Recognizing Cross-Institutional Fiscal and Administrative Barriers and Facilitators to Conducting Community-Engaged Clinical and Translational Research
Purpose: This qualitative study examined fiscal and administrative (i.e., pre- and post-award grants process) barriers and facilitators to community-engaged research among stakeholders across 4 Clinical and Translational Science Awards (CTSA) institutions. Method: A purposive sample of 24 key informants from 3 stakeholder groups—community partners, academic researchers, and research administrators—from the CTSA institutions at the University of North Carolina at Chapel Hill, Medical University of South Carolina, Vanderbilt University Medical Center, and Yale University participated. Semistructured interviews were conducted in March–July 2018, including questions about perceived challenges and best practices in fiscal and administrative processes in community-engaged research. Transcribed interviews were independently reviewed and analyzed using the Rapid Assessment Process to facilitate key theme and quote identification. Results: Community partners were predominantly Black, academic researchers and research administrators were predominantly White, and women made up two-thirds of the overall sample. Five key themes were identified: level of partnership equity, partnership collaboration and communication, institutional policies and procedures, level of familiarity with varying fiscal and administrative processes, and financial management expectations. No stakeholders reported best practices for the institutional policies and procedures theme. Cross-cutting challenges included communication gaps between stakeholder groups, lack of or limits in supporting community partners' fiscal capacity, and lack of collective awareness of each stakeholder group's processes, procedures, and needs. Cross-cutting best practices centered on shared decision-making and early and timely communication between all stakeholder groups in both pre- and post-award processes. Conclusions: Findings highlight the importance of equitable processes, triangulated communication, transparency, and recognizing and respecting different financial management cultures within community-engaged research. This work can be a springboard used by CTSA institutions to build on available resources that facilitate co-learning and discussions between community partners, academic researchers, and research administrators on fiscal readiness and administrative processes for improved community-engaged research partnerships. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B55. Acknowledgments: Adina Black and Elisa D. Quarles served as reviewers in the Rapid Assessment Process. Adina Black provided administrative support in developing this manuscript. Jennifer Teixeira, director of research administration in the Office of Sponsored Research at University of North Carolina at Chapel Hill, contributed to the conceptualization of this project. The authors thank the stakeholders—community partners, academic researchers, and research administrators—for participating in this study. Funding/Support: This work was supported, in part, by the Clinical and Translational Science Awards Program, funded by the National Center for Advancing Translational Sciences of the National Institutes of Health: grants #UL1TR002489 (University of North Carolina at Chapel Hill), #UL1TR001450 (Medical University of South Carolina), #UL1TR002243 (Vanderbilt University Medical Center), and #UL1TR001863 (Yale University). Other disclosures: None reported. Ethical approval: The University of North Carolina at Chapel Hill Institutional Review Board approved this study on September 8, 2017 (IRB#15-0849). Disclaimers: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Correspondence should be addressed to Lori Carter-Edwards, University of North Carolina at Chapel Hill, Campus Box 7064, 160 N. Medical Dr., Chapel Hill, NC 27599; telephone: (919) 966-5305; email: lori_carter-edwards@unc.edu; Twitter: @NCTraCS. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2020 by the Association of American Medical Colleges
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Effect of Continuing Professional Development on Health Professionals' Performance and Patient Outcomes: A Scoping Review of Knowledge Syntheses
Purpose: Continuing professional development (CPD) programs, which aim to enhance health professionals' practice and improve patient outcomes, are offered to practitioners across the spectrum of health professions through both formal and informal learning activities. Various knowledge syntheses (or reviews) have attempted to summarize the CPD literature; however, these have primarily focused on continuing medical education or formal learning activities. Through this scoping review, the authors seek to answer the question, What is the current landscape of knowledge syntheses focused on the impact of CPD on health professionals' performance defined as behavior change and/or patient outcomes? Method: In September 2019, the authors searched PubMed, Embase, CINAHL, Scopus, ERIC, and PsycINFO for knowledge syntheses published between 2008 and 2019 that focused on independently practicing health professionals and reported outcomes at Kirkpatrick's levels 3 and/or 4. Result: Of the 7,157 citations retrieved from databases, 63 satisfied the inclusion criteria. Of these 63 syntheses, 38 (60%) included multicomponent approaches, and 27 (43%) incorporated eLearning interventions – either stand-alone or in combination with other interventions. While a majority of syntheses (n = 42 [67%]) reported outcomes affecting health care practitioners' behavior change and/or patient outcomes, most of the findings reported at Kirkpatrick level 4 were not statistically significant. Ten of the syntheses (16%) mentioned the cost of interventions though this was not their primary focus. Conclusions: Across health professions CPD is an umbrella term incorporating formal and informal approaches in a multi-component approach. eLearning is increasing in popularity but remains an emerging technology. Several of the knowledge syntheses highlighted concerns regarding both the financial and human costs of CPD offerings, and such costs are being increasingly addressed in the CPD literature. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B56. Acknowledgments: The authors would like to thank Rhonda Allard, a medical librarian at Uniformed Services University of the Health Sciences, for helping design, refine, and conduct the searches for this study. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense or the Henry M. Jackson Foundation for Military Medicine. Correspondence should be addressed to Anita Samuel, Uniformed Services University of the Health Sciences, Department of Medicine, Graduate Programs in Health Professions Education, 4301 Jones Bridge Road, Bethesda, MD 20814; telephone: (301) 295-9539; email: anita.samuel.ctr@usuhs.edu. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "work of the United States Government" for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2020 by the Association of American Medical Colleges
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Personalized Graduate Medical Education and the Global Surgeon: Training for Resource-Limited Settings
Problem: The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings. Approach: The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum—including 2 years dedicated to global surgery—with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty. Outcomes: There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities. Next Steps: To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step towards contributing to the delivery of safe surgical care worldwide. Acknowledgements: The authors wish to thank Miriam King, MEd, Scott LeMaire, MD, Chad Wilson, MD, MPH, C. Anne Morrison, MD, MPH, Walter Johnson, MD, MPH, MBA, Neema Kaseje, MD, MPH, Nader Masserweh, MD, MPH, Josephine Koller, BBA, Sydney Webster, MEd, Jaye Chambers, Allyson Bremer, Woods McCormack, MA, Bip Nandi, MBBChir, Heather Vasser, MD, Kathryn Gunter, MD, Michael Coburn, MD, Michael Belfort, MBBCH, DA (SA), MD, PhD, Jeffrey Wilkinson, MD, Rachel Pope, MD, MPH, Kelli Barbour, MD, Candy Wilburn, Etan Weinstock, MD, Peter Hotez, MD, PhD, John Dawson, MD, Christopher Perkins, MD, MS, Adam Gibson, JD, Taylor Napier, MA, Hisashi Nikaidoh, MD, Lynn Nikaidoh, Craig Brown, Sue Smith, JD, and John Collier, MDiv, MA. Funding/Support: Funding and support for the creation of the global surgery residency track were received from the Baylor College of Medicine Michael E. DeBakey Department of Surgery, Hitoshi Nikaidoh Memorial Endowment, George A. Robinson IV Foundation, Craig and Galen T. Brown Foundation, CHRISTUS Foundation for HealthCare, Caring Friends in Deed, and the Bridget L. Harrison, MD International Education Support Fund. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Rachel W. Davis, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX, 77030; telephone: (713) 798-6078; email: rachelwdavis@bcm.edu; Twitter: @RachelWDavis. © 2020 by the Association of American Medical Colleges
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Discharge Communication: A Multi-Institutional Survey of Internal Medicine Residents' Education and Practices
Purpose: To characterize residents' practices around hospital discharge communication and their exposure to transitions-of-care instruction in graduate medical education (GME). Method: In spring 2019, internal medicine residents at 7 academic medical centers completed a cross-sectional survey reporting the types of transitions-of-care instruction they experienced during their GME training and the frequency with which they performed 6 key discharge communication practices. The authors calculated a mean discharge communication score for each resident and, using multiple logistic regression, they analyzed the relationship between exposure to types of educational experiences and the discharge communication practices that residents reported to perform frequently (> 60% of time). The authors also used content analysis to explore factors that motivated residents to change their discharge practices. Results: The response rate was 63.5% (613/966). Resident discharge communication practices varied. Notably, only 17.0% (n = 104) reported routinely asking patients to "teach-back" or explain their understanding of the discharge plans. The odds of frequently performing key discharge communication practices were greater if residents received instruction based on observation of and feedback regarding their communication with patients at discharge (adjusted odds ratio [OR] 1.73; 95% confidence interval [CI], 1.07-2.81), or if they received explicit on-rounds teaching (adjusted OR 1.46; 95% CI, 1.04-2.230). In open-ended comments, residents reported that experiencing adverse patient events at some point in the post-discharge continuum was a major impetus for practice change. Conclusions: This study exposes gaps in hospital discharge communication with patients, highlights the benefits of workplace-based instruction on discharge communication skills, and reveals the influence of adverse events as a source of hidden curricula. The results suggest that developing faculty to incorporate transitions-of-care instruction in their rounds teaching and integrating experiences across the post-discharge continuum into residents' education may foster physicians-in-training who are champions of effective transitions of care within the fragmented healthcare system. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/B54. Acknowledgements: The authors would like to thank Shreya Singhal and Megan Sutter, PhD, for statistical assistance, as well as Amy Ou, MD, Masha Slavin, MD, Bilal Alqam, MD, Marina Baskharoun, MD, Nick Gowen, MD, Paul Williams, MD, and Derek Hupp, MD, for help distributing the survey. Funding/Support: Dr. Shreya P. Trivedi's time was supported by Health Resources and Services Administration-T32 grant (T32HP22238). Other disclosures: None reported. Ethical approval: Ethical approval was received from each participating institution. Previous presentations: The findings of this study were presented as a virtual oral presentation for the Lipkin Finalist Award for the Society of General Internal Medicine On-Demand 2020 National Conference. Data: The data for this study were not collected from outside sources. Correspondences should be addressed to Shreya Trivedi, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, Massachusetts 02215; telephone: (215) 527-9238; email: strived1@bidmc.harvard.edu; Twitter: @ShreyaTrivediMD. © 2020 by the Association of American Medical Colleges
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Sin-Eaters
No abstract available
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The Accelerating Change in Medical Education Consortium: Key Drivers of Transformative Change
The American Medical Association's (AMA's) Accelerating Change in Medical Education (ACE) initiative, launched in 2013 to foster advancements in undergraduate medical education, has led to the development and scaling of innovations influencing the full continuum of medical training. Initial grants of $1 million were awarded to 11 U.S. medical schools, with 21 schools joining the consortium in 2016 at a lesser funding level. Almost one-fifth of all U.S. MD- and DO-granting medical schools are represented in the 32-member consortium. In the first 5 years, the consortium medical schools have delivered innovative educational experiences to approximately 19,000 medical students who will provide a potential 33 million patient care visits annually. The core initiative objectives focus on competency-based approaches to medical education and individualized pathways for students; training in health systems science; and enhancing the learning environment. At the close of the initial 5-year grant period, AMA leadership sought to catalogue outputs and understand how the structure of the consortium may have influenced its outcomes. Themes from qualitative analysis of stakeholder interviews as well as other sources of evidence aligned with the 4 elements of the transformational leadership model (inspirational motivation, intellectual stimulation, individualized consideration, and idealized influence) and can be used to inform future innovation interventions. For example, the ACE initiative has been successful in stimulating change at the consortium schools and propagating those innovations broadly, with outputs involving medical students, faculty, medical schools, affiliated health systems, and the broader educational landscape. In summary, the ACE initiative has fostered a far-reaching community of innovation that will continue to drive change across the continuum of medical education. Acknowledgements: The authors wish to thank Carrie Radabaugh and Catherine Welcher. Ilene Harris, PhD, and Laura Hirshfield, PhD, University of Illinois College of Medicine Department of Medical Education, completed the mid-grant qualitative review. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: The Accelerating Change in Medical Education program evaluation protocol was determined to be exempt from ethical review by the University of Illinois at Chicago institutional review board (# 2014-0079). Previous presentations: The authors presented portions of this article at the American Medical Association Annual Meeting in Chicago, Illinois, June 8-12, 2019. Correspondence should be addressed to Kimberly D. Lomis, American Medical Association, 330 N. Wabash Avenue, Chicago, IL 60611; telephone: (312) 464-5572, email: Kimberly.Lomis@ama-assn.org; Twitter: @KimLomisMD. © 2020 by the Association of American Medical Colleges
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Medical Education in Nepal: Impact and Challenges of the COVID-19 Pandemic
During the COVID-19 pandemic, there has been a global shift toward online distance learning due to travel limitations and physical distancing requirements as well as medical school and university closures. In low- and middle-income countries like Nepal, where medical education faces a range of challenges—such as lack of infrastructure, well-trained educators, and advanced technologies—the abrupt changes in methodologies without adequate preparation are more challenging than in higher income countries. In this article, the authors discuss the COVID-19-related changes and challenges in Nepal that may have a drastic impact on the career progression of current medical students. Outside the major cities, Nepal lacks dependable internet services to support medical education, which frequently requires access to and transmission of large files and audiovisual material. Thus, students who are poor, physically disadvantaged, and who do not have a home situation conducive to online study may be affected disproportionately. Further, the majority of teachers and students do not have sufficient logistical experience and knowledge to conduct or participate in online classes. Moreover, students and teachers are unsatisfied with the digital methodologies, which will ultimately hamper the quality of education. Students' clinical skills development, research activities, and live and intimate interactions with other individuals are being affected. Even though Nepal's medical education system is struggling to adapt to the transformation of teaching methodologies in the wake of the pandemic, it is important not to postpone the education of current medical students and future physicians during this crisis. Looking ahead, medical schools in Nepal should ensure that mechanisms are proactively put into place to embrace new educational opportunities and technologies to guarantee a regular supply of high-quality physicians capable of both responding effectively to any future pandemic and satisfying the nation's future health care needs. Acknowledgments: The authors would like to express their sincere thanks to Professor Andy Crump for helping with revisions and giving valuable comments on the manuscript. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Shailendra Sigdel, Department of Cardiothoracic and Vascular Anesthesiology, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, 44600 Kathmandu, Nepal; email: sailendra.sigdel@mmc.tu.edu.np. © 2020 by the Association of American Medical Colleges
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Making Doctors Effective Managers and Leaders: A Matter of Health and Well-Being
The COVID-19 crisis has forced physicians to make daily decisions that require knowledge and skills they did not acquire as part of their biomedical training. Physicians are being called upon to be both managers—able to set processes and structures—and leaders—capable of creating vision and inspiring action. Although these skills may have been previously considered as just nice to have, they are now as central to being a physician as physiology and biochemistry. While traditionally only selected physicians have received management training, either through executive or joint degree programs, the authors argue that the pandemic has highlighted the importance of all physicians learning management and leadership skills. Training should emphasize skills related to interpersonal management, systems management, and communication and planning; be seamlessly integrated into the medical curriculum alongside existing content; and be delivered by existing faculty with leadership experience. While leadership programs, such as the Pediatric Leadership for the UnderServed Program at the University of California, San Francisco, and the Clinical Process Improvement Leadership Program at Mass General Brigham, may include project work, instruction by clinical leaders, and content delivered over time, examples of leadership training that seamlessly blend biomedical and management training are lacking. The authors present the Leader and Leadership Education and Development curriculum used at the Uniformed Services University of the Health Sciences, which is woven through 4 years of medical school, as an example of leadership training that approximates many of the principles espoused here. The COVID-19 pandemic has stretched the logistical capabilities of health care systems and the entire United States, revealing that management and leadership skills—often viewed as soft skills—are a matter of life and death. Training all physicians in these skills will improve patient care, the well-being of the health care workforce, and health across the United States. Acknowledgments: The authors wish to thank Erin Barry for the additional insight she provided into the LEAD program. Funding/Support: None reported. Other disclosures: L.S. Rotenstein is a cofounder at CareZooming. R.S. Huckman receives compensation for executive teaching from Kaiser Permanente, Partners HealthCare (now Mass General Brigham), MD Anderson Cancer Center, OhioHealth, and Ochsner Health; serves as an advisory board member for RubiconMD, Arena, and Carrum Health; and being an uncompensated trustee of the Brigham and Women's Physician's Organization and Brigham Health. C.K. Cassel serves on the Regional Executive Advisory Board for Kaiser Permanente Mid-Atlantic States, the board of directors of the Greenwall Foundation, and the board of directors of the Presbyterian Health System in New Mexico. She is also an advisor to startups Honor, Wellsheet, TARTLE, and OnlyBoth. Ethical approval: Reported as not applicable. Correspondence should be addressed to Lisa S. Rotenstein, 75 Francis Street, Boston, MA, 02215; email: LRotenstein@partners.org; Twitter: @LisaRotenstein. © 2020 by the Association of American Medical Colleges
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Building a System to Engage and Sustain Research Careers for Physicians
There are increasing needs for physician–investigators to translate the rapid expansion of knowledge, technology/interventions, and big data into the clinical realm at a time of increasing age-related disabilities and communicable diseases. Yet the number of physician–investigators has continued to decline, and only a small number of medical school graduates in the United States are actively engaged in research. This problem may be particularly pronounced in small- and medium-sized academic institutions due to more limited educational and mentoring infrastructure. Neither efforts by the federal government, nor isolated institutional programs alone, have been effective yet in solving this problem. This article describes an integrated institutional strategy undertaken at Penn State College of Medicine that is focused on developing and sustaining a physician–investigator work force. Key elements of this strategy are new programs to close gaps in the professional life cycle of physician–investigators, dedicated senior leaders collaborating with an experienced and diverse advisory committee, and a data-driven approach to programmatic evaluation. In this article, the implementation of integrated institutional programs including Mock Review (MoRe) for evaluation of grant proposals prior to submission, physician–scientist Faculty Mentoring (FaMe), and effort matching programs are described. Detailed tactics are offered for tailoring these programs to a particular institution's background to maximize both efficiency and sustainability. The overarching strategy includes engaging multidisciplinary faculty as mentors and mentees, partnering with both clinical and basic science departments, integrating new programs with established approaches, and cultivating an emerging generation of physician–investigators as near-peer mentors and future leaders. This approach may serve as a useful paradigm for building an environment to nurture junior physician–investigators at other mid-sized academic institutions, and may also have value for larger institutions in which there is fragmentation of the efforts to sustain the research careers of physicians. Acknowledgements: The authors thank Dr. Kevin Grigsby for encouraging the writing of this manuscript and providing constructive feedback, Ellen Miller for assisting with data collection and analyses, and Dr. Charles McCollister Evarts for providing important perspectives regarding the history of the Penn State Milton S. Hershey College Of Medicine. The authors also thank Drs. Mechelle Lewis, Joslyn Kirby, Rebecca Bascom, Nancy Olsen, Charles Lang, Rachel Dokholyan, Jennifer Kraschnewski, Thomas Ma, Kevin Harter, Jeffrey Sundstrom, Neil Thomas, and Sheila Vrana for critically reviewing the manuscript and/or providing constructive comments. Funding/Support: Although authors are funded via different sources, all analyses, interpretations, and conclusions are those of the authors and not the research sponsors. Xuemei Huang has received research funding from the National Institutes of Health (R01 ES019672, U01 NS082151, U01 NS112008); the Michael J. Fox Foundation for Parkinson's Research, Alzheimer's Association; Alzheimer's Research UK; the Weston Brain Institute; Bristol Myers Squibb/Biogen; Pfizer, Inc.; and the U.S. Department of Defense. Sinisa Dovat has received research funding from the National Institutes of Health CA209829; R01CA213912; Hyundai Hope on Wheels Scholar Grant; Four Diamonds Fund of the Pennsylvania State University College of Medicine; Bear Necessities Pediatric Cancer Foundation; Alex's Lemonade Stand Foundation; and the John Wawrynovic Leukemia Research Scholar Endowment. Richard Mailman has received research funding from the National Institutes of Health R01 (R01 NS105471); the Children's Miracle Network; and Pfizer, Inc. Debora Berini has received no research funding. Diane Thiboutot has received research funding from the National Institutes of Health (1KL2TR002015). Leslie Parent has received research funding from the National Institutes of Health (R01 CA076534) and is co-director of the Penn State Medical Scientist Training Program that is funded by NIH T32 GM118294-05. There are no other funding sources, and none of the above cause a conflict with the current publication. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: This article represents the opinions of the authors alone and does not reflect an official position of the Pennsylvania State University or Penn State Health. Correspondence should be addressed to Xuemei Huang, 500 University Drive, H037, Penn State Health-Milton S. Hershey Medical Center, Hershey, PA 17033; telephone: (717) 531-1530; email: xuemei@psu.edu. © 2020 by the Association of American Medical Colleges |
Abstract: Neuroendocrine differentiation is characterized by endocrine and neuronal features with prominent dense secretory granules and neuropeptides. Neuroendocrine differentiation of skin tumors is of unknown clinical significance. Nonetheless, the acknowledgment of this line of differentiation is important to prevent diagnostic pitfalls and subsequent inappropriate management. This review aims at summarizing the skin neoplasms that can express neuroendocrine markers.
Abstract: To determine whether distal interphalangeal joint psoriatic arthritis (DIP PsA) and nail psoriasis are anatomically linked, we studied 2 fingers taken from a cadaver presenting a typical cutaneous and nail psoriasis in the setting of a dactylitis limited to the fourth toe. This comprehensive study of the inflammatory pattern of DIP PsA is discussed in the context of the controversial theory of the nail as a musculoskeletal appendage. Both the extensor and flexor entheses were focally and quite markedly infiltrated by lymphocytes and showed variable fibrosis and neovascularization. In addition, some clusters of giant cells were seen. Synovial perivascular inflammation was focally relatively dense. Discrete periostitis and bone inflammation of the intertrabecular spaces were seen, maximally at the insertion of the extensor and flexor tendons. The retained superficial fibrocartilaginous and tendinous cuff separated the inflamed extensor enthesis from the surrounding connective tissues. The thick proximal periosteum constituted a barrier between the inflamed bone and the matrical hypoderm. The lateral sections showed inflammation at 3 levels as follows: the enthesis of the interosseous ligament and collateral ligament, periosteum, and nail epithelium. In the 3 specimens, the inflammatory foci involving entheses and nails were prominent and never contiguous. This suggests that DIP PsA is not merely an extensor enthesitis and that the nail unit remains a microanatomical structure independent from the extensor enthesis, even with severe DIP PsA.
Abstract: Desmoplastic melanoma can be difficult to diagnose and on average have a significantly higher T stage at the time of diagnosis compared with conventional melanomas. Histologically, these tumors typically consist of spindle cells in a fibrous matrix. The spindle cells may display fibroblast and/or Schwann cell–like features. In this study, we describe the features of 12 cases of desmoplastic melanoma closely simulating neurofibroma. Although the spindle cells in these tumors may be indistinguishable from those of neurofibroma, features such as prominent fibroplasia (12/12), poor lateral circumscription (8/9), diffuse infiltration of subcutaneous tissue (7/9), and lymphoid aggregates (10/12) may be helpful clues to the diagnosis. No immunohistochemical markers were reliable in distinguishing neurofibroma-like desmoplastic melanomas from neurofibroma. Clinical follow-up was available in 8 cases, of which 4 were initially misdiagnosed as benign neoplasms and given no further re-excision. All 4 of these cases recurred; 2 of which showed transformation to a more aggressive phenotype.
Abstract: With the advent of better molecular characterization of Spitz melanocytic neoplasms, there has been increasing effort to better understand and describe the relationships between specific driver fusion and/or mutations with the clinical and histomorphological characteristics of the lesions. Structural rearrangements in mitogen activated protein kinase genes have recently been noted to be important in Spitz neoplasms. Only very few reports, however, have described in detail melanocytic tumors with in frame deletions in MAP2K1. Cases in the literature with this aberration have been described as having a diagnosis of Spitz, deep penetrating nevi, or pigmented epithelioid melanocytoma. In this study, we describe a cohort of 6 cases with MAP2K1 activating in frame deletions. The morphologic spectrum of the cases was broad. Common features of these cases include Spitzoid cytomorphology (5/6) cases, prominent melanin pigmentation (4/6) cases, and deep penetrating nevi–like plexiform architecture (3/6) cases. The diagnoses at the time of clinical care of these cases included nevus of Reed (1/6), desmoplastic Spitz tumor (1/6), BAPoma (1/6), deep penetrating melanocytic nevus (2/6), and melanoma (1/6). Clinical follow-up was available in 3 of the 6 cases. None of the patients had a tumor recurrence. This builds on the growing literature to help expand the spectrum of changes associated with Spitzoid melanocytic neoplasms.
Abstract: Tattoos are a common practice in the 21st century. Although most modern pigments are organic and made of vegetable or plastic compounds, they still sometimes elicit an adverse reaction in the skin. Identifying the tattoo pigment in such biopsies is not always an easy task. To study how tattoo inks appear in the skin, we injected 14 different colors of commercial tattoo ink into normal skin obtained from a mastectomy specimen. One unstained section was obtained from each case, as well as one section stained with hematoxylin-eosin from each case. All sections were observed under the microscope. Stained and unstained sections were also examined under polarized light. We did not observe any modification of the ink color with the staining process with hematoxylin-eosin. However, some pigments appeared differently in stained and unstained sections than in the vial. Pink was the most difficult color to identify from the eosinophilic tissue. None of the colors showed any birefringent particles. However, in some unstained slides under polarized light, the color of the pigment appeared more similar to the one in the vial than in the stained slide.
Background: Fluorescence in situ hybridization (FISH) and single nucleotide polymorphism (SNP) arrays are well-established molecular tests for the analysis of challenging melanocytic lesions. A 23-gene expression signature (GES), marketed as myPath Melanoma, is a recently introduced molecular test that categorizes melanocytic lesions as "benign," "malignant," and "indeterminate." There are few studies on the concordance between FISH, SNP, and GES in the analysis of melanocytic lesions. Methods: A single-institution retrospective analysis of 61 contiguous cases of challenging melanocytic lesions with molecular analysis by 2 or more techniques. The primary objective was to determine the intertest agreement, which was calculated as percent agreement. A secondary objective was to determine the combined-test performance, that is, the frequency of obtaining a successful test (a test with an abnormal or normal, benign or malignant result) when 2 or more molecular tests were performed. Results: Of the 61 cases, 58 cases were submitted for analysis using the GES assay, 44 cases were submitted for FISH analysis, and 21 cases were submitted for SNP array analysis. Percent agreement between GES and FISH array was 50.9% (18/34), which improved to 69.7% (18/23) when indeterminate/equivocal results were excluded. Similarly, percent agreement between GES and SNP array was 57.1% (8/14); this improved to 77.8% (7/9) when indeterminate/equivocal results were excluded. In 44% of cases submitted for GES and FISH and in 39% of cases submitted for GES and SNP, one test was successful and the other was not. Conclusion: For challenging melanocytic lesions, the choice of a molecular test is consequential as the GES assay correlated with FISH and SNP arrays approximately only half of the time. This improved when cases with indeterminate/equivocal results were excluded from the calculations. The combined-test analysis supports the utility of conducting more than one molecular test, as this increased the odds of obtaining a successful test.
Abstract: Deep penetrating nevus (DPN) is an intradermal, sometimes compound benign melanocytic lesion, which involves the reticular dermis, occasionally reaching the subcutis, which can raise concern for melanoma both clinically and histologically. Recently, it has been genetically defined by the combination of MAPK activating and β-catenin activating mutations. We sought to investigate genetic alterations in 2 cases of combined nevi of congenital melanocytic and DPN. Case 1 was a 16-year-old woman with a pigmented lesion on the trunk since birth, which was completely excised. Histopathological examination revealed a combined congenital nevus with a DPN. Comparative genomic hybridization showed no major genetic alterations, except for gain of 6q11.1 and point mutation of B-RAF V600E. Case 2 was a 62-year-old woman with a congenital pigmented lesion on the back. The lesion was diagnosed as a combined nevus of congenital and DPN. Comparative genomic hybridization showed no genetic alterations, and the NRAS Q61K was detected in both components. DPN is in most cases part of a combined nevus. Our cases showed strong and uniform nuclear expression of β-catenin and cyclin D1 in the DPN component suggesting the evolution of the congenital nevus to the DPN clone by acquiring β-catenin activating mutation.
Abstract: A 57-year-old man had a 2-year history of a painful nodule on the right sole. Physical examination revealed an 8 × 8 mm hyperkeratotic plaque with a central fissure. Excisional biopsy disclosed epithelial invagination surrounded by the acanthotic epidermis with parakeratotic hyperkeratosis and focal hypergranulosis. The invaginated epithelium lacked a cornified layer and was composed of a mixture of small basaloid squamous cells and goblet cells showing tubular structures. The patient was diagnosed with mucinous syringometaplasia. Our literature review established that surrounding acanthosis with hyperkeratosis typically tends to conceal mucinous syringometaplastic changes. Because mucinous syringometaplasia often presents as an asymptomatic papule/nodule with no distinct ulcer, fissure, or depressed area, cases may be overlooked.
Abstract: Melanomas with complete histological regression have been seen very infrequently. On the other hand, the diagnosis of metastatic melanoma is based on the histopathology and positivity of markers such as S100, Melan-A, and HMB-45 whose sensitivity is 99%, 82%, and 76%, respectively. It is very rare that metastatic melanomas and even more primary melanoma are negative for all of these markers. In these rare cases, there is usually a known primary. We present the case of a 82-year-old woman with a erythematous mass in the left groin and a 1-cm black–bluish irregular nodule on the skin of the ipsilateral foot. This lesion was clinical and dermoscopically compatible with primary melanoma. In the histological evaluation of the skin, a dermis full of melanophages and hemosiderophages were found in a background of fibrosis, scarce lymphocytic infiltrate, and neovascularization. Any cells expressing melanocytic markers were observed. It was diagnosed as tumoral melanosis. Lymph nodes showed a proliferation of atypical epithelioid cells with eosinophilic cytoplasm. Mitosis was conspicuous. Tumoral cells were vimentin and CD99 positive, and S100, CD34, HMB-45, Melan-A, SOX 10, tyrosinase, C-KIT, CD45, and CKAE1/AE3 negative, and BRAF-V600 mutated was detected. During follow-up, atypical vitiligo-like lesions were discovered, suggesting the diagnosis of metastatic melanoma totally regressed in our patient.
Abstract: BRCA1-associated protein (BAP1)-inactivated melanocytic tumor (BIMT) is a group of epithelioid melanocytic neoplasms characterized by the loss of function of BAP1, a tumor suppressor gene located on chromosome 3p21. They occur sporadically or in the setting of an autosomal-dominant cancer susceptibility syndrome that predisposes to the development of different internal malignancies. Most of these cutaneous lesions are associated with a BRAF-mutated melanocytic nevus and therefore are included in the group of combined nevi in the last WHO classification of skin tumors. Apart from a BRAF mutation, an NRAS mutation has been reported in rare cases, whereas in some lesions no driver mutation has been detected. Here, we report 2 cases of BIMTs with a BAP1 mutation and a RAF1 fusion. Both lesions proved to be BRAF and NRAS wild type and were associated with a conventional melanocytic nevus with dysplastic junctional features. We suggest that RAF1 fusions can represent an underlying driver genetic event in these cases. Our study extends the morphological and molecular spectrum in BIMTs.
