Expert Testimony on Proximate Cause

Expert testimony is common in tort litigation, especially on issues of standard of care and cause-in-fact. Rule 704 of the Federal Rules of Evidence and its state counterparts abolished the prohibition of testimony on ultimate issues, leading to the possibility of expert testimony on the often crucial issue of proximate cause. The situation is easy to imagine. After counsel has qualified an expert witness and elicited an opinion that the particular act or omission caused the injury in question, counsel might very well be tempted to inquire whether the witness has an opinion as to whether the act or omission was a proximate or legal cause of the accident. Or, counsel may merge the two lines of inquiry and ask whether the act or omission proximately resulted in the accident or injury to the plaintiff. The inquiry seems harmless. The term proximate is commonly understood to mean only near or close to. The question is not innocuous, however. The issue of expert testimony on the question of proximate cause implicates several restrictions on expert testimony that survive the broad permission of Rule 704, and touches upon the serious issue of the proper roles of expert and fact-finder in the application of law to facts. The few published cases that have considered the issue of expert testimony on proximate cause are split.\u27 The question arises far more often, however, than is indicated by the relative scarcity of reported decisions. This Article addresses the usefulness and propriety of expert testimony on the issue of proximate cause. After briefly defining the concept of proximate cause, this Article argues that expert testimony on proximate cause is inadmissible under Rule 704, despite the general admissibility of testimony on ultimate issues. In addition, opinion on proximate cause is inadmissible because it fails to clear the separate hurdles of Rules 702\u27 and 4036 of the Federal Rules of Evidence. A technical expert on standard of care or actual cause is not qualified to opine on the issue of proximate cause and thus fails the expertise test of Rule 702. Furthermore, even the testimony of a genuine expert on the issue of proximate cause should be excluded because such testimony fails the helpfulness test of Rule 702. Finally, expert testimony on the issue of proximate cause is inadmissible under Rule 403 because its probative value is substantially outweighed by the possibility that such testimony will confuse the issues and mislead the jury

A novel codon insert in protease of clade B HIV type 1.

A novel combination of three codon inserts in the pol coding region of HIV-1 RNA was identified in a highly antiretroviral experienced study subject with HIV-1 infection. A one codon insert was observed in the protease region between codon 40 and 41 simultaneously with a two codon insert present in the reverse transcriptase region at codon 69

Human immunodeficiency virus type 1 mutants resistant to nonnucleoside inhibitors of reverse transcriptase arise in tissue culture

We have recently described a nonnucleoside compound that specifically inhibits the reverse transcriptase of human immunodeficiency virus type 1 (HIV-1), the causative agent of AIDS. This compound, nevirapine (BI-RG-587), interacts with highly conserved tyrosine residues at positions 181 and 188 in the reverse transcriptase to inhibit the recombinant enzyme and virus replication in cell culture with 50% inhibitory concentrations in the 40 nM range. HIV-1 variants resistant to nevirapine emerged with passage in cell culture in the presence of drug. This resistant phenotype was stable with continued passage in the absence of drug. These mutants had a substitution of cysteine for the tyrosine at position 181. Introduction of this mutation into the recombinant enzyme increased the inhibitory concentration of nevirapine 100-fold. Substitution of cysteine for tyrosine at residue 181 into the wild-type viral genome conferred a similar reduction in susceptibility to nevirapine. Mutants were also resistant to a tetrahydroimidazo[4,5,1-jk][1,4]benzodiazepin-2(1H)-one and -thione derivative and two 6-phenylthiouracil derivatives but retained their sensitivity to the other reverse transcriptase inhibitors, 3'-azido-3'-deoxythymidine and foscarnet

Absence of detectable HIV-1 viremia after treatment cessation in an infant

An infant born to a woman with human immunodeficiency virus type 1 (HIV-1) infection began receiving antiretroviral therapy (ART) 30 hours after birth owing to high-risk exposure. ART was continued when detection of HIV-1 DNA and RNA on repeat testing met the standard diagnostic criteria for infection. After therapy was discontinued (when the child was 18 months of age), levels of plasma HIV-1 RNA, proviral DNA in peripheral-blood mononuclear cells, and HIV-1 antibodies, as assessed by means of clinical assays, remained undetectable in the child through 30 months of age. This case suggests that very early ART in infants may alter the establishment and long-term persistence of HIV-1 infection

2022 update of the drug resistance mutations in HIV-1

The 2022 edition of the IAS-USA drug resistance mutations list updates the Figure last published in September 2019. The mutations listed are those that have been identified by specific criteria for evidence and drugs described. The Figure is designed to assist practitioners to identify key mutations associated with resistance to antiretroviral drugs, and therefore, in making clinical decisions regarding antiretroviral therapy

Adaptation to Different Human Populations by HIV-1 Revealed by Codon-Based Analyses

Several codon-based methods are available for detecting adaptive evolution in protein-coding sequences, but to date none specifically identify sites that are selected differentially in two populations, although such comparisons between populations have been historically useful in identifying the action of natural selection. We have developed two fixed effects maximum likelihood methods: one for identifying codon positions showing selection patterns that persist in a population and another for detecting whether selection is operating differentially on individual codons of a gene sampled from two different populations. Applying these methods to two HIV populations infecting genetically distinct human hosts, we have found that few of the positively selected amino acid sites persist in the population; the other changes are detected only at the tips of the phylogenetic tree and appear deleterious in the long term. Additionally, we have identified seven amino acid sites in protease and reverse transcriptase that are selected differentially in the two samples, demonstrating specific population-level adaptation of HIV to human populations

Effect of Influenza Vaccination on Viral Replication and Immune Response in Persons Infected with Human Immunodeficiency Virus Receiving Potent Antiretroviral Therapy

Nineteen patients infected with human immunodeficiency virus (HIV) with varying levels of viral suppression achieved with antiretroviral therapy were evaluated to determine whether trivalent influenza vaccine activated HIV replication. Humoral immune responses and CD4+ lymphocyte subsets were compared in 5 HIV-uninfected vaccinated subjects. Transient elevations of plasma HIV RNA levels (76-89 copies/mL) appeared within 2 weeks in 3 of 11 patients with 50 copies/mL. HIV DNA decreased in patients with <400 RNA copies/mL at baseline and showed an HIV RNA increase after vaccination (n = 8) when compared with 8 patients with <50 copies/mL at baseline who lacked viral response to vaccination. Concurrent decreases in proviral DNA and memory phenotype CD4+ cells in association with increased plasma HIV RNA after vaccination in patients with <400 RNA copies/mL at baseline suggest that in vivo mobilization of the latently infected cell reservoir may occur during potent antiretroviral therap

Local and regional ecological morphology of dung beetle assemblages across four biogeographic regions

Aim Niche partitioning within species assemblages is thought to influence species packing and/or total niche space occupied. The evolution of dung beetles (Scarabaeinae) is likely to have been strongly influenced by inter-specific competition, leading to niche partitioning. We consider whether local-scale processes leave a signature in regional patterns of functional diversity in dung beetle assemblages, and investigate the correlation between total exploited ecomorphological space and density of species packing with increased species richness. We test whether ecomorphological space occupied by local assemblages reflects that of their regional species pool, and the extent to which ecomorphological space is convergent or divergent within functional groups across regional pools. Location Neotropics, Africa, Australia and Madagascar. Methods Dung beetle assemblages were collected in a standardized manner from four biogeographic regions. Ecomorphological similarity among the assemblages was assessed by multivariate analysis of 19 linear measurements for 300 species and three functional nesting types (roller, tunneller or dweller), firstly on a local level within the Neotropics and Afrotropics, and then between the regional species pools. Results Key body measurements, in particular the hind tibia, separated rollers and tunnellers into largely non-overlapping entities along the first three axes of the shape analysis. Three Neotropical assemblages, which vary widely in species numbers, each harboured a similar amount of morphometric variation, resulting in increasingly dense species packing with greater species richness. Similar findings were obtained in two South African assemblages. Assemblages in the four biogeographic regions showed largely similar distributions of ecomorphological variation, including the separation of rollers and tunnellers, despite their distant phylogenetic relationships. Ecomorphological similarity among regions was particularly high in tunnellers, whilst the rollers exhibited greater regional differentiation. Main conclusions Local assemblages evidently represent the full diversity of functional groups available in the regional pool, even in species-poor assemblages. There is a strong trend towards convergence in morphology separating tunnellers and rollers in phylogenetically independent lineages. The ecomorphological similarity of regional assemblages suggests that morphological convergence is the result of common selective forces active within the assemblages themselves. This lends support to the widely hypothesized effect of inter-specific interactions and niche partitioning in determining assemblage composition and lineage evolution in the Scarabaeinae. © 2011 Blackwell Publishing Ltd

Effect of Treatment, during Primary Infection, on Establishment and Clearance of Cellular Reservoirs of HIV-1

Patients in whom virologic suppression is achieved with highly active antiretroviral therapy (HAART) retain long-lived cellular reservoirs of human immunodeficiency virus type 1 (HIV-1); this retention is an obstacle to sustained control of infection. To assess the impact that initiating treatment during primary HIV-1 infection has on this cell population, we analyzed the decay kinetics of HIV-1 DNA and of infectivity associated with cells activated ex vivo in 27 patients who initiated therapy before or <6 months after seroconversion and in whom viremia was suppressed to <50 copies/mL. The clearance rates of cellular reservoirs could not be distinguished by these techniques (median half-life, 20 weeks) during the first year of HAART. The clearance of HIV-1 DNA slowed significantly during the subsequent 3 years of treatment (median half-life, 70 weeks), consistent with heterogeneous cellular reservoirs being present. Total cell-associated infectivity (CAI) after 1 year of treatment was undetectable (<0.07 infectious units/million cells [IUPM]) in most patients initiating treatment during primary infection either before (9/9) or <6 months after (6/8) seroconversion. In contrast, all 17 control patients who initiated HAART during chronic infection retained detectable CAI after 3-6 years of treatment (median reservoir size, 1.1 IUPM; P<.0005). These results suggest that treatment <6 months after seroconversion may facilitate long-term control of cellular reservoirs that maintain HIV-1 infection during treatmen

CD32 is expressed on cells with transcriptionally active HIV but does not enrich for HIV DNA in resting T cells

The persistence of HIV reservoirs, including latently infected, resting CD4+ T cells, is the major obstacle to cure HIV infection. CD32a expression was recently reported to mark CD4+ T cells harboring a replication-competent HIV reservoir during antiretroviral therapy (ART) suppression. We aimed to determine whether CD32 expression marks HIV latently or transcriptionally active infected CD4+ T cells. Using peripheral blood and lymphoid tissue of ART-treated HIV+ or SIV+ subjects, we found that most of the circulating memory CD32+ CD4+ T cells expressed markers of activation, including CD69, HLA-DR, CD25, CD38, and Ki67, and bore a TH2 phenotype as defined by CXCR3, CCR4, and CCR6. CD32 expression did not selectively enrich for HIV- or SIV-infected CD4+ T cells in peripheral blood or lymphoid tissue; isolated CD32+ resting CD4+ T cells accounted for less than 3% of the total HIV DNA in CD4+ T cells. Cell-associated HIV DNA and RNA loads in CD4+ T cells positively correlated with the frequency of CD32+ CD69+ CD4+ T cells but not with CD32 expression on resting CD4+ T cells. Using RNA fluorescence in situ hybridization, CD32 coexpression with HIV RNA or p24 was detected after in vitro HIV infection (peripheral blood mononuclear cell and tissue) and in vivo within lymph node tissue from HIV-infected individuals. Together, these results indicate that CD32 is not a marker of resting CD4+ T cells or of enriched HIV DNA–positive cells after ART; rather, CD32 is predominately expressed on a subset of activated CD4+ T cells enriched for transcriptionally active HIV after long-term ART