Oklahoma University Medical Center Research Articles

Effect of CFTR modulator therapy on cystic fibrosis-related diabetes

Half of adults with cystic fibrosis (CF) develop CF-related diabetes (CFRD). CFRD contributes to worsened pulmonary function and malnutrition. We undertook this study to determine the effect of cystic fibrosis transmembrane regulator (CFTR) modulators on CRFD. We reviewed the medical records of adults with CF who followed in the CF clinic at Oklahoma University Medical Center. We collected data for age at diagnosis of CF and CFRD, CF mutations present, first date of ivacaftor therapy either alone or in combination, insulin use, pulmonary function, body mass index data, and home glucose monitoring results. Clinical resolution of CFRD was taken as discontinuation of routine insulin and resolution of high interstitial home glucose values. We identified 69 adult CF patients, of whom 31 had CFRD. Among these 14 CFRD patients taking ivacaftor alone or in combination, four patients completely stopped using insulin. Another patient went from three times a day pre-prandial insulin to using insulin once a week. Home blood glucose and hemoglobin A1c values supported resolution of CFRD. Three patients continued to have hypoglycemia despite stopping insulin. No CFRD patient not taking CFTR modulators markedly changed the insulin regimen. Pulmonary function was preserved in those patients with resolved CFRD (FEV1 +6.75% ±7.6), whereas it worsened in CFRD patients who either were not taking CFTR modulators (FEV1 -2.09% ±3.9) or who had no response of CFRD status (FEV1 -4.9% ±7.6). About one-third of patients on CFTR modulator therapy had resolution or near resolution of CFRD.

Epidemiology, Clinical Presentation, and Seasonal Variation in the Diagnosis of Children with Eosinophilic Esophagitis in Oklahoma.

Eosinophilic esophagitis (EoE) is characterized by upper gastrointestinal tract symptoms in association with esophageal mucosal biopsy specimens containing ≥15 intraepithelial eosinophils per high-power field. The etiology of EoE remains unclear, but an immunologic response to various foods and aeroallergens has been implicated. Seasonal variation has been reported in the diagnosis of EoE. The epidemiology and seasonal variation of EoE has never been studied in Oklahoma. The aim of this retrospective study was to determine epidemiology, clinical presentation, and seasonal variation of EoE in children seen from 2008 to 2015 at The Children's Hospital at Oklahoma University Medical Center (OUMC). This was a single-center study involving the medical records of children aged 0 to 18 years with a diagnosis of EoE at OUMC in the Department of Pediatric Gastroenterology from January 2008 to December 2015. All charts with "eosinophilic esophagitis" in the diagnostic search history were reviewed. A diagnosis of EoE was defined as presence of ≥15 eosinophils per high-power field in the esophageal mucosal biopsy. The data extracted from the medical records included demographics, previous proton pump inhibitor use prediagnosis, clinical presentation, blood and skin allergy testing, and month of diagnosis. Seasons were distributed as spring (March-May), summer (June-August), fall (September-November), and winter (December-February). Seventy-nine patients with a diagnosis of EoE were seen at OUMC between 2008 and 2015. One patient was excluded because of insufficient medical records. The average age (±standard deviation) at diagnosis was 7.5 (±4.92) years with an age range of 1 to 17 years. χ2 analysis showed a significant sex distribution, with 72% males and 27% females (P = 0.0001). The most common presenting symptoms were dysphagia (35%) and vomiting (28%). When patients were grouped seasonally using the χ2 test, there was an increase in the diagnosis of EoE cases during the spring months when compared with other seasons (P = 0.0006). Forty-five percent of patients were diagnosed in the spring, 22% in the fall, 19% in the summer, and 14% in the winter. Our data demonstrate that there is a seasonal variation in the diagnosis of EoE, with more cases diagnosed in the spring months. These findings relate to the increase in aeroallergens and pollen distribution during the spring months in Oklahoma.

1208: HIGH- VERSUS LOW-DOSE DEXAMETHASONE TO PROMOTE PEDIATRIC EXTUBATION SUCCESS

1Medical University of South Carolina, Charleston, SC 2Children’s Hospital at Oklahoma University Medical Center, Oklahoma City, OK 3Medical University of South Carolina, Charleston, SC

Platelet Counts During Pregnancy

(N Engl J Med. 2018;379:32–43) In the present study, the authors evaluated platelet counts in women (15 to 44 y of age) who delivered at the Oklahoma University Medical Center between 2011 and 2014. Their objectives were to (1) evaluate the potential severity of gestational thrombocytopenia (<150,000 platelets/mm3 at the time of delivery) in uncomplicated pregnancies and risk for recurrence, (2) determine whether there was a relationship between identified pregnancy complications and platelet counts, and (3) ascertain associations between preexisting disorders and thrombocytopenia and any impact on pregnancy course.

Platelet Counts during Pregnancy

BackgroundPlatelet counts of less than 150,000 per cubic millimeter during uncomplicated pregnancies are described as gestational thrombocytopenia if no alternative cause is identified. Platelet counts may be even lower in women with pregnancy-related complications. However, the occurrence and severity of thrombocytopenia throughout pregnancy are not defined.MethodsWe evaluated platelet counts throughout pregnancy in women who delivered at Oklahoma University Medical Center between 2011 and 2014. These platelet counts were compared with those of nonpregnant women who were included in the National Health and Nutrition Examination Survey from 1999 through 2012.ResultsAmong the 15,723 deliveries that occurred during the study period, 7351 women had sufficient data for our analyses. Of these women, 4568 had uncomplicated pregnancies, 2586 had pregnancy-related complications, and 197 had preexisting disorders associated with thrombocytopenia. Among the women who had uncomplicated pregnancies, the mean platelet count in the first trimester (mean gestation, 8.7 weeks) was 251,000 per cubic millimeter, which was lower than the mean platelet count in the 8885 nonpregnant women (273,000 per cubic millimeter) (P<0.001). At the time of delivery, 9.9% of the women with uncomplicated pregnancies had a platelet count below 150,000 per cubic millimeter. During the course of the uncomplicated pregnancies and deliveries, only 45 women (1.0%) had a platelet count below 100,000 per cubic millimeter. Among the 12 women with uncomplicated pregnancies who had a platelet count below 80,000 per cubic millimeter, only 5 (0.1%, among whom the range of platelet counts was 62,000 to 78,000 per cubic millimeter; median, 65,000) were identified by medical record review as having no alternative cause for the thrombocytopenia. Platelet counts of less than 150,000 per cubic millimeter at the time of delivery were more common among women who had pregnancy-related complications than among women who had uncomplicated pregnancies (11.9% vs. 9.9%, P=0.01). Throughout their pregnancies and deliveries, 59 women (2.3%) with pregnancy-related complications had a platelet count below 100,000 per cubic millimeter, and 31 (1.2%) had a platelet count below 80,000 per cubic millimeter.ConclusionsMean platelet counts decreased during pregnancy in all the women, beginning in the first trimester. In women who have a platelet count of less than 100,000 per cubic millimeter, a cause other than pregnancy or its complications should be considered. (Funded by the National Heart, Lung, and Blood Institute.)

A Hybrid Form of Telemedicine: A Unique Way to Extend Intensive Care Service to Neonates in Medically Underserved Areas.

More than 90% of neonatal intensive care units (NICUs) in the United States are in urban areas, denying rural residents' easy NICU access. Telemedicine use for patient contact and management, although studied in adults and children, is understudied in neonates. A hybrid telemedicine system, with 24/7 neonatal nurse practitioner coverage and with a neonatologist physically present 3 days per week and telemedicine coverage the remaining days, was recently implemented at Comanche County Memorial Hospital's (CCMH) Level II NICU. To compare outcomes of moderately ill infants between 32-35 weeks gestational age (GA) managed by our hybrid telemedicine program with outcomes of similar neonates receiving standard care in a Level IV NICU at Oklahoma University Medical Center (OUMC). This was a retrospective, noninferiority study comparing outcomes of neonates receiving hybrid telemedicine versus standard care. All 32-35 weeks GA infants admitted between July 2013 and June 2015 were included. OUMC infants came from areas geographically comparable with CCMH. Infants requiring prolonged mechanical ventilation or advanced subspecialty services were excluded. Outcome variables were length of stay, type and duration of respiratory support, length of antibiotic therapy, and time to full enteral feedings. Eighty-seven neonates at CCMH and 56 neonates at OUMC were included in the analysis. Compared with neonates at OUMC, neonates at CCMH had shorter hospitalizations, fewer days of supplemental oxygen, and fewer noninvasive ventilation support days, and reached full enteral feeds sooner. The hybrid telemedicine system is a safe and effective strategy for extending intensive care to neonates in medically underserved areas.

Clinical Chemistry Residency Training Program at the Oklahoma University Medical Center.

At the University of Oklahoma Health Sciences Center Department of Pathology, we view excellence in training in clinical chemistry as an important element of our highly regarded clinical pathology residency training program. Over the years, this program has evolved into essential components that overall have proven to be most effective in producing high-quality clinical pathologists. These components are described below. ### Clinical Chemistry Training Overview Our chemistry resident teaching rotation consists of 14-week blocks (Table 1) that span 3 separate months of training in chemistry as well as other areas of the automated core laboratory, including phlebotomy, specimen processing and receiving, point-of-care testing, toxicology, endocrinology, hematology, coagulation, urinalysis, and specimen referral testing. The 3 separate months include introductory training (first-year residents), intermediate training (second-year residents), and advanced training (third- and fourth-year residents) in an effort to make our program progressive and therefore consistent with Accreditation Council for Graduate Medical Education (ACGME) (1) accreditation requirements. This progressive training “journey” allows a resident to gradually assume the role of a fully competent Laboratory Director. View this table: Table 1. Topics covered in a 14-week clinical chemistry residency training. The textbooks used for the chemistry rotation are The Professional Practice in Clinical Chemistry: A Review (2), Contemporary Practice in Clinical …

Pediatric News

The Pediatric Pharmacy Advocacy Group presented the Lexi-Comp Best Practice Awards at the 22nd Annual PPAG Meeting and 2013 Pediatric Pharmacy Conference on May 4, 2013 in Indianapolis, Indiana. To be considered for the award, practitioners must submit a description of their program. Awards are evaluated based upon innovation, creativity, cost effectiveness, improvement in practice and leadership. All pediatric pharmacy practitioners are eligible and encouraged to apply.Shannon Manzi, PharmD, from Children’s Hospital Boston was recognized for her implementation of a pharmacist-led pharmacogenomics service. Shannon is currently the Director of the Clinical Pharmacogenomics Service at Children’s Hospital Boston. She is also the team leader for Emergency and Combined Services in the Department of Pharmacy. She graduated from the University of Rhode Island’s PharmD program in 1996. She has practiced pediatric pharmacy for over 15 years, and pediatric emergency pharmacy for 10 years. You can read more about this Best Practice here: http://www.ppag.org/22AM/Manzi_A.pdfJackie Magers, PharmD, BCPS, Kristen Gawronski, PharmD, and Lindsay Schray, PharmD received recognition for their work targeting higher Vancomycin Trough Concentrations in neonates. Jacqueline K. (Schneider) Magers graduated from Jamestown College, Jamestown, ND in 2001 with a BA in Biochemistry and Summa Cum Laude honors. She earned her Doctorate of Pharmacy from The Ohio State University in 2001 with Summa Cum Laude honors. She went on to complete a general practice pharmacy residency at The Nebraska Medical Center and a specialty residency in Neonatology and Women’s Health at The Ohio State University. Currently Jackie works at Nationwide Children’s Hospital in Columbus, Ohio as a NICU Clinical Pharmacy Specialist. Topics of interest include infectious disease, nutrition and pulmonary hypertension. To learn more, please click here: http://www.ppag.org/22AM/Magers.pdf“The Presidential Chairman's Citation' is chosen annually by the sitting president of the Pediatric Pharmacy Advocacy Group (PPAG) and is awarded to an individual that has made a significant and direct impact on the organization. This year’s president, Amy Potts, PharmD, selected Peter Johnson, PharmD an associate professor at the University of Oklahoma. Dr. Johnson received this accolade in recognition of his outstanding service as PPAG’s representative on the Taskforce that recognize Pediatric Pharmacy as a Pharmacy Specialty. The Taskforce was a joint effort of the American College of Clinical Pharmacy, American Society of Health-System Pharmacists and PPAG. Dr. Johnson received his doctor of pharmacy from the University of Mississippi School of Pharmacy in 2004 and completed a PGY1 and PGY2 residencies at the University of Kentucky Chandler Medical Center in Lexington, KY. He is currently an assistant professor in the College of Pharmacy and adjunct assistant professor in the Department of Pediatrics-Section of Critical Care at the University of Oklahoma. Dr. Johnsons is currently a Clinical Pharmacy Specialist-Pediatric Critical Care at the Children’s Hospital at Oklahoma University Medical Center. The Citation was presented on May 3, 2013 at the 22nd Annual PPAG Meeting in Indianapolis, Indiana.The American College of Clinical Pharmacy (ACCP), the American Pharmacists Association (APhA), the American Society of Health-System Pharmacists (ASHP), and the Pediatric Pharmacy Advocacy Group (PPAG) jointly submitted a petition to the Board of Pharmacy Specialties (BPS) requesting recognition of Pediatric Pharmacy Practice as a Specialty. In response to that petition the BPS Board of Directors has voted to recognize pediatric pharmacy as a BPS Specialty. Peter Johnson, PharmD from the University of Oklahoma represented PPAG on the joint task force. Others on the task force included Lea Eiland, PharmD (ASHP), Marcia Buck, PharmD (ACCP), and Chasity Shelton, PharmD (APhA).BPS issued a call for nominations to serve on the Pediatric Pharmacy Specialty Councils and will appoint a 9-member council, which will convene in the Fall of 2013. Examination item writing for the new specialty exam will begin between the fourth quarter of 2013 and the first quarter of 2014 with the first exam being administered in 2015.For more information from BPS, please direct your browser to: http://bpsweb.org/news/pr_041513.cfm.“The Spirit of PPAG Award” recognizes outstanding member contributions to the Association. The recipients of this Award embody and exemplify the values of PPAG and inspire action in others. The Award recognizes those “behind the scene” contributors that usually go unnoticed, but are not less important. Recipients are chosen by peers working on committees or on particular projects. Recipients are officially recognized at the “Town Hall Business Meeting” during the PPAG Annual Meeting each year. This year recipients are Drs. Crumby, Nichols and Whitmore.Ashley Crumby, PharmD, Assistant Clinical Professor at Purdue University, for her contributions to the Education Committee coordinating hospital tours of Riley Children’s Hospital. Kristen Nichols, PharmD, Assistant Professor at Butler University, for her contributions to the Education Committee coordinating hospital tours of Riley Children’s Hospital. Maria Whit-more, PharmD, Pediatric Critical Care Clinical Pharmacist at Peyton Manning Children’s Hospital, for her contributions to the Education Committee coordinating hospital tours of Peyton Manning Children’s Hospital at St. Vincent.

Providing Critical Laboratory Results on Time, Every Time to Help Reduce Emergency Department Length of Stay

To develop a fully automated core laboratory, handling samples on a "first in, first out" real-time basis with Lean/Six Sigma management tools. Our primary goal was to provide services to critical care areas, eliminating turnaround time outlier percentage (TAT-OP) as a factor in patient length of stay (LOS). A secondary goal was to achieve a better laboratory return on investment. In 2011, we reached our primary goal when we calculated the TAT-OP distribution and found we had achieved a Six Sigma level of performance, ensuring that our laboratory service can be essentially eliminated as a factor in emergency department patient LOS. We also measured return on investment, showing a productivity improvement of 35%, keeping pace with our increased testing volume. As a result of our Lean process improvements and Six Sigma initiatives, in part through (1) strategic deployment of point-of-care testing and (2) core laboratory total automation with robotics, middleware, and expert system technology, physicians and nurses at the Oklahoma University Medical Center can more effectively deliver lifesaving health care using evidence-based protocols that depend heavily on "on time, every time" laboratory services.

Implementing a Monthly Interdisciplinary Team Meeting to Promote Optimal Outcomes for High‐Risk Obstetric Patients and Their Newborns

Purpose for the Program Coordination of care for high‐risk obstetric patients and their infants is vital to promoting optimal outcomes. When an obstetric patient receives a diagnosis of some form of fetal anomaly, she begins to receive close follow‐up care and supervision. The patient also needs to obtain additional information about the fetal diagnosis and have questions answered. Information can be provided by prenatal consults with a neonatologist or other pediatric specialists that will be involved with the infant's care after delivery and by other personnel, such as nurses, social workers, and hospital chaplains. A coordinated plan of care promotes the exchange of information between physicians and all other healthcare professionals involved in care of the mother and infant. Proposed Change To develop a comprehensive plan of care for both mother and infant. Under the direction of an obstetric geneticist at the Oklahoma University Medical Center, an interdisciplinary team was developed. All staff that might be involved with planning and coordination of care were invited to the initial meeting. A discussion was held to review the basic format of the proposed monthly meeting. All in attendance agreed to the model. Implementation, Outcomes, and Evaluation A spreadsheet was developed to enter each month's new patients. The data in the spreadsheet included basic demographic information, expected date of delivery, parity, fetal diagnosis, maternal issues, and the suggested plan of care. At each monthly meeting, each patient that was new to the system was discussed and ultrasound images were provided for review. Furthermore, the upcoming planned deliveries for the month were also discussed. This provided time for the multidiscipline professionals to come together and review complex cases to plan for the most comprehensive care. The monthly meeting has now been in place for 3 years and continues to evolve. It has been very successful in providing a venue for multidisciplined healthcare professionals to be informed of the patients and provide their input into the plan of care. Implications for Nursing Practice Nursing leadership for women's services and the neonatal intensive care unit (NICU) attend the meetings. A weekly updated case list is used to inform of patient delivery plans and potential admissions to the NICU. This knowledge can be communicated to staff as needed and used in considering availability of beds, staffing needs, and needs for specialized staff availability for certain deliveries. Coordination of care for high‐risk obstetric patients and their infants is vital to promoting optimal outcomes. When an obstetric patient receives a diagnosis of some form of fetal anomaly, she begins to receive close follow‐up care and supervision. The patient also needs to obtain additional information about the fetal diagnosis and have questions answered. Information can be provided by prenatal consults with a neonatologist or other pediatric specialists that will be involved with the infant's care after delivery and by other personnel, such as nurses, social workers, and hospital chaplains. A coordinated plan of care promotes the exchange of information between physicians and all other healthcare professionals involved in care of the mother and infant. To develop a comprehensive plan of care for both mother and infant. Under the direction of an obstetric geneticist at the Oklahoma University Medical Center, an interdisciplinary team was developed. All staff that might be involved with planning and coordination of care were invited to the initial meeting. A discussion was held to review the basic format of the proposed monthly meeting. All in attendance agreed to the model. A spreadsheet was developed to enter each month's new patients. The data in the spreadsheet included basic demographic information, expected date of delivery, parity, fetal diagnosis, maternal issues, and the suggested plan of care. At each monthly meeting, each patient that was new to the system was discussed and ultrasound images were provided for review. Furthermore, the upcoming planned deliveries for the month were also discussed. This provided time for the multidiscipline professionals to come together and review complex cases to plan for the most comprehensive care. The monthly meeting has now been in place for 3 years and continues to evolve. It has been very successful in providing a venue for multidisciplined healthcare professionals to be informed of the patients and provide their input into the plan of care. Nursing leadership for women's services and the neonatal intensive care unit (NICU) attend the meetings. A weekly updated case list is used to inform of patient delivery plans and potential admissions to the NICU. This knowledge can be communicated to staff as needed and used in considering availability of beds, staffing needs, and needs for specialized staff availability for certain deliveries.

Determining a definite diagnosis of primary immune thrombocytopenia by medical record review

The objective of this study is to establish a method to identify patients with primary immune thrombocytopenia (ITP) utilizing administrative data from diverse data sources that would be appropriate for epidemiologic studies of ITP, regardless of patients' age and source of health care. Medical records of the Oklahoma University Medical Center, 1995-2004, were reviewed to document the accuracy of the administrative code ICD-9-CM 287.3 for identifying children and adults with ITP, using novel, explicit levels of evidence to identify patients with a definite diagnosis. The proportion of patients diagnosed by hematologists compared to non-hematologists and the proportion of patients diagnosed as outpatients compared to inpatients were determined. For children, age <16 years, 323 outpatient medical records were reviewed; 225 adult outpatient medical records were reviewed. The positive predictive value for the administrative code for identifying patients with a definite diagnosis of ITP by a hematologist was 0.72 in children and 0.69 in adults. In 98% of children and 92% of adults seen as outpatients, the definite diagnosis of ITP was established by a hematologist. One hundred eighteen child and 141 adult inpatient medical records were reviewed. In 95% of children and 83% of adults, the definite diagnosis of ITP by a hematologist was established as an outpatient. This study confirmed the previously reported positive predictive value for the administrative code for identifying patients with ITP. Additionally, it was determined that analysis of hematologists' outpatient administrative codes identified most children and adults with ITP. Am. J. Hematol. 2012. © 2012 Wiley Periodicals, Inc.

Lactation Rounds: A System to Improve Hospital Productivity

Currently, there are no national guidelines on appropriate staffing for hospital lactation, and a central goal in today's health care climate is to provide optimal patient care while making the best use of available resources. This article describes a successful effort to improve patient care, lactation productivity, and employee satisfaction through a system of lactation rounds at Oklahoma University Medical Center (OUMC). Outcomes included more accurate data collection and distribution of resources for patient care, increased lactation service productivity, and increased employee satisfaction.

All-Terrain Vehicle Injuries in Children

All-terrain vehicles (ATVs) were introduced in the early 1970s. Injury rates in children and adolescents were alarming. The Consumer Products Safety Commission 2002 annual report revealed 5239 deaths attributed to ATVs between 1982 and 2002. One third (n = 1706) involved children younger than 16 years. The Consumer Products Safety Commission entered into a 10-year decree with ATV manufacturers in 1988 in an attempt to decrease ATV injuries and deaths. The purpose of this study was to assess the experience at the Oklahoma University Medical Center Level 1 Trauma Center by review of the trauma registry for patients younger than 16 years injured in ATV accidents. A retrospective review of the trauma registry was performed in children younger than 16 years who presented as a result of injury attributed to 3- or 4-wheel ATVs since 2001. A total of 73 patients fit the search description. The average age was 9.9 years. The average Injury Severity Score was 10.3 (Level 1 trauma, 20.0; Level 2 trauma, 8.3). All 4 deaths were attributed to head injury (average age, 12.5 years.). The most common injuries were extremity fractures (36 fractures), head injury (33 injuries), and facial trauma (20 injuries). Of the fractures, 8 were open (6 upper extremities all around the elbow and 2 lower extremity tibia fractures). Extremity fractures occurred in nearly half of our patients with a slightly higher number of upper extremity injuries. The rate and severity of fractures about the elbow is especially alarming. All-terrain vehicle injuries involving children continue to be a concern. Despite the 1988 decree, ATV injuries continue to be a significant source of morbidity and mortality among children. Orthopaedic injuries of the extremities are common in these patients. In this series, the only cause of death was head injury. Orthopaedic injuries are the norm in children and adolescents injured in ATV accidents. Although some legislation is in place, the level of compliance is unclear. Legislation requiring helmet use and age limits failed in Oklahoma this year. Perhaps a comprehensive community education program would be the most effective in decreasing ATV morbidity and mortality in children.

Lynn Walters, MSN, MBA, RNC, CNAA, BC and Patricia Reid Ponte, RN, DNSc, FAAN

Editor's note: Nurse Leader is pleased to bring you a closer look at the 2005 winners of the American Organization of Nurse Executives' annual awards. All winners have been asked to describe their work in their own words. The third installment of this special online-only section features the recipients of the Organizational Innovation Nurse Director Award, Lynn Waters, MSN, MBA, RNC, CNAA, BC, and the McKesson "Keeping Patients Safe" Award, Patricia Reid Ponte, RN, DNSc, FAAN.

Accumulation of the p53 tumor-suppressor gene product in oral leukoplakia

(1) To determine whether the protein of the suppressor gene p53 accumulates in leukoplakia of the oral cavity in individuals who use snuff; and (2) to determine whether a correlation exists between the accumulation of p53 protein and the degree of epithelial dysplasia present in oral leukoplakia.Retrospective analysis of archival tissue specimens.The University Hospital, a tertiary referral hospital affiliated with the Oklahoma University Medical Center, Oklahoma City, Oklahoma.In the first part of the study, biopsy specimens of leukoplakia from 12 persons who used snuff were compared with specimens from uninvolved oral mucosa of the same persons and with biopsy specimens from 12 nontobacco-using persons. In the second part of the study, accumulation of p53 protein was determined in 42 archival paraffin-embedded specimens from oral leukoplakia and correlated with the degree of epithelial dysplasia.Accumulation of p53 protein was assessed by immunoperoxidase staining with four different primary antibodies. Positive cells were counted in five consecutive high-power fields.In part one, the average number of positive cells in the leukoplakia of snuff-users (21.89 +/- 4.33; mean +/- SE) was higher than that of normal-appearing mucosa (4.00 +/- 1.0; p < 0.05) and that of nontobacco-using controls (7.00 +/- 5.04). In part two, the average number of positive cells was higher in the moderately dysplastic (140.36 +/- 30.03) and severely dysplastic lesions (232.86 +/- 26.85) than in the mildly dysplastic lesions (14.53 +/- 3.33; p < 0.05). The correlation between the degree of epithelial dysplasia and the number of cells positive is strong (Spearman's correlation coefficient = 0.853).The accumulation of p53 protein in leukoplakia of snuff-users is higher than in normal-appearing oral mucosa from both snuff-users and nontobacco-using controls. A strong correlation exists between the degree of epithelial dysplasia present in oral leukoplakia and the number of cells staining positive for p53. The accumulation of p53 protein holds potential as an intermediate end point in studies of chemoprevention of oral cancer.

A Report of Multiple Periodic Anniversary Reactions in One Individual

Case Studies1 March 1963A Report of Multiple Periodic Anniversary Reactions in One IndividualJAMES H. EARLS, STEWART WOLF, M.D., F.A.C.P.JAMES H. EARLSSearch for more papers by this author, STEWART WOLF, M.D., F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-58-3-530 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptDespite the widespread interest in bodily disorders occurring repeatedly on the anniversary of emotionally distressing events, there have been comparatively few reports of the anniversary reaction in the literature since its original description by Hilgard in 1953 (1). The present case report concerns one patient with 3 anniversary reactions each recurring periodically. The reactions involved the respiratory system, gastrointestinal tract, and the integument.CASE REPORTA 72-year-old woman came to the Oklahoma University Medical Center in March, 1962, with the complaints of hay fever each August for the past 38 years, diarrhea each July for the past 20 years, and...