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Objectives: The American Academy of Pediatrics (AAP) calls for the inclusion of office-based pediatricians in disaster preparedness and response efforts. However, there is little research about disaster preparedness and response on the part of pediatric practices. This study describes the readiness of pediatric practices to respond to disaster and delineates factors associated with increased preparedness., Methods: An AAP survey was distributed to members to assess the state of pediatric offices in readiness for disaster. Potential predictor variables used in chi-square analysis included community setting, primary employment setting, area of practice, and previous disaster experience., Results: Three-quarters (74%) of respondents reported some degree of disaster preparedness (measured by 6 indicators including written plans and maintaining stocks of supplies), and approximately half (54%) reported response experience (measured by 3 indicators, including volunteering to serve in disaster areas). Respondents who reported disaster preparation efforts were more likely to have signed up for disaster response efforts, and vice versa., Conclusions: These results contribute information about the state of pediatric physician offices and can aid in developing strategies for augmenting the inclusion of office-based pediatricians in community preparedness and response efforts.

Despite mounting evidence that social factors and public policies affect state infant mortality rates (IMRs), few researchers have examined variation in IMRs associated with those factors and policies. We quantified disparities in infant mortality by state social factors and public policy characteristics. We hypothesized that some social factors and public policies would be more strongly associated with infant mortality than others, and that states with similar factors and policies would form clusters with varying levels of infant mortality. We examined associations of women's economic empowerment, health and well-being, political participation, reproductive rights, and work and family-related policies with state IMRs in 2012 and 2015, using indicators created by the Institute for Women's Policy Research. Methods included generalized linear models, principal component analysis, and cluster analysis. Health and well-being predicted IMRs (2012, 2015, both p < .05), as did poverty and opportunity, and reproductive rights (2012, p < .10). Consistent with our hypothesis, states formed clusters, with the states in each cluster having similar social factors and public policies, and similar IMRs. Women's health status and insurance coverage were more predictive of state IMRs than other social factors. Improving health and insurance coverage may be an effective way to reduce state IMRs.

In the estimation of proportions by group testing, unequal sized groups results in an ambiguous ordering of the sample space, which complicates the construction of exact confidence intervals. The total number of positive groups is shown to be a suitable statistic for ordering outcomes, provided its ties are broken by the MLE. We propose an interval estimation method based on this quantity, with a mid-P correction. Coverage is evaluated using group testing problems in plant disease assessment and virus transmission by insect vectors. The proposed method provides good coverage in a range of situations, and compares favorably with existing exact methods., (© 2019 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background: Onchocerciasis a neglected tropical disease that historically has been a major cause of morbidity and an obstacle to economic development in the developing world. It is caused by infection with Onchocerca volvulus, which is transmitted by black flies of the genus Simulium. The discovery of the potent effect of Mectizan (ivermectin) on O. volvulus microfilariae and the decision by its manufacturer to donate the drug for onchocerciasis spurred the implementation of international programs to control and, more recently, eliminate this scourge. These programs rely primarily on mass distribution of ivermectin (MDA) to the afflicted populations. However, MDA alone will not be sufficient to eliminate onchocerciasis where transmission is intense and where ivermectin MDA is precluded by co-endemicity with Loa loa. Vector control will likely be required as a supplemental intervention in these situations., Methodology/principal Findings: Because biting by the black fly vectors is often a major nuisance in onchocerciasis afflicted communities, we hypothesized that community members might be mobilized to clear the breeding sites of the vegetation that represents the primary black fly larvae attachment point. We evaluated the effect of such a community based "slash and clear" intervention in multiple communities in Northern Uganda. Slash and Clear resulted in 89-99% declines in vector biting rates. The effect lasted up to 120 days post intervention., Conclusions/significance: Slash and clear might represent an effective, inexpensive, community- based tool to supplement ivermectin distribution as a contributory method to eliminate onchocerciasis and prevent recrudescence., Competing Interests: The authors have declared that no competing interests exist.

Onchocerciasis is a neglected tropical disease that has plagued mankind for decades with pathologies that involve the eyes and the skin. The WHO and the global health community have earmarked the disease for global elimination by 2045. However, as control programmes shift focus from reduction of the burden of the disease to elimination, new tools and strategies may be needed to meet targets. Monitoring Onchocerca volvulus larvae in the black fly vectors is an important tool needed to monitor disease dynamics and certify elimination. For decades, human landing collections have been the sole means of acquiring vectors for monitoring of the disease. This procedure has been plagued with ethical concerns and sometimes the inability to harvest enough black flies needed to carry out effective monitoring. Since the 1960s, the WHO recognized the need to replace human landing collections but relatively few field studies have designed and tested alternative traps. This review article systematically discusses some of the key traps tested, their successes, and their challenges. It is the aim of the review to direct research and development focus to the most successful and promising vector traps which could potentially replace the human landing collections.

Entomological measures of transmission are important metrics specified by the World Health Organization to document the suppression and interruption of transmission of Onchocerca volvulus , the causative agent of onchocerciasis. These metrics require testing of large numbers of vector black flies. Black fly collection has relied on human landing collections, which are inefficient and potentially hazardous. As the focus of the international community has shifted from onchocerciasis control to elimination, replacement of human landing collections has become a priority. The Esperanza window trap (EWT) has shown promise as an alternative method for collection of Simulium damnosum s.l., the primary vector of O. volvulus in Africa. Here, we report the results of a community-based trial of the EWT in northern Uganda. Traps operated by residents were compared with human landing collections in two communities over 5 months. Three traps, when operated by a single village resident, collected over four times as many S. damnosum as did the two-men collection team. No significant differences were noted among the bait formulations. The results suggest that EWTs may be effectively operated by community residents and that the trap represents a viable alternative to human landing collections for entomological surveillance of O. volvulus transmission.

Many blackfly species (Diptera: Simuliidae) are economically important insect pests, both as nuisance biters and as vectors of pathogens of medical and veterinary relevance. Among the important blackfly pest species in North America is Simulium vittatum Zetterstedt sensu lato. The objective of this study was to identify compounds excreted by mammalian hosts that are attractive to host-seeking S. vittatum females. The attractiveness of putative compounds to colonized S. vittatum was tested through electrophysiological (electroantennography; n = 58 compounds) and behavioural (Y-tube assays; n = 7 compounds in three concentrations) bioassays. Five compounds were significantly attractive to host-seeking S. vittatum females: 1-octen-3-ol; 2-heptanone; acetophenone; 1-octanol, and naphthalene. These candidate compounds might be useful as attractants in traps that could be developed for use in alternative or complementary management tactics in programmes to suppress nuisance blackfly populations, or for the collection of samples in which to study the transmission ecology of pathogens transmitted by blackflies of the S. vittatum complex., (© 2016 The Royal Entomological Society.)

The suite of pheromones that promote communal oviposition by Simulium vittatum, a North American black fly species, was identified and characterized using gas chromatography-mass spectrometry, electrophysiological, and behavioral bioassays. Behavioral assays demonstrated that communal oviposition was induced by egg-derived compounds that were active at short range and whose effect was enhanced through direct contact. Three compounds (cis-9-tetradecen-1-ol, 1-pentadecene, and 1-tridecene) were identified in a non-polar solvent extract of freshly deposited S. vittatum eggs that were capable of inducing the oviposition response. Electroantennography demonstrated that two of these three compounds (1-pentadecene and 1-tridecene) actively stimulated antennal neurons. Identification of the oviposition pheromones of this family may be helpful in developing control measures for nuisance black flies and for medically-important species such as Simulium damnosum sensu lato.

Background: Entomological indicators are considered key metrics to document the interruption of transmission of Onchocerca volvulus, the etiological agent of human onchocerciasis. Human landing collection is the standard employed for collection of the vectors for this parasite. Recent studies reported the development of traps that have the potential for replacing humans for surveillance of O. volvulus in the vector population. However, the key chemical components of human odor that are attractive to vector black flies have not been identified., Methodology/principal Findings: Human sweat compounds were analyzed using GC-MS analysis and compounds common to three individuals identified. These common compounds, with others previously identified as attractive to other hematophagous arthropods were evaluated for their ability to stimulate and attract the major onchocerciasis vectors in Africa (Simulium damnosum sensu lato) and Latin America (Simulium ochraceum s. l.) using electroantennography and a Y tube binary choice assay. Medium chain length carboxylic acids and aldehydes were neurostimulatory for S. damnosum s.l. while S. ochraceum s.l. was stimulated by short chain aliphatic alcohols and aldehydes. Both species were attracted to ammonium bicarbonate and acetophenone. The compounds were shown to be attractive to the relevant vector species in field studies, when incorporated into a formulation that permitted a continuous release of the compound over time and used in concert with previously developed trap platforms., Conclusions/significance: The identification of compounds attractive to the major vectors of O. volvulus will permit the development of optimized traps. Such traps may replace the use of human vector collectors for monitoring the effectiveness of onchocerciasis elimination programs and could find use as a contributing component in an integrated vector control/drug program aimed at eliminating river blindness in Africa.

Uganda is the only African country whose onchocerciasis elimination program uses a two-pronged approach of vector control and mass drug distribution. The Ugandan program relies heavily upon the use of serosurveys of children to monitor progress toward elimination. The program has tested over 39,000 individuals from 11 foci for Onchocerca volvulus exposure, using the Ov16 ELISA test. The data show that the Ov16 ELISA is a useful operational tool to monitor onchocerciasis transmission interruption in Africa at the World Health Organization (WHO) recommended threshold of < 0.1% in children. The Ugandan experience has also resulted in a re-examination of the statistical methods used to estimate the boundary of the upper 95% confidence interval for the WHO prevalence threshold when all samples tested are negative. This has resulted in the development of Bayesian and hypergeometric statistical methods that reduce the number of individuals who must be tested to meet the WHO criterion.

Background: Human landing collections are currently the standard method for collecting onchocerciasis vectors in Africa and Latin America. As part of the efforts to develop a trap to replace human landing collections for the monitoring and surveillance of onchocerciasis transmission, comprehensive evaluations of several trap types were conducted to assess their ability to collect Simulium ochraceum sensu lato, one of the principal vectors of Onchocerca volvulus in Latin America., Methodology/principal Findings: Diverse trap designs with numerous modifications and bait variations were evaluated for their abilities to collect S. Ochraceum s.l. females. These traps targeted mostly host seeking flies. A novel trap dubbed the "Esperanza window trap" showed particular promise over other designs. When baited with CO2 and BG-lure (a synthetic blend of human odor components) a pair of Esperanza window traps collected numbers of S. Ochraceum s.l. females similar to those collected by a team of vector collectors., Conclusions/significance: The Esperanza window trap, when baited with chemical lures and CO2 can be used to collect epidemiologically significant numbers of Simulium ochraceum s.l., potentially serving as a replacement for human landing collections for evaluation of the transmission of O. volvulus.

We present a frequentist Bernoulli-Beta hierarchical model to relax the constant prevalence assumption underlying the traditional prevalence estimation approach based on pooled data. This assumption is called into question when sampling from a large geographic area. Pool screening is a method that combines individual items into pools. Each pool will either test positive (at least one of the items is positive) or negative (all items are negative). Pool screening is commonly applied to the study of tropical diseases where pools consist of vectors (e.g. black flies) that can transmit the disease. The goal is to estimate the proportion of infected vectors. Intermediate estimators (model parameters) and estimators of ultimate interest (pertaining to prevalence) are evaluated by standard measures of merit, such as bias, variance and mean squared error making extensive use of expansions. Using the hierarchical model an investigator can determine the probability of the prevalence being below a prespecified threshold value, a value at which no reemergence of the disease is expected. An investigation into the least biased choice of the α parameter in the Beta ( α, β ) prevalence distribution leads to the choice of α = 1.

Objective: State public health preparedness units (SPHPUs) were developed in response to federal funding to improve response to disasters: a responsibility that had not traditionally been within the purview of public health. The SPHPUs were created within the existing public health organizational structure, and their placement may have implications for how the unit functions, how communication takes place, and ultimately how well the key responsibilities are performed. This study empirically identifies a taxonomy of similarly structured SPHPUs and examines whether this structure is associated with state geographic, demographic, and threat-vulnerability characteristics., Design: Data representing each SPHPU were extracted from publically available sources, including organizational charts and emergency preparedness plans for 2009. A cross-sectional segmentation analysis was conducted of variables representing structural attributes., Setting and Participants: Fifty state public health departments., Main Outcome Measures: Variables representing "span of control" and "hierarchal levels" were extracted from organizational charts. Structural "complexity" and "centralization" were extracted from state emergency preparedness documents and other secondary sources., Results: On average, 6.6 people report to the same manager as the SPHPU director; 2.1 levels separate the SPHPU director from the state health officer; and a mean of 13.5 agencies collaborate with SPHPU during a disaster. Despite considerable variability in how SPHPUs had been structured, results of the cluster and principal component analysis identified 7 similarly structured groups. Neither the taxonomic groups nor the individual variables representing structure were found to be associated with state characteristics, including threat vulnerabilities., Conclusions: Our finding supports the hypothesis that SPHPUs are seemingly inadvertently (eg, not strategically) organized. This taxonomy provides the basis for which future research can examine how SPHPU structure relates to performance measures and preparedness strategies.

Host blood meals in seven mosquito species previously shown to be infected with eastern equine encephalitis virus at a site in the Tuskegee National Forest in southcentral Alabama were investigated. Of 1374 blood meals derived from 88 different host species collected over 6 years from these seven mosquito species, 1099 were derived from Culex erraticus. Analysis of the temporal pattern of Cx. erraticus meals using a Runs test revealed that the patterns of feeding upon avian and mammalian hosts from March to September of each year were not randomly distributed over time. Similarly, meals taken from the three most commonly targeted host species (yellow-crowned night heron, great blue heron, and white-tailed deer) were not randomly distributed. A Tukey's two-way analysis of variance test demonstrated that although the temporal pattern of meals taken from avian hosts were consistent over the years, the patterns of meals taken from the individual host species were not consistent from year to year.

The control of bovine tuberculosis and atypical mycobacterioses in cattle in developing countries is important but difficult because of the existence of wildlife reservoirs. In cattle farms in Tanzania, mycobacteria were detected in 7.3% of 645 small mammals and in cow's milk. The cattle farms were divided into "reacting" and "nonreacting" farms, based on tuberculin tests, and more mycobacteria were present in insectivores collected in reacting farms as compared to nonreacting farms. More mycobacteria were also present in insectivores as compared to rodents. All mycobacteria detected by culture and PCR in the small mammals were atypical mycobacteria. Analysis of the presence of mycobacteria in relation to the reactor status of the cattle farms does not exclude transmission between small mammals and cattle but indicates that transmission to cattle from another source of infection is more likely. However, because of the high prevalence of mycobacteria in some small mammal species, these infected animals can pose a risk to humans, especially in areas with a high HIV-prevalence as is the case in Tanzania.

The number of new gadolinium-enhancing lesions discovered via magnetic resonance imaging is a well-established outcome for multiple sclerosis studies, especially Phase II Studies. Due to the high cost of magnetic resonance imaging scans, many investigators select participants for the presence of lesions. While this selection procedure is thought to improve the power of inferences, the effect of screening for baseline activity on parameter estimation and interval coverage has not yet been examined. The objective of this study was to investigate the performance of the negative binomial distribution for modeling lesion count data in multiple sclerosis when patients have been selected for activity on a baseline scan. We performed computer simulations to investigate the influence of the screening process on inferences made using a negative binomial model about treatment effects in two independent samples. We also demonstrate how the statistical properties of screening can be incorporated into trial design. We demonstrate that when the negative binomial distribution is used to model lesion counts, while screening for baseline activity improves point estimation, this practice also has the potential to decrease interval coverage and inflate the Type I error rate. For data that is to be modeled using a negative binomial distribution, screening for baseline activity can create a trade-off between cost effectiveness and a higher than desired false positive rate that must be carefully considered in planning Phase II trials.

Two promoters from the human filarial parasite Brugia malayi have been mapped in detail. The essential domains of both promoters lacked canonical eukaryotic core promoter motifs. However, the largest contiguous essential domain in both promoters flanked and included the splice leader addition site. These findings suggested that the region flanking the trans-splicing addition site might represent a conserved core domain in B. malayi promoters. To test this hypothesis, the putative promoters of 12 trans-spliced genes encoding ribosomal protein homologues from B. malayi were isolated and tested for activity in a B. malayi transient transfection system. Of the 12 domains examined, 11 produced detectable reporter gene activity. Mutant constructs of the six most active promoters were prepared in which the spliced leader acceptor site and the 10 nt upstream and downstream of the site were deleted. All deletion constructs exhibited >90% reduction in reporter gene activity relative to their respective wild type sequences. A conserved pyrimidine-rich tract was located directly upstream from the spliced leader splice acceptor site which contained a conserved T residue located at position -3. Mutation of the entire polypyrimidine tract or the conserved T individually resulted in the loss of over 90% of reporter gene activity. In contrast, mutation of the splice acceptor site did not significantly reduce promoter activity. These data suggest that the region surrounding the splice acceptor site in the ribosomal promoters represents a conserved essential domain which functions independently of splice leader addition.

Reptiles and amphibians constitute a significant portion of vertebrate biomass in terrestrial ecosystems and may be important arbovirus reservoirs. To investigate mosquito preference for ectothermic hosts, feeding indices were calculated from data collected in Tuskegee National Forest, Alabama, USA. Four mosquito species fed upon ectothermic hosts, with Culex peccator and Cx. territans feeding primarily upon ectotherms. These two species appeared to target distinct species with little overlap in host choice. Culex peccator was a generalist in its feeding patterns within ectotherms, and Cx. territans appeared to be a more specialized feeder. Six of eleven ectotherm species fed upon by Cx. territans were fed upon more often than predicted based upon abundance. Spring peepers were highly preferred over other host species by Cx. territans. Blood meals taken from each host species varied temporally, with some hosts being targeted fairly evenly throughout the season and others being fed upon in seasonal peaks.

Marked spatiotemporal variabilities in mosquito infection of arboviruses, exemplified by the transmission of West Nile virus (WNV) in America, require adaptive strategies for mosquito sampling, pool screening and data analyses. Currently there is a lack of reliable and consistent measures of risk exposure, which may compromise comparison of surveillance data. Based on quantitative reasoning, we critically examined fundamental issues regarding mosquito sampling design and estimation of transmission intensity. Two surveillance strategies were proposed, each with a distinct focus, i.e. targeted surveillance for detection of low rates of mosquito infection and extensive surveillance for evaluation of risk exposure with high levels of mosquito infection. We strongly recommend the use of indicators embodying both mosquito abundance and infection rates as measures of risk exposure. Aggregation of surveillance data over long periods of time and across broad areas obscures patterns of focal arboviral transmission. We believe that these quantitative issues, once addressed by mosquito surveillance programs, can improve the epidemiological intelligence of arbovirus transmission.

Unravelling gene regulatory mechanisms in human filarial parasites will require an understanding of their basic promoter structure. Only a single promoter from a human filarial parasite has been characterised in detail, the 70 kDa heat shock promoter of Brugia malayi (BmHSP70). This promoter was found to lack features found in a typical eukaryotic promoter. To determine if this was unique to the BmHSP70 promoter, a detailed analysis was undertaken of the promoter for the B. malayi small subunit 12 kDa ribosomal protein (BmRPS12) gene. The BmRPS12 promoter contained a unique tandem repeat structure. Deletion of these repeats resulted in the loss of 80% of promoter activity. Block replacement mutagenesis identified five regions outside the repeat which were essential for promoter activity. No predicted binding sites for proteins that normally associate with the typical eukaryotic core promoter domains were found in the essential domains or the repeat region. However, the repeat region contained many putative binding sites for GATAA transcription factor family proteins. Of 20 upstream domains of other ribosomal protein genes, one contained a repeat structure similar to that found in the BmRPS12 promoter, and the majority encoded putative GATAA transcription factor binding sites. This study demonstrates that the BmRPS12 promoter, like the BmHSP70 promoter, is distinct from a typical eukaryotic promoter.

With the rising number of patients with human immunodeficiency virus (HIV)/AIDS in developing countries, the control of mycobacteria is of growing importance. Previous studies have shown that rodents and insectivores are carriers of mycobacteria. However, it is not clear how widespread mycobacteria are in these animals and what their role is in spreading them. Therefore, the prevalence of mycobacteria in rodents and insectivores was studied in and around Morogoro, Tanzania. Live rodents were trapped, with three types of live traps, in three habitats. Pieces of organs were pooled per habitat, species, and organ type (stratified pooling); these sample pools were examined for the presence of mycobacteria by PCR, microscopy, and culture methods. The mycobacterial isolates were identified using phenotypic techniques and sequencing. In total, 708 small mammals were collected, 31 of which were shrews. By pool prevalence estimation, 2.65% of the animals were carriers of mycobacteria, with a higher prevalence in the urban areas and in Cricetomys gambianus and the insectivore Crocidura hirta. Nontuberculous mycobacteria (Mycobacterium chimaera, M. intracellulare, M. arupense, M. parascrofulaceum, and Mycobacterium spp.) were isolated from C. gambianus, Mastomys natalensis, and C. hirta. This study is the first to report findings of mycobacteria in African rodents and insectivores and the first in mycobacterial ecology to estimate the prevalence of mycobacteria after stratified pool screening. The fact that small mammals in urban areas carry more mycobacteria than those in the fields and that potentially pathogenic mycobacteria were isolated identifies a risk for other animals and humans, especially HIV/AIDS patients, that have a weakened immune system.

An experimental study of lateral displacement of ganglion cells (GCs) from foveal cones in six human retinas is reported. At 406-675 microm in length, as measured in radially oriented cross-sections, Henle fibers are substantially longer than previously reported. However, a new theoretical model indicates that the discrepancies in these reports are mainly due to meridional differences. The model takes into account the effects of optical degradation and peripheral ON/OFF asymmetry and predicts a central GC:cone ratio of 2.24:1. It provides estimates of cumulative counts and GC receptive field density at 0 degrees -30 degrees along the principal meridians of the visual field.

The source of bloodmeals in 2,082 blood-fed mosquitoes collected from February 2002 through December 2003 in Memphis and surrounding areas of Shelby County, Tennessee were determined. Members of the genus Culex and Anopheles quadrimaculatus predominated in the collections. Members of the Cx. pipiens complex and Cx. restuans were found to feed predominately upon avian hosts, though mammalian hosts made up a substantial proportion of the bloodmeals in these species. No significant difference was seen in the host class of bloodmeals in mosquitoes identified as Cx. pipiens pipiens, Cx. p. quinquefasciatus, or hybrids between these two taxa. Anopheles quadrimaculatus and Cx. erraticus fed primarily upon mammalian hosts. Three avian species (the American Robin, the Common Grackle, and the Northern Cardinal) made up the majority of avian-derived bloodmeals, with the American Robin representing the most frequently fed upon avian host. An analysis of these host feeding data using a modification of a transmission model for Eastern Equine encephalitis virus suggested that the American Robin and Common Grackle represented the most important reservoir hosts for West Nile virus. A temporal analysis of the feeding patterns of the dominant Culex species did not support a shift in feeding behavior away from robins to mammals late in the summer. However, a significant degree of temporal variation was noted in the proportion of robin-derived bloodmeals when the data were analyzed by semi-monthly periods throughout the summers of 2002 and 2003. This pattern was consistent with the hypothesis that the mosquitoes were preferentially feeding upon nesting birds.

To study the impact of mass Mectizan treatment on Onchocerca volvulus transmission in Mexico, entomological surveys were carried out in the endemic foci of Oaxaca, Southern Chiapas, and Northern Chiapas. Collected flies were screened by polymerase chain reaction (PCR) for O. volvulus parasites. The prevalence of infected and infective flies was estimated using the PoolScreen algorithm and with a novel probability-based method. O. volvulus infective larvae were not detected in flies from 6/13 communities. In 7/13 communities, infective flies were detected, with prevalences ranging from 1.6/10,000 to 29.0/10,000 and seasonal transmission potentials ranging from 0.4 to 3.3. Infected and infective flies were found in a community in Northern Chiapas, suggesting that, according to World Health Organization criteria, autochthonous transmission exists in this focus. These data suggest that O. volvulus transmission in Mexico has been suppressed or brought to a level that may be insufficient to sustain the parasite population.

Measuring transmission of a vector-borne infection is essential to understanding infection dynamics. When infection prevalence in the vector population is low, transmission is often measured by pool screening (also referred to as group testing). Several investigators have developed statistical methods to recover infection prevalence estimates from pool screen data. These are based on models that contain certain assumptions, and a pool screening approach must be designed to take these into account if accurate estimates of infection prevalence are to be obtained. Here we describe these assumptions and discuss appropriate sampling protocols. The sources of error inherent in pool screening are described, and we show that, under most conditions in which one would want to use group testing, most of the error results from sampling and not the pooling process. Issues involved in developing a sampling protocol, including the total number of insects to be screened and optimal pool size, are explored. The meaning of confidence intervals associated with prevalence estimates and the appropriate interpretation of these intervals are discussed.

The present study investigated whether fluctuating asymmetry can serve as a useful biomarker of environmental stress in the eastern mosquitofish (Gambusia holbrooki). Fluctuating asymmetry was measured in sexually mature females sampled from two Florida, USA, coastal streams: The Fenholloway River, which is dominated by effluent from a paper mill, and Spring Creek, a tributary to the Fenholloway River (Taylor County, FL, USA) that does not receive paper mill effluent. Nine morphometric (lengths of the A and B scales, fifth pectoral fin ray, supraorbital canal, and preorbital canal and the sixth gill raker on the first brachial arch; orbit diameter; distance from the dorsal-ventral midpoint of the eye socket to the base of the pectoral fin; and distance from the postorbital canal to the operculum) and five meristic traits (numbers of scales in the lateral line, radii on the A and B scales, pectoral fin rays, and gill rakers on the first brachial arch) were included. For each of the three indexes of fluctuating asymmetry that were used, the majority of the traits showed a higher level of fluctuating asymmetry in fish from the Fenholloway River than in fish from Spring Creek. For two of the indexes, the difference was significant. Comparisons of mean values for fluctuating asymmetry (over all traits) for each fish and the means of a composite index of asymmetry both indicated that fish from the Fenholloway River had significantly greater overall fluctuating asymmetry than those from Spring Creek. Results of the present study are consistent with the hypothesis that environmental stress increased the level of fluctuating asymmetry in fish from the Fenholloway River. Thus, fluctuating asymmetry appears to be a useful biomarker for stress-induced developmental instability in the eastern mosquitofish.

Eastern equine encephalitis virus (EEEV) is one of several arthropod-borne viruses (arboviruses) endemic to the United States. Interactions between arthropod (mosquito) vectors and avian amplification host populations play a significant role in the dynamics of arboviral transmission. Recent data have suggested the hypothesis that an increased rate of successful feeding on young-of-the-year (YOY) birds might play a role in the dynamics of EEEV transmission. To test this hypothesis, we developed a model to explore the effect of the interactions of the vectors and avian host populations on EEEV transmission. Sensitivity analyses conducted using this model revealed eleven parameters that were capable of disproportionately affecting the predicted level of EEEV infection in the vertebrate reservoir and vector populations. Of these, four parameters were related to the interaction of the vector with young-of-the-year birds. Furthermore, adult birds could not substitute for young-of-the-year in initiating and maintaining a predicted enzootic outbreak of EEEV. Taken together, the model predicted that young-of-the-year birds play a key role in establishing and maintaining enzootic outbreaks of EEEV.

Little is known concerning promoter structure in the filarial parasites. Recently, transient transfection methods have been developed for the human filarial parasite Brugia malayi. These methods have been employed to localize the promoter for the 70kDa heat shock protein (BmHSP70) to a region extending 394nt upstream from the initiating codon of the BmHSP70 open reading frame. Replacement mutagenesis was used to define the elements necessary for BmHSP70 promoter activity in detail. Four domains, ranging in size from six to 22 nucleotides, were found to be necessary for full promoter activity. The two most distal domains encoded a binding site for the heat shock transcription factor and a putative binding site for the GAGA transcription factor, motifs that are found in many other HSP70 promoters. However, none of the essential domains contained sequences typical of cis elements that are usually found in the core domain of a eukaryotic promoter. The largest essential domain was located at positions -53 to -32, and included the splice leader addition site. These data suggest that the regulatory domains of the BmHSP70 promoter were similar to those found in other eukaryotes, but that the core promoter domain exhibited features that appeared to be distinct from those found in most other well-characterized eukaryotic promoters. An analysis of two additional promoters of B.malayi highly transcribed genes suggests that they also lack features commonly found in most eukaryotic core promoters, suggesting that the unique features of the BmHSP70 core promoter are not confined to this gene.

Background: This study evaluates a multiple treatment approach (ie, pharmacologic preconditioning [diazoxide], sodium-proton exchange inhibition [cariporide], and controlled reperfusion) to improve the outcome from severe cardiac ischemia-reperfusion injury that occurs during a cardiac operation., Methods: Five groups of 10 pigs (group 1: control, group 2: diazoxide, group 3: cariporide, group 4: controlled reperfusion, and group 5: combination of diazoxide and cariporide-controlled reperfusion) underwent 75 minutes of left anterior descending occlusion, 1 hour of cardioplegic arrest, and 2 hours of reperfusion. Prior to occlusion, each group received an infusion of vehicle alone (ie, dimethylsulfoxide for the control and the controlled reperfusion groups) or vehicle with drug (ie, diazoxide or cariporide, or both for all other groups). Infarct size (primary outcome) was measured and was normalized to the region at risk. Regional function (secondary outcome) was measured using preload recruitable work area., Results: Infarct size as a function of area at risk was decreased by cariporide-controlled reperfusion, and combination treatment compared with the control group (14 +/- 6%, 15 +/- 8%, and 9 +/- 4% vs 24 +/- 9%; p < 0.02), and variation in infarct size was decreased by combination treatment compared with the controlled reperfusion group alone (p < 0.02). Recovery of systolic function during reperfusion significantly improved in the left anterior descending region in the cariporide and combination groups compared with the control, controlled reperfusion, or diazoxide groups (group-time effect, p < 0.05)., Conclusions: Combined use of controlled reperfusion, cariporide, and diazoxide decreases myocyte necrosis and loss of systolic function compared with an untreated control group. Combination treatment has the potential to improve the results of cardiac surgery, however further improvements are needed before clinical application.

Epidemiological, clinical and genetic data have all suggested that the filarial parasite Onchocerca volvulus, the causative agent of onchocerciasis (or river blindness) exists as two strains in West Africa. The severe strain induces severe ocular disease in a large proportion of the infected population, while the mild strain induces little ocular disease. Although DNA probes based upon a non-coding repeat sequence family can distinguish the two strains, the underlying basis for this difference in pathogenicity is not understood. Recently, several studies have implicated products produced by the Wolbachia endosymbiotic bacterium of O. volvulus in the pathogenesis of onchocerciasis. This suggested the hypothesis that differences in the Wolbachia endosymbiont population might be responsible for the pathogenic differences noted in the two strains. To test this hypothesis, quantitative PCR assays were used to measure the amount of Wolbachia DNA per nuclear genome in a collection of well characterized samples of mild and severe strain O. volvulus. The median ratio of Wolbachia DNA to nuclear DNA was significantly greater in severe strain parasites than in mild strain parasites. These data support the hypothesis that the pathogenic differences seen in severe and mild strain O. volvulus may be a function of their relative Wolbachia burden and provide additional support to the hypothesis that Wolbachia products may play a central role in the pathogenesis of ocular onchocerciasis.

The species composition and population dynamics of adult mosquitoes in a wetland near Iuka, MS, were analyzed over a 6-yr period (1997-2002) and reverse transcription-polymerase chain reaction (PCR) detection rates of arboviruses determined during five of those years. Blood meals of three likely vector species were identified using a PCR-based method that allows identification of the host to species. Culex erraticus (Dyar & Knab) composed 51.9% of the population during the 6-yr period with 295 females collected per trap night. Eastern equine encephalomyelitis (EEE) virus was detected in six genera of mosquitoes [Coquillettidia perturbans (Walker), Culex restuans Theobald, Culex salinarius Coquillett, Culex erraticus (Dyar & Knab), Anopheles crucians Wiedemann, Anopheles quadrimaculatus Say, Aedes vexans (Meigen), Ochlerotatus triseriatus Say, and Psorophora ferox Humboldt) with positive pools occurring in 1998, 1999, and 2002. Culiseta melanura Coquillett occurred at a low level (< 1%) and was not infected. Saint Louis encephalitis virus was detected once in a single pool of Cx. erraticus in 1998. Neither West Nile virus nor LaCrosse virus was found. Minimum infection rates per 1000 females tested of competent vectors of EEE virus were variable and ranged from 0.14 for Cx. erraticus to 40.0 for Oc. triseriatus. Thirty-nine species of birds were identified in the focus with blood-engorged mosquitoes found to contain meals (n = 29) from eight avian species. The majority of meals was from the great blue heron, Ardea herodias L. (n = 55%), but when bird abundance data were adjusted for avian mass, the brown-headed cowbird, Molothrus ater (Boddaert); blue jay, Cyanocitta cristata (L.); and northern mockingbird, Mimus polyglottos (L.), were overrepresented as hosts.

Onchocerca volvulus exists in at least two strains in West Africa, while its black-fly vectors consist of sibling species, dwelling in the savanna and forest/transition zones. In transition and degraded forest zones both parasite strains and different sibling species of the vector can be sympatric. The strain of parasite in infected humans and in vector black-flies was determined in two bioclimes along the Bandama river of Côte d'Ivoire. The upper Bandama is located in the savanna bioclime while the Middle Bandama is located in a degraded forest zone. At both sites, savanna-dwelling sibling species of the Simulium damnosum sensu lato species complex predominated. The severe-strain of O. volvulus was the predominant strain at both sites. However, severe-strain parasites represented a significantly larger proportion of those found in the vector population than in the human population in the degraded forest of the Middle Bandama. These data suggest that in degraded forest areas recently invaded by savanna-dwelling species of S. damnosunz s.l. transmission of the severe-strain of the parasite might be more efficient than transmission of the mild-strain.

We conducted a 2-year (1997-1999) longitudinal, entomological and virological study in three dengue endemic villages in Vellore district, Tamil Nadu, to understand the dynamics of dengue transmission. Aedes aegypti (Linn.), Ae. albopictus (Skuse) and Ae. vittatus (Bigot) were the prevalent vector species. Aedes aegypti was breeding throughout the year with a Breteau index ranging from 9.05 to 45.49. Aedes albopictus and Ae. vittatus were prevalent mainly in the rainy season. Small water holding containers (cemented tanks/cisterns) were the perennial breeding source of Ae. aegypti, and its abundance was significantly higher in semi-urbanized central areas than the peripheral areas of the villages. From 271 pools (4016 specimens) of adult females, eight dengue virus (DENV) isolates were obtained of which seven were from Ae. aegypti and one from Ae. albopictus. This is the first report of DENV isolation from Ae. albopictus in rural India. Infection rates in the two species were comparable. However, due to higher and perennial prevalence, Ae. aegypti is considered as primary vector with Ae. albopictus playing a secondary role. Despite circulation of all four serotypes (DENV 1-4) detected mainly during the transmission season, the high anthropophilic index of the vectors and their abundance, no human dengue case was reported, suggesting silent dengue transmission.

An important variable in the amplification and escape from the enzootic cycle of the arboviral encephalitides is the degree of contact between avian hosts and mosquito vectors. To analyze this interaction in detail, blood-fed mosquitoes that were confirmed vectors of eastern equine encephalomyelitis (EEE) virus were collected in 2002 from an enzootic site in central Alabama during the time this virus was actively transmitted. Avian-derived blood meals were identified to the species level of the host, and the proportion derived from each species was compared with the overall composition of the avifauna at the study site. The EEE vector mosquito species fed significantly more on some bird species and less on other species than expected given the overall abundance, biomass, or surface area of the local avifauna. When viewed collectively, these data suggest that these mosquitoes are selectively targeting particular avian species.

Objective: To determine the predictive value of serum levels of creatine phosphokinase (CPK) and alkaline phosphatase (ALP) in identifying patients with spinal cord injury (SCI) who are at risk to develop heterotopic ossification (HO) at the hips., Design: Prospective cohort study., Setting: Tertiary-care level I trauma center., Participants: Consecutive sample of 18 adults with acute traumatic SCI. Patients were excluded if they had medical or surgical conditions that are known to cause elevated enzyme levels., Interventions: Not applicable., Main Outcome Measures: Conventional hip radiographs were taken approximately 3 weeks after injury and again from between 3 to 6 months after injury. Serum ALP and CPK were measured approximately 3 weeks after SCI. Patients were later separated into 2 groups: group 1 was comprised of those who developed HO and group 2 was comprised of those who did not., Results: The initial radiographs showed no evidence of HO in either group. The radiographs taken at 3 to 6 months showed HO in 7 of 18 patients. The levels of CPK at the initial evaluation were significantly higher (R=.947, P<.0024) in group 1 than in group 2 and correlated with the severity of HO. There was no correlation between serum ALP levels and subsequent development of HO between the 2 groups (P=.07)., Conclusion: Elevated serum levels of CPK have value in predicting the HO.

Background: This study determines whether controlled reperfusion or diazoxide improves intramyocyte Na(+) homeostasis using a porcine model of severe ischemia-reperfusion injury., Methods: Three groups (n = 10 pigs per group) had 75 minutes of left anterior descending artery occlusion during bypass. Group 1 had no treatment (control group), group 2 had controlled reperfusion (500 mL warm cardioplegia) (controlled reperfusion group), and group 3 had diazoxide (50 micromol/L before left anterior descending artery occlusion) (diazoxide group). Biopsies were taken from the left anterior descending artery region before ischemia and at 3, 5, and 10 minutes postreperfusion. Intra-myocyte Na(+) and water contents were determined using atomic absorption spectroscopy, and Na(+) concentrations were calculated., Results: Intra-myocyte Na(+) increased for the diazoxide group pigs at 3-minutes postreperfusion (21.9 +/- 2.9 vs 34.0 +/- 3.4 micromol/mL; p = 0.02), but decreased to 19.9 +/- 3.2 micromol/mL at 10 minutes postreperfusion (p = 1.0 vs baseline). At 10 minutes postreperfusion, intra-myocyte Na(+) in the controlled reperfusion group was lower than baseline (22.3 +/- 2.7 vs 17.2 +/- 3.1 micromol/mL; p < 0.001). Intra-myocyte Na(+) at 10 minutes postreperfusion for the diazoxide and controlled reperfusion groups was lower than for the control group (p < 0.05)., Conclusions: Diazoxide and controlled reperfusion improved intra-myocyte Na(+) homeostasis after severe ischemia-reperfusion injury.

Biolistic transient transfection of Brugia malayi embryos with constructs driving the expression of a luciferase reporter gene was used to identify regions of the upstream sequence of the heat shock protein 70 (HSP70) gene of B. malayi necessary for transgene expression. Analysis of 1160 nucleotides upstream of the start codon of the HSP70 gene identified several potentially important elements, including putative CAAT and TATA boxes, a core promoter domain, a polypurine stretch, and a spliced leader addition site. Nested deletion analysis of the HSP70 upstream domain mapped the promoter of the HSP70 gene to the region 396 to 31 nucleotides upstream of the start codon. This encompassed the putative CAAT and TATA boxes, and putative core promoter. Deletion of the putative CAAT box did not result in any diminution of reporter activity, while constructs in which the TATA box or core promoter were deleted retained roughly half of the activity of the undeleted construct. Unlike the native gene, transcripts derived from constructs containing the HSP70 upstream sequences were not trans-spliced. However, incorporation of the 495 nucleotides downstream of the start codon (encompassing exon 1, intron 1 and part of exon 2) resulted in the production of transcripts that were correctly cis- and trans-spliced. Similarly, a construct containing the 495 downstream nucleotides in which most of exon 1 was deleted, was correctly cis- and trans-spliced. This finding suggests that downstream intron sequences in addition to the splice leader addition site are necessary for trans-splicing in B. malayi.

Objectives: Surgical resection after preoperative chemotherapy in patients with non-small cell lung cancer might only be best for patients who are responders. We compared positron emission tomographic scanning with 2-fluoro-2-deoxy-d-glucose (FDP-PET scanning) with computed tomographic scanning to evaluate their ability to predict this response for the primary tumor, N1 and N2 lymph nodes., Methods: All patients with non-small cell lung cancer who had an initial FDP-PET scan staging with tissue biopsy, neoadjuvant chemotherapy, repeat FDP-PET scanning, and repeat biopsies were prospectively studied., Results: There were 34 patients (24 men; median age, 64 years). Eleven patients had N2 disease, and 7 had N1 disease. Twenty-seven patients received chemotherapy, and 7 patients received chemotherapy and radiation. All but 9 patients underwent resection. Statistical analysis showed FDP-PET scanning to be more specific (P <.0001), to have a higher positive predictive value (P =.0018), and to have a higher negative predictive value (P <.0001) than computed tomographic scanning for predicting residual tumor at the primary site. FDP-PET scanning was more sensitive (P <.0001) and more accurate (P <.0001), had a higher positive predictive value (P <.0001), and had a higher negative predictive value (P =.0002) than computed tomographic scanning for paratracheal nodes (number 2 and 4 lymph nodes). FDP-PET scanning had a higher positive predictive value (P <.0001) than computed tomographic scanning for the other N2 (numbers 5, 6, 7, 8, and 9) lymph nodes., Conclusions: Repeat FDP-PET scanning is more specific and has a higher positive predictive value and negative predictive value than computed tomographic scanning for detecting residual tumor in the lung in patients with non-small cell lung cancer who have received preoperative chemotherapy. It is more sensitive and accurate for paratracheal N2 nodes as well. However, there is no significant difference in its detection of N1 lymph nodes.

Background: Preconditioning and inhibition of sodium-proton exchange attenuate myocardial ischemia-reperfusion injury by means of independent mechanisms that might act additively when used together. The hypothesis of this study is that treatment with a sodium-proton exchange inhibitor and a mitochondrial adenosine triphosphate-sensitive potassium channel opener produces superior functional recovery and a greater decrease in left ventricular infarct size compared with treatment with either drug alone in a model of severe global ischemia., Methods: Isolated crystalloid-perfused rat hearts (n = 8 hearts per group) were administered vehicle (control, 0.04% dimethyl sulfoxide), diazoxide (100 micromol/L in 0.04% dimethyl sulfoxide), cariporide (10 micromol /L in 0.04% dimethyl sulfoxide), or diazoxide and cariporide before 40 minutes of ischemia at 35.5 degrees C to 36.5 degrees C and 30 minutes of reperfusion., Results: The combination group had superior postischemic systolic function compared with that seen in the cariporide, diazoxide, and control groups (recovery of developed pressure: 91% +/- 7% vs 26% +/- 5%, 35% +/- 6%, and 16% +/- 3%, respectively; P <.05). Postischemic diastolic function in the combination group was superior compared with that seen in the other groups (change(pre-post) diastolic pressure of 67 +/- 4 mm Hg with control, 49 +/- 11 mm Hg with diazoxide, 59 +/- 10 mm Hg with cariporide, and 3 +/- 3 mm Hg with diazoxide and cariporide combination; P <.05). The left ventricular infarct area was less in the combination group compared with that in the cariporide, diazoxide, and control groups (6% +/- 2% vs 35% +/- 7%, 25% +/- 3%, and 37% +/- 9%, respectively; P <.05)., Conclusions: Combining a selective mitochondrial adenosine triphosphate-sensitive potassium channel opener with a selective reversible inhibitor of sarcolemmal sodium-proton exchange improves recovery of contractile function from severe global ischemia in the isolated buffer-perfused rat heart. The putative mechanism for this benefit is superior protection of mitochondrial function.

The prevalence of infected and infective black flies was estimated by pool screen polymerase chain reaction (PCR) amplification in the three river basins in Ecuador endemic for onchocerciasis. Mass distribution of ivermectin (Mectizan) resulted in dramatic declines in the prevalence of infected and infective flies. In the Rio Santiago river basin, no infections were detected, suggesting that transmission had ceased. The ratio of infected to infective flies in Simulium exiguum was 10-fold lower than the corresponding ratio for Simulium quadrivittatum, suggesting that S. exiguum is a more-competent vector for Onchocerca volvulus than S. quadrivittatum. However, the prevalence of infective flies in the two species was not different, suggesting that S. quadrivittatum may play an important vectorial role where it is the dominant human-biting species. The data demonstrate that pool screen PCR is an efficient way to monitor transmission in areas subject to control, and to certify an area as free of O. volvulus transmission.

Background: Air leaks prolong hospital stay., Methods: A prospective algorithm was applied to patients. If patients were ready for discharge but still had an air leak, a Heimlich valve was placed and they were discharged. If the leak was still present after 2 weeks, the tube was clamped for a day and removed., Results: There were 669 patients. Factors that predicted a persistent air leak were FEV1% of less than 79% (p = 0.006), history of steroid use (p = 0.002), male gender (p = 0.05), and having a lobectomy (p = 0.01). Types of air leaks on day 1 that eventually required a Heimlich valve were expiratory leaks (p = 0.02), leaks that were an expiratory 4 or more (p < 0.0001), and the presence of a pneumothorax concomitant with an air leak (p < 0.0001). Thirty-three patients were placed on a Heimlich valve, and 6 patients had a pneumothorax or subcutaneous emphysema develop; all patients had an expiratory 5 leak or larger (p < 0.0001). Thirty-three patients went home on a valve. Seventeen patients had leaks that resolved by 1 week, 6 by 2 weeks, and the remaining 9 had their tubes removed without problems., Conclusions: Steroid use, male gender, a large leak, a leak with a pneumothorax, and having a lobectomy are all risk factors for a persistent leak. Discharge on a Heimlich valve is safe and effective for patients with a persistent leak unless the leak is an expiratory 5 or more. Once home on a valve, most air leaks will seal in 2 weeks; if not, chest tubes can be safely removed regardless of the size of the leak or the presence of a pneumothorax.

Background: Previous studies showed low resting phosphocreatine/adenosine triphosphate (PCr/ATP) ratios within this patient population compared with controls; however, these low PCr/ATP did not correlate with endomyocardial biopsy rejection. One possible explanation is the presence of cardiac allograft vasculopathy (CAV), which might be manifested as a transient ischemic event in the mildly stressed transplanted heart. If transient ischemia is invoked through the (31)P magnetic resonance spectroscopy (MRS) stress test, monitoring of such an event should be achievable and thus implicating possible ischemic involvement., Methods: Heart transplant patients (n = 25) and normal controls (n = 11) were studied using the (31)P MRS stress test; 10 patients tested positive (> 2 standard deviations [SDs] from control values). Patients also were monitored for heart rate and blood pressure with the handgrip exercise generating a small increase in the rate-pressure product., Results: The percent change (%Delta) in the PCr/ATP ratio in the control group was 1.50% +/- 10.6; the transplant population showed an overall change of -6.7% +/- 18.5. The responders, those that were at or below the 2 SD line from control, had a -25.6 +/- 3.6% Delta PCr/ATP; whereas the non-responders reflect a 5.1 +/- 13.4%. The responders' response is quite striking when considering the threshold for an abnormal PCr/ATP %Delta in response to stress testing was -19.7%, which was the 2 SD mark below the mean value for the reference population., Discussion: The (31)P MRS stress test showed that a possible transient ischemic event occurred in a subset of patients, thus implicating possible CAV in the cardiac transplant patient. Such an approach may provide an early diagnosis of this disease.

Background: Intramyocyte sodium (Na+) increases during ischemia and reperfusion, which causes myocardial calcium (Ca2+) uptake and leads to myocyte injury or death. This study determines if ischemic preconditioning and myocyte sodium-hydrogen ion (Na+-H+) exchange (NHE) inhibition decreases Na+ gain that otherwise occurs with cardioplegic arrest and reperfusion., Methods: Pigs had 1 hour of cardioplegic arrest followed by reperfusion. Group 1 had no intervention (controls). Group 2 received dimethyl amiloride (DMA, an NHE inhibitor), and group 3 had ischemic preconditioning before cardioplegic arrest. Precardioplegia to postreperfusion change in intramyocyte ion content was measured with atomic absorption spectrometry. The time to initial electrical activity and number of defibrillations needed to establish an organized rhythm postreperfusion were used as electrophysiologic variables to measure ischemia-reperfusion injury., Results: Intramyocyte Na+ content for group 1 increased from 45.9+/-6.7 to 61.9+/-22.5 micromol/g (p = 0.02). Group 2 had an insignificant decrease in intramyocyte Na+ of 27.7+/-19.58 micromol/g (p = 0.06), and group 3 had an insignificant decrease of 10.8+/-46.33 micromol/g (p = 0.48). Interstitial water increased significantly in all groups, but there were no significant increases in intramyocyte water content. Electrophysiologic recovery was similar for all three groups., Conclusions: The NHE inhibition and ischemic preconditioning each eliminated the increase in intramyocyte Na+ content that otherwise occurred with cardioplegic arrest and reperfusion in this porcine model. Because their mechanisms are distinct, it is possible that an additive beneficial effect against ischemia-reperfusion injury can be achieved by using NHE inhibition together with a preconditioning stimulus as prereperfusion therapy.

Background: Surgeons treat air leaks differently. Our goal was to evaluate whether it is better to place chest tubes on suction or water seal for stopping air leaks after pulmonary surgery. A second goal was to evaluate a new classification system for air leaks that we developed., Methods: Patients were prospectively randomized before surgery to receive suction or water seal to their chest tubes on postoperative day (POD) #2. Air leaks were described and quantified daily by a classification system and a leak meter. The air-leak meter scored leaks from 1 (least) to 7 (greatest). The group randomized to water seal stayed on water seal unless a pneumothorax developed., Results: On POD #2, 33 of 140 patients had an air leak. Eighteen patients had been preoperatively randomized to water seal and 15 to suction. Air leaks resolved in 12 (67%) of the water seal patients by the morning of POD #3. All 6 patients whose air leak did not stop had a leak that was 4/7 or greater (p < 0.0001) on the leak meter. Of the 15 patients randomized to suction, only 1 patient's air leak (7%) resolved by the morning of POD #3. The randomization aspect of the trial was ended and statistical analysis showed water seal was superior (p = 0.001). The remaining 14 patients were then placed to water seal and by the morning of POD #4, 13 patients' leaks had stopped. Of the 32 total patients placed to seal, 7 (22%) developed a pneumothorax and 6 of these 7 patients had leaks that were 4/7 or greater (p = 0.001)., Conclusions: Placing chest tubes on water seal seems superior to wall suction for stopping air leaks after pulmonary resection. However, water seal does not stop expiratory leaks that are 4/7 or greater. Pneumothorax may occur when chest tubes are placed on seal with leaks this large.