Improving Provider Experience and Increasing Patient Access Through Nurse Practitioner-Physician Primary Care Teams.

Team-based care may address burnout in primary care; few studies have examined the impact of nurse practitioner-physician (NP-MD) teams on provider burnout. This article describes a model of NP-MD care teams in an urban safety-net primary care practice. Average time to third next available appointment with a team provider (either NP or MD) decreased by nearly 20 days after implementation of the model. In total, 79% of MDs reported that the model was very or extremely helpful in reducing the burden of work between visits and 100% of NPs reported that they were very or extremely satisfied with their current job.

Histopathologic features of melanoma in difficult-to-diagnose lesions: A case-control study.

BACKGROUND: Dermatopathology is considered the gold standard for melanoma diagnosis, but a subset of cases is difficult to diagnose by histopathology. OBJECTIVE: The goals of this study were to measure the accuracy of histopathologic features in difficult-to-diagnose melanocytic tumors and the interobserver agreement of those features. METHODS: This is a case-control study of histopathologic features of melanoma in 100 difficult-to-diagnose melanocytic neoplasms (40 melanomas and 60 nevi). Slides were blindly evaluated by 5 dermatopathologists. Frequencies, predictive values, and interobserver agreement were calculated. Univariate and multivariate logistic regression analyses were performed to identify the most influential features in arriving at a diagnosis of melanoma. RESULTS: Asymmetry, single-cell melanocytosis, solar elastosis, pagetoid melanocytosis, and broad surface diameter were most influential in arriving at a diagnosis of melanoma. Asymmetry and single-cell melanocytosis were most predictive of melanoma. Fleiss kappa was <0.6 for interobserver agreement in 9/10 histopathologic features of melanoma. LIMITATIONS: This study is limited by the small sample size, selection bias, and binary classification of melanocytic lesions. CONCLUSION: Our results indicate histopathologic features of melanoma in difficult-to-diagnose lesions vary in accuracy and reproducibility.

Stress, coping and safety compliance in a multinational gold mining company.

The primary objective of this study was to investigate the relationship of work stress, consisting of role stressors and job insecurity, with safety compliance at work. A secondary objective was to test for the possible moderating effect of individual employees' coping behaviour between experienced work stress and job insecurity, and their safety compliance. A cross-sectional survey design was used (n = 771). An electronic survey, with a biographical questionnaire and scales on role conflict, role ambiguity, role overload, job insecurity, coping and safety compliance at work, was administered. The results indicated that specific aspects of work stress, notably role conflict, role ambiguity and quantitative job insecurity, and of coping, namely an avoidance style and changing the situation, were important in understanding safety compliance. A moderating effect of avoidance coping was also found.

Neuroendocrine tumors: beyond the abdomen.

Several classification systems for neuroendocrine tumors (NETs) exist, which use variable terminology and criteria for grading and staging. This variability in terminology can cause confusion and difficulty in recognizing which tumors are, in fact, members of this heterogeneous group of malignancies. The largest group of NETs, the gastroenteropancreatic NETs, has been well described and characterized; however, there are less-recognized extra-abdominal NETs that can arise from nearly any organ in the body. In this article, the clinical features and imaging appearances of the extra-abdominal NETs will be reviewed, compared, and contrasted. This diverse group consists of paragangliomas, Merkel cell carcinomas, esthesioneuroblastomas, NETs of the lung, and medullary thyroid carcinomas. Recognition of these tumors as part of the larger group of NETs is important for understanding how best to approach imaging for their diagnosis, staging, and potential treatment. Familiarity with the computed tomographic and magnetic resonance imaging appearances and the role of radionuclide imaging of these heterogeneous groups aids in the correct diagnosis and in treatment planning.

EGFR and MYC gene copy number aberrations are more common in squamous cell carcinoma than keratoacanthoma: a FISH study.

Epidermal growth factor receptor (EGFR) and MYC genomic aberrations have been described in cutaneous squamous cell carcinoma (SCC) but have not been widely investigated in keratoacanthoma (KA). EGFR and MYC were evaluated by fluorescence in situ hybridization and immunohistochemistry in 8 verrucae, 19 involuting KA (IKA), 23 classic KA (CKA), 6 atypical KA (AKA) and 19 SCC. Increased EGFR gene copy number was seen in 9 of 23 CKA and 14 of 19 SCC (p = 0.03). Increased MYC gene copy number was observed in 7 of 23 CKA and 17 of 19 SCC (p = 0.0001). MYC gene amplification was more common in SCC than CKA (p = 0.005), while EGFR gene amplification was rare and not significant. MYC protein overexpression was identified in 6 of 23 CKA and 14 of 19 SCC (p = 0.005). There was no statistical difference in EGFR protein overexpression in SCC and CKA (p = 0.06). EGFR and MYC aberrations were rare in IKA. AKA showed EGFR and MYC anomalies at an incidence intermediate between CKA and SCC. EGFR and MYC gene copy number aberrations are more common in SCC than KA. The incidence of aberrations parallels the degree of cytologic atypia in KA.

Clinicopathologic and biomarker analysis of invasive pleomorphic lobular carcinoma as compared with invasive classic lobular carcinoma: an experience in our institution and review of the literature.

Pleomorphic lobular carcinoma (PLC) is a distinct morphological variant of invasive lobular carcinoma (ILC). Although PLC retains the distinctive loosely cohesive and single-file growth pattern of ILC, it has specific distinguishable characteristics, including enlarged nuclei with greater nuclear irregularity, increased hyperchromasia, prominent nucleoli, increased mitotic activity, and abundant eosinophilic cytoplasm. We compared the clinicopathologic features and biomarker expression of PLC and ILC. Fifty-eight cases of classic ILC (5.3%) and 7 cases of PLC (0.6%) were identified from our file between January 2002 and December 2010. Histopathologic data and tumor biomarkers were recorded. Clinical follow-up information (3-93 months; median, 29 months) for distant metastasis and survival was also gathered. Fisher exact test was used, and results were considered statistically significant if P value is less than .05. Our results showed that compared with classic ILC, PLC was more frequently grade III (P < .01), estrogen receptor negative (P < .001), and has Ki-67 greater than 10% (P < .002). In conclusion, PLC is more frequently higher grade and may exhibit an adverse biomarker profile (negative estrogen receptor and high Ki-67) as compared with classic ILC. However, no significant differences were found between PLC and classic ILC for axillary lymph node/distant metastases and survival.

Posterior reversible encephalopathy syndrome on computed tomography perfusion in a patient on "Triple H" therapy.

INTRODUCTION: This article reports a case of posterior reversible encephalopathy syndrome on compyted tomography (CT) perfusion in a patient on "Triple H" (hypertension, hypervolemia, and hemodilution) therapy following aneurysmal rupture repair. CASE REPORT: "Triple H" therapy is used in the postoperative course for treatment of vasospasm to prevent stroke and hemorrhage by maintaining cerebral perfusion pressure. DISCUSSION: A potential complication includes vasogenic edema from dysfunction of cerebral blood vessel autoregulation. CT perfusion can detect alterations in cerebral blood flow and volume caused by these hemodynamic changes.

The representation of homophones: Evidence from anomia.

Current models of word production provide different accounts of the representations of homophones--words that sound the same but have different meanings (e.g., muscle/mussel; (a) walk/(to) walk). A point of disagreement concerns frequency: While some models assume that homophone processing varies as a function of the frequency of the individual homophonic forms, other models predict that the combined frequency of the homophonic forms (e.g., the frequency of muscle+mussel) determines how homophones are processed. These contrasting views were tested in a series of experiments with AW, an English-speaking brain-damaged woman who showed anomia, a deficit of word phonology retrieval in speech production. AW's semantic processing was intact. In oral naming, we observed a frequency effect: AW was significantly more successful in producing high- as opposed to low-frequency words. Our results consistently demonstrated that AW's successful naming reflected the frequency of the individual homophonic forms, rather than the combined frequency of the homophonic forms. Our results provide support for models of speech production that identify the frequency of the individual homophones as the critical factor in homophone naming.