Diagnosis and management of gastric-type endocervical adenocarcinoma: A case report and review of the literature.

Gastric-type endocervical adenocarcinoma (GEA), a rare subtype of cervical cancer, has garnered increasing attention recently for its distinctive histopathological features, unique classification, genetic characteristics, and variable clinical outcomes compared to squamous cell and adenocarcinoma subtypes. Historically, GEA has evolved from a poorly understood entity to a distinct subtype of cervical adenocarcinoma, only recently recognized in the 2020 World Health Organization (WHO) classification. Accordingly, characteristic morphological features define GEA, shedding light on the diagnostic challenges and potential misclassification that can occur in clinical practice. Genetic alterations, including KRAS, ARID1A, and PIK3CA mutations, play a pivotal role in the development and progression of GEA. This article reviews a case of GEA and aims to provide a contemporary overview of the genetic mutations and molecular pathways implicated in GEA pathogenesis, highlighting potential therapeutic targets and the prospects of precision medicine in its management. Patients with GEA have variable clinical outcomes, with some exhibiting aggressive behavior while others follow a more indolent course. This review examines the factors contributing to this heterogeneity, including stage at diagnosis, histological grade, and genetic alterations, and their implications for patient prognoses. Treatment strategies for GEA remain a topic of debate and research. Here, we summarize the current therapeutic options, including surgery, radiation therapy, and chemotherapy, while also exploring emerging approaches, such as targeted therapies and immunotherapy. This article provides a comprehensive overview of GEA, synthesizing current knowledge from historical perspectives to contemporary insights, focusing on its classification, genetics, outcomes, and therapeutic strategies.

Evidence and best practices for trauma-informed care in gynecologic oncology patients.

Diagnosing, treating, and managing gynecologic cancer can lead to significant physical and emotional stress, which may have lasting effects on a patient's overall health and quality of life. The physical symptoms of gynecologic cancer, such as pain, discomfort, and loss of function, may also contribute to emotional distress and anxiety. Further, the diagnosis, treatment, and surveillance of gynecologic cancer may be traumatic due to the need for invasive exams and procedures, especially in women with a history of sexual assault or other traumatic experiences.Women with gynecologic cancer may experience various emotional and psychological symptoms, including anxiety, depression, post-traumatic stress disorder, and fear of recurrence. Trauma-informed care is an approach to healthcare that emphasizes the recognition and response to the impact of trauma on a patient's life. Further, trauma-informed care acknowledges that prior traumatic experiences may affect a patient's mental and physical health and that the healthcare system may unintentionally re-traumatize patients.Implementation of trauma-informed care can improve patient outcomes, increase patient satisfaction with care, and reduce the risk of re-traumatization during cancer treatment and follow-up care. Therefore, gynecologic oncology providers should become familiar with the principles and practices of trauma-informed care and implement trauma-informed screening tools to identify patients who may benefit from additional support or referrals to mental health services. This review will explore the importance of trauma-informed care in patients with gynecologic cancer and its impact on outcomes. Further, we discuss principles and evidence-based practices of trauma-informed care and strategies to implement trauma-informed screening tools to identify patients who may benefit from additional support or referrals to mental health services.

Assessment of socioeconomic and racial differences in patients undergoing concurrent gynecologic oncology and urogynecology surgeries: a National Inpatient Sample (NIS) database study.

OBJECTIVE: To assess social determinants of health impacting patients undergoing gynecologic oncology versus combined gynecologic oncology and urogynecology surgeries. METHODS: We identified patients who underwent gynecologic oncology surgeries from 2016 to 2019 in the National Inpatient Sample using the International Classification of Diseases-10 codes. Demographics, including race and insurance status, were compared for patients who underwent gynecologic oncology procedures only (Oncologic) and those who underwent concurrent incontinence or pelvic organ prolapse procedures (Urogynecologic-Oncologic). A logistic regression model assessed variables of interest after adjustment for other relevant variables. RESULTS: From 2016 to 2019 the National Inpatient Sample database contained 389 (1.14%) Urogynecologic-Oncologic cases and 33 796 (98.9%) Oncologic cases. Urogynecologic-Oncologic patients were less likely to be white (62.1% vs 68.8%, p=0.02) and were older (median 67 vs 62 years, p<0.001) than Oncologic patients. The Urogynecologic-Oncologic cohort was less likely to have private insurance as their primary insurance (31.9% vs 38.9%, p=0.01) and was more likely to have Medicare (52.2% vs 42.8%, p=0.01). After multivariable analysis, black (adjusted odds ratio (aOR) 1.41, 95% CI 1.05 to 1.89, p=0.02) and Hispanic patients (aOR 1.53, 95% CI 1.11 to 2.10, p=0.02) remained more likely to undergo Urogynecologic-Oncologic surgeries but the primary expected payer no longer differed significantly between the two groups (p=0.95). Age at admission, patient residence, and teaching location remained significantly different between the groups. CONCLUSIONS: In this analysis of a large inpatient database we identified notable racial and geographical differences between the cohorts of patients who underwent Urogynecologic-Oncologic and Oncologic procedures.

Primary Care Engagement Among Individuals with Experiences of Homelessness and Serious Mental Illness: an Evidence Map.

BACKGROUND: Experiences of homelessness and serious mental illness (SMI) negatively impact health and receipt of healthcare. Interventions that promote the use of primary care services for people with both SMI and homelessness may improve health outcomes, but this literature has not been evaluated systematically. This evidence map examines the breadth of literature to describe what intervention strategies have been studied for this population, elements of primary care integration with other services used, and the level of intervention complexity to highlight gaps for future intervention research and program development. METHODS: We followed an a priori protocol developed in collaboration with clinical stakeholders. We systematically searched the published literature to identify interventions for adults with homelessness who also had SMI. We excluded case reports, editorials, letters, and conference abstracts. Data abstraction methods followed standard practice. Data were categorized into intervention strategies and primary care integration strategies. Then we applied the Complexity Assessment Tool for Systematic Reviews (iCAT_SR) to characterize intervention complexity. RESULTS: Twenty-two articles met our inclusion criteria evaluating 15 unique interventions to promote engagement in primary care for adults with experiences of homelessness and SMI. Study designs varied widely from randomized controlled trials and cohort studies to single-site program evaluations. Intervention strategies varied across studies but primarily targeted patients directly (e.g., health education, evidence-based interactions such as motivational interviewing) with fewer strategies employed at the clinic (e.g., employee training, multidisciplinary teams) or system levels (e.g., data sharing). We identified elements of primary care integration, including referral strategies, co-location, and interdisciplinary care planning. Interventions displayed notable complexity around the number of intervention components, interaction between intervention components, and extent to which interventions were tailored to specific patient populations. DISCUSSION: We identified and categorized elements used in various combinations to address the primary care needs of individuals with experiences of homeless and SMI.

Implementing remote triage in large health systems: A qualitative evidence synthesis.

Remote triage (RT) allows interprofessional teams (e.g., nurses and physicians) to assess patients and make clinical decisions remotely. RT use has developed widespread interest due to the COVID-19 pandemic, and has future potential to address the needs of a rapidly aging population, improve access to care, facilitate interprofessional team care, and ensure appropriate use of resources. However, despite rapid and increasing interest in implementation of RT, there is little research concerning practices for successful implementation. We conducted a systematic review and qualitative evidence synthesis of practices that impact the implementation of RT for adults seeking clinical care advice. We searched MEDLINE®, EMBASE, and CINAHL from inception through July 2018. We included 32 studies in this review. Our review identified four themes impacting the implementation of RT: characteristics of staff who use RT, influence of RT on staff, considerations in selecting RT tools, and environmental and contextual factors impacting RT. The findings of our systemic review underscore the need for a careful consideration of (a) organizational and stakeholder buy-in before launch, (b) physical and psychological workplace environment, (c) staff training and ongoing support, and (d) optimal metrics to assess the effectiveness and efficiency of implementation. Our findings indicate that preimplementation planning, as well as evaluating RT by collecting data during and after implementation, is essential to ensuring successful implementation and continued adoption of RT in a health care system.

Effectiveness of Acute Care Remote Triage Systems: a Systematic Review.

BACKGROUND: Technology-based systems can facilitate remote decision-making to triage patients to the appropriate level of care. Despite technologic advances, the effects of implementation of these systems on patient and utilization outcomes are unclear. We evaluated the effects of remote triage systems on healthcare utilization, case resolution, and patient safety outcomes. METHODS: English-language searches of MEDLINE (via PubMed), EMBASE, and CINAHL were performed from inception until July 2018. Randomized and nonrandomized comparative studies of remote triage services that reported healthcare utilization, case resolution, and patient safety outcomes were included. Two reviewers assessed study and intervention characteristics independently for study quality, strength of evidence, and risk of bias. RESULTS: The literature search identified 5026 articles, of which eight met eligibility criteria. Five randomized, two controlled before-and-after, and one interrupted time series study assessed 3 categories of remote triage services: mode of delivery, triage professional type, and system organizational level. No study evaluated any other delivery mode other than telephone and in-person. Meta-analyses were unable to be performed because of study design and outcome heterogeneity; therefore, we narratively synthesized data. Overall, most studies did not demonstrate a decrease in primary care (PC) or emergency department (ED) utilization, with some studies showing a significant increase. Evidence suggested local, practice-based triage systems have greater case resolution and refer fewer patients to PC or ED services than regional/national systems. No study identified statistically significant differences in safety outcomes. CONCLUSION: Our review found limited evidence that remote triage reduces the burden of PC or ED utilization. However, remote triage by telephone can produce a high rate of call resolution and appears to be safe. Further study of other remote triage modalities is needed to realize the promise of remote triage services in optimizing healthcare outcomes. PROTOCOL REGISTRATION: This study was registered and followed a published protocol (PROSPERO: CRD42019112262).

The contribution of health anxiety to retrospectively-recalled emergency department visits within a sample of patients in residential substance abuse treatment.

With the burden of emergency department (ED) use increasing, research examining the factors associated with ED visits among individuals who use the ED most frequently is needed. Given that substance use is strongly linked to ED visits, this study sought to examine the factors associated with greater ED visits among patients with substance use disorders (SUD). More precisely, we examined whether health anxiety incrementally contributes to the prediction of ED visits for medical care among adult patients (N = 118) in a residential substance abuse disorder treatment facility. As predicted, health anxiety was significantly positively correlated with ED visits during the past year. Furthermore, health anxiety remained a significant predictor of ED visits after accounting for sociodemographic variables, frequency of substance use, and physical health status. These results suggest that health anxiety may contribute to increased ED visits for medical care among individuals with SUD.

Temporal Progression of Aortic Valve Pathogenesis in a Mouse Model of Osteogenesis Imperfecta.

Organization of extracellular matrix (ECM) components, including collagens, proteoglycans, and elastin, is essential for maintaining the structure and function of heart valves throughout life. Mutations in ECM genes cause connective tissue disorders, including Osteogenesis Imperfecta (OI), and progressive debilitating heart valve dysfunction is common in these patients. Despite this, effective treatment options are limited to end-stage interventions. Mice with a homozygous frameshift mutation in col1a2 serve as a murine model of OI (oim/oim), and therefore, they were used in this study to examine the pathobiology of aortic valve (AoV) disease in this patient population at structural, functional, and molecular levels. Temporal echocardiography of oim/oim mice revealed AoV dysfunction by the late stages of disease in 12-month-old mice. However, structural and proteomic changes were apparent much earlier, at 3 months of age, and were associated with disturbances in ECM homeostasis primarily related to collagen and proteoglycan abnormalities and disorganization. Together, findings from this study provide insights into the underpinnings of late onset AoV dysfunction in connective tissue disease patients that can be used for the development of mechanistic-based therapies administered early to halt progression, thereby avoiding late-stage surgical intervention.

Examining the association between emotion regulation difficulties and probable posttraumatic stress disorder within a sample of African Americans.

This study examined the associations between emotion dysregulation and probable posttraumatic stress disorder (PTSD) among 180 African American undergraduates enrolled in a historically black college in the southern United States. Trauma-exposed participants with probable PTSD reported significantly higher levels of overall emotion dysregulation and the specific dimensions of lack of emotional acceptance, difficulties engaging in goal-directed behavior when upset, difficulties controlling impulsive behaviors when distressed, and limited access to effective emotion regulation strategies than participants without Criterion A traumatic exposure and those with Criterion A traumatic exposure but no PTSD (controlling for age and negative affect). Furthermore, results indicated that participants with Criterion A traumatic exposure but no PTSD were significantly less likely to report difficulties controlling impulsive behaviors when distressed and limited access to effective emotion regulation strategies than participants without Criterion A traumatic exposure (controlling for age and negative affect). These findings extend extant research on the role of emotion dysregulation in PTSD, thus providing support for the relevance of emotion dysregulation to PTSD among African American adults in particular.

Discrepancies between explicit and implicit self-esteem: implications for mate retention strategies and perceived infidelity.

The purpose of the present study was to examine whether the association between explicit self-esteem and relationship outcomes was moderated by implicit self-esteem. This was accomplished by asking 210 undergraduates who were currently involved in romantic relationships to complete measures of their explicit self-esteem, implicit self-esteem, mate retention strategies, and likelihood of future infidelity. Implicit self-esteem was found to moderate the association between high explicit self-esteem and relationship outcomes for male participants such that men with discrepant high self-esteem (i.e., high explicit self-esteem but low implicit self-esteem) reported less use of mate retention strategies and perceived a greater likelihood of future infidelity in their relationships during the next year. These findings provide additional support for the idea that fragile self-esteem may have consequences for the manner in which individuals perceive their relationships.

Irrational health beliefs and health anxiety.

The Irrational Health Belief Scale (IHBS) assesses the tendency to appraise health-related information in an irrational manner. Despite the central role that dysfunctional assumptions about health play in the cognitive-behavioral model of hypochondriasis and health anxiety, researchers have not examined the relation between health anxiety and the types of irrational health beliefs assessed by the IHBS. Two samples (n = 198, n = 295) of students completed the IHBS and measures of anxiety and health anxiety. In both studies, the IHBS was correlated with health anxiety, and this association was mediated by anxiety. These findings suggest that the range of dysfunctional beliefs associated with health anxiety is greater than was initially described by the cognitive-behavioral model.

Lead and conduct problems: a meta-analysis.

This meta-analysis examined the association between conduct problems and lead exposure. Nineteen studies on 8,561 children and adolescents were included. The average r across all 19 studies was .19 (p < .001), which is considered a medium effect size. Studies that assessed lead exposure using hair element analysis yielded considerably larger effect sizes than those that assessed lead exposure using blood, tooth, or bone lead levels. Excluding the 3 hair analysis studies, the average r was .15 (p < .001). The age of the participants did not significantly moderate the relation between lead exposure and conduct problems. Overall, the relation between lead exposure and conduct problems was strikingly similar in magnitude to the relation between lead exposure and decreased IQ.

Emergency Department Interventions for Older Adults: A Systematic Review.

OBJECTIVES: To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults. DESIGN: A conceptual model informed, protocol-based systematic review. SETTING: Emergency Department (ED). PARTICIPANTS: Older adults 65 years of age and older. METHODS AND MEASUREMENT: Medline, Embase, CINAHL, and PsycINFO were searched for English-language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi-strategy) and key intervention components present (ie, assessment, referral plus follow-up, and contact both before and after ED discharge ["bridge"]). The effect of ED interventions on clinical (functional status, quality of life [QOL]), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated. RESULTS: A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit. CONCLUSION: Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.

Life Program: Pilot Testing a Palliative Psychology Group Intervention.

BACKGROUND: Psychosocial interventions for palliative care populations, individuals with life-limiting illness, improve distress; however, less is known about these interventions among military Veterans. OBJECTIVES: This quality improvement project evaluated a palliative psychology group intervention to reduce depression, anxiety, and stress among Veterans with advanced life-limiting illness. METHODS: Veterans receiving palliative care at a mid-Atlantic VA healthcare system were referred by a mental health provider. The group intervention was delivered face-to-face in six to eight weekly sessions, with groups of four to eight participants. The intervention (Life Program), was a hybrid of cognitive-behavioral therapy and acceptance and commitment therapy that targeted: personal values, mindfulness, and psychological flexibility. A single-arm pre-post-test design was used to assess depression, anxiety, and stress, and satisfaction with the intervention. RESULTS: Seventy-five percent (39/52) of all Veterans who were contacted expressed interest and agreed to participate. Seventeen of 39 enrolled Veterans completed all sessions. The mean age of participants who completed the program was 63.06 (standard deviation = 8.47). Most participants were male (88%), Caucasian (58%), and had a cancer diagnosis (65%). Mean pre-post reductions in depression (18.82 vs. 13.20), anxiety (16.59 vs. 14.59), stress (19.18 vs. 13.88), and psychological inflexibility were observed. Mean differences in symptom severity were clinically meaningful. Barriers to feasibility included transportation issues and illness burden. CONCLUSIONS: Veterans who completed all sessions of a palliative psychology group intervention had reductions in depression, anxiety, and stress. Estimates of the treatment effects may be inflated using completer data alone. Further research is needed to inform ways to improve program engagement and adherence and examine efficacy in Veterans with advanced life-limiting illness.

Psychotherapy Targeting Depression and Anxiety for Use in Palliative Care: A Meta-Analysis.

BACKGROUND: Research on the effectiveness of evidence-based practices in the treatment of depression and anxiety with palliative care populations is primarily limited to individuals having specific conditions such as cancer. OBJECTIVE: This meta-analysis examined the effect of psychotherapy on depression and anxiety among individuals with any condition appropriate for palliative care. METHODS: We searched PubMed, PsycINFO, Cochrane Library, and EMBASE databases until August 2017. Eligible studies were randomized controlled trials of psychotherapy that reported outcomes of depression and anxiety and included adults with serious illnesses. RESULTS: The current meta-analysis included 32 randomized controlled trials with 36 samples including 1536 participants undergoing psychotherapy. Overall, findings suggest that psychotherapy in palliative care populations reduced depression (large effect) and anxiety (small effect) symptoms. Psychotherapy also improved quality of life (small effect). Significant moderators of intervention effects included type of intervention and provider, number and length of treatment sessions, and sample age. Cognitive-behaviorally based and other therapies (e.g., acceptance, mindfulness) showed significant effects, as did interventions delivered by mental health providers. More treatment sessions were associated with greater effect sizes; longer sessions were associated with decreased effect sizes. As the sample age increased, the study effect size decreased. CONCLUSION: Findings suggest that psychotherapy for individuals with serious illnesses appropriate for palliative care can mitigate symptoms of depression and anxiety and improve quality of life. Methodological reporting and quality of research designs in studies of psychotherapy for palliative patient populations could be improved. Future research is needed with a broader range of patient populations.

Steroids in second degree caustic burns of the esophagus: a systematic pooled analysis of fifty years of human data: 1956-2006.

BACKGROUND AND OBJECTIVE: Although steroids are usually withheld in grades I and III esophageal burns, controversy continues regarding their use in grade II burns. Two analyses, including data from 1956-1991 and 1991-2003, respectively, disagreed in their therapeutic recommendations. Our objective is to re-evaluate the usefulness of steroids in grade II burns. METHODS: The two previous analyses and their references were reviewed. Medline was searched for additional recent human reports. Inclusion criteria were endoscopically documented grade II burns and at least ten days of steroids or no steroids. Pooled data were evaluated by X(2) test with alpha set at 0.05. RESULTS: Prior analyses identified 12 studies, and one additional study was found during the literature search for a total of 328 patients. 30/244 patients receiving steroids and 16/84 patients who did not receive steroids developed strictures, respectively. This difference was not statistically significant. Heterogeneity of the data prevented formal metanalysis. CONCLUSION: Although methodologically limited, the existing data fail to support the use of steroids in patients with caustic-induced grade II esophageal burns.

Renal infarction during the use of rizatriptan and zolmitriptan: two case reports.

Rizatriptan and zolmitriptan are both used to relieve acute migraine and cluster headaches. The mechanism of action is similar to the other triptans, in that they reverse abnormal cerebral vasodilation through their activity as 5-HT1B receptor agonists. Triptan-induced vasoconstriction is attributed to its activity on peripheral 5-HT1B receptors and has rarely been reported to result in stroke, myocardial infarction and ischemic colitis. We present two cases of renal infarction associated with therapeutic triptan use. The first patient is a 57-year-old man with a history of hypertension that was well controlled on valsartan and hydrochlorothiazide. He was recently diagnosed with cluster headaches and was treated with indomethacin, prednisone, butalbital-acetaminophen-caffeine and hydrocodone without relief. He then received two therapeutic doses of rizatriptan on each of the two days prior to presentation. Subsequently, he presented to the emergency department complaining of nausea, vomiting and right-sided abdominal pain. A computerized tomography (CT) scan of the abdomen and pelvis with intravenous contrast revealed a very large wedge shaped infarction of the right kidney. The second patient is a 34-year-old man with a past medical history significant only for life-long migraine headaches successfully treated for the past six years with zolmitriptan. Shortly after taking one therapeutic dose of zolmitriptan, he presented to the emergency department complaining of nausea and left-sided abdominal pain. A CT scan of the abdomen and pelvis with intravenous contrast revealed multiple wedge-shaped infarctions of the left kidney. Renal infarction was confirmed in both patients by arteriogram of the renal arteries. Although both rizatriptan and zolmitriptan are effective in the treatment of migraine and cluster headaches, they may induce peripheral vasospasm leading to renal infarction.