Lower accuracy in prediction of delivery date in Stockholm County following introduction of new guidelines

INTRODUCTION

In Stockholm County, new guidelines for predicting the day of delivery were introduced in 2010. Recent clinical use has indicated that the predictive quality might be suboptimal. This study compares the accuracy of three equations applied during the first (crown-rump length or bi-parietal diameter) and second trimesters (bi-parietal diameter or bi-parietal diameter combined with femur length).

MATERIAL AND METHODS

The accuracy of estimated delivery date was compared in 14 239 ultrasound exams using median deviations from actual birth date, proportion of postterms, births within ±seven days of estimated delivery date, accuracy variations depending on fetal size, alternative fetal measurements obtained on the same occasion, and menstrual age.

RESULTS

The bi-parietal diameter and crown-rump length formulae overestimated pregnancy length by two and three days respectively, causing 7-8% of pregnancies to be labelled postterm. A combined bi-parietal diameter+femur length formula overestimated by one day, with 5.1% postterms. No significant difference was found in the proportion of births within ±seven days. Second trimester estimated delivery date assessment had larger median variations than did first trimester assessment and suffered from shifting deviations across fetal size. The comparison of different biometry formulae in the same individual demonstrated one day extra deviation for bi-parietal diameter and three days extra deviation for crown-rump length compared with the combined bi-parietal diameter+femur length formula.

CONCLUSIONS

The algorithms and dating occasions tested seem inappropriate for the present 280-day term definition. Alternative formulae ought to be sought, and the assumed duration of pregnancy reconsidered; 283 days corresponds to the observed pregnancy length calculated from last menstrual period, and would better fit the observed results for first trimester ultrasound scans.

Differential vasodilation of human placental and myometrial arteries related to myofilament Ca(2+)-desensitization and the expression of Hsp20 but not MYPT1

Endothelial-dependent regulation of vascular tone occurs in part via protein kinase G1α-mediated changes in smooth muscle myofilament sensitivity to Ca(2+). Tissue-specific differences in PKG-dependent relaxation have been attributed to altered expression of myofilament-associated proteins that are substrates for PKG binding. These include the alternative splicing of the myosin targeting subunit (MYPT1) of myosin light chain phosphatase to yield leucine zipper positive (LZ(+)) and negative (LZ(-)) isovariants, with the former being required for PKG-mediated relaxation, and/or altered expressions of telokin, vasodilator-stimulated phosphoprotein (VASP) or heat shock protein Hsp20. During human pregnancy the uterine and placental circulations remain distinct entities and, as such, their mechanisms of vascular tone regulation may differ. Indeed, the sensitivity of myometrial arteries to endothelial-dependent agonists has been suggested to be greater than that of placental arteries. We tested the hypothesis that this was related to tissue-specific changes in PKG-mediated myofilament Ca(2+)-desensitization and/or the expressions of PKG-interacting myofilament-associated proteins. Permeabilized human placental and myometrial arteries were constricted with maximal activating Ca(2+) (pCa 4.5), or sub-maximal Ca(2+) (pCa 6.7) and the thrombane mimetic U46619, and exposed to 8-Br-cGMP. In each case, relaxation was significantly greater in myometrial arteries (e.g. relaxation in pCa 4.5 to 8-Br-cGMP was 49 ± 9.7%, n = 7) than placental arteries (relaxation of 23 ± 6.6%, n = 6, P < 0.05). MYPT1 protein levels, or MYPT1 LZ(+)/LZ(-) mRNA ratios, were similar for both artery types. Of other proteins examined, only Hsp20 expression was significantly elevated in myometrial arteries than placental arteries. These results demonstrate that the reduced human placental artery relaxation to PKG stimulation lies partly at the level of myofilament (de)activation and may be related to a lower expression of Hsp20 than in myometrial arteries.

Pregnant women's perspectives on decision-making when a fetal malformation is detected by ultrasound examination

OBJECTIVES

The aims of the study were to explore factors influencing the decision to continue or terminate pregnancy due to detection of fetal malformation following ultrasound examination, to elucidate the need for more information or other routines to facilitate the decision-making process and to assess satisfaction with the decision made.

DESIGN

Descriptive study.

SETTING

Four fetal care referral centres in Stockholm, Sweden.

POPULATION

Pregnant women with a detected fetal malformation.

METHODS

Data was collected by questionnaires. 134 women participated, 99 completing the questionnaire. Descriptive statistical analysis was performed.

RESULTS

Both women who continued and those who terminated pregnancy based their decision on the severity of the malformation. Other reasons for terminating the pregnancy were aspects including socioeconomic considerations. None stated religious factors. The doctor at the fetal care unit also had an influence on the decision-making. The timeframe receiving information was regarded as long enough in duration but not the number of occasions. In both groups the women made the decision by themselves or together with their partners. The majority experienced that they had made the right decision. Women who terminated their pregnancy had a significant higher rate (51.2%) (p < or = 0.004) of previous abortions than those in the continuing group (23.2%).

CONCLUSION

The decision to continue or terminate the pregnancy was to a great extent based on the severity of the malformation. Religious aspects did not seem to influence the decision. Many women expressed a need for additional occasion of information. The vast majority of women were satisfied with their decision.

Prediction of hypotension during spinal anesthesia for cesarean section and its relation to the effect of crystalloid or colloid preload

BACKGROUND

If parturients prone to develop caval compression in the supine position were identified before delivery, this might be a method of predicting hypotension during caesarean section under spinal anesthesia. Colloid preloading is superior to crystalloid in reducing the risk for spinal anesthetic-induced hypotension. It is postulated that parturients preoperatively susceptible to the supine position would benefit the most from colloid preloading.

METHODS

Fifty-five healthy parturients scheduled for elective cesarean section under spinal anesthesia were preoperatively investigated with a supine stress test with measurement of maternal heart rate, blood pressure, right uterine artery pulsatility index and symptoms in the left lateral and supine positions. They were then randomized to receive a colloid or crystalloid preload before anesthesia.

RESULTS

The stress test was positive, indicating a reduced tolerance to the supine position, in 36%. The sensitivity and specificity of the stress test for clinically significant hypotension (symptomatic hypotension) for patients randomized to the crystalloid group (n=25) were 69 and 92% respectively. Patients with a positive stress test receiving a crystalloid preload showed a higher frequency of hypotension compared to all other groups, 90% vs. 33%, (P=0.003) and also a greater need for ephedrine, mean dose (SD): 20.0 (9.7) vs. 8.4 (9.0) mg (P=0.002).

CONCLUSIONS

Pregnant women with a positive preoperative supine stress test constitute a subset at increased risk for clinically significant hypotension during cesarean delivery under spinal anesthesia. These women seem more likely to benefit from prophylactic colloid solution than women with a negative stress test.

Colloid vs. crystalloid preloading to prevent maternal hypotension during spinal anesthesia for elective cesarean section

BACKGROUND

Hypotension associated with spinal anesthesia for cesarean section is still a clinical problem. Colloid solutions seem preferable to crystalloid solutions for preloading. In most studies the overall rate of hypotension is reported. Few studies have, however, investigated the maternal and neonatal consequences of different levels of maternal hypotension.

METHODS

In this randomized, double-blinded study 110 patients presenting for elective cesarean section received either 1000 ml acetated Ringer's solution or 1000 ml 3% dextran 60 solution immediately before spinal anesthesia. The effect on overall hypotension, clinically significant hypotension (hypotension associated with maternal discomfort defined as nausea, retching/vomiting, dizziness or chest symptoms) and severe hypotension (systolic arterial pressure <80 mmHg) was studied.

RESULTS

Dextran reduced the incidence of overall hypotension from 85 to 66% (P=0.03), reduced the incidence of clinically significant hypotension from 60 to 30% (P=0.002) and reduced the incidence of severe hypotension from 23 to 3.6% (P=0.004) compared to Ringer's solution. There were neither differences in neonatal outcome between treatment groups nor between neonates grouped after severity of maternal hypotension.

CONCLUSION

Clinically significant hypotension seems to be a more suitable outcome variable than overall hypotension. The protective effect of the colloid solution increased with increased severity of hypotension.

Health-seeking patterns among fatally ill Capeverdian women

The circumstances of 94 deaths among females aged 15-49 years in Cape Verde were investigated to assess their access to effective care. Persons associated with the deceased women were interviewed (verbal autopsy) to explore contributing causes of death, perceived illnesses and treatment efforts. The certainty of diagnosis and avoidability of the fatal outcome were assessed by a panel ofexperts. A model of health care accessibility is elaborated to identity restricting (delay) factors. Deliberate avoidance of modern medical care and reliance on traditional medicine were major delay factors, while unawareness of the severity of symptoms and affordability limits were minor delay factors in this population. A detailed sorting of cases by health care level is used to identify the effectiveness of diagnosing, referral and care provided. Since a high proportion of avoidable deaths occurred in hospital, the quality of care may have been sub-optimal.

Developmentally regulated appearance of spliced variants of type XII collagen in the cornea

PURPOSE

To determine whether temporal and spatial changes in the distribution of the long and short alternatively spliced variants of type XII collagen are associated with any specific morphogenetic events in pre- and postnatal development of the cornea and surrounding tissues.

METHODS

The distribution of alternatively spliced variants of type XII collagen in fetal and newborn rabbit tissues was analyzed immunohistochemically using monoclonal antibodies that recognize either only the long form or both the short and the long forms of type XII collagen.

RESULTS

During early fetal development of the cornea in rabbit (days 14 -17), the short form of type XII collagen was detected in the corneal stroma, the sclera, and the stroma in the rudimentary eyelid folds, whereas the long form was present only in the sclera. The long form was first evident in the cornea at day 24 but only in the posterior stroma. At later stages of prenatal development, the distribution of the long variant gradually extended toward the anterior stroma and in the newborn rabbit, the long variant was distributed throughout the entire stroma. However, in the eyelid, although the short form was present along the entire subepidermal regions both during fetal and neonatal development, the long form was transiently expressed between days 21 and 24 and was restricted to the subepidermal regions at the junction of the opposing eyelids. The long form of type XII collagen was first detectable in the basal epithelial cells and in its basement membrane (BM) at day 12 after birth, just before the opening of the eyelids. It continued to be present in the corneal BM zone in the adult rabbit but was not present in the limbal or conjunctival BM zone.

CONCLUSIONS

The expression and distribution of the alternatively spliced forms of type XII collagen are developmentally and differentially regulated in the cornea, the sclera, and the eyelid. Although the short form is expressed in the stromal matrices of the cornea and surrounding tissues from early stages of corneal development, the appearance and distribution of the long variant form of type XII collagen coincide with the pattern of stromal condensation. Its first appearance in the corneal epithelial BM precedes the eyelid opening by 1 to 2 days, possibly suggesting that it may be involved in the tighter anchoring of the corneal epithelium to the underlying tissue or in promoting stromal condensation to assist in the separation of the corneal epithelium from the juxtaposed palpebral conjunctival epithelium of the eyelid.

Calpain III mutation analysis of a heterogeneous limb-girdle muscular dystrophy population

OBJECTIVE

To determine the frequency of calpain III mutations in a heterogeneous limb-girdle muscular dystrophy (LGMD) population.

BACKGROUND

Mutations of the calpain III gene have been shown to cause a subset of autosomal recessive LGMDs. Patient populations studied to date have been primarily of French and Spanish origin, in which calpain III may cause 30% of autosomal recessive MDs. The incidence of calpain III mutations in non-French/Spanish MD patients has not been studied thoroughly. No sensitive and specific biopsy screening methods for detecting patients with abnormal calpain III protein are available. Thus, detection of patients relies on direct detection of gene mutations.

METHODS

The authors studied the calpain III gene in 107 MD patient muscle biopsies exhibiting normal dystrophin. Muscle biopsy RNA was produced for each patient, and the entire calpain III complementary DNA was screened for mutations by reverse-transcriptase PCR/single-strand conformation polymorphism using three different conditions.

RESULTS

The authors identified nine patients (eight unrelated) with causative mutations. Six of the seven distinct mutations identified are novel mutations and have not been described previously.

CONCLUSION

The results suggest that approximately 9.2% of patients in the heterogeneous population with an LGMD diagnosis will show mutations of the calpain III gene. Interestingly, two patients were heterozygous for a single mutation at the DNA level, whereas only the mutant allele was observed at the RNA level. This suggests that there are undetectable, nondeletion mutations that ablate expression of the calpain III gene.

Deaths among women of reproductive age in Cape Verde: causes and avoidability

SUBJECT

In 1992-93 all deaths (n=97) of women 15 to 49 years old in three islands of Cape Verde were investigated to determine the cause of death, the maternal mortality ratio, the reliability of cause-of-death ascertainment, and the level of avoidability.

METHOD

Data were obtained through interviews with the deceased person's family members and other knowledgeable persons (verbal autopsy) and through hospital files.

RESULTS

The overall mortality rate was 163 per 100,000 women 1549 years old, and the maternal mortality ratio was 127 per 100,000 live births. A plausible diagnosis could be determined in 77%. The most frequent causes of death were circulatory disorders, external causes, maternal causes, infectious diseases. and neoplasms.

CONCLUSIONS

It was estimated that three of four of the deaths were avoidable with locally available resources. Since access to health care in the study area is not a major hindrance, a further decrease of female mortality depends mainly on improved quality of care in health facilities.

A Rho-associated protein kinase: differentially distributed in limbal and corneal epithelia

PURPOSE

The authors have developed monoclonal antibodies (mAbs) to characterize the sequential biochemical changes in corneal epithelial cells after they differentiate from stem cells, located in the limbus, and migrate centripetally to follow the pathway of terminal differentiation. The purpose of this study was to identify a protein (recognized by mAb HE1/11F) with increased expression associated with the transition of the limbal epithelium to corneal epithelium.

METHODS

The distribution and identification of the protein(s) were performed using an indirect immunohistochemical staining technique and a western blot analysis, respectively. A rabbit corneal epithelial cDNA library, constructed in the Uni-Zap XR vector, was screened with mAb HE1/11F to select cDNA clones expressing polypeptide(s) recognized by this mAb. Additional overlapping cDNA clones were obtained from a primer extension cDNA library to determine the sequence of the complete open reading frame encoding the protein recognized by mAb HE1/11F.

RESULTS

Rabbit corneal epithelium exhibited strong immunostaining with mAb HE1/11F, however, the limbal epithelial cells stained weakly. HE1/11F recognized 160-kDa (HEBM1) and 100-kDa (HEBM2) polypeptides in the corneal epithelial extracts. The amino acid sequence of the protein deduced from the nucleotide sequence of the cDNA exhibited a close homology to that of a RhoA (Ras-related small GTPase)-associated serine-threonine kinase (ROCK-I or Rho-associated coiled-coil kinase). A 160-kDa RhoA-binding polypeptide with a molecular mass similar to that of HEBM1 and ROCK-I was detected in the corneal epithelial extracts. These findings strongly suggested that HEBM1 was rabbit ROCK-I. The identity of HEBM1 was further confirmed from the reactivity of mAb HE1/11F with ROCK-I immunoprecipitated from rabbit corneal epithelial extracts using anti-ROCK-I antibodies.

CONCLUSIONS

The increased expression of a protein identified as ROCK-I from cDNA analyses is associated with rabbit corneal epithelial differentiation and transition from the limbal to corneal surface. Therefore, a RhoA signaling pathway is likely to be associated with corneal epithelial differentiation (maturation). A close homology among the cDNA sequences of rabbit, mouse, rat, and human ROCK-I indicates that this RhoA-associated kinase is a well-conserved protein.

Risk factors for perinatal death in Cape Verde

Risk factors for perinatal death in the Cape Verde islands were assessed among 104 bereaved mothers and 292 mothers of surviving infants in an area-based case-control study in 1992-93. Prospectively gathered information on risk factors was obtained from medical records supplemented with post-partum interviews and anthropometric measurements of mothers and infants. No autopsies were performed. Multiple logistic regression analysis was applied. Out of 23 alleged maternal and two alleged infant risk factors, the following seven proved significantly and independently correlated with perinatal death: first pregnancy (odds ratio [OR] = 2.9); previous hypertensive disease (OR = 4.2); previous perinatal death (OR = 4.6); pre-eclampsia (OR = 7.0); non-cephalic fetal presentation (OR = 17.1); male infant (OR = 2.1) and maternal post-partum fever (OR = 3.1). The perinatal mortality rate was calculated as 37-46/1000 total births. A reduction in the mortality rate warrants antenatal and obstetric care with emphasis on primiparous women; improved detection and treatment of hypertensive disorders and genital infections; and improved intrapartum fetal observation and resuscitation routines.

Type XII collagen contributes to diversities in human corneal and limbal extracellular matrices

PURPOSE

To characterize diversities in the extracelhtlar matrices (ECMs) of the corneal and the surrounding limbal epithelium and stroma.

METHODS

Immunohistochemical analyses were employed for screening monoclonal antibodies (mAbs) developed against ECM components of the human corneal epithelial basement membrane (BM) zone. In the current study, mAb BM8 was used as the monospecific probe to characterize its antigen (AgBM8) immunochemically, and to immunoselect a complementary DNA (cDNA) clone encoding AgBM8. Direct biochemical and cDNA sequence analyses were performed for the further characterization of AgBM8. An indirect colloidal gold-conjugated antibody technique was employed for immunoelectron microscopic analysis to study the distribution of AgBM8 in the corneal ECMs.

RESULTS

The protein AgBM8, isolated from rabbit corneal stromal and epithelial tissues, was identified as the long-splice variant form of type XII collagen based on its size (approximately 340 kDa disulfide-linked subunits), the presence of collagenous domain(s) and a noncollagenous domain of approximately 300 kDa in its subunit structure, and its internal amino acid sequences. The identity of AgBM8 was further confirmed from the amino acid sequence (517 amino acids) deduced from the sequence of a cDNA immunoselected with mAb BM8. Immunofluorescence analyses indicated that the long form of type XII collagen is present in the ECMs of corneal stroma and in the sclera, as well as in the corneal epithelial BM zone but is absent in the limbal and conjunctival epithelial BM zones. It was not detectable in the subepithelial loose connective tissues in the limbus and in the bulbar conjunctiva. Immunoelectron microscopic analyses indicated that the long variant form of type XII collagen is present in corneal epithelial BM, Bowman's membrane, and the interfibrillar matrix of the corneal stroma. In the stroma, colloidal gold was distributed along the collagen fibrils with a periodicity of 150 to 200 nm.

CONCLUSIONS

The long variant form of human type XII collagen, a member of the fibril-associated collagens with interrupted triple helices, referred to as FACITs, contributes to the differences in the BM zones of the cornea and limbus. Although many of the dense connective tissues in adult animals contain the short variant form of type XII collagen, human corneal stroma, the BM zone, and the sclera contain the long variant form as the predominant form of type XII collagen. In the corneal stroma, type XII collagen may be organized along the collagen fibrils in a uniform head-to-tail pattern.

Ectopic intrathyroidal thymus diagnosed as a solid thyroid lesion: case report and review of the literature

The authors report a case of a 6-year-old boy in whom aberrant thymic tissue was misdiagnosed as an intrathyroidal solid lesion. The patient underwent hemithyroidectomy and did well. Because cervical ectopic thymus rarely produces symptoms, the true incidence in children is unclear. Surgeons need to consider this rare entity, not to mistake it as a thyroid neoplasm, and not to perform extensive thyroid resection.

Detection of Neisseria gonorrhoeae from air-dried genital samples by single-tube nested PCR

A single-tube nested PCR method was developed for the detection of Neisseria gonorrhoeae. The optimized assay had a detection limit of less than 0.3 cell. Five different storage conditions for gonococcal specimens were compared with respect to the PCR detection of bacteria. For air-dried gonococcal slides containing three bacteria, DNA was detected after 8 weeks at ambient temperature, and for slides containing 300 bacteria, DNA could be detected after 24 weeks at ambient temperature. Air-dried storage combined with analysis by the single-tube nested PCR and a commercially available PCR (Amplicor) was used to test 350 cervical specimens from women in the West African island nation of Cape Verde. The in-house PCR detected 17 cases of N. gonorrhoeae infection, while the Amplicor system detected 14 cases of N. gonorrhoeae infection. No specimen was negative by the in-house PCR assay and positive by the Amplicor PCR. This sensitive nested PCR assay, combined with air-dried storage, allows for the detection of gonococci when specimen storage and transport times are extended and freezing conditions are not available.

Evaluation of antenatal risk factors lit Cape Verde

The prevalence of antenatal risk factors and their association with adverse pregnancy outcome were prospectively studied in the county of Praia, Cape Verde. Of 4693 women registering for antenatal care, 8% were randomly selected from October 1991 through December 1992. Eventually 358 women were observed until puerperium when a physical examination and a structured interview took place. Three out of four women of the cohort were exposed to risk factors according to the existing risk classification in Praia, and 9% presented high risk factors. Thirty two percent of the cohort faced adverse pregnancy outcomes. Adverse pregnancy outcomes were significantly increased among women who presented high risk factors, but 82% of all adverse outcomes occurred among other women. The antenatal risk classification investigated cannot be considered an effective tool for detection of women at risk of adverse pregnancy outcome.

Maternal risk factors for preterm birth and low birthweight in Cape Verde

BACKGROUND

Fifteen years after the implementation of an antenatal risk screening program in Cape Verde, the first assessment of an association between maternal obstetric characteristics and preterm birth or low birthweight (LBW) infants was undertaken.

METHODS

A cohort of 353 systematically selected antenatal clinic attenders in the county of Praia, Cape Verde, was studied prospectively during the period October 1991 through December 1992. The cohort was followed past the perinatal period and information was obtained according to a pretested structured questionnaire. In the analysis of preterm birth and LBW, multiple logistic regression was listed to estimate the relative risks of ll background variables.

RESULTS

The prevalence of preterm birth (<37 gestational weeks) was 12%, and the prevalence of LBW infants was 8%. Low birthweight (<2500 grams) was significantly associated with low maternal age (< or = 19 years, RR=3.7); nulliparity (RR=5.2) and obstetric history of previous LBW infant (RR-6.5). The risk of preterm birth was significantly increased if the woman had an obstetric history of hypertension or convulsions (RR=2.6).

CONCLUSIONS

In the setting studied, teenage women and women with previous pregnancy hypertension should be given selective attention in antenatal care to achieve improved pregnancy outcome. Primary prevention is needed to lower the prevalence of teenage pregnancies.

[Lipid island (xanthelasma) of the duodenal mucosa--a rarely found diagnosis and differential diagnosis]

A case report ist given on a 54-year-old patient with the so called lipid island (xanthelasma) in the duodenal mucosa. Xanthelasmas are very rarely located in the duodenal mucosa. The diagnosis and differential diagnosis of this entity are reported. The relevance of histochemistry and immunohistochemistry for differentiation of signet ring carcinoma cells in the mucosa is discussed.

[Occupationally-induced liver damage--vinyl chloride-induced angiosarcoma]

A 45-year-old chemical worker (exposure to vinyl chloride: 500-1612 mg VC/m3 over 248 months) fell ill with a haemangiosarcoma of the liver. This is the first case observed in workers exposed to VC in East Germany. We did not succeed in making the definite histological diagnosis until after the patient's death. The first pathological findings were revealed through the increase in the gamma glutamyl transpeptidase, through sonography and computer tomography of the liver. Numerous tumor biopsies produced either no material or healthy liver tissue, which led to difficulties in therapy. The only chance of effective treatment is an early liver transplantation.

Involvement of the central nervous system in malignant lymphomas of mice

19% of the male and 49% of the female AKR mice with spontaneously developed lymphomas show an involvement of the central nervous system (CNS) in the form of a tumor cell infiltration of the leptomeninx. A significantly higher rate of lymphomas was achieved by syngeneic transplantation of lymphoma cells (intraperitoneal inoculation) in the CNS with 87% in both sexes. Morphologically, there were no differences between the leptomeningeal infiltrations in spontaneously developed and transplanted lymphomas. Spontaneous and induced lymphomas of the AKR mouse may be suitable as a simple model for investigations on CNS lymphomas in experimental oncology.

[Lymphogranulomatosis in childhood]

Hodgkin's disease is relatively rare in children. The lymph node biopsies of 66 children with Hodgkin's disease were reclassified and discussed in relation to age and sex. The youngest patient was a 2-year-old boy. Mixed cellularity was the most common histologic type (37.9%-25 cases) showing a slight preponderance of boys (14 cases). Nodular sclerosis comprised 31.8% (21 cases) and the lymphocyte predominant type was found in 19.7% (13 cases) in contrast to the low incidence of the lymphocyte depletion type (6.1%-4 cases). At the age of 2 to 10 years Hodgkin's disease prevailed in boys. Our results are discussed regarding the findings of the literature.

[Megakaryocytic pseudomyelosis with severe thrombocytosis]

A 66-year-old female patient complained of loss of body weight and fatigue. The clinical examination revealed a thrombocytosis with a maximum count of 3.200 . 10(9) platelets and a leukocytosis with maximally 25 . 10(9) white cells in the peripheral blood. The bone marrow showed a large increase of megakaryocytes. Under the diagnosis of megakaryocytic myelosis a chemotherapy with 186 mg busulfan was performed. In the course of this treatment the clinical picture of a sepsis occurred which could not be controlled by antibiotics. The patient died four months after her admission to the clinic. The essential findings in autopsy were a caseous tuberculosis of the lymph nodes with haematogenic generalization which appeared as a septic tuberculosa gravissima ("typhobacillosis" Landouzy). The bone marrow was atrophic. Spleen liver and lymph nodes were without evidence for a myeloproliferative disorder. Thus, the initial diagnosis had to be changed to a megakaryocytic pseudomyelosis with massive thrombocytosis as a reaction to the tuberculous infection. The differential diagnosis of megakaryocytic myelosis, other disorders of the myeloproliferative syndrome, and the reactive thrombocytosis are discussed.

[Involvement of the central nervous system in generalized non-Hodgkin's lymphomas (author's transl)]

The value of the Kiel classification of non-Hodgkin's lymphomas (NHL) in neuro-oncology is supported by a systematic prospective study of the CNS in 131 autopsies with NHL. In 31 (23.7%) cases the CNS was involved, mainly in lymphoblastomas (11) and immunocytomas (10). Tumour manifestations of the CNS were found in 17 (20%) out of 84 low grade and 13 (34%) high grade malignant NHL. In plasmocytomas of the bone marrow the CNS was rarely affected. As only one fourth of the CNS infiltrations in lymphomas showed naked-eye appearances, a careful histologic examination of the brain, spinal cord, nerve roots and spinal ganglia, respectively, is necessary for evaluation of the CNS involvement in NHL. The cause of the different incidence of CNS manifestation in various types of NHL is obscure. Further investigations including immunologic, clinical and therapeutic studies have to be carried out for solving this problem.

[Diagnosis and differential diagnosis of primary lymph node plasmacytomas]

A case of 75 year-old man is reported, who died of a tuberculous leptomeningomyeloencephalitis complicating a generalized primary lymph node plasmacytoma. The malignant lymphoma has been diagnosed in a lymph node biopsy from the right supraclavicular region seven years before the death and was treated with cytostatics over a period of four and a half months. Autopsy revealed the neoplastic involvement of supraclavicular and axillary lymph nodes, tumour infiltration of the sternum and diffuse neoplastic plasmacytosis of the bone marrow. The lymph node plasmacytoma has to be differentiated from reactive lymph node plasmacytosis, angioimmunoblastic lymphadenopathy with excessive plasmacytosis, lymphoplasmacytic immunocytoma, metastasis of an extramedullary plasmacytoma or of a multiple myeloma, and from a lymph node involved by plasma-cell leukemia.

[The Bland-White-Garland syndrome in adult age]

The clinical and post-mortem findings in a 59-year-old female patient with an anomalous origin of the left coronary artery are described. This case in the age over fifty is the fourth to be published. The clinical picture was characterized as an antero-lateral myocardial infarction with disturbances of the conduction and with a mitral insufficiency. At autopsy fibrotic areas resulting from myocardial infarction were found in the ventricular septum and in the anterior as well in the posterior muscular wall of the heart. The histological alterations of the arterial wall suggested that the function of the central part of the left coronary artery was that of a vene, while the peripheral parts served as arterio-venous anastomoses. The occurrence of this anomaly in our autopsy material was 0.1 0/00. The pathophysiology is discussed.

[Familial preductal aortic coarctation. Report on a sibling observation]

The cases of two siblings, who died of preductal coarctation of the aorta, are reported. The rare familiar congenital cardiopathies are of special importance for the etiological questions and for judgement of the prognosis of inheritance.