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2.
AMA J Ethics ; 21(10): E852-857, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31651384

RESUMO

Blood products are a scarce resource in our health care system. This article discusses a pediatric case involving large quantities of blood products transfused at the end of life. It argues that decision aids could help clinicians determine when to request ethics consultation or re-evaluation of blood product usage in a specific patient care situation and considers questions about scarce resource allocation, futility, and parental involvement in decision making.

3.
Arch Pathol Lab Med ; 2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31429605

RESUMO

CONTEXT.­: There is a wide disconnect between patients and the pathologists who make their diagnoses. Recent literature highlights successful programs in which patients meet with pathologists to review their pathology reports and see their tissue under a microscope. We do not know how many patients are interested in such a service, nor do we understand what drives interested patients to want to meet with their pathologist and what specific value it may provide. OBJECTIVE.­: To quantify patient interest in a patient-pathologist consultation program and qualitatively assess motivations for patient interest or disinterest. DESIGN.­: Subjects were recruited from an academic cancer center and a local community cancer support group to respond to a survey about their interest in a patient-pathologist consultation program. Both online forms and paper surveys were available. The online survey was promoted via social media. RESULTS.­: There was a high level of patient interest, with 75% of respondents indicating they were definitely interested in a patient-pathologist consultation program. Key themes of interest were enhanced understanding of the diagnosis and disease, an opportunity to demystify the diagnostic process, and the perception that additional knowledge would empower the patient. CONCLUSIONS.­: In a select group of cancer patients, there is a very high level of interest in a patient-pathologist consultation program. Pathologists, clinicians, and hospital leadership should work together to pilot these programs in diverse settings. Additional quantitative work to scale interventions for the interested population and qualitative work to design effective, patient-centered consultation programs and to assess value are needed.

4.
Surg Pathol Clin ; 12(3): 733-743, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31352985

RESUMO

The gastrointestinal tract is a common extranodal site of involvement by lymphomas. These may be diagnostically challenging because they can mimic a variety of benign conditions and may be difficult to subclassify when malignant. The classification of gastrointestinal lymphomas is an evolving area with some recent changes. Although some of these entities are rare, they are important to recognize because of the variable clinical presentations, comorbidities, and treatment implications. This article explores new and revised entities in gastrointestinal lymphoproliferative disorders.


Assuntos
Neoplasias Gastrointestinais/diagnóstico , Transtornos Linfoproliferativos/diagnóstico , Doença Celíaca/complicações , Doença Crônica , Diagnóstico Diferencial , Neoplasias Gastrointestinais/genética , Neoplasias Gastrointestinais/terapia , Humanos , Transtornos Linfoproliferativos/genética , Transtornos Linfoproliferativos/terapia , Prognóstico
5.
Arch Pathol Lab Med ; 142(11): 1347-1351, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30407861

RESUMO

Herein we review the following selection of gastrointestinal lymphomas: monomorphic epitheliotropic intestinal T-cell lymphoma; indolent T-cell lymphoproliferative disorder of the gastrointestinal tract; intestinal T-cell lymphoma, not otherwise specified; duodenal-type follicular lymphoma; and Epstein-Barr virus-positive mucocutaneous ulcer. Definitions reflect the 2016 revision of the World Health Organization classification of lymphoid neoplasms. Clinical, morphologic, and immunophenotypic characteristics of each entity are emphasized.


Assuntos
Neoplasias Gastrointestinais/diagnóstico , Neoplasias Gastrointestinais/patologia , Linfoma/diagnóstico , Linfoma/patologia , Humanos
7.
Narrat Inq Bioeth ; 8(1): 1-3, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29657164

RESUMO

This symposium includes twelve personal narratives from physicians with family members or close personal friends with medical illnesses. This issue also includes three commentaries on these narratives by scholars in the fields of bioethics, sociology, and law. The aim of this issue is to explore the benefits and potential harms that may arise when physicians are involved in the care of relatives, a role often fraught with conflicting moral obligations.


Assuntos
Tomada de Decisões/ética , Ética Médica , Família , Obrigações Morais , Relações Médico-Paciente/ética , Médicos/ética , Bioética , Cuidadores , Humanos , Narração , Papel Profissional
8.
Arch Pathol Lab Med ; 141(11): 1469-1475, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29072952

RESUMO

Primary cutaneous acral CD8+ T-cell lymphoma is a new provisional entity in the 2016 revision of the World Health Organization classification of lymphoid neoplasms. This is a challenging diagnosis because of its rarity, as well as its morphologic and immunophenotypic overlap with other CD8+ cytotoxic lymphoid proliferations. Appropriate classification of this entity is crucial because of its indolent clinical behavior compared with other CD8+ T-cell lymphomas. Knowledge of the clinical setting, sites of involvement, and morphologic features can aid in correct diagnosis. Here, we review the clinical and pathologic features of primary cutaneous acral CD8+ T-cell lymphoma with an emphasis on the differential diagnosis among other C8+ T-cell lymphomas.


Assuntos
Linfócitos T CD8-Positivos/patologia , Linfoma Cutâneo de Células T/diagnóstico , Biomarcadores Tumorais/metabolismo , Linfócitos T CD8-Positivos/metabolismo , Diagnóstico Diferencial , Extremidades , Humanos , Imuno-Histoquímica/tendências , Imunofenotipagem/tendências , Linfoma de Células T/diagnóstico , Linfoma de Células T/metabolismo , Linfoma de Células T/patologia , Linfoma Cutâneo de Células T/metabolismo , Linfoma Cutâneo de Células T/patologia , Linfoma Cutâneo de Células T/terapia , Paniculite/diagnóstico , Paniculite/metabolismo , Paniculite/patologia , Prognóstico
10.
Cancer Biother Radiopharm ; 32(9): 309-319, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29083933

RESUMO

INTRODUCTION: Non-Hodgkin Lymphoma patients respond differently to therapy according to inherent biological variations. Pretherapy biomarkers may improve dose-response prediction. MATERIALS AND METHODS: Hybrid single-photon emission computed tomography (SPECT)/computed tomography (CT) three-dimensional imaging at multiple time points plus follow-up positron emission tomography (PET)/CT or CT at 2 and 6 months post therapy were used to fit tumor response to combined biological effect and cell clearance models from which three biological effect response parameters (radiosensitivity, cold effect sensitivity, and proliferation potential) were determined per patient. A correlation of biological effect parameters and pretherapy biomarker data (ki67, p53, and phospho-histone H3) allowed a dose-based equivalent biological effect (EBE) to be calculated for each patient. RESULTS: Significant correlations were found between biological effect parameters and pretherapy biomarkers. Optimum correlations were found by splitting the patient data according to p53 status. Response correlation of progression free survival (PFS) and EBE were significantly improved compared with PFS and absorbed dose alone. CONCLUSIONS: It is possible and desirable to use pretherapy biomarkers to enhance the predictive potential of dose calculations for patient-specific treatment planning.


Assuntos
Biomarcadores Tumorais/análise , Linfoma não Hodgkin/radioterapia , Modelagem Computacional Específica para o Paciente , Planejamento da Radioterapia Assistida por Computador/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Relação Dose-Resposta à Radiação , Feminino , Humanos , Linfoma não Hodgkin/diagnóstico por imagem , Linfoma não Hodgkin/mortalidade , Linfoma não Hodgkin/patologia , Masculino , Pessoa de Meia-Idade , Radioimunoterapia/métodos , Dosagem Radioterapêutica , Tomografia Computadorizada de Emissão de Fóton Único , Tomografia Computadorizada por Raios X , Resultado do Tratamento
11.
AJOB Empir Bioeth ; 8(3): 153-160, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28949894

RESUMO

BACKGROUND: Although a mechanism for resolving ethical issues in patient care is required for accreditation of American hospitals, there are no formal qualifications for providing clinical ethics consultation (CEC), and there remains great variability in the composition of ethics committees and consult services. Consequently, the quality of CEC also varies depending on the qualifications of those performing CEC services and the format of CEC utilized at an institution. Our institution implemented an online CEC comment system to build upon existing practices to promote consistency and broad consensus in CEC services and enable quality assurance. METHODS: This qualitative study explored the use of an online comment system in ethics consultation and its impact on consensus building and quality assurance. All adult ethics consultations recorded between January 2011 and May 2015 (n = 159) were analyzed for themes using both open and directed coding methods. RESULTS: We found that comments broadly reflected three categories: expressions of approval/agreement (87% of consults), comments about the case (89%), and comments about the written record (72%). More than one-third of consults included responses to other comments (37%). The most common types of "comments about the case" included requests for additional information (36%), recommendations for additional services (21%), and references to formal policies/standards (28%). Comments often spanned multiple categories and themes. Comments about the written record emphasized accessibility, clarity, and specificity in ethics consultation communication. CONCLUSIONS: We find the online system allows for broad committee participation in consultations and helps improve the quality of CEC provided by allowing for substantive discussion and consensus building. Further, we find the use of an online comment system and subsequent records can serve as an educational tool for students, trainees, and ethics committee members.


Assuntos
Comunicação , Eticistas , Comitês de Ética Clínica , Consultoria Ética , Ética Clínica , Sistemas On-Line , Adulto , Consenso , Humanos , Pesquisa Qualitativa , Controle de Qualidade
12.
Leuk Res ; 56: 44-51, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28193567

RESUMO

B lymphoblastic leukemia (B-ALL) in adults has a higher risk of relapse and lower long-term survival than pediatric B-ALL, but data regarding genetic prognostic biomarkers are much more limited for adult patients. We identified 70 adult B-ALL patients from three institutions and performed genome-wide analysis via single nucleotide polymorphism (SNP) arrays on DNA isolated from their initial diagnostic sample and, when available, relapse bone marrow specimens to identify recurring copy number alterations (CNA). As B-cell developmental genes play a crucial role in this leukemia, we assessed such for recurrent deletions in diagnostic and relapse samples. We confirmed previous findings that the most prevalent deletions of these genes occur in CDKN2A, IKZF1, and PAX5, with several others at lower frequencies. Of the 16 samples having paired diagnostic and relapse samples, 5 showed new deletions in these recurrent B-cell related genes and 8 showed abolishment. Deletion of EBF1 heralded a significant negative prognostic impact on relapse free survival in univariate and multivariate analyses. The combination of both a CDKN2A/B deletion and an IKZF1 alteration (26% of cases) also showed a trend toward predicting worse overall survival compared to having only one or neither of these deletions. These findings add to the understanding of genomic influences on this comparably understudied disease cohort that upon further validation may help identify patients who would benefit from upfront treatment intensification.


Assuntos
Leucemia-Linfoma Linfoblástico de Células Precursoras B/genética , Leucemia-Linfoma Linfoblástico de Células Precursoras B/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/genética , Variações do Número de Cópias de DNA , Feminino , Marcadores Genéticos/genética , Genômica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Polimorfismo de Nucleotídeo Único , Prognóstico , Adulto Jovem
13.
Arch Pathol Lab Med ; 140(10): 1074-8, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27684979

RESUMO

Plasmablastic lymphoma (PBL) is a challenging diagnosis given its rarity and lack of expression of markers that are usually used by pathologists in establishing hematopoietic lineage. However, knowledge of the characteristic clinical setting, sites of involvement, and morphologic features of plasmablastic lymphoma can aid in the correct diagnosis of a suspected large cell lymphoma that is negative for B-cell- and T-cell-specific antigens. Herein, we review the clinical and pathologic features of plasmablastic lymphoma with an emphasis on the differential diagnosis of hematolymphoid neoplasms with immunoblastic morphology and/or evidence of plasmacytic differentiation by immunophenotype.


Assuntos
Linfócitos B/patologia , Plasmócitos/patologia , Linfoma Plasmablástico/diagnóstico , Antígenos CD20/metabolismo , Linfócitos B/metabolismo , Diagnóstico Diferencial , Humanos , Imunofenotipagem , Fator de Transcrição PAX5/metabolismo , Plasmócitos/metabolismo , Linfoma Plasmablástico/metabolismo , Linfoma Plasmablástico/terapia , Prognóstico , Análise de Sobrevida
14.
Hastings Cent Rep ; 46(5): 9-10, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27649822

RESUMO

When a gynecologist asks a twenty-one-year-old patient about her use of contraception, he is surprised that she would like to have a tubal ligation. The patient says that she would "never want to bring a child into this screwed up world." She has discussed tubal ligation with her boyfriend of one year, and he has told her that he accepts her decision. She asks her doctor if she can schedule the procedure as soon as possible. Her gynecologist mentions that he is concerned that she is very young and may eventually change her mind about having children. She insists that she has thought about it carefully and is certain that she wants the procedure. Her doctor feels very uncomfortable about this request. He consults the hospital ethics committee. Should he do as the patient asks or suggest that she wait at least six months and reconsider?


Assuntos
Atitude Frente a Saúde , Tomada de Decisões , Educação de Pacientes como Assunto/métodos , Relações Médico-Paciente , Esterilização Tubária/psicologia , Feminino , Humanos , Saúde da Mulher , Adulto Jovem
15.
AMA J Ethics ; 18(8): 786-92, 2016 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-27550562

RESUMO

Preferential treatment of patients whom we deem "very important" is a practice that is common in our health care system. The impact of this designation and the care that results is rarely studied or scrutinized. Although we assume that this type of treatment results in superior outcomes, this assumption can be wrong for a variety of reasons, which we discuss here. In addition to expressing unjust preferential treatment for some patients and not others, VIP medicine could compromise patient safety.


Assuntos
Ética Médica , Disparidades em Assistência à Saúde/ética , Serviço Hospitalar de Patologia/ética , Patologia Clínica/ética , Justiça Social , Biópsia , Assistência à Saúde , Humanos , Masculino , Patologistas/ética
16.
AMA J Ethics ; 18(8): 826-32, 2016 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-27550567

RESUMO

Electronic health records (EHR) now include patient portals where patients can obtain clinical reports, including notes, radiology reports, and laboratory/anatomic pathology results. Although portals increase patient access to information, no guidelines have been developed for hospitals about appropriate delays in posting different types of pathology reports to the EHR. Delays exist as a matter of policy to allow physicians time to answer questions and provide emotional support when discussing sensitive results with patients. Some types of results are more sensitive than others, however, including results of cancer, genetic, and HIV testing. Ethical questions about patient access to test results online are discussed.


Assuntos
Acesso à Informação/ética , Serviços de Diagnóstico/ética , Revelação/ética , Registros Eletrônicos de Saúde , Patologia Clínica/ética , Portais do Paciente/ética , Relações Médico-Paciente , Emoções , Ética Clínica , Hospitais , Humanos
17.
Surg Pathol Clin ; 9(1): 11-28, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26940265

RESUMO

B-cell non-Hodgkin lymphomas with plasmacytic differentiation are a diverse group of entities with extremely variable morphologic features. Diagnostic challenges can arise in differentiating lymphoplasmacytic lymphoma from marginal zone lymphoma and other low-grade B-cell lymphomas. In addition, plasmablastic lymphomas can be difficult to distinguish from diffuse large B-cell lymphoma or other high-grade lymphomas. Judicious use of immunohistochemical studies and molecular testing can assist in appropriate classification.


Assuntos
Linfoma de Células B/diagnóstico , Macroglobulinemia de Waldenstrom/diagnóstico , Diagnóstico Diferencial , Humanos , Imunofenotipagem , Linfoma de Células B/imunologia , Linfoma de Células B/patologia , Linfoma de Zona Marginal Tipo Células B/diagnóstico , Linfoma de Zona Marginal Tipo Células B/imunologia , Linfoma de Zona Marginal Tipo Células B/patologia , Plasmocitoma/diagnóstico , Plasmocitoma/imunologia , Plasmocitoma/patologia , Leucemia-Linfoma Linfoblástico de Células Precursoras/diagnóstico , Leucemia-Linfoma Linfoblástico de Células Precursoras/imunologia , Leucemia-Linfoma Linfoblástico de Células Precursoras/patologia , Prognóstico , Macroglobulinemia de Waldenstrom/imunologia , Macroglobulinemia de Waldenstrom/patologia
18.
J Infect Dis ; 213(7): 1180-8, 2016 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-26597256

RESUMO

BACKGROUND: Severe H1N1 influenza can be lethal in otherwise healthy individuals and can have features of reactive hemophagocytic lymphohistiocytosis (HLH). HLH is associated with mutations in lymphocyte cytolytic pathway genes, which have not been previously explored in H1N1 influenza. METHODS: Sixteen cases of fatal influenza A(H1N1) infection, 81% with histopathologic hemophagocytosis, were identified and analyzed for clinical and laboratory features of HLH, using modified HLH-2004 and macrophage activation syndrome (MAS) criteria. Fourteen specimens were subject to whole-exome sequencing. Sequence alignment and variant filtering detected HLH gene mutations and potential disease-causing variants. Cytolytic function of the PRF1 p.A91V mutation was tested in lentiviral-transduced NK-92 natural killer (NK) cells. RESULTS: Despite several lacking variables, cases of influenza A(H1N1) infection met 44% and 81% of modified HLH-2004 and MAS criteria, respectively. Five subjects (36%) carried one of 3 heterozygous LYST mutations, 2 of whom also possessed the p.A91V PRF1 mutation, which was shown to decrease NK cell cytolytic function. Several patients also carried rare variants in other genes previously observed in MAS. CONCLUSIONS: This cohort of fatal influenza A(H1N1) infections confirms the presence of hemophagocytosis and HLH pathology. Moreover, the high percentage of HLH gene mutations suggests they are risk factors for mortality among individuals with influenza A(H1N1) infection.


Assuntos
Exoma , Predisposição Genética para Doença , Vírus da Influenza A Subtipo H1N1 , Influenza Humana/genética , Linfo-Histiocitose Hemofagocítica/genética , Síndrome de Ativação Macrofágica/genética , Estudos de Coortes , Feminino , Genótipo , Células HEK293 , Humanos , Influenza Humana/mortalidade , Células Matadoras Naturais/fisiologia , Masculino , Mutação , Perforina/genética , Perforina/metabolismo , Análise de Sequência de DNA
19.
Arch Pathol Lab Med ; 139(10): 1205-10, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26414463

RESUMO

Large atypical cells with morphologic and immunophenotypic features resembling Reed-Sternberg cells can be seen in the background of reactive lymphadenopathies as well as non-Hodgkin lymphomas. The presence of these cells is an important diagnostic pitfall that must be recognized by pathologists who regularly interpret lymph node biopsies. A thorough evaluation of the morphologic and immunophenotypic features of these cells and the cellular milieu is crucial in achieving the correct diagnosis. In this review, examples of lymphomas presenting with Reed-Sternberg-like cells will be provided. Additionally, a detailed description of the common morphologic and immunophenotypic features of these cells, as well as strategies that can be used to distinguish them from the Reed-Sternberg cells of classical Hodgkin lymphoma, will be emphasized.


Assuntos
Doença de Hodgkin/diagnóstico , Linfoma não Hodgkin/diagnóstico , Células de Reed-Sternberg/patologia , Linfócitos B/metabolismo , Linfócitos B/patologia , Biomarcadores Tumorais/metabolismo , Diagnóstico Diferencial , Doença de Hodgkin/metabolismo , Humanos , Imunofenotipagem , Linfoma não Hodgkin/metabolismo , Células de Reed-Sternberg/metabolismo , Linfócitos T/metabolismo , Linfócitos T/patologia
20.
Arch Pathol Lab Med ; 139(10): 1253-7, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26414470

RESUMO

Invasive lobular carcinoma of the breast is a relatively common diagnosis. However, other carcinomatous as well as noncarcinomatous neoplasms, either primary or metastatic to the breast, may mimic invasive lobular carcinoma. As treatment may differ, establishing the correct diagnosis is paramount to providing the appropriate care for these patients. This review outlines important mimics of invasive lobular carcinoma and the key clinicopathologic and immunohistochemical features as well as additional studies helpful in establishing their diagnoses.


Assuntos
Neoplasias da Mama/diagnóstico , Mama/patologia , Carcinoma Lobular/diagnóstico , Mama/metabolismo , Neoplasias da Mama/metabolismo , Carcinoma Lobular/metabolismo , Diagnóstico Diferencial , Feminino , Fator de Transcrição GATA3/metabolismo , Humanos , Queratina-7/metabolismo , Invasividade Neoplásica , Receptores Estrogênicos/metabolismo
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