Nosocomial transmission of Mycobacterium tuberculosis in kangaroo mother care units: a risk in tuberculosis-endemic areas

BACKGROUND AND AIM

Kangaroo mother care (KMC) has become the standard of care for low-risk preterm babies born in developing countries. However, the potential risk of nosocomial transmission of Mycobacterium tuberculosis within KMC units, particularly in tuberculosis-endemic areas, has not been explored. We report an infant (sentinel case) who was admitted to our paediatric intensive care unit (PICU) with extensive pulmonary tuberculosis.

METHODS AND RESULTS

When interviewed, the mother reported no household contact with a tuberculosis source case, but mentioned that she shared a KMC room with someone who had symptoms suspicious of tuberculosis. We found molecular evidence that nosocomial transmission of M. tuberculosis occurred within the KMC unit and conducted a contact investigation of all infants exposed to this infectious source case during her stay in the KMC unit.

CONCLUSION

We present the findings of the contact investigation and discuss the implications of these findings for KMC units, particularly in tuberculosis-endemic areas.

Bacille Calmette-Guérin vaccine-induced disease in HIV-infected and HIV-uninfected children

BACKGROUND

Bacille Calmette-Guérin (BCG)--a live, attenuated vaccine--is routinely given to neonates in settings where tuberculosis is endemic, irrespective of human immunodeficiency virus (HIV) exposure. HIV-infected infants and other immunodeficient infants are at risk of BCG-related complications. We report the presentation, treatment, and mortality of children who develop BCG disease, with emphasis on HIV-infected children. In addition, we present a revised classification of BCG disease in children and propose standard diagnostic and management guidelines.

METHODS

This retrospective, hospital-based study was conducted in the Western Cape Province, South Africa. Mycobacterium tuberculosis complex isolates recovered from children aged <13 years during the period of August 2002 through January 2005 were speciated by polymerase chain reaction to confirm Mycobacterium bovis BCG. Clinical data were collected through medical file review. BCG disease was classified according to standard and revised disease classifications. Mortality was assessed at the end of the study period.

RESULTS

BCG disease was diagnosed in 25 children; 22 (88%) had local disease, and 8 (32%) had distant or disseminated disease; 5 children (20%) had both local and distant or disseminated disease. Seventeen children were HIV infected; 2 children had other immunodeficiencies. All 8 children with distant or disseminated disease were immunodeficient; 6 were HIV infected. The mortality rate was 75% for children with distant or disseminated disease.

CONCLUSIONS

BCG vaccination poses a risk to infants perinatally infected with HIV and to other primary immunodeficient children. The proposed pediatric BCG disease classification reflects clinically relevant disease categories in HIV-infected children. The suggested diagnostic and treatment guidelines should improve existing case management and surveillance. Prospective evaluation of management strategies for BCG disease in HIV-infected and HIV-uninfected children is essential.

The burden of childhood tuberculosis: a public health perspective

The burden of childhood tuberculosis (TB) reflects recent transmission within a community and the level of TB control achieved within the adult (maintenance host) population. Children contribute little to the maintenance of the TB epidemic, but they may suffer severe TB-related morbidity and mortality. This review describes the main determinants of the burden of childhood TB within a particular community. Basic infectious disease principles identify the community, and not the individual, as the central entity that sustains an epidemic. The prevalence of TB is determined by the community's exposure to Mycobacterium tuberculosis, and their vulnerability to developing disease following exposure. The main variables that influence both exposure and vulnerability are discussed. Multiple variables are linked to poverty, and it is their cumulative effect, rather than the exact degree of poverty, that seems most important. Diligent contact tracing and the use of preventive chemotherapy will reduce the TB-related suffering of children. The burden of childhood TB, however, is a reflection of our ability to control the epidemic; this remains the ultimate challenge. Current efforts to control the TB epidemic aim to reduce transmission by treating sputum smear-positive adults, while very little emphasis is placed on reducing the vulnerability of high-burden communities. Successful control of the epidemic is the most effective way to reduce the burden of childhood TB, but this will require a holistic approach that acknowledges the importance of sustainable poverty alleviation.

Clonal expansion of a globally disseminated lineage of Mycobacterium tuberculosis with low IS6110 copy numbers

Knowledge of the clonal expansion of Mycobacterium tuberculosis and accurate identification of predominant evolutionary lineages in this species remain limited, especially with regard to low-IS6110-copy-number strains. In this study, 170 M. tuberculosis isolates with </=6 IS6110 insertions identified in Cape Town, South Africa, were characterized by principal genetic grouping, restriction fragment length polymorphism analysis, spoligotyping, IS6110 insertion site mapping, and variable-number tandem repeat (VNTR) typing. These analyses indicated that all but one of the isolates analyzed were members of principal genetic group 2 and of the same low-IS6110-copy-number lineage. The remaining isolate was a member of principal genetic group 1 and a different low-IS6110-copy-number lineage. Phylogenetic reconstruction suggests clonal expansion through sequential acquisition of additional IS6110 copies, expansion and contraction of VNTR sequences, and the deletion of specific direct-variable-repeat sequences. Furthermore, comparison of the genotypic data of 91 representative low-IS6110-copy-number isolates from Cape Town, other southern African regions, Europe, and the United States suggests that certain low-IS6110-copy-number strain spoligotypes and IS6110 fingerprints were acquired in the distant past. These clones have subsequently become widely disseminated and now play an important role in the global tuberculosis epidemic.

Transposition rates of Mycobacterium tuberculosis IS6110 restriction fragment length polymorphism patterns

To determine the rate at which IS6110 restriction fragment length polymorphism (RFLP) patterns in Mycobacterium tuberculosis change over time, we applied a smooth nonparametric survival model to several data sets, including data from previous publications on the rate of change. The results strongly suggest a simple parametric model, with an instantaneous change at time zero and essentially a zero rate of change thereafter. Our interpretation of the results is that at the time of collection of the first isolate, more than one strain is present. We speculate that the selection of mutant strains is most likely during rapid growth, revival of the dormant bacteria, and/or adaptation to a new host. The parameter most accurately describing changing RFLP patterns is the proportion of isolates with band changes, rather than the half-life or the rate of change.

IS6110-mediated deletion polymorphism in isogenic strains of Mycobacterium tuberculosis

Previous studies have described IS6110-mediated polymorphism as an important driving force in Mycobacterium tuberculosis genome evolution and have provided indirect evidence for IS6110-driven deletion events. This study provides the first description of an IS6110-mediated deletion event in truly isogenic strains. We also provide further support for the hypothesis that the region from Rv1754 to Rv1765 is a hot spot for IS6110 insertion and deletion events.

Genotypic and phenotypic characterization of drug-resistant Mycobacterium tuberculosis isolates from rural districts of the Western Cape Province of South Africa

Genotypic and phenotypic analysis of drug-resistant Mycobacterium tuberculosis isolates from the Western Cape Province of South Africa showed that drug resistance is widespread and recently transmitted. Multidrug-resistant (MDR) isolates comprise 40% of this collection, and a large pool of isoniazid monoresistance may be a future source of MDR tuberculosis.

Use of genetic distance as a measure of ongoing transmission of Mycobacterium tuberculosis

The stability of the genotypic marker IS6110, used to define the epidemiology of Mycobacterium tuberculosis, is one of the most important factors influencing the interpretation of DNA fingerprint data. We propose that evolved strains should be considered together with clustered strains to represent chains of ongoing transmission. For the present study we used a large set of fingerprint data for strains collected between 1992 and 1998 from residents of a community with a high incidence of tuberculosis in Cape Town, South Africa. Interstrain genetic distances were calculated by counting the banding pattern mismatches in the IS6110 DNA fingerprints of different isolates. These data demonstrate that the propensity to change by one or two bands is independent of the IS6110 copy number. Hence, the genetic distance between pairs of isolates can be simply expressed as the number of differences in the banding patterns. From this foundation, a data set which identifies newly evolved strains has been generated. Inclusion of these evolved strains into various molecular epidemiological calculations significantly increased the estimate of ongoing transmission in this study setting. The indication is that nearly all cases of tuberculosis in this community are due to ongoing transmission. This has important implications for tuberculosis control, as it indicates that the control measures used at present are unable to reduce the level of transmission. This technique may also be applicable to the study of low-incidence tuberculosis outbreaks as well as the analysis of epidemiological data from other disease epidemics.

Protocol for a national multi-centre study of magnetic resonance imaging screening in women at genetic risk of breast cancer

The protocol of the national multicentre study of Magnetic Resonance Imaging (MRI) as a method of screening for breast cancer in women at genetic risk is described. The sensitivity and specificity of contrast-enhanced MRI will be compared with two-view X-ray mammography in a comparative trial. Approximately 500 women below the age of 50 at high genetic risk of breast cancer will be recruited per year for 3 years, with annual MRI and X-ray examination continuing for up to 5 years. A symptomatic cohort will be measured in the initial phase of the study to ensure consistent reporting between centres. The MRI examination will comprise an initial high-sensitivity screening measurement, followed by a high-specificity measurement in equivocal cases. Retrospective analysis will identify the most specific indicators of malignancy. Sensitivity and specificity, together with diagnostic performance, diagnostic impact and therapeutic impact will be assessed with reference to pathology, follow-up and changes in diagnostic certainty and therapeutic decisions. The psychological impact of screening in this high-risk group will be ascertained.

Danish Bacille Calmette-Guerin Vaccine-Induced Disease in Human Immunodeficiency Virus-Infected Children

An analysis of isolates of Mycobacterium tuberculosis complex was performed to determine the prevalence of bacille Calmette-Guérin (BCG) disease among human immunodeficiency virus (HIV)-infected children. Speciation was done with polymerase chain reaction; 183 isolates from mycobacterial cultures for 49 HIV-infected patients were analyzed. The Danish Mycobacterium bovis BCG strain was isolated from 5 patients. No cases of Tokyo M. bovis BCG strain disease were detected. All patients were asymptomatic at birth, <12 months of age, and severely immunodeficient at presentation. Four patients had regional axillary adenitis ipsilateral to the vaccination site, and 2 had pulmonary BCG disease. Two patients with regional BCG disease had simultaneous pulmonary M. tuberculosis infection. Although chest radiographic features were similar to those seen in patients with tuberculosis, BCG disease should be considered in HIV-infected infants with right axillary adenitis ipsilateral to the vaccination site. Young, symptomatic, HIV-infected infants are at risk for BCG-related complications. Controlled, population-based studies are needed to assess the risk of BCG in HIV-infected children.

IS6110-mediated deletion polymorphism in the direct repeat region of clinical isolates of Mycobacterium tuberculosis

This study investigates the phenomenon of IS6110-mediated deletion polymorphism in the direct repeat (DR) region of the genome of Mycobacterium tuberculosis. Clinical isolates and their putative predecessors were compared using a combination of DR region restriction fragment length polymorphism, IS6110 DNA fingerprinting, spoligotyping, and DNA sequencing, which allowed the mapping of chromosome structure and deletion junctions. The data suggest that adjacently situated IS6110 elements mediate genome deletion. However, in contrast to previous reports, deletions appear to be mediated by inversely oriented IS6110 elements. This suggests that these events may occur via mechanisms other than RecA-mediated homologous recombination. The results underscore the important role of IS6110-associated deletion hypervariability in driving M. tuberculosis genome evolution.

Historic and recent events contribute to the disease dynamics of Beijing-like Mycobacterium tuberculosis isolates in a high incidence region

SETTING

A retrospective study in an urban setting with a high tuberculosis incidence.

OBJECTIVE

To study the molecular epidemiology and disease dynamics of a prevalent Mycobacterium tuberculosis strain family, F29, a subset of the Beijing strains.

DESIGN

Multi-locus DNA fingerprinting and genomic analysis was used to characterise F29 isolates. Demographic and molecular epidemiologic data were correlated with those of other isolates from the setting. The geographic locations of five F29 strain clusters were plotted using a geographic information system (GIS) and an index for geographic distribution was calculated. Their cumulative temporal occurrence was also plotted.

RESULTS

The genomic similarity of F29 to the Beijing-strains was confirmed. A high degree of clustering predicted high disease transmission. Spatial distribution was mostly widespread except for one cluster. Smaller foci of transmission were observed. The temporal spread showed ongoing transmission.

CONCLUSION

F29 belongs to the Beijing strain group. The prevalence and high degree of strain clustering, with limited geographic clustering, indicates that F29 strains are endemic in the study community. However, recent epidemiologic events also contributed to the disease spread. The combination of molecular epidemiologic, spatial and temporal data has enhanced our understanding of the disease dynamics of Beijing strains in our study community.

Use of spoligotyping for accurate classification of recurrent tuberculosis

The spoligotyping method has become an important tool for the tracking of Mycobacterium tuberculosis strains in different epidemiological settings. In this study, we demonstrate the ability of the spoligotyping technique to accurately determine the pathogenetic mechanism of recurrent disease. This methodology has advantages over conventional restriction fragment length polymorphism methods which may be useful in large-scale intervention studies.

Calculation of the stability of the IS6110 banding pattern in patients with persistent Mycobacterium tuberculosis disease

The interpretation of molecular epidemiologic data of Mycobacterium tuberculosis infection is dependent on the understanding of the stability and evolutionary characteristics of the DNA fingerprinting marker used to classify clinical isolates. This study investigated the stability of the IS6110 banding pattern in serial tuberculosis isolates collected from patients resident in an area with a high incidence of tuberculosis. Evolutionary changes were observed in 4% of the strains, and a half-life (t(1/2)) of 8.74 years was calculated, assuming a constant rate of change over time. This rate may be composed of a high rate of change seen during the early disease phase (t(1/2) = 0.57 years) and a low rate of change seen in the late disease phase (t(1/2) = 10.69 years). The early rate probably reflects change occurring during active growth prior to therapy, while the low late rate may reflect change occurring during or after treatment. We demonstrate that the calculation of these rates is strongly influenced by the time interval between onset of disease and sputum sampling. These calculations are further complicated by partial replacement of the original strain population, resulting in the sporadic appearance of clonal variants in sputum specimens. Therefore, the true extent of genetic diversity may be underestimated within each host, thereby influencing molecular epidemiological data used to establish transmission chains.

Molecular analysis of clinical isolates of Mycobacterium tuberculosis collected from patients with persistent disease in the Khartoum region of Sudan

SETTING

Patients with positive smears for acid-fast bacilli were enrolled at tuberculosis (TB) clinics in the Khartoum region of Sudan.

OBJECTIVE

To identify the presence of drug resistant genotypes in M. tuberculosis isolates which are difficult to treat.

METHODS

Genus specific PCR-SSCP was performed to confirm the presence of M. tuberculosis in clinical isolates. Genotypic drug resistance testing was performed by mutation analysis and spoligotyping was used to monitor transmission and to identify epidemic strains.

RESULTS

Fifty (48%) of the original 105 samples were classified as M. tuberculosis. Four (4%) of the samples were typed as mycobacteria other than TB, while the remaining (n =50) samples were refractory to further molecular analysis. The fifty amplifiable M. tuberculosis samples were used for subsequent mutation analysis and typing. Mutations were identified in the genes conferring resistance to INH (kat G, 12%), RIF (rpoB, 8%), SM (r psL and rrs, 30%) and EMB (embB, 4%). Two of the samples (4%) had mutations in genes associated to both INH and RIF and can be classified as MDR-TB. Thirty-three percent (13/39) of the persistant tuberculosis cases (5/18 treatment failure; 5/14 relapse; 3/7 defaulter) had mutations accounting for drug resistance. A total of 27 different spoligotypes were identified from 49/50 samples. Twenty-nine (59%) of the isolates were grouped into one of seven clusters, while 20 (41%) showed unique patterns. One patient was infected with M. bovis.

CONCLUSION

This is the first molecular approach to characterize clinical isolates of M. tuberculosis from Sudan. The results show that drug resistance is indeed a serious problem and it may compliment the efforts of the National Tuberculosis Programme to improve strategies to control this disease.

Evolution of the IS6110-based restriction fragment length polymorphism pattern during the transmission of Mycobacterium tuberculosis

Interpretation of the molecular epidemiological data of Mycobacterium tuberculosis is dependent on the validity of the assumptions that have been made. It is assumed that the IS6110 banding pattern is sufficiently stable to define epidemiological events representing ongoing transmission. However, molecular epidemiological data also support the observation that the IS6110 banding pattern may change over time. Factors affecting this rate may include the nature and duration of disease in a host and the opportunity to experience different host environments during the transmission cycle. To estimate the rate of IS6110 change occurring during the process of transmission, M. tuberculosis isolates from epidemiologically linked patients were genotypically characterized by restriction fragment length polymorphism (RFLP) analysis. The identification of IS6110 banding pattern changes during ongoing transmission suggested that a rate could be estimated. IS6110 change was significantly associated with strains with >5 IS6110 elements (P = 0.013) and was not observed in low-copy-number isolates. The minimum rate of appearance of variant strains was calculated to be 0.14 variant cases per source-case per year. This data suggest that clustering of isolates based on identical RFLP patterns is expected to underestimate transmission in patients infected with high-copy-number isolates. A model based on the rate of appearance of both variant and invariant strains demonstrates that the genotypically defined population structure may change by 18.6% during the study period of approximately 6.5 years. The implications for the use of RFLP data for epidemiologic study are discussed.

Expression, characterization and subcellular localization of the Mycobacterium tuberculosis PPE gene Rv1917c

SETTING

The PPE gene family of Mycobacterium tuberculosis is thought to be of immunological significance. One member, Rv1917c, is highly polymorphic in clinical isolates.

OBJECTIVE

To characterize Rv1917c gene polymorphism and expression, and to determine the cellular location and glycosylation status of the encoded protein.

DESIGN

Tandem repeat regions of Rv1917c were amplified and sequenced to determine the molecular basis for the gene polymorphism. RT-PCR analysis was utilized to detect expression of Rv1917c mRNA in liquid cultures of M. tuberculosis H37Rv. The gene was cloned as a 3'-terminal green fluorescent protein (GFP) fusion, downstream of an acetamide-inducible promoter, and expressed in Mycobacterium smegmatis and Mycobacterium bovis BCG. The expression product was characterized in terms of cellular location and glycosylation status.

RESULTS

PCR and sequence data demonstrated that variable numbers of tandem repeats within Rv1917c contribute to gene polymorphism. RT-PCR analysis demonstrated that Rv1917c mRNA is expressed in liquid cultures of M. tuberculosis H37Rv. Expression of the recombinant protein in M. smegmatis and M. bovis BCG was visualized by fluorescence microscopy and flow cytometry. A protein of the predicted size (166 kDa) was confirmed by Western blotting. Cell fractionation studies demonstrated that the recombinant protein is hydrophobic, suggestive of cell wall-association, while flow cytometric data derived from antibody binding experiments suggested that it is surface exposed. Analysis of the glycosylation status of the expressed protein failed to demonstrate glycosylation.

CONCLUSION

Rv1917c mRNA is expressed in M. tuberculosis H37Rv, and Rv1917c gene polymorphism is associated with variable numbers of tandem repeats. The recombinant Rv1917c protein is surface exposed.

Radiological peer review of interval cancers in the East Anglian breast screening programme: what are we missing? East Anglian Breast Screening Programme

OBJECTIVE

To determine whether association between classification of interval cancers (false negative, minimal sign, true interval, occult) and tumour characteristics can indicate areas for improvement in effectiveness of screening.

SETTING

East Anglian regional Breast: Screening Programme.

METHOD

The consensus classification of interval cases, obtained through peer review, was compared with tumour characteristics: size; grade; and nodal status, and with radiological signs. A set of 923 cancers with known tumour characteristics, presenting in unscreened women, was available for comparison.

RESULT

In total, 385 interval cases were analysed. Prognosis of interval cancers was at least as good as that of cancers in unscreened women, with fewer node positive cases. No significant relation was found between classification of cases and age of patients. True intervals tended to present later after a negative screen, although false negatives commonly presented earlier. Occult cancers were significantly smaller than false negatives. Analysis of histological type yielded little of relevance, and mammographic appearance was similar in all classifications. At diagnosis, cancers in the low risk group were more likely to be seen as spiculate masses, whereas high risk cases more often appeared as opacities. A higher proportion of interval cases had been assessed than in the normal screened population.

CONCLUSION

Sensitivity may be improved by reducing false negative and minimal sign cases (21% of interval cancers in East Anglia). These will include tumours in all risk groups, and with all radiological features, thus no particular age group or radiological feature may be targeted for improvement. Misdiagnosis at assessment reduces sensitivity and therefore merits particular study.

Molecular evolution of Mycobacterium tuberculosis: phylogenetic reconstruction of clonal expansion

SETTING

M. tuberculosis isolates were collected from patients attending health clinics in a high incidence urban community and in a low incidence rural setting in South Africa.

OBJECTIVE

To reconstruct the evolutionary history of a group of closely related M. tuberculosis isolates using IS6110, DRr and MTB484(1) restriction fragment length polymorphism (RFLP) data.

DESIGN

Mycobacterium tuberculosis isolates containing an average of ten IS6110 elements, with a similarity index of > or = 65% were genotypically classified by DNA fingerprinting using the IS6110 derived probes IS-3' and IS-5', as well as the DRr and MTB484(1) probes, in combination with PvuII or Hinfl endonuclease digestion. These RFLP data were subjected to phylogenetic analysis using both genetic distance and parsimony algorithms.

RESULTS

Phylogenetic analysis predicted the existence of two independently evolving lineages, possibly evolving from a common ancestral strain. The topology of the phylogenetic tree was supported by comprehensive bootstrapping and the specific partitioning of DNA methylation phenotypes. The observed difference in the branch lengths of the two lineages may suggest differential evolutionary rates. Isolates collected from different geographical regions demonstrate independent evolution, suggesting that it is highly unlikely that strains have been recently transmitted between the two regions. The number of evolutionary events identified in this strain family differs significantly from that of previously characterized strain families, implying that evolutionary rate may be strain family dependent.

CONCLUSION

Based on this analysis we propose that the algorithm used to calculate recent epidemiological events should be revised to incorporate the evolutionary characteristics of individual strain families, thereby enhancing the accuracy of molecular epidemiological calculations.

Cryptococcosis in human immunodeficiency virus-negative patients in the era of effective azole therapy

We conducted a case study of human immunodeficiency virus (HIV)-negative patients with cryptococcosis at 15 United States medical centers from 1990 through 1996 to understand the demographics, therapeutic approach, and factors associated with poor prognosis in this population. Of 306 patients with cryptococcosis, there were 109 with pulmonary involvement, 157 with central nervous system (CNS) involvement, and 40 with involvement at other sites. Seventy-nine percent had a significant underlying condition. Patients with pulmonary disease were usually treated initially with fluconazole (63%); patients with CNS disease generally received amphotericin B (92%). Fluconazole was administered to approximately two-thirds of patients with CNS disease for consolidation therapy. Therapy was successful for 74% of patients. Significant predictors of mortality in multivariate analysis included age > or =60 years, hematologic malignancy, and organ failure. Overall mortality was 30%, and mortality attributable to cryptococcosis was 12%. Cryptococcosis continues to be an important infection in HIV-negative patients and is associated with substantial overall and cause-specific mortality.

Detection of acoustic repetition for very long stochastic patterns

Guttman and Julesz (1963) employed recycling frozen noise segments (RFNs) as model stimuli in their classic study of the lower limits for periodicity detection and short-term auditory memory. They reported that listeners can hear iteration of these stochastic signals effortlessly as "motorboating" for repetition periods ranging from 50 to 250 msec and as "whooshing" from 250 msec to 1 sec. Both motorboating and whooshing RFNs are global percepts encompassing the entire period, as are RFNs in the pitch range (repetition periods shorter than 50 msec). However, with continued listening to whooshing (but not motorboating) RFNs, individuals hear recurrent brief components such as clanks and thumps that are characteristic of the particular waveform. Experiment 1 of the present study describes a cross-modal cuing procedure that enables listeners to store and then recognize the recurrence of portions of frozen noise waveforms that are repeated after intervals of 10 sec or more. Experiment 2 compares the relative saliencies of different spectral regions in enabling listeners to detect repetition of these long-period patterns. Special difficulty was encountered with the 6-kHz band of RFNs, possibly due to the lack of fine-structure phase locking at this frequency range. In addition, a similarity is noted between the organizational principles operating over particular durational ranges of stochastic patterns and the characteristics of traditional hierarchical units of speech having corresponding durations.

Interval cancer peer review in East Anglia: implications for monitoring doctors as well as the NHS breast screening programme

AIM

To devise a method for reviewing interval cancers that will both educate radiologists and facilitate improvement of breast screening practice. To evaluate different methods for case classification to find one that best serves this purpose.

METHOD

The method of peer review and the means by which interval cancers are classified is described. The way in which cases are designated false-negative is an issue of acceptability for radiologists, and so three different methods are evaluated. Each is applied to the data set collected in this region over a 3-year period.

RESULTS

For cases read by five readers, when a consensus method was used for classifying cases, the proportion of cases classified as false-negative was 14%. Using a method in which only one of the five readers had to classify a case as false-negative for it to be categorized as such, the proportion of false-negative cases rose to a maximum of 38%. The minimum proportion of cases that could be considered to be false-negative was 6% and was obtained when all five readers had to classify a case as false-negative for it to be so categorized. Consistent with its majority viewpoint, the consensus method gave results for proportions of total cases classified as false-negative which were similar to those given by methods in which cases are classified as false-negative if either three of five readers, or at least 60% of readers, classified it as such.

CONCLUSION

For the peer review method to achieve its dual aims of educating radiologists and auditing performance, the participating radiologists must share ownership of the results and view the analysis as fair. The method used to classify interval cancers as false-negative will influence the number so classified. A consensus method has been found to give a result that is both fair and acceptable to our radiologist. Using this method 16% of all reviewed cases were classified as false-negative and 60% as true interval cancers. Britton, P. D. (2001). Clinical Radiology56, 44-49.

Mapping of IS6110 flanking regions in clinical isolates of Mycobacterium tuberculosis demonstrates genome plasticity

Southern hybridization was used in combination with IS6110 insertion-locus-specific probes in a comparative study to determine the structure of chromosomal domains flanking IS6110 elements in clinical isolates of Mycobacterium tuberculosis. The resulting restriction fragment length polymorphism (RFLP) data demonstrated three mutational mechanisms responsible for the polymorphisms observed: IS6110 insertion, chromosomal mutation and deletion. The frequency of IS6110 insertion within many of the chromosomal regions demonstrates that preferential integration regions are common in M. tuberculosis. Mapping the IS6110 insertion positions and chromosomal deletions in relation to the M. tuberculosis H37Rv and M. bovis BCG genome sequences reveals numerous disruptions of predicted open reading frames (ORFs). A phylogenetic tree, based on the mutational data, showed a number of independently evolving lineages of M. tuberculosis, while analysis of the mutational events occurring at each branch point suggests both divergent and convergent evolution. A significant positive correlation was demonstrated between the mutation rate and the frequency of occurrence of different isolates in families of strains, suggesting that evolution may impact on strain 'fitness' or that strain proliferation may increase the chance of mutation. We conclude that the genome of clinical isolates of M. tuberculosis continues to evolve.

Magnetic resonance imaging screening in women at genetic risk of breast cancer: imaging and analysis protocol for the UK multicentre study. UK MRI Breast Screening Study Advisory Group

The imaging and analysis protocol of the UK multicentre study of magnetic resonance imaging (MRI) as a method of screening for breast cancer in women at genetic risk is described. The study will compare the sensitivity and specificity of contrast-enhanced MRI with two-view x-ray mammography. Approximately 500 women below the age of 50 at high genetic risk of breast cancer will be recruited per year for three years, with annual MRI and x-ray mammography continuing for up to 5 years. A symptomatic cohort will be measured in the first year to ensure consistent reporting between centres. The MRI examination comprises a high-sensitivity three-dimensional contrast-enhanced assessment, followed by a high-specificity contrast-enhanced study in equivocal cases. Multiparametric analysis will encompass morphological assessment, the kinetics of contrast agent uptake and determination of quantitative pharmacokinetic parameters. Retrospective analysis will identify the most specific indicators of malignancy. Sensitivity and specificity, together with diagnostic performance, diagnostic impact and therapeutic impact will be assessed with reference to pathology, follow-up and changes in diagnostic certainty and therapeutic decisions. Mammography, lesion localisation, pathology and cytology will be performed in accordance with the UK NHS Breast Screening Programme quality assurance standards. Similar standards of quality assurance will be applied for MR measurements and evaluation.

Intelligibility of bandpass speech: effects of truncation or removal of transition bands

An intelligibility of over 90% was reported for keywords in "everyday" 1/3-octave sentences centered on 1500 Hz and having steep transition band slopes of 100 dB/octave [Warren et al., Percept. Psychophys. 57, 175-182 (1995)]. A subsequent study by Warren and Bashford [J. Acoust. Soc. Am. 106, L47-L52 (1999)] found that it was not the 1/3-octave passband, but the transition bands that were chiefly responsible for this high intelligibility: When the passband and transition bands were segregated using filter slopes of 1000 dB/octave, the isolated passband had an intelligibility score of only 24%, while the pair of transition bands had a score of over 80%. In the present study, experiment 1 examined the distribution of information along the transition bands' slopes by truncation at graded downpoints: Truncation at downpoints of 40 dB or more produced no significant change in intelligibility. Experiment 2 closed the gap separating the transition bands so that their slopes intersected at 1500 Hz. This triangular band had a negligible passband (as defined conventionally by 3-dB downpoints) and an intelligibility score of 60%; truncation at downpoints of 50 dB or more produced no significant change in intelligibility. Experiment 3 determined the intelligibilities of rectangular bands (1000-dB/octave slopes) centered on 1500 Hz. Their bandwidths ranged from 3 to 12 semitones in 1-semitone steps, resulting in intelligibility scores increasing monotonically from 14% to 94%. Calculations based upon experiments 2 and 3 showed that the triangular band truncated at 30-dB downpoints had half the intelligibility of a rectangular band having the same frequency range.

Rationale for a national multi-centre study of magnetic resonance imaging screening in women at genetic risk of breast cancer

In 1994, the UK National Health Service identified as a research priority that magnetic resonance imaging (MRI) should be assessed as a screening tool for young, pre-menopausal women who are at a high genetic risk of developing breast cancer. In 1997 a national multicentre study was established to compare MRI with X-ray mammography as a method for screening for breast cancer in this group of women. This paper reviews the relevant literature and describes the rationale that led to the setting up of this study.

Disruption of coding regions by IS6110 insertion in Mycobacterium tuberculosis

SETTING

The insertion sequence IS6110 is widely used as a DNA fingerprinting probe for the classification of Mycobacterium tuberculosis strains. This study has focused on the characterization of regions disrupted by insertion of the IS6110 element.

OBJECTIVE

To characterize IS6110 insertion loci in clinical isolates of M. tuberculosis, in terms of their genomic location and genetic identity, to ascertain whether IS6110 transposition could be a mechanism driving phenotypic change.

DESIGN

Thirty-three IS6110 insertion loci were cloned from 8 clinical isolates of M. tuberculosis. Clones representing DR locus insertions were identified by hybridization (n = 4), and all other clones were characterized by DNA sequencing (n = 29). The sequence data was analyzed in conjunction with that of 43 other insertion loci identified in published literature and DNA sequence databases.

RESULTS

The 76 sequences analyzed represented 66 unique insertion loci (including 9 unique insertions into the ipl locus). When mapped to the H37Rv genome, the majority of unique insertion loci demonstrated disruption of coding regions by IS6110 (n = 42; including the ipl insertions), while the remainder either occurred within intergenic regions (n = 17), or could not be mapped to the H37Rv genome sequence (n = 7). Mapping of the insertion loci reveals distribution throughout the chromosome, with isolated preferential insertion loci.

CONCLUSIONS

This study has demonstrated the occurrence of 66 unique IS6110 insertion loci dispersed throughout the M. tuberculosis genome, with an unexpectedly high incidence of IS6110 insertions occurring within coding regions. However, the IS6110-mediated coding region disruptions identified here may only have limited impact on phenotype, as most of the coding regions disrupted are members of multiple gene families. Disruption of individual members of a family of genes may have no effect on phenotype or could have a minor or major impact, depending on the specificity and activity of the encoded protein.

Localization of breast lesions shown only on MRI--a review for the UK Study of MRI Screening for Breast Cancer. Advisory Group of MARIBS

The UK study of screening for breast cancer compares mammography and dynamic contrast enhanced MRI of the breast in women at high genetic risk of developing cancer. Owing to the high sensitivity of MR in the breast, it is anticipated that some lesions will be visible only on MR. A key issue for the study is how to localize these lesions for histological verification and removal. This article reviews available methods and describes the current UK expertise and recent European developments. The use of MR compatible wires and markers has been explored in a phantom. The use of these markers in vivo is demonstrated in a case imaged by MR and mammography and further discussed. The susceptibility artefacts produced on MRI, and technical properties associated with these needles, wires and markers are discussed. The clinical pathway by which these lesions will be worked up for the study, and the quality control procedures for keeping the number of such biopsies to a minimum, are described. There is an urgent need for further centres in the UK to become proficient at removing lesions found only on MRI in support of this study and other breast MRI applications. The management of these lesions must be resolved in order to realize the full potential of MRI for screening for breast cancer in women at genetic risk, and for other diagnostic applications.

Transmission of a multidrug-resistant Mycobacterium tuberculosis strain resembling "strain W" among noninstitutionalized, human immunodeficiency virus-seronegative patients

Since 1990, several outbreaks of multidrug-resistant tuberculosis (MDR-TB) have been described among institutionalized patients infected with human immunodeficiency virus (HIV). We describe a community MDR-TB outbreak among HIV-seronegative patients in Cape Town, South Africa. Isolates were characterized by restriction fragment length polymorphism (RFLP) analysis and dot-blot hybridization analysis of mutations conferring resistance for isoniazid, rifampin, streptomycin, and ethambutol. All isolates were identical on RFLP analysis. In 2 patients, RFLP analysis showed exogenous reinfection during or after treatment for drug-susceptible TB. Mutation analysis confirmed the genotypic identity of the isolates. The infecting strain was genotypically related to strain W, which is responsible for the majority of MDR-TB outbreaks in New York City. Transmission of MDR-TB is thus not limited to HIV-seropositive patients in an institutional setting but occurs within a community.

Intelligibility of 1/3-octave speech: greater contribution of frequencies outside than inside the nominal passband

We reported previously that "everyday" sentences were highly intelligible when limited to a 1/3-octave passband centered at 1,500 Hz and having transition-band slopes of approximately 100 dB/octave. The present study determined the relative contributions to intelligibility made by the passband (PB) and the transition bands (TBs) by partitioning the same bandpass sentences using 2,000-order FIR filtering. Intelligibility scores were: PB with both TBs, 92%; deletion of both TBs (leaving only the 1/3-octave PB with nearly vertical slopes), 24%; deletion of the PB (leaving both TBs separated by a 1/3-octave gap), 83%. These and other results indicate a remarkable ability to compensate for severe spectral tilt and the consequent importance of considering frequencies outside the nominal passband in interpreting studies using filtered speech.

How reliable is modern breast imaging in differentiating benign from malignant breast lesions in the symptomatic population?

AIM

To assess the ability of mammography and ultrasound individually and in combination to predict whether a breast abnormality is benign or malignant in patients with symptomatic breast disease.

MATERIALS AND METHODS

Patients included were those in whom histological confirmation of the abnormality following surgical excision was available. Mammographic and ultrasound appearances were prospectively classified using a four-point scale (1 = no significant lesion, 2 = benign lesion, 3 = possibly malignant, 4 = probably malignant).

RESULTS

Histological confirmation following surgical excision was available in 559 patients, of which 303 were benign and 256 were malignant. The imaging classification was correlated with histology in these 559 lesions. In predicting final histology, the sensitivity and specificity of mammography alone were 78.9 and 82.7%, respectively, of ultrasound alone were 88.9 and 77.9%, respectively, and of mammography and ultrasound in combination were 94.2 and 67.9%, respectively. Only one patient had both a mammogram and ultrasound reported as normal (category 1 for both tests) in whom subsequent histology revealed a carcinoma (0.4% of all carcinomas).

CONCLUSION

We found that the extensive use of ultrasound increases the cancer detection rate in this selected population by 14%.

Rapid genomic diversification of Helicobacter pylori

Helicobacter pylori was cultured from antrum and corpus gastric biopsies from 65 patients originating from two separate groups: (i) a geographically linked group and (ii) a geographically nonlinked group. Genomic DNA was recovered from the clinical isolates and subjected to restriction fragment length polymorphism (RFLP) analysis after digestion with DraI. Southern blots were probed with the oligonucleotide (GTG)5, the riboprobe pKK3535, and the cagA gene probe pMC3. (GTG)5 and cagA DNA fingerprints and ribopatterns suggested that most of the patients were infected with their own unique strain; however, some were infected with multiple strains. Minor genomic differences were detected in many antrum/corpus sample pairs (clonal variants), suggesting rapid evolutionary change in domains detected by (GTG)5. The high degree of genomic diversity detected by (GTG)5 may reflect structural versatility of these domains. The genomic diversity indicates that infection by H. pylori in a defined community does not appear to be limited to certain RFLP types.

A comparison of the effectiveness of 28 kV (grid) versus 25 kV (no grid) mammographic techniques for breast screening

The purpose of this study was to compare the clinical effectiveness of breast screening using a mammographic technique of 25 kV without a grid, with one of 28 kV with a grid. Effectiveness is judged by cancer detection, interval cancer rates, sensitivity and specificity calculations and tumour characteristics. The doses on standard physics tests given by the three machines when these exposure factors are selected were compared to see whether there is any scientific basis for recommendations on which is the more effective technique. The experiment was undertaken in the prevalence round of a screening programme set up in the UK in 1987. The main comparison is on 25,078 women randomized to one or other technique after March 1989. Comparison can also be made with the preceding 8482 women, who were examined by the 25 kV method, but not randomized and in whom there were a variety of other differences. In the randomized group there was no statistically significant difference in cancer detection. A minor difference in overall numbers without statistical significance was seen in favour of the 28 kV grid technique, but is offset by a greater interval cancer rate in this group. Small cancer detection was equal in the two groups. By contrast, the first 8482 women showed significantly worse screening performance, both in lower overall and small cancer detection rate, and in increased number of interval cancers, for which the explanation is likely to be complex. The dose measurements show that the use of a higher tube potential with the grid mitigates the dose increase that may have been expected. The choice between these two techniques is therefore neither automatically made by greater cancer detection nor made on grounds of dose. There was a minor dose penalty in using the 28 kV technique with grid.

Oligonucleotide (GTG)5 as an epidemiological tool in the study of nontuberculous mycobacteria

Analysis of restriction fragment length polymorphisms in the genome of Mycobacterium tuberculosis (DNA fingerprinting) has proved to be a useful epidemiological tool in the study of tuberculosis within populations or communities. However, to date, no similar method has been developed to study the epidemiology of nontuberculous mycobacteria (NTM). In this communication, we report that a simple oligonucleotide repeat, (GTG)5, can be used to accurately genotype all species and strains of NTM tested. We suggest that this technology is an easily applied and accurate tool which can be used for the study of the epidemiology of NTM.

Spectral restoration of speech: intelligibility is increased by inserting noise in spectral gaps

In order to function effectively as a means of communication, speech must be intelligible under the noisy conditions encountered in everyday life. Two types of perceptual synthesis have been reported that can reduce or cancel the effects of masking by extraneous sounds: Phonemic restoration can enhance intelligibility when segments are replaced or masked by noise, and contralateral induction can prevent mislateralization by effectively restoring speech masked at one ear when it is heard in the other. The present study reports a third type of perceptual synthesis induced by noise: enhancement of intelligibility produced by adding noise to spectral gaps. In most of the experiments, the speech stimuli consisted of two widely separated narrow bands of speech (center frequencies of 370 and 6,000 Hz, each band having high-pass and low-pass slopes of 115 dB/octave meeting at the center frequency). These very narrow bands effectively reduced the available information to frequency-limited patterns of amplitude fluctuation lacking information concerning formant structure and frequency transitions. When stochastic noise was introduced into the gap separating the two speech bands, intelligibility increased for "everyday" sentences, for sentences that varied in the transitional probability of keywords, and for monosyllabic word lists. Effects produced by systematically varying noise amplitude and noise bandwidth are reported, and the implications of some of the novel effects observed are discussed.

The vowel-sequence illusion: intrasubject stability and intersubject agreement of syllabic forms

Earlier studies have found that listeners presented with a loud and clear repeating sequence of brief steady-state vowels typically report hearing two voices with distinctly different timbres repeating different syllables that either are English words or occur in English words. One of the simultaneous voices is generally based upon frequencies below, and the other above, the "crossover frequency" at approximately 1500 Hz that divides normal speech into regions contributing equally to intelligibility. It has been hypothesized that the lack of linguistic content halts the processing of vowel sequences at the syllabic level, and that the spectral splitting corresponding to the concurrent voices reflects a mechanism for independent processing of different frequency regions that can lead to increased intelligibility under difficult listening conditions. The present study employed twelve randomly selected arrangements of the same six 70-ms vowels, and it was determined that: (1) individuals reported the same perceptual organizations the following week; (2) insertion of a brief silent gap between restatements of a sequence resulted in reports of similar (and occasionally identical) syllables by different listeners hearing the same sequence; and (3) when two listeners' responses differed, they could nevertheless identify the particular vowel sequences corresponding to each other's verbal forms. Spectrograms of vowel sequences were compared with time-aligned spectrograms of a speaker's synchronous production of the forms as they were being heard, and some common features of the acoustic patterns were noted. It is suggested that vowel sequences provide a reliable and useful tool for probing aspects of the perceptual organization of speech sounds that are normally obscured by additional linguistic processing.

Binaural release from temporal induction

This study examined the effects of interaural phase difference (IPhD) relations in temporal induction (TI)-that is, the perceived continuity of a fainter sound (inducee) through an interrupting higher amplitude sound (inducer). The extent of TI was measured both directly as the upper amplitude level for continuity and indirectly as the loudness reduction of the inducer. It was found that TI was inhibited when the IPhD of the inducer and the IPhD of the inducee differed. It was also found that the extent of induction was positively related to the masking potential of the inducer as measured by the binaural masking level difference procedure. These results suggest that TI involves processes that are affected by interaural phase differences and that the masking potential rule, shown by previous studies to apply in the frequency domain, applies also in the IPhD domain. The present findings are consistent with the hypothesis that TI results from allocation of a portion of the neural excitation produced by the inducer over to the inducee if the inducer has the appropriate masking potential. As a consequence, obliterated signals can be selectively restored on the basis of both frequency-specific monaural cues and azimuth-related binaural cues, abilities that can enhance detection of signals under the noisy conditions of everyday life.

Use of speech-modulated noise adds strong "bottom-up" cues for phonemic restoration

When deleted segments of speech are replaced by extraneous sounds rather than silence, the missing speech fragments may be perceptually restored and intelligibility improved. This phonemic restoration (PhR) effect has been used to measure various aspects of speech processing, with deleted portions of speech typically being replaced by stochastic noise. However, several recent studies of PhR have used speech-modulated noise, which may provide amplitude-envelope cues concerning the replaced speech. The present study compared the effects upon intelligibility of replacing regularly spaced portions of speech with stochastic (white) noise versus speech-modulated noise. In Experiment 1, filling periodic gaps in sentences with noise modulated by the amplitude envelope of the deleted speech fragments produced twice the intelligibility increase obtained with interpolated stochastic noise. Moreover, when lists of isolated monosyllables were interrupted in Experiment 2, interpolation of speech-modulated noise increased intelligibility whereas stochastic noise reduced intelligibility. The augmentation of PhR produced by modulated noise appeared without practice, suggesting that speech processing normally involves not only a narrowband analysis of spectral information but also a wideband integration of amplitude levels across critical bands. This is of considerable theoretical interest, but it also suggests that since PhRs produced by speech-modulated noise utilize potent bottom-up cues provided by the noise, they differ from the PhRs produced by extraneous sounds, such as coughs and stochastic noise.

The value of the second view in screening mammography

A prospective study of 33,734 women was undertaken during the prevalent round of the UK National Breast Screening Programme. The cancer detection rates and recall rates were compared between a one view and a two view technique. In one fifth of the women, only the single oblique view examination was read. To lose the bias that would have been introduced by the prior knowledge that a second view would be available, the radiologists reading the oblique view did not know whether or not a craniocaudal view would subsequently be available. Readings were available from two radiologists in each case. The cancer detection rate increased from 7.6 per thousand to 8.2 per thousand women screened, with 14 more cancers detected with the two view technique. This represents 6.5% of all screen detected cancers (95% CI 3.2-9.8). The recall rate was reduced from 8.8% to 6.6% by the second view (p < 0.001). There was a significantly higher biopsy rate in the two view group (10.6/1000 versus 8.6/1000) (p = 0.004). This higher biopsy rate is part of the price paid for the higher detection rate. The additional tumours included small invasive cancers. The National Health Service (NHS) cost of each additional cancer diagnosed was 4129 pounds and the NHS plus private cost was 2742 pounds. These findings have practical applications for the National Breast Screening Programme. There would be resource implications on routinely applying two view screening to the prevalent round, but even greater costs if applied to the incident screening round.

Comparison of single reading with double reading of mammograms, and change in effectiveness with experience

In the prevalence round of screening for breast cancer at a single centre, the benefit of the second radiological report has been assessed using data from 33,734 women, their screening results and knowledge of the interval cancers. The service was set up under the UK National Breast Screening Programme, and the data show evidence of learning by both individuals and the team as a whole. Of the 269 cancers detected by screening, 33 would not have been diagnosed if the only report available had been the first. The recall recommendation rate associated with the first report was 6.9% and 236 cancers were detected. The recall recommendation rate associated with all queries of all the reports was 10% (3354 queries). Had these 3354 queries all been investigated (instead of the 1423 actually recalled) only a further three cancers would have been detected. Sensitivity of the programme as a whole was substantially better than that of individual radiologists, while the specificity was maintained. The decision pathway by which recalls were agreed between the two radiologists resulted in a low recall rate (4.2%) for the programme as a whole, and is a critical factor in gaining the benefit of the improved sensitivity without a concomitant deterioration in the specificity. With the passage through the prevalent round, recall rates steadily fell, the malignant to benign biopsy ratio improved and sensitivity increased. The second radiological report yielded 14% additional cancers diagnosed and contributed very significantly to good sensitivity and so to the effectiveness of screening. Economic analysis of the results will be reported in a further paper.

Aphasics can distinguish permuted orders of phonemes--but only if presented rapidly

Speech consists of a rapid succession of phonemes, and receptive aphasia has been attributed to an impairment in temporal acuity that interferes with the ability to discriminate between different arrangements of brief sounds. The present study reports evidence that aphasic listeners could distinguish between permuted orders of steady-state vowels occurring at rates matching or exceeding those employed in natural speech production. They could not, however, distinguish between different arrangements when the rate of presentation was slowed, although this task could be accomplished with ease by nonaphasic listeners. Our results suggest that the poor comprehension of language by aphasics is not the consequence of deficits in the ordering of brief sounds, but rather involves difficulties in performing tasks requiring specific psycholinguistic skills.

Spectral redundancy: intelligibility of sentences heard through narrow spectral slits

The intelligibility of word lists subjected to various types of spectral filtering has been studied extensively. Although words used for communication are usually present in sentences rather than lists, there has been no systematic report of the intelligibility of lexical components of narrowband sentences. In the present study, we found that surprisingly little spectral information is required to identify component words when sentences are heard through narrow spectral slits. Four hundred twenty listeners (21 groups of 20 subjects) were each presented with 100 bandpass filtered CID ("everyday speech") sentences; separate groups received center frequencies of 370, 530, 750, 1100, 1500, 2100, 3000, 4200, and 6000 Hz at 70 dBA SPL. In Experiment 1, intelligibility of single 1/3-octave bands with steep filter slopes (96 dB/octave) averaged more than 95% for sentences centered at 1100, 1500, and 2100 Hz. In Experiment 2, we used the same center frequencies with extremely narrow bands (slopes of 115 dB/octave intersecting at the center frequency, resulting in a nominal bandwidth of 1/20 octave). Despite the severe spectral tilt for all frequencies of this impoverished spectrum, intelligibility remained relatively high for most bands, with the greatest intelligibility (77%) at 1500 Hz. In Experiments 1 and 2, the bands centered at 370 and 6000 Hz provided little useful information when presented individually, but in each experiment they interacted synergistically when combined. The present findings demonstrate the adaptive flexibility of mechanisms used for speech perception and are discussed in the context of the LAME model of opportunistic multilevel processing.

Auditory induction: reciprocal changes in alternating sounds

When portions of a sound are replaced by a potential masker, the missing fragments may be perceptually restored, resulting in apparent continuity of the interrupted signal. This phenomenon has been examined extensively by using pulsation threshold, auditory induction, and phonemic restoration paradigms in which two sounds, the inducer and the inducee, are alternated (ABABA...), and the conditions required for apparent continuity of the lower amplitude inducee are determined. Previous studies have generally neglected to examine concomitant changes produced in the inducing sound. Results from the present experiments have demonstrated decreases in the loudness of inducers using inducer/inducee pairs consisting of tone/tone and noise/noise, as well as the noise/speech pairs associated with phonemic restorations. Interestingly, reductions in inducer loudness occurred even when the inducee was heard as discontinuous, and these decreases in loudness were accompanied by graded increases in apparent duration of the inducee, contrary to the conventional view of auditory induction as an all-or-none phenomenon. Under some conditions, the reduced loudness of the inducer was coupled with a marked alteration in its timbre. Especially profound changes in the inducer quality occurred when the alternating stimuli were tones having the same frequency and differing only in intensity--it seems that following subtraction of components corresponding to the inducee, an anomalous auditory residue remained that did not correspond to the representation of a tone.

Spectral fissioning in phonemic transformations

Listeners presented with a repeated sequence of brief (30- to 100-msec) steady-state vowels hear phonemic transformations--they cannot identify the vowels, but they perceive two simultaneous utterances that differ in both phonemic content and timbre (Warren, Bashford & Gardner, 1990). These utterances consist of either English words or syllables that occur in English words. In the present study, we attempted to determine whether the two percepts represent alternative interpretations of the same formant structures, or whether different portions of the vowels are used for each verbal organization. It was found that separate spectral regions are employed for each verbal form: Components below 1500 Hz were generally used for one form, and components above 1500 Hz for the other. Hypotheses are offered concerning the processes responsible for the verbal organization of the vowel sequences and for the splitting into two spectrally limited forms. It appears that the tendency to organize spectral regions separately competes with, and can overcome, the tendency to integrate the different spectral components of speech into a single auditory image. A contralateral induction paradigm was used in a procedure designed to quantitatively evaluate these opposing forces of spectral fission and fusion.

When acoustic sequences are not perceptual sequences: the global perception of auditory patterns

Warren, Bashford, and Gardner (1990) found that when sequences consisting of 10 40-msec steady-state vowels were presented in recycled format, minimal changes in order (interchanging the position of two adjacent phonemes) produced easily recognizable differences in verbal organization, even though the vowel durations were well below the threshold for identification of order. The present study was designed to determine if this ability to discriminate between different arrangements of components is limited to speech sounds subject to verbal organization, or if it reflects a more general auditory ability. In the first experiment, 10 40-msec sinusoidal tones were substituted for the vowels; it was found that the easy discrimination of minimal changes in order is not limited to speech sounds. A second experiment substituted 10 40-msec frozen noise segments for the vowels. The succession of noise segments formed a 400-msec frozen noise pattern that cannot be considered as a sequence of individual sounds, as can the succession of vowels or tones. Nevertheless, listeners again could discriminate between patterns differing only in the order of two adjacent 40-msec segments. These results, together with other evidence, indicate that it is not necessary for acoustic sequences of brief items (such as phonemes and tones) to be processed as perceptual sequences (that is, as a succession of discrete identifiable sounds) for different arrangements to be discriminated. Instead, component acoustic elements form distinctive "temporal compounds," which permit listeners to distinguish between different arrangements of portions of an acoustic pattern without the need for segmentation into an ordered series of component items.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous photocoagulation of deep vascular lesions using a fiberoptic laser wand

A new technique is presented for the treatment of deep vascular lesions. A potassium-titanyl-phosphate (KTP), argon, or Nd:YAG laser is attached to a fiberoptic wand, which is passed percutaneously. The laser is activated and coagulates the lesion without direct injury to the skin. Eleven hemangiomas and two lymphangiomas have been treated using this technique. A reduction in size of the lesions was obtained in all patients. Repeat treatments were done to improve results in six patients. Conventional transcutaneous laser therapy was used as an adjunct in four patients. Average patient follow-up was 29 months. No major complications have been noted in this series. Percutaneous fiberoptic photocoagulation has been found to be a safe, long-lasting technique for the treatment of deep vascular lesions.

Increasing the intelligibility of speech through multiple phonemic restorations

Outside of the laboratory, listening conditions are often less than ideal, and when attending to sounds from a particular source, portions are often obliterated by extraneous noises. However, listeners possess rather elegant reconstructive mechanisms. Restoration can be complete, so that missing segments are indistinguishable from those actually present and the listener is unaware that the signal is fragmented. This phenomenon, called temporal induction (TI), has been studied extensively with nonverbal signals and to a lesser extent with speech. Earlier studies have demonstrated that TI can produce illusory continuity spanning gaps of a few hundred milliseconds when portions of a signal are replaced by a louder sound capable of masking the signal were it actually present. The present study employed various types of speech signals with periodic gaps and measured the effects upon intelligibility produced by filling these gaps with noises. Enhancement of intelligibility through multiple phonemic restoration occurred when the acoustic requirements for TI were met and when sufficient contextual information was available in the remaining speech fragments. It appears that phonemic restoration is a specialized form of TI that uses linguistic skills for the reconstruction of obliterated speech.

Tweaking the lexicon: organization of vowel sequences into words

The ability of listeners to distinguish between different arrangements of the same three vowels was investigated for repeating sequences having item durations ranging from 10 msec (single glottal pulses) up to several seconds/vowel. Discrimination was accomplished with ease by untrained subjects at all item durations. From 30 through 100 msec/vowel, an especially interesting phenomenon was encountered: The sequences of steady-state vowels were organized into words, with different words heard for the different arrangements of items. In a second experiment, repeating sequences of random arrangements of 10 40-msec vowels were employed. When sets of four such sequences were presented to listeners, distinctive words were heard, which permitted each arrangement to be discriminated from the others. In addition, minimal differences (reversing the order of a single contiguous pair of vowels) in the 10-item sequences could be detected via verbal mediation. Hypotheses are offered concerning mechanisms responsible for these results.

Illusory continuity of interrupted speech: speech rate determines durational limits

Deleted segments of speech can be restored perceptually if they are replaced by a louder noise. An earlier study of this "phonemic restoration effect" found that, when recorded discourse was interrupted periodically by noise, the durational limit for illusory continuity corresponded to the average word duration. The present study employed a different passage of discourse recorded by a different speaker. Durational limits for apparent continuity of discourse interrupted by noise were measured at the normal (original) playback speed, as well as at rates that were 15% greater and 15% less. At the normal playback rate, once again the limit of continuity approximated the average word duration--but of especial interest was the finding that changes in playback rate produced proportional changes in continuity limits. These results, together with other evidence, suggest that phonemic restorations represent a special linguistic application of a general auditory mechanism (auditory induction) producing appropriate syntheses of obliterated sounds, and that for discourse the limits of illusory continuity correspond to a fixed amount of verbal information, and not a fixed temporal value.