Feasibility of delivering vitamin A supplementation (VAS) and deworming through routine community health services in Siaya County, Kenya: A cross-sectional study.

Vitamin A deficiency and soil-transmitted helminth infection are serious public health problems in Kenya. The coverage of vitamin A supplementation and deworming medication (VASD) provided through mass campaigns is generally high, yet with a cost that is not sustainable, while coverage offered through routine health services is low. Alternative strategies are needed that achieve the recommended coverage of >80% of children twice annually and can be managed by health systems with limited resources. We undertook a study from September to December 2021 to compare the feasibility and coverage of VASD locally delivered by community health volunteers (CHV) ("intervention arm") to that achieved by the bi-annual Malezi Bora campaign event ("control arm"). This comparative cross-sectional study was conducted in sub-counties of Siaya County using both qualitative and quantitative methods. VASD were offered through the CHS in Alego Usonga and through Malezi Bora in Bondo Sub-County. Coverage was assessed by a post-event coverage survey among caregivers of children aged 6-59 months (n = 307 intervention; n = 318 control). Key informant interviews were conducted with n = 43 personnel across both modalities, and 10 focus group discussions were conducted with caregivers of children aged 6-59 months to explore knowledge, attitudes and perceptions of the two strategies. VAS coverage by CHV was 90.6% [95% CI: 87.3-93.9] compared to 70.4% [95% CI: 65.4-75.4] through the Malezi Bora, while deworming coverage was 73.9% [95% CI: 69.0-78.7] and 54.7% [95% CI: 49.2-60.2], respectively. With sufficient training and oversight, CHV can achieve superior coverage to campaigns.

Outcomes of a food voucher program and factors associated with the recovery rate of children with moderate acute malnutrition in Far North Cameroon.

BACKGROUND: Research on moderate acute malnutrition (MAM) is limited, despite its high prevalence. This study examined outcomes of bi-weekly locally available foods provided via a food voucher program (FVP) on nutritional recovery [mid-upper arm circumference (MUAC) ≥ 125 mm] from MAM (defined as MUAC between 115 and 124 mm) and identified the factors associated with recovery rate in Kaélé health district, Far North Region of Cameroon. METHODS: This was a prospective study with 474 MAM children aged 6-59 months. Food voucher distribution and MUAC screening were conducted at 6 bi-weekly visits or until the child was recovered. Time to recovery was evaluated with multivariate Cox proportional regression hazard models with associations quantified using adjusted hazard ratio (aHR). The trend for MUAC, including its determinants, was examined with multivariate linear mixed effect models. RESULTS: The recovery rate was 78.3% by 6 weeks after the first food basket; 3.4% remained MAM, and 5.9% were transferred for treatment for severe acute malnutrition (SAM defined as MUAC < 115 mm). Boys were 34% more likely to recover from MAM than girls [aHR = 1.34, 95%CI (1.09, 1.67)]. Children aged 24-53 months were 30% more likely to recover than those aged 6-11 months [aHR = 1.30, 95%CI (0.99, 1.70)]. A one unit increase in weight-for-height Z-score (WHZ) was associated with 1.89-fold greater likelihood of recovery [aHR = 1.89, 95%CI (1.66, 2.14)]. Male children had on average 1.82 mm greater increase in MUAC than female children (p < 0.001). One unit increase in WHZ was associated with 3.42 mm increase in MUAC (p = 0.025). Children aged 12-23 and 24-53 months had 1.03 mm and 2.44 mm, respectively, greater increase in MUAC over the program than children aged 6-11 months (all p < 0.01). CONCLUSION: The recovery rate of MAM children treated with the FVP met the Sphere standards for targeted supplementary feeding programs (> 75%). Child's WHZ, gender and age were significant factors associated with MUAC increase and recovery from MAM in the FVP. These findings indicate the FVP approach shows promise as an effective alternative treatment for MAM with consideration of associated factors and merits further evaluation.

Incidence of Dissociation With Low-Dose Pre-hospital Ketamine in Geriatric Patients With Trauma-Related Pain.

Introduction Sub-dissociative ketamine has been used increasingly for the treatment of acute pain in a wide variety of settings. While there are studies evaluating its use in the geriatric population, no studies have described its safety in the pre-hospital geriatric trauma patient. The objective of this study was to define the incidence of dissociation with low-dose pre-hospital ketamine in geriatric trauma patients. Methods Using our county emergency medical services database, we identified all trauma patients greater or equal to 65 years of age who received pre-hospital ketamine for pain after the implementation of a low-dose ketamine protocol. We retrospectively reviewed pre-hospital and emergency department records for demographics, traumatic injuries, Glasgow Coma Score, emergency department length of stay and disposition, and hospital length of stay. This group was compared to a similar population of trauma patients, transported prior to the ketamine protocol. The comparison group was chosen by matching the ketamine group to more than double the number of non-ketamine patients. Records were obtained from two separate trauma centers. Our primary outcome was documentation of "ketamine-related dissociation" by either the pre-hospital, emergency department or trauma provider. Secondary outcomes included emergency department length of stay and intensive care unit admission. Results Seventy-nine patients received ketamine with records available for analysis. One hundred ninety-three non-ketamine patients were compared to this group. There were nosignificant differences between the two groups in regards to age, weight, gender, or mechanism of injury. The injury severity score was higher in the ketamine group. Nine patients (11%) had documented dissociation after ketamine, with six of these patients back to baseline mentation by arrival to the emergency department. The emergency department length of stay was shorter in the ketamine group. The rate of intensive care unit admission was the same between both groups. Conclusions Pre-hospital sub-dissociative ketamine in geriatric trauma patients is associated with brief episodes of dissociation in a small minority of patients.

COVID-19 Restrictions Are Associated With a Significant Decrease of All Common Respiratory Viral Illnesses in Children.

To combat the spread of coronavirus disease 2019 (COVID-19), significant measures were enacted including school and business closures, social distancing, and facial coverings. We hypothesized that this would have an impact on all respiratory infections in children. Using nasopharyngeal panel test results of children in the emergency department, we evaluated cross-sectional data from February to May in both 2019 and 2020. Respiratory panel testing included 11 common respiratory viruses and bacteria. After the restrictions were enacted, we observed a large drop in the number and percentage positive of all common respiratory viral infections in 2020 compared with the same time in 2019. When analyzing data from children <2 years old, a similar decrease was seen. Restrictions enacted to prevent the spread of COVID-19 were associated with a significant decrease in respiratory viral infections in children of all ages. This association could guide future public health recommendations and guidelines.

Adolescent Girls' Nutritional Status and Knowledge, Beliefs, Practices, and Access to Services: An Assessment to Guide Intervention Design in Nepal.

BACKGROUND: Despite growing recognition of the importance of the adolescent period for health and nutritional well-being, scant evidence exists to inform interventions. Beyond limited understanding of adolescents' knowledge and practices, gaps in adolescent research also include limited understanding of how best to reach them with programs and policies and how the contexts in which they live present barriers and opportunities. Given that most studies on adolescent health and nutrition have used data from surveys of women of reproductive age, this study also sought to understand variation among younger and older adolescents and those who were already mothers. OBJECTIVES: The primary aim was to support the design of an evidence-based adolescent program (Suaahara) in Nepal by describing adolescent girls' nutritional status; their exposure to information and services, knowledge, and practices in nutrition, health, family planning, and water, sanitation, and hygiene (WASH); and contextual factors; and to quantify variation by stage of adolescence. METHODS: Using the first round (2017) from a panel of Nepalese adolescent girls, we categorized adolescent girls as: younger (10-14.9 y; n = 512), older (15-19.9 y; n = 325), and mothers (15-19.9 y; n = 256). Descriptive analyses generated proportions and means ± SDs, with statistical significance testing of differences. RESULTS: The prevalence of underweight was highest in younger adolescents, whereas the prevalence of overweight/obesity in mothers was double that of the other 2 groups. More younger adolescents were in school, but fewer owned a mobile phone or had radio access. Exposure, knowledge, and behaviors across thematic areas also differed by stage of adolescence. CONCLUSIONS: These findings have implications for Suaahara and other programs and policies aiming to support the health and nutritional well-being of adolescent girls. Heterogeneity among adolescent girls should be considered when identifying which interventions are needed and have the most potential for each subpopulation.

Fostering CHANGE: Lessons from implementing a multi-country, multi-sector nutrition-sensitive agriculture project.

Using agriculture to improve nutrition is an approach growing in popularity, with programs becoming increasingly complex and multisectoral. While there is an active line of research assessing the impacts of such programs, little has been written about the process of successfully implementing them. As such, this paper uses a multisectoral nutrition-sensitive agriculture program implemented in four African countries as a case study to address key challenges in and lessons learned from implementation. We highlight the overall flexibility of nutrition-sensitive agriculture but also the need to adapt certain aspects to the particular context, as well as the opportunities for cross-context learning (and the limits to this). Integrating rigorous evaluation into such complex programs and forging diverse cross-sectoral partnerships offer both rewards and challenges, upon which we reflect. Main lessons learned from the program include the importance of carefully sequencing interventions, retaining flexibility in implementation, allowing for considerable time for cross-sector integration and coordination, and considering community impacts when designing research.

Use of the Essential Nutrition Actions framework improved child growth in Bangladesh.

The Essential Nutrition Actions (ENA) framework is an evidence-based set of cost-effective, integrated tools for training health and community workers to promote optimal nutrition practices for the first 1,000 days. This ENA pilot project (ENAPP) was implemented with United States Agency for International Development (USAID) funding from August 2008 to September 2009 in six unions of the working area of an existing USAID-funded, Title II programme in southern Bangladesh. ENAPP, which targeted governmental and non-governmental service providers, was intended to strengthen the behaviour change component of the nutrition strategy of this project. Following a qualitative review of ENAPP's activities, this evaluation uses administrative (growth monitoring) data and propensity score matching of pre-intervention characteristics to create multiple counterfactuals for difference-in-difference estimations of the impact of ENAPP on child nutritional status. Records indicated that government and community healthcare workers received intensive training, and these staff reported that they could effectively integrate ENA messages into their existing responsibilities. Both longitudinal and cross-sectional analyses indicate that ENAPP was successful in increasing children's weight-for-age z-scores, and the difference in z-scores between the treatment and the comparison group increased with time. The materials and methods used in this pilot project should be scaled up, based on the success of these tools and the project's ability to link with and influence the local health system.

Process evaluation improves delivery of a nutrition-sensitive agriculture programme in Burkina Faso.

Evidence is emerging from rigorous evaluations about the effectiveness of nutrition-sensitive agriculture programmes in improving nutritional outcomes. Additional evidence can elucidate how different programme components and pathways contribute and can be optimized for impact. The International Food Policy Research Institute, with Helen Keller International, designed a comprehensive framework to evaluate the delivery, utilization, and impact of Helen Keller International's enhanced homestead food production programme in Burkina Faso. After 18 months of implementation, a process evaluation was conducted to examine programme impact pathways, using key informant and semistructured interviews with implementing agents and beneficiaries, and with residents of control communities. Data were analyzed by International Food Policy Research Institute and reviewed with project managers and partners through multiple workshops to identify opportunities to strengthen implementation. Findings illuminated gaps between intended and actual delivery schemes, including input constraints, knowledge gaps among community agents in agriculture and young child nutrition practices, and lower than expected activity by community volunteers. In response, staff developed measures to overcome water constraints and expand vegetable and poultry production, retrained volunteers in certain techniques of food production and counselling for nutrition behaviour change, added small incentives to motivate volunteers, and shaped both immediate and long-term changes to the programme model. Working closely with International Food Policy Research Institute on the evaluation activities also expanded the repertoire of research methods and skills of Helen Keller International staff. Process evaluation can strengthen programme delivery, utilization, and design. Collaboration between researchers and implementers can improve programme effectiveness, project staff capacity, and advance delivery science.

Using formative research to promote antenatal care attendance and iron folic acid supplementation in Zinder, Niger.

In Niger, use of antenatal care (ANC) and iron folic acid (IFA) supplements is suboptimal. The objectives of this paper are as follows: (a) to conduct formative research to understand barriers and beliefs among pregnant women related to ANC, IFA supplementation, and pregnancy outcomes; (b) assess the quality of currently provided ANC services; (c) use the findings to guide the development of programmatic interventions to improve coverage of ANC services and IFA supplementation of pregnant women. Structured in-home interviews (n = 72) and focus groups (n = 4) were conducted with pregnant women in 4 randomly selected villages in rural Zinder. ANC consultations (n = 33) were observed in 5 randomly selected health centres, and exit interviews were conducted with all pregnant women and seven health agents following these observations. During workshops with stakeholders, results of the formative research were interpreted, and programmatic interventions were developed. In home interviews, 72% of women reported having attended at least one ANC visit. They also reported husbands (71%), mothers (40%), and friends (33%) supporting ANC attendance. Among those having attended ANC, only 65% reported taking IFA the day prior to the interview. Three of five health centres visited had IFA in stock. Health staff did not provide IFA supplements during 18 of 33 observed ANC consultations of which only 7 cases could be explained by the lack of IFA supplements in stock. Findings were used to design a 3-pronged intervention: (a) behaviour change communication activities in communities; (b) quality improvement activities in health centres to strengthen ANC; and (c) provision of key supplies required for ANC.

Institutionalizing community-focused maternal, newborn, and child health strategies to strengthen health systems: A new framework for the Sustainable Development Goal era.

BACKGROUND: Stronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies. DISCUSSION: In this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, "learning for leverage," NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, "thought leadership," NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, "joint venturing," NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts. CONCLUSION: With additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.

Combining Home Garden, Poultry, and Nutrition Education Program Targeted to Families With Young Children Improved Anemia Among Children and Anemia and Underweight Among Nonpregnant Women in Nepal.

BACKGROUND: The impact of food-based interventions on child and maternal anthropometry and anemia has not been adequately studied. OBJECTIVE: This study tested the effect of an enhanced homestead food production (EHFP) program consisting of home garden, poultry raising, and nutrition education implemented over 2.5 years versus control (no intervention) on anthropometry and anemia among children (12-48 months) and their mothers. METHODS: An unblinded cluster-randomized controlled trial involving pre- and post-surveys with independent samples was conducted in rural areas of Baitadi District, Nepal. Data (including weight, height/length, and hemoglobin) were obtained from 2106 and 2614 mother-child pairs at baseline and follow-up, respectively. Changes in outcome variables (stunting, underweight, wasting, and anemia among children and underweight and anemia among mothers) were compared between the study groups using mixed-effects logistic regression models. RESULTS: At follow-up, anemia was significantly lower among children (odds ratio, OR [95% confidence interval, CI]: 0.76 [0.59-0.98]) and mothers (OR [95% CI]: 0.62 [0.48-0.82]) in the treatment group compared to the control. Underweight was lower among mothers in the treatment group compared to the control (OR [95% CI]: 0.61 [0.46-0.82]). There was no impact on child anthropometry. CONCLUSION: The EHFP intervention improved anemia among children aged 12 to 48 months and their mothers in Baitadi District of Nepal. The intervention also reduced underweight among these women, but had no impact on child growth, in this district.

Safety and Mortality Benefits of Delivering Vitamin A Supplementation at 6 Months of Age in Sub-Saharan Africa.

BACKGROUND: Vitamin A supplementation (VAS) among children 6 to 59 months of age reduces vitamin A deficiency (VAD)-related mortality. Child health days (CHDs) only reach an estimated 16.7% of children at exactly 6 months, leaving uncovered children at risk of VAD-related mortality; similarly, VAS provided at 9 months of age with measles-containing vaccine leaves infants unprotected for 3 months. OBJECTIVE: Using data from sub-Saharan Africa, we estimated the mortality benefits and safety of providing VAS at age 6 months, compared to delivery through CHDs and at 9 months. METHODS: We modeled VAS-preventable mortality benefits at 6 months as a function of published VAS effect sizes, intervention coverage, and proportion of infant deaths occurring between 6 and 11 months. To evaluate safety, we modeled the effect of different VAS coverage scenarios on maximum hepatic vitamin A concentrations (HVACs). RESULTS: VAS linked to a 6-month visit could reduce infant mortality by an additional 1.95 (95% confidence interval [CI]: 1.38-2.52) and 1.63 (95% CI: 1.15-2.11) percentage points compared to VAS through CHDs and at 9 months, respectively. The HVAC models indicate that VAS at 6 months is safe even in the presence of a second VAS dose 1 month later and other food-based vitamin A control strategies. CONCLUSION: Advancing the first VAS dose to 6 months should be considered in settings where VAS is currently given first at 9 months. A 6-month VAS dose should also be considered in settings where VAS is delivered through CHDs. VAS delivery at 6 months could also serve as a platform to deliver other high-impact interventions.

Using Field Data and GIS-Derived Variables to Model Occurrence of Williamson's Sapsucker Nesting Habitat at Multiple Spatial Scales.

Williamson's sapsucker (Sphyrapicus thyroideus) is a migratory woodpecker that breeds in mixed coniferous forests in western North America. In Canada, the range of this woodpecker is restricted to three small populations in southern British Columbia, precipitating a national listing as 'Endangered' in 2005, and the need to characterize critical habitat for its survival and recovery. We compared habitat attributes between Williamson's sapsucker nest territories and random points without nests or detections of this sapsucker as part of a resource selection analysis to identify the habitat features that best explain the probability of nest occurrence in two separate geographic regions in British Columbia. We compared the relative explanatory power of generalized linear models based on field-derived and Geographic Information System (GIS) data within both a 225 m and 800 m radius of a nest or random point. The model based on field-derived variables explained the most variation in nest occurrence in the Okanagan-East Kootenay Region, whereas nest occurrence was best explained by GIS information at the 800 m scale in the Western Region. Probability of nest occurrence was strongly tied to densities of potential nest trees, which included open forests with very large (diameter at breast height, DBH, ≥57.5 cm) western larch (Larix occidentalis) trees in the Okanagan-East Kootenay Region, and very large ponderosa pine (Pinus ponderosa) and large (DBH 17.5-57.5 cm) trembling aspen (Populus tremuloides) trees in the Western Region. Our results have the potential to guide identification and protection of critical habitat as required by the Species at Risk Act in Canada, and to better manage Williamson's sapsucker habitat overall in North America. In particular, management should focus on the maintenance and recruitment of very large western larch and ponderosa pine trees.

Using formative research to design a context-specific behaviour change strategy to improve infant and young child feeding practices and nutrition in Nepal.

Global recommendations on strategies to improve infant feeding, care and nutrition are clear; however, there is limited literature that explains methods for tailoring these recommendations to the local context where programmes are implemented. This paper aims to: (1) highlight the individual, cultural and environmental factors revealed by formative research to affect infant and young child feeding and care practices in Baitadi district of Far Western Nepal; and (2) outline how both quantitative and qualitative research methods were used to design a context-specific behaviour change strategy to improve child nutrition. Quantitative data on 750 children aged 12-23 months and their families were collected via surveys administered to mothers. The participants were selected using a multistage cluster sampling technique. The survey asked about knowledge, attitude and behaviours relating to infant and young child feeding. Qualitative data on breastfeeding and complementary feeding beliefs and practices were also collected from a separate sample via focus group discussions with mothers, and key informant interviews with mothers-in-law and husbands. Key findings revealed gaps in knowledge among many informants resulting in suboptimal infant and young child feeding practices - particularly with relation to duration of exclusive breastfeeding and dietary diversity of complementary foods. The findings from this research were then incorporated into a context-specific nutrition behaviour change communication strategy.

Lymphocytic gastritis is not associated with active Helicobacter pylori infection.

BACKGROUND: Lymphocytic gastritis (LG), characterized by marked intra-epithelial lymphocytosis in the gastric mucosa, has been frequently associated with both celiac disease (CD) and H. pylori gastritis. The aim of this study was to review and correlate the morphology of LG with the presence of CD and H. pylori. MATERIALS AND METHODS: Gastric biopsies diagnosed with LG from 1/1/2006 to 8/1/2013 at our institution and corresponding small bowel biopsies, when available, were reviewed for verification of the diagnosis and to assess for the presence of H. pylori and CD. Immunohistochemical (IHC) staining for H. pylori was performed on all gastric biopsies. Demographic, clinical, and laboratory data were obtained from the medical record. RESULTS: Fifty-four of the 56 cases that met inclusion criteria demonstrated significant intra-epithelial lymphocytosis as the predominant histologic abnormality; however, none were associated with H. pylori infection by IHC staining. Two cases that also showed a prominent intra-epithelial and lamina propria neutrophilic infiltrate were both positive for H. pylori and were excluded from further study. Of the 36 small bowel biopsies available, 19 (53%) showed changes in CD. CONCLUSIONS: LG is not a distinct clinicopathologic entity, but a morphologic pattern of gastric injury that can be secondary to a variety of underlying etiologies. When restricted to cases with lymphocytosis alone, LG is strongly associated with CD and not with active H. pylori infection. However, cases that also show significant neutrophilic infiltrate should be regarded as "active chronic gastritis" and are often associated with H. pylori infection. A morphologic diagnosis of LG should prompt clinical and serologic workup to exclude underlying CD.

The increasing incidence of remote metastasis: a case report of metastatic hepatocellular carcinoma to the rectosigmoid.

As the fifth most common malignancy worldwide, survival rates of hepatocellular carcinoma (HCC) have only slightly improved over the years due to early-stage detection. HCC is well known to metastasize to the lung, lymph nodes, and musculoskeletal regions; however, only 0.5% to 6% of HCCs metastasize to the gastrointestinal tract. In the case described here, a CT scan and subsequent colonoscopy of a 51-year-old Asian male with a history of hepatitis B and HCC revealed a mass lesion of metastatic HCC 12 cm from the anal verge. Because metastatic HCC to the lower gastrointestinal tract has only recently been reported, it is speculated that the prolonged survival of patients is also increasing the incidence of extrahepatic metastasis, giving the disease greater opportunity to spread to more distant regions of the body. This case may be the farthest metastasis within the gastrointestinal tract to date.

The optimal number of biopsy fragments to establish a morphologic diagnosis of eosinophilic esophagitis.

OBJECTIVES: Eosinophilic esophagitis (EoE) is characterized clinically by dysphagia, chest pain, and food impaction, and morphologically by increased numbers of intraepithelial eosinophils and marked basal hyperplasia of the squamous mucosa. The consensus criteria for a diagnosis of EoE include the presence of ≥15 eosinophils/HPF in biopsies from both proximal and distal esophagus in the absence of other causes of esophageal eosinophilia, and the lack of clinical response to proton pump inhibitor therapy. Because of the variability in the distribution of intraepithelial eosinophils among biopsy fragments and the lack of standardized biopsy practices, we sought to determine the optimal number of esophageal biopsies from the mid and distal esophagus needed to reach the minimum morphologic criteria of ≥15 eosinophils/HPF. METHODS: From 5 January 2009 to 26 September 2011, 771 patients were diagnosed with EoE at our institution. From that patient population, 102 sequential cases were chosen for further study, all of whom had biopsies taken from the mid and distal esophagus. Cases with only gastric mucosa present and biopsies taken from patients with a previous diagnosis of EoE were excluded. The original H&E-stained slides were reviewed, and the number of biopsy fragments containing squamous mucosa was recorded. By using a × 40 objective and × 10 oculars (field diameter=0.52 mm, field area=0.21 mm(2)), the number of eosinophils per high power field (EOS/HPF) in up to three HPFs was counted in each biopsy fragment. RESULTS: The EOS/HPF were counted in 1,342 biopsy fragments. The number of biopsy fragments obtained from the mid esophagus ranged from 1 to 20 (mean 7; median 7) and those obtained from the distal esophagus ranged from 1 to 18 (mean 6; median 5). There was no significant difference between the mean number of EOS/HPF from the mid (26) and lower (25) esophagus or between the mean peak number of EOS/HPF from the mid (69.1) and lower (60.4) esophagus. The probability of one, four, five, and six biopsy fragments containing >15 EOS/HPF was 0.63, 0.98, 0.99, and >0.99, respectively. CONCLUSIONS: From these data, at least four biopsy fragments should be submitted from the mid and/or proximal esophagus to optimize the chances of a positive diagnosis of EoE in populations not known to have undergone previous proton pump inhibitor therapy. However, the yield is not increased beyond six biopsy fragments. In order to morphologically exclude a diagnosis of reflux esophagitis as the cause of intraepithelial eosinophilia, distal esophageal biopsies, if obtained, must be accompanied by more proximal biopsies (i.e., mid esophagus or higher).

Angiotensin-II inhibitor (olmesartan)-induced collagenous sprue with resolution following discontinuation of drug.

Collagenous sprue (CS) is a pattern of small-bowel injury characterized histologically by marked villous blunting, intraepithelial lymphocytes, and thickened sub-epithelial collagen table. Clinically, patients present with diarrhea, abdominal pain, malabsorption, and weight loss. Gluten intolerance is the most common cause of villous blunting in the duodenum; however, in a recent case series by the Mayo Clinic, it has been reported that olmesartan can have a similar effect. In this case report, a 62-year-old female with a history of hypothyroidism and hypertension managed for several years with olmesartan presented with abdominal pain, weight loss, and nausea. Despite compliance to a gluten-free diet, the patient's symptoms worsened, losing 20 pounds in 3 wk. Endoscopy showed thickening, scalloping, and mosaiform changes of the duodenal mucosa. The biopsy showed CS characterized by complete villous atrophy, lymphocytosis, and thickened sub-epithelial collagen table. After 2 mo cessation of olmesartan, the patient's symptoms improved, and follow-up endoscopy was normal with complete villous regeneration. These findings suggest that olmesartan was a contributing factor in the etiology of this patient's CS. Clinicians should be aware of the possibility of drug-induced CS and potential reversibility after discontinuation of medication.

Incidence of diagnostic change in colorectal polyp specimens after deeper sectioning at 2 different laboratories staffed by the same pathologists.

OBJECTIVES: To calculate the incidence of nondiagnostic (ND) colorectal (CR) polyp cases in which deeper tissue sectioning rendered new diagnostic information--particularly adenomas--in 2 laboratories staffed by the same pathologists. METHODS: After initial diagnosis, 100 ND CR polyps from each laboratory were reexamined with 3 deeper levels to establish rates of diagnostic conversion based on biopsy specimen location and original observation(s). RESULTS: Deeper sectioning rendered new diagnostic information in 43 (21.5%) of 200 biopsy specimens and specifically adenomas in 16 (8.0%) of 200 biopsy specimens. CONCLUSIONS: These results support routine ordering of deeper levels on ND CR polyps to improve adenoma detection rates, especially those cases without any histologic abnormality. If another biopsy in the same case already is adenomatous, examination of deeper levels may not be necessary, as it may not have any significant effect on the clinical management of the patient.