Bush Foundation

Nail unit melanocytic lesions present a unique set of diagnostic challenges because of the unfamiliarity with clinical assessment and the lack of experience with histologic examination. Because the first surgical specimen received in the pathology laboratory is typically small, sometimes suboptimal biopsy, the distinction between melanoma and its histologic mimics can be difficult. For this reason, there has been a continued interest in the development of ancillary markers that may assist in the differential diagnosis of nail unit melanocytic lesions. Upregulation of preferentially expressed antigen in melanoma (PRAME) has been reported to be a common event in melanomas, and PRAME immunohistochemistry has been shown to be helpful in evaluating various melanocytic neoplasms. In this study, we evaluated PRAME protein expression in a series of nail unit melanocytic lesions. Twenty-five nail unit melanomas (including small biopsy and amputation specimens) and 32 control benign melanocytic lesions were retrospectively retrieved. Nuclear PRAME staining was scored as percentage and intensity labeling. All melanoma cases showed the nuclear expression of PRAME, which was usually diffuse and strong. In specimens where the neoplastic cells are limited in number, the staining was restricted to the tumor cells, corresponding to the initial H&E impression. All control cases were negative for PRAME expression. PRAME expression is helpful in distinguishing between melanomas and other nail unit melanocytic lesions. This antibody also proved to be diagnostically valuable in detecting melanoma cells in small specimens with minimal disease.

Efforts to accomplish successful results from community change processes have caused researchers and practitioners to develop new approaches to engage local resources in ways that can bring about positive community development outcomes. Collective impact (CI) as an approach has been shown to lead to sustained improvements and is gaining use around the world in working on community development concerns. This volume examines the application of CI to a variety of development issues and offers insights into approaches that seem to have generated positive and sustainable outcomes. Of special interest is the applicability of the techniques in different governmental settings and locations.

This paper applies the concepts of 'adaptive leadership', as developed by Ron Heifetz, MD, to the practice of medicine. Literature review and theory development. Patients are complex adaptive systems facing both adaptive and technical health challenges. Technical health challenges are amenable to the simple or complicated expert-mediated technical interventions that are common in modern medicine, but complex adaptive challenges can only be addressed by patients doing the adaptive work to learn new attitudes, beliefs and behaviours. In medicine, we often make the mistake of offering technical interventions in lieu of supporting patients' adaptive work. This error can result in poor clinical outcomes and wasted resources. Expecting simple or complicated technical 'solutions' to resolve complex adaptive health challenges is a failure of adaptive leadership and violates Ashby's law of requisite variety. Adaptive leadership behaviours correspond to and complement doctor practices that have been shown to improve health outcomes and doctor-patient communication. Adopting an adaptive leadership framework in the practice of medicine will require adaptive work on our part, but it promises to improve the doctor-patient relationship, increase our effectiveness as healers and reduce unnecessary health care utilization.