Histologic improvement after 6 weeks of dietary elimination for eosinophilic esophagitis may be insufficient to determine efficacy

BACKGROUND: Elimination diets are used to treat eosinophilic esophagitis (EoE), with success (remission) defined at endoscopy and oesophageal biopsy as fewer than 15 eosinophils per high power field (HPF). Response is assessed after 6 weeks of treatment by convention, but we have observed that this period of time may be insufficient. OBJECTIVE: To characterise a subset of patients with EoE who require prolonged (>6 weeks) of dietary therapy to achieve histologic remission. METHODS: A retrospective search of electronic medical records of 2 cohorts with EoE attending the Department of Gastroenterology, University of Chapel Hill North Carolina, and Eastern Health, Melbourne Australia. Patients who underwent elimination diet, had esophageal biopsy after 6 or more weeks of dietary restriction that demonstrated ongoing esophageal inflammation (>15 eosinophils per HPF), and who then continued dietary therapy followed by repeat endoscopy demonstrating remission (<15 eosinophils per HPF) were included. RESULTS: Seven patients met inclusion criteria, average esophageal eosinophil counts prior to diet was 38.5 (range, 15–65). Following the initial period of diet (mean of 6 weeks and 4 days) eosinophil count decreased (average, 21.5/HPF; range 15–40/HPF). After extended dietary elimination (mean, 13 weeks; range, 7–22 weeks), histological resolution was achieved (average peak eosinophil count of 5.2; range, 0–14) in all cases. Endoscopic appearance and symptoms both improved following the initial period of dietary elimination, thereby preceding the histological resolution, and were sustained. CONCLUSION: A subset of patients has full histologic response to prolonged elimination diet, that lags initial symptomatic and endoscopic improvement.

Clopidogrel use after myocardial revascularization: prevalence, predictors, and one-year survival rate

Abstract Introduction: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario. Objective: Identify predictors of clopidogrel following CABG. Methods: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG. Results: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032). Conclusion: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG.

Ketorolac eye drops reduce inflammation and delay re-epithelization in response to corneal alkali burn in rabbits, without affecting iNOS or MMP-9 / Colírio de cetorolaco reduz inflamação e atrasa a epitelização em resposta a queimadura por álcali em coelhos, sem afetar iNOS ou MMP-9

Purposes: To assess the effects of 0.5% ketorolac tromethamine without preservatives on the expression of iNOS and MMP-9 in alkali burn ulcers. Methods: Twelve eyes of 120-day-old male rabbits were treated (TG) every 6 h with 0.5% ketorolac tromethamine and 12 other eyes were treated with saline solution (CG), immediately after the occurrence of ulcers by 1 M sodium hydroxide (NaOH). Re-epithelialization was monitored using fluorescein every 6 h. After 24 h, six corneas (n=6) of each group were collected (M1). The others (n=6) were collected after reepithelialization (M2). At both moments, the inflammatory infiltrate and the conditions of the newly formed epithelium were histologically analyzed. iNOS and MMP-9 were evaluated by immunohistochemistry. Results: Mean epithelialization time in TG was 55 ± 0.84 h. In CG, it was 44 ± 1.06 h (p=0.001). At M1, corneas of TG had lower inflammatory exudation compared with (p <0.001). At M2, TG revealed discrete inflammatory exudation (p>0.05) and lower numbers of epithelial layers compared with CG. The mean iNOS in stromal cells did not differ in TG over both moments compared with CG (p>0.05) At M2, the central corneal region expressed more iNOS in both groups compared with the peripheral region. No significant differences were observed in iNOS scores of epithelial immunostaining between the groups and across M1 and M2 (p=0.69). Epithelial immunostaining scores for MMP-9 did not differ in TG compared with CG (p=0.69). The average immunostaining score of MMP-9 in stromal cells showed no differences between groups or moments. There was no correlation between immunostaining of iNOS and MMP-9 or between the amount of inflammatory cells and immunostaining of iNOS. Conclusions: Use of 0.5% keratolac tromethamine reduced inflammation and delayed reepithelialization in a cornea alkali burn model without impacting the expression of iNOS or MMP-9. .

Objetivos: Avaliarem-se os efeitos do cetorolaco de trometamina 0,5%, sem conservante, sobre a expressão da iNOS e da MMP-9, em córneas com úlceras químicas. Métodos: Doze olhos de coelhos machos, 120 dias de idade, foram tratados (GT ), a cada 6 horas, com o cetorolaco de trometamina 0,5% e outros 12 com solução salina (GC), imediatamente à ocorrência de úlceras por hidróxido de sódio (NaOH) 1 mol/L. A reepitelização foi monitorada por fluresceína a cada seis horas. Decorridas 24 horas, seis córneas (n=6) de cada grupo foram colhidas (primeiro momento). As demais (n=6) o foram após a sua reepitelização (segundo momento). Em ambos os momentos, avaliaram-se o infiltrado inflamatório e as condições do epitélio neoformado (HE). Por imuno-histoquímica, avaliou-se a imunomarcação de iNOS e de MMP-9. Resultados: A média do tempo de epitelização no GT foi de 55 ± 0,84 horas. No GC, ela foi de 44 ± 1,06 horas (p=0,001). Às 24 horas, as córneas do GT apresentaram menor exsudação inflamatória (p<0,01). No segundo momento, o GT mostrou discreta exsudação inflamatória (p>0,05) e menor número de camadas epiteliais comparativamente ao GC. A média de imunomarcação de iNOS em células do estroma não diferiu do GT, em ambos os momentos (p>0,05). No segundo momento, a região central da córnea expressou mais iNOS, comparativamente à periférica, em ambos os grupos. Não se observaram diferenças significativas nos escores de imunomarcação epitelial de iNOS entre os grupos e os momentos (p=0,69). Os escores de imunomarcação epitelial para MMP-9 não diferiram entre os grupos (p=0,69). A média de imunomarcação da MMP-9 em células do estroma não exibiram diferenças entre os grupos e momentos da avaliação (p=0,32). Não houve correlação entre a imunomarcação de iNOS e de MMP-9, assim como quanto ao quantitativo de células inflamatórias e à imunomarcação de iNOS. Conclusões: Cetorolaco 0,5% reduziu a inflamação e atrasou a epitelização na queimadura corneal ...

Clotting Factor XIII and desmopressin improve hemostasis in uncontrolled bleeding

PURPOSE: To investigate hemostatic effects of supplementary factor XIII and desmopressin (DDAVP) in resuscitation of uncontrolled bleeding. METHODS: Fifty-four rabbits were randomized in nine groups: G1: Sham; G2: FXIII and normotensive resuscitation (NBP); G3: FXIII and permissive hypotension (PH) (MAP 60% baseline); G4: FXIII/DDAVP/NBP; G5: FXIII/DDAVP/PH; G6: NBP only; G7: FXIII no hemorrhage; G8: FXIII/DDAVP no hemorrhage; G9: PH only. Thromboelastometry and intra-abdominal blood loss were assessed. Scanning electron microscopy (EM) of the clots was performed. RESULTS: Compared to Sham, only G8 (FXIII/DDAVP w/o hemorrhage) showed clotting time (CT) significantly lower (p<0.05). NBP alone (G6) resulted in significantly prolonged CT compared to G2, G3 and G5 (p<0.05). Similarly, median alpha angle was significantly larger in G3,4,5, and 9 compared to G6 (p<0.05). Area under the curve was significantly greater in G5 than G2. Intra-abdominal blood loss was lower in G5 and G9 compared to G2 and G6. FXIII/DDAVP and PH resulted in more robust fibrin mesh by EM. CONCLUSIONS: Normotensive resuscitation provokes more bleeding and worsens coagulation compared to pH, that is partially reversed by factor XIII and desmopressin. FXIII and DDAVP can synergistically improve coagulation. Permissive hypotension reduces bleeding regardless of those agents. .

Academic Medicine Education Institute (AM·EI): Transforming the Educational Culture of Health Professionals

<p><b>INTRODUCTION</b>The Academic Medicine Education Institute (AM∙EI), jointly established by Duke-NUS Graduate Medical School (Duke-NUS) and Singapore Healthcare Services (SingHealth), is a newly formed health professions education academy designed to cultivate best education practices and create a community of health professions educators. To achieve the aims of AM∙EI, the needs of SingHealth educators have to be understood. Therefore, this study was carried out to assess educators' perceptions towards the current education climate and their academic needs.</p><p><b>MATERIALS AND METHODS</b>A 28-item questionnaire consisting of free-response, Likert-type and ranking questions was developed. The questionnaire was electronically distributed to 200 medical and nursing educators, and made available to attendees of the 2012 Singhealth Duke-NUS Scientific Congress through hardcopies.</p><p><b>RESULTS</b>A total of 150 completed questionnaires were received (94 from electronic survey and 56 from Congress). Five themes emerged from the analysis of responses to free-response questions: 1) faculty development, 2) development of a community of educators, 3) recognition for educational efforts, 4) institutional support, and 5) better communication about SingHealth educational activities. Respondents were in highest agreement with the statements (rating of 3.7 out of 5): "The SingHealth education programmes are high quality", "New learning or teaching methods are welcomed in this institution/hospital", and "An academic appointment is important to me". The competencies that respondents felt to be the most important were facilitating discussions, presentation skills, and providing feedback (respective means = 5.1, 5, 5 of 7).</p><p><b>CONCLUSION</b>This needs assessment provided us with important insights regarding SingHealth medical educators' perceptions of their education environment and established key priorities for the AM∙EI's programming efforts.</p>

Surveying the Impact of Work Hours and Schedules on Commercial Motor Vehicle Driver Sleep

BACKGROUND: Given the long hours on the road involving multiple and interacting work stressors (i.e., delivery pressures, irregular shifts, ergonomic hazards), commercial drivers face a plethora of health and safety risks. Researchers goal was to determine whether and to what extent long-haul trucker work schedules influence sleep duration and quality. METHODS: Survey and biometric data collected from male long-haul truck drivers at a major truckstop in central North Carolina over a six month period. RESULTS: Daily hours worked (mean = 11 hours, 55 minutes) and frequency of working over government-mandated daily HOS regulations (23.8% "frequently or always") were statistically significant predictors of sleep duration. Miles driven per week (mean = 2,812.61), irregular daily hours worked (63.8%), and frequency of working over the daily hour limit (23.8% "frequently or always") were statistically significant predictors of sleep quality. CONCLUSION: Implications of findings suggest a comprehensive review of the regulations and operational conditions for commercial motor vehicle drivers be undertaken.

Relationships between Body Mass Index and Social Support, Physical Activity, and Eating Habits in African American University Students

PURPOSE: We aimed to examine the relationships between obesity and the level of social support for healthy behaviors, amount of physical activity (PA), and dietary habits in African Americans. METHODS: The subjects were 412 university students who visited a health promotion center at North Carolina A&T State University, Greensboro, NC, USA between September 1, 2009 and April 30, 2010. We administered a social support survey, the National Institutes of Health Fruit, Vegetable, and Fat Screener, the Paffenbarger PA Questionnaire, and measures of body mass index, waist circumference (WC), and blood pressure. Data were analyzed using a one-way analysis of variance and logistic regression analyses. RESULTS: Results showed that men in the overweight group had WC and systolic blood pressure (SBP) measurements associated with increased risk of cardiovascular disease (CVD) and below average PA; those in the obese group had WC, SBP, and diastolic blood pressure (DBP) measurements associated with CVD risk and below average PA. Women in the overweight group had WC and SBP measurements associated with CVD risk, and those in the obesity group had WC, SBP, and DBP measurements associated with CVD risk and below average PA. Logistic regression analysis showed that increasing PA by 1,000 kcal/week decreased the prevalence of obesity by 9.3% in men and 9.0% in women. CONCLUSION: Thus, low PA was a significant risk factor for obesity among African Americans. However, the level of social support and consumption of fruits, vegetables, and fat were not found to be significant risk factors in this study.

Anti-Enteric Neuronal Antibodies and the Irritable Bowel Syndrome

BACKGROUND/AIMS: Functional gastrointestinal disorders are those in which no abnormal metabolic or physical processes, which can account for the symptoms, can be identified. The irritable bowel syndrome (IBS) is a significant functional disorder, which affects 10-20 percent of the population worldwide. Predominant symptoms of IBS are abnormal defecation associated with abdominal pain, both of which may be exacerbated by psychogenic stress. Our study was designed to test a hypothesis that symptoms in a subset of patients with a diagnosis of IBS are associated with an autoimmune degenerative neuropathy in the enteric nervous system. METHODS: Serum was collected from Rome II-IBS patients and controls at the University of North Carolina Functional Gastrointestinal Diseases Center. Assay procedures were immunohistochemical localization of antibody binding to enteric neurons and human protein microarray assay for antigens recognized by antibodies in the sera. RESULTS: Eighty-seven percent of IBS sera and 59% of control sera contained anti-enteric neuronal antibodies. Antibody immunostaining was seen in the nucleus and cytoplasm of neurons in the enteric nervous system. Protein microarray analysis detected antibody reactivity for autoantigens in serum with anti-enteric neuronal antibodies and no reactivity for the same autoantigens in samples not containing anti-enteric neuronal antibodies in our immunostaining assay. Antibodies in sera from IBS patients recognized only 3 antigens out of an 8,000 immunoprotein array. The 3 antigens were: (1) a nondescript ribonucleoprotein (RNP-complex); (2) small nuclear ribonuclear polypeptide A; and (3) Ro-5,200 kDa. CONCLUSIONS: Results of the present study suggest that symptoms in a subset of IBS patients might be a reflection of enteric neuronal damage or loss, caused by circulating anti-enteric autoimmune antibodies.

Using Formative Research to Design an Epidemiologic Survey: The North Carolina Study of Home Care and Hospice Nurses / 한국역학회지

OBJECTIVES: Formative research can serve as a means of obtaining important information for designing an epidemiologic study, but descriptions of this approach in the epidemiologic literature are lacking. The objective of this paper is to describe the use of three formative research techniques in designing a survey of home care and hospice nurses. METHODS: We conducted two focus groups, seven key informant interviews, and approximately fifteen hours of direct observation among home care and hospice nurses recruited by word of mouth in North Carolina in 2006. RESULTS: We used information obtained from the formative research to decide which survey design would likely be most successful with this population (mail survey, as opposed to Internet survey or in-person interviews), which measure to use for the denominator of the blood exposure incidence rates (number of visits, as opposed to patient-time), and which items and response options to include in the questionnaire, as well as to identify specific survey techniques that would likely increase the response rate (emphasizing the regional focus of the study; sending the questionnaire to the home address). CONCLUSION: When particular information for planning a study is unavailable from the literature or the investigator's experience, formative research can be an effective means of obtaining that information.

Barriers to participation in a worksite wellness program

The purpose of this research was to determine barriers that prevent participation in an employee wellness program, Wellness Wednesdays: "Eat & Meet" About Healthy Living, conducted at East Carolina University (ECU) in Greenville, North Carolina. All ECU ARAMARK employees (n = 481) over the age of 18 were eligible to participate in the wellness program. Weekly 30 minute classes, taught by a Registered Dietitian, on various nutrition- and health-related topics were conducted for 10-weeks. Five question knowledge quizzes were administered to participants at the end of each class to determine the comprehension of material presented. Qualitative interviews (n = 19) were conducted with employees (participants and non-participants) and the program organizer after the completion of the 10-week program to identify barriers to program participation. A total of 50 (10.4% of the total number of potential participants) ECU ARAMARK employees, managers, and leadership team directors attended Wellness Wednesdays at least once during the 10-week program. Employees, on average, scored 71-100% on the weekly knowledge quizzes administered at the end of each class. The most common barriers to participation reported included (most often to least often reported): insufficient incentives, inconvenient locations, time limitations, not interested in topics presented, undefined reasons, schedule, marketing, health beliefs, and not interested in the program. Results showed that employee wellness programs can be effective in increasing knowledge of employees on nutrition- and health-related topics. However, program planning that addresses identified barriers including insufficient incentives, inconvenient locations, and time limitations may facilitate higher participation in future worksite wellness opportunities.

Beliefs, benefits, barriers, attitude, intake and knowledge about peanuts and tree nuts among WIC participants in eastern North Carolina

The objective of this study was to assess beliefs (e.g. advantages, disadvantages, benefits, barriers) and knowledge about eating peanuts and tree nuts. Personal interviews based on the Theory of Planned Behavior were conducted to elicit beliefs about eating nuts. Then, a cross-sectional survey was administered to WIC participants from one county in North Carolina. One-hundred-twenty-four WIC participants (mean (SD) age=28.39 (8.09) completed the study. Most were Caucasian (51.6%) females (96%). About one third believed that eating nuts may help to lower cholesterol level. However, only about one forth believed that nuts can lower a risk of a heart attack or diabetes. More than one third believed that eating nuts will cause weight gain. The knowledge of respondents' about nutrient content of nuts was low with correct answers to most questions about 20% or below. The mean (SD) positive attitude, negative attitude, benefits and barriers scores, based on a range from 1 to 5, were 2.53 (0.91), 3.25 (0.89), 2.97 (0.85) and 2.90 (0.76), respectively. WIC participants' beliefs regarding the health effects of nuts are inconsistent with the most recent research findings. They are in a need to education about benefits of eating nuts.

Benefits, barriers, self-efficacy and knowledge regarding healthy foods; perception of African Americans living in eastern North Carolina

African Americans in the United States suffer from many health disparities such as obesity, diabetes or hypertension. Lifestyle factors including diet and physical activity play an important role in prevention of these health conditions. The purpose of this research project was to assess beliefs, barriers and self-efficacy of eating a healthy diet and self efficacy of shopping for foods such as whole grains or foods designated as low fat or low sodium. Additionally, the objective was to assess beliefs about healthfulness, appropriate consumption, and protective aspect of specific foods including fruits, vegetables, and whole grains. The assessment was done using a survey instrument developed for this study. Data collection took place at two church locations. Data were obtained from 57 African Americans, mean age 50 years old (SD 12.70) completed the survey. The majority of respondents (58.1%) were females and most (75%) had at least some college education. Generally, benefits of eating healthy foods received considerably higher scores compared to barriers of eating healthy. A belief that healthy foods would help to take care of one's body received the highest mean score while a belief that healthy foods are too expensive had the highest score from all barriers. The results showed high self-efficacy of eating and purchasing healthy foods, high awareness of knowledge regarding foods associated with disease prevention but low awareness of recommendations for fruits and vegetables. The high scores for benefits, self-efficacy and knowledge regarding eating healthy foods did not translate into the perception of intake of such foods. Most participants believed that they do not eat enough of healthy foods. Interventions design to help African Americans make dietary changes should be culturally relevant and should involved working on a community level utilizing messages that are familiar and relevant to African Americans.

Infectious disease among enslaved African Americans at Eaton's Estate, Warren County, North Carolina, ca. 1830-1850

The skeletal remains of 17 people buried in the Eaton Ferry Cemetery in northern North Carolina provide a means of examining health and infectious disease experience in the XIX century South. The cemetery appears to contain the remains of African Americans enslaved on the Eaton family estate from approximately 1830-1850, and thus offers a window into the biological impacts of North American slavery in the years preceding the Civil War. The sample includes the remains of six infants, one child, and one young and nine mature adults (five men, four women, and one unknown). Skeletal indices used to characterize health and disease in the Eaton Ferry sample include dental caries, antemortem tooth loss, enamel hypoplasia, porotic hyperostosis, periosteal lesions, lytic lesions, and stature. These indicators reveal a cumulative picture of compromised health, including high rates of dental disease, childhood growth disruption, and infectious disease. Specific diseases identified in the sample include tuberculosis and congenital syphilis. Findings support previous research on the health impacts of slavery, which has shown that infants and children were the most negatively impacted segment of the enslaved African American population.

Corticosteroid-responsive enteropathy of infancy.

Nineteen American infants aged less than three months developed persistent diarrhoea, acidosis, hypoalbuminaemia, and malnutrition, without evidence of enteric pathogens. Symptoms began 11-59 days before admission to the University of North Carolina Children's Hospital, and infants were fed semielemental formula. Despite further treatment with amino acid-based formula by continuous nasogastric infusion, diarrhoea persisted. Endoscopic biopsies showed inflammation in the stomach, duodenum, and/or colon. A trial of intravenous corticosteroids was initiated in 14 infants. Corticosteroids were associated with rapid resolution of diarrhoea (duration after corticosteroids = 3.8 +/- 1.7 days [mean +/- SD]). In contrast, five infants with identical history were not treated with corticosteroids. In three infants, diarrhoea lasted for 92-147 days versus 31 +/- 3 total days in the treated group. In the other two infants, diarrhoea worsened after discharge, but were treated later with corticosteroids, with rapid resolution. Corticosteroids were uneventfully weaned over a four-month period. The results suggest that a trial of corticosteroids in infants with unresponsive persistent diarrhoea of unknown origin is beneficial and deserves prospective evaluation.