Placental histopathology, maternal characteristics and neonatal outcome in cases of preterm birth in a high-risk population in South Africa

Background. Preterm birth remains a global health concern and is one of the most common pregnancy complications associated with perinatal morbidity and mortality.Objective. To investigate placental pathology and its associations with obstetric, maternal and neonatal outcomes in the Eastern Cape region of South Africa (SA) in order to help understand its associations with preterm birth in that region. Methods. In this prospective study, placentas were collected consecutively from patients attending a public tertiary referral hospital in SA, delivering preterm (n=100; 28 - 34 weeks gestational age) and term (n=20; >36 weeks gestational age). Placentas were submitted for histopathology, and comparisons with maternal characteristics and neonatal outcomes in preterm birth were undertaken.Results. Histological analysis revealed pathology in all preterm placentas (100%), with maternal vascular malperfusion (47%) and abruptio placentae (41%) most commonly identified. Acute chorioamnionitis (21%) was associated with term births (p=0.002). Maternal characteristics and neonatal outcomes significantly associated with preterm birth included pre-eclampsia (p=0.006), neonatal respiratory distress syndrome (p=0.004) and neonatal jaundice (p=0.003). Intrauterine demise (p=0.004) and alcohol abuse (p≤0.005) were significantly associated with term delivery. The number of mothers delivering preterm who were HIV-positive was high (41%). Conclusion. The pathology identified in all preterm placentas supports the need to update institutional policies for submission of placentas from all preterm births for histopathology, particularly in countries with a high burden of preterm birth.

Direct comparison of liquid-based and smear-based cytology with and without rapid on-site evaluation for fine needle aspirates of thoracic tumors

BACKGROUND

Liquid-based cytology (LBC) and rapid on-site evaluation (ROSE) are proposed to improve the quality of fine needle aspirates (FNA) and their diagnostic yield compared with conventional smear cytology (CSC). This prospective study directly compared outcomes of sonar-guided FNA of thoracic tumors supported by LBC, CSC, or CSC with ROSE.

METHODS

Three aspirates each for both LBC and CSC with separate 22G spinal needles in a randomized, alternating sequence during 64 transthoracic FNA of thoracic tumors were collected. Smears were prepared by cytology staff on site but evaluated with ROSE only when all six samples had been collected. If no diagnostic material was found on the first three CSC additional needle passes guided by ROSE were performed.

RESULTS

Final diagnoses were non-small cell lung cancer in 50 (78.1%), small cell lung cancer in 11 (17.2%), mesothelioma in 1 (1.6%), and inflammation in 2 cases (3.1%), respectively. LBC and CSC were diagnostic in 42 (65.6%) and 49 (76.6%) cases, respectively (P = 0.039), with both methods diagnostic in 41 cases (64.1%). Fifteen cases (23.4%) remained undiagnosed following three passes for CSC but 9 (14.1%) of these were diagnosed using FNA and ROSE with a total yield of 58 cases (90.6%; P < 0.001).

CONCLUSION

The diagnostic yield of transthoracic FNA submitted for LBC is significantly lower than with CSC when slides are prepared professionally. ROSE significantly increases the yield of transthoracic FNA.

Impact of routine sputum cytology in a population at high risk for bronchial carcinoma

SETTING

Sub-Saharan Africa carries a high burden of lung cancer, with limited access to specialised health care.

OBJECTIVE

To investigate the diagnostic value of sputum cytology and its potential in reducing the need for invasive diagnostic procedures in a high-risk population.

DESIGN

We collected spontaneously expectorated sputum from 108 patients referred for a diagnostic procedure for suspected lung cancer between June 2010 and June 2012, and examined the diagnostic yield of sputum cytology for malignant cells as well as factors predicting a positive result.

RESULTS

Bronchial carcinoma was diagnosed in 90 patients (83.3%), of whom 35 (38.9%) had sputum cytology positive for malignant cells with 100% diagnostic accuracy. Positive sputum cytology was significantly associated with endobronchial tumour and obstruction seen during bronchoscopy (OR 4.69 and OR 8.89, respectively), and with a histology of squamous cell carcinoma (OR 1.9). All but one patient with positive sputum were inoperable (97.1%), and we estimated that up to a third of all invasive procedures could be avoided if sputum cytology was used for triage.

CONCLUSION

Sputum cytology had a high yield and accuracy in this high-risk group. Its routine use in selected patients is likely to result in reduced costs and less patient risk and discomfort.

Transbronchial fine needle aspiration biopsy and rapid on-site evaluation in the setting of superior vena cava syndrome

There is a paucity of prospective data on flexible bronchoscopy with rapid on-site evaluation (ROSE) in the setting of superior vena cava (SVC) syndrome. The aims of this prospective study were to assess the diagnostic yield and safety of these investigations and specifically to evaluate the role of ROSE in limiting the need for tissue biopsies. Over a 5-year period 48 patients (57.4 ± 9.7 years) with SVC syndrome secondary to intrathoracic tumors underwent flexible bronchoscopy with TBNA and ROSE. Endobronchial Forceps biopsy was reserved for visible endobronchial tumors with no on-site confirmation of diagnostic material. ROSE confirmed diagnostic material in 41 cases (85.4%), and in only one of the remaining cases did the addition of a forceps biopsy increase the diagnostic yield (overall diagnostic yield of 87.5%). No serious complications were noted. The final diagnoses made included nonsmall lung cancer (n = 27), small cell lung cancer (n = 16), and metastatic carcinoma (n = 3). Two undiagnosed cases died of suspected advanced neoplasms (unknown primary tumors). We conclude that TBNA has a high diagnostic yield and is safe in the setting of SVC syndrome. With the addition of ROSE, tissue biopsy is required in the minority of cases.

Label-free quantitative proteomics reveals differentially regulated proteins influencing urolithiasis

Urinary proteins have been implicated as inhibitors of kidney stone formation (urolithiasis). As a proximal fluid, prefiltered by the kidneys, urine is an attractive biofluid for proteomic analysis in urologic conditions. However, it is necessary to correct for variations in urinary concentration. In our study, individual urine samples were normalized for this variation by using a total protein to creatinine ratio. Pooled urine samples were compared in two independent experiments. Differences between the urinary proteome of stone formers and nonstone-forming controls were characterized and quantified using label-free nano-ultraperformance liquid chromatography high/low collision energy switching analysis. There were 1063 proteins identified, of which 367 were unique to the stone former groups, 408 proteins were unique to the control pools, and 288 proteins were identified for comparative quantification. Proteins found to be unique in stone-formers were involved in carbohydrate metabolism pathways and associated with disease states. Thirty-four proteins demonstrated a consistent >twofold change between stone formers and controls. For ceruloplasmin, one of the proteins was shown to be more than twofold up-regulated in the stone-former pools, this observation was validated in individuals by enzyme-linked immunosorbent assay. Moreover, in vitro crystallization assays demonstrated ceruloplasmin had a dose-dependent increase on calcium oxalate crystal formation. Taken together, these results may suggest a functional role for ceruloplasmin in urolithiasis.

Assisting cytopathology training in medically under-resourced countries: defining the problems and establishing solutions

Cytology is able to deliver rapid accurate diagnoses with minimal equipment and laboratory infrastructure at minimal cost, and this is especially so for fine needle biopsy (FNB), which is a powerful diagnostic tool in medically resource-poor environments, where histopathology laboratories are small in number and poorly supported financially. The crucial element in the development of cytology services is to train a sufficient number of well trained cytopathologists and cytotechnologists to create a 'critical mass' of personnel who not only provide routine diagnostic services, but also can train an ever expanding number of pathologists, cytotechnologists, and health workers. A review of practical programs to train cytopathologists and cytotechnologists in their own countries will be presented, including a recent series of FNB and cytology tutorials run in sub Saharan Africa. The need for local cytopathology programs and the potential for both local and visiting cytopathologists to provide a faculty will be discussed, as well as a range of possible programs which can bring African pathologists and trainee pathologists to Western institutions for periods of their training. Ideally, the regional Societies of Cytology, including the recently formed West African Society of Cytology, will establish their own diagnostic protocols, training programs, syllabuses, examinations and accreditation and career pathways for both cytopathologists and cytotechnologists, and organize tutorials where they will invite overseas faculty to contribute. Crucially, these new societies will empower cytopathologists and cytotechnologists to approach health services and governments to state the need for cytology services as a cost-effective accurate diagnostic service that enhances patient care.

The use of light-emitting diode fluorescence to diagnose mycobacterial lymphadenitis in fine-needle aspirates from children

BACKGROUND

Fine-needle aspiration biopsy (FNAB) is a simple, safe and effective method for investigating suspected mycobacterial lymphadenitis in children. Fluorescence microscopy can provide rapid mycobacterial confirmation. Light-emitting diodes (LEDs) provide a cheap and robust excitation light source, making fluorescence microscopy feasible in resource-limited settings.

OBJECTIVE

To compare the diagnostic performance of LED fluorescence microscopy on Papanicolaou (PAP) stained smears with the conventional mercury vapour lamp (MVL).

METHODS

FNAB smears routinely collected from palpable lymph nodes in children with suspected mycobacterial disease were PAP-stained and evaluated by two independent microscopists using different excitatory light sources (MVL and LED). Mycobacterial culture results provided the reference standard. A manually rechargeable battery-powered LED power source was evaluated in a random subset.

RESULTS

We evaluated 182 FNAB smears from 121 children (median age 31 months, interquartile range 10-67). Mycobacterial cultures were positive in 84 of 121 (69%) children. The mean sensitivity with LED (mains-powered), LED (rechargeable battery-powered) and MVL was respectively 48.2%, 50.0% and 51.8% (specificity 78.4%, 86.7% and 78.4%). Inter-observer variation was similar for LED and MVL (κ = 0.5).

CONCLUSION

LED fluorescence microscopy provides a reliable alternative to conventional methods and has many favourable attributes that would facilitate improved, decentralised diagnostic services.

Mycobacterial transport medium for routine culture of fine needle aspiration biopsies

Fine needle aspiration biopsy (FNAB) offers a simple outpatient technique for specimen collection in child tuberculosis suspects with peripheral lymphadenopathy. To perform FNAB with mycobacterial culture on an outpatient basis requires use of a sterile transport medium to facilitate bedside inoculation, maintain organism viability and reduce contamination risk en route to the laboratory. The mycobacterial yield and time to positive culture following bedside inoculation into standard mycobacterial growth indicator tubes were compared with initial inoculation into an inexpensive "in-house" liquid growth medium. Of 150 FNAB performed, 57 (38%) cultured Mycobacterium tuberculosis complex. There was one case each with non-tuberculous mycobacteria and Mycobacterium bovis BCG; the remaining 55 being M tuberculosis. Results were concordant in 142 (94.7%) bedside and laboratory inoculation pairs. There was no significant difference in time to positive culture between bedside and laboratory inoculation (16.2 days (SD 0.87) vs 17.1 days (SD 0.85)). Provision of inexpensive specimen transport bottles and practical tuition in FNAB should improve cost-effective diagnosis of tuberculosis at the primary healthcare level.

Fine needle aspiration biopsy: an undervalued diagnostic modality in paediatric mycobacterial disease

Mycobacterial disease, and particularly tuberculosis (TB), is an escalating problem in developing countries, fuelled by the parallel human immunodeficiency virus (HIV) pandemic. In TB endemic countries children carry a very high burden of disease, which may be unrecognised due to the difficulty in making a diagnosis based on clinical, radiological or laboratory methods. One of the main hurdles is the difficulty of obtaining adequate specimens for bacteriological confirmation of disease in children. TB lymphadenitis is the most common extra-pulmonary manifestation of TB, and up to 22% of children with persistent cervical lymphadenopathy and no local cause may have tuberculous adenitis. Fine needle aspiration biopsy (FNAB), a simple and safe out-patient procedure that can be performed by nurses in resource-limited settings, and that provides material for direct microscopy as well as culture and susceptibility testing, provides an excellent opportunity to obtain bacteriological confirmation. However, it remains a greatly underutilised specimen collection modality. This review provides a comprehensive overview of the difficulties faced in the diagnosis of paediatric TB in resource-limited settings, and suggests ways to utilise FNAB as a practical modality for the rapid and effective diagnosis of mycobacterial disease in the significant subset of patients who present with peripheral lymphadenopathy. It also provides detail on how best to perform the technique, and suggests ways of making it more widely available in resource-limited settings, which carry the brunt of the paediatric TB disease burden.

Fine-needle aspiration biopsy: a first-line diagnostic procedure in paediatric tuberculosis suspects with peripheral lymphadenopathy?

OBJECTIVE

To evaluate the diagnostic yield and time to diagnosis of fine-needle aspiration biopsy (FNAB) vs. routine respiratory specimens collected from children with a palpable peripheral lymph node mass and symptoms suspicious of tuberculosis (TB).

DESIGN

We performed a retrospective review of laboratory records at Tygerberg Hospital over a 4-year period from January 2003 to December 2006. All children (aged <13 years) in whom an FNAB and other mycobacterial specimens were collected as part of their diagnostic workup were included.

RESULTS

In 95 children, the following specimens were collected: FNAB (n = 95), gastric aspirates (n = 142), other respiratory specimens (n = 36), non-respiratory specimens (n = 26). Mycobacterial disease was diagnosed in 70 (73.7%) patients. Children without respiratory specimens (n = 6) and/or with Mycobacterium bovis bacille Calmette-Guérin disease (n = 15) were excluded from comparative analysis. In the remainder, FNAB was positive in 45/74 (60.8%) vs. any respiratory specimen in 29/74 (39.2%, P < 0.001). The mean time to bacteriological diagnosis with FNAB was 7.1 days (95%CI 4.2-10.1) compared to 22.5 days (95%CI 15.8-29.1) for any respiratory specimen.

CONCLUSION

FNAB is a simple, rapid and effective modality for achieving confirmation of mycobacterial disease in paediatric TB suspects with a palpable peripheral lymph node mass.

Water column organic carbon in a Pacific marginal sea (Strait of Georgia, Canada)

Marginal seas provide a globally important interface between land and interior ocean where organic carbon is metabolized, buried or exported. The trophic status of these seas varies seasonally, depending on river flow, primary production, the proportion of dissolved to particulate organic carbon and other factors. In the Strait of Georgia, about 80% of the organic carbon in the water column is dissolved. Organic carbon enters at the surface, with river discharge and primary production, particularly during spring and summer. The amount of organic carbon passing through the Strait (approximately 16x10(8) kg C yr(-1)) is almost twice the standing inventory (approximately 9.4x10(8) kg C). The organic carbon that is oxidized within the Strait (approximately 5.6x10(8) kg yr(-1)) presumably supports microbial food webs or participates in chemical or photochemical reactions, while that which is exported (7.2x10(8) kg yr(-1)) represents a local source of organic carbon to the open ocean.

Joined by geochemistry, divided by history: PCBs and PBDEs in Strait of Georgia sediments

Polychlorinated biphenyls (PCBs) are relict contaminants, while polybrominated diphenyl ethers (PBDEs) are in increasing use. Using sediment cores collected in the Strait of Georgia, we demonstrate that the surface sediment concentration of PCBs is largely determined by environmental processes, such as sediment accumulation and mixing rates, while that of PBDEs is strongly influenced by proximity to source. The Iona Island wastewater outfall appears to be a primary pathway for PBDEs. As well, Vancouver Harbour is highly contaminated with both classes of chemical. BDE-209, the main component of deca-BDE, is the dominant PBDE congener. Environmental debromination is not evident. Currently, the ranges of the surface concentration of PCBs and PBDEs are similar to one another, but that will change in the future, as the concentration of PBDEs continues to rise. The experience with PCBs suggests that if PBDEs were banned today, it would take decades for inorganic sediment to bury them.

A review of subtidal benthic habitats and invertebrate biota of the Strait of Georgia, British Columbia

The initial phase of a collaborative ambient monitoring program (AMP) for the Strait of Georgia (SoG) (Marine Environmental Research, in press.) has focused on the benthos, sedimentary regimes, organic and contaminant cycling in subtidal regions of the strait. As part of that project, we review the primarily subtidal benthic invertebrate faunal communities found in the SoG, with particular reference to habitats and sediment conditions. This topic has not been addressed in the primary literature for over 20 years. Benthic biota are the baseline sentinels of the influence of natural and anthropogenic inputs to sediments. They are also a fundamental component of the food chain at the seafloor, and their community ecology must be clearly understood in order to predict how anthropogenic activities and climate change will affect our coastal oceans. The purpose of this review is to provide context on habitats and biota in the SoG, and to highlight topics and geographic areas where our knowledge of the benthos is limited or lacking.

Ultrasound-assisted transthoracic biopsy: fine-needle aspiration or cutting-needle biopsy?

The present study compared the diagnostic yield of ultrasound-assisted cutting-needle biopsy (CNB) and fine-needle aspiration biopsy (FNAB) in chest lesions. A physician performed ultrasound and FNAB with a 22-G spinal needle in all patients, directly followed by a 14-G CNB in patients without contraindication. A total of 155 consecutive lesions arising from the lung (74%), pleura (12%), mediastinum (11%) or chest wall (3%) in patients with a final diagnosis of lung carcinoma (74%), other malignant tumours (12%), non-neoplastic disease (9%) or unknown (5%) were prospectively included. The overall diagnostic yield was 87%. Combined specimens were obtained in 123 lesions (79%). In these, yields of FNAB, CNB and both methods combined were 82, 76 and 89%, respectively. FNAB was significantly better than CNB in lung carcinoma (95 versus 81%) but CNB was superior in noncarcinomatous tumours and in benign lesions. On-site cytology was 90% sensitive and 100% specific for predicting a positive FNAB. One patient required drainage for pneumothorax (0.6%). Ultrasound-assisted fine-needle aspiration biopsy performed by chest physicians is an accurate and safe initial diagnostic procedure in patients with a high clinical probability of lung carcinoma. All other patients should undergo concurrent fine-needle aspiration biopsy and cutting-needle biopsy.

Transbronchial needle aspirates: how many passes per target site?

Transbronchial needle aspiration is a bronchoscopic sampling method for a variety of bronchial and pulmonary lesions. The present study investigated whether and how serial needle passes contribute to the yield of transbronchial needle aspiration at specific target sites. A total of 1,562 needle passes, performed at 374 target sites in 245 patients with neoplastic disease (82%), non-neoplastic disease (15%) or undiagnosed lesions (3%), were prospectively recorded and rated for anatomical location, size, bronchoscopic appearance and underlying disease. Positive aspirates were obtained in 75% of patients and at 68% of target sites. A diagnosis was established with the first, second, third and fourth needle pass at 64, 87, 95 and 98% of targets, respectively. The absolute yield varied strongly with target site features, but the stepwise increment to the maximum yield provided by serial passes was similar across target sites. In conclusion, three transbronchial needle passes per site are appropriate when only a tissue diagnosis is sought and when alternative sites or sampling modalities are available. At least four or five passes should be carried out at lymph node stations critical for the staging of lung cancer.

Safety and Yield of Ultrasound-Assisted Transthoracic Biopsy Performed by Pulmonologists

BACKGROUND

Transthoracic ultrasound (US) has gained popularity as a tool for visualizing pleural effusions and assisting thoracentesis or chest drain placement. In the absence of effusion, US just as well demonstrates solid masses involving or abutting the pleura, yet biopsy of such lesions is not widely performed by chest physicians.

OBJECTIVE

To assess the feasibility and the safety of US-assisted cutting needle biopsy performed by chest physicians in routine practice.

METHODS

Lesions involving or abutting the pleura > or =20 mm in diameter on US were sampled with a 14-gauge cutting needle under local anesthesia. Biopsy site, needle direction and depth of penetration were determined with US. The procedure was performed without direct US guidance in 'free-hand' technique.

RESULTS

Ninety-one patients underwent 96 cutting-needle biopsies for suspected peripheral lung tumors (n = 44, 46%), pleural-based (n = 39, 41%), mediastinal (n = 10, 10%), or chest wall lesions (n = 3, 3%), which were single in 71%, multiple in 6% and diffuse in 23%. Sensitivity for malignant neoplasms (n = 65) was 85.5% and 100% for mesothelioma (n = 10). Pneumothorax occurred in 4%.

CONCLUSIONS

US-assisted cutting-needle biopsy of lesions > or =20 mm in diameter is safe in the hands of pulmonologists. The yield for neoplastic disease including mesothelioma is high.

Why is recurrent myocardial ischaemia a predictor of adverse outcome in unstable angina? An observational study of myocardial ischaemia and its relation to coronary anatomy

OBJECTIVE

To establish why recurrent myocardial ischaemia predicts adverse outcome in patients with refractory unstable angina on maximal medical treatment.

DESIGN

Prospective observational study in 101 patients with refractory unstable angina who underwent continuous ST-segment monitoring and kept detailed pain charts prior to cardiac catheterization. Setting Tertiary referral centre.

RESULTS

Significant coronary disease was identified in 90 subjects with 74 (82%) having multivessel disease, 41 (46%) complex lesion morphology, and 10 (11%) subjects with definite features of intra-coronary thrombus. The frequency of complex lesions or intra-coronary thrombus did not differ in relation to the extent of coronary disease. Recurrent chest pain was present in 72 of the 90 (80%) subjects, while transient ischaemia was detected in 26 (29%). The presence of transient ischaemia was a powerful predictor of complex lesions or thrombus (odds ratio 7.1;P<0.001). Subjects with severe recurrent chest pain had a greater frequency of intracoronary thrombus (odds ratio 9.5;P<0.05).

CONCLUSIONS

In unstable angina once the normal mechanisms causing myocardial ischaemia (i.e. increased myocardial demand and coronary vasoconstriction) have been treated using maximal antianginal treatment, the continued development of transient myocardial ischaemia is strongly associated with complex coronary lesion morphology and intracoronary thrombus. It is already known that patients with complex lesion morphology and intracoronary thrombus have an adverse outcome in unstable angina and therefore it is this association that explains why transient ischaemia is a predictor of poor outcome in unstable angina.

Synthesis and characterization of the dimercury(I)-linked compound [PPn]4[(Re7C(CO)21Hg)2]. Oxidative cleavage of the mercury-mercury bond leading to carbidoheptarhenate complexes of mercury(II), including [PPN][Re7C(CO)21Hg(S=C(NME2)2)]

The reaction of [PPN](3)[Re(7)C(CO)(21)] with Hg(2)(NO(3))(2).2H(2)O in dichloromethane formed the complex [PPN](4)[(Re(7)C(CO)(21)Hg)(2)] ([PPN](4)[1]), isolated in 60% yield. Analogous salts of [1](4-) with [PPh(4)](+) and [NEt(4)](+) were also prepared. The crystal structure of [PPN](4)[1] showed that two carbidoheptarhenate cores are linked by a dimercury(I) unit (d(Hg-Hg) = 2.610(4) A), with each individual mercury atom face-bridging. Oxidative cleavage of the Hg-Hg bond in [1](4-) was effected by 4-bromophenyl disulfide to form [Re(7)C(CO)(21)HgSC(6)H(4)Br](2-) ([4](2-)), by I(2) to form [Re(7)C(CO)(21)HgI](2-) ([5](2-)), and by Br(2) to form [Re(7)C(CO)(21)HgBr](2-) ([6](2-)). Oxidation of [1](4-) by ferrocenium ion (2 equiv) in the presence of tetramethylthiourea resulted in the derivative [Re(7)C(CO)(21)HgSC(NMe(2))(2)](-) ([7](-)). The molecular structure of [PPN][7] was determined by X-ray crystallography. This is the first example of a carbidoheptarhenate-mercury complex with a neutral ligand on mercury, and ligand exchange was demonstrated by displacement with triethylphosphine. Complex [7](-) can also be prepared by protonating [Re(7)C(CO)(21)HgO(2)CCH(3)](2-) in the presence of tetramethylthiourea. Cyclic voltammetry data to calibrate and compare the redox properties of compounds [1](4-) and [7](-) have been measured.

A single institutional experience with 43 pregnancies in essential thrombocythemia

OBJECTIVES

We describe the periconception circumstances and outcome of 43 consecutive pregnancies in an unselected group of young women with essential thrombocythemia (ET).

PATIENTS AND METHODS

We retrospectively studied 74 consecutive cases of young women with ET seen at our institution, among whom 43 pregnancies occurred in 20 patients.

RESULTS

Of the 43 pregnancies, 22 (51%) were successful (21 term and 1 preterm live births) and 21 (49%) ended in miscarriages (1 ectopic pregnancy, 2 elective abortions, 16 first-trimester spontaneous abortions, 1 stillbirth at 22 wk, and 1 abruptio placentae at 33 wk). Management of ET at the time of conception included either no specific therapy (16 cases) or the use of aspirin alone (24 cases), a cytoreductive agent (2 cases), or heparin (1 case). There were no significant differences with respect to platelet count or the effect of treatment with aspirin, either at the time of conception or during the first trimester, among cases of successful pregnancies (22), all miscarriages (21), or first-trimester spontaneous abortions (16). The findings were similar when the analysis was restricted to only first-time pregnancies. In patients with multiple pregnancies, the outcome of a subsequent pregnancy was not predicted by the outcome of the first. In general, in successful cases the last two trimesters were mostly uneventful, with healthy offspring being reported in all cases.

CONCLUSIONS

Pregnant patients with ET have an increased risk of first-trimester abortion which is not predictable by preconception platelet count or aspirin therapy. In addition, our experience does not support the use of prophylactic platelet apheresis during delivery.

Trisomy 18 with total cranio-rachischisis and thoraco-abdominoschisis

We describe a further case of trisomy 18 with total cranio-rachischisis and radial agenesis, and report the first case with thoraco-abdominoschisis. We review these rare findings in trisomy 18.

Hydrolethalus syndrome in a non-Finnish family: confirmation of the entity and early prenatal diagnosis

We present a family in which the first affected child presented with a 'milder' form of the hydrolethalus syndrome and survived to seven months, and two subsequent pregnancies with typical features detected early by ultrasound evaluation. We propose that the 'milder' cases are indeed true cases of the hydrolethalus syndrome and that allelic variability may be responsible for these 'non-typically Finnish' findings. We also demonstrate that, especially in families where there has been a previously affected fetus, echographic diagnosis can be made in the first trimester, as early as the 11th week of gestation.

The cytomorphology of papillary serous carcinoma of the endometrium in cervical smears

BACKGROUND

An investigation into the determination of cytomorphologic criteria that may distinguish papillary serous carcinoma of the endometrium (PSC) from typical endometrioid carcinoma (TEC) in cervical smears was undertaken. Preoperative identification of this poor prognostic variant of endometrial carcinoma may influence the surgical management of these cases and the choice of adjuvant therapy.

METHODS

The cervical smears of 12 cases of histologically confirmed PSC; 12 cases of TEC, including 2 villoglandular/papillary variants, and 6 cases of mixed PSC and papillary endometrioid carcinoma were reviewed. In all cases an initial diagnosis of malignancy had been made on the cervical smears. Twenty-seven criteria were evaluated and the relation between the cytologic characteristics and the type of adenocarcinoma, the degree of association, and the intergroup homogeneity were tested.

RESULTS

Features strongly associated with PSC were hypercellular smears with a background tumor diathesis, papillae, bare nuclei, and cells with large pleomorphic nuclei and bulky dense cytoplasm. In contrast, TEC showed a relatively monomorphic population of cells with moderately enlarged oval nuclei and delicate cytoplasm. In the mixed tumors, the features were similar to those of PSC, suggesting preferential exfoliation of the PSC component of the tumor.

CONCLUSIONS

Assessment of the cytomorphology of PSC and TEC of the endometrium in Papanicolaou stained cervical smears is possible using statistically significant diagnostic criteria.

Natural killer cell lymphoma in cytology: breaking all the rules--a case report

A testicular mass aspirate was received from a 22-yr-old patient with known non-Hodgkin's lymphoma. The cells were large and pleomorphic, occurring in syncytial fragments and demonstrating abundant cytoplasm. No lymphoglandular bodies were seen. As characteristic lymphoma criteria were not present, a cytodiagnosis of germ-cell tumor was suggested, and testicular biopsy advised. The final histopathology report, however, was of a CD 56-positive (large-cell) T-natural killer cell lymphoma, of which this appears to be the first example described and illustrated cytologically.

Cytopathology of follicular dendritic cell tumors

Follicular dendritic cell tumors are rarely described entities, arising from antigen-presenting immune accessory cells, found within B-lymphocyte follicles in nodal and extranodal sites. We report two cases, one associated with Castleman's disease, in whom fine-needle aspiration biopsy was performed followed by surgical biopsy. The diagnosis was confirmed using immunoreactivity with CD21 and CD35 antibodies and by ultrastructural demonstration of interdigitating cell processes with desmosomes. Both the cytologic and histologic findings are presented, and the differential diagnoses are discussed. Awareness of this entity and recognition of the pathologic features may lead to a presumptive diagnosis which must be confirmed using imunohistochemistry and/or electron microscopy.

Tetra-amelia and splenogonadal fusion in Roberts syndrome

Roberts-SC phocomelia syndrome comprises limb deficiencies of variable severity, facial clefts, and other anomalies. Tetra-amelia may also be associated with facial clefts and similar anomalies. We report on a female infant with severe tetra-amelia, micrognathia, cleft palate, splenogonadal fusion, and premature centromere separation. We propose that this represents the severe expression of the Roberts-SC phocomelia syndrome.

Lethal neonatal mandibuloacral dysplasia

We report on a case of lethal neonatal mandibuloacral dysplasia. Large confluent fontanelles, sparse fine hair and eyebrows, pseudo-exophthalmos, micrognathia, bulbar digits, and short clavicles were present. In addition, we describe for the first time the presence of glandular hypospadias in this disorder. We propose that this neonatally lethal case represents severe expression of mandibuloacral dysplasia.

Acute effect of oestrogen replacement therapy on treadmill performance in postmenopausal women with coronary artery disease

The significant reduction in cardiovascular morbidity and mortality following oestrogen replacement therapy in postmenopausal women is only partly explained by an improved lipid profile. Given acutely, oestradiol causes vasodilatation and increases coronary blood flow and, in large doses, improves treadmill performance in postmenopausal women with coronary artery disease. However, the significance of oestrogen-mediated vasodilatation is unknown since the acute effects of oestradiol in doses and preparations commonly used clinically have not been tested. The aim of this study was to evaluate the acute effects of conventional replacement therapy with 17 beta-oestradiol on treadmill performance in 16 postmenopausal women with angina in a randomized, double-blind, placebo-controlled cross-over trial. Following baseline treadmill testing a transdermal oestrogen patch releasing 50 micrograms oestradiol. 24 h-1 or matching placebo was applied and the exercise test repeated 24 h later. The patch was then removed. Seven to 14 days later the sequence was repeated using the alternative patch. The changes in time to angina, time to 1 mm ST segment depression and total exercise time for each treatment compared with the corresponding baseline test were calculated. Plasma 17 beta-oestradiol increased with active therapy from 56 +/- 30 pmol.l-1 to 204 +/- 90 pmol.l-1, indicating adequate replacement. Compared with their respective baseline exercise tests there were no differences between active and placebo patches for time to angina (active: 13 +/- 55 s vs placebo: 10 +/- 47 s), time to 1 mm ST segment depression (active: -30 +/- 52 s vs placebo: 24 +/- 71 s) or total exercise time (active: 14 +/- 45 s vs placebo: 13 +/- 35 s). Despite the recognized acute vasodilator action of larger doses of oestrogen, doses conventionally used in hormone replacement therapy had no acute effect on treadmill performance in this group of postmenopausal women with coronary artery disease.

HPV typing of vulvovaginal condylomata in children

OBJECTIVE

To determine the human papillomavirus (HPV) subtypes in vulvovaginal warts in prepubescent children.

DESIGN

Histopathology case series.

SETTING

Outpatient and gynaecology clinics of hospitals in the greater Johannesburg area.

PATIENTS

All cases of vulvovaginal warts diagnosed in children under the age of 12 years received at the South African Institute for Medical Research, Johannesburg, during the period 1 January 1991 to 31 December 1993.

MAIN OUTCOME MEASURES

Positivity for "genital' HPV types 6, 11, 16, 18, 31, 33 and 35 using non-isotopic in situ hybridisation (NISH) and polymerase chain reaction (PCR).

RESULTS

Eight of the 9 vulvovaginal warts contained HPV 11 when assessed by means of NISH (89%). PCR amplified HPV DNA in all 9 (100%) of the biopsies.

CONCLUSION

Detection of genital subtypes of HPV in childhood condylomata acuminata points strongly to sexual abuse, but should only be used as a guide to further investigation by a multidisciplinary team.

Detection of herpes simplex virus DNA in spontaneous abortions from HIV-positive women using non-isotopic in situ hybridization

The purpose of this study was to determine the prevalence of Herpes simplex virus (HSV) endometritis in spontaneous abortions in HIV-positive women using non-isotopic in situ hybridization (NISH). Post-abortal endometrial curettings from 18 HIV-positive women were investigated for the presence of HSV-1 and HSV-2 DNA with NISH. In addition, 18 unselected post-abortal endometrial curettings in HIV-negative women were used as controls, together with samples of normal proliferative and secretory endometrium. Thirteen of the 18 specimens (72 per cent) from the HIV-positive study group demonstrated the presence of HSV DNA, while 2 of the 18 HIV-negative group (11 per cent) showed a positive signal. Although the prevalence of HSV endometritis in the HIV-positive group was significantly higher than in the HIV-negative group (P < 0.05), a causal role for the virus in inducing the abortion remains to be determined. In addition, the significance of HSV endometritis with regard to the clinical management of HIV-positive patients is as yet uncertain.

Chest pain in women: clinical, investigative, and prognostic features

OBJECTIVE

To characterise clinical, investigative, and prognostic features of women referred with chest pain who subsequently underwent coronary angiography.

DESIGN

Analysis of all women with angina referred to one consultant during 1987-91 who subsequently underwent coronary angiography, with follow up to present day.

SETTING

Cardiothoracic centre.

SUBJECTS

Women with normal coronary arteries; women with coronary artery disease shown on angiography; men with coronary artery disease matched for age; men referred with chest pain during the same period subsequently found to have normal coronary arteries.

MAIN OUTCOME MEASURES

Risk factor analysis; results of exercise testing and coronary angiography; intervention; morbidity and mortality.

RESULTS

Women comprised 23% (202/886) of patients referred with chest pain who subsequently underwent angiography. 83/202 women had normal coronary angiograms compared with 55/684 men (41% v 8%, P < 0.01). Diabetes mellitus was the only risk factor more frequently encountered in women with coronary artery disease (P = 0.001). The specificity and positive predictive value of exercise testing before angiography were significantly lower in women than men (71% v 93%, P < 0.001 and 76% v 95%, P < 0.001, respectively). Revascularisation procedures were as common in women with coronary artery disease as in men (81 (68%) v 70 (59%)), and there was no difference in event rate during follow up. Many patients with normal coronary arteries, irrespective of sex, had symptoms during follow up (61 (73%) women, 36 (65%) men) and continued to take antianginal drugs (27 (33%) women, 14 (28%) men); 14 (17%) women and six (11%) men required hospital readmission for severe symptoms.

CONCLUSIONS

In this series, although women comprised the minority of patients referred with chest pain, a diagnosis of normal coronary arteries was five times more common in women than men. Risk factor analysis and exercise testing were of limited value in predicting coronary artery disease in women. There was no sex bias regarding revascularisation procedures, and outcome was similar. A diagnosis of non-cardiac chest pain in patients with normal coronary arteries was of little benefit to the patient with regard to morbidity.