Onychoscopic Analysis of Cyclophosphamide-Induced Polydactylic Bluish-Gray Discoloration in a Case of Pemphigus Foliaceus.

Cyclophosphamide, an alkylating agent, has rarely been observed to cause a bluish discoloration of nails, an occurrence that is typically underreported. We describe the case of a middle-aged male undergoing dexamethasone-cyclophosphamide pulse therapy for pemphigus foliaceus, who exhibited bluish-gray discoloration of the nails. It is crucial to differentiate this presentation from other conditions such as nail apparatus melanoma (NAM), which may manifest in a slightly different manner. We also report the onychoscopic findings observed in this case.

Actinomycetoma in a patient with pre-existing sensorineural hearing loss: a linezolid-based treatment paradigm.

Mycetoma is a chronic granulomatous infectious disease with a triad of subcutaneous swelling, discharging sinuses and the presence of granules. The infection may occur following minor trauma or penetrating thorn injury. We report a case of a man in his 40s with a history of thorn prick 9 years ago, followed by the formation of painless discharging sinuses on the right foot for the past 2 years. Clinical, local epidemiological, histopathological examination and Gram stain confirmed the diagnosis of actinomycetoma. Prior to initiating the Welsh regimen, a pretreatment assessment of the patient's auditory function was conducted through pure tone audiometry, indicating the existence of pre-existing high-frequency bilateral sensorineural hearing loss. The patient was treated with linezolid as an alternative to amikacin, at a dosage of 600 mg two times per day, leading to complete resolution within 3 weeks. This underscores linezolid's efficacy as a safe and cost-effective alternative for actinomycetoma, without causing ototoxic side effects.

Curricular Reform in Serious Illness Communication and Palliative Care: Using Medical Students' Voices to Guide Change.

PURPOSE: To gather and leverage the voices of students to drive creation of required, integrated palliative care curricula within undergraduate medical education in Massachusetts, which is lacking in a majority of U.S. medical schools. METHOD: The study was conducted by the Massachusetts Medical Schools' Collaborative, a working group committed to ensuring all medical students in Massachusetts receive foundational training in serious illness communication (SIC) and palliative care. Eight focus groups (2 per participating medical school) were conducted during January-May 2021 and included a total of 50 students from Boston University Chobanian & Avedisian School of Medicine, Harvard Medical School, Tufts University School of Medicine, and the UMass Chan Medical School. Data collected from focus groups were discussed and coded. Themes were identified using the immersion/crystallization qualitative data analysis approach. RESULTS: Six key themes emerged. Students viewed SIC as essential to high-quality medical practice regardless of specialty, and believed training in SIC skills and palliative care should be required in medical school curricula. Students preferred to learn and practice these skills using frameworks, particularly in real-world situations. Students recognized the expertise of palliative care specialists and described them as a scarce, often misunderstood resource in health care. Students reported it was mostly "luck" if they were included in family meetings and observed good role models. Finally, students desired practice in debriefing after difficult and emotional situations. CONCLUSIONS: This study confirms long-standing themes on students' experiences with SIC and palliative care topics, including feeling inadequately prepared to care for seriously ill patients as future physicians. Our study collected students' perspectives as actionable data to develop recommendations for curricular change. Collaborative faculty also created recommendations based on the focus group data for immediate and ongoing SIC and palliative care curricular change in Massachusetts, which can apply to medical schools nationwide.

Deconstructing Racism, Hierarchy, and Power in Medical Education: Guiding Principles on Inclusive Curriculum Design.

In the context of current U.S. racial justice movements, analysis of racism in medicine within medical education is a critical task for all institutions. To educate the next generation of physicians about racism in medicine and out of concern that the curriculum required critical assessment and change, a group of students and faculty at Boston University School of Medicine (BUSM) initiated a longitudinal curricular analysis through a vertical integration group, commissioned by the Medical Education Committee, from May 2019 to June 2020. The curriculum analysis and the major outcomes and guiding principles that emerged from it are described as a path forward, toward a more inclusive curriculum. The major elements of this analysis included a comprehensive internal curricular assessment and an external assessment of peer institutions that led to the development of key curricular recommendations and overarching equity and specific racially focused equity competencies. The curricular recommendations fall into the following domains: (1) challenging the persistence of biological/genetic notions of race, (2) embedding structural practices in medical education to dismantle racism in medicine, and (3) promoting institutional climate change. Initial steps to implement these recommendations are described. The authors believe that the historic and present reality of racism in America and in medicine has impacted medical education specifically, and more broadly, the practice of medicine, trainee experience, and patient outcomes. The key findings of the BUSM analysis are transferable to other medical education institutions, and the described review process can support peer institutions as they engage in the imperative work of institutional reflection and addressing the salient ideas and practices that uphold racism in medicine.

Electronic FRAIL score may predict treatment outcomes in older adults with myeloma.

INTRODUCTION: Frailty is a known risk factor for older patients with myeloma. Here we present realworld data using a computer-generated frailty assessment score (FRAIL score), based on 5 clinically derived parameters, in predicting patient outcomes. METHODS: Older patients with newly diagnosed multiple myeloma who received frontline treatment with cyclophosphamide-bortezomib-dexamethasone had their FRAIL score retrospectively assessed. Treatment outcomes were assessed using standard IMWG criteria, and event free survival and overall survival determined. RESULTS: 155 patients were analysed. Compared to those who were assessed as non-frail (FRAIL score 0-1) likely-frail patients (score ≥ 2) were less likely to complete the full course of treatment (24.3% vs 53.4%, p = 0.002), and more likely to terminate treatment due to toxicities (35.1% vs 22.0%, p = 0.109), as well as having a greater number of patients stop treatment early for reasons other than toxicity or progression (27.0% vs 10.2%, p = 0.010). After a median follow up of 42.5 months, likely-frail patients were found to have a trend for shorter event-free survival (median EFS, 8.7 vs 17.9 months, p = 0.064) and statistically inferior overall survival (median OS, 30.2 vs 49.8 months, p < 0.001). After adjusting for age, stage, and Charlson comorbidity index, FRAIL score was prognostic for OS (HR = 3.47, 95% CI 1.88-6.4), but not EFS (HR = 1.28, 95%CI 0.79-2.06). CONCLUSION: The FRAIL score is independently predictive of overall survival in older patients with myeloma receiving bortezomib-based induction chemotherapy and can help identify those patients more likely to experience treatment toxicity.

T-cell lymphomas in a tertiary care center of Mangalore.

BACKGROUND: The clinicomorphology and immunohistochemical features of T-cell lymphomas have been documented. AIM: The aim of the study was to evaluate the spectrum of clincopathological features of T-cell lymphoma with immunohistochemistry correlation in a tertiary care center. MATERIALS AND METHODS: The present study was conducted on 19 biopsy specimens received from the Department of Pathology, Kasturba Medical College, from referral hospitals of Mangalore city. Cases of nodal and extranodal T-cell lymphomas diagnosed between January 2012 and December 2015 were selected with evaluation of clinical data, histomorphological features, and immunophenotyping. Appropriate panel of antibodies was chosen after morphological evaluation of the cases. RESULTS: Of the 19 cases of T-cell lymphomas, 14 were nodal disease and 5 were extranodal disease. Among the nodal lymphomas, five were primary peripheral T-cell lymphoma-not otherwise specified (PTCL-NOS), four were cases of lymphoblastic lymphoma, three were cases of angioimmunoblastic T-cell lymphomas, and two were cases of anaplastic large-cell lymphoma anaplastic lymphoma kinase (ALK) negative. In extranodal disease, two were mycosis fungoides of skin, one case each of subcutaneous panniculitis-like T-cell lymphoma, T-cell lymphoblastic lymphoma of tonsil, and T-cell lymphoma of the stomach. CONCLUSIONS: The diagnosis and subclassification of PTCLs is necessary for therapeutic and prognostic purposes.

Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review.

BACKGROUND: GPs often act as gatekeepers, authorising patients' access to specialty care. Gatekeeping is frequently perceived as lowering health service use and health expenditure. However, there is little evidence suggesting that gatekeeping is more beneficial than direct access in terms of patient- and health-related outcomes. AIM: To establish the impact of GP gatekeeping on quality of care, health use and expenditure, and health outcomes and patient satisfaction. DESIGN AND SETTING: A systematic review. METHOD: The databases MEDLINE, PreMEDLINE, Embase, and the Cochrane Library were searched for relevant articles using a search strategy. Two authors independently screened search results and assessed the quality of studies. RESULTS: Electronic searches identified 4899 studies (after removing duplicates), of which 25 met the inclusion criteria. Gatekeeping was associated with better quality of care and appropriate referral for further hospital visits and investigation. However, one study reported unfavourable outcomes for patients with cancer under gatekeeping, and some concerns were raised about the accuracy of diagnoses made by gatekeepers. Gatekeeping resulted in fewer hospitalisations and use of specialist care, but inevitably was associated with more primary care visits. Patients were less satisfied with gatekeeping than direct-access systems. CONCLUSION: Gatekeeping was associated with lower healthcare use and expenditure, and better quality of care, but with lower patient satisfaction. Survival rate of patients with cancer in gatekeeping schemes was significantly lower than those in direct access, although primary care gatekeeping was not otherwise associated with delayed patient referral. The long-term outcomes of gatekeeping arrangements should be carefully studied before devising new gatekeeping policies.

Systematic review: the etiology of esophageal squamous cell carcinoma in low-income settings.

INTRODUCTION: Esophageal carcinoma causes over 380 000 deaths per year, ranking sixth worldwide in mortality amongst all malignancies. Globally, the squamous cell subtype is most common and accounts for 80% of esophageal cancers. Nonetheless, esophageal squamous cell carcinoma is much more poorly understood than esophageal adenocarcinoma, including what is driving such high prevalences, why it often presents in young patients, and shows such marked geographical delineations Areas covered: The current literature was searched for articles focusing on aetiopathogenesis of squamous cell esophageal carcinoma via a systematic review, particularly in low-resource settings. This was supplemented by papers of interest known to the authors. Expert commentary: Current putative mechanisms include polycyclic aromatic hydrocarbons, nitrosamines, acetaldehyde, cyclo-oxygenase-2 pathways, androgen and their receptor levels, as well as smoking & alcohol, micronutrient deficiencies and diet, mycotoxins, thermal damage, oral hygiene and microbiotal factors, inhaled smoke, viral infections such as HPV, and chronic irritative states. Etiology is likely multifactorial and varies geographically. Though smoking and alcohol play a predominant role in high-income settings, there is strong evidence that mycotoxins, diet and temperature effects may play an under-recognized role in low and middle-income settings.

Integrating a nationally scaled workforce of community health workers in primary care: a modelling study.

OBJECTIVE: To model cost and benefit of a national community health worker workforce. DESIGN: Modelling exercise based on all general practices in England. SETTING: United Kingdom National Health Service Primary Care. PARTICIPANTS: Not applicable. DATA SOURCES: Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake. MAIN OUTCOME MEASURES: We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients. RESULTS: Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease. CONCLUSION: A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.

The pitfalls in cytology diagnosis of poorly differentiated neuroendocrine carcinoma of lung and their treatment response.

CONTEXT: Lung is the most common site of small cell carcinoma (SCLC) - a poorly differentiated neuroendocrine carcinoma (PDNEC). SCLC comprises 15-20% of the invasive cancers of the lung. AIM: This study was conducted to appraise the accuracy and pitfalls of the diagnosis of PDNEC on cytology along with treatment responses if available. SETTINGS AND DESIGN: Retrospective study for 2 years yielded 21 cases on cytology. SUBJECTS AND METHODS: Slides of fine-needle aspiration of lymph nodes, the tumor, bronchial brush, and bronchoalveolar lavage specimens were used. The histological correlation was obtained as were treatment responses. RESULTS: Eighteen SCLCs were confirmed on review. Of these, 13 initial reports were concordant and five, discordant. The rest three cases which initially reported as SCLC were found to be negative (2) and combined SCLC (1). One SCLC with concordant initial and reviewed diagnoses failed to confirm on histopathology. The patients, all heavy smokers, were predominantly males in the seventh to eighth decade age group. The sensitivity and specificity of reviewed diagnoses were better than that of the original. The difference between histopathology and cytology diagnoses (reviewed and original) was statistically insignificant. All patients were categorized as "extensive stage" by positron emission tomography-computerized tomography, and five were treated with etoposide and cisplatin with/without radiotherapy. CONCLUSION: Age group (61-70) and gender (males) distribution were statistically significant. Intermediate variants of SCLC may be misdiagnosed as adenocarcinoma. Similarly, combined SCLC may be missed on cytology if the observer does not sustain a high index of suspicion. Unequivocal cytology diagnosis opposed to negative histopathology report demands repeat biopsy.