Fluorescent In Situ Hybridization (FISH).

In situ hybridization (ISH) is a technique that uses nucleic acid probes to allow for visualization of nucleic acid sequences in cellular/tissue preparations. Both enzymatic and fluorescent ISH studies can be used as adjunct studies, and in some cases are vital to making specific diagnoses. This chapter will focus on fluorescent in situ hybridization.

Efficacy, Effectiveness, Safety, and Cost-effectiveness of Epidural Adhesiolysis for Treating Failed Back Surgery Syndrome. A Systematic Review.

BACKGROUND: Failed back surgery syndrome (FBSS) has a profound impact on patients' quality of life and represents a major clinical challenge and a significant economic burden for society. Adhesiolysis is used as a treatment to eliminate perineural/epidural adhesions in patients with chronic pain attributed to FBSS. OBJECTIVE: To evaluate the efficacy, effectiveness, safety, and cost-effectiveness of epidural adhesiolysis compared with other procedures for treating FBSS. METHOD: A systematic review was conducted. The electronic databases Medline/PreMedline, EMBASE, Cochrane Library Plus, Centre for Reviews and Dissemination databases, SCOPUS, Science Citation Index, and PEDRO were consulted through April 2017. Predefined criteria were used to determine inclusion of the studies and to assess their methodological quality. RESULTS: Ten reports were included. No randomized controlled trials (RCTs) on efficacy or cost-effectiveness were found. Three reports (corresponding to two RCTs, N = 212) suggested that adhesiolysis was effective, especially for pain and disability. However, both studies presented serious methodological flaws. In addition to RCTs, seven observational studies with high risk of bias reported data on effectiveness and safety. Fifty-eight adverse events were reported among 130 patients undergoing endoscopic adhesiolysis, and 19 among the 110 undergoing percutaneous adhesiolysis. CONCLUSIONS: The evidence on the efficacy and cost-effectiveness of adhesiolysis for treating FBSS is nonexistent, whereas evidence on its effectiveness and safety is insufficient. Incorporating data from observational studies did not improve the quality of the evidence on effectiveness.

Late breast cancer recurrence with bone marrow metastases and acute pulmonary hypertension.

Bone marrow is one of the most common sites of metastasis from breast cancer. Micrometastases to the bone marrow usually evade the systemic therapies used for the treatment of cancer and eventually lead to relapse later in the course of the illness. We report here a unique case of parallel progression of these bone marrow metastases in a patient with breast cancer who had a relapse a few years after treatment of her primary breast cancer, and she presented with diffuse marrow involvement and pulmonary hypertension without any definitive metastases elsewhere.

An unusual presentation of chronic lymphocytic leukemia.

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a B-cell lymphocytic neoplasm with indolent clinical course. If identified early, observation is opted. Many variables lead to the initiation of treatment. Authors describe a 62-year-old male presenting with shortness of breath and found to have white cell count of 1360 × 109/L and subsequently was diagnosed with CLL/SLL. The patient received leukapheresis along with tumor lysis treatment and systemic chemotherapy with fludarabine, cyclophosphamide, and rituximab regimen. His course was complicated with deep venous thrombosis, extensive cutaneous, and sinus mucosa involvement by CLL/SLL. The patient clinically improved and on follow-up clinic visits documented normalization of his white cell counts. The case report brings up a rare presentation of CLL/SLL with such an extreme high white cell count, leukostasis symptoms and extramedullary involvement of disease and encourages providers to be vigilant of rare presentation of CLL/SLL.

Effectiveness of a decision aid for patients with depression: A randomized controlled trial.

BACKGROUND: Shared decision making is an important component of patient-centred care and decision aids are tools designed to support patients' decision making and help patients with depression to make informed choices. OBJECTIVE: The study aim was to assess the effectiveness of a web-based decision aid for patients with unipolar depression. DESIGN: Randomized controlled trial. SETTING AND PARTICIPANTS: Adults diagnosed with a major depressive disorder and recruited in primary care centres were included and randomized to the decision aid (n=68) or usual care (n=79). INTERVENTION: Patients in the decision aid group reviewed the decision aid accompanied by a researcher. OUTCOME MEASURES: Knowledge about treatment options, decisional conflict, treatment intention and preference for participation in decision making. We also developed a pilot measure of concordance between patients' goals and concerns about treatment options and their treatment intention. RESULTS: Intervention significantly improved knowledge (P<.001) and decisional conflict (P<.001), and no differences were observed in treatment intention, preferences for participation, or concordance. One of the scales developed to measure goals and concerns showed validity issues. CONCLUSION: The decision aid "Decision making in depression" is effective improving knowledge of treatment options and reducing decisional conflict of patients with unipolar depression. More research is needed to establish a valid and reliable measure of concordance between patients' goals and concerns regarding pharmacological and psychological treatment, and the choice made.

Effect of the statin choice encounter decision aid in Spanish patients with type 2 diabetes: A randomized trial.

OBJECTIVE: Statin choice, an encounter decision aid (DA), was developed in the USA to facilitate shared decision making between patients and clinicians about the use of statins to reduce cardiovascular risk. We aimed to assess the efficacy of this DA, compared to usual primary care, in Spanish patients with type 2 diabetes. METHODS: Cluster randomized trial with 29 clinicians and 168 patients. Knowledge of statins, cardiovascular risk perception, decisional conflict, anxiety and satisfaction with the decision making process were assessed immediately after intervention, and self-reported adherence at three months. RESULTS: Intervention significantly improved knowledge (p=0.01), perception of the 10-year risk of myocardial infarction without (p=0.01) and with statins (p=0.08), and satisfaction (p=0.01). There were no significant differences in decisional conflict, anxiety, consultation time or adherence, although more intervention patients reported taking all pills during the last week (92.7% vs. 81%; p=0.19). CONCLUSION: The statin choice DA improved the quality of decision making about statins. PRACTICE IMPLICATIONS: This trial contributes to the body of evidence substantiating the efficacy of statin choice and extending it to Spanish clinicians and their patients with type 2 diabetes. TRIAL REGISTRATION: This trial is registered with the European Union Clinical Trials Register (EudraCT: 2010-023912-14).

Patient participation in a Clinical Guideline Development for Systemic Lupus Erythematosus.

OBJECTIVE: To incorporate patients' perspective in the design of a clinical practice guideline (CPG) for Systemic Lupus Erythematosus in Spain. METHODS: A systematic review (SR) of literature and a Delphi-based consultation to patients were carried out. RESULTS: From the SR, most relevant health problems are classified as physical, psychological, familial, and socio-economic. Dissatisfaction is mainly due to unmet information needs and limited access to care. In the consultation (n=102), most frequently reported health problems were pain, fatigue, photosensitivity, mood disorders, renal damage, poor concentration, and memory loss. Dissatisfaction with poor coordination between primary and specialized care was reported. Information to improve self-management and on alternative therapies was requested. Relevant topics from both sources were merged and discussed by the guideline development group (including a patient representative) to set the key questions underpinning the CPG. CONCLUSION: Patient involvement in CPG development by a combination of methods can enhance patient-centered care by achieving clinical practice responsive to their needs. PRACTICE IMPLICATIONS: Involving patients in CPG development is feasible and useful to improve the advance of Health Services toward patient-centered care. A multicomponent strategy for involvement is suggested to address the gap between the available evidence and contextual current patient needs and preferences.

The utility of B-cell receptor gene rearrangement studies in diagnosing diffuse large B-cell lymphoma with plasmacytic differentiation.

We present the case of a 50-year-old man with nodal diffuse large B-cell lymphoma characterized by CD10, BCL-6, and BCL-2 expression and a complex karyotype, including t(14;18)(q32;q21) and del6q, suggesting transformation from an antecedent follicular lymphoma. Following rituximab-based chemotherapy, residual nodal disease was characterized by a proliferation of plasmacytoid cells positive for CD138, MUM-1, and cytoplasmic kappa light chain. Immunoglobulin heavy chain and kappa light chain gene rearrangement studies detected the same clone in the diagnostic and post-therapy lymph node specimens. This case illustrates the diagnostic utility of B-cell receptor gene rearrangement studies in detecting a clonal relationship in lymphoma cases with extensive morphologic and immunophenotypic variation following chemotherapy.

First reported case of Ehrlichia ewingii involving human bone marrow.

A 65-year-old female with a history of multiple tick bites presented with fever and pancytopenia. Intracytoplasmic rickettsial morulae were detected on peripheral smear and bone marrow biopsy specimens, and PCR amplified Ehrlichia ewingii DNA from both specimens. To our knowledge, this is the first report of E. ewingii infection of human bone marrow.

En busca de una salud más participativa: compartiendo decisiones de salud / Looking for a more participative healthcare: sharing medical decision making

El modelo de atención en salud paternalista está derivando hacia modelos más participativos, como lo es la toma de decisiones compartidas (TDC), en el que se considera al paciente como agente responsable y autónomo. La TDC representa un enfoque terapéutico en el que profesionales y pacientes comparten la mejor evidencia científica disponible para tomar una decisión, incorporando los valores y preferencias del paciente. Este intercambio de información puede facilitarse mediante el uso de herramientas de ayuda para la TDC, que han demostrado ser efectivas para mejorar el conocimiento, la satisfacción del paciente, y reducir el conflicto decisional. En este sentido, las habilidades comunicacionales ejercen un rol fundamental en el establecimiento de la relación profesional - paciente, facilitando el intercambio de información y preferencias de manera efectiva y respetuosa. Esta aproximación terapéutica podría apoyar la reducción de las disparidades en salud que prevalecen en Latinoamérica, al facilitar que las personas puedan participar informada y activamente en el cuidado de su salud.

The healthcare model is shifting from a paternalistic towards a more inclusive and participative approach, such as shared decision making (SDM). SDM considers patients as autonomous and responsible agents. SDM is a therapeutic approach where healthcare providers and patients share the best evidence available to make a decision according to the values and preferences of the patient. Decision aids are tools that can facilitate this information exchange. These tools help patients to increase knowledge about options, reduce decisional conflict and improve satisfaction. Additionally, communication skills play a key role within the professional-patient relationship, as they facilitate sharing information and preferences in an effective and respectful manner. This therapeutic approach could support the reduction of health inequalities that affect Latin America, as it promotes an active and informed participation of patients in their healthcare process.

Sociodemographic and clinical predictors of compliance with antidepressants for depressive disorders: systematic review of observational studies.

BACKGROUND: The literature shows that compliance with antidepressant treatment is unsatisfactory. Several personal and disease-related variables have been shown to be related to compliance behavior. The objective of this study was to review the literature about sociodemographic and clinical predictors of compliance in patients with depressive disorders. METHODS: The Medline, Embase, Cochrane Central, PsycInfo, and Cinahl databases were searched until May 2012. Studies that analyzed sociodemographic and clinical predictors or correlates of compliance in patients with depressive disorder were included. A quantitative synthesis was not performed because of the heterogeneity and availability of the data reported. For similar reasons, the results were not classified according to the different phases of treatment. The search was limited to studies published in English and Spanish. RESULTS: Thirty-two studies fulfilled the inclusion criteria. The most consistent associations with compliance were found for age (older patients showed more compliance) and race (white patients were more likely to adhere to treatment than minority ethnic groups). Few studies assessed clinical factors, and the most plausible predictors of compliance were certain comorbidities and substance abuse. Severity of depression did not play an important role in predicting compliance. CONCLUSION: The impact of the variables studied on compliance behavior appeared to be inconsistent. Identifying potential predictors of compliance with antidepressant treatment is important, both for the routine practice of the mental health professional and for refining interventions to enhance adherence and target them to specific populations at risk of noncompliance.

[Promoting citizen participation in healthcare through PyDEsalud.com]. / Promoción de la participación ciudadana en cuidados de salud a través de PyDEsalud.com.

This project supports the initiative promoted by the Spanish National Health System to provide informational materials, in printed or interactive format, to encourage public participation in decision making and healthcare. We present the newly created PyDEsalud.com, a web platform aimed at people with chronic diseases with a high socioeconomic impact, such as breast cancer, depression, and diabetes. This platform uses scientific methodology and contains three information service modules (Patients' experiences, Shared decision making, and Research needs), aimed at promoting health education for patients and families.

[Looking for a more participative healthcare: sharing medical decision making]. / En busca de una salud más participativa: compartiendo decisiones de salud.

The healthcare model is shifting from a paternalistic towards a more inclusive and participative approach, such as shared decision making (SDM). SDM considers patients as autonomous and responsible agents. SDM is a therapeutic approach where healthcare providers and patients share the best evidence available to make a decision according to the values and preferences of the patient. Decision aids are tools that can facilitate this information exchange. These tools help patients to increase knowledge about options, reduce decisional conflict and improve satisfaction. Additionally, communication skills play a key role within the professional-patient relationship, as they facilitate sharing information and preferences in an effective and respectful manner. This therapeutic approach could support the reduction of health inequalities that affect Latin America, as it promotes an active and informed participation of patients in their healthcare process.

Attitudes toward concordance in psychiatry: a comparative, cross-sectional study of psychiatric patients and mental health professionals.

BACKGROUND: Concordance and Shared Decision-Making (SDM) are considered measures of the quality of care that improves communication, promotes patient participation, creates a positive relationship with the healthcare professional, and results in greater adherence with the treatment plan. METHODS: This study compares the attitudes of 225 mental health professionals (125 psychiatrists and 100 psychiatry registrars) and 449 psychiatric outpatients towards SDM and concordance in medicine taking by using the "Leeds Attitude toward Concordance Scale" (LATCon). RESULTS: The internal consistency of the scale was good in all three samples (Cronbach's α: patients = 0.82, psychiatrists = 0.76, and registrars = 0.82). Patients scored significantly lower (1.96 ± 0.48) than professionals (P < .001 in both cases), while no statistically significant differences between psychiatrists (2.32 ± 0.32) and registrars (2.23 ± 0.35) were registered; the three groups showed a positive attitude towards concordance in most indicators. Patients are clearly in favor of being informed and that their views and preferences be taken into account during the decision-making process, although they widely consider that the final decision must be the doctor's responsibility. Among mental health professionals, the broader experience provides a greater conviction of the importance of the patient's decision about treatment. CONCLUSIONS: We observed a positive attitude towards concordance in the field of psychotropic drugs prescription both in professionals and among patients, but further studies are needed to address the extent to which this apparently accepted model is reflected in the daily practice of mental health professionals.

Mental health professionals' attitudes to partnership in medicine taking: a validation study of the Leeds Attitude to Concordance Scale II.

PURPOSE: To explore psychiatrists' attitudes toward concordance by validating the Leeds Attitude to Concordance Scale II (LATCon II) in a Spanish sample. METHODS: This was a cross-sectional survey. An opportunistic sample of 125 psychiatrist and 100 psychiatry registrars attending a national conference completed the LATCon II questionnaire and sociodemographic and professional data. The principal component analysis of the LATCon II items was performed. Associations with sociodemographic and mental health professional variables were calculated. RESULTS: Principal component analysis yielded three components labeled "communication/empathy," "shared control," and "eventual paternalistic style." Women obtained significantly lower scores than men on the second component. Mental health professional variables were not related to attitude to concordance. CONCLUSIONS: Psychiatrists show a favorable attitude to involve patients in a process of reciprocal communication, where patients' preferences, values, and expectations are considered, but they are more cautious in their attitude to sharing decisions with patients. There is scope for the different kinds of research in this area: studying sex-based differences in psychiatrists' attitudes to concordance and also exploring the gap in mental health care between patients' and professionals' views of shared decision making. Only in this way can the real partnership for shared decision making be fully understood.