Chorioamnionitis, not epidural analgesia, is associated with maternal fever during labour.

PURPOSE: Maternal fever is associated with chorioamnionitis and has been linked to labour epidural analgesia (LEA). The purpose of this study was to determine possible associations between LEA and chorioamnionitis, maternal fever, operative delivery rate, and neonatal outcome. METHODS: Data from 14,073 patients were entered into a database over a two-year period. From this database, 62 nulliparous parturients with clinical chorioamnionitis (amnionitis), but without LEA were identified (Group I). Two other groups who received LEA were matched for parity and gestation: Group II - LEA with concomitant amnionitis (n=50) and, Group III - LEA without concomitant amnionitis (n=201). The diagnosis of chorioamnionitis was confirmed by histologic examination. Results are expressed as mean +/- SD and analyzed at P <0.05 using ANOVA or Chi-square. RESULTS: No differences were noted among the groups in the operative delivery rate or Apgar scores at five minutes. The percentage of patients with maternal fever during labour (38.0 degrees C) with amnionitis was significantly less in Group III compared to the other groups (100% in both Groups I and II vs 1.0% in Group III; P=0.000). Likewise, Group III had a lower percentage of neonates with Apgar scores <7 at one minute (35.5% in Group I, 20.0% in Group II, 17.4% in Group III; P=0.010). The percentage of histologic chorioamnionitis was significantly higher in both amnionitis groups compared to Group III (67.7% in Group I, 56.0% in Group II, 4.0% in Group III; P=0.000). CONCLUSION: LEA without chorioamnionitis is not associated with maternal fever (38.0 degrees C), increased operative delivery rates or low Apgar scores.

Fetal endothelial cells express vascular cell adhesion molecule in the setting of chorioamnionitis.

PROBLEM: In intrauterine infection, inflammatory mediators may be released into the fetal circulation prior to fetal infection. We hypothesize that, in chorioamnionitis, inflammation alters fetal blood vessels. To test this, fetal endothelial cells were examined for vascular cell adhesion molecule (VCAM). METHOD OF STUDY: Umbilical cords (n = 9) from placentas with chorioamnionitis were immunostained for VCAM. Controls from preterm preeclamptic pregnancies (n = 7) without histologic inflammation were selected, and matched for gestational age and method of delivery. VCAM sections were reviewed by a pathologist blinded to clinical diagnoses. RESULTS: All endothelial cells from each of the nine cords from placentas with chorioamnionitis had strong VCAM staining. Two of nine samples also had acute cord vasculitis. No cord endothelial cells from preeclamptic placentas demonstrated similar VCAM staining (p < 0.01). CONCLUSION: Histologic chorioamnionitis was associated with VCAM expression of the umbilical cord vessels. In chorioamnionitis, inflammatory mediators may have entered the fetal circulation to activate endothelial cells. Intrauterine inflammation was not restricted to the chorioamnion, but also involved the fetal circulation.

Dual phase hepatic CT: influence of scanning direction on liver attenuation.

OBJECTIVE: We measured changes in hepatic attenuation during arterial and portal phase acquisition of hepatic CT in the craniocaudal and caudocranial directions. SUBJECTS AND METHODS: In 10 of 20 patients undergoing dual phase helical CT during staging for colorectal cancer, images in both phases were obtained in the craniocaudal direction. Ten patients underwent imaging in the caudocranial direction. Attenuation values in the aorta and in the peripheral and central liver regions of interest were measured on each slice. Central and peripheral liver attenuation was also measured in 10 additional patients undergoing unenhanced CT. RESULTS: Both peripheral and central regions of interest revealed progressively increasing attenuation during the arterial phase, irrespective of scanning direction. During the portal phase, hepatic attenuation was stable in the craniocaudal direction but decreased in the caudocranial direction (p < 0.05, Wilcoxon's signed rank sum test). Central hepatic attenuation was lower than peripheral attenuation in unenhanced livers and in enhanced livers during both phases of caudocranial acquisition. We determined no significant difference during the arterial phase of enhancement in the craniocaudal direction. CONCLUSION: The direction of acquisition does not influence sequential liver enhancement during the arterial phase. Craniocaudal acquisition produces more stable enhancement during the portal phase. Differences in attenuation between the central and peripheral areas of the liver are probably unrelated to contrast administration.

Lateral placental growth occurs by trophoblast cell invasion of decidual veins.

During human pregnancy, growth of the placenta is proportionally greater than the growth of the decidual surface, suggesting that trophoblast cells invade the decidua at the placenta's margin. We hypothesized that a method of lateral placental growth was trophoblast cell invasion of decidual veins. This was investigated in two in situ pregnancies and in tissues from 100 women undergoing elective termination at 8-12 weeks of gestation. Decidua was compared to normal secretory endometrium. Histological sections were stained by immunohistochemistry to identify trophoblast cell and vascular antigens, as well as vascular cell adhesion molecule (VCAM), integrin subunits beta(1)and beta(4), and oncofetal fibronectin. Dilated veins were observed in all decidua but not in the secretory endometrium. Decidual and myometrial veins contained villi, trophoblast cell islands and syncytial elements. Decidual endothelial cells expressed vascular cell adhesion molecule (VCAM). Villous trophoblast cells were integrin subunits beta(4)positive and beta(1)negative. Trophoblast cell islands in the placenta and within decidual veins were integrin subunits beta(1)positive and beta(4)negative. Trophoblast cell islands and villi attached to veins, and mononuclear cells, invaded decidual stroma. Oncofetal fibronectin was present at sites of trophoblast invasion. These findings suggest that a method of lateral placental growth is trophoblast cell invasion of veins.

Dynamic contrast-enhanced MR imaging and dual-phase helical CT in the preoperative assessment of suspected pancreatic cancer: a comparative study with receiver operating characteristic analysis.

OBJECTIVE: The purpose of this study was to compare dynamic contrast-enhanced MR imaging and dual-phase helical CT in the preoperative assessment of patients with suspected pancreatic carcinoma. SUBJECTS AND METHODS: Thirty-three consecutive surgical candidates (20 men, 13 women; 39-81 years old) were included. MR imaging comprised fast spin-echo (TR/TE 4000/91), fat-suppressed T1-weighted spin-echo (500/15), and T1-weighted breath-hold gradient-echo fast low-angle shot (100/4; flip angle, 80 degrees) images before and after the administration of gadopentetate dimeglumine. Helical CT used 5-mm collimation with a pitch of 1:1.5-1.7; images were obtained 20 and 65-70 sec after injection of 150 ml of contrast material. Two pairs of interpreters who were unaware of the results of the other imaging method independently scored each examination for the presence of a lesion and for surgical resectability using a five-point scale. Results were correlated with surgery (n = 25) or consensus review (n = 8). Receiver operating characteristic methodology was used to analyze the results for resectability, and positive predictive values were calculated. RESULTS: Both MR imaging and helical CT revealed 29 of 31 lesions. In determining lesion resectability, the mean areas under the receiver operating characteristic curves were 0.96 and 0.81 (p = .01) and the positive predictive values were 86.5% and 76% (p = .02) for MR imaging and helical CT, respectively. CONCLUSION: MR imaging and helical CT performed equally well in lesion detection. MR imaging was significantly better in the assessment of resectability of pancreatic tumors.

Syncytiotrophoblastic fragments in first-trimester decidual veins: evidence of placental perfusion by the maternal circulation early in pregnancy.

OBJECTIVE: To determine whether maternal placental perfusion occurs in the first trimester, this study compared veins in endometrium with those in decidua. We hypothesize that veins draining the placenta become dilated and contain syncytiotrophoblastic fragments. STUDY DESIGN: Normal late-secretory endometrial biopsy specimens (n = 10) were compared with elective abortion decidua at 7 to 11 weeks (n = 100). Tissue sections were processed by routine staining and immunohistochemical studies. The cross sections of veins and glands were counted in 25 decidual biopsy specimens, and the number of syncytiotrophoblastic fragments in veins or glands was determined. Statistical significance by chi(2) or linear regression analysis was P <.05. RESULTS: All sets of decidua had dilated veins; no secretory endometrium did. Intravenous syncytiotrophoblastic fragments were seen in 91 of 100 sets of decidua. There were more syncytial elements in veins (572/6845, 8.4%) than in glands (13/23,310, 0.06%) (P <.001). CONCLUSION: Decidual veins were distended and contained syncytiotrophoblastic fragments, consistent with maternal intervillous perfusion in the first trimester.

Transfusion of fetal cord blood cells: an improved method of hematopoietic stem cell transplantation?

Hematopoietic stem cells circulate in the fetal blood and may be isolated from the placenta through the umbilical cord after birth. These cells have been safely isolated, and transplanted into recipients to treat malignancies and marrow failure. Cord blood stem cells may be used for genetic disorders. Compared to other sources of stem cells, recipients of cord blood stem cells have fewer and less severe episodes of graft versus host disease. This may be because intrauterine graft (fetus) versus host (mother) disease is harmful to the pregnancy. Controversies persist surrounding the harvest and use of these cells.

Staging lymphoma with CT: comparison of contiguous and alternate 10 mm slice techniques.

PURPOSE: To compare two computed tomography (CT) techniques, contiguous 10 mm and alternate 10 mm slices of the chest, abdomen and pelvis, for initial staging of lymphoma. SUBJECTS AND METHODS: Fifty-two consecutive patients referred at initial diagnosis for lymphoma staging by CT were examined with contiguous 10 mm slices of the chest, abdomen and pelvis. Oral contrast was administered, but no intravenous contrast. Two sets of films for each examination were printed, one with 10 mm contiguous slices and one with 10 mm alternate slices. The two sets of films for each patient were reviewed separately in a randomized order and blinded fashion by two independent observers. Discrepancies were reviewed by a third observer and subsequently resolved by consensus. RESULTS: Staging assessments by both techniques were concordant in 51 of 52 cases: one patient was recorded as stage II on the alternate slice technique, but stage III with contiguous slices but this difference did not affect management. Inter-technique agreement was very good (kappa=0.97). The staging assessments showed discrepancies between the two observers in 12 of the 52 cases which were independent of technique (kappa=0.71; good agreement). Consensus review showed them to result from differences in perception in seven cases and differences in interpretation of abnormalities in five cases. CONCLUSION: Our findings support the use of an alternate 10 mm slice technique in the staging of lymphoma at initial diagnosis. Observer variation was greater than the difference between techniques.

Decidual spiral artery remodelling begins before cellular interaction with cytotrophoblasts.

Endometrial arteries undergo structural alterations during pregnancy to increase blood flow to the intervillous space. It is hypothesized that physiologic change in decidual arteries is similar to vascular remodelling seen in other organs. Histologic features of spiral arteries in secretory endometrial biopsies were compared blindly to decidual arteries from elective abortions. Similar sections were stained for trophoblastic and vascular antigens. Spiral arteries in endometrium from ectopic (tubal) and intrauterine pregnancies were compared also. Evidence of decidual endothelial activation was sought using antibodies to vascular cell adhesion molecule (VCAM-1). As expected, decidual arteries were significantly different than arteries in secretory endometrium: there was more endothelial basophilia, vacuolation, and arterial dilation in early pregnancy. Some vessels had disorganized or hypertrophied smooth muscle layers. Similar structural alterations were seen in endometrium of ectopic pregnancies, and in the decidua parietalis of intrauterine pregnancies. Immunohistochemical studies confirmed that these alterations occurred in the absence of cellular interaction with extravillous cytotrophoblasts. Independently of trophoblasts, decidual endothelial cells expressed VCAM-1. It is concluded that the initial stages of physiologic change are characterized by vascular remodelling, which occur in the absence of trophoblast invasion of the spiral arteries. Arterial modifications in decidua begin as a maternal response to pregnancy.

Umbilical cord agenesis in limb body wall defect.

The term "Limb Body Wall Defect" (LBWD) refers to a variable group of congenital defects having in common abdomino- or thoraco-schisis and limb deficiency. Three general pathogenic mechanisms have been proposed for this disorder: amnion rupture, vascular disruption, and embryonic malformation. We hypothesize that there are subsets of "Limb Body Wall Defect," which have similar structural abnormalities and a common pathogenesis. We report on five cases of LBWD that were selected by using more restrictive criteria. An infant or fetus was included if it had abdominoschisis with a broad attachment of skin to amnion at the site of the abdominal wall defect, limb defects, and umbilical cord agenesis. Autopsy detected additional common structural defects. All had evisceration of the gastrointestinal structures into the extra-embryonic coelomic space with structural abnormalities of the intestines. All had scoliosis, thoracic deformities, pulmonary hypoplasia, and structural abnormalities of the cloaca and urogenital ridge. Four of five had meningomyelocele. Three had exstrophy of the cloaca. The four females all had ovarian agenesis and incomplete Mullerian fusion. None had normal development of the external genitalia. We propose that the pathogenesis was a primary malformation of body wall closure, with abnormal fusion of the amnion, which had occurred in the first month of development.

Premature rupture of the amniotic membranes diagnosed by placental bed biopsy.

Biopsies of the maternal placental bed are usually made to investigate abnormalities of the uteroplacental vasculature. A placental bed biopsy was taken from a 36-year-old, gravida 4, para 3 woman. She had delivered normally at 39 weeks of gestation, following spontaneous labor, without clinical signs of premature rupture of the membrane. She was discharged without complications of the delivery. The placental bed biopsy showed histologic signs of amniotic rupture. There were desquamated stratified squamous epithelial cells in edema fluid between muscle fibers, surrounded by intense neutrophilic inflammation. Uterine venules contained fibrin clots with squamous epithelial cells. Some veins had plugs of detached, coiled, and occlusive amniotic thrombi. To our knowledge, histologic evidence of amniotic membrane rupture and amniotic fluid thrombosis with local embolization has not been previously reported in a biopsy of the placental bed.

Preliminary experience with medical applications of rapid prototyping by selective laser sintering.

Rapid prototyping techniques, originally developed for building components from computer aided designs in the motor industry, are now being applied in medicine to build models of human anatomy from high resolution multiplanar imaging data such a computed tomography (CT). The established technique of stereolithography and the more recent selective laser sintering (SLS), both build up an object layer by layer. Models have applications in surgical planning, for the design of customised implants and for training. Preliminary experience of using the SLS technique for medical applications is described, addressing questions regarding image processing, data transfer and manufacture. Pilot models, built from nylon, included two skills (a child with craniosynoslosis and an adult with hypertetorism) and a normal femur which was modelled for use in a bioengineering test of an artificial hip. The dimensions of the models were found to be in good agreement with the CT data from which they were built-for the child's skull the difference between the model and the CT data was less than 1.0 +/- 0.5 mm in each direction. Our experience showed that, with care, a combination of existing software packages may be used for data conversion. Ideally, image data of high spatial resolution should be used. The pilot models generated sufficient clinical interest for the technique to be pursued in the orthopaedic field.

Multispiral three-dimensional computed tomography in the investigation of craniosynostosis: technique optimization.

21 infants with craniosynostosis were studied with a new three-dimensional (3D) computed tomography (CT) methodology. We describe technique optimization using multiple spiral data acquisitions with low dose (85 mAs) technique. One caudal volume of 3 mm slice thickness was obtained with a further two volumes of 1 mm slice thickness at the vertex. Image reconstruction of spiral raw data allowed overlapping 3 mm sections to be generated without the dose increase that would result from conventional axial CT scanning. We illustrate common technical artefacts of 3D CT and explain their cause and solution. A dramatic dose reduction to the lens was achieved with no loss in 3D image quality. Lens dose was 8.91 mSv compared with 24.6 mSv using the standard paediatric head technique.

The effect of combined immunosuppression with systemic low-dose cyclosporin and topical fluocinolone acetonide on the survival of rat hind-limb allografts.

Sixty rat hind-limb allotransplantations across strong histocompatibility barriers were performed. Group I (isograft controls), (Lewis-Brown-Norway [LBN] to LBN) limb transplantations were performed; Group II (rejection controls), LBN limbs transplanted to Lewis rat LEW recipients with no immunosuppressive treatment; Group III (steroid group), fluocinolone acetonide (50 micrograms/ml) was applied topically; Group IV (cyclosporine group), 4 mg/kg of cyclosporine was administered subcutaneously daily; Group V (combination group), combined systemic cyclosporine with topical fluocinolone acetonide was administered daily. Group II: Limb rejection was present on the fourth day. Group III: Limb survival was extended for 3 weeks with no signs of skin rejection in 75% of animals. Group IV: Rejection was complete at 3 weeks. Group V: Limbs survived to 6 weeks. Topical steroid prevented skin rejection and delayed rejection of other components of the composite allograft. Combined treatment of topical steroid and low cyclosporine doses significantly extended survival rate of limb allografts.

Monitoring normal and aberrant electrocardiographic activity from an endotracheal tube: comparison of the surface, esophageal, and tracheal electrocardiograms.

INTRODUCTION: We designed an endotracheal (ET) tube with orthogonally spaced ECG cuff electrodes. This ET tube was evaluated in dogs and sheep to determine (1) whether ECGs recorded from our tube were sufficient to make accurate clinical decisions concerning heart rate and rhythm; and (2) whether metallic cuff electrodes in direct contact with the trachea could induce mucosal burn injury during episodes of defibrillation. METHODS: Using experimental animals, we obtained ECGs from their tracheae and compared our findings with ECGs obtained from surface and esophageal electrodes. The electrical activity of the heart was modified by increasing the depth of anesthesia, occluding the left coronary artery, and administering beta-adrenergic drugs. Before the dogs were euthanized, they were subjected to episodes of transthoracic and intrathoracic defibrillation at energy levels of 200 to 400 J. A postmortem pathological examination of the trachea was performed to determine the incidence of mucosal burn injury. RESULTS: Tracheal electrocardiography provided valid information on heart-rate monitoring and certain morphology profiles. The R-R, PR, QRS, and QT intervals measured from the trachea had a correlation of 1.0, 0.96, 0.83, and 0.98, respectively, when compared with the same intervals obtained from surface electrodes. Two tracheae subjected to intrathoracic defibrillation at > 300 J revealed evidence of minor burn injury. Some localized epithelium loss was displayed in all tracheae; we attributed this to tracheal intubation. CONCLUSION: Tracheal electrocardiography may be useful in trauma patients who require intubation where injury precludes placement of chest ECG electrodes.

Vascular rejection in cardiac transplantation: Histologic, immunopathologic, and ultrastructural features.

Although the majority of rejection found in cardiac transplant biopsies is cellular in type, a variety of vascular alterations occur in cardiac biopsies, constituting different forms of rejection that can be recognized using light microscopic and immunopathologic criteria. In this report, pathologic aspects of the vascular alterations associated with vascular and mixed rejection of cardiac allografts are described in detail. Methods and controls used in this report are identical to those previously reported. The histologic, immunopathologic, and ultrastructural findings associated with vascular rejection and other vascular processes in cardiac allografts are discussed. The relationship of these findings to chronic allograft rejection and potential pathogenetic mechanisms of these vascular changes are also detailed.

Intrapulmonary neuroglial heterotopia.

Nonteratomatous intrapulmonary neuroglial heterotopia not associated with birth trauma or frank vascular embolization has been described rarely. This article briefly reviews the literature, and presents two additional cases of intrapulmonary neuroglial heterotopia. We found 14 cases in the literature. Twelve of these cases had central nervous system disruption, where neuroglial elements were in direct contact with amniotic fluid. Several hypotheses have been proposed, including fetal aspiration of detached neural fragments within amniotic fluid, neural crest migration defects, and vascular embolization with implantation. Of our two cases, one represents the first occurrence where central nervous system abnormalities were secondary to mechanical disruption, rather than to a primary neural tube defect. Our second case represents the youngest documented occurrence (17 weeks gestation) of intrapulmonary neuroglial heterotopia. Additionally, immunohistochemical studies were performed on these lesions, the results of which favor their neural origin. We present these findings and suggest they support the aspiration mechanism for neuroglial heterotopia in lung tissue.

Osteochondrodysplasia in Fryns syndrome.

Various skeletal abnormalities have been identified in roentgenograms of persons with Fryns syndrome, but to our knowledge, no histopathologic description of bone or cartilage has been published. We describe disordered endochondral and intramembranous bone formation in a premature female infant with Fryns syndrome. This infant and a full sibling (ie, had same set of parents) with Fryns syndrome in addition exhibited delayed ossification of the basiocciput and of cervical vertebral bodies, also previously undescribed in Fryns syndrome. These findings expand the spectrum of Fryns syndrome to include osteochondrodysplasia.