Rebecca Thomas

Child protection and domestic violence: Training, practice, and policy issues

This article traces the experiences of four of the five Department of Health and Human Services (DHHS) recipients who received funding to provide domestic violence training to child welfare agencies in four areas of the United States.1 The article begins with the developing research that documents the connection between child abuse and domestic violence and explores the fertile ground for tensions between battered women and their advocates and child protective service (CPS) workers. The article also presents findings from the experiences of the DHHS funded programs, their accomplishments, and the obstacles they faced in integrating domestic violence into child welfare practice with the ultimate goal of protecting the mother-child unit. Finally, it concludes with practice and policy recommendations for researchers and practitioners who are working at the intersection of these abuses.

Esophageal dilation: simple and effective treatment for adults with eosinophilic esophagitis and esophageal rings and narrowing

The goal of this article is to present the results of the long-term treatment with esophageal dilation of a consecutive series of adults with eosinophilic esophagitis (EoE). EoE in adults is a disease of middle aged white males, with recurrent food impactions and dysphagia. The exact treatment of EoE is unknown due to the uncertainty of the pathogenesis. Currently, the long-term follow-up of adult EoE patients is limited. Sixteen consecutive adult patients (12 males/4 females between ages 27 and 58 years) with EoE underwent a detailed history and baseline upper gastrointestinal endoscopy (EGD) with multiple esophageal biopsies. Thirteen had esophageal dilation. Fifteen were on proton pump inhibitor (PPI) therapy. After dilation, one patient was treated with a restrictive diet. One patient took prn fluticasone. Most of the patients had allergy testing for food and aeroallergens. Follow-up evaluation with similar testing was on average 22 months (range: 12-40 months). Six patients were not available for follow-up. None of the remaining 10 patients had a food impaction; one required further esophageal dilation. Only two patients had intermittent dysphagia. The average dysphagia score decreased from 2.1 to 0.3 (P < 0.002). The average number of eosinophils at follow-up was not significantly different from baseline (120 eosinophils/HPF proximally and 165 eosinophils/HPF distally (P= 0.75). The gross endoscopy findings were unchanged in all patients except one who normalized. A total of 62% and 75% of patients had positive tests for aeroallergens and food allergens, respectively. Over an average of two years, esophageal dilation provided excellent symptomatic relief among 10 adult EoE patients despite no improvement in the mucosal eosinophilia or gross endoscopic appearance.

Simplified method of hepatic fibrosis quantification: design of a new morphometric analysis application

Abstract: Introduction: Semiquantitative evaluation of liver specimens is considered the standard method for measuring fibrosis; however, these systems lack the precision of a quantitative technique.

Increased Barrett's esophagus for the decade between 1991 and 2000 at a single university medical center.

Barretts esophagus is being diagnosed increasingly in the United States. The aim of this study was to determine whether the increased diagnosis of Barretts esophagus is due to endoscopic reporting and/or a truly increasing rate. This retrospective study reviewed 18,183 endoscopy reports at Temple University Hospital from January 1991 through December 2000. Annual rates of new cases of endoscopically suspected Barretts esophagus were determined. Biopsy results were reviewed for the diagnosis of Barretts esophagus (i.e., specialized intestinal metaplasia). Rates of Barretts esophagus increased from 3.22 to 8.28 per 100 endoscopies (257%; P < 0.01) on endoscopy and from 0.67 to 2.76 per 100 endoscopies (412%; P < 0.01) on histology from 1991 to 2000. Twenty-four and seven-tenths percent (252/1020) of patients suspected at endoscopy to have Barretts esophagus were confirmed by histology. This study demonstrates an increasing rate of new cases of suspected Barretts esophagus on endoscopy and confirmed Barretts esophagus on histology over the last decade. The endoscopic impression of Barretts esophagus was about four times higher than the confirmed diagnosis of Barretts esophagus (intestinal metaplasia) on histology.

A decade (1991–2000) of increasing incidence of endoscopic and histologic Barrett’s esophagus (BE) at a single academic medical center

Purpose: BE is being diagnosed increasingly by endoscopists. The aim of this study was to determine whether increased EGD reporting of BE can be confirmed histologically, and whether it represents a true increasing incidence of BE or is the result of increasing number of EGDs.

Acoustic Liver Biopsy in Patients with Hepatitis C and Advanced Liver Fibrosis Using Endoscopic Ultrasound

BackgroundTransabdominal ultrasound cannot be used to quantitate fibrosis in patients with advanced liver fibrosis due to variability in the abdominal wall thickness and composition. This variability can be eliminated by using endoscopic ultrasound.AimThe purpose of this study was to determine the amount of fibrosis in the liver of hepatitis C patients with advanced fibrosis using endoscopic ultrasound.MethodsEndoscopic ultrasound images of the liver were recorded by keeping the gain, contrast, frequency, magnification and acoustic power constant on the ultrasound processor. Videotaped images of the liver were digitized on Image-Pro Plus software. Using adobe Photoshop, a histogram was produced to quantitate the luminosity of the five areas of interest per image. Quantification of the ultrasound images were done by two independent investigators blinded to the Ishak liver fibrosis score. The mean luminosity of the ultrasound images were compared with the Ishak fibrosis score. The study was performed in seven patients (mean age 54xa0years; 3 male, 4 female) with hepatitis C and advanced liver fibrosis.ResultsThe correlation between the two independent investigators for the ultrasound images was 0.93. The correlation between the mean luminosity on ultrasound images to the Ishak fibrosis score was rxa0=xa00.77, rxa0=xa00.72 and rxa0=xa00.73 for the most hyperechoic area of interest, total hyperechoic area and for the entire liver, respectively.ConclusionA new technique was developed that uses endoscopic ultrasound to evaluate the degree of fibrosis in patients with advanced liver fibrosis. There is a good correlation between the luminosity on endoscopic ultrasound and the Ishak fibrosis score.

Su1443 Gastric Neuromuscular Pathology and Therapeutic Outcome of Gastric Electric Stimulation in Patients With Refractory Gastroparesis

Treatment of gastroparesis (GP) often requires long-term adherence to dietary modifications and medications. Patient beliefs on internal (self) and external (others) control of their health and patient empowerment (self activation) have been shown in other chronic diseases to impact disease presentation and outcome. AIMS: 1) Compare health locus of control and patient activation in patients with diabetic (DG) and idiopathic (IG) gastroparesis; and 2) Compare health locus of control and patient activation measure in patients with delayed gastric emptying to patients with similar symptoms but normal gastric emptying.METHODS: This prospective study evaluated patients from June 2014 to October 2014 referred for refractory symptoms of gastroparesis. Patients completed Patient Assessment of Upper GI Symptoms (PAGI-SYM), Multidimensional Health Locus of Control (MHLOC), and Patient Activation Measure (PAM-13). MHLOC measures three localizations of health control: internality (belief that health status depends only on personal decision and behaviors); chance externality (belief that health status is determined by chance, fate or luck), and powerful others externality (conviction that health depends on powerful people such as doctors, family members or close friends). RESULTS: 40 patients with refractory gastroparesis symptoms were evaluated. Of the 31 patients with delayed GES, 8 were diabetic and 19 idiopathic. Patient activation scores were similar between normal GES vs delayed GES (61.1±14.9 [SD] vs 57.9±12.1) and DG vs IG (58.6±12.7 vs 58.4±12) (Table 1). These activation scores translate to patients beginning to take action to self-manage their own disease (Level 3). Abdominal pain was negatively correlated to PAM scores in patients with delayed gastric emptying (r=-0.30; p=0.09). When evaluating localization of health control, powerful others externality was higher in patients with delayed GES compared to normal emptying (3.4±0.9 vs 2.9±0.7; p=0.16) and DG compared to IG (3.9±0.9 vs 3.2±0.9; p= 0.11) (Table 2). The other localizations such as internality and chance externality were similar when comparing patients with normal GES to delayed GES and DG to IG. DISCUSSION: This study investigates the role of internal and external control and patient activation in patients with gastroparesis. Our study suggests higher abdominal pain severity scores were related to lower activation levels. Furthermore, patients with delayed gastric emptying tend to have higher scores for powerful others externality compared to patients with normal gastric emptying. Within the subset of GP, patients with DG had higher scores for powerful others externality. These results suggest a reliance of patients with gastroparesis, especially diabetic patients and those with abdominal pain, on powerful others (including physicians), rather than themselves. Table 1. Patient Activation Measure in patients with normal GES vs delayed GES and diabetic GP vs idiopathic GP

Pathology of Gastroparesis

While symptoms of gastroparesis are defined, the pathogenesis of this condition is poorly understood. Furthermore, gastric emptying scintigraphy, the gold standard for diagnostic testing, does not correlate with symptom severity. Some patients with the classic constellation of symptoms for gastroparesis have normal or near-normal gastric emptying patterns. Uncertainty of underlying pathophysiology underscores the struggle to develop effective therapies. The inability of the stomach to effectively empty its solid and liquid contents into the duodenum in the absence of a mechanical obstruction defines gastroparesis. Gastric emptying is dependent on well-coordinated efforts by multiple components in the gastric wall. Different cells, structures, and mechanisms are hypothesized to be responsible for gastroparesis. Currently, however there is a lack of histopathologic evidence to substantiate most of these hypotheses.

1087 Gastric Interstitial Cells of Cajal Quantification on Full Thickness Gastric Biopsy Provides Prognostic Information for Treatment Responses to Gastric Electric Stimulation

and SMW total scores remained when analysis was limited to normal or delayed gastric emptying (p<0.05, p<0.05). Only 13% (3/24) needed tube feeds and 13% (3/24) parenteral nutrition after GES. School absences decreased from 57% to 31% of school days. Overall, 65% (13/20) reported their health was much improved after GES versus 15% (3/20) the same or worse. The majority (15/20) were satisfied with GES. Three were not satisfied due to lack of improvement, one developed back pain and another was later diagnosed with an eating disorder. Five reported complications. Four had discomfort or tenderness at the implantation site and another had a dead battery. Conclusions: In the largest series to date of pediatric patients who have undergone GES for GP and/or FD, we have found significant and sustained improvement not only in upper GI symptoms but also in quality of life and perception of global health. Patients were less dependent on tube feeding or parenteral nutrition and had fewer school absences. The majority is satisfied with the decision to place GES. Future studies are needed to assess for possible placebo effect and to evaluate predictors of outcome and long-term prognosis.

Antiviral Treatment for Hepatitis C Cirrhosis: Is the Effort Justified?

Cirrhosis resulting from chronic hepatitis C virus (HCV) infection occurs in 20% to 40% of infected individuals. Chronic HCV infection is the most common cause of cirrhosis in the United States (1) and is the most common diagnosis that leads to liver transplantation, and in many parts of the world, it is the leading disease associated with hepatocellular carcinoma (2). The prevalence of hepatitis C in the U.S. population has been estimated at 1.8% (3). This estimate, derived from NHANES III (Third National Health and Nutrition Examination Survey) data obtained from 1988 to 1994, is conservative; NHANES excluded incarcerated and homeless persons, groups that have high rates of HCV infection, and tested only a single sample for each participant. Furthermore, ongoing immigration of persons from countries with a high prevalence of hepatitis C continually swells the numbers of people with hepatitis C in the United States. Most persons infected with hepatitis C are asymptomatic until they present with advanced disease after a 20- to 30-year silent period of chronic infection. Although some groups champion widespread screening for HCV infection (4), others actively discourage screening all persons at average risk for HCV infection (5). Regardless, clinicians do diagnose HCV infections and must make therapeutic decisions about treating these infections in asymptomatic persons. A variety of treatments are available. Natural interferon can eradicate virus, and a combination of ribavirin with pegylated (synthetic) interferon can help clear virus and prevent progression of liver disease and development of hepatocellular carcinoma (6, 7). These treatments, however, cause adverse effects, such as fatigue, depression, and hematologic problems. Many patients cannot tolerate these effects, and drug withdrawals are particularly frequent when treating previously asymptomatic patients. Treatment of cirrhotic patients is often considered too late in the natural history of progressive liver disease to be worthwhile. The concept of treating cirrhotic patients, however, has recently gained popularity for several reasons. First, eradication of virus seemingly confers some degree of protection against development of hepatocellular carcinoma (8). Second, viral clearance before liver transplantation avoids development of posttransplantation recurrent hepatitis C (thereby obviating the need for posttransplantation antiviral therapy) (9). Third, viral eradication is sometimes accompanied by reversal of cirrhosis, as Mallet and colleagues document in this issue (10). Finally, histopathologically documented regression of cirrhosis seems to be associated with decreased risk for disease-related morbidity and with improved survival rates (10). Although improved histologic appearance has been reported previously after viral eradication in hepatitis C cirrhosis, Mallet and colleagues further demonstrate that the documented improvement in histology is associated with a reduction in cirrhosis-related complications and prolonged survival. They thereby extend the findings of Veldt and associates (11), who showed improved outcome in patients with advanced fibrosis who were successfully treated for hepatitis C. Of note, Mallet and associates also documented reversal of cirrhosis in a patient who remained viremic after antiviral treatment. Shiffman and coworkers (12) reported this type of outcome in their cohort, which led to formulation of 2 long-term maintenance treatment investigations (interferon in the HALT-C [Hepatitis C Long-term Treatment Against Cirrhosis] study and PILOT 1). Neither of these investigations demonstrated improved outcomes in the absence of viral elimination. Reversibility of fibrosis in cirrhosis has been well documented after treatment for several specific diseases. For example, investigators have reported reversibility for hemochromatosis (13), Wilson disease (14), autoimmune hepatitis (15), primary biliary cirrhosis (16), secondary biliary cirrhosis, hepatitis B, hepatitis C (17), and hepatitis D. In 1 large study of patients with hepatitis C, 49% showed regression of fibrosis after treatment (18), whereas in the smaller group of patients with hepatitis D, 4 of 36 who started with active cirrhosis and received high-dose interferon had no fibrosis on the last liver biopsy, which was performed a mean of 11.5 years after completion of therapy. All 8 patients with autoimmune hepatitis and cirrhosis or extensive fibrosis had a marked reduction in or disappearance of fibrosis after treatment. Documentation of such reversal requires the 4 following techniques: at least 1 pretreatment and at least 1 posttreatment liver biopsy; a formalin-fixed, paraffin-embedded, Masson trichrome-stained liver tissue sample that is at least 2.5 cm in length (which is still only 1/50000 to 1/200000 of the liver); use of standard methods for evaluation of fibrosis with the Ishak, METAVIR (19), or Scheuer scoring system; and review by a single pathologist. Multiple cores of liver tissue, ideally from different parts of the liver, will greatly increase the reliability of the evaluation and minimize sampling errors. The diameter of the core of tissue should be as large as possible: Macronodular cirrhosis is more likely to be downgraded on needle biopsy, because the diameter of the nodule may exceed the diameter of the tissue core. The most widely used systems for the staging of fibrosis are the METAVIR and Ishak systems; the METAVIR system contains grades from F0 (no fibrosis) to F4 (cirrhosis) and is easier to use because it has fewer categories, but the Ishak system, which has categories from 1 (some fibrosis portal expansion) to 5 (precirrhosis) and 6 (cirrhosis), allows finer tuning. Patterns of fibrosis are different in different diseases. Perisinusoidal and perivenular fibrosis dominate in alcoholic liver disease and nonalcoholic fatty liver disease. Portal, septal (portal to central vein, or portal to portal), and bridging fibrosis are more common in viral hepatitis, autoimmune hepatitis, and primary biliary cirrhosis. Certain aspects of fibrosis seem to be more amenable to regression: perisinusoidal fibrosis more than portal fibrosis, delicate fibrosis more than broad bands of fibrosis, and early cirrhosis more than established cirrhosis. Regression of fibrosis after treatment is separate from the other components of cirrhosis, namely, regenerative nodules and vascular shunting. It is generally conceded that fibrosis becomes irreversible at some point in cirrhosis, thus reinforcing the need for early treatment. Despite these observations and reservations, the implied belief that the scarring in the cirrhotic liver is permanent is no longer tenable. Rather, cirrhosis is, for at least some period, a dynamic process with biochemical events that underpin collagen deposition. This process justifies current efforts to identify compounds that might affect the chemistry of fibrosis (20). In conclusion, the answer to the question posed in the title of this editorial is a qualified yes: Treat patients with hepatitis C cirrhosis with antiviral therapy as long as they can tolerate the treatment. Such patients may have much to gain from a short period of discomfort.