Jesus R. Guajardo

Clinical and immunopathologic effects of swallowed fluticasone for eosinophilic esophagitis

BACKGROUND & AIMS Eosinophilic esophagitis (EE) is a recently recognized clinical disorder that is understood poorly. We aimed to determine the efficacy of swallowed fluticasone propionate on the immunopathologic features associated with EE. METHODS A retrospective analysis was performed on 20 pediatric patients with EE. Inclusion criteria specified a peak eosinophil density of > or =24 cells per 400x field in the esophagus and treatment with swallowed fluticasone between 2 endoscopic assessments. Histologic specimens were examined for eosinophil and CD8(+) lymphocyte infiltration, papillary lengthening, and proliferation of the basal layer as determined by monoclonal anti-Ki-67 (MIB-1) antibody staining. RESULTS The mean time interval between endoscopic assessments was 4.8 months. The patients were divided equally between allergic and nonallergic groups based on the results of skin-prick testing. All of the nonallergic patients responded to fluticasone propionate. The endoscopic appearance of the mucosa improved and microscopic evaluation showed markedly reduced eosinophil infiltration, reduced basal layer hyperplasia documented by a reduced number of MIB-1(+) cells, and a reduced number of CD8(+) lymphocytes. However, allergic patients were relatively refractory to therapy; 20% had a partial response, whereas 20% had no detectable improvement. Esophageal eosinophil levels before and after therapy in all patients strongly correlated with the level of epithelial cell proliferation as measured by MIB-1 staining. CONCLUSIONS Collectively, these results suggest that patients treated with swallowed fluticasone have improved endoscopic, histologic, and immunologic parameters associated with EE. However, patients with identifiable allergies who fail dietary elimination may have a blunted response to treatment.

Morning report: focus and methods over the past three decades.

Residents rank morning report as the most important educational activity of their residency training. Although there is a lack of documented evidence as to the educational value of morning report, the practice is ubiquitous across almost all primary care residency programs in North America. The ever-changing practice of medicine and ongoing demands for evidence in medical education force us to examine essential aspects of morning report in order to base future decisions about morning report on sound educational evidence. Thus, a systematic review of the published literature on morning report was done in order to identify the various purposes and modalities of morning report, to find evidence in support of its educational value, and to discuss possible future directions for research on morning report. The term ‘‘morning report’’ is used to describe case-based conferences where residents, attending physicians, and others meet to present and discuss clinical cases. The term includes resident reports, morning or housestaff conferences, and morning sessions but excludes work rounds or teaching rounds. In a typical morning report, the team on duty during the night presents recently admitted patients, followed by a general discussion of the cases and related topics.

XLA-associated neutropenia treatment: A case report and review of the literature

X-linked agammaglobulinemia (XLA) is a primary B-cell deficiency syndrome with an incidence of 5 to 10 cases per million. The current treatment approach includes intravenous immunoglobulin and aggressive antibiotic regimens for infections. Besides recurrent infections, XLA patients may present with other manifestations, such as alopecia, enteropathy, amyloidosis, and neutropenia. Neutropenia, which has been shown in up to 25% of affected patients, might also contribute to the degree of severity of bacterial infections that have been reported in these cases. Here we present our experience with the granulocyte colony-stimulant factor, filgrastim (Neupogen), in the treatment of neutropenia in a 14-month-old child with XLA.

Feasibility of spirometry testing in preschool children

The primary purpose of this study was to evaluate the feasibility of obtaining acceptable and reproducible spirometry data in preschool aged children (3–5 years) by technicians without prior experience with spirometry.

Improved screening for cystic fibrosis-related diabetes by an integrated care team using an algorithm.

To determine whether implementation of a standardized, clinic‐based algorithm improves compliance with cystic fibrosis‐related diabetes (CFRD) screening guidelines.

3D Virtual Worlds: Assessing the Experience and Informing Design

Teams meet in 3D virtual worlds more frequently than ever before, yet the tools for evaluating 3D collaboration environments are underdeveloped. To close the 3D collaboration tool evaluation gap, the authors integrate lessons from the gaming industry and distributed work research. They develop two complementary approaches. First, the individual user’s perspective using eye-tracking (ET) is addressed, and second, the collaborative experience of the group using a technique called All-Views-Qualitative-Analysis (AVQA) is evaluated. The latter integrates the points-of-view of all subjects in a small group collaborating on a creative work task in a 3 dimensional virtual world. The authors show how these techniques enable evaluation of 3D environment design from the perspective of human computer interaction theory and theories related to distributed work. The paper discusses why designers should seek ways to leverage the advantages of 3D collaboration technologies and avoid recreating mirrors of physical space in these environments.

Does Aeroallergen Sensitization Cause or Contribute to Eosinophilic Esophagitis

Eosinophilic esophagitis is an atopic disease defined clinically by esophageal symptoms in combination with a dense esophageal eosinophilia. EoE is triggered and maintained by exposure to certain foods and it is known that dietary modification controls symptoms and achieves disease remission. Recently, aeroallergens have been implicated in the pathogenesis of EoE. To examine the role of aeroallergens in EoE, we reviewed the published literature. Sensitization and production of IgE antibodies to foods and aeroallergens in subjects with EoE has been demonstrated. However, the evidence suggests only a minor role for IgE-mediated immune reactions in EoE. There is some evidence to support an association of EoE diagnosis and flares with environmental allergen exposure, and animal studies support the notion that EoE may be induced by exposure to inhalant allergens. Some studies show that newly diagnosed cases of EoE follow a seasonal pollen distribution (summer and spring), but the weight of evidence does not support the seasonal occurrence of diagnosis or worsening of symptoms. Overall, we conclude that the current evidence does not support causality in inhalant allergen exposure and the genesis nor exacerbations of EoE in humans, although there is a possibility that inhalant allergen sensitization could play a modifying role in EoE in the context of cross-reacting food allergens.

Neuralgic Amyotrophy Associated with Antibiotic Therapy

Objective TO report a case of neuralgic amyotrophy associated with antibiotic therapy. Case Summary: A 22-year-old male with cystic fibrosis had been nonadherent to treatment for 4 years; when he returned to the clinic with symptoms, his forced expiratory volume in 1 second dropped from 84% predicted to 43% predicted. He was admitted to the hospital for treatment after failing to improve on oral ciprofloxacin and inhaled tobramycin. Treatment was initialed with intravenous tobramycin 560 mg daily and piperacillin/tazobactam 4.5 g infused every 6 hours. He continued inhaled tobramycin 300 mg twice daily, his home doses of pancreatic replacement enzymes and vitamins, albuterol 2.5 mg by high flow nebulizer (HFN) 4 times daily, and dornase alpha 2.5 by HFN daily. Sputum cultures were positive for methicillin-resistant Staphylococcus aureus, and intravenous vancomycin 1 g every 8 hours was added to the treatment regimen on hospital day 7. The patient developed bilateral shoulder pain followed by decreased function of his upper extremities 2 days later. He was treated with oral ibuprofen 600 mg every 6 h and oral cyclobenzaprine 5 mg daily, which improved his pain, but the shoulder stiffness remained throughout his hospital stay and persisted for 2 months following discharge. These symptoms resolved but recurred rapidly (within 24 h) and were more debilitating following a second exposure to the same antibiotics at the same doses 8 months later when the patient was readmitted for treatment of another cystic fibrosis-retated pulmonary exacerbation. Discussion: To our knowledge, this is the first case report illustrating neuralgic amyotrophy triggered by exposure to the antibiotics vancomycin, tobramycin, and piperacillin/tazobactam. After analysis of the case, ruling out other possibilities and using the Naranjo probability scale, we found that there is a highly probable likelihood that the symptoms presented by our patient were secondary to his drug therapy. Neuralgic amyotrophy is a rare condition of unknown etiology that has never before been associated with administration of these antibiotics, individually or in combination. Because of the specifics of the clinical history, we were unable to ascertain whether this complication was due to a single antibiotic or to the combination. It is quite possible that vancomycin was the only culprit, but impossible to ensure with the available evidence. Conclusions: Clinicians should be aware of this adverse reaction when facing similar complex neurologic symptoms in patients who are receiving the antibiotic treatment described here, especially vancomycin.

Assessing Multiple Perspectives in Three Dimensional Virtual Worlds: Eye Tracking and All Views Qualitative Analysis (AVQA)

The Human Computer Interaction community is beginning to wrestle with the challenges of effective interaction design for groups collaborating in 3 dimensional virtual worlds. Understanding of the requirements and design processes necessary to support these new technologies is still emerging. While the gaming community has developed heuristics for game design over a 25 year period, the adaptation of this knowledge for the design of virtual collaboration spaces has been limited. Following a research through design approach, we create novel integrations and applications of Human Computer Interaction research methods in an attempt to understand the collaborative work of a small group of individuals in a 3 dimensional virtual world. Specifically, the fine grained perspective provided by eye-tracking (ET), and a more coarse unit of analysis, provided by All-Views-Qualitative-Analysis (AVQA), are applied to understand non-gaming interaction in 3 dimensional virtual worlds. To formalize an integrated method, we describe three lenses for analyzing eye-tracking data in graphics intensive and animated virtual applications. Then, we combine those outcomes with a single method for integrating and analyzing the points-of-view of all subjects in a small group collaborating on a creative work task in a 3 dimensional virtual world. Through these examples, we illustrate the benefits of this type of research for 3 dimensional virtual world designers.

Proceedings of the Annual Hawaii International Conference on System Sciences

The Human Computer Interaction community is beginning to wrestle with the challenges of effective interaction design for groups collaborating in 3 dimensional virtual worlds. Understanding of the requirements and design processes necessary to support these new technologies is still emerging. While the gaming community has developed heuristics for game design over a 25 year period, the adaptation of this knowledge for the design of virtual collaboration spaces has been limited. Following a research through design approach, we create novel integrations and applications of Human Computer Interaction research methods in an attempt to understand the collaborative work of a small group of individuals in a 3 dimensional virtual world. Specifically, the fine grained perspective provided by eye-tracking (ET), and a more coarse unit of analysis, provided by All-Views-Qualitative-Analysis (AVQA), are applied to understand non-gaming interaction in 3 dimensional virtual worlds. To formalize an integrated method, we describe three lenses for analyzing eye-tracking data in graphics intensive and animated virtual applications. Then, we combine those outcomes with a single method for integrating and analyzing the points-of-view of all subjects in a small group collaborating on a creative work task in a 3 dimensional virtual world. Through these examples, we illustrate the benefits of this type of research for 3 dimensional virtual world designers.