Cost modelling rehabilitation in the home for reconditioning in the Australian context.

BACKGROUND: Inpatient rehabilitation services are challenged by increasing demand. Where appropriate, a shift in service models towards more community-oriented approaches may improve efficiency. We aimed to estimate the hypothetical cost of delivering a consensus-based rehabilitation in the home (RITH) model as hospital substitution for patients requiring reconditioning following medical illness, surgery or treatment for cancer, compared to the cost of inpatient rehabilitation. METHODS: Data were drawn from the following sources: the results of a Delphi survey with health professionals working in the field of rehabilitation in Australia; publicly available data and reports; and the expert opinion of the project team. Delphi survey data were analysed descriptively. The costing model was developed using assumptions based on the sources described above and was restricted to the Australian National Subacute and Non-Acute Patient Classification (AN-SNAP) classes 4AR1 to 4AR4, which comprise around 73% of all reconditioning episodes in Australia. RITH cost modelling estimates were compared to the known cost of inpatient rehabilitation. Where weighted averages are provided, these were determined based on the modelled number of inpatient reconditioning episodes per annum that might be substitutable by RITH. RESULTS: The cost modelling estimated the weighted average cost of a RITH reconditioning episode (which mirrors an inpatient reconditioning episode in intensity and duration) for AN-SNAP classes 4AR1 to 4AR4, to be A$11,371, which is 28.1% less than the equivalent weighted average public inpatient cost (of A$15,820). This represents hypothetical savings of A$4,449 per RITH reconditioning substituted episode of care. CONCLUSIONS: The hypothetical cost of a model of RITH which would provide patients with as comprehensive a rehabilitation service as received in inpatient rehabilitation, has been determined. Findings suggest potential cost savings to the public hospital sector. Future research should focus on trials which compare actual clinical and cost outcomes of RITH for patients in the reconditioning impairment category, to inpatient rehabilitation.

Developing a model for rehabilitation in the home as hospital substitution for patients requiring reconditioning: a Delphi survey in Australia.

BACKGROUND: Reconditioning for patients who have experienced functional decline following medical illness, surgery or treatment for cancer accounts for approximately 26% of all reported inpatient rehabilitation episodes in Australia. Rehabilitation in the home (RITH) has the potential to offer a cost-effective, high-quality alternative for appropriate patients, helping to reduce pressure on the acute care sector. This study sought to gain consensus on a model for RITH as hospital substitution for patients requiring reconditioning. METHODS: A multidisciplinary group of health professionals working in the rehabilitation field was identified from across Australia and invited to participate in a three-round online Delphi survey. Survey items followed the patient journey, and also included items on practitioner roles, clinical governance, and budgetary considerations. Survey items mostly comprised statements seeking agreement on 5-point Likert scales (strongly agree to strongly disagree). Free text boxes allowed participants to qualify item answers or make comments. Analysis of quantitative data used descriptive statistics; qualitative data informed question content in subsequent survey rounds or were used in understanding item responses. RESULTS: One-hundred and ninety-eight health professionals received an invitation to participate. Of these, 131/198 (66%) completed round 1, 101/131 (77%) completed round 2, and 78/101 (77%) completed round 3. Consensus (defined as ≥ 70% agreement or disagreement) was achieved on over 130 statements. These related to the RITH patient journey (including patient assessment and development of the care plan, case management and program provision, and patient and program outcomes); clinical governance and budgetary considerations; and included items for initial patient screening, patient eligibility and case manager roles. A consensus-based model for RITH was developed, comprising five key steps and the actions within each. CONCLUSIONS: Strong support amongst survey participants was found for RITH as hospital substitution to be widely available for appropriate patients needing reconditioning. Supportive legislative and payment systems, mechanisms that allow for the integration of primary care, and appropriate clinical governance frameworks for RITH are required, if broad implementation is to be achieved. Studies comparing clinical outcomes and cost-benefit of RITH to inpatient rehabilitation for patients requiring reconditioning are also needed.

Factors associated with repeated influenza vaccine uptake among aged care staff in an Australian sample from 2017 to 2019.

BACKGROUND/AIM: Influenza vaccination is strongly recommended every year for aged care staff to protect themselves and minimise risk of transmission to residents. This study aimed to determine the factors associated with repeated annual influenza vaccine uptake among Australian aged care staff from 2017 to 2019. METHODS: Demographic, medical and vaccination data collected from the staff, who participated in an observational study from nine aged care facilities under a single provider in Sydney Australia, were analysed retrospectively. Based on the pattern of repeated influenza vaccination from 2017 to 2019, three groups were identified: (1) unvaccinated all three years; (2) vaccinated occasionally(once or twice) over three years; and (3)vaccinated all threeyears. Multinomial logistic regression analysis was performed to better understand the factors associated with the pattern of repeated influenza vaccination. RESULTS: From a total of 138 staff, between 2017 and 2019, 28.9 % (n = 40) never had a vaccination, while 44.2 % (n = 61) had vaccination occasionally and 26.8 % (n = 37) had vaccination all three years. In the multinomial logistic regression model, those who were<40 years old (OR = 0.57, 95 % CI: 0.19-0.90, p < 0.05) and those who were current smokers (OR = 0.20; 95 % CI: 0.03-0.76, p < 0.05) were less likely to have repeated vaccination for all three years compared to the unvaccinated group. Those who were<40 years old (OR = 0.61; 95 % CI: 0.22-0.68, p < 0.05) and those who were born overseas (OR = 0.50; 95 % CI:0.27-0.69, p < 0.05) were more likely to be vaccinated occasionally compared to the unvaccinated group. CONCLUSION: The significant predictors of repeated vaccine uptake across the three-year study period among aged care staff were age, smoking status and country of birth (Other vs Australia). Targeted interventions towards the younger age group (<40 years old), smokers and those who were born overseas could improve repeated influenza vaccination uptake in the aged care workforce.

Australian residential aged care home staff experiences of implementing an intervention to improve palliative and end-of-life care for residents: A qualitative study.

Access to high-quality and safe evidence-based palliative care (PC) is important to ensure good end-of-life care for older people in residential aged care homes (RACHs). However, many barriers to providing PC in RACHs are frequently cited. The Quality End-of-Life Care (QEoLC) Project was a multicomponent intervention that included training, evidence-based tools and tele-mentoring, aiming to equip healthcare professionals and careworkers in RACHs with knowledge, skills and confidence in providing PC to residents. This study aims to understand: (1) the experiences of healthcare professionals, careworkers, care managers, planners/implementers who participated in the implementation of the QEoLC Project; and (2) the barriers and facilitators to the implementation. Staff from two RACHs in New South Wales, Australia were recruited between September to November 2021. Semi-structured interviews and thematic data analysis were used. Fifteen participants (seven health professionals [includes one nurse, two clinical educators, three workplace trainers, one clinical manager/nurse], three careworkers and five managers) were interviewed. Most RACH participants agreed that the QEoLC Project increased their awareness of PC and provided them with the skills/confidence to openly discuss death and dying. Participants perceived that the components of the QEoLC Project had the following benefits for residents: more appropriate use of medications, initiation of timely pain management and discussions with families regarding end-of-life care preferences. Key facilitators for implementation were the role of champions, the role of the steering committee, regular clinical meetings to discuss at-risk residents and mentoring. Implementation barriers included: high staff turnover, COVID-19 pandemic, time constraints, perceived absence of executive sponsorship, lack of practical support and systems-related barriers. The findings underline the need for strong leadership, supportive organisational culture and commitment to the implementation of processes for improving the quality of end-of-life care. Furthermore, the results highlight the need for codesigning the intervention with RACHs, provision of dedicated staff/resources to support implementation, and integration of project tools with existing systems for achieving effective implementation outcomes.

Australian inpatient cancer rehabilitation as seen by patients receiving care pre and post intervention: Insights into unmet needs in the cancer and rehabilitation journey.

OBJECTIVE: The objective of this study is to explore both the negative and positive lived experiences of cancer survivors during specialist inpatient rehabilitation programmes. METHODS: This phenomenological study explored the negative and positive perspectives of cancer survivors with residual disability, during their inpatient rehabilitation. Semi-structured interviews conducted with 22 inpatients on admission and discharge were analysed using the protocols of Interpretative Phenomenological Analysis. RESULTS: Experiences of inpatient cancer rehabilitation were not independent of the whole cancer trajectory. Rather, for these inpatients, processing and ruminating upon challenges to self from the moment of cancer diagnosis and throughout treatments indicated that more emotional and psychosocial support may be useful throughout cancer rehabilitation and the whole cancer trajectory. CONCLUSION: Understanding the concurrent sources of psychological distress and growth in these cancer survivors as they recover from life changing events provides a unique consumer evaluation of an inpatient cancer rehabilitation service and the overall cancer experience. This study has implications for developing insight into the impact that the cancer trajectory has on the individual and reinforces the importance of a holistic approach to rehabilitation that includes a supported mind, body and spirit appreciation of healing.

Marek's Disease in an Indian Peafowl (Pavo cristatus) with Clinical Ocular Disease and Paraparesis.

Marek's disease (MD) is caused by virulent strains of Gallid alphaherpesvirus type 2 (MD virus serotype 1; MDV 1) and frequently causes a lymphoproliferative disorder in poultry and other galliform birds worldwide. However, within the peafowl (Phasianinae) subfamily, there are only rare confirmed reports of MD. Here we report MD in an Indian peafowl (Pavo cristatus), which clinically presented with hindlimb paraparesis and intraocular swelling of the right eye. Soft, off-white to tan masses within the right eye, sciatic nerves and coelomic cavity were identified at post-mortem examination which effaced the cranial pole of the kidneys and diffusely effaced the testes. Lymphoid neoplasia was identified histologically at all of these sites and there was extensive hepatic lymphoid cell infiltration, which had not been grossly evident. The T-cell origin of the lymphoid cells was confirmed by immunohistochemistry for CD3 antigen. A virulent strain of MDV 1 was detected by real-time polymerase chain reaction in DNA samples extracted from the kidney and testes. As MD is rare in peafowl it should be considered as a differential diagnosis for intraocular and coelomic masses with associated clinical signs.

Australian inpatient cancer rehabilitation, as seen by patients receiving care, pre- and post-intervention.

OBJECTIVE: Rehabilitation is increasingly recognised as effective in addressing impairment and functional disability after cancer treatment. Few studies have investigated the lived positive and negative experiences of cancer patients receiving rehabilitation. METHOD: Semi-structured in-depth interviews were conducted with 22 inpatient volunteers, at their admission and discharge from a subacute hospital rehabilitation unit. We heard narratives of their experiences and their individual goals in our programmes, seeking to make positive and negative subjective interpretations of these. We undertook Interpretative Phenomenological Analysis (IPA) of interviews. RESULTS: Patients described an immense array of personal challenges, including coping with and adapting to functional losses, whilst assimilating the reality that life might not continue as before. They were often living and rehabilitating after the residual effects of cancer treatments, whilst facing new challenges that threatened their quality of life. Although rehabilitation usually improved patients' functional abilities, many still increasingly needed to depend on others in daily life. CONCLUSION: Understanding the narrative of these experiences provides a unique consumer evaluation of an inpatient cancer rehabilitation service. Individuals described a healing environment, where they received multiple therapies and set goals to improve daily living function, as they continued along their personal cancer trajectories.

Multidisciplinary healthcare providers' experience of working in an inpatient cancer rehabilitation unit in Sydney, Australia.

OBJECTIVE: Scant research explores health professionals' experiences of providing inpatient cancer rehabilitation services, either from the negative or positive perspectives. METHOD: This report explores the lived experiences of 14 multidisciplinary health professionals providing cancer rehabilitation services within an inpatient setting. Their interpretations provide a distinctive evaluation of an inpatient, cancer rehabilitation service, both negative and positive, and the impacts of their experiences on them and their patients. Data from semi-structured focus groups and interviews were analysed using Interpretative Phenomenological Analysis (IPA: Psychology and Health, 11, 1996, 261-271) to produce thematic results. RESULTS: Health professionals' focus groups and interviews produced one superordinate theme: Therapeutic community. Subordinate themes were Healing and Hope, Limited by the System, Moral Integrity and Growth, with further subthemes; Invalidation, Moral dilemmas, Gratitude and Humility. Positive views of the specialist service were tempered with issues associated with finite resources and staff feeling unsupported in their person-centred approach. Although rehabilitation was the primary focus of the unit, metastatic cancer may behave unpredictably; symptom recurrences meant that a dialogue of accepting palliative care and dying as a phase of life was also an important factor raised by some patients and families in our setting. Referral to palliative specialists for this dialogue was incorporated in the context of the rehabilitation care provided. CONCLUSION: Study participants provided a unique window, encompassing both negative and positive perspectives, to understanding their deep commitment to quality of care, despite resource limitations. Professionals in this inpatient team worked to provide optimal multidisciplinary services relevant to each individual's need to move towards strength and independence.

Can specially trained community care workers effectively support patients and their families in the home setting at the end of life?

Surveys indicate that many Australians would prefer to die at home, but relatively few do. Recognising that patients and their families may not have the support they need to enable end-of-life care at home, a consortium of care providers developed, and received funding to trial, the Palliative Care Home Support Program (PCHSP) across seven health districts in New South Wales, Australia. The programme aimed to supplement end-of-life care in the home provided by existing multidisciplinary community palliative care teams, with specialist supportive community care workers (CCWs). An evaluation of the service was undertaken, focussing on the self-reported impact of the service on family carers (FCs), with triangulation of findings from community palliative care teams and CCWs. Service evaluation data were obtained through postal surveys and/or qualitative interviews with FCs, community palliative care teams and CCWs. FCs also reported the experience of their loved one based on 10 items drawn from the Quality of Death and Dying Questionnaire (QODD). Thematic analysis of surveys and interviews found that the support provided by CCWs was valued by FCs for: enabling choice (i.e. to realise end-of-life care in the home); providing practical assistance ("hands-on"); and for emotional support and reassurance. This was corroborated by community palliative care teams and CCWs. Responses by FCs on the QODD items indicated that in the last week of life, effective control of symptoms was occurring and quality of life was being maintained. This study suggests that satisfactory outcomes for patients and their families who wish to have end-of-life care in the home can be enabled with the additional support of specially trained CCWs. A notable benefit of the PCHSP model, which provided specific palliative care vocational training to an existing community care workforce, was a relatively rapid increase in the palliative care workforce across the state.

Integration of trauma and rehabilitation services is the answer to more cost-effective care.

BACKGROUND: The pathway from acute trauma care to inpatient rehabilitation has not been previously studied in New South Wales (NSW), Australia. This study aimed to examine the outcomes of patients transferred from a trauma service to its 'in-house' rehabilitation service (Group A) compared with outcomes of patients transferred from a designated trauma centre to an external rehabilitation service (Group B). This is carried out to identify any inefficiencies, delays and opportunities for improvement. METHODS: This is a retrospective cohort study using linked registry data. This study included all patients admitted after a motor vehicle collision to trauma services in NSW over the period of 2009-2012, who required inpatient rehabilitation. Those requiring specialized brain or spinal injury rehabilitation or those who went to private rehabilitation units were excluded. RESULTS: There were 249 patients in this cohort with majority (59%) in Group A and the remainder in Group B. There was no significant difference between the age of the patients, injury severity or acute length of stay (LOS) between the two groups. Admission and discharge functional independence measure scores were also similar between the two groups. There was a significant difference in the LOS in rehabilitation (30 days for Group A compared with 40 days in Group B, P = 0.02). CONCLUSIONS: Transferring patients to an external rehabilitation service from a designated trauma service is less efficient than providing the same care by the 'in-house' rehabilitation service. There may be opportunities to improve the efficiency of trauma management and reduce costs.

Asthma deaths outside the hospital in an urban community from 2004 to 2008.

BACKGROUND: Several studies have been performed reviewing medical examiner's autopsy reports of asthma deaths. None, to our knowledge, have focused on the characteristics of asthma deaths in the urban community alone. OBJECTIVE: To characterize factors related to asthma deaths occurring outside the hospital setting in an urban community. METHODS: We reviewed the medical records of 22 patients who died outside the hospital of asthma and underwent autopsy performed by the Milwaukee County medical examiner from 2004 to 2008. RESULTS: The mean age of the patients was 32 years (range, 12-71 years), 11 patients were male, and 14 patients (64%) were African American. Seventeen patients (77%) died during the night or shortly on awakening. Twelve patients (55%) died in June, July, or August. A history of illicit drug, alcohol, or tobacco use was discovered in 13 patients (59%). Toxicologic test results for drugs of abuse were positive in 4 patients (18%). Twenty patients were using or overusing a short-acting ß-agonist, 1 patient was taking omalizumab, and none were taking long-acting ß-agonists alone. Two patients were taking no medications. Asthma severity and medication adherence were not consistently reported. Lung pathologic testing revealed eosinophils in 18 patients and a lack of neutrophils in every case. CONCLUSION: In this small and limited series of asthma deaths occurring in an urban setting outside the hospital, individuals were more likely to be African Americans, with deaths occurring more frequently at night, during the summer months, and in those with substance abuse and not taking anti-inflammatory asthma medications.

Interphase fluorescence in situ hybridization analysis of chromosome 12p abnormalities is useful for distinguishing epidermoid cysts of the testis from pure mature teratoma.

PURPOSE: The distinction of epidermoid cyst of the testis from teratoma is of critical importance because the former is benign and the latter is a malignant tumor that may have associated metastasis of either teratomatous or non-teratomatous germ cell tumor types. Chromosome 12p abnormalities are seen in the vast majority of testicular germ cell tumors of adults and are present in all histologic subtypes. In this study, we investigated the clinical utility of interphase fluorescence in situ hybridization (FISH) analysis of chromosome 12p abnormalities for distinguishing epidermoid cysts of the testis from pure mature teratoma. EXPERIMENTAL DESIGN: Sixteen testicular epidermoid cysts and 17 testicular teratomas were investigated for isochromosome 12p [i(12p)] and 12p overrepresentation using interphase FISH analysis. RESULTS: Neither i(12p) nor 12p overrepresentation were observed in 16 epidermoid cyst cases, whereas i(12p) was detected in 76% of teratomas and 12p overrepresentation was identified in 29% of teratomas. Overall, 88% of testicular teratomas had chromosome 12p abnormalities. CONCLUSIONS: FISH identification of i(12p) and/or 12p overrepresentation in routinely processed surgical specimens is a useful ancillary diagnostic tool in distinguishing testicular epidermoid cysts from teratoma.

Analysis of ovarian teratomas for isochromosome 12p: evidence supporting a dual histogenetic pathway for teratomatous elements.

Teratomas are the most common germ cell tumor (GCT) of the ovary and include several types with a range of clinical behavior. As in testicular teratomas, they may be benign, malignant or a component of a mixed GCT. In the testis, data support separate pathogeneses for prepubertal and postpubertal teratomas, with derivation of the former from a nontransformed germ cell and the latter from differentiation of a nonteratomatous, malignant GCT. The absence of cytogenetic abnormalities (including isochromosome 12p (i(12p)) in mature ovarian teratomas suggests that they may be analogous to prepubertal testicular teratomas, but there are no data regarding genetic changes in the teratomatous components of ovarian mixed GCTs. We therefore studied the teratomatous components of six mixed GCTs of the ovary using fluorescence in situ hybridization (FISH) for i(12p). Six mixed GCTs of the ovary occurred in patients 4-33 years of age; all had teratomatous and yolk sac tumor components and three also contained foci of embryonal carcinoma. Using FISH with 12p telomeric and 12 centromeric probes, five of six (83%) cases had detectable i(12p) in their nonteratomatous components, and four of six (66%) in the teratomatous component. One of the two cases without demonstrable i(12p) in the teratomatous portion of the mixed GCT also did not have identifiable 12p abnormalities in other elements of the mixed GCT. By comparison, five pure, mature ovarian teratomas and three pure, immature ovarian teratomas showed no evidence of either i(12p) or other forms of 12p amplification. These findings support that teratoma in mixed ovarian GCTs has a different pathogenesis compared to pure teratoma of the ovary. Furthermore, the findings of i(12p) in both the teratomatous and nonteratomatous components of ovarian mixed GCTs supports that the teratoma derives from other components, similar to the situation in the testis.

Preoperative prediction of small volume cancer (less than 0.5 ml) in radical prostatectomy specimens.

PURPOSE: The detection of low volume and early stage prostate cancer has increased with the widespread use of prostate specific antigen screening for prostatic adenocarcinoma. This increased detection has led to efforts to stratify patient risk and the potential benefits of various treatments based on preoperative clinical and biopsy data. We examined various clinical parameters and prostate biopsy features to determine which variables are most predictive of small volume (less than 0.5 ml) cancer at prostatectomy. MATERIALS AND METHODS: We studied 336 patients who underwent prostatectomy for prostate cancer. Radical prostatectomy specimens were completely embedded and whole mounted. Final tumor volume in the radical prostatectomy specimens was determined by the grid method. Clinical data were gathered by a review of patient charts. Various preoperative clinical and biopsy findings were analyzed to determine factors predictive of small volume cancer at prostatectomy. RESULTS: A total of 55 patients (16%) were found to have small volume cancer (less than 0.5 ml). On univariate logistic regression certain variables were significant predictors of small volume cancer, namely the highest Gleason score from all positive biopsy sites (p = 0.001), the Gleason score from the biopsy site with the highest percent of adenocarcinoma (p = 0.006), the highest percent of adenocarcinoma at any biopsy site (p <0.0001), the percent of adenocarcinoma at the biopsy site with the highest Gleason score (p <0.0001), the highest percent of cores positive for adenocarcinoma at any biopsy site (p = 0.001), the percent of cores with carcinoma at the site with the highest Gleason score (p = 0.002), the number of positive sites (p <0.0001) and tumor bilaterality (p <0.0001). None of the clinical parameters that we studied, including preoperative prostate specific antigen (p = 0.52), clinical stage (p = 0.62) or patient age (p = 0.94), was predictive of small volume cancer. On multivariate analysis the highest percent of adenocarcinoma at any site (adjusted OR 0.95, 95% CI 0.92 to 0.97, p <0.0001) and the number of positive biopsy sites (adjusted OR 0.97, 95% CI 0.96 to 0.99, p <0.0001) were significant predictors of small volume cancer. CONCLUSIONS: The number of positive biopsy sites and the highest percent of adenocarcinoma at any biopsy site are significant predictors of small volume cancer in radical prostatectomy specimens.

Bladder neck invasion is an independent predictor of prostate-specific antigen recurrence.

BACKGROUND: The 1997 TNM staging system for prostatic carcinoma and the 2002 revision thereof classified prostatic carcinoma with bladder neck involvement classified as pT4 disease. This classification is based on the belief that tumors that invade surrounding structures are more aggressive and warrant higher staging than tumors that do not invade surrounding structures. Recent reports in the literature suggested that microscopic involvement of the bladder neck does not carry independent prognostic significance. Therefore, resection specimens with bladder neck involvement should not be classified as pT4. The current study prospectively examined the prognostic significance of bladder neck involvement by prostatic carcinoma. METHODS: The authors analyzed the totally embedded and whole-mounted radical prostatectomy specimens from 364 consecutive patients. The mean patient age was 66 years (range, 41-77 years). The bladder neck, which had been coned from the specimen, was cut in a perpendicular fashion. Involvement of the bladder neck was defined as the presence of neoplastic cells within the smooth muscle bundles of the coned bladder neck. The data were prospectively collected. Bladder neck involvement was analyzed in relation to age, preoperative prostate-specific antigen (PSA) level, prostate weight, Gleason score, final pathologic classification, tumor volume, surgical margin status, the presence of high-grade prostate intraepithelial neoplasm, multifocality, seminal vesicle invasion, extraprostatic extension, perineural invasion, and PSA recurrence. RESULTS: Bladder neck involvement was found in 22 (6%) of 364 patients. Univariate results indicated that bladder neck involvement versus no bladder neck involvement was significantly associated with preoperative PSA (P < 0.001), higher pathologic classification (P < 0.001), larger tumor volume (P < 0.001), extraprostatic extension (P < 0.001), positive surgical margins (P < 0.001), and PSA recurrence (P = 0.003). In a multivariate logistic regression model controlling for pathologic classification, Gleason score, and surgical margin status, bladder neck involvement was an independent predictor of PSA recurrence (P = 0.04). The adjusted odds ratio for bladder neck involvement was 3.3 (95% confidence interval, 1.04-10.03). CONCLUSIONS: In the current study, bladder neck involvement was an independent predictor of early PSA recurrence. The data demonstrated the importance of continued assessment of bladder neck invasion and supported the placement of tumors with bladder neck involvement in a stage that recognizes the prognostic implications of such involvement.

Intraocular inflammatory myofibroblastic tumor with ALK overexpression.

We report a case of an intraocular inflammatory myofibroblastic tumor nearly filling the vitreous cavity of the eye of a 50-year-old man. The tumor was composed of a mixture of spindle cells and mixed inflammatory elements, including numerous plasma cells. The differential diagnosis included inflammatory pseudotumor and neoplastic mimics of this condition. Further investigation with immunohistochemistry revealed the mass to be composed of myofibroblasts, positive for smooth muscle actin stains and with weak anaplastic lymphoma kinase (ALK) expression in some tumor cells. Evaluation by fluorescence in situ hybridization revealed the tumor cells to have multiple copies of chromosome 2 and ALK but no rearrangement of the ALK gene. The authors propose that multiple copies of the ALK gene may be involved in inflammatory myofibroblastic tumor tumorigenesis, in addition to ALK gene rearrangements.