Distinguishing probable atypical anorexia nervosa from weight loss alone in a national sample of U.S. Military Veterans: Disentangling the roles of weight suppression and cognitive concerns

OBJECTIVE

Veterans are at high risk for eating disorders (EDs), and specifically for atypical anorexia nervosa (atypical AN). The current study aimed to better understand this under-studied disorder and how it differs from weight loss without ED cognitive features.

METHOD

Secondary analyses were conducted with data from a national study of Veterans (N = 882, 49.4% women). Participants were categorized into four mutually exclusive groups using the Eating Disorder Diagnostic Scale 5: probable atypical AN, a cognitive concerns group (Cog Only), a weight suppressed group (WS Only), and a no ED control group. Adjusted regression models were used to compare groups on measures of eating pathology and mental health. Three weight suppression thresholds (5%, 10%, and 15%) for probable atypical AN were also tested.

RESULTS

The sample was comprised of 12% probable atypical AN, 23.6% Cog Only, 16.3% WS Only, and 48.1% Control. The probable atypical AN group was most like the Cog Only group except for higher levels of dietary restraint. Atypical AN fared worse and was least like the Control group followed by the WS Only group. All weight suppression thresholds significantly predicted dietary restraint, with 5% being the best predictor.

DISCUSSION

Results found that probable atypical AN is a distinct clinical entity and that the exact weight suppression threshold associated with atypical AN is less important than having any weight suppression. Findings highlight the clinical significance of atypical AN and the importance of gaining a better understanding of how to address this clinical entity.

PUBLIC SIGNIFICANCE

Atypical anorexia nervosa is a relatively underexamined but highly prevalent eating disorder in the Veteran population. Results show that ED cognitive features are more closely linked to clinically significant eating pathology and poor mental health than weight suppression alone suggesting that negative thinking about weight gain and appearance, regardless of the presence or severity of weight loss, may signal the need for specialized intervention.

Pain Care at Home to Amplify Function: Protocol Article

Guidelines recommend strategies to optimize opioid medication safety, including frequent reassessment of the benefits and harms of long-term opioid therapy. Prescribers, who are predominantly primary care providers (PCPs), may lack the training or resources to implement these guideline-concordant practices. Two interventions have been designed to assist PCPs and tested within the Veterans Health Administration (VHA). Telemedicine Collaborative Management (TCM) provides primarily medication management support via care manager-prescriber teams. Cooperative Pain Education and Self-Management (COPES) promotes self-management strategies for chronic pain via cognitive behavior therapy techniques. Each intervention has been shown to improve prescribing and/or patient outcomes. The added value of combining these interventions is untested. With funding and central coordination by the Integrative Management of Chronic Pain and Opioid Use Disorder for Whole Recovery (IMPOWR) Network of the National Institutes of Health Helping to End Addiction Long-term (HEAL) Initiative, we will conduct a multisite patient-level randomized hybrid II effectiveness-implementation trial within VHA to compare TCM to TCM + COPES on the primary composite outcome of pain interference and opioid safety, secondary outcomes of alcohol use, anxiety, depression, and sleep, and other consensus IMPOWR Network measures. Implementation facilitation strategies informed by interviews with healthcare providers will target site-specific needs. The impact of these strategies on TCM implementation will be assessed via established formative and summative evaluation techniques. Economic analyses will evaluate intervention cost-effectiveness.

Qualitative Analysis of Patient Perspectives of Buprenorphine After Transitioning From Long-Term, Full-Agonist Opioid Therapy Among Veterans With Chronic Pain

Guidelines recommend consideration of modification, tapering, or discontinuation of long-term, full-agonist opioid therapy when harms outweigh benefits; one alternative to tapering or discontinuing full-agonist opioids for the management of chronic pain is switching to the partial agonist buprenorphine. As the use of buprenorphine for pain expands, understanding the patient experience during and after the transition to buprenorphine is critical. We conducted 45- to 60-minute semistructured qualitative interviews with 19 patients to understand the experiences of patients with chronic pain actively maintained on buprenorphine after previously receiving full-agonist, long-term opioid therapy. Patients were recruited from 2 medical centers via provider referral. Through thematic analysis, 5 overall themes were identified, including satisfaction with buprenorphine, the importance of preconceptions about buprenorphine, experiences with transitions, patient-provider communication, and potential contributions to racial disparities in pain care. While we heard a range of experiences, most patients were satisfied with buprenorphine, reporting either equivalent pain control to their previous regimens or reporting less analgesia but improved functioning due to a reduction in side effects (eg, mental clarity). Patients also emphasized the importance of a nonjudgmental, patient-centered approach, including education about the risks and benefits of buprenorphine. The few Black patients interviewed all reported limited access to pain care, which is consistent with the well-documented existence of racial disparities in access to pain treatment. As buprenorphine is used more frequently for pain management, provider education focused on pain treatment disparities, patient-centered approaches informed by motivational interviewing, and increasing acceptance of buprenorphine as an option for pain are needed. PERSPECTIVE: Qualitative analyses of patient experiences transitioning from full-agonist opioids to buprenorphine for chronic pain revealed general satisfaction. Patients reflected on functioning, tradeoffs between analgesia and side effects, patient-centered care, and access to treatment, highlighting how future research should focus on outcomes valued by patients.

Validation of the EDDS-5 self-report survey against the SCID-5 diagnostic interview in US veterans

The aim of our study was to validate the Eating Disorder Diagnostic Scale (EDDS-5) updated for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) with a diverse veteran population against a clinician-administered interview based on the Structured Clinical Interview for DSM-5 (SCID-5). Our sample included 343 veterans, 18-75 years, recruited April 2019 to December 2022 who completed the EDDS-5 as well as other eating disorder and mental health measures. A subsample of these veterans received clinical interviews (n = 166), which were used to validate the EDDS-5. We found that despite multiple proposed modifications, the EDDS-5 performed poorly at correctly identifying diverse veterans who were diagnosed as having eating disorders through clinician-administered interviews. The sensitivity was very low, indicating that using the EDDS-5 did not identify many true positives and may also over diagnose those without true eating disorders. The EDDS-5 may not be the best for screening or diagnostic purposes among diverse samples like veterans.

The 24-hour food frequency assessment screening tool (FAST24): Development and evaluation of a novel dietary screener to identify foods associated with weight change

BACKGROUND & AIMS

Brief screening questionnaires can identify 'at risk' behaviors in clinical settings. However, there is currently no screener for dietary intake specifically developed using foods associated with body weight change and increased risk for multiple chronic conditions and diseases.

METHODS

We developed a novel brief dietary screener, the 24-Hour Food Frequency Assessment Screening Tool Questionnaire (FAST24), to identify intake of foods associated with weight change. University students completed the FAST24 and the Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) at two time points to assess acceptability and determine preliminary criterion validity against food categories from the United States Department of Agriculture (USDA) Food Patterns Equivalents Database (FPED).

RESULTS

202 individuals (age 20.4 ± 3.6 years; 65.7% females) completed the FAST24 in an average time of 2 min compared to 24 min for the ASA24. Over half of the food items from the FAST24 were matched to, and correlated with, standard USDA food pattern components (r's ranging from .15 to .58, p's < .05). Food items from the dietary data from the FAST24 were also highly correlated with the more intensive ASA24 application (r's ranging from .23 to .82, p's < .01), and were less time-consuming and burdensome to complete (p's < .0001).

CONCLUSIONS

Findings support the continued refinement of the FAST24 as a rapid, valid primary care assessment tool for measuring USDA dietary intake patterns. Use of a short, simple screener such as the FAST24 has the potential for integration into large healthcare delivery settings to help establish a baseline for promoting relative behavior changes critical for long-term health and well-being.

Delphi study to explore a new diagnosis for "ineffective" long-term opioid therapy for chronic pain

ABSTRACT

A challenge in clinical, research, and policy spheres is determining whether and how to apply the Diagnostic and Statistical Manual-5 Opioid Use Disorder criteria to patients receiving long-term opioid therapy (LTOT) for the management of chronic pain. This study explored perspectives on the merits of creating a new diagnostic entity to characterize the problems that arise for certain patients prescribed LTOT and develop consensus on its definition and diagnostic criteria. We conducted 3 rounds of online surveys and held one discussion-based workshop to explore a new diagnostic entity and generate consensus with subject matter experts (n = 51) in pain and opioid use disorder, including a wide range of professional disciplines. The first survey included open-ended questions and rapid qualitative analysis to identify potential diagnostic criteria. Rounds 2 and 3 involved rating potential diagnostic criteria on a Likert-type scale to achieve consensus. The workshop was a facilitated conversation aimed at further refining criteria. Three-quarters of Delphi panelists were in favor of a new diagnostic entity; consensus was reached for 19 potential diagnostic criteria including benefits of LTOT no longer outweighing harms and a criterion related to difficulty tapering. A subgroup of expert panelists further refined the new diagnostic entity definition and criteria. Consensus on potential criteria for the new diagnostic entity was reached and further refined by a subgroup of experts. This Delphi study represents the opinions of a small group of subject matter experts; perspectives from other experts and additional stakeholder groups (including patients) are warranted.

Development and Psychometric Assessment of the Weight and Eating Quality of Life (WE-QOL) Scale in US Military Veterans

BACKGROUND

The Veterans Health Administration (VHA) is in need of population health approaches to address overweight and obesity-related diseases. BMI serves as a simple, blunt metric to monitor these efforts. However, emerging research has demonstrated that healthcare weigh-ins contribute to weight stigma which paraodoxically is associated with weight gain. An alternative metric is urgently needed for VHA's MOVE!® Weight Management Program and other eating- and weight-related services.

OBJECTIVE

To develop a brief population health metric called the Weight and Eating Quality of Life (WE-QOL) Scale and assess its psychometric properties.

DESIGN

The literature was reviewed for relevant weight- and eating-specific QOL measures to identify unique and overlapping constructs. Eight items, representing these constructs, comprised the new brief WE-QOL Scale. A survey study was conducted with data analyzed in STATA.

PARTICIPANTS

A total of 213 consecutively evaluated US Veterans attending an orientation session for MOVE!.

MAIN MEASURES

The WE-QOL Scale, as well as a widely used generic health-related QOL measure, the European Quality of Life Screener (EQ-ED-5L), and relevant validated measures.

KEY RESULTS

WE-QOL descriptive findings demonstrated severe impacts on physical activity and physical discomfort for approximately 30% of the sample each; moderate-to-severe impacts on daily responsibilities, emotional distress, and shame and guilt for one-third of the sample each and public distress for one-fourth of the sample. The WE-QOL Scale performed as well as, or better than, the EQ-ED-5L for internal consistency (Cronbach's alpha = 0.91) and associations to relevant constructs (BMI, eating pathology, and physical activity).

CONCLUSIONS

Findings support the reliability and construct validity of the WE-QOL Scale. The WE-QOL Scale has potential to provide a standardized population health metric that could be used as a screening tool and clinical reminder to identify, refer, and assess outcomes for Veterans with weight and disordered eating issues. Future research could be targeted at using this measure to improve patient care and quality of care.

Arguments for and Against a New Diagnostic Entity for Patients With Chronic Pain on Long-Term Opioid Therapy for Whom Harms Outweigh Benefits

The goal of this study was to understand perspectives on whether a new diagnostic entity, distinct from Diagnostic and Statistical Manual - 5 (DSM-5) opioid use disorder (OUD), is needed for patients with chronic pain on long-term opioid therapy (LTOT) for whom the harms of continued opioid therapy outweigh the benefits. Data were collected as part of a larger Delphi study. We used rapid and thematic qualitative methods to analyze data from 51 panelists with expertise in internal medicine, psychiatry, psychology, and related fields. Three-quarters of panelists supported a new diagnostic entity; common themes included recognizing distinct experiences of patients prescribed LTOT, addressing problems with DSM-5 OUD criteria, facilitating research and improved treatment, and reducing stigma. Thirteen panelists opposed the creation of a new diagnostic entity; common themes included similarities in biological underpinnings of patients prescribed LTOT and diagnosed with OUD, belief that the continuum of OUD captured patients' experiences, finding better ways to address problems with DSM-5 OUD criteria, and concerns about stigma. While this expert panel disagreed about the need for a new diagnostic entity, there was an overall acknowledgement that the current implementation of DSM-5's OUD diagnosis is not meeting the needs of LTOT providers or patients. PERSPECTIVE: The DSM-5's OUD diagnosis may not adequately meet the needs of patients on LTOT for whom the harms of continued opioid therapy outweigh the benefits. Experts do not agree on how to address this problem; more work is needed to determine if a new diagnostic entity would be beneficial.

Patient and provider experiences using a site-to-site telehealth model for medication abortion

BACKGROUND

In the site-to-site telehealth for medication abortion model, patients visit a health center to meet with a remote clinician using telehealth technology. This model is safe, effective, and acceptable to patients and providers. The objective of this study was to document the experiences of patients and providers using telehealth for medication abortion in Planned Parenthood health centers across different geographical contexts in the United States.

METHODS

We conducted in-depth interviews with Planned Parenthood medication abortion patients who either met with a clinician at the clinic via telehealth or in-person about their experiences receiving care. We also interviewed Planned Parenthood staff members about their experiences implementing telehealth for medication abortion at their health center.

RESULTS

We interviewed 29 patients who received care at Planned Parenthood health centers in five states. Both telehealth and in-person patients described positive interactions with health center staff and clinicians. The vast majority of telehealth patients said that they felt comfortable speaking with the clinician over telehealth and had no trouble using the telehealth technology. We interviewed 12 providers, including clinicians and administrative staff, who worked in seven states. Providers largely thought that telehealth for medication abortion expanded access to medication abortion.

CONCLUSIONS

Across different locations, our findings indicate that patients found telehealth for medication abortion services to be highly acceptable and providers found that telehealth services may help improve medication abortion access. As the use of telehealth for medication abortion expands, future research should include additional measures of quality to ensure that services are acceptable across different identities and experiences, including age, race, gender, and income level.

Atypical Anorexia Nervosa, not so atypical after all: Prevalence, correlates, and clinical severity among United States military Veterans

OBJECTIVE

DSM-5 Atypical Anorexia Nervosa (AAN), a new eating disorder diagnosis, presents similarly to Anorexia Nervosa (AN) in the absence of severe underweight. The prevalence of AAN and other DSM-5 eating disorders was estimated in a sample of Veterans. Sociodemographic, mental health, and eating behavior correlates were examined.

METHOD

Iraq and Afghanistan war era Veterans (N = 1137, 51.6% female) completed the Eating Disorder Diagnostic Scale-5 for probable AAN diagnosis, and validated measures of eating pathology and mental health, between February 2016 and October 2019. Multivariate analyses compared Veterans with AAN to those with and without any DSM-5 eating disorder.

RESULTS

Among completers, 13.6% of women and 4.9% of men in the sample met criteria for probable AAN and 19.2% of women and 13.9% of men for another eating disorder. Mean age was 41 years, and on average BMIs were classified as overweight (BMI = 28.8, SD = 5.6) despite being at least 10% lower than their lifetime highest weight. Two-thirds reported dietary restraint on more than half the days in the past month. On measures of mental health, the AAN group had worse functioning than the no eating disorder group, similar functioning to Veterans with Binge Eating Disorder (BED), and better functioning than Veterans with Bulimia Nervosa (BN).

DISCUSSION

Results support AAN as a highly prevalent and clinically significant diagnosis. Findings highlight the need to identify and address eating disorders, particularly other specified eating disorders not meeting criteria for AN, BN, or BED, in active military and Veteran, and other high-risk and underserved, populations.

Associations between adverse childhood experiences and weight, weight control behaviors and quality of life in Veterans seeking weight management services

INTRODUCTION

A neglected area of trauma research with Veterans is the study of Adverse Childhood Experiences (ACEs). The present study aimed to examine the prevalence of ACEs, and to explore relationships between ACEs and measures of weight, eating behaviors and quality of life in weight loss seeking Veterans.

METHODS

Participants were 191 Veterans [mean age 58.9 (SD = 12.8), mean Body Mass Index (BMI) 35.4 (SD = 6.1), 86.9% male, 33.7% racial/ethnic minority] receiving care at VA Connecticut Healthcare System (VA CT) who attended an orientation session of VA's behavioral weight management program. Participants completed a measure of ACEs and measures related to weight, eating and health.

RESULTS

Among completers, 68.6% endorsed at least one ACE. The average number of reported ACEs was 2.2 (SD = 2.5), with 48.7% of Veterans reporting more than one type of ACE. Women were more likely to report any ACE (88.0% vs. 65.6%, p = .025) and reported significantly more ACEs compared to males (4.2 vs. 1.9, p < .001). ACEs were associated with lower physical activity (p = .05), lower quality of life (p's < 0.05), and lower weight-related quality of life (p < .01), but not weight, weight control strategies, binge eating, or alcohol use.

CONCLUSION

ACEs are common among weight loss seeking Veterans, particularly among female Veterans. Findings suggest that there is a high rate of ACEs in Veterans, which are associated with exercise and quality of life outcomes, but not diet and weight outcomes.

Introduction of telemedicine for medication abortion: Changes in service delivery patterns in two U.S. states

OBJECTIVE(S)

Telemedicine for medication abortion (teleMAB) is safe and effective, yet little is known about how its introduction affects service delivery. We assessed changes in service delivery patterns 1 year after introducing teleMAB at Planned Parenthood in 2 U.S. states.

STUDY DESIGN

Retrospective records analysis using electronic health record data from Planned Parenthood health centers in Montana and Nevada from 2015 to 2018. We included all patients receiving medication or aspiration abortion in the year before and after introducing site-to-site teleMAB. Outcomes included: the proportion of medication abortions (vs. aspiration); gestational age at abortion; time to appointment; and distance traveled. We compared outcomes pre- and postimplementation using χ², t tests, and Mann-Whitney U tests.

RESULTS

We analyzed data for 3,038 abortions: 1,314 pre- and 1,724 postimplementation. In Montana, the proportion of medication abortions increased postimplementation (60% vs. 65%, p = 0.04). Mean gestational age was similar: 58 versus 57 days (p = 0.35). Mean time to appointment decreased (14 vs. 12 days, p < 0.0001), as did one-way distance traveled by patients (134 vs. 115 miles, p = 0.03). In Nevada, where Planned Parenthood only provided medication abortion, total medication abortions increased (461 vs. 735). Mean gestational age remained stable (51 vs. 51 days, p = 0.33), as did time to appointment (8 vs. 8 days, p = 0.76). Mean one-way distance traveled was 47 miles in the preperiod versus 34 miles in the postperiod (p = 0.22).

CONCLUSION(S)

Medication abortion increased after the introduction of telemedicine in both states, though we cannot account for abortions performed by other providers. Telemedicine has the potential to improve access to medication abortion.

IMPLICATIONS

Telemedicine has the potential to improve or maintain access to medication abortion and should be taken to scale where feasible. Continued efforts are needed to mitigate or reverse policy restrictions on telemedicine for medication abortion.

Evaluation of NutriDense low-phytate corn and added fat in growing and finishing swine diets

Two experiments were conducted to evaluate the effects of NutriDense low-phytate corn in conjunction with increasing added dietary fat on growing and finishing pig performance. Diets in both experiments were corn-soybean meal-based, with yellow dent or NutriDense low-phytate corn and 0, 3, or 6% added choice white grease arranged in a 2 x 3 factorial design. There were 25 to 28 pigs per pen and 7 pens (replications) per treatment in both experiments. In Exp. 1, a total of 1,162 gilts with an initial BW of 44.6 kg were used in a 28-d growth study. A constant true ileal digestible (TID) Lys:ME ratio of 2.80 g/Mcal and available P:ME ratio of 0.90 g/Mcal were maintained in all treatment diets. Overall (d 0 to 28), there were no corn source x added fat interactions (P >/= 0.79). Regardless of corn source, ADG and G:F increased (linear, P = 0.03) with increasing added fat. There were no differences (P >/= 0.34) in pig growth performance between those fed NutriDense low-phytate or yellow dent corn. In Exp. 2, a total of 1,128 gilts with an initial BW of 81.6 kg were used in a 28-d growth study. A constant TID Lys:ME ratio of 2.15 g/Mcal of ME and available P:ME ratio of 0.75 g/Mcal were maintained in all treatment diets. Overall (d 0 to 28), there was a tendency (P = 0.07) for a corn source x added fat interaction for G:F, which can be explained by the improved G:F in pigs fed yellow dent corn only when 6% fat was added to the diet, whereas G:F was improved at both 3 and 6% added fat in pigs fed NutriDense low-phytate corn. There were no differences (P >/= 0.18) in growth performance between pigs fed NutriDense low-phytate or yellow dent corn. These results indicate that increasing added fat improved growth performance regardless of the corn source. In addition, growth performance was similar for pigs fed NutriDense low-phytate or yellow dent corn.

Surrogate end points in pulmonary arterial hypertension: assessing the response to therapy

Recent discoveries in the disease pathophysiology of pulmonary arterial hypertension have been translated into effective therapies tested in clinical trials. The studies have focused on surrogate and intermediate end points, thought to reflect quantity and quality of life, respectively. The authors present the necessary requirements for establishing the reliability and validity of such end points before they may be used dependably. The authors also review the available data, strengths, and weaknesses of potential end points in pulmonary arterial hypertension.

Transbronchial biopsy in usual interstitial pneumonia

BACKGROUND

Usual interstitial pneumonia (UIP) is a slowly progressive, usually fatal form of idiopathic interstitial pneumonia for which there is no effective treatment. Transbronchial biopsy (TBB) has been utilized only to exclude other diseases such as sarcoidosis, lymphangitic carcinoma, and infection, for example, but TBB is generally considered to have little role in confirming UIP.

OBJECTIVE

To determine whether diagnostic changes of UIP can be appreciated on TBB specimens.

DESIGN

Retrospective analysis of TBB specimens from patients with proven UIP.

SETTING

Two study sites in the United States.

PARTICIPANTS

Twenty-one patients with UIP confirmed by surgical lung biopsy and/or lung explant, and 1 patient with UIP confirmed by clinical and radiographic findings along with follow-up information.

MEASUREMENTS AND RESULTS

Adequate tissue for diagnosis was available in 18 cases; in 7 cases (32% overall), there were varying combinations of interstitial fibrosis in a patchwork pattern along with fibroblast foci and/or honeycomb change. These features were considered diagnostic of UIP. Interstitial fibrosis along with fibroblast foci or honeycomb change were seen in two other cases, but the fibrosis lacked a patchwork pattern, and these features were considered consistent with UIP. Nonspecific interstitial fibrosis alone was found in nine cases.

CONCLUSIONS

In summary, characteristic histologic features of UIP can be identified on TBB specimens more often than previously appreciated. TBB may be more useful in confirming UIP than previously recognized.

Evaluation and significance of tetracycline stability in rabies vaccine baits

Tetracycline is widely used as a biomarker for bait consumption by wildlife; tetracycline is incorporated into bones and teeth and can be detected by fluorescence microscopy several weeks postconsumption. During 2003, the United States Department of Agriculture distributed more than 10 million tetracycline-containing rabies-vaccine baits to control the spread of wildlife vectored rabies to humans, pets, and livestock. To estimate the percentage of target species consuming the baits, raccoons and skunks were collected in baited areas and teeth were analyzed for the presence of the biomarker. Several incidents of low biomarker detection rates prompted an investigation of the stability of the biomarker in the baits. Baits were collected at several points along the manufacturing and distribution chain. Baits were analyzed for free and polymer-bound tetracycline and the less active isomer epitetracycline. Results indicated that a portion of the tetracycline was converted to epitetracycline. Additionally, significant quantities of both compounds were trapped in the polymer, which is homogeneously distributed throughout the bait. The results of this study suggest that approximately 40% of the target quantity of tetracycline was unavailable for absorption. This situation could contribute to low biomarker detection rates and suggests that formulation modification should be considered.

Hy-Line W-36 and Hy-Line W-98 laying hens respond similarly to dietary phosphorus levels

Two experiments were conducted to determine if 2 laying hen strains, Hy-Line W-36 and Hy-Line W-98, would respond similarly to being fed corn-soybean meal diets (17% CP and 3.8% Ca) deficient in nonphytate P (NPP). In experiment 1, 3 diets with varying NPP levels (0.10, 0.14, and 0.45%) were fed to 6 replicate groups of 12 hens of each Hy-Line strain from 20 to 50 wk of age. Body weight, egg weight, egg mass, feed intake, and NPP intake were higher for W-98 hens compared with W-36 hens throughout the 30-wk period. The 0.10% NPP dietary treatment was terminated for both strains at 35 wk of age due to similar low egg production. Within each strain, there was no significant difference in egg production performance for hens fed 0.14% NPP compared with hens fed 0.45% NPP. In experiment 2,3 diets with varying levels of NPP (0.10, 0.13, and 0.45%) were fed to 5 replicate groups of 12 hens of each Hy-Line strain from 95 to 112 wk of age. The 0.10% NPP treatment rapidly and severely depressed egg production and was terminated at 99 wk of age for both strains. In addition, egg production and egg mass were depressed similarly in both strains fed 0.13% NPP. In conclusion, this research indicates that Hy-Line W-36 and Hy-Line W-98 hens responded similarly to dietary NPP deficiency, suggesting that both strains have similar NPP requirements.

Phytase, citric acid, and 1alpha-hydroxycholecalciferol improve phytate phosphorus utilization in chicks fed a corn-soybean meal diet

Previous research from our laboratory has shown that phytase, citric acid, and 1alpha-hydroxycholecalciferol [1alpha-(OH) D3] individually improve phytate P use in young chicks fed a P-deficient corn-soybean meal (C-SBM) diet. The current study was conducted to evaluate combinations of these additives on phytate P utilization. In 3 chick experiments, male crossbred chicks (New Hampshire x Columbian) were fed experimental diets from 8 to 21 d of age. The C-SBM basal diet used in all assays contained no supplemental P and was calculated to provide 23% CP, 0.13% nonphytate P (0.39% total P), 0.62% Ca, 25 mg of cholecalciferol/kg, and 3,260 kcal of TME/kg. In all 3 experiments, factorial arrangements (2 x 2 or 2 x 2 x 2) were used to evaluate 2 levels of phytase (0 and 300 units/kg), citric acid (0 and 3 or 4%), and 1alpha(OH) D3 (0 and 5, 10, or 15 microg/kg). Phytase, citric acid, and 1alpha-(OH) D3 each increased weight gain and tibia ash in all 3 experiments. There were some significant interactions among the compounds, but these were not consistent across experiments. Using standard curve methodology for tibia ash data, it was estimated that 0.03, 0.02, and 0.04% P were released by 3% citric acid, 300 units of phytase/kg, and 5 microg 1alpha-(OH) D3/kg, respectively, and that the combination of all 3 compounds resulted in the release of 0.13% P. Our results indicate that all 3 compounds increased phytate P use, and that their effects were generally additive, with some possible synergism between citric acid and 1alpha-(OH) D3.

Minimum Phosphorus Requirement of One-Cycle and Two-Cycle (Molted) Hens

In experiment 1 (one cycle), hens were fed diets containing 0.10, 0.115, 0.125, 0.135, 0.15, or 0.45% available P (AP) from 40 to 56 wk of age, with the last diet being a positive control. Egg production, egg mass, and BW were reduced (P < 0.05) by all lower AP levels except 0.15% AP when compared with the 0.45% AP treatment. In the second experiment (two cycles with a molt), hens were initially fed diets containing 0.10, 0.12, 0.14, 0.16, 0.18, 0.20, or 0.45% AP from 21 to 63 wk of age. Diets containing 0.10, 0.12, and 0.14% AP were terminated at 35, 39, and 50 wk, respectively, due to low egg production and increased mortality. Hens fed 0.16% AP also had significantly lower production performance than hens fed 0.45% AP during the first cycle. Hens on the 0.16 to 0.45% AP treatments were induced molted at 64 wk of age by 10 d of feed removal. The hens were then returned to the same AP layer diet they had been fed from 21 to 63 wk. For the 68 to 108 wk postmolt second-cycle period, hens fed the 0.16 to 0.20% AP diets (166 to 209 mg/d) had significantly lower egg production, egg mass, and feed efficiency than hens fed 0.45% AP. The results of our study indicated that first-cycle hens required approximately 0.18% AP or 198 mg AP/hen per day, and molted hens in their second cycle had a requirement that was greater than 0.20% AP or 209 mg AP/hen per day.

1alpha-hydroxycholecalciferol has little effect on phytate phosphorus utilization in laying hen diets

Previous research in our laboratory demonstrated marked increases in phytate P utilization when P-deficient corn-soybean meal diets were supplemented with 1a-hydroxycholecalciferol [1alpha-(OH) D3] and fed to chicks. Our objective was to determine if 1alpha-(OH) D3 would improve phytate P utilization when supplemented to vitamin D-adequate laying hen diets. The five experimental treatments were 1) P-deficient corn-soybean basal diet [17% CP, 3.8% Ca, and 0.10% nonphytate NPP)], 2) basal with 2.5 microg/kg 1alpha-(OH) D3, 3) basal with 5 microg/kg 1alpha-(OH) D3, 4) basal with 10 microg/kg 1alpha-(OH) D3, and 5) basal with 0.35% supplemental inorganic P (0.45% NPP, positive control). Diets were fed to six replicate groups of 12 HyLine W-98 White Leghorn laying hens from 44 to 52 wk of age. Hen-day egg production was significantly depressed by 47 wk of age for the basal diet treatment and by 47, 49, and 48 wk of age, respectively, for the 2.5, 5, and 10 microg/kg of 1alpha-(OH) D3 treatments compared to the positive control diet. Supplementation with 5 or 10 microg/kg 1alpha-(OH) D3 did improve (P < 0.05) egg production, but egg production for those treatments was much lower than that for the 0.45% NPP treatment. Our results indicate that 1alpha-(OH) D3 did not substantially improve P utilization in laying hens fed corn-soybean meal diets.

Efficacy of high available phosphorus corn in laying hen diets

Our objective was to determine if high available phosphorus corn would provide sufficient available phosphorus (AP) to laying hens fed corn-soybean meal diets from 57 to 69 wk of age. Six replications of 12 Dekalb Sigma Leghorn hens were fed a normal yellow dent (YD) corn-soybean meal diet or high available phosphorus (HAP) corn-soybean meal diet without and with 0.04% supplemental inorganic P. The unsupplemented YD diet was calculated to contain 17% CP, 3.8% Ca, and 0.10% AP, and the unsupplemented HAP diet contained 17% CP, 3.8% Ca, and 0.16% AP. In addition, a positive control, YD diet (17% CP, 3.8% Ca, 0.45% AP) was also fed. The HAP corn was directly substituted for YD on a weight basis, and the amount of soybean meal was kept constant in all diets. Egg production, hen body weight, egg weight, egg mass, feed consumption, and feed efficiency were measured. The YD and the YD + 0.04% P treatments were terminated at 61 and 65 wk of age, respectively, due to severe depressions in egg production. Egg production and egg mass for hens fed HAP diets were not different (P > 0.05) from those of hens fed the 0.45% AP diet; however, hens fed the unsupplemented HAP diet did have lower hen body weights and feed intake (P < 0.05) compared to hens fed the positive control diet. Our results indicate that HAP corn contains more available P than normal YD corn and that hens can be fed HAP corn-soybean meal diets containing little or no P supplementation with only minimal effects on production performance.

Phytase effects on amino acid digestibility in molted laying hens

Two hundred sixteen previously molted Dekalb Delta Leghorn laying hens (78 wk of age) were utilized to determine the effect of phytase on the ileal digestibility of amino acids. The hens were randomly arranged in a 3 x 2 factorial to evaluate three diet types that were corn-soybean meal (C-SBM), C-SBM-meat and bone meal (C-SBM-MBM), and C-SBM-wheat middlings (C-SBM-WM) and two levels of phytase (0 or 300 U/kg of diet). Each treatment was administered to four replicates of nine hens per replicate. Hens were fed the experimental diets for 21 d, and daily egg production and feed intake were recorded. After 21 d, the hens were euthanized, and ileal contents were collected for amino acid and digestible energy determination. Egg production of the hens did not differ among the treatments (P > 0.05). A significant interaction between diet type and phytase level for Ala, Gly, Leu, and Met was observed. The interaction resulted because phytase numerically increased amino acid digestibilities for the C-SBM-MBM and C-SBM-WM diets, but phytase addition numerically decreased the amino acid digestibilities for the C-SBM diet. Diet type had a significant effect on digesibilites of most amino acids. The latter effect was due primarily to lower amino acid digestibilities for the C-SBM-MBM diet than the C-SBM-WM diet. Phytase had no significant affect on digestibility of any amino acid. Ieal digestible energy was significantly affected by diet type but not by phytase. In conclusion, diet type had a significant effect on apparent ileal amino acid digestibility and digestible energy, but phytase had no consistent effect.

Efficacy of phytase for increasing protein efficiency ratio values of feed ingredients

Data previously reported in several studies have suggested that phytase improves amino acid digestibility in chicks. It was the objective of the current study to determine if phytase would increase the protein efficiency ratio (PER) values (g weight gain per g protein intake) for several feed ingredients fed to chicks. Six experiments were conducted and ingredients evaluated were casein, soybean meal, canola meal, cottonseed meal, peanut meal, wheat middlings, wheat bran, rice bran, defatted rice bran, meat and bone meal, and corn gluten meal. Casein was evaluated to serve as a phytate-free control ingredient. Each feedstuff was analyzed for CP and included in cornstarch:dextrose diets as the only source of protein to provide 10% dietary protein in Experiments 1 to 5 or 18% dietary protein (soybean meal) in Experiment 6. Dietary Ca and nonphytate P levels were varied among experiments and ranged from 0.95 to 1.5% Ca and 0.35 to 0.675% nonphytate P. The test ingredient diets were fed with 0 or 1,200 units of phytase/kg to New Hampshire x Columbian chicks from 8 to 17 or 20 d of age. The PER values varied greatly among ingredients, ranging from 1.4 for corn gluten meal to 4.2 for canola meal. Phytase addition had no significant effect (P > 0.10) on PER values for any of the ingredients evaluated, except for an increase for casein in one experiment. The results indicated that 1,200 U of phytase/kg did not significantly increase protein utilization of several feed ingredients as assessed by a PER chick growth assay.

Looking beyond nursing for clues to effective leadership

Effective leadership is one of the most elusive keys to organizational success yet it is a key ingredient to making any organization work. Leadership is also changing in nature. Our current faster, more flexible, flatter organizations face intense competition and require dynamic leadership. This article synthesizes research conducted during the past 5 years that quantifies what separates superior leaders from average leaders. Although this research originated from a study of top global nonhealthcare organizations, it relates to the nursing profession. The author discusses key elements of the research, including emotional intelligence and its link to performance.

The effect of citric acid on the calcium and phosphorus requirements of chicks fed corn-soybean meal diets

Data previously reported from our laboratory indicated that supplementation of a corn-soybean meal diet with citric acid improves P utilization in chicks. The four experiments reported herein were conducted to further evaluate the effects of citric acid on Ca and P utilization for chicks fed a corn-soybean meal diet. Diets in all experiments were fed to chicks from 8 to 21 or 22 d of age. The first experiment evaluated the effect of 6% citric acid on the Ca requirement of chicks. A Ca-deficient basal diet [23% CP, 0.54% Ca, 0.45% available P (AP)] containing 0 to 0.7% supplemental Ca in 0.1% increments was fed with or without 6% citric acid. The results indicated that citric acid did not significantly affect the Ca requirement. A second experiment evaluated different levels of citric acid (0, 2, 4, or 6%) on P utilization, and results indicated that 4 and 6% citric acid produced the largest responses in growth and tibia ash. Experiments 3 and 4 were then conducted to determine whether 4 or 6% citric acid would reduce the level of supplemental P required. Dietary treatments were a P-deficient basal diet (23% CP, 1.0 or 1.3% Ca, 0.20% AP) supplemented with 0 to 0.25% inorganic P with or without 4 or 6% citric acid. When diets contained citric acid, weight gain and tibia ash were maximized at lower AP levels than when diets contained no citric acid. The results of this study indicate that citric acid increases P utilization in corn-soybean meal diets and reduces the AP requirement by approximately 0.10% of the diet.

Citric acid does not improve phosphorus utilization in laying hens fed a corn-soybean meal diet

Data previously obtained from our laboratory have indicated that citric acid was very effective at improving phytate-P utilization in chicks fed a P-deficient corn-soybean meal (SBM) diet. The objective of the current study was to determine if citric acid would have similar effects in a commercial strain of Single Comb White Leghorn laying hens (n = 432) fed a corn-SBM diet containing 0.10% available P (AP). Dietary treatments were a corn-SBM basal diet (0.10% AP, 3.8% Ca, and 17% CP) supplemented with 0, 1, 2, 3, or 4% citric acid and a positive control diet containing 0.45% AP. Each of the six dietary treatments were fed to six replicate groups of 12 hens from 22 to 40 wk of age. No significant differences in performance were observed among treatments during the first 4 wk of the experiment. Hen-day egg production, feed consumption, feed efficiency, and egg yield were subsequently depressed in hens fed 0, 1, 2, 3, or 4% citric acid compared with hens fed 0.45% AP. The results of this study indicate that citric acid does not improve the utilization of dietary P in laying hens fed a corn-SBM diet containing 3.8% Ca.

High chromium yeast supplementation improves glucose tolerance in pigs by decreasing hepatic extraction of insulin

Twenty Landrace x Yorkshire cross pigs (body wt, 47.9+/-2.9 kg) were used to evaluate effects of dietary high chromium (Cr) yeast supplementation on plasma kinetics of glucose, insulin and C-peptide. Pigs were provided free access to either a control diet (C) containing 204 microg Cr/kg or a diet supplemented with an additional 200 microg Cr/kg as high Cr yeast (CR) for between 23 and 30 d. After overnight food deprivation, dextrose (500 g/L) was infused through a jugular vein catheter at a dose of 0.5 g glucose/kg body weight with an infusion rate of 10 g glucose/min within 6 min. High Cr yeast supplementation did not affect body weight gain or food intake. There were no differences in fasting plasma concentrations of either glucose or C-peptide, although basal plasma concentration of insulin tended to be higher in pigs fed CR (P<0.10). Plasma glucose concentrations were lower (P<0.01) at postinfusion times 5, 10, 15 and 20 min in pigs fed CR. Plasma insulin concentrations in pigs fed CR were higher (P<0.05) at 2 and 0 min before the completion of dextrose infusion. However, the increase in plasma insulin concentrations was not accompanied by a comparable elevation in plasma C-peptide concentrations. The 30-min (postinfusion) area of plasma glucose concentrations tended to be lower (P<0.10) in pigs fed CR, but there were no differences in 30-min areas of either plasma insulin or plasma C-peptide concentrations between treatments. Plasma clearance rates of glucose, insulin and C-peptide were higher and their half-lives shorter (P<0.05) in pigs fed CR. In conclusion, dietary high Cr yeast supplementation improved glucose tolerance, possibly through a decrease in hepatic extraction of insulin.

Granulomatous vasculitis associated with herpes virus: a persistent, painful, postherpetic papular eruption

Cutaneous granulomatous vasculitis manifesting as a postherpetic reaction pattern is uncommon hand has previously been reported as a delayed complication of varicella-zoster virus infection. We describe three patients who had persistent, painful, postherpetic papules in a zosteriform distribution that histologically demonstrated a small vessel granulomatous vasculitis. Herpes simplex virus DNA detected by the polymerase chain reaction technique was demonstrated in two cases.

Surface dosimetry in phototherapy: comparison of three ultraviolet B lamps used in the treatment of psoriasis

The quantitation (dosimetry) of ultraviolet B irradiation (UVB) administered during phototherapy for psoriasis is fundamental to this modality of treatment because only absorbed irradiation can cause a photochemical reaction and, hence, a phototherapeutic effect. Significant differences may exist in surface dosimetry achieved with different UVB irradiators, and this could have important consequences for the observed clinical efficacy of phototherapy as well as practical implications for avoiding burning when transferring patients between systems. Multiple anatomically referenced polysulphone photodosimeters were applied to the skin of five subjects receiving treatment for severe psoriasis. Three subjects were irradiated with both a free-standing hot quartz lamp and a fluorescent cabinet. Two others were irradiated with a flat bank of fluorescent tubes. Topographical maps of surface irradiation were constructed. 'Cold' areas (< 50% of stated dose) included the neck, upper chest, shoulders, and anterolateral thighs for the hot quartz lamp; the medial arms, medial legs, and feet for the cabinet; and the lateral arms, forearms, lower legs, and feet for the bank of tubes. 'Hot' areas (> 100% of stated dose) included the forearms and posterior thighs for the hot quartz lamp; the lateral arms, dorsal forearm, and abdomen for the cabinet: and the central trunk (anterior and posterior) for the bank of tubes. Thus, striking differences in surface irradiation exist among the three UVB irradiators studied, and this has an impact on the results of phototherapy for psoriasis. Knowledge of these differences is of practical importance in achieving maximum therapeutic potential as well as minimizing the risk of burning reactions, particularly if patients are to be transferred between systems.

Lipomembranous (membranocystic) fat necrosis. Clinicopathologic correlation of 38 cases

Clinicopathologic correlation of cutaneous biopsy specimens demonstrating typical lipomembranous fat necrosis was performed. Material from 732 biopsies of various subcutaneous inflammatory disorders seen at our institution in the past 5 years was screened for typical lipomembranous (membranocystic) changes in the panniculus, and 39 specimens from 38 patients with these changes were identified. The most common clinical context in which this condition was observed was in chronic sclerotic plaques of the lower legs associated with venous insufficiency (37% of the total cases). All patients were women, and the majority were obese. Typical lipomembranous fat necrosis was also observed in eight cases (21%) of erythema nodosum, three (8%) of morphea or subcutaneous morphea (or both), two (5%) of lupus panniculitis, two (5%) of necrobiosis lipoidica, and in single cases of polyarteritis nodosa, necrotizing vasculitis, and erysipelas. Six cases (16%) had no definite underlying disease. The mean age of all patients was 57 years (range 32-86 years), and 34 patients (89%) were women. Of the five major categories identified, lipomembranes lining macrocysts and microcysts were most prominent in the venous insufficiency- and morphea-related cases and were much less prominent in erythema nodosum, lupus panniculitis, and necrobiosis lipoidica, which generally showed histopathologic findings typical of these disorders. In addition to lining the macrocystic and microcystic cavities formed in the fat lobules, lipomembranes were prominent in areas of septal fibrosis in all cases associated with morphea and necrobiosis lipoidica and in 35% and 25% of venous insufficiency- and erythema nodosum-related cases, respectively. In lupus panniculitis, lipomembranes were most prominent in areas of hyaline necrosis. We conclude that lipomembranous fat necrosis is most likely a nonspecific form of ischemic fat degeneration that may be induced by various clinical entities. This change is most often seen in venous insufficiency-associated chronic sclerotic plaques typically observed in middle-aged obese women, and we propose the term stasis-associated lipomembranous panniculitis (SALP) to describe this most common form of lipomembranous fat necrosis.

Aleukemic monocytic leukemia cutis

Aleukemic leukemia cutis is a rare condition in which leukemic cells invade the skin before they appear in peripheral blood or bone marrow specimens. Herein we describe a 67-year-old man who underwent assessment because of papules and nodules on his back and lower extremities. A biopsy of these lesions confirmed a dense, predominantly monocytic infiltrate of the dermis and subcutaneous tissue. Immunohistochemical stains were positive for CD43 (Leu-22) as well as monocytic markers. Bone marrow and peripheral blood examinations failed to reveal leukemia. Treatment was based on the results of the skin biopsy, and the patient is doing well 1 year after therapy.

Lymphoma associated with human immunodeficiency virus infection

OBJECTIVE

To describe lymphoma associated with human immunodeficiency virus (HIV) infection.

DESIGN

A review of HIV-related lymphoma and its associated epidemiology, etiopathogenesis, and clinicopathologic characteristics is presented. Major studies of therapeutic regimens for HIV-related lymphoma are discussed. Factors that could contribute to a poor prognosis are summarized.

RESULTS

Malignant lymphoma that develops in patients with HIV infection fulfills diagnostic criteria for the acquired immunodeficiency syndrome (AIDS). The incidence is increasing and varies by subtype of lymphoma, age, sex, race, and risk factors. B-cell hyperactivation is thought to contribute to the development of lymphoma. The mechanisms that may show transformed cell hyperproliferation and clonal expansion are HIV itself or other viruses (for example, Epstein-Barr virus), growth factors, aberrant oncogene or tumor-suppressor gene expression, and factors that induce genetic instability or DNA damage or alter host or viral genome repair. Treatment of HIV-related lymphoma is associated with toxicity, infectious complications, low rate of complete response, and brief median survival time.

CONCLUSION

Persons with HIV-induced immune dysregulation have a high risk for the development of aggressive non-Hodgkin's lymphoma characterized by histologic evidence of a high-grade malignant process, B-cell phenotype, an unusual extranodal involvement, and a poor prognosis. The potential role of specific viruses, antiviral treatments, and other therapeutic strategies are future areas of investigation.

Malignancy-associated multicentric reticulohistiocytosis: a clinical, histological and immunophenotypic study

The clinical, histopathological, and immunophenotypic characteristics of four cases of malignancy-associated multicentric reticulohistiocytosis (MMR) and one case each of diffuse cutaneous reticulohistiocytosis (DCR) and isolated reticulohistiocytoma (IR), are reviewed. In all four cases of MMR the cutaneous lesions and joint manifestations were judged to be concurrent with the diagnosis of malignancy. Malignancies observed included one case each of pancreatic adenocarcinoma, squamous cell carcinoma of the lung, metastatic melanoma and intraperitoneal grade 4 mucinous adenocarcinoma of uncertain origin. Histologically, all six cases demonstrated the typical changes of a diffuse histiocytic and multinucleated giant cell infiltrate with ground-glass cytoplasm, predominantly in the upper dermis. Immunohistochemical investigation revealed strong cytoplasmic staining with KP-1 (CD68) in all six cases. Prominent membrane staining was noted with leucocyte common antigen (CD45) in four cases (three MMR and one IR), and CD3 in four cases (three MMR and one IR). Weak membrane staining with Leu 22 (CD43) was noted in two MMR cases. UCHL-1 (CD45RO), L26 (CD20), S-100 and BerH2 stains were all uniformly negative. A prominent number of perilesional factor XIIIa-positive dermal dendrocytes were noted in the single case of IR, in contrast with the other five cases. We conclude that MMR, DCR and IR are histopathologically and immunohistochemically similar. The pattern of immunoreactivity observed is consistent with a monocyte-macrophage origin of the infiltrating tumour cells. We emphasize the paraneoplastic association of multicentric reticulohistiocytosis, which we have observed in four of 13 such cases (31%) evaluated at our institution.

Degos syndrome: malignant atrophic papulosis

Malignant atrophic papulosis is a rare disorder characterized by pathognomonic cutaneous lesions that have been associated with multiple infarctive thrombotic lesions of other viscera, most notably the gastrointestinal tract and the central nervous system. Systemic involvement may develop from weeks to years after the onset of the characteristic cutaneous lesions or, rarely, may precede the cutaneous lesions. However, the existence of patients with a prolonged, purely cutaneous variant of this disease has been increasingly appreciated, and this brings into question the appropriateness of applying the term "malignant" to all patients who have the peculiar characteristic cutaneous lesions of malignant atrophic papulosis. Despite half a century of sporadic investigation, the precise cause of this disease remains unknown, and accurate classification of this entity as a primary vasculopathy or primary coagulopathy has not been possible. Unfortunately, no effective therapy exists for those patients in whom systemic involvement develops.

Diagnostic immunohistochemistry of cutaneous metastatic breast carcinoma: a statistical analysis of the utility of gross cystic disease fluid protein-15 and estrogen receptor protein

BACKGROUND

For accurate classification of cutaneous metastatic carcinoma, reliable tumor-specific immunohistochemical markers would be valuable.

OBJECTIVE

Our purpose was to analyze the sensitivity, specificity, and positive predictive value of gross cystic disease fluid protein-15 (GCDFP-15) and estrogen receptor protein (ERP) for diagnosing cutaneous metastatic breast carcinoma.

METHODS

Tissue sections from 68 consecutive cases of cutaneous metastatic carcinoma were stained for GCDFP-15 and ERP. Hematoxylin-eosin-stained slides and immunostained slides were reviewed in a blinded fashion before retrospective chart review to ascertain the underlying primary tumor type.

RESULTS

Of 42 cases of cutaneous metastatic breast carcinoma, 30 were positive for GCDFP-15. Of 41 cases of metastatic breast carcinoma, 30 were positive for ERP. Calculated sensitivity, specificity, and positive predictive value for GCDFP-15 for diagnosing cutaneous metastatic breast carcinoma were 71%, 91%, and 94%, respectively, and 73%, 100%, and 100% for ERP, respectively. Combined values of these indices for both stains were 83%, 91%, and 95%, respectively.

CONCLUSION

GCDFP-15 and ERP are valuable markers for cutaneous metastatic breast carcinoma and should be used in combination.

The role of genetic variation in thiopurine methyltransferase activity and the efficacy and/or side effects of azathioprine therapy in dermatologic patients

BACKGROUND

Thiopurine methyltransferase (TPMT) is one of three major enzymes involved in the metabolism of azathioprine and its active metabolite 6-mercaptopurine. Thiopurine methyltransferase activity is determined by an allelic polymorphism for either high (TPMTH) or low (TPMTL) enzyme activity. Homozygotes for the low activity allele are known to be at risk for profound myelosuppression with azathioprine. Heterozygotes may be at risk for myelosuppression. Homozygotes for the high activity allele may be inadequately immunosuppressed with conventional, empiric doses of azathioprine. We analyzed TPMT activity in red blood cell (RBC) lysates and determined the TPMT genotypes (based on normal population screening) of 28 dermatologic patients. This information was correlated with the observed efficacy and side effects of azathioprine therapy.

OBSERVATIONS

Two patients with TPMT levels of less than 12.5 U/mL RBCs (both TPMTH heterozygotes) experienced leukopenia (white blood count < 4.0 x 10(9)/L) with azathioprine doses around 1.5 mg/kg. A third patient who experienced leukopenia had a TPMT level at the lower end of the homozygous range (15.5 U/mL RBCs) but received the highest dose of azathioprine (2.6 mg/kg) of all patients in this series. Ten patients with TPMT levels of more than 18.5 U/mL RBCs (all TPMTH homozygotes) receiving less than 1.5 mg/kg of azathioprine were judged to have a poor clinical response. In comparison, seven patients with TPMT levels between 12.5 and 18.5 U/mL RBCs (six TPMTH homozygotes and one TPMTH heterozygote) receiving 0.9 to 1.8 mg/kg of azathioprine had a favorable clinical response. Adverse effects of gastrointestinal upset and liver function test abnormalities did not appear to correlate with TPMT activity.

CONCLUSION

The TPMTH heterozygotes may be at increased risk for myelosuppression with standard, empiric doses of azathioprine. On the other hand, homozygotes for TPMTH, particularly those with TPMT levels at the upper end of the homozygous range, may have a poor clinical response to azathioprine due to inadequate empiric dosing.

Lipomembranous (membranocystic) changes associated with morphea: a clinicopathologic review of three cases

Lipomembranous (membranocystic) changes represent a distinctive form of pathology in adipose tissue. Although first described in the rare neurodegenerative disorder now called Nasu-Hakola disease, this change has also been observed in a variety of relatively common inflammatory and noninflammatory dermatoses. We report three cases of morphea associated with marked lipomembranous (membranocystic) changes in the subcutaneous adipose tissue.

Hidroacanthoma simplex: an ultrastructural and immunohistochemical study

A representative case of hidroacanthoma simplex was studied with routine light microscopy, immunohistochemistry, and electron microscopy. Staining with the periodic acid-Schiff reagent and immunostaining with anti-keratin antibodies were useful in demarcating the tumor cells from adjacent normal epithelium. However, antibodies to carcinoembryonic antigen and epithelial membrane antigen did not help us to segregate or identify the neoplastic cells. Electron microscopy revealed tumor cells markedly different in appearance from luminal cells of the acrosyringium. Hidroacanthoma simplex does not appear to be derived from luminal cells of the acrosyringium. We propose criteria for the histologic diagnosis of this benign neoplasm.

Sales: evaluating the return on investment

In this article, a case study is presented to illustrate the ways in which sales programs have evolved in healthcare organizations over the last few years. The importance of developing a system of tracking sales so revenues can be tied to sales efforts is emphasized.

The polymerase chain reaction. Applications in dermatology

Within the space of the last 5 years, application of the revolutionary in vitro method of deoxyribonucleic acid (DNA) amplification known as the polymerase chain reaction (PCR), has become ubiquitous. The rapidly increasing number of clinical and research articles utilizing this technology, both in the dermatologic and general medical literature, requires one to have at least a basic understanding of how the PCR is conducted, what it has to offer, and the potential shortcomings. Such knowledge will hopefully allow a more critical appraisal of an increasingly complex literature. This review aims to describe the methodology and medical applications of this powerful technique with special consideration to the increasing role PCR may have on dermatologic research and practice.

Sales force can lead to dollars for OH (occupational health) services

As hospitals enter the 1990s, one of the challenges they will face is finding additional sources of revenue. Occupational Health (OH) programs offer an opportunity for increased dollars--but only for hospitals willing to use sales tactics common to corporate America. In the following article, the author tells how an institution can sell OH services.

Occupational health programs can generate new revenue

A hospital may find an untapped source of revenue by setting up occupational health services. Starting with treatment of workers' compensation cases, an occupational health program may open the door to additional revenue through family practice or group health plans. A preliminary feasibility study of market conditions, operational needs, and potential obstacles is essential to successful program management.

Bovine aortic and human dura mater valves: a comparative study in artificial hearts in calves

Thirty-one glutaraldehyde-treated bovine aortic valves (BAVs) and 105 glycerol-treated human dura mater valves (HDVs) were used in 51 various artificial hearts up to 316 days in calves. Multiple valves were implanted in the same animal under different hemodynamic conditions. A comparative study of these valves was performed in terms of blood compatibility and durability with relation to the different hemodynamic environments. Both BAVs and HDVs showed good blood compatibility. The degradation of collagen bundles of the valves began as early as 7 days in BAVs and 13 days in HDVs, and was seen in the hinged portions of the cusps. The fiber separation and resultant void formation were followed with insudation of blood elements and subsequent calcification. Calcification was dystrophic in nature and was encountered in 70.9% of BAVs and 7.6% of HDVs. All 17 BAVs used more than 30 days were calcified; in HDVs the earliest calcified lesion was seen in a 78 day specimen. The pathological changes were more severe in the left side than the right of the total artificial hearts. These results clearly indicated that the HDV is more durable than the glutaraldehyde-treated BAV. It was suggested that degradation of these tissue valves is greatly affected by the degree of hemodynamic stress on the valve cusp. Although glutaraldehyde treatment has increased the durability of tissue valves in general, the structure of the valve tissue also plays an important role in long-term durability.

The dura mater valve: in vitro characteristics and pathological changes after implantation in calves

Human dura mater valves of various sizes with rigid and flexible stents were tested in an in vitro pulsatile mock circulatory system. A 22-mm flexible stent valve incorporating a new fabrication technique showed almost the same pressure gradient as a 28-mm rigid stent valve. The backflow/stroke volume ratio was about 4% at a net flow of 10 L/min. One hundred and five rigid stent-mounted dura mater valves were used in 51 pump implantations for up to 316 days. Collagen fiber degeneration began three months after implantation. Microscopic and macroscopic calcification of the valve tissue was seen in eight out of 105 valves, giving an overall incidence of 7.6%. The calcified degeneration was dystrophic in nature, not accompanied by cellular reactions, and was seen in the areas of the valve under stress. The degenerative changes were more severe in the left side than in the right side of the total artificial heart. These findings suggest that mechanical damage to the tissue plays an important role in the pathogenesis of calcification.