Psychosocial outcomes for preschool children and families after surgery for complex congenital heart disease.

The purpose of the current study was to assess the psychosocial outcomes of preschool-aged survivors (ages 3-6 years) of hypoplastic left heart syndrome (HLHS; n=13) and transposition of the great arteries (TGA; n=13). Parents completed the following measures: Pediatric Quality of Life Inventory, Impact on the Family Scale, Parenting Stress Index, Parent Behavior Checklist, and Child Behavior Checklist. Quality of life scores did not differ from those of healthy controls. Parents of children with HLHS reported more negative impact of the child's illness on the family and more parenting stress than parents of children with TGA. Parents of both groups of children were more permissive in their parenting style than parents of healthy controls. Children with HLHS had higher rates of attention and externalizing behavior problems than children with TGA. The results highlight the need for practitioners working with these children and families to ask about parental stress, family functioning, and behavioral expectations for the child in the context of routine medical/cardiac follow-up.

Interspecies transmission of Enterozytozoon bieneusi supported by observations in laboratory animals and phylogeny.

Enterocytozoon bieneusi is emerging as an important cause of chronic diarrhoea in AIDS patients. Its reservoirs and transmission patterns are unknown. In this study, we have examined E. bieneusi sequences from four Rhesus macaques of different origin, which were kept at one animal facility. The sequences were identical in all animals, which suggested that infection had occurred within the facility. Full sequence agreement of E. bieneusi from macaques was found with an E. bieneusi genotype that occurs frequently in humans. To clarify, the relevance of possible inter-species transmission from man to macaque, a phylogenetic analysis was conducted including all sequences of E. bieneusi deposited in GenBank. The hitherto used system of diverse nomenclatures could be reduced to an outlier group and three main lineages, one of which could be further sub-divided into five subgroups. Based in this phylogeny, an association of parasites and host species could be observed for main lineages 2 and 3, as well as for most of the subgroups of main lineage 1. For confirmation, the phylogeny of main lineage 1 was reconstructed with an alternative method of distance estimation, yielding essentially the same parasite-host associations. Zoonotic potential of E. bieneusi is thus supported on a phylogenetic basis.

Missing the target: a comparison of buyback and fatality related guns.

OBJECTIVES: To determine whether the firearms recovered in buyback programs in a large urban community are the types most closely associated with firearm fatalities in the same geographic area. METHODS: The type, caliber, and manufacturer of 941 handguns recovered in Milwaukee County 1994-96 buyback programs were compared with 369 homicide related and 125 suicide related handguns used in Milwaukee during 1994-97. RESULTS: Buyback handguns differed substantially from those used in homicide and suicide. One third of buyback handguns were semiautomatic pistols versus two thirds of homicide related handguns (p<0.001) and 40% of suicide related handguns (p=NS). Over 75% of buyback handguns were small caliber compared with 24% of homicide and 32% of suicide handguns (p<0.001). The top two manufacturers of buyback handguns represented 30% of these guns but only 5% of fatality related handguns (p<0.001). Companies currently out of business manufactured 15% of buyback handguns versus 7% of fatality related handguns (p<0.001). CONCLUSIONS: Handguns recovered in buyback programs are not the types most commonly linked to firearm homicides and suicides. Although buyback programs may increase awareness of firearm violence, limited resources for firearm injury prevention may be better spent in other ways.

Characteristics of a pathogenic molecular clone of an end-stage serum-derived variant of simian immunodeficiency virus (SIV(F359)).

End-stage simian immunodeficiency virus (SIV) isolates are suggested to be the most fit of the evolved virulent variants that precipitate the progression to AIDS. To determine if there were common characteristics of end-stage variants which emerge from accelerated cases of AIDS, a molecular clone was derived directly from serum following in vivo selection of a highly virulent SIV isolate obtained by serial end-stage passage in rhesus monkeys (Macaca mulatta). This dominant variant caused a marked cytopathic effect and replicated to very high levels in activated but not resting peripheral blood lymphocytes. Furthermore, although this clone infected but did not replicate to detectable levels in rhesus monocyte-derived macrophages, these cells were able to transmit infection to autologous T cells upon contact. Interestingly, although at low doses this end-stage variant did not use any of the known coreceptors except CCR5, it was able to infect and replicate in human peripheral blood mononuclear cells homozygous for the Delta 32 deletion of CCR5, suggesting the use of a novel coreceptor. It represents the first pathogenic molecular clone of SIV derived from viral RNA in serum and provides evidence that not only the genetic but also the biological characteristics acquired by highly fit late-stage disease variants may be distinct in different hosts.

Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis.

BACKGROUND: Ambulance crashes have become an increasing source of public concern. Emergency medical services directors have little data to develop ambulance operation and risk management policies. OBJECTIVE: To describe fatal ambulance crash characteristics, identifying those that differentiate emergency and nonemergency use crashes. METHODS: This was a retrospective analysis of all fatal ambulance crashes on U.S. public roadways reported to the Fatality Analysis Reporting System (FARS) database from 1987 to 1997. Main outcome measures were 42 variables describing crash demographics, crash configuration, vehicle description, crash severity, and ambulance operator and vehicle occupant attributes. RESULTS: Three hundred thirty-nine ambulance crashes caused 405 fatalities and 838 injuries. These crashes occurred more often between noon and 6 PM (39%), on improved (99%), straight (86%), dry roads (69%) during clear weather (77%), while going straight (80%), through an intersection (53%), and striking (81%) another vehicle (80%) at an angle (56%). Most crashes (202/339) and fatalities (233/405) occurred during emergency use. These crashes occurred significantly more often at intersections (p < 0.001), at an angle (p < 0.001), with another vehicle (p < 0.001). Most crashes resulted in one fatality, not in the ambulance. Thirty pedestrians and one bicyclist comprised 9% of all fatalities. In the ambulance, most serious and fatal injuries occurred in the rear (OR 2.7 vs front) and to improperly restrained occupants (OR 2.5 vs restrained). Sixteen percent of ambulance operators were cited; 41% had poor driving records. CONCLUSIONS: Most crashes and fatalities occurred during emergency use and at intersections. The greater burden of injury fell upon persons not in the ambulance. Rear compartment occupants were more likely to be injured than those in the front. Crash and injury reduction programs should address improved intersection control, screening to identify high-risk drivers, appropriate restraint use, and design modifications to the rear compartment of the ambulance.

Independence of herpesvirus-induced T cell lymphoma from viral cyclin D homologue.

Cyclin D family members are cellular protooncogenes, and their viral homologues in the Kaposi's sarcoma-associated herpesvirus (KSHV, human herpesvirus type 8 [HHV-8]) and the closely related Herpesvirus saimiri have been implicated as putative cofactors of viral transformation and pathogenesis. KSHV is regularly found in Kaposi's sarcoma and in the primary effusion B cell lymphoma and Castleman's disease associated with immunosuppression and AIDS. H. saimiri strain C488 transforms human and marmoset T cells in vitro and causes polyclonal T cell lymphoma in New World monkeys. The viral cyclins stimulate cell cycle progression of quiescent fibroblasts, and they form active cyclin-dependent kinase (CDK)6 complexes of broad substrate specificity that can resist and downregulate cellular CDK inhibitors. This study shows that the viral cyclin of H. saimiri strain C488 is not required for viral replication, T cell transformation, and pathogenicity in New World primates.

Age and gender patterns in motor vehicle crash injuries: importance of type of crash and occupant role.

To evaluate the interaction of gender, age, type of crash, and occupant role in motor vehicle crash injuries leading to hospitalization, we analyzed 1997 Wisconsin hospital discharge data for patients with primary E-code diagnoses of motor vehicle injuries. The overall ratio of males to females (M/F ratio) hospitalized for motor vehicle crash injuries was 1.33 (95% confidence interval (CI): 1.26-1.41). The M/F ratio varied by type of crash and differed for passengers and drivers. For injuries sustained in collisions between vehicles, the M/F ratio was 0.96 (95% CI: 0.87-1.05); in loss of control accidents the M/F ratio was 1.95 (95% CI: 1.76-2.17). Within each type of crash, the M/F ratio for drivers was similar to that for the entire type; the M/F ratio for passengers was about half of the type total. Expressed as rates of hospitalization per 100,000 people in the general population, hospitalizations of drivers in collisions with another motor vehicle increased steeply in males, but not in females, beginning at about age 70. For drivers in loss of control crashes, male rates exceeded female rates in all age groups, with peaks in the groups 15-24 and 85-89. For passengers, injury rates from collisions with other motor vehicles were greater for females, especially in the elderly, and injury rates from loss of control crashes were similar for both genders, with peaks at 15-24 and 85-94. The higher fatality of men in loss of control motor vehicle crashes, compared to women, suggests an important area for further investigation.

Safety and immunogenicity of ALVAC wild-type human p53 (vCP207) by the intravenous route in rhesus macaques.

p53 is over-expressed in approximately 50% of human cancers, and transfer of cytotoxic T lymphocytes (CTL) against wild-type p53 protects mice against p53-over-expressing tumors, suggesting that p53 might be an attractive target for immunotherapy. Immunization of mice with a recombinant canarypox virus, ALVAC, expressing human wild-type p53 (vCP207) prevented growth of p53-over-expressing tumors. Since intravenous administration induced better immune responses in mice than other routes, we have proposed to use this route in cancer patients. However, because this vector has never been administered intravenously to humans, and because of the possibility of inducing auto-immunity to a self-antigen, we felt it was necessary to first evaluate safety in rhesus macaques. We found that three intravenous administrations of vCP207 at proportional doses up to 10x those proposed for humans produced no abnormalities in hematologic or clinical chemistry parameters. Serologic markers of autoimmunity and inflammation were unaffected, despite the >95% amino acid identity between human and rhesus p53. Pathological examination of numerous tissues yielded findings comparable to those in animals given placebo. Some animals showed anti-p53 antibody responses following vaccination, indicating that tolerance could be broken to some extent. However, with the exception of one animal with a possible delayed type hypersensitivity reaction to p53 protein, we did not see evidence for a cell-mediated response. The safety profile in monkeys with ALVAC-p53 provides encouragement for using such live, modified vectors via the intravenous route for human immunotherapy.

The added diagnostic value of automated QT-dispersion measurements and automated ST-segment deviations in the electrocardiographic diagnosis of acute cardiac ischemia.

The purpose of this study was to determine the added value of automated QT dispersion and ST-segment measurements to physician interpretation of 12-lead electrocardiograms (ECGs) in patients with chest pain. To date, poor reproducibility of manual measurements and lack of shown added value have limited the clinical use of QT dispersion. Twelve-lead ECGs (n = 1,161) from the Milwaukee Prehospital Chest Pain Database were independently classified by 2 physicians into 3 groups (acute myocardial infarction (AMI), acute cardiac ischemia (ACI), or nonischemic), and their consensus was obtained. QT-end and QT-peak dispersions were measured by a computerized system. The computer also identified ST-segment deviations. Sensitivity, specificity, and positive predictive values (PPVs) and negative predictive values (NPV) for AMI and ACI were evaluated independently and in combinations. For AMI, physicians' consensus classification was remarkably good (sensitivity, 48%, specificity, 99%). Independent classification by QT-end and QT-peak dispersions or ST deviations was not superior to the physicians' consensus. Optimal classification occurred by combining automated QT-end dispersion and ST deviations with physicians' consensus. This combination increased sensitivity for the diagnoses of AMI by 35% (65% vs 48%, P < .001) and ACI by 55% (62% vs 40%, P < .001) compared with physicians' consensus, while maintaining comparable specificity. This study supports a potential clinical role for automated QT dispersion when combined with other diagnostic methods for detecting AMI and ACI.

Herpesvirus saimiri vFLIP provides an antiapoptotic function but is not essential for viral replication, transformation, or pathogenicity.

Apoptosis of infected cells is an important host defense mechanism, and many viruses have exploited antiapoptotic proteins that interfere with crucial cellular pathways. Viral FLICE inhibitory proteins (vFLIPs) are encoded by rhadinoviruses like herpesvirus saimiri, the related Kaposi's sarcoma-associated herpesvirus-human herpesvirus 8 (KSHV/HHV8), and the poxvirus responsible for molluscum contagiosum. The vFLIPs can block the interaction of the death receptor-adapter complex with the cellular effector FLICE (caspase-8), and this prevents the initiation of the downstream caspase cascade. KSHV/HHV8 vFLIP overexpression can confer resistance to T-cell-mediated apoptosis and acts as a tumor progression factor in a murine B-cell lymphoma model. To analyze the function of herpesvirus vFLIPs in the genetic background of the virus and in a model for viral pathogenesis, we deleted the vFLIP gene (open reading frame 71) from the genome of herpesvirus saimiri strain C488. The viral deletion mutant was viable and replicated like the wild-type virus. An antiapoptotic effect could be attributed to the vFLIP gene, but we also show that the vFLIP gene of herpesvirus saimiri is dispensable for viral transformation of T cells in vitro and for pathogenicity in cottontop tamarins in vivo.

Microsporidia and Candida spores: their discrimination by Calcofluor, trichrome-blue and methylene-blue combination staining.

Faeces of immunocompromised patients are often contaminated with the chitin-containing spores of microsporidia and Candida, which exclude the use of the chitin-specific fluorescent brightener Calcofluor white M2R for the identification of microsporidian spores. We developed a combination staining of Calcofluor white M2R with modified trichrome-blue staining and subsequent methylene-blue incubation which permits discrimination between these two types of spores. As a basis for diagnosis, a difference in the fluorescence pattern (365-440 nm) is combined with a difference in the light microscopic staining pattern. Under fluorescence conditions microsporidia spores have a spotted, brilliant white Calcofluor fluorescence and can easily be identified, while Candida spores show a reddish purple colour. Under the light microscope microsporidian spores show a light red colour with nonstained vacuole spots or strips in contrast to the yeast spores with their red-brown colour. This combination technique offers a highly specific means for the diagnosis of microsporidia spores in faeces.

Antiretroviral therapy during primary immunodeficiency virus infection can induce persistent suppression of virus load and protection from heterologous challenge in rhesus macaques.

A limited period of chemotherapy during primary immunodeficiency virus infection might provide a long-term clinical benefit even if treatment is initiated at a time point when virus is already detectable in plasma. To evaluate this strategy, we infected rhesus macaques with the pathogenic simian/human immunodeficiency virus RT-SHIV and treated them with the antiretroviral drug (R)-9-(2-phosphonylmethoxypropyl)adenine (PMPA) for 8 weeks starting 7 or 14 days postinfection. PMPA treatment suppressed viral replication efficiently in all of the monkeys. After chemotherapy ended, virus replication rebounded and viral RNA in plasma reached levels comparable to that of the controls in four of the six monkeys. However, in the other two animals, virus loads peaked only moderately after withdrawal of the drug and then declined to low or even undetectable levels. These low levels of viremia remained stable for at least 31 weeks after cessation of therapy. At this time point, these two monkeys were challenged with SIV(8980) to evaluate whether the host responses which were able to keep RT-SHIV replication under control were also sufficient to protect against infection with a highly pathogenic heterologous virus. Both monkeys proved to be protected against the heterologous virus. In one of the two animals, low levels of SIV(8980) replication were detected. Thus, by chemotherapy during the acute phase of pathogenic virus replication, we could achieve not only persistent virus load suppression in two out of six monkeys but also protection from subsequent heterologous challenge. By this chemotherapeutic attenuation, the replication kinetics of attenuated viruses could be mimicked and a vaccination effect similar to that induced by live attenuated simian immunodeficiency virus vaccines was achieved.

Successful suppression of the early rejection of pig islets in monkeys.

Primary nonfunction (PNF) is seen very frequently after xenogeneic transplantation of islets of Langerhans. In a pig-to-rat model we recently observed that no PNF occurs when the islets are kept in culture at 37 degrees C for 1-2 weeks prior to transplantation. In order to investigate the rejection mechanisms in a preclinical model, we transplanted cultured porcine islets under the capsule of both kidneys in four cynomolgous monkeys. Islets were isolated from adult sows by means of digestion with Liberase in University of Wisconsin solution (UWS). The digest was purified by a density gradient of OptiPrep in UWS. Highly purified (>95%) islets were cultured 1-2 weeks in RPMI. All monkeys showed significant titers of preformed anti-pig antibodies. The immunosuppression of the monkeys consisted of cyclophosphamide (Cy) (2 days), cyclosporin A (CsA), and prednisolone. Anticipating a fast rejection we carried out nephrectomies at different time points within 2 weeks after transplantation. Following unilateral nephrectomy, well-preserved islets with no signs of rejection were observed between 3 and 7 days posttransplant. Later, between days 11 and 15 posttransplant, histology in the first three animals demonstrated no islets. In the fourth monkey histology on day 11 showed islets with excellent morphology and some small focal infiltrates. The highest CsA blood levels (around 1000 ng/ml) were found in animals with the best graft survival. We conclude that cultured porcine islets can be grafted without hyperacute rejection in monkeys with preformed anti-pig antibodies. In the presence of high levels of CsA only marginal signs of a cellular immune response were observed 11 days after transplantation.

An anti-HIV strategy combining chemotherapy and therapeutic vaccination.

Combination chemotherapy using potent anti-retroviral agents has led to significant advances in the clinical management of human immunodeficiency virus (HIV) disease. However, the emergence of multiple drug-resistant mutants, the high need for compliance to adhere to demanding drug-dosing schemes, and the remaining toxic side-effects of drugs make the perspective of life-long treatment unattractive and possibly unrealistic. Therefore, means must be sought to shorten the time span during which treatment is necessary. Such means could be to stimulate an efficient immune response during the period of low virus load and restored CD4 + cell levels, which might be capable of keeping the virus under long-lasting control after treatment is stopped. Here we tested this concept of combined chemotherapy/ therapeutic vaccination in a non-human primate model. Rhesus macaques chronically infected with the chimeric simian/human immunodeficiency virus (SHIV) containing the HIV type 1 (HIV-1) HXBc2 gene for reverse transcriptase (RT) in the genomic background of simian immunodeficiency virus (SIV)(mac239) (RT-SHIV) were treated with (R)-9-(2-phosphonylmethoxypropyl)adenine (PMPA), a potent anti-HIV drug. When virus load had decreased significantly, we immunized with SIV genes env, gag/pol, rev, tat, and nef inserted in two different expression vector systems. Four weeks after the second immunization, drug treatment was stopped. Animals were monitored to determine if virus load stayed low or if it increased again to the original levels and if CD4+ T-cell levels remained stable. Humoral and cellular immune responses were also measured. This combined chemotherapy/ therapeutic vaccination regimen induced a significant reduction in the steady-state level of viremia in one out of two chronically infected rhesus macaques. Chemotherapeutic treatment alone did not achieve reduction of viremia in two chronically infected animals. The nature of the immune responses assumed to have been induced by vaccination in one out of the two monkeys remains to be elucidated.

Prognostic factors for persons with idiopathic chronic fatigue.

BACKGROUND: The simultaneous examination of a large number of patient characteristics in a prospective study of patients with chronic fatigue. OBJECTIVE: To compare the relative importance of these characteristics as prognostic factors. METHODS: The data analyzed were from 199 subjects in a registry of persons who were aged 18 years or older and had idiopathic fatigue for at least 6 months. All subjects completed an extensive baseline questionnaire that provided information about fatigue, demographic characteristics, medical conditions, lifestyle, sleeping habits, psychological characteristics, and the presence of criteria for chronic fatigue syndrome. Changes in fatigue severity from baseline to 2-year follow-up were tested for an association with risk factors at baseline and with changes in symptoms other than fatigue during the follow-up period. RESULTS: The following characteristics at baseline significantly and independently predicted greater fatigue improvement: less unclear thinking, fewer somatoform symptoms not used to define chronic fatigue syndrome, infrequent awakening, fewer hours sleeping, and being married. Of 29 subjects who at baseline reported no somatoform symptoms unrelated to chronic fatigue syndrome and who thought clearly most of the time, 8 substantially improved, compared with 1 of 29 subjects who had more than 2 somatoform symptoms and never thought clearly (P = .01). Improvements in the following symptoms were significantly and independently associated with improvements in fatigue: unclear thinking, depression, muscle aches, and trouble falling asleep. CONCLUSIONS: This study identified characteristics of subjects that seem to be of prognostic importance for idiopathic chronic fatigue. Symptoms that change concomitantly with changes in fatigue may be intrinsically linked to fatigue.

Prevention of renal allograft rejection in primates by blocking the B7/CD28 pathway.

BACKGROUND: There is accumulating evidence that blockade of the costimulatory pathways offers a valid approach for immune suppression after solid organ transplantation. In this study, the efficacy of anti-CD80 and anti-CD86 monoclonal antibodies (mAbs) in combination with cyclosporine (CsA) to prevent renal allograft rejection was tested in non-human primates. METHODS: Rhesus monkeys were transplanted with a partly major histocompatibility complex-matched kidney on day 0. Anti-CD80 and anti-CD86 mAbs were administered intravenously daily for 14 days starting at day - 1. CsA was given intramuscularly for 35 days starting just after transplantation. The kidney function was monitored by determining serum creatinine levels. RESULTS: The combination of anti-CD80 and anti-CD86 mAbs completely abrogated the mixed lymphocyte reaction. Untreated rhesus monkeys rejected the kidney allograft in 5-7 days. Treatment with anti-CD80 plus anti-CD86 mAbs resulted in a significantly prolonged graft survival of 28+ 7 days (P=0.025). There were no clinical signs of side effects or rejection during treatment. Kidney graft rejection started after the antibody therapy was stopped. The anti-mouse antibody response was delayed from day 10 to 30 after the first injection. No difference in graft survival was observed between animals treated with CsA alone or in combination with anti-CD80 and anti-CD86 mAbs. However, treatment with anti-CD80 and anti-CD86 mAbs reduced development of vascular rejection. CONCLUSIONS: In combination, anti-CD80 and antiCD86 mAbs abrogate T-cell proliferation in vitro, delay the anti-mouse antibody response in vivo, and prevent graft rejection and development of graft vascular disease in a preclinical vascularized transplant model in non-human primates.

Prestige of training programs and experience of bypass surgeons as factors in adjusted patient mortality rates.

OBJECTIVES: The relation of physician performance to physician training and experience is not well understood. The aim of this study was to examine whether indicators of physician background and experience were associated with an objective measure of physician performance. METHODS: Physician background information obtained from the Directory of Board-Certified Medical Specialists was linked to physician risk-adjusted mortality rates obtained from three statewide data bases of coronary artery bypass surgeons. Subjects were 275 surgeons who performed CABG surgery on 83,547 patients during the years 1989 to 1992. Surgical performance was measured by the mortality ratio (MR), the ratio of the observed to the predicted patient mortality rate as determined by detailed clinical information. Training institutions and physicians were characterized as prestigious if they were listed as outstanding in published articles. RESULTS: Surgical performance was not associated with graduation from an American medical school; attendance at a prestigious medical school, residency, or fellowship program; or an academic appointment. Mortality ratios decreased with increased volume and increased with years of experience, age, and academic rank. Surgeons were more likely to be considered a "best doctor" if they had more years experience and trained at a prestigious residency or fellowship program. CONCLUSIONS: Training at a prestigious institution was associated with identification as a "best" doctor but not with lower mortality ratios.