Reinforced versus standard stapler transection on postoperative pancreatic fistula in distal pancreatectomy: multicentre randomized clinical trial

BACKGROUND

Postoperative pancreatic fistula is the leading cause of morbidity after distal pancreatectomy. Strategies investigated to reduce the incidence have been disappointing. Recent data showed a reduction in postoperative pancreatic fistula with the use of synthetic mesh reinforcement of the staple line.

METHODS

An RCT was conducted between May 2014 and February 2016 at four tertiary referral centres in Sweden. Patients scheduled for distal pancreatectomy were eligible. Enrolled patients were randomized during surgery to stapler transection with biological reinforcement or standard stapler transection. Patients were blinded to the allocation. The primary endpoint was the development of any postoperative pancreatic fistula. Secondary endpoints included morbidity, mortality, and duration of hospital stay.

RESULTS

Some 107 patients were randomized and 106 included in an intention-to-treat analysis (56 in reinforced stapling group, 50 in standard stapling group). No difference was demonstrated in terms of clinically relevant fistulas (grade B and C): 6 of 56 (11 per cent) with reinforced stapling versus 8 of 50 (16 per cent) with standard stapling (P = 0.332). There was no difference between groups in overall postoperative complications: 45 (80 per cent) and 39 (78 per cent) in reinforced and standard stapling groups respectively (P = 0.765). Duration of hospital stay was comparable: median 8 (range 2-35) and 9 (2-114) days respectively (P = 0.541).

CONCLUSION

Biodegradable stapler reinforcement at the transection line of the pancreas did not reduce postoperative pancreatic fistula compared with regular stapler transection in distal pancreatectomy. Registration number: NCT02149446 (http://www.clinicaltrials.gov).

VIRUS — A Laboratory Information System for Clinical Virology

A system covering request registration, analytical orders, printing of worksheets, result reporting, result control and printing of patient reports is presented. Additionally, interim reports can be produced; accounting is automatic, and group requests and requests for new analyses of old samples can be handled. The system meets the demand for retrospective analysis which arises when acute intermediate and convalescent sera have to be analyzed simultaneously. Consequently, results from the same type of analysis performed on the same sample on different occasions can be handled and presented in a clear way on the VDU and on the report.

All work is performed on-line in real time via VDU screens. All data are stored on a 3 x 100 Mbyte disk chive which can accommodate approximately 6 years’ work.

The system has been implemented as a terminal system with 5 VDU: s and one line printer connected to an IBM 370/158 computer. The IMS data base management system has been utilized.

Reassuringly low carriage of enteropathogens among healthy Swedish children in day care centres

OBJECTIVES

Infectious gastroenteritis is one of the most common diseases among children and has a considerable impact on health and socio-economy. Day care centres are high-risk environments for infections. The aim of this study was to investigate if asymptomatic preschool children constitute a reservoir for potential enteropathogens.

STUDY DESIGN

In total, 438 individual diapers were collected from day care centres in Uppsala, Sweden, during spring and autumn, and molecular techniques were used to estimate the prevalence of asymptomatic carriage of multiple enteropathogens.

METHODS

Faecal samples were analysed with multiplex polymerase chain reaction (PCR) (xTAG^® Gastrointestinal Pathogen Panel; Luminex Corporation, Toronto, Canada) targeting 21 different pathogens. Samples with a median fluorescence intensity above threshold were re-analysed with a second PCR assay.

RESULTS

Sixteen of the 438 samples were positive for enteropathogens, 1.6% for enteric adenovirus, 0.7% for Campylobacter spp., and 0.7% for norovirus.

CONCLUSIONS

Preschool children in Uppsala constitute a limited reservoir for potential enteropathogens.

Impact of delay between imaging and treatment in patients with potentially curable pancreatic cancer

Background

Locoregional pancreatic ductal adenocarcinoma (PDAC) may progress rapidly and/or disseminate despite having an early stage at diagnostic imaging. A prolonged interval from imaging to resection might represent a risk factor for encountering tumour progression at laparotomy. The aim of this study was to determine the therapeutic window for timely surgical intervention.

Methods

This observational cohort study included patients with histologically confirmed PDAC scheduled for resection with curative intent from 2008 to 2014. The impact of imaging-to-resection/reassessment (IR) interval, vascular involvement and tumour size on local tumour progression or presence of metastases at reimaging or laparotomy was evaluated using univariable and multivariable regression. Risk estimates were approximated using hazard ratios (HRs).

Results

Median IR interval was 42 days. Of 349 patients scheduled for resection, 82 had unresectable disease (resectability rate 76·5 per cent). The unresectability rate was zero when the IR interval was 22 days or shorter, and was lower for an IR interval of 32 days or less compared with longer waiting times (13 versus 26·2 per cent; HR 0·42, P = 0·021). It was also lower for tumours smaller than 30 mm than for larger tumours (13·9 versus 32·5 per cent; HR 0·34, P < 0·001). Tumours with no or minor vascular involvement showed decreased rates of unresectable disease (20·6 per cent versus 38 per cent when there was major or combined vascular involvement; HR 0·43, P = 0·007). However, this failed to reach statistical significance on multivariable analysis (P = 0·411), in contrast to IR interval (P = 0·028) and tumour size (P < 0·001).

Conclusion

Operation within 32 days of diagnostic imaging reduced the risk of tumour progression to unresectable disease by half compared with a longer waiting time. The results of this study highlight the importance of efficient clinical PDAC management.

Hospital teaching status and volume related to mortality after pancreatic cancer surgery in a national cohort

BACKGROUND

The association between hospital teaching status and mortality after pancreatic resection is not well explored. Although hospital volume is related to short-term mortality, the effect on long-term survival needs investigation, taking into account hospital teaching status and selective referral patterns.

METHODS

This was a nationwide retrospective register-based cohort study of patients undergoing pancreatic resection between 1990 and 2010. Follow-up for survival was carried out until 31 December 2011. The associations between hospital teaching status and annual hospital volume and short-, intermediate- and long-term mortality were determined by use of multivariable Cox regression models, which provided hazard ratios (HRs) with 95 per cent c.i. The analyses were mutually adjusted for hospital teaching status and volume, as well as for patients' sex, age, education, co-morbidity, type of resection, tumour site and histology, time interval, referral and hospital clustering.

RESULTS

A total of 3298 patients were identified during the study interval. Hospital teaching status was associated with a decrease in overall mortality during the latest interval (years 2005-2010) (university versus non-university hospitals: HR 0·72, 95 per cent c.i. 0·56 to 0·91; P = 0·007). During all time periods, hospital teaching status was associated with decreased mortality more than 2 years after surgery (university versus non-university hospitals: HR 0·86, 0·75 to 0·98; P = 0·026). Lower annual hospital volume increased the risk of short-term mortality (HR for 3 or fewer compared with 4-6 pancreatic cancer resections annually: 1·60, 1·04 to 2·48; P = 0·034), but not long-term mortality. Sensitivity analyses with adjustment for tumour stage did not change the results.

CONCLUSION

Hospital teaching status was strongly related to decreased mortality in both the short and long term. This may relate to processes of care rather than volume per se. Very low-volume hospitals had the highest short-term mortality risk.

Diagnostic value of abdominal drainage in individual risk assessment of pancreatic fistula following pancreaticoduodenectomy

Background

The use of prophylactic abdominal drainage following pancreaticoduodenectomy (PD) is controversial as its therapeutic value is uncertain. However, the diagnosis of postoperative pancreatic fistula (POPF), the main cause of PD-associated morbidity, is often based on drain pancreatic amylase (DPA) levels. The aim of this study was to assess the predictive value of DPA, plasma pancreatic amylase (PPA) and serum C-reactive protein (CRP) for diagnosing POPF after PD.

Methods

Patients undergoing PD with prophylactic drainage between 2008 and 2012 were studied prospectively. DPA, PPA and CRP levels were obtained daily. Differences between groups with clinically relevant POPF (International Study Group on Pancreatic Fistula (ISGPF) grade B/C) and without clinically relevant POPF (no POPF or ISGPF grade A) were evaluated. Receiver operating characteristic (ROC) analyses were performed to determine the value of DPA, PPA and CRP in prediction of POPF. Risk profiles for clinically relevant POPF were constructed and related to the intraoperative pancreatic risk assessment.

Results

Fifty-nine (18·7 per cent) of 315 patients developed clinically relevant POPF. DPA, PPA and CRP levels on postoperative day (POD) 1–3 differed significantly between the study groups. In predicting POPF, the DPA level on POD 1 (cut-off at 1322 units/l; odds ratio (OR) 24·61, 95 per cent confidence interval 11·55 to 52·42) and POD 2 (cut-off at 314 units/l; OR 35·45, 14·07 to 89·33) was superior to that of PPA on POD 1 (cut-off at 177 units/l; OR 13·67, 6·46 to 28·94) and POD 2 (cut-off at 98 units/l; OR 16·97, 8·33 to 34·59). When DPA was combined with CRP (cut-off on POD 3 at 202 mg/l; OR 16·98, 8·43 to 34·21), 90·3 per cent of postoperative courses could be predicted correctly (OR 44·14, 16·89 to 115·38).

Conclusion

The combination of serum CRP and DPA adequately predicted the development of clinically relevant pancreatic fistula following PD.

Usefulness of real-time PCR for lytA, ply, and Spn9802 on plasma samples for the diagnosis of pneumococcal pneumonia

In the present study, we evaluated rapid real-time PCR assays for ply, Spn9802, and lytA applied to plasma samples for the detection of Streptococcus pneumoniae in patients with community-acquired pneumonia (CAP). In a prospective study of CAP aetiology, an EDTA plasma sample was collected together with blood culture in 92 adult CAP patients and 91 adult controls. Among the 92 CAP patients, lytA PCR was positive in eight (9%), Spn9802 PCR was positive in 11 (12%) and ply PCR was positive in 19 (21%) cases. Of 91 controls, the ply PCR was positive in eight cases (9%), but no positive cases were noted by Spn9802 or lytA PCRs. Ten CAP patients had pneumococcal bacteraemia. Compared to blood culture, PCR for lytA, Spn9802 and ply had sensitivities of 70% (7/10), 60% (6/10) and 70% (7/10), and specificities of 96% (79/82), 94% (77/82) and 85% (70/82) respectively. With blood culture and/or culture of representative sputum, and/or urinary antigen detection, S. pneumoniae was identified in 31 CAP patients. Compared to these tests in combination, PCR for lytA, Spn9802 and ply showed sensitivities of 26% (8/31), 32% (10/31) and 42% (13/31), and specificities of 100% (61/61), 98% (60/61) and 90% (55/61) respectively. We conclude that Spn9802 and lytA PCRs may be useful for the rapid detection of bacteraemic pneumococcal pneumonia, whereas ply PCR is not specific enough for routine use and blood PCR with small plasma volumes is not useful for the detection of nonbacteraemic pneumococcal pneumonia.

Is quantitative PCR for the pneumolysin (ply) gene useful for detection of pneumococcal lower respiratory tract infection?

The pneumolysin (ply) gene is widely used as a target in PCR assays for Streptococcus pneumoniae in respiratory secretions. However, false-positive results with conventional ply-based PCR have been reported. The aim here was to study the performance of a quantitative ply-based PCR for the identification of pneumococcal lower respiratory tract infection (LRTI). In a prospective study, fibreoptic bronchoscopy was performed in 156 hospitalized adult patients with LRTI and 31 controls who underwent bronchoscopy because of suspicion of malignancy. Among the LRTI patients and controls, the quantitative ply-based PCR applied to bronchoalveolar lavage (BAL) fluid was positive at >or=10(3) genome copies/mL in 61% and 71% of the subjects, at >or=10(5) genome copies/mL in 40% and 58% of the subjects, and at >or=10(7) genome copies/mL in 15% and 3.2% of the subjects, respectively. Using BAL fluid culture, blood culture, and/or a urinary antigen test, S. pneumoniae was identified in 19 LRTI patients. As compared with these diagnostic methods used in combination, quantitative ply-based PCR showed sensitivities and specificities of 89% and 43% at a cut-off of 10(3) genome copies/mL, of 84% and 66% at a cut-off of 10(5) genome copies/mL, and of 53% and 90% at a cut-off of 10(7) genome copies/mL, respectively. In conclusion, a high cut-off with the quantitative ply-based PCR was required to reach acceptable specificity. However, as a high cut-off resulted in low sensitivity, quantitative ply-based PCR does not appear to be clinically useful. Quantitative PCR methods for S. pneumoniae using alternative gene targets should be evaluated.

Evolution of human endogenous retroviral sequences: a conceptual account

Endogenous retroviruses (ERVs) most likely are remnants of ancient retroviral infections. ERVs preserve functions of exogenous retroviruses to a varying extent, and can be parasites, symbionts or more or less neutral genetic 'junk'.Their evolution has two facets, pre- and post-endogenization. Although the two are not clearly separated, the first pertains to retroviral evolution in general and the second to the fate of repetitive DNA and the evolution of the host organism and its genome. The study of ERVs provides much material for the understanding of retroviral evolution. This sequence archive reflects the history of successes and shortcomings of antiviral resistance, but also of strategic evolutionary decisions regarding genome organization and new gene acquisition. This review discusses retroviral evolution illustrated through HERVs, bioinformatic prerequisites for ERV studies, the endogenization process and HERV evolution post-endogenization, including relation to disease. (Part of a multi-author review).

The rapid molecular subtyping and pathotyping of avian influenza viruses

Highly conserved nucleotide stretches flanking the cleavage site of the haemagglutinin (HA) gene of influenza type A viruses were utilised for generating PCR amplicons from a broad range of avian influenza viruses (AIV) in a one-step real-time SYBR Green RT-PCR assay. The nucleotide sequencing of the amplified PCR products simultaneously reveals both the HA subtype and the pathotype of the AIV isolates, as we demonstrated in case of H5 subtype viruses. The specificity of the assay was confirmed by investigating 66 strains of AIV and nine heterologous pathogens, including influenza B, C and various avian pathogenic viruses. This assay enables a general HA subtype identification and pathotype determination of AIV isolates providing a useful alternative tool for avian influenza diagnosis.

Telomeric location of retroviral oncogenes in humans

The position relative to centromeres and telomeres has been investigated in 42 proto-oncogenes that have been localized in specific bands of the human chromosomes. It turned out that the 26 retroviral oncogenes had a predominant telon territory (near telomeres). The difference from the non-retrovirally transduced oncogenes is significant (p less than 0.01). Moreover, all oncogenes studied avoid the shortest and the longest arms. The results support the idea that genes with different properties tend to have different gene territories within the human chromosomes.

Recent enterovirus infection in type 1 diabetes: evidence with a novel IgM method

Enterovirus (EV) infection has been associated with Type 1 (T1D) diabetes and on a few occasions virus could be isolated at onset of the disease. Using two such isolates as antigens in a quantitative PCR enhanced immunoassay (T1D-EV-QPIA) we have measured IgM antibodies against such potentially diabetogenic viruses in serum from 33 newly diagnosed T1D children, 24 siblings, and 27 healthy children. Sera were also analysed with regard to autoantibodies against GAD65, the cytokine TNF-alpha and the chemokine IP-10. EV-RNA detection was performed on peripheral blood mononuclear cells (PBMC). IgM antibodies against this "new" EV antigen were more frequent in serum from T1D children than in serum from siblings and/or controls (P < 0.001). EV-RNA was detected more frequently in PBMC from T1D children than in healthy control children (P < 0.001) and also compared to the siblings (P < 0.003). The cytokine TNF-alpha was less frequently detected in serum from the T1D children compared with serum from siblings and/controls (P < 0.001). A positive correlation was found between the results obtained with the T1D-EV-QPIA and the EV-PCR (P < 0.001). These findings are in line with earlier findings of an increased frequency of enteroviral infections in newly diagnosed T1D patients. In addition, we found that T1D children at onset of the disease had lower frequencies of the chemokine TNF-alpha in their serum than age- and sex-matched controls had, suggesting an impaired immune response.

Search for DNA of exogenous mouse mammary tumor virus-related virus in human breast cancer samples

Earlier reports of a human exogenous retrovirus (HMTV) related closely to mouse mammary tumor virus (MMTV) led us to search for these viral sequences in breast cancer tissues and normal tissues. A real-time PCR was developed based on MMTV and published HMTV envelope sequences. The real-time PCR method can detect one to ten copies of MMTV target DNA. Tissue samples were collected prospectively from 18 breast cancer patients and 11 non-malignant control cases, as well as peripheral blood leukocytes from the same women. Despite the high sensitivity of the real-time PCR method used, none of the samples were positive for HMTV DNA or RNA. The absence of HMTV DNA in both breast cancer samples and controls indicates either that the concentration of putative HMTV DNA in the breast cancers was too low for detection or that it did not exist there.

SYBR Green real-time reverse transcription-polymerase chain reaction assay for the generic detection of coronaviruses

Coronaviruses are etiologic agents of respiratory and enteric diseases in humans and in animals. In this study, a one-step real-time reverse transcription-polymerase chain reaction (RT-PCR) assay based on SYBR Green chemistry and degenerate primers was developed for the generic detection of coronaviruses. The primers, designed in the open reading frame 1b, enabled the detection of 32 animal coronaviruses including strains of canine coronavirus, feline coronavirus, transmissible gastroenteritis virus (TGEV), bovine coronavirus (BCoV), murine hepatitis virus (MHV) and infectious bronchitis virus (IBV). A specific amplification was also observed with the human coronaviruses (HCoV) HCoV-NL63, HCoV-OC43, HCoV-229E and severe acute respiratory syndrome coronavirus (SARS-CoV). The real-time RT-PCR detected down to 10 cRNA copies from TGEV, BCoV, SARS-CoV and IBV. In addition, the assay exhibited a high sensitivity and specificity on clinical samples from different animal species. The developed assay represents a potential tool for laboratory diagnostics and for detecting still uncharacterized coronaviruses.

Classification of highly similar crude oils using data sets from comprehensive two-dimensional gas chromatography and multivariate techniques

Comprehensive two-dimensional gas chromatography (GCxGC) has proven to be an extremely powerful separation technique for the analysis of complex volatile mixtures. This separation power can be used to discriminate between highly similar samples. In this article we will describe the use of GCxGC for the discrimination of crude oils from different reservoirs within one oil field. These highly complex chromatograms contain about 6000 individual, quantified components. Unfortunately, small differences in most of these 6000 components characterize the difference between these reservoirs. For this reason, multivariate-analysis (MVA) techniques are required for finding chemical profiles describing the differences between the reservoirs. Unfortunately, such methods cannot discern between 'informative variables', or peaks describing differences between samples, and 'uninformative variables', or peaks not describing relevant differences. For this reason, variable selection techniques are required. A selection based on information between duplicate measurements was used. With this information, 292 peaks were used for building a discrimination model. Validation was performed using the ratio of the sum of distances between groups and the sum of distances within groups. This step resulted in the detection of an outlier, which could be traced to a production problem, which could be explained retrospectively.

Comprehensive multi-dimensional chromatographic studies on the separation of saturated hydrocarbon ring structures in petrochemical samples

Characterization of complex petrochemical samples has been a classical subject of comprehensive two-dimensional (2D) gas chromatography (GC x GC). Macroscopic properties of these samples can be described accurately by separation of compounds in classes of identical molecular functionality. Ring structures in the carbon backbone of these compounds, which can be divided in saturated and unsaturated, are amongst the foremost functionalities affecting samples properties. Unfortunately, GC x GC tuned for separation of both saturated and unsaturated ring structures is likely to result in convoluted chromatograms when a distribution of both molecular properties is present in the sample. An independent liquid chromatographic (LC) separation preceding GC x GC could be used to resolve the mixture based on unsaturated rings, allowing saturated rings to be resolved separately in the GC x GC separation. This three-dimensional separation (abbreviated LC-GC x GC) was performed after rigorous evaluation of LC as part of a multidimensional separation using LC x GC. Group-type separation was achieved using this separation for components with either saturated or unsaturated rings. Results of this separation were used to compare information obtained by GC x GC with LC-GC x GC.

Uptake of amplifiable fragments of retrotransposon DNA from the human alimentary tract

Few attempts have been made to study the transfer of DNA from ingested food across the intestinal barrier. A low uptake of ingested DNA has been observed in mice, cattle and poultry. There have been no reports on humans so far. Maintenance of species barriers, protection against retrotransposons, optimisation of oral DNA vaccines and the fate of genetically modified foodstuffs are issues where this topic is of importance. We therefore used the high-copy-number rabbit retrotransposon RERV-H, and rabbit mitochondrial DNA, to study the transfer of DNA from ingested rabbit meat into the bloodstream of two human volunteers. A quantitative PCR was used to measure RERV-H levels in food and in the blood. Amplification with the primers selected results in the generation of a 250-bp fragment of RERV-H. Transfer across the intestinal epithelium could be demonstrated in both subjects. Levels of the fragment in the bloodstream peaked at 1-3 h after ingestion of the experimental meal. One hour after a meal of rabbit meat containing 10(14) copies of RERV-H DNA, a maximum concentration of 200 copies of RERV-H DNA per ml of peripheral blood was observed, which corresponds to the uptake of approximately 10(6) RERV-H DNA copies in 1 h. RERV-H DNA was detected in both cellular and plasma compartments. Both rabbit retrotransposon and mitochondrial DNA was taken up from the human alimentary tract. The size of the fragments detected is similar to that of SINE retrotransposons (approximately 300 bp). The fate and functionality of alimentary DNA in humans will require further study.

Gas chromatographic methods for oil analysis

In the past 50 years. gas chromatography (GC) has played a most important role in the analysis of oil. In this review, the early history is briefly reviewed; next developments in this highly relevant application area since about 1985 are highlighted. The main topic of interest are the introduction and decisive role of capillary GC, the use of selective detection techniques, the versatility of coupled-column techniques and, specifically, the additional power of comprehensive two-dimensional GC.

Prevalence of blood-borne viral infections (cytomegalovirus, human herpesvirus-6, human herpesvirus-7, human herpesvirus-8, human T-cell lymphotropic virus-I/II, human retrovirus-5) among blood donors in Latvia

The identification of blood-borne viral infections is important in transfusion medicine. The aim of this study was to evaluate the prevalence of human herpesvirus (HHV) [cytomegalovirus (CMV), HHV-6, HHV-7 HHV-8] and human retrovirus (HRV) (human T-cell lymphotropic virus (HTLV)-I/II, HRV-5) infections among apparently healthy Latvian blood donors. DNA extracted from peripheral blood leukocytes (PBL) of 150 individuals was tested for herpesviruses by sensitive polymerase chain reaction (PCR) technique. None of the blood donors was positive for HHV-8 infection, while the incidence of latent beta-herpesvirus infections was high: single infection by CMV, HHV-6, and HHV-7 was detected in 2.6%, 8.0%, and 43.3% of blood donors, respectively. Simultaneous dual and triple infections of these viruses were observed in 28.0% and 4.7% of individuals, respectively. Active infection by CMV and HHV-6 was not found, but HHV-7 DNA was present in plasma of 10.6% of the blood donors. While all blood donors were HTLV-II and HRV-5 negative, 4.6% of HTLV-I seronegative blood donors were positive for the HTLV-I tax gene, although none of them harbored sequences for structural genes of the provirus. Based on our results, we conclude that monitoring of beta-herpesvirus infections in blood donors can be important in cases of transfusions to immunocompromised persons. HHV-8, as well as the retroviruses HTLV-II and HRV-5, were not found in blood of Latvian blood donors. More investigations are required to explain the presence of the HTLV-I tax sequence in seronegative blood donors.

Sequence evolution and cross-reactive antibody responses to hypervariable region 1 in acute hepatitis C virus infection

Hepatitis C virus (HCV) infection may result in acute resolving or chronic infection. Patients that clear the infection have a more vigorous cellular immune response and an early humoral response to the hypervariable region 1 (HVR1) of the E2 envelope protein. To analyse further the properties of the early anti-HVR1 response, cross-reactivity of anti-HVR1 responses was assessed in five patients with acute HCV infection, who were infected by the same virus strain during a nosocomial outbreak. The sequence evolution of HVR1 was examined in sequential serum samples up to 37 months post infection. Peptides were synthesised corresponding to the obtained HVR1 sequences and unrelated HVR1 sequences, and antibody reactivity to the peptides in sequential sera was investigated by ELISA. The results suggest an association between specific gaps in humoral immunity and the HVR1 sequence evolution during early infection. Possible interpretations of this phenomenon include immune escape mechanisms or suppression of specific anti-HVR1 antibodies.

Human retrovirus type 5 sequences in non-Hodgkin's lymphoma of T cell origin

DNA of a recently described fifth exogenous retrovirus (HRV-5) has been found in blood samples from patients with autoimmune diseases and lymphoma. We analyzed HRV-5 sequence in DNA extracted from whole blood of 17 patients with T cell non-Hodgkin's lymphoma (NHL) and 186 patients with hematological malignancies other than NHL, using a sensitive PCR technique. While all samples of patients with hematological malignancies other than NHL were negative, 2 of the 17 patients with T cell NHL were HRV-5 DNA positive. Both HRV-5-positive patients had T cell NHL of high-grade malignancy (stage IV) and diffuse distribution of the lymphoma, including infiltration of bone marrow or lung and pleura. The difference in HRV-5 DNA detection frequency between NHL and control groups is significant (p value of 0.0004 judged by the Fisher exact test). These data, together with our previous finding of HRV-5 DNA in three B cell NHL cases, are compatible with an association between HRV-5 and NHL, of both T cell and B cell origin.

Broad Spectrum of Time of Detection, Primary Symptoms and Disease Progression in Infants with HIV-1 Infection

The relationship between time of HIV-1 detection, appearance of symptoms and disease progression was studied in all 24 HIV-1-infected infants from a cohort of 117 children who were born to HIV-1-infected mothers and monitored from birth. HIV isolation from plasma and mononuclear cells, HIV-1 DNA PCR (polymerase chain reaction) and, retrospectively, a quantitative assay for HIV-1 RNA were used for virus detection. Two infants possibly exhibited a symptomatic primary HIV infection. More children with than without symptoms during the first year of life progressed to immunological class 3 (P=0.013) and to AIDS or death (P=0.003) during follow-up. HIV-1 was detected within 4 days of age in 4 of 16 infants: 3 of them became symptomatic within 1 year, as did 6 of the remaining 12 infants (not statistically significant). All four infants in whom virus was detected within 4 days of age progressed to severe immunosuppression, compared to 6 of 14 in whom the virus detection test was initially negative prior to the first positive result (n.s.). Two children with previous repeatedly negative HIV detection tests were diagnosed with HIV-1 infection at 8 and 9 months, respectively. Repeated blood sampling is needed for the diagnosis of HIV-1 infection in perinatally exposed infants, and virus detection tests for exclusion of HIV-1 infection must be used with caution.

Activation of type I interferon system in systemic lupus erythematosus correlates with disease activity but not with antiretroviral antibodies

The objective was to investigate the relation between serum levels of interferon-alpha (IFN-alpha), the activity of an endogenous IFN-alpha inducing factor (SLE-IIF), clinical and immunological disease activity as well as serum levels of antiretroviral antibodies in SLE. Serum levels of IFN-alpha were measured in serial sera from 30 patients sampled at different stages of disease activity (SLEDAI score). The SLE-IIF activity was measured by its ability to induce IFN-alpha production in cultures of normal peripheral blood mononuclear cells. Both serum IFN-alpha and SLE-IIF increased markedly at flare in serially followed patients. The SLEDAI score, levels of anti-dsDNA antibodies and IL-10 correlated positively, and complement components Clq, C3 and leukocytes correlated inversely with serum concentrations of IFN-alpha. The extent of multiple organ involvement correlated with serum IFN-alpha. No relation between concentrations of retroviral peptide binding antibodies and IFN-alpha or SLE-IIF activity was found. The close relationship between disease activity in SLE patients and IFN-alpha serum levels suggests that activation of the type 1 IFN system might be of importance in the disease process.

Identification of novel porcine endogenous betaretrovirus sequences in miniature swine

PCR amplification of genomic DNA from miniature swine peripheral blood lymphocytes, using primers corresponding to highly conserved regions of the polymerase (pol) gene, allowed the identification of two novel porcine endogenous retrovirus (PERV) sequences, PMSN-1 and PMSN-4. Phylogenetic analyses of the nucleotide sequences of PMSN-1 and PMSN-4 revealed them to be most closely related to betaretroviruses. The identification of PERVs belonging to the Betaretrovirus genus shows that endogenous retroviruses of this family are more broadly represented in mammalian species than previously appreciated. Both sequences contained inactivating mutations, implying that these particular loci are defective. However, Southern blot analysis showed additional copies of closely related proviruses in the miniature swine genome. Analyses of fetal and adult miniature swine tissues revealed a broad mRNA expression pattern of both PMSN-1 and PMSN-4. The most abundant expression was detected in whole bone marrow c-kit(+) (CD117(+)) progenitor bone marrow cells, fetal liver, salivary gland, and thymus. It appears unlikely that functional loci encoding these novel PERV sequences exist, but this remains to be established. The betaretrovirus sequences described in this report will allow such investigations to be actively pursued.

Increased immunoglobulin G, but not M, binding to endogenous retroviral antigens in HIV-1 infected persons

The modes of interaction between products of human endogenous retroviral (HERV) sequences and the immune system are largely unknown. In HIV infected persons, an exogenous retrovirus adds further complexity to the situation. Therefore, 14 synthetic peptides with sequences derived from conserved regions of various endogenous retroviruses (ERVs) and from related exogenous retroviruses were used to search for IgG and IgM antibodies that bind to such antigens in 15 HIV-1 seropositive and 17 seronegative immunosuppressed patients. IgG binding to three peptides, namely, the C-terminal half of murine leukemia virus (MLV) capsid protein, the conserved portion of HERV-H transmembrane protein, and the Pol region of human mouse mammary tumor virus (MMTV)-like (HML3) sequence, was observed in both groups. Binding was, however, more frequent and more firm in HIV-1 positive samples (P<0.0001, Wilcoxon rank sum test). IgM binding to the same peptides showed no significant differentiation between the two groups of patients. Binding to both immunoglobulin isotypes was sometimes variable over time in both groups. No correlation of either IgG or IgM peptide binding with progression to AIDS in HIV-1 infected individuals was observed. Inhibition studies using analogous endogenous and exogenous retroviral peptides, including HIV-1, demonstrated specificity of the IgG antibodies for a narrow range of MLV- and MMTV-like retroviral antigens, and excluded cross-reactivity of antibodies to HIV-1 as a cause of these observations. Thus, unlike IgG, IgM binding to retroviral antigens was ubiquitous. It is suggested that anti-HERV IgM belong to a class of natural antibodies and might serve as primers in the mediation of humoral immune responses to more or less related exogenous retroviruses. Increased IgG binding in HIV-1 infected individuals could result from such priming, or reflect higher HERV antigen expression.

Varieties of long-term outcome among patients in psychoanalysis and long-term psychotherapy. A review of findings in the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (STOPP)

This paper reports the main findings of a large-scale study of subsidized psychoanalysis and long-term psychotherapy. More than 400 people in various phases, before, during and after subsidized psychoanalysis or long-term psychodynamic psychotherapy, were followed up for a period of three years with personal interviews, questionnaires and official statistics. Our analyses revealed progressive improvement the longer patients were in treatment--impressively strong among patients in psychoanalysis--on self-rating measures of symptom distress and morale. Improvement, however, was equally weak in both groups on a self-rating measure of social relations. Dosage factors (treatment duration and session frequency in combination) partly accounted for the outcome differences between those referred to psychoanalysis and those referred to long-term psychotherapy. Attitudes and ideals among therapists and analysts concerning the goals and means of psychotherapy were also associated with patient outcome, although in rather complex ways. A significant part of the outcome differences between patients in psychoanalysis and in psychotherapy could be explained by the adoption, in a large group of therapists, of orthodox psychoanalytic attitudes that seemed to be counterproductive in the practice of psychotherapy but not in psychoanalysis. It is suggested that this effect may be a negative transfer of the psychoanalytic stance into psychotherapeutic practice and that this may be especially pronounced when the attitudes are not backed up by psychoanalytic training.

Comparison of comprehensive two-dimensional gas chromatography and gas chromatography--mass spectrometry for the characterization of complex hydrocarbon mixtures

In this paper, we compare the current separation power of comprehensive two-dimensional gas chromatography (GCxGC) with the potential separation power of GC-mass spectrometry (GC-MS) systems. Using simulated data, we may envisage a GC-MS contour plot, that can be compared with a GCxGC chromatogram. Real examples are used to demonstrate the current potential of the two techniques in the field of hydrocarbon analysis. As a separation technique for complex hydrocarbon mixtures, GCxGC is currently about as powerful as GC-MS is potentially powerful. GC-MS has not reached its potential separation power in this area, because a universal, soft ionization method does not exist. The greatest advantage of GCxGC is, however, its potential for quantitative analysis. Because flame-ionisation detection can be used, quantitative analysis by GCxGC is much more robust, reliable and reproducible.

[Newly discovered human retroviruses. Association with disease is still undetermined]

Retroviruses are enveloped RNA viruses which can transcribe RNA to DNA and integrate into the chromosomal DNA of their host cell. Heritable integrations give rise to endogenous retroviral sequences (ERVs). The rest is exogenous, infecting from individual to individual. This survey highlights an emerging scenario in human retrovirology. Humans have thousands of distinct ERVs. Although most are damaged by mutations, many are expressed as RNA, a few also as proteins and viral particles. The latter are not known to be infectious. Obviously, human ancestors encountered many different exogenous retroviruses, some of which may still be extant. In fact, an exogenous retrovirus related to ERVs was recently discovered. It is the fifth human exogenous retrovirus, human retrovirus 5 (HRV-5). It succeeds the two human T-lymphotropic viruses (HTLVs) and the two human immunodeficiency viruses (HIVs). The newly discovered endogenous and exogenous human retroviruses are now being investigated for association with disease. There are indications of selective ERV activation in multiple sclerosis, schizophrenia and seminoma. HRV-5 has been associated with rheumatoid arthritis, systemic lupus erythematosus and non-Hodgkin lymphoma. It is not yet known whether these first observations signal a pathogenic role for the newly discovered retroviruses.

Structural prerequisites for intersubtype B and D antigenicity of the third variable envelope region (V3) of human immunodeficiency virus type 1

To elucidate the structural requirements for intersubtype antigenicity of human immunodeficiency virus type 1 (HIV-1) third variable envelope region (V3), synthetic peptides were used in enzyme immunoassays (EIAs) with serum samples from persons with proven or probable subtype B and D infections. Mathematical analyses of results from EIAs with singly substituted V3 peptides revealed important residues determining overall N-terminal V3 peptide antigenicity. This information was used to design V3 immunogens, rabbit antiserum to which were tested in EIA and for in vitro neutralization of molecular clones of HIV-1(MN) and HIV-1(MAL). Intersubtype-reactive epitopes were distributed toward the N-terminal half of the V3 loop. Lysine at position 310, arginine at position 311, and isoleucine at position 314, all derived from the MN primary sequence, were major determinants of intersubtype V3 antigenicity. Combinations of residues that enhanced antigenicity often contained lysine at position 310. Threonine at position 308 was common in the least advantageous combinations. V3 immunogens modified to achieve optimal antigenicity induced antiserum with augmented cross-neutralization of virus from MAL and MN molecular clones, suggesting one approach to subunit vaccine development.

Human retrovirus 5 sequences in peripheral blood cells of patients with B-cell non-Hodgkin's lymphoma

A recently described sequence from a probable 5th human exogenous retrovirus, HRV-5, is related to type A, B and D retroviruses. It was initially detected in a salivary gland biopsy from a patient with Sjögren's syndrome, but it is not consistently associated with this disease. We searched for the HRV-5 sequence in DNA extracted from whole blood of 300 blood donors, 81 patients with hematological malignancy and 21 patients with neurological disease using PCR. While samples from none of the blood donors and the neurological patients became positive, 3 of the 81 patients with hematological malignancy were HRV-5 DNA positive. All 3 had B-cell non-Hodgkin's lymphoma of low grade. The difference in frequency between NHL and controls is statistically significant. HRV-5 DNA was found in DNA from whole blood and in plastic-adherent cells but not in tumor cell DNA. Thus, monocytes/macrophages may be preferred targets for HRV-5. Our result, together with a previous finding of HRV-5 DNA in 2 NHL cases, is compatible with an association between HRV-5 and NHL, whether causal or not.

Comparative studies on neutralisation of primary HIV-1 isolates by human sera and rabbit anti-V3 peptide sera

IgG binding to V3 peptides and serum neutralising responses were studied in four HIV-1 infected individuals with progressive disease over a period of 31-70 months. The 18-20 mer peptides comprised residues 299-317 (numbering of HIV1 MN) in the N-terminal half of the V3 loop of the envelope glycoprotein gp120 and were derived from the sequences of autologous, as well as heterologous isolates. All four individuals studied lacked anti-V3 IgG binding to at least one autologous V3 sequence. V3 peptides to which autologous sera lacked binding IgG were all immunogenic in rabbits and induced antisera that were broadly cross-reactive by EIA and broadly cross-neutralising to primary HIV-1 isolates. This indicates that the peptides are immunogenic per se and that the respective human hosts have selective defects in recognising the corresponding V3 sequences. Despite the absence of antibody binding to autologous V3 peptides, the human sera had neutralising antibodies to autologous (three out of four cases), as well as heterologous isolates (all cases). Moreover, in vitro exposure of the patients' isolates to autologous neutralising serum or the homologous rabbit antiserum selected for variants with amino acid substitutions close to the crown of the V3 loop or in regions outside the sequence corresponding to peptides used for immunisation. The amino acid exchanges affected V3 positions known to be antigenic and which are also prone to change successively in infected persons. It is likely that neutralising antibodies recognise both linear and conformational epitopes in the V3 loop. Apparently, there are several, but restricted, numbers of ways for this structure to change its conformation and thereby give rise to neutralisation resistant viruses.

Development of an on-line coupling of liquid-liquid extraction, normal-phase liquid chromatography and high-resolution gas chromatography producing an analytical marker for the prediction of mutagenicity and carcinogenicity of bitumen and bitumen fumes

A fast and fully automated system for the determination of polycyclic aromatic compounds (PACs) is described. The system has been developed to produce an analytical 'marker', correlating chemical characteristics (including PAC analysis) with mutagenicity and carcinogenicity. The products of interest are bitumen fumes, bitumen and other (heavy or even residual) oil products, regardless of their boiling range. Dimethyl sulphoxide (DMSO) extractables obtained from a flow-injection analysis (FIA) system are introduced on-line in a normal-phase liquid chromatographic (NPLC) system. Here, the PACs are separated from the DMSO and possible co-extracted heavy residual species. The final step incorporates on-line gas chromatographic analysis of the three-to-six-ring PAC fraction, followed by flame-ionisation detection for quantification. It was demonstrated that data obtained from samples in the distillate lubrication-oil range correlate well with data obtained from the manual DMSO-extraction method standardised by the Institute of Petroleum as IP346.

A novel serological technique: polymerase chain reaction enhanced immunoassay. Application to enterovirus IgM diagnosis

The polymerase chain reaction (PCR) method is a sensitive, specific and rapid technique for virus detection. The principles of a PCR enhanced immunoassay (PIA) are described. The method combines solid phase serological techniques with the PCR, providing a versatile and sensitive method for antibody detection. By linking the antigenicity of virus particles with their content of nucleic acid, the method provides new possibilities for virus serology: for example, antibody specificity can be coupled to viral sequence in patients with chronic infections caused by highly variable viruses such as HIV and HCV. An application of the PIA technique is described for the detection of anti-enterovirus IgM. IgM is captured to anti-human IgM-coated microwell plates. The anti-enterovirus IgM is allowed to bind crude enterovirus antigen. Bound virus is heat denatured and the released RNA is used as a template for reverse transcription PCR (RT-PCR) amplification. Amplicons are detected by hybridisation to an affinity labelled probe in a microwell colorimetric assay. In a pilot study, 18 serum specimens from patients with enterovirus infections were examined. Using a mixture of ten crude enterovirus antigens, the frequency of IgM positivity was 6/18 (33%). Titres between 1/500 and 1/100,000 were recorded. Predominantly type-specific antibodies were detected. The results were compared with a procapsid enterovirus radioimmunoassay (RIA). After further optimisation, the PIA has the potential to be a clinically useful assay for the detection of antiviral antibodies.

Isolation of a human endogenous retroviral HERV-H element with an open env reading frame

About 100 elements of the human endogenous retroviral HERV-H family have full-length env genes potentially coding for Env proteins with sequences highly similar to the immunosuppressive peptide CKS-17 from the MLV transmembrane protein p15E. However, previously sequenced HERV-H env genes have contained stop codons or framehifts. To isolate elements with open env reading frames, we first tried to assess the diversity of HERV-H env genes by comparing PCR-generated env sequences from genomic DNA with published HERV-H sequences. A region at the beginning of env displayed a similarity of 84-98% among 15 different elements. We then used a probe from one of the PCR-generated clones, 98% similar to the consensus sequence in this region, to screen a human genomic lambda library. Three HERV-H elements displaying ca. 98% identity in the env gene were isolated and were shown to have integrated relatively recently, after the divergence of the orangutan and the african great ape lineages. One of these elements, HERV-H19, had a 1752-bp open env reading frame, producing a 77-kDa Env protein in in vitro translation reactions. This is the first demonstration of a coding competent member of the HERV-H family. These findings raise the possibility that HERV-H Env proteins may play a biological role in human cells.

Characterization of human MMTV-like (HML) elements similar to a sequence that was highly expressed in a human breast cancer: further definition of the HML-6 group

Previously, we found a retroviral sequence, HML-6.2BC1, to be expressed at high levels in a multifocal ductal breast cancer from a 41-year-old woman who also developed ovarian carcinoma. The sequence of a human genomic clone (HML-6.28) selected by high-stringency hybridization with HML-6.2BC1 is reported here. It was 99% identical to HML-6.2BC1 and gave the same restriction fragments as total DNA. HML-6.28 is a 4.7-kb provirus with a 5'LTR, truncated in RT. Data from two similar genomic clones and sequences found in GenBank are also reported. Overlaps between them gave a rather complete picture of the HML-6.2BC1-like human endogenous retroviral elements. Work with somatic cell hybrids and FISH localized HML-6.28 to chromosome 6, band p21, close to the MHC region. The causal role of HML-6.28 in breast cancer remains unclear. Nevertheless, the ca. 20 Myr old HML-6 sequences enabled the definition of common and unique features of type A, B, and D (ABD) retroviruses. In Gag, HML-6 has no intervening sequences between matrix and capsid proteins, unlike extant exogenous ABD viruses, possibly an ancestral feature. Alignment of the dUTPase showed it to be present in all ABD viruses, but gave a phylogenetic tree different from trees made from other ABD genes, indicating a distinct phylogeny of dUTPase. A conserved 24-mer sequence in the amino terminus of some ABD envelope genes suggested a conserved function.

Diversity of human endogenous retrovirus class II-like sequences

Class II human endogenous retroviruses (HERVs), often referred to as mouse mammary tumour virus (MMTV)-like or HERV-K elements, have similarities to several animal infectious retroviruses. Single clones from each of nine class II HERV groups (NMWV 1 to NMWV 9), isolated from a human breast cancer cell genomic library, were sequenced over a 244 bp stretch of the conserved reverse transcriptase region. These sequences were aligned to related exogenous and endogenous retroviruses and a phylogenetic tree was constructed. Sequences with more than 80% identity were considered as members of one group and we report here that the class II HERV family consists of at least ten groups. Three of the sequenced clones, from groups NMWV 3, 7 and 9, could not be related to any other previously identified elements and constituted their own groups. NMWV 8 had no similarity to any retroviral sequences in the sequenced region and is so far considered to be non-retroviral.

Two domains of the Borna disease virus p40 protein are required for interaction with the p23 protein

Borna disease virus (BDV) has five major open reading frames, which encode the proteins p40, p23, gp18, p57 and p190. By analogy with other negative-strand RNA viruses, p40 is a putative nucleoprotein and p23 is a putative phosphoprotein. These proteins are known to form complexes with each other and with the polymerase protein in other viruses. In this paper, it is shown that BDV p40 and p23 can form complexes with each other in infected cells. Furthermore, the amino acids of p40 that are necessary for formation of this complex have been mapped.

Screening for human T cell leukaemia/lymphoma virus among blood donors in Sweden: cost effectiveness analysis

OBJECTIVE

To analyse the cost effectiveness of a national programme to screen blood donors for infection with the human T cell leukaemia/lymphoma virus.

DESIGN

Three models for calculating the costs and benefits of screening were developed. The first model analysed the cost of continuously testing all donations; the second analysed the cost of initially testing new blood donors and then retesting them after five years; the third analysed the cost of testing donors only at the time of their first donation. Patients who had received blood components from donors confirmed to be infected with the virus were offered testing.

SETTING

Sweden.

MAIN OUTCOME MEASURES

Prevalence of infection with the virus among blood donors, the risk of transmission of the virus, screening costs, and the outcome of infection.

RESULTS

648 497 donations were tested for the virus; 1625 samples tested positive by enzyme linked immunosorbent assay. 6 were confirmed positive by western blotting. The prevalence of infection with the virus was 2/100 000 donors. 35 patients who had received blood infected with the virus were tested; 3 were positive. The cost of testing every donation was calculated to be $3.02m (1.88m pounds); this is 18 times higher than the cost of testing new donors only, and only 1 additional positive donor would be discovered in 7 years. Regardless of the model used, screening was estimated to prevent only 1 death every 200 years at a minimum cost of $36m (22.5m pounds).

CONCLUSION

Based on these estimates the Swedish National Board of Health and Welfare decided that only new blood donors would be screened for infection with the virus.

Coamplification and dispersion of adjacent human endogenous retroviral HERV-H and HERV-E elements; presence of spliced hybrid transcripts in normal leukocytes

In an RT-PCR study of HERV-H spliced subgenomic transcripts, we found transcripts with HERV-H leader and protease-encoding sequences spliced to HERV-E integrase-encoding sequences in lymphocytes from healthy blood donors. In other cell types, including two T-cell leukemia cell lines, these transcripts were absent. The PCR fragments of the hybrid transcripts contained two open reading frames (ORFs). One was a hybrid HERV-H protease/HERV-E integrase ORF and the other was the HERV-E envelope surface glycoprotein ORF. Alternative splice products were also identified. The genomic DNA origin of the hybrid transcripts was shown to be a HERV-H element with a large 3'-end deletion, adjacent to a HERV-E element lacking the 5'-LTR. This hybrid structure was shown to be amplified and dispersed to six different human chromosomes. Thus, a relatively large part of full-length HERV-E elements (15-20%) is potentially under the transcriptional control of HERV-H LTRs. The HERV-H/HERV-E junction was present in multiple copies also in the chimpanzee and gorilla, but not in the orangutan or old world monkeys.

Spliced human endogenous retroviral HERV-H env transcripts in T-cell leukaemia cell lines and normal leukocytes: alternative splicing pattern of HERV-H transcripts

The majority of human endogenous retroviral HERV-H elements in the human genome have large deletions in pol and lack most of env, 5-10% are more or less complete with a potentially immunosuppressive transmembrane protein-encoding env region. Spliced HERV-H env transcripts were detected in T-cell leukaemia cell lines and lymphocytes from healthy blood donors by using RT-PCR. The transcripts all contained a splice donor in the leader region downstream from the primer-binding site and a previously unreported splice acceptor in the integrase-encoding region of pol, absent in the HERV-H deletion elements. In singly spliced transcripts the leader and integrase regions were joined directly whereas in multiply spliced transcripts they were joined with an alternative exon from the protease-encoding region located between the two regions. env transcripts from three different HERV-H elements were identified: one element similar to a HERV-H consensus sequence was primarily amplified from the T-cell leukaemia cell lines and two other more defective elements were amplified from normal lymphocytes. One of these elements was shown to be a reintegrated spliced transcript where the protease and integrase regions were joined, removing most of pol but leaving gag intact. Other spliced transcripts, joining the protease region and the 3'-LTR, were also amplified. The fact that HERV-H elements with an intact env splice acceptor also use the splice sites in the protease-encoding region suggests that this unusual multiple splice pattern could have a biological function in the intact HERV-H.

Prevalence and risk factors for HTLV-II infection in 913 injecting drug users in Stockholm, 1994

The prevalence and risk factors for acquisition of human T-cell lymphotropic virus type I and II (HTLV-I and II) were investigated in a prospective study of 913 injecting drug users (IDUs) in Stockholm in 1994. Epidemiologic data were recorded, and blood samples were tested for antibodies against HTLV-I and HTLV-II; human immunodeficiency virus (HIV) types 1 and 2; and hepatitis A (HAV), B (HBV), C (HCV), and D (HDV). Positive serologic results for HTLV were confirmed by Western blot (WB) and polymerase chain reaction (PCR). Of the 905 participants with conclusive HTLV-II status, 29 (3.2%) were HTLV-II positive, and all but three were of Nordic descent. None was HTLV-I infected. One person was infected as early as 1981, before HIV had reached the IDU population in Sweden. The prevalence of HTLV-II infection was 12% among HIV-1-seropositive and 1.8% among HIV-1-seronegative participants. The overall seroprevalences were 14% for HIV-1, 0% for HIV-2, 41% for HAV, 75% for HBV, 92% for HCV, and 8% for HDV. Although amphetamine has been the main injecting drug in Sweden for several decades, heroin abuse combined with a debut of injecting drugs before 1975 was identified as the most important risk factor associated with HTLV-II infection. HAV and HIV seropositivity were also independent risk factors.