Seasonal variation of eosinophil counts in histologically normal colonic mucosal biopsies

INTRODUCTION

The eosinophil counts in colonic biopsies are affected by geographical and possibly seasonal variations. This study aims to investigate the significance of seasonal variations of eosinophil counts in histologically normal colonic mucosal biopsies.

MATERIALS AND METHODS

This is a retrospective, cross sectional study that included 337 cases of normal colonic biopsies. The number of eosinophils per high power field was counted in the most densely populated area. The eosinophilic counts were compared among genders, age groups, biopsy sites and in various months and seasons. Two tailed T-test was used to compare means and a p value < 0.05 was considered significant.

RESULTS

173 (51%) of cases were from males. The age range was between 18-82 with the mean being 51.7 years (SD= 17.5). 181 (54%) biopsies were from the right colon and 156 (46%) from the left colon. There was a statistically significant difference between eosinophil counts in the right colon (mean 20.2, SD 13.2) and left colon (mean 13.8, SD10.1); p value <0.001. The mean eosinophil counts was highest in autumn (21.1) followed by spring (18.3). The counts in winter and summer were close (15.2 and 15.1 respectively). There was a statistically significant difference between counts in autumn and summer (p=0.013) and between autumn and winter (p=0.008). However, there was no statistically significant differences between autumn and spring counts (p=0.183). When stratified according to site, this pattern of statistical significance was observed in the right colon but not the left colonic mucosal biopsies.

CONCLUSION

There are significant seasonal variations of eosinophil counts in normal colonic biopsies which are more pronounced in the right colon. Pathologists and gastroenterologists need to be aware of these variations and to take them into account when determining if a patient has tissue eosinophilia.

Examining the trajectory and predictors of post-concussion sleep quality in children and adolescents

OBJECTIVES

This study aimed to 1) determine if post-concussion sleep quality of children and adolescents differed from healthy sleep estimates; 2) describe the trajectory of parameters of sleep quality; 3) determine factors that predict sleep quality outcomes; and 4) compare sleep parameter outcomes between asymptomatic and symptomatic participants at 4 weeks post-concussion.

METHODS

Nightly actigraphy estimates of sleep in 79 children and adolescents were measured throughout 4 weeks post-concussion. Total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), number of arousals (NOA), and average arousal length (AAL) were measured.

RESULTS

Child and adolescent participants experienced significantly poorer SE and longer WASO duration throughout 4 weeks of recovery and adolescents experienced significantly longer TST. SE significantly improved with time post-injury (p = .047). Older age was associated with longer TST (p = .003) and female sex was associated with longer WASO (p = .025) and AAL duration (p = .044). Week 4 sleep parameter outcomes were not significantly different between asymptomatic and symptomatic participants.

CONCLUSIONS

The sleep quality of youth is adversely affected by concussion, particularly in females. Sleep quality appears to improve with time but may require more than 4 weeks to return to normal.

Automatically Identifying Financial Stress Information from Clinical Notes for Patients with Prostate Cancer

Background

Financial stress, one of the social determinants, is common among cancer patients because of high out-ofpocket costs for treatment, as well as indirect costs. The National Academy of Medicine (NAM) has advised providers to recognize and discuss cost concerns with patients in order to enhance shared decision-making for treatment and exploration of financial assistant programs. However, financial stress is rarely assessed in clinical practice or research, thus, under-coded and under-documented in clinical practice. Natural language processing (NLP) offers great potential that can automatically extract and process data on financial stress from clinical free text existing in the patient electronic health record (EHR).

Methods

We developed and evaluated an NLP approach to identify financial stress from clinical narratives for patients with prostate cancer. Of 4,195 eligible prostate cancer patients, we randomly sampled 3,138 patients (75%) as a training dataset (150,990 documents) to develop a financial stress lexicon and NLP algorithms iteratively. The remaining 1,057 patients (25%) were used as a test dataset (55,516 documents) to evaluate the NLP algorithm performance. The common terms representing financial stress were "financial concerns," "unable to afford," "insurance issue," "unemployed," and "financial assistance." Negations were used to exclude false mentions of financial stress.

Results

Applying both pre- and post-negation, the NLP algorithm identified 209 patients (6.0%) from the training sample and 66 patients (6.2%) with 161 notes from the test sample as having documented financial stress. Two independent domain experts manually reviewed all 161 notes with NLP identified positives and randomly selected 161 notes with NLP-identified negatives, the NLP algorithm yielded 0.86 for precision, 1 for recall, and 0.9.2 for F-score.

Conclusions

Financial stress information is not commonly documented in the EHR, neither in structured format nor in clinical narratives. However, natural language processing can accurately extract financial stress information from clinical notes when such narrative information is available.

Circulating Endothelial Progenitor Cells in Youth: Fitness, Physical Activity and Adiposity

Circulating endothelial progenitor cells (EPCs) are early markers of cardiovascular impairment. The role of EPCs in youth remains unclear, and is complicated by differences in how cells are identified. This study (1) described EPCs in pre- and late-pubertal males and females, (2) examined their association with fitness, activity and adiposity, and (3) compared EPCs to published cell definitions. 94 participants completed 2 sessions. During the first session, aerobic fitness (Wpeak) and moderate-to-vigorous physical activity (MVPA) were assessed. During the second session, percent body fat (%BF) was determined by DXA, and a fasted blood sample was collected to measure EPCs by flow cytometry. EPCs were identified as CD31(+)CD34(bright)CD45(dim)CD133(+). Samples were reanalyzed and cell counts were compared to 8 previously published EPC definitions. EPCs were similar in pre- and late-pubertal males and females (p>0.05). Neither EPC concentrations nor proportions were correlated with Wpeak (ρ=- 0.04 to-0.06), MVPA (ρ=- 0.09 to - 0.07) or %BF (ρ=0.20 to 0.14). Agreement between cell data analyzed according the different cell definitions ranged from Κ=-0.06 to 0.82. Our findings suggest that EPCs were not associated with fitness, MVPA or adiposity in youth. The overall poor agreement across definitions may be indicative of distinct EPC subpopulations.

Idiopathic retroperitoneal fibrosis presenting as recurrent scrotal edema: Report of a case and review of the literature

Primary or idiopathic retroperitoneal fibrosis, first described by Ormond in 1948, is a rare and elusive diagnosis, requiring a high level of suspicion. Patients usually present with entrapment of retroperitoneal organs, the most common being the ureters, causing hydronephrosis and acute kidney injury. Here, we present the case of a 56-year-old male presenting for recurrent and intermittent scrotal edema. Upon routine laboratory workup, he was found to have an elevated creatinine level. Imaging showed encasement of bilateral ureters. Bilateral ureteral stents were placed with relief of his obstructive uropathy, followed by normalization of creatinine. The patient later underwent laparoscopic release of retroperitoneal adhesions. Biopsies taken from the operative site showed fibroblast proliferation and elements of acute and chronic inflammation. With further workup of etiologies being negative, he was diagnosed with idiopathic retroperitoneal fibrosis.

Myxedema ascites with high CA-125: Case and a review of literature

Ascites appearing in a previously healthy female patient is usually ascribed to a variety of causes, among which, is a cancerous process, especially if it comes with a raised CA-125 level. Although the CA-125 antigen is present on more than 80% of malignant epithelial ovarian tissue of non-mucinous type, it is also found on both healthy and malignant cells of mesothelial and non-mesothelial origin. Myxedema ascites which is caused by hypothyroidism is a rare entity, but on the other hand is easy to treat. It is one of the differential diagnoses when the ascites is refractory to treatment and no other obvious cause can be identified. If the diagnosis is delayed, patients will frequently receive unnecessary procedures, while treatment has very good response rates and ascites resolve with serum CA-125 normalization after adequate hormonal treatment.

Exercise and inflammation in pediatric Crohn's disease

We examined inflammatory cells, cytokines and growth factors in response to acute bouts of moderate intensity continuous exercise and high intensity intermittent exercise in youth with Crohn's disease and in healthy matched-controls. 15 patients and 15 controls performed 30 min of cycling at 50% of peak mechanical power (PMP) and 6 bouts of 4×15-s of cycling at 100% PMP. Blood was collected at rest, at the mid-point, at the end of exercise and at 30 and 60 min into recovery. In patients with CD, both types of exercise increased immune cells and GH and decreased IGF-I. Moderate intensity exercise induced a greater increase in leukocytes (p<0.05), neutrophils (p<0.05), lymphocytes (p<0.001), monocytes (p<0.05), IL-6 (p<0.05), IL-17 (p<0.05) and GH (p<0.05) and a similar decrease in IGF-I, compared with high intensity exercise. TNF-α did not change significantly with either exercise. Responses in patients were similar compared with controls; however, in patients monocytes remained elevated significantly longer in response to MICE. Youth with Crohn's disease can engage in distinctly different types of exercise without a significant acute exacerbation of inflammation.

Reproducibility of computer-assisted joint alignment measurement in OA knee radiographs

OBJECTIVES

(1) To investigate the reproducibility of computer-assisted measurements of knee alignment angle (KA) from digitized radiographs of osteoarthritis (OA) participants requiring total knee arthroplasty (TKA) and (2) to determine whether landmark choice affects the precision of KA measurements on radiographs.

METHODS

Using a custom algorithm, femoral, central, and tibial measurement-guiding rules were interactively placed on digitized posteroanterior fixed-flexion knee radiographs by mouse control and positioned according to different anatomic landmarks. The angle subtended by lines connecting these guiding rules was measured by three readers to assess interobserver, intraobserver and experience-inexperience reproducibility. Test-retest reproducibility was evaluated with duplicate radiographs from a healthy cohort. Reproducibility was assessed using root-mean square coefficients of variation (RMSCV%). The Bland-Altman method was performed on data obtained from varying anatomic landmarks (confidence interval, CI= 95%).

RESULTS

From 16 healthy and 30 TKA participants, reproducibility analyses revealed a high degree of intraobserver (n=38, RMSCV=0.56%), interobserver (n=38, RMSCV=0.72%), test-retest (n=16, RMSCV=0.87%) and experience-inexperience (n=38, RMSCV=0.73%) reproducibility with variances below 1%. Varying the orientation of tibial and femoral rules according to anatomic landmarks produced a difference that exceeded an a priori limit of agreement of -1.11 degrees to +1.67 degrees.

CONCLUSION

Our custom-designed software provides a robust method for measuring KAs within digitized knee radiographs. Although test-retest analyses were only performed in a healthy cohort, we anticipate a similar degree of reproducibility in an OA sample. A standardized set of anatomic landmarks employed for KA measurement is recommended since arbitrary selection of landmarks resulted in imprecise KA measurement even with a computer-assisted technique.

Prenatal diagnosis for congenital adrenal hyperplasia in 532 pregnancies

Congenital adrenal hyperplasia (CAH) refers to a family of monogenic inherited disorders of adrenal steroidogenesis most often caused by enzyme 21-hydroxylase deficiency (21-OHD). In the classic forms of CAH (simple virilizing and salt wasting), androgen excess causes external genital ambiguity in newborn females and progressive postnatal virilization in males and females. Prenatal treatment of CAH with dexamethasone has been successfully used for over a decade. This article serves as an update on 532 pregnancies prenatally diagnosed using amniocentesis or chorionic villus sampling between 1978 and 2001 at New York Presbyterian Hospital-Weill Medical College of Cornell University. Of the 532 pregnancies, 281 were prenatally treated for CAH due to the risk of 21-hydroxylase deficiency. Follow-up telephone interviews with mothers, genetic counselors, endocrinologists, pediatricians, and obstetricians were performed in all cases. Of the pregnancies evaluated, 116 babies were affected with classic 21-OHD. Of these, 61 were female, 49 of whom were treated prenatally with dexamethasone. Dexamethasone administered at or before 9 wk gestation (in proper doses) was effective in reducing virilization. There were no statistical differences in the symptoms during pregnancy between mothers treated with dexamethasone and those not treated with dexamethasone, except for weight gain, edema, and striae, which were greater in the treated group. No significant or enduring side-effects were noted in the fetuses, indicating that dexamethasone treatment is safe. Prenatally treated newborns did not differ in weight from untreated, unaffected newborns. Based on our experience, prenatal diagnosis and proper prenatal treatment of 21-OHD are effective in significantly reducing or eliminating virilization in the newborn female. This spares the affected female the consequences of genital ambiguity, genital surgery, and possible sex misassignment.

Prenatal diagnosis for congenital adrenal hyperplasia in 532 pregnancies

Congenital adrenal hyperplasia (CAH) refers to a family of monogenic inherited disorders of adrenal steroidogenesis most often caused by enzyme 21-hydroxylase deficiency (21-OHD). In the classic forms of CAH (simple virilizing and salt wasting), androgen excess causes external genital ambiguity in newborn females and progressive postnatal virilization in males and females. Prenatal treatment of CAH with dexamethasone has been successfully used for over a decade. This article serves as an update on 532 pregnancies prenatally diagnosed using amniocentesis or chorionic villus sampling between 1978 and 2001 at New York Presbyterian Hospital-Weill Medical College of Cornell University. Of the 532 pregnancies, 281 were prenatally treated for CAH due to the risk of 21-hydroxylase deficiency. Follow-up telephone interviews with mothers, genetic counselors, endocrinologists, pediatricians, and obstetricians were performed in all cases. Of the pregnancies evaluated, 116 babies were affected with classic 21-OHD. Of these, 61 were female, 49 of whom were treated prenatally with dexamethasone. Dexamethasone administered at or before 9 wk gestation (in proper doses) was effective in reducing virilization. There were no statistical differences in the symptoms during pregnancy between mothers treated with dexamethasone and those not treated with dexamethasone, except for weight gain, edema, and striae, which were greater in the treated group. No significant or enduring side-effects were noted in the fetuses, indicating that dexamethasone treatment is safe. Prenatally treated newborns did not differ in weight from untreated, unaffected newborns. Based on our experience, prenatal diagnosis and proper prenatal treatment of 21-OHD are effective in significantly reducing or eliminating virilization in the newborn female. This spares the affected female the consequences of genital ambiguity, genital surgery, and possible sex misassignment.

Facilitating physician referrals on the World Wide Web: representation and appropriate utilization of clinical expertise

In highly integrated and increasingly complex health care systems, the identification and proper utilization of clinical staff expertise are key factors for efficiently delivering high quality patient care. To achieve these capabilities on an enterprise-wide scale, we have embarked on a multi-phased project to develop World Wide Web (WWW)-based physician referral capabilities for two large teaching hospitals. Currently, users may search for information concerning the education, training, board certifications, and self-designated clinical interests of staff members. Address, phone number, email address, and a photo are also presented. Our experience indicates that institutional changes are required to successfully deploy and maintain online physician referral services and that accurate and equitable representation of clinical expertise and the incorporation of referral guidelines require an incremental introduction of a carefully planned program that addresses the needs of clinicians, administrators, and health care policy-makers.

Genetic analysis of 11 beta-hydroxysteroid dehydrogenase

11 beta-Hydroxysteroid dehydrogenase (11 beta-OHSD) catalyzes the interconversion of cortisol and cortisone. This activity is postulated to protect the Type I (mineralocorticoid) receptor from excessive concentrations of cortisol, allowing aldosterone to function as a mineralocorticoid. An enzyme with 11 beta-OHSD activity was isolated from rat liver and the corresponding rat and human cDNA and genomic clones isolated. This enzyme is a member of the short-chain dehydrogenase family. Using site-directed mutagenesis, it was demonstrated that the amino terminus and two highly conserved residues, Tyr-179 and Lys-183, are required for enzymatic function. Examination of patients with apparent mineralocorticoid excess, a syndrome of juvenile hypertension thought to represent 11 beta-OHSD deficiency, did not reveal any mutations in the HSD11 gene. This disorder may involve an additional enzyme with 11 beta-OHSD activity or possibly another cortisol metabolizing enzyme.

The representation of time in clinical patient simulations

Simulated clinical scenarios are generally compressed in time to enhance educational effectiveness and to minimize testing time. Designers should consider how to best control potential sources of distortion in the perception of time and how to best communicate the passage of time to the user.

Transcripts originating in intron 1 of the HSD11 (11 beta-hydroxysteroid dehydrogenase) gene encode a truncated polypeptide that is enzymatically inactive

There is evidence for the presence in the kidney of more than one isoform of 11 beta-hydroxysteroid dehydrogenase (11HSD), an enzyme that interconverts cortisol and cortisone (in rodents, corticosterone and 11-dehydrocorticosterone). A specific isoform might arise from transcripts in the kidney that are known to originate in intron 1; translation from these transcripts is predicted to initiate at the codon that in the full-length rat enzyme encodes Met27. Alignment of the full-length rat and human 11HSD sequences with other members of the short chain dehydrogenase family suggests that initiation of translation at Met27 might yield a functional enzyme, since the amino-termini of most of these enzymes occur at equivalent positions. We confirmed that short transcripts are found in the kidney and are detectable at lower levels in the liver and lung. In vitro transcription and translation of short cDNA demonstrated that the AUG encoding Met27 is indeed a functional initiation codon. However, Chinese hamster ovary cells transfected with short cDNA in the pCMV4 vector expressed apparently low levels of the corresponding truncated polypeptide and had no 11HSD activity. Thus, the functional significance of transcripts originating in intron 1 is unclear.

Tyr-179 and Lys-183 are essential for enzymatic activity of 11 beta-hydroxysteroid dehydrogenase

Tyr-179 and Lys-183 are likely to be functionally important residues in 11 beta-hydroxysteroid dehydrogenase, as these amino acids are absolutely conserved in all members of the "short chain dehydrogenase" family. We modified these residues by site-directed mutagenesis of rat cDNA and transfected these constructs into CHO cells. A highly but not absolutely conserved residue, Asp-110, was also studied. Mutation of Tyr-179 to Phe or Ser completely abolished enzymatic activity (interconversion of corticosterone and 11-dehydrocorticosterone), as did Lys-183-->Arg. Asp-110-->Asn affected activity only mildly. Tyr-179 and Lys-183 may be directly involved in the catalytic function of this class of enzymes.