Biomedical subjects

K A Easley

Publications and source records attributed to K A Easley.

At least 37 records · Page 2Linked to original sources

PubMed1999

Colonic epithelial lymphocytosis without a thickened subepithelial collagen table: a clinicopathologic study of 40 cases supporting a heterogeneous entity.

Lymphocytic colitis (LC) is classically described as a triad of chronic nonbloody, watery diarrhea, normal or nearly normal endoscopy findings, and colonic epithelial lymphocytosis without a thickened subepithelial collagen table (SECT). It is unknown how often patients with colonic epithelial lymphocytosis without a thickened SECT actually present with this classic triad. Cases diagnosed histologically as lymphocytic or microscopic colitis were reviewed. Criteria for inclusion were the presence of at least 15 surface lymphocytes per 100 epithelial cells and the absence of a thickened SECT (<12 microm). Clinical features and course were recorded by chart review and telephone follow-up. Forty patients met the inclusion criteria, including 25 women and 15 men with a mean age of 63.2 years (range, 25-83 years). Twenty-eight patients had the classic triad and were designated as having classic LC. The other 12 patients fulfilled the histologic criteria but not the clinical or endoscopic criteria for classic LC and were classified as having atypical LC (constipation, five patients; macroscopic colitis at endoscopy, five patients; hematochezia, one patient; and incidental finding, one patient). Clinically, patients with classic LC were predominantly women and had a higher incidence of autoimmune disease (p = 0.03) than did those with atypical LC. Histologically, surface eosinophilia was significantly greater in patients with classic LC (p = 0.04). Twenty patients were using nonsteroidal antiinflammatory drugs at the time of their colonic biopsy. Surface epithelial lymphocyte counts were higher in these patients, particularly in the distal sigmoid colon (p = 0.02). Fourteen patients had associated autoimmune disease, including three patients with sprue diagnosed by small bowel biopsy, all of whom responded to gluten withdrawal. Diarrhea present in 25 patients, without documented evidence of celiac sprue, was self-limited in five, resolved with treatment in three, required intermittent treatment in eight, daily treatment in five, and was refractory to treatment in four. All eight patients who experienced spontaneous or treatment-related symptom resolution had classic LC. No histologic feature correlated with clinical course. In conclusion, our study shows that colonic epithelial lymphocytosis without a thickened SECT is a histologic finding seen in a heterogeneous group of patients. Within this heterogeneous group is a distinct subset of patients who have the classic clinicopathologic triad of LC. This subset of patients has striking similarities to patients with collagenous colitis, lending further support to a close relationship between these two entities. Atypical LC comprises a heterogeneous group and includes patients with idiopathic constipation, coexisting LC and inflammatory bowel disease, and possibly infectious colitides. Because of the clinical heterogeneity among our study population, the descriptive term colonic epithelial lymphocytosis may be a more prudent diagnosis than lymphocytic colitis in the absence of adequate clinical information.

Adult↗

PubMed1999

Unexpected non-HIV causes of death in children born to HIV-infected mothers. Pediatric Pulmonary and Cardiac Complications of Vertically Transmitted HIV Infection Study Group.

INTRODUCTION: A high incidence of sudden, unexplained deaths in infants born to HIV-infected mothers has been noted in several epidemiologic studies. During the course of a prospective study of heart and lung disease in children born to HIV-infected mothers, we noted that of 5 unexpected non-HIV-related deaths, 4 were attributed to traumatic events. METHODS: The Pediatric Pulmonary and Cardiac Complications of Vertically Transmitted HIV Infection (P2C2) study is a multicenter, prospective investigation of the incidence of heart and lung disease in HIV-infected children. A total of 805 children were enrolled and followed for 5 to 7 years with serial immunologic, pulmonary and cardiac function studies. During the study, a multidisciplinary committee was formed to review the cause of death for those patients who died. The committee used results of pulmonary, cardiac, and laboratory tests, hospital summaries, as well as autopsy and coroners' reports. The committee formed a consensus about the underlying and contributing causes of death for each subject using the definitions from the 1989 US Standard Certificate of Death. RESULTS: A total of 121 deaths occurred during the course of the P2C2 study. Of the 121 deaths, 5 were traumatic or sudden and unexpected and judged by the Mortality Review Committee to be unrelated to HIV infection. The median age at the time of death was 1.3 months and ranged from 1.2 to 37.8 months. Two infants died of trauma: a skull fracture and subdural hematoma in 1 infant and multiple skeletal fractures consistent with battered child syndrome in the other infant. The third infant died of accidental suffocation at home at 1.2 months of age. The fourth infant died suddenly and unexpectedly at home at 1.3 months of age. The autopsy showed no sign of HIV or other infection and was consistent with sudden unexpected death or SIDS. One non-HIV-related death occurred when a 38-month-old child died together with the mother in an unwitnessed drowning. The cumulative mortality rate attributable to trauma and sudden death at 4 months of age was 0.95% (95% CI: 0.02-1. 87%) and the infant mortality rate was 9.5/1000 live births. Three children were born prematurely at 30, 33, and 36 weeks' gestational age, respectively, and 3 mothers admitted using recreational drugs before or during pregnancy. DISCUSSION: These traumatic and sudden non-HIV-related deaths accounted for 4.1% (5/121) of the deaths during the entire P2C2 study period and for 20% (4/20) of the deaths in the first year of life. Four deaths were attributable to accidental and nonaccidental trauma rather than to other common causes of infant death. One death was a sudden unexpected death, similar to SIDS, a leading cause of infant death in the United States. The majority of previously reported non-HIV-related deaths in infants born to HIV-infected mothers have been attributed to SIDS or to unexplained sudden death. In contrast with other reports, 4 of the 5 children in our series died of accidental or nonaccidental trauma and only 1 was a sudden unexplained death. It is unlikely that HIV exposure is related directly to the deaths described in this report; however, maternal HIV infection may be a marker for factors that place the child at risk for sudden or traumatic death. SUMMARY: This report suggests that children born to HIV-infected mothers may be at increased risk for traumatic or sudden, unexplained, non-HIV-related death. These children seem to be at risk regardless of their own HIV infection status. Furthermore, 4 of the deaths in our study occurred within the first few months of life, suggesting that this is a period of increased vulnerability. Studies to identify associated risk factors for non-HIV-related deaths are needed to identify these high-risk infants. Children born to HIV-infected mothers may be more vulnerable than was recognized previously and may be in need of increased social services, especially in early infancy.

Cause of Death↗

PubMed1999

Cardiac complications in children with human immunodeficiency virus infection. Pediatric Pulmonary and Cardiac Complications of Vertically Transmitted HIV Infection (P2C2 HIV) Study Group, National Heart, Lung, and Blood Institute.

OBJECTIVE: Although numerous cardiac abnormalities have been reported in HIV-infected children, precise estimates of the incidence of cardiac disease in these children are not well-known. The objective of this report is to describe the 2-year cumulative incidence of cardiac abnormalities in HIV-infected children. METHODOLOGY DESIGN: Prospective cohort (Group I) and inception cohort (Group II) study design. SETTING: A volunteer sample from 10 university and public hospitals. PARTICIPANTS: Group I consisted of 205 HIV vertically infected children enrolled at a median age of 22 months. This group was comprised of infants and children already known to be HIV-infected at the time of enrollment in the study. Most of the children were African-American or Hispanic and 89% had symptomatic HIV infection at enrollment. The second group included 611 neonates born to HIV-infected mothers, enrolled during fetal life or before 28 days of age (Group II). In contrast to the older Group I children, all the Group II children were enrolled before their HIV status was ascertained. INTERVENTIONS: According to the study protocol, children underwent a series of cardiac evaluations including two-dimensional echocardiogram and Doppler studies of cardiac function every 4 to 6 months. They also had a 12- or 15-lead surface electrocardiogram (ECG), 24-hour ambulatory ECG monitoring, and a chest radiograph every 12 months. OUTCOME MEASURES: Main outcome measures were the cumulative incidence of an initial episode of left ventricular (LV) dysfunction, cardiac enlargement, and congestive heart failure (CHF). Because cardiac abnormalities tended to cluster in the same patients, we also determined the number of children who had cardiac impairment which we defined as having either left ventricular fractional shortening (LV FS) </=25% after 6 months of age, CHF, or treatment with cardiac medications. RESULTS: CARDIAC ABNORMALITIES: In Group I children (older cohort), the prevalence of decreased LV function (FS </=25%) was 5.7% and the 2-year cumulative incidence (excluding prevalent cases) was 15.3%. The prevalence of echocardiographic LV enlargement (LV end-diastolic dimension z score >2) at the time of the first echocardiogram was 8. 3%. The cumulative incidence of LV end-diastolic enlargement was 11. 7% after 2 years. The cumulative incidence of CHF and/or the use of cardiac medications was 10.0% in Group I children. There were 14 prevalent cases of cardiac impairment (LV FS </=25% after 6 months of age, CHF, or treatment with cardiac medications) in Group I. After excluding these prevalent cases, the 2-year cumulative incidence of cardiac impairment was 19.1% among Group I children and 80.9% remained free of cardiac impairment after 2 years of follow-up. Within Group II (neonatal cohort), the 2-year cumulative incidence of decreased LV FS was 10.7% in the HIV-infected children compared with 3.1% in the HIV-uninfected children. LV dilatation was also more common in Group II infected versus uninfected children (8.7% vs 2.1%). The cumulative incidence of CHF and/or the use of cardiac medications was 8.8% in Group II infected versus 0.5% in uninfected subjects. The 1- and 2-year cumulative incidence rates of cardiac impairment for Group II infected children were 10.1% and 12.8%, respectively, with 87.2% free of cardiac impairment after the first 2 years of life. MORTALITY: In the Group I cohort, the 2-year cumulative death rate from all causes was 16.9% [95% CI: 11.7%-22. 1%]. The 1- and 2-year mortality rates after the diagnosis of CHF (Kaplan-Meier estimates) were 69% and 100%, respectively. In the Group II cohort, the 2-year cumulative death rate from all causes was 16.3% [95% CI: 8.8%-23.9%] in the HIV-infected children compared with no deaths among the 463 uninfected Group II children. Two of the 4 Group II children with CHF died during the 2-year observation period and 1 more died within 2 years of the diagnosis of CHF. The 2-year mortality rate after the

Adolescent↗

PubMed1998

Prevalence of congenital cardiovascular malformations in children of human immunodeficiency virus-infected women: the prospective P2C2 HIV Multicenter Study. P2C2 HIV Study Group, National Heart, Lung, and Blood Institute, Bethesda, Maryland.

OBJECTIVES: The purpose of the study was to assess the effects of maternal HIV-1 (human immunodeficiency virus) infection and vertically transmitted HIV-1 infection on the prevalence of congenital cardiovascular malformations in children. BACKGROUND: In the United States, an estimated 7000 children are born to HIV-infected women annually. Previous limited reports have suggested an increase in the prevalence of congenital cardiovascular malformations in vertically transmitted HIV-infected children. METHODS: In a prospective longitudinal multicenter study, diagnostic echocardiograms were performed at 4-6-month intervals on two cohorts of children exposed to maternal HIV-1 infection: 1) a Neonatal Cohort of 90 HIV-infected, 449 HIV-uninfected and 19 HIV-indeterminate children; and 2) an Older HIV-Infected Cohort of 201 children with vertically transmitted HIV-1 infection recruited after 28 days of age. RESULTS: In the Neonatal Cohort, 36 lesions were seen in 36 patients, yielding an overall congenital cardiovascular malformation prevalence of 6.5% (36/558), with a 8.9% (8/90) prevalence in HIV-infected children and a 5.6% (25/449) prevalence in HIV-uninfected children. Two children (2/558, 0.4%) had cyanotic lesions. In the Older HIV-Infected Cohort, there was a congenital cardiovascular malformation prevalence of 7.5% (15/201). The distribution of lesions did not differ significantly between the groups. CONCLUSIONS: There was no statistically significant difference in congenital cardiovascular malformation prevalence in HIV-infected versus HIV-uninfected children born to HIV-infected women. With the use of early screening echocardiography, rates of congenital cardiovascular malformations in both the HIV-infected and HIV-uninfected children were five- to ten-fold higher than rates reported in population-based epidemiologic studies but not higher than in normal populations similarly screened. Potentially important subclinical congenital cardiovascular malformations were detected.

Cohort Studies↗

PubMed1998

Left ventricular structure and function in children infected with human immunodeficiency virus: the prospective P2C2 HIV Multicenter Study. Pediatric Pulmonary and Cardiac Complications of Vertically Transmitted HIV Infection (P2C2 HIV) Study Group.

BACKGROUND: The frequency of, course of, and factors associated with cardiovascular abnormalities in pediatric HIV are incompletely understood. METHODS AND RESULTS: A baseline echocardiogram (median age, 2.1 years) and 2 years of follow-up every 4 months were obtained as part of a prospective study on 196 vertically HIV-infected children. Age- or body surface area-adjusted z scores were calculated by use of data from normal control subjects. Although 88% had symptomatic HIV infection, only 2 had CHF at enrollment, with a 2-year cumulative incidence of 4.7% (95% CI, 1.5% to 7.9%). All mean cardiac measurements were abnormal at baseline (decreased left ventricular fractional shortening [LV FS] and contractility and increased heart rate and LV dimension, mass, and wall stresses). Most of the abnormal baseline cardiac measurements correlated with depressed CD4 cell count z scores and the presence of HIV encephalopathy. Heart rate and LV mass showed significantly progressive abnormalities, whereas FS and contractility tended to decline. No association was seen between longitudinal changes in FS and CD4 cell count z score. Children who developed encephalopathy during follow-up had depressed initial FS, and FS continued to decline during follow-up. CONCLUSIONS: Subclinical cardiac abnormalities in HIV-infected children are common, persistent, and often progressive. Dilated cardiomyopathy (depressed contractility and dilatation) and inappropriate LV hypertrophy (elevated LV mass in the setting of decreased height and weight) were noted. Depressed LV function correlated with immune dysfunction at baseline but not longitudinally, suggesting that the CD4 cell count may not be a useful surrogate marker of HIV-associated LV dysfunction. However, the development of encephalopathy may signal a decline in FS.

AIDS Dementia Complex↗

PubMed1998

The seroprevalence of cagA-positive Helicobacter pylori strains in the spectrum of gastroesophageal reflux disease.

BACKGROUND & AIMS: The role of Helicobacter pylori in the pathogenesis of gastroesophageal reflux disease (GERD) is unknown. We determined the prevalence of cagA-positive (cagA+) H. pylori strains in patients with GERD or its complications compared with controls of similar age. METHODS: A total of 153 consecutive patients with GERD, Barrett's esophagus, and Barrett's esophagus complicated by dysplasia or adenocarcinoma were compared with 57 controls who underwent upper endoscopy for reasons other than GERD. H. pylori infection and CagA antibody status were determined by histology and enzyme-linked immunosorbent assay. RESULTS: H. pylori prevalence was lower (34%) in patients with GERD and its sequelae than in the control group (45.6%)(P = 0.15). Regardless of the group, increasing age was associated with higher prevalence of H. pylori (P = 0.003). When compared with controls (42.3%), the prevalence of cagA+ H. pylori strains decreased (P = 0.008) in patients with more severe complications of GERD (GERD, 36.7% [nonerosive GERD, 41.2%; erosive GERD, 30.8%]; Barrett's esophagus, 13.3%; and Barrett's with adenocarcinoma/dysplasia, 0%). CONCLUSIONS: Prevalence of H. pylori in patients with GERD and its sequelae was lower but not significantly different than that of a control group. However, patients carrying cagA+ strains of H. pylori may be protected against the complications of GERD, especially Barrett's esophagus and its associated dysplasia and adenocarcinoma.

Adult↗

PubMed1998

Sublingual hyoscyamine for patient comfort during screening sigmoidoscopy: a randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: Screening sigmoidoscopy is an underutilized method for detecting early colorectal cancer, and patient discomfort is one reason for poor compliance in the general population. The possible benefit of a well-tolerated, low-cost antispasmodic medication, sublingual hyoscyamine, used before flexible sigmoidoscopy was assessed in a randomized, double-blinded, placebo-controlled trial. METHODS: One hundred fifty patients were enrolled and randomized to receive two sublingual hyoscyamine tablets (0.125 mg/tablet) or the placebo 10 minutes before sigmoidoscopy. Patient comfort and the endoscopist's perception of the ease of insertion were measured using a 100 mm visual analog scale. The depth of sigmoidoscope insertion was measured in centimeters, and complications were recorded. RESULTS: The median age was 55 years (range 25 to 83 years). There were 100 men (66.7%) and 50 women (33.3%). Approximately half (n = 76, 50.7%) had a prior sigmoidoscopy or colonoscopy. No statistical differences were found between treatment group means for age, gender, pain score, ease of insertion, or depth of insertion. The hyoscyamine group tended to have lower mean pain (32.4 vs. 37.7, p = 0.18) and difficulty (29.9 vs. 33.7, p = 0.31) scores and greater depth of sigmoidoscope insertion (51.3 vs. 47.7, p = 0.07); however, the differences were not statistically significant. The treatment groups differed with a higher percentage of the hyoscyamine group having a previous endoscopy (60.0% vs. 41.3%, p = 0.02); however, no significant differences were detected between mean pain scores as related to treatment when controlling for previous experience with endoscopy (p = 0.31). CONCLUSIONS: In this study, hyoscyamine administered in the sublingual route did not significantly improve patient comfort, ease of insertion, or the depth of sigmoidoscope insertion during screening sigmoidoscopy. The search for alternative methods to improve patient comfort during screening endoscopy should continue.

Adjuvants, Anesthesia↗

PubMed1998

Reassessment of the incubation time in a controlled clinical comparison of the BacT/Alert aerobic FAN bottle and standard anaerobic bottle used aerobically for the detection of bloodstream infections.

This study assessed the minimum incubation time required to detect bloodstream infections during a controlled clinical comparison of the performance characteristics of the BacT/Alert aerobic FAN bottle and the standard anaerobic bottle used aerobically except on a selective basis. Blood was collected from adults with suspected bloodstream infections and inoculated into each bottle, which was monitored in the BacT/Alert Microbial Detection System. The anaerobic bottle was vented before incubation except when cultures were obtained from patients on the colorectal and gynecologic surgical and emergency services. Statistical analysis was limited to those culture sets in which each bottle was inoculated with > or = 8 mL of blood and bacterial growth was considered to be clinically significant. A total of 682 positive cultures from 243 patients satisfied the inclusion criteria. Significantly more isolates of Staphylococcus aureus (p < 0.001), S. epidermidis (p < 0.001), other coagulase-negative staphylococci (p < 0.001), Enterococcus spp. (p = 0.04), Escherichia coli (p = 0.03), all Enterobacteriaceae (p < 0.001), Pseudomonas aeruginosa (p = 0.001), and Candida spp. (p < 0.001) were detected by the aerobic FAN bottle. Significantly more septic episodes due to S. aureus, S. epidermidis, other coagulase-negative staphylococci, Enterobacteriaceae, P. aeruginosa, and Candida spp. were detected by the aerobic FAN bottle. Significantly more bacterial isolates were detected by the aerobic FAN whether or not antibiotics were being administered at the time of blood culture, whereas there were significantly fewer positive cultures in the vented standard anaerobic bottle when patients were receiving antimicrobial therapy than when they were not. All but 5% of positive cultures were detected within three days. Only six of the cultures requiring four or five days of incubation represented true misses, and only one of these six resulted in a change in therapy which, however, did not affect the patent's outcome.

Adult↗

PubMed1998

The clinical significance of a biopsy-based diagnosis of focal active colitis: a clinicopathologic study of 31 cases.

Focal active colitis (FAC) is a common pattern of injury in colorectal biopsy specimens. Recently, FAC was found to be a marker of an infectious colitis-like diarrheal illness and ischemic colitis but not of Crohn's disease. We evaluated 31 cases of FAC at the Cleveland Clinic Foundation, Cleveland. Ohio, between 1982 and 1992, to assess the clinical significance of this histologic finding. We evaluated the degree of neutrophil-mediated crypt epithelial injury, the degree of neutrophil-mediated surface epithelial injury, and the lamina propria cellularity and cell type. In each biopsy specimen, all of the above features were scored as 1+ (involving < 10%), 2+ (10-25%), or 3+ (26-50%) of the specimen. Clinical follow-up for the 31 patients ranged from 1 to 51 months (mean, 26 mo). Clinical diagnoses included infectious-type colitis (15 cases, 48%); incidental FAC (9 cases, 29%), occurring in asymptomatic patients undergoing screening for colonic neoplasia; ischemic colitis (3 cases, 10%); and Crohn's disease (4 cases, 13%). Histologically, all of the cases had some degree of cryptitis, and 24 (77%) of the 31 had neutrophil-mediated surface epithelial injury. In 13 (42%) of the 31, there was an expansion of the lamina propria by neutrophils, in 12 (39%) by eosinophils, and in 11 (35%) by plasma cells. None of the histologic features correlated with specific clinical diagnostic categories (Fisher's exact test). In conclusion, FAC most commonly correlates clinically with an infectious-type of colitis. On occasion, FAC might be a harbinger of Crohn's disease. Histologic features are not useful in predicting specific clinical diagnoses as a correlate to FAC.

Bacterial Infections↗

PubMed1997

Endocervical adenocarcinoma in situ: an analysis of cellular features.

Cytologists increasingly encounter atypical endocervical cells, because of the increasing incidence of endocervical adenocarcinoma and the use of improved endocervical sampling devices. These atypical endocervical cells can cause diagnostic problems, especially in recognizing adenocarcinoma in situ (AIS) and distinguishing it from a variety of nonneoplastic changes. We analyzed 33 cervical smears from 22 patients with confirmed AIS and compared these to 19 cervical smears from 17 patients having atypical endocervical cells of undetermined significance and negative follow-up, including at least one tissue biopsy per case, to further investigate the cytologic features of AIS. The AIS smears typically had crowded three-dimensional cellular aggregates, with markedly hyperchromatic nuclei having altered polarity. Frequently, a minor component of AIS formed strips of distinctly columnar cells or sheets. Individual AIS cells occurred in 22 (67%) smears, but these were usually inconspicuous. The AIS smears also had increased nuclear to cytoplasmic ratios (100%), enlarged nuclei (94%), feathering (88%), rosettes (85%), nucleoli (76%), apoptosis (73%), mitoses (64%), multiple nucleoli (18%), and ciliated atypical cells (3%). Cytologic features occurring significantly (P < or = 0.001) more often in AIS cases were a predominance of three-dimensional crowded aggregates (79% vs. 32%), altered nuclear polarity in most groups (88% vs. 16%), marked hyperchromasia (91% vs. 16%), apoptosis (73% vs. 26%), an increased nuclear to cytoplasmic ratio (100% vs. 63%), feathering (88% vs. 26%), and individual atypical cells (67% vs. 16%). In summary, we identified a number of architectural and cellular features that occurred significantly more often in AIS cases than in cases having atypical endocervical cells of undetermined significance and negative follow-up.

Adenocarcinoma↗

PubMed1997

Chest radiographic data acquisition and quality assurance in multicenter studies.

BACKGROUND: Multicenter studies rely on data derived from different institutions. Forms can be designed to standardize the reporting process allowing reliable comparison of data. OBJECTIVE: The purpose of the report is to provide a standardized method, developed as a part of a multicenter study of vertically transmitted HIV, for assessing chest radiographic results. MATERIALS AND METHODS: Eight hundred and five infants and children were studied at five centers; 3057 chest radiographs were scored. Data were entered using a forced-choice, graded response for 12 findings. Quality assurance measures and inter-rater agreement statistics are reported. RESULTS: The form used for reporting chest radiographic results is presented. Inter-rater agreement was moderate to high for most findings, with the best correlation reported for the presence of bronchovascular markings and/or reticular densities addressed as a composite question (kappa = 0.71). The presence of nodular densities (kappa = 0.56) and parenchymal consolidation (kappa = 0.57) had moderate agreement. Agreement for lung volume was low. CONCLUSION: The current tool, developed for use in the pediatric population, is applicable to any study involving the assessment of pediatric chest radiographs for a large population, whether at one or many centers.

Child↗

PubMed1997

The lack of association between adenocarcinoma of the esophagus and gastric surgery: a retrospective study.

BACKGROUND: The cause of the rapid increase in the incidence of adenocarcinoma of the esophagus since the 1970s is unknown. OBJECTIVE: To test the hypothesis that duodenogastroesophageal reflux causes adenocarcinoma of the esophagus by comparing the frequency of gastric surgery (a human model of duodenogastroesophageal reflux) and other potential risk factors between patients with adenocarcinoma and patients with squamous cell carcinoma of the esophagus. METHODS: Medical records of all patients with adenocarcinoma or squamous cell carcinoma of the esophagus seen at the Cleveland Clinic Foundation between 1987 and 1994 were reviewed. The following data were retrieved: age, gender, race, tumor location, history of gastric surgery and gastroesophageal reflux symptoms, and use of tobacco, alcohol, histamine-2 receptor antagonists, and proton pump inhibitors. RESULTS: The data of 325 patients with adenocarcinoma (73.5%) and 117 patients with squamous cell carcinoma (26.5%) were analyzed. No differences were found between the groups in age, proportion with gastric surgery (patients with adenocarcinoma: 1.2%, 95% confidence interval 0.3-3.1%; patients with squamous cell carcinoma: 0.9%, 95% confidence interval 0.0-4.7%), smoking (76.7 vs 81.6%), or alcohol use (71.8 vs 79.1%). Significant risk factors associated with adenocarcinoma of the esophagus were male gender, white race, distal cancer location, and Barrett's esophagus. CONCLUSIONS: Previous gastric surgery is rarely found in patients with esophageal cancer and is performed with equal frequency in patients with adenocarcinoma and those with squamous cell carcinoma of the esophagus. This suggests that gastric surgery and its associated duodenogastroesophageal reflux do not play a role in the etiology and rising incidence of adenocarcinoma of the esophagus. White males in their mid-60s with Barrett's esophagus who smoke and drink alcohol are at highest risk for adenocarcinoma of the esophagus.

Adenocarcinoma↗

PubMed1997

A method for comparing positive rates of two blood culture systems.

McNemar's test is used to compare two marginal positive rates from an independent sample of paired binary data. When the pairs are not mutually independent, the McNemar's test may not be valid. In this paper, we propose a random-effects regression model for comparing two marginal probabilities from nonindependent matched pairs data with covariates. An example of comparing positive rates of two blood culture systems illustrates this method. In this example, there is no external gold standard, the paired data are clustered, the data with negative results from both systems are not available, and one culture-specific covariate is involved. The computing method for the maximum likelihood estimation is efficient.

Biometry↗

PubMed1996

Myxoid/round cell liposarcoma of the extremities. A clinicopathologic study of 29 cases with particular attention to extent of round cell liposarcoma.

Round cell liposarcoma, a high-grade sarcoma, is a poorly differentiated form of myxoid liposarcoma, which is low grade. It is not known, however, how much of a round cell component within an otherwise typical myxoid liposarcoma results in a neoplasm that behaves as a high-grade sarcoma. Twenty-nine cases of myxoid liposarcoma of the extremities with or without a component of round cell liposarcoma were studied to semiquantitate the amount of round cell component needed to adversely affect prognosis. An estimate of the percent of necrosis, round cell liposarcoma, myxoid liposarcoma, and transitional areas was obtained for each slide on all cases. Transitional areas were defined as those that displayed an increased cellularity compared with typical myxoid liposarcoma, but in which the cells remained spindled, did not have overlapping nuclear borders, and retained an easily discernible plexiform vascular pattern. The amount of necrosis was subtracted from the total material available for evaluation, and a composite estimate of the percent of round cell, myxoid, and transitional areas was obtained. Two tumors were located on the upper extremity, 27 on the lower extremity; tumor size ranged frm 3 to 30 cm (median, 14 cm). All 29 tumors had a myxoid component, with a range from 12 to 100% (median, 73%). The range of transitional component for all 29 tumors was 0 to 88% (median, 11%). Twenty-one tumors had transitional areas (range, 4-88%). The range of round cell component for all 29 tumors was 0 to 58% (median, 0%). Twelve tumors had round cell areas (range, 1-58%). Seventeen patients are either alive without disease, or died from unrelated causes at 24-202 months (median, 96 months). Twelve patients are either alive with metastases or died of disease at 10 to 180 months (median, 53 months). Patients with > 5% round cell component in their initial tumor had a statistically significant higher rate of metastasis or death due to disease than those with < or = 5% round cell liposarcoma (p = 0.05). In addition, patients with myxoid liposarcoma with transitional areas did not fare worse than those with myxoid liposarcoma alone. In conclusion, we found that a round cell component of > 5% portends a higher risk of metastasis or death from disease. Furthermore, transitional areas alone do not appear to alter the prognosis of myxoid liposarcoma. Thus, only those areas that are unequivocally round cell liposarcoma should be designated as high grade.

Adolescent↗

PubMed1996

Histopathologic findings in 107 uterine leiomyomas treated with leuprolide acetate compared with 126 controls.

The reported histopathologic findings in leiomyomas treated with leuprolide acetate (LA) differ. We examined 233 myomectomy specimens, including 107 myomas from 30 patients (mean age, 34.7 +/- 4.6 years) treated with LA. Their histopathologic findings were compared with those from a control group of 126 myomas from 30 untreated patients (mean age 32.7 +/- 5.3 years). The LA-treated leiomyomas had myxoid change (n = 2; 1.9%), total necrosis (n=4; 3.7%), focal necrosis (n = 5; 4.7%), calcifications (n = 5; 4.7%), hemorrhage (n = 8, 7.5%), vascular changes (n = 12; 11.2%), hydropic degeneration (n = 22; 20.5%), and hyalinization (n = 61; 57.0%). None of these changes differed significantly from the untreated controls. None of the LA-treated leiomyomas had nuclear atypia, whereas nuclear atypia occurred in four (3.2%) of the untreated leiomyomas; this difference was also not significant. Mitotic figures were present in 8.4% of the LA-treated myomas and 8.5% of untreated controls. The number of mitotic figures per 10 high-power fields was slightly higher in the untreated myomas, but the difference was not statistically significant (range, 0-3 for treated, 0-5 for controls). The degree of cellularity did not differ between the two groups. In conclusion, (a) LA-treated myomas do not significantly differ from untreated myomas with respect to nuclear atypia, calcification, total coagulative necrosis, focal coagulative necrosis, hemorrhage, vascular changes, myxoid change, hydropic degeneration, hyalinization, mitotic activity, or cellularity; and (b) the mechanism leading to a reduction in the size of myomas treated with LA is not apparent from routine histologic examination.

Adult↗

PubMed1995

The prevalence of coronary artery disease in liver transplant candidates over age 50.

The prevalence of angiographically proven coronary artery disease (CAD) in adults with end-stage liver disease who undergo evaluation for liver transplantation is unknown; also it is unclear if cholestatic liver disease represents an independent risk factor. Patients with end-stage liver disease over age 50 having liver transplantation were studied using coronary angiography. Arterial stenosis was graded as normal, mild (< 30%), moderate (30 to 70%), or severe (> 70%). Risk factors for CAD were also assessed (male sex, smoking, hypertension, diabetes, family history of premature heart disease). Complications related to the angiography and decision making based on the findings were recorded. Thirty seven patients (23 females) with a median age of 61 years (range 50 to 71) underwent angiography. Thirteen patients (35.1%) had cholestatic liver disease. Thirty patients had no history of heart disease. The overall prevalence of severe coronary artery disease was 16.2% (95% confidence interval [CI] = 6.2% to 32.0%). No association was detected between CAD and cholestatic liver disease (P = 0.72). After eliminating seven patients with a prior history of angina (n = 1), myocardial infarction (n = 1), or coronary revascularization (n = 5), the frequency of moderate or severe CAD was 13.3% (95% CI = 3.8% to 30.7%). No association was detected between unsuspected CAD and cholestatic liver disease (P = 0.61). Diabetes was the most important risk factor for moderate or severe disease (P = 0.01). Patients without risk factors had significantly less CAD than the group as a whole regardless of the liver disease type (P = 0.02). Two patients experienced transient renal insufficiency after the angiography. Three patients with severe CAD were denied transplantation. We conclude that CAD represents a significant problem in patients over age 50 undergoing liver transplant evaluation. Cholestatic liver disease was not associated with a significantly higher prevalence of moderate or severe CAD in our population. Diabetes was the most predictive risk factor, and those without risk factors do not require extensive preoperative cardiac evaluation.

Age Factors↗

PubMed1995

ThinPrep versus conventional smear cytologic preparations in the analysis of thyroid fine-needle aspiration specimens.

Paired fine-needle aspiration specimens were analyzed from 41 surgically resected thyroid nodules, to compare diagnostic accuracy, amount (absent, mild, moderate, or marked) and pattern (diffuse, droplets, or both) of colloid, nuclear detail (poor, satisfactory, or excellent) and cytoplasmic detail (intact or disrupted) in ThinPrep (TP) (Cytyc, Marlborough, MA) versus conventional smear (CS) cytologic preparations. The 41 surgical specimens included 25 colloid nodules, 6 papillary carcinomas, 4 follicular adenomas, 2 minimally invasive (encapsulated) follicular carcinomas, 3 Hashimoto's thyroiditis, and 1 Grave's disease. Both techniques identified seven of the eight carcinomas with the minimally invasive follicular carcinomas categorized as hypercellular follicular nodule, possibly malignant (HCFN). One papillary carcinoma was classified as a HCFN by both TP and CS techniques. The four follicular adenomas were classified as HCFN based on the TP slides. One oxyphilic follicular adenoma, associated with focal lymphocytic thyroiditis, was misinterpreted as Hashimoto's thyroiditis on a conventional smear. Three colloid nodules were interpreted as HCFN based on the TP slides. Two of these were similarly classified based on the conventional smear. ThinPrep slides contained less colloid and the colloid occurred as droplets rather than a diffuse pattern. TP slides had better nuclear detail but more often disrupted cytoplasm. In conclusion, the TP process does alter some cellular features; however, we experienced similar diagnostic accuracy with the TP and conventional smear preparations.

Biopsy, Needle↗

PubMed1995

Controlled clinical comparison of Isolator and BACTEC 9240 Aerobic/F resin bottle for detection of bloodstream infections.

A controlled clinical comparison was carried out with the BACTEC 9240 Aerobic/F resin bottle and the Isolator system with adult patients suspected of having bloodstream infections. A total of 10,500 paired specimens were collected, of which 1,122 from 520 patients were positive. There were 68 false-positive BACTEC bottles; 259 positive cultures that were excluded from analysis because the bottle, the Isolator, or both failed to meet the minimum volume criterion of 8 ml of blood; and 207 positive cultures that were excluded because the isolates were found to be clinically insignificant or of indeterminate clinical significance on the basis of patient assessment. A total of 656 positive cultures from 258 patients formed the basis of the analysis. Significantly more Staphylococcus aureus isolates (P = 0.03), Staphylococcus epidermidis isolates (P = 0.03), members of the family Enterobacteriaceae (P = 0.03), and Pseudomonas aeruginosa isolates (P = 0.04) were recovered from the resin bottle, and there was no category of organism that was recovered significantly more frequently from the Isolator system. With patients receiving antibiotics at the time of blood culture, S. aureus, S. epidermidis, and gram-negative bacilli were recovered significantly more frequently from the resin bottle. No significant differences between systems were found with cultures from patients not receiving antibiotics at the time of blood culture. Only 12 clinically significant organisms were recovered from the bottle on terminal subcultures, and only 1 of these had not been previously isolated from another blood culture set (10 of the 12) or from the companion Isolator (1 of 12). The Aerobic/F resin bottle continuously monitored in the BACTEC 9240 instrument proved to be superior to the Isolator in overall yield of organisms causing bloodstream infection in adults and required less technician time for specimen processing and examination than the Isolator system.

Adult↗