Fulminant hepatic and multiple organ failure following acute viral tonsillitis: a case report.

BACKGROUND Pyogenic tonsillitis may often be observed in the general Western population. In severe cases, it may require antibiotic treatment or even hospitalization and often a prompt clinical response will be noted. Here we present an unusual case of progressive multiple organ failure including fulminant liver failure following acute tonsillitis initially mistaken for "classic" pyogenic (that is bacterial) tonsillitis. CASE PRESENTATION A 68-year-old previously healthy white man was referred with suspicion of pyogenic angina. After tonsillectomy, he developed acute liver failure and consecutive multiple organ failure including acute hemodynamic, pulmonary and dialysis-dependent renal failure. Immunohistopathological analysis of his tonsils and liver as well as serum polymerase chain reaction analyses revealed herpes simplex virus-2 to be the causative pathogen. Treatment included high-dose acyclovir and multiorgan supportive intensive care therapy. His final outcome was favorable. CONCLUSIONS Fulminant herpes simplex virus-2-induced multiple organ failure is rarely observed in the Western hemisphere and should be considered a potential diagnosis in patients with tonsillitis and multiple organ failure including acute liver failure. From a clinical perspective, it seems important to note that fulminant herpes simplex virus-2 infection may masquerade as "routine" bacterial severe sepsis/septic shock. This persevering condition should be diagnosed early and treated goal-oriented in order to gain control of this life-threatening condition.

Uso de marcadores moleculares para la racionalización y evaluación de la calidad en las colecciones de Recursos Fitogenéticos de trigo

Esta tesis tiene dos objetivos generales: el primero, analizar el uso de proteínas del endospermo y SSRs para la racionalización de las colecciones de trigo, y el segundo, estudiar la influencia de las proteínas del endospermo, del año de cultivo y del abonado nitrogenado en la calidad en un grupo de variedades locales españolas. Dentro del primer objetivo, se estudió la diversidad genética de la colección de Triticum monococcum L. (escaña menor), y de una muestra de la colección de Triticum turgidum L. (trigo duro) del CRF-INIA, con 2 y 6 loci de gliadinas, y 6 y 24 SSRs, para la escaña menor y el trigo duro, respectivamente. Ambas colecciones presentaron una gran diversidad genética, con una gran diferenciación entre las variedades y pequeña dentro de ellas. Los loci de gliadinas mostraron una gran variabilidad, siendo los loci Gli-2 los más útiles para distinguir variedades. En la escaña menor, las gliadinas presentaron mayor poder de discriminación que los SSRs; aunque en trigo duro los SSRs identificaron más genotipos. El número de alelos encontrado fue alto; 24 y 38 en gliadinas, y 29 y 203 en SSRs, en escaña menor y trigo duro, respectivamente. En trigo duro, se identificaron 17 alelos nuevos de gliadinas lo que demuestra que el germoplasma español es muy singular. En ambas especies, se detectaron asociaciones entre la variación alélica en prolaminas y el origen geográfico y filogenético de las variedades. La utilidad de las proteínas (6 loci de gliadinas, 2 loci de gluteninas y proteína total) y de los SSRs (24 loci) para verificar duplicados, y analizar la variabilidad intraaccesión, se estudió en 23 casos de duplicados potenciales de trigo duro. Los resultados indicaron que tanto los biotipos como las accesiones duplicadas mostraban el mismo genotipo en gliadinas, pocas diferencias o ninguna en las subunidades de gluteninas HMW y proteína total, y diferencias en menos de tres loci de SSRs. El mismo resultado se obtuvo para los biotipos de la colección de T. monococcum. Sin embargo, las discrepancias observadas en algunos casos entre proteínas y SSRs demostraron la utilidad del uso conjunto de ambos tipos de marcadores. Tanto las proteínas como los SSRs mostraron gran concordancia con los caracteres agro-morfológicos, especialmente cuando las diferencias entre los genotipos eran grandes. Sin embargo, los caracteres agro-morfológicos fueron menos discriminantes que los marcadores moleculares. Para el segundo objetivo de la tesis, se analizó la variación alélica en siete loci de prolaminas relacionados con la calidad en trigo duro: Glu-A1 y Glu-B1 de gluteninas HMW, Glu-A3, Glu-B3 y Glu-B2 de gluteninas B-LMW, y Gli-A1 y Gli-B1 de gliadinas. La submuestra analizada incluía variedades locales de todas las provincias españolas donde se ha cultivado tradicionalmente el trigo duro. Todos los loci, excepto el Glu-B2, mostraron gran variabilidad genética, siendo los Glu-3 los más polimórficos. En total, se identificaron 65 alelos, de los que 29 eran nuevos, que representan una fuente importante de variabilidad genética para la mejora de la calidad. Se detectaron diferencias en la composición en prolaminas entre la convar. turgidum y la zona norte, y la convar. durum y la zona sur; el genotipo Glu-B3new-1 - Gli-B1new-1 fue muy común en la convar. turgidum, mientras que el Glu-B3a - Gli-B1c, asociado con mejor calidad, fue más frecuente en la convar. durum. En la convar. turgidum, se observó mayor variabilidad que en la convar. durum, principalmente en los loci Glu-B1 y Glu-B3, lo que indica que esta convariedad puede ser una fuente valiosa de nuevos alelos de gluteninas. Esta submuestra fue evaluada para calidad (contenido en proteína, P, y test de sedimentación, SDSS) con dos dosis de abonado nitrogenado (N), y en dos años diferentes. No se detectaron interacciones Variedad × Año, ni Variedad × N en la calidad. Para la P, los efectos ambientales (año y N) fueron mayores que el efecto de la variedad, siendo, en general, mayor la P con dosis altas de N. La variedad influyó más en el test SDSS, que no se vio afectado por el año ni el N. El aumento del contenido en proteína no influyó significativamente sobre la fuerza del gluten estimada con el SDSS. Respecto a la influencia de las prolaminas en la fuerza del gluten, se confirmó la superioridad del Glu-B3a; aunque también se detectó una influencia alta y positiva de los alelos nuevos Glu-A3new-1, y Glu-B3new-6 y new-9. La no correlación entre el rendimiento (evaluado en un trabajo anterior) y la P, en las variedades adaptadas a bajo N, permitió seleccionar cuatro variedades locales con alto rendimiento y buena fuerza del gluten para producción con bajo N. SUMMARY There are two main objectives in this thesis: The first, to analyse the use of endosperm proteins and SSRs to rationalize the wheat collections, and the second, to study the influence on quality of endosperm proteins, year and nitrogen fertilization in a group of Spanish landraces. For the first objective, we studied the genetic diversity of the collection of Triticum monococcum L. (cultivated einkorn), and of a sample of the collection of Triticum turgidum L. (durum wheat) maintained at the CRF-INIA. Two and 6 gliadin loci, and 6 and 24 SSRs, were used for einkorn and durum wheat, respectively. Both collections possessed a high genetic diversity, being the differentiation large between varieties and small within them. Gliadin loci showed great variability, being the loci Gli-2 the most useful for distinguish among varieties. In einkorn, the gliadins showed higher discrimination power than SSRs; although SSRs identified more genotypes in durum wheat. Large number of alleles were found; 24 and 38 in gliadins, and 29 and 203 in SSRs, for einkorn and durum wheat, respectively. In durum wheat, 17 new alleles of gliadins were identified, which indicate that Spanish durum wheat germplasm is rather unique. Some associations between prolamin alleles and geographical and phylogenetic origin of varieties were found in both species. The value of endosperm proteins (6 gliadin loci, 2 glutenin loci and total protein) and SSRs (24 loci) for validation of duplicates, and monitoring the intra-accession variability, was studied in 23 potential duplicates of durum wheat. The results indicated that biotypes and duplicated accessions showed identical gliadin genotype, few or none differences in HMW glutenin subunits and total protein, and less than three different SSR loci. A similar result was obtained for biotypes of T. monococcum. However, the discrepancies in some cases support the convenience to use together both marker systems. A good concordance among endosperm proteins, agro-morphological traits and SSRs were also found, mainly when differences between genotypes were high. However, agro-morphological traits discriminated less between accessions than molecular markers. For the second objective of the thesis, we analysed the allelic variation at seven prolamin loci, involved in durum wheat quality: Glu-A1 and Glu-B1 of HMW glutenin, Glu-A3, Glu-B3 and Glu-B2 of B-LMW glutenin, and Gli-A1 and Gli-B1 of gliadin. The subsample analysed included landraces from all the Spanish provinces where the crop was traditionally cultivated. All the loci, except for Glu-B2, showed high genetic variability, being Glu-3 the most polymorphic. A total of 65 alleles were studied, 29 of them being new, which represent an important source of variability for quality improvement. Differences in prolamin composition were detected between convar. turgidum and the North zone, and the convar. durum and the South zone; the genotype Glu-B3new-1 - Gli-B1new-1 was very common in the convar. turgidum, while the Glu- B3a - Gli-B1c, associated with better quality, was more frequent in the convar. durum. Higher variability was detected in the convar. turgidum than in the convar. durum, mainly at the Glu-B1 and Glu-B3, showing that this convariety could be a valuable source of new glutenin alleles. The subsample was evaluated for quality (protein content, P, and sedimentation test, SDSS) with two doses of nitrogen fertiliser (N), and in two different years. No significant Variety x Year or Variety x Nitrogen interactions were detected. For P, environmental (year and N) effects were higher than variety effect, being P values , in general, larger with high dose of N. The variety exhibited a strong influence on SDSS test, which was not affected by year and N. Increasing values of P did not significantly influence on gluten strength, estimated with the SDSS. Respect to the prolamin effects on gluten strength, the superiority of Glu-B3a was confirmed; although a high positive effect of the new alleles Glu-A3new-1, and Glu-B3new-6 and new-9 was also detected. The no correlation between yield (evaluated in a previous research) and P, in the landraces adapted to low N, allowed to select four landraces with high yield and high gluten strength for low N production.

Sub-bandgap spectral photo-response analysis of Ti supersaturated Si

We have analyzed the increase of the sheet conductance (ΔG□) under spectral illumination in high dose Ti implanted Si samples subsequently processed by pulsed-laser melting. Samples with Ti concentration clearly above the insulator-metal transition limit show a remarkably high ΔG□, even higher than that measured in a silicon reference sample. This increase in the ΔG□ magnitude is contrary to the classic understanding of recombination centers action and supports the lifetime recovery predicted for concentrations of deep levels above the insulator-metal transition.

Ruling out the impact of defects on the below band gap photoconductivity of Ti supersaturated Si

In this study, we present a structural and optoelectronic characterization of high dose Ti implanted Si subsequently pulsed-laser melted (Ti supersaturated Si). Time-of-flight secondary ion mass spectrometry analysis reveals that the theoretical Mott limit has been surpassed after the laser process and transmission electron microscopy images show a good lattice reconstruction. Optical characterization shows strong sub-band gap absorption related to the high Ti concentration. Photoconductivity measurements show that Ti supersaturated Si presents spectral response orders of magnitude higher than unimplanted Si at energies below the band gap. We conclude that the observed below band gap photoconductivity cannot be attributed to structural defects produced by the fabrication processes and suggest that both absorption coefficient of the new material and lifetime of photoexcited carriers have been enhanced due to the presence of a high Ti concentration. This remarkable result proves that Ti supersaturated Si is a promising material for both infrared detectors and high efficiency photovoltaic devices.

Resistance to endotoxic shock and reduced neutrophil migration in mice deficient for the Src-family kinases Hck and Fgr

Signal transduction through the leukocyte integrins is required for the processes of firm adhesion, activation, and chemotaxis of neutrophils during inflammatory reactions. Neutrophils isolated from knockout mice that are deficient in the expression of p59/61hck (Hck) and p58c-fgr (Fgr), members of the Src-family of protein tyrosine kinases, have been shown to be defective in adhesion mediated activation. Cells from these animals have impaired induction of respiratory burst and granule secretion following plating on surfaces that crosslink β2 and β3 integrins. To determine if the defective function of hck−/−fgr−/− neutrophils observed in vitro also results in impaired inflammatory responses in vivo, we examined responses induced by lipopolysaccharide (LPS) injection in these animals. The hck−/−fgr−/− mice showed marked resistance to the lethal effects of high-dose LPS injection despite the fact that high levels of serum tumor necrosis factor α and interleukin 1α were detected. Serum chemistry analysis revealed a marked reduction in liver and renal damage in mutant mice treated with LPS, whereas blood counts showed a marked neutrophilia that was not seen in wild-type animals. Direct examination of liver sections from mutant mice revealed reduced neutrophil migration into the tissue. These data demonstrate that defective integrin signaling in neutrophils, caused by loss of Hck and Fgr tyrosine kinase activity, results in impaired inflammation-dependent tissue injury in vivo.

Evidence for rapid disappearance of initially expanded HIV-specific CD8+ T cell clones during primary HIV infection

Down-regulation of the initial burst of viremia during primary HIV infection is thought to be mediated predominantly by HIV-specific cytotoxic T lymphocytes, and the appearance of this response is associated with major perturbations of the T cell receptor repertoire. Changes in the T cell receptor repertoire of virus-specific cytotoxic T lymphocytes were analyzed in patients with primary infection to understand the failure of the cellular immune response to control viral spread and replication. This analysis demonstrated that a significant number of HIV-specific T cell clones involved in the primary immune response rapidly disappeared. The disappearance was not the result of mutations in the virus epitopes recognized by these clones. Evidence is provided that phenomena such as high-dose tolerance or clonal exhaustion might be involved in the disappearance of these monoclonally expanded HIV-specific cytotoxic T cell clones. These findings should provide insights into how HIV, and possibly other viruses, elude the host immune response during primary infection.

Modes of action of aspirin-like drugs: Salicylates inhibit Erk activation and integrin-dependent neutrophil adhesion

The anti-inflammatory effects of high-dose salicylates are well recognized, incompletely understood and unlikely due entirely to cyclooxygenase (COX) inhibition. We have previously reported a role for activation of the kinase Erk in CD11b/CD18 integrin-dependent adhesiveness of human neutrophils, a critical step in inflammation. We now report the effects of salicylates on neutrophil Erk and adhesion. Exposure of neutrophils to aspirin or sodium salicylate (poor COX inhibitor) inhibited Erk activity and adhesiveness of formylmethionyl-leucyl-phenylalanine- and arachidonic acid-stimulated neutrophils, consistent with anti-inflammation but not COX inhibition (IC50s = 1–8 mM). In contrast, indomethacin blocked neither Erk nor adhesion. Inhibition of Mek (proximal activator of Erk) also blocked stimulation of Erk and adhesion by formylmethionyl-leucyl-phenylalanineand arachidonic acid. Salicylate inhibition of Erk was independent of protein kinase A activation and generation of extracellular adenosine. These data are consistent with a role for Erk in stimulated neutrophil adhesion, and suggest that anti-inflammatory effects of salicylates may be mediated via inhibition of Erk signaling required for integrin-mediated responses.

Identification of nitric oxide synthase as a protective locus against tuberculosis

Mutagenesis of the host immune system has helped identify response pathways necessary to combat tuberculosis. Several such pathways may function as activators of a common protective gene: inducible nitric oxide synthase (NOS2). Here we provide direct evidence for this gene controlling primary Mycobacterium tuberculosis infection using mice homozygous for a disrupted NOS2 allele. NOS2−/− mice proved highly susceptible, resembling wild-type littermates immunosuppressed by high-dose glucocorticoids, and allowed Mycobacterium tuberculosis to replicate faster in the lungs than reported for other gene-deficient hosts. Susceptibility appeared to be independent of the only known naturally inherited antimicrobial locus, NRAMP1. Progression of chronic tuberculosis in wild-type mice was accelerated by specifically inhibiting NOS2 via administration of N6-(1-iminoethyl)-l-lysine. Together these findings identify NOS2 as a critical host gene for tuberculostasis.

Inhibition of the visual cycle in vivo by 13-cis retinoic acid protects from light damage and provides a mechanism for night blindness in isotretinoin therapy

Isotretinoin (13-cis retinoic acid) is frequently prescribed for severe acne [Peck, G. L., Olsen, T. G., Yoder, F. W., Strauss, J. S., Downing, D. T., Pandya, M., Butkus, D. & Arnaud-Battandier, J. (1979) N. Engl. J. Med. 300, 329–333] but can impair night vision [Fraunfelder, F. T., LaBraico, J. M. & Meyer, S. M. (1985) Am. J. Ophthalmol. 100, 534–537] shortly after the beginning of therapy [Shulman, S. R. (1989) Am. J. Public Health 79, 1565–1568]. As rod photoreceptors are responsible for night vision, we administered isotretinoin to rats to learn whether night blindness resulted from rod cell death or from rod functional impairment. High-dose isotretinoin was given daily for 2 months and produced systemic toxicity, but this caused no histological loss of rod photoreceptors, and rod-driven electroretinogram amplitudes were normal after prolonged dark adaptation. Additional studies showed, however, that even a single dose of isotretinoin slowed the recovery of rod signaling after exposure to an intense bleaching light, and that rhodopsin regeneration was markedly slowed. When only a single dose was given, rod function recovered to normal within several days. Rods and cones both showed slow recovery from bleach after isotretinoin in rats and in mice. HPLC analysis of ocular retinoids after isotretinoin and an intense bleach showed decreased levels of rhodopsin chromophore, 11-cis retinal, and the accumulation of the biosynthetic intermediates, 11-cis and all-trans retinyl esters. Isotretinoin was also found to protect rat photoreceptors from light-induced damage, suggesting that strategies of altering retinoid cycling may have therapeutic implications for some forms of retinal and macular degeneration.

Excessive tumor-elaborated VEGF and its neutralization define a lethal paraneoplastic syndrome

Vascular endothelial growth factor (VEGF) is a potent endothelial cell mitogen and key regulator of both physiologic and pathologic (e.g., tumor) angiogenesis. In the course of studies designed to assess the ability of constitutive VEGF to block tumor regression in an inducible RAS melanoma model, mice implanted with VEGF-expressing tumors sustained high morbidity and mortality that were out of proportion to the tumor burden. Documented elevated serum levels of VEGF were associated with a lethal hepatic syndrome characterized by massive sinusoidal dilation and endothelial cell proliferation and apoptosis. Systemic levels of VEGF correlated with the severity of liver pathology and overall clinical compromise. A striking reversal of VEGF-induced liver pathology and prolonged survival were achieved by surgical excision of VEGF-secreting tumor or by systemic administration of a potent VEGF antagonist (VEGF-TRAPR1R2), thus defining a paraneoplastic syndrome caused by excessive VEGF activity. Moreover, this VEGF-induced syndrome resembles peliosis hepatis, a rare human condition that is encountered in the setting of advanced malignancies, high-dose androgen therapy, and Bartonella henselae infection. Thus, our findings in the mouse have suggested an etiologic role for VEGF in this disease and may lead to diagnostic and therapeutic options for this debilitating condition in humans.

Intravenous injection of soluble antigen induces thymic and peripheral T-cells apoptosis.

The mechanism by which tolerance is induced via systemic administration of high doses of aqueous antigen has been analyzed by using mice transgenic for a T-cell receptor specific for the influenza virus hemagglutinin (HA) peptide comprising amino acids 126-138. After intravenous injection of 750 (but not 75) micrograms of HA peptide, a state of hyporesponsiveness was rapidly induced. In the thymus, in situ apoptosis in the cortex and at the corticomedullary junction was responsible for a synchronous and massive deletion of CD4+ CD8+ thymocytes. In secondary lymphoid organs, HA-reactive T cells were initially activated but were hyporesponsive at the single cell level. After 3 days, however, those cells were rapidly deleted, at least partially, through an apoptotic process. Therefore, both thymic and peripheral apoptosis, in addition to T-cell receptor desensitization, contribute to high-dose tolerance.

Discovery of adrenomedullin in rat ischemic cortex and evidence for its role in exacerbating focal brain ischemic damage.

Focal brain ischemia is the most common event leading to stroke in humans. To understand the molecular mechanisms associated with brain ischemia, we applied the technique of mRNA differential display and isolated a gene that encodes a recently discovered peptide, adrenomedullin (AM), which is a member of the calcitonin gene-related peptide (CGRP) family. Using the rat focal stroke model of middle cerebral artery occlusion (MCAO), we determined that AM mRNA expression was significantly increased in the ischemic cortex up to 17.4-fold at 3 h post-MCAO (P < 0.05) and 21.7-fold at 6 h post-MCAO (P < 0.05) and remained elevated for up to 15 days (9.6-fold increase; P < 0.05). Immunohistochemical studies localized AM to ischemic neuronal processes, and radioligand (125I-labeled CGRP) displacement revealed high-affinity (IC50 = 80.3 nmol) binding of AM to CGRP receptors in brain cortex. The cerebrovascular function of AM was studied using synthetic AM microinjected onto rat pial vessels using a cranial window or applied to canine basilar arteries in vitro. AM, applied abluminally, produced dose-dependent relaxation of preconstricted pial vessels (P < 0.05). Intracerebroventricular (but not systemic) AM administration at a high dose (8 nmol), prior to and after MCAO, increased the degree of focal ischemic injury (P < 0.05). The ischemia-induced expression of both AM mRNA and peptide in ischemic cortical neurons, the demonstration of the direct vasodilating effects of the peptide on cerebral vessels, and the ability of AM to exacerbate ischemic brain damage suggests that AM plays a significant role in focal ischemic brain injury.

Passive immunotherapy for retroviral disease: influence of major histocompatibility complex type and T-cell responsiveness.

Administration of virus-specific antibodies is known to be an effective early treatment for some viral infections. Such immunotherapy probably acts by antibody-mediated neutralization of viral infectivity and is often thought to function independently of T-cell-mediated immune responses. In the present experiments, we studied passive antibody therapy using Friend murine leukemia virus complex as a model for an immunosuppressive retroviral disease in adult mice. The results showed that antibody therapy could induce recovery from a well-established retroviral infection. However, the success of therapy was dependent on the presence of both CD4+ and CD8+ T lymphocytes. Thus, cell-mediated responses were required for recovery from infection even in the presence of therapeutic levels of antibody. The major histocompatibility type of the mice was also an important factor determining the relative success of antibody therapy in this system, but it was less critical for low-dose than for high-dose infections. Our results imply that limited T-cell responsiveness as dictated by major histocompatibility genes and/or stage of disease may have contributed to previous immunotherapy failures in AIDS patients. Possible strategies to improve the efficacy of future therapies are discussed.

The cell wall components peptidoglycan and lipoteichoic acid from Staphylococcus aureus act in synergy to cause shock and multiple organ failure.

Although the incidence of Gram-positive sepsis has risen strongly, it is unclear how Gram-positive organisms (without endotoxin) initiate septic shock. We investigated whether two cell wall components from Staphylococcus aureus, peptidoglycan (PepG) and lipoteichoic acid (LTA), can induce the inflammatory response and multiple organ dysfunction syndrome (MODS) associated with septic shock caused by Gram-positive organisms. In cultured macrophages, LTA (10 micrograms/ml), but not PepG (100 micrograms/ml), induces the release of nitric oxide measured as nitrite. PepG, however, caused a 4-fold increase in the production of nitrite elicited by LTA. Furthermore, PepG antibodies inhibited the release of nitrite elicited by killed S. aureus. Administration of both PepG (10 mg/kg; i.v.) and LTA (3 mg/kg; i.v.) in anesthetized rats resulted in the release of tumor necrosis factor alpha and interferon gamma and MODS, as indicated by a decrease in arterial oxygen pressure (lung) and an increase in plasma concentrations of bilirubin and alanine aminotransferase (liver), creatinine and urea (kidney), lipase (pancreas), and creatine kinase (heart or skeletal muscle). There was also the expression of inducible nitric oxide synthase in these organs, circulatory failure, and 50% mortality. These effects were not observed after administration of PepG or LTA alone. Even a high dose of LTA (10 mg/kg) causes only circulatory failure but no MODS. Thus, our results demonstrate that the two bacterial wall components, PepG and LTA, work together to cause systemic inflammation and multiple systems failure associated with Gram-positive organisms.

Animal model for the therapy of acquired immunodeficiency syndrome with reverse transcriptase inhibitors.

The reverse transcriptase (RT) of the human immunodeficiency virus type 1 (HIV-1) is the major target for antiretroviral therapy of the acquired immunodeficiency syndrome (AIDS). While some inhibitors exhibit activity against most retroviral RTs, others are specific for the HIV-1 enzyme. To develop an animal model for the therapy of the HIV-1 infection with RT inhibitors, the RT of the simian immunodeficiency virus (SIV) was replaced by the RT of HIV-1. Macaques infected with this SIV/HIV-1 hybrid virus developed AIDS-like symptoms and pathology. The HIV-1-specific RT inhibitor LY300046.HCl, but not zidovudine [3'-azido-3'-deoxythymidine (AZT)] delayed the appearance of plasma antigenemia in macaques infected with a high dose of the chimeric virus. Infection of macaques with the chimeric virus seems to be a valuable model to study the in vivo efficacy of new RT inhibitors, the emergence and reversal of drug resistance, the therapy of infections with drug-resistant viruses, and the efficacy of combination therapy.