Fetoscopic Laser Ablation for Twin-to-Twin Transfusion Syndrome: A 15-year Review of Perinatal Survival

Objective Twin to twin transfusion syndrome (TTTS) complicates 5-15% of monochorionic twin pregnancies and untreated is associated with a 90% mortality rate. The aim was to present the perinatal survival of patients with TTTS treated with laser ablation, by a national fetal medicine team. Methods This was a review of all cases of TTTS treated with fetoscopic laser ablation performed from March 2006 through to December 2020. All patients treated with fetoscopic laser were identified from the hospital database. The perinatal outcomes for the overall cohort and the individual Quintero stages were determined. Results A total of 155 cases of TTTS underwent fetoscopic laser ablation during the study period. The median gestational age at diagnosis was 19+1 weeks, with a mean growth discordance of 23.6%. The Quintero stage at diagnosis was: Stage 1 6.5% (10/155), Stage 2 49% (76/155), Stage 3 38.7% (60/155), Stage 4 5.8% (9/155). There was at least one survivor in 83.2% (129/155) of pregnancies, with dual survival in 52.9% (82/155). An increase in the rate of any survivor was observed from 75% (2006-2014) to 94% (2014-2020) (p<0.05). Dual survival decreased with increasing Quintero Stage (p<0.05). 80.6% (125/155) of pregnancies delivered prior to 34+6 weeks gestation. Conclusion Fetoscopic laser ablation is the recommended first line treatment for severe TTTS. We observed a survival rate of at least one twin in 83.2% pregnancies which is comparable to internationally published data on single-centre outcomes.

Euploid First-Trimester Cystic Hygroma: A More Benign Entity than Previously Thought?

OBJECTIVE

Studies summarizing the outcome of first-trimester septated cystic hygroma are generally based on small studies or from multiple centers with limited ascertainment. We reviewed the natural history of a large cohort of such cases from a single tertiary referral center, with the aim being to establish contemporary outcome data, particularly in the setting of normal karyotype.

METHODS

A retrospective cohort study from 2007 to 2017 was conducted at a single tertiary referral prenatal diagnosis center. Data were analyzed from a prospectively collated fetal anomaly database. Search terms were "increased nuchal translucency (NT)," "cystic hygroma," and "septated cystic hygroma." All cases were confirmed to have NT >3 mm with septations. Cases of simple increased NT without septations were excluded.

RESULTS

During the study period, over 110,000 pregnancies were delivered at our center, resulting in 410 cases of septated cystic hygroma diagnosed prior to 14 weeks' gestation. Pregnancy outcome was obtained in 99% (405/410) of cases, with detailed pathology outcome available in 92% (378/410). A total of 87% (351/405) underwent invasive prenatal testing, and postnatal chromosome status was established in further 27 cases. A total of 61% (230/378) had abnormal chromosomal status. Of the 39% (148/378) with normal chromosomal status, only 13% (19/148) had a significant structural fetal abnormality, which included 7 cardiac and 12 noncardiac abnormalities. Overall, the perinatal loss was 62% (253/405). The total survival rate in the setting of euploid cystic hygroma without structural abnormality was 84% (108/129).

CONCLUSIONS

Counseling regarding outcomes in the setting of first-trimester septated cystic hygroma initially focuses on the strong likelihood of an abnormal karyotype, which occurs in 61% of cases. However, once fetal chromosomal abnormality is excluded, our results demonstrate only a 13% incidence of major structural fetal abnormality, which appears significantly less than previously reported. Normal fetuses have a 77% survival rate. These data represent the largest single-center study of first-trimester cystic hygroma with complete outcome data and therefore will be useful for contemporary patient counseling. Such counseling can be more positive than previously expected, once chromosomal abnormality is first excluded.

PCR vs karyotype for CVS and amniocentesis-the experience at one tertiary fetal medicine unit

Purpose

Despite the rise of non-invasive screening tests for fetal aneuploidy, invasive testing during pregnancy remains the definitive diagnostic tool for fetal genetic anomalies. Results are rapidly available with polymerase chain reaction (PCR) tests, but cases have been reported whereby initial results were not confirmed after pregnancy termination and the fetal karyotype was ultimately normal. We sought to examine the potential discordance between PCR and karyotype for fetal aneuploidy.

Methods

The results from all amniocentesis and CVS tests performed over a 6-year period in a large tertiary level fetal medicine unit were reviewed. The results of PCR and karyotype were recorded and discrepancies examined. Pregnancy outcomes were also recorded.

Results

A total of 1222 invasive tests were performed (716 amniocentesis and 506 CVS). Within the cohort having amniocentesis, 11 had discrepant results (normal QF-PCR result but with a subsequent abnormal karyotype). There was 1 case among this group which QF-PCR should have identified. Within the CVS group, 7 patients had discrepant results. All had a diploid QF-PCR and would not have been identified as abnormal by it.

Conclusion

PCR can be reliably used to determine aneuploidy of chromosomes 13, 18, and 21. However, in cases of sex chromosome aneuploidy, its performance is less reliable and warrants waiting for a complete karyotype. Given such discordance, we advise waiting for karyotype for all invasive tests performed in the presence of a normal ultrasound before advising a patient of a diploid QF-PCR result or potentially terminating a normal pregnancy.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

An expert consensus definition of failure of a treatment to provide adequate relief (F-PAR) for chronic constipation - an international Delphi survey

BACKGROUND

As treatments for constipation become increasingly available, it is important to know when to progress along the treatment algorithm if the patient is not better.

AIM

To establish the definition of failure of a treatment to provide adequate relief (F-PAR) to support this management and referral process in patients with chronic constipation.

METHODS

We conducted an international Delphi Survey among gastroenterologists and general practitioners with a special interest in chronic constipation. An initial questionnaire based on recognised rating scales was developed following a focus group. Data were collected from two subsequent rounds of questionnaires completed by all authors. Likert scales were used to establish a consensus on a shorter list of more severe symptoms.

RESULTS

The initial focus group yielded a first round questionnaire with 84 statements. There was good consensus on symptom severity and a clear severity response curve, allowing 67 of the symptom-severity pairings to be eliminated. Subsequently, a clear consensus was established on further reduction to eight symptom statements in the final definition, condensed by the steering committee into five diagnostic statements (after replicate statements had been removed).

CONCLUSIONS

We present an international consensus on chronic constipation, of five symptoms and their severities, any of which would be sufficient to provide clinical evidence of treatment failure. We also provide data representing an expert calibration of commonly used rating scales, thus allowing results of clinical trials expressed in terms of those scales to be converted into estimates of rates of provision of adequate relief.

Prevalence, symptom patterns and management of episodic diarrhoea in the community: a population-based survey in 11 countries

BACKGROUND

The extent of episodic diarrhoea in the community is relatively unknown.

AIM

To ascertain the prevalence, symptoms and management behaviours associated with self-reported diarrhoea across 11 countries.

METHODS

Community screening surveys were conducted using quota sampling of respondents to identify a nationally representative sample of individuals suffering from 'episodic' diarrhoea (occurring once a month or more often). Second-phase in-depth surveys provided data on epidemiology, symptoms, attributed causes and management of episodic diarrhoea.

RESULTS

A total of 11 508 phase 1 and 6613 phase 2 surveys were completed. The prevalence of self-reported episodic diarrhoea ranged from 16% to 23% across the 11 countries. The majority of episodic diarrhoea sufferers were female (57%) and were not diagnosed with pre-existing irritable bowel syndrome (IBS); IBS diagnosis ranged from 9% in Mexico to 44% in Italy. Diarrhoea was frequently attributed to anxiety/stress, food-related causes, gastrointestinal 'sensitivity' and menstruation. Accompanying symptoms included 'stomach pain/cramping' (35-62%), 'stomach grumbling' (29-68%) and 'wind' (18-74%). The proportion of episodic sufferers who reported treating their symptoms with remedies or medications ranged between 46% in Belgium and Canada and 90% in Mexico.

CONCLUSIONS

A substantial proportion of the population in middle- to high-income countries report episodic diarrhoea in the absence of a pre-existing diagnosis. These symptoms are likely to be associated with substantial social and economic costs, and have implications on how best to configure and guide self-led, pharmacist-led and primary care management.

Outcome following selective fetoscopic laser ablation for twin to twin transfusion syndrome: an 8 year national collaborative experience

OBJECTIVE

With the recognition of the role of fetoscopic laser ablation for twin to twin transfusion syndrome (TTTS), there is a requirement for auditable standards for this technically challenging and specialized treatment. The purpose of this study is to report on the perinatal and medium-term neurodevelopmental outcomes following an 8-year national single center experience in the management of TTTS using the selective fetoscopic laser ablation technique.

STUDY DESIGN

An audit of all cases of TTTS treated with selective laser ablation by a single national fetal medicine team was performed. Overall perinatal survival and medium-term neurodevelopmental outcomes were reported and correlated with gestational age at diagnosis, placental location, volume of amnio-reduction, Quintero staging and percentage inter-twin growth discordance. Procedure-related complications were recorded.

RESULTS

The overall fetal survival for the first 105 consecutive cases of TTTS was 61% (128/210 fetuses). Dual survival occurred in 47% (49/105) of cases, and with a single survival rate of 28% (30/105), perinatal survival of least one infant was achieved in 75% (79/105) of cases. No correlation was found between any clinical or sonographic marker and perinatal outcome, although dual survival was noted to be significantly decreased with increasing Quintero stage (p=0.041). Currently, 86% of survivors have been reported to have a normal medium-term neurological outcome.

CONCLUSION

Fetoscopic laser ablation is the established optimal treatment for severe twin to twin transfusion syndrome (TTTS). We report comparable short and medium-term outcomes following the selective fetoscopic technique comparing results from our national program with internationally published single-center outcomes, supporting the efficacy and safety of this treatment at our center.

Public involvement in research: assessing impact through a realist evaluation

Background

This study was concerned with developing the evidence base for public involvement in research in health and social care. There now is significant support for public involvement within the National Institute for Health Research, and researchers applying for National Institute for Health Research grants are expected to involve the public. Despite this policy commitment, evidence for the benefits of public involvement in research remains limited. This study addressed this need through a realist evaluation.

Aim and objectives

The aim was to identify the contextual factors and mechanisms that are regularly associated with effective public involvement in research. The objectives included identifying a sample of eight research projects and their desired outcomes of public involvement, tracking the impact of public involvement in these case studies, and comparing the associated contextual factors and mechanisms.

Design

The research design was based on the application of realist theory of evaluation, which argues that social programmes are driven by an underlying vision of change – a ‘programme theory’ of how the intervention is supposed to work. The role of the evaluator is to compare theory and practice. Impact can be understood by identifying regularities of context, mechanism and outcome. Thus the key question for the evaluator is ‘What works for whom in what circumstances . . . and why?’ (Pawson R.The Science of Evaluation. London: Sage; 2013). We therefore planned a realist evaluation based on qualitative case studies of public involvement in research.

Setting and participants

Eight diverse case studies of research projects in health and social care took place over the calendar year 2012 with 88 interviews from 42 participants across the eight studies: researchers, research managers, third-sector partners and research partners (members of the public involved in research).

Results

Case study data supported the importance of some aspects of our theory of public involvement in research and led us to amend other elements. Public involvement was associated with improvements in research design and delivery, particularly recruitment strategies and materials, and data collection tools. This study identified the previously unrecognised importance of principal investigator leadership as a key contextual factor leading to the impact of public involvement; alternatively, public involvement might still be effective without principal investigator leadership where there is a wider culture of involvement. In terms of the mechanisms of involvement, allocating staff time to facilitate involvement appeared more important than formal budgeting. Another important new finding was that many research proposals significantly undercosted public involvement. Nurturing good interpersonal relationships was crucial to effective involvement. Payment for research partner time and formal training appeared more significant for some types of public involvement than others. Feedback to research partners on the value of their contribution was important in maintaining motivation and confidence.

Conclusions

A revised theory of public involvement in research was developed and tested, which identifies key regularities of context, mechanism and outcome in how public involvement in research works. Implications for future research include the need to further explore how leadership on public involvement might be facilitated, methodological work on assessing impact and the development of economic analysis of involvement.

Funding details

The National Institute for Health Research Health Service and Delivery programme.

Search for gravitational-wave bursts from soft gamma repeaters

We present a LIGO search for short-duration gravitational waves (GWs) associated with soft gamma ray repeater (SGR) bursts. This is the first search sensitive to neutron star f modes, usually considered the most efficient GW emitting modes. We find no evidence of GWs associated with any SGR burst in a sample consisting of the 27 Dec. 2004 giant flare from SGR 1806-20 and 190 lesser events from SGR 1806-20 and SGR 1900+14. The unprecedented sensitivity of the detectors allows us to set the most stringent limits on transient GW amplitudes published to date. We find upper limit estimates on the model-dependent isotropic GW emission energies (at a nominal distance of 10 kpc) between 3x10;{45} and 9x10;{52} erg depending on waveform type, detector antenna factors and noise characteristics at the time of the burst. These upper limits are within the theoretically predicted range of some SGR models.

Infantile gastroenteritis in the community: a cost-of-illness study

Rotavirus infections are the main cause of gastroenteritis in infants and children and it is expected that by the age of 5 years, nearly every child will have experienced at least one episode of rotavirus gastroenteritis. While severe cases are hospitalized, milder disease is either treated at home or by the GP, and as such the true prevalence of rotavirus infection in the community, and the burden of disease, is unknown. This paper reports the results of a cost-of-illness study which was conducted alongside a structured community surveillance study. Forty-eight percent of our sample was found to have rotavirus acute gastroenteritis; and the average total cost of a child presenting with rotavirus gastroenteritis ranged between pound sterling 59 and pound sterling 143 per episode, depending on the perspective. Given the prevalence and severity of the disease, the estimated burden of rotavirus gastroenteritis to society is pound sterling 11.5 million per year.

Structured surveillance of infantile gastroenteritis in East Anglia, UK: incidence of infection with common viral gastroenteric pathogens

The aim of this study was to investigate the burden of disease associated with gastroenteric viruses (rotavirus, norovirus, sapovirus, astrovirus and enteric adenovirus) using structured surveillance of children aged <6 years in the community. Faecal samples were collected between 2000 and 2003 from 685 children with symptoms of gastroenteritis. The children comprised three groups; 223 in the structured surveillance cohort, 203 in a community cohort and 259 in a cohort of hospitalized children. All samples were tested for the presence of viral pathogens using molecular methods. Questionnaires were sent to the parents/carers of the children recruited to the structured surveillance cohort in order to collect data that would allow an estimation of the severity of illness by means of the Vesikari score, and of the cost associated with gastrointestinal disease in this age group. A viral aetiological agent was detected in 53.5% of samples tested. Rotavirus was the most common pathogen found in all three cohorts followed by norovirus and enteric adenoviruses. Multiple viruses were found in 8% of the samples, and commonly involved rotavirus and any other virus. G1P[8] was the most commonly detected rotavirus strain and there was no significant difference in the distribution of rotavirus genotypes among the three cohorts. Analysis of the questionnaires indicated that rotavirus infections were likely to be more severe than any other virus infection, and children from whom a viral pathogen was identified were more likely to require rehydration therapy.

Upper limits on a stochastic background of gravitational waves

The Laser Interferometer Gravitational-Wave Observatory has performed a third science run with much improved sensitivities of all three interferometers. We present an analysis of approximately 200 hours of data acquired during this run, used to search for a stochastic background of gravitational radiation. We place upper bounds on the energy density stored as gravitational radiation for three different spectral power laws. For the flat spectrum, our limit of omega0 < 8.4 x 10(-4) in the 69-156 Hz band is approximately 10(5) times lower than the previous result in this frequency range.

Outcomes following unilateral uterine artery embolisation

Uterine artery embolisation has been described as successful only when both arteries are embolised. However, results in patients with one congenitally absent or previously ligated artery are unknown. Women suffering from symptomatic uterine myomata were treated at a university teaching hospital, a community hospital and an outpatient surgery centre. Retrospective review of patient response to embolisation was assessed by chart review and questionnaire. Uterine and dominant fibroid size response was assessed by comparing pre- and post-embolisation ultrasound examinations. This study analysed three patient groups within the general population: those who underwent unilateral embolisation because of technical failure, those who ultimately underwent bilateral embolisation after initial technical failure and those who underwent unilateral embolisation because of an absent uterine artery. 12 patients underwent unilateral embolisation, 4 of whom underwent this procedure because of an absent uterine artery. Three of these four patients had a congenitally absent uterine artery arising from the internal iliac artery and all three experienced successful outcomes. The fourth patient had a previously ligated internal iliac artery and her symptoms worsened after the procedure. Eight patients had unilateral embolisation due to technical failure. Five of these patients underwent a subsequent procedure during which the contralateral uterine artery was embolised. Four of these five patients had successful outcomes and one was lost to follow-up. Another of the eight patients suffered an arterial injury leading to technical failure, and was lost to follow-up. Of the two remaining patients with unilateral technical failure, only one had a successful outcome. This study concluded that patients who undergo unilateral embolisation for technical reasons should be offered a second embolisation procedure shortly after the initial procedure. Patients with a congenitally absent uterine artery may respond with similar success to those who underwent bilateral embolisation. In contrast, the patient with a previously ligated internal iliac artery failed. The numbers in this study are too small for statistical analysis and subsequent studies should be performed to confirm these findings.

Cross sectional study of reporting of epileptic seizures to general practitioners

OBJECTIVE

Comparison of reporting of recent epileptic seizures by patients to a doctor and anonymously.

DESIGN

Cross sectional study of patients with epilepsy by comparison of paired questionnaires.

SETTING

Rural and urban general practices in Norfolk.

PARTICIPANTS

122 patients aged over 16 years and able to self complete a questionnaire who were recruited by 31 general practitioners when attending for review of their epilepsy.

MAIN OUTCOME MEASURE

The difference in reported occurrence of seizure to general practitioners and in a linked anonymous questionnaire.

RESULTS

18 patients failed to report a seizure in the past year to their general practitioner (uncontrolled epilepsy). 40% (24/60) of people with epilepsy who anonymously reported a seizure in the past year held a driving licence, but only six revealed this to their general practitioner. The unemployment rate was 34%, substantially higher than the 9% in the general population. Measures of anxiety, depression, and stigmatization were higher in patients with uncontrolled epilepsy.

CONCLUSIONS

A significant proportion of patients with epilepsy under-report their seizures. Recognition of underreporting is important if patients are to benefit from adequate and appropriate treatment. General practitioners' ability to treat epilepsy is hampered by their role in regulating the rights of epileptic patients to hold a driving licence or access certain occupations.

Why do patients default from follow-up at a genitourinary clinic?: a multivariate analysis

OBJECTIVE

Firstly to compare the proportion of patients defaulting from follow up at a genitourinary medicine clinic with those attending other hospital based clinics. Secondly to determine which factors are associated with non attendance at a city centre genitourinary medicine clinic.

METHODOLOGY

The proportion of patients who defaulted at a genitourinary medicine clinic, a general medical clinic, a general surgical clinic and a dermatology clinic during March 1995 were compared. A multivariate logistic regression analysis was performed comparing attenders and non attenders at the genitourinary medicine clinic with respect to time of appointment, diagnosis, previous contacts with clinic staff, potential domestic commitments and patient demographics in a prospective case control study.

RESULTS

The default rate at the genitourinary medicine clinic was 15% compared with 13%, 15% and 14% for medical, surgical and dermatology clinics respectively. Patients who defaulted from the genitourinary medicine clinic (167) were compared with 172 attenders and significant differences found for timing of appointments, area of residence, frequency of counselling by the health advisor and age of the patient. Other factors such as the diagnosis, whether a woman had children, sexual orientation, whether negative results had been given over the phone, source of referral, sex of patient, employment status and the weather were not found to be significantly associated with defaulting from an appointment.

CONCLUSIONS

The time of the appointment and being seen by a health advisor were the only variables identified over which the clinic has control and therefore could potentially reduce non attendance rates.

Clinical results from intracytoplasmic sperm injection at monash IVF

The impact of a modification of the intracytoplasmic sperm injection (ICSI) technique on fertilization and pregnancy rates was examined in a retrospective analysis of 171 consecutive ICSI treatment cycles (156 patients). Patients were selected for ICSI on the basis of severe oligoasthenozoospermia (65 patients) or following conventional in vitro fertilization (IVF) with failed or poor fertilization (70 patients). Seven patients in which epididymal or testicular sperm was used, 10 patients with sperm antibodies and 4 patients with retrograde ejaculation or who required electro-ejaculation were also treated with ICSI. In the first 105 cycles (102 patients), single sperm, rendered immotile, were injected into the ooplasm of 979 metaphase II (M II) oocytes using an established technique (Method 1). In the following 66 cycles (513 M II oocytes injected), the ICSI procedure was modified by increased aspiration of the oolemma to ensure the intracytoplasmic deposition of sperm (Method 2). The patient groups did not differ between the two injection procedures. The normal (two pronuclear) fertilization rate increased significantly (P < 0.001) from 34.3% with Method 1 to 73.1% with Method 2, with no difference in the oocyte degeneration rate (4.3% v. 4.5% respectively). The incidence of failed fertilization was significantly (P < 0.01) reduced from 17.1% (18 cycles) to 1.6% (1 cycle) with the change in technique. As a consequence of the increased fertilization rates with Method 2, more embryos were available for assessment and transfer, and a pregnancy rate per oocyte retrieval of 21.2% was obtained for Method 2. Fertilization, embryo transfer and pregnancies were obtained in all patient groups treated with ICSI.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum antibodies to structural proteins of hantavirus arise at different times after infection

An enzyme-linked immunosorbent assay (ELISA) was developed for the quantification of serum antibodies against group-specific epitopes of the glycoproteins (G1, G2) and nucleoprotein (NP) of the genus Hantavirus. This assay was used to study the kinetics of the development of serum antibodies after natural infection with Puumala-like virus in humans. To this end a panel of 34 serum samples collected from individuals at different times after natural infection was tested by the ELISA. The samples were also tested for specific IgM and IgG levels against Puumala-like virus, which provided confirmatory data about the presumed timing of infection. It was shown that serum antibodies against the G1 epitope were present in the acute and early convalescent period just before antibodies to the NP epitope could be demonstrated. In contrast, antibodies to two G2 epitopes were present not earlier than in the convalescent and late convalescent period. Since all these categories of antibodies seem to persist for long periods, antibodies against the G1 epitope and the NP epitope may be of specific diagnostic value. Furthermore, levels of G1-specific antibodies and antibodies to either NP or G2 may allow estimation of the time elapsed following initial infection.

Identification of Hantavirus serotypes by testing of post-infection sera in immunofluorescence and enzyme-linked immunosorbent assays

Serum samples were collected from 27 individuals who had been infected with a member of the genus Hantavirus in the Netherlands or Belgium during the last 15 years. These samples were tested in an immunofluorescence assay (IFA) and two enzyme-linked immunosorbent assay (ELISA) systems, using different virus strains that represented each of the four recently proposed serotypes of this genus. The serum samples from 11 individuals who had been infected through contacts with laboratory rats showed the highest reactivities with Hantaan virus (serotype I) and SR-11 (serotype II) in the IFA and ELISA systems. The samples of 16 individuals who had probably been infected through contacts with wild rodents showed the highest reactivities with Hällnäs virus (serotype III) in the IFA. All except two of these also showed the highest reactivity with Hällnäs virus in the two different ELISA systems.

Expression of the structural proteins of dengue 2 virus and yellow fever virus by recombinant vaccinia viruses

Vaccinia virus recombinants were constructed which contained cDNA sequences encoding the structural region of dengue 2 virus (PR159/S1 strain) or yellow fever virus (17D strain). The flavivirus cDNA sequences were expressed under the control of the vaccinia 7.5k early/late promotor. Cultured cells infected with these recombinants expressed immunologically reactive flavivirus structural proteins, precursor prM and E. These proteins appeared to be cleaved and glycosylated properly since they comigrated with the authentic proteins from dengue 2 virus- and yellow fever virus-infected cells. Mice immunized with the dengue/vaccinia recombinant showed a dengue-specific immune response that included low levels of neutralizing antibodies. Immunization of mice with the yellow fever/vaccinia recombinant was less effective at inducing an immune response to yellow fever virus and in only some of the mice were low titers of neutralizing antibodies produced.

Nonstructural proteins nsP3 and nsP4 of Ross River and O'Nyong-nyong viruses: sequence and comparison with those of other alphaviruses

We have sequenced the nsP3 and nsP4 region of two alphaviruses, Ross River virus and O'Nyong-nyong virus, in order to examine these viruses for the presence or absence of an opal termination codon present between nsP3 and nsP4 in many alphaviruses. We found that Ross River virus possesses an in-phase opal termination codon between nsP3 and nsP4, whereas in O'Nyong-nyong virus this termination codon is replaced by an arginine codon. Previous studies have shown that two other alphaviruses, Sindbis virus and Middelburg virus, possess an opal termination codon separating nsP3 and nsP4 [E.G. Strauss, C.M. Rice, and J.H. Strauss (1983), Proc. Natl. Acad. Sci. USA 80, 5271-5275], whereas Semliki Forest virus possesses an arginine codon in lieu of the opal codon [K. Takkinen (1986), Nucleic Acids Res. 14, 5667-5682]. Thus, of the five alphaviruses examined to date, three possess the opal codon and two do not. Production of nsP4 requires readthrough of the opal codon in those alphaviruses that possess this termination codon and the function of the termination codon may be to regulate the amount of nsP4 produced. It is an open question then as to whether alphaviruses with no termination codon use other mechanisms to regulate the activity of this gene. The nsP4s of these five alphaviruses are highly conserved, sharing 71-76% amino acid sequence similarity, and all five contain the Gly-Asp-Asp motif found in many RNA virus replicases. The nsP3s are somewhat less conserved, sharing 52-73% amino acid sequence similarity throughout most of the protein, but each possesses a nonconserved C-terminal domain of 134 to 246 amino acids of unknown function.

Hemorrhagic fever with renal syndrome (nephropathia epidemica) in Norway: seroepidemiology 1981-1985

An indirect fluorescent antibody technique (IFAT) was applied to serologically confirm the clinical diagnosis in 507 nephropathia epidemica (NE) suspected patients. Hantaan virus (HV), the agent of Korean hemorrhagic fever, which is serologically related to the NE agent, was used as antigen. Both IgG and IgM reactions were detected. High levels of IgG antibodies to HV were common, even in the acute phase of illness. Over a 5-year period, a total of 35% of the NE suspected patients revealed antibodies to HV, but this varied considerably in the different years. In 2 endemic areas the serological confirmation of the NE diagnosis was 60%. 82% of the seropositive NE patients lived in 4 endemic areas. The bank vole (Clethrionomys glareolus) was common in all areas and predominant in 2. The wood mouse (Apodemus sylvaticus) was abundant in the other 2. In years with high bank vole population, the number of seropositive NE cases increased, with a peak in October/November. When the bank vole population was low, the relatively few seropositive NE cases occurred more regularly throughout the year. Subclinical infections were common. Antibodies to HV were detected in 74% male and 26% female NE patients, but the ratio varied between age groups.

An epidemiological survey of nephropathia epidemica in Sweden

The indirect immunofluorescence test (IFT) using the Hantaan virus (agent of Korean hemorrhagic fever, KHF) was applied for detection of antibodies to nephropathia epidemica (NE). From 103 patients with symptoms suggesting NE, 61% revealed KHF/NE antibodies in the convalescent sera. All seropositive patients seemed to have acquired their disease in NE endemic areas (north of the 60th parallel). Only patients found to have a typical clinical NE (fever, abdominal pain and renal engagement) were seropositive. Antibodies to KHF/NE were found in 4.2% of sera from 647 healthy persons living in NE endemic areas. Signs of local clusters were found. Subclinical or mild disease seems common. Proof of man to man spread of the disease was not found. Sera from 355 persons living outside NE endemic areas were also tested and 2.4% contained KHF/NE antibodies.

Characterization of the viral RNA species of prototype dengue viruses

Dengue virus isolates have been grown in the Igarashi clone C6/36 Aedes albopictus cells in amounts suitable for biochemical studies. Oligonucleotide fingerprint analyses have been used to characterize the virion 40 S RNA species of the four prototype dengue (DEN) serotype viruses: DEN 1, Hawaiian strain; DEN 2, New Guinea C strain (both insect and mouse brain passaged derivatives); DEN 3, H-87 strain; and DEN 4, H-241 strain. Comparisons of the largest oligonucleotides derived by ribonuclease T1 digestion of these 40 S DEN virion RNA species indicate that ther are few, if any, large oligonucleotides that are homologous between any two fo the four dengue prototype strains. Preliminary analyses of the 40 S RNA 5' terminal sequence of DEN 3 virion RNA indicate that it has the composition of m7GpppAmpXp.

Biochemical studies on the Phlebotomus fever group viruses (Bunyaviridae family)

Analyses of the virion polypeptides and genomes of several Phlebotomus fever group viruses, Karimabad, Punta Toro, Chagres, and the sandfly fever Sicilian serotype viruses, have established that they are biochemically similar to the accepted members of the Bunyaviridae family. Like snowshoe hare virus (a member of the California serogroup of the Bunyavirus genus of the Bunyaviridae family), Karimabad, Punta Toro, Chagres, and the sandfly fever Sicilian serotype viruses all have three viral RNA species, designated large (L), medium (M), and small (S). Oligonucleotide fingerprint analyses of Karimabad and Punta Toro virus RNA species indicated that their L, M, and S RNA species are unique. By polyacrylamide gel electrophoresis it was determined for Karimabad virus that the apparent molecular weights of its L, M, and S RNA species are 2.6 X 10(6), 2.2 X 10(6), and 0.8 X 10(6), respectively. For Punta Toro virus, the apparent molecular weights of its L, M, and S RNA species are 2.8 X 10(6), 1.8 X 10(6), and 0.75 X 10(6), respectively. The major internal nucleocapsid (N) protein of Karimabad virus was found to have a molecular weight of 21 X 10(3). A similar polypeptide size class was identified in preparations of sandfly fever Sicilian serotype, Chagres, and Punta Toro viruses. The Karimabad virus glycoproteins formed the external surface projections on virus particles and could be removed from virus preparations by protease treatment. The glycoproteins in an unreduced sample could be resolved into two size classes by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. They had apparent molecular weights of 62 X 10(3) and 50 X 10(3) in continuous polyacrylamide gels. When Karimabad virus preparations were reduced with 1% beta-mercaptoethanol, prior to resolution by continuous polyacrylamide gel electrophoresis, all the viral glycoprotein was recovered in a single size class, having an apparent molecular weight of 62 X 10(3). Two or three major virion polypeptides have been identified in preparations of Punta Toro, Chagres, and sandfly fever Sicilian serotype viruses.