Efficacy and safety of nadroparin in the treatment of pregnant women with antiphospholipid syndrome: a prospective cohort study

The optimal therapeutic management of patients with antiphospholipid syndrome (APS) during pregnancy is debatable. In the present prospective cohort study the use of a low molecular weight heparin (LMWH) (nadroparin), administered alone twice daily in 30 pregnant women who were diagnosed with APS on the basis of the current classification criteria, is evaluated. Dosage was adjusted according to anti-Xa levels in the patients as the pregnancies progressed. Three women, in whom an important gradual fall in platelet count in the first trimester did not respond to increased nadroparin doses, were shifted to a second-line treatment protocol. Fetal loss occurred in two of the 27 remaining women (7.40%), while 25 (92.59%) delivered 25 live infants, between the 32nd and 40th weeks of gestation. No fetal problems were registered during pregnancies, while maternal complications occurred in two of the 25 patients (8%). Moreover, there were no thrombotic events in any of the women during the study. Patient compliance was good and only minor side-effects were reported. The results of this study indicate that nadroparin alone is useful and safe in the management of pregnant patients with APS. However, in consideration of the good pregnancy outcome obtained in patients with only pregnancy morbidity when heparin and aspirin were used together, other studies comparing nadroparin twice daily with once daily plus Aspirin would be useful to ascertain which is more effective in these patients.

Ovarian tumors secreting insulin

Combined ovarian germ cell and neuroendocrine tumors are rare. Only few cases of hyperinsulinism due to ovarian ectopic secretion have been hypothesized in the literature. An ovarian tumor was diagnosed in a 76-year-old woman, referred to our department for recurrent hypoglycemia with hyperinsulinism. In vivo tests, in particular fasting test, rapid calcium infusion test, and Octreotide test were performed. Ectopic hyperinsulinemic hypoglycemia was demonstrated in vivo and hypoglycemia disappeared after hysteroadnexectomy. Histological exam revealed an ovarian germ cell tumor with neuroendocrine and Yolk sac differentiation, while immunostaining showed insulin positivity in neuroendocrine cells. A cell culture was obtained by tumoral cells, testing Everolimus, and Pasireotide. Insulin was detected in cell culture medium and Everolimus and Pasireotide demonstrated their potentiality in reducing insulin secretion, more than controlling cell viability. Nine cases of hyperinsulinism due to ovarian ectopic secretion reported in literature have been reviewed. These data confirm the ovarian tissue potentiality to induce hyperinsulinemic hypoglycemic syndrome after neoplastic transformation.

Sensorineural hearing loss in very low birth weight infants with histological chorioamnionitis

OBJECTIVE

Histological chorioamnionitis (HCAM) has been associated with inflammatory diseases of preterm infants. Recently we have observed that it increased the risk of speech delay and hearing loss. So the aim of this study was to evaluate the relationship between sensorineural hearing loss (SNHL) of VLBW infants and HCAM.

METHODS

We performed an observational study on VLBW infants admitted to the NICU of Padua. Each patient with HCAM was matched with one control without HCAM. All infants underwent hearing screening before discharge by means of automated transient-evoked otoacustic emissions and automated auditory brainstem responses, which were repeated at 3 and 6 months of age with tympanometry measurement. Incidence of SNHL at 6 months of age was compared in the 2 groups and risk factors for hearing loss were studied.

RESULTS

Two of 77 (2.6%) newborns with HCAM e 6/73 (8.2%) without it presented SNHL at 6 months of corrected age (p = 0.16). Multivariable logistic regression analysis identified surgical ligation of patent ductus arteriosus (PDA) as independent predictors of SNHL (OR: 5.75, 95% CI 1.34-24.84, p = 0.02), whereas the effect of HCAM on SNHL was only near to statistical significance level.

CONCLUSIONS

Surgical ligation of PDA is associated with an increased risk of SNHL in VLBW infants, regardless of HCAM.

Gonadal function in males with autoimmune Addison's disease and autoantibodies to steroidogenic enzymes

Steroidogenic enzyme autoantibodies (SEAbs) are frequently present and are markers of autoimmune premature ovarian failure (POF) in females with autoimmune Addison's disease (AAD). The prevalence and significance of SEAbs in males with AAD have not yet been defined. We studied the prevalence of SEAbs in a large cohort of males with AAD and assessed the relationship between SEAbs positivity and testicular function. A total of 154 males with AAD (mean age 34 years) were studied. SEAbs included autoantibodies to steroid-producing cells (StCA), detected by immunofluorescence, and steroid 17α-hydroxylase (17α-OHAbs) and side chain cleavage enzyme (SCCAbs) measured by immunoprecipitation assays. Gonadal function was evaluated by measuring follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TT), sex hormone-binding globulin (SHGB), anti-müllerian hormone (AMH) and inhibin-B (I-B). Twenty-six males, 10 SEAbs((+)) and 16 SEAbs((-)), were followed-up for a mean period of 7·6 years to assess the behaviour of SEAbs and testicular function. SEAbs were found in 24·7% of males with AAD, with the highest frequency in patients with autoimmune polyendocrine syndrome type 1 (APS-1). The levels of reproductive hormones in 30 SEAbs((+)) males were in the normal range according to age and were not significantly different compared to 55 SEAbs((-)) males (P > 0·05). During follow-up, both SEAbs((+)) and SEAbs((-)) patients maintained normal testicular function. SEAbs were found with high frequency in males with AAD; however, they were not associated with testicular failure. This study suggests that the diagnostic value of SEAbs in males with AAD differs compared to females, and this may be related to the immunoprivileged status of the testis.

Programmed cell death 4 and microRNA 21 inverse expression is maintained in cells and exosomes from ovarian serous carcinoma effusions

BACKGROUND

Ovarian serous carcinoma (OSC) is a fatal gynecologic malignancy usually presenting with bilateral localization and malignant peritoneal effusion. Programmed cell death 4 (PDCD4) is a tumor suppressor gene whose expression is directly controlled by microRNA-21 (miR-21). Exosomes are small cell-derived vesicles that participate in intercellular communication, delivering their cargo of molecules to specific cells. Exosomes are involved in several physiological and pathological processes including oncogenesis, immunomodulation, angiogenesis, and metastasis. The current study analyzed the expression of PDCD4 and miR-21 in resected OSC specimens and in cells and exosomes from OSC peritoneal effusions.

METHODS

PDCD4 was immunohistochemically examined in 14 normal ovaries, 14 serous cystadenoma (CA), and 14 OSC cases. Quantitative reverse transcriptase-polymerase chain reaction analysis of PDCD4 and miR-21 expression was performed in CA and OSC cases and in cells and exosomes obtained from 10 OSC and 10 nonneoplastic peritoneal effusions. miR-21 was also evaluated by in situ hybridization.

RESULTS

Immunohistochemistry demonstrated a gradual PDCD4 loss from normal ovaries to CA and OSC specimens. Quantitative reverse transcriptase-polymerase chain reaction displayed higher PDCD4 messenger RNA levels in CA specimens compared with OSC cases and highlighted miR-21 overexpression in OSC specimens. In situ hybridization detected miR-21 only in OSC cells. This PDCD4 and miR-21 inverse expression was also noted in cells and exosomes from OSC peritoneal effusions compared with nonneoplastic effusions.

CONCLUSIONS

PDCD4 and miR-21 are involved in OSC oncogenesis. The transfer of miR-21 by exosomes could promote oncogenic transformation in target cells distant from the primary tumor without direct colonization by cancer cells and could be used as a diagnostic tool.

An epidemiological study investigating the relationship between chorangioma and infantile hemangioma

OBJECTIVES

This study aimed to verify whether the infantile hemangioma (IH) incidence in children whose placentas showed a chorangioma is higher than in the general population, thus addressing the hypothesized relationship between chorangioma and IH.

METHODS

All chorangioma diagnoses by the 1st Service of Pathology, University of Padova in 2004-2010, based on the analysis of placentas sent by the Department of Gynecological Sciences and Human Reproduction (University of Padova), were identified. Demographic, anamnestic and clinical data were collected from the mothers and newborns; mothers and pediatricians were interviewed by telephone within 1 year after birth to verify if any IH appeared. The incidence rates of IH and other adverse events (IUGR, preterm delivery, cesarean section, stillbirth) were compared with national and regional data, when available, or with estimates from the scientific literature.

RESULTS

Thirty-eight chorangioma diagnoses were found. Of 33 infants born with a placenta affected by chorangioma, 18 infants had IH. The IH incidence recorded in our series (55%) was significantly higher than that recorded in national and regional surveys and in the scientific literature. Similar findings have been observed for the incidence of stillbirth, preterm birth and low birth weight incidence.

CONCLUSIONS

The IH incidence observed in our series appears to be significantly higher than that recorded among the general population, suggesting that an association between placental chorangioma and IH could exist which should be further verified in prospective studies.

Fetal placental inflammation is associated with poor neonatal growth of preterm infants: a case-control study

OBJECTIVE

To determine whether there is an association between histological chorioamnionitis (HCA) and postnatal growth of preterm infants in the neonatal period.

METHOD

This case-control study is part of a larger prospective histological study on placentas performed in all deliveries prior to 32 weeks of gestation. Eligible cases involved all placentas with a diagnosis of HCA. Control subjects were those without HCA, matched 1:1 with case subjects according to gestational age (±1 week). Placental inflammatory status and serial weight gain were analyzed for all infants during the first four postnatal weeks. Based on placental inflammation extension, HCA was defined as maternal HCA (MHCA) or fetal HCA (FHCA).

RESULTS

Of the 320 mother-infant pairs, 71 (22.1%) presented with HCA (27 MHCA and 44 FHCA). Decreases in weight gain at 21 and 28 days were associated with the presence of FHCA (β coefficient ± SE = -4.40 ± 2.21, p = 0.05 and -6.92 ± 2.96, p = 0.02, respectively), whereas no significant differences were found between MHCA and no-HCA groups. FHCA and MHCA were not identified as risk factors of weekly weight gain, after adjusting for possible confounders (maternal ethnicity, parity, smoking during pregnancy, infant gender, IUGR status, SGA status, antenatal steroids, total fluid intake, late-onset sepsis, BPD).

CONCLUSIONS

We found an association between fetal placental inflammation and poor neonatal growth but we were not able to identify a specific week wherein weight gain could be mostly affected. Placental findings may be used to identify preterm infants at risk of postnatal growth failure.

Relationship between the neonatal white blood cell count and histologic chorioamnionitis in preterm newborns

OBJECTIVE

The aim was to examine the relationship between neonatal white blood cell (WBC) count and the diagnosis of histologic chorioamnionitis (HCA).

DESIGN

We measured WBC, a widely used marker of inflammation, to evaluate whether the values at birth were associated with HCA.

SETTING

NICU, Department of Pediatrics of Padua University, Padua, Italy.

SUBJECTS

WBC count was evaluated in 71 preterm neonates (<32 weeks of gestation) with HCA and in a control group without HCA on day 1, 3, and 6 after delivery. Logistic regression analysis and diagnostic accuracy analysis were used to assess the association between WBC counts and HCA.

MAIN RESULTS

WBC levels were significantly higher in infants with HCA than in those without HCA (Median IQR, WBC (x10(9)/l): day 1, 13.2 (6.2-21.8) vs 8.1 (6-11.4), p < 0.001; day 3, 17.4 (11.4-26.9) vs 6.3 (5.2-8.3), p < 0.001; day 6, 18.4 (11.1-31) vs 6.5 (4.4-9), p < 0.0001). The neonatal WBC count on the third day of life was the most sensitive parameter associated with HCA (sensitivity: 0.80; specificity: 0.88). The cut-off value based on the ROC curve was 10 (x10(9)/l).

CONCLUSIONS

WBC count in the third day of life is strongly associated with HCA.

In vitro model for IgE mediated food allergy

BACKGROUND

In intestinal food allergy, the non-specificity of gastrointestinal symptoms and the limited access to the reacting organ are the reasons for the limited understanding of the pathophysiology of this disease and the difficulties in establishing an appropriate diagnosis in the individual patient.

OBJECTIVE

To develop an in vitro model reproducing pathophysiological mechanisms of IgE mediated food allergy.

METHODS

Distal duodenum biopsies of nine patients with food allergy and 10 control subjects were cultured for 3 h with medium alone and with 1 mg/ml of peptic-tryptic digest of wheat gliadin, wheat albumins, and apple proteins. Each biopsy was used for conventional histological examination and for immunohistochemical detection of IgE-positive cells. We have also analyzed the expression of tight junction proteins, occludin, claudin-1, and ZO-1 by immunoconfocal microscopy. Histamine and tryptase release were measured in the culture medium and collected at 0, 30 min, and 3 h of culture using an enzyme and radio immunoassay, respectively.

RESULTS

Exposure of small intestinal biopsy specimens of patients with food allergy to food allergens led to a significative increase of IgE-positive cells with a significative increase of histamine and tryptase release and an altered expression of tight junction proteins. No differences were found in intestinal biopsies of controls, cultured with or without food antigens.

CONCLUSIONS

Small intestinal organ culture is a functional model of food allergy and could be considered as an in vitro oral food challenge, with evident reduction of costs and risks for the patients.

Proximal-type epithelioid sarcoma of the mons pubis: report of a case

INTRODUCTION

Proximal-type epithelioid sarcoma (PES) represents an extremely rare and aggressive form of soft tissue neoplasm, typically presenting as a painless subcutaneous nodule in the trunk often located in the genital area.

CASE REPORT

A 46-year-old female was subjected to the excision of a growing soft tissue mass in the mons pubis that, at histology, was identified as PES. The tumor showed an extreme aggressiveness involving subsequently adjoining structures and lymph nodes despite subsequent wide surgical resections during the following months.

DISCUSSION

Gynecologists should pay careful attention to all soft tissue masses of the perineal area or external genitalia. It is important to know the possible genital localization of PES which, although rare, is an aggressive high-grade soft tissue tumor with a deceitful behavior, poorly sensitive to chemotherapy and radiotherapy. Surgery, though wide and demolitive, often fails to obtain the necessary radicality.

Umbilical arterial necrotic vasculopathy associated with fetal ascites

Immune and nonimmune neonatal ascites may be part of hydrops fetalis or may be an isolated finding. However, a significant percentage of nonimmune ascites do not have an identifiable pathogenesis and are considered idiopathic. We report a case of fetal ascites and umbilical arterial necrotic vasculopathy, an association not previously described.

Neurodevelopmental outcome in preterm histological chorioamnionitis

The role of histological chorioamnionitis in neonatal neurological outcome is not yet fully understood. The present study aimed to assess the neurodevelopmental outcome of preterm babies born after pregnancy complicated by histological chorioamnionitis. Clinical data were prospectively collected for consecutive premature neonates born before 32 weeks of gestation, admitted to Neonatal Intensive Care Unit of Padua University from January 1998 to December 2001. Placental histology was performed. Outcome at 18 months of corrected age was evaluated by a standardized postal parental questionnaire. Among 104 placentas examined, 41 (39.4%) were diagnosed with histological chorioamnionitis. Reply to the postal questionnaire was available from 76.1% of the families. The relative risk of disability in vision, hearing, speech and motor development was higher in the histological chorioamnionitis than in the non-histological chorioamnionitis group, with statistical significance in speech delay (relative risk 2.37; 95% confidence interval: 1.33-4.22) and hearing loss (relative risk 2.76; 95% confidence interval:1.64-4,64). To our knowledge this is the first report suggesting preterm histological chorioamnionitis as a possible risk factor for hearing loss and speech delay.

Histological inflammatory responses in the placenta and early neonatal brain injury

We investigated the relationship between the severity of histological inflammatory responses in the placenta, chorionic plate, and umbilical cord in conjunction with the intraventricular hemorrhage (IVH) risk in premature infants. Clinical data were prospectively collected for 287 consecutive premature neonates born before 32 completed weeks of gestation and admitted to the level III neonatal intensive care unit of the Department of Pediatrics at Padua University from January 1999 to December 2004. Placental histology for histological chorioamnionitis (HCA) was graded and scored according to Redline and others. The diagnosis of IVH (grades I-IV) was graded according to Volpe's classification. Among the placentas of the 287 preterm examined infants, 68 (23.6%) were diagnosed with acute HCA. Overall incidence of IVH was 11.8%. Of 68 preterm neonates with HCA, 11 developed IVH (16.1%). Maternal HCA at the higher grades and stages increased the risk of IVH: 7 (64%) of the 11 preterm infants with maternal HCA grade 3 developed IVH (RR; 95% CI 2.05; 1.1-3.6) and 8 (73%) of the 11 preterm neonates with stage 3 developed IVH (RR; 95% CI 1.59; 1.0-2.5). Conversely, fetal inflammation was not associated with an increased risk of IVH. In conclusion, the IVH risk in preterm infants at less than 32 gestation weeks is significantly associated with severe grade and stage maternal HCA inflammatory scores.

Celiac disease in North Italian patients with autoimmune thyroid diseases

BACKGROUND

Patients with autoimmune thyroid diseases (AITDs) are prone to develop other autoimmune manifestations and to display autoimmune polyendocrine syndromes. An increased prevalence of celiac disease (CD) was demonstrated in adult European and Italian patients with AITDs; conversely, an increased prevalence of AITDs was demonstrated in patients with CD. An IgA deficiency is the most frequent immunodeficiency in humans and, in general, high frequency of this disorder was demonstrated in those with autoimmune diseases.

AIM

To define the prevalence of both CD and IgA deficiency in North Italian patients with AITDs.

METHODS

276 Italian patients with AITD were enrolled (mean age 42.6 years range 12-89, 186 of whom had chronic thyroiditis and 90 had Graves' disease). The tissue transglutaminase autoantibodies of the IgA class (IgA-tTGAbs) were evaluated using an ELISA method in these patients. Furthermore, the serological levels of the IgA were determined.

RESULTS

Five of the patients (1.8%) were affected by previously diagnosed CD and were on a gluten-free diet. Ten out of the remaining 271 patients (3.6%) were found to be positive for celiac-related autoantibodies. All of these patients agreed to undergo endoscopy and duodenal biopsies and silent CD was found in 5 of them but 5 had not histopathological signs of CD. CD (clinical, silent or latent) was present in 15/276 (5.4%) of the North Italian patients with AITD; this prevalence is significantly higher with respect to the general population (p < 0.00001). The genetic pattern of the 10 patients with both AITDs and CD was characterized by the presence of DQ2 in 8 patients and DQ8 in 2. An IgA deficiency was present in 2/276 of the patients (0.72%).

CONCLUSIONS

CD is significantly increased in patients with thyroid autoimmune disorders for this reason it is important to screen for CD in patients with AITDs.

Lack of intestinal mucosal toxicity of Triticum monococcum in celiac disease patients

OBJECTIVE

The treatment of celiac disease is based on lifelong withdrawal of foods containing gluten. Unfortunately, compliance with a gluten-free diet has proved poor in many patients (mainly due to its low palatability), emphasizing the need for cereal varieties that are not toxic for celiac patients. In evolutionary terms, Triticum monococcum is the oldest and most primitive cultivated wheat. The aim of this study was to evaluate the toxicity of T. monococcum on small intestinal mucosa, using an in vitro organ culture system.

MATERIAL AND METHODS

Distal duodenum biopsies of 12 treated celiac patients and 17 control subjects were cultured for 24 h with T. aestivum (bread) gliadin (1 mg/ml) or with T. monococcum gliadin (1 mg/ml). Biopsies cultured with medium alone served as controls. Each biopsy was used for conventional histological examination and for immunohistochemical detection of CD3 + intraepithelial lymphocytes (IELs) and HLA-DR. Secreted cytokine protein interferon-gamma (IFN-gamma) was measured in the culture supernatant using an enzyme-linked immunoadsorbent assay.

RESULTS

Significant morphological changes, HLA-DR overexpression in the crypt epithelium and an increased number of CD3 + IELs, found after bread gliadin exposure, were not observed in celiac biopsies cultured with T. monococcum gliadin. In contrast, with bread gliadin, there was no significant IFN-gamma response after culture with monococcum gliadin. Similarly, biopsies from normal controls did not respond to bread or monococcum gliadin stimulation.

CONCLUSIONS

These data show a lack of toxicity of T. monococcum gliadin in an in vitro organ culture system, suggesting new dietary opportunities for celiac patients.

An immunohistochemical study of morules in endometrioid lesions of the female genital tract: CD10 is a characteristic marker of morular metaplasia

PURPOSE

To analyze immunohistochemically morules in endometrioid lesions to show that CD10 is a sensitive marker for morular metaplasia.

EXPERIMENTAL DESIGN

Immunohistochemical analysis of 53 instances of morular metaplasia comprising 1 cyclic endometrium and 52 endometrioid lesions associated with focal glandular complexity corresponding to 9 polyps, 4 atypical polypoid adenomyomas, 24 complex endometrial hyperplasias (18 with and 6 without atypia), 12 grade 1 endometrioid adenocarcinomas in early clinical stages of both uterus and ovary, and three ovarian adenofibromas. Immunohistochemistry in paraffin sections was done for CD10, beta-catenin, estrogen and progesterone receptors, and cytokeratins 5-6, 7, 8, 13, 18, 19, 20, and 34beta-E12.

RESULTS

Morules were negative for estrogen and progesterone receptors and had beta-catenin-positive nuclei. Cytokeratins 8, 18, 19 were positive; cytokeratins 7 and 20 were negative; and cytokeratins 5-6, 13, and 34beta-E12 were weakly positive. All cases revealed strongly positive membranous CD10 staining in morules, which was absent in glands. CD10 positivity allowed easy identification of morules at low power in various types of surgical specimens and in curettings. CD10 also highlighted early morular metaplasia in glandular epithelium. In cases associated with squamous, keratinizing metaplasia, CD10 discriminated between both types of metaplasia.

CONCLUSIONS

CD10 staining represents a useful marker of morules in endometrioid neoplasms of the female genital tract, permitting identification of lesions usually associated with an attenuated malignancy. Considering the immunohistochemical and genetic similarities of morules in tumors of different organs, it is likely that this marker may be also useful to diagnose morular metaplasia in similar neoplasms of extragenital locations.

Celiac disease in North Italian patients with autoimmune Addison's disease

OBJECTIVE

Patients with autoimmune Addison's disease (AAD) are prone to develop other autoimmune manifestations. An increased prevalence of celiac disease (CD) has recently been demonstrated in Northern European patients with AAD. IgA deficiency is the most frequent type of immunodeficiency among humans and is present in about one in every 600 individuals in the population. IgA deficiency is frequent in patients with other autoimmune diseases, but data concerning AAD are still unavailable.

DESIGN

The aim was to define the prevalence of CD and of IgA deficiency in a group of Italian patients with AAD.

METHODS

One hundred and nine patients with AAD were enrolled and examined for tissue transglutaminase autoantibodies of the IgA class, circulating levels of IgA and adrenal cortex antibodies.

RESULTS

Two (1.8%) of the patients were affected by already diagnosed CD and were already on a gluten-free diet. Out of the remaining 107 patients, four (3.7%) were found to be positive for IgA antibodies to human tissue transglutaminase. Three of the four patients who were positive for tissue transglutaminase autoantibodies agreed to undergo endoscopy and duodenal biopsies and, in one, a latent form of CD was identified. The clinical, silent or latent form of CD was present in six out of 109 (5.4%). This prevalence was significantly higher (P = 0.0001) than that reported for the Northern Italian population which was equal to 0.063%. Specifically, CD was present in 12.5% of the autoimmune polyglandular syndrome (APS) type 1 cases, in four out of 60 (6.7%) of the APS type 2 cases and in one out of 40 (2.5%) of the isolated AAD cases. IgA deficiency was present in two out of 109 patients (1.8%), all of whom had normal IgG anti-gliadin. Autoantibodies to the adrenal cortex were detected in 81 out of 109 patients (74.3%).

CONCLUSIONS

In patients with AAD there is a high prevalence of both CD and IgA deficiency. Consequently, it is important to screen for CD with tissue transglutaminase autoantibodies of the IgA class and for IgA levels.

Histological chorioamnionitis and neonatal leukemoid reaction in low-birth-weight infants

We investigated whether histological chorioamnionitis (HCA) is a risk factor predisposing to leukemoid reaction (LR) and whether LR is associated with the preterm parturition syndrome and the systemic fetal inflammation response syndrome. A prospective histological study on placentas was performed in preterm infants (<or=32(+6) weeks' gestation) admitted to level III neonatal intensive care unit of Padua University from January 1998 to December 2003. Development of LR was related to evidence of HCA. Among the placentas of the 223 preterm examined infants, 61 (27%) were diagnosed with HCA. Overall incidence of LR was 5.3%. Of 61 preterm neonates with HCA, 8 (13%) developed LR; moreover, 4 (2%) of 162 preterm infants without HCA developed LR (odds ratio = 7.4). Neonates with both LR and HCA differ from neonates with LR and without HCA in occurrence of prolonged rupture of membranes (62.5% versus 0%, P < .01), mode of delivery (37.5% versus 100% cesarean delivery, P < .01), gestational age (26 +/- 1.6 versus 29.7 +/- 1.7 gestational weeks, P < .01), and bronchopulmonary dysplasia incidence (63% versus 25%, P < .01). Histological chorioamnionitis placental findings increase the risk for neonatal LR. The LR in low-birth-weight neonates with HCA is significantly associated with earlier delivery and bronchopulmonary dysplasia. Pathogenetic mechanisms of neonatal LR in low-birth-weight infants without HCA remain undefined.

Endometrial cancer: asymptomatic endometrial findings. Characteristics of postmenopausal endometrial cancer

Endometrial cancer affects patients at every age, however it occurs more frequently in menopause (> 50) and in postmenopause (> 70). The most frequent symptoms are bleeding and vaginal discharge. When hematometra or pyometra is present the patient may feel pain. In some cases endometrial adenocarcinoma is asymptomatic and the diagnosis is casually made during ultrasound examination or by histological examination of a uterus surgically removed for other indications. In these cases the most frequent findings are polyps and abnormally increased thickness of the endometrial mucosa. In postmenopause polyps and abnormal endometrial thickness are usually limited to a small area and surrounded by atrophic mucosa. Higher incidence rates of endometrial cancer were correlated with polyps and an increased number of serous type tumors were identified in the > 65-year age group. Endometrial carcinoma may be estrogen correlated or non-estrogen associated. Patients in postmenopause are often affected by non-estrogen correlated endometrial carcinoma. According to Kurman and other authors the first type of endometrial adenocarcinoma (estrogen correlated) is characterized by low-grade malignancy. On the contrary, non-estrogen correlated neoplasia is more aggressive. In our case series including 102 women aged > 70 years with endometrial carcinoma we found that survival was correlated with stage and grading - early stages were the most frequent and the grade increased with stage. In fact all the patients with relapses had grade 2 or 3 adenocarcinomas. Thirty-one patients > 70 years (30.69%) had a non-endometrioid type of cancer.

Obesity Reduces the Expression of GLUT4 in the Endometrium of Normoinsulinemic Women Affected by the Polycystic Ovary Syndrome

GLUT4 is the most important glucose transporter in insulin-dependent tissues. A decrease of its expression by the adipocytes was reported in polycystic ovary syndrome (PCOS), regardless of obesity and glucose tolerance. In PCOS, abnormal menstrual cycles, abnormal insulin secretory patterns, and obesity, which are risk factors for endometrial diseases, frequently coexist. The endometrial effects of insulin are direct through specific insulin receptors. However, it is unknown whether the endometrium expresses GLUT4 and can be considered an insulin-regulated tissue. In this study, we investigated this question, and we investigated whether obesity modulates this expression in PCOS normoinsulinemic patients. We assayed GLUT4 in the endometrial samples from 18 normoinsulinemic PCOS patients and 9 controls in the advanced follicular phase of the cycle; 10 patients were lean and 8 obese, and all were aged between 23 and 32 years. Most tissue was immediately frozen for RT-PCR; some tissue was saved for histology and immunohistochemistry. GLUT4 mRNA expression was measured in three samples for every patient and expressed as mean +/- SE of an arbitrary unit. In obese PCOS subjects, endometrial GLUT4 expression was significantly lower than in the lean ones (24.0 +/- 6.8 vs. 65.2 +/- 24.4; P < 0.005) and the controls (53.2 +/- 10.7). Lean PCOS and control subjects showed similar values. GLUT4 immunostaining was strong in the epithelial and absent in the stromal cells. We demonstrated endometrial GLUT4 expression. The similar results in lean PCOS and control subjects suggest that endometrial GLUT4 expression is not affected by PCOS itself, whereas it is reduced by obesity in PCOS patients.

Evidence for the presence of glucose transporter 4 in the endometrium and its regulation in polycystic ovary syndrome patients

Glucose transporter 4 (GLUT4) seems to be involved in the mechanism of insulin resistance in polycystic ovary syndrome (PCOS) patients (PCOSs) in both muscular and adipose tissue. The observation that insulin stimulates glucose oxidation in endometrial cells led us to investigate the presence of GLUT4 in this tissue and whether a defect of GLUT4 is present at the endometrial level in PCOSs. We also investigated whether body weight influences GLUT4 expression in this syndrome. GLUT4 mRNA content was examined by real-time quantitative RT-PCR and immunostaining reaction in the endometrial tissue of nine normal subjects, nine lean and eight obese hyperinsulinemic (h-INS), and eight lean and 10 obese normoinsulinemic (n-INS) PCOSs. GLUT4 mRNA and its positive immunostaining reaction were present in epithelial cell level in the endometrium of both normal and PCOS subjects. Significantly higher levels of GLUT4 were observed in normal and lean n-INS PCOSs in comparison with other groups. In both n-INS and h-INS obese PCOSs, GLUT4 was significantly lower than in lean subjects. However, obese n-INS and lean h-INS PCOSs showed a similar low GLUT4 expression, whereas obese h-INS PCOSs showed the lowest expression when compared with other groups. In conclusion, our data demonstrate that GLUT4 is present in the endometrium of normal and PCOS subjects and that hyperinsulinism and obesity seem to have a negative effect on endometrial GLUT4 expression in PCOS.

Transcriptional downregulation of tight junction protein ZO-1 in active coeliac disease is reversed after a gluten-free diet

Coeliac disease is an autoimmune enteropathy characterized by an enhanced permeability of the intestinal epithelial barrier. In epithelial cells paracellular permeability is regulated by intercellular tight junction. The cytoplasmic protein ZO-1 interacts directly with F-actin and plays a pivotal role in the structural and functional organization of tight junction.

AIM

The aim of this study was to investigate the expression and localization of ZO-1 in the intestinal mucosa of coeliac patients.

PATIENTS AND METHODS

Twenty patients with active coeliac disease, seven of whom underwent a repeat biopsy following a gluten-free diet and 27 control subjects, were studied. In all subjects, three biopsies were obtained from distal duodenum during upper gastrointestinal endoscopy. ZO-1 protein localization and levels were detected by immunofluorescence followed by confocal microscopy analysis and immunoblotting. ZO-1 mRNA expression was assessed by RT-PCR. F-actin distribution was also investigated.

RESULTS

In patients with active coeliac disease, both ZO-1 protein levels and mRNA were clearly reduced. Cytoskeletal organization was disrupted with F-actin staining concentrated at the subcortical and basal surface regions. Abnormalities in ZO-1 expression and actin organization were reversed after a gluten-free diet.

CONCLUSIONS

In active coeliac disease, ZO-1 protein expression is downregulated at the transcriptional level in association with F-actin redistribution. These changes are completely reversed after a gluten-free diet and could contribute to the increased intestinal paracellular permeability observed in this disorder.

Epidermoid cyst and primary trabecular carcinoid of the ovary: case report

In the literature and in our experience epidermoid cysts and carcinoids of the ovary are rare benign pathologies which occur more frequently in younger women. They probably are a one-sided development of a teratoma, which arise from germ cells after the first meiotic division due to either a meiosis I or a meiosis II non dysjunction. Diagnosis is possible only with histological examination and immunohistochemistry which allow us to differentiate carcinoids from sex-cord tumors and ependymomas. Prognosis is very good because the rate of malignant transformation is 1.4%-2% and the rate of complications is 14%. Thus conservative surgical therapy associated with long-term follow-up is the treatment of choice.

Relationship between neonatal leukemoid reaction and bronchopulmonary dysplasia in low-birth-weight infants: a cross-sectional study

Leukemoid reaction in low-birth-weight (LBW) infants is a rare, recently documented phenomenon, implicated in the sequence of multiorgan inflammatory diseases of preterm infants. The aim of the present paper is to establish whether a neonatal leukemoid reaction is related to bronchopulmonary dysplasia (BPD) development in LBW infants. The design was a case-controlled, retrospective study of all premature infants (born </=31 weeks' gestation) admitted to the neonatal intensive care unit (NICU) over a period of 3 years, from January 1998 to December 2000. The infants who developed BPD formed the study group, while the remainder without pulmonary sequelae, matched for gestational age formed the control group. Leukemoid reaction was considered a white blood cell (WBC) count >40,000/mm 3. The relation between BPD occurrence and WBC counts was studied by Bayesian analysis, dividing WBC counts in 5 progressive bands of 10,000 WBC/mm 3, starting from <10,000 to >40,000/mm 3. Five of 50 BPD infants studied demonstrated WBC counts >40,000/mm 3, with an incidence of 10%, while no control preterm infants presented neonatal leukemoid reaction; the estimated number difference is statistically significant ( p <0.001). There was no other significant association demonstrated between maternal or neonatal variables and leukemoid reaction, including chorioamnionitis, sepsis, and the use of antenatal steroids. Our findings provide further data for the identification of prematures exposed to pro-inflammatory cytokines in utero; the injury responsible for BPD in a subset of prematures may begin with a transient leukemoid reaction.

Endometrial hyperplasia with berrylike squamous metaplasia and pilomatrixomalike shadow cells. Report of an intriguing cytohistologic case

BACKGROUND

The usefulness of endometrial cytology as a diagnostic method in asymptomatic women, especially in postmenopause, in the interpretation of composite pictures characterized by borderline features between atypical hyperplasia and well-differentiated adenocarcinoma, especially if associated metaplastic features are present, is somewhat controversial.

CASE

An asymptomatic, 50-year-old, postmenopausal woman underwent a Pap smear and endometrial cytology for routine screening, disclosing three-dimensional, sometimes pseudopapillary groupings of hyperplastic endometrial glandular cells with focal atypia in direct continuity with large, squamoid cells of the keratinizing type and shadow cells. Histologic examination of endometrial tissue was advised, and two subsequent endometrial biopsies and hysteroscopic ablation were performed. The borderline character of the lesion (complex atypical hyperplasia vs. well-differentiated adenocarcinoma) with concomitant squamous metaplasia and pilomatrixomalike shadow cells prevented diagnostic agreement between several pathologists.

CONCLUSION

Diagnostic cytology with direct endometrial sampling represents a valuable diagnostic screening tool for the differential diagnosis between normal and pathologic endometrium, a mucosal picture that deserves a subsequent (histologic) diagnostic procedure. In a few cases, as in the one presented above, even histologic examination, especially of so-called borderline lesions, reveals squamous or other types of metaplasia that can lead to interobserver discrepancies.

Prevalence of coeliac disease in primary biliary cirrhosis and of antimitochondrial antibodies in adult coeliac disease patients in Italy

BACKGROUND

Although an association between primary biliary cirrhosis and coeliac disease has recently been reported in Northern Europe, there are still conflicting data concerning this issue.

AIM

To evaluate both the prevalence of coeliac disease in a series of primary biliary cirrhosis patients and that of antimitochondrial antibodies in a series of adult biopsy proven coeliac disease patients from Northern Italy.

PATIENTS AND METHODS

A total of 87 primary biliary cirrhosis patients (79 female, 8 male) were screened for both IgA-transglutaminase antibodies and antiendomysium antibodies and, in those with either IgA-transglutaminase antibodies or antiendomysium antibodies positivity, upper endoscopy with distal duodenum biopsy was offered. In those who refused upper endoscopy, the intestinal permeability test with lactulose/mannitol excretion was performed.

RESULTS

Antiendomysium antibodies positivity was detected in 3 subjects (3.4%), all of whom had serum IgA-transglutaminase antibodies above the normal range, and fulfilled the diagnosis of coeliac disease. Of 21 other patients with serum IgA-transglutaminase antibodies above the normal range, 17 underwent upper endoscopy which revealed normal duodenum architecture. The remaining 4 patients underwent the lactulose/mannitol excretion test which was within the normal range. Sera from 108 adult coeliac disease patients were tested for antimitochondrial antibodies and positivity was found in 4 patients (3.7%): all had normal liver biochemistry tests, whereas 2 of them also presented thyroid disease. Antibodies directed to the 74-kDa polypeptide of antimitochondrial antibodies were found in 3 out of 4 antimitochondrial antibodies+ve patients.

CONCLUSIONS

These results suggest an association between primary biliary cirrhosis and coeliac disease similar to that observed in the Northern European series. In conclusion, screening for coeliac disease with antiendomysium antibodies in primary biliary cirrhosis is justified, and screening for antimitochondrial antibodies is advisable in adult coeliac disease patients.

Duodenal periampullary gangliocytic paraganglioma: report of two cases with immunohistochemical and ultrastructural study

We report two cases of Gangliocytic Paraganglioma (GP) of the ampulla of Vater occurring in a 63-year-old and a 34-year-old individual. The patients were both admitted for a long history of intermittent gastrointestinal bleeding and abdominal discomfort, with no other symptoms. At endoscopy, the GP appeared as a polypoid, ulcerated mass in the ampullar region, measuring 2.5x1.8 and 2 cm, respectively. Microscopically, the tumors showed similar features and were composed of epithelial cells (more than 50%), spindle cells, and ganglion-like cells. The epithelial cells showed clear cytoplasm and formed nests (zellballen or paraganglioma-like groups), and less frequently, cords (carcinoid-like), extending to mucosa and submucosa. Ganglion cells were sparse, constantly associated with the spindle cells. Both epithelial and ganglion cells were synaptophysin, chromogranin A, and anti-neurofilament immunoreactive. The spindle cells were all S-100 positive. Ultrastructural studies revealed dark and light cells, rare elongated cellular processes, secretory granules, and fine fibrils resembling neurofilaments. The histogenesis of GP is still a matter of debate, however its neoplastic nature is supported by the occasionally reported malignant evolution.

Rectosigmoid endometriosis: diagnosis and surgical management

The recurrence of endometriosis varies from 6% to 10% and, among the non-gynaecological sites, the bowel is involved in 12%-37%. Various symptoms, such as dysmenorrhea, dyspareunia, chronic pelvic pain, diarrhoea, constipation, cyclic rectal bleeding, colic-abdominal pain up to intestinal occlusion characterize this pathology. Surgery seems to be the best treatment especially for gastrointestinal symptoms; conservative surgery should be performed, particularly in young patients. Four cases of intestinal endometriosis were reevaluated.