Hypoplasia and neuronal immaturity of the hypoglossal nucleus in sudden infant death.

OBJECTIVE: To report the case of five month old female baby with a history of episodes of gastro-oesophageal reflux and pneumonia. Her sudden death offered a unique insight into the possible role of delayed neuronal maturation and hypoplasia of the hypoglossal nucleus in representing a likely morphological substrate of sudden death. METHODS: Morphometric analysis was carried out with an Image-Pro Plus Image analyser (Media Cybernetics) on both sides of the brain stem. RESULTS: Hypoplasia and neuronal immaturity of the hypoglossal nucleus were demonstrated, accompanied by hypoplasia of the arcuate nucleus. CONCLUSIONS: Much attention should be paid to the possible role of the hypoglossal nucleus in determining a lethal outcome in infancy through impairment of deglutition and subsequent recurrent episodes of pneumonia, and as a necropsy finding.

Sudden infant death triggered by dive reflex.

The dive reflex is the reflex mechanism most frequently considered in the aetiopathogenesis of sudden infant death syndrome (SIDS). This seems to persist in human beings as an inheritance from diver birds and amphibians. It has been reported that washing the face with cold water or plunging into cold water can provoke cardiac deceleration through the intervention of the ambiguus and the vagal dorsal nuclei. This report describes a case of SIDS that offers a unique insight into the role of the dive reflex in determining a lethal outcome. Examination of the brainstem on serial sections revealed severe bilateral hypoplasia of the arcuate nucleus and gliosis of the other cardiorespiratory medullary nuclei. The coronary and cardiac conduction arteries presented early atherosclerotic lesions. The possible role of parental cigarette smoking in the pathogenesis of arcuate nucleus hypoplasia and early coronary atherosclerotic lesions is also discussed.

Intimal preatherosclerotic thickening of the coronary arteries in human fetuses of smoker mothers.

BACKGROUND: Many studies have described the development of preatherosclerotic coronary artery lesions in infancy. The observations reported in the literature regarding the fetal origin of coronary artery lesions are rare and controversial. OBJECTIVES: To identify the features of preatherosclerotic coronary artery lesions in late fetal stillborns and the possible atherogenic role of maternal cigarette smoking. METHODS; We examined 22 stillborns (13 males and nine females), all of whom had died sine causa after the 32nd week of gestation. All underwent autopsy. Twelve of the mothers smoked over five cigarettes per day before and during the pregnancy. The four major epicardial coronary arteries were isolated along their whole length, embedded in paraffin and serially cut for histologic examination and immunohistochemical studies, particularly searching for the proliferating cell nuclear antigen and c-Fos expression. Alterations of chromosome 7 were also investigated by the fluorescence in situ hybridization technique. RESULTS: In over 50% of the fetuses, almost all from smoker mothers, multifocal structural alterations of coronary walls were evident. The smooth muscle cells (SMCs) presented loss of polarity, forming columns perpendicular to the axis of the media and infiltrating the subendothelial connective tissue. Increased amounts of mucoid ground substance were also observed in the subendothelial connective tissue. In all the cases with coronary alterations, study of the biological markers showed intense c-Fos positivity of the SMCs. CONCLUSIONS: Preatherosclerotic intimal alterations of the coronary arteries are already detectable in the prenatal period and are significantly associated with maternal cigarette smoking.

Densitometric evaluation of DNA content in colorectal cancer.

The aim of the present study was to provide information on the DNA content in colorectal tumours using densitometric techniques on histological samples and correlating the findings with age, sex, histological grade, stage, presence or absence of lymph-node metastasis and survival time. The distribution of DNA values was significantly related with the histological grade. Dukes' stage and infiltration of the peritumoral lymph-nodes. The distribution of DNA values was not significantly correlated with age and sex. From the data obtained in this study it can be concluded that evaluation of DNA content in colorectal adenocarcinoma can be used as a prognostic test that is complementary to histological investigation. The ploidy can provide information for classifying the degree of malignancy and can also be used to determine which tumours are biologically most aggressive.

Pantethine reduces plasma cholesterol and the severity of arterial lesions in experimental hypercholesterolemic rabbits.

Pantethine (P), a coenzyme A precursor, was administered to cholesterol-fed rabbits (0.5% cholesterol diet + 1% pantethine) for 90 days. At the end of treatment, plasma total cholesterol levels were reduced 64.7% and the HDL/total cholesterol ratio increased in P-treated animals; a significant rise of the apo A-I/A-II ratio was detected in HDL. VLDL lipid and protein levels were, on the other hand, reduced by P. The cholesterol-ester content of both liver and aortic tissues was not significantly affected by P. Although the total aortic area with evident plaques was reduced only 18.2%, the microscopical examination of sections from the major vessels of P-treated animals, showed a reduction in the severity of lesions, both in the aorta and in the coronary arteries. These findings suggest that P, in addition to significantly lowering plasma cholesterol levels in rabbits on an experimental diet, may modify lipid deposition in major arteries, possibly by affecting lipoprotein composition and/or exerting an arterial protective effect.

Chromosomal alterations in atherosclerotic plaques.

Alterations of chromosomes 7 and 11 have been involved in the progression of atherosclerosis. Twenty-three carotid endarterectomy specimens were studied for the presence of alterations in chromosomes 7 and 11, and fibroblastic growth factor-3 (FGF-3) gene amplification. Besides classic histological stainings, immunophenotyping of cellular and vascular components and fluorescence in situ hybridization (FISH) were performed. At the caps, unstable plaques (n=18) showed inflammatory infiltration of macrophages, smooth muscle cells, and T-lymphocytes. Specifically in these regions, the FISH showed varying percentages of trisomy (15/18) and tetrasomy (8/15) of chromosome 7. In four cases polisomy 7 was noted in some nuclei. Monosomy of chromosome 11 and gene amplification of FGF-3 gene was observed. The FISH of the five stable plaques and normal arterial walls showed no chromosome alterations; furthermore, chromosome 3, which is not involved in atherosclerotic progression, presented a normal ploidy of smooth muscle cells in stable and unstable plaques and normal arterial walls. In conclusion, chromosome 7 and 11 alterations and FGF-3 gene amplification are components of unstable plaques, and might contribute to the evolution of stable plaques into complicated plaques.

Autopsy findings in three patients with von Willebrand disease type IIB and type III: presence of atherosclerotic lesions without occlusive arterial thrombi.

It has been reported that pigs with severe von Willebrand disease (vWd) are protected from spontaneous and diet-induced atherosclerosis, but there are very few studies in human patients. Autopsies were carried out on three patients with vWd (one case with the type IIB variant and two cases with type III, a variant similar to that protecting pigs from atherosclerosis), aged 73, 44 and 52 years at the time of death. Hemorrhagic diathesis was an important cause of death for these patients. Atherosclerosis lesions were found in all patients, though of different extent and localization: severe lesions in all vascular areas in the patient with type IIB, few and slighter in all areas in the two patients with type III, except that in one of them there were moderately severe lesions in the coronary arteries. There was no clinical or pathologic evidence of thrombosis in the coronary arteries or other arteries. These data indicate that severe vWd did not protect completely against the development of atherosclerosis, although it is possible that intensive lifelong treatment with plasma concentrates had a modifying influence in these patients.

Cardiac amyloidosis involving the conduction system and the aortocoronary neuroreceptors. Clinicopathologic correlates.

In a patient with cardiac primary amyloidosis with conduction disturbances and dynamic cardiocirculatory disorders, the specialized system of the heart and the hitherto neglected cardiac nerve plexus and annexed aortocoronary glomera were studied histologically. Amyloid deposition in the conduction system and in the nerves and neuroreceptors seemed to correlate with the dysrhythmic manifestations, and, respectively, with some undue responses to vasodilator therapy. The possible hazards deriving from involvement of the aortocoronary glomera in patients with amyloidosis have been pointed out accordingly.

Pathologic substrates for arrhythmogenesis in chronic chagasic cardiopathy.

Here are described the results of a histopathological study on 12 autopsy hearts of subjects deceased secondary to chronic chagasic cardiopathy in order to clarify the nature and the pathogenetic mechanism of its arrhythmogenic potential. The arrhythmogenic hazards of chagasic cardiomyopathy are mainly due to the striking disruptive fibrotic changes with ensuing electrical instability of the ventricular myocardium. Lesions of the conduction system, focal epiperineuritis, and an inconstant and questionable "neuronal depletion" of the cardiac plexuses in the disease play a concomitant role.

Pathology of the heart and conduction system in a case of sudden death due to a cardiac fibroma in a 6-month-old child.

A 6-month-old female infant considered to be in good health died suddenly and unexpectedly. Post-mortem examination was requested, with clinical diagnosis of sudden infant death syndrome. Gross examination revealed, however, the presence of a cardiac mass 4.5 X 4 x 3.5 cm in diameter. Histological examination of the heart confirmed the presence of a cardiac fibroma. In the present case, the sudden death could have been due to the left ventricular outflow obstruction, as much as to conductive disturbances caused by overstretching and compression of the atrioventricular node and of the bundle branches. Hemodynamic and conductive abnormalities are presumed to have provoked bradycardia degenerating into ventricular fibrillation and sudden death. Necroscopy studies of sudden death should always include histological examination of the cardiac conduction system but seldom do.

Sudden Infant Death Syndrome (SIDS): a study of cardiac conduction system.

The theory that Sudden Infant Death Syndrome (SIDS) may be related to lethal cardiac arrhythmias or heart block due to structural abnormalities of the conduction system is attractive and still of particular interest. We analyze 69 autopsied cases of SIDS (46 males and 23 females, infants ranging in age from 3 to 365 days) and 24 age-matched cases of explained death (ED) as controls (16 males and 8 females), infants who died from extracardiac cause (cerebral and respiratory). SIDS and ED groups were divided into three subgroups according to the age: (A) from 3 to 60 days; (B) from 61 to 120 days; (C) from 121 to 365 days. Histological observations were focused on the cardiac conduction system (CCS) which was examined on serial sections with the technique devised by one of the present authors (L. Rossi). The following findings were observed: resorptive degeneration (97.10% of SIDS, 75% of ED), His bundle dispersion (33. 33% of SIDS, 16.66% of ED), Mahaim fibers (21.73% of SIDS, 8.3% of ED), cartilaginous meta-hyperplasia (5.79% of SIDS, 4.16% of ED), persistent fetal dispersion (24.63% of SIDS, 16.66% of ED), intramural right bundle (20.29% of SIDS, 25% of ED), left sided His bundle (20.29% of SIDS and 8.3% of ED), hemorrhage of the atrio-ventricular junction (15.94% of SIDS), septation of the bifurcation (13.04% of SIDS), atrio-ventricular node (AVN) dispersion (7.24% of SIDS), sino-atrial node hypoplasia (5.79% of SIDS), Zahn node (1.45% of SIDS), His bundle hypoplasia (1.45% of SIDS), intramural left bundle (1.45% of SIDS), AVN dualism (2.89% of SIDS), and His bundle dualism (2.89% of SIDS, 4.16% of ED). Only the presence of resorptive degeneration was significantly higher in SIDS than in ED cases (p = 0.004). Regarding the subgroups, the only significant difference was the higher presence of intramural right bundle in SIDS-A than in SIDS-B (p = 0.01). Despite the non-specificity of most of these findings, we believe that these changes, associated with particular conditions and/or neurovegetative stimuli, could cause potentially malignant arrhythmias. These data suggest the need for an accurate approach and examination of the cardiac conduction system in all cases of sudden death in infancy

Cardiac extrinsic neuropathy: Lesions of the mediastinal paraganglia in chronic chagasic cardiomyopathy.

The pathology of cardiac innervation, both intrinsic and external to the heart (mediastinal paraganglia included), is scarcely known, yet it can be critical to life-threatening disorders in cardiac performance or to reflexes discharging outside the heart, or both. This article focuses on such a fundamental and ill-understood subject through an anatomoclinical outlook of mediastinal paraganglia lesions in the setting of sudden death in chronic chagasic cardiomyopathy.

Myocardial inflammatory infiltrate in human chronic chagasic cardiomyopathy: Immunohistochemical findings.

Chagas' disease is the most common form of chronic myocarditis in the world. It is characterized by a progressive chronic myocarditis that leads to cardiomegaly, arrhythmias, cardiac failure, and thromboembolic phenomena. This communication reports studies on the immunohistochemistry of chronic infiltrates in 30 endomyocardial biopsies and in contracting and specialized myocardium of autopsies of four patients suffering from Chagas' cardiomyopathy. Expression of the following antigens was studied: common leucocyte antigen (CLA-CD45R), L-26(CD20), CD68, kappa and lambda light chains and T-UCLH-1 (CD45RO), and MB-1. Streptavidin-peroxidase and streptavidin-alkaline phosphatase with biotinylated anti-mouse IgG were used as detection systems. Double immunostaining for the simultaneous demonstration of T lymphocytes (CD45R0) and macrophages was performed using both immunoenzymatic techniques consecutively. Expression of CD31 was detected for the demonstration of endothelial cells. In endomyocardial biopsies, tissue forms of trypanosomes were not found. The percentage of fibrous tissue was 24.1% ± 12.8% (range 8.2%-49%). Eosinophils were scarce (1/high-power field), but associated with necrotic areas of the myocardium. Mast cells were scarce or absent. They were always situated in fibrotic areas. The most remarkable finding was the presence of infiltrates consisting of macrophages and CLA-positive mononuclear cells. Twenty-six and one-half percent of them were T lymphocytes, and 10.5% were B lymphocytes. Lymphocytic infiltration was particularly associated with necrotic and degenerative myocardial lesions. Thirty percent of the infiltrate was composed of macrophages (positive CD68 cells). The remaining infiltrate was composed of mononuclear cells resembling macrophages and CLA-negative mononuclear cells. Contacts between CD68-positive cells and T lymphocytes were frequently found. CD31 antibodies clearly pointed out normal endothelial cells, in either normal or damaged vessels. No isolated cells positive for these antibodies were found within the mononuclear infiltrate. In autopsied hearts, myocardial lesions consisted of a chronic inflammatory process with fibrotic scars and extensive mononuclear infiltrates. No amastigote nests were found. A statistically significant difference (p < 0.05) was obtained when the percentage of fibrosis was compared in the specialized and contracting myocardiums (51.6% ± 18% vs. 43.4 % ± 8%). Eosinophils were scarce in infiltrates, reaching 5%, and they were associated with necrotic myocardium. Mast cells also were scarce or absent in specialized and in contracting myocardium. Almost all the lymphocytic population was T lymphocytes. Such infiltrates were more prominent in the working myocardium (39%) and in the specialized cells of the left branch of the His bundle than in the atrioventricular node and in the right Hisian branch (34.4%). The 31% of mononuclear cells were CD68 positive, thus corresponding to macrophages. Contacts among T lymphocytes and macrophages were frequently observed. Although much that is concerned with Chagas' cardiomyopathy is controversial, these may be the major ingredients for its pathogenesis: the parasite or a part of it, lymphocytes and macrophages, and fibrosis. Then a multifactorial or "combined theory" may be suggested to explain the sequence of events that lead to the chronic stage of the disease.

Polydeoxyribonucleotide (defibrotide) protects against post-ischemic behavioral, electroencephalographic and neuronal damage in the gerbil.

The effectiveness of defibrotide, a single-stranded polydeoxyribonucleotide compound, in preventing damage caused by cerebral ischemia was studied. Global ischemia was induced in anesthetized gerbils by bilateral carotid artery occlusion for 10 min. Defibrotide (100 mg/kg) or saline was injected, i.v., immediately after reperfusion. The following parameters were evaluated simultaneously: (1) electroencephalographic (EEG) spectral power, recorded before, during and after the ischemic period; (2) body temperature, monitored with a rectal thermistor probe after reperfusion for 120 min; (3) spontaneous motility, evaluated through a photocell system and quantified in terms of total distance travelled in 30 min, 1 h after recirculation and at periods over 15 days; (4) mnemonic functions assessed by passive avoidance test from 3 to 15 days after ischemia; (5) histological examination, 7 days after reperfusion, counting CA1 hippocampal neuronal cells. The ischemia-induced complete flattening of spectral power was significantly reversed (P < 0.01) by post-ischemic treatment with defibrotide between 30 and 90 min after ischemia. A complete recovery of total EEG spectral power was seen in the defibrotide group at 6 h and the saline ischemic group at 1 day. Seven days after bilateral carotid occlusion, there was a significant decrease in spectral power (-70% +/- 6) together with a loss of the number of CA1 cells in the saline ischemic group (-64%). Treatment with defibrotide significantly protected against the decrease in spectral power (-30% +/- 7) and cell loss (-9%). Finally, the number of animals found to be protected against the ischemia-induced flattening was significantly larger for defibrotide-treated gerbils than for saline-treated animals throughout the experiment except for the third day. Body temperature was significantly decreased only at 30 min after reperfusion in both ischemic and sham-operated groups. Defibrotide reduced ischemia-induced hypermotility but only 6 h after the insult. The ischemia-induced impairment of memory was partially reversed within 3 days in the defibrotide-treated animals and fully reversed within 7 days in the defibrotide group and 15 days in the saline group. Our results demonstrate that defibrotide, even when administered after the post-ischemic period, possesses anti-ischemic properties. The mechanism by which defibrotide protects the ischemic reperfused brain is still largely unknown. However, a neuroprotection via adenosine A1 and A2 subtype receptor interaction can be put forward.

Prognostic significance of different biomarkers in non-small cell lung cancer.

The purpose of our study was to examine the prognostic significance of different biomarkers [DNA content, proliferating cell nuclear antigen labeling index (PCNA-LI), p53 mutation and apoptosis], in 152 surgically resected non-small cell lung cancer (NSCLC). The ploidy was carried out by densitometry; PCNA-LI, p53 and apoptosis were determined with immunohistochemistry. The results were correlated to histology, stage and patient survival. A considerable variability of the PCNA indices, ranging from 0 to 33.5% with a mean value of 7.0%, was found. DNA evaluation showed a prevalence of aneuploid tumors (62%) with a DNA index >1. Overexpression of p53 protein and apoptotic positivity were observed in low percentages of cases (16% and 32% respectively). Only stage and PCNA-LI were found to be significant prognostic factors on multivariate analysis. PCNA was superior to stage in predicting shortened survival of patients with NSCLC. PCNA immunostaining can be applied on a routine basis in formalin-fixed, paraffin-embedded samples of NSCLC to predict patient prognosis and thus to identify patients in need of additional postoperative therapies.

Cardiac malignant lymphoma: a case report.

A 76 year old man, who had undergone tonsillectomy for non Hodgkin's malignant lymphoma, died suddenly in rapidly evolving cardiogenic shock with electrocardiographic signs of acute lateral myocardial infarction. Post mortem examination showed three cardiac lesions, two in the left ventricle and one in the right atrium, corresponding to the "crista terminalis". Histologic examination of autopsy samples confirmed the presence of lymphoma in the heart, partially affecting the sino atrial node (NSA) but excluding other sites. There was no evidence of acute myocardial infarction in spite of the clinical signs and symptoms. An infarction-type electrocardiographic pattern associated with conduction disturbances in patients with lymphoma should suggest the possibility of cardiac localization of the disease.

The role of different biomarkers (DNA, PCNA, apoptosis and karyotype) in prognostic evaluation of superficial transitional cell bladder carcinoma.

BACKGROUND: In order to clarify the variable behaviour of transitional cell bladder carcinomas (TCBC) with same clinico-pathologic pattern, we investigated the prognostic significance of various biomarkers (PCNA, DNA, apoptosis, karyotype). MATERIALS AND METHODS: We studied 177 superficial TCBC (stage T1) undergoing transurethral resection (TUR). Analysis of biological indicators was performed on serial paraffin sections: DNA by static cytometry, karyotype by fluorescence in situ hybridisation (FISH), PCNA and apoptosis by immunohistochemistry. RESULTS: The most salient results are represented by prevalence of diploidy (56%), a mean PCNA labeling index (PCNA-LI) of 8.2%, nonrandom trisomies and tetrasomies of chromosome 7, and a high presence of apoptosis (in 72% of cases). These data were not related to histological grading. Multivariate analysis showed that only PCNA-LI is a an independent prognostic marker for patient survival (p = 0.01). Besides, we observed a worse prognosis in the presence of both very high PCNA indices and low or absent apoptosis. CONCLUSIONS: The results of this study suggest that tumor prognostic potential in TCBC should be evaluated on the basis of the association between PCNA cell kinetics and cell apoptosis information.

Prognostic significance of different biological markers (DNA index, PCNA index, apoptosis, p53, karyotype) in 126 adenocarcinoma gastric biopsies.

BACKGROUND: The different clinical evolution of gastric adenocarcinomas with the same clinico-pathologic characteristics prompted the authors to investigate the prognostic significance of different biological markers. METHODS: One hundred twenty-six preoperative cancer gastric biopsies, selected according the stage evaluated after following gastrectomy, were examined for DNA content by means the static cytometry, proliferating cell nuclear antigen (PCNA), p53 mutation, apoptosis by immunohistochemistry and karyotype using fluorescence in situ hybridization (FISH) techniques. RESULTS: The gastric cancers, ail belonging at stage III, were adenocarcinomas histologically typed as: 26 well differentiated (G1), 45 moderately differentiated (G2), 43 poorly differentiated (G3) and 12 of undifferentiated type with signet-ring cells. The tumours showed a prevalence of diploidy (68%), a mean PCNA-LI of 4.8%, trisomy of chromosome 7 in 40% of the cases, low presence of apoptosis (30%) and p53 mutation (17%). Only apoptosis was significantly correlated to histological diagnosis (p = 0.009). A multivariate analysis showed that the DNA content and PCNA-LI were the only independent prognostic markers for survival (p = 0.005 and p = 0.0002 respectively). CONCLUSIONS: The evaluation of these two biological variables, especially of the PCNA index, on gastric cancer biopsies may be useful in predicting the aggressiveness of each tumor and in identifying patients in need of additional perioperative therapies.

Sudden cardiac death in the indeterminate phase of Chagas' disease associated with acute infarction of the right carotid body.

We recently came across a case of a patient in the indeterminate phase of Chagas' disease who died suddenly with cardiac arrhythmia associated with acute infarction of the right carotid body due to occlusive thrombosis in the glomic artery. Although the available data in this case do not offer definite evidence to support a cause-and-effect relationship between carotid body infarction and patient's sudden cardiac arrest, it is very likely that the acute infarction of the carotid body could be the distinct morphological counterpart of the functional disturbance. The infarction would affect the vagal-sympathetic interactions augmenting sympathetic action.

Inflammatory cells, apoptosis and Chlamydia pneumoniae infection in atherosclerosis.

Chlamydia pneumoniae (CP), chromosomal alterations and apoptosis were suggested as contributing factors in the pathogenesis of atherosclerosis. Early (EP) and unstable plaques (UP) were studied in order to assess infiltrate composition, the apoptotic index, chromosome 7 stability and to investigate the concurrent presence of CP in EP and UP. Paraffin embedded sections of three iliac arteries and four aortas from young donors (EP), and four coronaries and nine carotid arteries (UP) were used. Aside from histological techniques, immunophenotypification for macrophages, T and B cells, smooth muscle and endothelial cells; FISH and DNA nick end labeling were performed. The amplifications with PCR for CP infection were negative in all specimens. In the EP, a focal myointimal thickening with foam cells and scarce smooth muscle cells was observed. Macrophages were most frequent in the intima (10.8%) while T and B cells were found in 2.3 and 1.5%. In the UP a thin cap covering a lipid-rich core with widespread vascularization and with severe luminal obstruction was observed. Macrophages were increased (21%), and T (1.5%) and B cells (3.5%) in the caps and inner areas of the lipid cores. At these sites, the FISH showed trisomy and tetrasomy of chromosome 7 and apoptosis was very frequent (10-30%). Macrophages in intimal lesions is one of the most prominent, consistent and permanent features in EP, and an elevated apoptotic index and chromosome 7 instability might contribute to evolution from stable to complicated plaques, while CP seems to play no role. However, further studies are needed with more cases to confirm this last observation.