Predictors of Severity of Influenza-Related Hospitalizations: Results From the Global Influenza Hospital Surveillance Network (GIHSN)

BACKGROUND

The Global Influenza Hospital Surveillance Network (GIHSN) has since 2012 provided patient-level data on severe influenza-like-illnesses from >100 participating clinical sites worldwide based on a core protocol and consistent case definitions.

METHODS

We used multivariable logistic regression to assess the risk of intensive care unit admission, mechanical ventilation, and in-hospital death among hospitalized patients with influenza and explored the role of patient-level covariates and country income level.

RESULTS

The data set included 73 121 patients hospitalized with respiratory illness in 22 countries, including 15 660 with laboratory-confirmed influenza. After adjusting for patient-level covariates we found a 7-fold increase in the risk of influenza-related intensive care unit admission in lower middle-income countries (LMICs), compared with high-income countries (P = .01). The risk of mechanical ventilation and in-hospital death also increased by 4-fold in LMICs, though these differences were not statistically significant. We also find that influenza mortality increased significantly with older age and number of comorbid conditions. Across all severity outcomes studied and after controlling for patient characteristics, infection with influenza A/H1N1pdm09 was more severe than with A/H3N2.

CONCLUSIONS

Our study provides new information on influenza severity in underresourced populations, particularly those in LMICs.

Coronavirus sampling and surveillance in bats from 1996-2019: a systematic review and meta-analysis

The emergence of SARS-CoV-2 highlights a need for evidence-based strategies to monitor bat viruses. We performed a systematic review of coronavirus sampling (testing for RNA positivity) in bats globally. We identified 110 studies published between 2005 and 2020 that collectively reported positivity from 89,752 bat samples. We compiled 2,274 records of infection prevalence at the finest methodological, spatiotemporal and phylogenetic level of detail possible from public records into an open, static database named datacov, together with metadata on sampling and diagnostic methods. We found substantial heterogeneity in viral prevalence across studies, reflecting spatiotemporal variation in viral dynamics and methodological differences. Meta-analysis identified sample type and sampling design as the best predictors of prevalence, with virus detection maximized in rectal and faecal samples and by repeat sampling of the same site. Fewer than one in five studies collected and reported longitudinal data, and euthanasia did not improve virus detection. We show that bat sampling before the SARS-CoV-2 pandemic was concentrated in China, with research gaps in South Asia, the Americas and sub-Saharan Africa, and in subfamilies of phyllostomid bats. We propose that surveillance strategies should address these gaps to improve global health security and enable the origins of zoonotic coronaviruses to be identified.

Optimising predictive models to prioritise viral discovery in zoonotic reservoirs

Despite the global investment in One Health disease surveillance, it remains difficult and costly to identify and monitor the wildlife reservoirs of novel zoonotic viruses. Statistical models can guide sampling target prioritisation, but the predictions from any given model might be highly uncertain; moreover, systematic model validation is rare, and the drivers of model performance are consequently under-documented. Here, we use the bat hosts of betacoronaviruses as a case study for the data-driven process of comparing and validating predictive models of probable reservoir hosts. In early 2020, we generated an ensemble of eight statistical models that predicted host-virus associations and developed priority sampling recommendations for potential bat reservoirs of betacoronaviruses and bridge hosts for SARS-CoV-2. During a time frame of more than a year, we tracked the discovery of 47 new bat hosts of betacoronaviruses, validated the initial predictions, and dynamically updated our analytical pipeline. We found that ecological trait-based models performed well at predicting these novel hosts, whereas network methods consistently performed approximately as well or worse than expected at random. These findings illustrate the importance of ensemble modelling as a buffer against mixed-model quality and highlight the value of including host ecology in predictive models. Our revised models showed an improved performance compared with the initial ensemble, and predicted more than 400 bat species globally that could be undetected betacoronavirus hosts. We show, through systematic validation, that machine learning models can help to optimise wildlife sampling for undiscovered viruses and illustrates how such approaches are best implemented through a dynamic process of prediction, data collection, validation, and updating.

Projecting the SARS-CoV-2 transition from pandemicity to endemicity: Epidemiological and immunological considerations

In this review, we discuss the epidemiological dynamics of different viral infections to project how the transition from a pandemic to endemic Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) might take shape. Drawing from theories of disease invasion and transmission dynamics, waning immunity in the face of viral evolution and antigenic drift, and empirical data from influenza, dengue, and seasonal coronaviruses, we discuss the putative periodicity, severity, and age dynamics of SARS-CoV-2 as it becomes endemic. We review recent studies on SARS-CoV-2 epidemiology, immunology, and evolution that are particularly useful in projecting the transition to endemicity and highlight gaps that warrant further research.

Assessing the risk of human-to-wildlife pathogen transmission for conservation and public health

The SARS‐CoV‐2 pandemic has led to increased concern over transmission of pathogens from humans to animals, and its potential to threaten conservation and public health. To assess this threat, we reviewed published evidence of human‐to‐wildlife transmission events, with a focus on how such events could threaten animal and human health. We identified 97 verified examples, involving a wide range of pathogens; however, reported hosts were mostly non‐human primates or large, long‐lived captive animals. Relatively few documented examples resulted in morbidity and mortality, and very few led to maintenance of a human pathogen in a new reservoir or subsequent “secondary spillover” back into humans. We discuss limitations in the literature surrounding these phenomena, including strong evidence of sampling bias towards non‐human primates and human‐proximate mammals and the possibility of systematic bias against reporting human parasites in wildlife, both of which limit our ability to assess the risk of human‐to‐wildlife pathogen transmission. We outline how researchers can collect experimental and observational evidence that will expand our capacity for risk assessment for human‐to‐wildlife pathogen transmission.

The science of the host-virus network

Better methods to predict and prevent the emergence of zoonotic viruses could support future efforts to reduce the risk of epidemics. We propose a network science framework for understanding and predicting human and animal susceptibility to viral infections. Related approaches have so far helped to identify basic biological rules that govern cross-species transmission and structure the global virome. We highlight ways to make modelling both accurate and actionable, and discuss the barriers that prevent researchers from translating viral ecology into public health policies that could prevent future pandemics.

The future of zoonotic risk prediction

In the light of the urgency raised by the COVID-19 pandemic, global investment in wildlife virology is likely to increase, and new surveillance programmes will identify hundreds of novel viruses that might someday pose a threat to humans. To support the extensive task of laboratory characterization, scientists may increasingly rely on data-driven rubrics or machine learning models that learn from known zoonoses to identify which animal pathogens could someday pose a threat to global health. We synthesize the findings of an interdisciplinary workshop on zoonotic risk technologies to answer the following questions. What are the prerequisites, in terms of open data, equity and interdisciplinary collaboration, to the development and application of those tools? What effect could the technology have on global health? Who would control that technology, who would have access to it and who would benefit from it? Would it improve pandemic prevention? Could it create new challenges? This article is part of the theme issue 'Infectious disease macroecology: parasite diversity and dynamics across the globe'.

Memory deficits among children with craniopharyngiomas

OBJECTIVE

To describe neuropsychological functioning (with a specific focus on cognition and memory) after surgical treatment of craniopharyngiomas.

METHODS

Sixteen patients who were between 6 and 15 years of age at the time of surgery comprised the sample. Each child had been treated for a craniopharyngioma with surgery only, on Dana-Farber Cancer Institute Protocol 92-077.

RESULTS

The overall level of cognitive functioning was well within the average range, with both language and visuospatial functioning being generally intact; however, specific memory problems, in both the language and visuospatial domains, were evident.

CONCLUSION

Although general cognitive functioning was intact after the surgical treatment of craniopharyngiomas, difficulties in the retrieval of learned information were observed. Neuropsychological assessments, with a focus on memory recall, should be a component of the medical management plan for each child.

cAMP response element-binding protein-binding protein mediates thyrotropin-releasing hormone signaling on thyrotropin subunit genes

Transcription of pituitary alpha-glycoprotein hormone subunit (alpha-GSU) and thyrotropin beta subunit (TSH-beta) genes is stimulated by thyrotropin-releasing hormone (TRH). Since cAMP response element-binding protein (CREB)-binding protein (CBP) integrates a number of cell signaling pathways, we investigated whether CBP is important for TRH stimulation of the TSH subunit genes. Cotransfection of E1A in GH(3) cells completely blocked TRH stimulation of the TSH subunit genes, suggesting that CBP is a key factor for TRH signaling in the pituitary. CBP and Pit-1 acted synergistically in TRH stimulation of the TSH-beta promoter, and amino acids 1-450 of CBP were sufficient for the TRH effect. In contrast, on the human alpha-GSU promoter, CREB and P-Lim mediated TRH signaling. Intriguingly, CREB was phosphorylated upon TRH stimulation, leading to CBP recruitment to the alpha-GSU promoter. CBP also interacted with P-Lim in a TRH-dependent manner, suggesting that P-Lim is an important factor for non-cAMP response element-mediated TRH stimulation of this promoter. Distinct domains of CBP were required for TRH signaling by CREB and P-Lim on the alpha-GSU promoter, amino acids 450-700 and 1-450, respectively. Thus, the amino terminus of CBP plays a critical role in TRH signaling in the anterior pituitary via both Pit-1-dependent and -independent pathways, yielding differential regulation of pituitary gene products.

The molecular basis of hypopituitarism

Pit-1 is a pituitary-specific transcription factor responsible for pituitary development and hormone expression in mammals. My laboratory and others have recently described several patients with combined pituitary hormone deficiency (CPHD) due to point mutations in the pit-1 gene. In addition to pit-1, other nuclear factors appear to be necessary for full expression of pituitary genes. A zinc finger transcription factor, Zn-15, is responsible with pit-1 for synergistic activation of the GH gene. The Pr1 gene is regulated synergistically by pit-1 and the estrogen receptor. Finally, the pit-1 gene itself is regulated by an enhancer element located > 10 kb upstream of the transcriptional start. This element contains several pit-1 DNA binding sites and retinoic acid response elements (RAREs). On one of these elements, pit-1 and RAR interact functionally to mediate a synergistic response to RA. Recent data from our laboratory suggests that RA induction of the pit-1 gene can be impaired by pit-1 gene mutations. Study of pit-1 mutations and their diverse pathophysiological mechanisms should increase our understanding of anterior pituitary gland development and gene regulation in normal and disease states.

Adenocarcinoma arising in interposed colon: report of a case

A rare occurrence of primary adenocarcinoma arising in an interposed colon nearly seven years after the surgery is described. Remarkably, there were no symptoms from a large mass in the transposed bowel. Diagnosis was made fortuitously while searching for the cause of the patient's iron-deficiency anemia. The rationale for careful preoperative screening of the colonic segment intended for transplant to exclude pre-existing pathology is reemphasized. The various methods of evaluating the postoperative colon graft and their advantages and limitations are discussed.

Genetic regulation of the embryology of the pituitary gland and somatotrophs

Extrinsic and intrinsic signaling gradients determine expression patterns of pituitary-specific factors in the developing anterior pituitary gland. The temporal and spatial relations of these developmental factors are required for the determination of each of the pituitary cell lineages. Rpx is required for early differentiation of the anterior pituitary. The determination of the somatotroph cell line is dependent on the transcription factors Lhx3, Prop-1, and Pit-1. Pit-1 also plays a role in the activation and regulation of the somatotroph gene product, GH. Additional factors such as CREB and the GHRH receptor, may be involved in somatotroph determination, while Zn-15 and Pitx2 may be involved in GH gene activation.

CREB-independent regulation by CBP is a novel mechanism of human growth hormone gene expression

Hypothalamic growth hormone-releasing hormone (GHRH) stimulates growth hormone (GH) gene expression in anterior pituitary somatotrophs by binding to the GHRH receptor, a G-protein-coupled transmembrane receptor, and by mediating a cAMP-mediated protein kinase A (PKA) signal-transduction pathway. Two nonclassical cAMP-response element motifs (CGTCA) are located at nucleotides -187/-183 (distal cAMP-response element; dCRE) and -99/-95 (proximal cAMP-response element; pCRE) of the human GH promoter and are required for cAMP responsiveness, along with the pituitary-specific transcription factor Pit-1 (official nomenclature, POU1F1). Although a role for cAMP-response element binding protein (CREB) in GH stimulation by PKA has been suggested, it is unclear how the effect may be mediated. CREB binding protein (CBP) is a nuclear cofactor named for its ability to bind CREB. However, CBP also binds other nuclear proteins. We determined that CBP interacts with Pit-1 and is a cofactor for Pit-1-dependent activation of the human GH promoter. This pathway appears to be independent of CREB, with CPB being the likely target of phosphorylation by PKA.

Transcription Factors and Hypopituitarism

Several homeodomain factors are found in the developing anterior pituitary lobe. The production of these developmental transcription factors has distinct temporal and spatial patterns. By interacting with each other, as well as with other extrinsic and intrinsic signals, they control cell determination and specification. Here, we discuss transcription factors that have been shown to have an in vivo role in pituitary cell-type specification.

Defective retinoic acid regulation of the Pit-1 gene enhancer: a novel mechanism of combined pituitary hormone deficiency

Pit-1 is a pituitary-specific transcription factor responsible for pituitary development and hormone expression in mammals. Pit-1 contains two protein domains, termed POU-specific and POU-homeo, which are both necessary for DNA binding and activation of the GH and PRL genes and regulation of the PRL, TSH-beta subunit (TSH-beta), and Pit-1 genes. Pit-1 is also necessary for retinoic acid induction of its own gene during development through a Pit-1-dependent enhancer. Combined pituitary hormone deficiency is caused by defective transactivation of target genes in the anterior pituitary. In the present report, we provide in vivo evidence that retinoic acid induction of the Pit-1 gene can be impaired by a Pit-1 gene mutation, suggesting a new molecular mechanism for combined pituitary hormone deficiency in man.

A novel mechanism for cyclic adenosine 3',5'-monophosphate regulation of gene expression by CREB-binding protein

The pituitary-specific transcription factor, Pit-1, is necessary to mediate protein kinase A (PKA) regulation of the GH, PRL, and TSH-beta subunit genes in the pituitary. Since these target genes lack classical cAMP DNA response elements (CREs), the mechanism of this regulation was previously unknown. We show that CREB binding protein (CBP), through two cysteine-histidine rich domains (C/H1 and C/H3), specifically and constitutively interacts with Pit-1 in pituitary cells. Pit-1 and CBP synergistically activate the PRL gene after PKA stimulation in a mechanism requiring both an intact Pit-1 amino-terminal and DNA-binding domain. A CBP construct containing the C/H3 domain [amino acids (aa) 1678-2441], but not one lacking the C/H3 domain (aa 1891-2441), is sufficient to mediate this response. Neither construct augments PKA regulation of CRE-containing promoters. Fusion of either CBP fragment to the GAL4 DNA-binding domain transferred complete PKA regulation to a heterologous promoter. These findings provide a mechanism for CREB-independent regulation of gene expression by cAMP.

Familial growth hormone deficiency associated with MRI abnormalities

Idiopathic growth hormone deficiency is, in most cases, a sporadic condition. In a number of these patients magnetic resonance imaging (MRI) demonstrates a small anterior pituitary, small or absent pituitary stalk, and ectopically located posterior pituitary. These findings have been attributed to a developmental defect, trauma, or ischemia at birth. We report on a case of familial isolated growth hormone deficiency with mother and son demonstrating the MRI findings described above. The son also had a Chiari type I malformation and medial deviation of the carotid arteries secondary to a narrow skull base. Testing failed to identify a mutation in either the Pit-1 gene or GH gene cluster. This case appears to be an autosomal dominant defect in early development, lending support to the hypothesis that dysgenesis, rather than birth trauma, may cause a small anterior pituitary and ectopic posterior pituitary.

Optic chiasm astrocytomas of childhood. 1. Long-term follow-up

We reviewed 61 patients seen from 1975 to 1994 with a biopsy-confirmed optic chiasm astrocytoma or a characteristic clinical and imaging presentation. The mean age at diagnosis was 72 months, including 30 who were less than 5 years old. The mean tumor diameter at presentation was 31 mm among 54 tumors measured. Tumors involved the optic nerve in 41, hypothalamus in 38, optic tract in 15, and optic radiations in 2. Four patients, all with neurofibromatosis, received no treatment. Forty patients received conventional radiation therapy at a mean age of 89 months. Chemotherapy was given to 19 children and 7 of these were followed for greater than 1 year. Six of these 7 had progressive disease which required subsequent surgery and/or radiation therapy. Thirty-six patients underwent surgery. We restricted our analysis of outcome to those 38 patients followed for longer than 60 months. Development was normal in 13%, mildly disabled in 53%, severely disabled in 21% and dead in 13%. Children were severely disabled or dead in 47% if younger than 5 years at diagnosis, and 21% if older. There was no endocrine dysfunction in 18% and new endocrine failure was seen in 61%. More posterior tumors did not portend a poorer prognosis. Children less than 5 years old had a poorer prognosis. Neurofibromatosis did not have a marked effect on outcome. Intracranial hypertension was an indicator of a poor prognosis. No specific treatment modality was clearly superior in terms of long-term survival or improvement in quality of life.

Role of Pit-1 in the gene expression of growth hormone, prolactin, and thyrotropin

To date, nine different mutations in the Pit-1 gene resulting in CPHD have been described in mammals. Four of these mutations alter residues important for DNA binding or alter the predicted alpha helical nature of the Pit-1 protein (A158P, R172X, E250X, and W261C). The A158P mutation, however, has minimal effects on DNA binding. Four mutations lie outside alpha helical regions (P24L, R143Q, K216E, and R271W) and do not significantly alter DNA binding either experimentally or by prediction. One mutation is a large deletion of the Pit-1 gene locus in the Jackson dwarf mouse. Mutant Pit-1 proteins that do not interfere with binding cause CPHD through interference with target gene activation and regulation. The R271W mutant acts as a dominant inhibitor of transcription of the GH and Prl genes. The A158P mutant is incapable of activating transcription from the GH-I site and has low activation of transcription of the distal enhancer and proximal promoter sites of Prl and of 320 bp of the 5' GH promoter sequence. Some mutant proteins interfere with nuclear receptors. For example, the K216E mutant has defective retinoic acid signaling on the Pit-1 gene enhancer. There is phenotypic variability in the degree of CPHD and in pituitary size in patients with Pit-1 gene mutations. Since Pit-1 has different functions in the somatotroph, lactotroph, and thyrotroph, it is not surprising that point mutations in different regions of the gene interfere in different ways with Pit-1 function. A mutant Pit-1 may be able to carry out its developmental role, but may be aberrant in GH and Prl gene activation or Pit-1 autoregulation. Study of Pit-1 mutations and their diverse pathophysiologic mechanisms should increase the understanding of anterior pituitary gland development and gene regulation in normal and disease states.

A "hot spot" in the Pit-1 gene responsible for combined pituitary hormone deficiency: clinical and molecular correlates

Pit-1 is a member of the POU family of transcription factors regulating mammalian development. Pit-1 is thought to be the major cell-specific activator of both the somatotrophs and lactotrophs in the anterior pituitary. When bound to DNA, Pit-1 activates GH and PRL gene expression. Pit-1 is also important for hormonal regulation of the PRL and TSH-beta genes by TRH and cAMP. We studied two unrelated patients with GH, PRL, and TSH deficiencies. Both patients have the same point mutation in the POU homeodomain of the Pit-1 gene (R271W). Patient 1 was studied as an adult and had combined deficiencies of GH, PRL, and TSH. Patient 2, who was studied in infancy, also had GH and PRL deficiencies, but had low thyroid hormone levels with a measurable basal level of TSH and a delayed response of TSH to TRH. Consequently, the current description of Pit-1 gene mutations leading to complete GH, PRL, and TSH deficiencies needs to be expanded to GH and PRL deficiencies associated with a compromise of the thyrotroph's ability to synthesize TSH.

Prostaglandin infusion therapy for intermittent digital ischemia in a patient with mixed connective tissue disease. Case report and review of the literature

Intermittent digital ischemia is frequently resistant to therapy despite various treatment modalities. Recent studies have reported the successful treatment of intermittent digital ischemia with prostaglandin infusion therapy. We present a severe case of intermittent digital ischemia associated with mixed connective tissue disease, responsive to prostaglandin E1 infusion therapy.

Folliculitis decalvans--response to rifampin

Folliculitis decalvans is a rare follicular inflammatory disease of the scalp. It is characterized by initial perifollicular inflammatory changes followed by peripheral extension and eventual circumscribed patches of cicatricial alopecia. The disease is known for its resistance to treatment, resulting in an unfavorable prognosis. The cause of the disease is unknown, although a bacterial etiology is postulated. We report a classic case that was temporized with various antibiotics and only subsequently resolved after ten weeks of therapy with rifampin. The patient has remained free of disease for more than one year. We present a brief review of the cicatricial alopecias and discuss rifampin therapy for this condition.

Scleromyxedema: therapeutic response to isotretinoin in three patients

Scleromyxedema is a rare type of papular mucinosis that exhibits a generalized lichenoid pattern. A wide variety of clinical manifestations can occur in patients with this disease. Cutaneous involvement is characteristic, but neurologic, cardiovascular, renal, neoplastic, and other systemic manifestations have been described. A monoclonal gammopathy may be present. Many treatment modalities have been used in the past for scleromyxedema. None, however, have shown consistently favorable results. This report concerns the cases of three patients with scleromyxedema who were treated with isotretinoin.

Hemodynamics and intrathoracic pressure transmission during controlled mechanical ventilation and positive end-expiratory pressure in normal and low compliant lungs

PEEP can significantly reduce cardiac output. This reduction in cardiac output is frequently attributed to transmission of airway pressure to intrathoracic vascular structures. We designed an acute lung injury (ALI) model in swine (n = 7) characterized by low lung thorax compliance (CLT) and compared the fractional transmission of airway pressure to pleura (PPL) and pericardium (PPC) and hemodynamics to normal animals (n = 5) during controlled mechanical ventilation (CMV) and PEEP. Fractional transmission of PEEP to PPL and PPC was reduced significantly from 62 +/- 8% and 54 +/- 19 (SD)% to 34 +/- 7% and 36 +/- 9% in normal and ALI animals, respectively. End-inspiration tracheal pressure was significantly higher in the low compliant group; thus, cardiac output was equally depressed in both groups despite reduction in fractional airway pressure transmission in ALI animals, possibly because absolute inspiratory PPL and PPC were similar due to increased pressure required to inflate injured lungs. The results of this investigation do not support the presumption that low CLT blunts hemodynamic consequences of CMV and PEEP.

Granuloma annulare-like eruption due to chronic Epstein-Barr virus infection

A 32-year-old woman afflicted with a severe, chronic Epstein-Barr virus (CEBV) infection of 12 months' duration developed an unusual, granuloma annulare-like eruption. The cutaneous disorder, which paralleled the clinical course of her disease, was characterized by slightly raised, erythematous, annular lesions predominantly involving the face and arms, with sporadic involvement elsewhere. Histopathologic examination of biopsy material obtained from affected skin disclosed a granulomatous dermatitis. The patient's symptoms and cutaneous eruption resolved after systemic corticosteroid therapy. This eruption may represent a distinct cutaneous component of CEBV infection with clinically granuloma annulare-like features or the mere serendipitous association of CEBV infection and an unusual granulomatous dermatitis. Because of the unusual clinical appearance of the eruption and its clear correlation with disease activity, we speculate that it likely represents a distinct cutaneous condition, heretofore unreported, caused by CEBV infection.

High- and low-affinity receptors regulate platelet responses to phorbol diesters and teleocidin

We examined binding of 3H-phorbol dibutyrate (3H-PDBu) to gel filtered human platelets (GFP) and discovered that GFP possess two classes of receptors for phorbol diesters (PDE). High-affinity (HA) receptors, approximately 5000/GFP, bound 3H-PDBu with an apparent dissociation constant (KD) of approximately 12 nM. Low-affinity receptors were approximately 5 times more numerous (2.4 X 10(4)/GFP) and had a 10-fold lower affinity for 3H-PDBu (apparent KD = 115 nM). The potencies of phorbol myristate acetate (PMA) and PDBu paralleled their binding affinities to the PDE receptors. Teleocidin (Tel), although structurally distinct from PDE, competed with 3H-PDBu for its HA-receptors (KI Tel = 1.9 nM). Binding of PDE to HA- or LA- receptors was rapid, reversible, saturable and stereospecific. The HA- and LA-receptors modulated different platelet responses. HA-receptors regulated the secretion of beta-thromboglobulin from alpha-granules and the release of N-acetyl-beta-D-hexosaminidases from lysosomes. LA-receptors mediated both platelet aggregation and the release of serotonin from dense granules. This is the first demonstration of two physiologically active classes of PDE/Tel receptors in human platelets, and demonstrates that particular platelet responses may be directed by distinct classes of receptors for specific agonists.

The dermatologic exam

This article provides a comprehensive approach to the patient presenting with dermatologic concerns. Emphasis is placed on the unique aspects of skin disease with regard to history and physical exam. Illustrations to demonstrate primary and secondary lesions, shape and configuration of the lesion, and regional distribution or pattern of involvement have been included. In addition, aids to diagnosis and instructions for slide preparations, patch testing, and performing skin biopsies are presented.

Development and learning in the offspring of rats fed an alcohol diet on a short- or long-term basis

The offspring of rats fed a diet containing 12.5% (v/v) ethanol prior to, and during, gestation (LTE) were compared to the offspring of rats fed the same diet during gestation only (STE) in three studies. In Study I the neonates were tested on a variety of neuroreflex tasks, in Study II the offspring were tested in an activity wheel and open field, and in Study III the offspring were trained in a runway under partial or consistent reward conditions. Results indicated that STE offspring were delayed in developing fur and in opening their eyes, they righted more rapidly, and were slower in developing a reaction to and habituating to an auditory stimulus than their controls (STC) and the LTE offspring. Generally, movement was greater for ethanol exposed offspring and the LTE offspring showed more persistent fear-related responses than the STE offspring. No statistically reliable differences in learning or extinction were found among the groups, although a trend towards better learning and less resistance to extinction was noted in the LTE animals. Long-term alcohol use seems to attenuate the effects of gestational alcohol in rats.

Common and uncommon cutaneous findings in patients with ataxia-telangiectasia

This series describes some common and uncommon cutaneous findings in twelve patients with ataxia-telangiectasia (A-T). All patients had the characteristic telangiectasia as described previously. However, the telangiectases did not conform to a classic photodistribution . Our series did include one patient with a pathologic reaction to light-simulating hydroa aestivale or vacciniforme . In addition, there were three patients with acanthosis nigricans in two unrelated families. Vitiligo, impetigo, recurrent herpetic gingivostomatitis, hirsutism, lipoatrophy, gray hair, progeroid changes and hyper- and hypopigmented macules were noted in our patients. Many of our patients had one or more caf'e au lait like-lesions in a dermatomal distribution. In addition, several of the family members showed one or more café au lait-like lesions, suggesting the possibility that this finding may represent a phenotypic expression in the skin of carriers of this cancer-prone syndrome.

Effects of gestational alcohol on the development of neonatal reflexes in the rat

The offspring of rats fed a diet containing 10% (v/v) of ethanol were tested for developmental differences from controls on a variety of maturational events and reflexes. Results indicated slower development of fur onset and ear (pinnae) opening, more rapid and vigorous righting responses and shorter dowel-grasping times in the offspring of ethanol-fed dams. No differences in rooting reflex, Babinski reflex, or in the visual placing response were found. These findings were seen as consistent with the interpretation that gestational alcohol exposure results in reduction in the ability of subjects to inhibit responses. The reduction in inhibition is not inconsistent with damage to the hippocampal area of the brain.

Specific binding of [3H]phorbol dibutyrate to phorbol diester-responsive and -resistant clones of a human myeloid leukemia (KG-1) line 1

Phorbol diesters induce macrophage-like differentiation in KG-1 and HL-60 human acute myelogenous leukemia cell lines. We developed a cloned subline of KG-1, known as KG-1a, that does not differentiate when exposed to phorbol diesters. Both KG-1 and KG-1a cells have a single class of specific high-affinity receptors for labeled phorbol-12,13-dibutyrate with a mean Kd of 1.47 +/- 0.10 (S.E.) X 10(-8) M and 0.85 +/- 0.20 X 10(-8) M for the sensitive parental KG-1 line and the resistant KG-1a subline, respectively (p less than 0.025). The number of [3H]phorbol-12,13-dibutyrate binding sites (mean +/- S.E.) per cell was 3.85 +/- 0.98 X 10(5) and 3.94 +/- 0.31 X 10(5) on KG-1 and resistant KG-1a cells, respectively. We observed no significant decrease of specific binding with time (down regulation) in either KG-1, KG-1a, or HL-60 cells, suggesting that down regulation of specific phorbol-12,13-dibutyrate binding is not critical to induction of differentiation. Our data also confirm that the presence of specific high-affinity phorbol receptors on leukemic cells does not assure that phorbol diesters can trigger their differentiation.