Intraplacental Choriocarcinoma in Twin Pregnancy Causing Fetomaternal Haemorrhage and Single Twin Demise: Case Report

Gestational choriocarcinoma is a rare aggressive form of gestational trophoblastic neoplasia. In cases of intraplacental choriocarcinoma, the tumour is confined to the placenta. Intraplacental choriocarcinoma in twin pregnancies is a very rare occurrence with less than 5 previously reported cases in the literature. In this case, a 34-year-old primiparous woman, pregnant with dichorionic diamniotic twins, underwent an emergency caesarean section for fetal distress at 35 weeks gestation after presenting in preterm labour. Twin A was delivered with no signs of life. The demise was attributed to fetomaternal haemorrhage (FMH) secondary to intraplacental choriocarcinoma. The mother's HCG normalised quickly postpartum with no radiological signs of metastatic disease. She has been managed conservatively with monthly HCG surveillance with no signs of recurrence. Twin B remains well with negative HCG surveillance. Although gestational choriocarcinoma can be aggressive and associated with poor obstetric outcomes, it has a good prognosis when diagnosed and treated early. The importance of detailed histopathological placental examination and clinical suspicion for choriocarcinoma following FMH is highlighted by this case.

Childhood interstitial lung diseases in immunocompetent children in Australia and New Zealand: a decade's experience

BACKGROUND

Childhood interstitial lung disease (chILD) represents a rare heterogeneous group of respiratory disorders. In the absence of randomized controlled clinical trials, global collaborations have utilized case series with an aim to standardising approaches to diagnosis and management. Australasian data are lacking. The aim of this study was to calculate prevalence and report the experience of chILD in Australasia over a decade.

METHODS

Paediatric pulmonologists in Australia and New Zealand involved in the care of patients aged 0-18 years with chILD completed a questionnaire on demographics, clinical features and outcomes, over a 10 year period. These data, together with data from the 2 reference genetics laboratories, were used to calculate prevalence.

RESULTS

One hundred fifteen cases were identified equating to a period prevalence (range) of 1.5 (0.8-2.1) cases/million for children aged 0-18years. Clinical data were provided on 106 patients: the <2 year group comprised 66 children, median age (range) 0.50 years (0.01-1.92); the ≥2 year group comprised 40 children, median age 8.2 years (2.0-18.0). Management approach was heterogeneous. Overall, 79% of patients had a good clinical outcome. Mortality rate was 7% in the study population.

CONCLUSION

chILD is rare in Australasia. This study demonstrates variation in the investigations and management of chILD cases across Australasia, however the general outcome is favorable. Further international collaboration will help finesse the understanding of these disorders.

Human fetal lung morphometry at autopsy with new modeling to quantitate structural maturity

OBJECTIVES

To demonstrate a simplified morphometric procedure, including a new model for acinar structural maturity, applicable to autopsy fetal lung and present reference values for these parameters.

STUDY DESIGN

Cases with autopsy consent for research were studied. To simplify analysis only critical morphometric parameters were measured to allow calculation of gas-exchange surface area.

SUBJECT SELECTION

A total of 58 fetuses, 16-40 weeks were included. Subjects were rejected with any condition predisposing to pulmonary hypo/hyperplasia, significant maceration, or if lung weight/bodyweight or microscopy identified pulmonary hypoplasia or lung growth disorders.

METHODOLOGY

Lungs were inflation fixed, weights and volumes determined, sampled, then returned to the body. Volume densities (V_V ) of parenchyma/non-parenchyma and air-space/gas-exchange tissue, gas-exchange surface density (S_V ), and total surface area (SA) were determined. The number, mean radius, and septal thickness of modeled airspace-spheres were calculated. Equations were generated for each parameter function of gestation and bodyweight.

RESULTS

From 16 to 40-week weights and volumes increased as power functions from ∼4 g/mL to ∼90 g/mL. Parenchyma/non-parenchyma changed little-75:25 (16 weeks) to 71:29 (term). Parenchyma was 10% airspace:90% tissue early and 50:50 by term. Gas-exchange S_V increased from 175 to 450 cm² /cm³ and total SA increased from 0.059 to 4.793 m² . There were 3.31 × 10⁶ airspace-spheres, 12 µ radius, septal thickness 30 µ at 16 weeks, increasing to 56.92 × 10⁶ , 26 µ radius, septal thickness 13 µ by term.

CONCLUSIONS

Morphometry can feasibly be performed at autopsy, providing more informative quantitative data on lung structural development than current methods utilized. This reference data set compares well with published data.

Ectrodactyly and Lethal Pulmonary Acinar Dysplasia Associated with Homozygous FGFR2 Mutations Identified by Exome Sequencing

Ectrodactyly/split hand-foot malformation is genetically heterogeneous with more than 100 syndromic associations. Acinar dysplasia is a rare congenital lung lesion of unknown etiology, which is frequently lethal postnatally. To date, there have been no reports of combinations of these two phenotypes. Here, we present an infant from a consanguineous union with both ectrodactyly and autopsy confirmed acinar dysplasia. SNP array and whole-exome sequencing analyses of the affected infant identified a novel homozygous Fibroblast Growth Factor Receptor 2 (FGFR2) missense mutation (p.R255Q) in the IgIII domain (D3). Expression studies of Fgfr2 in development show localization to the affected limbs and organs. Molecular modeling and genetic and functional assays support that this mutation is at least a partial loss-of-function mutation, and contributes to ectrodactyly and acinar dysplasia only in homozygosity, unlike previously reported heterozygous activating FGFR2 mutations that cause Crouzon, Apert, and Pfeiffer syndromes. This is the first report of mutations in a human disease with ectrodactyly with pulmonary acinar dysplasia and, as such, homozygous loss-of-function FGFR2 mutations represent a unique syndrome.

Congenital Disseminated Extrarenal Malignant Rhabdoid Tumor

Soft tissue tumors arising in association with genetic or malformation syndromes have been increasingly reported. Malignant rhabdoid tumor (MRT) is a highly aggressive neoplasm of infancy and young childhood, characterized by typical morphology and biallelic inactivation of the SMARCB1 (INI1/hSNF5/BAF47) gene on chromosome 22q.2 which encodes a subunit of the SWI/SNF ATP-dependent chromatin remodeling complex. Congenital infantile disseminated MRT represents a unique clinicopathologic presentation of this tumor. We report a case occurring in a female neonate who presented at birth a voluminous left thigh mass. Surgical biopsy performed at day 9 showed morphology and immunoprofile of MRT. Staging evaluation identified hypercalcemia and distant nodules. The mass showed rapid growth. Despite chemotherapy, the tumor progressed with exteriorization through the biopsy scar. Chemotherapy was discontinued and treatment limited to palliative care and the child died on day 51. The tumor was homozygous for the SMARCB1 deletion with apparent de novo heterozygous germ line deletion in the infant, not identified in the parents.

Plexiform pulmonary arteriopathy in a 2 year-old boy

Idiopathic pulmonary arterial hypertension is a rare disease in children. We report a case of a 2-year old boy admitted to the intensive care unit of our hospital for severe dyspnea and epistaxis. Laboratory investigations showed hemolytic anemia with schizocytes and severe thrombocytopenia. Cardiac investigations diagnosed supra-systemic pulmonary arterial hypertension, which was refractory to maximal medical treatment. On evolution, he had several cardiac arrests and finally died 8 days after admission. Autopsy was performed and showed typical lesions of idiopathic pulmonary hypertensive arteriopathy characterized by plexiform lesions of the interlobular arteries containing numerous disseminated intravascular microthrombi. The rest of the family was screened, DNA was stored, and genetic study of BMPR2 was planned.

Stage I seminoma in a 15-year-old boy

Seminomas are very rare tumours in children and adolescents. We describe a case of seminoma in a 15-year-old boy who was managed with orchidectomy but no adjuvant therapy. He remains relapse-free 8 years after surgery as determined by clinical, radiological and serological surveillance. This study emphasizes the uncertainty over the need for adjuvant treatment in the management of seminoma in the adolescent patient, in particular in prepubescent children.

Restricted fetal growth and lung development: a morphometric analysis of pulmonary structure

Intrauterine growth restriction (IUGR) in humans increases the risk of lung disease and impaired function suggesting that adverse intra-uterine conditions can alter lung development. We hypothesized that placental restriction (PR) of fetal growth would alter lung structure in late gestation. PR involved removal of implantation sites in pre-pregnant ewes. Normal (n = 7) and PR (n = 11) fetuses were delivered at day 140 gestation. Lungs were fixed by tracheal infusion, processed and analyzed by morphometry. PR reduced ponderal index (PI) of lambs by 13%, increased lung volume:body weight (BW) (19%), and decreased the proportion of lung volume that comprised parenchyma from 86.5(2.6)% to 76.7(2.1)% with no change in absolute volume of non-parenchyma. Within the parenchyma, PR increased the proportion comprising airspace from 42.0(2.2)% to 55.5(1.7)% with smaller (-13%) more dense (18%) airsacs/alveoli present. The overall effect was a reduction in total gas-exchange surface density (-10%). Lung wet-weight and volume, parenchymal volume, gas-exchange tissue, and airspace volumes and gas-exchange surface area correlated positively with BW and crown-rump length (CRL) for all animals. The relative lung weight and volume correlated negatively with BW, CRL, and lung weight:BW with PI. Lung weight, lung volume, parenchymal volume, airspace perimeter, percent of parenchymal gas-exchange tissue, gas-exchange surface density, and area correlated positively with PI. The results indicate increased sparing of lung growth but with increasing structural changes, predominantly within lung parenchyma, with increasing growth restriction. Structural alterations associated with PR and poor fetal growth may be important in the pathogenesis of impaired lung function associated with IUGR.

Urogenital nonunion--the case for laparoscopy for the impalpable testis

A case of urogenital nonunion is presented to illustrate the importance of laparoscopy for the impalpable testis. A 4-year-old boy with an impalpable left testis underwent laparoscopy. This revealed not only the vas deferens entering the deep inguinal ring but also a small intraabdominal testis supplied by the testicular vessels. Exploration of the inguinal canal revealed the vas deferens terminating in a nubbin of tissue. Histology identified epididymal structures both adjacent to the testis and in the terminal nubbin of the vas deferens. This is an example of urogenital nonunion. Complete separation of the vas and testis with epididymal structures attached to each is very unusual, with only four other cases reported. Laparoscopy should be the initial procedure for impalpable testis. A blind-ending vas deferens found on exploration of the inguinal canal might be taken as evidence of the vanishing testis syndrome. However, this conclusion should not be drawn unless laparoscopy has demonstrated testicular vessels entering the internal inguinal ring.

Enteric duplications presenting as antenatally detected abdominal cysts: is delayed resection appropriate?

PURPOSE

The aim of this study was to evaluate delayed elective resection of antenatally detected enteric duplication cysts.

METHODS

A retrospective casenote study of intraabdominal cysts detected antenatally between January 1991 and January 2002 found 37 fetuses with cysts. Twelve were enteric duplications. Two were duodenal, 1 was an 85-cm tubular jejunoileal duplication, and 9 were ileocecal. Asymptomatic cysts were followed with serial ultrasound scars and resected electively over 14 months.

RESULTS

Three neonates had small bowel obstruction demanding laparotomy: 1 of the 2 infants with duodenal duplication cysts, 1 infant with an ileocecal duplication, and the infant with the tubular duplication. One with an ileocecal duplication became symptomatic at 2 months and underwent a laparotomy. Seven had their duplications resected electively between 6 weeks and 14 months, and the other is still being followed. Four of the 7 asymptomatic duplications electively resected contained gastric mucosa.

CONCLUSIONS

Intraabdominal enteric duplication cysts are increasingly likely to be detected antenatally. The majority are likely to remain asymptomatic for several months at least, after which a resection can be planned. The prevalence of gastric mucosa suggests that they should not be left indefinitely. Laparoscopically assisted resection of ileocecal duplications is safe and effective.

Limb-body wall complex: a case series

OBJECTIVE

Limb-body wall complex (LBWC) is a rare fetal polymalformation of uncertain etiology, but it has been regarded as sporadic in nature with a low recurrence risk. We review a case series in light of recent evidence about possible genetic and environmental associations.

METHODS

All abortions or births coded as limb-body wall defect or fetal acrania/exencephaly or with unclassified polymalformation between January 1996 and January 2001 were audited.

RESULTS

During the 5-year period there were 33,286 live births in our region. Eleven cases met the criteria of LBWC giving an incidence of 0.33/1000 live births. In 50%, 50% and 30% of women a history of cigarette, alcohol and marijuana use, respectively, was noted. Furthermore, 40% of the women had a history of a previous infant with a congenital anomaly. One patient delivered two consecutive male infants with LBWC.

CONCLUSIONS

Whilst the majority of cases of LBWC are sporadic, some women may have an underlying genetic predisposition. It may be prudent to advise against the use of alcohol, cigarettes and other drugs and to offer an ultrasound scan in a tertiary referral center in a subsequent pregnancy.

Analysis of the conducting airway system in the lung: a new method combining morphometry with mathematical modeling for airway classification

Although the lung is structurally complex, it is suitable for morphometric analysis of the structural determinants of lung function in health and disease. Analysis of the organized branching airways has been problematic because of the need to identify and classify airways before structural characteristics of different-order branches can be determined. Airway casts have been used to identify relationships between branches, measure some structural features, and develop mathematical models that describe simply the relationships between generations. However, cast preparation destroys surrounding tissue, including the airway wall, thus precluding analysis of these structural elements. We describe a new approach using tissue sections which combines the classification of airways into Strahler order (SO) with tissue structural analysis. Lung-tissue sections are prepared, and outer (OD) and inner (ID) diameters are determined over a wide range of airways. The line equation relating log OD vs. SO is determined using measured values for SO1 (terminal bronchioles) and SO8 (first branch bronchi). Mean ODs can then be calculated for each of the other SO groups, and measurements can be classified. Calculations can be made for the mean number of branches and airway lengths (given the log linear relationship of these factors with SO and morphometrically determined volume densities for airway lumen), and for individual airway resistance and total resistances for each SO. For an example, mean data are presented for airways in the adult sheep (n = 13). The methodology presented allows identification of subtle alterations in airway structures which may be affecting selected orders of airways, with specific implications for changes in lung function.

Non-alcoholic steatohepatitis in children and adolescents

We describe 17 children with non-alcoholic steatohepatitis. All had elevated levels of serum liver enzymes and 16 were morbidly obese. Liver biopsy showed variable steatosis and fibrosis in nine patients. At follow-up, 12 of 14 patients had persistent morbid obesity and 11 had elevated liver enzyme levels.

Effect of immediate versus slow intrauterine reduction of congenital diaphragmatic hernia on lung development in the sheep: a morphometric analysis of term pulmonary structure and maturity

The incidence of congenital diaphragmatic hernia (CDH) is 1:1,200-5, 000, and the condition is associated with high mortality and morbidity attributed principally to associated pulmonary hypoplasia. One treatment approach has been for intrauterine intervention to induce lung growth to a sufficient level to allow survival at birth. Repair of the hernia in utero has been attempted, using a method of immediate reduction and repair of the hernia (patch) compared to a slow reduction method using a silastic "silo" sewn over the diaphragm defect to contain the hernial contents. In animal studies, this second method has been associated with lower fetal morbidity and mortality. This study, utilizing the sheep model of CDH, focuses on analysis of lung structural development and maturation, comparing the efficacy of the immediate vs. slow methods of hernial repair in preventing/reversing pulmonary hypoplasia. We hypothesized that: a) Both the immediate (patch) and slow (silo) methods of hernia repair performed in the lamb model of CDH will stimulate lung growth and structural development and restore lung structure and maturity towards normal levels by term gestation; b) Effects will be detectable by morphometric measurement of the following parameters: lung volume; parenchyma to nonparenchyma tissue ratio; volume density of connective tissue in nonparenchyma; gas exchange tissue to airspace ratio; gas exchange surface area; capillary loading; alveolar/airspace density; and alveolar perimeter; c) Effects will be seen in all lobes of the lung; and d) There will be no significant difference in lung size or structural parameters between the two groups. Forty-four pregnant ewes were allocated randomly to one of four groups. Fetal lambs in three groups (n = 36) underwent CDH creation at days 72-74 of gestation. Of surviving lambs showing an adequate hernia, 9 were not operated on further, 11 underwent "repair" using a silastic chimney around the hernial contents (slow reduction), and 11 underwent "repair" by a silastic patch over the diaphragmatic defect (immediate reduction). The fourth group were normal controls. All surviving lambs (n = 8 in each group) were delivered by Cesarian section at 141-143 days (term = 145-149 days). Lungs were obtained at autopsy, inflation-fixed, divided into lobes, and sampled, and morphometric analysis was performed. Comparisons were made between these groups and with matched normal controls and CDH untreated animals prepared in conjunction and previously reported. The lungs from the CDH animals treated by both methods of fetal hernia repair showed significant lung growth and structural development and maturation, although they remained significantly hypoplastic compared to normal. There were minor differences in the lung parameters between these two groups, with a tendency for the slow method to provide more normal parameter values. An exception was the increase in lung volume that was greater for the immediate (patch) method, particularly in the left lower lobe. In conclusion, intrauterine hernia repair by both methods is capable of partially reversing total lung and lobar structural hypoplasia and immaturity. The slow reduction method, with reduced potential for mortality and morbidity, is at least as good at reversing pulmonary hypoplasia as the immediate method. Alternative intrauterine interventions to prevent or reverse pulmonary hypoplasia are discussed and compared with the hernia repair methods used in this study.

Fire deaths in children in South Australia from 1989 to 1998

A study was undertaken of childhood deaths caused by fires in South Australia over a 10-year period from 1989 to 1998. A total of 23 deaths of children occurred with an age range of 2 months to 16 years (mean 5 years 10 months; M:F = 13:10). Fourteen deaths were associated with house fires, four with fires in cars and four were miscellaneous or unspecified. While house fire deaths remained the major cause of childhood fire deaths (65%), deaths in car fires accounted for a significant proportion of cases (17%). Although the numbers are small, cars represented a specific danger because of their confined space with highly flammable interiors, lockable doors, and built in non-childproof lighters. Cars should not be regarded as suitable places to leave young children, or for children to play in unsupervised.

Chronic deciduitis in the placental basal plate: definition and interobserver reliability

This study tested whether concordance could be achieved for abnormal inflammation in the basal decidua of placental specimens among 6 pathologists experienced in placental pathology. Thirty microscope slides were evaluated by the pathologists for chronic deciduitis. They also scored the severity and extent of inflammation and the presence of plasma cells. No definition of chronic deciduitis was provided. Concordance (5/6 or 6/6 agreement) was achieved in 23 cases (76%). Spearman's rank correlation showed that the diagnosis of chronic deciduitis was almost identical to the assessment of the severity of the inflammation. A regression analysis showed that the perception of severity (and hence chronic deciduitis) was influenced by the other 2 variables, extent and plasma cells. The results were shared with the pathologists, and 25 cases (excluding those with previous 6/6 consensus) were reevaluated. Concordance was now achieved in the 83% of those remaining cases. Using a threshold based on the severity and the extent of lymphocytes, and the presence of plasma cells, pathologists are able to diagnose chronic deciduitis with sufficient concordance to be of value in clinical correlation studies.

Morphometric analysis of preterm fetal pulmonary development in the sheep model of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) in humans carries high mortality/morbidity attributed to associated pulmonary hypoplasia. An understanding of the effects of CDH on fetal lung growth is important for development of successful treatments. This study aimed to quantitate structural differences between normal and CDH-affected preterm lamb lungs. We hypothesized that (a) pulmonary hypoplasia is present in preterm CDH-affected lungs; (b) the relative degree of pulmonary hypoplasia increases with gestation; and (c) the left upper lobe (LUL) is affected most. Fetal lambs were allocated to two groups. One group underwent surgery (72-74 days gestation) inducing CDH. Both groups (n = 7, n = 7) were delivered by cesarean section at 129 days (term: 145-149). Lungs were obtained at autopsy, were inflation-fixed, processed for histology, and morphometry was performed. Preterm lungs of CDH-affected lambs in comparison to those of normal lambs demonstrated a reduction in the following: lung weight (37.7 g vs. 116.3 g); lung weight:body weight (0.012 vs. 0.040); fixed lung volume (33.6 ml vs. 96.9 ml); gas-exchange surface area (4.56 m(2) vs. 13.70 m(2)); parenchyma:nonparenchyma (59:41 vs. 72:28); and parenchymal airspace:tissue (16:84 vs. 35:65). Non-parenchyma connective tissue was increased (58%), airspaces were more numerous (1077/mm(2)) and smaller (perimeter 76.6 microm), gas-exchange surface density (2394 cm(-1)) was greater and capillary loading (0.04 ml/m(2)) was reduced compared to preterm normal lung (49%; 778/mm(2); 108.7 microm; 2003 cm(-1), 0.11 ml/m(2), respectively). The LUL was affected most. These data quantitate pulmonary hypoplasia in preterm CDH-affected lambs. Comparisons with published data indicate increasing relative hypoplasia as gestation proceeds. Fetal interventions will affect lung development, depending on timing, with intervention still likely to be worthwhile during late gestation.

Drowning deaths in toddlers and preambulatory children in South Australia

Infants who are preambulatory and toddlers who have only just learned to walk have particular characteristics that give them a unique susceptibility to drowning in certain circumstances. A study of drowning deaths in 32 infants and children <2 years of age in South Australia over a 35-year period from March 1963 to February 1998 was undertaken. The age range was 3 to 24 months (average, 15.4 months), and there was a male:female ratio of 21:11. Drownings occurred in home swimming pools (N = 10); baths (N = 9); waterways (i.e., rivers, irrigation ditches, sea; N = 5); buckets, bins, sinks (N = 4); and fish ponds (N = 3). Details were lacking in one case. Two cases raised questions regarding the manner of death and the possibility of inflicted injury. Specific problems that occur in the assessment of infant drownings include the vulnerability of infants to accidental and nonaccidental drowning, the absence of autopsy findings in inflicted drowning, and the lack of independent witnesses to the fatal episodes. Although the numbers of childhood drownings have declined in recent years, specific situations that remain dangerous for infants include unsupervised bathing and access to swimming pools, fish ponds, and industrial buckets containing water. Complete submersion does not have to occur for drowning to take place.

Morphometric analysis of postnatal lung development in a marsupial: transmission electron microscopy

Postnatal lung development in the tammar wallaby was investigated using transmission electron microscopy and stereological morphometry. Volume densities of interstitial, epithelial and endothelial tissue and capillaries in the parenchymal septa were measured as were surface densities of the airspaces and gas exchange capillaries. Absolute changes in these parameters were related to body mass. Three phases of development were identified. During the ectothermic period, in the first 70 days after birth when the lung was in the terminal air sac phase, the most marked change was an increase in volume density of septal interstitium. The transitional period between ectothermy and endothermy, between 70 and 180 days after birth, corresponded to the alveolar phase and was characterised by accelerated increase in air space surface area. Maturation of the parenchymal septa and establishment of the mature capillary system occurred largely after 180 days when endothermy was established. The anatomical diffusion factor in the tammar wallaby adult is similar to that for eutherians.

Pathologic features of farm and tractor-related fatalities in children

A study of 15 childhood fatalities due to farm or tractor-related accidents demonstrated extensive injuries typified by crushing, evisceration, and amputation of limbs. Although these injuries are characteristic of industrial accidents in adults, such accidents do not commonly occur in children. However, the unique circumstance of the farm, which incorporates home and industrial environments, results in particularly severe patterns of injuries in accidental childhood deaths. A knowledge of the range of machines that are used and the environment of the farm facilitates assessment of the types of injuries that may be found at autopsy in cases of pediatric farm accident.

Morphometric analysis of postnatal lung development in the tammar wallaby: light microscopy

Postnatal growth of the lung in the tammar wallaby, Macropus eugenii, was investigated using morphometric techniques with light microscopy. Lung volume, parenchymal and non-parenchymal volume densities were measured. Volume densities of parenchymal airspace and tissue and non-parenchymal conducting airways and large blood vessels were determined. Lung volume and all the other parameters that were measured showed a biphasic increase in relation to increase in body mass. All parameters, with the exception of airway volume, increased relatively slowly in relation to increase in mass in the first 70 days after birth, when the pouch young are ectothermic. Between 70 and 180 days, during the period of transition from ectothermy to endothermy, the parameters increased more rapidly, suggesting accelerated lung growth in preparation for the extra metabolic demands associated with the establishment of thermoregulatory control in the pouch young. Specific lung volume in the adult tammar is lower than that of eutherians of equivalent mass, however, the parenchymal volume is relatively high.

Effect of antenatal tracheal occlusion on lung development in the sheep model of congenital diaphragmatic hernia: a morphometric analysis of pulmonary structure and maturity

The incidence of congenital diaphragmatic hernia (CDH) is 1:1,207-5,000, and the condition is associated with high mortality and morbidity, attributed principally to associated pulmonary hypoplasia. Repairing the diaphragmatic defect by antenatal surgery has high mortality, mainly due to premature labor. Antenatal tracheal occlusion, which is achievable by less invasive methods, stimulates lung growth (weight and DNA). However, its effectiveness in reversing structural and maturational abnormalities and its optimal timing requires further investigation. We hypothesized that (1) antenatal tracheal occlusion performed in the lamb model of congenital diaphragmatic hernia will stimulate lung growth and structural development and restore lung structure and maturity toward normal levels by term gestation; (2) effects will be detectable by morphometric measurements of the following parameters: lung volume, ratio of parenchyma to nonparenchyma, volume density of connective tissue within nonparenchyma, ratio of gas exchange tissue to airspace in parenchyma, gas exchange surface area, capillary loading, alveolar/airspace density and alveolar perimeter; (3) effects will be seen in all lobes of the lung; and (4) a greater effect will be observed when tracheal occlusion is performed early rather than late in gestation. Fourteen lambs underwent CDH creation at gestation day 72-74 followed by tracheal occlusion at day 101 (n = 7) or 129 (n = 7). They were delivered by Cesarean section at 143 days (term = 145-149). Lungs were obtained at autopsy, inflation fixed, divided into lobes, and sampled; morphometric analysis was performed. Comparisons were made with previously reported results from control lungs of normal lambs and lambs with untreated CDH. In comparison with untreated lungs, antenatal tracheal occlusion at both times resulted in increased volumes for total lung and lobes, increased volume density of parenchyma and of airspace within parenchyma, and increased gas exchange surface areas. Normal values for gas exchange surface area density, and alveolar density and perimeter were attained and the lungs appeared more mature than non-occluded lungs. Tracheal occlusion earlier in gestation produced a greater effect, achieving greater than normal values for lung volumes and volume densities, whereas the capillary loading value was similar to normal lung. Later occlusion achieved less than normal values for lung volumes and volume densities, with a reduced capillary loading value. We conclude that antenatal tracheal occlusion is capable of reversing structural total lung and lobar hypoplasia and immaturity caused by CDH as determined by morphometrically determined parameters. The effect is greater when tracheal occlusion is performed early rather than late in gestation. The results are encouraging for development of treatment methods for humans with antenatally diagnosed CDH.

Farm and tractor-related fatalities in children in South Australia

OBJECTIVE

To analyse the circumstances surrounding farm and tractor-related childhood fatalities in South Australia, to identify potentially dangerous situations and to delineate prevention strategies.

METHODS

A retrospective search of files was conducted at the Women's and Children's Hospital Department of Histopathology from 1981 to 1996, and the State Coroner's Office from 1988 to 1996.

RESULTS

Fifteen fatalities were identified comprising 11 boys and four girls (age range, 2 years 11 months to 13 years; average, 6 years). Activities prior to death included riding on a tractor/trailer (n=8); playing near a field grain storage bin (n=2); playing near machinery (n=2); sleeping in a car near a burn off (n=1); walking around a dam (n=1) and riding as a passenger on a motorbike (n=1). Causes of death included multiple skull fractures and cerebral damage (n=11), asphyxia (n=2), drowning (n=1) and incineration (n=1).

CONCLUSIONS

The most dangerous activity involved children riding unrestrained on tractors; falls resulted in extensive injuries from tractor rear wheels or towed machinery. Allowing children on farms to ride on tractors or machinery only if there is a safe seat with a restraining harness would substantially reduce the number of fatal farm-related childhood injuries in South Australia.

Morphometric estimate of gas-exchange tissue in the new-born tammar wallaby, Macropus eugenii

The lung of the new-born marsupial is at the terminal air sac stage of development. The maturational status of the lung of new-born tammar wallaby was assessed using established morphometric techniques and the results were compared with data from a morphometric study of the lung of the rat. Volume densities of the parenchyma and non-parenchyma, conducting airways and blood vessels, the relative volumes of airspace and tissue, the thickness and the composition of the septa differed between the two species. In addition the volume of capillaries and the surface area of the effective gas-exchange tissue was greater in the new-born rat than in the new-born tammar pouch young. The lung of the new-born tammar appears to be at an earlier phase of the terminal air sac stage than that of the new-born rat. Lung development up to birth appears to be commensurate to the metabolic needs of the organism at birth.

Morphometric analysis of pulmonary development in the sheep following creation of fetal diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) in humans is relatively common and associated with high mortality attributed mainly to pulmonary hypoplasia. Previous animal models have induced CDH late in gestation, in contrast to the human situation, and only limited morphometric analyses have been reported. We undertook early surgical creation of CDH in fetal lambs, days 72-74 of gestation (n = 8), with unoperated lambs (n = 8) as controls. At 143 days (term = 145-149) a cesarean section was performed and the lungs were obtained, inflation fixed, divided into lobes, and processed for morphometry. In the CDH group the total lung volumes (51.3 mL compared to 223.8 mL) and gas exchange surface areas (5.85 m2 versus 26.43 m2) were less than one quarter of control values. Capillary loading was reduced from 0.3 mL/m2 in controls to 0.12 mL/m2 in CDH and parenchymal volume reduced from 77% in controls to 57% in CDH. Within parenchyma, gas exchange tissue volume was increased in CDH (66%) compared with controls (50%). CDH lungs had primitive air sacs/alveoli that were smaller (perimeter 83 microns) and more numerous (1321 per mm2) than in controls (perimeter 132 microns, 504 per mm2). The left lung and left upper lobe were affected most. Induction of CDH in the lamb at this early age results in quantifiable, reproducible pulmonary hypoplasia from which comparisons can be made with the human condition.

Congenital diaphragmatic hernia: lung compliance after antenatal tracheal obstruction or surgical correction of the defect

Fetal lambs with diaphragmatic herniae (CDH) created surgically at 73 days' gestation were subjected to three different forms of intrauterine correction: silastic patch correction of the diaphragmatic defect plus an abdominal patch at 101 days gestation; an intrathoracic "silo" at 101 days; and a tracheal "plug" obstruction at 101 or 129 days. At 143 days' gestation (term 145-149 days), the lambs were delivered by caesarean section and ventilated for 30 min before undergoing respiratory compliance measurements. These results were compared to those of normal lambs and animals with uncorrected herniae. The total respiratory system compliance values in those groups undergoing corrections were remarkably similar: those with any form of correction had a significant improvement (P < 0.05) compared to those with herniae and no correction (patch = 1.57 = ± 0.182 ml/cm H2O; silo = 1.53 ± 0.179; plug at 101 days = 1.66 ± 0.311; plug at 129 days = 2.00 ± 0,175; without correction = 0.62 ± 0.073). None, however, reached the values of those with normal lungs: 2.72 ± 0.223 (P < 0.05). This improvement in compliance in all corrected groups suggests that fetal tracheal obstruction is as effective as the two more invasive forms of open fetal surgery carried out in this study and, as this procedure lends itself to surgery through a small uterine incision or "minimally invasive" surgery, it may be the procedure of choice to reduce the incidence of preterm labour for those human fetuses undergoing antenatal correction of a CDH.bb.

In vivo purging with high-dose cytarabine followed by high-dose chemoradiotherapy and reinfusion of unpurged bone marrow for adult acute myelogenous leukemia in first complete remission

PURPOSE

To evaluate in a prospective study the efficacy of autologous bone marrow transplantation (BMT) in adult patients with acute myelogenous leukemia (AML) in first remission, using a single course of high-dose Cytarabine (HD Ara-C) consolidation therapy as in vivo purging.

PATIENTS AND METHODS

Sixty consecutive adult patients with AML in first complete remission (CR) were treated with HD Ara-C consolidation therapy as a method of in vivo purging before marrow collection. High-dose therapy consisted of fractionated total-body irradiation (FTBI) 12 Gy, intravenous etoposide 60 mg/kg, and cyclophosphamide 75 mg/kg, followed by reinfusion of cryopreserved marrow.

RESULTS

Sixty patients underwent consolidation treatment with HD Ara-C with the intent to treat with autologous BMT. Sixteen patients were unable to proceed to autologous BMT (10 patients relapsed, one died of sepsis, one developed cerebellar toxicity, two had inadequate blood counts, and two refused). Forty-four patients underwent autologous BMT and have a median follow-up time of 37 months (range, 14.7 to 68.7) for patients who are alive with no relapse. The cumulative probability of disease-free survival (DFS) at 24 months in the intent-to-treat group is 49% (95% confidence interval [CI], 37% to 62%) and in those who actually underwent autologous BMT is 61% (95% CI, 46% to 74%). The probability of relapse was 44% (95% CI, 31% to 58%) and 33% (95% CI, 20% to 49%) for the intent-to-treat and autologous BMT patients, respectively.

CONCLUSION

This approach offers a relatively high DFS rate to adult patients with AML in first CR. The results of this study are similar to those achieved with allogeneic BMT.

Small bowel stricture due to vascular compromise: a late complication of Henoch-Schönlein purpura

Henoch-Schönlein purpura is a multisystem disorder of unknown etiology that primarily affects children. Gastrointestinal manifestations are common in the acute, active phase with 2 to 5% of patients developing significant lesions requiring surgical intervention. Late complications are unusual and infrequently documented. We report a case of chronic small bowel obstruction due to an ischemic stricture of the distal ileum presenting 3 months after an episode of Henoch-Schönlein purpura.

Anomalous coronary arteries: a multicenter pediatric autopsy study

Anomalous coronary arteries (ACAs) are a potential cause of myocardial ischemia resulting in arrhythmias, angina, infarction, and sudden death. We analyzed 7857 pediatric autopsy cases from four tertiary centers to gain an overall picture of the range and significance of ACAs within this pediatric autopsy population. The incidence of ACAs was 0.5%, with ectopic origin from the aorta (43%) being most frequent, followed by ACA arising from the pulmonary trunk (40%). The mean age at death was 2.2 years (4 h-14 years). ACAs were associated with other anomalies in 57% of cases, 43% of these being cardiac defects. Growth retardation was noted in 50% of the cases. Examination of the heart showed cardiomegaly in 92% of cases, which was marked (> 95 percentile) in 63%, but histologically apparent ischemic damage was seen in only 50% of cases. ACAs arising from the pulmonary trunk were associated with earlier death (1.4 years), more frequent cardiomegaly (100%), and more frequent myocardial scarring (92%) than other types of anomalies. Although the terminal presentation was sudden death in 45% of cases, ACAs associated with other cardiac defects presented mainly with problems related to the latter anomalies. The results highlight the need to examine coronary arteries carefully during the pediatric autopsy. Not only are the positions of the coronary artery ostia important, but also the variations in the angles of arterial take-off, initial courses through the aortic adventitia, subsequent courses, and presence of ostial ridges or membranes that may result in significant compromise of blood flow.

Paraproteinemic crystalloidal keratopathy: an ultrastructural study of two cases, including immunoelectron microscopy

The ultrastructural appearances of corneal crystalloidal deposits are described in two patients with an IgG-kappa paraproteinemia of uncertain pathogenesis. The crystalloids in one patient were overwhelmingly intracellular and were found mainly in stromal keratocytes, but also in basal corneal epithelial cells and the limbal vascular endothelium. Four types of crystalloid or immunoprotein-containing granules were recognizable in this case: 1) fibrillary crystalloids with a curvilinear filamentous substructure; 2) angulated geometric crystalloids that often had a linear filamentous substructure and transverse or oblique periodicity; 3) cordlike crystalloids; and 4) lysosomelike granules with amorphous contents. Immunoelectron microscopy demonstrated that all of these structures labeled for kappa-light chains, and rectangular type 2 crystalloids showed approximately a twofold greater concentration of the colloidal gold probe than the type 1 fibrillary crystalloids. The evidence suggested development of the crystalloids within lysosomes, with a progression from the granules containing amorphous material, through fibrillary crystalloids, to the geometric structures. The circumferential distribution of the corneal deposits, as well as the presence of vascular endothelial crystalloids and reduplication of external laminae around limbal blood vessels, suggests that the crystalloids originated predominantly or entirely from the blood, with transport of immunoprotein across damaged limbal microvasculature. The abnormal vasculature may also have contributed to corneal edema, which in turn may have exacerbated corneal opacification. The crystalloidal deposits in the other case were exclusively extracellular; they were located beneath and between corneal basal epithelial cells, and predominantly as a mantle around individual keratocytes. The crystalloids in this case consisted overwhelmingly of thick-walled tubules about 40 nm in diameter that labeled for both kappa-light chains and gamma chains with the colloidal gold immunoprobe. In addition, lucent vesicles within keratocytes were found only in sections labeled for kappa-light chains and were positive. The factors that might contribute to the formation of corneal crystalloidal deposits in immunoproliferative disorders are discussed, and include: 1) an inherent propensity for crystallization of some immunoglobulins or kappa-light chains, perhaps because of abnormal molecular structure; and 2) local factors in the cornea that might promote deposition and crystallization of immunoprotein, such as temperature, pH, the water content, and extracellular matrix components.

Carcinoma of the anus treated with primary radiation therapy and chemotherapy

Between 1983 to 1989, 24 patients with previously untreated carcinoma of the anal canal (less than 3 centimeters in five patients and more than 3 centimeters in 19 patients) were entered in a prospective nonrandomized protocol of primary radiotherapy (4,050-4,500 cGy days one to 28) and chemotherapy (10 milligrams per meter squared of mitomycin C, on day two and 1,000 milligrams of 5-fluorouracil per molar squared for days two to five and 28 to 32). Therapy was discontinued for two patients because of severe (grade 4) skin reactions. The remaining patients tolerated the regimen well, with the exception of two patients who had grade 3 hematologic toxicity and three patients with grade 3 to 4 complications of the gastrointestinal tract. All of the patients who completed the regimen had a complete clinical and pathologic response when restaged six weeks after completion of therapy. All patients with lesions of less than 3 centimeters and 13 of 19 patients with lesions greater than 3 centimeters have remained free of disease (median follow-up period of 41 months; median survival rate of 36 months). Before 1983, 19 patients underwent abdominal perineal resection as primary treatment for carcinoma of the anus. Only six of seven patients with lesions less than 3 centimeters and zero of the 12 patients with lesions equal or greater than 3 centimeters have remained alive and free of disease. Eighteen of 24 patients treated with chemotherapy and radiotherapy only have remained free of disease and have preserved anal function. These results are superior to those reported with primary surgical treatment and primary radiotherapy only.

Embryogenesis of enterocystomas-enteric duplication cysts of the tongue

Enteric duplication cysts of the tongue are unusual lesions that may be confused with dermoid cysts, hemangiomas, lingual thyroid remnants, ranulas, and cystic hygromas. Two cases of lingual enteric duplications are reported in a 5-year-old boy and a 4-month-old boy. In the first case the cyst was lined by gastric-type epithelium, and in the second by colonic-type epithelium. Theories of pathogenesis of enteric duplications include development from small epithelial inclusions trapped during fusion of primordial tissues, from incomplete coalescence of lacunas that form between epithelial cells of the solid core of the developing gut, from persistence of epithelial buds within the wall of the bowel, or from nests of trapped entodermal cells. However, each of these theories presents problems with respect to lingual enteric cysts, as possible trapping of epithelium by fusing primordia does not explain the presence of heterotopic mucosa, and the tongue does not develop in the same manner as the hollow viscera. It becomes apparent therefore that enteric duplication cysts are a heterogeneous group of lesions that share some morphologic features, but perhaps not the same pathogenesis.

Health quality of life and colorectal cancer

BACKGROUND

Quality of life associated with cancer and radiation treatment includes the dimensions of psychologic and physical well-being, nutrition concerns/side effects, and radiation treatment-related anxiety/adjustment. An understanding of the impact of colorectal cancer and radiation treatment on these aspects of health quality of life can be reached by comparing this diagnostic group to others undergoing similar treatment.

METHODS

Thirty-six patients with colorectal cancers, 41 with uterocervical cancers, 43 with genitourinary tumors, 13 with leukemia or bone metastasis, and 129 with head and neck cancers undergoing radiation therapy provided complete health quality of life index (QLI-RT) data during weeks 1 and 3 of treatment and at the first follow-up visit after treatment completion. The QLI-RT was found to be reliable and valid.

RESULTS

Those with colorectal cancer had similar QLI-RT summary scores as the other groups at the beginning of treatment and during the follow-up period. QLI-RT scores tended to range from 62 to 84 for the summary score and individual-item scores; this was a narrow span considering the QLI-RT uses a 0-100-mm linear analog-response scale. The exceptions were strength, which elicited scores in the 46-68 range and a couple of responses to worrying about radiation therapy. The largest change in QLI-RT score in relation to the treatment trajectory was 11 mm.

CONCLUSIONS

These findings tend to support the notion that patients with cancer try to maintain health quality of life at an acceptable level despite the occurrence of stressful negative events. Future research should explore the stable versus dynamic attributes of health quality of life to learn more about the factors that contribute to the adaptive process that maintains such quality of life at an acceptable level.

Anomalous coronary arteries arising from the aorta associated with sudden death in infancy and early childhood. An autopsy series

Anomalous coronary arteries arising from the aorta are a recognized cause of myocardial ischemia and sudden death. Death has been precipitated by exercise in most cases. We present the results of an autopsy study in which sudden and unexpected deaths associated with coronary anomalies were found in three children (less than 2 years of age). In two cases, death was not associated with exercise. In two case, the myocardium was morphologically normal, and in the third case, there was an extensive recent anterior myocardial infarct with a background of established fibrosis. Coronary artery anomalies may be easily overlooked in this age group because of small vessel size and difficulty in dissection; this is particularly so when there are normally placed ostia. One consequence of this is potential for confusion with sudden infant death syndrome.

Fraction size in external beam radiation therapy in the treatment of melanoma

RTOG 83-05 was a prospective randomized trial evaluating the effectiveness of high dose per fraction irradiation in the treatment of melanoma. Retrospective analysis suggested a dose response curve of melanoma to external beam irradiation as the dose per fraction is increased. RTOG 83-05 randomized patients with measureable lesions to 4 x 8.0 Gy in 21 days once weekly to 20 x 2.5 Gy in 26-28 days, 5 days a week. One hundred thirty-seven patients were randomized and 126 patients were evaluable: 62 patients in the 4 x 8.0 Gy arm and 64 patients in 200 x 2.5 Gy arm. Patient characteristics were essentially identical. Stratification was performed on lesions less than 5 cm or greater than or equal to 5 cm. The study was closed on May 31, 1988 when interim statistical analysis suggested that further accrual would not reveal a difference between arms. Response rate overall was complete remission 23.8%, partial remission 34.9%. The 4 x 8.0 Gy arm exhibited a complete remission of 24.2% and partial remission of 35.5%. The 20 x 2.5 Gy arm exhibited a complete remission of 23.4% and partial remission of 34.4%. There was no difference between arms.

Regional cycles of perfusion and non-perfusion in the lung of the term fetal rabbit

The spatial distribution of pulmonary blood flow and its change over time was investigated in term fetal rabbits, using the plasma tracer fluorescein-isothiocyanate-labeled bovine serum albumin (FITC-BSA). A tracer bolus was injected intravenously and allowed to circulate in vivo for increasing periods of time (2-30 minutes) prior to arrest of the circulation and tissue preparation. Initially, fluorescence was present in the vasculature of 43% of lung parenchymal tissue, disposed as discrete regions or "lobules." Interspersed regions of lung tissue received no tracer inflow. With increasing tracer circulation times (10, 20, and 30 minutes), a greater percentage of lung cross-sectional area contained vessels exhibiting tracer fluorescence (64, 96, and 100%, respectively). In the fetal lung, a high pulmonary vascular resistance (PVR) is maintained. Our studies indicate that, at any given moment, fetal pulmonary blood flow is distributed only to a proportion of discrete lung "lobules," while interspersed "lobules" receive no flow at all. The "lobules" alternate between these "high" and "low" vascular resistance states with a periodicity of approximately 35 minutes, comprising 22 minutes of non-perfusion followed by 13 minutes of perfusion. This circulatory pattern permits both the maintenance of high PVR and uniform lung development. Further, by directing flow to only a portion of the vasculature, greater microvascular flow rates are achieved and hence the risk of blood sludging and stasis is reduced. Recruitment of these "non-perfused" regions at birth could thus produce a significant reduction in PVR.

Changes in the spatial distribution of pulmonary blood flow during the fetal/neonatal transition: an in vivo study in the rabbit

The spatial distribution of pulmonary blood flow was investigated in term fetal and neonatal rabbit littermates, using the plasma tracer fluorescein-isothiocyanate bovine serum albumin (FITC-BSA). A tracer bolus was injected intravenously and allowed 2 minutes to circulate in vivo, prior to arrest of the circulation and tissue preparation. In the fetus, fluorescence was only present in 43% of the lung volume, contained within discrete regions of "lobules." Some 57% of lung volume received no tracer inflow at all (during 2 min). In the fetal lung, the size of the potential airspaces in the perfused regions was 1.5 times larger than those in the nonperfused regions. In the fetus, a high pulmonary vascular resistance (PVR) is maintained. It is generally accepted that pulmonary blood flow in the fetus is evenly distributed to the entire vascular bed. Our results show that fetal pulmonary blood flow is distributed to discrete "lobules," while (over a 2 min period) the majority of "lobules" receive no flow at all. Thus, by directing flow to a lesser proportion of the vasculature, greater flow rates are achieved, and the risk of blood sludging and stasis is reduced. Alternation of perfusion with nonperfusion in each "lobule," perhaps regulated by the lobular arterioles, would permit both maintenance of the high fetal PVR and uniform lung development. In the neonatal lung, the plasma tracer was distributed uniformly to the entire vascular bed. This suggests that some of the reduction in PVR at birth is due to recruiting 50-60% of lung vasculature.

The effect of boron supply on the growth and seed production of subterranean clover (Trifolium subterraneum L.)

There has been little research on the boron (B) status of subterranean clover, despite strong indications of deficiency of B in southern Australia where clover decline has been reported. This paper describes glasshouse experiments to vary the level of B supply to clover grown on soils low in B. On a soil farmed in a cereal clover rotation, herbage yields of clover increased by 25% with applied B, but seed yields, negligible without B, increased 21-fold. On two other acid soils, from pastures, there were also large responses to B in seed yield (1.5- and 5.1-fold respectively); liming increased the responses (8- and 55.2-fold). However, herbage production was less responsive to B (25% and 1.7-fold with liming); on the unlimed soils, application of B depressed yield (- 1 and -21%). This is attributed to there being enough B to sustain herbage growth, but inadequate for seed formation. These results show that herbage yield, conventionally employed in the past, is not a satisfactory index of B status for total performance in subterranean clover. The response to B in seed yield was associated with increases in: numbers of seed set (75% to 22.6-fold, depending on the particular combination of soil and liming); size of seed (10% to 1.2-fold); proportion of buried seed (20%-70%). It is suggested that these favour establishment and persistence of clover and that clover decline may well involve deficiency of B. It was shown that concentration of B in the plant does not necessarily relate predictably to yield of herbage and that reduction in seed yield may not be heralded by foliar symptoms, since seed requirement exceeds that of herbage.

Quality of Life Index for Patients with Cancer

The purpose of this study was to develop an instrument for measuring the quality of life of cancer patients. Quality of life was measured with 14 linear analogue scale items concerning general physical condition, normal activities, and personal attitudes on general quality of life. The tool was tested with four subject groups: oncology outpatients receiving chemotherapy (43) or radiation therapy (39), oncology inpatients receiving chemotherapy (48), and nonpatient volunteers (48). Test-retest reliability coefficients for these samples ranged from r = .11 to .97, with 52 of the 56 possible r's greater than .60, p less than .01; internal consistency was .88, p less than .01. Construct and discriminant validity were indicated, while concurrent validity between quality of life scores and physician estimates of Karnofsky ratings, prognosis, and quality of life were poor.