Malignant melanoma and adenocarcinoma of a Barrett oesophagus.

An adenocarcinoma with a malignant melanoma in a Barrett oesophagus is extremely rare. We did not find any other cases in the English literature. The diagnosis of a malignant melanoma can be difficult but can be made by tissue examination with a special immunoreaction with several markers to see it expresses S-100, but lacks activity for KER and EMA. S-100 is relatively non-specific as a single immunodeterminant in the diagnostic separation of melanoma and anaplastic carcinoma, but very sensitive. Immunohistochemically, these tumours react to S-100 protein, neuron-specific enolase and HMB-45 antibody (less sensitive than S-100), but not to cytokeratin or CEA. In our case it was obvious that there were two different tumours because the MM was negative for cytokeratin, but the adenocarcinoma was positive for cytokeratin.

Prenatal screening in rural Bangladesh: from prediction to care.

The role of antenatal care is being increasingly questioned, particularly in resource poor environments. The low predictability of antenatal markers for adverse maternal outcomes has led some to reject antenatal care as an efficient strategy in the fight against maternal and perinatal mortality. Few studies, however, have assessed the predictability of adverse outcomes other than dystocia or perinatal death, and most studies have been hospital based. This population-based cohort study was undertaken to assess whether prenatal screening can identify women at risk of severe labour or delivery complications in a rural area in Bangladesh. Antenatal risk markers, signs and symptoms were assessed for their association with severe maternal complications including dystocia, malpresentation, haemorrhage, hypertensive diseases, twin delivery and death. The results of the study suggest that antenatal screening by trained midwives fails to adequately distinguish women who will need special care during labour and delivery from those who will not need such care. The large majority of the women with dystocia or haemorrhage had no warning signs during pregnancy. A single blood pressure measurement and the assessment of fundal height, on the other hand, may detect a substantial number of women with hypertensive diseases and twin pregnancies. In addition, women who had an antenatal visit were four times more likely to deliver with a midwife than women who had no antenatal visit. Antenatal care may not be an efficient strategy to identify those most in need for obstetric service delivery, but if promoted in concurrence with effective emergency obstetric care, and delivered in skilled hands, it may become an effective instrument to facilitate better use of emergency obstetric care services.

A comparison of three verbal autopsy methods to ascertain levels and causes of maternal deaths in Matlab, Bangladesh.

BACKGROUND: Verbal autopsies have been widely used to determine the levels and causes of maternal death but few studies have assessed the reliability of various methods. METHODS: We compared the levels and causes of maternal mortality in three data sources from Matlab, Bangladesh: (1) maternal deaths identified through a unique demographic surveillance system (DSS); (2) maternal deaths identified as a result of a previous detailed investigation into the levels and causes of maternal mortality; and (3) maternal deaths identified in the current special study. All studies used lay reporting, but differed in terms of the nature of the study, the sex of the interviewer, the format of the questionnaire and the procedure to derive the diagnosis. RESULTS: There were substantial disagreements between the routine reporting and the special studies. The DSS identified 67.2% of all deaths occurring during pregnancy or within 42 days postpartum (82.3% of direct obstetric deaths, 70.0% of deaths due to induced abortions and 42.4% of indirect obstetric deaths). Extending the definition of maternal deaths to 90 days postpartum increased the numbers of maternal deaths between 1987 and 1993 from 174 to 196. The two special studies also disagreed in the ascertainment of the causes of maternal deaths and yielded different cause of death distributions; the proportion of direct obstetric deaths (excluding abortion) was 50.4% in the current system compared to 44.5% previously (P = 0.001). CONCLUSIONS: This study confirms the known difficulties in the ascertainment of the levels and causes of maternal mortality. The large disparities in the levels and causes of maternal mortality using three different methods of lay reporting in a population with an almost complete vital registration system add to the growing concern about the inaccuracies in the measurement of maternal mortality.

Decline in maternal mortality in Matlab, Bangladesh: a cautionary tale.

BACKGROUND: A study in Matlab, Bangladesh, has provided evidence favouring a community-based maternity-care delivery system. 3 years of this programme coincided with a significant reduction in direct obstetric mortality compared with the 3 years before the programme. We have examined whether the effects of the programme are sustained over time. METHODS: Using data from the continuing demographic survelliance system and from special investigations into the rates and causes of maternal mortality during 1976-93, we compared the trends in direct obstetric maternal mortality ratios in the Maternal and Child Health and Family Planning (MCH-FP) area (which has received extensive services in health and family planning since 1977) with those in the comparison area (with no such intensive health inputs). We divided the areas and time periods into discrete groups that best represented the effects of the introduction of the maternity-care programme. FINDINGS: Direct obstetric mortality declined by 3% per year (rate ratio 0.97 per year [95% CI 0.95-0.99]); there was no difference between the MCH-FP and comparison areas (1.00 [0.96-1.05]). Direct obstetric mortality halved between 1976-86 and 1987-89 in the northern MCH-FP area, where the maternity-care programme was initiated in 1987 (0.50 [0.22-0.99]), but showed no change in the southern MCH-FP area, which had no such intervention at that time (1.07 [0.64-1.72]). After 1990, when the programme was expanded throughout the MCH-FP area, the southern part showed a downward (non-significant) trend in direct obstetric mortality (0.68 [0.35-1.32]). However, direct obstetric mortality also declined between 1987 and 1989 in the southern comparison area (0.48 [0.26-0.83]) in the absence of an intense maternity-care programme, and remained stable thereafter. In the northern comparison area, there was no such decline in direct obstetric mortality (0.78 [0.40-1.40]). INTERPRETATION: Although the introduction of the maternity-care programme coincided with declining trends in direct obstetric mortality in the areas covered by the programme, a decline also occurred in one of the areas not receiving any such interventions. Caution is required in the interpretation of short-term trends in one indicator in studies designed without random allocation of interventions into treatment and control groups.

PIP: This study examines the impact of the Maternal-Child Health and Family Planning (MCH-FP) program in the Matlab, Bangladesh. Data were obtained from the Matlab surveillance system for treatment and comparison areas. This study reports the trends in maternal mortality since 1976. The MCH-FP area received extensive services in health and family planning since 1977. Services included trained traditional birth attendants and essential obstetric care from government district hospitals and a large number of private clinics. Geographic ease of access to essential obstetric care varied across the study area. Access was most difficult in the northern sector of the MCH-FP area. Contraception was made available through family welfare centers. Tetanus immunization was introduced in 1979. Door-to-door contraceptive services were provided by 80 female community health workers on a twice-monthly basis. In 1987, a community-based maternity care program was added to existing MCH-FP services in the northern treatment area. The demographic surveillance system began collecting data in 1966. During 1976-93 there were 624 maternal deaths among women aged 15-44 years in Matlab (510/100,000 live births). 72.8% of deaths were due to direct obstetric causes: postpartum hemorrhage, induced abortion, eclampsia, dystocia, and postpartum sepsis. Maternal mortality declined in a fluctuating fashion in both treatment and comparison areas. Direct obstetric mortality declined at about 3% per year. After 1987, direct obstetric mortality declined in the north by almost 50%. After the 1990 program expansion in the south, maternal mortality declined, though not significantly, in the south. Maternal mortality declined in the south comparison area during 1987-89 and stabilized. The comparison area of the north showed no decline.

Postoperative spindle cell nodule of bladder.

We describe a new tumor of the bladder resembling sarcoma. The tumor typically develops after damage to the bladder wall, and the clinicopathologic features make it possible to recognize it as a benign lesion rather than the malignant lesions for which it can be mistaken.

Ia+ dendritic cells lining the dermo-epidermal junction in bullous skin disorders, associated with the deposition of immune complexes.

Skin biopsies from 34 patients, presenting with a variety of bullous skin disorders were investigated, using routine light microscopy and immunohistochemistry. In bullous skin diseases characterized by deposition of complement factors (CF) and/or immunoglobulins (Ig), a monolayer of OKIa+1, OKT-6, OKM-1 dendritic cells was found at the dermo-epidermal junction. Retrospectively, these cells were easily recognized on paraffin embedded, H & E stained material. In bullous skin disorders, showing no deposition of CF and/or Ig, this monolayer of dendritic cells was lacking. It is suggested that these OKIa+1, OKT-6, OKM-1 dendritic cells at the dermo-epidermal junction represent some type of antigen presenting cells, not corresponding to Langerhans cells, veiled cells or indeterminate cells.

Usefulness of enzyme-1 and immunohistochemistry in the diagnosis of juvenile xanthogranuloma.

Skin biopsies from two children with juvenile xanthogranuloma were studied. Enzyme- and immunohistochemistry was used to establish the mononuclear phagocytic nature of the proliferating dermal elements. The usefulness of both techniques in the diagnosis and the differential diagnosis of this disease is suggested.

Cystadenoma of the common bile duct demonstrated by endoscopic retrograde cholangiography: an uncommon cause of extrahepatic obstruction.

Obstructive jaundice may rarely be caused by a benign tumor of the biliary tract. We describe a patient in whom the diagnosis of cystadenoma of the common bile duct was established. Complete resection of the tumor could be carried out. The clinical, radiological, and histological features of this neoplasm are reviewed.

Sonographic diagnosis of intraluminal bile duct neoplasm: a report of 3 cases.

Intraluminal growing tumors of the bile duct are uncommon causes of jaundice. The sonographic appearance of 2 hilar cholangiocarcinomas or Klatskin tumors and a benign extrahepatic biliary cystadenoma is described. Compared to contrast studies of the bile ducts, sonography better defined the intraductal character of the neoplasms. However, the ultrasound appearance did not allow differentiation between the adenocarcinomas and the benign cystadenoma.