Rheumatoid-nodule-like cutaneous granuloma associated with recombinase activating gene 1-deficient severe combined immunodeficiency: A rare case.

Cutaneous granulomas without detectable infectious etiology rarely occur in children and adults with primary immunodeficiency disorders. These cutaneous granulomas are primarily seen in combined variable immunodeficiency, ataxia-telangiectasia, and severe combined immunodeficiency (SCID) and can emulate the reaction patterns seen in sarcoidosis and granuloma annulare. To date, the literature has described only six cases of non-infectious cutaneous granulomas in SCID. We report an unusual case of cutaneous granuloma, mimicking a sarcoma, in a 40-year old male with recombinase activating gene 1-deficient SCID, who presented with a slow-growing globus mass over the lateral aspect of the right elbow. There was heterogeneous enhancement on MRI, which was concerning for neoplasm but no malignancy was found on frozen or permanent sections. GMS, PAS with diastase, and AFB stains, as well as microbiology cultures, were negative. An AE1/AE3 stain was negative and a CD163 stain highlighted histiocytes. No infectious etiology was identified and histopathology revealed palisaded granulomatous dermatitis, most closely resembling a rheumatoid nodule. Although cutaneous manifestations have been reported in nearly half of primary immunodeficiency disorder cases, non-infectious cutaneous granulomas are exceedingly rare in SCID. To our knowledge, this is the first case report of cutaneous palisaded granulomatous dermatitis mimicking a rheumatoid nodule in a major joint.

Effects of a predictive preventive model for prevention of Clostridium difficile infection in patients in intensive care units.

BACKGROUND: Health care-acquired Clostridium difficile infection (HACDI) is associated with adverse outcomes at both the organization and patient level. Factors that increase risk for development of HACDI have been identified. Objectives of this study were to develop a predictive screening tool to identify patients at risk for HACDI and implement a bundle of mitigation interventions. METHODS: A predictive screening tool was developed based on risk factors identified in the literature and validated by retrospective analysis of all HACDI cases occurring in critically ill patients during 2013. The tool was used to screen all patients admitted to an intensive care unit. Evidence-based interventions (bundle) were implemented for patients identified as being at high risk for HACDI. Effectiveness of the model was measured by reduction of HACDI rate during the intervention period compared with the preintervention period. RESULTS: During the 12-month intervention period 217 high-risk patients were identified as infected with Clostridium difficile. Sixty-two of these met exclusion criteria, resulting in a study population of 157 patients. During the preintervention phase, 10 cases of HACDI occurred (overall incidence rate, 14.7). During the 12-month study period, 2 cases of HACDI were identified (incidence rate, 3.12). The reduction was statistically significant. CONCLUSION: A strategy for identifying patients at increased risk and implementation of multidisciplinary risk-mitigation strategies is effective in reducing incidence of HACDI.

Addressing Issues in the Development and Use of the Composite International Reference Values as Rorschach Norms for Adults.

This article describes 3 studies evaluating normative reference data for the Rorschach Comprehensive System (CS; Exner, 2003, 2007), with a particular focus on the viability of the Composite International Reference Values (CIRVs) that were compiled from 21 adult studies by Meyer, Erdberg, and Shaffer (2007). Study 1 documented how the CIRV norms are virtually identical when organized into 3 groups differentiated by the quality of their data collection effort, including an optimal group of 4 samples that relied on multiple experienced examiners and provided ongoing quality control over administration and coding. Analyses also showed that relative to the group of more optimal samples, the group of less optimal samples did not produce more variability in summary scores within or across samples or lower interrater reliability for coding. Study 2 used the existing CS reference norms to generate T scores for the CIRV means and documented how the CS norms make other samples of healthy nonpatients look psychologically impaired in multiple domains. Study 3 documented with examples from 4 different countries how 2 sets of within-country local norms produced notably different results on some variables, which compromises the ability of local norms to be used instead of the CIRVs. Taken together, the 3 studies provide support for the use of CIRVs in clinical practice as norms that are generalizable across samples, settings, languages, and cultures and that account for the natural variability that is present when clinicians and researchers contend with the ambiguity contained in the standard CS reference materials concerning the proper ways to administer and code. We conclude by urging CS users to rely on the CIRVs when making clinical inferences and to adopt alternative methods of ensuring they are following cohesively standardized administration and coding guidelines.

Social disclosure about lymphoedema symptoms: A qualitative study among Japanese breast cancer survivors.

Disclosing illness-related problems is the first step in help-seeking. The aim of this qualitative study was to explore Japanese breast cancer (BC) survivors' decision-making about disclosure of lymphoedema symptoms to people in their social networks. A total of ten women participated in group discussions in Japan. A dual analytic approach, thematic analysis and conceptual analysis, was applied to the transcripts. Two themes (perceived responsibility of social roles within the family and unsupportive reactions to BC from others) affected participants' decision-making. Support programs for Japanese BC survivors who feel unable to disclose lymphoedema symptoms to family members are suggested.

Technology complementing military psychology programs and services in the Pacific Regional Medical Command.

The Tripler Army Medical Center is the only federal tertiary care hospital serving the Pacific Regional Medical Command. Due to Tripler's large area of responsibility, many behavioral health professionals are starting to employ more technology during their sessions. As explained in this article, virtual reality and telepsychology efforts are proving to benefit military service members and their families in the Pacific Rim.

Positive changes in Japanese breast cancer survivors: a qualitative study.

Despite traumatic experiences of cancer, survivors often report positive changes. Since little research has been conducted into such changes among Japanese breast cancer survivors, our knowledge is minimal. This qualitative study aimed to explore the nature of the positive changes among this group. A thematic analysis suggested that participants had experienced seven types of positive change: Attitudinal changes towards life, strengthening trust in family and friends, increased appreciation of life, self-development, future perspectives, education for friends, and efforts towards bodily change. Awareness of vulnerability in life, received social support and social comparisons appear to trigger some of the positive changes.

Development of the Psycho-social Discomfort Scale (PsDS): investigation of psychometric properties among Japanese breast cancer survivors.

OBJECTIVE: To develop a new scale to assess psycho-social discomfort in breast cancer (BC) survivors in Japanese society and to investigate its psychometric properties. METHOD: A total of 248 Japanese BC survivors completed both the Psycho-social Discomfort Scale (PsDS) and WHO Quality of Life BREF Japanese version (WHO QoL-Jp). A principal component factor analysis (with promax rotation) was performed, and internal consistency was examined using Cronbach's alpha. Divergent and convergent validities and criterion validity were examined using the Spearman's R. RESULTS: The factor analysis extracted three factors: 'internalised stigma (IS)', 'social disclosure of BC (SD)', and 'psychological resources to live with BC (PR)'. The factors were moderately correlated. The scale had good internal consistency (alpha = 0.80). All sub-scales were inversely correlated with all the domains in the WHO QoL-Jp (r = -0.09 to -0.47). BC stage was significantly correlated with the SD sub-scale, and type of surgery was significantly correlated with the IS sub-scale. CONCLUSIONS: The PsDS has 25 items. It measures psycho-social discomfort that Japanese BC survivors experienced or were experiencing in their community. It has a simple factor structure, relatively good internal consistency, and a satisfactory divergent validity.

Information provision and problem-solving processes in Japanese breast cancer survivors with lymphoedema symptoms.

BACKGROUND: In Japan, a high proportion of breast cancer (BC) survivors develop lymphoedema as a consequence of the treatment received. Japanese BC survivors are generally not provided with standardised information about risks, early signs and symptom management. The effects of (in)adequate information on the problem-solving processes among Japanese BC survivors with lymphoedema symptoms have not been investigated. PURPOSE: The aim of this study was to explore how the provision of medical information by doctors affected the problem-solving processes of Japanese BC survivors with lymphoedema symptoms. METHOD: Ten Japanese BC survivors participated in audio-taped focus group discussions. Transcripts were analysed using an inductive thematic analysis. RESULTS: Analysis identified two phases during which participants attempted to address problems with managing their lymphoedema symptoms - a help-seeking phase and an evaluation phase. Perceptions of information provision affected emotional responses to the onset and cognitive appraisals of lymphoedema symptoms (seen as accepted or burden). However, perceptions of information provision did not affect help-seeking behaviours from surgeons or adherence behaviours. Participants often perceived compression sleeves as inefficient and not worth continuing. CONCLUSION: This study suggests that information provision is a key process in helping BC patients to adjust to symptoms of lymphoedema. In order to promote effective symptom management, doctors and nurses should provide support not only during the help-seeking phase but also the evaluation phase. Further research on the most effective ways to change negative treatment beliefs should be conducted.

Impact of card rotation on the frequency of Rorschach reflection responses.

In this article, we describe the impact of Rorschach (Exner, 2003) card rotation and orientation preference on reflection responses. We anticipated exposure to sideways-orientated cards would facilitate landscape-type reflections, particularly for cards people find appealing to view sideways. When we examined 4 experimental conditions using an undergraduate sample, results in Experiments 1 (n = 123) and 2 (n = 38) showed that viewing the cards sideways produced a large increase in reflections. In Experiment 3 (n = 69), we examined preferences to view each card in a particular orientation. Cards producing higher rates of landscape reflections in the experimental conditions that encouraged turning were strongly correlated with preferences to view those cards sideways. The results imply reflections are in part a function of stimulus properties from viewing the card in a rotated orientation and not just the personal characteristics of the test taker.

Adherence to treatment in adolescents with cystic fibrosis: the role of illness perceptions and treatment beliefs.

OBJECTIVES: This study was conducted to explore the relationships between illness perceptions, emotional representations, treatment beliefs and reported adherence in adolescents with cystic fibrosis (CF). METHODS: Thirty-eight adolescents completed questionnaires assessing their perceptions of CF, beliefs about prescribed treatments and reported adherence to chest physiotherapy, enzyme supplements, and antibiotics. RESULTS: Reported non-adherence to chest physiotherapy was associated with the way in which patients judged their personal need for treatment relative to their concerns about potential adverse effects. Patients reported strong doubts about the necessity of chest physiotherapy. Reported non-adherence to antibiotics was related to doubts about the necessity of antibiotics, believing that CF is not amenable to treatment control. Despite these beliefs about treatment, participants perceived CF as a chronic condition. CONCLUSIONS: The findings provide preliminary support for the self-regulatory model, using the necessity-concerns framework to operationalize treatment beliefs, in explaining adherence to treatment in adolescents with CF.

Adherence to chest physiotherapy in adults with cystic fibrosis.

Chest physiotherapy (CP) is seen as a cornerstone of Cystic Fibrosis (CF) treatment. However, previous studies have suggested that adherence to CP is low. This study of adults with CF (N = 563) investigated CP adherence and associated factors. Only 29.5 per cent reported undertaking daily CP. Predictors of adherence included problems with fitting CP into lifestyle, a perception that CP does not help, physical consequences of CP, doing exercises instead and doing CP as and when necessary. These variables accounted for 45 per cent of the variance in adherence. Content analysis revealed a number of themes related to adherence to CP. Future studies should explore the benefits of daily CP and attempt to devise simple interventions to maximize adherence to CP.

Development of a pictorial scale of pain intensity for patients with communication impairments: initial validation in a general population.

This study evaluated a new six-point ordinal scale for measuring pain intensity. Seventy-two participants aged between 23 and 87 years rated the intensity of 'present pain' as well as remembered episodes of 'severe' and 'mild' pain on the scale of pain intensity (SPIN), a 10 cm visual analogue scale (VAS) and a 0-10 numeric scale, in random order. Retesting followed an intervening assessment. Participants' comments on the scales were analysed thematically. Spearman's correlation between scales all exceeded 0.78 (p

Mammalian germ-line transgenesis by transposition.

Transposons have been used in invertebrates for transgenesis and insertional mutagens in genetic screens. We tested a functional transposon called Sleeping Beauty in the one-cell mouse embryo. In this report, we describe experiments in which transposon vectors were injected into one-cell mouse embryos with mRNA expressing the SB10 transposase enzyme. Molecular evidence of transposition was obtained by cloning of insertion sites from multiple transgenic mice produced by SB10 mRNA/transposon coinjection. We also demonstrate germ-line transmission and expression from transposed elements. This technique has promise as a germ-line transgenesis method in other vertebrate species and for insertional mutagenesis in the mouse.