Antibiotics from rare actinomycetes, beyond the genus Streptomyces

Throughout the golden age of antibiotic discovery, Streptomyces have been unsurpassed for their ability to produce bioactive metabolites. Yet, this success has been hampered by rediscovery. As we enter a new stage of biodiscovery, omics data and existing scientific repositories can enable informed choices on the biodiversity that may yield novel antibiotics. Here, we focus on the chemical potential of rare actinomycetes, defined as bacteria within the order Actinomycetales, but not belonging to the genus Streptomyces. They are named as such due to their less-frequent isolation under standard laboratory practices, yet there is increasing evidence to suggest these biologically diverse genera harbour considerable biosynthetic and chemical diversity. In this review, we focus on examples of successful isolation and genera that have been the focus of more concentrated biodiscovery efforts, we survey the representation of rare actinomycete taxa, compared with Streptomyces, across natural product data repositories in addition to its biosynthetic potential. This is followed by an overview of clinically useful drugs produced by rare actinomycetes and considerations for future biodiscovery efforts. There is much to learn about these underexplored taxa, and mounting evidence suggests that they are a fruitful avenue for the discovery of novel antimicrobials.

Artificial intelligence for natural product drug discovery

Developments in computational omics technologies have provided new means to access the hidden diversity of natural products, unearthing new potential for drug discovery. In parallel, artificial intelligence approaches such as machine learning have led to exciting developments in the computational drug design field, facilitating biological activity prediction and de novo drug design for molecular targets of interest. Here, we describe current and future synergies between these developments to effectively identify drug candidates from the plethora of molecules produced by nature. We also discuss how to address key challenges in realizing the potential of these synergies, such as the need for high-quality datasets to train deep learning algorithms and appropriate strategies for algorithm validation.

ActinoBase: tools and protocols for researchers working on Streptomyces and other filamentous actinobacteria

Actinobacteria is an ancient phylum of Gram-positive bacteria with a characteristic high GC content to their DNA. The ActinoBase Wiki is focused on the filamentous actinobacteria, such as Streptomyces species, and the techniques and growth conditions used to study them. These organisms are studied because of their complex developmental life cycles and diverse specialised metabolism which produces many of the antibiotics currently used in the clinic. ActinoBase is a community effort that provides valuable and freely accessible resources, including protocols and practical information about filamentous actinobacteria. It is aimed at enabling knowledge exchange between members of the international research community working with these fascinating bacteria. ActinoBase is an anchor platform that underpins worldwide efforts to understand the ecology, biology and metabolic potential of these organisms. There are two key differences that set ActinoBase apart from other Wiki-based platforms: [1] ActinoBase is specifically aimed at researchers working on filamentous actinobacteria and is tailored to help users overcome challenges working with these bacteria and [2] it provides a freely accessible resource with global networking opportunities for researchers with a broad range of experience in this field.

Multi-omics analysis of the specialised metabolism of two novel Pseudonocardia spp. isolated from the deep Southern Ocean

Multidrug-resistant pathogens have become a global threat. In this context, filamentous Actinobacteria has been proven to be an exceptional source of antimicrobial metabolites. In particular, rare actinomycetes isolated from marine environments have been proposed as a potential source of yet untapped specialised metabolites. In this study, two novel species, Pseudonocardia abyssalis sp. nov. and Pseudonocardia oceani sp. nov, isolated from deep Southern Ocean sediments are described, both in terms of their phenotypic and genomic characterization. Furthermore, the genomic architecture, with a focus on Biosynthetic Gene Cluster (BGC), across eight strains belonging to the two novel species were investigated. A total of 14 Gene Cluster Families (GCF) were identified, of which five GCFs comprise BGCs from both species, and nine were specific to each species. Moreover, a correlation of GCFs to phylogeny was observed. Following genome analysis, a comparative mass-spectrometry based metabolomics analysis was carried out with one strain from each new species, as well as Pseudonocardia ammonioxydans and Pseudonocardia sediminis, also of marine origin. The metabolomics profiles agreed with the GCF distribution, where a group of ubiquitous metabolites were produced by both new Pseudonocardia spp., while groups of species-specific metabolites were also detected. This metabolic-repertoire was found to be elicitated through the addition of N-acetyl glucosamine (GlcNAc), revealing chemically-inducible bioactivity against the fungi Candida albicas and multidrug-resistant Candida auris. These results showcase the power of a combined genomic-metabolomics approach to investigate rare-actinomycetes from understudied locations and have uncovered a wealth of both biosynthetic and chemical diversity for further investigation.

Overcoming drug resistance, the natural way

Colistin is an antibiotic of last resort for treating Gram-negative bacterial infections, but resistance is spreading rapidly. In a recent issue of Nature, Wang et al. use genome mining to identify and synthesize a natural variant that bypasses colistin resistance and offers new hope for tackling antimicrobial resistance.

The Natural Products Atlas 2.0: a database of microbially-derived natural products

Within the natural products field there is an increasing emphasis on the study of compounds from microbial sources. This has been fuelled by interest in the central role that microorganisms play in mediating both interspecies interactions and host-microbe relationships. To support the study of natural products chemistry produced by microorganisms we released the Natural Products Atlas, a database of known microbial natural products structures, in 2019. This paper reports the release of a new version of the database which includes a full RESTful application programming interface (API), a new website framework, and an expanded database that includes 8128 new compounds, bringing the total to 32 552. In addition to these structural and content changes we have added full taxonomic descriptions for all microbial taxa and have added chemical ontology terms from both NP Classifier and ClassyFire. We have also performed manual curation to review all entries with incomplete configurational assignments and have integrated data from external resources, including CyanoMetDB. Finally, we have improved the user experience by updating the Overview dashboard and creating a dashboard for taxonomic origin. The database can be accessed via the new interactive website at https://www.npatlas.org.

Pseudonocardia abyssalis sp. nov. and Pseudonocardia oceani sp. nov., two novel actinomycetes isolated from the deep Southern Ocean

The actinomycetes strains KRD168T and KRD185T were isolated from sediments collected from the deep Southern Ocean and, in this work, they are described as representing two novel species of the genus Pseudonocardia through a polyphasic approach. Despite sharing >99 % 16S rRNA gene sequence similarity with other members of the genus, comparative genomic analysis allowed species delimitation based on average nucleotide identity and digital DNA-DNA hybridization. The KRD168T genome is characterized by a size of 6.31 Mbp and a G+C content of 73.44 mol%, while the KRD185T genome has a size of 6.82 Mbp and a G+C content of 73.98 mol%. Both strains contain meso-diaminopimelic acid as the diagnostic diamino acid, glucose as the major whole-cell sugar, MK-8(H4) as a major menaquinone and iso-branched hexadecanoic acid as a major fatty acid. Biochemical and fatty acid analyses also revealed differences between these strains and their phylogenetic neighbours, supporting their status as distinct species. The names Pseudonocardia abyssalis sp. nov. (type strain KRD168T=DSM 111918T=NCIMB 15270T) and Pseudonocardia oceani (type strain KRD185T=DSM 111919T=NCIMB 15269T) are proposed.

Ranking microbial metabolomic and genomic links in the NPLinker framework using complementary scoring functions

Specialised metabolites from microbial sources are well-known for their wide range of biomedical applications, particularly as antibiotics. When mining paired genomic and metabolomic data sets for novel specialised metabolites, establishing links between Biosynthetic Gene Clusters (BGCs) and metabolites represents a promising way of finding such novel chemistry. However, due to the lack of detailed biosynthetic knowledge for the majority of predicted BGCs, and the large number of possible combinations, this is not a simple task. This problem is becoming ever more pressing with the increased availability of paired omics data sets. Current tools are not effective at identifying valid links automatically, and manual verification is a considerable bottleneck in natural product research. We demonstrate that using multiple link-scoring functions together makes it easier to prioritise true links relative to others. Based on standardising a commonly used score, we introduce a new, more effective score, and introduce a novel score using an Input-Output Kernel Regression approach. Finally, we present NPLinker, a software framework to link genomic and metabolomic data. Results are verified using publicly available data sets that include validated links.

A community resource for paired genomic and metabolomic data mining

Genomics and metabolomics are widely used to explore specialized metabolite diversity. The Paired Omics Data Platform is a community initiative to systematically document links between metabolome and (meta)genome data, aiding identification of natural product biosynthetic origins and metabolite structures.

Comparative Metabologenomics Analysis of Polar Actinomycetes

Biosynthetic and chemical datasets are the two major pillars for microbial drug discovery in the omics era. Despite the advancement of analysis tools and platforms for multi-strain metabolomics and genomics, linking these information sources remains a considerable bottleneck in strain prioritisation and natural product discovery. In this study, molecular networking of the 100 metabolite extracts derived from applying the OSMAC approach to 25 Polar bacterial strains, showed growth media specificity and potential chemical novelty was suggested. Moreover, the metabolite extracts were screened for antibacterial activity and promising selective bioactivity against drug-persistent pathogens such as Klebsiella pneumoniae and Acinetobacter baumannii was observed. Genome sequencing data were combined with metabolomics experiments in the recently developed computational approach, NPLinker, which was used to link BGC and molecular features to prioritise strains for further investigation based on biosynthetic and chemical information. Herein, we putatively identified the known metabolites ectoine and chrloramphenicol which, through NPLinker, were linked to their associated BGCs. The metabologenomics approach followed in this study can potentially be applied to any large microbial datasets for accelerating the discovery of new (bioactive) specialised metabolites.

Linking biosynthetic and chemical space to accelerate microbial secondary metabolite discovery

Secondary metabolites can be viewed as a chemical language, facilitating communication between microorganisms. From an ecological point of view, this metabolite exchange is in constant flux due to evolutionary and environmental pressures. From a biomedical perspective, the chemistry is unsurpassed for its antibiotic properties. Genome sequencing of microorganisms has revealed a large reservoir of Biosynthetic Gene Clusters (BGCs); however, linking these to the secondary metabolites they encode is currently a major bottleneck to chemical discovery. This linking of genes to metabolites with experimental validation will aid the elicitation of silent or cryptic (not expressed under normal laboratory conditions) BGCs. As a result, this will accelerate chemical dereplication, our understanding of gene transcription and provide a comprehensive resource for synthetic biology. This will ultimately provide an improved understanding of both the biosynthetic and chemical space. In recent years, integrating these complex metabolomic and genomic data sets has been achieved using a spectrum of manual and automated approaches. In this review, we cover examples of these approaches, while addressing current challenges and future directions in linking these data sets.

Linking genomics and metabolomics to chart specialized metabolic diversity

Microbial and plant specialized metabolites constitute an immense chemical diversity, and play key roles in mediating ecological interactions between organisms. Also referred to as natural products, they have been widely applied in medicine, agriculture, cosmetic and food industries. Traditionally, the main discovery strategies have centered around the use of activity-guided fractionation of metabolite extracts. Increasingly, omics data is being used to complement this, as it has the potential to reduce rediscovery rates, guide experimental work towards the most promising metabolites, and identify enzymatic pathways that enable their biosynthetic production. In recent years, genomic and metabolomic analyses of specialized metabolic diversity have been scaled up to study thousands of samples simultaneously. Here, we survey data analysis technologies that facilitate the effective exploration of large genomic and metabolomic datasets, and discuss various emerging strategies to integrate these two types of omics data in order to further accelerate discovery.

Awakening ancient polar Actinobacteria: diversity, evolution and specialized metabolite potential

Polar and subpolar ecosystems are highly vulnerable to global climate change with consequences for biodiversity and community composition. Bacteria are directly impacted by future environmental change and it is therefore essential to have a better understanding of microbial communities in fluctuating ecosystems. Exploration of Polar environments, specifically sediments, represents an exciting opportunity to uncover bacterial and chemical diversity and link this to ecosystem and evolutionary parameters. In terms of specialized metabolite production, the bacterial order Actinomycetales, within the phylum Actinobacteria are unsurpassed, producing 10 000 specialized metabolites accounting for over 45 % of all bioactive microbial metabolites. A selective isolation approach focused on spore-forming Actinobacteria of 12 sediment cores from the Antarctic and sub-Arctic generated a culture collection of 50 strains. This consisted of 39 strains belonging to rare A ctinomycetales genera including Microbacterium, Rhodococcus and Pseudonocardia. This study used a combination of nanopore sequencing and molecular networking to explore the community composition, culturable bacterial diversity, evolutionary relatedness and specialized metabolite potential of these strains. Metagenomic analyses using MinION sequencing was able to detect the phylum Actinobacteria across polar sediment cores at an average of 13 % of the total bacterial reads. The resulting molecular network consisted of 1652 parent ions and the lack of known metabolite identification supports the argument that Polar bacteria are likely to produce previously unreported chemistry.

The Natural Products Atlas: An Open Access Knowledge Base for Microbial Natural Products Discovery

Despite rapid evolution in the area of microbial natural products chemistry, there is currently no open access database containing all microbially produced natural product structures. Lack of availability of these data is preventing the implementation of new technologies in natural products science. Specifically, development of new computational strategies for compound characterization and identification are being hampered by the lack of a comprehensive database of known compounds against which to compare experimental data. The creation of an open access, community-maintained database of microbial natural product structures would enable the development of new technologies in natural products discovery and improve the interoperability of existing natural products data resources. However, these data are spread unevenly throughout the historical scientific literature, including both journal articles and international patents. These documents have no standard format, are often not digitized as machine readable text, and are not publicly available. Further, none of these documents have associated structure files (e.g., MOL, InChI, or SMILES), instead containing images of structures. This makes extraction and formatting of relevant natural products data a formidable challenge. Using a combination of manual curation and automated data mining approaches we have created a database of microbial natural products (The Natural Products Atlas, www.npatlas.org) that includes 24 594 compounds and contains referenced data for structure, compound names, source organisms, isolation references, total syntheses, and instances of structural reassignment. This database is accompanied by an interactive web portal that permits searching by structure, substructure, and physical properties. The Web site also provides mechanisms for visualizing natural products chemical space and dashboards for displaying author and discovery timeline data. These interactive tools offer a powerful knowledge base for natural products discovery with a central interface for structure and property-based searching and presents new viewpoints on structural diversity in natural products. The Natural Products Atlas has been developed under FAIR principles (Findable, Accessible, Interoperable, and Reusable) and is integrated with other emerging natural product databases, including the Minimum Information About a Biosynthetic Gene Cluster (MIBiG) repository, and the Global Natural Products Social Molecular Networking (GNPS) platform. It is designed as a community-supported resource to provide a central repository for known natural product structures from microorganisms and is the first comprehensive, open access resource of this type. It is expected that the Natural Products Atlas will enable the development of new natural products discovery modalities and accelerate the process of structural characterization for complex natural products libraries.

Temperature Driven Changes in Benthic Bacterial Diversity Influences Biogeochemical Cycling in Coastal Sediments

Marine sediments are important sites for global biogeochemical cycling, mediated by macrofauna and microalgae. However, it is the microorganisms that drive these key processes. There is strong evidence that coastal benthic habitats will be affected by changing environmental variables (rising temperature, elevated CO2), and research has generally focused on the impact on macrofaunal biodiversity and ecosystem services. Despite their importance, there is less understanding of how microbial community assemblages will respond to environmental changes. In this study, a manipulative mesocosm experiment was employed, using next-generation sequencing to assess changes in microbial communities under future environmental change scenarios. Illumina sequencing generated over 11 million 16S rRNA gene sequences (using a primer set biased toward bacteria) and revealed Bacteroidetes and Proteobacteria dominated the total bacterial community of sediment samples. In this study, the sequencing coverage and depth revealed clear changes in species abundance within some phyla. Bacterial community composition was correlated with simulated environmental conditions, and species level community composition was significantly influenced by the mean temperature of the environmental regime (p = 0.002), but not by variation in CO2 or diurnal temperature variation. Species level changes with increasing mean temperature corresponded with changes in NH4 concentration, suggesting there is no functional redundancy in microbial communities for nitrogen cycling. Marine coastal biogeochemical cycling under future environmental conditions is likely to be driven by changes in nutrient availability as a direct result of microbial activity.

An Integrative Approach to Decipher the Chemical Antagonism between the Competing Endophytes Paraconiothyrium variabile and Bacillus subtilis

An integrative approach combining traditional natural products chemistry, molecular networking, and mass spectrometry imaging has been undertaken to decipher the molecular dialogue between the fungus Paraconiothyrium variabile and the bacterium Bacillus subtilis, which were isolated as endophytes from the conifer Cephalotaxus harringtonia and are characterized by a strong and mutual antibiosis. From this study, we highlight that bacterial surfactins and a fungal tetronic acid are involved in such competition and that the fungus is able to hydrolyze surfactins to fight against the bacterial partner.

Sharing and community curation of mass spectrometry data with Global Natural Products Social Molecular Networking

The potential of the diverse chemistries present in natural products (NP) for biotechnology and medicine remains untapped because NP databases are not searchable with raw data and the NP community has no way to share data other than in published papers. Although mass spectrometry (MS) techniques are well-suited to high-throughput characterization of NP, there is a pressing need for an infrastructure to enable sharing and curation of data. We present Global Natural Products Social Molecular Networking (GNPS; http://gnps.ucsd.edu), an open-access knowledge base for community-wide organization and sharing of raw, processed or identified tandem mass (MS/MS) spectrometry data. In GNPS, crowdsourced curation of freely available community-wide reference MS libraries will underpin improved annotations. Data-driven social-networking should facilitate identification of spectra and foster collaborations. We also introduce the concept of 'living data' through continuous reanalysis of deposited data.

Sharing and community curation of mass spectrometry data with Global Natural Products Social Molecular Networking

The potential of the diverse chemistries present in natural products (NP) for biotechnology and medicine remains untapped because NP databases are not searchable with raw data and the NP community has no way to share data other than in published papers. Although mass spectrometry (MS) techniques are well-suited to high-throughput characterization of NP, there is a pressing need for an infrastructure to enable sharing and curation of data. We present Global Natural Products Social Molecular Networking (GNPS; http://gnps.ucsd.edu), an open-access knowledge base for community-wide organization and sharing of raw, processed or identified tandem mass (MS/MS) spectrometry data. In GNPS, crowdsourced curation of freely available community-wide reference MS libraries will underpin improved annotations. Data-driven social-networking should facilitate identification of spectra and foster collaborations. We also introduce the concept of 'living data' through continuous reanalysis of deposited data.

Competitive strategies differentiate closely related species of marine actinobacteria

Although competition, niche partitioning, and spatial isolation have been used to describe the ecology and evolution of macro-organisms, it is less clear to what extent these principles account for the extraordinary levels of bacterial diversity observed in nature. Ecological interactions among bacteria are particularly challenging to address due to methodological limitations and uncertainties over how to recognize fundamental units of diversity and link them to the functional traits and evolutionary processes that led to their divergence. Here we show that two closely related marine actinomycete species can be differentiated based on competitive strategies. Using a direct challenge assay to investigate inhibitory interactions with members of the bacterial community, we observed a temporal difference in the onset of inhibition. The majority of inhibitory activity exhibited by Salinispora arenicola occurred early in its growth cycle and was linked to antibiotic production. In contrast, most inhibition by Salinispora tropica occurred later in the growth cycle and was more commonly linked to nutrient depletion or other sources. Comparative genomics support these differences, with S. arenicola containing nearly twice the number of secondary metabolite biosynthetic gene clusters as S. tropica, indicating a greater potential for secondary metabolite production. In contrast, S. tropica is enriched in gene clusters associated with the acquisition of growth-limiting nutrients such as iron. Coupled with differences in growth rates, the results reveal that S. arenicola uses interference competition at the expense of growth, whereas S. tropica preferentially employs a strategy of exploitation competition. The results support the ecological divergence of two co-occurring and closely related species of marine bacteria by providing evidence they have evolved fundamentally different strategies to compete in marine sediments.

Molecular networking and pattern-based genome mining improves discovery of biosynthetic gene clusters and their products from Salinispora species

Genome sequencing has revealed that bacteria contain many more biosynthetic gene clusters than predicted based on the number of secondary metabolites discovered to date. While this biosynthetic reservoir has fostered interest in new tools for natural product discovery, there remains a gap between gene cluster detection and compound discovery. Here we apply molecular networking and the new concept of pattern-based genome mining to 35 Salinispora strains, including 30 for which draft genome sequences were either available or obtained for this study. The results provide a method to simultaneously compare large numbers of complex microbial extracts, which facilitated the identification of media components, known compounds and their derivatives, and new compounds that could be prioritized for structure elucidation. These efforts revealed considerable metabolite diversity and led to several molecular family-gene cluster pairings, of which the quinomycin-type depsipeptide retimycin A was characterized and linked to gene cluster NRPS40 using pattern-based bioinformatic approaches.

Exploring the diversity and metabolic potential of actinomycetes from temperate marine sediments from Newfoundland, Canada

Marine sediments from Newfoundland, Canada were explored for biotechnologically promising Actinobacteria using culture-independent and culture-dependent approaches. Culture-independent pyrosequencing analyses uncovered significant actinobacterial diversity (H'-2.45 to 3.76), although the taxonomic diversity of biotechnologically important actinomycetes could not be fully elucidated due to limited sampling depth. Assessment of culturable actinomycete diversity resulted in the isolation of 360 actinomycetes representing 59 operational taxonomic units, the majority of which (94 %) were Streptomyces. The biotechnological potential of actinomycetes from NL sediments was assessed by bioactivity and metabolomics-based screening of 32 representative isolates. Bioactivity was exhibited by 41 % of isolates, while 11 % exhibited unique chemical signatures in metabolomics screening. Chemical analysis of two isolates resulted in the isolation of the cytotoxic metabolite 1-isopentadecanoyl-3β-D-glucopyranosyl-X-glycerol from Actinoalloteichus sp. 2L868 and sungsanpin from Streptomyces sp. 8LB7. These results demonstrate the potential for the discovery of novel bioactive metabolites from actinomycetes isolated from Atlantic Canadian marine sediments.

Multilevel modeling of fetal and placental growth using echo-planar magnetic resonance imaging

OBJECTIVE

To quantify longitudinal increases in fetal, fetal liver, and fetal brain volume using echo-planar magnetic resonance imaging and to quantify the results using appropriate statistical modeling.

METHODS

Fifty-six singleton fetuses were studied using echo-planar (snap-shot) magnetic resonance imaging, between 19 weeks and term. They were assessed at a variety of different gestations and on a different number of occasions, thereby requiring multilevel statistical modeling to analyze the pattern of fetal growth.

RESULTS

Fetal volume varied according to the following equation: square root (radical) [fetal volume]=-37.71+2.17 x gestational age (GA)-0.004 x GA(2). The equation for fetal liver volume was radical[fetal liver volume]=9.47+0.56 x GA-0.02 x GA(2), for fetal brain volume was radical[fetal brain volume]=15.50+0.69 x GA-0.014 x GA(2), and for placental volume radical[placental volume]=28.54+0.95 x GA-0.039 x GA(2), where GA is the gestational age in weeks -30.

CONCLUSION

The assessment of fetal, fetal organ, and placental volume was feasible using echo-planar magnetic resonance imaging from 20 weeks to term. Multilevel statistical modeling can be applied to analyze sets of data with different measurements on different occasions. This information is useful clinically to assess abnormal fetal growth.

Fetal and placental volumetric and functional analysis using echo-planar imaging

Recent and past work using echo-planar imaging (EPI) in pregnancy has allowed important anatomic and physiological information to be obtained, giving advantages over conventional radiological methods such as ultrasound. EPI is a quick, convenient method of measuring organ volumes. The volumetric estimates throughout gestation correlate well with known fetal weight at these gestations. Relaxation time measurements also can be made in the placenta and lungs. By combining the changes in relaxation and volume with gestation in the future, it may be possible to develop an "index of maturity." This could be used to accurately reflect lung maturation. T1 and T2 parameters in the placenta decreased with gestational age and with abnormal placentation. EPI can be used to assess perfusion in the placenta and flow in the uterine arteries because of its rapid acquisition times. These techniques have been applied to assess perfusion within the fetal brain.

Antenatal factors at diagnosis that predict outcome in twin-twin transfusion syndrome

OBJECTIVE

We sought to identify clinical factors at diagnosis that predict outcome in twin-twin transfusion syndrome.

STUDY DESIGN

In this retrospective series 23 patients with twin-twin transfusion syndrome were seen in a tertiary referral fetal medicine center over a 3-year period. Ten antenatal factors were assessed to determine their ability to predict outcome by use of ordered logistic regression. These factors were the following: (1) absent or reversed end-diastolic flow in the umbilical artery, nonvisible bladder, anhydramnios, and estimated fetal weight of <3rd percentile in the donor; (2) pulsatile umbilical vein, either absent or reversed end-diastolic flow in the ductus venosus, or both, and tricuspid-mitral valve regurgitation in the recipient; and (3) gestational age at presentation, estimated fetal weight discordancy, absent arterioarterial anastomosis, and spontaneous rupture of the membranes or cervical change as pregnancy factors. Management comprised serial amnioreduction (n = 10), selective feticide (n = 5; 4 also had amnioreduction), septostomy (n = 4; 1 also had amnioreduction), and delivery (n = 2). Two patients miscarried before treatment.

RESULTS

The chance of survival of both twins fell and double deaths increased linearly with increasing number of adverse factors (P =.026). A low chance of survival was independently associated with absent or reversed end-diastolic flow in the donor umbilical artery (P =.02) and with a pulsatile umbilical vein or absent or reversed end-diastolic flow in the ductus venosus (P =.03) of the recipient. The probability of at least one twin surviving was only 33% if there was absent or reversed end-diastolic flow in the donor umbilical artery or 37% when abnormal venous recordings were seen in the recipient. An arterioarterial anastomosis detected at diagnosis also influenced prognosis, with all twins surviving when an arterioarterial anastomosis was identified (P =.04).

CONCLUSIONS

Three factors identified at diagnosis independently predict poor survival in twin-twin transfusion syndrome-absent or reversed end-diastolic flow in the donor umbilical artery, abnormal pulsatility of the venous system in the recipient, and absence of an arterioarterial anastomosis. These may have a role in the counseling of parents and in selecting the appropriate treatment strategy.

In utero perfusing fraction maps in normal and growth restricted pregnancy measured using IVIM echo-planar MRI

The aim of this study was to measure and portray blood movement in the placenta in vivo in normal and growth restricted pregnancies, using Intra Voxel Incoherent Motion (IVIM) magnetic resonance imaging. Thirteen patients with apparently normal healthy pregnancies were scanned at 31+/-7 (mean+/-s.d.) weeks gestation and seven patients with intrauterine growth restriction (IUGR) were scanned at 31+/-4 weeks. A region of interest (ROI) was defined encompassing the placenta between the decidual and chorionic plates. The volume of moving blood within each imaging voxel of the ROI was then calculated as a percentage of the total voxel volume (f per cent). This information was colour coded to produce maps of moving blood volume. The placenta was segmented length ways into two zones of approximately equal area, termed inner and outer, the latter being adjacent to the uterine wall. f was fitted for the average in the outer zone (f(out)) and inner zone (f(in)). The parameter (f(out)-f(in)) was then calculated for each subject. This was positive in 12/13 of the normal cases and zero for one case (+10 per cent+10, mean+/-s.d.). For pregnancy affected by IUGR this value was negative in all cases (-4 per cent+/-3). Perfusion fraction mapping identified differences in function within the normal placenta in vivo, and between the placentae of normal and IUGR pregnancies. The technique has potential applications in managing, and investigating the aetiology of, pregnancy compromise.

In vivo intravoxel incoherent motion measurements in the human placenta using echo-planar imaging at 0.5 T

This paper presents the first in vivo measurements of intravoxel incoherent motion in the human placenta, obtained using the pulsed gradient spin echo (PGSE) sequence. The aims of this study were two-fold. The first was to provide an initial estimate of the values of the IVIM parameters in this organ, which are currently unknown. The second aim was then to use these results to optimize the sequence timings for future studies. The moving blood fraction (f), diffusion coefficient (D), and pseudo-diffusion coefficient (D*) were measured. The average value of f was 26 +/- 6 % (mean +/- SD), D was 1.7 +/- 0.5 x 10(-3) mm2/sec, and D* was 57 +/- 41 x 10(-3) mm2/sec. For the optimized values of b, the expected percentage uncertainty in the fitted values of f, D, and D* for the placenta were sigmaf/f = 14.9%, sigmaD/D = 14.3%, sigmaD*/D* = 44.9%, for an image signal-to-noise of 20:1, and a total imaging time of 800 sec.

Infants exposed to MRI in utero have a normal paediatric assessment at 9 months of age

Any differences in detailed paediatric assessment at 9 months of age in infants exposed to echo planar MRI in utero from 20 weeks gestation to term were investigated by performing a case controlled prospective observational study of 20 infants. They had all had serial echo planar MRI in the antenatal period and were compared with a control group born at the same time who had not. Statistical analysis employed likelihood ratios, odds ratios and 95% confidence intervals. The mothers of the control infants had a significantly higher standard of educational attainment (p = 0.005). A small but significant decrease in length (p = 0.047), and an increase in gross motor function (p = 0.023) of the fetuses exposed to echo planar imaging were demonstrated. No other significant developmental or social differences were seen between the two groups. Infants at 9 months of age did not demonstrate any gross abnormality likely to be related to exposure to echo planar MRI in utero.

High failure rate of umbilical vessel occlusion by ultrasound-guided injection of absolute alcohol or enbucrilate gel

The success rate for injected umbilical vascular occlusion in the published literature exceeds 85 per cent. In this study we assessed the efficacy of two forms of injected sclerosants in achieving umbilical vessel occlusion. 12 cases of attempted ultrasound-guided occlusion over a 2 1/2 year period were reviewed. These were monochorionic (MC) twins (n=6), dichorionic twins (n=3) and singletons (n=3) undergoing fetocide for severe anomalies, or impending fetal demise. Absolute alcohol (n=6), enbucrilate gel (n=5) or both (n=1) were used in an attempt to achieve vascular occlusion. Complete vessel occlusion was achieved in only a third of cases (4/12), three with absolute alcohol and one with enbucrilate gel. In MC twins occlusion was successful in two of six cases. In contrast to previously published data, this large series, containing more cases than the total previously reported, shows considerably poorer success rates for injected umbilical vascular occlusion. Injection of currently available sclerosants can no longer be recommended for umbilical vascular occlusion in human fetuses.

First-trimester cord entanglement in monoamniotic twins

OBJECTIVE

Monoamniotic twinning occurs in only 1% of twin pregnancies, but carries a high perinatal mortality rate. Early and reliable diagnosis is essential if attempts are to be made to reduce the complication rate. We report color Doppler demonstration of cord entanglement in the first trimester, which is diagnostic of monoamnionicity.

METHODS

Two patients with twin pregnancies were examined in the first trimester with pulsed and color Doppler insonation of their umbilical arteries.

RESULTS

Cord entanglement was suspected and proved by demonstrating differing fetal heart rate patterns in the same direction on umbilical artery Doppler analysis of a common mass of cord vessels. Following appropriate counselling, medical amnioreduction was induced at 20 weeks of gestation to reduce fetal movements and worsening cord entanglement. Delivery was by elective Cesarean section at 32 weeks' gestation and monoamnionicity was confirmed.

CONCLUSION

We report a new sign for the demonstration of monoamnionicity in twin pregnancies in the first trimester. This should improve the reliability of early diagnosis, but further studies are required to confirm that, if cord entanglement occurs, it is usually present by the end of the first trimester.

The changes in magnetic resonance properties of the fetal lungs: a first result and a potential tool for the non-invasive in utero demonstration of fetal lung maturation

OBJECTIVE

To measure magnetic resonance parameters T1 and T2 of the fetal lungs and investigate the relationship of these parameters to changes in volume and gestation.

DESIGN

Prospective cross-sectional study.

SETTING

Large teaching hospital in Nottingham and the Magnetic Resonance Centre at the University of Nottingham.

POPULATION

Normal pregnancies from 20 weeks to term.

METHODS

T1, T2, and lung volume were measured in the fetus using echo-planar magnetic resonance imaging.

MAIN OUTCOME MEASURES

The relationship of T1 and T2 to gestational age and lung volume.

RESULTS

Linear regression demonstrated a significant relationship (P < 0.001) between gestational age and lung volume, T1 and T2. There was also a significant relationship between lung volume and T1 and T2 (P < 0-001).

CONCLUSIONS

Relaxation time measurements give additional information to lung volume estimation in the assessment of lung physiology in utero. We have demonstrated the progressive changes which take place in the fetal lungs between 20 weeks and term. The physiological changes which can be demonstrated with this non-invasive technique may have an important application in the demonstration of fetal lung maturity in a prospective non-invasive manner.

Assessment of fetal lung growth in utero with echo-planar MR imaging

PURPOSE

To measure changes in normal fetal lung volume with increasing gestation by using echo-planar magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Fifty-six singleton fetuses were examined longitudinally with respect to lung volume by using echo-planar MR imaging between 19 weeks gestation and term.

RESULTS

Lung volume increased exponentially with gestation from 8 to 125 mL. Volume was related to gestation by using the equation, volume = 0.8375e0.1249g (R2 = 0.77), where g = gestation. Lung volume had a direct relationship to fetal volume with increasing gestation (R2 = 0.75). There was no significant relationship between amniotic fluid volume and lung volume (R2 = 0.11).

CONCLUSION

Variation in lung volumes can be assessed by using echo-planar MR imaging, regardless of variations in amniotic fluid volume. These measurements are less than those obtained from postmortem and neonatal studies but are similar to those obtained by using three-dimensional ultrasonography. Lung volume estimations obtained by using echo-planar imaging may have important clinical and research applications when noninvassive assessment of lung volume is required.

The investigation of placental relaxation and estimation of placental perfusion using echo-planar magnetic resonance imaging

Echo-planar imaging (EPI) is a form of magnetic resonance imaging (MRI) which acquires images in milliseconds rather than minutes as with conventional MRI. The images produced using EPI are affected by the physiological environment in which the hydrogen atoms producing the signals are found, a process referred to as relaxation. Also by producing images a matter of milliseconds apart, quantification of perfusion within the tissue being imaged is feasible. The objective of this study was to investigate T1 and T2 relaxation times along with perfusion in placentae from normal pregnancies at different gestations and also to compare these to pregnancies complicated by abnormal placental function. A cross-sectional study of normal and compromised pregnancies from 20 weeks to term and a longitudinal study of normal pregnancy were performed. Placental T1, T2 relaxation times, and perfusion were measured using echo-planar magnetic resonance imaging. Placental T1 and T2 relaxation times decreased in normal pregnancy (P<0.001). Relaxation times in pregnancies associated with placental pathology appeared to be reduced for that gestation although the numbers were too small to allow any statistical validation. No differences in placental perfusion with gestation or between normal and compromised pregnancy were demonstrated using this technique. This is the first demonstration of placental magnetic resonance relaxation and perfusion measurements in normal pregnancy using echo-planar magnetic resonance imaging. In the future it may be possible to identify compromised pregnancies by differences in placental T1 and T2 relaxation times, using this novel non-invasive technique.

In vivo perfusion measurements in the human placenta using echo planar imaging at 0.5 T

This paper presents the first in vivo measurements of perfusion in the human placenta from 20 weeks gestational age until term, using the non-selective/selective inversion recovery echo-planar imaging sequence, in which data is alternately acquired following a selective and non-selective inversion pulse. Twenty pairs of images were collected, two each at the following inversion times: 20, 310, 610, 910, 1110, 1410, 1910, 2810, 3310, and 4510 ms with the sequence being repeated with a repetition time (TR) of 10 s. The results of these measurements were used to suggest the optimum sequence for future work in terms of the signal to noise ratio in the measured perfusion rate in a given measurement time. The sequence was also analyzed to determine the expected variability in the measurements. In normal pregnancies the average value of perfusion rate was found to be 176 (standard error = +/-24) ml/100 mg/min. (n = 16, standard deviation = 96 ml/100 mg/min). The expected variability in the measured parameters due to signal to noise ratio considerations alone was calculated to be 71%. For a maximum scanning time of 400 s, the optimum sequence for measuring placental perfusion was found to require 8 repetitions at each of 10 inversion times which were geometrically spaced (given by a(o), a(o)r, a(o)r2, a(o)r3, . . .), with a(o) = 850 ms, r = 1.073 and TR = 5 s, giving a pixel variability of 38%. Other timing schemes are recommended for measuring perfusion in other anatomical regions with different values of perfusion rate and longitudinal relaxation time.

Non-invasive mapping of placental perfusion

BACKGROUND

We aim to develop a clinical technique for the non-invasive measurement of placental perfusion, to enable early detection of intrauterine growth restriction (IUGR). Pregnancies with this complication are characterised by low placental perfusion.

METHODS

We measured placental perfusion by means of perfusion-sensitive echoplanar imaging (EPI); a rapid method of making magnetic resonance images. Perfusion measurements were done on six healthy volunteers with normal pregnancies and nine with pregnancies complicated by IUGR. Perfusion maps were created to assess the relation between placental perfusion and fetal size at birth.

FINDINGS

Pregnancies complicated by IUGR differed significantly from normal pregnancies in patterns of perfusion within the placenta (p<0.0001, ANOVA). Subsequent analysis showed that the proportion of placentas with low perfusion rates was higher in the IUGR group than in the normal group. A significant correlation between areas of reduced placental perfusion and fetal size was demonstrated (p=0.041, Spearman's rank correlation).

INTERPRETATION

Non-invasive imaging of placental perfusion by means of EPI has potential as a clinical tool in assessing the dynamics of placental perfusion.

Failure to detect intrauterine growth restriction following in utero exposure to MRI

Echo planar imaging is a form of MRI with short image acquisition times, which permits in utero fetal imaging without motion artefacts. Echo planar imaging has been used to measure accurately fetal organ volume and to assess placental function. Two small animal studies have suggested the possibility of intrauterine growth restriction consequent upon MRI. We thus performed a prospective study of pregnancies in which fetuses were exposed to echo planar imaging, compared with a control group in which there was no in utero echo planar imaging exposure. There were no significant differences between the groups when maternal age, parity, proportion of smokers and proportion of Caucasian women were compared. Although the gestational age of delivery was lower in the echo planar imaging group, the proportion of women delivering prematurely was not significantly different. Although infant birthweights were significantly lower in the MRI group, the corrected birthweight for gestational age centiles (individualized birthweight ratio) was not significantly different between the two groups. In utero exposure to echo planar imaging thus did not have a marked effect on intrauterine fetal growth. A 10 year follow-up study of all infants imaged in utero is being performed.

In vivo relaxation time measurements in the human placenta using echo planar imaging at 0.5 T

This paper presents the first in vivo measurements of the nuclear magnetic resonance relaxation times T1 and T2 at 0.5 T in the human placenta from 20 weeks gestational age until term, in both normal and compromised pregnancies. T1 measurements were performed by using both an inversion recovery sequence and the Look-Locher echo planar imaging (EPI) sequence on a total of 41 women with normal pregnancies and 11 women with compromised pregnancies. T2 measurements were performed by using a spin-echo EPI sequence on 36 women with normal pregnancies and 14 women with compromised pregnancies. In normal pregnancies, both the T1 values measured with the inversion recovery sequence and the T2 values were found to decrease with gestational age, the linear regression results gave T1 = -9.1t + 1538 r2 = 0.23 p = 0.03. T2 = -4.0t + 338 r2=0.47 p =410(-6) where t is the gestational age in weeks, and T1 and T2 are the relaxation times in milliseconds. T1 values measured very rapidly with the Look-Locher EPI sequence, but, therefore, with a much lower signal-to-noise ratio, showed no significant trends. The T1 values measured in the abnormal group were significantly lower than those measured in the normal group. Four out of eight patients with compromised pregnancies had placental T1 values lying outside the 90% confidence limits for the normal population based about the regression line, significantly more than expected by chance (p = 0.005). Ten out of fourteen of the T2 measurements in the abnormal group were below the regression line established for the normal group, with 4 lying below the 90% confidence interval, although these trends were only just significant (p = 0.06 and p = 0.03).

The aetiology and management of twin-twin transfusion syndrome

Twin-to-twin transfusion syndrome presents in the mid-trimester with gross discordance in amniotic fluid volume, and complicates 10-15 per cent of monochorionic twins. Recent studies suggest a primary vascular basis in which a paucity of the bidirectional superficial anastomoses normally found in monochorionic twins is unable to compensate for haemodynamic imbalance resulting from unidirectional transfusion along deeper arterio-venous anastomoses. It is associated with high rates of perinatal mortality from ruptured membranes, hydrops and growth restriction, and a significant morbidity from cardiac and neurological sequelae in particular. Serial aggressive amnioreduction is the current treatment of choice, with survival in around two thirds of cases. In the remaining third, with features suggesting a poor outcome, selective fetocide may have a role. Current attempts at vascular ablative therapies have been associated with inferior survival rates, but the long term therapeutic goal remains the identification and ablation of the shared chorionic vasculature.

Demonstration of changes in fetal liver erythropoiesis using echo-planar magnetic resonance imaging

This study investigated the variation in magnetic resonance characteristics of the fetal liver during a time of changing erythropoietic function. Echo-planar imaging was carried out in 25 normal pregnant women at 20 and 26 wk gestation. The signal intensity from regions of the fetal liver, background image, and maternal back muscle and the highest signal intensity from the maternal spinal cord were measured and compared with the signal intensity of amniotic fluid. Data are expressed as ratios, in arbitrary units (median pixel values; interquartile range shown in parentheses), and analyzed with the use of Wilcoxon's signed-rank test. At 20 wk, the signal intensity ratio of liver to amniotic fluid was 0.309 (0.231-0.365). At 26 wk, the ratio was 0.544 (0.429-0.616). The change was highly significant (P < 0.0001). No change in the signal intensity ratios of amniotic fluid compared with other measured parameters was noted. These data are consistent with known changes in fetal liver erythropoiesis occurring between 20 and 26 wk gestation and have potential use in early noninvasive physiological assessment of the fetus.

The development of magnetic resonance imaging in obstetrics

Following recent developments in imaging techniques which overcome the problem of fetal motion, magnetic resonance imaging (MRI) has the potential to improve non-invasive fetomaternal assessment. This article catalogues the development of MRI and the potential that exists for its use in obstetrics in the future.