Uncertain outcomes: adjusting for misclassification in antimalarial efficacy studies.

Evaluation of antimalarial efficacy is difficult because recurrent parasitaemia can be due to recrudescence or re-infection. PCR is used to differentiate between recrudescences and re-infections by comparing parasite allelic variants before and after treatment. However, PCR-corrected results are susceptible to misclassification: false positives, due to re-infection by the same variant present in the patient before treatment; and false negatives, due to variants that are present but too infrequent to be detected in the pre-treatment PCR, but are then detectable post-treatment. This paper aimed to explore factors affecting the probability of false positives and proposes a Monte Carlo uncertainty analysis to account for both types of misclassification. Higher levels of transmission intensity, increased multiplicity of infection, and limited allelic variation resulted in more false recrudescences. The uncertainty analysis exploits characteristics of study data to minimize bias in the estimate of efficacy and can be applied to areas of different transmission intensity.

An investigation of the interaction of iminosulfurane transdermal penetration enhancers with model skin preparations using NMR spectroscopy.

The (31)P NMR resonance from the inner and outer leaflets of DMPC in unilamellar vesicle bilayers has been split by use of the slowly penetrating paramagnetic shift reagent, Pr(3+). The perturbing effect of subsequently added iminosulfurane transdermal penetration enhancers (TPEs) is to accelerate the collapse of this splitting, especially in the case of the bromo derivative 3. The aforementioned acceleration of the splitting is enhanced by the addition of 16 mol% cholesterol. Conversely, 33 mol% cholesterol appears to seal the bilayer to the effect of the TPEs--even when present at 20 mol%. These observations are consistent with the deep penetration of the TPEs into the DMPC bilayer, i.e., the perturbation of the bilayer is transmembrane and supports a model in which a subset of the bromo TPE derivative 3 is kinetically trapped in the bilayer. This feature leads to an enhanced residence time of 3 in the bilayer, and by extension to the skin, and therefore to an explanation for the markedly enhanced activity of the bromo TPE derivative relative to that of other halogenated derivatives in the series of iminosulfuranes studied.

Horizontal gene transfer and the evolution of microvirid coliphage genomes.

Bacteriophage genomic evolution has been largely characterized by rampant, promiscuous horizontal gene transfer involving both homologous and nonhomologous source DNA. This pattern has emerged through study of the tailed double-stranded DNA (dsDNA) phages and is based upon a sparse sampling of the enormous diversity of these phages. The single-stranded DNA phages of the family Microviridae, including phiX174, appear to evolve through qualitatively different mechanisms, possibly as result of their strictly lytic lifestyle and small genome size. However, this apparent difference could reflect merely a dearth of relevant data. We sought to characterize the forces that contributed to the molecular evolution of the Microviridae and to examine the genetic structure of this single family of bacteriophage by sequencing the genomes of microvirid phage isolated on a single bacterial host. Microvirids comprised 3.5% of the detectable phage in our environmental samples, and sequencing yielded 42 new microvirid genomes. Phylogenetic analysis of the genes contained in these and five previously described microvirid phages identified three distinct clades and revealed at least two horizontal transfer events between clades. All members of one clade have a block of five putative genes that are not present in any member of the other two clades. Our data indicate that horizontal transfer does contribute to the evolution of the microvirids but is both quantitatively and qualitatively different from what has been observed for the dsDNA phages.

Consequences and costs of lower extremity injuries.

Lower extremity injuries resulting from motor vehicle crashes are common and have become relatively more important as more drivers with newer occupant restraints survive high-energy crashes. CIREN data provide a greater level of clinical detail based on coding guidelines from the Orthopedic Trauma Association. These detailed data, in conjunction with long-term follow-up data obtained from patient interviews, reveal that the most costly and disabling injuries are those involving articular (joint) surfaces, especially those of the ankle/foot. Patients with such injuries exhibit residual physical and psychosocial problems, even at one year post-trauma.

Patterns of epistasis in RNA viruses: a review of the evidence from vaccine design.

Epistasis results when the fitness effects of a mutation change depending on the presence or absence of other mutations in the genome. The predictions of many influential evolutionary hypotheses are determined by the existence and form of epistasis. One rich source of data on the interactions among deleterious mutations that has gone untapped by evolutionary biologists is the literature on the design of live, attenuated vaccine viruses. Rational vaccine design depends upon the measurement of individual and combined effects of deleterious mutations. In the current study, we have reviewed data from 29 vaccine-oriented studies using 14 different RNA viruses. Our analyses indicate that (1) no consistent tendency towards a particular form of epistasis exists across RNA viruses and (2) significant interactions among groups of mutations within individual viruses occur but are not common. RNA viruses are significant pathogens of human disease, and are tractable model systems for evolutionary studies--we discuss the relevance of our findings in both contexts.

Causes and outcomes of mild traumatic brain injury: an analysis of CIREN data.

Approximately one-half of vehicle occupants with traumatic brain injury (TBI) have a mild TBI (admission Glasgow Coma Scale (GCS) score of 13-15 with transient loss of consciousness). However, despite the label of "mild", many of these injuries result in long-term consequences; frequently these sequelae go unrecognized, as the patients are lost to medical follow-up. The Crash Injury Research Engineering Network (CIREN) project affords us the opportunity to examine the crash circumstances, injury sources and outcomes of mild TBI cases in greater detail.

Use of OKT3 for acute myocarditis in infants and children.

Acute viral myocarditis triggers an autoimmune phenomenon that aggressive immunosuppressive therapy with monoclonal OKT3 may suppress. We treated 5 patients, aged 15 months to 16.5 years, who had acute viral myocarditis and left ventricular ejection fraction (LVEF) of 5% to 20%, with a combination immunosuppressive regimen that included OKT3, intravenous immunoglobulin, methylprednisone, cyclosporine, and azathioprine. Within 2 weeks of therapy, all patients demonstrated normalization of LVEF to 50% to 74%, and on mid-term follow-up, we have found no recurrence of heart failure or progression to dilated cardiomyopathy. In patients with severe acute myocarditis, aggressive immunosuppressive regimen based on OKT3 is safe and may inhibit or reverse the immune response, resulting in dramatic improvement in myocardial function.

Kin selection and parasite evolution: higher and lower virulence with hard and soft selection.

Conventional models predict that low genetic relatedness among parasites that coinfect the same host leads to the evolution of high parasite virulence. Such models assume adaptive responses to hard selection only. We show that if soft selection is allowed to operate, low relatedness leads instead to the evolution of low virulence. With both hard and soft selection, low relatedness increases the conflict among coinfecting parasites. Although parasites can only respond to hard selection by evolving higher virulence and overexploiting their host, they can respond to soft selection by evolving other adaptations, such as interference, that prevent overexploitation. Because interference can entail a cost, the host may actually be underexploited, and virulence will decrease as a result of soft selection. Our analysis also shows that responses to soft selection can have a much stronger effect than responses to hard selection. After hard selection has raised virulence to a level that is an evolutionarily stable strategy, the population, as expected, cannot be invaded by more virulent phenotypes that respond only to hard selection. The population remains susceptible to invasion by a less virulent phenotype that responds to soft selection, however. Thus, hard and soft selection are not just alternatives. Rather, soft selection is expected to prevail and often thwart the evolution of virulence in parasites. We review evidence from several parasite systems and find support for soft selection. Most of the examples involve interference mechanisms that indirectly prevent the evolution of higher virulence. We recognize that hard selection for virulence is more difficult to document, but we take our results to suggest that a kin selection model with soft selection may have general applicability.

Drug utilization review of sedative/hypnotic agents in Texas Medicaid patients. Texas Medicaid Vendor Drug Program Drug Utilization Review Board.

OBJECTIVE: To assess use of sedative/hypnotic agents in Texas Medicaid patients and evaluate practitioner receptiveness to intervention letters concerning sedative/hypnotic prescribing generated by the Texas Medicaid Drug Utilization Review (DUR) Board. DESIGN: Retrospective DUR. SETTING: Texas Medicaid retrospective DUR program. PATIENTS OR OTHER PARTICIPANTS: 244 Texas Medicaid patients and 291 Texas physicians. INTERVENTION: Patient profiles for Texas Medicaid patients were reviewed retrospectively to quantify sedative/hypnotic prescribing practices. Intervention letters were prepared and sent to physicians directly involved in the care of patients receiving excessive sedative/hypnotic therapy. Physician responses were categorized based on information presented in the intervention letter and circumstances surrounding the identified patient. Prescribing practices were assessed approximately 1 year after the intervention to determine the impact of intervention letters on prescribing. MAIN OUTCOME MEASURE: Physician response to intervention letter. RESULTS: Responses were received from 208 of 291 physicians (71.5%). Approximately 40% of physicians agreed in principle with the suggestions offered by the Texas Medicaid DUR Board to minimize chronic sedative/hypnotic use. Almost one-half of these physicians had discontinued sedative/hypnotic therapy for the identified patients 1 year after the intervention. Approximately 9% justified continued sedative/hypnotic use based on patient diagnosis or refractory response to treatment, and 55 physicians (26.4%) were unwilling to alter therapy because of patient-specific factors. CONCLUSION: Through the use of retrospective DUR, Texas Medicaid patients receiving excessive amounts of sedative/hypnotic agents were identified and improvements in sedative/hypnotic therapy were initiated. DUR can be useful not only in identifying problem areas, but also in encouraging physicians to modify prescribing practices through educational means.

Evolvability of an RNA virus is determined by its mutational neighbourhood.

The ubiquity of mechanisms that generate genetic variation has spurred arguments that evolvability, the ability to generate adaptive variation, has itself evolved in response to natural selection. The high mutation rate of RNA viruses is postulated to be an adaptation for evolvability, but the paradox is that whereas some RNA viruses evolve at high rates, others are highly stable. Here we show that evolvability in the RNA bacteriophage phi6 is also determined by the accessibility of advantageous genotypes within the mutational neighbourhood (the set of mutants one or a few mutational steps away). We found that two phi6 populations that were derived from a single ancestral phage repeatedly evolved at different rates and toward different fitness maxima. Fitness measurements of individual phages showed that the fitness distribution of mutants differed between the two populations. Whereas population A, which evolved toward a higher maximum, had a distribution that contained many advantageous mutants, population B, which evolved toward a lower maximum, had a distribution that contained only deleterious mutants. We interpret these distributions to measure the fitness effects of genotypes that are mutationally available to the two populations. Thus, the evolvability of phi6 is constrained by the distribution of its mutational neighbours, despite the fact that this phage has the characteristic high mutation rate of RNA viruses.

Transplantation for congenital heart disease.

Refinements in surgical technique, donor and recipient myocardial preservation, and immunosuppression have brought pediatric heart transplantation for end-stage heart failure (whatever the cause) from the heyday of clinical experimentation to the realm of a viable therapeutic. Heart transplantation in this subpopulation yields excellent early and midterm survival. Acute rejection remains an important cause of morbidity and mortality after heart transplantation in children. Future improvement in quality of life for these patients calls for newer immunosuppressive strategies to reduce acute rejection episodes and ultimately improve long-term graft survival.

Sixteen-year experience with 1,000 heart transplants at UCLA.

1. The consecutive pre- and post-1994 eras have demonstrated improved survival for all age groups. This is linked to improved preservation methods, surgical technique and immunosuppression agents. 2. The use of marginal donor hearts for Status I and alternate elderly patients has followed the model of matching donor and recipient risk without affecting patient outcome and minimized the use of implantable assist devices. 3. A donor history of systemic gram-negative infection, hypertension, or traumatic intracranial bleeds was an important marker for risk. Younger age and shorter ischemia time could compensate for other hazards. 4. Heart transplantation in carefully selected elderly recipients yielded clinical results similar to those of younger patients with less rejection. 5. An adult alternate recipient list proved useful to prevent diversion of standard donors away from younger recipients. 6. Retransplantation for TCAD is acceptable but much less satisfactory for acute graft failure. 7. Trends show an increase in the use of implantable devices; refinement in technology for mechanical assist and replacement is forthcoming.

Cerebral blood flow velocity during repeatedly induced ventricular fibrillation.

STUDY OBJECTIVE: To investigate the effect of induced ventricular fibrillation and defibrillation on cerebral blood flow (CBF) was investigated using a transcranial Doppler. DESIGN: Prospective clinical study. SETTING: University hospital. PATIENTS: 12 ASA physical status III and IV patients who underwent implantable cardioverter defibrillator placement during general anesthesia. INTERVENTIONS: Cerebral blood flow velocity was measured repeatedly during induced ventricular fibrillation and subsequent defibrillation. MEASUREMENTS AND MAIN RESULTS: The mean flow velocity in the middle cerebral artery was measured using a transcranial Doppler. The mean flow velocities decreased significantly immediately after ventricular fibrillation was induced, but they returned to preventricular fibrillation levels immediately after successful defibrillation. Repeatedly induced ventricular fibrillations have no cumulative detrimental effect on the CBF velocity. CONCLUSIONS: Repetitively induced ventricular fibrillation and defibrillation during the insertion of implantable cardioverter defibrillator did not show any detrimental changes in CBF. Transcranial Doppler may be a more sensitive device than other currently available cerebral monitors to detect changes in cerebral circulation during a brief episode of ventricular fibrillation and defibrillation.

Evolution by small steps and rugged landscapes in the RNA virus phi6.

Fisher's geometric model of adaptive evolution argues that adaptive evolution should generally result from the substitution of many mutations of small effect because advantageous mutations of small effect should be more common than those of large effect. However, evidence for both evolution by small steps and for Fisher's model has been mixed. Here we report supporting results from a new experimental test of the model. We subjected the bacteriophage phi6 to intensified genetic drift in small populations and caused viral fitness to decline through the accumulation of a deleterious mutation. We then propagated the mutated virus at a range of larger population sizes and allowed fitness to recover by natural selection. Although fitness declined in one large step, it was usually recovered in smaller steps. More importantly, step size during recovery was smaller with decreasing size of the recovery population. These results confirm Fisher's main prediction that advantageous mutations of small effect should be more common. We also show that the advantageous mutations of small effect are compensatory mutations whose advantage is conditional (epistatic) on the presence of the deleterious mutation, in which case the adaptive landscape of phi6 is likely to be very rugged.

Hybrid frequencies confirm limit to coinfection in the RNA bacteriophage phi6.

Coinfection of the same host cell by multiple viruses may lead to increased competition for limited cellular resources, thus reducing the fitness of an individual virus. Selection should favor viruses that can limit or prevent coinfection, and it is not surprising that many viruses have evolved mechanisms to do so. Here we explore whether coinfection is limited in the RNA bacteriophage phi6 that infects Pseudomonas phaseolicola. We estimated the limit to coinfection in phi6 by comparing the frequency of hybrids produced by two marked phage strains to that predicted by a mathematical model based on differing limits to coinfection. Our results provide an alternative method for estimating the limit to coinfection and confirm a previous estimate between two to three phages per host cell. In addition, our data reveal that the rate of coinfection at low phage densities may exceed that expected through random Poisson sampling. We discuss whether phage phi6 has evolved an optimal limit that balances the costly and beneficial fitness effects associated with multiple infections.

Peer evaluation. A visual picture.

To meet the criteria of role accountability, nursing competence and ongoing staff development, an improved peer-evaluation system was designed to continuously monitor these new roles. This peer-evaluation process converts evaluation input into data, giving staff a visual picture of how their performance compares within their peer group. This peer-evaluation process was designed as a tool to assist in staff growth and development, not as a punitive system.

Antigenic variation in Neisseria gonorrhoeae: production of multiple lipooligosaccharides.

Individual cells of Neisseria gonorrhoeae may express a single lipooligosaccharide (LOS) component on their cell surfaces, or they may simultaneously express multiple LOS structures. Strain FA19 expresses LOS components that react with monoclonal antibodies (MAbs) 2-1-L8 and 1B2. The genetic locus responsible for this phenotype in FA19 was identified by isolating a clone that is able to impart the ability to simultaneously express both LOS molecules to strain 1291, a strain expressing only the MAb 1B2-reactive LOS. This clone, pCLB1, was characterized, and the gene responsible for the expression of both LOS components was determined to be lsi2. DNA sequence analysis of lsi2(Fa19) indicates that there are several differences between the DNA sequences of lsi2(FA19) and lsi2(1291). The region responsible for the LOS-specific phenotype change in lsi2(FA19) was identified by deletion and transformation analysis, mapping to a polyguanine tract within lsi2 where lsi2(FA19) possesses a +2 frameshift relative to lsi2(1291). The polyguanine tract in lsi2(FA19) was modified by site-directed mutagenesis to change the sequence to GGGAGGTGGCGGA to prevent frameshifting during DNA replication, transcription, and/or translation. Transformants of strain 1291 containing this DNA sequence express a single MAb 2-1-L8-reactive LOS component, the same phenotype exhibited by lsi2-defective strains. These data indicate that FA19 is able to generate a small amount of functional Lsi2 protein via transcriptional and/or translational frameshifting, and this limited amount of protein allows for the expression of MAb 1B2-reactive LOS molecules.

Evaluation of physician intervention letters.

OBJECTIVES: The Omnibus Budget Reconciliation Act of 1990 requires that Medicaid Agencies perform drug utilization review (DUR). The Texas Medicaid Agency, in cooperation with the Texas DUR Board, have chosen to mail intervention letters to physicians with patient profiles that indicate possible inappropriate use of medications. The objective of this study was to assess the effect of intervention letters indicating duplicative anti-ulcer medications. METHODS: Analysis of Medicaid prescription claims produced 335 patient profiles involving concurrent therapy. Physicians for 174 patients were selected randomly to receive an intervention letter, a response form, and a stamped envelope. The remaining patients served as a control group. RESULTS: A 71.2% response rate was obtained. Of these responses, 48.9% agreed with the letter and 19.1% disagreed with the letter. Profiles generated 6 months after the letters were sent indicated that 47.7% of the patients in the experimental group were still on concurrent therapy compared with 64.4% of patients in the control group (P = 0.007). CONCLUSIONS: The high response rate to the letter, the moderately high agreement with the letters, and the statistically significant reduction of duplicative therapy in the experimental group indicate that intervention letters can be an effective way to change prescribing. Future research is needed to assess the effects of educational intervention letters for other drug categories, for other populations, and for longer periods of time; and the effect these changes may have on true patient outcomes.

Isolated vertigo as a manifestation of vertebrobasilar ischemia.

OBJECTIVE: We sought to demonstrate that isolated episodes of vertigo can be the only manifestation of vertebrobasilar ischemia. BACKGROUND: Isolated persistent vertigo is classically ascribed to labyrinthine disorders and is only rarely considered to reflect vertebrobasilar ischemia. METHODS: We retrospectively analyzed all of the records of the Saint Louis University Stroke Registry between January 1, 1992 and September 1, 1993. We set out to identify those patients discharged with a diagnosis of transient ischemic attack (TIA) in the vertebrobasilar system. We reviewed their clinical records and the results of their diagnostic studies. RESULTS: We screened 600 admissions and found 29 patients with vertebrobasilar circulation TIAs. Of these, five men and one woman had episodic vertigo for at least 4 weeks as their only presenting symptom. All six patients had one of two abnormal patterns on magnetic resonance angiography (MRA): focal basilar stenosis or widespread vertebrobasilar slow flow. In three patients, the MRA findings were confirmed by cerebral angiography. Five patients were treated with warfarin and one with aspirin. Two patients developed brainstem infarctions, one of them fatal. CONCLUSIONS: Isolated vertigo can be the only manifestation of vertebrobasilar ischemia. Its frequency may be underestimated in clinical practice. Noninvasive testing is helpful both for diagnosis and follow-up.