Identification of Intestinal Lamina Propria Plasma Cells by Surface Transmembrane Activator and CAML Interactor Expression

Plasma cells secrete an abundance of Abs and are a crucial component of our immune system. The intestinal lamina propria harbors the largest population of plasma cells, most of which produce IgA. These Abs can bind to beneficial gut bacteria to reinforce intestinal homeostasis and provide protection against enteric pathogens. Plasma cells downregulate many cell-surface proteins commonly used to identify B cells. In mice, expression of the surface marker CD138 has been widely used to identify plasma cells in lymph nodes, bone marrow, and spleen. Intestinal plasma cells require liberation via extensive tissue processing involving treatment with collagenase. We report that detection of CD138 surface expression is reduced following collagenase treatment. Using a mouse in which yellow fluorescent protein expression is controlled by the plasma cell requisite transcription factor Blimp-1, we show that surface detection of transmembrane activator and CAML interactor captures a significant proportion of Ab-secreting plasma cells in the intestinal lamina propria and gut-draining mesenteric lymph nodes. Additionally, we describe a flow cytometry panel based on the detection of surface markers to identify murine B cell subsets in the intestinal lamina propria and, as a proof of concept, combine it with a cutting-edge fate-tracking system to characterize the fate of germinal center B cells activated in early life. By identifying plasma cells and other key intestinal B subsets in a manner compatible with several downstream applications, including sorting and culturing and in vitro manipulations, this efficient and powerful approach can enhance studies of mucosal immunity.

Single-cell Profiling Uncovers a Muc4-Expressing Metaplastic Gastric Cell Type Sustained by Helicobacter pylori-driven Inflammation

Mechanisms for Helicobacter pylori (Hp)-driven stomach cancer are not fully understood. In a transgenic mouse model of gastric preneoplasia, concomitant Hp infection and induction of constitutively active KRAS (Hp+KRAS+) alters metaplasia phenotypes and elicits greater inflammation than either perturbation alone. Gastric single-cell RNA sequencing showed that Hp+KRAS+ mice had a large population of metaplastic pit cells that expressed the intestinal mucin Muc4 and the growth factor amphiregulin. Flow cytometry and IHC-based immune profiling revealed that metaplastic pit cells were associated with macrophage and T-cell inflammation. Accordingly, expansion of metaplastic pit cells was prevented by gastric immunosuppression and reversed by antibiotic eradication of Hp. Finally, MUC4 expression was significantly associated with proliferation in human gastric cancer samples. These studies identify an Hp-associated metaplastic pit cell lineage, also found in human gastric cancer tissues, whose expansion is driven by Hp-dependent inflammation.

Significance

Using a mouse model, we have delineated metaplastic pit cells as a precancerous cell type whose expansion requires Hp-driven inflammation. In humans, metaplastic pit cells show enhanced proliferation as well as enrichment in precancer and early cancer tissues, highlighting an early step in the gastric metaplasia to cancer cascade.

Twice the tolerance

A gut microbiota-derived antigen elicits distinct subsets of regulatory T cells to suppress inflammation in mice.

Cytokine therapy in necrotizing enterocolitis: A promising treatment for preterm infants

Necrotizing enterocolitis (NEC) is an intestinal disorder that disproportionately affects premature infants and lacks in effective therapeutics. Mihi and colleagues1 demonstrated that the cytokine interleukin-22 promotes intestinal epithelial regeneration and reduces disease severity in an experimental model of NEC.

Akkermansia muciniphila induces intestinal adaptive immune responses during homeostasis

Intestinal adaptive immune responses influence host health, yet only a few intestinal bacteria species that induce cognate adaptive immune responses during homeostasis have been identified. Here, we show that Akkermansia muciniphila, an intestinal bacterium associated with systemic effects on host metabolism and PD-1 checkpoint immunotherapy, induces immunoglobulin G1 (IgG1) antibodies and antigen-specific T cell responses in mice. Unlike previously characterized mucosal responses, T cell responses to A. muciniphila are limited to T follicular helper cells in a gnotobiotic setting, without appreciable induction of other T helper fates or migration to the lamina propria. However, A. muciniphila-specific responses are context dependent and adopt other fates in conventional mice. These findings suggest that, during homeostasis, contextual signals influence T cell responses to the microbiota and modulate host immune function.

B cell receptor and Toll-like receptor signaling coordinate to control distinct B-1 responses to both self and the microbiota

B-1a cells play an important role in mediating tissue homeostasis and protecting against infections. They are the main producers of 'natural' IgM, spontaneously secreted serum antibodies predominately reactive to self antigens, like phosphatidylcholine (PtC), or antigens expressed by the intestinal microbiota. The mechanisms that regulate the B-1a immunoglobulin (Ig) repertoire and their antibody secretion remain poorly understood. Here, we use a novel reporter mouse to demonstrate that production of self- and microbiota-reactive antibodies is linked to BCR signaling in B-1a cells. Moreover, we show that Toll-like receptors (TLRs) are critical for shaping the Ig repertoire of B-1a cells as well as regulating their antibody production. Strikingly, we find that both the colonization of a microbiota as well as microbial-sensing TLRs are required for anti-microbiota B-1a responses, whereas nucleic-acid sensing TLRs are required for anti-PtC responses, demonstrating that linked activation of BCR and TLRs controls steady state B-1a responses to both self and microbiota-derived antigens.

Sex Bias in Sepsis

Though critical for preventing fatal sepsis, the mechanisms mediating the capture of bloodstream bacteria are incompletely understood. New work by Zeng et al. (2018) demonstrates that estrogen-regulated innate antibodies protect females and newborns from death following bloodstream infection with enteropathogenic Eschericia coli.

Living in Peace: Host-Microbiota Mutualism in the Skin

Commensal microbes colonize the skin where they promote immune development and prevent infection without inducing damaging inflammatory responses. In this issue of Cell Host & Microbe, Scharschmidt et al. (2017) show that during hair follicle development, commensals induce regulatory T cell migration to the skin to ensure cutaneous homeostasis.

Maternal IgG and IgA Antibodies Dampen Mucosal T Helper Cell Responses in Early Life

To maintain a symbiotic relationship between the host and its resident intestinal microbiota, appropriate mucosal T cell responses to commensal antigens must be established. Mice acquire both IgG and IgA maternally; the former has primarily been implicated in passive immunity to pathogens while the latter mediates host-commensal mutualism. Here, we report the surprising observation that mice generate T cell-independent and largely Toll-like receptor (TLR)-dependent IgG2b and IgG3 antibody responses against their gut microbiota. We demonstrate that maternal acquisition of these antibodies dampens mucosal T follicular helper responses and subsequent germinal center B cell responses following birth. This work reveals a feedback loop whereby T cell-independent, TLR-dependent antibodies limit mucosal adaptive immune responses to newly acquired commensal antigens and uncovers a broader function for maternal IgG.

TLR5 stops commensals in their tracks

IgA antibodies help maintain intestinal immune homeostasis with resident commensal species; however, the precise mechanisms regulating IgA induction and the epitopes recognized by these antibodies remain incompletely understood. In this issue of Cell Host & Microbe, Tyler et al. (2013) demonstrate that TLR5-dependent induction of anti-flagellin antibodies prevents commensal association with the intestinal mucosa by limiting bacterial motility.

Type I interferons directly inhibit regulatory T cells to allow optimal antiviral T cell responses during acute LCMV infection

Inhibition of T reg cells by type I IFNs is necessary for the generation of optimal antiviral T cell responses during acute LCMV infection.

Regulatory T (T reg) cells play an essential role in preventing autoimmunity but can also impair clearance of foreign pathogens. Paradoxically, signals known to promote T reg cell function are abundant during infection and could inappropriately enhance T reg cell activity. How T reg cell function is restrained during infection to allow the generation of effective antiviral responses remains largely unclear. We demonstrate that the potent antiviral type I interferons (IFNs) directly inhibit co-stimulation–dependent T reg cell activation and proliferation, both in vitro and in vivo during acute infection with lymphocytic choriomeningitis virus (LCMV). Loss of the type I IFN receptor specifically in T reg cells results in functional impairment of virus-specific CD8⁺ and CD4⁺ T cells and inefficient viral clearance. Together, these data demonstrate that inhibition of T reg cells by IFNs is necessary for the generation of optimal antiviral T cell responses during acute LCMV infection.

Phenotypical and functional specialization of FOXP3+ regulatory T cells

Forkhead box P3 (FOXP3)(+) regulatory T (T(Reg)) cells prevent autoimmune disease, maintain immune homeostasis and modulate immune responses during infection. To accomplish these tasks, T(Reg) cell activity is precisely controlled, and this requires T(Reg) cells to alter their migratory, functional and homeostatic properties in response to specific cues in the immune environment. We review progress in understanding the diversity of T(Reg) cells, T(Reg) cell function in different anatomical and inflammatory settings, and the influence of the immune environment on T(Reg) cell activity. We also consider how these factors affect immune-mediated disease in the contexts of infection, autoimmunity, cancer and transplantation.

Perfusion cell seeding on large porous PLA/calcium phosphate composite scaffolds in a perfusion bioreactor system under varying perfusion parameters

A promising approach to bone tissue engineering lies in the use of perfusion bioreactors where cells are seeded and cultured on scaffolds under conditions of enhanced nutrient supply and removal of metabolic products. Fluid flow alterations can stimulate cell activity, making the engineering of tissue more efficient. Most bioreactor systems are used to culture cells on thin scaffold discs. In clinical use, however, bone substitutes of large dimensions are needed. In this study, MG63 osteoblast-like cells were seeded on large porous PLA/glass scaffolds with a custom developed perfusion bioreactor system. Cells were seeded by oscillating perfusion of cell suspension through the scaffolds. Applicable perfusion parameters for successful cell seeding were determined by varying fluid flow velocity and perfusion cycle number. After perfusion, cell seeding, the cell distribution, and cell seeding efficiency were determined. A fluid flow velocity of 5 mm/s had to be exceeded to achieve a uniform cell distribution throughout the scaffold interior. Cell seeding efficiencies of up to 50% were achieved. Results suggested that perfusion cycle number influenced cell seeding efficiency rather than fluid flow velocities. The cell seeding conducted is a promising basis for further long term cell culture studies in large porous scaffolds.

The transcription factor T-bet controls regulatory T cell homeostasis and function during type 1 inflammation

Several subsets of Foxp3⁺ regulatory T (T_reg) cells work in concert to maintain immune homeostasis. However, the molecular bases underlying the phenotypic and functional diversity of T_reg cells remain obscure. We show that in response to interferon-γ, Foxp3⁺ T_reg cells upregulated the T helper 1 (T_H1)-specifying transcription factor T-bet. T-bet promoted expression of the chemokine receptor CXCR3 on T_reg cells, and T-bet⁺ T_reg cells accumulated at sites of T_H1-mediated inflammation. Furthermore, T-bet expression was required for the homeostasis and function of T_reg cells during type-1 inflammation. Thus, within a subset of CD4⁺ T cells, the activities of Foxp3 and T-bet are overlaid, resulting in T_reg cells with unique homeostatic and migratory properties optimized for suppression of T_H1 responses in vivo.

T-bet controls regulatory T cell function during type-1 inflammatory responses (89.33)

Regulatory T cells (TR) expressing the transcription factor Foxp3 play a critical role in preventing autoimmunity and restraining immune responses during infection. To accomplish these tasks, several subsets of TR work in concert to maintain normal immune homeostasis in secondary lymphoid tissues and at peripheral sites. However, the molecular basis underlying the phenotypic and functional differences of TR subsets remain obscure. Here, we show that during type 1 inflammatory responses, Foxp3+ TR upregulate the TH1-specifying transcription factor T-bet. These Foxp3+T-bet+ cells retain regulatory function, and do not produce the pro-inflammatory TH1 cytokine IFN-γ. Within TR, T-bet directs expression of the TH1-associated chemokine receptor CXCR3, and T-bet+ TR accumulate at sites of microbial replication in mice during persistent infection with Mycobacterium tuberculosis. T-bet-deficient TR show diminished proliferation and are outcompeted by wild type TR during strong TH1 responses in vivo. Furthermore, T-bet expression by TR is required for their proper homeostasis and function during TH1-driven autoimmunity. Thus, our data define a unique population of CD4+ T cells in which the activities of Foxp3 and T-bet are overlaid, resulting in functional TR capable of expanding during type-1 inflammation and suppressing TH1 responses in vivo.

(NIH -DK072295, AI067750, AI069889)

Plastidic trnFUUC pseudogenes in North American genus Boechera (Brassicaceae): mechanistic aspects of evolution

The origin and maintenance of a plastidic tandem repeat next to the TRNF (UUC) gene were analyzed in the genus BOECHERA in a phylogenetic context and were compared to published analogous examples that emerged in parallel in the Asteraceae and Juncaceae, respectively. Although we identified some features common to these taxonomic groups with respect to structure and origin of the region, obvious differences were encountered, which argue against a specific mechanism or evolutionary principle underlying the parallel origin and maintenance of the TRNF-tandem repeats in those families. In contrast to the situation in the Asteraceae, no reciprocal recombinant repeat types have been observed in the Brassicaceae. Forty copy types, classified into three groups, were isolated from 103 chloroplast haplotypes of BOECHERA and it was demonstrated that they are composed of four subregions of various origins. We discuss various mutation mechanisms such as DNA replication slippage, and inter- and intrachromosomal recombination which were reported to mediate variation in copy numbers and other types of observed sequence length polymorphism. It is shown that the observed molecular structure of the tandem repeat region did not fully fit the particular patterns expected under a scenario of evolution including any of the known mechanisms. Nevertheless, it appeared that intermolecular unequal crossing-over is most likely the driving force in the evolution of this tandem repeat. However, it remains to be explained, why no reciprocal recombinant copy types have been observed. The reconstructed phylogenetic relationships among copies reflected different evolutionary scenarios as follows: (1) A single and ancient origin of copies pre-dates the radiation of BOECHERA. (2) Parallel expansion and shortening of the tandem repeat within different BOECHERA lineages. (3) Conservation of the first copy, as it was the only one present in all chloroplast haplotypes.

Influence of tissue conductivity anisotropy on EEG/MEG field and return current computation in a realistic head model: A simulation and visualization study using high-resolution finite element modeling

To achieve a deeper understanding of the brain, scientists, and clinicians use electroencephalography (EEG) and magnetoencephalography (MEG) inverse methods to reconstruct sources in the cortical sheet of the human brain. The influence of structural and electrical anisotropy in both the skull and the white matter on the EEG and MEG source reconstruction is not well understood. In this paper, we report on a study of the sensitivity to tissue anisotropy of the EEG/MEG forward problem for deep and superficial neocortical sources with differing orientation components in an anatomically accurate model of the human head. The goal of the study was to gain insight into the effect of anisotropy of skull and white matter conductivity through the visualization of field distributions, isopotential surfaces, and return current flow and through statistical error measures. One implicit premise of the study is that factors that affect the accuracy of the forward solution will have at least as strong an influence over solutions to the associated inverse problem. Major findings of the study include (1) anisotropic white matter conductivity causes return currents to flow in directions parallel to the white matter fiber tracts; (2) skull anisotropy has a smearing effect on the forward potential computation; and (3) the deeper a source lies and the more it is surrounded by anisotropic tissue, the larger the influence of this anisotropy on the resulting electric and magnetic fields. Therefore, for the EEG, the presence of tissue anisotropy both for the skull and white matter compartment substantially compromises the forward potential computation and as a consequence, the inverse source reconstruction. In contrast, for the MEG, only the anisotropy of the white matter compartment has a significant effect. Finally, return currents with high amplitudes were found in the highly conducting cerebrospinal fluid compartment, underscoring the need for accurate modeling of this space.

Protein structure similarity clustering and natural product structure as guiding principles for chemical genomics

The majority of all proteins are modularly built from a limited set of approximately 1,000 structural domains. The knowledge of a common protein fold topology in the ligand-sensing cores of protein domains can be exploited for the design of small-molecule libraries in the development of inhibitors and ligands. Thus, a novel strategy of clustering protein domain cores based exclusively on structure similarity considerations (protein structure similarity clustering, PSSC) has been successfully applied to the development of small-molecule inhibitors of acetylcholinesterase and the 11beta-hydroxysteroid dehydrogenases based on the structure of a naturally occurring Cdc25 inhibitor. The efficiency of making use of the scaffolds of natural products as biologically prevalidated starting points for the design of compound libraries is further highlighted by the development of benzopyran-based FXR ligands.

White Matter Asymmetry in the Human Brain: A Diffusion Tensor MRI Study

Language ability and handedness are likely to be associated with asymmetry of the cerebral cortex (grey matter) and connectivity (white matter). Grey matter asymmetry, most likely linked to language has been identified with voxel-based morphometry (VBM) using T(1)-weighted images. Differences in white matter obtained with this technique are less consistent, probably due to the relative insensitivity of the T(1) contrast to the ultrastructure of white matter. Furthermore, previous VBM studies failed to find differences related to handedness in either grey or white matter. We revisited these issues and investigated two independent groups of subjects with diffusion-tensor imaging (DTI) for asymmetries in white matter composition. Using voxel-based statistical analyses an asymmetry of the arcuate fascicle was observed, with higher fractional anisotropy in the left hemisphere. In addition, we show differences related to handedness in the white matter underneath the precentral gyrus contralateral to the dominant hand. Remarkably, these findings were very robust, even when investigating small groups of subjects. This highlights the sensitivity of DTI for white matter tissue differences, making it an ideal tool to study small patient populations.

Extensive chloroplast haplotype variation indicates Pleistocene hybridization and radiation of North American Arabis drummondii, A. x divaricarpa, and A. holboellii (Brassicaceae)

Arabis drummondii, A. holboellii and their hybrid A. x divaricarpa are widespread perennials of open habitats in North America. A phylogenetic analysis based on noncoding chloroplast DNA sequences (trnL intron and trnL/F intergenic spacer) resolved A. drummondii as a monophyletic taxon, but found A. holboellii to bear chloroplast haplotypes from highly diverged evolutionary lineages. This raised the question of a possible polyphyletic origin of A. holboellii. Arabis x divaricarpa was found to be of recent and polytopic origin, a result consistent with its presumed hybrid origin. One hundred and three chloroplast haplotypes were detected within 719 Arabis accessions investigated. The majority of chloroplast-types were estimated to have arisen prior to the Wisconsin glaciation. Phylogeographical analysis using nested clade analysis, suggested for A. holboellii (i). past fragmentation events, partitioning genetic variation in several instances between the Sierra Nevada, the Southern Rocky Mountains and the Colorado Plateau on the one hand and the Central to Northern Rockies of the United States and adjacent Cascades on the other; and for both parental species (ii). recolonization of major areas formerly covered by the Wisconsin glaciation by three haplotypes; and (iii). restricted gene flow indicating isolation by distance in areas south of the last glacial maximum. Arabis x divaricarpa is closely codistributed with its parental species and resampled their haplotypes. The highest genetic diversity was found in the Rocky Mountains from Idaho and Montana south to Utah and Colorado. This area was further hypothesized to have played a major role in the origin of both parental species and probably represented an important glacial refugium. However, evidence for glacial refugia was also found in arctic and boreal regions of Alaska and near the Great Lakes. In comparison to nuclear ribosomal internal transcribed spacer data, chloroplast DNA divergence was very high and evidently predated the origin of A. drummondii and possibly A. holboellii. Divergence of major chloroplast lineages dates back to the middle of the Pleistocene at least. Extensive hybridization is the most likely evolutionary factor working on A. holboellii to explain the revealed discrepancy in nuclear DNA and chloroplast DNA diversification.

Distortion-free diffusion tensor imaging of cranial nerves and of inferior temporal and orbitofrontal white matter

The main impact of functional neuroimaging has been its ability to locate neuronal activity either directly (EEG, MEG) or through the hemodynamic response caused by neuronal activity (PET, fMRI). In the past decade functional neuroimaging has been extended to investigate how brain regions interact, using the concepts of functional and effective connectivity. These concepts are further strengthened by estimates of anatomical connectivity of the same subject. A tool to determine anatomical connectivity in vivo may be provided by diffusion tensor imaging (DTI) methods. These can be used to determine the orientation of fiber bundles in white matter on the basis of the diffusion characteristics of water. Commonly, DTI data are acquired using echo planar imaging which suffers from susceptibility artifacts in orbitofrontal and inferior temporal cortex. Here we demonstrate the use of an alternative pulse sequence, diffusion-weighted single-shot STEAM, for assessing fiber orientation in orbitofrontal cortex and the cranial nerves. The scope of DTI needs to be extended to these structures to investigate psychiatric disorders in which orbitofrontal pathology or temporo-frontal disconnection have been postulated.

Comparative genomics and regulatory evolution: conservation and function of the Chs and Apetala3 promoters

DNA sequence variations of chalcone synthase (Chs) and Apetala3 gene promoters from 22 cruciferous plant species were analyzed to identify putative conserved regulatory elements. Our comparative approach confirmed the existence of numerous conserved sequences which may act as regulatory elements in both investigated promoters. To confirm the correct identification of a well-conserved UV-light-responsive promoter region, a subset of Chs promoter fragments were tested in Arabidopsis thaliana protoplasts. All promoters displayed similar light responsivenesses, indicating the general functional relevance of the conserved regulatory element. In addition to known regulatory elements, other highly conserved regions were detected which are likely to be of functional importance. Phylogenetic trees based on DNA sequences from both promoters (gene trees) were compared with the hypothesized phylogenetic relationships (species trees) of these taxa. The data derived from both promoter sequences were congruent with the phylogenies obtained from coding regions of other nuclear genes and from chloroplast DNA sequences. This indicates that promoter sequence evolution generally is reflective of species phylogeny. Our study also demonstrates the great value of comparative genomics and phylogenetics as a basis for functional analysis of promoter action and gene regulation.

Comparative evolutionary analysis of chalcone synthase and alcohol dehydrogenase loci in Arabidopsis, Arabis, and related genera (Brassicaceae)

We analyzed sequence variation for chalcone synthase (Chs) and alcohol dehydrogenase (Adh) loci in 28 species in the genera Arabidopsis and Arabis and related taxa from tribe Arabideae. Chs was single-copy in nearly all taxa examined, while Adh duplications were found in several species. Phylogenies constructed from both loci confirmed that the closest relatives of Arabidopsis thaliana include Arabidopsis lyrata, Arabidopsis petraea, and Arabidopsis halleri (formerly in the genus Cardaminopsis). Slightly more distant are the North American n = 7 Arabis (Boechera) species. The genus Arabis is polyphyletic-some unrelated species appear within this taxonomic classification, which has little phylogenetic meaning. Fossil pollen data were used to compute a synonymous substitution rate of 1.5 x 10 substitutions per site per year for both Chs and Adh. Arabidopsis thaliana diverged from its nearest relatives about 5 MYA, and from Brassica roughly 24 MYA. Independent molecular and fossil data from several sources all provide similar estimates of evolutionary timescale in the Brassicaceae.

Treatment refusal/attrition among adults randomly assigned to programs at a drug treatment campus: The New Jersey Substance Abuse Treatment Campus, Seacaucus, NJ

The New Jersey Substance Abuse Treatment Campus was funded to assess the feasibility of establishing a new model for delivering substance abuse treatment services and to serve as a research laboratory for conducting comparative evaluations of those services. The 350-bed campus was designed to improve treatment effectiveness by providing special services needed by underserved populations, and reduce treatment costs by serving large numbers of clients, centralizing services, and sharing facilities. First-time clients who met preliminary eligibility requirements during phone screening were randomly assigned to therapeutic community and chemical dependency programs. We used data collected on 1,573 adults who were ultimately accepted for admission to analyze treatment refusals and attrition during the 25 days after admission. Only 6.4% of the clients refused admission when informed of their treatment assignment. Planned duration of the residential phase of treatment, gender, and language spoken (English/Spanish) interacted with one another and differentially predicted treatment refusal/attrition. These findings may be useful for understanding treatment refusal and attrition in substance abuse treatment programs.

A comparison of neonatal mortality risk prediction models in very low birth weight infants

BACKGROUND

Risk-adjusted severity of illness is frequently used in clinical research and quality assessments. Although there are multiple methods designed for neonates, they have been infrequently compared and some have not been assessed in large samples of very low birth weight (VLBW; <1500 g) infants.

OBJECTIVES

To test and compare published neonatal mortality prediction models, including Clinical Risk Index for Babies (CRIB), Score for Neonatal Acute Physiology (SNAP), SNAP-Perinatal Extension (SNAP-PE), Neonatal Therapeutic Interventions Scoring System, the National Institute of Child Health and Human Development (NICHD) network model, and other individual admission factors such as birth weight, low Apgar score (<7 at 5 minutes), and small for gestational age status in a cohort of VLBW infants from the Washington, DC area.

METHODS

Data were collected on 476 VLBW infants admitted to 8 neonatal intensive care units between October 1994 and February 1997. The calibration (closeness of total observed deaths to the predicted total) of models with published coefficients (SNAP-PE, CRIB, and NICHD) was assessed using the standardized mortality ratio. Discrimination was quantified as the area under the curve (AUC) for the receiver operating characteristic curves. Calibrated models were derived for the current database using logistic regression techniques. Goodness-of-fit of predicted to observed probabilities of death was assessed with the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

The calibration of published algorithms applied to our data was poor. The standardized mortality ratios for the NICHD, CRIB, and SNAP-PE models were.65,.56, and.82, respectively. Discrimination of all the models was excellent (range:.863-.930). Surprisingly, birth weight performed much better than in previous analyses, with an AUC of.869. The best models using both 12- and 24-hour postadmission data, significantly outperformed the best model based on birth data only but were not significantly different from each other. The variables in the best model were birth weight, birth weight squared, low 5-minute Apgar score, and SNAP (AUC =.930).

CONCLUSION

Published models for severity of illness overpredicted hospital mortality in this set of VLBW infants, indicating a need for frequent recalibration. Discrimination for these severity of illness scores remains excellent. Birth variables should be reevaluated as a method to control for severity of illness in predicting mortality.

Therapeutic efficacy of oral lactobacillus preparation for antibiotic-associated enteritis in guinea pigs

Enteritis is a potential complication of antimicrobial agent use, particularly in certain species of rodents. The organism most frequently implicated in this disease is Clostridium difficile. Anecdotal information suggests that administration of yogurt or other Lactobacillus-containing products in conjunction with antimicrobial agents will prevent or minimize the effects of antibiotic-associated enteritis. We wanted to determine whether a single subcutaneous injection of clindamycin phosphate could induce enteritis in guinea pigs and whether a commercial Lactobacillus preparation would ameliorate the clinical effects of antibiotic administration in these animals. Juvenile male guinea pigs were divided into three treatment groups. Group 1 guinea pigs (n=8) received a single saline injection followed by an oral Lactobacillus preparation twice daily; group 2 (n=8) received a single antibiotic injection followed by an oral Lactobacillus preparation twice daily; group 3 (n=8) received a single antibiotic injection. Attitude, body temperature, body weight, and feed and water consumption were recorded for each guinea pig 7 days prior to and after treatment. Fecal samples were collected and necropsies performed on each guinea pig at the time of euthanasia. C. difficile and other enteric pathogens were not isolated from any group before or after treatment, although some guinea pigs receiving the antibiotic developed enteritis. There were no significant clinical differences between guinea pigs receiving antibiotics with the oral Lactobacillus preparation, and those receiving antibiotics alone. The results of this study suggest that a single injection of clindamycin phosphate can induce enteritis in guinea pigs and that oral administration of a Lactobacillus-containing product is ineffective in preventing clinical disease in guinea pigs administered clindamycin phosphate.

A randomized controlled trial of smoking cessation intervention in pregnancy in an academic clinic

To evaluate the effectiveness of a physician-based intervention to promote smoking cessation during pregnancy, we conducted this randomized controlled trial in the resident-staffed prenatal clinics at the University of North Carolina Women's Hospital . Two hundred fifty prenatal patients who smoked were enrolled at their first visit and randomly assigned to the intervention or the usual-care group. Resident physicians provided self-help materials to intervention subjects and used a script to set goals with them at each prenatal visit. Subjects who set quit dates were contacted by volunteer cessation counselors. To verify smoking status, subjects provided a self-report and breath carbon monoxide (CO) sample at each visit. Controls were similarly assessed at enrollment and at three additional predetermined intervals. Twenty percent of intervention subjects and 10% of controls reported cessation, which was verified by CO level (P = .052). Fifty-one percent of subjects reduced their consumption by half or more, compared with 30% of controls (P = .002). The intervention is effective in promoting smoking cessation and reduction. In addition, this technique is inexpensive, readily accepted by staff, and efficient.

Equal effectiveness of very-low-intensity anticoagulation and standard low-intensity anticoagulation: a pilot study

We compared the efficacy of very-low-intensity oral anticoagulation (OA) with that of the recommended standard low-intensity oral anticoagulation, using international normalized ratios (INRs). We enrolled 101 patients into a pilot study--51 patients in the very-low-intensity anticoagulation arm (INR 1.4 to 2.0) and 50 in the standard low-intensity anticoagulation arm (INR 2.0 to 3.0). They were monitored for thrombotic/embolic and hemorrhagic complications for an average follow-up of 1.5 years. Two thrombotic/embolic events occurred in the very-low-intensity group; no thrombotic/embolic events occurred in the standard low-intensity group. No major bleeding occurred in the very-low-intensity group; one major hemorrhagic event occurred in the standard low-intensity group. These findings did not achieve a statistically significant difference in major complications between the two groups. It appears that very-low-intensity OA (INR 1.4 to 2.0) is as effective in preventing thromboses as standard low-intensity OA (INR 2.0 to 3.0).

Induction of labour with intravaginal misoprostol in the second and third trimesters of pregnancy

OBJECTIVE

To confirm the effectiveness of misoprostol as a labour-induction agent.

DESIGN AND SETTING

One hundred and ten consecutive second- and third-trimester hospital patients. Patients with intra-uterine deaths (group A) received 100 micrograms misoprostol 4-hourly and those with live fetuses (group B) 50 micrograms misoprostol 4-hourly until labour commenced.

SUBJECTS

Forty-eight patients in group A (group A1 second trimester 27, group A2 third trimester 21); 62 mainly hypertensive patients in group B.

OUTCOME MEASURES

These were the amount of misoprostol required to induce labour; duration of induction and labour; success and completeness of vaginal delivery; neonatal outcome; and cost.

RESULTS

In group A1, labour was successfully induced in 21/27 (77.8%) patients with 157.4 micrograms misoprostol; and in 19/21 (90.5%) patients in group A2 with 128.9 micrograms misoprostol. Cost per successful induction was R0.55 and R0.44 respectively. Mean induction times were 13.2 hours and 13.4 hours respectively. All patients delivered vaginally but incompletely in 7/21 group A1 and 1/19 group A2 patients. In group A2, the mean duration of labour was 5.97 hours. In group B induction was successful in 51/62 (82%) with 95.1 micrograms of misoprostol; the mean cost was R0,32. Twelve out of 51 (23%) received oxytocin and 44/51 delivered vaginally. Mean duration of induction was 11.4 hours and of labour 5.4 hours. Two babies had low Apgar scores. There were two stillbirths (perinatal mortality rate 39.2/1000), both apparently unrelated to misoprostol.

CONCLUSIONS

Misoprostol is an effective, easy to use, apparently safe and cheap drug for the induction of labour.

Influence of nitric oxide on the hemodynamic response to hemorrhage in conscious rabbits

We investigated the role of nitric oxide, an endothelium-derived relaxing factor, in the hemodynamic response to acute hemorrhage in conscious rabbits. Chronically instrumented rabbits were treated with the nitric oxide synthase inhibitor N-nitro-L-arginine methyl ester (L-NAME) or vehicle and hemorrhaged until mean arterial pressure fell below 40 mmHg. Control animals were treated with L-NAME or vehicle but not subjected to hemorrhage. L-NAME increased mean arterial pressure and decreased heart rate in control animals. Hindquarters and mesenteric blood flow velocity and conductance were reduced by L-NAME. Nitric oxide synthase inhibition also produced significant changes in the hemodynamic response to hypotensive hemorrhage. Mean arterial pressure was higher and regional vascular conductances were lower throughout hemorrhage and during recovery. L-NAME treatment significantly (but in some cases, subtly) altered the characteristic pattern of changes in vascular conductance associated with acute hypotensive hemorrhage and recovery. Similar experiments with other arginine analogues or phenylephrine infusion showed that L-NAME's effects during hemorrhage were due to nitric oxide synthase inhibition. We conclude that nitric oxide plays a role in the hemodynamic response to acute hemorrhage in the rabbit and is essential for the full expression of the vasodilation associated with hypotensive hemorrhage.

[Labor, method of delivery and maternofetal transmission of HIV]

Within a prospective study of the course of HIV-infection in women, 80 HIV-infected women without AIDS were delivered of 80 children between 1985 and September 1992. The median of the age of gestation was 38 weeks. Until 1988 Caesarean section was chosen as mode of delivery (45 women). Later when the mode of delivery appeared to have no influence on the frequency of maternofetal HIV transmission, vaginal delivery was preferred (35 women). None of the infants was breastfed. Three infants --delivered vaginally--died within the first 6 months of life before their infection status could be determined. Seventy-seven children could be observed for 18 months or longer regularly every three months. 10 of the 77 children were found to be HIV- infected by serological, virological and clinical criteria. Taking into account the mode of delivery, of 32 children who were delivered vaginally or by emergency Caesarean section 8 were found to be HIV-infected. None of 26 children delivered by elective Caesarean section after an uneventful pregnancy is infected. In 19 women Caesarean section was performed within 2 hours after onset of labour or after episodes of preterm labour which required hospital admission for treatment. Two children of these women are infected. No differences of CD4+ cell counts and p24 antigenaemia could be determined between the mothers of the three groups. The risk of fetal HIV infection was increased by preterm labour (p < 0.01) and the mode of delivery (p < 0.01). A correlation between loss of CD4 cells in the mother and increased risk of infection for the child is seen in children born spontaneously or delivered by emergency Caesarean section (p < 0.001). No correlation was found between the length of labour at delivery, the time of the rupture of membranes before birth as well as of the parity and the risk of fetal infection in that group. These findings point to labour as an important factor which increases the risk of maternofetal transmission of HIV. The onset of labour is accompanied by dramatic immunological alterations as a sudden increase of chemotactics and inflammatory cytokines at the maternofetal interface. The accumulation and stimulation of maternal immune cells will--if these cells are carriers of HIV--result in production and release of infectious HIV. This virus may accumulate in the maternofetal interface or gain access to the amniotic cavity. Since amniotic fluid is swallowed by the fetus, the largest potential port of entry for HIV in the fetus are the fetal lungs and the gastrointestinal tract. For the prevention of maternofetal transmission of HIV delivery before onset of labour or alternatively the protection of the fetus during parturition by means of potent antiviral compounds can be considered.

[Blood donors as the sentinel population for sexually transmissible diseases--results of a sociodemographic study and survey of sexual behavior]

A multipurpose survey in a representative sample of the german population was conducted to obtain sociodemographic data together with data on blood donation history and acceptance of HIV antibody tests. A self-administered questionnaire was used to gather information on sexual behaviour. This questionnaire was completed by 62.2% of the participants between 18 and 64 years of age. Comparison between donors and nondonors shows that donors are typically members of the more "socially active" groups: they are younger, gainfully employed, and have attained higher educational levels. The analysis of the data on sexual behaviour reveals that donors are on the average sexually more active than nondonors. Blood donors are a suitable sentinel population to monitor sexually transmitted diseases in the population outside the risk groups for HIV infection.

Improvement of the predictive value of CD4+ lymphocyte count by beta 2-microglobulin, immunoglobulin A and erythrocyte sedimentation rate. The Multicentre Cohort Study Group

OBJECTIVE

To evaluate whether the use of immunological markers in addition to CD4+ lymphocyte count can improve the prediction of the probability of developing AIDS within a given period.

DESIGN AND SETTING

Prospective multicentre cohort study of homosexual men.

PATIENTS

A total of 447 HIV-positive homosexual men followed prospectively at 6-month intervals (median time of observation, 47 months).

METHODS

Estimation of AIDS-free time using lifetable plots by Cutler and Ederer and Weibull parametric models. A stepwise multivariate regression analysis was used to calculate the optimal combination of the parameters studied.

RESULTS

In general CD4+ lymphocyte counts are most important for the prediction of AIDS-free time. The use of serum levels of beta 2-microglobulin (beta 2M), immunoglobulin A (IgA) and erythrocyte sedimentation rate (ESR) can significantly improve the predictive value of CD4+ lymphocyte counts. However, the usefulness of these parameters depends on the stage of HIV disease. In patients with a CD4+ lymphocyte count > 500 x 10(6)/l, only IgA level had a significant predictive value; none of the other parameters significantly improved the model. In patients with a CD4+ lymphocyte count < 500 x 10(6)/l, the absolute number of CD4+ cells itself was the most important single predictive parameter, but the prediction of AIDS was significantly improved by the addition of the other parameters investigated. The most powerful combination of parameters in this group was CD4+ count, beta 2M and ESR.

CONCLUSION

Determination of serum IgA, beta 2M and ESR in addition to CD4+ lymphocyte count may aid the choice of specific therapeutic regimens or systems of care for HIV-positive individuals.

Toxic effects of zidovudine in asymptomatic human immunodeficiency virus-infected individuals with CD4+ cell counts of 0.50 x 10(9)/L or less. Detailed and updated results from protocol 019 of the AIDS Clinical Trials Group

BACKGROUND

Protocol 019 of the AIDS Clinical Trials Group is a multicenter, double-blind, placebo-controlled trial of zidovudine (3'-azido-3'-deoxythymidine; formerly AZT) in human immunodeficiency virus-infected asymptomatic individuals. The initial results in the stratum of subjects entering with CD4+ cell counts of 0.50 x 10(9)/L or less have been reported, but without a detailed analysis of toxic effects.

METHODS

This detailed and updated report analyzes the toxic effects that occurred in 1567 subjects (91% men; 89% white) in this stratum of protocol 019 who received placebo (494 subjects), a 500-mg daily dose of zidovudine (544 subjects), or a 1500-mg daily dose of zidovudine (529 subjects). Hematologic, hepatic, and renal effects and patient-reported symptoms and clinical signs were monitored.

RESULTS

Severe anemia (hemoglobin level, < 80 g/L) was associated with both the 500-mg zidovudine group and the 1500-mg group compared with placebo. The estimated 18-month risks of severe anemia were 0.4%, 2.0%, and 9.7% for the placebo, 500-mg zidovudine, and 1500-mg zidovudine groups, respectively. Predictive baseline measures were lower hemoglobin level in the 1500-mg group and the two zidovudine groups combined and lower platelet count in the 500-mg zidovudine group. The risk of a first severe anemia developing was greatest in months 3 through 8 of treatment. Of the 44 subjects with severe anemia in the zidovudine groups, 18 (41%) progressed from mild anemia (hemoglobin level, 95 to 109 g/L) to severe anemia on consecutive visits (usually 2 to 4 weeks apart). Severe neutropenia (absolute neutrophil count, < 750 x 10(6)/L) did not occur significantly more often in the 500-mg zidovudine group but did in the 1500-mg zidovudine group. Moderate neutropenia (absolute neutrophil count, < 1300 x 10(6)/L) did develop significantly more often in the 500-mg zidovudine group (165 subjects) than in the placebo group (71 subjects). Mild (or worse) elevations of bilirubin levels were uncommon but occurred more often with zidovudine. Severe nausea (and/or vomiting) was rare (2.8% of subjects) but was associated with zidovudine. Milder patient-reported events were common, and a number were associated with zidovudine.

CONCLUSION

Zidovudine at the 500-mg/d dosage appears to be tolerable in many patients with asymptomatic human immunodeficiency virus infection and CD4+ cell counts of 0.50 x 10(9)/L or less. Increased clinical surveillance for anemia may be warranted in certain patients.

Changes in the spectrum of AIDS-defining conditions and decrease in CD4+ lymphocyte counts at AIDS manifestation in Germany from 1986 to 1991

OBJECTIVES

Analysis of changes in the spectrum of AIDS-defining conditions and their correlation with CD4+ lymphocyte counts in different risk groups associated with HIV transmission.

METHODS

Review of data from all adult AIDS cases reported in Germany between 1986 and 1991.

RESULTS

Among AIDS cases diagnosed between 1986 and 1991, the proportion of cases with lymphoma and wasting syndrome increased, while the proportion of Kaposi's sarcoma decreased. Homosexual men, but not intravenous drug users, showed a decrease in the proportion of cases in Pneumocystis carinii pneumonia and an increase in the proportions with toxoplasmosis and cytomegalovirus infection. The median CD4+ lymphocyte count at time of AIDS diagnosis decreased from 73 x 10(6)/l in 1986 (25 and 75 percentiles, 28 and 212) to 47 x 10(6)/l in 1990 (25 and 75 percentiles, 20 and 120; P less than 0.01). This decrease was the result of reduced CD4+ lymphocyte counts of individuals presenting with opportunistic infections; there was no corresponding change for individuals with non-infectious AIDS-defining conditions.

CONCLUSIONS

AIDS diagnosis is now occurring at a later time in the natural history of HIV infection than in 1986, and the relative frequency of specific AIDS-defining conditions has changed. Most pronounced is a decrease of Pneumocystis carinii pneumonia. Changes in the natural history of HIV infection due to therapeutic and prophylactic interventions must be considered when interpreting epidemiological data in the course of the AIDS epidemic. These changes also have implications for the planning and execution of medical care.

[AIDS in Germany: clinical manifestations of AIDS]

Since 1982, voluntary anonymous reports that meet the criteria of the WHO/CDC-AIDS definition are being collected by the Federal Health Office. By December 31st, 1989 a total of 4,306 AIDS cases has been registered. More than 80% of the reported cases are homo- and bisexual men and injection drug-users. The remaining cases are divided between hemophiliacs, persons who get infected by heterosexual contacts, blood transfusion recipients, and children infected pre- or perinatally. In 16% of all cases AIDS was diagnosed only on the basis of a Kaposi's sarcoma (KS) and in another 6% on the basis of KS and an opportunistic infection (OI). KS occurred mostly in homo- and bisexual men. The relative proportion of KS has steadily decreased from 30% up to 1986 to less than 20% in 1989. The overall incidence of KS decreased mainly due to the decrease of KS in homosexual men with AIDS. OI were diagnosed in 70% of the cases. Pneumocystis-carinii-pneumonia is most frequent (47%), followed by candida-oesophagitis (19%) and toxoplasmosis of brain in 9.5%. A malignant lymphoma was diagnosed in 3% of the cases. Furthermore, HIV-encephalopathy was seen in 2.8% and HIV-wasting-syndrome in 1.6% of cases. There is a different spectrum of diseases at the first manifestation of AIDS diagnosed in injecting drug-users. The reasons for this may be due to different life-style in this group.

[Estimate of the total number of HIV-infected subjects in the Federal Republic of Germany based on data from the AIDS Center]

On the basis of an analysis of the data from the mandatory reporting of detected HIV infections and the reports to the central AIDS case registry an attempt is made to determine the total number of HIV infected individuals in the FRG. Results of surveys of testing behaviour in different risk groups were included in the calculations. For the calculation different estimates were used as to the total number of detected HIV infections, distribution of infections and percentage of detected infections in different risk groups. Depending on the estimates chosen a "best case" calculation yields 29,515 and the "worst case" calculation 81,949 HIV infected persons at the end of 1990. A synoptic analysis by the AIDS Center of the Federal Health Office resulted in an estimate of 50,000 to 60,000 HIV infected individuals in the FRG which is well between the "best" and "worst case" estimates.

The increased frequency of cervical dysplasia-neoplasia in women infected with the human immunodeficiency virus is related to the degree of immunosuppression

Cytologic and histologic investigations of the uterine cervix and studies of the lymphocyte functions were performed in human immunodeficiency virus-infected and human immunodeficiency virus antibody-negative women to study possible linkages between human papillomavirus-induced dysplasia and degree of human immunodeficiency virus-induced immunosuppression. Cytologic smears of the uterine cervix of 111 human immunodeficiency virus-infected women were compared with findings in 76 female intravenous drug users negative for human immunodeficiency virus antibodies and in a group of 526 women of the outpatient population of the hospital. Cervical dysplasia-neoplasia (including five cases of invasive carcinoma) was seen in 41% of the human immunodeficiency virus-infected patients. In human immunodeficiency virus-negative intravenous drug users dysplasia-neoplasia was seen in 9%, and in the sample from outpatients in 4%, including two cases of invasive carcinoma (p less than 0.01). Cytologic features that were attributable to infection with human papillomavirus were observed in human immunodeficiency virus-infected women four times more often than in the sample from the outpatient population (p less than 0.01). Frequency and severity of dysplasia appear to increase with diminishing numbers of CD4+ helper/inducer T lymphocytes and correlated significantly (p less than 0.01) with a loss of blastogenic response to phytohemagglutinin, pokeweed mitogen, and tetanus toxoid. These results suggest an increased risk for the development of dysplasia of the uterine cervix in women with human immunodeficiency virus infection, which is related to the degree of immunosuppression.

[Intestinal spirochetosis in HIV infection: prevalence, isolation and morphology of spirochetes]

The prevalence of intestinal spirochaetosis was investigated in 39 HIV-positive homosexual males (mean age 39 [24-65] years) in different stages of HIV infection (3 with the lymphadenopathy syndrome, 8 with AIDS-related complex and 28 with AIDS). Biopsies for cultural and histological demonstration of spirochaetes were obtained during routine ileoscopies. At the time of examination 35 of the 39 patients had intestinal symptoms. 27 patients had had no previous antimicrobial treatment. In 12 of the 27 previously untreated patients with intestinal symptoms spirochaetes were demonstrated, to different extent, from the terminal ileum to the rectum, while the treated group of eight and the control group of four were negative. There were no significant inflammatory changes histologically. Treatment with metronidazole in most cases improved symptoms. In their ultrastructure the microorganisms showed several complete convolutions, cone-shaped cell endings, cell length of 4-18 microns, cell diameter of 0.21-0.35 microns and five subterminal flagella. Morphological considerations favour the inclusion of these microorganisms in the genus Treponema rather than Brachyspira.

Zidovudine in asymptomatic human immunodeficiency virus infection. A controlled trial in persons with fewer than 500 CD4-positive cells per cubic millimeter. The AIDS Clinical Trials Group of the National Institute of Allergy and Infectious Diseases

Zidovudine (AZT) is a potent inhibitor of the replication of the human immunodeficiency virus (HIV), and it has been shown to improve survival in advanced HIV disease. We conducted a randomized, double-blind trial in adults with asymptomatic HIV infection who had CD4+ cell counts of fewer than 500 per cubic millimeter on entry into the study. The subjects (92 percent male) were randomly assigned to one of three treatment groups: placebo (428 subjects); zidovudine, 500 mg per day (453); or zidovudine, 1500 mg per day (457). After a mean follow-up of 55 weeks (range, 19 to 107), 33 of the subjects assigned to placebo had the acquired immunodeficiency syndrome (AIDS), as compared with 11 of those assigned to receive 500 mg of zidovudine (P = 0.002; relative risk, 2.8; 95 percent confidence interval, 1.4 to 5.6) and 14 of those assigned to receive 1500 mg of zidovudine (P = 0.05; relative risk, 1.9; 95 percent confidence interval, 1.0 to 3.5). In the three treatment groups, the rates of progression (per 100 person-years) to either AIDS or advanced AIDS-related complex were 7.6, 3.6, and 4.3, respectively. As compared with those assigned to placebo, the subjects in the zidovudine groups had significant increases in the number of CD4+ cells and significant declines in p24 antigen levels. In the 1500-mg zidovudine group, severe hematologic toxicity (anemia or neutropenia) was more frequent than in the other groups (P less than 0.0001). In the 500-mg zidovudine group, nausea was the only toxicity that was significantly more frequent (in 3.3 percent) than in the placebo group (P = 0.001). We conclude that zidovudine is safe and effective in persons with asymptomatic HIV infection and fewer than 500 CD4+ cells per cubic millimeter. Additional study will be required to determine whether such treatment will ultimately improve survival for persons infected with HIV.

Otitis media in early childhood and cognitive, academic, and classroom performance of the school-aged child

The relationship between the occurrence of otitis media during the first 3 years of life and cognitive, academic, and classroom performance during the third year of elementary school was evaluated in 44 socioeconomically disadvantaged children. The children attended a research day-care program where their otitis media experience and psychoeducational development were documented prospectively from birth. No significant relationship was found between otitis media in early childhood and performance on tests of verbal intelligence or academic achievement in the third year of school. The number of days of otitis media before 3 years of age was significantly correlated with teachers' ratings of children's attentional behavior in the classroom, however. Children with more early otitis media tended to be rated as less task oriented and less able to work independently than children with less otitis media. This was an exploratory study of a small number of children. Further study of the potential association is needed.

Otitis media in early childhood and its relationship to later phonological development

The relationship between otitis media during the first 3 years of life and subsequent speech development was examined in 55 socioeconomically disadvantaged children who attended a research day-care program. The children were participants in a longitudinal study of child development in which the number of episodes of otitis media and the duration of each otitis episode were reported prospectively from infancy. Standardized tests of speech were administered between the ages of 2 1/2 and 8 years. No significant relationship was found between otitis media in early childhood and number of common phonological processes or consonants in error used during the preschool years. However, the number of days of otitis media before age 3 was associated with the total number of phonological processes used by children between the ages of 4 1/2 and 8 years. Although these findings suggest that phonological processes after age 4 1/2 tend to drop out more slowly for children with a history of otitis media than of children without histories, no consistent patterns were observed for individual phonological processes or for the total number of consonants in error in this age range.