Esophageal Eosinophilia Treated With Long-Duration Proton Pump Inhibitor Therapy.

We present a case of proton pump inhibitor-responsive eosinophilic esophagitis (PPI-REE) in a patient with severe dysphagia and markedly elevated baseline esophageal eosinophilia that was previously deemed unresponsive to PPI. Upon reintroduction to PPI therapy with monthly endoscopy and dilation over the course of 4 months, the patient improved clinically and resolved her mucosal eosinophilia. Our case suggests that a longer duration of PPI therapy may be required for histologic improvement, especially in patients with very high mucosal eosinophil count.

Caustic Injury and Stricture of the Esophagus After Long-Term Phenytoin Use.

A 50-year-old man with a history of epilepsy controlled with phenytoin presented for evaluation of dysphagia. History revealed the patient was taking his phenytoin daily without water. Barium esophagram showed severe stricturing of the mid-esophagus. Upper endoscopy revealed diffuse gross mucosal abnormality with a thick stricture and occasional exudate. Biopsies were consistent with a drug-induced injury with lymphocytic infiltration and epithelial cell necrosis.

Transfusion medicine knowledge in Postgraduate Year 1 residents.

BACKGROUND: Transfusion medicine is a complex important subspecialty of pathology. A transfusion carries measurable risks and benefits. Although fellowship training exists in transfusion medicine, the majority of transfusion decisions are made by clinicians without formal training. STUDY DESIGN AND METHODS: A total of 116 recently graduated medical students entering 10 residency programs at a single medical center over 2 years were evaluated using a standardized patient encounter to determine baseline knowledge. Transfusion medicine knowledge was assessed during the encounter by obtaining verbal consent for red blood cell transfusion, answering patient questions, and completing a written quiz. Final performance was scored using a peer-reviewed data collection sheet. RESULTS: Scores ranged from 24.0% to 67.1%. Postgraduate Year 1 (PGY-1) residents graduating from allopathic medical schools had higher scores than those from osteopathic schools (mean, 41.3% vs. 37.5%; p = 0.036). There was no significant difference between PGY-1 residents entering primary care versus surgical specialties (38.2% and 41.6%; p = 0.10). Although not significant, PGY-1 residents with previous transfusion medicine education demonstrated a trend toward better performance than those without prior education (47.0% vs. 43.0%; p = 0.057). A total of 17.2% of PGY-1's could define transfusion-related acute lung injury, 6.0% knew the transfusion transmission rate of human immunodeficiency virus, 5.2% knew the transfusion transmission rate of hepatitis C virus, and 0% knew the indication for blood product irradiation. CONCLUSIONS: Marked knowledge deficits in transfusion medicine were noted. If the results of this study could be reproduced at other training institutions, medical schools may be willing to donate more resources into transfusion medicine education.

Progressive bevacizumab-associated renal thrombotic microangiopathy.

Vascular endothelial growth factor (VEGF) is integral to the integrity of the glomerular filtration barrier. Bevacizumab is a humanized monoclonal antibody directed against VEGF with expanding clinical applications for metastatic solid tumours. We describe a case of a 61-year-old female with ovarian cancer and baseline chronic kidney disease who received three doses of bevacizumab and subsequently developed progressive renal clearance dysfunction and nephrotic range proteinuria. A renal biopsy was performed 4 months after drug discontinuation and was consistent with TMA. At baseline, prior to bevacizumab exposure, her estimated glomerular filtration rate (eGFR) was 44 mL/min/1.73 m(2) and she had no proteinuria. At the completion of therapy, eGFR was 27 mL/min/1.73 m(2) with 1+ proteinuria on urinalysis. Her renal failure and proteinuria continued to progress 5 months after discontinuation of bevacizumab therapy, at which time eGFR was 11 mL/min/1.73 m(2) and proteinuria was 5.5 g/24 h. Non-remitting TMA after bevacizumab therapy in patients with pre-existing chronic kidney disease has not been previously reported. Further studies are needed to assess the safety of this drug in patients with chronic kidney disease.

Incidental pathologic findings in open resectional gastric bypass specimens with routine cholecystectomy and appendectomy.

BACKGROUND: Morbid obesity has become a public health epidemic in the United States. With this epidemic, the demand for surgical intervention has led to rapid growth in the field of bariatric surgery. Although various procedures exist, one of the procedures offered at our institution is resectional Roux-en-Y gastric bypass with incidental cholecystectomy and appendectomy. This procedure allows for pathologic assessment of otherwise normal viscera routinely removed as a part of the gastric bypass. The purpose of this study was to determine the incidence of abnormal findings of the extirpated, gallbladder, appendix, and distal stomach after gastric bypass surgery. METHODS: We performed a retrospective review of 427 patients undergoing Roux-en-Y at a tertiary level medical center. RESULTS: Abnormal findings were divided according to the organ. In the gastric remnant, the reported pathologic findings included chronic or active gastritis in 66, fundic gland polyps in 7, intestinal metaplasia in 3, gastric ulcers in 2, gastropathy in 2, lymphoid aggregate in 1, diverticulum in 1, a developmental cyst in 1, and leiomyoma in 1. We analyzed 311 appendixes and found the following abnormalities: fibrous obliteration of the appendiceal lumen in 76, carcinoids in 2, infarcted appendicial epiploica in 2, follicular hyperplasia in 2, and subserosal endometriosis in 1. In the gallbladder the sole abnormality, other than cholelithiasis, was an adenomyoma. Other resected findings included five Meckel's diverticula, one bile duct adenoma, and one sigmoid diverticulum. CONCLUSION: The results of our study have shown that the resection of grossly normal and asymptomatic organs results in a very low prevalence of clinically significant incidental pathologic findings.

Prognostic significance of reactivation of telomerase in breast core biopsy specimens.

BACKGROUND: Telomerase is not expressed in most somatic tissues, but activity has been shown in breast carcinoma and up to 90% of solid tumors. We sought to determine whether activation of telomerase, as shown by immunohistochemical staining for human telomerase reverse transcriptase (hTERT), held prognostic significance in core breast biopsy specimens. METHODS: We identified women with atypical ductal hyperplasia (ADH) on core biopsy who either had underlying cancer or ADH. Immunohistochemistry with anti-hTERT antibody was performed on biopsy specimens, and staining was evaluated. RESULTS: Core biopsy specimens stained strongly with the hTERT antibody in 7 (70%) specimens with ADH on open biopsy and 6 (86%) with underlying cancer. The difference was not statistically significant (P = .43). CONCLUSIONS: Our study suggests telomerase may be activated early in the pathogenesis of breast cancer. The immunohistochemical evaluating expression of hTERT does not reliably identify those patients with ADH on core biopsy who are likely to have cancer.

AlloDerm tympanoplasty of tympanic membrane perforations.

PURPOSE: To study the effectiveness of AlloDerm (LifeCell Corporation, Branchburg, NJ) as a graft material in underlay tympanoplasty by comparison to autologous fascia in a chronic tympanic membrane perforation animal model. MATERIALS AND METHODS: Seventeen chinchillas underwent creation of bilateral chronic tympanic membrane perforations over a 6-week period. Twenty-two stable perforations were divided equally between the experimental AlloDerm and control fascia graft groups. The grafts were surgically placed through a postauricular tympanomeatal flap. The tympanic membranes were examined at 4 and 10 weeks and then harvested for histopathological analysis. Tympanoplasty operative times, perforation closure rates, and gross and histological analyses were compared between the AlloDerm and fascia grafts. RESULTS: A statistically significant difference in mean surgical time was recorded between the AlloDerm (47 minutes) and fascia (68 minutes) grafting procedures (t test, P =.001). Perforation closure was achieved in 90% of the AlloDerm and 100% of the fascia treated tympanic membranes. Gross and histopathologic inspections revealed no significant differences. Microscopically, AlloDerm and fascia grafts had similar inflammatory responses, but AlloDerm showed increased fibroblast infiltration and neovascularization. CONCLUSION: The avoidance of donor site morbidity, reduction of surgical time, and excellent gross and histologic outcomes in this animal model reveal that AlloDerm could be a safe, cost-effective alternative to autologous fascia. Further study would be necessary in human clinical trials.