Quantitative chromogenic immunohistochemical image analysis in cellprofiler software.

Visual grading of chromogenically stained immunohistochemical (IHC) samples is subjective, time consuming, and predisposed to considerable inter- and intra-observer variations. The open-source digital analysis software, CellProfiler has been extensively used for fluorescently stained cells/tissues; however, chromogenic IHC staining is routinely used in both pathological and research diagnostics. The current investigation aimed to compare CellProfiler quantitative chromogenic IHC analyses against the gold standard manual counting. Oral mucosal biopsies from patients with chronic graft-versus-host disease were stained for CD4. Digitized images were manually counted and subjected to image analysis in CellProfiler. Inter-observer and inter-platform agreements were assessed by scatterplots with linear regression and Bland-Altman plots. Validation comparisons between the manual counters demonstrated strong intra-observer concordance (r2 = 0.979), particularly when cell numbers were less than 100. Scatterplots and Bland-Altman plots demonstrated strong agreement between the manual counters and CellProfiler, with the number of positively stained cells robustly correlating (r2 = 0.938). Furthermore, CellProfiler allowed the determination of multiple variables simultaneously, such as area stained and masking to remove any nonstained tissue and white gaps, which also demonstrated reliable agreement (r2 = >0.9). CellProfiler demonstrated versatility with the ability to assess large numbers of images and allowed additional parameters to be quantified. CellProfiler allowed rapid high processing capacity of chromogenically stained chronic inflammatory tissue that was reliable, accurate, and reproducible and highlights potential applications in research diagnostics.

CHESS: ten years of research and development in consumer health informatics for broad populations, including the underserved.

This paper reviews the research and development around a consumer health informatics system CHESS (The Comprehensive Health Enhancement Support System) developed and tested by the Center for Health Systems Research and Analysis at the University of Wisconsin. The review will place particular emphasis on what has been found with regard to the acceptance and use of such systems by high risk and underserved groups.

Increasing understanding of patient needs during and after hospitalization.

BACKGROUND: The value of patient satisfaction surveys in health care improvement remains controversial. This study examined the value of alternative ways of identifying patient needs and estimating importance of those needs in improving the impact of satisfaction surveys. METHODS: Ninety-one acute myocardial infarction (AMI) patients from three southeast U.S. community hospitals were surveyed in 1992. Critical incident and person-focused interviews were used to identify patient needs. Besides overall/global satisfaction with care, patients rated satisfaction with and importance of 12 care delivery and 18 information and support needs. Unmet need scores (importance minus satisfaction) were estimated. Derived importance scores were assessed by correlating global satisfaction with individual need satisfaction scores. A two-step process for identifying priority areas for improvement was proposed. RESULTS: Patients identified and assigned greater scores to unmet needs for information and support needs (not included in typical satisfaction surveys) compared to typically assessed care delivery needs (p < 0.0001). Direct importance ratings differed substantially from those derived through correlation analyses (r = 0.28, p > 0.3 for care delivery needs and r = -0.17, p > 0.4 for information and support needs). Needs that received high importance and low satisfaction scores were all information and support needs. DISCUSSION: Needs that patients consider very important are usually ignored in typical patient surveys. Derived approaches typically used to assess importance of need from satisfaction data may provide misleading results. If satisfaction surveys are to result in real performance improvement, a fresh examination of the content and importance assessment strategies, as proposed, is needed.

Impact of a patient-centered, computer-based health information/support system.

BACKGROUND: Consumer health information systems potentially improve a patient's quality of life and activate patient self-care. OBJECTIVES: Test a computerized system (CHESS: Comprehensive Health Enhancement Support System), which, in this application, provided HIV-positive patients with information, decision support, and connections to experts and other patients. Would patients given in-home access to computers use the system, improve their quality of life, reduce health-risk behaviors, and use medical services more efficiently? RESEARCH DESIGN: Randomized controlled trial: CHESS computers in experimental subjects' homes in Madison or Milwaukee, Wisconsin, for 3 or 6 months; controls received no intervention. Subjects were compensated for self-report surveys completed before, during, and after CHESS installation. SUBJECTS: Of 204 HIV-positive patients recruited (90% male, 84% white, average education some college, and 65% experiencing HIV-related symptoms), 90% completed the study. MEASURES: Self-reports of quality of life and frequency and duration of use of medical services. RESULTS: CHESS was used daily with little difference between demographic subgroups. While CHESS was in the home, its users reported quality-of-life improvements: active life, negative emotions, cognitive function, social support, and participation in health care. They also reported spending less time during ambulatory care visits, making more phone calls to providers, and experiencing fewer and shorter hospitalizations. CONCLUSIONS: A computer-based personal health support system can improve a patient's quality of life and promote more efficient use of health care.

The quality of interactive computer use among HIV-infected individuals.

This study examined how HIV-infected individuals used an interactive health software package called CHESS (Comprehensive Health Enhancement Support System). CHESS packages information and support in a variety of ways; the research examined how a subset of users whose posttest scores in a larger randomized trial showed significant improvement in quality of life compared on use patterns of CHESS with those who did not improve. The evidence presented here points to the nature of CHESS use more than it does to the amount of CHESS use. Those whose quality of life improved were among the most involved in their use of CHESS information tools. That is, even though Discussion Group accounted for the majority of all CHESS uses and time spent with the system, total use and Discussion Group use appeared less important than use of the information tools, especially if that use was at least somewhat sustained and involved.

Long-term results of an intensive treatment program for adults and adolescents who stutter.

In order to determine the long-term effects of an intensive treatment program, 17 adult and 25 adolescent stutterers were tested 2 or 3 times during a 12- to 24-month post-intensive treatment phase. The results of this study are intended to augment and supplement the growing body of evidence about the effects of intensive treatment programs on adult and adolescent stutterers. Follow-up measures included surprise phone calls to clients at home/work and a self-administered Speech Performance Questionnaire. Careful training of speech raters was undertaken to ensure high reliability of speech measures. Results from the phone call samples indicated that about 69% of the subjects maintained a satisfactory level of post-treatment fluency, with an additional 7% maintaining a level that was judged to be marginally satisfactory. On the self-administered Questionnaire, 80% of the subjects rated their speech fluency as good or fair 12 to 24 months after treatment.

The use and impact of a computer-based support system for people living with AIDS and HIV infection.

CHESS (the Comprehensive Health Enhancement Support System) is an interactive, computer-based system to support people facing AIDS/HIV Infection and other health-related crises or concerns. CHESS provides information, referral to service providers, support in making tough decisions and networking to experts and others facing the same concerns. CHESS is designed to improve access to health and human services for people who would otherwise face psychological, social, economic or geographic barriers to receiving services. CHESS has been evaluated in a random-assignment study with over 200 men and women living with AIDS and HIV infection. When CHESS was placed in subjects' homes for 3-6 months, use of CHESS was extremely heavy, with the average subject using CHESS 138 times for 39 hours. Compared with a control group which did not receive CHESS, subjects who used CHESS reported significantly higher quality of life in several dimensions, including social support and cognitive functioning. Users also reported significant reductions in some types of health care costs, especially inpatient services (hospitalizations). All segments of the study population used and benefited from CHESS, including women, minorities and those subjects with lower levels of education. Thus, CHESS appears to be an effective means of delivering education and support to the diverse populations which are affected by AIDS and HIV infection.

Will HIV-positive people use an interactive computer system for information and support? A study of CHESS in two communities.

A study of use of an interactive computer system (CHESS--Comprehensive Health Enhancement Support System) by HIV-Positive people was conducted in Madison and Milwaukee during Fall 1992 and Winter 1993. Computers were placed in homes, and use monitored by the computer. Results showed that the system was used heavily by both samples, and that gender (women used it more) age, (younger used it more), living arrangements (those living alone used it more), and need for health care information (those who felt the most need used it more) but not education predicted use of CHESS. The authors argue that heavy CHESS use by a wide variety of HIV-positive people suggests that the computer can overcome "information poor" barriers in health information campaigns.

CHESS: a computer-based system for providing information, referrals, decision support and social support to people facing medical and other health-related crises.

CHESS (the Comprehensive Health Enhancement Support System) is an interactive, computer-based system to support people facing health-related crises or concerns. CHESS provides information, referral to service providers, support in making tough decisions and networking to experts and others facing the same concerns. CHESS will improve access to health and human services for people who would otherwise face psychological, social, economic or geographic barriers to receiving services. CHESS has developed programs in five specific topic areas: Academic Crisis, Adult Children of Alcoholics, AIDS/HIV Infection, Breast Cancer and Sexual Assault. The lessons learned, and the structures developed, will serve as a model for future implementation of CHESS programs in a broad range of other topic areas. CHESS is designed around three major desired outcomes: 1) improving the emotional health status of users; 2) increasing the cost-effective use of health and human services; and 3) reducing the incidence of risk-taking behaviors that can lead to injury or illness. Pilot-testing and initial analysis of controlled evaluation data has shown that CHESS is extensively used, is useful and easy-to-use, and produces positive emotional outcomes. Further evaluation in continuing.

Stuttering: current status of theory and therapy.

When people become concerned about stuttering, either their own or their child's, they typically seek help from their family physician or pediatrician. Characteristics and effects of stuttering can help the physician determine whether the child's speech patterns are within normal range or could be early warning signs of stuttering. Referral to a speech-language pathologist should be considered when any of the following are noted: excessive part-word repetitions or sound prolongations; signs of tension, such as lip tremors, facial grimaces, or breath holding associated with speech; indications of embarrassment or apprehension; and a tendency to withdraw from speech opportunities. The authors briefly review theories on the causes of stuttering, describe current therapy, and identify some specialized treatment centres.

Inhibition by pentachlorophenol of the initiating and promoting activities of 1'-hydroxysafrole for the formation of enzyme-altered foci and tumors in rat liver.

The hepatocarcinogen 1'-hydroxysafrole (HOS) exhibited weak initiating activity and strong promoting activity for the induction of enzyme-altered foci and tumors in rat liver. Thus, administration of a single dose of HOS to rats 18 h after a 70% hepatectomy, followed by administration of phenobarbital (PB) in the diet for 6 months, induced a low, but statistically significant, number of foci of enzyme-altered cells. This treatment did not result in gross liver tumors, even when the PB treatment was continued for 16 months. Large numbers of enzyme-altered foci developed when HOS was administered in the diet at levels of 0.05-0.25% to rats previously administered a single dose of N,N-diethylnitrosamine (DEN) 24 h after a 70% hepatectomy. Similarly, rats given a single dose of DEN 24 h after a partial hepatectomy and then fed 0.10 or 0.25% of HOS in the diet for 10 months developed a high incidence of hepatocellular carcinomas. In the absence of pretreatment with DEN, dietary administration for at least 4 months of 0.10 or 0.25% of HOS induced significant numbers of enzyme-altered foci; these data and liver tumor induction by continuous feeding of HOS, in the absence of pretreatment with DEN, provide additional evidence for an initiating, as well as a promoting, activity of HOS in rat liver. Concurrent administration of the hepatic sulfotransferase inhibitor pentachlorophenol with HOS in each of the above assays almost completely inhibited the initiating and promoting activities of HOS for the formation of enzyme-altered foci and tumors; these data strongly suggest that both the initiating and promoting activities are mediated by the sulfuric acid ester, 1'-sulfooxysafrole. HOS also exhibited initiating activity in adult mouse liver. Thus, dietary administration of 0.25% of HOS for only 1 month, followed by administration of the hepatic tumor promoter 1,4-bis[2-(3,5-dichloropyridyloxy)]benzene resulted in a high incidence and multiplicity of hepatomas by 10 months. In the absence of the promoter, administration of HOS for only 1 month induced no hepatomas; 1,4-bis[2-(3,5-dichloropyridyloxy)]benzene alone induced only a low incidence. In mice not given the promoter, continuous administration of HOS for 3-6 months was required for hepatoma development by 16 months.

The metabolic sulfonation and side-chain oxidation of 3'-hydroxyisosafrole in the mouse and its inactivity as a hepatocarcinogen relative to 1'-hydroxysafrole.

The chemically synthesized sulfuric acid esters of 1'-hydroxysafrole and 3'-hydroxyisosafrole, 1'-sulfooxysafrole and 3'-sulfooxyisosafrole, respectively, are both strong electrophiles. Each ester reacted with deoxyguanosine (dGuo) in aqueous solution to form both safrol-1'-yl- and isosafrol-3'-yl-deoxyguanosine adducts. Both 1'-hydroxysafrole and 3'-hydroxyisosafrole were also formed from each ester in the presence of water. When either 1'-[3H]hydroxysafrole or 3'-[3H]hydroxyisosafrole was incubated with mouse liver cytosols fortified with 3'-phosphoadenosine-5'-phosphosulfate (PAPS) and RNA, similar levels of RNA- and protein-bound adducts were formed; thus, the hepatic sulfotransferase activities for these two substrates appear to be similar. In contrast, the levels of hepatic nucleic acid and protein adducts formed after administration of 3'-[3H]hydroxyisosafrole to mice were only 2-4% and 8-14%, respectively, of those obtained after an equimolar dose of 1'-[3H]hydroxysafrole. Likewise, when 3'-hydroxyisosafrole was injected into 12-day-old male B6C3F1 mice at a level of 0.1 or 2.5 mumol/g body wt., the average numbers of hepatomas per mouse (0.2 and 0.4, respectively) were not significantly increased over the average number for mice treated only with the solvent (0.2). By contrast, mice that received 0.1 mumol of 1'-hydroxysafrole/g body wt. developed about 2 hepatomas per mouse. The metabolism of 3'-hydroxyisosafrole in the rat and mouse differed markedly from that of 1'-hydroxysafrole. 3'-Hydroxyisosafrole rapidly underwent side-chain oxidation to yield 3,4-methylenedioxycinnamic acid and 3,4-methylenedioxybenzoic acid. In the first 4 h, 3,4-methylenedioxybenzoyl glycine and 3,4-methylenedioxycinnamoyl glycine, the major urinary metabolites, together accounted for 39% and 63% of the dose administered to rats and mice, respectively. The glucuronide of 3'-hydroxyisosafrole was not detected in the urine, whereas urinary excretion of the glucuronide of 1'-hydroxysafrole at 2 h accounted for approx. 40% of a dose of 1'-hydroxysafrole.

Strong evidence from studies with brachymorphic mice and pentachlorophenol that 1'-sulfoöxysafrole is the major ultimate electrophilic and carcinogenic metabolite of 1'-hydroxysafrole in mouse liver.

The role of sulfation of 1'-hydroxysafrole in the formation of hepatic macromolecular adducts and in hepatic tumor formation in mice given 1'-hydroxysafrole was investigated by the use of: (a) mice treated with the specific sulfotransferase inhibitor pentachlorophenol; and (b) brachymorphic mice, which are characterized by a deficiency in the hepatic synthesis of 3'-phosphoadenosine 5'-phosphosulfate. Cytosolic sulfotransferase activity for 1'-hydroxysafrole in both mouse and rat liver was significantly inhibited by 10 microM pentachlorophenol, usually by greater than 90%. Prior administration of nontoxic amounts of pentachlorophenol, either in the diet of adult female CD-1 mice or by i.p. injection of 12-day-old male C57BL/6 X C3H F1 (hereafter called B6C3F1) mice, resulted in an 85% decrease in the level of adducts formed from 1'-hydroxysafrole in hepatic DNA and RNA as compared to those of non-pentachlorophenol-treated animals. Likewise, the chronic administration of a nontoxic level of pentachlorophenol in the diet of adult female CD-1 mice strongly inhibited hepatic tumor induction by long-term dietary administration of either safrole or 1'-hydroxysafrole. Initiation of hepatic tumors by a single i.p. injection of 1'-hydroxysafrole to 12-day-old male B6C3F1 mice was strongly inhibited by prior treatment with pentachlorophenol. Under these conditions, the hepatocarcinogenicity of diethylnitrosamine was not inhibited by pentachlorophenol. Supplementation with adenosine triphosphate and sulfate of hepatic cytosols from adult female or 12-day-old brachymorphic progeny of a B6C3 background outbred to B6C3F1 mice (B6C3F2), of either sex, resulted in 5- to 10-fold less binding of 1'-hydroxysafrole to added RNA than when cytosols from phenotypically normal B6C3F2 mice were used. On administration of [3H]-1'-hydroxysafrole to adult female or 12-day-old brachymorphic B6C3F2 mice of either sex, the levels of hepatic DNA and RNA adducts were 7- to 12-fold lower than those obtained in phenotypically normal B6C3F2 mice of the same age and sex. Brachymorphic mice were also much less responsive than their phenotypically normal littermates to the induction of liver tumors by 1'-hydroxysafrole; lower incidences were observed both when the carcinogen was fed chronically to adult females and when it was administered to males only prior to weaning. Thus, all of these data strongly support the conclusion that 1'-sulfoöxysafrole is the major ultimate electrophilic and tumor-initiating metabolite of 1'-hydroxysafrole.

Stuttering: recent developments in theory and in therapy.

When parents are concerned about the development of stuttering in their child they often consult their pediatrician or family physician. Theories on the development of stuttering are briefly examined in this article, and guidelines are provided to help the physician determine if the child's dysfluencies are within the normal range. Referral to a speech therapist should be considered when any of the following are noted: excessive repetition of the first syllable of words; tremor of the muscles of mouth or jaw, increase in pitch or loudness, or evidence of fear or emotion as the child struggles with a word; evidence that the child avoids certain words or situations; and excessive concern of parents, teachers or the dysfluent individual. Two approaches to therapy, traditional and behavioural, are described. The latter has resulted in significant gains in fluency among stutterers.