Fetoscopic laser ablation for twin-to-twin transfusion syndrome in Malaysia: A 15-month retrospective cohort review from an emerging centre in South East Asia

INTRODUCTION

The authors aim to review the early outcomes of fetostopic laser ablation (FLA) to improve outcomes for twin-to-twin transfusion syndrome (TTTS) in an emerging national centre in Malaysia.

MATERIALS AND METHODS

This is a retrospective cohort study of 17 monochorionic diamniotic (MCDA) twin pregnancies with severe TTTS treated by FLA over 15 months in a single centre by a single operator after performing simulations.

RESULT

The overall survival rate at day 28 after birth for at least one twin was 76% while the dual-twin survival was 64%. The survival rates at day 28 after birth for at least one twin for stages II, III and IV were 90% vs 40% vs 100% (p=0.054) while dual survival rates were 80% vs 0% vs 100% (p=0.05), respectively. The rate of miscarriage was higher with anterior placentation compared to posterior placentation (33% vs 18%, p=0.660). There was one case of recurrent TTTS and no twin anaemia-polycythaemia sequence post-FLA. The fetal medicine unit in Ipoh is the national centre in Malaysia which covers the whole country, including the western coast of the Borneo Island (Sabah, Sarawak and Labuan) accessible only by air travel. All three cases from Borneo Island had resolved TTTS after FLA and dual neonatal survival at day 28 after birth.

CONCLUSION

This data from an emerging new fetoscopic laser centre in Malaysia indicates results consistent with the published international learning curve and within the limits of good clinical governance.

Uptake rates, knowledge, attitudes, and practices toward seasonal influenza vaccination among healthcare workers in Lebanon

Despite recommendations and their occupational risk to influenza infection vaccine hesitancy remains a challenge among healthcare workers (HCWs). No studies have been conducted in Lebanon to assess the influenza vaccine's acceptance among HCWs. We conducted a survey to assess factors associated with vaccine uptake and practices among HCWs in Lebanon. Only 40.4% of the HCWs reported receiving the 2018-2019 seasonal vaccine and 1 out 5 routinely received the seasonal vaccine. One-third of the HCWs reported having free access to the influenza vaccine. The willingness to receive the vaccine decreased had it been offered for a fee. Self, family and community protection (55.5%) was a key vaccination enabler. While, viral evolution, concerns regarding vaccine efficacy and side effects, and cost of vaccine ranked as top vaccination barriers. The majority of the HCWs (75%) recommended the vaccine to their patients. Past influenza vaccination (Odds ratio (OR) = 2.37, CI 1.48,3.79), willingness to receive the vaccine for free (OR = 6.93, CI 4.27-11.34) or having diagnosed influenza (OR = 1.81, CI 1.12-2.92) were significantly associated with HCWs' willingness to recommend the vaccine to patients. Better knowledge about influenza and vaccination was strongly associated with the willingness to receive and recommend the vaccine (p < .001). The vaccination rate among HCWs in Lebanon was suboptimal despite the positive attitudes toward the influenza vaccine. Interventions that enhance vaccine accessibility and knowledge are warranted to improve vaccination coverage among HCWs.

Mental health and psychosocial wellbeing of Syrians affected by armed conflict

AIMS

This paper is based on a report commissioned by the United Nations High Commissioner for Refugees, which aims to provide information on cultural aspects of mental health and psychosocial wellbeing relevant to care and support for Syrians affected by the crisis. This paper aims to inform mental health and psychosocial support (MHPSS) staff of the mental health and psychosocial wellbeing issues facing Syrians who are internally displaced and Syrian refugees.

METHODS

We conducted a systematic literature search designed to capture clinical, social science and general literature examining the mental health of the Syrian population. The main medical, psychological and social sciences databases (e.g. Medline, PubMed, PsycInfo) were searched (until July 2015) in Arabic, English and French language sources. This search was supplemented with web-based searches in Arabic, English and French media, and in assessment reports and evaluations, by nongovernmental organisations, intergovernmental organisations and agencies of the United Nations. This search strategy should not be taken as a comprehensive review of all issues related to MHPSS of Syrians as some unpublished reports and evaluations were not reviewed.

RESULTS

Conflict affected Syrians may experience a wide range of mental health problems including (1) exacerbations of pre-existing mental disorders; (2) new problems caused by conflict related violence, displacement and multiple losses; as well as (3) issues related to adaptation to the post-emergency context, for example living conditions in the countries of refuge. Some populations are particularly vulnerable such as men and women survivors of sexual or gender based violence, children who have experienced violence and exploitation and Syrians who are lesbian, gay, bisexual, transgender or intersex. Several factors influence access to MHPSS services including language barriers, stigma associated with seeking mental health care and the power dynamics of the helping relationship. Trust and collaboration can be maximised by ensuring a culturally safe environment, respectful of diversity and based on mutual respect, in which the perspectives of clients and their families can be carefully explored.

CONCLUSIONS

Sociocultural knowledge and cultural competency can improve the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement, both within Syria and in countries hosting refugees from Syria.

Hepatoprotective effect of Matricaria chamomilla.L in paraquat induced rat liver injury

Paraquat (PQ), an effective and widely used herbicide, has been proven to be safe when appropriately applied to eliminate weeds. However, PQ poisoning is an extremely frustrating clinical condition with a high mortality and with a lack of effective treatments in humans. PQ is known to induce injury via a redox cyclic reaction. The purpose of this study was to investigate the effect of aqueous extract Matricaria chamomilla.L (M. chamomilla) against PQ-induced liver injury in association with its antioxidant activity.The male rats were treated by gastric gavage daily with PQ (5 mg/kg/day) and M. chamomilla (50 mg/kg/day) were administered alone or in combination for 7 days. After treatments, total antioxidant capacity (TAC), total thiol molecules (TTG) levels and catalase (CAT) activity in liver tissue were measured. At the end of the experiment, plasma and lung tissue of the animals was separated. The activity of enzymatic scavengers such as CAT, TAC and TTG were measured in liver homogenate.In this sample, the TAC and TTG were lower in the PQ group as compared with control group. Co-administration of PQ with M. chamomilla extract increased TAC and TTG in liver tissue as compared with PQ group.In conclusion, M. chamomilla as natural antioxidant may be considered beneficial for the protection oxidative liver injury in PQ poisoning.

Modeling effluent distribution and nitrate transport through an on-site wastewater system

Properly functioning on-site wastewater systems (OWS) are an integral component of the wastewater system infrastructure necessary to renovate wastewater before it reaches surface or ground waters. There are a large number of factors, including soil hydraulic properties, effluent quality and dispersal, and system design, that affect OWS function. The ability to evaluate these factors using a simulation model would improve the capability to determine the impact of wastewater application on the subsurface soil environment. An existing subsurface drip irrigation system (SDIS) dosed with sequential batch reactor effluent (SBRE) was used in this study. This system has the potential to solve soil and site problems that limit OWS and to reduce the potential for environmental degradation. Soil water potentials (Psi(s)) and nitrate (NO(3)) migration were simulated at 55- and 120-cm depths within and downslope of the SDIS using a two-dimensional code in HYDRUS-3D. Results show that the average measured Psi(s) were -121 and -319 cm, whereas simulated values were -121 and -322 cm at 55- and 120-cm depths, respectively, indicating unsaturated conditions. Average measured NO(3) concentrations were 0.248 and 0.176 mmol N L(-1), whereas simulated values were 0.237 and 0.152 mmol N L(-1) at 55- and 120-cm depths, respectively. Observed unsaturated conditions decreased the potential for NO(3) to migrate in more concentrated plumes away from the SDIS. The agreement (high R(2) values approximately 0.97) between the measured and simulated Psi(s) and NO(3) concentrations indicate that HYDRUS-3D adequately simulated SBRE flow and NO(3) transport through the soil domain under a range of environmental and effluent application conditions.

Gujjar lung: a disease mimicking miliary tuberculosis

Gujjar lung is a chronic lung disease caused due to the long-term exposure to pinewood smoke inhalation in Gujjar community and the people residing at the hilly regions of the Indian sub-continent. This is characterized clinically by progressive cough and dyspnea, distinct radiological patterns and pathological features of anthracotic nodules and fibrosis. A typical case with miliary mottling on chest radiograph is presented and the relevant literature reviewed.

Dermatologic complications after liver transplantation: a single-center experience

OBJECTIVE

To report our experience with dermatological complications after both deceased donor liver transplantation (DDLT) and living-donor liver transplantation (LDLT).

PATIENTS AND METHODS

Between April 2001 and November 2006, a total of 116 liver transplantation (LT) procedures were performed (73 DDLTs and 43 LDLTs) in 112 patients (4 re-transplants). Posttransplant dermatological problems were recorded.

RESULTS

Among 112 OLT recipients, 14 patients (12.5%) experienced dermatologic problems: epidermolysis bullosa acquisita in one patient, which was self-limiting; graft-versus-host-disease in one patient treated with high-dose steroids; Kaposi sarcoma in one patient treated with surgical excision and conversion to sirolimus-based immunosuppression; drug-induced cutaneous vasculitis with deep thigh ulcer formation treated by drug discontinuation and surgical excision of the ulcer; herpes zoster in one patient treated with intravenous antiviral therapy; herpes simplex in two patients treated with local antiviral cream; cyclosporine-induced gingival hyperplasia treated with conversion to FK506; cyclosporine-induced hypertrichosis treated with conversion to FK506; steroid-induced skin hyperpigmentation in one patient treated with steroid withdrawal; hypomagnesemia-induced hair loss treated with daily oral magnesium supplement; pressure-induced alopecia areata in two patients that was self-limiting; and finally, one patient with a pressure-induced heel ulcer that was treated conservatively. In 8 of 14 patients (57%) who suffered from dermatologic problems, the complication was primarily related to immunosuppressive drugs.

CONCLUSIONS

In our experience, dermatologic complications following LT are not uncommon and usually related to immunosuppressive therapy. Most complications could be prevented by optimizing immunosuppression. The majority of complications were easily managed by simple adjustment of immunosuppression.

Immunomodulation of autoimmune and inflammatory diseases with intravenous immunoglobulin

Intravenous immunoglobulin (IVIg) has been used in the treatment of primary and secondary antibody deficiencies for over two decades. Since the early 1980s, the therapeutic efficacy of IVIg has been established in idiopathic thrombocytopenic purpura, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, myasthenia gravis, dermatomyositis and Kawasaki syndrome, and the prevention of graft versus host disease in recipients of allogeneic bone marrow transplants. Its use has also been reported in a large number of other autoimmune and systemic inflammatory conditions. In this review, we discuss the mechanisms by which IVIg exerts immunomodulatory effects in immune pathologies.

Postoperative alopecia areata: Is pressure-induced ischemia the only cause to blame?

INTRODUCTION

Postoperative alopecia areata (PAA) following surgery has been reported, especially after certain gynecologic and cardiac procedures; however, no cases have been reported after liver transplant (LT). Localized pressure associated with prolonged anesthesia is usually blamed. Herein we report a few cases of PAA encountered especially in relation to LT procedures.

OBJECTIVE

To report our PAA cases, identifying possible contributing risk factors.

METHODS

Between April 2001 and May 2003 the data on eight PAA cases were analyzed for age, sex, type of surgery, duration of anesthesia, type of head support, periods of hypotension, and psychiatric comorbidity.

RESULTS

Median age of affected patients was 27 years (10 to 44) and the male/female ratio 3/5. The type of surgery included: two LT recipients, two LT donors, three cardiac valve replacements, and one coronary bypass surgery. Median anesthesia time was 6 hours (3 to 12). Sponge or jelly donut was used for head support with frequent change of its position as per protocol. There were no significant periods of hypotension. Surprisingly, almost all patients had a documented psychiatric comorbidity, mainly anxiety, adjustment/adaptation, or mood disorders.

CONCLUSIONS

PAA is a rare complication following certain surgeries including both donor and recipient LT procedures. Although pressure-induced ischemia is the most likely etiological factor, we believe that psychiatric comorbidity plays a major role in its development. Therefore, preoperative thorough psychiatric counseling in addition to frequent intraoperative head repositioning will help to avoid this minor but distressing postoperative complication.

Salmonella typhi endocarditis: a case report

Salmonella are a rare cause of infective endocarditis. This report describes a case where Salmonella typhi was isolated from the blood and urine of a patient with echocardiographically documented aortic valve disease and endocarditis. The patient was treated with two weeks of ceftriaxone (3 g/day) and amikacin (15 mg/kg/day), followed by a further two weeks of ceftriaxone (3 g/day) alone. He made a complete recovery.

Presence of functional endothelin-1 receptors in nuclear membranes of human aortic vascular smooth muscle cells

Our previous work showed that the nucleus plays a role in excitation-contraction coupling and that the channels and receptors could be present at the nuclear membrane. In the study reported here, the objective was to test the hypothesis that endothelin-1 (ET-1) receptors are functional at the level of the nuclear membranes and that their stimulation importantly regulates free nucleoplasmic Ca2+ level. Using a Fluo-3 Ca2+ measurement technique in human vascular smooth muscle cells (HVSMC), superfusion with increasing concentrations of extracellular ET-1 induced a dose-dependent sustained increase of free cytosolic ([Ca]c), nuclear ([Ca]n) Ca2+ and contraction with an EC50 near 3 x 10(-10) M. Like the extracellular ET-1, the cytosolic application of ET-1 using the perforated sarcolemma membrane technique, induced a dose-dependent increase of nuclear free calcium of HVSMC with an EC50 of 2 x 10(-11) M. These results strongly suggest that ET-1 receptors are functional at the level of the nuclear membranes. Furthermore, the sensitivity of ET-1 receptors at the nuclear membrane level seems to be higher than that of the receptors at the sarcolemma membrane. Finally, our results suggest that cytosolic ET-1 may play a role in preventing HVSMC nuclear calcium overload, thus protecting the cells from apoptosis.

Cockayne syndrome

We report four cases of Cockayne Syndrome in a family of seven children. Apart from the usual clinical and laboratory features, sparse eye lashes and high arched palate in two patients, conjunctival and corneal edema in one, and proximal muscle weakness in one patient were noticed as additional findings.

Neuropeptide Y induced increase of cytosolic and nuclear Ca2+ in heart and vascular smooth muscle cells

It was reported that neuropeptide Y (NPY) affects cardiac and vascular smooth muscle (VSM) function probably by increasing intracellular Ca2+. In this study, using fura-2 microfluorometry and fluo-3 confocal microscopy techniques for intracellular Ca2+ measurement, we attempted to verify whether the action of NPY receptor's stimulation in heart and VSM cells modulates intracellular Ca2+ and whether this effect is mediated via the Y1 receptor type. Using spontaneously contracting single ventricular heart cells of 10-day-old embryonic chicks and the fluo-3 confocal microscopy Ca2+ measurement technique to localize cytosolic ([Ca]c) and nuclear ([Ca]n) free Ca2+ level and distribution, 10-10 M of human (h) NPY significantly (P < 0.05) increased the frequency of cytosolic and nuclear Ca2+ transients during spontaneous contraction. Increasing the concentration of hNPY (10(-9) M) did not further increase the frequency of Ca2+ transients. The L-type Ca2+ channel blocker, nifedipine (10(-5) M), significantly (P < 0.001) blocked the spontaneous rise of intracellular Ca2+ in the absence and presence of hNPY (10(-10) and 10(-9) M). However, the selective Y1 receptor antagonist, BIBP3226 (10(-6) M), significantly decreased the hNPY-induced (10(-10) and 10(-9) M) increase in the frequency of Ca2+ transients back to near the control level (P < 0.05). In resting nonworking heart and human aortic VSM cells, hNPY induced a dose-dependent sustained increase of basal resting intracellular Ca2+ with an EC50 near 10(-9) M. This sustained increase was cytosolic and nuclear and was completely blocked by the Ca2+ chelator EGTA, and was significantly decreased by the Y1 receptor antagonist BIBP3226 in both heart (P < 0.05) and VSM (P < 0.01) cells. These results strongly suggest that NPY stimulates the resting basal steady-state Ca2+ influx through the sarcolemma and induces sustained increases of cytosolic and nuclear calcium, in good part, via the activation of the sarcolemma membrane Y1 receptor type in both resting heart and VSM cells. In addition, NPY also increased the frequency of Ca2+ transients during spontaneous contraction of heart cells mainly via the activation of the Y1 receptor type, which may explain in part the active cardiovascular action of this peptide.

Drug-related hospitalization at a tertiary teaching center in Lebanon: incidence, associations, and relation to self-medicating behavior

OBJECTIVE

In Lebanon there is very limited restriction on drug use. Accordingly, self-medication is highly prevalent. This study examined the influence of these factors on the development of drug-related illnesses that lead to hospitalization.

METHODS

Patients admitted to the medical and pediatric wards of a tertiary teaching center in Beirut, Lebanon, over a period of 6 months were interviewed and their charts were reviewed. Admissions attributable to adverse drug reactions or therapeutic failures were identified and characterized with respect to demographic factors, medical history, drug intake, and self-medicating behavior. The influence of these variables on the development of drug-related illnesses was examined by logistic regression.

RESULTS

Of 1745 adults and 457 children, there were 177 (10.2%) and 36 (7.9%) drug-related illnesses, respectively. Adverse drug reactions accounted for 7.0% and 5.7% and therapeutic failures for 3.2% and 2.2% of adult and pediatric admissions, respectively. Self-medication was commonly practiced (52.6% of adults and 41.6% of children). Logistic regression analysis revealed that female sex increased the risk of adverse drug reaction in adults, whereas self-medication decreased the risk. In children, the risk of adverse drug reaction was increased in lower socioeconomic groups, whereas the risk of therapeutic failure was increased by a positive history of atopy or drug reaction.

CONCLUSIONS

These results provide the first detailed analysis of the problem of drug-related illnesses in a developing country and identify a number of related or risk factors. Despite the lack of regulation of drug dispensing and the unchecked access to drugs in Lebanon, the incidence of drug-related illnesses is not different from that in Western nations. This finding may have relevance to policies of drug regulation in other countries.

Nuclear targeting by growth factors, cytokines, and their receptors: a role in signaling?

The role of membrane receptors is regarded as being to transduce the signal represented by ligand binding from the external cell surface across the membrane into the cell. Signals are subsequently conveyed from the cytoplasm to the nucleus through a combination of second-messenger molecules, kinase/phosphorylation cascades, and transcription factor (TF) translocation to effect changes in gene expression. Mounting evidence suggests that through direct targeting to the nucleus, polypeptide ligands and their receptors may have an important additional signaling role. Ligands such as those of the platelet-derived and fibroblast growth factor classes, as well as cytokines such as interferon-gamma and interleukins-1 and -5, have been found to localize in the nucleus through the action of nuclear localization sequences (NLSs). Where tested, these NLSs appear to be essential for full signaling activity and may be responsible for cotranslocating receptors to the nucleus in complexes with their ligands. The implication is that, subsequent to endocytosis at the membrane, particular polypeptide ligands or their receptors, or both, may translocate to the nucleus to participate directly in gene regulation.

Nuclear targeting by growth factors, cytokines, and their receptors: a role in signaling?

The role of membrane receptors is regarded as being to transduce the signal represented by ligand binding from the external cell surface across the membrane into the cell. Signals are subsequently conveyed from the cytoplasm to the nucleus through a combination of second-messenger molecules, kinase/phosphorylation cascades, and transcription factor (TF) translocation to effect changes in gene expression. Mounting evidence suggests that through direct targeting to the nucleus, polypeptide ligands and their receptors may have an important additional signaling role. Ligands such as those of the platelet-derived and fibroblast growth factor classes, as well as cytokines such as interferon-gamma and interleukins-1 and -5, have been found to localize in the nucleus through the action of nuclear localization sequences (NLSs). Where tested, these NLSs appear to be essential for full signaling activity and may be responsible for cotranslocating receptors to the nucleus in complexes with their ligands. The implication is that, subsequent to endocytosis at the membrane, particular polypeptide ligands or their receptors, or both, may translocate to the nucleus to participate directly in gene regulation.

The use of confocal microscopy in the investigation of cell structure and function in the heart, vascular endothelium and smooth muscle cells

In recent years, fluorescence microscopy imaging has become an important tool for studying cell structure and function. This non invasive technique permits characterization, localisation and qualitative quantification of free ions, messengers, pH, voltage and a pleiad of other molecules constituting living cells. In this paper, we present results using various commercially available fluorescent probes as well as some developed in our laboratory and discuss the advantages and limitations of these probes in confocal microscopy studies of the cardiovascular system.

Interleukin-1-producing plasma cells in close contact with hepatocytes in patients with chronic active hepatitis

BACKGROUND/AIMS

In chronic active liver diseases (CALD) with viral aetiology, a population of plasma cells localised in the piecemeal necrosis areas was previously detected by means of autoradiography after in vitro 3H-proline incorporation, a method which proved much more sensitive than conventional immunohistochemical procedures. These plasma cells, characteristically located in niches among hepatocytes, in close contact with collagen fibrils, have been hypothesised to exert a role in fibrogenesis stimulation, and particularly in collagen synthesis, possibly through secretion of lymphokines. Specifically, we investigated the presence of interleukin-1, well known to play a crucial role in inflammation and production of collagen by epithelial cells, and to be present in activated plasma cells of myeloma.

METHODS

The immunohistochemical localisation of interleukin-1beta in biopsies of patients suffering from chronic active hepatitis was studied, using an affinity-purified rabbit polyclonal antibody.

RESULTS

The strongest interleukin-1beta immunostaining was observed in the above-described plasma cell population, identified by anti-immunoglobulin antibodies, and 3H-proline incorporation.

CONCLUSIONS

The ability of plasma cells to produce interleukin-1 during viral CALD suggests that in these pathologies plasma cells play a major role, mainly of paracrine nature. Interleukin-1, possibly together with other mediators, might in turn stimulate the production of collagen. Hepatocytes of the piecemeal necrosis area appear to be possible candidates for this synthesis, as they show a significant labelling after 3H-proline incorporation, which is absent from hepatocytes far from necrotic areas.

Bradykinin activates R-, T-, and L-type Ca2+ channels and induces a sustained increase of nuclear Ca2+ in aortic vascular smooth muscle cells

The mechanism(s) fo Ca2+ entry stimulated by bradykinin (BK) and the receptor subtype responsible for this effect were examined in human and rabbit aortic vascular smooth muscle cells (VSMCs). Using the whole-cell voltage clamp technique, BK (10(-6)M) significantly (p < 0.05) increased both T- and L-type Ca2+ currents (ICa) in rabbit aortic VSMCs. Using the fura-2 total intracellular Ca2+ ([Ca]i) measurement technique, BK (10(-6) M) induced a transient increase of [Ca]i followed by a sustained component. Pretreatment of rabbit VSMCs with sarcoplasmic reticulum (SR) Ca2+ releaser caffeine (1-5 mM) significantly decreased the BK-induced transient increase of [Ca]i without affecting the sustained component induced by this hormone. This sustained phase was blocked by extracellular application of the Ca2+ chelator EGTA. Using the fluo-3 confocal microscopy Ca2+ measurement technique to localize cytosolic ([Ca]c) and nuclear ([Ca]n) free Ca2+ distribution, the resting sustained concentration of Ca2+ in the cytoplasm of rabbit and human aortic VSMCs was less than that in the nucleus. BK (10(-7) M) induced a nonsignificant sustained increase of [Ca]c but significant (p < 0.05) sustained increase of [Ca]n that was reversed but not prevented by the specific B1 receptor antagonist R126 (10(-6) M) as well as by the B2 receptor antagonist R817 (10(-6) M). In both VSMC preparations, the specific B1 agonist R211 (10(-9) to 10(-7) M) rapidly induced a nonsignificant increase of [Ca]c but a significant (p < 0.05) sustained increase of [Ca]n that was prevented but not reversed by the B1 selective antagonist R126 (10(-6) M). The sustained increase of [Ca]c and [Ca]n induced by BK and B1 receptor agonist was blocked by extracellular application of EGTA. These results strongly suggest that B1 and probably B2 receptors are functional in human and rabbit aortic VSMCs. BK-induced transient increase of [Ca]i is mainly due to the stimulation of T- and L-type Ica as well as to Ca2+ release from caffeine- and ryanodine-sensitive Ca2+ pools. The sustained component induced by the hormone or the B1 agonist is mainly nuclear and is due to the stimulation of Ca2+ influx through the R-type Ca2+ channels that are present at the sarcolemma and the nuclear membranes.

Proline-incorporating cells in chronic active liver diseases

The incorporation of 3H-proline in cells of liver biopsy specimens from patients with chronic active liver diseases has been studied by light and electron microscopic autoradiography. The labeled proline is incorporated by hepatocytes of the external rows of the residual liver lobule, by the cells of the proliferating bile ductule and very actively by the plasma cells localized at the boundary between the inflammatory infiltrate and the liver lobule. These plasma cells, which are often in close contact with the hepatocytes at the edge of the liver lobule, appear to be either negative or positive after the immunohistochemical tests for the k and lambda chains of immunoglobulins. Results are discussed in relation to both the synthesis of collagen and the role of the immunocompetent cells during the process of the piecemeal necrosis.