Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

A socioeconomic gradient related to type 2 diabetes (T2D) prevalence has been demonstrated in high-income countries. However, there is no evidence of such a socioeconomic gradient regarding diabetes complications. Thus, the aim of this systematic review was to collect data on risk of complications according to socioeconomic status in patients with T2D.

METHODS

PubMed and EMBASE were searched for English-language observational studies evaluating the prevalence or incidence of micro- and macrovascular complications according to individual and geographical socioeconomic status (SES). Observational studies reporting the prevalence and risk of micro- and macrovascular diabetes complications, according to an individual or geographical index of deprivation, were selected, and estimated crude and adjusted risks for each complication were reported.

RESULTS

Among the 28 included studies, most described a clear relationship between SES and diabetes complications, especially retinopathy (in 9 of 14 studies) and cardiopathy (in 8 of 9 studies). Both individual and area-based low SES was associated with an increased risk of complications. However, very few studies adjusted their analyses according to HbA_1c level.

CONCLUSION

Evaluation of SES is necessary for every T2D patient, as it appears to be a risk factor for diabetes complications. However, the available studies are insufficient for gradation of the impact of low socioeconomic level on each of these complications. Regardless, strategies for the improved screening, follow-up and care of high-risk patients should now be implemented.

Determinants of 20-year non-progression to Type 2 diabetes in women at very high risk: the E3N cohort study

AIMS

To identify the most important determinants associated with not developing Type 2 diabetes in women considered to be at very high risk.

METHODS

Between 1995 and 2014, we followed 402 women from the E3N cohort study who were considered to be at very high risk of Type 2 diabetes based on the D.E.S.I.R. score. We then computed a classification and regression tree model to identify, among a large set of risk factors, the top risk factors associated with not having Type 2 diabetes at the end of the follow-up.

RESULTS

During follow-up, 117 women (29%) were diagnosed with Type 2 diabetes, while 285 (71%) were still free of the disease in 2014. A low Western dietary pattern score was the top characteristic associated with not developing Type 2 diabetes, as only 20% of the women at very high risk in the E3N study with that characteristic developed Type 2 diabetes (compared with 29% overall). In women with a moderate or high Western dietary pattern score, the most important characteristic associated with not developing Type 2 diabetes was a high total dietary antioxidant capacity, as only 26% of these women ultimately developed Type 2 diabetes.

CONCLUSIONS

We showed that the top characteristic associated with not developing Type 2 diabetes, despite being at very high risk, was a healthy diet, characterized by limiting Western dietary habits, but with a high intake of antioxidant-rich foods. This underscores the importance of diet in the prevention of Type 2 diabetes in people at high risk.

Targeting Complement Pathways During Cold Ischemia and Reperfusion Prevents Delayed Graft Function

The complement system plays a critical role in ischemia-reperfusion injury (IRI)-mediated delayed graft function (DGF). To better understand the roles of complement activation pathways in IRI in kidney transplantation, donor kidneys were treated ex vivo with terminal complement pathway (TP) inhibitor, anti-rat C5 mAb 18A10, or complement alternative pathway (AP) inhibitor TT30 for 28 h at 4°C pretransplantation in a syngeneic kidney transplantation rat model. All 18A10- and 67% of TT30-pretreated grafts, but only 16.7% of isotype control-pretreated grafts, survived beyond day 21 (p < 0.01). Inhibitor treatment in the final 45 min of 28-h cold ischemia (CI) similarly improved graft survival. Systemic posttransplant treatment with 18A10 resulted in 60% increased graft survival beyond day 21 (p < 0.01), while no TT30-treated rat survived > 6 days. Our results demonstrate that AP plays a prominent role during CI and that blocking either the AP or, more effectively the TP prevents ischemic injury and subsequent DGF. Multiple complement pathways may be activated and contribute to reperfusion injury; blocking the TP, but not the AP, posttransplant is effective in preventing reperfusion injury and increasing graft survival. These results demonstrate the feasibility of using complement inhibitors for prevention of DGF in humans.

Augmented gp130-mediated cytokine signalling accompanies human gastric cancer progression

H. pylori infection accounts for most cases of gastric cancer, but the initiating events remain unclear. The principal H. pylori pathogenicity-associated CagA protein disrupts intracellular SHP-2 signalling pathways including those used by the IL-6 family cytokines, IL-6 and IL-11. Imbalanced IL-6 family cytokine signalling in the gp130(757FF) mouse model of gastric cancer arising from hyperactivation of oncogenic STAT3 after altered SHP-2 : ERK1/2 signalling produces dysplastic antral tumours preceded by gastritis and metaplasia. In a cohort of patient gastric biopsies with known H. pylori and CagA status, we investigated whether (i) STAT3 and ERK1/2 activation is altered in H. pylori-dependent gastritis; (ii) these profiles are more pronounced in CagA+ H. pylori infection; and (iii) the expression of pro-inflammatory cytokines that activate STAT3 and ERK 1/2 pathways is associated with progression to gastric cancer. IL-6, IL-11, and activated STAT3 and ERK1/2 were quantified in antral biopsies from gastritic stomach, metaplastic tissue, and resected gastric cancer tissues. We observed significantly increased STAT3 and ERK1/2 activation (p = 0.001) in H. pylori-dependent gastritis, which was further enhanced in the presence of CagA+ H. pylori strains. Of known gastric ligands that drive STAT3 activation, IL-6 expression was increased after H. pylori infection and both IL-6 and IL-11 were strongly up-regulated in the gastric cancer biopsies. This suggests a mechanism by which IL-11 drives STAT3 activation and proliferation during gastric cancer progression. We addressed this using an in vitro approach, demonstrating that recombinant human IL-11 activates STAT3 and concomitantly increases proliferation of MKN28 gastric epithelial cells. In summary, we show increased STAT3 and ERK1/2 activation in H. pylori-dependent gastritis that is likely driven in an IL-6-dependent fashion. IL-11 expression is associated with adenocarcinoma development, but not gastritic lesions, and we identify a novel mechanism for IL-11 as a potent inducer of proliferation in the human gastric cancer setting.

Cerebellar atrophy in temporal lobe epilepsy affects procedural memory

The authors examined a cognitive function mediated by the cerebellum, classical eyeblink conditioning, and its relationship to cerebellar volume in healthy controls (n = 59) and temporal lobe epilepsy subjects (n = 77). Controls demonstrated better conditioning, larger cerebellar volumes, and an association between conditioning and cerebellar volume that was not observed in epilepsy patients. These findings provide support for the hypothesis that cerebellar atrophy in epilepsy affects procedural memory.

Rapidly growing mass on the tricuspid valve in an elderly woman: a diagnostic dilemma

BACKGROUND

Papillary fibroelastoma is a rare, benign cardiac valve tumour, which can mimic conditions such as atrial myxoma and infective endocarditis.

CASE REPORT

An elderly lady presented with shortness of breath and chest pain and a mass on echocardiogram, which was confirmed on surgical excision to be a papillary fibroelastoma.

DISCUSSION

There were aspects of this lady's case that caused confusion over the diagnosis and showed how rare conditions can cause diagnostic problems.

The nature and course of neuropsychological morbidity in chronic temporal lobe epilepsy

OBJECTIVE

To characterize the nature and degree of cognitive morbidity in patients with chronic temporal lobe epilepsy compared with healthy control subjects, determine the association between the duration of epilepsy and cognitive morbidity, and ascertain whether there are factors that moderate the association between duration of disorder and cognitive impairment.

METHODS

Temporal lobe epilepsy (n = 96) and healthy control (n = 82) subjects were assessed with a comprehensive neuropsychological battery. Test performances were adjusted for age, gender, and education and transformed to a common metric (z scores). Analyses included group comparisons and correlations of duration of epilepsy with cognitive morbidity.

RESULTS

Patients with temporal lobe epilepsy exhibited not only worse memory function (p < 0.05) but worse performance across measures of intelligence, language, executive function, and motor speed (p < 0.05). Chronicity of epilepsy was related to worsening mental status (r = 0.42, p < 0.001). This relationship was particularly evident among those individuals with less (r = 0.58, p < 0.001) compared with more (r = 0.25, NS) cerebral reserve, operationally defined by years of formal education.

CONCLUSIONS

Neuropsychological morbidity in chronic temporal lobe epilepsy is widespread in nature despite a focal epileptic process. Cross-sectional analyses demonstrate that increasing duration of epilepsy is associated with worsening mental status. Individuals with less educational attainment (low cerebral reserve) exhibit especially poor cognitive function in association with chronicity of epilepsy.

Biliary epithelial trefoil peptide expression is increased in biliary diseases

AIMS

Maintenance of the cellular integrity of the biliary epithelium may involve the production of mucins and mucin-associated peptides. In the luminal gastrointestinal tract, mucins and the mucin-associated trefoil peptides (TFF) are integral to cytoprotection and cellular repair of the mucosa.

METHODS AND RESULTS

Samples of normal and diseased human liver tissue were examined using histological and immunohistochemical techniques, for the expression of TFF and mucins. Bile ducts were classified as small, medium or large depending upon the number of biliary epithelial cells. TFF expression was demonstrated in biliary epithelial cells of both normal and diseased liver tissue. TFF expression was greatest in the large bile ducts. In normal liver tissue, expression of at least one TFF was demonstrated in 2-7% of small bile ducts, 5-31% of medium bile ducts and 31-85% of large bile ducts. Seventy-seven percent of large bile ducts secreted mucins and all three TFF concurrently, compared with 3% of medium bile ducts and no small bile ducts. Biliary disease resulted in an increased expression of TFF1 and TFF3 in the medium bile ducts.

CONCLUSIONS

The biliary epithelial cells in normal and diseased human liver tissue express TFF, particularly in the larger bile ducts. TFF expression may be up-regulated or induced in biliary diseases as a response to injury, as is seen in epithelial damage elsewhere in the gastrointestinal tract.

Id2 is a target of the beta-catenin/T cell factor pathway in colon carcinoma

Activation of beta-catenin/T cell factor (TCF) transcription as a result of mutations in the adenomatous polyposis coli (APC) and/or beta-catenin genes occurs in the majority of colon tumors. An increasing number of genes, including c-myc and cyclin D1, have been implicated as targets of this pathway. We now report that the dominant negative helix-loop-helix regulator Id2 is also a target of the beta-catenin/TCF transcription pathway in colon adenocarcinoma. Investigation of the mechanism for the overexpression of Id2 in colon carcinoma cells demonstrated that the Id2 promoter is activated, and the Id2 protein is up-regulated by beta-catenin. Conversely, reducing free beta-catenin blocked this induction of promoter activity. We have also used an electrophoretic mobility shift assay and supershift to identify a motif in the Id2 promoter that binds to TCF4 protein. Site-directed mutagenesis of this motif abolished promoter reporter activity. Both transfection of Id2 into SW480 cells and induction of Id2 in HT29 colon cells was found to increase anchorage-independent survival of these cells. Growing evidence associates disruption to Id2 expression with tumorigenesis, and our findings suggest that this dysregulation of Id2 expression is due to the activation of the beta-catenin/TCF pathway.

Evaluation of a new rapid urine screening analyser: cellFacts

The aim of this study was to evaluate a new urine screening analyser in a Hospital Bacteriology Laboratory: the Cellfacts Urine Screening Analyser (Microbial Systems Limited (MSL), Coventry, England). A cohort of 1036 urine specimens were analysed by both the CellFacts and routine traditional methods. Using the CDC urinary tract infection decision levels, and compared to reference methods, the sensitivity and specificity were respectively 88.9% and 76.2%, and the predictive negative value and predictive positive value respectively 93.3% and 64.8%. Compared to the microscopy, the correlations of white blood cell count and red blood cell count were good, respectively (r = 0.8, p < 0.0001) and (r = 0.6, p < 0.0001). These results indicate that, although several positive samples were not reported, CellFacts facilitates efficient, rapid screening of infected urine specimens. This leads to perform a cytobacteriological analysis only on those results screened as positive by the automatic analysis system.

Utility of history, examination and laboratory tests in screening those returning to Europe from the tropics for parasitic infection

OBJECTIVES

To examine the utility of the different elements of screening expatriates and travellers returned from the tropics for parasitic disease (exposure history, symptoms, examination and laboratory tests).

METHODS

In phase 1 (conducted prospectively 1990-91), 1029 asymptomatic returnees had a detailed questionnaire and interview on risk-behaviour, physical examination and laboratory tests. In phase 2 (1997-98), 510 consecutive patients referred for routine screening (276 symptomatic and 234 asymptomatic) were screened with laboratory tests.

RESULTS

Exposure history did not correlate reliably with parasite burden. In phase 1 physical examination revealed 387 abnormalities, only three of which indicated parasitic disease. Schistosomal serology was positive in 11% (CI 9-13) of these asymptomatic cases including patients with light or no reported freshwater exposure. Stool microscopy was positive in 19% (CI 16-22) of cases not correlated with reported eating habits, and eosinophilia was present in 8% (CI 6-10). In phase 2 reported symptoms did not correlate with parasitic disease. Schistosomiasis was present in 15% (CI 13-24) of asymptomatic and 18% (CI 13-22) of symptomatic individuals (OR 1.2 P = 0.46); stool microscopy was positive in 14% of both symptomatic and asymptomatic patients, and eosinophilia in 9% of symptomatic and 6% of asymptomatic individuals.

CONCLUSION

Potentially serious asymptomatic infection is common in travellers. Detailed exposure history, symptom history and physical examination added little to detecting cases. Stool microscopy, schistosomal serology and eosinophil count all had good yield. Filarial serology had low yield in patients without eosinophilia.

Necrotizing pulmonary granulomata in a marijuana smoker

We describe the case of a heavy marijuana and tobacco smoker who presented with progressive exertional dyspnea of 2 months' duration, and bilateral nodular lung infiltrates. Examination of the lung fields was normal, and lung function tests showed mild airflow obstruction with moderately reduced gas transfer. BAL returned green-black fluid consisting predominantly of macrophages laden with carbon pigment. Thoracoscopic lung biopsy showed miliary necrotizing granulomata with an alveolar exudate of carbon-laden macrophages within macroscopically blackened lung. The differential diagnosis of pulmonary granulomata in this patient is discussed.

Methylation of exon 2 of p16 is associated with late stage oesophageal cancer

Methylation of the p16 gene was studied in 16 oesophageal tumours. Five (31%) of the tumours were found to be methylated in exon 1 and eight (50%) were methylated in exon 2. The loss of p16 protein correlated with methylation of exon 1 (P = 0.005). However, methylation of exon 2, but not exon 1, was found to be associated with late stage tumours (P = 0.01). We conclude that the methylation of exon 2 of p16 may have effects on the progression of oesophageal tumours that are independent of the expression of the p16 protein.

Medical repatriation of British diplomats resident overseas

BACKGROUND

The aim of this study was to analyse medical evacuations and short tours (collectively known as medevacs) in British Foreign and Commonwealth Office (FCO) staff and dependents residing overseas. Further aims were to look for groups with a disproportionate number of medical evacuations/short tours, and to identify events which may have been predictable in retrospect. For the purposes of this study, a medical evacuation was defined as a journey to the UK or an appropriate regional referral center for medical treatment or review, and a medical short tour was an early termination of posting for medical reasons.

METHOD

The medical records of all staff and dependents who had been medically evacuated/short toured in 1995 were retrospectively analysed. Information collected included demographic details, whether the medevac was an emergency or a predicted necessity, why the medevac was required, the diagnosis, and the time from medical clearance to medevac.

RESULTS

In 1995, 160 medevacs involving 137 individuals were authorized. This represented 3.08% of individuals overseas, with only 0.4% of individuals posted overseas being evacuated with new medical events within 1 year of medical clearance. The proportion of medevacs for staff was significantly higher than for dependents (spouses and children), and staff in their 20s and fast-stream diplomats (young "high-flyers" with a university education) were over-represented in the evacuee group. Non-physical problems were predominant in the latter groups. The main reason for evacuation (70%) was that medical facilities were considered unsuitable, and just over half of the medevacs (51%) were considered by the investigating team to have been unpredictable.

CONCLUSIONS

Only a small percent of individuals posted overseas required medevac. The likelihood of evacuation was significantly higher in staff when compared to dependents, and certain grades/age groups appeared to be over-represented in the evacuee group. These groups are possibly more vulnerable, particularly to non-physical problems, and this is a potential area for future research. A prospective study of medical events overseas is proposed to see if these results are reproduced. If these findings are confirmed, medical clearance and FCO posting procedures may need to be altered for groups which are identified as being vulnerable.

Murine allergic respiratory responses to the major house dust mite allergen Der p 1

BACKGROUND

Although many studies have examined chronic asthma, limited data exist on acute immunopathogenic events induced by allergens. The aim of the study was to investigate the acute cellular, serologic and histopathologic events in airway inflammation produced by intranasal challenge of mice sensitised to the major house dust mite allergen Der p 1.

METHODS

C57BL/6 mice were immunised subcutaneously with Der p 1 in alum. Mice were bled and challenged intranasally with Der p 1 on day 14 and killed on day 17. Lungs were fixed in situ, processed and stained with haematoxylin and eosin. The degree of inflammation and eosinophil infiltration was quantified by image analysis. Specific IgE was determined by passive cutaneous anaphylaxis. Cells from spleen and draining lymph nodes were cultured for 24 h with Der p 1, and IL-3/GM-CSF released into supernatants was measured by bioassay.

RESULTS

Intranasal challenge of sensitised mice induced eosinophilic influx into the large and small airways and the alveolar regions of the lung, mucus plugging and in severe cases numerous Charcot-Leyden crystals. The quantitation of the inflammation induced by different sensitisation and challenge doses showed that optimal inflammation could be produced using only 1 microg of allergen for both sensitisation and challenge. The degree of inflammation was not related to the titre of IgE antibody and was indeed produced in its absence. T cell reactivity of spleen cells to the allergen was decreased suggesting cell migration or inactivation.

CONCLUSIONS

Mice sensitised and challenged intranasally with as little as 1 microg of Der p 1 produced an extensive pulmonary eosinophilic inflammation which shared many of the features of the inflammation found in asthma. The small amount of allergens required and the use of intranasal challenge should provide a useful model.

Ivermectin in the treatment of onchocerciasis in Britain

Thirty-one patients with onchocerciasis were treated with a single dose of 150-200 micrograms/kg ivermectin. They were observed for three days to detect acute reactions and were reassessed clinically and parasitologically three, six and twelve months after treatment. 22 patients were expatriates. All had early, light and often localised infections and were not reexposed to infection during the course of the study. 25 patients completed follow-up. Patients who relapsed were retreated with the same dose after an interval of not less than five months. Adverse reactions were less severe than those experienced by similar patients treated with diethylcarbamazine and only one patient was given corticosteroids. 17 patients (68%) relapsed within one year and two thirds of these had done so within 6 months. A similar pattern was seen after the second dose. A single dose of ivermectin, repeated every three to six months as necessary, is likely to be the treatment of choice for patients in non-endemic areas, lightly infected with Onchocerca volvulus, until a safe macrofilaricidal drug emerges. One third of such patients may be cured with each treatment.

Measurement of acute phase proteins for assessing severity of Plasmodium falciparum malaria

Seventeen adult patients with acute Plasmodium falciparum malaria, admitted to the Hospital for Tropical Diseases, were studied. Serial measurements of the serum concentration of C-reactive protein, serum amyloid A protein, and percentage parasitaemia were determined, together with initial measurement of serum electrolytes, liver function, haemoglobin, white cell and platelet counts. Initial C-reactive protein and serum amyloid A concentrations were increased (C-reactive protein mean 49.0 mg/l serum amyloid A 28 mg/l) falling towards the normal range by the seventh day of treatment. There was a significant correlation between the pretreatment parasite count and clinical and laboratory markers of inflammation. C-reactive protein and serum amyloid A concentrations correlated inversely with the serum sodium. These results indicate that measurement of acute phase reactants such as C-reactive protein and serum amyloid A may prove valuable in assessing the severity of P falciparum malaria, and in following the response to antimalarial treatment.

The primary antibody response of malaria patients to Plasmodium falciparum sexual stage antigens which are potential transmission blocking vaccine candidates

Thirty serum samples collected from adult patients attending the Hospital for Tropical Diseases, London, with P. falciparum malaria, were studied. Sera were screened by indirect immunofluorescence for anti-gametocyte antibodies. Twelve of the serum samples taken from 14 patients with primary infections were found to have both IgM and IgG antibodies to gametocyte antigens and total Ig titres comparable with those of patients who had had previous malaria attacks. Sera of individuals from hyperendemic areas have been found to immunoprecipitate the 230 and 48/45 kD gametocyte surface antigens which are known targets of transmission blocking antibodies. To investigate the epitope specificity of the serum samples from our adult patients, competitive ELISAs with 3 monoclonal antibodies (MAbs) that block transmission and recognize different epitopes on the 48/45 Kd antigen, were carried out. Specific antibodies for these epitopes were found in 60% of the sera while nearly a third were able to inhibit the binding of at least two MAbs.

Human gnathostomiasis

Following a meal that included raw fish in Bangladesh, a woman aged 40 years had symptoms suggestive of gnathostomiasis. The presentation of her illness and the results of investigations are reported.

Studies on immunisation of pigs with the Bartha strain of Aujeszky's disease virus

The K strain of Aujeszky's disease virus (ADV) grown in Vero cells was used to vaccinate pigs. Following intramuscular inoculation, the pigs remained healthy, no vaccine virus was excreted and virus could be detected only at the inoculation site. One inoculation gave good protection against challenge with a virulent strain of ADV, and the amount of virulent ADV excreted was geatly curtailed. Following vaccination only low leads of serum neutralizing antibody were detected (geometric mean titre 1/2), but three weeks after challenge very high levels were found (GMT 1/1773). Intranasal vaccination gave similar results. There was minimal excretion of vaccine virus. The clinical reaction on challenge was less severe than in the intramuscularly challenged group, although lower antibody levels were detected three wekks following challenge (GMT 1/483). A field trial, using this strain given subcutaneously, indicated that one inoculation of this vaccine is effective.

Further studies on experimental bacterial pneumonia: ultrastructural changes produced in the lungs by Salmonella cholerae-suis

The development of ultrastructural changes in the lungs of pigs was examined at intervals from 6 hours to 14 days after intranasal infection with virulent Salm. cholerae-suis. Most bacteria were phagocytosed by PMN and pulmonary macrophages immediately after arrival in distal airways and alveoli. During the first few days after infection oedema fluid formed in interalveolar septa and alveoli, there was exudation of fibrin and degenerative changes of a mild nature occurred in epithelial cells. Bacteria laden phagocytic cells migrated through the tissues to pulmonary lymphatics and capillaries. Many bacteria survived and multiplied in phagocytes, causing necrosis of the cells from the fifth to the seventh day, when large numbers of organisms were liberated into the tissues. This phase coincided with widespread exudation and maximum destruction of lung tissue. Although necrosis appeared to be caused by free organisms, at no stage did bacteria become attached to, or penetrate, pulmonary cells, and it is suggested that injury is mediated by a toxin produced by Salm. cholerae-suis. Many alveoli were distended by osmiophilic lamellar material released by degenerating type II pneumonocytes. This appearance and later hyperplasia of type II epithelial cells and excessive secretion of lamellar bodies was typical of the changes in human alveolar lipoproteinosis. From the ninth day onwards the number of bacteria in the lung fell dramatically, organisms were confined to circumscribed abscesses and lymphoid tissue developed throughout the lungs.

Ultrastructure of phagocytosis of Salmonella cholerae-suis by pulmonary macrophages in vivo

Phagocytosis of virulent Salmonella cholerae-suis in the lungs of pigs was studied by electron microscopy during the period 6 hours-14 days after intranasal infection. All bacteria were phagocytosed by polymorphonuclear leucocytes (PMN) and pulmonary macrophages soon after arrival in distal airways and alveoli. Many organisms were destroyed but some survived and later multiplied within phagocytes. Bacteria were also carried in phagocytic cells to lymphatics and pulmonary capillaries, thereby establishing bacteraemia. Between the 5th and 7th days bacteria caused necrosis of the phagocytes and were released into the tissues in very large numbers. Destruction of all types of lung cell was widespread during this period but the Salmonellae did not penetrate pulmonary cells. From the 9th day onwards bacteria in the lung were restricted to circumscribed abscesses and lymphoid tissue developed throughout the lungs. These latter changes coincided with the appearance of circulating specific antibody.

The histopathology of Fasciola hepatica infections in sheep

Experimental infections of lambs with Fasciola hepatica are described. The growth rate of the parasite, time of entry to the bile ducts, and time of patency are recorded and a preferential migration of the parasite in the liver parenchyma noted. The gross and histological lesions produced in the liver from 1 to 40 weeks after infection are described and compared with previous observations in cattle.

The parenchymal migration of the parasite is shown to consist of two phases, a free migrating phase up to the 6th week, and a localized phase after the 6th week prior to entry into the bile ducts. Hepatic cell regeneration is observed and hepatic fibrosis is minimal. The localized phase of migration is associated with a unique peripheral palisade of giant cells in the fluke tracts and with the formation of pseudofollicular aggregation of lymphocytes. The presence of flukes in the bile ducts produces fibrosis of the duct walls. The walls, however, remain pliable and expanded to accommodate the parasites and calcification was never observed.