CD, or not CD, that is the question: a digital interobserver agreement study in coeliac disease

OBJECTIVE

Coeliac disease (CD) diagnosis generally depends on histological examination of duodenal biopsies. We present the first study analysing the concordance in examination of duodenal biopsies using digitised whole-slide images (WSIs). We further investigate whether the inclusion of immunoglobulin A tissue transglutaminase (IgA tTG) and haemoglobin (Hb) data improves the interobserver agreement of diagnosis.

DESIGN

We undertook a large study of the concordance in histological examination of duodenal biopsies using digitised WSIs in an entirely virtual reporting setting. Our study was organised in two phases: in phase 1, 13 pathologists independently classified 100 duodenal biopsies (40 normal; 40 CD; 20 indeterminate enteropathy) in the absence of any clinical or laboratory data. In phase 2, the same pathologists examined the (re-anonymised) WSIs with the inclusion of IgA tTG and Hb data.

RESULTS

We found the mean probability of two observers agreeing in the absence of additional data to be 0.73 (±0.08) with a corresponding Cohen's kappa of 0.59 (±0.11). We further showed that the inclusion of additional data increased the concordance to 0.80 (±0.06) with a Cohen's kappa coefficient of 0.67 (±0.09).

CONCLUSION

We showed that the addition of serological data significantly improves the quality of CD diagnosis. However, the limited interobserver agreement in CD diagnosis using digitised WSIs, even after the inclusion of IgA tTG and Hb data, indicates the importance of interpreting duodenal biopsy in the appropriate clinical context. It further highlights the unmet need for an objective means of reproducible duodenal biopsy diagnosis, such as the automated analysis of WSIs using artificial intelligence.

Impact of the transition to digital pathology in a clinical setting on histopathologists in training: experiences and perceived challenges within a UK training region

AIMS

With increasing utility of digital pathology (DP), it is important to consider the experiences of histopathologists in training, particularly in view of the varied access to DP across a training region and the consequent need to remain competent in reporting on glass slides (GS), which is also relevant for the Fellowship of the Royal College of Pathologists part 2 examination. Understanding the impact of DP on training is limited but could aid development of guidance to support the transition. We sought to investigate the perceptions of histopathologists in training around the introduction of DP for clinical diagnosis within a training region, and the potential training benefits and challenges.

METHODS

An anonymous online survey was circulated to 24 histopathologists in training within a UK training region, including a hospital which has been fully digitised since summer 2020.

RESULTS

19 of 24 histopathologists in training responded (79%). The results indicate that DP offers many benefits to training, including ease of access to cases to enhance individual learning and teaching in general. Utilisation of DP for diagnosis appears variable; almost half of the (10 of 19) respondents with DP experience using it only for ancillary purposes such as measurements, reporting varying levels of confidence in using DP clinically. For those yet to undergo the transition, there was a perceived anxiety regarding digital reporting despite experience with DP in other contexts.

CONCLUSIONS

The survey evidences the need for provision of training and support for histopathologists in training during the transition to DP, and for consideration of their need to maintain competence and confidence with GS reporting.

HPB P41 Pitfalls in establishing a preoperative diagnosis; correlating the radiological and histopathological findings of suspected intraductal papillary neoplasm of the bile duct (IPNB)

Background

Intraductal papillary neoplasm of the bile duct (IPNB) represents a cohort of uncommon biliary tract tumours. It is commonly unrecognised or misdiagnosed in cross sectional imaging of the liver. This rare tumour is of significant clinical importance as it serves as a pre-cursor lesion for Cholangiocarcinoma. The diagnostic work up of a patient with a suspected IPNB remains predominantly based on imaging and as of yet no consensus has been achieved regarding the optimal diagnostic algorithm. The aim of this study was to compare the radiological and clinico-pathological features of patients with confirmed or suspected IPNB managed in a single tertiary center.

Methods

Retrospective review of a departmental database of consecutive patients with suspected IPNB was performed. Clinical information regarding patient demographics, disease presentation, radiological imaging characteristics and histo-pathological features was analysed.

Results

Eighteen patients with suspected IPNB were noted, of which histological confirmation was present in eight cases (62%). The most frequent presentation of IPNB was of an incidental finding (50%). The diagnosis of IPNB was made following MRI in 63% of cases. Invasive adenocarcinoma was present in five patients (63%). In the remaining three patients, low grade dysplasia was noted within their IPNB tumours.

Conclusions

IPNB is frequently associated with concurrent invasive malignancy. Observation alone is insufficient. Radiological assessment of these tumours remains as the fundamental investigation for diagnosis. However, without confirmatory histology perioperatively, the diagnosis cannot be assured therefore the decision for management must be based upon a patient-centered discussion and a careful evaluation of risk.

RFID analysis of the complexity of cellular pathology workflow—An opportunity for digital pathology

Digital pathology (DP) offers potential for time efficiency gains over an analog workflow however, to date, evidence supporting this claim is relatively lacking. Studies available concentrate on specific workflow points such as diagnostic reporting time, rather than overall efficiencies in slide logistics that might be expected. This is in part a result of the complexity and variation in analog working, and the challenge therefore in capturing this. We have utilized RFID technology to conduct a novel study capturing the movement of diagnostic cases within the analog pathway in a large teaching hospital setting, thus providing benchmark data for potential efficiency gains with DP. This technology overcomes the need to manually record data items and has facilitated the capture of both the physical journey of a case and the time associated with relevant components of the analog pathway predicted to be redundant in the digital setting. RFID tracking of 1,173 surgical pathology cases and over 30 staff in an analog cellular pathology workflow illustrates the complexity of the physical movement of slides within the department, which impacts on case traceability within the system. Detailed analysis of over 400 case journeys highlights redundant periods created by batching of slides at workflow points, including potentially 2–3 h for a case to become available for reporting after release from the lab, and variable lag-times prior to collection for reporting, and provides an illustration of patterns of lab and pathologist working within the analog setting. This study supports the challenge in evidencing efficiency gains to be anticipated with DP in the context of the variation and complexity of the analog pathway, but also evidences the efficiency gains that may be expected through a greater understanding of patterns of working and movement of cases. Such data may benefit other departments building a business case for DP.

Interferon-Gamma-Producing CD8+ Tissue Resident Memory T Cells Are a Targetable Hallmark of Immune Checkpoint Inhibitor-Colitis

BACKGROUND & AIMS

The pathogenesis of immune checkpoint inhibitor (ICI)-colitis remains incompletely understood. We sought to identify key cellular drivers of ICI-colitis and their similarities to idiopathic ulcerative colitis, and to determine potential novel therapeutic targets.

METHODS

We used a cross-sectional approach to study patients with ICI-colitis, those receiving ICI without the development of colitis, idiopathic ulcerative colitis, and healthy controls. A subset of patients with ICI-colitis were studied longitudinally. We applied a range of methods, including multiparameter and spectral flow cytometry, spectral immunofluorescence microscopy, targeted gene panels, and bulk and single-cell RNA sequencing.

RESULTS

We demonstrate CD8⁺ tissue resident memory T (T_RM) cells are the dominant activated T cell subset in ICI-colitis. The pattern of gastrointestinal immunopathology is distinct from ulcerative colitis at both the immune and epithelial-signaling levels. CD8⁺ T_RM cell activation correlates with clinical and endoscopic ICI-colitis severity. Single-cell RNA sequencing analysis confirms activated CD8⁺ T_RM cells express high levels of transcripts for checkpoint inhibitors and interferon-gamma in ICI-colitis. We demonstrate similar findings in both anti-CTLA-4/PD-1 combination therapy and in anti-PD-1 inhibitor-associated colitis. On the basis of our data, we successfully targeted this pathway in a patient with refractory ICI-colitis, using the JAK inhibitor tofacitinib.

CONCLUSIONS

Interferon gamma-producing CD8⁺ T_RM cells are a pathological hallmark of ICI-colitis and a novel target for therapy.

Experience from the first UK inter-regional specialist multidisciplinary meeting in the diagnosis and management of IgG4-related disease

Immunoglobulin G4-related disease (IgG4-RD) is a complex multisystem fibro-inflammatory disorder, requiring diagnostic differentiation from malignancy and other immune-mediated conditions, and careful management to minimise glucocorticoid-induced toxicity and prevent progressive organ dysfunction. We describe the experience of the first inter-regional specialist IgG4-RD multidisciplinary team meeting (MDM) incorporating a broad range of generalists and specialists, held 6-weekly via web-link between Oxford University Hospitals NHS Foundation Trust and University College London Hospitals NHS Foundation Trust. Over 3 years, there were 206 discussions on 156 patients. Of these, 97 (62%) were considered to have definite or possible IgG4-RD; 67% had multi-organ involvement and 23% had a normal serum IgG4. The average number of specialist opinions sought prior to MDM was four per patient. Management was changed in the majority of patients (74%) with the treatment escalation recommended in 61 cases, including 19 for rituximab. Challenges arose from delays and misdiagnosis, cross-specialty presentation and the management of sub-clinical disease. Our cross-discipline IgG4-RD MDM enabled important diagnostic and management decisions in this complex multisystem disorder, and can be used as a model for other centres in the UK.

Quantitative multiparametric magnetic resonance imaging can aid non-alcoholic steatohepatitis diagnosis in a Japanese cohort

BACKGROUND

Non-invasive assessment of non-alcoholic steatohepatitis (NASH) is increasing in desirability due to the invasive nature and costs associated with the current form of assessment; liver biopsy. Quantitative multiparametric magnetic resonance imaging (mpMRI) to measure liver fat (proton density fat fraction) and fibroinflammatory disease [iron-corrected T1 (cT1)], as well as elastography techniques [vibration-controlled transient elastography (VCTE) liver stiffness measure], magnetic resonance elastography (MRE) and 2D Shear-Wave elastography (SWE) to measure stiffness and fat (controlled attenuated parameter, CAP) are emerging alternatives which could be utilised as safe surrogates to liver biopsy.

AIM

To evaluate the agreement of non-invasive imaging modalities with liver biopsy, and their subsequent diagnostic accuracy for identifying NASH patients.

METHODS

From January 2019 to February 2020, Japanese patients suspected of NASH were recruited onto a prospective, observational study and were screened using non-invasive imaging techniques; mpMRI with LiverMultiScan^®, VCTE, MRE and 2D-SWE. Patients were subsequently biopsied, and samples were scored by three independent pathologists. The diagnostic performances of the non-invasive imaging modalities were assessed using area under receiver operating characteristic curve (AUC) with the median of the histology scores as the gold standard diagnoses. Concordance between all three independent pathologists was further explored using Krippendorff’s alpha (a) from weighted kappa statistics.

RESULTS

N = 145 patients with mean age of 60 (SD: 13 years.), 39% females, and 40% with body mass index ≥ 30 kg/m² were included in the analysis. For identifying patients with NASH, MR liver fat and cT1 were the strongest performing individual measures (AUC: 0.80 and 0.75 respectively), and the mpMRI metrics combined (cT1 and MR liver fat) were the overall best non-invasive test (AUC: 0.83). For identifying fibrosis ≥ 1, MRE performed best (AUC: 0.97), compared to VCTE-liver stiffness measure (AUC: 0.94) and 2D-SWE (AUC: 0.94). For assessment of steatosis ≥ 1, MR liver fat was the best performing non-invasive test (AUC: 0.92), compared to controlled attenuated parameter (AUC: 0.75). Assessment of the agreement between pathologists showed that concordance was best for steatosis (a = 0.58), moderate for ballooning (a = 0.40) and fibrosis (a = 0.40), and worst for lobular inflammation (a = 0.11).

CONCLUSION

Quantitative mpMRI is an effective alternative to liver biopsy for diagnosing NASH and non-alcoholic fatty liver, and thus may offer clinical utility in patient management.

Role of digital pathology in diagnostic histopathology in the response to COVID-19: results from a survey of experience in a UK tertiary referral hospital

The COVID-19 pandemic has challenged our diagnostic services at a time when many histopathology departments already faced a diminishing workforce and increasing workload. Digital pathology (DP) has been hailed as a potential solution to at least some of the challenges faced. We present a survey of pathologists within a UK National Health Service cellular pathology department with access to DP, in which we ascertain the role of DP in clinical services during this current pandemic and explore challenges encountered. This survey indicates an increase in uptake of diagnostic DP during this period, with increased remote access. Half of respondents agreed that DP had facilitated maintenance of diagnostic practice. While challenges have been encountered, these are remediable, and none have impacted on the uptake of DP during this period. We conclude that in our institution, DP has demonstrated current and future potential to increase resilience in diagnostic practice and have highlighted some of the challenges that need to be considered.

Immune checkpoint inhibitor-related colitis assessment and prognosis: can IBD scoring point the way?

BACKGROUND

Immune checkpoint inhibitors (ICI) improve survival but cause immune-related adverse events (irAE). We sought to determine if CTCAE classification, IBD biomarkers/endoscopic/histological scores correlate with irAE colitis outcomes.

METHODS

A dual-centre retrospective study was performed on patients receiving ICI for melanoma, NSCLC or urothelial cancer from 2012 to 2018. Demographics, clinical data, endoscopies (reanalysed using Mayo/Ulcerative Colitis Endoscopic Index of Severity (UCEIS) scores), histology (scored with Nancy Index) and treatment outcomes were analysed.

RESULTS

In all, 1074 patients were analysed. Twelve percent (134) developed irAE colitis. Median patient age was 66, 59% were male. CTCAE diarrhoea grade does not correlate with steroid/ infliximab use. G3/4 colitis patients are more likely to need infliximab (p < 0.0001) but colitis grade does not correlate with steroid duration. CRP, albumin and haemoglobin do not correlate with severity. The UCEIS (p = 0.008) and Mayo (p = 0.016) scores correlate with severity/infliximab requirement. Patients with higher Nancy indices (3/4) are more likely to require infliximab (p = 0.03).

CONCLUSIONS

CTCAE assessment does not accurately reflect colitis severity and our data do not support its use in isolation, as this may negatively impact timely management. Our data support utilising endoscopic scoring for patients with >grade 1 CTCAE disease, and demonstrate the potential prognostic utility of objective histologic scoring.

Pulmonary hyalinising granuloma: a rare and elusive cause of multiple lung nodules

A 72-year-old woman was referred with incidentally detected multiple lung nodules, one of which was identified as ¹⁸F-fluorodeoxyglucose (FDG)-avid on positron emission tomography. Extensive workup followed, including numerous radiographs, surveillance scans and a CT-guided biopsy which demonstrated chronic inflammation only. Following a wedge-resection, a diagnosis of pulmonary hyalinising granuloma (PHG) was made. PHG is a cause of FDG-avid single or multiple pulmonary nodules and can mimic lung cancer or metastatic disease radiologically. The diagnosis is often difficult to make with minimally invasive techniques such as needle-guided biopsies which do not tend to yield the diagnosis and requires surgical resection for definitive diagnosis and exclusion of malignancy.

Lupus causing small bowel obstruction

A 20-year-old female patient was admitted to hospital in 2015 with 1 year history of recurrent abdominal pain, distension, borborygmi and nausea. The patient had a background of systemic lupus erythematous (SLE) diagnosed 4 years before, with skin, joint and renal involvement. The initial investigations have shown a long segment of ileal inflammation with upstream obstruction. Differential diagnoses were mainly SLE enteritis or concomitant Crohn's. Patient failed the initial conservative management and had a laparotomy with small bowel (SB) resection and ileostomy. The histology was suggestive of autoimmune enteritis. Although bowel involvement is a frequent feature of SLE, surgery for obstruction is extremely rare. Postoperatively, she had an emergency admission and was diagnosed with SB volvulus with perforation. She underwent further resection and stoma refashioning in 2016. As a consequence, she developed short gut syndrome. Eventually, the stoma was reversed and parenteral nutrition was stopped and weight became stable.

Exophytic cystic liver lesion: an unusual presentation of a hepatocellular carcinoma in a young female

Hepatocellular carcinoma (HCC) is one of the most common malignant primary liver tumours. However, primary hepatic carcinomas are rare in young adults, accounting for approximately 1% of tumours in people below the age of 20. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are the two most important aetiological agents of HCC. The average age at onset of HBV-related HCC (~50 years old) is 10 years younger than that of HCV-related HCC (61-64 years). Evidence for an association between the oral contraceptive pill (OCP) and development of HCC remains inconclusive. Here, we describe a case of a 28-year-old woman with normal background liver, who presented with a large palpable abdominal mass due to a bilobar, exophytic, cystic lesion arising from the right lobe of the liver, later diagnosed as HCC on histological analysis. We highlight the need for considering HCC even in the unusual setting of a cystic, exophytic lesion.

Interobserver Variability in Histologic Evaluation of Liver Fibrosis Using Categorical and Quantitative Scores

Objectives

The aim of the study was to investigate the interobserver agreement for categorical and quantitative scores of liver fibrosis.

Methods

Sixty-five consecutive biopsy specimens from patients with mixed liver disease etiologies were assessed by three pathologists using the Ishak and nonalcoholic steatohepatitis Clinical Research Network (NASH CRN) scoring systems, and the fibrosis area (collagen proportionate area [CPA]) was estimated by visual inspection (visual-CPA). A subset of 20 biopsy specimens was analyzed using digital imaging analysis (DIA) for the measurement of CPA (DIA-CPA).

Results

The bivariate weighted κ between any two pathologists ranged from 0.57 to 0.67 for Ishak staging and from 0.47 to 0.57 for the NASH CRN staging. Bland-Altman analysis showed poor agreement between all possible pathologist pairings for visual-CPA but good agreement between all pathologist pairings for DIA-CPA. There was good agreement between the two pathologists who assessed biopsy specimens by visual-CPA and DIA-CPA. The intraclass correlation coefficient, which is equivalent to the κ statistic for continuous variables, was 0.78 for visual-CPA and 0.97 for DIA-CPA.

Conclusions

These results suggest that DIA-CPA is the most robust method for assessing liver fibrosis followed by visual-CPA. Categorical scores perform less well than both the quantitative CPA scores assessed here.

Altered expression of epithelial-to-mesenchymal transition proteins in extraprostatic prostate cancer

Epithelial to mesenchymal transition (EMT) of cancer cells involves loss of epithelial polarity and adhesiveness, and gain of invasive and migratory mesenchymal behaviours. EMT occurs in prostate cancer (PCa) but it is unknown whether this is in specific areas of primary tumours. We examined whether any of eleven EMT-related proteins have altered expression or subcellular localisation within the extraprostatic extension component of locally advanced PCa compared with other localisations, and whether similar changes may occur in in vitro organotypic PCa cell cultures and in vivo PCa models. Expression profiles of three proteins (E-cadherin, Snail, and α-smooth muscle actin) were significantly different in extraprostatic extension PCa compared with intra-prostatic tumour, and 18/27 cases had an expression change of at least one of these three proteins. Of the three significantly altered EMT proteins in pT3 samples, one showed similar significantly altered expression patterns in in vitro organotypic culture models, and two in in vivo Pten-/- model samples. These results suggest that changes in EMT protein expression can be observed in the extraprostatic extension component of locally invasive PCa. The biology of some of these changes in protein expression may be studied in certain in vitro and in vivo PCa models.

The Ueno method for substaging pT1 colorectal adenocarcinoma by depth and width measurement: an interobserver study

AIM

Early pT1 polyp colorectal cancers (CRCs) present challenges for accurate pathology substaging. Haggitt and Kikuchi stages depend on polyp morphology and are often difficult to apply due to suboptimal orientation or fragmentation, or absence of the muscularis propria in polypectomy or submucosal resection specimens. European guidelines for quality assurance suggest using Ueno's more objective approach, using depth and width measurements beyond muscularis mucosae. We have investigated interobserver variation using Ueno's approach.

METHOD

Ten consecutive pT1 polyp CRCs were identified and the slides assessed by six gastrointestinal pathologists for depth and width of invasion. A further 60 polyps were studied by a group of specialist and general pathologists. Agreement was assessed by analysis of variance. A polyp CRC is classified as high risk if it has a depth ≥ 2000 μm or a width ≥ 4000 μm and low risk with a depth < 2000 μm or a width < 4000 μm. Concordance for the dichotomized values was assessed using the kappa statistic.

RESULTS

The intraclass correlation coefficient (ICC) for depth was 0.83 and for width 0.56 in the 10-polyp group. The ICC for the 60-polyp CRCs was 0.67 for depth and 0.37 for width. In both groups, when polyp CRCs are divided into high- and low-risk categories based on depth, there was substantial and moderate agreement (κ = 0.80 and 0.47) but only fair agreement when based on width (κ = 0.34 and 0.35).

CONCLUSION

Ueno's method has the advantage of being independent of polyp morphology. Our study shows better concordance for depth measurement and reproducibility in nonfragmented specimens, with poorer agreement when based on width.

Discrepancy rates in liver biopsy reporting

Medical liver biopsy reporting is challenging, and maintaining competency with small case numbers is potentially difficult. This study evaluates the discrepancies identified in cases referred to a specialist centre between the specialist reports and those of the referring general departments. Fifty consecutive recently referred cases were selected, and original and final reports were compared. Discrepancies were classified as per the Royal College of Pathologists guidelines and scored for potential clinical impact. The overall rate of discrepancy was 38% with most of these due to differences in interpretation of morphology. Seventy per cent of these discrepancies were judged to have major clinical impact (26% of all referred cases). This study highlights the need for robust systems of quality control of liver biopsies in a general setting.

Spectrum of histopathological changes encountered in stented colorectal carcinomas

AIMS

Self-expanding metallic stents (SEMS) are increasingly being used in obstructing colorectal cancer (CRC) as a 'bridge to surgery', allowing conversion of potentially high-risk emergency resections to elective procedures. Stenting may cause a wide array of histological changes. We present the largest series to date of stented CRC, performed and reported at a single institution.

METHODS AND RESULTS

Stented CRC specimens received in January 2006 to December 2011 were identified from our pathology database. Slides for each case were independently reviewed by two pathologists, and a consensus was reached. A total of 72 CRCs were identified, 15 at or proximal to the splenic flexure, and 57 left-sided. Thirty-six were stage pT3 and 36 were stage pT4. Perforation was observed in 14 cases. The effects of stenting on the tumour included tumour necrosis (100%) and flat ulceration (77.8%). The spectrum of changes in the background bowel included mimics of inflammatory bowel disease, tumour regression post-neoadjuvant therapy, and ischaemia.

CONCLUSIONS

Given the inclusion of stenting of CRC as a bridge to surgery in the current NICE guidelines, we expect to see increasing numbers of such cases. In our study, a range of changes were encountered that mimic other bowel diseases, from simple fissuring to chronic inflammatory bowel disease and neoadjuvant regression change.

Local recurrence after stenting for obstructing left-sided colonic cancer

BACKGROUND

Self-expanding metallic stents (SEMS) may be used in acute obstructing left-sided colonic cancers to avoid high-risk emergency surgery. However, oncological safety remains uncertain. This study evaluated the long-term oncological outcome of SEMS as a bridge to elective curative surgery versus emergency resection.

METHODS

A consecutive prospective cohort of patients admitted with obstructing left-sided colonic cancer between 2006 and 2012 was analysed. The decision to stent as a bridge to surgery or to perform emergency surgery was made by the on-call consultant colorectal surgeon in conjunction with a consultant interventional radiologist; when appropriate, they performed the stent procedure together. Primary outcomes were local and distant recurrence, and overall survival. Secondary outcomes were postoperative complications, in-hospital mortality, proportion of procedures undertaken laparoscopically, and anastomosis and stoma rates.

RESULTS

In total, 105 patients with obstructing left-sided colonic cancer were treated with curative intent; 62 were treated with SEMS as a bridge to surgery and 43 had emergency resection. In patients aged 75 years or less, stenting and delayed surgery was associated with a higher local recurrence rate compared with emergency surgery at the end of follow-up (32 versus 8 per cent; P = 0·038). This did not translate into a significant difference in overall survival.

CONCLUSION

SEMS was associated with an increased local recurrence rate.

How often do our liver core biopsies reach current definitions of adequacy?

Needle core biopsy is a key tool in diagnosis and assessment of many medical liver diseases, but there is evidence that the combination of small size of the specimen obtained and the patchy nature of many of these diseases can result in misdiagnosis or incorrect staging. The Royal College of Pathologists has therefore published guidelines for assessment of adequacy. To assess whether these guidelines were being observed, we reviewed cases reported in our department over a 15-year period. Results showed that only 19.8% of cores would be considered adequate, 56.4% were suboptimal and 23.8% were inadequate. We discuss the issues around recommendations on the minimum size of liver biopsies, potential factors limiting biopsy size and whether further refinement of the guidelines for adequacy is required.

Lipid-rich ("clear cell") neuroendocrine tumors of the pancreas in MEN I patients

The presence of "clear" or lipid-rich cells within pancreatic neuroendocrine tumors is thought to be pathognomonic of von Hippel-Lindau (VHL) disease, especially in the context of multiple tumors. However, we encountered the presence of lipid-rich cells in six of 16 patients (eight microadenomas/adenomas) who had multiple endocrine neoplasia type I (MEN I). Three of the lesions (two microadenomas and one adenoma) were composed entirely of lipid-rich cells while the remaining five lesions had a component of lipid-rich cells. All lesions containing lipid-rich cells were negative for α-inhibin, but positive for chromogranin and synaptophysin. In addition, four of the eight lesions were glucagon positive. None of the patients had clinical symptoms related to hormone production. We suggest that lipid-rich cells are not reflexly indicative of VHL, and that they may be encountered in a proportion of cases of MEN I either focally or constituting the entire neuroendocrine lesion.

Characteristics of volunteers and families in a neonatal home visitation project: the Kempe Community Caring Program

OBJECTIVE

The purpose of this paper is to review literature related to home visitation support for new families using volunteer visitors and to describe characteristics of volunteers of the Kempe Community Caring Program, a home visitor support program for first time parents. Suggestions for effectively utilizing volunteers in family support programs are made.

METHOD

Program data was collected and reviewed on 592 volunteer home visitors and the 1,144 families they served. Several evaluations and assessments were performed in order to attempt to measure the success of the intervention. Motivation for volunteering, longevity with program, and the extent of sociodemographic match between visitor and client were reviewed and discussed.

RESULTS

Information on matched volunteer-client pairs was limited; however, speculations were made that neither motivation to participate nor sociodemographic match were critical factors in determining success of the intervention. Duration of volunteer participation was influenced by marital status, but not by age. Married volunteers stayed with the program significantly longer than unmarried volunteers. Low risk families demonstrated slightly improved confidence in parental function after receiving home visitation by a volunteer.

CONCLUSION

This program suggests that new mothers may benefit from receiving the services of a volunteer home visitor; specifically, their confidence as parents and ability to establish positive relationships show slight improvement. Likewise, volunteers and families felt satisfied with the supportive relationships generated. In addition, a volunteer profile emerged which may be beneficial to similar programs' recruiting efforts.

Cells within the bulge region of mouse hair follicle transiently proliferate during early anagen: heterogeneity and functional differences of various hair cycles

Based on cell kinetic, morphological and several biological considerations, we have recently proposed that hair follicle stem cells reside in the bulge area of the upper follicle. We predicted that during early anagen the normally slow-cycling bulge stem cells may be activated by the abutting dermal papilla cells to undergo transient proliferation giving rise to keratinocytes of the lower follicle. In the present work, we performed tritiated thymidine-labeling of DNA-synthesizing cells and colcemid-arrest of mitotic figures on the skins of 20-23 and 75-80 day old SENCAR mice, when the follicles entered the anagen phase of the 2nd and 3rd hair cycles. The results clearly indicate that the normally slow-cycling bulge cells indeed undergo transient proliferation during early anagen. Similar results were obtained when the telogen follicles are experimentally induced to enter the 3rd hair cycle by plucking and by topical applications of phorbol ester or tretinoin. These results support the notion that bulge cells are follicular stem cells, and that transient proliferation of these cells is a critical feature of early anagen. However, the long duration of the 2nd telogen (> 30 days in mouse) suggests that a new anagen phase does not automatically result from the physical proximity of dermal papilla to the bulge cells, and that another 'factor' is required for the initiation of the 3rd anagen. The tremendous difference in the durations of the first and second telogen (lasting for 2-3 days and > 50 days, respectively) suggests that follicles can exist in a non-cycling state that may be conceptually equivalent to the G0 state of the cell cycle. Our results also underscore the fact that the first hair cycle is distinct from all the subsequent hair cycles in their cellular origin and morphological sequence, and thus should be regarded as a neogenic event.