There is Little or No Association Between Independently Assessed Communication Strategies and Patient Ratings of Clinician Empathy.

BACKGROUND: Quality of care is increasingly assessed and incentivized using measures of patient-reported outcomes and experience. Little is known about the association between measurement of clinician communication strategies by trained observers and patient-rated clinician empathy (a patient-reported experience measure). An effective independent measure could help identify and promote clinician behaviors associated with good patient experience of care. QUESTIONS/PURPOSES: (1) What is the association between independently assessed clinician communication effectiveness and patient-rated clinician empathy? (2) Which factors are associated with independently assessed communication effectiveness? METHODS: One hundred twenty adult (age > 17 years) new or returning patients seeking musculoskeletal specialty care between September 2019 and January 2020 consented to video recording of their visit followed by completion of questionnaires rating their perceptions of providers' empathy levels in this prospective study. Patients who had operative treatment and those who had nonoperative treatment were included in our sample. We pooled new and returning patients because our prior studies of patient experience found no influence of visit type and because we were interested in the potential influences of familiarity with the clinician on empathy ratings. We did not record the number of patients or baseline data of patients who were approached, but most patients (> 80%) were willing to participate. For 7% (eight of 120 patients), there was a malfunction with the video equipment or files were misplaced, leaving 112 records available for analysis. Patients were seen by one provider among four attending physicians, four residents, or four physician assistants or nurse practitioners. The primary study question addressed the correlation between patient-rated clinician empathy using the Jefferson Scale of Patient Perceptions of Physician Empathy and clinician communication effectiveness, independently rated by two communication scholars using the Liverpool Communication Skills Assessment Scale. Based on a subset of 68 videos (61%), the interrater reliability was considered good for individual items on the Liverpool Communication Skills Assessment Scale (intraclass correlation coefficient [ICC] 0.78 [95% confidence interval (CI) 0.75 to 0.81]) and excellent for the sum of the items (that is, the total score) (ICC = 0.92 [95% CI 0.87 to 0.95]). To account for the potential association of personal factors with empathy ratings, patients completed measures of symptoms of depression (the Patient-Reported Outcome Measurement Information System depression computerized adaptive test), self-efficacy in response to pain (the two-item Pain Self-Efficacy Questionnaire), health anxiety (the five-item Short Health Anxiety Inventory), and basic demographics. RESULTS: Accounting for potentially confounding variables, including specific clinicians, marital status, and work status in the multivariable analysis, we found higher independent ratings of communication effectiveness had a slight association (odds ratio [OR] 1.1 [95% CI 1.0 to 1.3]; p = 0.02) with higher (dichotomized) ratings of patient-rated clinician empathy, while being single was associated with lower ratings (OR 0.40 [95% CI 0.16 to 0.99]; p = 0.05). Independent ratings of communication effectiveness were slightly higher for women (regression coefficient 1.1 [95% CI 0.05 to 2.2]); in addition, two of the four attending physicians were rated notably higher than the other 10 participants after controlling for confounding variables (differences up to 5.8 points on average [95% CI 2.6 to 8.9] on a 36-point scale). CONCLUSION: The observation that ratings of communication effectiveness by trained communication scholars have little or no association with patient-rated clinician empathy suggests that either effective communication is insufficient for good patient experience or that the existing measures are inadequate or inappropriate. This line of investigation might be enhanced by efforts to identify clinician behaviors associated with better patient experience, develop reliable and effective measures of clinician behaviors and patient experience, and use those measures to develop training approaches that improve patient experience. LEVEL OF EVIDENCE: Level I, prognostic study .

Human herpesvirus 8-negative effusion-based large B-cell lymphoma: a distinct entity with unique clinicopathologic characteristics.

Rare cases of human herpesvirus 8 (HHV8)-negative effusion-based large B-cell lymphoma (EB-LBCL) occur in body cavities without antecedent or concurrent solid mass formation. In contrast to HHV8 + primary effusion lymphoma (PEL), EB-LBCL has no known association with HIV or HHV8 infection. However, the small sample sizes of case reports and series worldwide, especially from non-Japanese regions, have precluded diagnostic uniformity. Therefore, we conducted a retrospective, multi-institutional study of 55 cases of EB-LBCL and performed a comprehensive review of an additional 147 cases from the literature to identify distinct clinicopathologic characteristics. In our study, EB-LBCL primarily affected elderly (median age 80 years), immunocompetent patients and manifested as lymphomatous effusion without a solid component. The lymphomatous effusions mostly occurred in the pleural cavity (40/55, 73%), followed by the pericardial cavity (17/55, 31%). EB-LBCL expressed CD20 (53/54, 98%) and PAX5 (23/23, 100%). Most cases (30/36, 83%) were of non-germinal center B-cell subtype per the Hans algorithm. HHV8 infection was absent (0/55, 0%), while Epstein-Barr virus was detected in 6% (3/47). Clinically, some patients were managed with drainage alone (15/34, 44%), while others received rituximab alone (4/34, 12%) or chemotherapy (15/34, 44%). Eventually, 56% (22/39) died with a median overall survival (OS) of 14.9 months. Our findings were similar to those from the literature; however, compared to the non-Japanese cases, the Japanese cases had a significantly higher incidence of pericardial involvement, a higher rate of chemotherapy administration, and longer median OS. Particularly, we have found that Japanese residence, presence of pericardial effusion, and absence of MYC rearrangement are all favorable prognostic factors. Our data suggest that EB-LBCL portends a worse prognosis than previously reported, although select patients may be managed conservatively. Overall, EB-LBCL has distinct clinicopathologic characteristics, necessitating the establishment of separate diagnostic criteria and consensus nomenclature.

Can Crafted Communication Strategies Allow Musculoskeletal Specialists to Address Health Within the Biopsychosocial Paradigm?

BACKGROUND: Musculoskeletal specialists who attempt to discuss the connection between mental health (thoughts and emotions) and physical health (symptom intensity and activity tolerance) with patients, may fear that they risk offending those patients. In a search for language that creates comfort with difficult conversations, some specialists favor a biomedical framework, such as central sensitization, which posits abnormal central neuron activity. Without addressing the relative accuracy of mind- or brain-based conceptualizations, we addressed crafted and practiced communication strategies as conversation starters that allow specialists to operate within a biopsychosocial framework without harming the relationship with the patient. QUESTIONS/PURPOSES: We measured (1) patient resonance with various explanations of the mind-body connection, including examples of both mind- and brain-based communication strategies, and (2) factors associated with resonance and emotional reactions to the explanations. METHODS: In this cross-sectional study, all adult new and returning patients who were literate in English and who attended several musculoskeletal specialty offices were invited to complete questionnaires addressing reactions to one of seven explanations of the mind-body connection assigned using a random number generator. Acknowledging that the relative accuracy of mind-based and nerve- or brain-based strategies are speculative, we developed the following conversation starters: two explanations that were cognitively framed ("the mind is a great story teller"; one positively framed and one negatively framed), two emotionally framed explanations ("stressed or down"; one positively framed and one negatively framed), one mentioning thoughts and emotions in more neutral terms ("mind and body work together … thoughts and emotions affect the way your body experiences pain"), and two biomedical neurophysiology-based explanations ("nerves get stuck in an over-excited state" and "overstimulated nerves"), all crafted with the assistance of a communication scholar. It was unusual for people to decline (although the exact number of those who did was not tracked) and 304 of 308 patients who started the questionnaires completed them and were analyzed. In this sample, 51% (155 of 304) were men, and the mean ± SD age was 49 ± 17 years. Reactions were measured as resonance (a 1 to 5 Likert scale regarding the degree to which the stated concept aligns with their understanding of health and by inference is a comfortable topic of discussion) and self-assessment manikins using circled figurines to measure feelings of happiness (frowning to smiling figures), stimulation/excitement (a relaxed sleepy figure to an energized wide-eyed figure), and security/control (small to large figures). These are commonly used to quantify the appeal and emotive content of a given message. Patients also completed surveys of demographics and mental health. Multilevel multivariable linear regression models were constructed to assess factors associated with resonance, happiness, excitement, and control. RESULTS: Controlling for potential confounding variables such as demographics and mental health measures, a relatively neutral biopsychosocial explanation ("mind and body work together") had the greatest mean resonance (4.2 ± 0.8 versus 3.8 ± 0.9 for the other explanations; p < 0.01) and the largest regression coefficient for resonance (0.78 [95% confidence interval 0.41 to 1.15]). The next-most-resonant explanations were biomedical ("excitable nerves", "over-excited state"). Biopsychosocial explanations that mention stress, distress, or cognitive bias ("mind is a great storyteller") had lower resonance. People with greater unhealthy cognitive bias regarding pain (more catastrophic thinking) were less comfortable with all the explanations (lower resonance, regression coefficient -0.03 [95% CI -0.06 to -0.01]). Emotional reactions were relatively comparable with the exception that people felt less control and security with specific explanations such as "excitable nerves" and "mind is a great storyteller." CONCLUSION: Crafted communication strategies allow musculoskeletal specialists to address health within the biopsychosocial paradigm without harming their relationship with the patient. CLINICAL RELEVANCE: Musculoskeletal specialists may be the first clinicians to notice mental health opportunities. It may be helpful for them to develop and practice effective communication strategies that make mental health a comfortable topic of discussion.

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying.

BACKGROUND: Research consistently documents no correlation between the duration of a musculoskeletal specialty care visit and patient experience (perceived empathy of the specialist and satisfaction with care). Based on a combination of clinical experience and other lines of research, we speculate that longer visits are often related to discordance between specialist and patient interpretation of symptoms and weighting of available test and treatment options. If this is true, then the specific duration of time discussing the specialist's interpretations and options with the patient (expertise transfer) might correlate with satisfaction with care and perceived empathy of the clinician even if the total visit time does not. QUESTIONS/PURPOSES: (1) What demographic or mental health factors are associated with the duration of expertise transfer? (2) What factors, including the duration of expertise transfer, are associated with the patient's satisfaction with the visit and perceived clinician empathy? METHODS: In a cross-sectional study, 128 new and returning English-speaking adult outpatients seeking care from one of three orthopaedic specialists in two urban practices between September and November 2019 were enrolled and agreed to audio recording of the visit. A total of 92% (118) of patients completed the questionnaire and had a usable recording. Participants completed a sociodemographic survey, the Patient-Reported Outcome Measure Information System Depression computer adaptive test (PROMIS Depression CAT; a measure of symptoms of depression), the Short Health Anxiety Index (SHAI-5; a measure of symptoms of hypochondriasis, a form of symptoms misinterpretation), the Pain Catastrophizing Scale (PCS-4; a measure of misinterpretation of symptoms), an ordinal measure of patient satisfaction (dichotomized into satisfied or not because of strong ceiling effects), and the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE; a measure of perceived clinician empathy). The duration of expertise transfer and the total duration of the visit were measured by two raters with acceptable reliability using software that facilitates segmentation of the visit audio recording. To determine factors associated with the duration of expertise transfer, satisfaction, and empathy, we planned a multivariable analysis controlling for potential confounding variables identified in exploratory bivariable analysis. However, there were insufficient associations to merit multivariable analysis. RESULTS: A longer duration of expertise transfer had a modest correlation with catastrophic thinking (r = 0.24; p = 0.01). Complete satisfaction with the visit was associated with less health anxiety (6 [interquartile range 5 to 7] for complete satisfaction versus 7 [5 to 7] for less than complete satisfaction; p = 0.02) and catastrophic thinking (4 [1 to 7] versus 5 [3 to 11]; p = 0.02), but not with the duration of expertise transfer. Greater perceived clinician empathy had a slight correlation with less health anxiety (r = -0.19; p = 0.04). CONCLUSION: Patients with greater misinterpretation of symptoms experience a slightly less satisfying visit and less empathetic relationship with a musculoskeletal specialist despite a longer duration of expertise transfer. This supports the concept that directive strategies (such as teaching healthy interpretation of symptoms) may be less effective then guiding strategies (such as nurturing openness to alternative, healthier interpretation of symptoms using motivational interviewing tactics, often over more than one visit or point of contact). LEVEL OF EVIDENCE: Level II, therapeutic study.

Does a Previsit Phone Call from the Surgeon Reduce Decision Conflict?

Background: There is some evidence that previsit strategies can make in-person visits more productive and efficient. We compared between people who received a phone call before a musculoskeletal specialty visit and people who did not with respect to several factors: (1) decision conflict (difficulty deciding between two or more options), (2) perceived clinician empathy after an in-person visit, and (3) arrival for the scheduled in-person appointment. We also recorded the specialist's opinion that the phone call alone could adequately replace an in-person visit while maintaining quality, safety, and effectiveness. Materials and Methods: In this prospective randomized-controlled trial, 122 patients were enrolled and randomized to receive a previsit phone call by an orthopedic surgeon before a scheduled visit or not. After the in-person visit, patients completed a (1) demographic questionnaire including age, gender, race/ethnicity, marital status, level of education, work status, and comorbidities; (2) Decision Conflict Scale; and (3) Jefferson Scale of Patient Perceptions of Physician Empathy. Results: No significant difference was found between the two groups in decision conflict, perceived empathy, or not attending the scheduled visit. Of the 55 successful phone calls, the surgeon felt that 50 (91%) had the potential to safely and effectively replace an in-person visit. Conclusion: Although a previsit phone call did not reduce decision conflict or improve the patient experience as measured after one visit, there may be merit in studying an increased number of touch points, particularly with some subsets of illness featuring substantial stress or misconceptions. The identified potential for the application and transfer of specialty expertise through telephone alone also merits additional study.

MFAssignR: Molecular formula assignment software for ultrahigh resolution mass spectrometry analysis of environmental complex mixtures.

Ultrahigh resolution mass spectrometry is widely used for nontargeted analysis of complex environmental and biological mixtures, such as dissolved organic matter, due to its unparalleled ability to provide accurate mass measurements. Accurate and efficient characterization of these mixtures is critical to being better able to evaluate their effect on human health and climate. This characterization requires accurate mass signals free from isobaric interferences, instrument noise, and mass measurement biases, allowing for molecular formula identification. To address this need, an open source post-processing pipeline for ultrahigh resolution mass spectra of environmental complex mixtures software was developed. MFAssignR contains functions that perform noise estimation, 13C and 34S polyisotopic mass filtering, mass measurement recalibration, and molecular formula assignment as part of a consistent data processing environment. Novel applications of mass defect analysis were used in the functions for noise estimation and isotope pair identification. Using formula extensions, exact mass measurements are converted to unambiguous molecular formulas via data dependent pathways, reducing a priori decisions. Optional molecular formula ambiguity and multiple non-oxygen heteroatoms are provided for custom user applications, including isotopically labeled reactive species, halogen-containing species, or tandem ultrahigh resolution mass spectrometry. This represents uncommon flexibility for an open-source software package. To evaluate the performance of MFAssignR, it was used to characterize a sample of biomass burning influenced organic aerosol and the results were compared to those from other available methods of molecular formula assignment and noise estimation. The differences between the methods are described here. Overall, the inclusion of a full pipeline of data preparation functions and the data-dependent ambiguity reductions in MFAssignR render excellent results and make MFAssignR well-suited for the consistent and efficient analysis of environmental complex mixtures. MFAssignR is publicly available via GitHub.

Development of a health communication campaign to promote the Texas prescription monitoring program.

Given the role opioid overprescribing has played in the current overdose crisis, reducing the supply of prescription opioids available for misuse has gained widespread support. Prescription monitoring programs (PMPs) have been identified as a tool for achieving this goal, but little is known about how to promote PMP use to prescribers. This paper describes the process of developing a health communication campaign to support the adoption of the Texas PMP. After formative research, message development and concept testing, a range of campaign concepts and messages were tested and final recommendations determined. The messages and lessons learned have utility beyond Texas.

γ-Aminobutyric Acid Type A (GABAA) Receptor Subunits Play a Direct Structural Role in Synaptic Contact Formation via Their N-terminal Extracellular Domains.

The establishment of cell-cell contacts between presynaptic GABAergic neurons and their postsynaptic targets initiates the process of GABAergic synapse formation. GABAA receptors (GABAARs), the main postsynaptic receptors for GABA, have been recently demonstrated to act as synaptogenic proteins that can single-handedly induce the formation and functional maturation of inhibitory synapses. To establish how the subunit composition of GABAARs influences their ability to induce synaptogenesis, a co-culture model system incorporating GABAergic medium spiny neurons and the HEK293 cells, stably expressing different combinations of receptor subunits, was developed. Analyses of HEK293 cell innervation by medium spiny neuron axons using immunocytochemistry, activity-dependent labeling, and electrophysiology have indicated that the γ2 subunit is required for the formation of active synapses and that its effects are influenced by the type of α/ß subunits incorporated into the functional receptor. To further characterize this process, the large N-terminal extracellular domains (ECDs) of α1, α2, ß2, and γ2 subunits were purified using the baculovirus/Sf9 cell system. When these proteins were applied to the co-cultures of MSNs and α1/ß2/γ2-expressing HEK293 cells, the α1, ß2, or γ2 ECD each caused a significant reduction in contact formation, in contrast to the α2 ECD, which had no effect. Together, our experiments indicate that the structural role of GABAARs in synaptic contact formation is determined by their subunit composition, with the N-terminal ECDs of each of the subunits directly participating in interactions between the presynaptic and postsynaptic elements, suggesting the these interactions are multivalent and specific.

"The uncertainty is what is driving me crazy": the tripartite model of uncertainty in the adolescent and young adult cancer context.

Building on scholarship indicating that uncertainty is a fundamental component of the cancer experience, this study focuses on an understudied population: adolescents and young adults (AYAs) with cancer. Because AYAs' health outcomes lag behind those of older and younger people with cancer, scholars have recommended that the subjective experiences of AYAs be better understood. Using the tripartite model of uncertainty sources as a guiding framework, we analyzed naturally occurring messages from an online discussion forum for AYA cancer survivors. The majority of messages communicating uncertainty expressed medical uncertainty regarding the complexities of understanding treatment options and sequelae. Results indicated that several overarching areas of AYA uncertainty correspond to themes reported by other cancer populations, but that some distinctive concerns arise amid the normative complexities of late adolescence and young adulthood.

The relationship of perceived empathy with levels of pain intensity and incapability among patients visiting a musculoskeletal specialist.

BACKGROUND: People that have more intense symptoms and greater incapability might have less rapport with the clinicians that care for them. OBJECTIVE: This study tested the hypothesis that perceived clinician empathy is related to pain intensity and magnitude of incapability among people seeing a musculoskeletal specialist. PATIENT INVOLVEMENT: After a consult with a musculoskeletal specialist, 211 adult patients completed a survey recording demographics, and measures of pain intensity, incapability, and perceived clinician empathy. RESULTS: Higher perceived empathy was associated with being in a committed relationship and, to a modest degree (r = -0.16) lower pain intensity in bivariate and multivariable analyses. DISCUSSION: People experiencing greater pain may be slightly less likely to perceive the clinician as empathetic. PRACTICAL VALUE: Study of the relationship between the patient's experience of care and patient and clinician personal factors can inform efforts to improve patient experience. Advances may depend on experience measures with more normal distributions and less ceiling effect.

An interactive e-learning module on peripheral blood smear analysis is an effective option for teaching pathology trainees.

OBJECTIVES: This study compares the effectiveness of an interactive e-learning module with a traditional text-based method for teaching peripheral blood smear analysis. METHODS: Pathology trainees at Accreditation Council for Graduate Medical Education residency programs were asked to participate. Participants completed a multiple-choice test on peripheral blood smear findings. Trainees were randomized into completing an e-learning module or a PDF reading exercise with the same educational content. Respondents rated their experience and completed a postintervention test composed of the same questions. RESULTS: In total, 28 participants completed the study; 21 improved their score in the posttest (mean, 21.6 correct answers) compared with the pretest (19.8; P < .001). This improvement was seen in both the PDF (n = 19) and interactive (n = 9) groups, with no difference in performance between the 2 groups. Trainees with less clinical hematopathology experience showed a trend of having the largest performance improvement. Most participants completed the exercise within 1 hour, rated the exercise as easy to navigate, were engaged, and reported learning new information about peripheral blood smear analysis. All participants indicated that they would likely complete a similar exercise in the future. CONCLUSIONS: This study suggests that e-learning is an effective tool for hematopathology education and equivalent to traditional narrative-based methods. This module could easily be incorporated into a curriculum.

Sources of uncertainty in type 2 diabetes: explication and implications for health communication theory and clinical practice.

According to the American Diabetes Association, nearly 24 million Americans live with type 2 diabetes, and clinical data project that this figure will increase 165% from 2000 to 2050. Thus, there is a pressing need to understand not only the physiological and medical needs, but also the psychological demands associated with the illness. Even though uncertainty has been explicated in various other illness contexts and potentially shapes the experience of type 2 diabetes, very little attention has been paid to the nature of uncertainty in this context. The present study examines the nature of uncertainty through qualitative interviews with 49 individuals diagnosed with type 2 diabetes. Using grounded theory methods, various themes emerged relative to the sources of uncertainty. These themes are discussed in light of their potential extension of health communication theory and application to intervention and educational programs for individuals living with type 2 diabetes.

Caring for a parent with lung cancer: caregivers' perspectives on the role of communication.

We investigated communication and care in the context of lung cancer through qualitative interviews with 35 adult children. Participants described two core influences on communication: situational and relational influences. Participants also suggested that the ways in which support was communicated impacted how they managed challenges and how they were able to cope with the loss of their parent. This research adds to the literature on caregiving and communicating social support by exploring the experiences of families coping with lung cancer. We suggest theoretical and practical implications for the ways family members might communicate about illness.

Dapsone-induced methemoglobinemia and hemolysis in a woman without G6PD deficiency presenting with idiopathic urticaria.

BACKGROUND: The appearance of bite cells associated with methemoglobinemia can be caused by oxidizing drugs such as dapsone in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency or high drug serum levels. Bite cells are often pathognomonic for oxidant injury in patients with G6PD deficiency and suggest active hemolysis. CASE PRESENTATION: We report a case of a woman with no prior history of G6PD deficiency who presented with anemia, methemoglobinemia and bite cells on peripheral blood smear after dapsone therapy for new onset idiopathic urticaria. Laboratory tests for G6PD, blood count and liver function were within normal limits prior to initiation of therapy. During the patient's hospital course, moderate methemoglobinemia and anemia were identified despite mildly increased serum G6PD level. These pathologies were reversed upon stopping dapsone therapy. CONCLUSION: This case highlights the potential for therapeutic levels of dapsone to induce side effects in patients without G6PD deficiency and highlights the importance of routine blood monitoring for anemia and hemolysis during the course of drug therapy.

A Two Question Screen for Mental Health Opportunities.

BACKGROUND: Shortened versions of validated PRO measures of coping strategies e.g. PSEQ-2, may facilitate screening and monitoring of psychological conditions such as depression and anxiety. The primary research question in this study assesses the sensitivity and specificity of a PSEQ-2 score of less than 10 for important symptoms of depression (a PHQ-2 score greater than 2), anxiety (GAD-2 score greater than 2), any impactful prior episode of psychological trauma, and QuickDASH greater than 49. Secondarily we assess the associations between self-efficacy and other demographic and psychological factors on the magnitude of limitations and pain intensity. METHODS: We performed a retrospective PRO evaluation in 926 adult patients attending an upper extremity clinic between 1st January 2018 and 31st January 2019. Demographic factors were assessed using electronic medical records and PRO data using an online platform. Patients included 556 (60%) women, 370 (40%) men (mean 51 years ± 14 (range, 19-88), mostly (n=584, 63%) with safety net insurance. RESULTS: A PSEQ-2 scoring threshold of less than 10 was 81% sensitive for a PHQ-2 score of 3 or greater, 84% sensitive for a GAD-2 score of 3 or greater, 84% sensitive for one or more important psychological traumas, and 82% sensitive for a QuickDASH of 50 or greater. PSEQ-2 less than 10 was independently associated with greater upper extremity limitations (ß=11 [6.3 to 17, 95% Confidence interval [C.I], P<0.001) and pain intensity (ß=0.92 (0.31 to 1.5, 95% C.I) P=0.003) amongst other psychological and demographic factors. CONCLUSION: A PSEQ-2 score of less than 10 might, along with verbal and non-verbal signs of distress, be a useful way to introduce the use of more sensitive screening questionnaires about anxiety or depression, or open up the option of speaking directly to mental or social health professionals. Future studies are required to test this hypothesis.

New developments in non-Hodgkin lymphoid malignancies.

The revised fourth edition of the World Health Organization (WHO) Classification of Tumours of Haematopoietic and Lymphoid Tissues (2017) reflects significant advances in understanding the biology, genetic basis and behaviour of haematopoietic neoplasms. This review focuses on some of the major changes in B-cell and T-cell non-Hodgkin lymphomas in the 2017 WHO and includes more recent updates. The 2017 WHO saw a shift towards conservatism in the classification of precursor lesions of small B-cell lymphomas such as monoclonal B-cell lymphocytosis, in situ follicular and in situ mantle cell neoplasms. With more widespread use of next generation sequencing (NGS), special entities within follicular lymphoma and mantle cell lymphoma were recognised with recurrent genetic aberrations and unique clinicopathological features. The diagnostic workup of lymphoplasmacytic lymphoma and hairy cell leukaemia has been refined with the discovery of MYD88 L265P and BRAF V600E mutations, respectively, in these entities. Recommendations in the immunohistochemical evaluation of diffuse large B-cell lymphoma include determining cell of origin and expression of MYC and BCL2, so called 'double-expressor' phenotype. EBV-positive large B-cell lymphoma of the elderly has been renamed to recognise its occurrence amongst a wider age group. EBV-positive mucocutaneous ulcer is a newly recognised entity with indolent clinical behaviour that occurs in the setting of immunosuppression. Two lymphomas with recurrent genetic aberrations are newly included provisional entities: Burkitt-like lymphoma with 11q aberration and large B-cell lymphoma with IRF4 rearrangement. Aggressive B-cell lymphomas with MYC, BCL2 and/or BCL6 rearrangements, so called 'double-hit/triple-hit' lymphomas are now a distinct entity. Much progress has been made in understanding intestinal T-cell lymphomas. Enteropathy-associated T-cell lymphoma, type II, is now known to not be associated with coeliac disease and is hence renamed monomorphic epitheliotropic T-cell lymphoma. An indolent clonal T-cell lymphoproliferative disorder of the GI tract is a newly included provisional entity. Angioimmunoblastic T-cell lymphoma and nodal T-cell lymphomas with T-follicular helper phenotype are included in a single broad category, emphasising their shared genetic and phenotypic features. Anaplastic large cell lymphoma, ALK- is upgraded to a definitive entity with subsets carrying recurrent rearrangements in DUSP22 or TP63. Breast implant-associated anaplastic large cell lymphoma is a new provisional entity with indolent behaviour. Finally, cutaneous T-cell proliferations include a new provisional entity, primary cutaneous acral CD8-positive T-cell lymphoma, and reclassification of primary small/medium CD4-positive T-cell lymphoma as lymphoproliferative disorder.

The Correlation of Communication Effectiveness and Patient Satisfaction.

This study assessed the correlation of 9 questions addressing communication effectiveness (the Communication Effectiveness Questionnaire [CEQ]) with other patient-reported experience measures (PREMs; satisfaction, perceived empathy) as well as patient-reported outcome measures (PROMs; pain intensity, activity tolerance) in patients with musculoskeletal illness or injury. In a cross-sectional study, 210 patients visiting an orthopedic surgeon completed the CEQ and measures of satisfaction with the visit, perceived empathy, pain intensity, and activity tolerance. We evaluated correlations between CEQ and other PREMs and CEQ and PROMs. We measured ceiling effects of the PREMs. Communication effectiveness correlated moderately with other PREMs such as satisfaction (ρ = 0.54; P < .001) and perceived empathy (ρ = 0.54; P < .001). Communication effectiveness did not correlate with PROMs: pain intensity (ρ = -0.01; P = .93) and activity tolerance (ρ = -0.05; P = .44). All of the experience measures have high ceiling effects: perceived empathy 37%, satisfaction 80%, and CEQ 46%. The observation of notable correlations of various PREMs, combined with their high ceiling effects, direct us to identify a likely common statistical construct (which we hypothesize as "relationship") accounting for variation in PREMs, and then develop a PREM which measures that construct in a manner that results in a Gaussian distribution of scores. At least within the limitations of current experience measures, there seems to be no association between illness (PROMs) and experience (PREMs).

Analysis of Online Reviews of Orthopaedic Surgeons and Orthopaedic Practices Using Natural Language Processing.

BACKGROUND: There is growing interest in measuring and improving patient experience. Machine learning-based natural language processing techniques may help identify instructive themes in online comments written by patients about their healthcare provider. Separating individual surgeon and orthopaedic office reviews, we analyzed themes that are discussed based on the rating category, the association with review length, the number of people posting more than one review for a surgeon or office, the mean number of reviews per rating category, and the difference in review tones. METHODS: On Yelp.com, we collected 11,614 free-text reviews-together with a one- to five-star rating-of orthopaedic surgeons. Using natural language processing, we identified the most frequently occurring word combinations among rating categories. Themes were derived by categorizing word combinations. Dominant tones (emotional and language styles) were assessed by the IBM Watson Tone Analyzer. We calculated chi-square tests for linear trend and Spearman's rank correlation coefficients to assess differences among rating category. RESULTS: For individual surgeons and orthopaedic offices, themes such as logistics, care and compassion, trust, recommendation, and customer service varied among rating categories. More positive reviews are shorter for individual surgeons and orthopaedic offices, while rating category was comparable among people posting more than one review for both groups. Tones of joy and confidence were associated with higher ratings. Sadness and tentative tones were associated with lower ratings. DISCUSSION: For individual orthopaedic surgeons and orthopaedic offices, patient experience may be influenced mostly by the patient-clinician relationship. Training in more effective communication strategies may help improve self-reported patient experience.

Talking points for the safe and effective alleviation of pain.

Evidence suggests that the alleviation of pain is enhancedby a strong patient-clinician relationship and attending to a patient's social and mental health. There is a limited role for medication, opioids in particular. Orthopaedic surgeons can use comprehensive biopsychosocial strategies to help people recover and can work with colleagues who have the appropriate expertise in order to maximize pain alleviation with optimal opioid stewardship. Preparing patients for elective surgery and caring for them after unplanned injury or surgery can benefit from planned and practiced strategies based in communication science. Cite this article: Bone Joint J 2020;102-B(9):1122-1127.

Flow Cytometric Analysis of Monocytes and Granulocytes May Be Useful in the Distinction of Myeloid Neoplasms from Reactive Conditions: A Single Institution Experience and Literature Review.

OBJECTIVE: To determine if the immunophenotype of monocytes and granulocytes could help differentiate between reactive conditions and myeloid neoplasms. MATERIALS: We analyzed 94 patients including acute myeloid leukemia (n=53), myelodysplastic syndrome (n=19), chronic myelomonocytic leukemia (n=13), and chronic myelogenous leukemia (n=9). Twenty-five cases of reactive condition were included as controls. RESULTS: Myeloid neoplasm cases showed significantly altered expression patterns including overexpression of CD56, altered expression of HLA-DR, underexpression of CD14, CD64, and altered expression of CD33 when compared to controls. CONCLUSIONS: There are significant and consistent differences in immunophenotype of monocytes and granulocytes in neoplastic groups versus controls. Immunophenotypic evaluation of monocytes and granulocytes in addition to blasts may be useful in flow cytometric assessment of minimal residual disease in myeloid neoplasms.