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Lukose R, Mazaharally M, Redline RW, Cox BJ. The Placenta Pathology Tool: an online application for understanding histopathologic lesions. Am J Obstet Gynecol 2024; 230:264-266. [PMID: 37531990 DOI: 10.1016/j.ajog.2023.07.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Rini Lukose
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Maria Mazaharally
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Raymond W Redline
- Departments of Pathology and Reproductive Biology, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Brian J Cox
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.
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Gonzalez FF, Voldal E, Comstock BA, Mayock DE, Goodman AM, Cornet MC, Wu TW, Redline RW, Heagerty P, Juul SE, Wu YW. Placental Histologic Abnormalities and 2-Year Outcomes in Neonatal Hypoxic-Ischemic Encephalopathy. Neonatology 2023; 120:760-767. [PMID: 37742617 PMCID: PMC10711751 DOI: 10.1159/000533652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/12/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE We aimed to examine the association between placental abnormalities and neurodevelopmental outcomes in a multicenter cohort of newborn infants with hypoxic-ischemic encephalopathy (HIE) that underwent therapeutic hypothermia. We hypothesized that subjects with acute placental abnormalities would have reduced risk of death or neurodevelopmental impairment (NDI) at 2 years of age after undergoing therapeutic hypothermia compared to subjects without acute placental changes. STUDY DESIGN Among 500 subjects born at ≥36 weeks gestation with moderate or severe HIE enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) Trial, a placental pathologist blinded to clinical information reviewed clinical pathology reports to determine the presence of acute only, chronic only, or both acute and chronic histologic abnormalities. We calculated adjusted relative risks (aRRs) for associations between placental pathologic abnormalities and death or NDI at age 2 years, adjusting for HIE severity, treatment assignment, and site. RESULT 321/500 subjects (64%) had available placental pathology reports. Placental abnormalities were characterized as acute only (20%), chronic only (21%), both acute and chronic (43%), and none (15%). The risk of death or NDI was not statistically different between subjects with and without an acute placental abnormality (46 vs. 53%, aRR 1.1, 95% confidence interval (CI): 0.9, 1.4). Subjects with two or more chronic lesions were more likely to have an adverse outcome than subjects with no chronic abnormalities, though this did not reach statistical significance (55 vs. 45%, aRR 1.24, 95% CI: 0.99, 1.56). CONCLUSION Placental pathologic findings were not independently associated with risk of death or NDI in subjects with HIE. The relationship between multiple chronic placental lesions and HIE outcomes deserves further study.
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Affiliation(s)
- Fernando F. Gonzalez
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Emily Voldal
- Department Biostatistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Bryan A. Comstock
- Department Biostatistics, University of Washington, Seattle, WA, USA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Amy M. Goodman
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
| | - Marie-Coralie Cornet
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Tai-Wei Wu
- Division of Neonatology, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Raymond W. Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Patrick Heagerty
- Department Biostatistics, University of Washington, Seattle, WA, USA
| | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Yvonne W. Wu
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA
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Redline RW, Roberts DJ, Parast MM, Ernst LM, Morgan TK, Greene MF, Gyamfi-Bannerman C, Louis JM, Maltepe E, Mestan KK, Romero R, Stone J. Placental pathology is necessary to understand common pregnancy complications and achieve an improved taxonomy of obstetrical disease. Am J Obstet Gynecol 2023; 228:187-202. [PMID: 35973475 PMCID: PMC10337668 DOI: 10.1016/j.ajog.2022.08.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 01/28/2023]
Abstract
The importance of a fully functioning placenta for a good pregnancy outcome is unquestioned. Loss of function can lead to pregnancy complications and is often detected by a thorough placental pathologic examination. Placental pathology has advanced the science and practice of obstetrics and neonatal-perinatal medicine by classifying diseases according to underlying biology and specific patterns of injury. Many past obstacles have limited the incorporation of placental findings into both clinical studies and day-to-day practice. Limitations have included variability in the nomenclature used to describe placental lesions, a shortage of perinatal pathologists fully competent to analyze placental specimens, and a troubling lack of understanding of placental diagnoses by clinicians. However, the potential use of placental pathology for phenotypic classification, improved understanding of the biology of adverse pregnancy outcomes, the development of treatment and prevention, and patient counseling has never been greater. This review, written partly in response to a recent critique published in a major obstetrics-gynecology journal, reexamines the role of placental pathology by reviewing current concepts of biology; explaining the most recent terminology; emphasizing the usefulness of specific diagnoses for obstetrician-gynecologists, neonatologists, and patients; previewing upcoming changes in recommendations for placental submission; and suggesting future improvements. These improvements should include further consideration of overall healthcare costs, cost-effectiveness, the clinical value added of placental assessment, improvements in placental pathology education and practice, and leveraging of placental pathology to identify new biomarkers of disease and evaluate novel therapies tailored to specific clinicopathologic phenotypes of both women and infants.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology and Reproductive Biology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center and Cleveland, OH.
| | - Drucilla J Roberts
- Department of Pathology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Mana M Parast
- Department of Pathology, Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA
| | - Linda M Ernst
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Terry K Morgan
- Department of Pathology and Obstetrics and Gynecology, Center for Developmental Health, Oregon Health Sciences University, Portland, OR
| | - Michael F Greene
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA
| | - Judette M Louis
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University South Florida, Tampa, FL
| | - Emin Maltepe
- Department of Pediatrics, University California, San Francisco, San Francisco, CA
| | - Karen K Mestan
- Department of Pediatrics and Neonatology, University of California, San Diego, School of Medicine and Rady Children's Hospital, San Diego, CA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland, Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI
| | - Joanne Stone
- Raquel and Jaime Gilinski Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
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Roberts DJ, Baergen RN, Boyd TK, Carreon CK, Duncan VE, Ernst LM, Faye-Petersen OM, Folkins AK, Hecht JL, Heerema-McKenney A, Heller DS, Linn RL, Polizzano C, Ravishankar S, Redline RW, Salafia CM, Torous VF, Castro EC. Neonatologist responsibility to ensure placentas are received for pathologic examination-response to comment on criteria for placental examination for obstetric and neonatal providers. Am J Obstet Gynecol 2023:S0002-9378(23)00067-4. [PMID: 36731816 DOI: 10.1016/j.ajog.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/03/2023]
Affiliation(s)
- Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St. WRN 219, Boston, MA 02114.
| | - Rebecca N Baergen
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY
| | - Theonia K Boyd
- Department of Pathology, Texas Children's Hospital, Houston, TX
| | | | - Virginia E Duncan
- Division of Women's Health, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL
| | - Linda M Ernst
- Department of Pathology, NorthShore University Health System, Evanstan, IL
| | - Ona M Faye-Petersen
- Departments of Pathology and Obstetrics and Gynecology, Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Ann K Folkins
- Department of Pathology, Stanford University and Stanford Healthcare, Stanford, CA
| | - Jonathon L Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | - Debra S Heller
- Department of Pathology, Rutgers New Jersey Medical School, Newark, NJ
| | - Rebecca L Linn
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Sanjita Ravishankar
- Case Western Reserve University School of Medicine, Clevelend, OH; Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Raymond W Redline
- Departments of Pathology and Reproductive Biology, Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - Vanda F Torous
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Eumenia C Castro
- Department of Pathology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
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5
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Roberts DJ, Baergen RN, Boyd TK, Carreon CK, Duncan VE, Ernst LM, Faye-Petersen OM, Folkins AK, Hecht JL, Heerema-McKenney A, Heller DS, Linn RL, Polizzano C, Ravishankar S, Redline RW, Salafia CM, Torous VF, Castro EC. Criteria for placental examination for obstetrical and neonatal providers. Am J Obstet Gynecol 2022; 228:497-508.e4. [PMID: 36549567 DOI: 10.1016/j.ajog.2022.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/28/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
Pathologic examination of the placenta can provide insight into likely (and unlikely) causes of antepartum and intrapartum events, diagnoses with urgent clinical relevance, prognostic information for mother and infant, support for practice evaluation and improvement, and insight into advancing the sciences of obstetrics and neonatology. Although it is true that not all placentas require pathologic examination (although alternative opinions have been expressed), prioritization of placentas for pathologic examination should be based on vetted indications such as maternal comorbidities or pregnancy complications in which placental pathology is thought to be useful for maternal or infant care, understanding pathophysiology, or practice modifications. Herein we provide placental triage criteria for the obstetrical and neonatal provider based on publications and expert opinion of 16 placental pathologists and a pathologists' assistant, formulated using a modified Delphi approach. These criteria include indications in which placental pathology has clinical relevance, such as pregnancy loss, maternal infection, suspected abruption, fetal growth restriction, preterm birth, nonreassuring fetal heart testing requiring urgent delivery, preeclampsia with severe features, or neonates with early evidence of multiorgan system failure including neurologic compromise. We encourage a focused gross examination by the provider or an attendant at delivery for all placentas and provide guidance for this examination. We recommend that any placenta that is abnormal on gross examination undergo a complete pathology examination. In addition, we suggest practice criteria for placental pathology services, including a list of critical values to be used by the relevant provider. We hope that these sets of triage indications, criteria, and practice suggestions will facilitate appropriate submission of placentas for pathologic examination and improve its relevance to clinical care.
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Affiliation(s)
- Drucilla J Roberts
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX.
| | - Rebecca N Baergen
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Theonia K Boyd
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Chrystalle Katte Carreon
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Virginia E Duncan
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Linda M Ernst
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Ona M Faye-Petersen
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Ann K Folkins
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Jonathon L Hecht
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Amy Heerema-McKenney
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Debra S Heller
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Rebecca L Linn
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Carolyn Polizzano
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Sanjita Ravishankar
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Raymond W Redline
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Carolyn M Salafia
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Vanda F Torous
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Eumenia C Castro
- Massachusetts General Hospital Department of Pathology and Harvard Medical School, Boston, MA; Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY; Texas Children's Hospital Department of Pathology, Houston, TX; Boston's Children's Hospital Department of Pathology and Harvard Medical School, Boston, MA; University of Alabama at Birmingham Department of Pathology, Division of Women's Health, Birmingham, AL; NorthShore University Health System, Department of Pathology, Evanston, IL; Heersink School of Medicine, University of Alabama at Birmingham, Departments of Pathology and Obstetrics and Gynecology, Birmingham, AL; Stanford Healthcare Department of Pathology and Stanford University, Stanford, CA; Beth Israel Deaconess Medical Center Department of Pathology and Harvard Medical School, Boston, MA; Cleveland Clinic, Cleveland, OH; Rutgers-New Jersey Medical School, Newark, NJ; Children's Hospital of Philadelphia, Department of Pathology, Philadelphia, PA; MidState Medical Center Department of Pathology, Meriden, CT; Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center Department of Pathology, Cleveland, OH; Case Western Reserve University School of Medicine Departments of Pathology and Reproductive Biology and University Hospitals Cleveland Medical Center, Cleveland, OH; Placental Analytics LLC, New Rochelle, NY; Texas Children's Hospital and Baylor College of Medicine, Department of Pathology, Houston, TX
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6
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Redline RW, Ravishankar S, Bagby C, Saab S, Zarei S. Diffuse and Localized SARS-CoV-2 Placentitis: Prevalence and Pathogenesis of an Uncommon Complication of COVID-19 Infection During Pregnancy. Am J Surg Pathol 2022; 46:1036-1047. [PMID: 35319524 PMCID: PMC9281407 DOI: 10.1097/pas.0000000000001889] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Coronavirus disease 2019 (COVID-19) infection in pregnancy has been associated with preterm delivery and preeclampsia. A less frequent and underrecognized complication is extensive placental infection which is associated with high rates of perinatal morbidity and mortality. The frequency, early pathogenesis, and range of lesions associated with this infection are poorly understood. We conducted a population-based study of placental pathology from all mothers with COVID-19 (n=271) over an 18-month period delivering within our health system. The overall prevalence of diffuse severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) placentitis, as defined by typical histology and immunohistochemical (IHC) staining for SARS-CoV-2 spike protein, was 14.8/1000, but increased to 59/1000 in preterm births. We also identified 3 cases with isolated small foci of localized SARS-CoV-2 placentitis, characterized by focal perivillous fibrin and intervillositis, which illustrate the early pathogenesis and suggest that infection may be contained in some cases. Two other placental lesions were more common in mothers with COVID-19, high-grade maternal vascular malperfusion in preterm deliveries and high-grade chronic villitis at term (5/5 cases tested of the latter were negative by IHC for SARS-CoV-2). Additional investigation of diffuse and localized SARS-CoV-2 placentitis by IHC showed loss of BCL-2, C4d staining in surrounding villi, and an early neutrophil-predominant intervillous infiltrate that later became dominated by monocyte-macrophages. We propose a model of focal infection of syncytiotrophoblast by virally infected maternal leukocytes leading to loss of BCL-2 and apoptosis. Infection is then either contained by surrounding fibrinoid (localized) or initiates waves of aponecrosis and immune activation that spread throughout the villous parenchyma (diffuse).
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Affiliation(s)
- Raymond W. Redline
- Department of Pathology, University Hospitals Cleveland Medical Center
- Departments of Pathology
- Reproductive Biology, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sanjita Ravishankar
- Department of Pathology, University Hospitals Cleveland Medical Center
- Departments of Pathology
| | - Christina Bagby
- Department of Pathology, University Hospitals Cleveland Medical Center
- Departments of Pathology
| | - Shahrazad Saab
- Department of Pathology, University Hospitals Cleveland Medical Center
- Departments of Pathology
| | - Shabnam Zarei
- Department of Pathology, University Hospitals Cleveland Medical Center
- Departments of Pathology
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7
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Redman EK, Thorpe J, Hackney DN, Redline RW, Wilson RA, Presicce P, Kallapur SG, Mesiano SA. Chorioamnionitis grade correlates with myometrial leukocyte infiltration and pro-labor progesterone receptor modification. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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8
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Redline RW. Placental pathology: Pathways leading to or associated with perinatal brain injury in experimental neurology, special issue: Placental mediated mechanisms of perinatal brain injury. Exp Neurol 2021; 347:113917. [PMID: 34748755 DOI: 10.1016/j.expneurol.2021.113917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 11/04/2022]
Abstract
Perinatal brain injury is a multifactorial process. In utero placental physiology plays a major role in neuroprotection and the normal development of the fetal central nervous system. Advances in placental pathology have clarified several specific mechanisms of injury and the histologic lesions most strongly associated with them. This review provides an updated summary of the relevant placental anatomy and physiology, the specific placental pathways leading to brain injury, the revised Amsterdam classification system for placental pathology, and the known associations of specific placental lesions with subtypes of adverse neurologic outcomes.
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Affiliation(s)
- Raymond W Redline
- Case Western Reserve University School of Medicine, Departments of Pathology and Reproductive Biology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, United States of America.
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9
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Chalak L, Redline RW, Goodman AM, Juul SE, Chang T, Yanowitz TD, Maitre N, Mayock DE, Lampland AL, Bendel-Stenzel E, Riley D, Mathur AM, Rao R, Van Meurs KP, Wu TW, Gonzalez FF, Flibotte J, Mietzsch U, Sokol GM, Ahmad KA, Baserga M, Weitkamp JH, Poindexter BB, Comstock BA, Wu YW. Acute and Chronic Placental Abnormalities in a Multicenter Cohort of Newborn Infants with Hypoxic-Ischemic Encephalopathy. J Pediatr 2021; 237:190-196. [PMID: 34144032 DOI: 10.1016/j.jpeds.2021.06.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/28/2021] [Accepted: 06/14/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the frequency of placental abnormalities in a multicenter cohort of newborn infants with hypoxic-ischemic encephalopathy (HIE) and to determine the association between acuity of placental abnormalities and clinical characteristics of HIE. STUDY DESIGN Infants born at ≥36 weeks of gestation (n = 500) with moderate or severe HIE were enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy Trial. A placental pathologist blinded to clinical information reviewed clinical pathology reports to determine the presence of acute and chronic placental abnormalities using a standard classification system. RESULTS Complete placental pathologic examination was available for 321 of 500 (64%) trial participants. Placental abnormalities were identified in 273 of 321 (85%) and were more common in infants ≥40 weeks of gestation (93% vs 81%, P = .01). A combination of acute and chronic placental abnormalities (43%) was more common than either acute (20%) or chronic (21%) abnormalities alone. Acute abnormalities included meconium staining of the placenta (41%) and histologic chorioamnionitis (39%). Chronic abnormalities included maternal vascular malperfusion (25%), villitis of unknown etiology (8%), and fetal vascular malperfusion (6%). Infants with chronic placental abnormalities exhibited a greater mean base deficit at birth (-15.9 vs -14.3, P = .049) than those without such abnormalities. Patients with HIE and acute placental lesions had older mean gestational ages (39.1 vs 38.0, P < .001) and greater rates of clinically diagnosed chorioamnionitis (25% vs 2%, P < .001) than those without acute abnormalities. CONCLUSIONS Combined acute and chronic placental abnormalities were common in this cohort of infants with HIE, underscoring the complex causal pathways of HIE. TRIAL REGISTRATION ClinicalTrials.gov: NCT02811263.
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Affiliation(s)
- Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Raymond W Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Amy M Goodman
- Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington School of Medicine, Washington, DC
| | - Toby D Yanowitz
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC and Magee Womens Hospital of UPMC, Pittsburgh, PA
| | - Nathalie Maitre
- Department of Pediatrics and Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | | | - Ellen Bendel-Stenzel
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - David Riley
- Department of Pediatrics, Cook Children's Medical Center, Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, TX
| | - Amit M Mathur
- Department of Pediatrics/Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St Louis, MO
| | - Rakesh Rao
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Tai-Wei Wu
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fernando F Gonzalez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Gregory M Sokol
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Brenda B Poindexter
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA
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10
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Redline RW, Vik T, Heerema-McKenney A, Jamtoy AH, Ravishankar S, Ton Nu TN, Vogt C, Ng P, Nelson KB, Lydersen S, Oskoui M. Interobserver Reliability for Identifying Specific Patterns of Placental Injury as Defined by the Amsterdam Classification. Arch Pathol Lab Med 2021; 146:372-378. [PMID: 34252177 DOI: 10.5858/arpa.2020-0753-oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Placental pathology is an essential tool for understanding neonatal illness. The recent Amsterdam international consensus has standardized criteria and terminology, providing harmonized data for research and clinical care. OBJECTIVE.— To evaluate the interobserver reliability of these criteria between pathologists at different levels of experience using digitally scanned slides from placentas in a birth population including a large proportion of normal deliveries. DESIGN.— This was a secondary analysis of selected placentas from a large case-control study of placental lesions associated with neonatal encephalopathy. Histologic slides from 80 placentas were digitally scanned and blindly evaluated by 6 pathologists. Interobserver reliability was assessed by positive and negative agreement, Fleiss κ, and interrater correlation coefficients. RESULTS.— Overall agreement on the diagnosis, grading, and staging of acute chorioamnionitis and villitis of unknown etiology was moderate to good for all observers and good to excellent for a subset of 4 observers. Agreement on the diagnosis and subtyping of fetal vascular malperfusion was poor to fair for all observers and fair to moderate for the subset of 4 pathologists. Agreement on accelerated villous maturation was poor. CONCLUSIONS.— This study critically evaluates interobserver reliability for lesions defined by the Amsterdam consensus using scanned images with a low frequency of pathologic lesions. Although reliability was good to excellent for inflammatory lesions, lower reliability for vascular lesions emphasizes the need to more explicitly define the specific histologic features and boundaries for these patterns.
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Affiliation(s)
- Raymond W Redline
- From the Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Redline, Ravishankar)
| | - Torstein Vik
- The Department of Clinical and Molecular Medicine (Vik, Vogt), Norwegian University of Science and Technology, Trondheim, Norway
| | - Amy Heerema-McKenney
- The Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Heerema-McKenney)
| | - Ann-Helen Jamtoy
- The Department of Pathology, St Olavs Hospital, Trondheim University Hospital, Norway (Jamtoy, Vogt)
| | - Sanjita Ravishankar
- From the Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Redline, Ravishankar)
| | | | - Christina Vogt
- The Department of Clinical and Molecular Medicine (Vik, Vogt), Norwegian University of Science and Technology, Trondheim, Norway.,The Department of Pathology, St Olavs Hospital, Trondheim University Hospital, Norway (Jamtoy, Vogt)
| | - Pamela Ng
- The Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada (Ng)
| | - Karin B Nelson
- The National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (Nelson)
| | - Stian Lydersen
- Department of Mental Health (Lydersen), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Maryam Oskoui
- The Departments of Pediatrics and Neurology and Neurosurgery (Oskoui), McGill University, Montreal, Quebec, Canada
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11
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Redline RW, Ravishankar S, Bagby CM, Saab ST, Zarei S. Four major patterns of placental injury: a stepwise guide for understanding and implementing the 2016 Amsterdam consensus. Mod Pathol 2021; 34:1074-1092. [PMID: 33558658 DOI: 10.1038/s41379-021-00747-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/09/2021] [Accepted: 01/09/2021] [Indexed: 01/05/2023]
Abstract
The Amsterdam classification system defines four major patterns of placental injury, maternal vascular malperfusion, fetal vascular malperfusion, acute chorioamnionitis, and villitis of unknown etiology, and lists the histologic findings that characterize each. However, there continues to be uncertainty regarding specific definitions, histologic mimics, grading and staging, and what combination of findings is required to diagnose each pattern of injury in a reproducible fashion. The purpose of this review is to clarify some of these issues by suggesting a stepwise approach to more fully realize the potential of this new classification system. In our view, the critical steps for correctly identifying and communicating each pattern of injury are (1) familiarity with the underlying pathophysiology and known clinical associations, (2) incorporation of important gross findings, (3) learning to recognize underlying architectural alterations and defining features at low power, (4) using higher magnification to narrow the differential diagnosis and assess severity (grading) and duration (staging), and (5) adopting a template for generating standardized placental reports that succinctly provide useful information for patient care and research applications.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, USA. .,Department of Reproductive Biology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Sanjita Ravishankar
- Department of Pathology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christina M Bagby
- Department of Pathology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Shahrazad T Saab
- Department of Pathology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Shabnam Zarei
- Department of Pathology, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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12
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Zeiad RKHM, Ferren EC, Young DD, De Lancy SJ, Dedousis D, Schillaci LA, Redline RW, Saab ST, Crespo M, Bhatti TR, Ackermann AM, Bedoyan JK, Wood JR. A Novel Homozygous Missense Mutation in the YARS Gene: Expanding the Phenotype of YARS Multisystem Disease. J Endocr Soc 2021; 5:bvaa196. [PMID: 33490854 PMCID: PMC7806200 DOI: 10.1210/jendso/bvaa196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Indexed: 12/31/2022] Open
Abstract
Aminoacyl-tRNA synthetases (ARSs) are crucial enzymes for protein translation. Mutations in genes encoding ARSs are associated with human disease. Tyrosyl-tRNA synthetase is encoded by YARS which is ubiquitously expressed and implicated in an autosomal dominant form of Charcot-Marie-Tooth and autosomal recessive YARS-related multisystem disease. We report on a former 34-week gestational age male who presented at 2 months of age with failure to thrive (FTT) and cholestatic hepatitis. He was subsequently diagnosed with hyperinsulinemic hypoglycemia with a negative congenital hyperinsulinism gene panel and F-DOPA positron-emission tomography (PET) scan that did not demonstrate a focal lesion. Autopsy findings were notable for overall normal pancreatic islet size and morphology. Trio whole exome sequencing identified a novel homozygous variant of uncertain significance in YARS (c.611A > C, p.Tyr204Cys) with each parent a carrier for the YARS variant. Euglycemia was maintained with diazoxide (max dose, 18 mg/kg/day), and enteral dextrose via gastrostomy tube (G-Tube). During his prolonged hospitalization, the patient developed progressive liver disease, exocrine pancreatic insufficiency, acute renal failure, recurrent infections, ichthyosis, hematologic concerns, hypotonia, and global developmental delay. Such multisystem features have been previously reported in association with pathogenic YARS mutations. Although hypoglycemia has been associated with pathogenic YARS mutations, this report provides more conclusive data that a YARS variant can cause hyperinsulinemic hypoglycemia. This case expands the allelic and clinical heterogeneity of YARS-related disease. In addition, YARS-related disease should be considered in the differential of hyperinsulinemic hypoglycemia associated with multisystem disease.
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Affiliation(s)
- Rawah K H M Zeiad
- Division of Pediatric Endocrinology, Department of Pediatrics, University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Case Western University School of Medicine, Cleveland, OH, USA
| | - Edwin C Ferren
- Department of Genetics and Genome Sciences and Center for Human Genetics, University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Case Western University School of Medicine, Cleveland, OH, USA
| | - Denise D Young
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Case Western University School of Medicine, Cleveland, OH, USA
| | - Shanelle J De Lancy
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, USA
| | - Demitrios Dedousis
- Department of Genetics and Genome Sciences and Center for Human Genetics, University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Case Western University School of Medicine, Cleveland, OH, USA
| | - Lori-Anne Schillaci
- Department of Genetics and Genome Sciences and Center for Human Genetics, University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Case Western University School of Medicine, Cleveland, OH, USA
| | - Raymond W Redline
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, USA
| | - Shahrazad T Saab
- Department of Pathology, Case Western University School of Medicine, Cleveland, OH, USA
| | - Maricruz Crespo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Case Western University School of Medicine, Cleveland, OH, USA
| | - Tricia R Bhatti
- Department of Pathology and Laboratory, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda M Ackermann
- Division of Endocrinology and Diabetes, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jirair K Bedoyan
- Department of Genetics and Genome Sciences and Center for Human Genetics, University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Case Western University School of Medicine, Cleveland, OH, USA
| | - Jamie R Wood
- Division of Pediatric Endocrinology, Department of Pediatrics, University Hospitals Cleveland Medical Center/Rainbow Babies and Children's Hospital, Case Western University School of Medicine, Cleveland, OH, USA
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13
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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14
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Abstract
The placenta can serve as a valuable source of information about maternal and fetal conditions during the pregnancy; however, the abilities to perform a preliminary gross examination and interpret a placental pathology report are variable among obstetricians. This article discusses the indications for placental submission to pathology; the essentials of gross examination, including elements that should be performed in the delivery suite; and the most common and clinically relevant histologic findings that may be encountered in the report.
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Affiliation(s)
- Sanjita Ravishankar
- Department of Pathology, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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15
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Zhou YY, Ravishankar S, Luo G, Redline RW. Predictors of High Grade and Other Clinically Significant Placental Findings by Indication for Submission in Singleton Placentas From Term Births. Pediatr Dev Pathol 2020; 23:274-284. [PMID: 32146874 DOI: 10.1177/1093526620904801] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Indications for placental submission are variable. Established guidelines are largely based on expert opinion, and there is a need for more evidence-based criteria. A 10-year database of term placentas was used to evaluate indications significantly associated with placental pathology. Lesions in 5 categories were separated into high- and low-grade subgroups. Two additional high-grade lesions were also evaluated. Indications associated with high-grade placental lesions were chronic monitoring abnormalities, severe preeclampsia, pregestational diabetes, maternal signs of infection, postdates pregnancy, artificial reproductive technology, drug abuse, umbilical cord entanglements, selected gross placental abnormalities, stillbirth, Apgar 5 minutes <6, small-for-gestational age infant, and macrosomia. Indications for which placental findings did not differ from the population as a whole were acute monitoring abnormalities, chronic hypertension, maternal obesity, vaginal bleeding, accessory lobe/multilobed placenta, meconium-stained fluid, single umbilical artery, and borderline large-for-gestational age infant. Other indications for submission were intermediate showing significant or borderline elevations in the prevalence of low- and high-grade lesions combined. We suggest on the basis of this study that guidelines for the submission of singleton term placentas could be modified to exclude cases with clinical indications that lack a significant association with placental lesions.
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Affiliation(s)
- Yi Yuan Zhou
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Sanjita Ravishankar
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Guangju Luo
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Raymond W Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,School of Medicine, Case Western Reserve University, Cleveland, Ohio
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16
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Miller AK, Azhibekov T, O'Toole JF, Sedor JR, Williams SM, Redline RW, Bruggeman LA. Association of preeclampsia with infant APOL1 genotype in African Americans. BMC Med Genet 2020; 21:110. [PMID: 32434471 PMCID: PMC7238556 DOI: 10.1186/s12881-020-01048-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/10/2020] [Indexed: 12/26/2022]
Abstract
Background Black women in the United States and Africa are at an increased risk for preeclampsia. Allelic variants in the gene for apolipoprotein LI, APOL1, are found only in populations of African ancestry, and have been shown to contribute significant risk for kidney disease. Recent studies suggest these APOL1 variants also may contribute risk for preeclampsia. Methods The association of preeclampsia with carriage of APOL1 risk alleles was evaluated in a case-control study of deliveries from black women at a single center in Cleveland, Ohio that included gross and histopathologic evaluations of placental tissues (395 cases and 282 controls). Using logistic regression models, associations between fetal APOL1 genotype and preeclampsia were evaluated using several case definitions based on prematurity and severity of preeclampsia, with uncomplicated term pregnancies as controls. Associations between APOL1 genotype and pathological features were also examined. Results The infant APOL1 genotype was significantly associated with preeclampsia in a dominant inheritance pattern with odds ratio of 1.41 (P=0.029, 95% CI 1.037, 1.926). Stratifying preeclampsia cases by preterm birth, significant associations were detected for both recessive (O.R.=1.70, P=0.038) and additive (O.R.=1.33, P=0.028) inheritance patterns. APOL1 genotype, however, was not significantly associated with pathological changes or other perinatal observations. Conclusions Preeclampsia appears to be another disease associated with APOL1 variants, however, further studies are needed to increase confidence in the mode of inheritance. By understanding the association of APOL1 variants with preeclampsia, genetic screening tests for APOL1 may be useful to predict at-risk pregnancies and targeted interventions may be developed to improve pregnancy outcomes.
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Affiliation(s)
- Anna K Miller
- Department of Genetics and Genome Sciences, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Timur Azhibekov
- Division of Neonatology, Department of Pediatrics, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, USA
| | - John F O'Toole
- Departments of Inflammation and Immunity and Nephrology, Cleveland Clinic, Case Western Reserve University School of Medicine, Cleveland, USA
| | - John R Sedor
- Departments of Inflammation and Immunity and Nephrology, Cleveland Clinic, Case Western Reserve University School of Medicine, Cleveland, USA.,Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Scott M Williams
- Department of Genetics and Genome Sciences, Case Western Reserve University School of Medicine, Cleveland, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Raymond W Redline
- Departments of Pathology and Reproductive Biology, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Leslie A Bruggeman
- Departments of Inflammation and Immunity and Nephrology, Cleveland Clinic, Case Western Reserve University School of Medicine, Cleveland, USA.
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17
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Abstract
UPDATE This article was updated on December 17, 2019, because a new reference was added post-publication. This new reference (Niemeier TE, Leddy LR, Chapin RW, Smith TM. Metachronous Aneurysmal Bone Cysts in a Fourteen-Year-Old Girl: A Case Report and Review of the Literature. JBJS Case Connect. 2013 Jun 12;3[2 Suppl 8]:1-7) has been inserted as reference 26, and the original references 26 and 29 through 35 have been renumbered accordingly. Additionally, Table I and several passages in the text have been updated to reflect the addition of the new reference. Specifically, in Table I, the study by Niemeier et al. has been inserted as the fifth row between the "Amer et al." and "Current case" rows. On page 3, the text that had read "To our knowledge, there are only 4 published cases of metachronous, polyostotic ABCs in 4 male patients-. The longest documented interval between clinical presentation of the first and second lesions is 15 years, whereas the shortest interval is 15 months." now reads "To our knowledge, there are only 5 published cases of metachronous, polyostotic ABCs in 4 male patients and 1 female patient-. The longest documented interval between clinical presentation of the first and second lesions is 15 years, whereas the shortest interval is 3 months." On page 7, the passage that had read "However, to our knowledge, there are only 4 published cases of metachronous, polyostotic ABCs, and all patients were males-. The current case demonstrates that females may also develop polyostotic disease. None of the 4 previously reported cases of metachronous, polyostotic ABCs demonstrated a previous history of malignancy-." now reads "However, to our knowledge, there are only 5 published cases of metachronous, polyostotic ABCs with only 1 case describing lesions in a female patient-. This is the second case demonstrating that females may also develop polyostotic disease. None of the 5 previously reported cases of metachronous, polyostotic ABCs demonstrated a previous history of malignancy-." Also on page 7, the sentence that had read "Metachronous ABCs are rare and have been reported to present anywhere from 15 months to 15 years after diagnosis of the initial lesion,." now reads "Metachronous ABCs are rare and have been reported to present anywhere from 3 months to 15 years after diagnosis of the initial lesion-."An erratum has been published: JBJS Case Connect. 2019 Dec 26;9(4):e0263ER. CASE We present a case involving an adolescent female who developed metachronous, polyostotic aneurysmal bone cysts (ABCs) of the left hemipelvis and left proximal tibia within a 16-month interval. At age 12 years, the left periacetabular ABC was initially treated with selective arterial embolization and percutaneous sclerotherapy, followed by intralesional curettage and bone grafting. At age 14 years, the left proximal tibia ABC was treated with intralesional curettage, bone grafting, and prophylactic internal fixation. She showed no evidence of recurrence of either lesion after 32 and 12 months, respectively. CONCLUSIONS Metachronous, polyostotic ABCs may occur in females. Metachronous lesions may present years after the initial ABC; therefore, additional imaging to rule out polyostotic disease is not indicated in the routine management of a solitary ABC. Patients with multiple ABCs should be managed by following the standard approach for treatment of each lesion.
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Affiliation(s)
- William M Naylor
- Department of Orthopaedic Surgery, University Hospitals Regional Hospitals, Richmond Heights, Ohio.,Department of Orthopaedic Surgery, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Christopher D Collier
- Department of Orthopaedic Surgery, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Raymond W Redline
- Department of Pathology, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Patrick J Getty
- Department of Orthopaedic Surgery, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, Ohio
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18
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Abstract
Examination of the placenta provides a unique opportunity to explore and understand the intrauterine environment, as well as providing a record of events that may be associated with adverse pregnancy outcomes, one of the most devastating of which is central nervous system (CNS) injury. A number of placental lesions have been described in association with various forms of neurologic injury. They can be divided into four major categories: sentinel events, inflammatory lesions, vascular lesions, and "biomarker" lesions, which are not themselves causative, but are often found in association with other lesions that are causative. The purpose of this review is to outline these placental lesions and summarize the types of CNS injury that have been described in association with each. Finally, one of the most important of all risk factors for CNS injury is the finding of multiple independent placental lesions. The effects of these lesions may be synergistic, particularly when metachronous, with an earlier lesion leaving the CNS more vulnerable to the effects of a later lesion.
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Affiliation(s)
- Sanjita Ravishankar
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
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19
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Affiliation(s)
- Raymond W. Redline
- Department of Pathology; University Hospitals Cleveland Medical Center; Cleveland OH USA
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20
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Abstract
Fetal vascular malperfusion is the most recent term applied to a group of placental lesions indicating reduced or absent perfusion of the villous parenchyma by the fetus. The most common etiology of malperfusion is umbilical cord obstruction leading to stasis, ischemia, and in some cases thrombosis. Other contributing factors may include maternal diabetes, fetal cardiac insufficiency or hyperviscosity, and inherited or acquired thrombophilias. Severe or high grade fetal vascular malperfusion is an important risk factor for adverse pregnancy outcomes including fetal growth restriction, fetal CNS injury, and stillbirth. Overall recurrence risk for subsequent pregnancies is low.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sanjita Ravishankar
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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21
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Lamm KYB, Johnson ML, Baker Phillips J, Muntifering MB, James JM, Jones HN, Redline RW, Rokas A, Muglia LJ. Inverted formin 2 regulates intracellular trafficking, placentation, and pregnancy outcome. eLife 2018; 7. [PMID: 29309034 PMCID: PMC5758111 DOI: 10.7554/elife.31150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/12/2017] [Indexed: 12/17/2022] Open
Abstract
Healthy pregnancy depends on proper placentation-including proliferation, differentiation, and invasion of trophoblast cells-which, if impaired, causes placental ischemia resulting in intrauterine growth restriction and preeclampsia. Mechanisms regulating trophoblast invasion, however, are unknown. We report that reduction of Inverted formin 2 (INF2) alters intracellular trafficking and significantly impairs invasion in a model of human extravillous trophoblasts. Furthermore, global loss of Inf2 in mice recapitulates maternal and fetal phenotypes of placental insufficiency. Inf2-/- dams have reduced spiral artery numbers and late gestational hypertension with resolution following delivery. Inf2-/- fetuses are growth restricted and demonstrate changes in umbilical artery Doppler consistent with poor placental perfusion and fetal distress. Loss of Inf2 increases fetal vascular density in the placenta and dysregulates trophoblast expression of angiogenic factors. Our data support a critical regulatory role for INF2 in trophoblast invasion-a necessary process for placentation-representing a possible future target for improving placentation and fetal outcomes.
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Affiliation(s)
- Katherine Young Bezold Lamm
- Center for the Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, United States.,Molecular and Developmental Biology Graduate Program, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, United States.,Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Maddison L Johnson
- Department of Biological Sciences, Vanderbilt University, Nashville, United States
| | - Julie Baker Phillips
- Department of Biological Sciences, Vanderbilt University, Nashville, United States
| | - Michael B Muntifering
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Jeanne M James
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Helen N Jones
- Molecular and Developmental Biology Graduate Program, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Raymond W Redline
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, United States
| | - Antonis Rokas
- Department of Biological Sciences, Vanderbilt University, Nashville, United States
| | - Louis J Muglia
- Center for the Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, United States.,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
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22
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Grimberg DC, Lau LW, Dahoud W, Couturier S, Redline RW, Kim AC. Pediatric Crohn's disease presenting with a large calcified pelvic mass. Journal of Pediatric Surgery Case Reports 2017. [DOI: 10.1016/j.epsc.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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23
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Shojaei H, Hong H, Redline RW. High-level expression of divergent endodermal lineage markers in gonadal and extra-gonadal yolk sac tumors. Mod Pathol 2016; 29:1278-88. [PMID: 27443515 DOI: 10.1038/modpathol.2016.131] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 11/09/2022]
Abstract
Yolk sac tumors occur at both gonadal and extra-gonadal sites. A recent case of ovarian endometrioid-pattern yolk sac tumor with strong diffuse expression of TTF-1 illustrated the potential for misdiagnosis due to divergent expression of endodermal lineage markers. The aim of this study was to investigate the expression of four divergent endodermal lineage markers, TTF-1, CDX2, Hep Par 1, and Napsin A, in gonadal and extra-gonadal yolk sac tumors of differing age, sex, and location (excluding foci of overt hepatoid differentiation). We identified 26 cases (5 ovarian, 15 testicular, and 6 extra-gonadal) containing yolk sac tumor as identified by typical histology and confirmed by positive immunohistochemical staining for alpha-fetoprotein and glypican-3. Mixed or ambiguous foci were confirmed by immunohistochemistry (SALL4 positive and Oct-4 negative). The relative proportion of three histologic patterns: reticular/cystic, solid/myxoid, and glandular was estimated. Percent positivity for the four divergent endodermal lineage markers was compared within yolk sac tumor areas according to site, age group, and histologic pattern. High-level (>25%) staining for one or more divergent endodermal lineage markers was seen in eleven cases: Hep Par 1 in seven cases, all post-pubertal, TTF-1 in four cases, two ovarian and two extra-gonadal, and CDX2 in three cases, with no age or site predilection. No case highly expressed all three divergent endodermal lineage markers, but four co-expressed high levels of two markers: two ovarian yolk sac tumors with TTF-1 and Hep Par 1, one testicular yolk sac tumor with CDX2 and Hep Par 1, and one extra-gonadal yolk sac tumors with TTF-1 and CDX2. While no absolute correlation of high-level divergent endodermal lineage marker expression with histologic subtype was observed, TTF-1 and CDX2 expression was predominantly seen in reticular/cystic and glandular areas while Hep Par 1 was most frequent in myxoid/solid and glandular areas.
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Affiliation(s)
- Hadi Shojaei
- Pathology Resident, Department of Pathology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Hong Hong
- Pathology Resident, Department of Pathology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Raymond W Redline
- Departments of Pathology and Reproductive Biology, University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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24
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Khong TY, Mooney EE, Ariel I, Balmus NCM, Boyd TK, Brundler MA, Derricott H, Evans MJ, Faye-Petersen OM, Gillan JE, Heazell AEP, Heller DS, Jacques SM, Keating S, Kelehan P, Maes A, McKay EM, Morgan TK, Nikkels PGJ, Parks WT, Redline RW, Scheimberg I, Schoots MH, Sebire NJ, Timmer A, Turowski G, van der Voorn JP, van Lijnschoten I, Gordijn SJ. Sampling and Definitions of Placental Lesions: Amsterdam Placental Workshop Group Consensus Statement. Arch Pathol Lab Med 2016; 140:698-713. [PMID: 27223167 DOI: 10.5858/arpa.2015-0225-cc] [Citation(s) in RCA: 941] [Impact Index Per Article: 117.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -The value of placental examination in investigations of adverse pregnancy outcomes may be compromised by sampling and definition differences between laboratories. OBJECTIVE -To establish an agreed-upon protocol for sampling the placenta, and for diagnostic criteria for placental lesions. Recommendations would cover reporting placentas in tertiary centers as well as in community hospitals and district general hospitals, and are also relevant to the scientific research community. DATA SOURCES -Areas of controversy or uncertainty were explored prior to a 1-day meeting where placental and perinatal pathologists, and maternal-fetal medicine specialists discussed available evidence and subsequently reached consensus where possible. CONCLUSIONS -The group agreed on sets of uniform sampling criteria, placental gross descriptors, pathologic terminologies, and diagnostic criteria. The terminology and microscopic descriptions for maternal vascular malperfusion, fetal vascular malperfusion, delayed villous maturation, patterns of ascending intrauterine infection, and villitis of unknown etiology were agreed upon. Topics requiring further discussion were highlighted. Ongoing developments in our understanding of the pathology of the placenta, scientific bases of the maternofetoplacental triad, and evolution of the clinical significance of defined lesions may necessitate further refinements of these consensus guidelines. The proposed structure will assist in international comparability of clinicopathologic and scientific studies and assist in refining the significance of lesions associated with adverse pregnancy and later health outcomes.
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Affiliation(s)
- T Yee Khong
- From SA Pathology, Women's and Children's Hospital, University of Adelaide, North Adelaide, Australia (Dr Khong); the Department of Pathology, National Maternity Hospital, Dublin, Ireland (Drs Mooney and Kelehan); the Department of Pathology, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel (Dr Ariel); the Department of Pathology, Kennemer Gasthuis, Haarlem, the Netherlands (Dr Balmus); the Department of Pathology, Boston Children's Hospital, and the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Boyd); the Departments of Pathology and Laboratory Medicine, and Pediatrics, University of Calgary, Calgary, Alberta, Canada (Dr Brundler); the Maternal & Fetal Health Research Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom (Ms Derricott); the Department of Pathology, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (Dr Evans); the Department of Pathology, University of Alabama at Birmingham, (Dr Faye-Petersen); the Department of Pathology, Rotunda Hospital, Dublin, Ireland (Dr Gillan); the Institute of Human Development, Faculty of Medical and Human Sciences
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25
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Mukherjee A, Chan ADC, Keating S, Redline RW, Fritsch MK, Machin GA, Cornejo-Palma D, de Nanassy J, El-Demellawy D, von Dadelszen P, Benton SJ, Grynspan D. The Placental Distal Villous Hypoplasia Pattern: Interobserver Agreement and Automated Fractal Dimension as an Objective Metric. Pediatr Dev Pathol 2016; 19:31-6. [PMID: 26275121 DOI: 10.2350/15-03-1619-oa.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The distal villous hypoplasia (DVH) pattern is a placental correlate of fetal growth restriction. Because the pattern seems to involve less complexity than do appropriately developed placental villi, we postulated that it may be associated with lower fractal dimension-a mathematical measure of complexity. Our study objectives were to evaluate interobserver agreement related to the DVH pattern among expert pathologists and to determine whether pathologist classification of DVH correlates with fractal dimension. A study set of 30 images of placental parenchyma at ×4 magnification was created by a single pathologist from a digital slide archive. The images were graded for the DVH pattern according to pre-specified definitions and included 10 images graded as "no DVH" (grade = 0), 10 with mild to moderate DVH (grade = 1), and 10 with severe DVH (grade = 2). The images were randomly sorted and shown to a panel of 4 international experts who similarly graded the images for DVH. Weighted kappas were calculated. For each image, fractal dimension was calculated by the Box Counting method. The correlation coefficient between (1) the averaged DVH scores obtained by the 5 pathologists and (2) fractal dimension was calculated. The mean weighted kappa score among the observers was 0.59 (range: 0.42-0.70). The correlation coefficient between fractal dimension and the averaged DVH score was -0.915 (P < 0.001). Expert pathologists achieve fair to substantial agreement in grading DVH, indicating consensus on the definition of DVH. Distal villous hypoplasia correlates extremely well with fractal dimension and represents an objective measure for DVH.
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Affiliation(s)
- Anika Mukherjee
- 1 Department of Pathology and Laboratory Medicine, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
| | - Adrian D C Chan
- 2 Department of Systems and Computer Engineering, Carleton University and Ottawa-Carleton Institute for Biomedical Engineering, Ottawa, ON, Canada
| | - Sarah Keating
- 3 Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Raymond W Redline
- 4 Department of Pathology, Case Western Reserve University, Cleveland, OH, USA
| | - Michael K Fritsch
- 5 Department of Pathology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Geoffrey A Machin
- 6 Professor Emeritus, Pediatric Pathology, University of Alberta, Edmonton, AB, Canada (Retired)
| | | | - Joseph de Nanassy
- 1 Department of Pathology and Laboratory Medicine, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
| | - Dina El-Demellawy
- 1 Department of Pathology and Laboratory Medicine, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
| | - Peter von Dadelszen
- 8 Department of Obstetrics & Gynaecology, University of British Columbia and BC Women's Hospital & Health Centre, Vancouver, BC, Canada
| | - Samantha J Benton
- 9 Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - David Grynspan
- 1 Department of Pathology and Laboratory Medicine, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
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26
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Bobanga ID, Redline RW, DeRoss AL. Oesophageal pseudodiverticulum after foregut duplication cyst excision: Case report and literature review. Afr J Paediatr Surg 2016; 13:50-3. [PMID: 27251526 PMCID: PMC4955461 DOI: 10.4103/0189-6725.181709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Oesophageal pseudodiverticula rarely occur after excision of benign oesophageal neoplasms. While management and outcomes have been reported in the adult leiomyoma literature, sparse data exist on the occurrence and management of pseudodiverticula after foregut duplication cyst excision. We discuss our experience with a paediatric patient and review relevant literature regarding operative techniques and surgical outcomes.
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Affiliation(s)
- Iuliana D Bobanga
- Department of General Surgery, University Hospital Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Raymond W Redline
- Department of Pathology, University Hospital Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Anthony L DeRoss
- Department of Pediatric Surgery, University Hospital Case Medical Center, Rainbow Babies and Children Hospital, Cleveland, Ohio, USA
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27
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Parikh A, Lee C, Joseph P, Marchini S, Baccarini A, Kolev V, Romualdi C, Fruscio R, Shah H, Wang F, Mullokandov G, Fishman D, D'Incalci M, Rahaman J, Kalir T, Redline RW, Brown BD, Narla G, DiFeo A. microRNA-181a has a critical role in ovarian cancer progression through the regulation of the epithelial-mesenchymal transition. Nat Commun 2015; 5:2977. [PMID: 24394555 PMCID: PMC3896774 DOI: 10.1038/ncomms3977] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 11/20/2013] [Indexed: 02/07/2023] Open
Abstract
Ovarian cancer is a leading cause of cancer deaths among women. Effective targets to treat advanced epithelial ovarian cancer (EOC) and biomarkers to predict treatment response are still lacking because of the complexity of pathways involved in ovarian cancer progression. Here we show that miR-181a promotes TGF-β-mediated epithelial-to-mesenchymal transition via repression of its functional target, Smad7. miR-181a and phosphorylated Smad2 are enriched in recurrent compared with matched-primary ovarian tumours and their expression is associated with shorter time to recurrence and poor outcome in patients with EOC. Furthermore, ectopic expression of miR-181a results in increased cellular survival, migration, invasion, drug resistance and in vivo tumour burden and dissemination. In contrast, miR-181a inhibition via decoy vector suppression and Smad7 re-expression results in significant reversion of these phenotypes. Combined, our findings highlight an unappreciated role for miR-181a, Smad7, and the TGF-β signalling pathway in high-grade serous ovarian cancer. Ovarian cancer is often diagnosed at a late stage when metastasis has already occurred. In this study, Parikh et al. show that mir-181a is involved in mediating the epithelial-to-mesenchymal transition in ovarian cancer, leading to activation of the TGF-β signalling pathway and metastasis.
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Affiliation(s)
- Aditya Parikh
- 1] Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA [2] Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA [3]
| | - Christine Lee
- 1] Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA [2] Case Comprehensive Cancer Center, Case Western Reserve University, 2103 Cornell Road, Cleveland, Ohio 44106, USA [3]
| | - Peronne Joseph
- Case Comprehensive Cancer Center, Case Western Reserve University, 2103 Cornell Road, Cleveland, Ohio 44106, USA
| | - Sergio Marchini
- Department of Oncology, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', via La Masa 19, 20156 Milano, Italy
| | - Alessia Baccarini
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - Valentin Kolev
- Department of Obstetrics and Gynecology, The Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - Chiara Romualdi
- Department of Biology, Universtia' degli studi di Padova, Via U.Bassi 58/B, Padova 35121, Italy
| | - Robert Fruscio
- 1] Clinic of Obstetrics and Gynecology, University of Milano-Bicocca, San Gerardo Hospital, 20900 Monza, Italy [2] MaNGO Group, 20156 Milano, Italy
| | - Hardik Shah
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - Feng Wang
- Department of Obstetrics and Gynecology, The Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - Gavriel Mullokandov
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - David Fishman
- Department of Obstetrics and Gynecology, The Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - Maurizio D'Incalci
- Department of Oncology, IRCCS-Istituto di Ricerche Farmacologiche 'Mario Negri', via La Masa 19, 20156 Milano, Italy
| | - Jamal Rahaman
- Department of Obstetrics and Gynecology, The Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - Tamara Kalir
- 1] MaNGO Group, 20156 Milano, Italy [2] Department of Pathology, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - Raymond W Redline
- Department of Pathology, University Hospitals Case Medical Center, 2103 Cornell Road, Cleveland, Ohio 44106, USA
| | - Brian D Brown
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA
| | - Goutham Narla
- 1] Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA [2] Department of Medicine, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA [3] Case Comprehensive Cancer Center, Case Western Reserve University, 2103 Cornell Road, Cleveland, Ohio 44106, USA [4] Institute for Transformative Molecular Medicine, Department of Medicine Case Western Q3 Reserve University, 2103 Cornell Road, Cleveland, Ohio 44106, USA
| | - Analisa DiFeo
- 1] Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, 1425 Madison Avenue, New York, New York 10029, USA [2] Case Comprehensive Cancer Center, Case Western Reserve University, 2103 Cornell Road, Cleveland, Ohio 44106, USA
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Abstract
Placental pathology can be useful in a variety of ways including immediate diagnosis of important conditions affecting the mother or infant, identifying conditions that are likely to recur in subsequent pregnancies, separating clinical syndromes into distinct pathological phenotypes for further investigation, and uncovering the underlying cause of unexpected adverse outcomes. Classification of placental lesions has evolved from being a purely descriptive exercise through a stage in which the major pathophysiological processes such as disorders of maternal implantation and the amniotic fluid infection syndrome were first described to a recently proposed comprehensive classification system that includes all of the major maternal and fetal vascular and infectious and idiopathic/immune inflammatory processes (Amsterdam Placental Workshop Group). Implementation of this unified system with reproducible grading and staging should help establish evidence-based recommendations for placental submission and facilitate progress in studying the pathogenesis, diagnosis, and treatment of obstetric disorders with an underlying placental etiology.
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Abstract
The clinical utility of placental pathology is both overestimated and underestimated, and the overall quality of placental pathology reporting, even at major medical centers, is highly variable. Clear benefits of examining placentas include the immediate diagnosis of treatable conditions in both the mother and the infant, clarification of the underlying etiology of adverse pregnancy outcomes, estimation of recurrence risk, and guidance for the management of future pregnancies. In order to realize these benefits and get the most out of their pathology departments, it is critical for clinicians to understand the range and implications of placental lesions. This article will review the nomenclature, diagnostic criteria and pitfalls, and clinical significance of seven common placental disease processes and a handful of other lesions.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106.
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Abstract
Numerous studies have addressed the significance of marginal and membranous umbilical cord (UC) insertion. Recent reports suggest that an eccentrically inserted UC may also be important. This case-control study assessed the potential relevance of peripheral insertion of UC (PIUC), defined as <3 cm from the nearest margin. Singleton placentas (n = 1418) submitted to the pathology department over an 18-month period were analyzed. Each case of PIUC (n = 119) was matched with a control placenta of the same gestational age. Placentas with marginal or membranous UC and multiple gestations were excluded. The overall prevalence of PIUC was 8.4%, but PIUC frequency was significantly increased in premature births at <28 weeks (21.4%, P < 0.001). There was no association with other adverse pregnancy outcomes. PIUC was associated with decreased placental weight Z-score (-0.69 ± 0.92 versus -0.22 ± 1.3, P = 0.0056), but not fetal weight Z-score, suggesting increased utilization of placental reserve. PIUC was also associated with relatively elongated placentas (length minus width: 2.6 ± 3.2 versus 1.0 ± 3.1, P = 0.006). PIUC tended to be more frequent in young primiparous mothers and was significantly less common in women with a history of prior curettage (66% vs 50%, P = 0.013). These data, together with equivalent rates of prior cesarean section, multiparity, and advanced maternal age, support a primary developmental disorder as opposed to secondary placental migration due to underlying uterine abnormalities ("trophotropism"). Except for a borderline significant association with findings suggestive of maternal malperfusion (P = 0.078), PIUC was not associated with other placental lesions.
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Affiliation(s)
- Guangju Luo
- 1 Department of Pathology, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, OH, USA
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31
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Abstract
The purpose of placental pathology is to explain adverse clinical outcomes. One of the most tragic of these outcomes is perinatal brain injury with subsequent neurodisability. Findings in the placenta can play an important role in documenting sentinel events, uncovering clinically silent thromboinflammatory disease processes, revealing developmental alterations in functional reserve, and suggesting alterations in related maternal and fetal physiology. These findings, when integrated with clinical data, provide a plausible explanation for an otherwise unexpected outcome and can be helpful for treating physicians and family members.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, 11100 Euclid Avenue 5, Cleveland, OH 44106, USA.
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32
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Nedrud JG, Czinn SJ, Ding H, Zagorski BM, Redline RW, Twaddell W, Blanchard TG. Lack of genetic influence on the innate inflammatory response to helicobacter infection of the gastric mucosa. Front Immunol 2012; 3:181. [PMID: 22783255 PMCID: PMC3389333 DOI: 10.3389/fimmu.2012.00181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 06/12/2012] [Indexed: 12/31/2022] Open
Abstract
Helicobacter pylori (H. pylori) is a bacterial pathogen that resides at the gastric mucosa and has a world-wide prevalence of over 50%. Infection usually lasts for the life of the host, and although all infected individuals will develop histologic gastritis only a subset will develop symptomatic gastritis, peptic ulcer disease, gastric MALT lymphoma, or gastric adenocarcinoma. The bacterial and host factors that determine clinical outcome and influence the development of widely varying diseases have not been elucidated. We compared disease in Helicobacter-infected severe combined immunodeficient (SCID) mice on different genetic backgrounds with their corresponding immunocompetent partners to determine if the genetics of the host significantly impacts the innate inflammatory outcome, independent of variations in bacterial virulence factors. BALB/c SCID and C57BL/6 SCID mice developed equivalent histologic gastritis by 8 weeks of infection. Immunocompetent BALB/c mice and C57BL/6 mice developed significantly lower or higher degrees of inflammation respectively. Innate inflammation in immunodeficient mice on the C57BL/6 background remained low even in the absence of the regulatory cytokine IL-10. These results demonstrate that adaptive immunity is not required for the generation of low level inflammation in response to Helicobacter infection and that the degree of inflammation is consistent among different genetic backgrounds. Additionally, this inflammation is limited even in the absence of regulatory T cells.
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Affiliation(s)
- John G Nedrud
- Department of Pathology, Case Western Reserve University Cleveland, OH, USA
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34
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Abstract
Acute chorioamnionitis is the principal antecedent of premature birth and an important contributor to specific neonatal and other complications that may extend throughout subsequent life. A large number of studies have addressed surrogate markers of in-utero inflammation including cytokines, chemokines, pathogen-associated molecular patterns, and elicited host proteins. However, chorioamnionitis means inflammation occurring within the chorioamnion and the only practical direct measure available to assess this finding in most placentas is histopathology. The maternal and fetal inflammatory response to the presence of organisms within the placental membranes, so-called histologic chorioamnionitis, is the focus of this review. The issues addressed are the nature and origin of the eliciting antigen, mode of spread to the placenta, general characteristics of placental immunity, and a specific characterization of the spectrum of pathologic lesions observed in placentas with membrane infection.
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Affiliation(s)
- Raymond W Redline
- Pediatric and Perinatal Pathology, Case Western Reserve University School of Medicine, OH 44106, USA.
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35
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DeLyria ES, Nedrud JG, Ernst P, Alam MS, Redline RW, Ding H, Czinn SJ, Xu J, Blanchard T. Vaccine-induced immunity against Helicobacter pylori in the absence of IL-17A. Helicobacter 2011; 16:169-78. [PMID: 21585602 PMCID: PMC3107727 DOI: 10.1111/j.1523-5378.2011.00839.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Helicobacter pylori (H. pylori) is a gram negative bacterium that can cause diseases such as peptic ulcers and gastric cancer. IL-17A, a proinflammatory cytokine that can induce the production of CXC chemokines for neutrophil recruitment, has recently been shown to be elevated in both H. pylori-infected patients and mice. Furthermore, studies in mouse models of vaccination have reported levels significantly increased over infected, unimmunized mice and blocking of IL-17A during the challenge phase in immunized mice reduces protective immunity. Because many aspects of immunity had redundant or compensatory mechanisms, we investigated whether mice could be protectively immunized when IL-17A function is absent during the entire immune response using IL-17A and IL-17A receptor knockout (KO) mice immunized against H. pylori. MATERIALS AND METHODS Gastric biopsies were harvested from naïve, unimmunized/challenged, and immunized/challenged wild type (WT) and KO mice and analyzed for inflammation, neutrophil, and bacterial levels. Groups of IL-17A KO mice were also treated with anti-IFNγ or control antibodies. RESULTS Surprisingly, all groups of immunized KO mice reduced their bacterial loads comparably to WT mice. The gastric neutrophil counts did not vary significantly between IL-17A KO and WT mice, whereas IL-17RA KO mice had on average a four-fold decrease compared to WT. Additionally, we performed an immunization study with CXCR2 KO mice and observed significant gastric neutrophils and reduction in bacterial load. CONCLUSION These data suggest that there are compensatory mechanisms for protection against H. pylori and for neutrophil recruitment in the absence of an IL-17A-CXC chemokine pathway.
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Affiliation(s)
- Elizabeth S. DeLyria
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH
| | - John G. Nedrud
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH
| | - Peter Ernst
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA
| | - M. Samiul Alam
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Raymond W. Redline
- Department of Pathology, Case Western Reserve University, School of Medicine, Cleveland, OH
| | - Hua Ding
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - Steven J. Czinn
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - Jinghua Xu
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - T.G. Blanchard
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD,Corresponding author: Thomas G. Blanchard, Dept of Pediatrics, Bressler Research Building, 13-043, University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, Voice: (410) 706-1772, Fax: (410) 328-1072,
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36
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Bedaiwy MA, Grob NM, Redline RW, Pinkerton J, Perriera LK, Lazebnik N. Gravid hysterectomy following history of recurrent ruptured uterus: case report. J Obstet Gynaecol Res 2011; 37:1497-502. [PMID: 21599800 DOI: 10.1111/j.1447-0756.2011.01540.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The risk of uterine rupture and its associated morbidities increases as the incidence of cesarean deliveries increases. There is little evidence guiding the management of pregnancy termination in patients with a history of uterine rupture. A 21-year-old woman with a history of a classical cesarean delivery and four subsequent uterine ruptures presented for termination of pregnancy at 17 weeks and 2 days. Ultrasound study noted anterior wall implantation of the placenta covering the classical cesarean scar as well as the subsequent cesarean section scars. A scheduled gravid hysterectomy was performed to complete the pregnancy termination and avoid recurrent uterine rupture. Pathological examination revealed marked attenuation and fibrosis of the anterior uterine wall with diffuse placenta accreta and focal placenta percreta justifying the decision for hysterectomy in this young patient. We therefore suggest that gravid hysterectomy rather than dilatation and evacuation should be considered for pregnancy termination in patients with history of recurrent uterine rupture and suspicion for abnormal placentation.
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Affiliation(s)
- Mohamed Ali Bedaiwy
- Department of Obstetrics and Gynecology, University, Cleveland, Ohio 44106, USA
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37
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Abstract
Multifocal chorangiomatosis (MC) is an uncommon villous capillary lesion sharing some features with villous chorangiosis and placental chorangioma. We prospectively identified 53 cases of MC among 5429 consecutively accessioned placentas of >20 weeks gestation over a 10-year period. Two gestational age (GA)-matched controls were selected for each case from the same cohort and a case control analysis of associated clinical and pathologic features was performed. Multifocal chorangiomatosis was seen at all GAs but was most frequent in very preterm placentas (<32 weeks). Avascular villi, villous chorangiosis, and distal villous immaturity were each seen in approximately half of placentas with MC. Other common placental findings included concentric narrowing of fetal villous arterioles, villous edema, and dysmorphic villi. Only one case had an associated placental chorangioma. Maternal factors significantly associated with MC were advanced maternal age, non-African-American ancestry, nonprimigravid status, and >5 previous pregnancies. Infants with placental MC had a significantly increased prevalence of congenital anomalies. Multifocal chorangiomatosis was subcategorized as extensive versus patchy based on the size of the largest focus (> versus < ×2 microscopic field). Fetuses with extensive MC, when compared with patchy MC, were more likely to have congenital anomalies and stillbirth and to be large for GA. Paradoxically, those with patchy MC were more likely to be small for GA. The results of this study suggest that MC may represent an abnormal proliferation of the paravascular capillary net in proximal villi related to fetoplacental developmental anomalies and abnormal fetal blood flow.
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Affiliation(s)
- Christina Bagby
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, OH, USA
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38
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Abstract
Disorders of the placental circulation, including the release of deleterious mediators to the fetus, are important risk factors for central nervous system complications. These disorders result in discrete patterns of placental injury detectable by a thorough placental pathologic examination. Consideration of the location, severity, multiplicity, and timing of these lesions is critical to a full understanding of their significance. Less than 10% of placentas from term infants that later develop cerebral palsy lack any evidence of placental abnormalities potentially related to adverse outcome.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine, OH 44106, USA.
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39
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Stuller KA, Ding H, Redline RW, Czinn SJ, Blanchard TG. CD25+ T cells induce Helicobacter pylori-specific CD25- T-cell anergy but are not required to maintain persistent hyporesponsiveness. Eur J Immunol 2009. [PMID: 19003932 DOI: 10.1002/eji.00838428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The gastric pathogen Helicobacter pylori infects over half the world's population. The lifelong infection induces gastric inflammation but the host fails to generate protective immunity. To study the lack of protective H. pylori immunity, CD4(+)CD25(+) T(reg) cells were investigated for their ability to down-regulate H. pylori-specific CD4(+)CD25(-) cells in a murine model. CD25(-) lymphocytes from infected mice were hyporesponsive to antigenic stimulation in vitro even in the absence of CD25(+) T(reg) cells unless treated with high-dose IL-2. Transfer of CD45RB(hi) naïve CD25(-) cells from infected mice into rag1(-/-) mice challenged with H. pylori resulted in severe gastritis and reduced bacterial loads, whereas transfer of CD45RB(lo) memory CD25(-) cells from H. pylori-infected mice resulted in only mild gastritis and persistent infection. CD25(-) cells stimulated in the absence of CD25(+) cells in rag1(-/-) mice promoted bacterial clearance, but lost this ability when subsequently transferred to WT mice harboring CD25(+) cells. These results demonstrate that CD25(+) cells induce anergy in CD25(-) cells in response to H. pylori infection but are not required to maintain hyporesponsiveness. In addition, CD25(+) cells are able to suppress previously activated CD25(-) cells when responding to H. pylori challenge in vivo.
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40
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DeLyria ES, Redline RW, Blanchard TG. Vaccination of mice against H pylori induces a strong Th-17 response and immunity that is neutrophil dependent. Gastroenterology 2009; 136:247-56. [PMID: 18948106 PMCID: PMC4960660 DOI: 10.1053/j.gastro.2008.09.017] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Revised: 08/07/2008] [Accepted: 09/11/2008] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Vaccine efficacy against gastric Helicobacter pylori infection has been shown in mice, but little is known about the mechanisms of bacterial clearance. Our aim was to investigate a possible T-cell/neutrophil pathway of vaccine-induced protection. METHODS Nonimmune and immunized mice were compared for their response to H pylori challenge. T-cell responses were assessed by recall assays. Interleukin (IL)-17-induced chemokine production was evaluated by cytokine enzyme-linked immunosorbent assay. In a kinetic study, biopsy specimens were collected at multiple time points postchallenge and assessed for bacterial load and inflammation. Relative levels of T cells, IL-17, interferon gamma, MIP-2, KC, and LIX were determined by quantitative polymerase chain reaction. The role of neutrophils was evaluated by antibody-mediated depletion of neutrophils following challenge. RESULTS Immunization induced strong interferon gamma- and IL-17-producing T-cell responses, and IL-17 was capable of inducing significant amounts of KC and MIP-2 from dendritic cells, macrophages, fibroblasts, and gastric epithelial cells. Challenge of immunized mice induced significantly greater gastritis than that of infected mice, preceding significantly lower bacterial loads by day 7. In immune mice, T-cell recruitment to the gastric mucosa correlated with a continuous rise in IL-17 and interferon gamma levels, followed by KC, MIP-2, and LIX production and the recruitment of significant numbers of neutrophils by day 5. Antibody-mediated depletion of neutrophils abrogated vaccine efficacy. CONCLUSIONS Vaccination of mice against H pylori results in a significant Th-17 cell recall response associated with increases in chemokines that attract neutrophils to the stomach, which are important for eradication of H pylori.
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Affiliation(s)
- Elizabeth S. DeLyria
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Raymond W. Redline
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Thomas G. Blanchard
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland,Corresponding author: Thomas Blanchard, Ph.D., Department of Pediatrics, University of Maryland School of Medicine, Bressler Research Building, 13-043, 655 West Baltimore Street, Baltimore, MD 21201, Voice: (410) 706-1772, Fax: (410) 328-1072,
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Stuller KA, Ding H, Redline RW, Czinn SJ, Blanchard TG. CD25+ T cells induce Helicobacter pylori-specific CD25- T-cell anergy but are not required to maintain persistent hyporesponsiveness. Eur J Immunol 2008; 38:3426-35. [PMID: 19003932 PMCID: PMC2753502 DOI: 10.1002/eji.200838428] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The gastric pathogen Helicobacter pylori infects over half the world's population. The lifelong infection induces gastric inflammation but the host fails to generate protective immunity. To study the lack of protective H. pylori immunity, CD4(+)CD25(+) T(reg) cells were investigated for their ability to down-regulate H. pylori-specific CD4(+)CD25(-) cells in a murine model. CD25(-) lymphocytes from infected mice were hyporesponsive to antigenic stimulation in vitro even in the absence of CD25(+) T(reg) cells unless treated with high-dose IL-2. Transfer of CD45RB(hi) naïve CD25(-) cells from infected mice into rag1(-/-) mice challenged with H. pylori resulted in severe gastritis and reduced bacterial loads, whereas transfer of CD45RB(lo) memory CD25(-) cells from H. pylori-infected mice resulted in only mild gastritis and persistent infection. CD25(-) cells stimulated in the absence of CD25(+) cells in rag1(-/-) mice promoted bacterial clearance, but lost this ability when subsequently transferred to WT mice harboring CD25(+) cells. These results demonstrate that CD25(+) cells induce anergy in CD25(-) cells in response to H. pylori infection but are not required to maintain hyporesponsiveness. In addition, CD25(+) cells are able to suppress previously activated CD25(-) cells when responding to H. pylori challenge in vivo.
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42
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Redline RW. Cerebral palsy in term infants: a clinicopathologic analysis of 158 medicolegal case reviews. Pediatr Dev Pathol 2008; 11:456-64. [PMID: 18544009 DOI: 10.2350/08-05-0468.1] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 06/05/2008] [Indexed: 11/20/2022]
Abstract
Our understanding of cerebral palsy (CP) in term infants is hindered by its low incidence and sporadic presentation. Many of these CP cases enter litigation, and a focused review of medicolegal consultations provides an opportunity to better understand the pathogenesis of these cases. In this study complete clinical and pathologic data from 158 cases of CP complicating singleton pregnancies after 36 weeks of gestation were prospectively collected over a 10-year period extending from 1998 to 2008. A hierarchical system was used to separate cases into the following 5 groups: (1) clinical/sentinel events (20%), (2) severe large fetoplacental vascular lesions (34%), (3) placental lesions indicative of chronic placental dysfunction (23%), and (4) placental lesions indicative of subacute/chronic adaptation to hypoxia (15%). The remaining 8% (group 5) of cases were idiopathic. Common to all subgroups was clinical and/or pathologic evidence of umbilical cord obstruction, which was observed in 63% of cases. The following clinical features significantly differed among subgroups. Group 1 had less maternal obesity and more cases involving multicystic encephalopathy. Group 2 had increased oligohydramnios, cerebral edema, nucleated red blood cell counts greater than 10 000/mm(3), hypoglycemia, pulmonary hypertension, and cardiac dysfunction. Group 3 had more preeclampsia and, together with group 2, more infants with a low ponderal index. Group 5 had a higher prevalence of positive family history of neurodevelopmental disorders. In conclusion, infant cases subject to litigation related to CP following term birth can be separated into distinct clinicopathologic subgroups with only a small number lacking either clinical/sentinel events or placental evidence of subacute or chronic in utero stress.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals Case Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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43
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Redline RW. Elevated circulating fetal nucleated red blood cells and placental pathology in term infants who develop cerebral palsy. Hum Pathol 2008; 39:1378-84. [PMID: 18614199 DOI: 10.1016/j.humpath.2008.01.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 01/04/2008] [Accepted: 01/07/2008] [Indexed: 10/21/2022]
Abstract
An elevated circulating fetal nucleated red blood cell count has long been recognized as an indicator of significant intrauterine stress. However, the nature of the causative events and their timing remain controversial. In this study, subacute and chronic placental lesions known to be associated with neurodisability were used as surrogates for antenatal stress. Mother-infant pairs with complete blood counts within 2 hours of delivery (n = 81) were drawn from a larger database of 152 term infants with cerebral palsy. An elevated nucleated red blood cell count (2.5 x 10(3)/mm(3)) in these infants was associated with a significantly increased prevalence of subacute or chronic placental lesions, whereas clinical findings did not significantly differ. The number of nucleated red blood cells per 10 high-power fields of villous parenchyma was directly correlated with the nucleated red blood cell count, and a threshold of 10 or more nucleated red blood cells predicted a nucleated red blood cell count greater than 2.5 x 10(3)/mm(3). Among individual placental lesions, multiple foci of avascular villi and chronic villitis were significantly associated with an elevated nucleated red blood cell count, whereas meconium-associated vascular necrosis showed a borderline association. Acute chorioamnionitis was the only placental lesion more common in the group without elevated nucleated red blood cell count. The presence of significant placental lesions was associated with an elevated nucleated red blood cell count in infants with or without either acidosis (cord pH <7.0) or birth asphyxia (American College of Obstetrics and Gynecology criteria). Acidosis and birth asphyxia were not significantly related to an elevated nucleated red blood cell count in infants without these placental lesions.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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44
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Redline RW, Sagar P, King ME, Krishnamoorthy KS, Grabowski EF, Roberts DJ. Case records of the Massachusetts General Hospital. Case 12-2008. A newborn infant with intermittent apnea and seizures. N Engl J Med 2008; 358:1713-23. [PMID: 18420504 DOI: 10.1056/nejmcpc0801164] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, USA
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45
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Abstract
Villitis of unknown etiology (VUE) is an important pattern of placental injury occurring predominantly in term placentas. Although overlapping with infectious villitis, its clinical and histologic characteristics are distinct. It is a common lesion, affecting 5% to 15% of all placentas. When low-grade lesions affecting less than 10 villi per focus are excluded, VUE is an important cause of intrauterine growth restriction and recurrent reproductive loss. Involvement of large fetal vessels in the placenta (obliterative fetal vasculopathy) in cases of VUE is a strong risk factor for neonatal encephalopathy and cerebral palsy. Although the etiology of the eliciting antigen is unknown, many other characteristics of the immune response have been clarified. VUE is caused by maternal T lymphocytes, predominantly CD8-positive, that inappropriately gain access to the villous stroma. Fetal antigen-presenting cells (Hofbauer cells) expand and are induced to express class II major histocompatibility complex molecules. Maternal monocyte-macrophages in the perivillous space likely amplify the immune response. Although much speculation exists that VUE represents a host-versus-graft reaction analogous to transplant rejection, other eliciting antigens have not been excluded. Irrespective of target antigen or antigens, the pathophysiologic implications of having activated maternal lymphocytes within vascularized fetal tissues are not trivial.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
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46
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Liu H, Redline RW, Han YW. Fusobacterium nucleatum induces fetal death in mice via stimulation of TLR4-mediated placental inflammatory response. J Immunol 2007; 179:2501-8. [PMID: 17675512 DOI: 10.4049/jimmunol.179.4.2501] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intrauterine infection plays a pivotal role in preterm birth (PTB) and is characterized by inflammation. Currently, there is no effective therapy available to treat or prevent bacterial-induced PTB. Using Fusobacterium nucleatum, a Gram-negative anaerobe frequently associated with PTB, as a model organism, the mechanism of intrauterine infection was investigated. Previously, it was shown that F. nucleatum induced preterm and term stillbirth in mice. Fusobacterial-induced placental infection was characterized by localized bacterial colonization, inflammation, and necrosis. In this study, F. nucleatum was shown to activate both TLR2 and TLR4 in vitro. In vivo, the fetal death rate was significantly reduced in TLR4-deficient mice (C57BL/6 TLR4(-/-) and C3H/HeJ (TLR4(d/d))), but not in TLR2-deficient mice (C57BL/6 TLR2(-/-)), following F. nucleatum infection. The reduced fetal death in TLR4-deficient mice was accompanied by decreased placental necroinflammatory responses in both C57BL/6 TLR4(-/-) and C3H/HeJ. Decreased bacterial colonization in the placenta was observed in C3H/HeJ, but not in C57BL/6 TLR4(-/-). These results suggest that inflammation, rather than the bacteria per se, was the likely cause of fetal loss. TLR2 did not appear to be critically involved, as no difference in bacterial colonization, inflammation, or necrosis was observed between C57BL/6 and C57BL/6 TLR2(-/-) mice. A synthetic TLR4 antagonist, TLR4A, significantly reduced fusobacterial-induced fetal death and decidual necrosis without affecting the bacterial colonization in the placentas. TLR4A had no bactericidal activity nor did it affect the birth outcome in sham-infected mice. TLR4A could have promise as an anti-inflammatory agent for the treatment or prevention of bacterial-induced preterm birth.
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Affiliation(s)
- Hongqi Liu
- Department of Periodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
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Redline RW, Minich N, Taylor HG, Hack M. Placental lesions as predictors of cerebral palsy and abnormal neurocognitive function at school age in extremely low birth weight infants (<1 kg). Pediatr Dev Pathol 2007; 10:282-92. [PMID: 17638433 DOI: 10.2350/06-12-0203.1] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Accepted: 01/29/2007] [Indexed: 12/31/2022]
Abstract
Extremely low birth weight (ELBW) infants (<1 kg) have high rates of neurodisability. Although previous studies have implicated placental lesions in adverse short-term neurologic outcomes in this population, none have assessed their effects in these children once they reach school age. We conducted a secondary analysis of placental pathology in a cohort study of inborn singleton ELBW infants born between 1992 and 1995 and evaluated for cerebral palsy (CP) and abnormal neurocognitive testing at 8 years of age (N = 129). The neurocognitive tests were the Kaufman Assessment Battery for Children (K-ABC) and 6 subtests of the NEPSY: A Developmental Neuropsychological Assessment. We found that placental lesions associated with maternal vascular underperfusion (increased syncytial knots and acute atherosis) were risk factors for CP, while villous edema was associated with low scores on both neurocognitive tests. Histologic chorioamnionitis (HCA) was not predictive of outcome in the population as a whole, but a severe fetal vascular response was associated with a lower NEPSY score in the subpopulation with HCA (N = 69). Placentas with increased syncytial knots, villous edema, and those with neither finding constituted nonoverlapping subgroups with distinct pathologic and perinatal characteristics. Among infants with villous edema (N = 25), those with neurologic impairment had lower gestational ages and more severe degrees of HCA. However, by logistic regression these other factors were not independent risk factors for abnormal neurocognitive testing, and only HCA with a severe fetal vascular response decreased the association of villous edema with low test scores for NEPSY, but not K-ABC.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case School of Medicine and Rainbow Babies and Children's Hospital, University Hospitals of Cleveland, Cleveland, OH 44106, USA.
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Abstract
The etiology of cerebral palsy and other related perinatal brain injuries is poorly understood. Infections of the central nervous system are rare but important causes of neurodisability. Recent evidence suggests that infections and other inflammatory conditions apparently limited to the placenta are also associated with an increased risk of neurologic impairment. A major hypothesis to explain this connection is that cytokines, activated inflammatory cells, and other mediators of the innate immune response are released into the fetal circulation where they can directly or indirectly affect the development or integrity of the central nervous system. This review surveys the organisms, mediators, and placental lesions that have been associated with perinatal brain injury.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, Case Western School of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio 44106, USA.
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Etling MR, Davies S, Campbell M, Redline RW, Fu P, Levine AD. Maturation of the mucosal immune system underlies colitis susceptibility in interleukin-10-deficient (IL-10−/−) mice. J Leukoc Biol 2007; 82:311-9. [PMID: 17456802 DOI: 10.1189/jlb.0606396] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Elevated mucosal IL-12/23p40 and IFN-gamma accompany early inflammation in IL-10-deficient (IL-10(-/-)) mice and then later decline while inflammation persists. This report addresses whether this cytokine profile reflects disease progression or inherent, age-related changes in mucosal immunity. IL-10(-/-) and wild-type (WT) mice were maintained in an ultrabarrier facility or transferred to conventional housing at 3, 12, or 30 weeks of age. Weight, stool changes, and histologic features were followed. Lamina propria mononuclear cells were cultured for cytokine analysis by ELISA. Ultrabarrier-housed IL-10(-/-) mice are statistically indistinguishable from WT mice by weight, disease activity index, and histologic inflammation. IL-10(-/-) mice but not WT, transferred at 3 weeks, develop colitis gradually, reaching a significant, sustained maximum by 15 weeks of age. Transfer at 12 weeks induces rapid disease onset in both strains, maximal at 15 weeks of age. Inflammation persists in IL-10(-/-), and WT recover. IL-10(-/-) and WT mice transferred at 30 weeks demonstrate transient diarrhea and weight loss but no chronic inflammation. Probiotics delay symptom onset only in the 12-week-old group. IFN-gamma production from ultrabarrier-housed IL-10(-/-) mice is elevated at 12 weeks of age, and older animals have decreased IFN-gamma and increased IL-4. IL-10 is important for suppressing inflammation after transfer at 3 weeks of age and limiting inflammation after transfer at 12 weeks but has little influence at 30 weeks of age. Colitis onset, progression, and response to probiotic therapy vary with immune system age, suggesting that a distinct, Th1-driven, age-dependent cytokine profile may contribute to increased colitis susceptibility in otherwise healthy mice.
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Affiliation(s)
- Michele R Etling
- Departments of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106-4952, USA
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Abstract
Thrombophilic states have been associated with a variety of adverse pregnancy outcomes. The underlying placental pathology linking thrombophilia to these outcomes closely resembles that seen in other pregnancy disorders associated with chronic obstruction of the maternal or fetal vasculature. No single placental lesion is pathognomonic for thrombophilia. However, the finding of typical pathologic lesions in the context of recurrent pregnancy loss, severe early onset disease, or neonatal coagulation abnormalities should prompt the consideration of an underlying thrombophilic state.
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Affiliation(s)
- Raymond W Redline
- Department of Pathology, University Hospitals of Cleveland, Cleveland, Ohio 44106, USA.
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