Low-temperature effect on the sterol-dependent processing of SREBPs and transcription of related genes in HepG2 cells

Lowering the growth temperature of HepG2 cells from 37 degrees C to 20 degrees C results in a 73% reduction in human squalene synthase (HSS) protein, a 76% reduction in HSS mRNA, and a 96% reduction in promoter activity of a secreted alkaline phosphatase-HSS reporter gene. A similar decrease in either mRNA or protein levels is observed for 3-hydroxy-3-methylglutaryl CoA reductase, farnesyl diphosphate synthase, the LDL receptor, and fatty acid synthase. All these proteins and mRNAs show either a decrease or a complete loss of sterol-dependent regulation in cells grown at 20 degrees C. In contrast, sterol regulatory element binding proteins (SREBPs)-1 and -2 exhibit a 2- to 3-fold increase in mRNA levels at 20 degrees C. The membrane-bound form of the SREBPs is dramatically increased, but the proteolytic processing to the nuclear (N-SREBP) form is inhibited under these conditions. Overexpression of the N-SREBP or SREBP cleavage-activating protein (SCAP), but not site-1 or site-2 proteases, restores the activation of the HSS promoter at 20 degrees C, most likely by liberating the SCAP-SREBP complex so that it can move to the Golgi for processing. These results indicate that the cholesterol synthesizing machinery is down-regulated at low temperatures, and points to the transport of the SCAP-SREBP complex to the Golgi as the specific down-regulated step.

Wegener's granulomatosis: an isolated lung mass responding to antituberculosis therapy and atypical course

We describe an unusual case of Wegener's granulomatosis (WG), in a middle aged, non-smoking female who presented with a lung mass with constitutional symptoms. FNABC from mass revealed a single ill-defined granuloma without necrosis. There was a definite clinical and radiological response to anti-tuberculosis treatment. She was later found to have another mass lesion in nasopharynx. ANCA was negative initially but became positive once disease flare up occurred. Multisystem involvement with clinical features of vasculitis were seen during the flare up and resulted in a fatal outcome. Unusual features and literature on this entity is discussed.

Intussusception due to gastrointestinal stromal tumour of the colon: diagnosis by colonoscopy

Intussusception of the intestine is rare in adults. We report a case of a 45-year-old male who presented with long-standing pyrexia of unknown origin, abdominal pain, gastrointestinal bleeding and constitutional symptoms. Colonoscopic examination revealed a large invaginated mass suggestive of colonic intussusception due to gastrointestinal stromal tumour of the colon. His symptoms disappeared after surgical removal of the tumour.

Symptom score does not correlate with gastritis grade and Helicobacter pylori infection in non ulcer dyspepsia

BACKGROUND

Non ulcer dyspepsia (NUD) is being postulated as one of the gastroduodenal manifestations of H. pylori infection. H. pylori infection may result in clinical symptoms as well as histological changes in NUD.

AIM

To compare clinical symptom score and histological changes in H. pylori (Hp) positive and negative untreated NUD patients.

METHODS

Forty six patients with dyspeptic symptoms and normal upper GI endoscopic examinations were included in this study. During endoscopy 2 biopsies each were taken from the antrum and body of the stomach. These biopsies were used for rapid urease test (RUT) and histological examination. Patients were diagnosed to have Hp infection if either of two tests were positive. There were two groups of patients: Hp positive and Hp negative NUD patients. Clinical scoring using Glasgow dyspepsia score (Max. 20) and histological analysis, using Sydney system (Max score 11) was done and compared for both the groups of patients. Clinical scoring, RUT and histological scoring were blinded to each other.

RESULTS

H. pylori was present in 29(63%) of the 46 patients. Mean clinical score for H. pylori positive patient was 10.9 while for Hp negative patient was 11.4. Total histological score for Hp positive and Hp negative patients was 3.37 Vs 1.76 (antrum) and 3.68 Vs 1.29(body) (p < .001), respectively. The only histological change found to be statistically significant between Hp positive and Hp negative patients was presence of lymphoid follicles (p < .05).

CONCLUSION

Clinical scoring does not correlate with the presence of H pylori or histological severity. In NUD patients positive for H. pylori, there is a significant increase in the severity of gastritis both in the antrum and the body.

Hepatic technetium-99m-mebrofenin iminodiacetate scans and serum gamma-glutamyl transpeptidase levels interpreted in series to differentiate between extrahepatic biliary atresia and neonatal hepatitis

Hepatic technetium-99m-mebrofenin iminodiacetate (99mTc-mebrofenin IDA) scans and serum gamma-glutamyl transpeptidase (GGTP) have high sensitivity for extrahepatic biliary atresia (EHBA). This study was based on the hypothesis that the interpretation of results of 99mTc-mebrofenin IDA scans and serum GGTP levels in series would result in a reduction of the false positivity observed with these tests individually. The aetiology of neonatal cholestasis in 132 study patients was: 25% (33/132) EHBA, 45.5% (60/132) neonatal hepatitis (NH) with an identifiable cause and 19.7% (26/132) idiopathic NH. Of the various clinical, biochemical and imaging parameters that were significantly different between patient groups, sensitivity for EHBA was: serum GGTP > or = 150 IU l(-1) (100%), 99mTc-mebrofenin IDA scans (100%), pale stools (82.8%) and total serum bilirubin > or = 12 mg dl(-1) (66%). However, specificity ranged from 48.5 to 79%. Of the 63 patients who had non-excreting IDA scans, operative cholangiograms could be avoided on the basis of a specific aetiological diagnosis of NH, made concurrently, in only 9 infants. The rest (54) underwent operative cholangiograms; 21 (39%) of these had patent biliary trees and therefore underwent the procedure unnecessarily. If serum GGTP (< 150 IU l(-1)) had been used as a screen after IDA scanning in these 54 patients, operative cholangiograms could have been avoided in another 12 patients and thereafter only 9/42 (21%) of the operative cholangiograms would have been considered unnecessary.

CONCLUSION

A diagnostic algorithm is proposed wherein serum GGTP level (at a cut-off level that maintains 100% sensitivity for EHBA) is used in series with non-excreting 99mTc-mebrofenin IDA scans (for patients with no specific aetiological label). This strategy reduces the false positivity of individual tests.

Ectopic pancreas associated with a choledochal cyst and extrahepatic biliary atresia

Two children with incidentally-diagnosed ectopic pancreatic tissue in the jejunum at surgery for extrahepatic biliary atresia (EHBA) and choledochal cyst (CC) are reported. No case has been reported in the literature describing the association of a CC with ectopic pancreas, and only one case of EHBA associated with ectopic pancreas has been reported. We believe that incidentally-detected ectopic pancreatic tissue should be excised, even though the patient is symptom-free, in order to prevent the risk of serious complications due to either the mass effect or the potential for acute pancreatitis, cystic degeneration, or malignant transformation at a later date.

Utility of fine-needle aspiration cytology in the classification of leprosy

The role of fine-needle aspiration cytology (FNAC) in the diagnosis of benign skin lesions has been restricted primarily to the evaluation of bacteriologic and morphologic indices in leprosy. This study was undertaken to evaluate the efficacy of FNAC in the diagnosis and classification of lepromatous lesions. Aspirates of 94 newly diagnosed cases of leprosy were studied, and the bacterial load was determined by modified Ziehl-Neelsen (ZN) stain. A skin biopsy was taken from the same site at the same sitting. Frozen and paraffin sections stained with hematoxylin-eosin (H&E) and ZN stains were examined from the biopsy specimen. In 61 of 94 cases (64.9%), the aspirates were satisfactory. Both diagnosis and classification of leprosy were possible in 40 of these 61 cases; the rest of the aspirates showed nonspecific chronic inflammation. The 39 cases of leprosy where a biopsy was available from the same site were classified on FNAC into tuberculoid (TT and BT), lepromatous (LL and BL), and midborderline (BB) subtypes. Taking the histologic diagnosis and Ridley-Jopling classification to be the gold standard, a strong concordance in tuberculoid leprosy cases (18 of 20 cases, 90%) and in lepromatous cases (15 of 16 cases, 93.7%) was observed. Midborderline cases of leprosy posed a problem, and a correct cytohistological correlation was observed in only one of the three cases.

Classical polyarteritis nodosa and microscopic polyangiitis--a clinicopathologic study

OBJECTIVE

To describe the clinical spectrum, laboratory features, histopathological findings and treatment outcome in patients with classical polyarteritis nodosa (PAN) and microscopic polyangiitis (MPA).

MATERIAL AND METHODS

Patients with PAN and MPA seen at a large teaching hospital in north India over a period of five years (1994-99) were included in the present study.

RESULTS

We encountered five patients with PAN and six patients with MPA during the study period. Of the five patients with PAN, two had systemic disease while three had limited PAN. The patients with limited PAN included two with cutaneous PAN and one with PAN confined to the nerves. Constitutional symptoms, musculoskeletal complaints, peripheral neuropathy and skin lesions dominated the clinical picture. Fifty percent of the MPA patients presented as pulmonary renal syndrome. All the patients with PAN were HBsAg and ANCA negative and had normal urinalysis findings. In contrast, all patients with MPA demonstrated an active urine sediment and 83.3% were pANCA positive. Some of the rare features encountered by us were the presence of antiphospholipid syndrome and extensive interstitial lung disease in MPA, and spontaneous recovery in one patient with systemic PAN. Treatment outcome was better in PAN as compared with MPA.

CONCLUSIONS

The clinical spectrum of PAN and MPA is quite varied. A good outcome is possible with the use of corticosteroids and cyclophosphamide.

Renal function and structure in subacute hepatic failure

BACKGROUND AND AIMS

Subacute hepatic failure (SHF) is a fatal complicaton of acute viral hepatitis. Renal failure has been implicated as the main cause of death in this disease. However, renal functional and structural evaluation in such patients have not been performed. The present prospective study evaluated the renal functional and structural abnormalities in patients with subacute hepatic failure.

METHODS

Fourteen consecutive patients with SHF, 11 with acute liver failure (ALF) and 15 with cirrhosis of the liver (Child's B or C) were included in the present study. All 40 patients had liver disease caused by hepatitis viruses. The glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) estimations were measured in all patients by the use of technetium-99m diethylenetriaminepentaacetic acid and [131I]-labeled ortho-iodohippuric acid, respectively. Ante-mortem or post-mortem liver biopsies were performed in all patients. In three patients with SHF, post-mortem kidney biopsies were also performed.

RESULTS

Thirty six percent (5/14) of patients with SHF, 18% (2/11) of patients with ALF and 20% (3/15) of patients with cirrhosis had renal failure. Seven patients with SHF, seven with ALF and nine with cirrhosis died. All the patients with renal failure in each of the three groups were among the deceased patients. Glomerular function was markedly affected among patients with SHF, which was shown by significantly higher (P < 0.05) proteinuria levels (0.367 +/- 0.38 g/24 h) compared to levels in patients with ALF (0.178 +/- 0.11 g/24 h) and cirrhosis (0.212 +/- 0.133 g/24 h). The GFR in SHF (56 +/- 27 mL/min per 1.73 m2) and cirrhotic patients (58 +/- 36 mL/min per 1.73 m2) was significantly lower compared to those in ALF patients (102 +/- 51 mL/min per 1.73 m2; P < 0.05). A significantly higher proportion (P < 0.05) of patients with SHF and cirrhosis (64 and 73%, respectively) had a GFR below 80 mL/min per 1.73 m2 compared to patients with ALF (18%). The GFR value among the deceased SHF patients (46 +/- 26 mL/min per 1.73 m2) was significantly lower (P < 0.05) than those SHF patients who survived (65 +/- 25 mL/min per 1.73 m2). However, similar features could not be documented among patients with ALF or cirrhosis. Subtle structural changes in the glomerulus were also noted in patients with SHF. These included mesangial proliferation and thickening, basal membrane thickening and increased cellularity with interstitial edema. The ERPF was markedly reduced (P = 0.058) among patients with SHF (347 +/- 131 mL/min per 1.73 m2) and cirrhosis (395 +/- 137 mL/min per 1.73 m2) in comparison to ERPF documented among patients with ALF (436 +/- 217 mL/min per 1.73 m2). Such a reduction in renal tubular blood flow, along with histologic documentation of hyaline presence, bile and grannular cast in the tubule, indicated a possible tubular dysfunction in patients with SHF.

CONCLUSION

It is concluded that glomerular and tubular dysfunction with subtle structural abnormalities does occur in patients with SHF. These are similar to renal changes in cirrhosis and may have similar pathogenetic mechanisms that require further evaluation.

Conjunctival dysfunction and mitomycin C-induced hypotony

PURPOSE

To determine the role of a physically intact conjunctiva in the development of chronic hypotony after mitomycin C-enhanced trabeculectomy.

METHOD

Three patients with mitomycin C-related hypotonic maculopathy, but without a leak on Siedel test, had a thorough evaluation of the bleb area and an anterior segment fluorescein angiography. The bleb was excised and a pedicle flap, rotated from the temporal conjunctiva, was sutured to cover the defect superiorly. The scleral flap and its sutures were not disturbed. The excised bleb was subjected to light and electron microscopy.

RESULTS

The Seidel test result was negative in all patients, but late phases of the anterior segment angiography showed a generalized seepage of aqueous from the bleb. After revision of the bleb, there was a gradual increase in the intraocular pressure, a reversal of the hypotonic maculopathy, and consequent improvement in visual acuity in all three patients, stable up to a minimum follow-up of 18 months. On histopathologic examination, the basement membrane was thickest under thin areas of the epithelium and thinnest below thicker epithelial layers.

CONCLUSION

A dysfunctional conjunctival barrier, as evidenced by the "sweating" of the bleb and histopathologic alterations in the epithelial barrier, could be responsible for the hypotonic maculopathy in these patients. Excision of the conjunctiva alone and replacement by a pedicle conjunctival graft offers a safe and effective method of treating chronic hypotony after mitomycin C-augmented trabeculectomy in such patients.

Acute hepatic failure in India: a perspective from the East

Acute hepatic failure (AHF) in India almost always presents with encephalopathy within 4 weeks of the onset of acute hepatitis. Further subclassification of AHF into hyperacute, acute and subacute forms may not be necessary in this geographical area, where the rapidity of onset of encephalopathy does not seem to influence survival. Viral hepatitis is the cause in approximately 95-100% of patients, who therefore constitute a more homogeneous population than AHF patients in the West. In India, hepatitis E (HEV) and hepatitis B (HBV) viruses are the most important causes of AHF; approximately 60% of cases are caused by to these viruses. Hepatitis B virus core mutants are very important agents in cases where hepatitis B results in AHF in this country. Half of the patients with AHF admitted to our centre are female, one-quarter of whom are pregnant. Therefore, pregnant females who contract viral hepatitis constitute a high-risk group for the development of AHF. However, the outcome of AHF in this group is similar to that in non-pregnant women and men. No association with any particular virus has been identified among sporadic cases of AHF. In our centre, approximately one-third of AHF patients survive with aggressive conservative therapy, whereas two-thirds of deaths occur within 72 h of hospitalization. Cerebral oedema and sepsis are the major fatal complications. Both fungal and gram-negative bacteria are major causes of sepsis. Among patients with AHF, despite the presence of sepsis, its overt clinical features (i.e. fever, leucocytosis) may be absent and objective documentation of the presence of sepsis in such patients is achieved by repeated culture of various body fluids. It should be possible to develop simple, clinical prognostic markers for AHF in this geographical region, in order to identify patients suitable for liver transplantation.

Epithelioid hemangioendothelioma of the greater omentum: report of a case

We report herein the case of an 11-year-old girl found to have an epithelioid hemangioendothelioma of the greater omentum. The child presented with a 4-month history of vague lower abdominal pain and gradually increasing generalized distension. Her symptoms and signs could not be ascribed to any specific organ system. Ultrasonography and computerized axial tomography revealed a mass lesion anterior to the bowel loops and a laparotomy revealed a huge lobulated mass, arising from the greater omentum, which was completely excised. She has remained well postoperatively without any adjunctive chemotherapy or radiotherapy.

Differential binding of proteins to peroxisomes in rat hepatoma cells: unique association of enzymes involved in isoprenoid metabolism

Farnesyl diphosphate synthase (FPPS: EC2.5.1.10), a key enzyme in isoprenoid metabolic pathways, catalyzes the synthesis of farnesyl diphosphate (FPP) an intermediate in the biosynthesis of both sterol and non-sterol isoprenoid end products. The localization of FPPS to peroxisomes has been reported (Krisans, S. K., J. Ericsson, P. A. Edwards, and G. A. Keller. 1994. J. Biol. Chem. 269: 14165;-14169). Using indirect immunofluorescence and immunoelectron microscopic techniques we show here that FPPS is localized predominantly in the peroxisomes of rat hepatoma H35 cells. However, the partial release of 60;-70% of cellular FPPS activity is observed by selective permeabilization of these cells with digitonin. Under these conditions, lactate dehydrogenase, a cytosolic enzyme, is completely released whereas catalase, a known peroxisomal enzyme, is fully retained. Digitonin treatment of H35 cells differentially affects the release of other peroxisomal enzymes involved in isoprenoid metabolism. For instance, mevalonate kinase and phosphomevalonate kinase are almost totally released (95% and 91%, respectively), whereas 3-hydroxy-3-methylglutaryl-CoA reductase is fully retained. Indirect immunoflourescence studies indicate that FPPS is localized in peroxisomes of Chinese hamster ovary (CHO)-K1 cells but is dispersed in the cytosol of ZR-82 cells, a mutant that lacks peroxisomes. Unlike in H35 cells, FPPS is completely released upon digitonin permeabilization of CHO-K1 and ZR-82 cells. In contrast, under the same permeabilization conditions, catalase is fully retained in CHO-K1 cells but completely released from ZR-82 cells. These studies indicate that FPPS and other enzymes in the isoprenoid biosynthetic pathways, involved in the formation of FPP, are differentially associated with peroxisomes and may easily diffuse to the cytosol. Based on these observations, the significance and a possible regulatory model in the formation of isoprenoid end-products are discussed.

Involvement of farnesyl protein transferase (FPTase) in FcarepsilonRI-induced activation of RBL-2H3 mast cells

Changes in farnesyl protein transferase (FPTase) activity and FPTase beta-subunit protein levels were determined in IgE-sensitized RBL-2H3 mast cells in response to polyvalent antigen administration. Ten minutes after the addition of DNP modified BSA to mast cells, whose high affinity receptor for IgE (FcvarepsilonRI) contained bound anti-DNP IgE, FPTase specific activity increased by 54 +/- 28%. Time course studies showed FPTase specific activity doubled during a 20- to 30-min period after antigen-induced cell aggregation. Also, an increase in FPTase beta-subunit protein during this time ( approximately 30%) was observed; this protein increase was not accompanied by a similar increase in FPTase beta-subunit m-RNA levels. The FcvarepsilonRI aggregation had no significant effect on the activities of other enzymes involved with farnesyl diphosphate (FPP) metabolism: FPP synthase, isopentenyl diphosphate isomerase, geranylgeranyl protein transferase, and squalene synthase. Specific inhibition of FPTase activity by manumycin was studied to determine what role FPTase plays in mast cell activation. Manumycin profoundly inhibited hexosaminidase release in activated cells, indicating FPTase is required for signal transduction involved with protein exocytosis from RBL-2H3 mast cells.

Thermal balloon endometrial ablator: a preclinical safety and effectiveness study

OBJECTIVE

To evaluate the preclinical safety and efficacy of the thermal balloon endometrial ablator (TBEA).

METHODS

Informed consent was taken from all patients for TBEA and hysterectomy at same sitting. TBEA was performed in vivo just before hysterectomy on 6 patients' uteri to determine uterine rupture, perforation and thermal damage to surrounding viscera and peritoneum. Temperatures in the pouch of Douglas, uterovesical peritoneum and serosa of uterus were taken by a sterile laboratory thermometer to note for any rise in temperature before, during and after the procedure. The extirpated uteri were then examined grossly for the nature and extent of thermal damage which was visible as a zone of erythema in the endomyometrium. Five extirpated uteri, 3 from the above group and 2 on whom TBEA was performed 3 months ago were histopathologically examined to study the nature and extent of damage to endomyometrial cells. A 5 mm longitudinal strip of uterus along with both the cornual ends were sectioned in such a way that it was representative of the entire uterus.

RESULTS

There was no evidence of uterine perforation, rupture or any damage to the surrounding viscera and peritoneum. There was no rise in temperature in most sites while TBEA was performed. The only area that felt warm was the surface of the uterus and there too the measured rise was only 1 degree C. On gross examination the zone of erythema measured 5.4 mm (mean) (range 3-9 mm). In those uteri subjected to histopathology immediately after TBEA early evidence of thermal damage was visible as hemorrhage, congestion, edema, eosinophilic infiltration and necrosis in 2 out of 3 cases. Late changes of thermal damage after TBEA were seen as basal endometrium and areas of hyalinization. The changes in general were patchy and not uniform.

CONCLUSIONS

TBEA is a safe device with no thermal damage to uterus and surrounding viscera. The mean zone of thermal damage in the endomyometrium is 5.4 mm. On histopathology, the early changes of thermal damage are hemorrhage, congestion, edema, eosinophilic infiltration and necrosis and the late changes are visible as areas of hyalinization and presence of basal endometrium.

Medullary thyroid carcinoma with melanin production--a case report

Melanin production in medullary thyroid carcinomas is rare. The present case illustrates melanin and other atypical features of medullary carcinoma of the thyroid in a fifty year old female. The diagnosis was suggested on the cytomorphological features seen on fine needle aspiration cytology smears. On histo-pathological examination the tumor was extensively pigmented with frequent mitosis. Amyloid was conspicuously scarce. Confirmation of diagnosis was done by immunohistochemical positivity for calcitonin and HMB-45 on tissue sections. The case is being presented in view of its rarity and distinct immunoreactivity. Review of literature is done and the implications of such dual positivity in the histogenesis and divergent phenotype of this tumor are discussed.

Adenocarcinoma of distal esophagus and gastroesophageal junction: long-term results of surgical treatment in a North Indian Center

This retrospective study reports our experience managing 78 patients with adenocarcinoma of the esophagus and gastroesophageal junction operated between January 1982 and December 1996. Altogether 18 patients presented with stage I and II disease, and 60 patients had stage III and IV disease at presentation; 56 patients (71.8%) were found to have resectable disease. Of these, transhiatal esophagectomy was possible in 51 patients. Transthoracic esophagectomy was done in 3 patients, and a left thoracoabdominal approach was used in 2 patients. The stomach was used as conduit in 50 patients and the colon in 6 patients. Twenty-two patients were found to have unresectable lesions at laparotomy and underwent various palliative procedures. Overall operative mortality was 6.3%. Mortality in the resectable group was only 3.6%. Follow-up ranges from 3 to 128 months, with four patients lost to follow-up at 1, 6, 8, and 10 months. The 5-year survival of the whole group according to Kaplan and Meier survival analysis was 21.27% with a median survival of 13.48 months. Univariate analysis using the log-rank test revealed stage of the disease and resectability to be significant predictors of survival. On multivariate analysis, curative resection appeared to be the most significant predictor of survival in patients undergoing resection.

Acneiform eruptions after facial beauty treatment

BACKGROUND

Female patients in the post-adolescent age group presented with predominantly deep-seated nodules and a few comedones situated mainly on the cheeks. As most of these subjects related the onset of their symptoms to antecedent facial beauty treatment, we decided to study the clinical and histologic profile of these patients.

METHODS

Thirty seven subjects (36 women and one man) were questioned in detail about their acneiform eruptions. The patients were examined and a biopsy of typical lesions was taken in eight patients.

RESULTS

On direct questioning, all patients related the onset of their lesions to facial beauty treatment taken 3-8 weeks previously. The predominant types of lesion were deep-seated nodules, although a few closed comedones were present in some cases. Most lesions took a long time to heal and, on healing, left behind hyperpigmentation. The cheeks were universally involved in all patients, and the chin and forehead were involved in 14. The histopathologic study revealed a predominantly peri-appendageal dermal infiltrate consisting of lymphocytes and histiocytes admixed with polymorphs. A granulomatous infiltrate was seen in one-third of the biopsies.

CONCLUSIONS

This eruption is unlike the earlier eruption described as acne cosmetica in being inflammatory, indolent, and often occurring after the first cream massage itself.

Histologic chorioamnionitis & its association with prematurity in a hospital-based study

This prospective study was undertaken to study the occurrence of histologic chorioamnionitis and determine its association with prematurity; and to assess whether colonization of the genital tract of pregnant women by genital mycoplasmas or Chlamydia trachomatis is a risk factor for histologic chorioamnionitis. A total of 268 women with singleton pregnancies of over 26 weeks gestation were subjected to high vaginal cultures of genital mycoplasmas and endocervical specimens for chlamydia antigen. Placental histopathology was performed on multiple sections. Histologic chorioamnionitis was documented in 22.4 per cent (60/208) placentae. Genital tract colonization with Ureaplasma urealyticum or C. trachomatis was not a risk factor for histologic chorioamnionitis. Neonates born in association with histologic chorioamnionitis had a mean birth weight 111 g lower than those born without this lesion (2626.9 +/- 702 g vs 2737.8 +/- 500 g, NS). The relative risk (95% confidence interval) of prematurity in the presence of histologic chorioamnionitis was 1.49 (0.87-2.53). Analysis of linear trend in proportions for prevalence of histologic chorioamnionitis with decreasing gestation showed a significant association (P = 0.047, 1-tail). These results taken together suggest that histologic chorioamnionitis may be a risk factor of prematurity, but of only a modest magnitude.

Mediastinal lymphangiomyoma in a child: report of a case

Lymphangiomas and lymphangiomyomas are benign abnormal collections of lymphatic vessels which form a cystic mass. The mediastinum is an uncommon location for these hamartomas in children, but may be life-threatening. We report herein the case of a 23-month-old boy who presented with stridor and a history of recurrent respiratory tract infections. Soon after his admission he suddenly developed respiratory failure and was found to have a multiloculated, cystic mediastinal mass which was initially thought to be a lymphangioma. The mass was extensively infiltrative, and histological examination showed prominent smooth muscle proliferation in the walls of the cysts, confirming a diagnosis of lymphangiomyoma. The terminology and relevant literature on the topic are reviewed following the presentation of this case.

Effectiveness of prenatal tetanus toxoid immunization against neonatal tetanus in a rural area in India

BACKGROUND

Neonatal tetanus is the cause of 23 to 73% of neonatal deaths in developing countries and continues to be an important killer in many parts of India.

METHODS

In this nonrandomized cohort study in a rural area in India, tetanus toxoid immunization status was recorded for 1688 pregnant women. Liveborn children were followed up for 30 days for the occurrence of neonatal tetanus. Nonimmunized and partially immunized women were asked their reasons for not receiving tetanus toxoid vaccine.

RESULTS

Complete prenatal immunization with tetanus toxoid during pregnancy (two doses 1 month apart) was associated with an 88% reduction in the risk of neonatal tetanus among the newborn children [95% confidence interval (CI) 59 to 98%]. In multivariable analysis only complete immunization and the use of clean instruments for cutting the umbilical cord were independently associated with a reduction in risk of neonatal tetanus. Registration by the health care provider before 29 weeks of gestation, being 5 km or less from the vaccination facility, having two or more contacts with the health provider and having some school education were independently associated with complete immunization.

CONCLUSIONS

Immunization of pregnant women with tetanus toxoid was the single most effective intervention against neonatal tetanus independent of other interventions.