The Sjögren's Working Group: The 2023 OMERACT meeting and provisional domain generation

Sjögren's disease (SjD) is a systemic autoimmune exocrinopathy with key features of dryness, pain, and fatigue. SjD can affect any organ system with a variety of presentations across individuals. This heterogeneity is one of the major barriers for developing effective disease modifying treatments. Defining core disease domains comprising both specific clinical features and incorporating the patient experience is a critical first step to define this complex disease. The OMERACT SjD Working Group held its first international collaborative hybrid meeting in 2023, applying the OMERACT 2.2 filter toward identification of core domains. We accomplished our first goal, a scoping literature review that was presented at the Special Interest Group held in May 2023. Building on the domains identified in the scoping review, we uniquely deployed multidisciplinary experts as part of our collaborative team to generate a provisional domain list that captures SjD heterogeneity.

Evolving and evaluating the OMERACT fellows program: insights and implications from OMERACT 2023 fellows

OBJECTIVE

To describe the evolution of the OMERACT Fellows Program (OM FP) and to evaluate the innovative changes implemented in the 2023 program.

METHODS

The OM FP, the first of its kind in global rheumatology, was developed in 2000 to mentor early career researchers in methods and processes for reaching evidence-driven consensus for outcome measures in clinical studies. The OM FP has evolved through continuing iterations of face to face and online feedback. Key new features delivered in 2023 included e-learning modules, virtual introductory pre-meetings, increased networking with Patient Research Partners (PRPs), learning opportunities to give and receive personal feedback, ongoing performance feedback during the meeting from Fellow peers, PRPs, senior OMERACTers (members of the OMERACT community) and Emerging Leader mentors, involvement in pitching promotions, two-minute Lightning Talks in a plenary session and an embedded poster tour. An online survey was distributed after the meeting to evaluate the program.

RESULTS

OM FP has included 208 fellows from 16 countries across 4 continents covering 47 different aspects of rheumatology outcomes since its inception. Over 50 % have remained engaged with OMERACT work. In 2023, 18 Fellows attended and 15 (83 %) completed the post-meeting survey. A dedicated OM FP was deemed important by all respondents, and 93 % would attend the meeting in future. The PRP/Fellow Connection Carousel and Lightning Talks were rated exceptional by 93 %. Key components to improve included clarification of expectations, overall workload, the Emerging Leaders Mentoring Program, and the content and duration of daily summary sessions.

CONCLUSION

The innovations in the 2023 OM FP were well received by the majority of participants and supports early career rheumatology researchers to develop collaborations, skills and expertise in outcome measurement. Implementation of feedback from Fellows will enhance the program for future meetings, continuing to facilitate learning and succession planning within OMERACT.

B cell-intrinsic Myd88 regulates disease progression in murine lupus

Nucleic acid-specific Toll-like receptors (TLRs) have been implicated in promoting disease pathogenesis in systemic lupus erythematosus (SLE). Whether such TLRs mediate disease onset, progression, or both remains undefined; yet the answer to this question has important therapeutic implications. MyD88 is an essential adaptor that acts downstream of IL-1 family receptors and most TLRs. Both global and B cell-specific Myd88 deficiency ameliorated disease in lupus-prone mice when constitutively deleted. To address whether Myd88 was needed to sustain ongoing disease, we induced B cell-specific deletion of Myd88 after disease onset in MRL.Faslpr mice using an inducible Cre recombinase. B cell-specific deletion of Myd88 starting after disease onset resulted in ameliorated glomerulonephritis and interstitial inflammation. Additionally, treated mice had reduced autoantibody formation and an altered B cell compartment with reduced ABC and plasmablast numbers. These experiments demonstrate the role of MyD88 in B cells to sustain disease in murine lupus. Therefore, targeting MyD88 or its upstream activators may be a viable therapeutic option in SLE.

Rubicon promotes rather than restricts murine lupus and is not required for LC3-associated phagocytosis

NADPH oxidase deficiency exacerbates lupus in murine models and patients, but the mechanisms remain unknown. It is hypothesized that NADPH oxidase suppresses autoimmunity by facilitating dead cell clearance via LC3-associated phagocytosis (LAP). The absence of LAP reportedly causes an autoinflammatory syndrome in aged, nonautoimmune mice. Prior work implicated cytochrome b-245, β polypeptide (CYBB), a component of the NADPH oxidase complex, and the RUN and cysteine-rich domain-containing Beclin 1-interacting protein (RUBICON) as requisite for LAP. To test the hypothesis that NADPH oxidase deficiency exacerbates lupus via a defect in LAP, we deleted Rubicon in the B6.Sle1.Yaa and MRL.Faslpr lupus mouse models. Under this hypothesis, RUBICON deficiency should phenocopy NADPH oxidase deficiency, as both work in the same pathway. However, we observed the opposite - RUBICON deficiency resulted in reduced mortality, renal disease, and autoantibody titers to RNA-associated autoantigens. Given that our data contradict the published role for LAP in autoimmunity, we assessed whether CYBB and RUBICON are requisite for LAP. We found that LAP is not dependent on either of these 2 pathways. To our knowledge, our data reveal RUBICON as a novel regulator of SLE, possibly by a B cell-intrinsic mechanism, but do not support a role for LAP in lupus.

B cell-intrinsic TLR9 expression is protective in murine lupus

Toll-like receptor 9 (TLR9) is a regulator of disease pathogenesis in systemic lupus erythematosus (SLE). Why TLR9 represses disease while TLR7 and MyD88 have the opposite effect remains undefined. To begin to address this question, we created 2 alleles to manipulate TLR9 expression, allowing for either selective deletion or overexpression. We used these to test cell type-specific effects of Tlr9 expression on the regulation of SLE pathogenesis. Notably, Tlr9 deficiency in B cells was sufficient to exacerbate nephritis while extinguishing anti-nucleosome antibodies, whereas Tlr9 deficiency in dendritic cells (DCs), plasmacytoid DCs, and neutrophils had no discernable effect on disease. Thus, B cell-specific Tlr9 deficiency unlinked disease from autoantibody production. Critically, B cell-specific Tlr9 overexpression resulted in ameliorated nephritis, opposite of the effect of deleting Tlr9. Our findings highlight the nonredundant role of B cell-expressed TLR9 in regulating lupus and suggest therapeutic potential in modulating and perhaps even enhancing TLR9 signals in B cells.

A naturally-occurring mutation in IL-17F reveals a protective role for the IL-17AF heterodimer in oropharyngeal candidiasis (OPC)

IL-17A is the original member of the IL-17 family of cytokines. Among the IL-17 family, IL-17F shares the most homology with IL-17A at the amino acid level. IL-17A and IL-17F exist as homodimers and also form a heterodimer (IL-17AF). All of these cytokine dimers signal through the same IL-17RA:IL-17RC receptor complex, but the ligands exhibit different signaling strengths (IL-17A > IL-17AF > IL-17F). We previously showed that IL-17 signaling is critical for immunity against oropharyngeal candidiasis (OPC), an opportunistic infection of the oral mucosa caused by the commensal fungus C. albicans. Mice lacking IL-17RA, IL-17RC, or the adaptor ACT1 all have higher oral fungal burdens than wild type (WT) following oral infection with C. albicans. IL-17A deficient mice are also mildly susceptible to C. albicans oral infection, but blockade of IL-17F does not cause disease susceptibility. Furthermore, double blockade of IL-17A and IL-17F during OPC reveals a cooperative antifungal activity of IL-17A and IL-17F. However, the role of the IL-17AF heterodimer still remains poorly understood. Here, we took advantage of a dominant-negative mutation (IL-17F.S65L) that was previously identified in chronic mucocutaneous candidiasis disease (CMCD) patients. This mutation blocks the signals of IL-17F and IL-17AF but not IL-17A. Using CRISPR/Cas9 technology, we created mice with the analogous IL-17F S65L mutation. These IL-17FS65L/S65L mice showed a similar degree of susceptibility as IL-17A−/− mice though less than IL-17RA−/− mice upon C. albicans oral infection. This result suggests that IL-17AF contributes to protection against OPC.

Murine lupus is neutrophil elastase-independent in the MRL.Faslpr model

Loss of tolerance to nuclear antigens and multisystem tissue destruction is a hallmark of systemic lupus erythematosus (SLE). Although the source of autoantigen in lupus remains elusive, a compelling hypothetical source is dead cell debris that drives autoimmune activation. Prior reports suggest that neutrophil extracellular traps (NETs) and their associated death pathway, NETosis, are sources of autoantigen in SLE. However, others and we have shown that inhibition of NETs by targeting the NADPH oxidase complex and peptidylarginine deiminase 4 (PADI4) did not ameliorate disease in spontaneous murine models of SLE. Furthermore, myeloperoxidase and PADI4 deletion did not inhibit induced lupus. Since NET formation may occur independently of any one mediator, to address this controversy, we genetically deleted an additional important mediator of NETs and neutrophil effector function, neutrophil elastase (ELANE), in the MRL.Faslpr model of SLE. ELANE deficiency, and by extension ELANE-dependent NETs, had no effect on SLE nephritis, dermatitis, anti-self response, or immune composition in MRL.Faslpr mice. Taken together with prior data from our group and others, these data further challenge the paradigm that NETs and neutrophils are pathogenic in SLE.

Kidney-infiltrating T cells in murine lupus nephritis are metabolically and functionally exhausted

While T cells are important for the pathogenesis of systemic lupus erythematosus (SLE) and lupus nephritis, little is known about how T cells function after infiltrating the kidney. The current paradigm suggests that kidney-infiltrating T cells (KITs) are activated effector cells contributing to tissue damage and ultimately organ failure. Herein, we demonstrate that the majority of CD4+ and CD8+ KITs in 3 murine lupus models are not effector cells, as hypothesized, but rather express multiple inhibitory receptors and are highly dysfunctional, with reduced cytokine production and proliferative capacity. In other systems, this hypofunctional profile is linked directly to metabolic and specifically mitochondrial dysfunction, which we also observed in KITs. The T cell phenotype was driven by the expression of an "exhausted" transcriptional signature. Our data thus reveal that the tissue parenchyma has the capability of suppressing T cell responses and limiting damage to self. These findings suggest avenues for the treatment of autoimmunity based on selectively exploiting the exhausted phenotype of tissue-infiltrating T cells.

Lupus and proliferative nephritis are PAD4 independent in murine models

Though recent reports suggest that neutrophil extracellular traps (NETs) are a source of antigenic nucleic acids in systemic lupus erythematosus (SLE), we recently showed that inhibition of NETs by targeting the NADPH oxidase complex via cytochrome b-245, β polypeptide (cybb) deletion exacerbated disease in the MRL.Faslpr lupus mouse model. While these data challenge the paradigm that NETs promote lupus, it is conceivable that global regulatory properties of cybb and cybb-independent NETs confound these findings. Furthermore, recent reports indicate that inhibitors of peptidyl arginine deiminase, type IV (Padi4), a distal mediator of NET formation, improve lupus in murine models. Here, to clarify the contribution of NETs to SLE, we employed a genetic approach to delete Padi4 in the MRL.Faslpr model and used a pharmacological approach to inhibit PADs in both the anti-glomerular basement membrane model of proliferative nephritis and a human-serum-transfer model of SLE. In contrast to prior inhibitor studies, we found that deletion of Padi4 did not ameliorate any aspect of nephritis, loss of tolerance, or immune activation. Pharmacological inhibition of PAD activity had no effect on end-organ damage in inducible models of glomerulonephritis. These data provide a direct challenge to the concept that NETs promote autoimmunity and target organ injury in SLE.

Representation of Women Among Academic Grand Rounds Speakers

This survey study finds that grand rounds audiences are not typically exposed to presenter lineups resembling their demographic gender profiles.

Assessing Antibody Strength: Comparison of MFI, C1q, and Titer Information

The presence of donor-specific HLA antibodies before or after transplantation may have different implications based on the antibody strength. Yet, current approaches do not provide information regarding the true antibody strength as defined by antigen-antibody dissociation rate. To assess currently available methods, we compared between neat mean fluorescence intensity (MFI) values, C1q MFI values, ethylenediaminetetraacetic acid (EDTA)-treated samples, as well as titration studies and peak MFI values of over 7000 Luminex-based single-antigen HLA antibody data points. Our results indicate that neat MFI values do not always accurately depict antibody strength. We further showed that EDTA treatment (6%) does not always remove all inhibitory factors compared with C1q or titration studies. In this study of patients presenting with multiple antibody specificities, a prozone effect was observed in 71% of the cohort (usually not affecting all antibody specificities within a single serum sample, though). Similar to titration studies, the C1q assay was able to address the issue of potential inhibition; however, its limitation is its low sensitivity and inability to detect the presence of weak antibodies. Titration studies are the only method among the approaches used in this study to provide information suggesting antigen-antibody dissociation rates and are, therefore, likely to provide better indication of true antibody strength.

Predicting XAFS scattering path cumulants and XAFS spectra for metals (Cu, Ni, Fe, Ti, Au) using molecular dynamics simulations

The ability of molecular dynamics (MD) simulations to support the analysis of X-ray absorption fine-structure (XAFS) data for metals is evaluated. The low-order cumulants (ΔR, σ(2), C3) for XAFS scattering paths are calculated for the metals Cu, Ni, Fe, Ti and Au at 300 K using 28 interatomic potentials of the embedded-atom method type. The MD cumulant predictions were evaluated within a cumulant expansion XAFS fitting model, using global (path-independent) scaling factors. Direct simulations of the corresponding XAFS spectra, χ(R), are also performed using MD configurational data in combination with the FEFF ab initio code. The cumulant scaling parameters compensate for differences between the real and effective scattering path distributions, and for any errors that might exist in the MD predictions and in the experimental data. The fitted value of ΔR is susceptible to experimental errors and inadvertent lattice thermal expansion in the simulation crystallites. The unadjusted predictions of σ(2) vary in accuracy, but do not show a consistent bias for any metal except Au, for which all potentials overestimate σ(2). The unadjusted C3 predictions produced by different potentials display only order-of-magnitude consistency. The accuracy of direct simulations of χ(R) for a given metal varies among the different potentials. For each of the metals Cu, Ni, Fe and Ti, one or more of the tested potentials was found to provide a reasonable simulation of χ(R). However, none of the potentials tested for Au was sufficiently accurate for this purpose.

The interferon signature and STAT1 expression in rheumatoid arthritis synovial fluid macrophages are induced by tumor necrosis factor α and counter-regulated by the synovial fluid microenvironment

OBJECTIVE

Type I interferons (IFNs) have emerged as potential activators of the IFN signature and elevated STAT-1 expression in rheumatoid arthritis (RA) synovium, but mechanisms that induce synovial IFN expression are unknown. Recently, tumor necrosis factor α (TNFα) was shown to induce a delayed IFN response in macrophages. We undertook this study to test whether TNFα, classically thought to activate inflammatory NF-κB target genes in RA, also contributes to the "IFN signature" in RA synovial macrophages.

METHODS

Synovial fluid (SF) macrophages purified from 24 patients with RA and 18 patients with spondylarthritides (SpA) were lysed immediately after isolation or were cultured ex vivo in the absence or presence of blockade of endogenous type I IFN or TNFα. Expression of IFN-inducible target genes was measured by quantitative reverse transcription-polymerase chain reaction, and expression of their corresponding proteins was measured by enzyme-linked immunosorbent assay.

RESULTS

Expression of an IFN signature and STAT1 in RA synovial macrophages was suppressed when type I IFNs or TNFα were blocked, whereas TNFα blockade did not affect expression of IFN response genes or STAT1 in SpA synovial macrophages. RA SF suppressed the IFN signature in RA synovial macrophages and in TNFα-, IFNα-, and IFNβ-stimulated control macrophages. Type I IFNs suppressed expression of IL8 and MMP9 in RA synovial macrophages and in TNFα-stimulated control macrophages.

CONCLUSION

Our findings identify a new function of TNFα in RA synovitis by implicating TNFα as a major inducer of the RA synovial IFN response. The results suggest that the expression of IFN response genes in RA synovium is regulated by interplay between TNFα and opposing homeostatic factors expressed in the synovial microenvironment.

A plastic miniature x-ray emission spectrometer based on the cylindrical von Hamos geometry

We present a short working distance miniature x-ray emission spectrometer (miniXES) based on the cylindrical von Hamos geometry. We describe the general design principles for the spectrometer and detail a specific implementation that covers Kβ and valence level emission from Fe. Large spatial and angular access to the sample region provides compatibility with environmental chambers, microprobe, and pump/probe measurements. The primary spectrometer structure and optic is plastic, printed using a 3-dimensional rapid-prototype machine. The spectrometer is inexpensive to construct and is portable; it can be quickly set up at any focused beamline with a tunable narrow bandwidth monochromator. The sample clearance is over 27 mm, providing compatibility with a variety of environment chambers. An overview is also given of the calibration and data processing procedures, which are implemented by a multiplatform user-friendly software package. Finally, representative measurements are presented. Background levels are below the level of the Kβ(2, 5) valence emission, the weakest diagram line in the system, and photometric analysis of count rates finds that the instrument is performing at the theoretical limit.

Total-reflection inelastic X-ray scattering from a 10-nm thick La0.6Sr0.4CoO3 thin film

To study equilibrium changes in composition, valence, and electronic structure near the surface and into the bulk, we demonstrate the use of a new approach, total-reflection inelastic x-ray scattering, as a sub-keV spectroscopy capable of depth profiling chemical changes in thin films with nanometer resolution. By comparing data acquired under total x-ray reflection and penetrating conditions, we are able to separate the O K-edge spectra from a 10 nm La0.6Sr0.4CoO3 thin film from that of the underlying SrTiO3 substrate. With a smaller wavelength probe than comparable soft x-ray absorption measurements, we also describe the ability to easily access dipole-forbidden final states, using the dramatic evolution of the La N4,5 edge with momentum transfer as an example.

Suppression of TNF-α and IL-1 signaling identifies a mechanism of homeostatic regulation of macrophages by IL-27

IL-27 is a pleiotropic cytokine with both activating and inhibitory functions on innate and acquired immunity. IL-27 is expressed at sites of inflammation in cytokine-driven autoimmune/inflammatory diseases, such as rheumatoid arthritis, psoriasis, inflammatory bowel disease, and sarcoidosis. However, its role in modulating disease pathogenesis is still unknown. In this study, we found that IL-27 production is induced by TNF-α in human macrophages (MΦ) and investigated the effects of IL-27 on the responses of primary human MΦ to the endogenous inflammatory cytokines TNF-α and IL-1. In striking contrast to IL-27-mediated augmentation of TLR-induced cytokine production, we found that IL-27 suppressed MΦ responses to TNF-α and IL-1β, thus identifying an anti-inflammatory function of IL-27. IL-27 blocked the proximal steps of TNF-α signaling by downregulating cell-surface expression of the signaling receptors p55 and p75. The mechanism of inhibition of IL-1 signaling was downregulation of the ligand-binding IL-1RI concomitant with increased expression of the receptor antagonist IL-1Ra and the decoy receptor IL-1RII. These findings provide a mechanism for suppressive effects of IL-27 on innate immune cells and suggest that IL-27 regulates inflammation by limiting activation of MΦ by inflammatory cytokines while preserving initial steps in host defense by augmenting responses to microbial products.

Indirect inhibition of Toll-like receptor and type I interferon responses by ITAM-coupled receptors and integrins

An important function of immunoreceptor tyrosine-based activation motif (ITAM)-coupled receptors is cross-regulation of heterologous receptor signaling, but mechanisms of cross-inhibition are poorly understood. We show that high-avidity ligation of ITAM-coupled beta2 integrins and FcgammaRs in macrophages inhibited type I interferon receptor and Toll-like receptor (TLR) signaling and induced expression of interleukin-10 (IL-10); signaling inhibitors SOCS3, ABIN-3, and A20; and repressors of cytokine gene transcription STAT3 and Hes1. Induction of inhibitors was dependent on a pathway composed of signaling molecules DAP12, Syk, and Pyk2 that coupled to downstream kinases p38 and MSKs and required integration of IL-10-dependent and -independent signals. ITAM-induced inhibitors abrogated TLR responses by cooperatively targeting distinct steps in TLR signaling. Inhibitory signaling was suppressed by IFN-gamma and attenuated in inflammatory arthritis synovial macrophages. These results provide an indirect mechanism of cross-inhibition of TLRs and delineate a signaling pathway important for deactivation of macrophages.

A short working distance multiple crystal x-ray spectrometer

For x-ray spot sizes of a few tens of microns or smaller, a millimeter-sized flat analyzer crystal placed approximately 1 cm from the sample will exhibit high energy resolution while subtending a collection solid angle comparable to that of a typical spherically bent crystal analyzer (SBCA) at much larger working distances. Based on this observation and a nonfocusing geometry for the analyzer optic, we have constructed and tested a short working distance (SWD) multicrystal x-ray spectrometer. This prototype instrument has a maximum effective collection solid angle of 0.14 sr, comparable to that of 17 SBCA at 1 m working distance. We find good agreement with prior work for measurements of the Mn Kbeta x-ray emission and resonant inelastic x-ray scattering for MnO, and also for measurements of the x-ray absorption near-edge structure for Dy metal using Lalpha(2) partial-fluorescence yield detection. We discuss future applications at third- and fourth-generation light sources. For concentrated samples, the extremely large collection angle of SWD spectrometers will permit collection of high-resolution x-ray emission spectra with a single pulse of the Linac Coherent Light Source. The range of applications of SWD spectrometers and traditional multi-SBCA instruments has some overlap, but also is significantly complementary.

Availability of child care in the United States: a description and analysis of data sources

Lack of high-quality, affordable, and accessible child care is an often-cited impediment to a manageable balance between work and family. Researchers, however, have been restricted by a scarcity of data on the availability of child care across all U.S. communities. In this paper we describe and evaluate several indicators of child care availability that have been released by the U.S. Census Bureau over the last 15 years. Using community- and individual-level analyses, we find that these data sources are useful for indicating child care availability within communities, even though they were collected for other purposes. Furthermore, our results generally suggest that the data on child care availability are equally valid across communities of different urbanicity and average income levels, although it appears that larger geographic areas more accurately capture the child care market of centers than that of family day care providers. Our analyses indicate that center child care is least available in nonmetropolitan, poor communities, and that family day care is most available in nonmetropolitan, mixed-income communities. We discuss the benefits and limitations of the data sources, and point to directions for future data developments and research.

Determination of the local structure of the first and second shells in ordered and disordered Ni-Mn alloys

The coordination numbers and the interatomic distances for 50, 75 and 80 at.% Ni-Mn alloys in ordered and disordered states are presented. A new method for determining the first and second nearest neighbor coordination numbers in a binary alloy is applied. It is shown that magnetic properties of these alloys depend on short range order in atomic arrangement.

Boys who join gangs: a prospective study of predictors of first gang entry

In a representative sample of boys who were in the 7th grade of an urban public school system at the start of a 6-year longitudinal study, more African American boys (23.8%) than non-Hispanic White boys (3.9%) had entered an antisocial gang by age 19. There were too few White gang members to study, but among African American boys, first gang entry was predicted prospectively by both baseline conduct disorder (CD) behaviors and increasing levels of CD behaviors prior to gang entry. This suggests that gang entry may be a further developmental step for some boys who are already on a trajectory of worsening antisocial behavior. Having friends prior to gang entry who engaged in aggressive delinquency increased the risk of gang entry further, but only during early adolescence. Family income and parental supervision also independently predicted gang entry, but the direction of their influences depended on the youth's age.

Research productivity in the areas of child abuse and domestic violence

Research productivity in the areas of child abuse and domestic violence was reviewed for the years 1990-1996 by examining articles published in Child Abuse and Neglect, the Journal of Family Violence, and the Journal of Interpersonal Violence. To examine productivity across institutions, quantification of productivity was based on ordinal position of authorship as previously used. Productivity across these three journals was also summed based on the 1987 composite productivity index formula of Howard, et al., and the data were compared with a productivity assessment based on a search process in the PsycLIT database. Rank-order correlations between the raw productivity total, the composite measure, and productivity based on first-authored publications in PsycLIT were all significant. The findings suggest that the composite measure represents a good estimate of productivity across the three journals and that publication in these three journals provides a good representation of research in the general areas of child abuse and domestic and interpersonal violence. The findings, along with implications regarding the relative utility of such information for selection of graduate programs that have a strong research focus on child abuse or domestic violence, are discussed.

Aggressive approach in the treatment of acute lead encephalopathy with an extraordinarily high concentration of lead

OBJECTIVE

To report a case of a 3-year-old child with an extraordinarily massive lead concentration, 26.4 micromol/L (550 microg/dL), following environmental exposure to lead paint in the home.

LITERATURE REVIEW

The relevant literature concerning the treatment of lead encephalopathy was reviewed during the treatment of this child and preparation of the manuscript. To our knowledge, the landmark article written by Julian Chisolm in 1968 is the only recent article that reported similarly high levels of lead concentration. This case, however, is the first in which 3 chelating agents were used for the treatment of lead encephalopathy. We also reviewed the literature on the use of whole bowel irrigation in heavy metal intoxications.

CONCLUSIONS

In this case, aggressive gut decontamination with whole bowel irrigation and triple chelation therapy with British anti-Lewisite, EDTA, and oral succimer was well tolerated and seemed effective for rapidly deleading the child. The extent to which her lead concentration increased while being treated with oral succimer alone necessitated further chelation with EDTA. Further evaluation is necessary to determine if triple chelation therapy is an appropriate method for severe lead intoxication, and if the use of whole bowel irrigation should be considered in heavy metal intoxication.

Prevalence of myopia between 3 months and 5 1/2 years in preterm infants with and without retinopathy of prematurity. Cryotherapy for Retinopathy of Prematurity Cooperative Group

PURPOSE

The purpose of the study was to examine spherical equivalent refractive errors, especially myopia, at six ages between 3 months and 5 1/2 years post-term in preterm children with birth weights of less than 1251 g.

DESIGN

A cohort study.

PARTICIPANTS

There were a total of 827 participants in the multicenter study of cryotherapy for retinopathy of prematurity (ROP). Approximately one third of the eyes did not develop ROP, whereas two thirds developed mild-to-severe ROP. None of the eyes underwent cryotherapy.

INTERVENTION

Refractive error was measured at 3 months, 1 year, and 5 1/2 years term due date at the five long-term follow-up centers. In most eyes, refractive error also was measured at 2, 3 1/2, and 4 1/2 years.

MAIN OUTCOME MEASURE

Myopia was defined as 0.25 diopter (D) or greater with high myopia as 5 D or greater.

RESULTS

The proportion of eyes with myopia in this preterm population was increased compared to published data on full-term children and was related to severity of both acute-phase and cicatricial-phase ROP. The percentage of eyes with myopia varied little across ages, ranging from 21.2% at 1 year to 15.7% at 4 1/2 years. The percentage of eyes with high myopia doubled from 1.8% to 3.9% between 3 months and 1 year and remained stable thereafter. The distribution of refractive errors in eyes with mild acute-phase ROP was similar to that of eyes with no ROP. In contrast, eyes with moderate or severe acute-phase ROP showed an increased prevalence of high myopia. The distribution of refractive errors changed between 3 months and 1 year with little change after 1 year. This pattern of refractive development differs from that of full-term infants. Birth weight, severity of ROP, and degree of myopia at 3 months predicted the presence of myopia and high myopia at 5 1/2 years of age.

CONCLUSIONS

The distribution of refractive errors in preterm infants from age 3 months to 5 1/2 years varies with severity of acute-phase ROP and cicatricial disease. Changes in refractive error distribution occur primarily between 3 months and 1 year and involve a decrease in the proportion of eyes with hyperopia and an increase in the proportion with high degrees of myopia.

Personal need for structure and attitudes toward homosexuality

The need of a sample of U.S. students to cognitively structure reality as measured by the Personal Need for Structure (PNS) Scale was examined as a predictor of attitudes toward homosexuality measured by the Attitudes Toward Lesbians and Gay Men (ATLG) Scale. Significant relationships between the two constructs and strong gender differences on the ATLG were found.

Maternal smoking during pregnancy and the risk of conduct disorder in boys

BACKGROUND

Previous animal and human studies have indicated that prenatal exposure to nicotine is associated with adverse reproductive outcomes, including altered neural structure and functioning, cognitive deficits, and behavior problems in the offspring. Our study extends previous research on humans by controlling a broad range of correlates of maternal smoking during pregnancy to determine if smoking is associated with behavior problems in the offspring severe enough to qualify for DSM-III-R diagnosis.

METHODS

Subjects were 177 clinic-referred boys, ages 7 to 12 years at the time of the first assessment, who underwent longitudinal assessment for 6 years using annual structured diagnostic interviews. Correlates of maternal smoking during pregnancy and previously identified demographic, parental, perinatal, and family risk factors for the disruptive behavior disorders were controlled in logistic regression analyses.

RESULTS

Mothers who smoked more than half a pack of cigarettes daily during pregnancy were significantly more likely to have a child with conduct disorder (odds ratio, 4.4; P = .001) than mothers who did not smoke during pregnancy. This association was statistically significant when controlling for socioeconomic status, maternal age, parental antisocial personality, substance abuse during pregnancy, and maladaptive parenting.

CONCLUSIONS

Maternal smoking during pregnancy appears to be a robust independent risk factor for conduct disorder in male offspring. Maternal smoking during pregnancy may have direct adverse effects on the developing fetus or be a marker for a heretofore unmeasured characteristic of mothers that is of etiologic significance conduct disorder.

Further observations on the measurement of fatty acid incorporation by erythrocyte ghosts to quantify unbound palmitate concentration in albumin-palmitate mixtures

Advantage has been taken of the extensive and reversible incorporation of long-chain fatty acids by erythrocyte ghosts to characterize the interaction of tritium-labeled palmitic acid with human serum albumin (pH 7.4, 37 degrees C). A stoichiometric binding constant for 1:1 complex formation (K1) of 4.6 (+/-0.3) x 10(8) M-1 was obtained from experiments in which erythrocyte ghosts were the source of fatty acid. An essentially identical estimate of 4.1 (+/-0.7) x 10(8) M-1 was obtained from a second series of experiments in which the [3H]palmitate was included with the albumin in the aqueous phase. The magnitude of the present K1 estimate, which is three- to fivefold larger than most recently reported values, reflects binding measurements restricted to a very limited range of unbound palmitate concentration (-0.2 nM) to ensure that the ligand is essentially monomeric. This use of erythrocyte ghosts to quantify the palmitate-albumin interaction has reinforced the basic tenets of a published procedure [I. N. Bojesen, and E. Bojesen (1992) J. Lipid Res. 33, 1327-1334], the major virtue of which is its ability to provide a direct measure of the equilibrium concentration of unbound fatty acid in albumin-palmitate mixtures.

Early retinal vessel development and iris vessel dilatation as factors in retinopathy of prematurity. Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) Cooperative Group

OBJECTIVE

To determine whether the extent of retinal vessel development present on early screening examinations for retinopathy of prematurity has prognostic value?

DESIGN

The prospectively collected data from the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity were used to compare the development of acute retinopathy of prematurity and long-term structural and visual outcomes for eyes with differing extents of retinal vessel development.

PATIENT

Study patients had eyes with the following vessel development. In zone I eyes, vessels extended from the disc less than twice the distance from the disc to the macula. In zone II eyes, vessels extended beyond zone I but not to the nasal ora serrata. Transitional eyes had vessels partly in zone I and partly in zone II.

RESULTS

The chance of developing threshold retinopathy of prematurity was inversely related to the early degree of vessel development: 54% for zone I eyes, 25% for transitional eyes, and 8% for zone II eyes. The presence of prominent iris vessels at 34 to 35 weeks of postmenstrual age was associated with increased risk for all three groups; zone I eyes almost always needed treatment (94%). The chance of having an unfavorable anatomic alteration of the posterior fundus, or poor vision at the ages of 1 year and 3 1/2 years, was also inversely related to the degree of early vessel development. Vessel development was an independently important factor even when birth weight, gestational age, and race were considered.

CONCLUSIONS

The degree of early retinal vessel development is a significant predictor of outcome from retinopathy of prematurity. Iris vessel dilatation is an important indication for greater vigilance in following these infants.

Sex differences in initial clearance of palmitate by human hepatocytes

To determine if the sex differences in clearance of long chain fatty acids by the liver observed in the rat are relevant to humans, the authors isolated hepatocytes from human adult males and females (five per group) and measured the initial (unidirectional) clearance of [3H]-palmitate from buffer containing albumin. The clearance was significantly higher (about twofold) in hepatocytes from females because of a higher permeability of the plasma membrane to the fatty acid. The livers had been perfused with University of Wisconsin (UW) solution and stored for 12-16 h before isolation of the cells. The magnitudes of the clearances in humans were similar to those in the rat when the livers were stored similarly, but lower than in cells isolated from fresh rat liver. When hepatocytes isolated from fresh rat liver were stored in UW solution, clearance of [3H]-palmitate was unaffected. Thus, hepatocytes prepared from intact liver stored for several hours in UW solution do not have as good preservation of function as hepatocytes isolated from fresh liver and then stored in UW solution.

Effects of gender and pregnancy on hepatocellular uptake of palmitic acid: facilitation by albumin

The human serum albumin (HSA)-dependent unbound clearance (Clu) of [3H]palmitic acid (PA) by hepatocyte suspensions isolated from immature and mature male and female and pregnant female rats was studied. The Clu values obtained experimentally were compared with the predictions of a noncompartmental diffusion-reaction (Bass-Pond) theory for the cellular uptake of protein-bound ligands. In all groups, as the concentration of HSA (Ca) was increased, there was a striking increase in Clu. These enhancement factors were predicted by the theory. Adult females had higher Clu values at high Ca values than males or immature females. Furthermore, at high Ca values, Clu in pregnant animals was twice as high as in the nonpregnant animals and four times as high as in the aged-matched males. The absolute values of Clu obtained experimentally in both pregnant and nonpregnant females exceeded the maximal predictions of the theory, using reasonable values of all of the parameters. Thus, according to current data on the physicochemical characteristics of the uptake system, the study demonstrates that some specialized process exists to facilitate hepatocellular uptake of fatty acid from albumin, and that it is potentiated by the female sex hormones.

Capillary hemangioma (infantile periocular hemangioma)

Capillary hemangiomas are the most common orbital tumors in children. They typically arise early in life, grow rapidly during a proliferative phase and then slowly regress in an involutional phase. The tumors may present as small isolated lesions of minimal clinical significance or as large disfiguring masses that can cause visual impairment and systemic symptomatology. Capillary hemangiomas are managed effectively by establishing a secure diagnosis, outlining the extent of the tumor, and understanding the natural history of the lesion, as well as its response to therapy. The ophthalmic and systemic manifestations of capillary hemangiomas are discussed in detail, as are the histopathology, radiologic findings, differential diagnosis, and therapeutic alternatives.

The development of the MMPI-A Immaturity Scale: findings for normal and clinical samples

The Immaturity (IMM) Scale was developed as a supplementary scale for the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A). This study describes the development of the IMM Scale and presents some concurrent validity data derived from the MMPI-A normative sample of 1,620 adolescents and a clinical sample of 122 adolescent inpatients. The IMM Scale was examined in relation to Biographical and Life Events data to identify external correlates for the MMPI-A normative sample. In the clinical sample, external correlates were derived from diagnostic and rating form data provided by the adolescents' treatment staff and by their parents. Current findings were discussed in terms of the relationship of correlate patterns to descriptions of the preconformist and conformist stages of Loevinger's (1976) concept of ego development, and future research directions were suggested.

Perceptions of MMPI item subtlety: influences of age and ethnicity

This study examined the influences of age and ethnicity on perceived item subtlety in Minnesota Multiphasic Personality Inventory (MMPI) Scales F and 9. One hundred twenty-one male adolescents (67 White, 54 Black) rated the items composing these scales in terms of their relationship to a psychological problem. The mean item ratings and subsequent subtle-obvious classifications were then compared to established ratings obtained from adults (Christian, Burkhart, & Gynther, 1978; Wiener, 1948). Results indicated significant differences in both item ratings and classifications between adolescents and adults on Scales F and 9. Significant differences between Black and White adolescents were found on Scale F but not on Scale 9, even when differences in verbal-comprehension abilities between groups were considered. These results suggest that it may be inappropriate to use current subtle-obvious keys with adolescents and minorities.

The Development of the Items-Easy (Ie) and Items-Difficult (Id) Subscales for the MMPI-A

This research involves the development, validation, and cross-validation of the Items-Easy (Ie) and Items-Difficult (Id) subscales for the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A; Butcher et al., 1992). These subscales were designed to assess the degree to which reading comprehension deficits may be responsible for significant elevations of validity Scale F and the standard clinical scales on adolescents' MMPI-A profiles. A difference score, bared on the two 13-item subscales, was created in order to compare subjects' responses to subsets of the more comprehensible (Ie) and less comprehensible (Id) items within the test. Hit rate, sensitivity, specificity, positive predictive power, and negative predictive power were calculated on the basis of simple (Id - Ie) and weighted (3Id - 1Ie) difference scores for the validation (N = 495) and cross-validation (N = 264) samples, and for specific high-F profile subsamples. Although some of the indices reflected classification accuracy as high as 95%, none of the indices yielded consistently high results across the various samples and subsamples. It has been concluded that the Ie and Id subscales should be used only for research purposes at this time.

Uptake of palmitate by hepatocyte suspensions: facilitation by albumin?

Albumin-dependent uptake of unbound [3H]palmitic acid by hepatocytes isolated from female rat livers was studied and the experimental results compared with the predictions of a noncompartmental diffusion-reaction theory for the cellular uptake of protein-bound ligands. The outright theoretical predictions involve values for the parameters of the system, some newly measured (hepatocyte radii and the rate constant for the dissociation of palmitate-albumin complex) and some taken from the literature (diffusion coefficients and the equilibrium association constant for the palmitate-albumin complex). The measured unbound clearance of [3H]palmitic acid, defined as the initial uptake velocity divided by the unbound [3H]palmitic acid concentration in the medium, was enhanced 6.6-fold as the concentration of human serum albumin was increased from approximately 5 to 480 microM. This enhancement factor was predicted by the theory, according to which the enhancement reflects codiffusion of bound ligand across the unstirred layer adjacent to the cell membrane and, therefore, an increased delivery of unbound ligand to the cell surface. In contrast, the absolute magnitude of the unbound clearance was consistent with the theory only for the lowest published value for the equilibrium association constant, 15 microM-1. For higher published values (62 and 94 microM-1), the magnitude of the unbound clearance observed experimentally was severalfold higher than that predicted by the theory. If in fact the association constant exceeds 30 microM-1, the data would imply that an albumin-dependent facilitation mechanism exists which enhances the availability of palmitate to the cell over and above the enhancement predicted by the diffusion-reaction theory.

Rorschach Depression indices with children and adolescents: concurrent validity findings

Exner (1983, 1986) developed and recently revised (1990b) a Rorschach Depression Index based on scores from variables in the Comprehensive System. This study evaluated both the original and the revised DEPIs for child and adolescent outpatient (n = 67) and inpatient (n = 99) samples in order to assess the diagnostic utility of these indices. There were no significant relationships between the original form and the revised form of the DEPI and clinical elevations on the Depression scale of the Personality Inventory for Children in the outpatient sample or treatment team diagnostic judgments in the inpatient sample. These findings sound a strong cautionary note for using only Rorschach Depression indices to diagnose depression in children and adolescents.

The relationship between residents' characteristics, their stress experiences, and their psychosocial adjustment at one medical school

Empirical research focused on the stressful aspects of residency training has largely ignored the interactions between residents' psychosocial and demographic characteristics, stressful experiences, emotional responsivity, and coping styles. This article presents the results of a questionnaire, completed by 165 residents, that consisted of the Profile of Mood States, the Hassles Scale, the Ways of Coping Questionnaire, and a series of questions regarding demographic data, social support system features, and residency stress factors. The residents reported that time demands and indebtedness were the major sources of stress in their residency programs. Social support variables were significantly related to the degrees to which the residents successfully coped with daily stress factors. While the women residents reported higher stress levels than did the men, they did not report higher levels of emotional distress. Finally, the lengths of time residents had spent in training were significantly related to the levels of their mood disturbances and daily hassles.

Acute-onset Brown's syndrome associated with pansinusitis

We treated a 5-year-old girl and a 6-year-old boy with acquired Brown's syndrome associated with pansinusitis. In both patients, the diagnosis was established roentgenographically, and the patients were treated with oral antibiotics. Systemic corticosteroids were used in one case, although their clinical value was uncertain. Patients presenting with acute-onset Brown's syndrome of undetermined cause should undergo computed imaging of the orbits and paranasal sinuses.

MMPI special scale clinical correlates for adolescent inpatients

Little research has focused on the clinical correlates of adolescents' Minnesota Multiphasic Personality Inventory (MMPI) special scale responses. We investigated the clinical correlates of the MacAndrew Alcoholism Scale (MAC), Anxiety (A), Repression (R), and Ego Strength (Es) scales, based on self-reported data from 68 inpatient adolescents and ratings by their nursing staff and individual therapists. Parametric and nonparametric analyses revealed patterns of clinically relevant descriptors for these scales in a manner largely consistent with findings derived from studies of adult respondents. Results are discussed in terms of implications for interpretation of each of these special scales and in relation to a general approach to understanding adolescents' MMPI profiles.

The relationship of MMPI and Sensation Seeking Scales to adolescent drug use

This study examined the relationship of Minnesota Multiphasic Personality Inventory (MMPI) measures, including the MacAndrew alcoholism (MAC) scale, and the Sensation Seeking Scales (SSS) to adolescents' drug use across nine drug categories. Subjects were 51 male and 72 female high school students between the ages of 14 and 18 (mean age = 16 years, 5 months). The drug use/abuse measure consisted of adolescents' self-reports on the Segal (1973) Alcohol-Drug Use Research Survey. Drug categories included for investigation were alcohol, amphetamines, barbiturates, caffeine, cocaine, hallucinogens, marijuana, narcotics, and tobacco. Scores from standard MMPI scales, the MAC scale, and the SSS were examined in relation to individual drug use outcomes, and multivariate procedures were used to predict polydrug versus single drug use patterns. Results demonstrated significant and meaningful relationships between personality measures and drug use among adolescents, with consistently strong findings for the SSS.

The effect of applicant age, job level, and accountability on perceptions of female job applicants

We used simulated videotaped employment interviews to assess the effect of accountability on impressions of female job applicants. One hundred and twenty American undergraduates majoring in business and personnel related areas were informed that they would be participating in the pilot testing of a new employee placement technique. The age of the job applicant (25, 40, or 55 years), the position for which they were being considered (assistant director or director), and the degree to which subjects were made to feel accountable for their impressions of the applicant (low or high accountability) were manipulated, resulting in a 3 x 2 x 2 between-subjects design. The predicted interaction between accountability and applicant age applicant age was found on age-related adjective checklist items. Increasing the subjects' accountability produced more stereotypical impressions of all applicants, along with a tendency to attribute the applicant's behavior to dispositional factors.

MMPI and Rorschach indices of schizophrenic and depressive diagnoses among adolescent inpatients

Although adolescent norms have been developed for the MMPI (e.g., Marks, Seeman, & Haller, 1974) and Rorschach (e.g., Exner, 1986a), little is known regarding the discriminate diagnostic validity of these measures with adolescents. This study investigated the usefulness of these measures in the detection of depression and schizophrenia among adolescent inpatients. Subjects (mean age = 15.3) consisted of 134 adolescents who received Rorschach and MMPI administrations at hospital admission. Clinical diagnoses resulted in the following groupings for this sample: schizophrenia = 15, dysthymic disorder = 41, major depression = 26, conduct disorder = 28, personality disorder = 18. MMPI scale Sc elevation was found to be the most effective single predictor of schizophrenic diagnoses, with a hit rate of .76, sensitivity of .62, and specificity of .78. Neither MMPI scale D scores nor Rorschach DEPI scores were found to be significantly related to patients' diagnoses. Results were interpreted in terms of prior findings in adult psychiatric populations and in relation to implications for the clinical assessment of adolescents.

Frozen section of the optic nerve in retinoblastoma surgery

The usefulness of the frozen section examination to determine the extension of retinoblastoma into the optic nerve is discussed. Frozen sections performed at the time of surgery in seven retinoblastoma patients revealed the presence of tumor at the resection margin of the optic nerve in two cases.