Diagnostic capacity, and predictive values of rapid diagnostic tests for accurate diagnosis of Plasmodium falciparum in febrile children in Asante-Akim, Ghana

Background

This study seeks to compare the performance of HRP2 (First Response) and pLDH/HRP2 (Combo) RDTs for falciparum malaria against microscopy and PCR in acutely ill febrile children at presentation and follow-up.

Methods

This is an interventional study that recruited children < 5 years who reported to health facilities with a history of fever within the past 72 h or a documented axillary temperature of 37.5 °C. Using a longitudinal approach, recruitment and follow-up of participants was done between January and May 2012. Based on results of HRP2-RDT screening, the children were grouped into one of the following three categories: (1) tested positive for malaria using RDT and received anti-malarial treatment (group 1, n = 85); (2) tested negative for malaria using RDT and were given anti-malarial treatment by the admitting physician (group 2, n = 74); or, (3) tested negative for malaria using RDT and did not receive any anti-malarial treatment (group 3, n = 101). Independent microscopy, PCR and Combo-RDT tests were done for each sample on day 0 and all follow-up days.

Results

Mean age of the study participants was 22 months and females accounted for nearly 50%. At the time of diagnosis, the mean body temperature was 37.9 °C (range 35–40.1 °C). Microscopic parasite density ranged between 300 and 99,500 parasites/µL. With microscopy as gold standard, the sensitivity of HRP2 and Combo-RDTs were 95.1 and 96.3%, respectively. The sensitivities, specificities and predictive values for RDTs were relatively higher in microscopy-defined malaria cases than in PCR positive-defined cases. On day 0, participants who initially tested negative for HRP2 were positive by microscopy (n = 2), Combo (n = 1) and PCR (n = 17). On days 1 and 2, five of the children in this group (initially HRP2-negative) tested positive by PCR alone. On day 28, four patients who were originally HRP2-negative tested positive for microscopy (n = 2), Combo (n = 2) and PCR (n = 4).

Conclusion

The HRP2/pLDH RDTs showed comparable diagnostic accuracy in children presenting with an acute febrile illness to health facilities in a hard-to-reach rural area in Ghana. Nevertheless, discordant results recorded on day 0 and follow-up visits using the recommended RDTs means improved malaria diagnostic capability in malaria-endemic regions is necessary.

Targeted community based interventions improved malaria management competencies in rural Ghana

Background

Malaria is one of the most challenging public health concerns in the developing world. To address its impact in endemic regions, several interventions are implemented by stakeholders. The Affordable Medicine Facility-malaria (AMFm) is an example of such interventions. Its activities include communication interventions to enhance the knowledge of caregivers of children under five years, licensed chemical sellers (LCS) and prescribers on malaria management with artemisinin-based combination therapy (ACT). This study was conducted to evaluate the effectiveness of the AMFm activities on malaria among targeted groups in two rural communities in Ghana.

Methods

A communication intervention study was conducted in the Asante-Akim North and South Districts of Ghana. Repeated cross-sectional pre and post surveys were deployed. Relevant malaria messages were designed and used to develop the information, education and communication (IEC) tools for the intervention. With the aid of posters and flipcharts developed by our study, community health workers (CHWs), prescribers, and licenced chemical sellers provided proper counselling to clients on malaria management. Trained CHWs and community based volunteers educated caregivers of children under five years on malaria management at their homes and at public gatherings such as churches, mosques, schools. Chi-square tests and logistic regression were run to determine associations and control for demographic differences respectively.

Results

There was significantly high exposure to malaria/ACT interventions in the intervention district than in the comparison district (OR = 16.02; 95% CI = 7.88–32.55) and same for malaria/ACT-related knowledge (OR = 3.63; 95% CI = 2.52–5.23). The participants in the intervention district were also more knowledgeable about correct administration of dispersible drug for children <5 years than their counterparts in the unexposed district.

Conclusion

Our data show that targeted interventions improve malaria based competences in rural community settings. The availability of subsidized ACTs and the intensity of the communication campaigns contributed to the AMFm-related awareness, improved knowledge on malaria/ACTs and management practices.

Effect of IPTp on Plasmodium falciparum antibody levels among pregnant women and their babies in a sub-urban coastal area in Ghana

Background

Women exposed to Plasmodium infection develop antibodies and become semi-immune. This immunity is suppressed during pregnancy making both the pregnant woman and the foetus vulnerable to the adverse effects of malaria, particularly by Plasmodium falciparum. Intermittent preventive treatment of malaria in pregnancy (IPTp) with Sulfadoxine–pyrimethamine (SP) tablets is one of the current interventions to mitigate the effects of malaria on both the pregnant woman and the unborn child. The extent to which IPTp may interfere with the acquisition of protective immunity against pregnancy-associated malaria (PAM) is undefined in Ghana.

Methods

Three-hundred-and-twenty pregnant women were randomly enrolled at the antenatal clinic (ANC) in Madina, Accra. Venous blood samples were obtained at first ANC registration and at 4-week intervals (post-IPTp administration). Placental and cord blood samples were obtained at delivery and the infants were followed monthly for 6 months after birth. Anti-IgG and IgM antibodies against a crude antigen preparation and the glutamate-rich protein (GLURP) of P. falciparum were quantified by the enzyme-linked immunosorbent assay (ELISA).

Results

There was a general decline in the trend of mean concentrations of all the antibodies from enrolment to delivery. The levels of antibodies in cord blood and placenta were well correlated. Children did not show clinical signs of malaria at 6 months after birth.

Conclusions

IgG against both crude antigen and GLURP were present in placenta and cord blood and it is therefore concluded that there is a trend of declining antibody from enrolment to delivery and IPTp-SP may have reduced malaria exposure, however, this does not impact on the transfer of antibodies to the foetus in utero. The levels of maternal and cord blood antibodies at delivery showed no adverse implications on malaria among the children at 6 months. However, the quantum and quality of the antibody transferred needs further investigation to ensure that the infants are protected from severe episodes of malaria.

Minimising invasiveness in diagnostics: developing a rapid urine-based monoclonal antibody dipstick test for malaria

OBJECTIVE

To generate monoclonal antibodies (MAbs) for developing a rapid malaria diagnostic urine-based assay (RUBDA), using Plasmodium-infected human urinary antigens.

METHODS

Plasmodium-infected human urinary (PAgHU) and cultured parasite (CPfAg) antigens were used to generate mouse MAbs. The reactivity and accuracy of the MAbs produced were then evaluated using microplate ELISA, SDS-PAGE, Western blotting assay, microscopy and immunochromatographic tests.

RESULTS

Ninety-six MAb clones were generated, of which 68.8% reacted to both PAgHU and CPfAg, 31.3% reacted to PAgHU only, and none reacted to CPfAg only. One promising MAb (UCP4W7) reacted in WBA, to both PAgHU and CPfAg, but not to Plasmodium-negative human urine and blood, Schistosoma haematobium and S. mansoni antigens nor measles and poliomyelitis vaccines.

CONCLUSION

MAb UCP4W7 seems promising for diagnosing Plasmodium infection. Urine is a reliable biomarker source for developing non-invasive malaria diagnostic tests. SDS-PAGE and MAb-based WBA appear explorable in assays for detecting different levels of Plasmodium parasitaemia.

Insights into the Affordable Medicines Facility-malaria in Ghana: the role of caregivers and licensed chemical sellers in four regions

Background

The Affordable Medicine Facility-malaria (AMFm) was an innovative global financing mechanism for the provision of quality-assured artemisinin-based combination therapy (ACT) across both the private and public health sectors in eight countries in sub-Saharan Africa. This study evaluated the effectiveness of AMFm subsidies in increasing access to ACT in Ghana and documented malaria management practices at the household and community levels during the implementation of the AMFm.

Methods

This study, conducted in four regions in Ghana between January, 2011 to December, 2012, employed cross-sectional mixed-methods design that included qualitative and quantitative elements, specifically household surveys, focus group discussions (FGD) and in-depth interviews.

Results

The study indicated high ACT availability, adequate provider knowledge and reasonably low quality-assured ACT use in the study areas, all of which are a reflection of a high market share of ACT in these hard-to-reach areas of the country. Adequate recognition of childhood malaria symptoms by licensed chemical seller (LCS) attendants was observed. A preference by caregivers for LCS over health facilities for seeking treatment solutions to childhood malaria was found.

Conclusions

Artemisinin-based combination therapy with the AMFm logo was accessible and affordable for most people seeking treatment from health facilities and LCS shops in rural areas. Caregivers and LCS were seen to play key roles in the health of the community especially with children under 5 years of age.

Fatal transfer of malignant melanoma from multiorgan donor to four allograft recipients

BACKGROUND

In this report we describe the transfer of malignant melanoma from a single donor to four solid organ transplant recipients, all of whom died from metastatic melanoma. METHODS AND CASE HISTORIES: The donor of a heart, liver, and two kidneys to four separate recipients died of intracerebral hemorrhage. The donor had no history or clinical evidence of melanoma. All four recipients, treated with standard immunosuppression protocols, developed metastatic malignant melanoma within 1 year after transplantation Three patients died within 14 months after transplantation, although the fourth, whose immunosuppressive therapy was discontinued, died of metastatic melanoma 30 months after renal transplantation.

FINDINGS

Tumors from all recipients were histologically identical. Donor origin of tumor cells was confirmed by polymerase chain reaction (PCR)-based DNA analysis for polymorphic short tandem tetrameric repeats (Geneprint STR, Promega Corp., Madison, WI). DNAs from nontumorous donor tissue and tumor tissue available from three recipients tested positive for CSF1P0 alleles 10 and 12 and for TH01 alleles 6 and 7, although DNAs from nonneoplastic recipient tissues all exhibited different allelotypes.

INTERPRETATION

Transmission of fatal or potentially fatal malignant tumors, notably malignant melanoma, from donor to recipient is an uncommon complication of solid organ transplantation. PCR-based genetic analysis permits definitive assignment of the source of posttransplant tumors.

Inguinal lymphadenitis caused by Entamoeba histolytica: case report and literature review

Liver abscesses are the most common manifestation of extraintestinal infection by Entamoeba histolytica. Involvement of other sites, including the peritoneum, pericardium, brain, or genitourinary tract, is unusual. We describe a case of inguinal necrotizing lymphadenitis caused by E histolytica. Our patient responded well to surgical drainage, metronidazole, and paramomycin therapy. A literature review of genitourinary and other uncommon sites of E histolytica infection is included.

A comparison of three malaria diagnostic tests, under field conditions in North-west Thailand

A hospital-based trial to compare the clinical diagnosis of malaria; microscopy, and a rapid diagnostic antigen capture detection dipstick (ParaSight-F) was conducted in North-west Thailand. 301 people who presented themselves at the hospital were selected. 204 (68%) were presumptively diagnosed as having malaria by the triage nurses; 64 (21.3%) were P. falciparum parasite positive, and 94 (32%) tested positive for P. falciparum with the ParaSight-F test strips. There was no association between hemoglobin levels (<10g/dl and > or = 10g/dl) and malaria, and although there was a good statistical association between temperature and malaria the specificity, sensitivity and positive predictive values were all low, indicating that temperature alone is a poor indicator of the disease. Based on the microscopy results, we found that a presumptive clinical diagnosis dramatically over-diagnosed malaria, and similarly there were a large number of false positives using the ParaSight-F test. We believe that many of the patients had received some form of malaria treatment prior to presentation at the hospital, and that the high number of false positives are explained by persistent antigenemia and the possibility of there being sequestered parasites following incomplete chemotherapy.

Unusual dural and skull-based mesenchymal neoplasms: a report of four cases

Dural and skull-base mesenchymal neoplasms other than meningiomas are rare. We report four such tumors, some of which are uncommon even in nonintracranial sites, in three adults and one child. The adult tumors consisted of a synovial sarcoma of the third ventricle region in a 19-year-old woman, a leiomyoma of the suprasellar region in a 57-year-old woman, and an Epstein-Barr virus (EBV)-associated smooth muscle tumor of the cavernous sinus in a 35-year-old woman with acquired immunodeficiency syndrome (AIDS). The pediatric tumor was an EBV-associated leiomyosarcoma of the left dural transverse sinus in a 14-year-old girl with common variable immunodeficiency syndrome. All tumors were thought to be primary in their dural or skull-base locations. The two EBV-associated smooth muscle tumors in immunocompromised patients expand the locations for EBV-associated smooth muscle tumors to dural and skull-base sites, the synovial sarcoma is unique to the intracranial space, and the sellar leiomyoma represents the third reported sellar smooth muscle tumor.

Large cell calcifying Sertoli cell tumor of the testis: contrasting features of six malignant and six benign tumors and a review of the literature

We report six malignant and six benign large cell calcifying Sertoli cell tumors of the testis and compare the features of malignant and benign cases based on these cases and those in the literature. All the tumors in this report consisted of sheets, nests, solid tubules, and cords of eosinophilic cells, with focal calcifications, as well as a substantial neutrophilic infiltrate in 11 of them. Analysis of our cases and those in the literature showed that the malignant tumors were unilateral and solitary and occurred at a mean age of 39 years (range 28-51 years), whereas the benign neoplasms were bilateral and multifocal in 28% of cases and occurred at a mean age of 17 years (range 2-38 years). Only one malignant tumor occurred in a patient with evidence of a genetic syndrome (Carney syndrome), whereas 36% of benign tumors had various genetic syndromes or endocrine abnormalities. Most of the tumors in the latter cases were bilateral and multifocal. There were strong associations of malignant behavior with size >4 cm, extratesticular growth, gross or microscopic necrosis, high-grade cytologic atypia, vascular space invasion, and mitotic rate greater than three mitoses per 10 high-power fields. All malignant cases exhibited at least two of these features, whereas all benign cases lacked any of them. The presence of any one of these features in a solitary large cell calcifying Sertoli cell tumor, especially in a patient >25 years of age, should be viewed as suspicious for malignant behavior, whereas the presence of two or more of these features indicates a strong probability of a malignant course. "Low" percentages (< or =35%) of tumor cells staining for proliferating cell nuclear antigen (PCNA) also may correlate with benign behavior, but some benign tumors have high PCNA values. Ki-67 values (MIB-1 antibody) did not correlate with biologic behavior, nor did immunostains for p53 protein.

Telomerase expression in normal endometrium, endometrial hyperplasia, and endometrial adenocarcinoma

Telomerase activity has been detected in a broad range of human cancers and its expression could be an important step in tumor progression. Here, telomerase activity by the telomeric repeat amplification protocol in cases of benign endometrium, endometrial hyperplasia, and endometrial adenocarcinoma was tested. Telomerase expression was detected in 13 of 14 cases of proliferative phase endometrium, in 7 of 12 cases of secretory phase endometrium, but was not detected in any of 7 cases of atrophic endometrium. Three of three cases with evidence of luteal phase defect and one of four cases of chronic endometritis also expressed telomerase activity. Hyperplastic endometrium was positive for telomerase in 13 of 17 cases. Telomerase activity was detected in 40 of 48 cases of endometrial adenocarcinoma, which included 36 of 43 cases of endometrioid adenocarcinoma and four of five cases of papillary serous carcinoma. The detection of telomerase in endometrial adenocarcinoma was not associated with either architectural grade, myometrial invasion, or stage. There was statistically significant association, however, between telomerase activity in benign atrophic endometrium versus any endometrial abnormality in women 52 years of age or older.

Longitudinal measurement of anticardiolipin antibodies during normal pregnancy: a prospective study

We have previously shown that elevation of anticardiolipin antibodies (aCL) at the first prenatal visit is associated with increased fetal loss in normal pregnancy. The variation in aCL levels during normal pregnancy has not been established. To examine this question we measured IgG, IgM and IgA aCL levels five times during pregnancy at weeks 5-15, 16-25, 26-35, 36-37 and at delivery. Data were analyzed to determine: (a) the within and between subject variability of aCL during pregnancy; (2) the temporal trend of aCL; and (3) the relation of serial measures of aCL with maternal complications of pregnancy. We divided our cohort of 354 subjects into two groups. Group A included those subjects with consistently normal levels of aCL and group B those subjects with at least one elevated level of aCL. In group A the within subject variability was relatively low (28-34%). In group B we found wide fluctuations in aCL levels and a within subject variability of 88-91%. Subjects in group B had no increase in maternal complications of pregnancy. The present data suggest that aCL may fluctuate significantly during normal pregnancy and there is little clinical value in measuring aCL on a serial basis during pregnancy.

Dedifferentiated chordoma. Response to aggressive chemotherapy in two cases

BACKGROUND

Dedifferentiated chordoma is an unusual and aggressive variant of chordoma which is likely to metastasize. Few reports exist of treatment of these tumors with chemotherapy.

METHODS

In 1988, two patients with dedifferentiated sacral chordomas were seen at the University of Chicago Hospitals. Both developed metastatic disease less than a year after sacral resection and radiation therapy. These patients' diagnoses, courses, and treatments were reviewed along with the literature on chemotherapy in both conventional and dedifferentiated chordomas.

RESULTS

Both patients obtained complete remissions, one to a six-drug regimen and the other to ifosfamide.

CONCLUSIONS

A trial of reasonably aggressive chemotherapy is warranted in patients with metastatic dedifferentiated chordoma. The optimum regimen is unclear, but agents active in high-grade sarcomas are logical choices.

Dedifferentiated chordoma. Response to aggressive chemotherapy in two cases

BACKGROUND

Dedifferentiated chordoma is an unusual and aggressive variant of chordoma which is likely to metastasize. Few reports exist of treatment of these tumors with chemotherapy.

METHODS

In 1988, two patients with dedifferentiated sacral chordomas were seen at the University of Chicago Hospitals. Both developed metastatic disease less than a year after sacral resection and radiation therapy. These patients' diagnoses, courses, and treatments were reviewed along with the literature on chemotherapy in both conventional and dedifferentiated chordomas.

RESULTS

Both patients obtained complete remissions, one to a six-drug regimen and the other to ifosfamide.

CONCLUSIONS

A trial of reasonably aggressive chemotherapy is warranted in patients with metastatic dedifferentiated chordoma. The optimum regimen is unclear, but agents active in high-grade sarcomas are logical choices.

Chronic hyperplastic sinusitis: association of tissue eosinophilia with mRNA expression of granulocyte-macrophage colony-stimulating factor and interleukin-3

BACKGROUND

We investigated the association among tissue eosinophilia, cellular infiltration, and cytokine mRNA expression in chronic hyperplastic sinusitis (CHS).

METHODS

Percutaneous biopsies of the maxillary sinuses and nasal polyps were performed in 12 adult patients (six men and six women) of whom seven were nonallergic and 11 were asthmatic. Tissues were compared with biopsy specimens from the inferior and middle turbinates of normal control subjects.

RESULTS

Histologically, an eosinophil-predominant inflammatory infiltrate was seen in 10 of 12 patients, whereas a mild to moderate neutrophilic infiltrate was seen in 4 of 12 patients. As determined by immunocytochemistry, diseased tissues and normal control tissues differed significantly in terms of the number of activated (EG2+) eosinophils (p = 0.005) but not in terms of CD3+ or CD4+ T lymphocytes, elastase-positive neutrophils or CD68+ macrophages. The number of eosinophils did not correlate with that of any other cell type. By in situ hybridization, CHS tissues showed significantly higher numbers of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin (IL)-3 mRNA-positive cells than normal control tissues (p = 0.002 and 0.0005, respectively) per high-powered field. There was a significant correlation between the number of infiltrating EG2+ eosinophils and cells that expressed mRNA for GM-CSF (r = 0.60, p = 0.041) or IL-3 (r = 0.69, p = 0.013). Furthermore, epithelial cells did not show detectable mRNA expression for GM-CSF or IL-3. No significant correlation was found between IL-5 mRNA expression and infiltrating EG2+ eosinophils in diseased tissues. However, the IL-5 density was significantly higher in the five patients with CHS who had positive allergy skin test results than in the seven patients with negative skin test results (p = 0.017) or in normal control subjects.

CONCLUSIONS

Our data support a role for GM-CSF and IL-3 in the eosinophilia characteristic of CHS and show that IL-5 mRNA expression is not a prominent feature of nonallergic inflammation. The cellular sources of GM-CSF and IL-3 in CHS remain to be definitely determined.

Differential gene expression in the amnion, chorion, and trophoblast of the human placenta

Human chorionic gonadotrophin (hCG), placental alkaline phosphatase (PLAP), and pregnancy-specific glycoprotein (PSG) are three major proteins produced by the trophoblast of the human placenta. Immunocytochemical studies suggest that PSG and hCG are also present in the human amnion. In this study, we examined whether amniotic and chorionic membranes were capable of expressing trophoblastic-specific genes. As previously reported, trophoblasts express high levels of hCG beta, hCG alpha, PLAP, and PSG. Both amnion and chorion were found to express PLAP and hCG beta mRNA. However, the hCG alpha transcript was expressed only by the amnion, but not by the chorion in the term placenta. Recent molecular cloning studies indicate that human PSGs are a group of closely related placental proteins that, together with the carcinoembryonic antigen family members, comprise a subfamily within the immunoglobulin superfamily. To demonstrate that amnion and chorion also express PSG transcripts, we employed ribonuclease protection analysis using probes specific to the 5' and 3' region of PSG mRNAs. Our data indicate that while amniotic as well as chorionic membrane expressed low levels of the PSG genes, only a certain subpopulation of PSG transcripts were expressed. Furthermore, the amnion and chorion demonstrated differences in PSG species expression from each other and from trophoblastic tissue. Thus, human amnion, chorion and trophoblast selectively express several placental genes.

Acute lung injury following treatment with high-dose cyclophosphamide, cisplatin, and carmustine: pharmacodynamic evaluation of carmustine

BACKGROUND

Therapy with high-dose cyclophosphamide, cisplatin, and carmustine (BCNU) plus autologous bone marrow transplantation has been extensively studied as treatment for patients with stage II or III breast cancer who have a 70% or greater risk of developing metastatic disease. This therapy is being used in a cooperative intergroup phase III clinical trial. In the cyclophosphamide-cisplatin-BCNU regimen, cyclophosphamide and BCNU, but not cisplatin, have been reported to cause acute lung injury, suggesting that either cyclophosphamide or BCNU may contribute to this injury.

PURPOSE

The purpose of this study was to analyze clinical and pharmacokinetic data from our ongoing phase II trials and to determine whether there is an association between BCNU pharmacokinetics and acute lung injury following cyclophosphamide-cisplatin-BCNU therapy.

METHODS

We performed a retrospective study of 38 patients treated following induction therapy or relapse, 29 with stage II-IV breast cancer and nine with intermediate and high-grade stage III-IV non-Hodgkin's lymphoma. These patients received therapy with cyclophosphamide at a dose of 1875 mg/m2 daily as a 1-hour intravenous infusion for 3 days, cisplatin at 55 mg/m2 per day as a 72-hour continuous intravenous infusion, and BCNU at 600 mg/m2 as a 2-hour infusion immediately following completion of the cisplatin infusion. Data from analysis of blood samples were used to calculate pharmacokinetic parameters for BCNU, and acute lung injury was determined on the basis of pulmonary function test results and histologic examination of lung biopsy specimens.

RESULTS

Our analysis showed that 20 (53%) of the 38 patients developed pulmonary injury following treatment. Twelve (60%) of the 20 had values for area under the curve (AUC) for BCNU concentration x time that exceeded 600 (micrograms/mL) x minute, whereas only two (11%) of the 18 without pulmonary injury had values above this level (P < .03). Thus, 12 (86%) of 14 patients with BCNU AUC greater than 600 (micrograms/mL) x minute developed lung injury.

CONCLUSIONS

These results suggest that BCNU exposure greater than 600 (micrograms/mL) x minute is associated with increased risk of acute lung injury after cyclophosphamide-cisplatin-BCNU therapy and may be a major cause of pulmonary drug injury following this regimen.

IMPLICATIONS

Strategies aimed at more uniform drug exposure or selective neutralization of chlorethylisocyanate, one of the two major hydrolysis products of BCNU, might reduce the incidence of acute lung injury following this regimen without major compromise of antitumor effect.

Application of the cavitron ultrasonic surgical aspirator (CUSA) for gynecological laparoscopic surgery using the rabbit as an animal model

OBJECTIVE

To study the potential application of the cavitron ultrasonic surgical aspirator (CUSA) in gynecological laparoscopic surgery using a rabbit animal model.

DESIGN

Twenty-six rabbits were prospectively randomized into two groups. Laparoscopically directed standard injuries were made on the randomly assigned horn and sidewall in all animals with the CUSA. Contralateral injuries were made with a contact neodymium-yttrium aluminum garnet (Nd:YAG) laser in group 1 and with bipolar cautery in group 2. Adhesion and inflammation scores were assessed for two animals in each group at 24, 48, and 72 hours, and seven animals in each group at 14 days.

SETTING

University animal research facility.

MAIN OUTCOME MEASURES

Adhesion and inflammation scores were compared between animals in the CUSA versus Nd:YAG study and the CUSA versus bipolar cautery at 14 days.

RESULTS

No significant difference in uterine or sidewall adhesion scores was noted between the CUSA versus Nd:YAG or the CUSA versus bipolar cautery. Bipolar cautery produced significantly less inflammation on the uterine horn compared with the CUSA (3.0 +/- 0.2 versus 5.3 +/- 0.7, P = 0.0001), but no difference in sidewall inflammation was noted between the CUSA compared with bipolar cautery. No difference in inflammation was observed between the CUSA and the Nd:YAG laser.

CONCLUSIONS

The bipolar cautery appears to be preferable to the CUSA for coagulation of uterine lesions, although dissection of the uterus is not possible with bipolar cautery. The CUSA and the Nd:YAG appear to be comparable for uterine horn dissection. Because the CUSA causes similar adhesion formation and tissue inflammation at the sidewall when compared with the Nd:YAG laser and bipolar cautery and may be less likely to damage blood vessels, ureters, or other collagen-rich tissues, the CUSA may represent a promising new surgical tool for laparoscopically directed peritoneal dissection.

Evaluation of cryopreserved allograft venous conduits in dogs

We investigated the effects of cryopreservation, immunosuppression, and antibiotic treatment on the patency and histologic appearance of venous conduits in the arterial circulation. Twenty-eight dogs received arterial replacements with autograft vein, fresh allograft, and two types of cryopreserved allograft vein implanted into both carotid and both femoral arteries. All animals were given aspirin, and half were given cyclosporine. After 3 months the vein grafts were harvested. Patency and light, transmission, and scanning electron microscopic criteria were scored to evaluate quality of preservation of the endothelium, the appearance of rejection, and the effects of cryopreservation with and without antibiotic pretreatment. The results show that patency is not statistically different based on graft type or treatment modality. The histologic appearance among the various vein types was remarkably similar at 3 months, with the exception of a cellular infiltrate present most prominently in the fresh allografts and least in the fresh autografts. Cyclosporine, even at a low dose, decreased the incidence of cellular infiltration. Preservation of endothelium was generally good in the cryopreserved allografts both with and without antibiotic pretreatment. In general, the effects of cryopreservation, cyclosporine, and antibiotics ameliorated the effects of venous allografting into an arterial position.

Intestinal and hepatic apolipoprotein B gene expression in abetalipoproteinemia

A 20-year-old woman with abetalipoproteinemia underwent orthotopic liver transplantation for cirrhosis, affording access to her liver and small intestine for study. Before transplantation, her plasma apolipoprotein B concentration was less than 1 mg/dL according to enzyme-linked immunosorbent assay, whereas after transplantation her plasma apolipoprotein B concentration was 76 mg/dL (all apolipoprotein B-100). Apolipoprotein B content was reduced in her intestine and liver compared with normal and cirrhotic controls. Cultured hepatocytes from the patient's explanted liver secreted a 1.006 g/mL less than or equal to d less than or equal to 1.063 g/mL lipoprotein rich in apolipoprotein E and a 1.063 g/mL less than or equal to d less than or equal to 1.21 g/mL lipoprotein containing apolipoproteins E and A-I with no immunodetectable apolipoprotein B in the culture medium. Normal hepatocytes secreted very low-density lipoprotein and low-density lipoprotein containing apolipoprotein B-100. Abetalipoproteinemic intestinal apolipoprotein B messenger RNA concentration was 4-5-fold higher than control values. However, the patient's liver apolipoprotein B messenger RNA level was one fifth that of control normal and cirrhotic liver. Analysis of the patient's intestinal and hepatic apolipoprotein B messenger RNA for posttranscriptional stop-codon insertion revealed normally edited transcripts. These results suggest that apolipoprotein B is synthesized as the product of a normally edited messenger RNA transcript, but not secreted, in abetalipoproteinemia.

Defect in fatty acid oxidation: laboratory and pathologic findings in a patient

The clinical, laboratory, and pathologic findings in a patient with a previously undescribed deficiency in fatty acid oxidation are summarized. The patient had a fatal defect in fatty acid metabolism profoundly affecting heart, skeletal muscle, liver, and kidney. Oxidation of palmitate was 38-51% of controls. Complementation assays demonstrated that the patient's fibroblasts complemented fibroblast lines from all known defects in fatty acid oxidation except long-chain acyl-CoA dehydrogenase deficiency. Urine and serum carnitine profiles also were indicative of a defect in the oxidation of long-chain substrate; however, the palmitoyl-CoA dehydrogenase activity was actually increased. This finding indicates that the patient had a defect that was distinct from, but possibly related to, long-chain acyl-CoA dehydrogenase deficiency. This patient demonstrates the laboratory and pathologic findings in defects in fatty acid oxidation and how they differ from those in Reye syndrome.

Endoscopic and histologic findings in the upper gastrointestinal tract of children with Crohn's disease

In an attempt to define endoscopic and histologic changes suggestive of upper gastrointestinal Crohn's disease (CD), the medical histories, endoscopic reports, and biopsies were reviewed from 24 pediatric patients with CD and 28 age-matched patients without CD in whom esophagogastroduodenoscopies were performed because of upper GI symptoms. No differences in the overall frequency of endoscopic abnormalities were found between the two groups. However, gastric erosions and ulcerations were more frequent in CD patients. Histological abnormalities in the stomach and duodenum were also more frequent in CD patients. Noncaseating granulomas were found in five patients with CD and in one patient without clinical, radiologic, or endoscopic evidence of CD. Focal inflammation in the stomach and duodenum occurred more frequently in CD patients. Two patients with CD had focal and deep chronic inflammatory infiltrates in the esophagus, which reached the submucosa. Abnormal histology was often seen in CD patients with normal endoscopic appearances. We conclude that superficial ulcerations seen during endoscopy and the histological finding of focal inflammation may represent upper GI CD in pediatric patients. Histological changes can be missed if biopsies are not taken from normal-appearing mucosa during endoscopy.

In situ distribution of the beta-subunit of platelet-derived growth factor receptor in nonneoplastic tissue and in soft tissue tumors

The distribution of the beta-subunit of platelet-derived growth factor receptor (PDGFR-beta) was assessed by a sensitive immunoalkaline phosphatase technique using the monoclonal antibody PR7212. Frozen tissue sections of several nonneoplastic human tissues were stained along with 42 soft tissue sarcomas, 16 benign soft tissue proliferations, and 7 epithelial tumors. In all nonneoplastic tissue, there was intense labeling of cell processes of perivascular fibroblasts or pericytes in and about the walls of muscular blood vessels and of fibroblast cell processes around some glandular and ductal epithelia. No PDGFR-beta was found in the endothelial cells of muscular arteries and veins, but cells of uncertain identity within some capillaries were immunoreactive and the possibility that endothelial cells of some small capillaries express PDGFR-beta could not be excluded. In kidney there was strong labeling of glomerular mesangial cells and interstitial fibroblasts. Some histological types of soft tissue sarcomas were uniformly and strongly labeled with anti-PDGFR-beta, but other types were infrequently labeled or unreactive. The order of decreasing frequency and strength of labeling of the various types of benign and malignant soft tissue proliferations was as follows: benign fibromatosis and neurofibroma greater than malignant fibrous histiocytoma greater than liposarcoma greater than leiomyosarcoma greater than rhabdomyosarcoma. No tumor cell labeling was detected in epithelioid, synovial or clear cell sarcomas, leiomyomas, or carcinomas, but there was usually strong labeling of fibroblast and/or pericyte cell processes within tumor, especially around blood vessels. We conclude that PDGFR-beta is strongly expressed by vascular and stromal tissues of most tumors and normal organs and by tumor cells of several types of soft tissue tumors and proliferations, most notably those of fibroblastic origin.

Expression of ras oncogene p21 protein in esophageal squamous cell carcinoma

In order to investigate the value of ras oncogene expression as a prognostic indicator in esophageal squamous cell carcinoma, we evaluated the level of ras oncogene protein product (p21) in 52 specimens resected between 1977 and 1986. All patients were followed until death or for at least 2 years. Pathology slides and archival paraffin blocks were retrieved for confirmation of the original diagnosis, study of histopathologic features, and measurement of p21 content. P21 titers were obtained using the RAP-5 monoclonal antibody in a semiquantitative immunohistochemical assay. Titer was expressed as the highest dilution of antibody giving definitive staining using the avidin-biotin peroxidase method. Ras oncogene was expressed in 88.5% of the specimens. We did not find a significant correlation between ras expression and any of a variety of clinical and histopathologic prognostic parameters. Although patients' median survival after resection of specimens with ras oncogene expression was less than half the median survival after removal of tumors without such expression, this difference was not statistically significant. Further prospective investigations are needed to assess the role of ras oncogene evaluation in clinical practice.

Indications for esophagectomy in nonmalignant Barrett's esophagus: a 10-year experience

Between 1978 and 1988, 88 patients were referred for the surgical treatment of nonmalignant Barrett's esophagus. Nineteen patients required esophageal resection. Male/female ratio was 13:6; age range was 13 to 84 years (mean age, 49.8 years; median age, 40 years). Preoperative studies demonstrated strictures in 11 patients and ulcers in 7. Penetrating Barrett's ulcer resistant to treatment was the indication for resection in 5 patients. Ulcers penetrated to the pericardium (1 patient), pulmonary vein (1), lung (1), and mediastinum (2). Other indications for resection included undilatable strictures (2), previous operations (4), high-grade dysplasia (3), parietal cells lining the esophagus (1), patient's refusal of long-term surveillance (2), and the inability to exclude adenocarcinoma preoperatively (2). Reconstruction was achieved by colon interposition (15) or esophagogastrostomy (4), with one postoperative death. Mean follow-up was 41 months and was 100% complete. Of the 18 patients, 3 have occasional regurgitation but none have any dysphagia or weight loss. Esophageal resection is indicated in a select group of patients with Barrett's esophagus. Absolute indications include a deep penetrating ulcer confirmed intraoperatively, high-grade dysplasia, strong suspicion of cancer, and multiple previous operations. Relative indications include strictures not responding to dilation and young patients refusing long-term surveillance.

Morphology in Ki-1(CD30)-positive non-Hodgkin's lymphoma is correlated with clinical features and the presence of a unique chromosomal abnormality, t(2;5)(p23;q35)

Ten patients with strongly Ki-1(CD30)-positive non-Hodgkin's lymphoma (NHL) were identified at our institution during the past 5 years. Based on morphology, the lymphomas of five of these patients were classified as anaplastic large-cell lymphoma (ALCL); the lymphomas of four patients lacked the morphologic features of ALCL (non-ALCL); and the lymphoma of one patient was unclassifiable. Significant clinical and cytogenetic differences were observed between patients with ALCL and those with non-ALCL. The patients with ALCL tended to be young at the time of diagnosis. They presented with peripheral lymphadenopathy, and two of the five patients had skin involvement. An identical reciprocal translocation involving chromosomes 2 and 5 [t(2;5)(p23;q35)] was observed in lymph nodes from each of the two ALCL patients whose chromosomes were studied. Four of the five patients with ALCL are alive and in complete remission 10-27 months after receiving systemic chemotherapy. In contrast, the patients with non-ALCL were heterogeneous with respect to clinical findings. All of the non-ALCLs were histologically aggressive; however, their morphology varied. The t(2;5) was absent in the lymphoma specimens from each of three non-ALCL patients studied. Three of the four patients died within 17 months after receiving systemic chemotherapy. Thus, differences in morphology are correlated with differences in the clinical findings, karyotype, and outcome in Ki-1-positive NHL.

Flow cytometric DNA analysis of squamous cell carcinoma of the esophagus

Although an abnormal amount of cellular DNA content is known to occur in squamous cell carcinoma of the esophagus, the significance and clinical relevance of this finding have yet to be elucidated. Paraffin-embedded blocks from 77 patients with squamous cell carcinoma of the esophagus were dewaxed and made into a suspension by mechanical mincing and enzymatic digestion. The nuclei were stained with propidium iodide, and the DNA content evaluated with flow cytometric study. The DNA index (DI) and the coefficient of variation were determined and the results were compared with other pathologic prognostic features. DNA aneuploidy was identified in 70.1% of the specimens and found to correlate significantly with both histologic grading (P less than 0.025) and the incidence of postoperative recurrence (P less than 0.05). Although the 5-year survival was slightly better in the euploid group than in the aneuploid group (28.8% and 19.1%, respectively), this difference was not statistically significant (P greater than 0.1). There was no correlation of the DI with the extent of wall penetration by the tumor, the incidence of lymph node metastases, or the surgical staging, features previously shown to correlate with prognosis in patients with esophageal carcinoma.

Correlation between automated karyometric measurements of squamous cell carcinoma of the esophagus and histopathologic and clinical features

The clinical staging of esophageal carcinoma is unreliable currently, making it difficult to select patients for aggressive therapy. To further refine staging criteria, the nuclear characteristics of a series of 31 patients with squamous cell carcinoma of the esophagus were studied using a computerized image analysis system (MicroTICAS). Karyometric measurements, including total nuclear DNA content, nuclear area, and nuclear roundness were compared with various clinical and histologic variables. Nearly all tumors (30 of 31) were aneuploid. Tumors with nuclear areas greater than 70 microns2 were associated with transmural esophageal penetration (P less than 0.05) and to a lesser extent with poor survival (less than 6 months; P = 0.06). Surprisingly, nuclear ploidy did not correlate with either variable. These data support a role for nuclear analysis on preoperative biopsy specimens as an adjunct in clinical staging.

A case report of three synchronous stage I malignant neoplasms

A patient with three synchronous, Stage I neoplasms of the ovary, kidney, and lung, who underwent resection of all lesions at the same operative procedure, is presented. The incidence of multiple primary malignancies and the prognosis for Stage I cancers of the ovary, kidney, and lung are reviewed.

Unusual urethral diverticulum lined by colonic epithelium with Paneth cell metaplasia

Diverticulum of the female urethra has an incidence of 1.4% to 4.7%. It is generally agreed that the majority of these are acquired lesions. There is, however, evidence that some are of congenital origin. Documented cases of diverticula with colon-type tissue are rare. A case of urethral diverticulum with colonic epithelium and features of Paneth cell metaplasia is presented. Causes, symptoms, diagnostic methods, and treatment are discussed.

Barrett's ulcer

A case of an ulcer developing within previously documented Barrett's epithelium is reported. The patient had symptoms of gastroesophageal reflux for many years and Barrett's esophagus beginning 21 cm from the incisor teeth was documented by endoscopy one year earlier. Hospitalization was necessitated by an upper gastrointestinal bleed which was found to be due to an ulcer at 29 cm from the incisors. There was no inflammation of the surrounding columnar epithelium nor was there any esophagitis within the squamous epithelium. This case documents that ulcers in Barrett's esophagus can arise de novo within the columnar epithelium despite the hypothesis that this epithelium is present because it is more resistant to acid/peptic damage than squamous epithelium. This suggests that some ulcers in Barrett's epithelium may be due to spontaneous degeneration of the epithelium as this patient had no esophagitis, suggesting that gastroesophageal reflux was not causing diffuse damage.

[3H]dopamine depletion from osmotically defined storage sites: effects of reserpine, 53 mM KCl, and d-amphetamine

A crude synaptosome-containing fraction (P2') prepared from rat striatal slices incubated with [3H]dopamine was exposed to hypoosmotic conditions and rapidly subjected to Millipore filtration. P2'-associated [3H]dopamine trapped on the filters was defined as hypoosmotic resistant, whereas P2'-associated [3H]dopamine that washed through the filters was defined as hypoosmotic sensitive. Electron microscopic examination of sections prepared from a P2' pellet that had been exposed to hypoosmotic conditions revealed extensive synaptosomal lysis. [3H]Dopamine accumulation and retention by the hypoosmotic-resistant fraction were reduced by reserpine. The proportional distribution of [3H]dopamine between hypoosmotic-resistant and -sensitive fractions was measured following in vitro exposure of the preloaded P2' fraction to reserpine, 53 mM KCl, and d-amphetamine. Each of these treatments resulted in a time-dependent loss of [3H]dopamine from the loaded P2' fraction without eliciting an alteration in the proportional distribution of [3H]dopamine between hypoosmotic-resistant and -sensitive fractions. Release induced by reserpine and d-amphetamine was independent of extrasynaptosomal Ca2+, whereas 53 mM KCl-induced release was dependent on extrasynaptosomal Ca2+. These results suggest that dopamine may be rapidly equilibrated between osmotically defined storage compartments, and thus specific compartmental depletion of loaded [3H]dopamine cannot be identified on the basis of osmotic lability.

Immunocytochemical localization of tyrosine hydroxylase in rat adrenal medulla by the peroxidase labeled antibody method: effects of enzyme activation on ultrastructural distribution of the enzyme

A monospecific antibody against tyrosine hydroxylase (TH), purified from a transplantable rat pheochromocytoma, was produced in rabbits. Immunohistochemical techniques were employed in order to determine if a relationship exists between the subcellular distribution of TH and the level of activation of the enzyme in the rat adrenal medulla. Tyrosine hydroxylase activity in adrenals removed from non-stressed rats following pentobarbital anesthesia was found to be 12.9 +/- 1.0 nmol DOPA formed x mg protein-1. The use of ether anesthesia (17.9 +/- 2.0 nmol DOPA formed x mg protein-1), and the administration of electroconvulsive shock (ECS) followed by decapitation (35.9 +/- 2.0 nmol DOPA formed x mg protein-1) was associated with an acute activation of adrenal TH. The subcellular distribution of TH within the cytosol of chromaffin cells from animals subjected to anesthesia or ECS, as determined by immunocytochemical techniques, was similar. In all treatment groups chromaffin cells were found which had TH associated with some chromaffin granules. The percentage of chromaffin granules which appeared to contain TH was lower in animals subjected to ECS plus decapitation as compared with anesthetized animals. These observations suggest that the activation of adrenal medullary TH is not associated with a shift in the subcellular distribution of the enzyme from the cytosol to membranous structures.

Hormonal effects on the regulation of hepatic heme biosynthesis

Drug-induced porphyrin accumulation occurs in chick embryo liver cells maintained in serum-free Waymouth MD 705/1 medium. Addition of insulin and thyroxine to the medium results in a marked enhancement of porphyrin accumulation. The addition of hydrocortisone results in a further enhancement of porphyrine accumulation. Several agents which are reported to increase intracellular adenosine 3':5'-monophosphate (cAMP) levels, viz. glucagon, sodium fluoride, cAMP or its dibutyryl derivative, 3-isobutyl-1-methylxanthine and papaverine enhanced drug-induced porphyrin biosynthesis. On the other have, agents which are reported to decrease intra-cellular cAMP levels, viz. alloxan and imidazole, diminished drug-induced porphyrin accumulation. cAMP appears to enhance, but not to function as a "second messenger" in drug-induced porphyrin biosynthesis. Drug-induced porphyrin accumulation in chick embryo liver cells depend upon the insulin to glucagon ratio. A low level of porphyrin accumulation occurs at insulin to glucagon ratios similar to those found following glucose administration in vivo, suggesting a possible explanation for the therapeutic effect of glucose in hepatic porphyria. The 5 alpha A(A:B trans) and 5 beta H(A:Bcis) steroids are equipotent in inducing delta-aminolevulinic acid synthetase and porphyrin accumulation in chick embryo liver cells maintained in serum-free culture medium. Thus, there is no specific steric requirement for porphyrin-inducing activity in steroids.

Porphyrin induction: equivalent effects of 5alphaH and 5betaH steroids in chick embryo liver cells

The 5alphaH (A : B trans) and 5betaH (A : B cis) steroids are equipotent in inducing delta-aminolevulinic acid synthetase and porphyrin accumulation in chick embryo liver cells maintained in serum-free culture medium. Thus there is no specific steric requirement for porphyrin-inducing activity in steroids.