Treatment in Kenyan rural health facilities: projected drug costs using the WHO-UNICEF integrated management of childhood illness (IMCI) guidelines

Guidelines for the integrated management of childhood illness (IMCI) in peripheral health facilities have been developed by WHO and UNICEF to improve the recognition and treatment of common causes of childhood death. To evaluate the impact of the guidelines on treatment costs, we compared the cost of drugs actually prescribed to a sample of 747 sick children aged 2-59 months in rural health facilities in western Kenya with the cost of drugs had the children been managed using the IMCI guidelines. The average cost of drugs actually prescribed per child was US$ 0.44 (1996 US$). Antibiotics were the most costly component, with phenoxymethylpenicillin syrup accounting for 59% of the cost of all the drugs prescribed. Of the 295 prescriptions for phenoxymethylpenicillin syrup, 223 (76%) were for treatment of colds or cough. The cost of drugs that would have been prescribed had the same children been managed with the IMCI guidelines ranged from US$ 0.16 per patient (based on a formulary of larger-dose tablets and a home remedy for cough) to US$ 0.39 per patient (based on a formulary of syrups or paediatric-dose tablets and a commercial cough preparation). Treatment of coughs and colds with antibiotics is not recommended in the Kenyan or in the IMCI guidelines. Compliance with existing treatment guidelines for the management of acute respiratory infections would have halved the cost of the drugs prescribed. The estimated cost of the drugs needed to treat children using the IMCI guidelines was less than the cost of the drugs actually prescribed, but varied considerably depending on the dosage forms and whether a commercial cough preparation was used.

Subacute and non-acute casemix in Australia

The costs of subacute care (palliative care, rehabilitation medicine, psychogeriatrics, and geriatric evaluation and management) and non-acute care (nursing home, convalescent and planned respite care) are not adequately described by existing casemix classifications. The predominant treatment goals in subacute care are enhancement of quality of life and/or improvement in functional status and, in non-acute care, maintenance of current health and functional status. A national classification system for this area has now been developed--the Australian National Sub-Acute and Non-Acute Patient Classification System (AN-SNAP). The AN-SNAP system, based on analysis of over 30,000 episodes of care, defines four case types of subacute care (palliative care, rehabilitation, psychogeriatric care, and geriatric evaluation and management and one case type of non-acute care (maintenance care), and classifies both overnight and ambulatory care. The AN-SNAP system reflects the goal of management--a change in functional status or improvement in quality of life--rather than the patient's diagnosis. It will complement the existing AN-DRG classification.

Autoimmune-associated congenital heart block: demographics, mortality, morbidity and recurrence rates obtained from a national neonatal lupus registry

OBJECTIVES

The present study describes the demographics, mortality, morbidity and recurrence rates of autoimmune-associated congenital heart block (CHB) using information from the Research Registry for Neonatal Lupus.

BACKGROUND

Isolated CHB detected at or before birth is strongly associated with maternal autoantibodies to 48-kD SSB/La, 52-kD SSA/Ro and 60-kD SSA/Ro ribonucleoproteins and is a permanent manifestation of the neonatal lupus syndromes (NLS). Available data are limited by the rarity of the disease.

RESULTS

The cohort includes 105 mothers whose sera contain anti-SSA/Ro or anti-SSB/La antibodies, or both, and their 113 infants diagnosed with CHB between 1970 and 1997 (56 boys, 57 girls). Of 87 pregnancies in which sufficient medical records were available, bradyarrhythmia confirmed to be CHB was initially detected before 30 weeks of gestation in 71 (82%) (median time 23 weeks). There were no cases in which major congenital cardiac anatomic defects were considered causal for the development of CHB; in 14 there were minor abnormalities. Twenty-two (19%) of the 113 children died, 16 (73%) within 3 months after birth. Cumulative probability of 3-year survival was 79%. Sixty-seven (63%) of 107 live-born children required pacemakers: 35 within 9 days of life, 15 within 1 year, and 17 after 1 year. Forty-nine of the mothers had subsequent pregnancies: 8 (16%) had another infant with CHB and 3 (6%) had a child with an isolated rash consistent with NLS.

CONCLUSIONS

Data from this large series substantiate that autoantibody-associated CHB is not coincident with major structural abnormalities, is most often identified in the late second trimester, carries a substantial mortality in the neonatal period and frequently requires pacing. The recurrence rate of CHB is at least two- to three-fold higher than the rate for a mother with anti-SSA/Ro-SSB/La antibodies who never had an affected child, supporting close echocardiographic monitoring in all subsequent pregnancies, with heightened surveillance between 18 and 24 weeks of gestation.

Identification of putative c-Myc-responsive genes: characterization of rcl, a novel growth-related gene

The c-Myc protein is a helix-loop-helix leucine zipper oncogenic transcription factor that participates in the regulation of cell proliferation, differentiation, and apoptosis. The biochemical function of c-Myc has been well described, yet the identities of downstream effectors are just beginning to emerge. We describe the identification of a set of c-Myc-responsive genes in the Rat1a fibroblast through the application of cDNA representational difference analysis (RDA) to cDNAs isolated from nonadherent Rat1a and Rat1a-myc cells. In this system, c-Myc overexpression is sufficient to induce the transformed phenotype of anchorage-independent growth. We identified 20 differentially expressed cDNAs, several of which represent novel cDNA sequences. We further characterized one of the novel cDNAs identified in this screen, termed rcl. rcl expression is (i) directly stimulated by c-Myc; (ii) stimulated in the in vivo growth system of regenerating rat liver, as is c-myc; and (iii) elevated in human lymphoid cells that overexpress c-myc. By using an anti-Rcl antibody, immunoblot analysis, and immunofluorescence microscopy, the Rcl protein was found to be a 23-kDa nuclear protein. Ectopic expression of the protein encoded by the rcl cDNA induces anchorage-independent growth in Rat1a fibroblasts, albeit to a diminished extent compared to ectopic c-Myc expression. These data suggest a role for rcl during cellular proliferation and c-Myc-mediated transformation.

Anti-ribosomal and 'P-peptide'-specific autoantibodies bind to T lymphocytes

Patients with systemic lupus erythematosus (SLE) frequently have anti-lymphocyte autoantibodies, some of which also bind to surfaces of neurons. Since anti-ribosomal P protein autoantibodies (anti-P) from SLE patients also bind to surfaces of neurons, we hypothesized that anti-P are anti-lymphocyte antibodies. A panel of human T lymphocytes was evaluated for anti-P binding by indirect immunofluorescence. Affinity-purified anti-ribosomal antibodies were used as a source of anti-P. These autoantibodies bound to the surfaces of all transformed T cell lines tested. This binding was not mediated by Fc receptors. It was inhibitable by ribosomes. Anti-P bound to circulating T lymphocytes from healthy adults and children. They also bound to thymocytes and cord blood T cells from normal neonates. Circulating T cells from SLE patients with anti-P bound less anti-P than cells from healthy controls. Two patients were studied on multiple occasions. The capacity of their T cells to bind anti-P correlated inversely with titres of anti-ribosomal antibodies. Anti-ribosomal antibodies, other than anti-P, also appear to bind to T cells. The surface of T cells contains a protein with the size and antigenicity of the ribosomal P protein, P0. We conclude that anti-ribosomal antibodies are a subset of anti-lymphocyte autoantibodies. Their possible role in the pathogenesis of lymphopenia or lymphocyte dysfunction in SLE has to be defined in further studies.

Epidemic cholera in Burundi: patterns of transmission in the Great Rift Valley Lake region

BACKGROUND

After a 14-year hiatus, epidemic cholera swept through Burundi between January and May, 1992. The pattern of transmission was similar to that in 1978, when the seventh pandemic first reached this region. Communities affected were limited to those near Lake Tanganyika and the Rusizi River. The river connects Lake Tanganyika with Lake Kivu to the north in Zaire and Rwanda.

METHODS

To identify sources of infection and risk factors for illness, an epidemiological study was carried out in Rumonge, a lake-shore town where 318 people were admitted to hospital with cholera between April 9 and May 31, 1992. The investigation included a case-control study of 56 case-patients and 112 matched controls.

FINDINGS

Attack rates according to street increased with the street's proximity to Lake Tanganyika (chi 2 test for linear trend, p < 0.01) which suggests that exposure to the lake was a risk factor for illness. Comparison of the 56 case-patients with matched controls showed that bathing in the lake (odds ratio 1.6, attributable risk percentage 37%) and drinking its water (2.78, 14%) were independently and significantly (p < 0.05) linked with illness. No food-borne risk factors were identified. Vibrio cholera 01 was isolated from Lake Tanganyika during, but not after, the outbreak in Rumonge. Isolates from the lake and from patients with acute watery diarrhoea had the same serotype, biotype, and antimicrobial susceptibility profiles. The number of cases rapidly declined when access to the lake was blocked.

INTERPRETATION

This study identifies bathing in contaminated surface water as a major risk factor for cholera in sub-Saharan Africa, and suggests that improving the quality of drinking water alone will have only limited impact on the transmission of the disease in the Great Rift Valley Lake region. The similarity in the patterns of transmission during the 1978 and 1992 epidemics suggests that extensive use of the Great Lakes and connecting rivers for transportation and domestic purposes may be the reason for the explosive cholera outbreaks that occur sporadically in this region.

The ultrastructural localization of 60-kDa Ro protein and human cytoplasmic RNAs: association with novel electron-dense bodies

The 60-kDa Ro ribonucleoprotein is an important target of humoral autoimmune responses. However, the ultrastructural locations of the 60-kDa Ro protein and its associated small cytoplasmic RNAs (Y RNAs) have not been previously determined, and the functions of the Ro protein and RNAs are not known. In this study, the cellular locations of the 60-kDa Ro protein and the Ro Y1 and Y4 RNAs are determined by immunoelectron microscopy and in situ hybridization electron microscopy, respectively. Both Ro protein and Y RNAs are concentrated in discrete areas of the nucleoplasm, nucleolus, and cytoplasm of cultured cells and human skin sections. The 60-kDa Ro protein and Y RNAs are also present diffusely in the cytoplasm, where they occur in ribosome-rich regions, and in the nucleus. The presence of Ro ribonucleoprotein components in nucleoli and in ribosome-rich cytoplasmic areas suggests a potential for the involvement of Y RNAs and/or 60-kDa Ro protein in ribosome synthesis, assembly, or transport. Double labeling experiments show that Ro protein and Y RNAs colocalize in the nucleoplasm, nucleolus, and cytoplasm. In addition, aggregates of Y RNA occur unassociated with 60-kDa Ro protein, and aggregates of 60-kDa Ro protein occur unassociated with Y RNA. Aggregates of both Ro protein and Y RNAs label previously unreported nuclear and cytoplasmic electron-dense bodies. We propose that these distinctive Ro-associated electron-dense bodies may represent structure(s) important for cellular transport and/or Ro function.

Palmitoyl-protein thioesterase and the molecular pathogenesis of infantile neuronal ceroid lipofuscinosis

Palmitoyl-protein thioesterase (PPT) has recently been shown to be the defective enzyme underlying the infantile form of neuronal ceroid lipofuscinosis (INCL). In this paper, we review the enzymology of PPT, evidence for its localization in lysosomes, and recent advances in understanding the metabolic defect caused by PPT deficiency. Absence of PPT activity in lysosomes isolated from INCL lymphoblasts is demonstrated. A model for the formation of the storage bodies in INCL involving defective autophagocytic proteolysis is proposed.

Cutaneous lupus erythematosus during the neonatal and childhood periods

Cutaneous lupus erythematosus may be related to maternal autoantibody production in the neonatal lupus syndrome, or may occur later in childhood, with or without findings of systemic lupus erythematosus (SLE). In the first section, we will discuss the transient, passively transferred neonatal disease, and in the second, we will discuss the persistent, actively acquired forms of lupus erythematosus in childhood.

A household survey of dysentery in Burundi: implications for the current pandemic in sub-Saharan Africa

To characterize the epidemiology of dysentery (defined as bloody diarrhoea) in Burundi, we reviewed national surveillance data and conducted a household cluster survey including two case--control studies: one at the household, the other at the individual level. We estimated that community incidences for dysentery (per 1000 residents) in Kibuye Sector were 15.3 and 27.3, and that dysentery accounted for 6% and 12% of all deaths, in 1991 and 1992, respectively. Factors associated (P < or = 0.05) with contracting dysentery were being female, using a cloth rag after defecation, a history of recent weight loss, and not washing hands before preparing food. The attributable risk, at the household level, of not washing hands before preparing food was 30%. Secondary household transmission accounted for at most 11% of dysentery cases. This study suggests that Shigella dysenteriae type 1 may be one of the leading causes of preventable mortality in Burundi and other African countries where effective antimicrobial agents are no longer affordable. Since hands were the most important mode of transmission of S. dysenteriae in this study, community-based interventions aimed at increasing hand washing with soap and water, particularly after defecation and before food preparation, may be effective for controlling dysentery epidemics caused by S. dysenteriae type 1 in Africa.

The recognition of human 60-kDa Ro ribonucleoprotein particles by antibodies associated with cutaneous lupus and neonatal lupus

The hY RNAs form a macromolecular complex with the 60-kDa Ro protein and may in addition be bound by the La protein. In this study, we examine the autoantibody responses to the intact protein-RNA complexes in 18 subacute cutaneous lupus (SCLE), 10 discoid lupus (DLE), and 18 neonatal lupus erythematosus (NLE) sera. All SCLE and NLE serum samples precipitated all four of the Ro hY RNAs, whereas none of the DLE serum samples precipitated the hY RNAs. Among the SCLE and NLE sera, there was a significant association between the amount of Ro hY RNAs precipitated and the concurrent presence of anti-La antibodies in the sera (p = 0.008), consistent with the hypothesis that both the 60-kDa Ro and the La proteins can bind the Ro hY RNAs. There was no correlation between the amount of hY RNAs precipitated and the titer of antibodies to the 60-kDa Ro protein in enzyme-linked immunosorbent assay (ELISA). This may be due to a difference in the epitopes formed by the antigen in the respective assays. The autoantibody response to Ro in SCLE and NLE, which is generally detectable by both immunodiffusion and ELISA, is directed to all the subsets of the Ro protein-hY RNA complexes. The autoantibody response in DLE, though frequently detectable by ELISA, is not of sufficient concentration or affinity to precipitate the Ro protein-RNA complexes. The autoantibody response to Ro in SCLE and NLE may include antibodies to epitopes created by the complexing of the 60-kDa Ro protein with hY RNA.

Development of complete heart block in an adult patient with Sjögren's syndrome and anti-Ro/SS-A autoantibodies

We describe the occurrence of complete heart block in a patient with Sjögren's syndrome. The patient's serum contained antibodies to both the 60-kd and 52-kd Ro proteins. This case indicates that although the adult atrioventricular node may be relatively resistant to the development of anti-Ro-associated heart block, it can nevertheless be affected.

A link between c-Myc-mediated transcriptional repression and neoplastic transformation

Recent studies indicate that the transcription factor c-Myc contributes to oncogenesis by altering the expression of genes involved in cell proliferation, but its precise function in neoplasia remains ambiguous. The ability of c-Myc to bind the sequence CAC(G/A)TG and transactivate appears to be linked to its transforming activity; however, c-Myc also represses transcription in vitro through a pyrimidine-rich cis element termed the initiator (Inr). In transfection experiments using the adenoviral major late (adML) promoter, which contains two Myc binding sites and an Inr, we determined that c-Myc represses transcription through the initiator in vivo. This activity requires the dimerization domain and amino acids 106 to 143, which are located within the transactivation domain and are necessary for neoplastic transformation. We studied a lymphoma-derived c-Myc substitution mutation at 115-Phe, which is within the region required for transcriptional suppression, and found the mutant more effective than wild-type c-Myc in transforming rodent fibroblasts and in suppressing the adML promoter. Our studies of both loss-of-function and gain-of-function c-Myc mutations suggest a link between c-Myc-mediated neoplastic transformation and transcriptional repression through the Inr.

Newly established MST-1 tumour cell line and tumour-infiltrating lymphocyte culture from a patient with soft tissue melanoma (clear cell sarcoma) and their potential applications to patient immunotherapy

The establishment and characterisation of paired autologous tumour cell line (MST-1) and tumour-infiltrating lymphocyte (TIL) culture from a tumour mass of a 14-year-old Taiwanese girl with soft tissue melanoma are described. MST-1 cells grown in vitro were heterogeneous in morphology, ranging from floating round cells, loosely attached round/oval or elongated cells with prominent pseudopod-like processes, to well-attached spindle and elongated dendritic cells without obvious pseudopods. Immunostaining revealed that major melanoma-associated antigens, such as S100 protein, HMB-45, melanotransferrin, chondroitin sulphate proteoglycan, and the gangliosides GD2 and GD3, were consistently expressed by the tumour tissue, severe combined immunodeficiency (SCID) mouse xenograft and derived cell lines. Flow cytometric analysis of the tumour DNA content showed an index of 1.8 relative to normal peripheral blood lymphocyte DNA. Chromosome analysis revealed all cells at a hypotetraploid level with several clonal chromosome aberrations, including deletions at 10p and 12q, an addition at 12q, translocations t(1;14) and t(5;6). Electron microscopy showed melanosome structures. This observation and the expression of the major melanoma-associated antigens were all indicative of the melanocytic origin of MST-1 tumour. Interleukin-2 (IL-2) expanded TILs had the predominant CD8+ phenotype and the capacity to lyse cells of the cultured autologous tumour. The availability of the soft tissue melanoma cell line, the SCID mouse xenograft tumour system as well as autologous TILs described herein would provide useful materials for identifying T-cell-defined antigens as well as a model system for devising individualised cancer biotherapeutic strategies. This cell line can also be used for further studies aimed at uncovering the histogenesis of this rare cancer.

Natural killer cells weakly resist engraftment of allogeneic, long-term, multilineage-repopulating hematopoietic stem cells

Natural killer (NK) cells effect hybrid resistance, in which parental hematopoietic cell grafts are rejected by F1 recipients. NK cells can also resist engraftment of fully MHC-mismatched allogeneic marrow. However, studies of NK cell-mediated alloresistance have relied on short-term proliferation, colony, or survival assays; therefore, their results may not reflect effects of NK cells on the engraftment of allogeneic pluripotent hematopoietic stem cells (PHSC). We have now addressed the role of NK cells in resisting engraftment of these most primitive hematopoietic cells, which provide long-term repopulation of multiple hematopoietic lineages. We took advantage of a nonmyeloablative conditioning regimen that permits allogeneic marrow engraftment and induction of mixed chimerism in mice to evaluate the effect of host NK cell depletion with mAb PK136 on long-term competitive repopulating ability of allogeneic marrow. Mice were pretreated with depleting anti-CD4 and anti-CD8 mAbs, then received 3 Gy of whole body irradiation and 7 Gy of thymic irradiation prior to allogeneic bone marrow transplantation. Depending on the strain combination used, statistically significant increases in long-term allogeneic repopulation of both myeloid and lymphoid cell lineages were observed in recipients depleted of NK cells before bone marrow transplantation compared with controls. Depletion of host NK cells alone was sufficient to enhance donor PHSC engraftment. However, a statistically significant increase in allogeneic reconstitution in NK cell-depleted chimeras compared with control chimeras was not observed in every experiment, and differences were most readily apparent in a strain combination in which recipient NK cells have been shown to have high resistance to engraftment of donor short-term repopulating cells. Chronic (16 weeks) anti-NK1.1 treatment resulted in higher levels of donor-type repopulation than that in animals receiving only pretransplant NK cell depletion. Our studies demonstrate for the first time that host NK cells resist engraftment of allogeneic long-term repopulating PHSC, and provide a model for studying the elements that determine what is regarded as "self" and "non-self" by newly developing NK cells.

Descending thoracic aortomyoplasty: a technique for clinical application

BACKGROUND

Descending thoracic aortomyoplasty is a form of skeletal muscle-powered cardiac assistance. Its use in clinical settings has been limited by the ligation of intercostal arteries necessary to complete a circumferential wrap of the aorta with the latissimus dorsi.

METHODS

This study assessed the feasibility and the efficacy of aortomyoplasty constructed with a modified latissimus dorsi. A pericardial patch was attached to the latissimus dorsi and divided around the preserved intercostal arteries. Nine alpine goats (37 +/- 2 kg) underwent descending aortomyoplasty using this technique. All intercostal arteries were preserved. After a 6-week recovery period, the animals underwent a 6-week, incremental electrical conditioning program. After 90 postoperative days, animals were examined under anesthesia with the myostimulator on and off.

RESULTS

Aortomyoplasty activation resulted in augmentation of mean diastolic aortic pressure by 16.0 +/- 0.9 mm Hg (23%). Significant improvements in cardiac index (40%), stroke volume index (37%), left ventricular stroke work index (49%), and mean arterial pressure (19%) were noted. An intravascular sonographic probe placed in the descending aorta revealed circumferential compression of the aorta during counterpulsation. Mean cross-sectional aortic area was reduced by 51.8%, from 210.1 +/- 7.1 to 108.9 +/- 6.7 mm2 during aortomyoplasty activation (p < 0.05). Histologic analysis confirmed the long-term patency of intercostal arteries.

CONCLUSIONS

Descending aortomyoplasty, modified with an interposing patch of pericardium, effectively transfers skeletal muscle force across the aortic wall and assists cardiac function. This technique allows preservation of all aortic branches, and with this novel approach, the clinical utility of aortomyoplasty can now be explored.

Do products of the myc proto-oncogene play a role in transcriptional regulation of the prothymosin alpha gene?

The Myc protein has been reported to activate transcription of the rat prothymosin alpha gene by binding to an enhancer element or E box (CACGTG) located in the first intron (S. Gaubatz et al., Mol. Cell. Biol. 14:3853-3862, 1994). The human prothymosin alpha gene contains two such motifs: in the promoter region at kb -1.2 and in intron 1, approximately 2 kb downstream of the transcriptional start site in a region which otherwise bears little homology to the rat gene. Using chloramphenicol acetyltransferase (CAT) reporter constructs driven either by the 5-kb human prothymosin alpha promoter or by a series of truncated promoters, we showed that removal of the E-box sequence had no effect on transient expression of CAT activity in mouse L cells. When intron 1 of the prothymosin alpha gene was inserted into the most extensive promoter construct downstream of the CAT coding region, a diminution in transcription, which remained virtually unchanged upon disruption of the E boxes, was observed. CAT constructs driven by the native prothymosin alpha promoter or the native promoter and intron were indifferent to Myc; equivalent CAT activity was observed in the presence of ectopic normal or mutant Myc genes. Similarly, expression of a transiently transfected wild-type prothymosin alpha gene as the reporter was not affected by a repertoire of myc-derived genes, including myc itself and dominant or recessive negative myc mutants. In COS-1 cells, equivalent amounts of the protein were produced from transfected prothymosin alpha genes regardless of whether genomic E boxes were disrupted, intron 1 was removed, or a repertoire of myc-derived genes was included in the transfection cocktail. More importantly, cotransfection of a dominant negative Max gene failed to reduce transcription of the endogenous prothymosin alpha gene in COS cells or the wild-type transfected gene in COS or L cells. Taken together, the data do not support the idea that Myc activates transcription of the intact human prothymosin alpha gene or reporter constructs that mimic its structure. Rather, they suggest that the human prothymosin alpha promoter and downstream elements are buffered so as to respond poorly, if at all, to transient fluctuations in transcription factors which regulate other genes.

Cell density and paradoxical transcriptional properties of c-Myc and Max in cultured mouse fibroblasts

Deregulated expression of the c-Myc oncoprotein occurs in several human malignancies. The c-Myc protein behaves as a transcription factor, and undoubtedly its role in carcinogenesis involves its ability to affect the expression of genes involved in cell growth. c-Myc has been reported to both activate and repress transcription in transient transfection experiments using reporter constructs bearing multiple copies of the c-Myc binding site, CAC (G/A) TG. We investigated these apparently paradoxical effects of c-Myc by determining if they arose from differences in the cell proliferation states of transfected cells. We found that endogenous c-Myc protein levels vary inversely with the degree of cell confluency, such that at low cell confluency, where endogenous levels of c-Myc are high and presumably endogenous levels of Max are limiting, exogenous c-Myc fails to affect basal transcription. In cells at high cell confluency, in which endogenous c-Myc levels are low, exogenous c-Myc augments transactivation by titrating the relative excess endogenous Max. These observations suggest that the apparently paradoxical behavior of c-Myc in transfection experiments is partially dependent on ambient cellular levels of c-Myc.

Severe illness in African children with diarrhoea: implications for case management strategies

To identify clinical disorders associated with severe illness in African children with diarrhoea, we studied a group of under-5-year-olds with diarrhoea who had been brought to a large public hospital in central Cote d'Ivoire. The general condition of children with diarrhoea was assessed and classified according to criteria recommended by WHO, and then used as a nonspecific indicator of severity. Of the 264 children with diarrhoea who were enrolled in the study, 196 had nonsevere illness and 68 severe illness. Children with severe illness were significantly more likely than those with nonsevere illness to be dehydrated (45% versus 11%), moderate-to-severely wasted (47% versus 29%), bacteraemic (26% versus 9%), severely anaemic (haemoglobin level <6 g/dl; 15% versus 6%), have Plasmodium falciparum parasitaemia (27% versus 14%), and have two or more of these five conditions (60% versus 14%). Nontyphoidal Salmonella spp. were present in 68% of the blood isolates but were not associated with seropositivity to human immunodeficiency virus (HIV). The study demonstrates the need for a more comprehensive approach to assessment and management of children with diarrhoea that ensures prompt recognition of bacteraemia, anaemia, wasting and malaria, as well as dehydration. Simple nonspecific observational criteria, such as those recommended by WHO for assessing and classifying general condition, are useful for identifying children with diarrhoea who are at high risk of having life-threatening clinical disorders, and can readily be used by health workers whose clinical training and access to diagnostic laboratory facilities are both limited.

Specific tolerance across a discordant xenogeneic transplantation barrier

Successful induction of tolerance across disparate (discordant) species barriers could overcome the organ shortage that presently limits clinical transplantation. We demonstrate here that xenogeneic swine thymic transplants can induce tolerance to swine antigens in mice, while positively selecting functional host CD4+ T cells. Immunologically normal C57BL/10 mice were thymectomized and depleted of T and natural killer cells; then they received transplants of fetal pig thymus and liver fragments. Mature mouse CD4+ T cells developed in the pig thymus grafts and migrated to the periphery. Swine grafts grew markedly and no anti-pig IgG response was produced. Mixed lymphocyte reactions confirmed that the new T cells were functional and were tolerant to pig antigens.

Concentration of autoantibodies to native 60-kd Ro/SS-A and denatured 52-kd Ro/SS-A in eluates from the heart of a child who died with congenital complete heart block

OBJECTIVE

To determine the serologic specificity of acid eluates from tissues of a child who died with congenital complete heart block (CCHB).

METHODS

Tissues were extracted, acid eluted, and the IgG and antibody titers determined on the eluates by enzyme-linked immunosorbent assay.

RESULTS

Antibodies to native 60-kd and denatured 52-kd Ro/SS-A were found to be enriched only in the heart eluate, and not in the eluates from brain, kidney, and skin.

CONCLUSION

These findings indicate a major role for anti-native 60-kd Ro/SS-A in the immunopathogenesis of CCHB.

The autoantibody response to Ro/SSA in cutaneous lupus erythematosus

BACKGROUND AND DESIGN

Seventeen patients with subacute cutaneous lupus erythematosus (SCLE) were compared with 15 patients with discoid lupus erythematosus (DLE) to evaluate the relationship of 60- and 52-kd Ro/SSA autoantibodies to the clinical diagnosis and to evaluate assays for anti-Ro/SSA.

RESULTS

All serum samples from patients with SCLE had precipitating anti-Ro/SSA antibodies in immunodiffusion, and all had high titer anti-60-kd Ro/SSA in enzyme-linked immunosorbent assay. Immunoblotting was inadequately sensitive for detecting anti-60-kd Ro/SSA. Fifteen patients with SCLE had anti-52-kd Ro/SSA (11 high titer, four low titer). Only one of the 15 patients with DLE had precipitating, high-titer anti-Ro/SSA. Nine other patients with DLE had low-titer anti-60-kd Ro/SSA, and four had low-titer anti-52-kd Ro-SSA. Low-titer anti-Ro/SSA did not confer an increased risk for photosensitivity in the DLE group.

CONCLUSIONS

High-titer, precipitating antibodies to Ro/SSA are typical of SCLE and unusual in DLE. Low-titer, nonprecipitating antibodies to Ro/SSA are common in DLE and could be an indication of pathogenic factors shared with SCLE. However, low titers of anti-Ro/SSA do not confer a significant risk for SCLE skin lesions. For the purpose of clinical evaluation of skin disease, immunodiffusion assays for anti-Ro/SSA are cost-effective and informative.

Increase in antimicrobial-resistant Salmonella infections in the United States, 1989-1990

To assess factors associated with antimicrobial-resistant Salmonella infections and trends in resistance, a prospective study of patients with culture-confirmed salmonellosis was done in 1989-1990. Patients with resistant infections were more likely than those with susceptible infections to be hospitalized (P = .006), to be < 1 year old (P = .003), to be black (P = .013), and to have recently been treated with an antimicrobial agent (P = .085). Compared with data from a similar study in 1979-1980, increases were seen in the percentage of patients with resistant infections (from 17% to 31%), in the resistance to ampicillin (10% to 14%), and in the frequency of isolates found in blood (1% to 11%). These data show that treatment of Salmonella infections may be complicated by growing resistance to clinically important antimicrobial agents and by an increasing frequency of extraintestinal complications. Antimicrobial agents with little demonstrated resistance should be considered for patients with complicated illness and at high risk of having a resistant infection.

Autoantibodies of neonatal lupus erythematosus

The most common manifestations of neonatal lupus erythematosus (NLE) are cutaneous lupus and congenital heart block. Autoantibodies to Ro/SSA occur in almost all cases of NLE. The autoantibody response to Ro/SSA is complex, and antibodies may be detected to 60-kD Ro/SSA, 52-kD Ro/SSA, La/SSB, and U1 ribonuclear protein in anti-Ro/SSA-positive sera. Which of these anti-Ro/SSA-related autoantibody specificities are important in the clinical expression of NLE is not conclusively established. We examined the autoantibody specificities in 20 maternal NLE sera to determine whether autoantibody specificities correlate with the clinical findings and to evaluate the relative importance of autoantibodies to the different Ro/SSA-associated proteins. Autoantibodies were examined using immunodiffusion, immunoblotting, and enzyme-linked immunosorbent assay. Eleven babies had NLE skin disease, 11 had heart block, and two had both skin disease and heart block. All 20 maternal sera had antibodies to 60-kD Ro/SSA. Eighteen of the 20 had antibodies to 52-kD Ro/SSA, nine had antibodies to La/SSB, and one had antibodies to U1 ribonuclear protein. The prevalence of anti-La/SSB was the same in the skin-disease and heart-block subsets of NLE. Titers of anti-60-kD Ro/SSA were significantly (p < 0.02) lower in NLE skin disease maternal sera than in the NLE heart-block maternal sera. These results point out the importance of 60-kD Ro/SSA as a potential target in NLE. We speculate that the lower titers of anti-60-kD Ro/SSA in the sera from mothers of babies with skin disease may be due to substantial deposition of antibodies in the mothers' and babies' skin, leading to lower circulating titers, or may reflect a lower threshold for development of skin disease than for heart block.

The importance of nonimmune factors in reconstitution by discordant xenogeneic hematopoietic cells

Bone marrow transplantation has been shown to induce donor-specific tolerance in rodent models. This approach could potentially be applied to xenotransplantation across discordant species barriers. To evaluate host factors resisting hematopoietic cell engraftment, we have developed two model systems utilizing the combination of swine into severe combined immunodeficient (SCID) mice. SCID mice lack functional B and T lymphocytes, and can therefore be used to evaluate nonimmune factors resisting marrow engraftment, and for adoptive transfer studies to test the role of immune cells and antibodies. First we transplanted swine bone marrow cells into SCID mice conditioned with whole-body irradiation (4 Gy). For nine weeks following the intravenous administration of 10(8) swine bone marrow cells, up to 3.8% of peripheral blood leukocytes were of swine origin, as determined by flow cytometry (FCM). These cells were all of the myeloid lineage. Swine IgG was also detectable in the serum for up to 14 weeks. The bone marrow of the reconstituted mice contained low percentages of swine myeloid cells, and swine myeloid progenitors could be detected for up to 20 weeks after bone marrow transplantation. In a second model, we grafted thymus and liver tissue from 45-69-day-old swine fetuses under the kidney capsule of 4 Gy-irradiated SCID mice. A suspension containing 10(8) swine fetal liver cells (FLC) was also administered i.p. Long-term repopulation with swine T cells was observed, with up to 1.5% swine T cells detected in the WBC, peritoneum, and spleen for at least 5.5 months postgrafting. These T cells expressed either CD4 or CD8, whereas up to 17.6% of cells in the thymic grafts expressed both CD4 and CD8. The i.p. FLC suspension was required for optimal long-term graft maintenance. Our studies show that (1) low level myeloid and B lymphocyte reconstitution can be achieved by transferring adult swine BMC to irradiated SCID recipients; (2) swine myeloid progenitors were detectable long-term in BMC of these mice, suggesting that stem cell engraftment was achieved; and (3) T cell reconstitution of SCID mice by swine progenitors requires cotransplantation of a swine stromal environment, as is provided by fetal swine thymus/liver grafts. We conclude that nonimmune factors such as those provided by species-specific stromal environments are important for reconstitution of some lineages by discordant hematopoietic stem cells.

Outbreaks of Salmonella enteritidis infections in the United States, 1985-1991

The spread of Salmonella enteritidis infections in the United States was tracked to identify potential risk factors and preventive measures. Isolation rates and information regarding outbreaks of S. enteritidis from 1985 through 1991 were determined by reports to the national Salmonella surveillance system and through the foodborne disease outbreak surveillance system. From 1985 through 1991, 380 outbreaks were reported involving 13,056 ill persons and 50 deaths. The proportion of Northeast outbreaks fell from 81% in 1985 to 55% in 1991 as the number of outbreaks in other areas increased. Grade A shell eggs were implicated in 82% of outbreaks. Case-fatality rates in nursing homes and hospitals were 70 times higher than in other settings. Cultures of environmental or animal specimens from all farms tested yielded S. enteritidis. Eggborne S. enteritidis infections are a major public health problem. Preventive measures, including educating consumers about proper handling of eggs, using pasteurized eggs, and controlling infections on egg farms, may stem the impact of this disease.

Neonatal lupus liver disease

Neonatal lupus erythematosus (NLE) is an autoimmune disease characterized by complete congenital heart block and/or transient skin lesions of subacute cutaneous lupus erythematosus. We report that in approximately 10% of cases of NLE with heart block or skin disease, liver disease also occurs (4 of 35 cases in our series). Cholestasis was the major feature in our cases. Although the cholestasis may be severe, the disease process appears to be transient and surviving babies have been healthy on follow-up. In one liver examined for antibody deposition, IgG antibody deposits, presumably of maternal origin, were present. Three maternal sera were examined for autoantibodies, including liver-specific autoantibodies. No liver-specific autoantibodies were found. Rather, the maternal autoantibodies too were the ubiquitous Ro/SSA-associated autoantigens. The autoantibodies bound the 60 kDa SSA/Ro ribonuclear protein (three of three sera), the 52 kDa SSA/Ro protein (two of three sera) and the SSB/La ribonuclear protein (two of three sera).

Antimicrobial-resistant Salmonella spp isolated from healthy broiler chickens after slaughter

Of 105 Salmonella organisms of any serotype selected from a sample of 1,824 serotyped salmonellae isolated during a nationwide bacteriologic survey of healthy broiler chickens after slaughter, 60 (57%) were resistant to 1 or more antimicrobial agents and 47 (45%) were resistant to 2 or more agents. Highest resistance was to tetracycline (45%), streptomycin (41%), sulfisoxazole (19%), gentamicin (10%), and trimethoprim/sulfamethoxazole (8%). Additional isolates of S typhimurium, heidelberg, agona, and enteritidis were selected from the sample of 1,824 isolates for testing because of the high frequency with which these 4 serotypes are isolated from human patients. The highest frequency of resistance among 104 isolates of S heidelberg, 92 isolates of S typhimurium, and 30 isolates of S agona was to streptomycin (33 to 57%), sulfisoxazole (33 to 50%), tetracycline (26 to 50%), and gentamicin (13 to 40%); 51 to 63% of these isolates were resistant to 1 or more agents and 37 to 59% were resistant to 2 or more agents. Resistance to ampicillin among these 3 serotypes was uncommon (0 to 4%). In contrast, 15 of 19 tested isolates (79%) of S enteritidis were resistant to ampicillin and 13 of the 19 isolates (68%) were resistant only to ampicillin. This pattern of resistance was associated with a specific bacteriophage type and indicated the potential role of bacterial clones in determining the frequency and patterns of antimicrobial resistance in populations of broiler chickens. Resistance to gentamicin and trimethoprim/sulfamethoxazole was higher than that previously reported and is of public health concern because of the frequency with which these drugs are used to treat bacterial infections in human patients.

Neonatal lupus erythematosus

Neonatal lupus erythematosus (NLE) is an autoimmune disease whose major findings are subacute cutaneous lupus erythematosus (SCLE) skin lesions and congenital heart block. Babies have maternal anti-Ro/SSA, anti-La/SSB, or anti-U1RNP autoantibodies. Anti-Ro/SSA are the predominant autoantibodies, having been found in about 95% of cases. The autoantibodies pass through the placenta from mother to child. Skin disease resolves at about the time that maternal autoantibodies can no longer be detected in the baby. NLE therefore provides the strongest clinical evidence that autoantibodies are involved in at least some manifestations of lupus erythematosus, but there is as yet no definitive evidence implicating autoantibodies in the disease process. Skin disease usually begins after birth, is transient, and does not result in scarring. Cardiac disease begins in utero, and the heart block is almost always permanent. Many babies require pacemakers, and about 10% die from complications related to cardiac disease. In some cases, transient liver disease or thrombocytopenia have been observed. Individuals who had NLE usually have healthy childhoods but may develop autoimmune disease in adulthood. Whether the later development of autoimmune disease is a common or an unusual event is not yet known. Mothers of babies with NLE may be asymptomatic initially, but with time usually develop symptoms of autoimmune disease. The most typical constellation of symptoms in our group of approximately 30 mothers of babies with NLE is that of Sjögren's syndrome. Most babies exposed to anti-Ro/SSA autoantibodies during gestation will not develop NLE. There is no test to determine prospectively which babies will be affected. Treatment during gestation is still controversial and, if attempted, should be reserved for fetuses with potentially life-threatening disease. Treatment after birth consists of topical management for skin disease and pacemaker implantation, if necessary, for heart block. Systemic steroids may be given for serious internal disease.

Clinical, histologic, and immunofluorescent distinctions between subacute cutaneous lupus erythematosus and discoid lupus erythematosus

Subacute cutaneous lupus erythematosus (SCLE) was originally described and distinguished from discoid lupus erythematosus (DLE) on the basis of clinical examination of the skin, but subsequent reports have questioned the concept of SCLE as a marker of a unique subset of LE patients. We classified 27 lupus patients, on the basis of cutaneous exam, as having discoid lupus skin lesions, subacute cutaneous skin lesions, or systemic lupus erythematosus (SLE) without DLE or SCLE lesions. Clinical features most characteristic of SCLE rather than DLE were superficial, non-indurated, non-scarring lesions, and photosensitivity, with lack of induration being the single most helpful finding. Histologic examination of lesional skin showed a relatively sparse, superficial infiltrate in SCLE and a denser, deeper infiltrate in DLE. A distinctive pattern of staining with direct immunofluorescence, particulate epidermal IgG deposition, was found in seven of seven SCLE patients (all anti-Ro/SSA positive) and none of the other patients. This distinctive pattern can be reproduced experimentally when anti-Ro/SSA autoantibodies are infused into human skin-grafted mice. Particulate dermal-epidermal junctional staining was the pattern seen in the patients who did not have SCLE. Clinically defining SCLE as a superficial inflammatory form of cutaneous lupus (i.e., considering lesions to be DLE if they are indurated) results in a meaningful segregation of SCLE and DLE patient groups. The epidermal IgG deposits unique to SCLE provide independent evidence that the clinical findings that were used to identify the patient groups actually identify distinctive cutaneous lupus subsets. The observation that antibodies are present in a different location in the skin in SCLE than in DLE indicates that SCLE and DLE are likely to have different pathomechanisms.

Neonatal lupus erythematosus syndrome: analysis of C4 allotypes and C4 genes in 18 families

We examined 18 families with infants who had neonatal lupus erythematosus (NLE) syndrome to determine whether abnormalities in C4 phenotypes and genotypes were an additional risk factor for this syndrome. Fifteen of 18 mothers of infants with NLE (83%) had C4 null allotypes compared with 36% of population controls (p = less than .001). This increased frequency was due mainly to the presence of C4A null allotypes (11/18, 61%). C4 gene abnormalities, i.e., deletion or probable duplication, were present in 100% (16/16) of mothers of infants with NLE. The most common molecular genetic abnormality in mothers of infants with NLE in this study was deletion of C4A genes. Duplication of C4A and C4B loci was also commonly seen. Duplication of C4A genes was detected only in mothers of infants with complete congenital heart block (CCHB), and duplication of C4B was detected only in mothers of infants with dermatitis. No significant increase in C4A or C4B null allotypes or protein deficiencies was noted in mothers of infants with neonatal lupus when compared with anti-Ro(SS-A)-positive mothers delivered of clinically normal infants. Fathers of infants with NLE showed a trend toward increase in C4B null allotypes when compared with population controls (75%, 3/4, p = .06). The two infants with CCHB examined were C4B protein-deficient, in contrast to infants with lupus dermatitis, who had frequent C4B null allotypes but no C4B protein deficiency. C4B null allotypes were not seen in unaffected siblings of infants with NLE and in only 1 of 7 anti-Ro(SS-A)-positive mothers who delivered clinically normal infants. We conclude that inheritance of C4A null allotypes is not predictive of increased risk of neonatal lupus when present in anti-Ro(SS-A)-positive women. Examination of paternal and maternal C4 genes of additional infants with NLE, in particular those with CCHB, and of normal infants born to anti-Ro(SS-A)-positive mothers--and of the normal infants' parents--is required to determine if abnormal C4B genes are a critical factor rendering susceptibility to the NLE syndrome.

Left ventricular mechanics in the preterm infant and their effect on the measurement of cardiac performance

The effects of the transition from fetal to postnatal circulation on left ventricular geometry, wall motion, and echocardiographic measurements of function in the human preterm infant are largely unknown. To determine whether abnormalities in left ventricular geometry are present in the normal preterm infant after birth and, if so, for how long, and to examine possible contributing factors and their effect on the measurement of cardiac performance, we obtained serial echocardiograms of 14 healthy preterm infants (gestational age, 33 +/- 2 weeks; birth weight, 1940 +/- 470 gm) at 9.5 +/- 3.5 days of age (time 1) and again at 51 +/- 16 days (time 2). Left ventricular shape and wall motion were measured and estimates of wall stress and mass were made. Performance was assessed by standard M-mode shortening fraction and by transverse two-dimensional area shortening. At time 1 septal flattening caused distortion of left ventricular shape. As the patients grew older, septal flattening resolved and the left ventricle tended to assume a circular cross-sectional shape. Wall-motion analysis demonstrated poor motion of the midseptum and anterior free wall at time 1, which improved at time 2 (p = 0.06). Left ventricular mass increased from 24 +/- 5 to 41 +/- 7 gm/m2 (p = 0.0001) and wall stress decreased from 49 +/- 21 to 38 +/- 13 gm/cm2 (p = 0.005) between time 1 and time 2. Shortening fraction was lower at time 1 than at time 2 (18% +/- 7% vs 28% +/- 8%; p = 0.001; normal limit = 28% to 45%); however, there was no significant difference in area shortening between time 1 and time 2 (49% +/- 10% vs 53% +/- 8%; normal limit = 45% to 65%). We conclude that the preterm newborn infant has distorted left ventricular shape and abnormal wall motion, which alter measurements of shortening fraction and persist for the first weeks of life. Area shortening may be necessary to assess left ventricular performance during the first weeks of life in the premature infant.

Yersinia enterocolitica: a frequent seasonal stool isolate from children at an urban hospital in the southeast United States

From 1 December 1988 through 28 February 1991, 7,290 rectal swab specimens received in our laboratory were screened for Yersinia enterocolitica. A total of 76 patients had Y. enterocolitica isolated from their stool samples. Of these patients, 59 (77.6%) were 12 months old or younger. Y. enterocolitica was second only to Salmonella spp. in this age group. Routine screening for Y. enterocolitica may be warranted in hospitals serving large pediatric populations.

Hyperendemic shigellosis in the United States: a review of surveillance data for 1967-1988

In 1988, 22,796 Shigella isolates were reported to the Centers for Disease Control, the highest number since national surveillance was begun in 1967. From 1986 to 1988, isolation rates increased from 5.4 to 10.1 per 100,000 persons. Increased isolation of Shigella sonnei, primarily among children and young women, occurred throughout the United States in a manner similar to the nationwide increase that occurred during the early 1970s. The highest rates during 1987-1988 were reported from countries with relatively high proportions of urban, ethnic ethnic minority, and poor residents, groups traditionally at high risk. The greatest percentage increases in isolation rates, however, occurred in relatively wealthy counties with predominantly white residents. Between 1967 and 1988, the proportion of Shigella species isolated from persons greater than or equal to 20 years of age increased 118%, while the proportion of the resident population in this age group increased only 16%. These data indicate a shift toward increased infection at older ages and the potential for periodic hyperendemic rates of shigellosis nationwide, which may be due to changing levels of immunity to S. sonnei.

An outbreak of shigellosis at an outdoor music festival

In August 1988, an estimated 3,175 women who attended a 5-day outdoor music festival in Michigan became ill with gastroenteritis caused by Shigella sonnei. Onset of illness peaked 2 days after the festival ended, and patients were spread throughout the United States by the time the outbreak was recognized. An uncooked tofu salad served on the last day was implicated as the outbreak vehicle (odds ratio = 3.4, p less than 0.0001). Over 2,000 volunteer food handlers prepared the communal meals served during the festival. This large foodborne outbreak had been heralded by a smaller outbreak of shigellosis among staff shortly before the festival began and by continued transmission of shigellosis from staff to attendees during the festival. S. sonnei isolated from women who became ill before, during, and after the festival had identical antimicrobial susceptibility patterns and plasmid profiles. Limited access to soap and running water for handwashing was one of the few sanitary deficits noted at this gathering. This investigation demonstrates the need for surveillance and prompt public health intervention when Shigella infections are recognized in persons attending mass outdoor gatherings, the singular importance of handwashing in reducing secondary transmission of shigellosis, and the potential for explosive outbreaks when communal meals are prepared by large numbers of food handlers.

Yersinia enterocolitica O:3: an emerging cause of pediatric gastroenteritis in the United States. The Yersinia enterocolitica Collaborative Study Group

After an outbreak of Yersinia enterocolitica infections among black children in Atlanta, a seven-hospital study was conducted to determine the importance of this pathogen in other communities with large black populations. Of 4841 stool specimens from patients with gastroenteritis examined between November 1989 and January 1990, Y. enterocolitica, Shigella, Campylobacter, and Salmonella were identified in 38, 49, 60, and 98 specimens, respectively; 34 (92%) of 37 Y. enterocolitica isolates were serotype O:3. Of the 38 patients with yersiniosis, 37 (97%) were children. Illnesses were clustered around the holidays, and 20 (62%) of 32 patients had been exposed to raw pork intestines in the 2 weeks before onset. Exposure was significantly associated with illness in a case-control study of eight patients identified at one hospital (P = .004). Infants less than or equal to 6 months old with yersiniosis were more likely to have immature-to-total neutrophil ratios greater than 0.50 than were infants of comparable age with salmonellosis (P = .02). Infrequently isolated in the past, Y. enterocolitica O:3 is emerging as an important enteric pathogen in this country, particularly among black children.

IgG subclasses in the serum and skin in subacute cutaneous lupus erythematosus and neonatal lupus erythematosus

IgG subclasses differ in their biologic and chemical properties, such as complement fixation, protein and cellular binding, and placental transfer. In this study, IgG subclasses of anti-Ro/SSA antibodies in subacute cutaneous lupus (SCLE) and neonatal lupus (NLE) are examined in the serum and in the skin. IgG subclasses in NLE beginning in utero (NLE-heart disease) are compared to subclasses in NLE beginning after birth (NLE-skin disease). Human skin was grafted onto athymic mice, mice were injected with one of eight anti-Ro/SSA maternal NLE sera (four heart block, four skin disease) or seven anti-Ro/SSA SCLE sera, and grafts were examined for IgG subclasses using monoclonal anti-human IgG subclass reagents in an immunofluorescent technique. Lesional skin was examined from four SCLE patients. IgG1 was the only IgG subclass detected in the grafts and skin lesions. IgG1 was the predominant anti-Ro/SSA IgG subclass detected in SCLE and NLE sera in an ELISA using a synthetic Ro/SSA polypeptide. These studies show that the maternal anti-Ro/SSA autoantibodies in NLE-heart disease sera are predominantly IgG1 and are therefore likely to be present in the fetus at the time of gestation, when heart block usually develops. Second, differences in the clinical presentations of NLE (in utero vs. postnatal disease) cannot be attributed to differences in anti-Ro/SSA IgG subclasses. Finally, the subclass bound in the skin in SCLE is IgG1, a subclass capable of mediating tissue injury via complement or cellular effectors.

Maternal autoantibodies and pregnancy--II: The neonatal lupus syndrome

NLE is manifested most typically as transient subacute cutaneous lupus lesions or isolated complete congenital heart block. Babies with NLE have maternal anti-Ro/SSA, anti-La/SSB, or anti-U1RNP autoantibodies. It is presumed, but not proven, that transmission of these autoantibodies through the placenta to the baby has resulted in disease. However, other factors such as inflammatory cells or complement activation may be necessary for disease to be expressed. About half of babies reported with NLE have had heart disease and about half have had skin disease. There have been a few reports of liver disease and a few of thrombocytopenia. Any combination of these findings is possible in a given infant. Possibly, other haematologic abnormalities, pneumonitis or neurological disease could occur, but the evidence that these other abnormalities are part of NLE is scant. Mortality in NLE has occurred in babies with severe cardiac disease. It is estimated that 10% or more of babies with cardiac NLE die in infancy. Of the remainder, perhaps half will require permanent pacemaker implantation. Thus, there is substantial morbidity and mortality with cardiac NLE. The skin disease, by contrast, is not serious and typically leaves little or no residua. Individuals who have had NLE may develop connective tissue disease in adulthood. Whether this is a common or an unusual occurrence is not yet known, since a large cohort of individuals with NLE has not yet been followed into adulthood. Mothers of babies with NLE are often initially asymptomatic. With time, they frequently develop connective tissue disease symptoms. In our experience, these have been largely symptoms of Sjögren's syndrome and have generally not been debilitating. Most babies of mothers with anti-Ro/SSA, anti-La/SSB, or anti-U1RNP autoantibodies do not develop NLE. There is no way to determine prospectively which fetus or infant will be affected and which of those affected will have life-threatening disease. Systemic therapies should be reserved for those infants who have life-threatening manifestations of NLE. It is not yet known whether treatment of the mother during gestation will be beneficial or harmful to fetuses with severe NLE cardiac disease.

A major autoepitope is present on the amino terminus of a human SS-A/Ro polypeptide

A human SS-A/Ro antigen is present on the polypeptide component of a particle composed of hyRNA and a 60 kD protein. We have now purified the Wil-2 cell 60 kilo dalton (kD) SS-A/Ro protein and determined its amino-terminal amino acid sequence. A synthetic peptide corresponding to residues 7 to 24 of this sequence (RoSP7-24) exhibited enzyme-linked immunosorbent assay (ELISA) binding activity with immunodiffusion-defined, monospecific anti-SS-A/Ro sera. In addition, ELISA binding of monospecific anti-SS-A/Ro sera to native SS-A/Ro antigen was partially inhibited (35%) by KLH-RoSP7-24. Sera from patients known to frequently produce precipitating anti-SS-A/Ro antibody (subacute cutaneous lupus erythematosus [SCLE], 56 patients; Sjögren's syndrome [SS], 41 patients; mothers of infants with neonatal LE [NLE], 10 individuals; infants with congenital heart block [CHB], 5 patients) were tested for reactivity to RoSP7-24 in ELISA. Overall, 38% of SCLE sera, 36% of SS sera, 50% of maternal NLE sera and 20% of CHB infant sera had anti-RoSP7-24 binding levels greater than 2 standard deviations above the mean of that of normal individuals. Of the sera which had anti-SS-A/Ro detected by double immunodiffusion and/or counterimmunoelectrophoresis, 68% of SCLE patients, 71% of SS patients, 55% of NLE mothers and 20% of CHB infants had significantly elevated RoSP7-24 ELISA binding levels. These findings strongly suggest that a major autoepitope of native human SS-A/Ro resides on the amino terminal portion of the Wil-2 SS-A/Ro 60 kD polypeptide.(ABSTRACT TRUNCATED AT 250 WORDS)