Intrauterine infection may be a major cause of stillbirth in Sweden.

AIM OF THE STUDY: To investigate intrauterine infection as a cause for unexplained stillbirth. METHODS: Chorioamnionitis was studied in a material of stillbirths (117 subjects from the years 1985-1994) from a region in the south Sweden. Control material (126 alive and healthy newborns and with healthy mothers) was gathered from the same region. RESULTS: Chorioamnionitis was a common diagnosis both with stillbirths and 'healthy' deliveries (82 and 68%, respectively). Extension of the inflammation to decidua basalis was seven times more common among stillbirths than among controls (odds ratio 7.2, confidence interval 2.8-21.9). The most common bacteria found at cultures were Escherichia coli, Coagulase negative staphylococcus, Enterococcus faecalis and group B Streptococcus. The risk for stillbirth was doubled if both inflammation and bacteria were present (odds ratio 2.3, confidence interval 0.92-5.8). Meconium discharge was more common among stillbirths than controls (odds ratio=4.7, confidence interval 1.7-14). There were no differences in any respect regarding macerated and non-macerated stillbirths. Our findings are similar to the results from studies in developing countries except for the higher incidence of stillbirths in such countries. CONCLUSIONS: Thus, a large part of otherwise unexplained stillbirths might be due to ascending infections.

Interaction between haemochromatosis and transferrin receptor genes in hepatocellular carcinoma.

In hepatocellular carcinoma (HCC) iron has been implicated as a risk factor primarily in patients with hereditary haemochromatosis (HH) and cirrhosis. The wild-type HH (HFE) protein complexes with the transferrin receptor (TFR), and two HFE mutations (Cys282Tyr and His63Asp) have been found to increase the affinity of the TFR for transferrin resulting in an increased cellular uptake of iron. In previous studies we found an interaction between HFE and TFR genotypes in multiple myeloma and breast and colorectal carcinomas. In the present investigation we have studied HFE and TFR genotypes in 54 Swedish patients with HCC, using DNA from archival samples of paraffin wax blocks. The same HFE-TFR interaction as in the previously studied neoplastic disorders was found. Individuals carrying the HFE282Tyr allele (homo- and heterozygotes) in combination with homozygosity for the TFR Ser allele showed an increased risk for HCC (OR = 3.5; 95% confidence interval, CI = 1.3-9.3), which was further increased in HFE Tyr homozygotes and compound (Tyr/Asp) heterozygotes in combination with TFR 142Ser homozygosity (OR = 17.2; 95% CI = 1.8-168.9). The presence of liver cirrhosis could only be assessed in part of the patient material. In patients with verified liver cirrhosis the risk figures were substantially increased: for HFE 282 Tyr carriers in combination with TFR 142 Ser/Ser OR = 7.2; 95% CI = 2.0-25.5 and for HFE 282Tyr homozygotes and compound heterozygotes in combination with TFR 142Ser homozygosity, OR = 62.8; 95% CI = 6.1-642.5.

Interobserver variation in diagnosing coeliac disease. A joint study by Danish and Swedish pathologists.

There is an almost 40-fold difference in incidence rates of symptomatic coeliac disease between Denmark and Sweden. In an attempt to explain this difference, the present study focused on the interobserver agreement when pathologists were assessing small intestinal biopsy specimens from children suspected of suffering from coeliac disease. The study was performed on 90 biopsy specimens from 73 children. Most of the biopsies came from children who turned out not to suffer from coeliac disease after a clinical evaluation including small intestinal biopsy. Using the kappa methodology, the interobserver agreement between two Danish pathologists and one Swedish pathologist, all of whom were experienced, was "moderate" to "substantial" or 0.57-0.75. Kappa indices when the pathologists evaluated selected histological elements were in the interval from 0.24 to 0.67. A comparison of a previous routine diagnostic assessment of the 90 biopsies (14 pathologists) with the results of the experienced pathologists in the present study gave kappa indices of from 0.53 to 0.57. The study could prove no major differences in the histopathological assessment of small intestinal biopsy specimens made by Danish and Swedish pathologists. The difference in clinical presentation of coeliac disease in Denmark and Sweden does not relate to differences in the histopathological assessment of small intestinal biopsies.

Clonal chromosomal abnormalities in congenital bile duct dilatation (Caroli's disease).

BACKGROUND: Caroli's disease is a rare congenital disorder characterised by cystic dilatation of the intrahepatic bile ducts and an increased risk of cholangiocellular carcinoma. The cause is unknown, but occasional familial clustering suggests that some cases are inherited, in particular when occurring in association with polycystic kidney disease and germline PKD1 gene mutations. To date, no gene responsible for familial isolated Caroli's disease has been identified, and no genetic investigations of liver tissue from patients with Caroli's disease have been reported. PATIENT/METHOD: A liver biopsy specimen from a patient with isolated Caroli's disease, without any signs of cholangiocellular carcinoma, was short term cultured and cytogenetically investigated after G banding with Wright's stain. RESULT: Cytogenetic analysis disclosed the karyotype 45-47,XX,der(3)t(3;8)(p23;q13), +2mar[cp6]/46,XX[18]. CONCLUSIONS: The finding of an unbalanced translocation between chromosomes 3 and 8 suggests that loss of distal 3p and/or gain of 8q is of pathogenetic importance in Caroli's disease. Alternatively, structural rearrangements of genes located in 3p23 and 8q13 may be of the essence. These chromosomal breakpoints may also pinpoint the location of genes involved in inherited forms of Caroli's disease not associated with polycystic kidney disease.

Nonrandom chromosomal aberrations and cytogenetic heterogeneity in gallbladder carcinomas.

Chromosome banding analysis of 11 short-term cultured gallbladder carcinomas revealed acquired clonal aberrations in seven tumors (five primary and two metastases). Three of these had one clone, whereas the remaining four were cytogenetically heterogeneous, displaying two to seven aberrant clones. Of a total of 21 abnormal clones, 18 had highly complex karyotypes and three exhibited simple numerical deviations. Double minutes and homogeneously staining regions were observed in one and two carcinomas, respectively. To characterize the karyotypic profile of gallbladder cancer more precisely, we have combined the present findings with our three previously reported cases, thereby providing the largest cytogenetic database on this tumor type to date. A total of 287 chromosomal breakpoints were identified, 251 of which were found in the present study. Chromosome 7 was rearranged most frequently, followed by chromosomes 1, 3, 11, 6, 5, and 8. The bands preferentially involved were 1p32, 1p36, 1q32, 3p21, 6p21, 7p13, 7q11, 7q32, 19p13, 19q13, and 22q13. Nine recurrent abnormalities could, for the first time, be identified in gallbladder carcinoma: del(3)(p13), i(5)(p10), del(6)(q13), del(9)(p13), del(16)(q22), del(17)(p11), i(17)(q10), del(19)(p13), and i(21)(q10). The most common partial or whole-arm gains involved 3q, 5p, 7p, 7q, 8q, 11q, 13q, and 17q, and the most frequent partial or whole-arm losses affected 3p, 4q, 5q, 9p, 10p, 10q, 11p, 14p, 14q, 15p, 17p, 19p, 21p, 21q, and Xp. These chromosomal aberrations and imbalances provide some starting points for molecular analyses of genomic regions that may harbor genes of pathogenetic importance in gallbladder carcinogenesis. Genes Chromosomes Cancer 26:312-321, 1999.

Spontaneous course of symptoms in primary sclerosing cholangitis: relationships with biochemical and histological features.

An analysis was made of the symptom diaries of 65 patients with primary sclerosing cholangitis (PSC) who recorded their symptoms of itching, pain and fever during a 3 year period. Symptoms occurred in 84% of the patients, with considerable individual variations in symptom load. Symptoms were usually intermittent. "Itching only" and "pain only" were the most frequent episode features. Most episodes lasted only 1-2 days. Fever seemed to be the most embarrassing symptom. Apart from close correlations between pruritus and serum ALP levels, there were no significant correlations between the symptom load and serum biochemistry or eleven different histological features. Even daily symptoms over a period of several months could disappear spontaneously. We conclude that most symptom episodes in PSC are mono-symptomatic and brief. Biochemical or histological data do not predict the appearance of symptoms.

Intralobar bronchopulmonary sequestration in the newborn--a congenital malformation.

BACKGROUND: Intralobar sequestration (ILS) has been suggested to be an acquired lesion. However, we have observed several young infants who had ILS. OBJECTIVES: Since this fact seems to indicate a congenital origin, we reviewed our experience. MATERIAL AND METHODS: A retrospective review of bronchopulmonary sequestration from the Departments of Radiology and Pathology in Lund between 1964 and 1997. RESULTS: We identified seven infants or young children with a diagnosis of intralobar sequestration. In each patient, the ILS was present before recurrent infection developed. Five had chest X-rays as neonates, one at 3 months and one at 11 months of age. All but one showed an abnormality on their first chest X-ray, consistent with sequestration. Six of the ILS were verified at angiography; all seven were surgically removed. Two of the children with ILS also had congenital cystic adenomatoid malformation (CCAM). Three children had both ILS and scimitar syndrome. CONCLUSIONS: The fact that ILS was present in seven newborn and young infants indicates that this lesion is, at least in some patients, a congenital malformation.

Biochemical and ultra-structural reactions to parenteral nutrition with two different fat emulsions in rats.

OBJECTIVE: To compare the effects on fat metabolism and Kupffer cell morphology by total parenteral nutrition (TPN) with two different fat emulsions. DESIGN: Thirty-two male Sprague-Dawley rats, divided into three groups, were investigated. Rats fed orally were used as a reference group, and a group of rats receiving TPN with fat emulsions containing pure long-chain triglycerides (LCT) was compared to a group of rats receiving fat emulsions containing both long-chain triglycerides and medium-chain triglycerides (MCT/LCT). The TPN regimens were equicaloric and administered continuously via a jugular catheter for 10 days. INTERVENTIONS: After suffocation, blood of the rats was collected for the determination of serum lipids. Epididymal fat and heart were collected for the analysis of lipoprotein lipase (LPL) activities, and liver specimens were saved for analyses of hepatic triglyceride concentration, as well as activities of hepatic lipase (HL) and lysosomal enzymes. Light and electron microscopy were used for examination of the Kupffer cell reaction. RESULTS: Directly after termination of parenteral feeding, the levels of serum triglycerides and high density lipoprotein (HDL) triglycerides were higher in the MCT/LCT group than in the LCT group, while no differences concerning cholesterol and phospholipid concentrations were found. No significant difference in liver steatosis was found between the two TPN groups. Comparison of the TPN groups showed that the MCT/ LCT group had significantly decreased LPL activity in adipose tissue, while the LCT group had significantly increased LPL activity in the heart. The activity of HL was low in both groups, but significantly lower in the LCT group. Lipid accumulation and an increased number of lysosomes were found in all Kupffer cell when TPN with LCTemulsions was used. Moreover, TPN induced a pronounced increase in various liver lysosomal enzyme activities, but there was no notable difference between LCT and MCT/LCT effects. CONCLUSIONS: Compared to treatment with pure LCTemulsions, treatment with MCT/LCT emulsions evoked weaker biochemical reactions in terms of lower activity of lipoprotein lipase in fat and heart together with higher serum and HDL triglyceride levels. Morphological signs of increased Kupffer cell activity such as the appearance of multiple lysosomes and fat vacuoles in the cytoplasm followed treatment with pure LCT emulsions. However, both TPN groups showed a marked increase in activities of liver lysosomal enzymes.

Frequent rearrangements of chromosomes 1, 7, and 8 in primary liver cancer.

Fifteen primary liver carcinomas (PLCs), including 12 hepatocellular carcinomas and three cholangiocellular carcinomas, were investigated cytogenetically after short-term culture. Ten tumors displayed clonal chromosomal abnormalities, whereas only normal karyotypes were detected in four cases, and one sample failed to grow in vitro. Structural rearrangements most often involved chromosomes 1, 7, and 8 and chromosome bands 1p36, 1q25, 3q10, 5q13, 6p10, 7p15, 7q22, 7q32, 8q10, 8q13, 14q10, and 17p11. Frequent genomic imbalances included gains of 1q, 3q, 6p, 7p, and 8q and losses of 1p, 8p, 10q, 14p, 17p, and 19p. A compilation of findings for all 19 cytogenetically abnormal PLCs reported to date, including the present cases, reveals that structural aberrations particularly affect 1p11, 1p22, 1p32, 1p34, 1p36, 1q25, 7p15, 7q22, 8q10, 8q13, 14q10, 16q24, and 17p11, and that the abnormalities frequently result in overrepresentation of 1q, 3q, 6p, 7p10-14, 8q, and 17q and underrepresentation of 1p34-36, 6q27, 7q32-qter, 8p, 13p, 14p, 16q24, and 17p. These genomic regions are likely to harbor genes of importance in hepatocarcinogenesis, and the present cytogenetic mapping may hence be of value for further molecular genetic investigations of PLC.

Cytogenetic abnormalities and clonal evolution in an adult hepatoblastoma.

Hepatoblastomas usually occur in children < 3 years of age, and only occasional adult cases have been described. To date, 20 cytogenetically abnormal childhood hepatoblastomas have been reported. Karyotypic investigations have shown that most hepatoblastomas are diploid or hyperdiploid, often displaying trisomies for chromosomes 2 and 20. We have cytogenetically investigated an adult hepatoblastoma for which no previous karyotypic data exist. A hypertriploid stemline with multiple numerical and structural chromosomal aberrations, including +2 and +20, was found. In addition, the tumor displayed extensive clonal evolution with 11 subclones. Although the tumor thus displayed some chromosomal abnormalities commonly observed in childhood tumors, providing further support for the importance of these abnormalities in the development of hepatoblastoma, the level of genomic complexity seen in the present case has never been described in childhood hepatoblastomas and may suggest a different etiology or pathogenesis.

A case control study of chorioamniotic infection and histological chorioamnionitis in stillbirth.

In order to elucidate the role and aetiology of chorioamnionitis in stillbirth a case referent study was carried out in 58 pregnant women with late foetal death (cases) and in 58 pregnant women at term with live foetus (referents) matched for age and parity in Maputo Mozambique. Samples from women, stillborns and liveborns, were collected for microbiological and histological assessment. Histological chorioamnionitis was diagnosed in 96% of the cases and in 67% of the referents (OR = 13.5; 95% CI: 2.9-123.9). Escherichia coli was the species most frequently isolated in stillborns; in 14/16 (88%) cases it was isolated from intracardiac fluid. E. coli was associated with chorioamnionitis in 28% of the stillborns as compared to 5% of the referents (OR = 6.9; 95% CI: 1.4-65.4). No group B streptococci were recovered from any placenta or newborn. Vasculitis was present in 12 (21%) cases and in 3 (5%) referents (OR = 4.8; 95%, CI: 1.2-27.7). Histological chorioamnionitis was thus associated with stillbirth. E. coli was common in stillborns. The presence of vasculitis in one fifth of the stillborns indicated that the foetus was alive at the onset of infection.

Biliary atresia: should all patients undergo a portoenterostomy?

PURPOSE: The management of noncorrectable extra hepatic biliary atresia includes portoenterostomy, although the results of the surgery are variable. This study was done to develop criteria that could successfully predict the outcome of surgery based on preoperative data, including percutaneous liver biopsy, allowing a more selective approach to the care of these babies. METHODS: The charts and biopsy results of 31 patients who underwent a Kasai procedure for biliary atresia between 1984 and 1994 were reviewed. Values for preoperative albumin, bilirubin, age of patient at Kasai, and lowest postoperative bilirubin were recorded. Surgical success was defined as postoperative bilirubin that returned to normal. A pathologist blinded to the child's eventual outcome graded the pre-Kasai needle liver biopsy results according to duct proliferation, ductal plate lesion, bile in ducts, lobular inflammation, giant cells, syncitial giant cells, focal necrosis, bridging necrosis, hepatocyte ballooning, bile in zone 1, 2, and 3, cholangitis, and end-stage cirrhosis. Clinical outcome was then predicted. RESULTS: Success after portoenterostomy could not reliably be predicted based on gender, age at Kasai, preoperative bilirubin or albumin levels. Histological criteria, however, predicted outcome in 27 of 31 patients (P < .01). Fifteen of 17 clinical successes were correctly predicted; as were 12 of 14 clinical failures (sensitivity, 86%; specificity, 88%). Individually, the presence of syncitial giant cells, lobular inflammation, focal necrosis, bridging necrosis, and cholangitis, were each associated with failure of the portoenterostomy (P < .05). Bile in zone 1 was associated with clinical success of the procedure (P < .05). CONCLUSIONS: Based on the predictive information available in a liver biopsy, we conclude that those patients who will not benefit from a Kasai procedure can be identified preoperatively, and channeled immediately to transplantation.

Hypereosinophilic syndrome in a child mosaic for a congenital triplication of the short arm of chromosome 8.

An 11-year-old boy with mental retardation, malformations, and the mosaic karyotype 47,XY,+i(8p)/46,XY presented with fever, headache and petechiae. Peripheral blood WBC was 190 x 10(9)/l; and contained > 90% mature eosinophils. Cytogenetic analysis of the eosinophils revealed no aberrations except the constitutional karyotype. The patient was diagnosed as having a hypereosinophilic syndrome. Shortly after initiation of therapy he died from extensive mural thrombi of the heart and thrombi of several other organs. This is the first case of congenital triplication of the short arm of chromosome 8 associated with hypereosinophilic syndrome, suggesting involvement of genes on chromosome 8p in the regulation of eosinopoiesis.

Lipid deposition in Kupffer cells after parenteral fat nutrition in rats: a biochemical and ultrastructural study.

OBJECTIVE: To study fat metabolism and evaluate lipid deposition in hepatocytes and Kupffer cells during parenteral nutrition (PN) with or without fat. DESIGN: 20 male Sprague-Dawley rats, divided into four groups, were investigated. Rats fed orally were used as a reference group and compared to three groups of rats receiving PN either without fat or with 33% of non-protein energy as fat or with 66% of non-protein energy as fat. The PN regimens were equicaloric and administered continuously via a jugular catheter for 7 days. INTERVENTIONS: After suffocation, blood was collected for determination of serum lipids. Epididymal fat and heart were collected for analysis of lipoprotein lipase activities, and pieces of liver were saved for analyses of liver triglyceride concentration and hepatic lipase activity. Light and electron microscopy were used for examination of lipid deposition in Kupffer cells. RESULTS: Directly after termination of parenteral feeding, the serum levels of triglycerides were similar in all PN groups, while the levels of non-high-density lipoprotein (HDL) cholesterol and non-HDL phospholipids were significantly increased in parallel with increased doses of fat. Lipid-free PN resulted in significantly less liver steatosis than high-fat PN. Lipid PN also resulted in downregulated hepatic lipase activity, signs of lipid accumulation in Kupffer cells and hepatocytes and an increased number of phagosomes in Kupffer cells. CONCLUSIONS: Fat vacuoles were found in Kupffer cells after lipid PN, although serum levels of triglycerides were not elevated and lipoprotein lipase activity were not depressed. The cells were distended by fat vacuoles after administration of PN solutions with a high fat concentration. Morphological signs of increased Kupffer cell activity were also found, suggesting that intravenous fat emulsions may activate macrophages.

Syphilis seroprevalence among pregnant women and its role as a risk factor for stillbirth in Maputo, Mozambique.

OBJECTIVE: To elucidate the role of current syphilis as a risk factor for foetal death. METHODS: Sera were obtained from 57 women with third trimester foetal death (cases) and 58 women with foetus alive (controls) matched for age and parity. All sera reactive in qualitative Rapid Plasma Reagin (RPR) analyses were tested with serial twofold dilutions to determine endpoint flocculation titres and tested with the micro-haemagglutination assay for Treponema pallidum (MHA-TP). Placental biopsies were sectioned and stained by haematoxylin-eosin and Warthin-Starry for light microscopy. SETTING: Central Hospital, in Maputo, Mozambique, from January 1990 to June 1991. RESULTS: The MHA-TP was reactive in 42% of cases and in 12% of controls (OR = 5.3; 95% CI: 1.9-15.4). The RPR card test was reactive at the dilution of 1.32 or greater in 28% of cases and in 7% of controls. All these results were confirmed by MHA-TP (OR = 5.3; 95% CI: 1.5-15.4). In 9/28 (32%) MHA-TP seroreactive women (7 cases and 2 controls) placental morphological changes indicated syphilitic infection. CONCLUSION: MHA-TP seroreactivity and high titre RPR were associated with stillbirth. Morphological changes presumptive of syphilis infection were found in 32% placentas histologically studied. Syphilis is a risk factor for foetal death in Maputo, Mozambique.

Stillbirths and intrauterine infection, histologic chorioamnionitis and microbiological findings.

OBJECTIVE: To analyze whether placental inflammation is associated with stillbirth in Zimbabwe. METHOD: Placentas from 66 stillbirths (> 22 weeks' gestation; patients with congenital malformations, diabetes or preeclampsia were excluded) and 66 term live births were studied for the presence and severity of chorioamnionitis. The morphological results were compared with earlier presented microbiological findings in the same material. RESULTS: Chorioamnionitis was present in 79% of stillbirths and 30% of live births (O.R. 8.5, 95% C.I. 4.0-18). Nine percent of stillbirths but no live births presented vasculitis of the chorionic plate, which verified an inflammatory response from the infant (O.R. 14, 95% C.I. 2.8-72). The same types of microorganisms were isolated from stillbirths and liveborns, but Escherichia coli and group B streptococci were more frequent among stillbirths. CONCLUSIONS: Morphological chorioamnionitis occurred 2.6 times more often in women with stillbirths than in women with live births. In 9% of stillbirths the infant showed an inflammatory response. Thus the infant was alive when the infection occurred and it is therefore reasonable to assume that infection was the cause of death.

The effect of pretreatment with endotoxin and lactobacillus on bacterial translocation in acute liver injury.

OBJECTIVE: To evaluate the effect of pretreatment with endotoxin or Lactobacillus reuteri pretreatment on bacterial translocation after acute liver injury. DESIGN: Experimental study. SETTING: University department, Sweden. SUBJECTS: 96 Sprague-Dawley rats were divided into four groups of 24 each. Three of them received intraperitoneal D-galactosamine, the fourth received pyrogen free water and was used as the normal control. Twenty-four hours later the study was terminated and samples collected. INTERVENTIONS: Endotoxin and L reuteri R2LC were injected intraperitoneally three days, one week, and two weeks before induction of liver injury. MAIN OUTCOME MEASURES: Extent of liver injury and bacterial translocation to mesenteric lymph nodes, liver, and systemic blood. RESULTS: The extent of liver injury and rate of bacterial translocation were lower three days after pretreatment with endotoxin, than after pretreatment with L reuteri. There was no other difference among the other groups. High concentrations of serum endotoxin were detected three days after pretreatment with endotoxin. There were no significant changes in small intestinal and caecal bacterial counts. CONCLUSION: Pretreatment with endotoxin effectively prevented liver injury by D-galactosamine and subsequent bacterial translocation. Pretreatment with L reuteri had no beneficial effect.

Clinical and immunohistochemical findings in a case of neonatal Marfan syndrome.

A newborn girl with extreme cardiomegaly discovered by fetal ultrasound after 34 gestational weeks is presented. The girl was delivered through a Caesarean section. After birth, multiple skeletal stigmata and generalized cardiac involvement with abnormal valves and dilated great arteries suggested Marfan syndrome. The girl died at the age of 10 h. The postmortem examinations showed cardiovascular lesions typical of Marfan syndrome. Immunofluorescence studies from cultured fibroblasts of the patient showed decreased amounts of immunostained fibrous material, supporting the clinical diagnosis of a severe Marfan syndrome.