Three variants of parathyroid hormone-related protein messenger RNA are expressed in human mammary gland

PTH-related protein (PTHrP) is found in a variety of tissues; particularly high levels are present in human milk. The structure of the human PTHrP gene is complex, and alternative splicing allows expression of three different variants PTHrP139, PTHrP173, and PTHrP141, respectively. To determine which of the variants are expressed in human mammary gland a reverse transcriptase polymerase chain reaction (RT-PCR) method was elaborated, distinguishing the three variants. mRNA isolated from human milk cells, human mammary epithelial cells (HMEC) and human nonlactating mammary gland cells were analyzed. The RT-PCR experiments resulted in amplification of DNA fragments corresponding to all three variants for all three cell sources tested. The nucleotide sequences of the PCR fragments were determined and verified to be identical to the reported sequences. Hence, it is concluded that human mammary gland epithelial cells express three variants of PTHrP. Whether these have different physiologic effects in the mammary gland or in the breast fed infant remain to be explored.

Surface exposure and species specificity of an immunoreactive domain of a 66-kilodalton outer membrane protein (P66) of the Borrelia spp. that cause Lyme disease

A chromosomally encoded 66-kDa protein (P66) of Borrelia spp. that cause Lyme disease has previously been shown to be associated with the spirochetal outer membrane. A topological model of P66 predicts a surface-exposed fragment which links the N- and C-terminal intramembranous domains of the protein (J. Bunikis, L. Noppa, and S. Bergström, FEMS Microbiol. Lett. 131:139-145, 1995). In the present study, an immunogenic determinant of P66 was identified by a comparison of the immunoreactivities of different fragments of P66 generated either by proteolytic treatment of intact spirochetes or as recombinant proteins expressed in Escherichia coli. The immune response to P66 during natural infection was found to be directed against the predicted surface domain which comprises amino acids at positions 454 through 491. A sequence comparison revealed considerable polymorphism of the surface domains of P66 proteins of different Lyme disease-causing Borrelia species. Five sequence patterns of this domain were observed in the B. garinii strains studied. In contrast, sequences of the relevant part of P66 of the B. afzelii and B. burgdorferi sensu stricto isolates studied were identical within the respective species. In immunoblotting, 5 of 17 (29.4%) sera from North American patients with early disseminated or persistent Lyme disease reacted against P66 of B. burgdorferi sensu stricto B31. These sera, however, failed to recognize P66 of B. afzelii and B. garinii, as well as an analog of P66 in the relapsing fever agent, B. hermsii. In conclusion, the topological model of P66 is supported by the demonstration of an apparent surface localization of an immunoreactive domain of this protein. Furthermore, analogous to the plasmid-encoded borrelial outer surface proteins, the predicted surface-exposed portion of chromosomally encoded P66 appears to be antigenically heterogenous.

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.

Simplified care of women with prolonged or persistent retention of the placenta: the use of paracervical block

Thirty patients with prolonged or persistent retention of the placenta were randomized to either paracervical block or intravenous cocktail of pethidine and diazepam. When paracervical block worked, the analgesia produced was better than that usually achieved with intravenous cocktail of pethidine and diazepam. From a cost-benefit point of view paracervical block is preferable to intravenous cocktail. No significant side-effects occurred during the trial.

A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique

OBJECTIVE

To evaluate the outcome of caesarean delivery performed by assistant medical officers and specialists in obstetrics and gynaecology with particular attention to post-operative complications.

DESIGN

We performed a nonrandomised analysis of 2071 consecutive caesarean deliveries at Maputo Central Hospital. Of these, 958 (46.3%) were performed by assistant medical officers (medical assistants trained for surgery) and the rest (53.7%) by specialists in obstetrics and gynaecology. The age and parity distributions of women in the two groups were almost identical.

SETTING

University Hospital in Maputo, covering all emergency obstetrics with about 48,000 deliveries per year.

POPULATION

Two thousand and seventy-one consecutive caesarean deliveries.

MAIN OUTCOME MEASURES

Post-operative complications and the duration of post-operative hospital stay.

RESULTS

There were no differences in the indications for caesarean delivery. The surgical interventions associated with caesarean delivery did not differ in the two groups. The only significant difference was in the group of superficial wound separation due to haematoma, which was slightly more common (0.35% vs 0.05%) in the group operated on by assistant medical officers (Odds Ratio 2.2; 95% Confidence Interval 1.3-3.9).

CONCLUSION

Training selected medical assistants to perform caesarean delivery, even on women in poor general condition, is justified in settings in which doctors are scarce.

Canary finches (Serinus canaria) as an avian infection model for Lyme borreliosis

To investigate if passerine birds can be used as an avian model for Lyme borreliosis, the Borrelia burgdorferi sensu stricto strain Sh2-82 was inoculated subcutaneously on Canary finches (Serinus canaria). Spirochaetes could be detected in the blood by direct microscopy and an immunofluorescence assay (IFA) up to 2 weeks after the inoculation. DNA amplification (PCR) revealed B. burgdorferi DNA in the serum for up to 3 weeks, in the faeces up to 4 weeks, and from several internal organs at autopsy 3 months after the inoculation. Of particular interest was the finding of B. burgdorferi DNA in the liver of all birds at the end of the experiment, indicating a persistent infection. Four weeks after the primary infection, all infected birds showed an increase in anti Borrelia IgG antibodies and after 6 weeks all birds had seroconverted. Except for a brief episode of diarrhoea, none of the birds showed any signs of disease. This study shows that passerine birds experience short-term spirochaetemia after infection with B. burgdorferi, but show few clinical symptoms. This suggests that, although these birds can act as reservoirs of B. burgdorferi s.s., they may be of less importance as long lasting amplifiers for this pathogen.

Child growth during weaning depends on whether mother is pregnant again

Few longitudinal studies are available which relate data on breastfeeding and growth of the last-born child to data on the mother's subsequent pregnancy. The purpose of the present prospective study from Bhutan was to compare growth rate of children weaned during a subsequent pregnancy, with those of children weaned at the same age, but from non-pregnant mothers. Measurements of weight of 113 children and interviews with their mothers were done monthly through 32 months during the children's first 3 years of life. The period of overlap between lactation and pregnancy had a median duration of 5 months, and increased with an average of one week for each month reduction in the subsequent birth interval (P< 0.01). Children who stopped breastfeeding during their mothers' subsequent pregnancy showed a reduced growth rate during the last months before termination of breastfeeding when compared to children weaned at the same age, but from non-pregnant mothers (P = 0.04), and when compared to children who continued breastfeeding (P = 0.06).

Molecular polymorphism of the lyme disease agent Borrelia garinii in northern Europe is influenced by a novel enzootic Borrelia focus in the North Atlantic

Lyme disease Borrelia species are distributed in temperate areas of North America and Eurasia. To elucidate the distribution of borreliae in subarctic regions, strains isolated from Ixodes ricinus and Ixodes uriae ticks found on islands in the northern Atlantic and Baltic Sea were molecularly characterized. All isolates were verified as Borrelia garinii by 16S rRNA gene analysis and immunoblotting with monoclonal antibodies specific for the outer surface proteins A and C. Three ribotypes (RTs) of B. garinii were delineated. I. ricinus complex-associated RT1 was phenotypically most heterogeneous. Two newly identified ribotypes were shared by different tick species and conformed to two established OspA serotypes. RT2 was restricted to the islands in the northern Baltic Sea, whereas RT3 was recovered also from ticks found in the North Atlantic. In conclusion, molecular polymorphism of the studied borrelia isolates suggests a complex enzootic potential of B. garinii in northern Europe and implies a novel, seabird tick I. uriae-associated enzootic focus of Lyme disease borreliae in the North Atlantic.

Frequent diarrhoeas in early childhood have sustained effects on the height, weight and head circumference of children in East Bhutan

Episodes of diarrhoea and nutritional status of 113 children in East Bhutan were recorded monthly from 7 to 36 months of age. A re-examination was carried out 20 months later. The load of diarrhoeal diseases in early childhood was negatively associated with the parameters of children's long-term nutritional status 20 months later. Also, when early nutritional status and socioeconomic factors are included in the model, the diarrhoea variable explains a significant part of the variation in height for age (p = 0.04, delta R2 = 0.035), weight for age (p = 0.03, delta R2 = 0.030) and head circumference (p = 0.0007, delta R2 = 0.077). This is not so for the variation in weight for height or mid-upper arm circumference (p > 0.1, delta R2 < 0.005). Stunting is widespread in the area, and the effects of diarrhoea on nutritional status are more likely to be sustained in settings where dietary intake is marginal.

Impact of intrapartum intravenous ampicillin on pregnancy outcome in women with preterm labor: a randomised, placebo-controlled study

The purpose of this study was to elucidate whether the use of intravenous ampicillin (vs. placebo therapy) in women in early active-phase preterm labor reduces infectious complications postpartum in mothers and their newborns. A randomised, double-blind, placebo-controlled study was carried out on 102 women with gestational age < 37 completed weeks in the active phase of labor (dilatation of cervix > or = 4 cm). Enrolled women received a loading dose of 5 g of ampicillin (n = 44) or placebo (n = 58) in intravenous infusion twice, 4 h apart. In a few cases, this interval was shortened in order to obtain a minimum interval of 1 h between the last dose and delivery. There was a significant reduction in the ampicillin group (vs. the placebo group) of the prevalence of neonatal infection (OR 19.0; 95% CI 5.5-80.8), histological chorioamnionitis (OR 5.9; 95% CI 2.0-19.4) and puerperal endometritis-myometritis (OR 3.7; 95% CI 1.3-10.3). It is concluded that women in the active phase of preterm labor and their newborns benefit from treatment with intravenous ampicillin. Antibiotic treatment reduces the incidence of neonatal infectious morbidity, of puerperal endometritis and of histological chorioamnionitis.

Ultrasonographic measurement of the symphysis pubis: a potential method of studying symphyseolysis in pregnancy

The width of the symphysis pubis was measured in a skeleton model using slide rule, ultrasonography and x-ray. Ultrasonography gave a 0.5-mm and x-ray a 1.0-mm narrower gap than the slide rule. Further, 15 nonpregnant females undergoing urography volunteered for an extra ultrasonography of the symphysis pubis. The widths of the symphysis as measured from the x-ray exposures and the ultrasonography were compared. Regression analysis gave a regression coefficient of 0.979 and a correlation coefficient of 0.850. Ultrasonography offers at least the same precision as x-ray for assessing the width of the symphyseal gap.

A randomised study on the impact of peroral amoxicillin in women with prelabour rupture of membranes preterm

One hundred and six third trimester pregnant women with prelabour rupture of membranes preterm were randomised to either peroral amoxicillin 0.75 g 3 times daily (n = 50) or placebo (n = 56) in a blinded way. The patients were hospitalised in bed for 7 days unless contractions started and delivery ensued. Only 1 patient was discharged after 7 days of treatment, while the remaining ones delivered within 1 week after admission. The average rupture-to-expulsion interval was 68.4 h in the placebo group and 91.7 h in the amoxicillin group, implying a significantly prolonged stay by 43% in the amoxicillin group (p = 0.03). The other outcome variables registered (birth weight, stillbirth prevalence, vaginal haemorrhage and postpartum endometritis-myometritis) did not differ significantly in the two treatment groups. There was a trend towards a longer duration of stay in the neonatal ward among newborns in the amoxicillin group suffering neonatal death (p = 0.06). It is concluded that antibiotic treatment of this group of women may be justified in settings were sexually transmitted diseases and other genital infections are prevalent, whereas such treatment is less likely to have an effect when genital infection is rare.

Amniotic fluid antibacterial activity and nutritional parameters in term Mozambican and Swedish pregnant women

Randomly selected parturients with term singleton pregnancies from two different settings, 83 from Mozambique and 90 from Sweden, entered the study. All of them underwent elective cesarean section, which enabled sterile harvesting of amniotic fluid (AF). AF samples were then tested for antibacterial activity (ABA). Background data and nutritional status were compared. Average age was 32.7 and 30.7 years (n.s.), average parity 6.6 and 1.6 (p < 0.0001), average number of antenatal visits 4.9 and 11.6 (p < 0.0001), and average birthweight 3,194 and 3,688 g (p < 0.01), respectively. Body mass index, mid-upper-arm circumference and hemoglobin did not show any significant differences. The average ABA of AF was more than 50% higher in Swedish than in Mozambican specimens (p < 0.0001). Less than one-sixth of MoZambican women reached the average ABA of AF from Swedish women. Bacterial outgrowth delay equal to or above 3 h was encountered in 13% of Mozambican AF as against 61% of Swedish AF (OR 0.10; 95% CI 0.05-0.19). Histopathological examinations of the placenta, nonplacental membranes and umbilical cord showed inflammatory lesions in 29% of the Mozambican parturients and in 13% of Swedish parurients (OR 2.65; 95% 1.00-6.98). It is probable that the lower antibacterial activity in Mozambican AFs reflects an increased vulnerability to ascending genital infections during late pregnancy.

Ampicillin in the treatment of preterm labor: a randomised, placebo-controlled study

This study was performed in order to assess whether the use of oral ampicillin vs. placebo therapy in women with latent-phase preterm labor delays delivery and improves pregnancy outcome. A prospective, randomised, double-blind, placebo-controlled study was performed of 110 women at 22-34 weeks of gestation. Patients received oral ampicillin 1 g (n = 59) or placebo (n = 51) every 8 h for 7 days. Outcome measures comprised gestational age at delivery, birth weight, Apgar score, perinatal death, neonatal infection, fetal growth restriction, histological chorioamnionitis and puerperal infection. In the ampicillin and placebo groups, respectively, the average gestational age at birth was 36.6 and 33.8 weeks (p < 0.05) and average birth weight 2,885 and 2,336 g (p < 0.05). Odds ratio (OR) for gestational age > 35 weeks and for birth weight > or = 2,500 g was 3.9 (95% CI 1.6-9.4). Neonatal infection (OR 15.5; 95% CI 4.6-65.7), intrauterine growth retardation (OR 9.6; 95% CI 2.8-41.3), histological chorioamnionitis (OR 13.0; 95% CI 3.4-72.2) and puerperal endometritis-myometritis (OR 65.3; 95% CI 9.3-2,715.7) occurred significantly less frequently among ampicillin-treated than among placebo-treated women. It is concluded that women in latent phase of preterm labor benefit from treatment with oral ampicillin, which prolongs the gestational age at delivery with ensuing increase in birth weight, reduction in the prevalence of histological chorioamnionitis and in neonatal and puerperal infectious morbidity.

Amniotic fluid interleukins in Swedish and Mozambican pregnant women

The aim of the study was to investigate inflammatory cytokines, interleukin-1 beta (IL-1 beta), interleukin-1 receptor antagonist (IL-1ra), IL-6, IL-8 in amniotic fluid, in a cohort of Swedish pregnant women from early to late pregnancy and Mozambican late pregnant women with and without signs of histologic chorioamnionitis. Eleven Swedish women were studied from early pregnancy (week 16-17) to late pregnancy (week 37-38). Amniotic fluid was collected via amniocentesis in early pregnancy and also in late pregnancy during elective Caesarean section. From Mozambican women, amniotic fluid was harvested transmurally through the uterus wall during elective Caesarean section. Half of the group of 30 women showed histological signs of chorioamnionitis and half of the group did not show such signs. A statistical, significant increase in IL-1ra, Il-6 and IL-8 values from early to late pregnancy was seen in the Swedish pregnant women. Among the Mozambican women, no statistically significant increase in the above-mentioned interleukins was observed when comparing women with and without histological signs of chorioamnionitis. Term Swedish and Mozambican women did not show differences in cytokine levels. There were no detectable values of IL-1 beta in either Swedish or Mozambican women. IL-1ra, IL-6 and IL-8 increased in amniotic fluid from the second to the third trimester in the Swedish cohort. No correlation was found between histological chorioamnionitis and elevated cytokine levels of amniotic fluid in term pregnant women not in labour. An equally good cytokine response was found among Swedish and Mozambican third-trimester non-labouring women.

Transhemispheric exchange of Lyme disease spirochetes by seabirds

Lyme disease is a zoonosis transmitted by ticks and caused by the spirochete Borrelia burgdorferi sensu lato. Epidemiological and ecological investigations to date have focused on the terrestrial forms of Lyme disease. Here we show a significant role for seabirds in a global transmission cycle by demonstrating the presence of Lyme disease Borrelia spirochetes in Ixodes uriae ticks from several seabird colonies in both the Southern and Northern Hemispheres. Borrelia DNA was isolated from I. uriae ticks and from cultured spirochetes. Sequence analysis of a conserved region of the flagellin (fla) gene revealed that the DNA obtained was from B. garinii regardless of the geographical origin of the sample. Identical fla gene fragments in ticks obtained from different hemispheres indicate a transhemispheric exchange of Lyme disease spirochetes. A marine ecological niche and a marine epidemiological route for Lyme disease borreliae are proposed.

Intrauterine death and infections during pregnancy

OBJECTIVE

To elucidate whether microbial infections are involved in the etiology of intrauterine death.

METHODS

One hundred four cases of stillbirth of unknown etiology and 96 age- and parity-matched referents with live births were analyzed with respect to microbial infection by cultures from the placenta, endocervix and internal organs of the fetuses, external sites of the babies and fetuses, and by serology for bacteria, viruses and Toxoplasma gondii.

RESULTS

In 17 cases in whom no other infectious agent was diagnosed, Escherichia coli was isolated from the placenta and one or more internal fetal organs. Tests for Treponema pallidum and Toxoplasma gondii were more frequently positive in cases than in referents (O.R. 8.3 and 3.9, respectively). There was no increased risk for intrauterine death in women with human immunodeficiency virus, cytomegalovirus, herpes simplex virus or rubella virus.

CONCLUSIONS

Our findings indicate that infections remain an important cause of intrauterine death in Zimbabwe.

Genital infections in the aetiology of late fetal death: an incident case-referent study

Women with prelabour fetal death in the third trimester were recruited in order to study the association between intra-uterine death and maternal genital colonization of bacteria. Fifty-eight women with verified fetal death were compared with a group of 58 women matched for age, parity and gestational length (the first referent group) and with women delivering liveborn neonates (second referent group). Cultures from the vagina, the endocervix, the amniotic fluid, the placenta, the conjunctivae of the newborn and the secretion of gastric aspirate of the newborn were carried out. Blood was taken for haemoglobin, thick film (malaria) and syphilis and HIV serology. Cases were more affected by previous stillbirths than first referents (OR = 11.88). Preterm delivery was significantly more common in cases than in second referents (OR = 57.70). Cases had significantly more often < 3 ANC visits (OR = 2.81). Cases had a lower body mass index than first referents (OR = 2.38). Temperature > or = 37 degrees C was 12 times more frequent in cases than in first referents (OR = 21.20) and four times more frequent than in second referents (OR = 6.60). Average birth weight among stillborns was 1954 g and in liveborns 3223 g (P = 0.001). The corresponding prevalence of LBW was 78% in cases and 0% among second referents (P < 0.001). Histological chorioamnionitis was significantly prevalent in cases than in second referents (OR = 4.97). Syphilis was significantly more common in cases than in first (OR = 7.71) and in second referents (OR = 5.30).(ABSTRACT TRUNCATED AT 250 WORDS)

Subsequent pregnancy affects morbidity of previous child

A prospective study of 113 children in rural Bhutan registered their morbidity and weight and their mothers' subsequent pregnancies, monthly for 32 months during the children's first 3 years of life. Children whose mothers had a subsequent birth interval of 18-30 months had an incidence of diarrhoea during the subsequent pregnancy 50% higher than their matched cohort whose mothers did not become pregnant (p = 0.02). The relative risk for diarrhoea calculated from pooled child months was 1.51. Children whose mothers became pregnant also tended to have a higher incidence of skin infections. Children, whose mothers were pregnant when they terminated breastfeeding, experienced an increased incidence of diarrhoea around weaning (p = 0.01). Children weaned at the same age from non-pregnant mothers did not show increased morbidity. This study, for the first time, relates observations of children's morbidity directly in time to the occurrence of the mother's subsequent pregnancy, and provides evidence of a causal relationship between a moderately short subsequent birth interval and a concurrent increase in morbidity for the study child.

Human milk kappa-casein and inhibition of Helicobacter pylori adhesion to human gastric mucosa

Readily digested caseins, which account for almost half of the protein content in human milk, are important as nutritional protein for breast-fed infants. It has also been advocated that part of the antimicrobial activity of human milk resides in the caseins, most likely the glycosyated K-casein. Top explore this possibility, we purified K-casein from human milk to homogeneity by a two-step size-exclusion chromatography procedure. Purified human K-casein, in contrast to K-casein purified from bovine milk, effectively inhibited the cell lineage-specific adhesion of fluoroisothiocyanate-labeled Helicobacter pylori to human gastric surface mucous cells. The inhibitory activity was abolished by metaperiodate oxidation and considerably reduced by preincubation with alpha-L-fucosidase but not with alpha-N-acetylneuraminidase or endo-beta-galactosidase. These results strongly support the view that fucose containing carbohydrate moieties of human K-casein are important for inhibition of H. pylori adhesion and, thus, infection. They also suggest that breastfeeding may protect from infection by H. pylori during early life and that species-specific glycosylation patterns, as illustrated by human bovine K-casein, partly determine both the narrow host spectrum of this human gastric pathogen and the capacity to resist infection.

An incident case-referent study of threatening preterm birth and genital infection

A total of 53 pregnant Mozambican women identified as having painful uterine contractions in the preterm period were studied and compared to referents, matched for age, parity, and gestational length, without such contractions. Both groups were studied regarding socio-economic and obstetric background factors, current clinical features, and microbiological findings in the lower genital tract. Cases tended to seek antenatal care earlier than referents. Salaried work outside the home was more common among cases (OR = 16.9). It was shown that affected cases had significantly more antenatal card risk factors (OR = 3.4) and that 10 times more cases than referents had elevated body temperature (OR = 16.7). Anaemia was more common among cases than among referents (OR = 3.7) and malaria parasitaemia was over-represented among cases (OR = 12.4). Mid-upper-arm circumference was shorter among cases than among referents (OR = 2.4). Anaerobic bacteria tended to be isolated from endocervix more often among cases than among referents (OR = 2.4). Only one woman in the study was HIV-1-positive. It is concluded that febrile infection is strongly associated with preterm labour and that salaried work outside home, anaemia, and malaria are significant risk factors in the setting studied.

Molecular analysis of a 66-kDa protein associated with the outer membrane of Lyme disease Borrelia

A 66-kDa protein (p66) associated with the outer membrane of Lyme disease Borrelia was analysed at the molecular level. The chromosomal genes encoding p66 in B. burgdorferi B31, B. afzelii ACAI, and B. garinii Ip90 were sequenced. Database searches revealed that the p66 gene sequences were homologous to a previously reported gene fragment of unknown function. The deduced amino acid sequences of p66 in different Lyme disease borreliae were 92-94% identical and had no homologs in the databases. Proteolytic cleavage patterns of p66 and a computer-predicted single trans-membrane helix suggested the presence of surface-exposed epitopes on the C-terminus.

Low birthweight and post partum endometritis-myometritis

BACKGROUND

The study aims at confirming or rejecting the hypothesis of an association between birthweight and post partum uterine infection.

METHODS

A case-referent study was performed on 51 puerperal women with clinical signs of endometritis-myometritis. To each case an otherwise healthy puerperal woman was recruited and matched for age, parity and days after delivery.

RESULTS

The proportion of women having had newborns with birthweight < 2500 g was 20/49 among cases and 2/50 among referents (odds ratio 16.6; 95% CI 3.5-152.3). Preterm births were registered in 15/50 cases and 2/49 referents (odds ratio 10.1; 95% CI 2.1-94.5). The average gestational age at delivery was approximately 2 weeks shorter among cases than among referents (37.5 versus 39.5 weeks).

CONCLUSIONS

Low birth weight was ten times more prevalent among women with puerperal infection than among healthy puerperal women. The findings indicate that giving birth to a low birth weight baby is strongly associated with ensuing puerperal infection, possibly by a subclinical antenatal intrauterine infection, predisposing to both adverse fetal and maternal outcomes of pregnancy.

The outer surface proteins of Lyme disease borrelia spirochetes stimulate T cells to secrete interferon-gamma (IFN-gamma): diagnostic and pathogenic implications

Late stages of borrelia Lyme disease infections may be difficult to diagnose because of unspecific symptoms and unreliable laboratory tests, being too unspecific or insensitive. The T cell immune response was thus evaluated in these patients by using a sensitive ELISPOT T cell assay that detects the secretion of IFN-gamma, i.e. a T helper 1 (Th1) response on the single-cell level. Three subcellular fractions of the Lyme borreliosis strain Borrelia afzelii were used for antigenic stimulation. The outer surface protein (Osp) fraction elicited the strongest response, discriminating between borrelia infections (n = 15) compared with other neurological diseases (n = 10) and normal controls (n = 12) (P = 0.0001). The more heterogeneous sonicated borrelia fraction also elicited a strong response, however, also in some of the controls. The flagellin fraction did not have a similar T cell-stimulating effect. When looking at subgroups of borrelia infections, central nervous system (CNS) infections (n = 7) revealed a lower T cell response in blood (P = 0.0128) compared with other borrelia manifestations (n = 8). Cerebrospinal fluid (CSF) lymphocytes were available from three patients with CNS borreliosis, and all showed a compartmentalization with higher responses to the Osp fraction in CSF compared with blood, also in the two patients without any intrathecal-specific antibody synthesis. The ELISPOT method is feasible for detecting a specific IFN-gamma T cell response in borrelia infections. This Th1 response may well be of pathogenic relevance.

Prevalence of Borrelia burgdorferi sensu lato-infected ticks on migrating birds

The prevalence of Lyme disease Borrelia-infected ticks on migrating birds was studied in Scandinavia. A total of 22,998 birds were caught at eight different bird observatories and examined for ticks. Five different species of ticks were found infesting the birds. The dominant species, Ixodesricinus, constituted 98.3% of the ticks collected. The presence of spirochetes was determined by an immunofluorescence assay of tick larvae and DNA amplification by PCR on all ticks. To determine which Borrelia burgdorferi sensu lato species were present, a species classification was performed by DNA amplification with species-specific 16S rDNA primers and by DNA sequencing (rDNA is DNA coding for rRNA). Flagellin gene sequences of all species of B. burgdorferi sensu lato previously recorded in Europe were observed. Borrelia garinii was the most prevalent Lyme disease Borrelia species in ticks collected from birds arriving from the South or Southeast in the spring, whereas the distribution was more heterogeneous in ticks from birds migrating from the Southwest. These data support the notion that birds are partly responsible for the heterogeneous distribution of Lyme disease Borrelia spirochetes in Europe.

Premature weaning in east Bhutan: only if mother is pregnant again

The relationship between breast-feeding and subsequent pregnancy in East Bhutan is examined, against the background of local attitudes to family planning. Ninety-eight mothers who had given birth 30-36 months earlier were interviewed. Semisolid supplementary feeding was introduced at a median age of 3 months. Median total duration of breast-feeding was 28 months, and day and night breast-feeding on demand was continued throughout. Median duration of postpartum amenorrhoea was 12 months, and was associated with the timing of the introduction of supplementary foods. There was a significant association between the occurrence of a subsequent pregnancy and early termination of breast-feeding. The relationships between breast-feeding pattern and pregnancy interval are complex, and their relative influence changes with time. During the first year postpartum, infertility during lactational amenorrhoea is important. During the second year there is a strong negative effect on lactation from the next pregnancy. The only important reason for ceasing to breast-feed within 2 years seems to be a new pregnancy.

Use of fundal height as a proxy for length of gestation in rural Africa

Lack of information on the date of the last menstrual period is a common problem in antenatal care in developing countries. The aim of this study was to see whether the fundal height can be used as a proxy for the length of gestation. A graph representing the expected remaining time to delivery was constructed from fundal height measurements in 7790 pregnant women delivered in a rural African hospital from 1970 to 1988. The graph was used to predict the probable week of delivery in 604 pregnant women giving birth to a singleton child in 1989. The mean deviation of the actual week of delivery from the predicted week was -0.6 (s.d. 3.4) weeks. In 270/604 cases (45%) delivery occurred within 2 weeks of the predicted week. Birthweight and perinatal mortality were strongly related to the deviation from the predicted week of delivery. The majority of perinatal deaths (34/50, 68%) occurred in children delivered early. The fundal height, as measured by paramedicals in routine antenatal care in rural Africa, may be used as a proxy for the length of gestation when the date of the last menstrual period is not known.

Socio-economic client characteristics and consequences of abortion in Nairobi

In Nairobi, 281 women presenting with alleged miscarriage were subdivided in the following subgroups, 91 spontaneous abortions (group 1), 152 suspected induced abortions (group 2) and 38 admittedly induced abortions (group 3). In the statistical analysis women in group 1 were compared with women from groups 2 and 3 combined (here referred to as group 4). Group 4 differed significantly from group 1 in the following respects: they were younger (p = 0.03) although they had previously born more babies (p = 0.008), lived more often together with their parents (p = 0.024), were less often married (p = 0.000012), worked more often as housewives (p = 0.00079), and lived in bigger households (p = 0.000015). No significant differences were encountered regarding religious beliefs. Group 4 women were more informed about contraceptives than group 1 (p = 0.04), particularly regarding injectables (p = 0.000096) and oral contraceptives (p = 0.0013) but also intra uterine devices (p = 0.024). Almost 90% of group 4 women indicated post abortion contraceptive interest, while only 1/3 of group 1 women did so. Group 3 women needed extensive parenteral treatment with a total hospital treatment cost amounting to 300 times that of group 1. The total cost of intravenous infusions was almost 10 times as high in group 3 as in group 1. The total number of days in hospital was significantly higher in group 4 than in group 1 (p = 0.0098).(ABSTRACT TRUNCATED AT 250 WORDS)

Subsequent pregnancy affects nutritional status of previous child: a study from Bhutan

In a rural area of Bhutan, anthropometric measurements of 113 children and interviews with their mothers were carried out monthly for 32 months. The purpose of the study was to investigate the effect of a mother's subsequent pregnancy on growth in weight of her last-born child. The children whose mothers had a subsequent birth interval of 18-30 months were matched for date of birth with children whose mothers did not become pregnant. Growth of the children during the subsequent pregnancy was compared with growth during the same period of children whose mothers were not pregnant. A statistically significant reduction of 28% was found (p < 0.05), which was most pronounced in early pregnancy. A similar trend was found for change in mid-upper-arm circumference (p < 0.05). The study provides evidence of a causal relationship between a moderate subsequent pregnancy interval and a concurrent reduction in growth rate for the previous child.

Vaginal misoprostol as an alternative to oxytocin for induction of labor in women with late fetal death

BACKGROUND

Induction of labor in women with late fetal death is often difficult in settings with scarce resources. The purpose of this study was to assess the value of vaginal misoprostol for induction of labor in women with such fetal death.

METHODS

In Maputo 156 women with late fetal death were allotted in a non-randomised way to either vaginal misoprostol or intravenous infusion of oxytocin. Treatment outcomes were compared as to cost-effectiveness and safety. In the misoprostol group none received more than 800 micrograms. Oxytocin infusion followed an established routine. Statistical analyses were performed by EPI Info software.

RESULTS

In cases with Bishop's score < 6 the induction-to-delivery interval averaged 14.8 hours in the misoprostol group and 31.0 hours in the oxytocin group (p = 0.001). The corresponding values for women with Bishop's score > or = 6 were 6.6 and 8.7 hours, respectively (p = 0.4). Women with intact membranes had an induction-to-delivery interval of 13.8 hours in the misoprostol group and 26.9 hours in the oxytocin group (p = 0.002). The corresponding values in women with ruptured membranes were 7.8 and 10.5 hours, respectively (p = 0.6). Successful induction was achieved in 81% of misoprostol-treated women at a dose of 100 micrograms or less.

CONCLUSIONS

Vaginal misoprostol is a safe, low-cost drug particularly suitable in women of high average parity having late, fetal death.

Reducing maternal mortality in Kigoma, Tanzania

An intervention programme aiming at a reduction of maternal deaths in the Regional Hospital, Kigoma, Tanzania, is analyzed. A retrospective study was carried out from 1984-86 to constitute a background for an intervention programme in 1987-91. The retrospective study revealed gross under-registration of data and clarified a number of potentially useful issues regarding avoidable maternal mortality. An intervention programme comprising 22 items was launched and the maternal mortality ratio was carefully followed in 1987-91. The intervention programme paid attention to professional responsibilities with regular audit-oriented meeting, utilization of local material resources, schedules for regular maintenance of equipment, maintenance of working skills by regular on-the-job training of staff, norms for patient management, provision of blood, norms for referral of severely ill patients, use of antibiotics, regular staff evaluation, public complaints about patient management, travel distance of all essential staff to the hospital, supply of essential drugs, the need of a small infusion production unit, the creation of culture facilities for improved quality of microbiology findings, and to efforts to stimulate local fund-raising. The results indicate that the maternal mortality ratio fell from 933 to 186 per 100,000 live births over the period 1984-91. Thus it is underscored that the problem of maternal mortality can be successfully approached by a low-cost intervention programme aiming at identifying issues of avoidability and focusing upon locally available problem solutions.

Expression of truncated and full-length forms of the Lyme disease Borrelia outer surface protein A in Escherichia coli

The lipidated major outer surface protein, OspA, of the Lyme disease spirochaete may be important in the pathogenesis during Lyme borreliosis. To produce sufficient amounts of purified OspA variants to perform pathogenesis studies in vivo and in vitro, different recombinant OspA expression systems in Escherichia coli were constructed. Recombinant OspA variants were produced as a full-length molecule, as a truncated variant lacking the N-terminal lipidated cysteine, or as a fusion protein with the synthetic dimer of Staphylococcus aureus protein A IgG binding domain (ZZ). In order to produce the full-length protein, four different promoters were evaluated. These were combined with either the OspA original signal sequence or the E. coli Brauns lipoprotein signal sequence, lpp. The most efficient production of the full-length lipidated OspA was mediated by the constitutive beta-lactamase promoter in combination with lipoprotein signal sequences. For production of truncated nonlipidated OspA the S. aureus protein A signal sequence was ligated to the OspA open reading frame. Alternatively, truncated OspA was produced intracellularly using expression vectors that lack signal sequences. Production of nonlipidated protein with a heterologous signal peptide resulted in a soluble protein located mainly in the periplasm and in the culture medium. The full-length lipidated OspA, on the other hand, was associated mainly with the membrane fraction. The production level of the lipidated recombinant OspA was much lower than the level obtained with the truncated ZZ-OspA fusion protein.

Subcutaneous implanted chambers in different mouse strains as an animal model to study genetic stability during infection with Lyme disease Borrelia

Tissue metal net cages were implanted subcutaneously in BALB/cJ and C3H/Tif mice as an experimental model of Borrelia burgdorferi infection. B. burgdorferi sensu stricto strain Sh2-82 could be isolated up to 14 weeks after the inoculation. However, a significant difference in infectivity between the two mice strains was observed. C3H/Tif mice were more susceptible to developing chronic B. burgdorferi s.s. infections than BALB/cJ mice. Although a B. burgdorferi infection was established, no rearrangements in the ospA and ospB genes were observed in any of the infected mice.

A comparative study of vaginal misoprostol and intravenous oxytocin for induction of labour

Fifty-two women who had labour induced by intravenous oxytocin were compared with 404 women in whom labour was induced by vaginal misoprostol (50-150 micrograms). The induction-to-delivery intervals in the oxytocin and misoprostol groups, respectively, had the following durations. With Bishop's score < 6, 24.3 vs. 14.4 h (p = 0.002), with Bishop's score > or = 6, 10.5 vs. 7.6 h (p = 0.02), with ruptured membranes, 8.8 vs. 8.5 h (p = 0.83), and with intact membranes, 19.6 vs. 13.1 h (p = 0.005). The Caesarean delivery rate was 17.3% in the oxytocin group and 8.7% in the misoprostol group (p = 0.09). Maternal complications were few and drug side effects rare. It is concluded that vaginal misoprostol is a valuable and cost-effective alternative to intravenous oxytocin infusion for induction of labour.

Endocervical pathogens in women with preterm and term labour

The purpose of this study was to compare the endocervical microflora of women in preterm and term labour and to determine whether the presence of a specific microflora is significantly associated with preterm labor. A prospective study was performed in Lithuania among 212 women in preterm labour (latent phase, n = 110; active phase, n = 102) and among 62 healthy women in term labour. Microbiological assessment included cultures for aerobic bacteria, yeasts, and Trichomonas vaginalis and direct immunofluorescence reaction for Chlamydia trachomatis, Escherichia coli (odds ratio 8.16; 95% confidence interval 1.27-340.23) and Staphylococcus aureus (odds ratio 7.79; 95% confidence interval 1.21-325.40) were significantly more often isolated from women in preterm than from women in term labour. The prevalence of C. trachomatis was the same in the preterm and in the term labour group. The pregnancy outcome during the latent or active phase of preterm labour with or without C. trachomatis infection did not differ. It is concluded that E. coli and S. aureus are significantly more prevalent in endocervical cultures from Lithuanian women in preterm than from those in term labour.

Expression of the flagellin gene in Borrelia is controlled by an alternative sigma factor

The flagellin genes from six Borrelia species were cloned, sequenced and characterized at the molecular level. The flagellin genes of two relapsing fever Borrelia species, B. hermsii and B. crocidurae, three Lyme disease genomic species, B. burgdorferi, B. afzelii and B. garinii, and the avian borreliosis agent, B. anserina, were compared and showed an 85-93% sequence identity to each other. Comparison of the fla genes from the different Lyme borreliosis spirochaetes revealed that they were 94-99% identical. Nucleotide sequencing of the fla gene and primer extension on isolated mRNA from both B. hermsii (as transcribed in Escherichia coli) and B. burgdorferi (as transcribed in the natural host) identified the putative transcriptional start points, the ribosomebinding sites and the promoter regions of these genes. The deduced promoter of the Borrelia flagellin gene resembled neither the sigma 70 promoter of prokaryotes, as seen for the genes for the outer-surface proteins A and B in Lyme disease Borrelia and the genes for the variable major proteins 7 and 21 of B. hermsii, nor the sigma 28 consensus promoter region of motility genes from other bacteria. Instead, the promoter of the fla gene in Borrelia has most similarity to the bacteriophage SP01 sigma gp33-34 promoter sequence of Bacillus subtilis.

Low birth weight and genital infections. An incident case-referent study

In an attempt to elucidate the potential association between genital infections and low birth weight (LBW) births, 51 women with LBW neonates were identified and compared to 51 women with normal birthweight (NBW) neonates. Both groups were matched according to age and parity. All women were subjected to interviews regarding socioeconomic background and obstetric history. The were examined clinical and tested regarding serum haemoglobin, malaria parasitaemia, syphilis and HIV serology. Cultures were taken from the vagina, endocervix, amniotic fluid and from various sites of newborn, including the conjunctivae and the stomach and from the interior of the placenta. Whilst socioeconomic background factors did not differ among cases and referents, previous neonatal death did. Significant differences were also found in mid-upper-arm circumference (OR 3.08) and body mass index (OR 6.00). The prevalence of alleged risk factors according to the antenatal card was similar among cases and referents. Birthweight < 2,000 g was significantly more often associated with chorioamnionitis than birthweight between 2,000 and 2,499 g (OR 5.46). Bacteriological findings did not show significant differences in cases and referents. Haemoglobin values and prevalence of malaria parasitaemia were similar as was the neonatal mortality. It is concluded that LBW births is difficult to predict by use of alleged risk factors in existing antenatal cards.

A case-control study on post-caesarean endometritis-myometritis in Mozambique

Post-caesarean endometritis-myometritis (PCEM) was diagnosed in 49 Mozambican women. They were compared with 47 control women without signs of PCEM after caesarean section. The patients and controls were matched for age, parity and days post partum. Features of the socio-economic background and of past and current obstetric history were registered. Endocervical, intracavitary and blood cultures were carried out. Screening for syphilis seropositivity and HIV-1 and HIV-2 antibodies was performed. Socio-economic and obstetric background factors were similarly distributed in cases and referents, though previous caesarean section was less frequent among cases than among referents (OR 0.12). Moderate high-risk factors in existing antenatal card tended to be more frequent among cases than among referents (OR 3.29). Microbiological findings indicated more anaerobes in the vagina, in the endocervix and in the uterine cavity, though the differences only approached significance. It is concluded that women with PCEM in the setting studied expose few characteristic background features discriminating them from women with uneventful post-caesarean outcome. Further research efforts should be directed towards case-control studies with focus upon surgical factors and on a more comprehensive microbiology and serology approach.

Aetiology of late fetal death in Maputo

BACKGROUND

To study the etiology of late fetal death in Maputo.

PATIENTS

Stillbirths (n = 163) in Maputo were compared to 207 live births.

RESULTS

A probable cause of fetal death could be determined in 112 cases (69%). Hypertension was the most common factor associated with stillbirth and occurred in 14% of the fetal deaths, followed by abruption of the placenta (13%), syphilis (8%), clinical intra-uterine infection (6%), malaria (4%), fetal malformation (4%), umbilical cord complications (4%) and anaemia (4%). Mothers of stillborns and referent mothers differed in the following parameters: fetal weight, gestational age, numbers of previous stillbirths, haemoglobin, packed cell volume (p < 0.001), age, number of pregnancies (p < 0.01), parity, number of live children and skinfold thickness (p < 0.05). In the stillborn cases where no probable cause of fetal death was established, newborn weight was significantly lower and estimated gestational age significantly shorter (p < 0.001), number of previous pregnancies and number of previous stillbirths were significantly larger (p < 0.05) than in the referent group, but otherwise no significant differences were found. In two randomly selected sub-groups, 28 mothers with stillbirth without probable diagnoses, and in 24 referent mothers, selected serum proteins and acute-phase reactants were determined. There were no statistically significant differences in the mean values of haptoglobin, pre-albumin, retinol-binding protein and alpha 1-antitrypsin in the two subgroups. The stillbirth subgroup had significantly higher mean values of C-reactive protein and serum orosomucoid than the referent group (p < 0.01).

CONCLUSION

Signs of maternal illness were present in one third of the mothers with stillbirth, and half of them required medical care. In one third there was no final diagnosis, but these mothers showed significantly higher mean values of acute phase reactants, suggesting low-grade infection.

Management of amniocentesis in women with oligohydramnios due to membrane rupture: evaluation of a cervical adapter

Thirty-five pregnant women with gestational age 22-37 completed weeks and with prelabour rupture of the membranes in the preterm period (PROM) volunteered to participate in the study. Sixteen women had a sterile cervical adapter, stopping the leakage of amniotic fluid, applied to the ectocervix for 24 h. The remaining 19 women were managed accordingly to prevailing expectant routine without the cervical adapter. All 35 women were assessed initially and after 24 h by ultrasound to obtain amniotic fluid index (AFI) registered. The results show that the average AFI value in the adapter group almost doubled while it changed insignificantly in the group without adapter. The difference in change between the two groups is significant (p < 0.001). There were no infectious complications in the newborn or in the mother. It is concluded that, in case amniocentesis is indicated to enable improved diagnostic accuracy in women with oligohydramnios due to PROM, application of the cervical adapter designed in this study will increase AFI and facilitate a less complicated amniocentesis.

[Malaria in Norway--a tropical disease off the track?]

Today, malaria is most often thought of as a tropical disease. Two and a half billion of the world's population live in malaria endemic areas, most of them in the tropics, and one million die of malaria annually. The explanation of the appearance and disappearance of malaria is multifactorial. However, increasing interest is being shown in the socioeconomic aspects of many diseases, and it is interesting to observe that diseases found in Europe as late as in the 18th and 19th century are also predominant in today's developing countries. Research in medical history can make a significant contribution to the efforts to find the reasons for the appearance and disappearance of a disease. It is well known that malaria was common on the European continent, but it is less well known that malaria also existed in Norway during the 19th century.