell adhesion molecule (EPCAM), pan-cytokeratin, and vimentin, by immunohistochemistry using a tissue microarray of a retrospective cohort of 25 patients with PDAC. The results were examined for association with survival by clinical stage and by degree of tumor differentiation. High DS markers expression -α-SMA, fibronectin, and vimentin- was associated with decreased survival at intermediate and advanced clinical stages (p=0.006-0.03), as well as with both poorly and moderately differentiated tumor grades (p=0.01-0.02). Interestingly, the same pattern was observed for EMT markers, i.e., EPCAM, pan-cytokeratin, and vimentin (p=0.00008-0.03). High expression of DS and EMT markers within each clinical stage and degree of tumor differentiation was associated with lower PDAC survival. Evaluation of these markers may have a prognostic impact on survival time variation in patients with PDAC.

Giant liver teratoma with gliosis peritonei treated by right extended hepatectomy: Overview and case report.

Germ cell tumors (GCTs) are considered as extragonadal if there is no evidence of a primary tumor in the testes or ovaries. GCTs can be classified as seminomas, non-seminomatous, mature teratomas, and immature teratomas based upon histology. Mature teratomas are generally found in prepuberal children. Less than 1% of them have been reported in the gastrointestinal tract and liver. Liver teratomas are extremely rare. There are only 11 cases reported in adults up to 2018. Isolated liver metastasis of ovarian teratoma is also very rare. We present a case of a late metachronous recurrence of liver cystic teratoma with gliosis peritonei in a female adult treated by a right extended hepatectomy along with a literature review.

Propuesta didáctica de una innovación educativa con las nuevas tecnologías en las Ciencias Básicas Biomédicas / Didactic proposal on educative innovation with the new technologies in Basic Biomedical Sciences

RESUMEN Fundamento: Los cambios tecnológicos impulsan nuevas opciones para la educación universitaria, lo cual posibilita la creación de entornos virtuales de aprendizaje, centrados en el estudiante, con la participación del docente como un facilitador del proceso. Objetivo: Diseñar una propuesta didáctica de innovación educativa con las tecnologías de la informática y las comunicaciones, para la simulación de una práctica de laboratorio de la asignatura Metabolismo-Nutrición, correspondiente a la disciplina Bases Biológicas de la Medicina. Metodología: Se realizó una investigación descriptiva-cualitativa, en los meses de mayo a junio del 2020. Se utilizaron los métodos: histórico-lógico, analítico-sintético e inductivo-deductivo. Se empleó: la revisión de documentos, la observación y la tormenta de ideas. Se tomó como población los docentes del Departamento de Ciencias Básicas Biomédicas, Facultad de Ciencias Médicas "Salvador Allende" de la Universidad de Ciencias Médicas de La Habana. Resultados: La innovación educativa se propuso para la simulación de una prueba de tolerancia oral a la glucosa, y consideró las necesidades formativas de los estudiantes y las competencias a desarrollar. Conclusiones: Se diseñó una propuesta didáctica de innovación educativa que emplea las potencialidades de la plataforma Moodle para la gestión de espacios de aprendizaje en línea. Las nuevas tecnologías constituyen una alternativa para la continuidad del proceso de enseñanza-aprendizaje en la presente situación de pandemia.

ABSTRACT Background: Technological changes boost new possibilities for university education, it makes possible the creation of e-learning contexts, centered on the student, with the participation of the teacher as the process's facilitator. Objective: To design a didactic proposal of educative innovation with information and communication technologies, for the simulation of a laboratory practice of the Nutrition- Metabolism subject, corresponding to the Biological Basis of Medicine discipline. Methodology: A qualitative-descriptive research was conducted from May to June 2020. The historical-logical, analytical-synthetic and inductive-deductive methods were used. Also document review, observation and brainstorm. The population was the teachers from the Basic Biomedical Sciences Department, at the Havana University of Medical Sciences, "Salvador Allende" Faculty Results: Educative innovation was proposed for the simulation of an oral glucose tolerance test, and considered the students' formative needs also the competences to be developed. Conclusions: A didactic proposal of educative innovation was designed using the potentialities of the Moodle platform for the management in the e-learning contexts. New technologies constitute an alternative for the continuity of the teaching-learning process at the present pandemic situation.

A Novel, Likely Pathogenic MAX Germline Variant in a Patient With Unilateral Pheochromocytoma.

CONTEXT: Inherited MYC-associated factor X (MAX) gene pathogenic variants (PVs) increase risk for pheochromocytomas (PCCs) and/or paragangliomas (PGLs) in adults and children. There is little clinical experience with such mutations. OBJECTIVE: This report highlights an important approach. METHODS: Clinical assessment, including blood chemistry, imaging studies, and genetic testing were performed. RESULTS: A 38-year-old Hispanic woman was diagnosed with PCC in 2015, treated with adrenalectomy, and referred to endocrinology clinic. Notably, she presented to her primary care physician 3 years earlier complaining of left flank pain, intermittent diaphoresis, and holocranial severe headache. We confirmed severe hypertension (180/100 mm Hg) over multiple antihypertensive regimens. Biochemical and radiological studies workup revealed high plasma metanephrine of 255 pg/mL (normal range, < 65 pg/mL) and plasma normetanephrine of 240 pg/mL (normal range, < 196 pg/mL). A noncontrast computed tomography scan of the abdomen revealed a 4.2 × 4.3 × 4.9-cm, round-shaped and heterogenous contrast enhancement of the left adrenal gland, and a 2-mm nonobstructive left kidney stone. A presumptive diagnosis of secondary hypertension was made. After pharmacological therapy, laparoscopic left adrenalectomy was performed and confirmed the diagnosis of pheochromocytoma. Based on her age, family history, and a high suspicion for genetic etiology, genetic testing was performed that revealed the presence of a novel likely pathogenic variant involving a splice consensus sequence in the MAX gene, designated c0.64-2A > G. CONCLUSION: The phenotype of MAX PV-related disease and paraganglioma are highlighted. The novel c0.64-2A > G mutation is reported here and should be considered in the diagnostic workup of similar cases.

Diseño de un programa para el automanejo en diabetes de personas mayores independientes y su familia mediante Intervention mapping, etapa 1 / Diabetes Self-Management Program Design for aged and their family through Intervetion maping, stage 1

Introducción: el automanejo en diabetes de personas mayores en México ha sido abordado de forma inadecuada con intervenciones centradas en el paciente, olvidando aquellas centradas en prevención, la atención primaria a la salud, y en conjunto con su familia, por lo que el Intervention mapping ofrece una propuesta integral. Objetivo: realizar el diagnostico comunitario de las personas mayores con diabetes y sus familias que habitan en la comunidad de San Luis Tlaxialtemalco en Xochimilco para el diseño de un programa de automanejo en diabetes, mediante Intervention mapping. Método: cuantitativo, descriptivo, exploratorio con una fase cualitativa, mediante el análisis de narrativas. Resultados: las características socioculturales de la comunidad, la identificación de los actores claves y las prácticas de cuidado que, aunque a primera vista parecieran ajenas al automanejo en diabetes de las personas mayores, son claves para poder realizar un trabajo de acompañamiento por parte de enfermería. Conclusiones: El diagnostico comunitario proporciono la base para el diseño del programa con intervenciones multinivel, además de mostrar los beneficios potenciales de aplicar el análisis de los determinantes socioculturales con participación de la comunidad dentro de la formación de enfermería, para construir programas orientados a la interdisciplinariedad e investigación en prevención de enfermedades crónicas.

Introduction: The Diabetes mellitus 2 Self-Management the aged in Mexico has been inadequately addressed with interventions focused on the patient, forgetting those focused on prevention, primary health care and in conjunction with the family, so the intervention mapping offers a comprehensive proposal. Objective: to carry out a community diagnosis of aged with diabetes and their families living in the community of San Luis Tlaxialtemalco in Xochimilco for the design of a diabetes self-management program through intervention mapping. Method: quantitative, descriptive, exploratory with a qualitative phase, through the analysis of narratives. Results: sociocultural characteristics of the community, identification of key actors and care practices that, although at first glance seem alien to diabetes self-management, are key to be able to carry out an accompanying work by nursing. Conclusions: The community diagnosis provided the basis for the design of the program with multilevel interventions, in addition to showing the potential benefits of applying the analysis of sociocultural determinants with community participation within nursing education, to build programs oriented to interdisciplinarity and research in chronic disease prevention.

A New bis(rhodamine)-Based Colorimetric Chemosensor for Cu2.

A novel sensor (RD) bearing rhodamine B and 4-tert-Butyl phenol unit have been designed and synthesized using microwave irradiation. The sensor allows selective detection of Cu2+ by forming absorptive complex and trigger the formation of highly colored ring-open spirolactam. The recognition ability of the sensor was investigated by absorbance, Job's plot, infrared (IR) and time dependent-density functional theory (TD-DFT) calculations.

ACROMEGALY AND A GIANT RETROPERITONEAL LIPOSARCOMA PRODUCING IGF-1.

OBJECTIVE: Liposarcoma is the most common histotype of retroperitoneal sarcomas, representing up to 45% of all cases. We report a rare combination of acromegaly and liposarcoma in the same individual. METHODS: Laboratory and imaging studies including an oral glucose tolerance test, measurements of growth hormone (GH) and insulin-like growth factor-1 (IGF-1), and a computed tomography scan were performed. RESULTS: The patient was a 60-year-old male with a history of acromegaly diagnosed on the basis of elevated IGF-1 at 1,373 ng/mL (age-appropriate reference range is 87 to 225 ng/mL) and macroadenoma treated with transsphenoidal surgery. He presented 8 years later with a history of abdominal distension and weight loss. Physical examination was notable for a right-sided abdominal mass that was tense and non-fluctuant. Two years earlier, he had a post oral glucose tolerance test GH level <0.25 ng/mL and IGF-1 level of 256 ng/mL (age-appropriate reference range is 55 to 206 ng/mL). Pituitary magnetic resonance imaging reported a 3.7 × 2.0-mm left-sided parasagittal lesion. Computed tomography scan showed a 25.0 × 22.0 × 32.3-cm heterogeneous giant mass in the right abdomen corresponding to a liposarcoma causing displacement of kidney, liver, and bowel loops. The patient was treated with a complete en bloc resection of the liposarcoma with the right kidney (45 × 33 × 17 cm) and tumor (9,400 g). Immunohistochemical examination revealed positive IGF-1 and GH staining. The patient suffered postoperative gastrointestinal bleeding that resulted in hemorrhagic shock and died on the 29th postoperative day after a cardiorespiratory arrest. CONCLUSION: Acromegalic patients are at increased risk of developing various types of neoplasms. This is the first documented coexistence of liposarcoma and history of acromegaly.

An Unusual Simultaneous Existence of Parathyroid Carcinoma and Papillary Thyroid Carcinoma: Case Report and Review of Literature.

Synchronous parathyroid and papillary thyroid carcinoma are extremely rare. To our knowledge, only 15 cases have been reported in the last four decades. We describe a 50-year-old female without significant past medical or family history and no previous trauma presented with left heel pain that prompted her to seek medical attention. Physical examination was notable for a painless nodule at the left thyroid lobe. Laboratory evaluation showed a serum calcium level of 14.3 mg/dL (8.6-10.3 mg/dL) and intact parathyroid hormone level of 1160 pg/mL (12-88 pg/mL). 99Tc-sestamibi dual-phase with single-photon emission computed tomography fused images showed increased uptake at the left-sided inferior parathyroid gland. Neck ultrasound showed a 1.4 cm heterogeneous nodule in the middle-third of the left thyroid gland and a solitary 1.9 cm vascularized and hypoechoic oval nodule that was considered likely to represent a parathyroid adenoma. Due to its clinical context (severe hypercalcemia and very high levels of PTH), parathyroid carcinoma (PC) was suspected although imaging studies were not characteristic. The patient underwent en bloc resection of the parathyroid mass and left thyroid lobe and central neck compartment dissection. Pathology analysis revealed classical papillary thyroid carcinoma of classical subtype and parathyroid carcinoma. Immunohistochemical staining was positive for cyclidin D1 and negative for parafibromin. High clinical suspicion is required for parathyroid carcinoma diagnosis in the presence of very high level of parathyroid hormone, marked hypercalcemia, and the existence of any thyroid nodule should be approached and the coexistence of other carcinomas should be considered.

Development and initial validation of the Therapist Cultural Comfort Scale.

The development and initial validation of a client-rated measure of therapist cultural comfort (the Therapist Cultural Comfort Scale [TCCS]) is reported. The first phase of the study involved content validation of the initial pool of items via consultation with (a) focus groups of doctoral student therapists and (b) experts in the field of multicultural counseling and psychotherapy. A 56-item pool generated during this phase, together with instruments used to gauge convergent and incremental validity, were administered to a community adult sample of current psychotherapy clients (N = 889). Exploratory factor analysis suggested 2 subscales representing negative and positive indicators of therapist cultural comfort. Item response theory principles guided final selection of subscale items. Analyses suggested good factor stability and reliability of the 13-item TCCS as well as strong measurement invariance across racial/ethnic minority status and gender. Total and subscale scores related as expected with other measures of multicultural constructs (cultural humility, missed cultural opportunities, and multicultural competencies). Generally, TCCS total and subscale scores also predicted working alliance and treatment progress above and beyond the effects of therapist general comfort. There were few differences in clients' perceptions of therapist cultural comfort based on client demographic characteristics. Implications for research and practice are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Control adecuado de la presión arterial en adultos con medicación antihipertensiva de dos Unidades de Salud Familiar de Luque y Fernando de la Mora, Paraguay, 2018

RESUMEN Introducción: la reducción de la presión arterial es una meta en el tratamiento de la hipertensión arterial primaria. Objetivos: determinar la frecuencia de control adecuado de la hipertensión arterial en adultos en tratamiento antihipertensivo de las Unidades de Salud Familiar de Luque y Fernando de la Mora, Paraguay. Metodología: estudio observacional, transversal, prospectivo, con componentes analíticos realizado en pacientes adultos hipertensos tratados en dos Unidades de Salud Familiar durante agosto y septiembre 2018. Se evaluaron variables sociodemográficas y clínicas. Se consideró presión arterial adecuada a todo valor <140/90 mm Hg. Resultados: se incluyeron 149 sujetos, con edad media 60±12 años, 68% del sexo femenino, 42% con sobrepeso-obesidad, 32% eran portadores de diabetes mellitus. Todos recibían tratamiento farmacológico antihipertensivo. El control adecuado de la hipertensión arterial se observó en 55%. Conclusiones: el control adecuado de la hipertensión arterial en pacientes adultos de dos Unidades de Salud Familiar fue 55%. Los antihipertensivos más usados fueron los inhibidores de enzima convertidora de angiotensina y los antagonistas de los receptores de angiotensina II.

ABSTRACT Introduction: The reduction of blood pressure is a goal in the treatment of primary arterial hypertension. Objectives: To determine the frequency of adequate control of arterial hypertension in adults under antihypertensive treatment at the Family Health Units of Luque and Fernando de la Mora, Paraguay. Methodology: Observational, cross-sectional, prospective study with analytical components performed in adult hypertensive patients treated in two Family Health Units during August and September 2018. Sociodemographic and clinical variables were evaluated. Adequate blood pressure was considered at any value <140/90 mm Hg. Results: One hundred forty nine subjects were included, with a average age of 60±12 years, 68% were women, 42% with overweight-obesity, and 32% were carriers of diabetes mellitus. All were receiving antihypertensive drug treatment. Adequate control of arterial hypertension was observed in 55%. Conclusions: The adequate control of hypertension in adult patients of two Family Health Units was 55%. The most commonly used antihypertensives were angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists.

Helicobacter pylori elicits B7H3 expression on gastric epithelial cells: Implications in local T cell regulation and subset development during infection.

Helicobacter pylori (H. pylori) is a gram negative bacterium that infects more than 50% of humanity and is associated with gastritis, peptic ulcer and gastric cancer. Although CD4+ T cells are recruited to the gastric mucosa, the host is unable to clear the bacteria. Previously, we demonstrated that H. pylori infection upregulates the expression of the T cell co-inhibitory molecule B7-H1 while simultaneously downregulating the expression of T cell co-stimulatory molecule B7-H2 on gastric epithelial cells (GEC), which together affect the Treg and Th17 cell balance and foster bacterial persistence. Because B7-H3, another member of the B7 family of co-inhibitory receptors, has been found to have important immunoregulatory roles and in cancer, in this study we examined the expression of B7-H3 molecules on GEC and how the expression is regulated by H. pylori during infection. Our study showed that both human and murine GEC constitutively express B7-H3 molecules, but their expression levels increased during H. pylori infection. We further demonstrated that H. pylori uses its type 4 secretion system (T4SS) components CagA and cell wall peptidoglycan (PG) fragment to upregulate B7-H3. Th17 cells and Treg cells which are increased during H. pylori infection also had an effect on B7-H3 induction. The underlying cell signaling pathway involves modulation of p38MAPK pathway. Since B7-H3 were shown to up-regulate Th2 responses, the phenotype of T cell subpopulations in mice infected with H. pylori PMSS1 or SS1 strains were characterized. A mixed Th1/Th2 response in H. pylori infected mice was observed. Consistent with previous findings, increased Treg cells and decreased Th17 cells in MLN of PMSS1 infected mice compared to SS1 infected mice was observed. Human biopsy samples collected from gastritis biopsies and gastric tumors showed a strong association between increased B7-H3 and Th2 responses in H. pylori strains associated with gastritis. T cell: GEC co-cultures and anti-B7-H3 blocking Ab confirmed that the induction of Th2 is mediated by B7-H3 and associated exclusively with an H. pylori gastritis strain not cancer or ulcer strains. In conclusion, these studies revealed a novel regulatory mechanism employed by H. pylori to influence the type of T cell response that develops within the infected gastric mucosa.

Immunotolerant p50/NFκB Signaling and Attenuated Hepatic IFNß Expression Increases Neonatal Sensitivity to Endotoxemia.

Sepsis is a major cause of neonatal morbidity and mortality. The current paradigm suggests that neonatal susceptibility to infection is explained by an innate immune response that is functionally immature. Recent studies in adults have questioned a therapeutic role for IFNß in sepsis; however, the role of IFNß in mediating neonatal sensitivity to sepsis is unknown. We evaluated the transcriptional regulation and expression of IFNß in early neonatal (P0) and adult murine models of endotoxemia (IP LPS, 5 mg/kg). We found that hepatic, pulmonary, and serum IFNß expression was significantly attenuated in endotoxemic neonates when compared to similarly exposed adults. Furthermore, endotoxemia induced hepatic p65/NFκB and IRF3 activation exclusively in adults. In contrast, endotoxemia induced immunotolerant p50/NFκB signaling in neonatal mice without evidence of IRF3 activation. Consistent with impaired IFNß expression and attenuated circulating serum levels, neonatal pulmonary STAT1 signaling and target gene expression was significantly lower than adult levels. Using multiple in vivo approaches, the source of hepatic IFNß expression in endotoxemic adult mice was determined to be the hepatic macrophage, and experiments in RAW 264.7 cells confirmed that LPS-induced IFNß expression was NFκB dependent. Finally, treating neonatal mice with IFNß 2 h after endotoxemia stimulated pulmonary STAT1 signaling and STAT1 dependent gene expression. Furthermore, IFNß treatment of endotoxemic neonatal animals resulted in significantly improved survival following exposure to lethal endotoxemia. In conclusion, endotoxemia induced IFNß expression is attenuated in the early neonatal period, secondary to impaired NFκB-p65/IRF3 signaling. Pre-treatment with IFNß decreases neonatal sensitivity to endotoxemia. These results support further study of the role of impaired IFNß expression and neonatal sensitivity to sepsis.

Immune evasion strategies used by Helicobacter pylori.

Helicobacter pylori (H. pylori) is perhaps the most ubiquitous and successful human pathogen, since it colonizes the stomach of more than half of humankind. Infection with this bacterium is commonly acquired during childhood. Once infected, people carry the bacteria for decades or even for life, if not treated. Persistent infection with this pathogen causes gastritis, peptic ulcer disease and is also strongly associated with the development of gastric cancer. Despite induction of innate and adaptive immune responses in the infected individual, the host is unable to clear the bacteria. One widely accepted hallmark of H. pylori is that it successfully and stealthily evades host defense mechanisms. Though the gastric mucosa is well protected against infection, H. pylori is able to reside under the mucus, attach to gastric epithelial cells and cause persistent infection by evading immune responses mediated by host. In this review, we discuss how H. pylori avoids innate and acquired immune response elements, uses gastric epithelial cells as mediators to manipulate host T cell responses and uses virulence factors to avoid adaptive immune responses by T cells to establish a persistent infection. We also discuss in this review how the genetic diversity of this pathogen helps for its survival.

Effect of Helicobacter pylori on gastric epithelial cells.

The gastrointestinal epithelium has cells with features that make them a powerful line of defense in innate mucosal immunity. Features that allow gastrointestinal epithelial cells to contribute in innate defense include cell barrier integrity, cell turnover, autophagy, and innate immune responses. Helicobacter pylori (H. pylori) is a spiral shape gram negative bacterium that selectively colonizes the gastric epithelium of more than half of the world's population. The infection invariably becomes persistent due to highly specialized mechanisms that facilitate H. pylori's avoidance of this initial line of host defense as well as adaptive immune mechanisms. The host response is thus unsuccessful in clearing the infection and as a result becomes established as a persistent infection promoting chronic inflammation. In some individuals the associated inflammation contributes to ulcerogenesis or neoplasia. H. pylori has an array of different strategies to interact intimately with epithelial cells and manipulate their cellular processes and functions. Among the multiple aspects that H. pylori affects in gastric epithelial cells are their distribution of epithelial junctions, DNA damage, apoptosis, proliferation, stimulation of cytokine production, and cell transformation. Some of these processes are initiated as a result of the activation of signaling mechanisms activated on binding of H. pylori to cell surface receptors or via soluble virulence factors that gain access to the epithelium. The multiple responses by the epithelium to the infection contribute to pathogenesis associated with H. pylori.

Spindle epithelial tumor with thymus-like differentiation of the thyroid (SETTLE): Report of two cases (one associated with a parathyroid adenoma).

Spindle epithelial tumor with thymus-like differentiation (SETTLE) is a rare tumor usually localized in the thyroid gland and perithyroid tissues. It is considered to arise from ectopic thymic tissue or branchial pouch remnants. It occurs more frequently in children and adolescents. We report 2 cases of spindle epithelial tumor with thymus-like differentiation localized in the thyroid gland, and 1 of them was associated with a parathyroid adenoma. We emphasize the need for a close and long-term follow-up in these patients.

Mortality and guideline-concordant care for older patients with schizophrenia: a retrospective longitudinal study.

BACKGROUND: Schizophrenia is associated with excess mortality and multimorbidity, which is possibly associated with difficulty in coordinating care for multiple mental and physical comorbidities. We analyzed the receipt by patients with schizophrenia of 11 types of guideline-concordant care and the association of such care with survival. METHODS: Guideline-concordant care over an 8-year period (financial years 2002 to 2009) was examined in a nationwide sample of 49,173 male veterans with schizophrenia, who were aged 50 years or older. Administrative databases from the electronic medical record system of the Veterans Health Administration (VA) provided comprehensive measures of patient demographics and medical information. Relying on the 2004 American Psychiatric Association guidelines, patterns in 11 types of care were identified and cluster-analyzed. Care types included cardiovascular, metabolic, weight management, nicotine dependence, infectious diseases, vision, and mental health counseling (individual, family, drugs/alcohol, psychiatric medication, and compensated work therapy). Survival analysis estimated association of care patterns with survival, adjusting for clinical and demographic covariates. RESULTS: There was an average of four chronic diseases in addition to schizophrenia in the cohort, notably hypertension (43%) and dyslipidemia (29%). Three longitudinal trajectories (clusters) were identified: 'high-consistent' (averaging 5.4 types of care annually), 'moderate-consistent' (averaging 3.8), and 'poor-decreasing' (averaging 1.9). Most veterans were receiving cardiovascular care (67 to 76%), hepatic and renal function assays (79 to 84%), individual counseling (72 to 85%) and psychiatry consults (66 to 82%), with the proportion receiving care varying by cluster group. After adjustment for age, baseline comorbidity, and other covariates, there was a greater survival rate for those with poor-decreasing care compared with high-consistent care, and for high-consistent compared with moderate-consistent care. CONCLUSIONS: Relatively low levels of guideline-concordant care were seen for older VA patients with schizophrenia, and trajectories of care over time were associated with survival in a non-intuitive pattern. The group with the lowest and decreasing levels of care was also the oldest, but nonetheless had the best age-adjusted and other covariate-adjusted survival rates, possibly because they were requiring less care relative to younger, sicker veterans, and thus their comorbidity burden was markedly lower. Notably, in the group with the sickest individuals (that is those with the highest comorbidity scores, who were very disabled), receiving guideline-concordant care was associated with improved survival in adjusted models compared with those patients receiving only moderate levels of care.