Elucidating the Relationship Between Maternal Diabetes and Neonatal Abstinence Syndrome: A 2017-2018 Project WATCH Study in Rural Appalachia.

BACKGROUND: Previous research indicated that diabetes during pregnancy results in a more permeable placenta. Based on this data, we hypothesized that women with maternal diabetes were more likely to have infants who developed neonatal abstinence syndrome (NAS). PURPOSE: The purpose of the study was to examine the association between maternal diabetes and NAS in a cohort of women reporting substance use during pregnancy. METHODS: This study used data from a population-based cohort of all newborns born in 2017 and 2018 (N = 36,974) in the state of West Virginia and restricted the analysis to those infants with intrauterine substance exposure (14%, n = 5188). Multiple logistic regression was performed to analyze the adjusted relationship between maternal diabetes and NAS while controlling for maternal and infant covariates. RESULTS: Just over 28% of women with diabetes had an infant who developed NAS, whereas 34.8% of women without diabetes had an infant who developed NAS. The adjusted odds ratio of infants developing NAS born to women with diabetes was 0.70 (95% confidence interval: 0.51, 0.94) compared with those born to mothers without diabetes after controlling for covariates. Contrary to our hypothesis, the study suggests that maternal diabetes during pregnancy is associated with a decreased risk of an infant developing NAS. IMPLICATIONS FOR PRACTICE: Future research generating from this hypothesis may lead to potential implications for practice for infants born to mothers with substance use during pregnancy and diabetes. IMPLICATIONS FOR RESEARCH: More research should be conducted to investigate the relationship between glucose metabolism and NAS.

Disparities in neonatal abstinence syndrome and health insurance status: A statewide study using non-claims real-time surveillance data.

BACKGROUND: Most studies examining the relationship between neonatal abstinence syndrome (NAS) and health insurance status in the United States (USA) have used administrative insurance claims data, which is subject to myriad limitations. We examined the association between NAS and health insurance status in a large geographically defined rural population in the United States, using non-claims data. METHODS: We utilized data from a population-based cohort of all newborns born in 2017-2019 in the rural state of West Virginia (WV) and restricted analyses to WV residents' births (n = 46 213). NAS was defined as neonatal withdrawal from many substances, including opiates and not limited to those cases that require pharmacological treatment. RESULTS: Medicaid covered more than half (52.6%) of all infants' births in the state of WV. The incidence of NAS was 85.8 and 12.7 per 1000 livebirths in the Medicaid and privately insured groups, respectively. Among all infants diagnosed with NAS, 86.1% were enrolled in the state's Medicaid programme. The risk of NAS in the Medicaid-insured newborns was higher than privately insured newborns in the unadjusted analysis (risk ratio (RR) 6.76, 95% confidence interval (CI) 5.95, 7.68) and the adjusted analysis RR 3.00, 95% CI 2.01, 4.49); adjusted risk difference 20.3 (95% CI 17.5, 23.1 cases per 1000 livebirths). CONCLUSIONS: NAS is an important indicator of the immediate effect of the opioid crisis. This study shows the disparity in NAS by health insurance status for a large rural population in the United States, and its burden on the state's Medicaid programme. Providing timely and accurate estimates of NAS is important for public health policies and decision making.

Prevalence of alcohol use in late pregnancy.

BACKGROUND: Prenatal alcohol exposure (PAE) can result in detrimental developmental complications. The objective of this study was to estimate the most recent PAE prevalence data for the state of West Virginia (WV) and associated factors. METHOD: In all, 1830 newborn residual dried blood spots (DBS) in the WV Newborn Screening Repository were analyzed for phosphatidylethanol (PETH). Data were matched with Project WATCH data (94% match, N = 1729). RESULTS: The prevalence of late pregnancy PAE was 8.10% (95%CI: 6.81, 9.38) for all births, 7.61% (95%CI: 6.26, 8.97) for WV residents only, and ranged from 2.27 to 17.11% by region. The significant factors associated with PAE included smoking (OR: 2.03, 95% CI: 1.40, 2.94), preterm births (OR: 1.88; 95% CI: 1.23, 2.89), birth weight of ≤2000 g vs. >3000 g (OR: 2.62, 95%CI: 1.19, 5.79), no exclusive breastfeeding intention (OR: 1.45, 95% CI: 1.02, 2.04), and not exclusively breastfeeding before discharge (OR: 1.61; 95% CI: 1.09, 2.38). CONCLUSION: The prevalence of PAE is higher than previously shown for the state. Accurate and timely estimates are vital to inform public health workers, policymakers, researchers, and clinicians to develop and promote effective prevention strategies to lower PAE prevalence and provide targeted interventions and treatment services for infants affected by PAE.

Association between birth weight and childhood cardiovascular disease risk factors in West Virginia.

The reported associations between birth weight and childhood cardiovascular disease (CVD) risk factors have been inconsistent. In this study, we investigated the relationship between birth weight and CVD risk factors at 11 years of age. This study used longitudinally linked data from three cross-sectional datasets (N = 22,136) in West Virginia; analysis was restricted to children born full-term (N = 19,583). The outcome variables included resting blood pressure [systolic blood pressure (SBP), diastolic blood pressure (DBP)] and lipid profile [total cholesterol (TC), low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL, and triglycerides (TG)]. Multiple regression analyses were performed, adjusting for child's body mass index (BMI), sociodemographics, and lifestyle characteristics. Unadjusted analyses showed a statistically significant association between birth weight and SBP, DBP, HDL, and TG. When adjusted for the child's BMI, the association between birth weight and HDL [b = 0.14 (95% CI: 0.11, 0.18) mg/dl per 1000 g increase] and between birth weight and TG [b = -0.007 (-0.008, -0.005) mg/dl per 1000 g increase] remained statistically significant. In the fully adjusted model, low birth weight was associated with higher LDL, non-HDL, and TGs, and lower HDL levels. The child's current BMI at 11 years of age partially (for HDL, non-HDL, and TG) and fully mediated (for SBP and DBP) the relationship between birth weight and select CVD risk factors. While effects were modest, these risk factors may persist and amplify with age, leading to potentially unfavorable consequences in later adulthood.

Association Between Breastfeeding and Childhood Cardiovascular Disease Risk Factors.

Introduction The immediate benefits of breastfeeding are well-established but the long-term health benefits are less well-known. West Virginia (WV) has a higher prevalence of cardiovascular disease (CVD) and lower breastfeeding rates compared to national averages. There is a paucity of research examining the relationship between breastfeeding and subsequent childhood CVD risk factors, an issue of particular relevance in WV. Methods This study used longitudinally linked data from three cross-sectional datasets in WV (N = 11,980). The information on breastfeeding was obtained retrospectively via parental recall when the child was in the fifth grade. The outcome variables included blood pressure measures [systolic blood pressure (SBP), diastolic blood pressure (DBP)] and lipid profile [total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), non-HDL, and triglycerides (TG)]. Multiple regression analyses were performed, adjusting for childhood body mass index (BMI) and additional covariates. Results Only 43% of mothers self-reported ever breastfeeding. The unadjusted analysis showed that children who were ever vs. never breastfed had significantly lower SBP (b = - 1.39 mmHg; 95% CI - 1.97, - 0.81), DBP (b = - 0.79 mmHg; 95% CI - 1.26, - 0.33), log-TG (b = - 0.08; 95% CI - 0.1, - 0.05), and higher HDL (b = 0.95 mg/dL; 95% CI 0.33, 1.56). After adjustment for the child's BMI, socio-demographic and lifestyle factors, log-TG remained significantly associated with breastfeeding (b = - 0.04; 95% CI - 0.06, - 0.01; p = 0.01). Conclusion The observed protective effect of any breastfeeding on childhood TG level was small but significant. This finding provides some support for a protective effect of breastfeeding on later CVD risk.

Capturing the statewide incidence of neonatal abstinence syndrome in real time: the West Virginia experience.

BACKGROUND: Neonatal abstinence syndrome (NAS) is one of the consequences at birth affecting the newborn after discontinuation of prenatal drug exposure to mainly opioids. The objective of this study was to determine the extent of the problem in the state of West Virginia (WV) using a real-time statewide surveillance system. METHODS: Project WATCH is a surveillance tool that since 1998 collects data on all infants born in the state of WV. NAS surveillance item was added to the tool in October 2016. This study examined all births (N = 23,667) in WV from October to December 2017. The data from six WV birthing facilities were audited for 1 month to evaluate how well this tool was capturing NAS data using κ-statistics. RESULTS: The 2017 annual incidence rate of NAS was 51.3 per 1000 live births per year for all births and 50.6 per 1000 live births per year for WV residents only. The κ-coefficient between the hospital medical records and Project WATCH data was 0.74 (95% confidence interval: 0.66-0.82) for NAS. CONCLUSION: The study provides justification to develop effective systems of care for the mother-infant dyad affected by substance use, especially targeting pregnant women in rural communities.

Updating a Perinatal Risk Scoring System to Predict Infant Mortality.

OBJECTIVE: The Birth Score Project (Project WATCH) began in the rural state of West Virginia (WV) in the United States in 1984. The project is intended to identify newborns with a greater risk of infant mortality. The primary objective of this study was to update the current Birth Score based on current literature and rigorous statistical methodology. STUDY DESIGN: The study merged data from the Birth Score, Birth Certificate (birth years 2008-2013), and Infant Mortality Data (N = 121,640). The merged data were randomly divided into developmental (N = 85,148) and validation (N = 36,492) datasets. Risk scoring system was developed using the weighted multivariate risk score functions and consisted of infant and maternal factors. RESULTS: The updated score ranged from 0 to 86. Infants with a score of ≥17 were categorized into the high score group (n = 15,387; 18.1%). The odds of infant mortality were 5.6 times higher (95% confidence interval: 4.4, 7.1) among those who had a high score versus low score. CONCLUSION: The updated score is a better predictor of infant mortality than the current Birth Score. This score has practical relevance for physicians in WV to identify newborns at the greatest risk of infant mortality and refer the infants to primary pediatric services and case management for close follow-up.

Implementing Universal Pulse Oximetry Screening in West Virginia: Findings from Year One.

BACKGROUND: In March 2012 the West Virginia legislature passed a law that mandates birth hospitals to perform pulse oximetry screening for all well-babies in the newborn nursery to improve the detection of critical congenital heart disease (CCHD). CCHD screening data collection began on September 1, 2012 at all 28 birthing hospitals. The purpose of this study was to review the first year of pulse oximetry screening outcomes and identify barriers to implementation and solutions to improve tracking and policy. METHODS: All WV birth hospitals were provided with the U.S. Department of Health and Human Services recommendations for CCHD screening, and the Center for Disease Control's recommended screening algorithm for review and reference. 20,115 infants were entered into the Birth Score database between September 1, 2012 and August 31, 2013. 19,283 (91%) infants were screened for CCHD. RESULTS: 17,101 (88.5%) infants passed, 19 infants failed, and 2,163 (11.2%) infants had missing data for the screening. 832 infants were not screened due to being admitted to the neonatal intensive care unit for reasons unknown. 17 of the 19 infants who failed the screening had a transthoracic echo report available for review. Of those 17 infants reviewed, seven were diagnosed with CCHD. CONCLUSIONS: 85% of the infants born in WV who received a Birth Score during the year reviewed were screened for CCHD. Given that the goal is to have 100% compliance with the pulse oximetry screening, additional investigations into factors affecting compliance may be necessary.

Association between Breastfeeding and Childhood Obesity: Analysis of a Linked Longitudinal Study of Rural Appalachian Fifth-Grade Children.

INTRODUCTION: Although breastfeeding is associated with improving numerous health outcomes for the child, its role in reducing childhood obesity is contested. Despite this controversy, both the CDC and the US Department of Health and Human Services promote breastfeeding as one of the strategies for reducing childhood obesity. Rural Appalachia has one of the highest rates of childhood obesity and low rates of breastfeeding, compared to rest of the nation. The aim of this study was to examine the association between breastfeeding and childhood obesity at 11 years in the rural Appalachian state of West Virginia (WV). METHODS: The study used linked data from two cross-sectional data sets to examine this relationship longitudinally in fifth-grade WV children. The main outcome variable was BMI adjusted percent (BMI%) and the main exposure was defined as occurrence of breastfeeding. Mean BMI% of children who were not breastfed was significantly higher, compared to children who were breastfed. RESULTS: The result of the multiple regression analysis showed that breastfeeding significantly predicted BMI% of children after controlling for maternal education, health insurance, family history of hypercholesterolemia and diabetes, child's asthma status, and birth weight of the infant. CONCLUSIONS: Our results are consistent with other studies that have shown a significant, but small, inverse association between breastfeeding and childhood obesity. Findings from this study suggest the need to improve breastfeeding rates in the rural Appalachian state of WV as one of the potential strategies to prevent obesity during childhood and adolescence.

Diagnostic utility of E-cadherin and P120 catenin cocktail immunostain in distinguishing DCIS from LCIS.

BACKGROUND: Breast carcinoma in situ (CIS) is classified into ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). DCIS is treated with surgical excision while LCIS can be clinically followed with or without hormonal treatment. Thus, it is critical to distinguish DCIS from LCIS. Immunohistochemical (IHC) staining for E-cadherin is routinely used to differentiate DCIS from LCIS in diagnostically challenging cases. Circumferential diffuse membranous staining of E-cadherin is the typical pattern in DCIS, whereas LCIS lacks or shows decreased E-cadherin expression. Recent studies have shown that DCIS has membranous staining of P120 catenin and LCIS has diffuse cytoplasmic staining of P120 catenin. We developed a cocktail composed of E-cadherin and P120 catenin primary antibodies so that only one slide is needed for the double immunostains. DESIGNS: Twenty-seven blocks of formalin-fixed paraffin-embedded tissue from 26 cases of DCIS or LCIS were retrieved from the archives of Houston Methodist Hospital. Four consecutive sections from the same blocks were used for H&E and immunohistochemical (IHC) stains. The E-cadherin antibody was a rabbit polyclonal antibody and the P120 catenin antibody was a mouse monoclonal antibody. The E-cadherin primary antibody was detected using a secondary antibody raised against rabbit antibody and was visualized with a brown color. The P120 catenin primary antibody was detected using a secondary antibody raised against mouse antibody and was visualized with a red color. RESULTS: Using individual antibodies, 15 of 15 DCIS lesions had diffuse circumferential membranous E-cadherin staining (brown stain) or P120 catenin staining (red stain). All 12 LCIS cases showed cytoplasmic P120 red staining or loss of E-cadherin staining when the single P120 catenin or E-cadherin antibody was used. When stained with the antibody cocktail, all 15 DCIS samples showed diffuse red and brown membranous staining without cytoplasmic stain; all 12 LCIS samples showed diffuse cytoplasmic red staining for P120 catenin but no membranous staining for E-cadherin. CONCLUSIONS: 1. This antibody cocktail can be applied in daily practice on paraffin-embedded tissue and is especially useful in small biopsies with small foci of CIS lesions. 2. Immunohistochemical staining with the antibody cocktail showed 100% concordance with the traditional single antibody immunostaining using either E-cadherin or P120 catenin antibody. 3. Our antibody cocktail includes E-cadherin as a positive membranous stain for DCIS and P120 catenin as a positive cytoplasmic stain for LCIS, which may enhance accuracy and confidence in the differential diagnoses.

Identifying multiple risks of low birth weight using person-centered modeling.

OBJECTIVES: Low birth weight outcomes result from multiple potential risks. The present study used latent class analysis to identify subgroups of women with multiple co-occurring risks and to examine the relationship of these risk classes to low birth weight outcome. METHODS: Data were analyzed on all live singleton births in 2010 and 2011 in West Virginia (N = 28,820). Ten risks were examined including marital status, stress, mother's age, parity status, reported smoking and drug use during pregnancy, delayed prenatal care, Medicaid coverage, uninsurance, and low education. RESULTS: Six latent classes were identified that ranged from a low-risk referent group to higher risk classes characterized by unique constellations of risk factors. Compared with the low-risk referent, all of the remaining five latent classes were significantly associated with increased odds of low birth weight. However, one class was at especially high risk; this class was characterized by unmarried women in the Medicaid program who reported drug use, smoking, stress, and late prenatal care (odds ratio, 4.78; 95% confidence interval, 4.07-5.61). CONCLUSIONS: The person-centered approach identified subgroups of women with unique risk profiles. The results suggest that eliminating a single risk would not resolve the low birth weight problem. Smoking, for example, co-occurs with higher stress and higher levels of drug use among a Medicaid population. It may be beneficial to develop and test tailored interventions to groups with specific co-occurring risks to reduce low birth weight outcomes. Programs targeted to women in the Medicaid program who also engage in substance use and experience stress are especially indicated.

PAX 8 expression in non-neoplastic tissues, primary tumors, and metastatic tumors: a comprehensive immunohistochemical study.

PAX 8 is a transcription factor that is essential for embryonic development of the kidney, Müllerian organs, and thyroid. It may also have a role in tumor development in these organs. The diagnostic utility of PAX 8 has not been comprehensively studied. Formalin-fixed, paraffin-embedded tissue samples for non-neoplastic tissues (n=1601), primary neoplasms (n=933), and metastatic neoplasms (n=496) were subjected to PAX 8 immunostain. In non-neoplastic tissues, PAX 8 was consistently noted in glomerular parietal epithelial cells, renal collecting ductal cells, atrophic renal tubular epithelial cells regardless of nephronic segments, and epithelial cells of the endocervix, endometrium, fallopian tube, seminal vesicle, epidydimis, thyroid, pancreatic islet cells, and lymphoid cells. PAX 8 was not seen in the rest of the tissue samples. In primary neoplasms, PAX 8 was expressed by 194 of 240 (89%) renal cell neoplasms, by 238 of 267 (89%) Müllerian-type neoplasms, by 65 of 65 (100%) thyroid follicular cell neoplasms, by 8 of 8 (100%) nephrogenic adenomas, and by 17 of 17 (100%) lymphomas. Weak focal staining was noted in 5 of 12 (42%) cases of parathyroid hyperplasia/adenoma and in 6 of 17 (35%) well-differentiated neuroendocrine tumors of the pancreas. PAX 8 was not seen in other neoplasms. In metastatic neoplasms, PAX 8 was expressed by 90 of 102 (88%) metastatic renal cell carcinomas, by 57 of 63 metastatic Müllerian tumors (90%), and by 6 of 6 metastatic papillary thyroid carcinomas (100%). There was also weak focal staining for 1 of 15 metastatic small cell carcinomas and for 1 of 9 metastatic well-differentiated neuroendocrine carcinomas. PAX 8 was not seen in other metastatic neoplasms. It can be successfully identified in routinely processed tissue samples, and its expression is mostly nuclear. PAX 8 expression in non-neoplastic mature tissues is limited to the organs, the embryonic development of which depends on this transcription factor. This tissue/cell-specific expression is maintained during both neoplastic transformation and metastasis. PAX 8 is a sensitive and specific marker for tumors of renal, Müllerian, or thyroid origin in both primary and metastatic sites.

Residence in coal-mining areas and low-birth-weight outcomes.

The objective of this study was to estimate the association between residence in coal mining environments and low birth weight. We conducted a cross-sectional, retrospective analysis of the association between low birth weight and mother's residence in coal mining areas in West Virginia. Birth data were obtained from the West Virginia Birthscore Dataset, 2005-2007 (n = 42,770). Data on coal mining were from the US Department of Energy. Covariates regarding mothers' demographics, behaviors, and insurance coverage were included. We used nested logistic regression (SUDAAN Proc Multilog) to conduct the study. Mothers who were older, unmarried, less educated, smoked, did not receive prenatal care, were on Medicaid, and had recorded medical risks had a greater risk of low birth weight. After controlling for covariates, residence in coal mining areas of West Virginia posed an independent risk of low birth weight. Odds ratios for both unadjusted and adjusted findings suggest a dose-response effect. Adjusted findings show that living in areas with high levels of coal mining elevates the odds of a low-birth-weight infant by 16%, and by 14% in areas with lower mining levels, relative to counties with no coal mining. After covariate adjustment, the persistence of a mining effect on low-birth-weight outcomes suggests an environmental effect resulting from pollution from mining activities. Air and water quality assessments have been largely missing from mining communities, but the need for them is indicated by these findings.

Diagnostic utility of P504S/p63 cocktail, prostate-specific antigen, and prostatic acid phosphatase in verifying prostatic carcinoma involvement in seminal vesicles: a study of 57 cases of radical prostatectomy specimens of pathologic stage pT3b.

CONTEXT: Seminal vesicle invasion by prostatic carcinoma is directly associated with tumor staging; verification is challenging when the tumor demonstrates cribriform or papillary growth patterns or there are back-to-back small-gland proliferations. P504S is overexpressed in prostatic carcinoma and high-grade prostatic intraepithelial neoplasia with cytoplasmic immunoreactivity. p63 has positive immunoreactivity in basal cell nuclei of benign prostatic glands. Many researchers use a combination of these antibodies and their different colors. OBJECTIVE: To evaluate the usefulness of a single-color P504S/p63 cocktail immunostain in verifying prostatic carcinoma within the seminal vesicle. DESIGN: Sections from 57 radical prostatectomy specimens of pathologic stage pT3b that contain seminal vesicle with prostatic carcinoma involvement were immunostained with primary antibodies against prostate-specific antigen (PSA) and prostatic acid phosphatase (PAP) and a cocktail of antibodies against P504S and p63. RESULTS: Prostatic carcinoma cells from all 57 cases were diffusely positive for P504S, PSA, and PAP with cytoplasmic staining and no p63 nuclear staining. Seminal vesicle epithelium from all 57 cases was negative for all 3 markers with distinct p63 nuclear staining of the basal cells. Benign prostatic tissue was positive for PSA and PAP, as well as for p63, but negative for P504S. CONCLUSIONS: The P504S/p63 one-color cocktail is a practical and cost-effective stain to differentiate prostatic carcinoma that involves the seminal vesicle from seminal vesicle epithelium. It is superior to PSA or PAP when sections contain both seminal vesicle and benign glands because PSA and PAP cannot distinguish benign from malignant glands.

PAX-2 expression in non-neoplastic, primary neoplastic, and metastatic neoplastic tissue: A comprehensive immunohistochemical study.

PAX-2 is a transcription factor that controls the development of the kidney, organs deriving from the mesonephric (Wolffian) duct, and those related to the Müllerian duct. Although PAX-2 is shown to be a sensitive marker for tumors derived from these organs, but whether it is specific, that is, whether other tumor types also express PAX-2, has not been systematically evaluated in either primary or metastatic tumors. Tissue sections from 937 normal or reactive tissue samples, 759 primary neoplasms, and 332 metastatic neoplasms were submitted to PAX-2 immunostain. Among the non-neoplastic tissue, PAX-2 was expressed in glomerular parietal epithelial cells, renal collecting duct cells, atrophic renal tubular cells, epithelial cells of ovarian surface, fallopian tube, endocervix, endometrium, seminal vesicle, and lymphocytes. Among the primary neoplasms, PAX-2 was noted in 104/122 (85%) of renal cell carcinoma, 31/95 carcinomas of Müllerian origin, 17/17 (100%) lymphomas, 4/4 (100%) nephrogenic adenomas, and 1/16 (6%) benign parathyroid tumors, but was negative in 477 other tumors. Among the metastatic tumors, PAX-2 was noted in 70/95 (74%) metastatic renal cell carcinomas, 14/20 (70%) metastatic tumors of Müllerian origin, 1/20 (5%) metastatic colon carcinoma of lymph nodes, 1/62 (2%) metastatic breast carcinoma of lymph nodes, but was not seen in the remaining 247 metastatic tumors. PAX-2 expression in non-neoplastic mature tissue is limited to the organs whose embryonic development depends on this transcription factor. PAX-2 is a sensitive and specific marker for tumors of renal or Müllerian origin in both primary and metastatic contexts.

WV Birth Score: maternal smoking and drugs of abuse.

The WV Birth Score began in 1984 and was revised in 2007. One part of the form is a score which predicts the top 18% of infants at risk for death in the first year of life. The other components collect information regarding the health of mothers and their infants. Data from the WV Birth Score between 2001 and 2009 reveal that the average smoking rate among mothers was 28.5%. The average maternal tobacco use rate among High Score infants (53.7%) is significantly higher than the average rate among mothers of Low Score infants (23.6%) (p < .0001). Infants born to women who smoked during pregnancy in 2007 weighed 250 grams less than infants of non-smoking women (p < 0.0001). A question on drug exposures during pregnancy reveals that marijuana is the most commonly reported drug on the Birth Score form. Only 5% of the mothers reported using at least one substance during their pregnancy. Smoking rates during pregnancy in WV are among the highest in the nation and lead to higher mortality rates in the infant born to mothers who smoke. Programs to impact smoking and other maternal health issues should be a priority in WV.

PAX-2 in the diagnosis of primary renal tumors: immunohistochemical comparison with renal cell carcinoma marker antigen and kidney-specific cadherin.

The diagnosis of renal cell carcinoma (RCC) remains problematic, especially in the context of metastasis or small needle biopsy specimens. The renal cell carcinoma marker (RCCM) and kidney-specific cadherin (KSC) are considered specific markers for RCC but are expressed preferentially in specific subtypes of RCC of lower grades. This study was aimed at evaluating the usefulness of PAX-2 in the diagnosis of renal tumors and comparing it with that of RCCM and KSC. Immunostaining for PAX-2, RCCM, and KSC was performed on consecutive tissue sections of 130 renal tumors. PAX-2 was successfully detected in routine tissue specimens. Although PAX-2 seems to be more sensitive than RCCM and KSC, there is significant staining overlap in relation to histologic subtypes, justifying the use of all 3 markers, which helps detect the vast majority of renal neoplasms. PAX-2 seems to have a significant role in renal neogenesis and may represent a novel therapeutic target.

Feasibility of a smoking cessation intervention for teens in the emergency department: reach, implementation fidelity, and acceptability.

BACKGROUND: Traditional efficacy research alone is insufficient to move interventions from research to practice. Motivational interviewing has been adapted for brief encounters in a variety of health care settings for numerous problem behaviors among adolescents and adults. Some experts suggest that motivational interviewing can support a population health approach to reach large numbers of teen smokers without the resource demands of multi-session interventions. OBJECTIVES: To determine the reach, implementation fidelity, and acceptability of a brief motivational tobacco intervention for teens who had treatment in a hospital emergency department. METHODS: Among 74 teens 14 to 19 years old, 40 received a brief motivational tobacco intervention and 34 received brief advice/care as usual at baseline. Follow-up data were collected from the interventional group at 1, 3, and 6 months and from the control group at 6 months. For the interventional group, data also were collected from the teens' parents, the health care personnel who provided the intervention, and emergency department personnel. RESULTS: Findings indicated low levels of reach, high levels of implementation fidelity, and high levels of acceptability for teen patients, their parents, and emergency department personnel. Data suggest that practitioners can operationalize motivational interventions as planned in a clinical setting and that patients and others with an interest in the outcomes may find the interventions acceptable. However, issues of reach may hinder use of the intervention among teens in clinical settings. CONCLUSIONS: Further investigation is needed on mechanisms to reduce barriers to participation, especially barriers related to patient acuity.

Efficacy of an emergency department-based motivational teenage smoking intervention.

INTRODUCTION: Motivational interviewing techniques have been minimally researched as a function of a teenage smoking intervention. The present study examined the efficacy of a theory-based motivational tobacco intervention (MTI). METHODS: A randomized two-group design was used to compare 6-month post-baseline quit and reduction rates among teenagers who received the MTI with those who received brief advice or care as usual. Participants were smokers aged 14 to 19 years (N = 75) who presented for treatment in a university-affiliated hospital emergency department (ED). Motivational interviewing techniques were used by trained providers to facilitate individual change; stage-based take-home materials also were provided. RESULTS: Similar to past clinic-based studies of motivational interviewing with teenage smokers, our study found negative results in terms of intervention efficacy for cessation. Six-month follow-up cessation rates were nonsignificant--two teenagers quit smoking. Among teenagers who were available at follow-up, a medium effect size (Cohen's h = .38) was found for reduction and a large effect size (Cohen's h = .69) was found for percentage reduction, although these results also were not statistically significant. CONCLUSION: Although the major findings of this study were not significant, the reductions in tobacco use suggest that motivational interviewing may be a clinically relevant counseling model for use in teenage smoking interventions. However, many questions remain, and the current literature lacks studies on trials with significant outcomes using motivational interviewing in smoking cessation. Additionally, more research is needed to examine the suitability of the ED for MTI-type interventions.

Non-dysplastic and dysplastic Barrett's mucosa and adenocarcinoma lack a subepithelial myofibroblastic cell layer.

A subepitheal myofibroblastic (SMF) cell layer has been described in the colon, and referred to as pericryptal myofibroblastic cell layer. SMF cells have been shown to produce basement membrane proteins, including type IV collagen and laminin. The aim of this work was to determine the status of the SMF cell layer in Barrett's metaplasia (BM), with and without dysplasia, and compare that to the previously reported distribution of SMF in normal colon and colonic adenomas and carcinoma. Sections of formalin-fixed, paraffin-embedded biopsies from 6 colonic adenomas and 5 colonic adenocarcinomas, as well as 4 cases of BM without dysplasia, 4 with low grade dysplasia, 4 high grade dysplasia and 4 with invasive adenocarcinoma were immunohistochemically stained for alpha smooth muscle actin using the immunoperoxidase method. A continuous layer of SMF cells was present in all normal colonic tissue and adenomas but was absent in all colorectal adenocarcinomas. Surprisingly, none of the cases of BM with or without dysplasia or carcinoma showed an organized SMF cell layer. Unlike the colon, the SMF cell layer is absent in BM even without dysplasia. We hypothesize that lack of the SMF cell layer in BM may contribute to the quick progression to esophageal adenocarcinoma, which, unlike that in the colon, occurs before an exophytic lesion becomes evident.