Low language capacity in childhood: A systematic review of prevalence estimates.

BACKGROUND AND AIMS: Epidemiological studies have provided invaluable insight into the origin and impact of low language skills in childhood and adolescence. However, changing terminology and diagnostic guidelines have contributed to variable estimations of the prevalence of developmental language difficulties. The aim of this review was to profile the extent and variability of low language prevalence estimates through a systematic review of epidemiological literature. METHODS: A systematic review of the empirical research (August 2022) was undertaken to identify studies that aimed to estimate the prevalence of low language skills in children (<18 years). A total of 19 studies published between 1980-2022 met inclusion criteria for review. RESULTS: Studies reported prevalence estimates of low language skills in children between 1 and 16 years. Estimated rates varied from 0.4% to 25.2%. More stable estimations were observed in studies of children aged 5 years and older and those that applied updated diagnostic criteria to performance on standardised assessments of receptive and expressive language. CONCLUSIONS AND IMPLICATIONS: The estimated prevalence of low language skills in childhood varies considerably in the literature. Application of updated diagnostic criteria, including the assessment of functional impact, is critical to inform advocacy efforts and govern social, health and educational policies. WHAT THIS PAPER ADDS: What is already known on the subject Epidemiological research has informed our understanding of the origin and impact of low language capacity in childhood. Childhood language disorder is met with a rich history of evolving terminology and diagnostic guidelines to identify children with low language skills. Inconsistent definitions of and methods to identify low language in children have resulted in variable prevalence estimates in population-based studies. Variability in prevalence estimates impacts advocacy efforts to inform social, health and educational policy for child language disorder. What this study adds A total of 19 studies published at the time of this review aimed to provide estimates of the proportion of children who experience low language skills. Prevalence estimates varied between 0.4% and 25.2%, with more stable estimates reported in studies of older school-age children and those which utilised standardised assessments of both expressive and receptive language. Few studies utilised assessments of functional impact of language difficulties, which is misaligned with updated diagnostic criteria for child language disorder. What are the clinical implications of this work? This review reports substantial variability in estimates of the proportion of children and adolescents who live with low language skills. This variability underscores the importance of applying updated diagnostic criteria to identify the prevalence low language in childhood. Efforts to estimate the prevalence of low language must include measures of functional impact of low language skills. This aligns with clinical recommendations, which call for routine assessment of functional outcomes. To this end, we require a unified understanding of the term 'functional impact' in the context of low language, including the development and evaluation of measures that assess impact across emotional, social and academic domains.

Growing Old in the Bible Belt: Resources for Aging LGBT Adults Living in the South.

There has been an increase in the literature about LGBT older adults in recent years; however, there is a need for further sociological quantitative research examining the impact of geographic region on LGBT aging. Utilizing data from a nationwide survey, this study focuses on the availability of LGBT-specific resources for LGBT aging adults living in the South. We examine the effects of community type and sociodemographics on the availability of LGBT-specific resources as well as the type of resources available. Findings reveal that in the South, community type, having a partner, household income, and education affect the LGBT-specific resources available. Of particular interest, LGBT-affirming faith organizations are identified as the resource most frequently available for LGBT aging adults in this region often referred to as the Bible Belt. Overall, this study sheds light on the LGBT-specific resources that are available to provide social support and help meet the unique needs of LGBT adults aging in the South.

Mechanisms of platelet aggregation.

Platelet aggregation is initiated by receptor activation coupled to intracellular signaling leading to activation of integrin alphaIIbbeta3. Recent advances in the study of platelet receptors for collagen, von Willebrand factor, thrombin, and adenosine diphosphate are providing new insights into the mechanisms of platelet aggregation.

Accretion of low-metallicity gas by the Milky Way.

Models of the chemical evolution of the Milky Way suggest that the observed abundances of elements heavier than helium ('metals') require a continuous infall of gas with metallicity (metal abundance) about 0.1 times the solar value. An infall rate integrated over the entire disk of the Milky Way of approximately 1 solar mass per year can solve the 'G-dwarf problem'--the observational fact that the metallicities of most long-lived stars near the Sun lie in a relatively narrow range. This infall dilutes the enrichment arising from the production of heavy elements in stars, and thereby prevents the metallicity of the interstellar medium from increasing steadily with time. However, in other spiral galaxies, the low-metallicity gas needed to provide this infall has been observed only in associated dwarf galaxies and in the extreme outer disk of the Milky Way. In the distant Universe, low-metallicity hydrogen clouds (known as 'damped Ly alpha absorbers') are sometimes seen near galaxies. Here we report a metallicity of 0.09 times solar for a massive cloud that is falling into the disk of the Milky Way. The mass flow associated with this cloud represents an infall per unit area of about the theoretically expected rate, and approximately 0.1-0.2 times the amount required for the whole Galaxy.

Influence of fibrillar collagen structure on the mechanisms of platelet thrombus formation under flow.

We have used real-time video microscopy to study the mechanisms of platelet adhesion to type I collagen fibrils of distinct structure exposed to flowing blood. Electron microscopy analysis by surface replication demonstrated morphological differences between acid-insoluble fibrils, displaying a regularly repeating striated pattern (banded collagen), and acid-soluble fibrils generated by pepsin treatment of insoluble collagen, smaller in size with a helical configuration (nonbanded collagen). These structural differences proved to be related to the role of platelet integrin alpha(2)beta(1) in stabilizing adhesion to collagen under a variety of flow conditions. Blocking alpha(2)beta(1) function with a monoclonal antibody had no effect on platelet adhesion to insoluble type I collagen coated at high density on a glass surface, whereas there was an absolute dependence of alpha(2)beta(1) function for the initial permanent arrest of platelets and subsequent thrombus formation on pepsin-solubilized type I collagen under the same conditions. In contrast, reconstituted, banded fibrils prepared from pepsin-solubilized type I collagen supported platelet adhesion and thrombus development even when platelet alpha(2)beta(1) function was blocked, a process that was greatly accelerated by pre-exposure of this substrate to autologous plasma under flow. These results implicate a collagen receptor(s) on platelets other than alpha(2)beta(1) that can selectively engage domains in banded, but not nonbanded type I collagen when alpha(2)beta(1) function is blocked. In addition, collagen structure may regulate the extent and affinity of the binding under flow of plasma components such as von Willebrand factor and/or other alpha(IIb)beta(3) ligands.

Specific synergy of multiple substrate-receptor interactions in platelet thrombus formation under flow.

We have used confocal videomicroscopy in real time to delineate the adhesive interactions supporting platelet thrombus formation on biologically relevant surfaces. Type I collagen fibrils exposed to flowing blood adsorb von Willebrand factor (vWF), to which platelets become initially tethered with continuous surface translocation mediated by the membrane glycoprotein Ib alpha. This step is essential at high wall shear rates to allow subsequent irreversible adhesion and thrombus growth mediated by the integrins alpha2beta1 and alpha(IIb)beta3. On subendothelial matrix, endogenous vWF and adsorbed plasma vWF synergistically initiate platelet recruitment, and alpha2beta1 remains key along with alpha(IIb)beta3 for normal thrombus development at all but low shear rates. Thus, hemodynamic forces and substrate characteristics define the platelet adhesion pathways leading to thrombogenesis.

Nucleotide polymorphisms in the alpha2 gene define multiple alleles that are associated with differences in platelet alpha2 beta1 density.

Three allelic differences in the alpha2 gene are associated with expression levels of the alpha2beta1 integrin on the platelet surface. We have previously defined two linked silent polymorphisms in the alpha2 gene coding region at nucleotides 807 (C or T) and 873 (G or A). We have now identified one rarer nucleotide polymorphism in the coding region at nucleotide 837 (T or C) and four additional linked polymorphisms within the introns that flank these coding sequences. Moreover, we have determined that the alloantigenic Br polymorphism, which resides in a distal coding region at nucleotide 1648, is also linked to the 837 polymorphism. Thus, three alpha2 gene alleles, defined by eight nucleotide polymorphisms, have now been discovered. Allele 1 (807T/837T/873A/Brb) is associated with increased levels of alpha2beta1; allele 2 (807C/837T/873G/Brb) and allele 3 (807C/837C/873G/Bra) are each associated with lower levels of alpha2beta1. Finally, we also show here that the rate of platelet attachment to type I collagen in whole blood under conditions of high shear rate (1,500/s) is proportional to the density of alpha2beta1 receptors on the platelet surface. Thus, the density of platelet alpha2beta1 could have an important impact on platelet adhesion to collagen in whole blood and therefore on platelet function in vivo, contributing to an increased risk of thrombosis or to bleeding in relevant disease states.

Initiation of platelet adhesion by arrest onto fibrinogen or translocation on von Willebrand factor.

We have identified two distinct mechanisms initiating the adhesion of flowing platelets to thrombogenic surfaces. The intergrin alpha IIb beta 3 promotes immediate arrest onto fibrinogen but is fully efficient only at wall shear rates below 600-900 s-1, perhaps because of a relatively slow rate of bond formation or low resistance to tensile stress. In contrast, glycoprotein Ib alpha binding to immobilized von Willebrand factor (vWF) appears to have fast association and dissociation rates as well as high resistance to tensile stress, supporting slow movement of platelets in continuous contact with the surface even at shear rates in excess of 6000 s-1. This eventually allows activated alpha IIb beta 3 to arrest platelets onto vWF under conditions not permissive of direct binding to fibrinogen. The coupling of these different functions may be crucial for thrombogenesis.

Clostridium sordellii toxic shock syndrome: a case report and review of the literature.

BACKGROUND: Since the 1980s, there have been isolated reports of a toxic shock syndrome associated with Clostridium sordellii necrotizing subcutaneous infections during the puerperium. Relatively localized fascial and muscle necrosis is noted at the surgical incision sites. However, circulating toxins produce marked edema, resulting in shock and cardiovascular collapse. Despite aggressive surgical and supportive therapy, all postpartum cases thus far have been fatal. CASE: A 24-year-old primipara developed an episiotomy infection which progressed to involve the underlying fascia and muscle. Despite early and adequate debridement of the devitalized tissue, she developed anasarca, marked leukocytosis, refractory hypotension, hypothermia, and a persistent coagulopathy, and expired on postpartum day 5. The cultures from the excised tissue grew C. sordellii All blood cultures were negative. CONCLUSION: Treatment modalities aimed solely at the eradication of the microbe and removal of necrotic tissue, although essential components of therapy, have proved inadequate. Future efforts should be directed toward neutralization or elimination of the circulating exotoxins responsible for the systemic shock.

Interaction of integrin alpha IIb beta 3 with multiple fibrinogen domains during platelet adhesion.

We have investigated how modulation of integrin alpha IIb beta 3 function influences the mechanisms that initiate platelet thrombus formation onto surface-bound fibrinogen and isolated fibrinogen domains. Under stationary conditions and with full activation of platelets blocked by prostaglandin E1, the carboxyl-terminal gamma 400-411 sequence is necessary for establishing initial contact with the immobilized substrate. Molecules containing a single copy of this sequence, like the plasmin-generated fibrinogen fragment D, support platelet spreading, but the resulting attachment to the surface is loose and disrupted by minimal peeling force. In contrast, platelets adhere firmly to intact fibrinogen under the same conditions, suggesting that recognition of contact sites outside a single D domain can secure the firm interaction not supported by a single gamma 400-411 sequence. If platelets are activated, the gamma 400-411 sequence is no longer necessary to initiate the adhesion process but becomes sufficient, even as a single copy, to mediate stable surface attachment in the absence of shear stress. Under conditions of flow, however, intact fibrinogen but not fragment D can support adhesion, regardless of whether platelets have the potential to become activated or not. These results indicate the functional relevance of multiple fibrinogen domains during the initial stages of the platelet adhesion process.

Nonoperative management of blunt hepatic injuries: safe at any grade?

Nonoperative management of blunt hepatic injury (BHI) has become more widely accepted. A prospective trial was undertaken to test the belief that clinical state could identify the patients with BHI confirmed by computed tomography (CT) who could be safely managed without a surgical operation. Patients were excluded from nonoperative management only if they manifested hemodynamic instability, the presence or suspicion of any other injury requiring laparotomy, or would be unavailable for controlled monitoring. Of 60 patients treated for BHI, 30 were managed nonoperatively. The 30 who had laparotomies served as a comparative group. The groups were statistically similar in age, sex, and Injury Severity Score (ISS). The group managed nonoperatively had significantly more severe BHI. There were no deaths or delayed laparotomies in the nonoperative management group. The groups had similar ICU and total hospital stays when analyzed as independent variables or with control for BHI grade and ISS. Transfusion requirements were significantly lower for the nonoperative management group when analyzed independently or when controlled for BHI grade, ISS, and the number of non-abdominal injuries. Nineteen (63%) patients managed nonoperatively were followed until their CT scans showed complete resolution. None had complications. We conclude that nonoperative management of BHI is a safe and effective technique applicable to hemodynamically stable patients who lack other indications for laparotomy and who can be adequately monitored.

Modulation of platelet function through adhesion receptors. A dual role for glycoprotein IIb-IIIa (integrin alpha IIb beta 3) mediated by fibrinogen and glycoprotein Ib-von Willebrand factor.

We have found that the form of glycoprotein (GP) IIb-IIIa (integrin alpha IIb beta 3) expressed on nonstimulated platelets is a functional receptor that mediates selective and irreversible adhesion to immobilized fibrinogen. This occurs even in the presence of the elevated intracellular cAMP levels induced by prostaglandin E1 or after inhibition of protein kinase C activity by sphingosine. In the absence of inhibitors, platelets adhering to fibrinogen through GP IIb-IIIa become fully activated and aggregate with one another. Immobilized von Willebrand factor (vWF), in contrast, is recognized by nonstimulated platelets through another receptor, GP Ib. This interaction leads to a change in the ligand recognition specificity of GP IIb-IIIa that can then bind to immobilized vWF and mediate irreversible platelet adhesion and aggregation; this process, however, is inhibited by elevated intracellular cAMP levels or blockade of protein kinase C activity. Therefore, GP Ib and GP IIb-IIIa induce platelet activation through the selective recognition of immobilized vWF and fibrinogen, respectively, in the absence of exogenous agonists. Moreover, "nonactivated" and "activated" GP IIb-IIIa exhibits distinctly different reactivity toward surface-bound vWF, and the functional switch can be induced by the binding of vWF to GP Ib. These findings demonstrate the modulation of platelet function by two different adhesion receptors, GP Ib and GP IIb-IIIa, as well as the distinct dual role of the latter as the necessary common mediator of irreversible adhesion and aggregation on both fibrinogen and vWF.

Selective recognition of adhesive sites in surface-bound fibrinogen by glycoprotein IIb-IIIa on nonactivated platelets.

We demonstrate that unstimulated platelets attach to immobilized fibrinogen in a selective process mediated by the membrane glycoprotein (GP) complex IIb-IIIa (alpha IIb beta 3). The initial attachment, independent of platelet activation, is followed by spreading and irreversible adhesion even in the presence of activation inhibitors. Using fibrinogen fragments derived from plasmin digestion, we found that unstimulated platelets do not attach to immobilized fragment E, which contains an Arg-Gly-Asp sequence at A alpha 95-97, and adhere to fragments X and D, both containing the gamma 400-411 dodecapeptide adhesion sequence, less efficiently than to intact fibrinogen. Thus, the carboxyl terminus of the A alpha chain, missing in the "early" fragment X used in these studies, appears to be involved in the interaction of fibrinogen with unstimulated platelets. In contrast, activated platelets adhere to immobilized fibrinogen and fragments X, D, and E in a time-dependent and equivalent manner. Although activated platelets adhere to immobilized vitronectin, fibronectin, and von Willebrand factor through GP IIb-IIIa, unstimulated platelets fail to adhere to vitronectin and have only a limited capacity to adhere to fibronectin and von Willebrand factor. These results demonstrate that GP IIb-IIIa on unstimulated platelets displays a recognition specificity for attachment to immobilized adhesive proteins that is distinct from that seen following platelet activation. Thus, unstimulated platelets selectively interact with fibrinogen, and the initial attachment is followed by spreading and irreversible adhesion in the absence of exogenous agonists. This process may be regulated by plasmin cleavage of the fibrinogen A alpha chain and may play an important role during normal hemostasis and during the pathological development of thrombotic vascular occlusions.

Binding of the snake venom-derived proteins applaggin and echistatin to the arginine-glycine-aspartic acid recognition site(s) on platelet glycoprotein IIb.IIIa complex inhibits receptor function.

In the present report we describe the platelet-binding characteristics of applaggin and echistatin, potent inhibitors of fibrinogen-dependent platelet aggregation derived from Agkistrodon piscivorus piscivorus and Echis carinatus snake venoms, respectively. Both molecules bound to unstimulated platelets in a specific and saturable manner. At saturation there were 37,100 +/- 3,150 (mean, +/- S.D.) molecules of applaggin and 27,200 +/- 2,816 molecules of echistatin bound/platelet, with dissociation constants (Kd) of 1.4 +/- 0.6 x 10(-7) M and 4.9 +/- 1.2 x 10(-7) M, respectively. Stimulation of platelets with ADP (10 microM) + epinephrine (2 microM) resulted in an increase in the number of molecules bound at saturation to 42,300 +/- 2,105 for applaggin and 32,185 +/- 3,180 for echistatin, with a Kd of 5.6 +/- 0.3 x 10(-8) M and 1.8 +/- 0.6 x 10(-7) M, respectively. The synthetic peptide (Arg)8-Gly-Asp-Val was a competitive antagonist of applaggin and echistatin binding to unstimulated platelets (Ki = 25 and 36 microM, respectively). Applaggin and echistatin inhibited the binding of fibrinogen to stimulated platelets in a dose-dependent manner, with an IC50 of 9 and 25 nM, respectively. In concert with inhibition of platelet aggregation, applaggin and echistatin inhibited platelet secretion and synthesis of thromboxane A2 induced by ADP, collagen, and human gamma-thrombin. The monclonal antibody, LJ-CP3, which inhibits the binding of Arg-Gly-Asp containing ligands to platelet GPIIb.IIIa, also inhibited applaggin binding to unstimulated platelets in a competitive manner (Ki = 4.5 microM). Thus, applaggin and echistatin bind to the platelet GPIIb.IIIa complex, and the Arg-Gly-Asp sequence plays a central role in mediating this interaction.

Agkistrodon piscivorus piscivorus platelet aggregation inhibitor: a potent inhibitor of platelet activation.

Applaggin (Agkistrodon piscivorus piscivorus platelet aggregation inhibitor) is a potent inhibitor of platelet activation. The protein is isolated from the venom of the North American water moccasin snake in three steps, including gel filtration, cation exchange, and reverse-phase HPLC procedures. The purified protein migrates as a 17,700-Da polypeptide by SDS/PAGE under nonreducing conditions and as a 9800-Da peptide in the presence of thiol. The behavior of applaggin on SDS/PAGE would indicate that the protein is a disulfide-linked dimer. Applaggin has been completely sequenced by Edman degradation and consists of 71 amino acids. The sequence is rich in cysteine and contains Arg-Gly-Asp at residues 50-52. Applaggin blocks platelet aggregation induced by ADP, collagen, thrombin, or arachidonic acid with IC50 values ranging from 12 to 128 nM (0.2-2.3 micrograms/ml) depending on the agonist and its concentration. This inhibition is found to correlate with inhibition of thromboxane A2 generation and of dense granule release of serotonin. Inhibition by applaggin of serotonin release induced by ADP, gamma-thrombin, and collagen was monitored in plasma under stirred conditions with [3H]serotonin-loaded platelets, and IC50 values for inhibition are found to range from less than 10 to 145 nM. At saturating concentrations, 125I-labeled applaggin (125I-applaggin) binds to 28,500 sites per unstimulated, washed platelet with a Kd of 1.22 x 10(-7) M. Binding of 125I-applaggin to platelets is inhibited by the synthetic undecapeptide Arg8-Gly-Asp-Val at 200 microM.

Thrombin-induced increase in surface expression of epitopes on platelet membrane glycoprotein IIb/IIIa complex and GMP-140 is a function of platelet age.

Platelets are heterogeneous in the content of membrane glycoprotein (GP)IIb/IIIa complex. To determine whether this heterogeneity is related to changes associated with platelet aging in the circulation, newly released platelets, obtained during recovery from nonimmune-mediated acute experimental thrombocytopenia in baboons, were studied. Monoclonal antibody (MoAb) binding to epitopes expressed on GPIIb/IIIa complex (LJ-CP8), GMP-140 (S12), and GPIa/IIa (12F1) was measured on control platelets (comprising platelets with a normal age distribution; mean age 60 to 72 hours) and newly formed platelets (mean age 12 hours), both in the resting state and after thrombin stimulation. Whereas LJ-CP8 binding to resting control platelets increased by 34% upon stimulation by gamma-thrombin from 30,885 +/- 1,171 to 41,458 +/- 1,311 molecules/platelet at saturating concentrations of antibody, LJ-CP8 binding to resting young platelets did not increase significantly upon thrombin stimulation (31,878 +/- 3,330 and 33,791 +/- 3,486 molecules/platelet, respectively). Similarly, binding of antibody S12 in response to maximal thrombin stimulation was reduced by 42% from 10,246 +/- 834 molecules/platelet at saturating concentrations of S12 for control platelets to 5,971 +/- 665 molecules/platelet for young platelets (P = .001). S12 binding to unstimulated platelets was less than 10% of the binding observed after thrombin stimulation at all concentrations of S12 for both control and young platelets. However, maximal binding of antibody 12F1 to resting control platelets did not differ significantly from that observed with resting young platelets (2,926 +/- 167 and 2,857 +/- 208 molecules/platelet, respectively), and 12F1 binding was unchanged after thrombin stimulation for both control and young platelets. We conclude that the thrombin-induced increase in the expression of epitopes on platelet membrane GPIIb/IIIa complex and GMP-140 is a function of platelet age.

Ultrasound assessment of the suspected scaphoid fracture.

A prospective study of 111 patients thought to have sustained a recent scaphoid fracture on clinical grounds but who were radiologically negative was undertaken over a period of 7 months. All such patients were subjected to ultrasound scanning within a week of their injury under double blind conditions. All patients were re-X-rayed 2-3 weeks after their injury. The authors' results suggest that ultrasonic diagnosis of the possibly fractured scaphoid is unreliable.

Urinary lactic acid dehydrogenase activity and the site of urinary tract infections.

A report that elevated urinary lactic acid dehydrogenase (LDH) isoenzyme 5 activity is a reliable tool for separating patients with upper from those with lower urinary tract infections (UTIs) led us to study urinary LDH enzyme activity in girls having bladder washout studies to localize the site of infection. Urinary LDH isoenzyme 5 activity in 64 instances of lower UTI was 16.1 +/- 3.3%, a value not significantly different than that of 18.2 +/- 12.6% found in 26 instances of upper tract infection (t = 0.8726, P = 0.1928). The data show that LDH isoenzyme 5 activity is of no value for localization of the site of a UTI. The data of these studies also showed that urinary LDH enzyme activity clearly separates girls with UTIs from those without infections, but it is unlikely that this finding will be of value in diagnosis or management.