Newly developed and validated eosinophilic esophagitis histology scoring system and evidence that it outperforms peak eosinophil count for disease diagnosis and monitoring

Eosinophilic esophagitis (EoE) is diagnosed by symptoms, and at least 15 intraepithelial eosinophils per high power field in an esophageal biopsy. Other pathologic features have not been emphasized. We developed a histology scoring system for esophageal biopsies that evaluates eight features: eosinophil density, basal zone hyperplasia, eosinophil abscesses, eosinophil surface layering, dilated intercellular spaces (DIS), surface epithelial alteration, dyskeratotic epithelial cells, and lamina propria fibrosis. Severity (grade) and extent (stage) of abnormalities were scored using a 4-point scale (0 normal; 3 maximum change). Reliability was demonstrated by strong to moderate agreement among three pathologists who scored biopsies independently (P ≤ 0.008). Several features were often abnormal in 201 biopsies (101 distal, 100 proximal) from 104 subjects (34 untreated, 167 treated). Median grade and stage scores were significantly higher in untreated compared with treated subjects (P ≤ 0.0062). Grade scores for features independent of eosinophil counts were significantly higher in biopsies from untreated compared with treated subjects (basal zone hyperplasia P ≤ 0.024 and DIS P ≤ 0.005), and were strongly correlated (R-square >0.67). Principal components analysis identified three principal components that explained 78.2% of the variation in the features. In logistic regression models, two principal components more closely associated with treatment status than log distal peak eosinophil count (PEC) (R-square 17, area under the curve (AUC) 77.8 vs. R-square 9, AUC 69.8). In summary, the EoE histology scoring system provides a method to objectively assess histologic changes in the esophagus beyond eosinophil number. Importantly, it discriminates treated from untreated patients, uses features commonly found in such biopsies, and is utilizable by pathologists after minimal training. These data provide rationales and a method to evaluate esophageal biopsies for features in addition to PEC.

Digital subtraction angiography of the renal arteries. Prospective comparison with conventional arteriography

Intravenous digital subtraction angiography (IV-DSA) of the aorta and renal arteries was compared with conventional arteriography of 40 patients with 92 renal arteries. Inadequate visualization of the vessel occurred in six renal arteries (6.5%). In arteries adequately imaged, for the evaluation of renal artery stenosis, the sensitivity of IV-DSA was 87.5% (28/32), the specificity 100% (54/54), and the accuracy 95.3% (82/86). Overall, accurate IV-DSA was obtained in 89.1% (82/92) of renal arteries and 85% (34/40) of the patients. IV-DSA is an accurate screening procedure for renal artery stenosis.

CT differentiation of subphrenic abscess and pleural effusion

The computed tomographic scans of 38 patients with proven subphrenic abscesses and 28 patients with proven pleural effusions were reviewed without knowledge of the final diagnosis. In 26% of cases the hemidiaphragm could be identified directly as a stripe, while in 71% of cases only the hemidiaphragmatic contour could be seen. In 3% of cases the hemidiaphragm position was indeterminate because insufficient scans of the chest or abdomen were obtained. In the cases where the hemidiaphragm position could be established, the computed tomographic diagnosis was correct in 100% of subphrenic abscesses and in 96% of pleural effusions. Methods of identifying the hemidiaphragm on computed tomography and the possible pitfalls are discussed.

Fistulas and sinus tracts: radiographic evaluation, management, and outcome

A retrospective review of 50 sinus tracts and 87 fistulas is presented. The etiologies, methods of radiographic evaluation including computed tomography and ultrasound, means of radiographic intervention, and disposition of sinus tracts and fistulas are discussed. Despite the newer imaging modalities, a sinogram or a fistulogram is still the best means of evaluating a sinus tract or fistula when an external communication is present. Computed tomography is helpful if exact spatial delineation of the tract is necessary or an associated abscess is suspected. Ultrasound examination is generally not useful, being limited by bowel gas and surgical incisions.

Pancreatic gas: indication of pancreatic fistula

Although pancreatic gas may be associated with pancreatic abscess, it was found that pancreatic gas indicates the presence of a fistula rather than abscess alone. Of 10 patients with pancreatic gas on computed tomography, fistulas were present in all. Fistulization results from pancreatic pseudocyst rupture or as a complication of phlegmonous pancreatitis. In most cases the fistula does not adequately decompress the pseudocyst or pancreatic phlegmon. In addition, fistulas may predispose to sepsis and hemorrhage. It is important to identify the presence of a pancreatic fistula since patient management may be altered.

Computed tomography of gastrointestinal leiomyosarcoma

Computed tomography (CT) was performed in 6 patients with gastrointestinal leiomyosarcoma. The characteristic CT findings were a large extraluminal mass, apparently mesenteric in location, with central areas of necrosis. These findings were present in 5 of the 6 patients. Enhancement of the rim of the tumor was seen in 2 of 3 patients who had scans before and after administration of intravenous contrast material. CT identified the site of origin of tumor in only 2 patients. The characteristic CT findings should suggest the diagnosis of gastrointestinal leiomyosarcoma.

Ct of congenital anomalies of the inferior vena cava

The authors report six congenital abnormalities of the inferior vena cava detected on computed tomography (CT). The CT findings of one of these, the left inferior vena cava, have not been previously reported. The embryology of the inferior vena cava and the possible congenital abnormalities that can occur are discussed. Congenital abnormalities of the inferior vena cava are rare but potentially important to the radiologist, the surgeon, and the patient. They are easily identified on CT and should be considered when interpreting any CT of the abdomen or chest.

RX for social death: the cancer patient as counselor

Cancer patients frequently encounter psychological problems distinct from those with other serious illnesses. Cancer's deadly nature and its drastic treatment often alienate patients from relatives and caregivers. The CanCervive program trained cancer patients to counsel other patients. They functioned as role models and provided opportunities for catharsis. Yet their own unresolved conflicts often led them to overidentify with patients. Volunteers lacked insight into their own feelings of stress at seeing dying patients and their own guilt over their relatively advantaged medical status. Despite this, they helped patients cope with their insecurities and dependency needs, and assisted with professional education.