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BACKGROUND: Immunocompromised individuals are known to respond inadequately to SARS-CoV-2 vaccines, placing them at high risk of severe or fatal COVID-19. Thus, immunocompromised individuals and their caregivers may still practice varying degrees of social or physical distancing to avoid COVID-19. However, the association between physical distancing to avoid COVID-19 and quality of life has not been comprehensively evaluated in any study. OBJECTIVE: We aim to measure physical distancing behaviors among immunocompromised individuals and the association between those behaviors and person-centric outcomes, including health-related quality of life (HRQoL) measures, health state utilities, anxiety and depression, and work and school productivity impairment. METHODS: A patient-informed protocol was developed to conduct the EAGLE Study, a large cross-sectional, observational study, and this paper describes that protocol. EAGLE is designed to measure distancing behaviors and outcomes in immunocompromised individuals, including children (aged ≥6 mo) and their caregivers, and nonimmunocompromised adults in the United States and United Kingdom who report no receipt of passive immunization against COVID-19. We previously developed a novel self- and observer-reported instrument, the Physical Distancing Scale for COVID-19 Avoidance (PDS-C19), to measure physical distancing behavior levels cross-sectionally and retrospectively. Using an interim or a randomly selected subset of the study population, the PDS-C19 psychometric properties will be assessed, including structural validity, internal consistency, known-group validity, and convergent validity. Associations (correlations) will be assessed between the PDS-C19 and validated HRQoL-related measures and utilities. Structural equation modeling and regression will be used to assess these associations, adjusting for potential confounders. Participant recruitment and data collection took place from December 2022 to June 2023 using direct-to-patient channels, including panels, clinician referral, patient advocacy groups, and social media, with immunocompromising diagnosis confirmation collected and assessed for a randomly selected 25% of immunocompromised participants. The planned total sample size is 3718 participants and participant-caregiver pairs. Results will be reported by immunocompromised status, immunocompromising condition category, country, age group, and other subgroups. RESULTS: All data analyses and reporting were planned to be completed by December 2023. Results are planned to be submitted for publication in peer-reviewed journals in 2024-2025. CONCLUSIONS: This study will quantify immunocompromised individuals' physical distancing behaviors to avoid COVID-19 and their association with HRQoL as well as health state utilities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/52643.
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COVID-19 , Huésped Inmunocomprometido , Distanciamiento Físico , Calidad de Vida , Humanos , COVID-19/prevención & control , COVID-19/epidemiología , Estudios Transversales , Huésped Inmunocomprometido/inmunología , Adulto , Masculino , Femenino , Estados Unidos/epidemiología , Reino Unido/epidemiología , NiñoRESUMEN
ABSTRACT: We report the case of a 72-year-old man with bilateral testicular involvement by mycosis fungoides (MF). The patient was diagnosed with MF 6 months prior, and testicular involvement was found upon staging. The rare behavior of MF, with early visceral involvement and no hematolymphoid organs affected, had a poor prognosis with patient death 14 months after the original diagnosis despite surgery and chemotherapy. The neoplastic cells showed a phenotypic switch from a CD4+/CD8- profile in the skin to a CD4-/CD8- in the testis and the same clone, confirmed with T-cell receptor gene rearrangement studies, making this the third reported case of MF affecting the testis and the first with clonality studies to confirm it. The clinical evolution may be related to its distinctive biology showcased in the neoplastic cell's switch to a more aggressive CD4-/CD8- profile and the early extension of the disease to an uncommon visceral site.
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We describe a rare case of a 33-year-old man presenting with a three-day history of dizziness and memory impairment. On clinical examination, he had a wide-based gait and postural instability. Laboratory tests were unremarkable. The patient underwent a CT scan, which showed an intraventricular heterogeneous mass, with calcifications. An MRI scan was performed, revealing a well-defined intraventricular lesion, with cystic and necrotic areas, hemorrhagic components, areas of restricted diffusion, and a peripheral solid component with post-contrast enhancement. This lesion was ultimately diagnosed as an anaplastic form of pleomorphic xanthoastrocytoma (PXA) (WHO grade 3). Prototypical PXA is a rare low-grade astrocytic tumor, almost always hemispheric. To our knowledge, this is only the third case report to describe an intraventricular PXA. Anaplastic forms of PXA have a more aggressive behavior and should be distinguished from other high-grade astrocytic neoplasms, especially from glioblastoma, isocitrate dehydrogenase (IDH)-wildtype variants (GB). Histopathological features of anaplastic forms of PXA (WHO grade 3) with epithelioid features are very similar to those of epithelioid glioblastoma and its differentiation is a common diagnostic challenge that should prompt genetic testing. Distinguishing between these two entities is crucial since the former is associated with significantly more survival benefits from targeted therapies (MAPK pathway inhibitors).
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Myelodysplastic/myeloproliferative neoplasms (MDS/MPN) are not a single disease, but rather a heterogenous group of entities which are increasingly subclassified according to recurrent genetic abnormalities. Chromosomal translocations involving meningioma 1 (MN1) and ETS variant 6 (ETV6) genes are extremely rare, but recurrent in myeloid neoplasms. We describe the case of a patient with a myelodysplastic/myeloproliferative neoplasm with neutrophilia, who developed an extramedullary T-lymphoblastic crisis with the t(12;22)(p13;q12) translocation as the only cytogenetic abnormality. This case shares several clinical and molecular features with myeloid/lymphoid neoplasms with eosinophilia. The treatment of this patient was challenging, as the disease proved to be highly refractory to chemotherapy, with allogenic stem cell transplantation as the only curative option. This clinical presentation has not been reported in association with these genetic alterations and supports the concept of a hematopoietic neoplasm originating in an early uncommitted precursor cell. Additionally, it stresses the importance of molecular characterization in the classification and prognostic stratification of these entities.
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Assessing public and patients' expectations and concerns about genomic data sharing is essential to promote adequate data governance and engagement in rare diseases genomics research. This cross-sectional study compared the views of 159 rare disease patients, 478 informal carers and 63 healthcare professionals in Northern Portugal about the benefits and risks of sharing genomic data for research, and its associated factors. The three participant groups expressed significantly different views. The majority of patients (84.3%) and informal carers (87.4%) selected the discovery of a cure for untreatable diseases as the most important benefit. In contrast, most healthcare professionals revealed a preference for the development of new drugs and treatments (71.4%), which was the second most selected benefit by carers (48.3%), especially by the more educated (OR (95% CI): 1.58 (1.07-2.34)). Lack of security and control over information access and the extraction of information exceeding research objectives were the two most often selected risks by patients (72.6% and 50.3%, respectively) and carers (60.0% and 60.6%, respectively). Conversely, professionals were concerned with genomic data being used to discriminate citizens (68.3%), followed by the extraction of information exceeding research objectives (54.0%). The latter risk was more frequently expressed by more educated carers (OR (95% CI): 1.60 (1.06-2.41)) and less by those with blue-collar (OR (95% CI): 0.44 (0.25-0.77) and other occupations (OR (95% CI): 0.44 (0.26-0.74)). Developing communication strategies and consent approaches tailored to participants' expectations and needs can benefit the inclusiveness of genomics research that is key for patient-centred care.
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Cuidadores , Enfermedades Raras , Estudios Transversales , Atención a la Salud , Genómica , Humanos , Enfermedades Raras/genética , Medición de RiesgoRESUMEN
ABSTRACT: Primary cutaneous anaplastic large cell lymphoma may harbor a 6p25.3 rearrangement, which has been associated with an epidermotropic small cell component. We report the case of a patient with said lymphoma harboring that rearrangement. It presented as a forehead nodule, histologically composed of an intermediate-to-large cell dermal component alongside a small-to-intermediate cell epidermotropic component. After multiple cutaneous and regional lymph node relapses, disease progression has been documented to a distant lymph node, despite local radiotherapy of the cutaneous lesions, chemotherapy, and anti-CD30 therapy, albeit with an indolent course over 6 years. Cases of pcALCL with nonregional lymph node involvement are unusual. Nevertheless, in this case, progression to a distant lymph node was not associated with an aggressive transformation of the disease.
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Linfoma Anaplásico Cutáneo Primario de Células Grandes/patología , Neoplasias Cutáneas/patología , Humanos , Ganglios Linfáticos/patología , Masculino , Persona de Mediana Edad , Recurrencia Local de NeoplasiaRESUMEN
Loss aversion is a fundamental tenet of behavioral economics and has led to many real-world applications. These applications, and some laboratory studies, show that people perform better under loss-avoidance than under gain incentives. This increased performance under loss-avoidance incentives has ubiquitously been explained by the notion that loss aversion causes people to exert more effort to avoid losses than to obtain gains. Only limited work, however, has directly examined whether people indeed choose to exert more effort to avoid losses than to obtain gains. Our primary aim was therefore to test this proposition. In an experiment with adults (N = 32) and in a subsequent experiment with children and adolescents (N = 29), we found that participants indeed exerted more effort to avoid losses than to obtain numerically equivalent gains. The effect sizes were large, with the effect being evident for most individual participants. As a secondary aim, in the study with adults, we also investigated whether the greater effort to avoid losses related to loss aversion measured using a task involving choices between prospects. Unexpectedly, the greater effort to avoid losses persisted robustly even after controlling for the effects of loss aversion measured using the task involving choices between prospects. We discuss two possible interpretations for this finding: our effort task may have been a more sensitive assessment of loss aversion than the task involving choices between prospects; alternatively, the processes underlying how much effort people choose to exert may partially differ from those engaged by choices between prospects. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Afecto , Motivación , Adolescente , Adulto , Niño , HumanosRESUMEN
BACKGROUND: During exposure therapy, patients report increases in fear that generally decrease within and across exposure sessions. Our main aim was to characterize these changes in fear ratings mathematically; a secondary aim was to test whether the resulting model would help to predict treatment outcome. METHODS: We applied tools of computational psychiatry to a previously published dataset in which 30 women with spider phobia were randomly assigned to virtual-reality exposures in a single context or in multiple contexts (n = 15 each). Patients provided fear ratings every minute during exposures. We characterized fear decrease within exposures and return of fear between exposures using a set of mathematical models; we selected the best model using Bayesian techniques. In the multiple-contexts group, we tested the predictions of the best model in a separate, test exposure, and we investigated the ability of model parameters to predict treatment outcome. RESULTS: The best model characterized fear decrease within exposures in both groups as an exponential decay with constant decay rate across exposures. The best model for each group had only two parameters but captured with remarkable accuracy the patterns of fear change, both at the group level and for individual subjects. The best model also made remarkably accurate predictions for the test exposure. One of the model's parameters helped predict treatment outcome. CONCLUSIONS: Individual patterns of fear change during exposure therapy can be characterized mathematically. This mathematical characterization helps predict treatment outcome.
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Terapia Implosiva , Trastornos Fóbicos , Arañas , Animales , Teorema de Bayes , Miedo , Femenino , Humanos , Trastornos Fóbicos/terapiaRESUMEN
Placental site trophoblastic tumour (PSTT) is a very rare form of gestational trophoblastic disease that grows slowly, secretes low levels of beta-subunit of human chorionic gonadotropin (ß-hCG), presents late-onset metastatic potential and is resistant to several chemotherapy regimens. Here, we report a case of PSTT in a 36-year-old woman who presented with amenorrhea and persistently elevated serum level of ß-hCG after a miscarriage. Transvaginal ultrasound revealed a hypovascular ill-defined solid lesion of the uterine fundus and MRI showed a tumour infiltrating the external myometrium with discrete early enhancement and signal restriction on diffusion-weighted imaging. PSTT was suspected, and after endometrial biopsy by hysteroscopy and posterior hysterectomy, microscopic examination allowed the final diagnosis. The level of ß-hCG dropped significantly in about a month after surgical treatment. Due to the rarity of PSTT, reporting new cases is crucial to improve the diagnosis and managing of these patients.
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Aborto Espontáneo/etiología , Gonadotropina Coriónica Humana de Subunidad beta/sangre , Enfermedad Trofoblástica Gestacional/diagnóstico , Tumor Trofoblástico Localizado en la Placenta/diagnóstico , Neoplasias Uterinas/diagnóstico , Adulto , Biopsia , Endometrio/diagnóstico por imagen , Endometrio/patología , Endometrio/cirugía , Femenino , Enfermedad Trofoblástica Gestacional/sangre , Enfermedad Trofoblástica Gestacional/complicaciones , Enfermedad Trofoblástica Gestacional/cirugía , Humanos , Histerectomía , Imagen por Resonancia Magnética , Embarazo , Salpingectomía , Tumor Trofoblástico Localizado en la Placenta/sangre , Tumor Trofoblástico Localizado en la Placenta/complicaciones , Tumor Trofoblástico Localizado en la Placenta/cirugía , Ultrasonografía , Neoplasias Uterinas/sangre , Neoplasias Uterinas/complicaciones , Neoplasias Uterinas/cirugíaRESUMEN
Gastrinomas are neuroendocrine tumors characterized by gastrin overexpression - 80% are sporadic and 20% are associated with multiple endocrine neoplasia type 1. A 75-year-old male patient, surgically treated at the age of 50 years for gastrinoma, followed on an outpatient basis because of chronic non-bloody diarrhea, was admitted to our hospital because of abdominal pain, watery diarrhea, and nonbiliary vomits. He was hypotensive and showed no response to fluids. Blood cultures were positive for Salmonella, and a diagnosis of septic shock due to Salmonella infection was made. The patient's condition improved, but the history of chronic diarrhea was still not explained. To investigate chronic diarrhea, gastrinoma recurrence was considered. Serum gastrin measurement was five times higher than the upper limit of the normal range (536 pg/mL). A positive somatostatin receptor scintigraphy was diagnostic for neuroendocrine tumor. Metastases were excluded. The patient was proposed to curative surgery, and a diagnosis of a well-differentiated neuroendocrine tumor was made.
Gastrinomas são tumores neuroendócrinos caracterizados por hipersecreção de gastrina - 80% são esporádicos e 20% associados a neoplasia endócrina múltipla tipo 1 (MEN1). Apresenta-se o caso de um homem, de 75 anos, tratado cirurgicamente aos 50 anos por gastrinoma, seguido em consulta de Medicina Interna por diarreia crónica não-sanguinolenta, internado no nosso hospital por dor abdominal, diarreia aquosa e vómitos não biliares. À admissão, apresentava-se hipotenso e pouco responsivo a fluidoterapia. As hemoculturas foram positivas para Salmonella e foi feito o diagnóstico de choque séptico por Salmonella. O doente melhorou, mas a história prévia de diarreia crónica não estava esclarecida. Para investigar a diarreia crónica, foi colocada como hipótese recidiva de gastrinoma. A medição de gastrina sérica foi cinco vezes superior ao limite superior do normal (536 pg/mL). A cintigrafia com receptores de somatostatina foi diagnóstica para tumor neuroendócrino. Foram excluídas metástases. O doente foi proposto para cirurgia curativa e foi feito o diagnóstico de tumor neuroendócrino bem diferenciado.
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Tourette syndrome (TS) is thought to involve dopaminergic disturbances, but the nature of those disturbances remains controversial. Existing hypotheses suggest that TS involves 1) supersensitive dopamine receptors, 2) overactive dopamine transporters that cause low tonic but high phasic dopamine, 3) presynaptic dysfunction in dopamine neurons, or 4) dopaminergic hyperinnervation. We review evidence that contradicts the first two hypotheses; we also note that the last two hypotheses have traditionally been considered too narrowly, explaining only small subsets of findings. We review all studies that have used positron emission tomography and single-photon emission computerized tomography to investigate the dopaminergic system in TS. The seemingly diverse findings from those studies have typically been interpreted as pointing to distinct mechanisms, as evidenced by the various hypotheses concerning the nature of dopaminergic disturbances in TS. We show, however, that the hyperinnervation hypothesis provides a simple, parsimonious explanation for all such seemingly diverse findings. Dopaminergic hyperinnervation likely causes increased tonic and phasic dopamine. We have previously shown, using a computational model of the role of dopamine in basal ganglia, that increased tonic dopamine and increased phasic dopamine likely increase the propensities to express and learn tics, respectively. There is therefore a plausible mechanistic link between dopaminergic hyperinnervation and TS via increased tonic and phasic dopamine. To further bolster this argument, we review evidence showing that all medications that are effective for TS reduce signaling by tonic dopamine, phasic dopamine, or both.
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Encéfalo/fisiopatología , Dopamina/fisiología , Neuronas Dopaminérgicas/fisiología , Síndrome de Tourette/fisiopatología , Animales , Encéfalo/diagnóstico por imagen , Humanos , Tomografía de Emisión de Positrones , Receptores Dopaminérgicos/fisiología , Tomografía Computarizada de Emisión de Fotón Único , Síndrome de Tourette/diagnóstico por imagen , Síndrome de Tourette/etiologíaAsunto(s)
Adenocarcinoma Sebáceo/patología , Neoplasias de la Mama/patología , Anciano , Femenino , HumanosRESUMEN
The 2017 edition of the WHO book on Classification of Tumours of Endocrine Organs includes a new section entitled 'Other encapsulated follicular-patterned thyroid tumours', in which the newly created NIFTP (non-invasive follicular thyroid neoplasm with papillary-like nuclear features) is identified and described in detail. Despite deleting the word 'carcinoma' from its name, NIFTP is not a benign tumor either and is best regarded as a neoplasm with 'very low malignant potential'. The main goal of the introduction of NIFTP category is to prevent overdiagnosis and overtreatment. Sampling constraints, especially when dealing with heterogeneous and/or large nodules, and difficulties in the invasiveness evaluation, are the major weaknesses of the histological characterization of NIFTP. At the cytological level, NIFTP can be separated from classic papillary carcinoma (cPTC) but not from encapsulated, invasive follicular variant PTC. The impact of NIFTP individualization for cytopathology is the drop of rates of malignancy for each Bethesda category in general and for indeterminate categories in particular. The biggest impact will be seen in institutions with a high frequency of FVPTC. The introduction of NIFTP has changed the utility of predictive values of molecular tests because RAS mutations and PAX8-PPARg rearrangements are frequently detected in NIFTP. This turns less promising the application of mutation detection panels as indicators of malignancy and will probably contribute to switch to a rule-out approach of molecular testing. Selection for surgery will go on being determined by a combined detection of clinical, cytological and ultrasound suspicious features.
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Adenocarcinoma Folicular/patología , Carcinoma Papilar/patología , Glándula Tiroides/patología , Neoplasias de la Tiroides/patología , Nódulo Tiroideo/patología , Adenocarcinoma Folicular/clasificación , Carcinoma Papilar/clasificación , Humanos , Neoplasias de la Tiroides/clasificación , Nódulo Tiroideo/clasificaciónRESUMEN
A case is presented of a 57-year-old man consulting for chronic diarrhea. Based on subsequent findings (thyroid nodule and metastases), the possibility of metastatic medullary thyroid carcinoma (MTC) was raised. Thyroidectomy allowed diagnosing a multicentric left lobe MTC. MTC is a rare cause of diarrhea, but should be considered, especially in the presence of signs or symptoms of alarm or nonresponse to empirical therapy.
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Editor's Note.-RadioGraphics continues to publish radiologic-pathologic case material selected from the American Institute for Radiologic Pathology (AIRP) "best case" presentations. The AIRP conducts a 4-week Radiologic Pathology Correlation Course, which is offered five times per year. On the penultimate day of the course, the best case presentation is held at the American Film Institute Silver Theater and Cultural Center in Silver Spring, Md. The AIRP faculty identifies the best cases, from each organ system, brought by the resident attendees. One or more of the best cases from each of the five courses are then solicited for publication in RadioGraphics. These cases emphasize the importance of radiologic-pathologic correlation in the imaging evaluation and diagnosis of diseases encountered at the institute and its predecessor, the Armed Forces Institute of Pathology (AFIP).
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Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/patología , Imagen por Resonancia Magnética/métodos , Tumores Fibrosos Solitarios/diagnóstico por imagen , Tumores Fibrosos Solitarios/patología , Tomografía Computarizada por Rayos X/métodos , Anciano , Diagnóstico Diferencial , Femenino , Humanos , Neoplasias Hepáticas/cirugía , Tumores Fibrosos Solitarios/cirugíaRESUMEN
Tourette syndrome is characterized by open motor behaviors - tics - but another crucial aspect of the disorder is the presence of premonitory urges: uncomfortable sensations that typically precede tics and are temporarily alleviated by tics. We review the evidence implicating the somatosensory cortices and the insula in premonitory urges and the motor cortico-basal ganglia-thalamo-cortical loop in tics. We consider how these regions interact during tic execution, suggesting that the insula plays an important role as a nexus linking the sensory and emotional character of premonitory urges with their translation into tics. We also consider how these regions interact during tic learning, integrating the neural evidence with a computational perspective on how premonitory-urge alleviation reinforces tics.
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Corteza Cerebral/fisiopatología , Modelos Neurológicos , Síndrome de Tourette/fisiopatología , Humanos , Sensación/fisiología , TicsRESUMEN
Tourette syndrome (TS) prominently involves dopaminergic disturbances, but the precise nature of those disturbances has remained elusive. A substantial body of empirical work and recent computational models have characterized the specific roles of phasic and tonic dopamine (DA) in action learning and selection, respectively. Using insights from this work and models, we suggest that TS involves increases in both phasic and tonic DA, which produce increased propensities for tic learning and expression, respectively. We review the evidence from reinforcement-learning and habit-learning studies in TS, which supports the idea that TS involves increased phasic DA responses; we also review the evidence that tics engage the habit-learning circuitry. On the basis of these findings, we suggest that tics are exaggerated, maladaptive, and persistent motor habits reinforced by aberrant, increased phasic DA responses. Increased tonic DA amplifies the tendency to execute learned tics and also provides a fertile ground of motor hyperactivity for tic learning. We review evidence suggesting that antipsychotics may counter both the increased propensity for tic expression, by increasing excitability in the indirect pathway, and the increased propensity for tic learning, by shifting plasticity in the indirect pathway toward long-term potentiation (and possibly also through more complex mechanisms). Finally, we review evidence suggesting that low doses of DA agonists that effectively treat TS decrease both phasic and tonic DA, thereby also reducing the propensity for both tic learning and tic expression, respectively.
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Dopamina/metabolismo , Aprendizaje/fisiología , Tics/metabolismo , Animales , Simulación por Computador , Humanos , Modelos Neurológicos , Síndrome de Tourette/metabolismoRESUMEN
Chronic granulomatous disease (CGD) is a genetically induced disease caused by mutations in one of the components of the NADPH-oxidase in phagocytes, characterized by life-threatening bacterial and fungal infections and granuloma formation. Treatment includes prevention of infectious complications and immunomodulation. However, a standard strategy is not yet defined. The authors report an X-linked CGD female carrier who presented during adulthood with diarrhea and colorectal ulcers, with high impairment of quality of life. Induction with infliximab 5 mg/kg (weeks 0, 2, and 6) with infectious prophylaxis was initiated. She continued infliximab 5 mg/kg every 8 weeks with complete symptomatic response at 15 months.
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We propose that schizophrenia involves a combination of decreased phasic dopamine responses for relevant stimuli and increased spontaneous phasic dopamine release. Using insights from computational reinforcement-learning models and basic-science studies of the dopamine system, we show that each of these two disturbances contributes to a specific symptom domain and explains a large set of experimental findings associated with that domain. Reduced phasic responses for relevant stimuli help to explain negative symptoms and provide a unified explanation for the following experimental findings in schizophrenia, most of which have been shown to correlate with negative symptoms: reduced learning from rewards; blunted activation of the ventral striatum, midbrain, and other limbic regions for rewards and positive prediction errors; blunted activation of the ventral striatum during reward anticipation; blunted autonomic responding for relevant stimuli; blunted neural activation for aversive outcomes and aversive prediction errors; reduced willingness to expend effort for rewards; and psychomotor slowing. Increased spontaneous phasic dopamine release helps to explain positive symptoms and provides a unified explanation for the following experimental findings in schizophrenia, most of which have been shown to correlate with positive symptoms: aberrant learning for neutral cues (assessed with behavioral and autonomic responses), and aberrant, increased activation of the ventral striatum, midbrain, and other limbic regions for neutral cues, neutral outcomes, and neutral prediction errors. Taken together, then, these two disturbances explain many findings in schizophrenia. We review evidence supporting their co-occurrence and consider their differential implications for the treatment of positive and negative symptoms.