Clinical and population-based study design considerations to accelerate the investigation of new antiretrovirals during pregnancy

Introduction

Pregnant women are routinely excluded from clinical trials, leading to the absence or delay in even the most basic pharmacokinetic (PK) information needed for dosing in pregnancy. When available, pregnancy PK studies use a small sample size, resulting in limited safety information. We discuss key study design elements that may enhance the timely availability of pregnancy data, including the role and timing of randomized controlled trials (RCTs) to evaluate pregnancy safety; efficacy and safety outcome measures; stand‐alone protocols, platform trials, single arm studies, sample size and the effect that follow‐up time during gestation has on analysis interpretations; and observational studies.

Discussion

Pregnancy PK should be studied during drug development, after dosing in non‐pregnant persons is established (unless non‐clinical or other data raise pregnancy concerns). RCTs should evaluate the safety during pregnancy of priority new HIV agents that are likely to be used by large numbers of females of childbearing age. Key endpoints for pregnancy safety studies include birth outcomes (prematurity, small for gestational age and stillbirth) and neonatal death, with traditional adverse events and infant growth also measured (congenital anomalies are best studied through surveillance). We recommend that viral efficacy be studied as a secondary endpoint of pregnancy RCTs, once PK studies confirm adequate drug exposure in pregnancy. RCTs typically use a stand‐alone protocol for new agents. In contrast, master protocols using a platform design can add agents over time, possibly speeding safety data ascertainment. To speed accrual, stand‐alone pregnancy trial protocols can include pre‐specified starting rules based upon adequate PK levels in pregnancy; and seamless master protocols or platform trials can include a pregnancy PK and safety component. When RCTs are unethical or cost‐prohibitive, observational studies should be conducted, preferably using target trial emulation to avoid bias.

Conclusions

Pregnancy PK needs to be obtained earlier in drug evaluation. Timely RCTs are needed to understand safety in pregnancy for high‐priority new HIV agents. RCTs that enrol pregnant women should focus on outcomes unique to pregnancy, and observational studies should focus on questions that RCTs are not equipped to answer.

Hematopoietic cell transplant nurse coordinators' perceptions of related donor care: a European survey from the EBMT Nurses Group

Allogeneic haematopoietic cell transplantation (HCT) is a curative procedure for patients with haematological malignancies and immune deficiencies. A human leukocyte antigen (HLA) identical sibling is only available for 25-35% of patients in need. The improvement in haplo-identical transplantation has led to a marked increase in cell donation from relatives. Despite international recommendations, discrepancies in related-donors (RD) care exist between centres, particularly regarding medical suitability criteria, consenting procedures and donor follow-up. This European survey aimed to explore hematopoietic cell transplantation coordinators nurses' (HCT-CNs) perceptions of RD care, in particular the association with the presence or not of an independent unit (IU). Ninety-three HCT-CNs from seventy-six EBMT centres responded, representing 19 countries (response rate: 27%). Our results did not show a significant association between IU and HCT-CNs perceptions of related-donors care. The practices for RD care vary among centres regarding presence or not of an IU (48%), person caring for RD (haematologist in 54%, HCT physician in 17%, HCT-CNs in 20%), person to whom the results of HLA typing are communicated, use of a booklet for RD, follow-up or not and periodicity of follow-up. Qualitative data highlight the related-donation ethical issues and the need for improvement in RD care. HCT-CNs' main concerns were: the necessary confidentiality to insure the voluntary status of RD, the perceived conflict of interest felt by professionals when managing both patients and RD, plus the psychosocial aspects of related-donation. Even if there is a variety of a practice among centres, the presence of an IU is not significantly associated with an improvement in RD care.

Leber Hereditary Optic Neuropathy and Longitudinally Extensive Transverse Myelitis

Leber Hereditary Optic Neuropathy is an inherited optic neuropathy caused by mitochondrial DNA point mutations leading to sudden, painless loss of vision. We report a case of an 8-year-old boy presenting with a radiological phenotype of longitudinally extensive transverse myelitis on a background of severe visual impairment secondary to Leber Hereditary Optic Neuropathy (LHON). He was found to have dual mitochondrial DNA mutations at 14484 (MTND6 gene) and 4160 (MTND1 gene) in a family with a severe form of LHON characterised by not only an unusually high penetrance of optic neuropathy, but also severe extra-ocular neurological complications. The m.14484T>C mutation is a common LHON mutation, but the m.4160T>C mutation is to our knowledge not reported outside this family and appears to drive the neurological manifestations. To our knowledge there have been no previous reports of spinal cord lesions in children with LHON.

Dynamically controlled deposition of colloidal nanoparticle suspension in evaporating drops using laser radiation

Dynamic control of the distribution of polystyrene suspended nanoparticles in evaporating droplets is investigated using a 2.9 μm high power laser. Under laser radiation a droplet is locally heated and fluid flows are induced that overcome the capillary flow, and thus a reversal of the coffee-stain effect is observed. Suspension particles are accumulated in a localised area, one order of magnitude smaller than the original droplet size. By scanning the laser beam over the droplet, particles can be deposited in an arbitrary pattern. This finding raises the possibility for direct laser writing of suspended particles through a liquid layer. Furthermore, a highly uniform coating is possible by manipulating the laser beam diameter and exposure time. The effect is expected to be universally applicable to aqueous solutions independent of solutes (either particles or molecules) and deposited substrates.

Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: the PEARL study

BACKGROUND

Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. We constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, we collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d'Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33-68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant.

CONCLUSIONS/RESULTS

We observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.

Presumptive diagnosis of severe HIV infection to determine the need for antiretroviral therapy in children less than 18 months of age

OBJECTIVE

To develop a new algorithm for the presumptive diagnosis of severe disease associated with human immunodeficiency virus (HIV) infection in children less than 18 months of age for the purpose of identifying children who require antiretroviral therapy (ART).

METHODS

A conditional probability model was constructed and non-virologic parameters in various combinations were tested in a hypothetical cohort of 1000 children aged 6 weeks, 6 months and 12 months to assess the sensitivity, specificity, and positive and negative predictive values of these algorithms for identifying children in need of ART. The modelled parameters consisted of clinical criteria, rapid HIV antibody testing and CD4+ T-lymphocyte (CD4) count.

FINDINGS

In children younger than 18 months, the best-performing screening algorithm, consisting of clinical symptoms plus antibody testing plus CD4 count, showed a sensitivity ranging from 71% to 80% and a specificity ranging from 92% to 99%. Positive and negative predictive values were between 61% and 97% and between 95% and 96%, respectively. In the absence of virologic tests, this alternate algorithm for the presumptive diagnosis of severe HIV disease makes it possible to correctly initiate ART in 91% to 98% of HIV-positive children who are at highest risk of dying.

CONCLUSION

The algorithms presented in this paper have better sensitivity and specificity than clinical parameters, with or without rapid HIV testing, for the presumptive diagnosis of severe disease in HIV-positive children less than 18 months of age. If implemented, they can increase the number of HIV-positive children successfully initiated on ART.

Nevirapine-associated hepatotoxicity was not predicted by CD4 count ≥250 cells/μL among women in Zambia, Thailand and Kenya

OBJECTIVE

The aim of the study was to determine risk factors for developing severe hepatotoxicity (grade 3 or 4 hepatotoxicity) and rash-associated hepatotoxicity (rash with ≥ grade 2 hepatotoxicity) among women initiating nevirapine-based antiretroviral therapy (ART).

METHODS

The Non-Nucleoside Reverse Transcriptase Inhibitor Response Study was a prospective cohort study carried out in Zambia, Thailand and Kenya. Between May 2005 and January 2007, we enrolled antiretroviral-naïve HIV-infected women initiating nevirapine-based ART. At enrollment and at weeks 2, 4, 8, 16 and 24, participants had serum alanine transferase (ALT) and aspartate transaminase (AST) measured and were evaluated clinically for hepatitis and rash.

RESULTS

Nevirapine-based ART was initiated in 820 women and baseline ALT or AST results were abnormal (≥ grade 1) in 113 (14%) women. After initiating nevirapine-based ART, severe hepatotoxicity occurred in 41 (5%) women and rash-associated hepatotoxicity occurred in 27 (3%) women. In a multivariate logistic regression model, severe hepatotoxicity and rash-associated hepatotoxicity were both associated with baseline abnormal (≥ grade 1) ALT or AST results, but not with a baseline CD4 cell count ≥250 cells/μL. Three participants (0.4%) died with symptoms suggestive of fatal hepatotoxicity; all three women had baseline CD4 count <100 cells/μL and were receiving anti-tuberculosis therapy.

CONCLUSION

Among women taking nevirapine-based ART, severe hepatotoxicity and rash-associated hepatotoxicity were predicted by abnormal baseline ALT or AST results, but not by a CD4 count ≥250 cells/μL. In resource-limited settings where transaminase testing is available, testing should focus on early time-points and on women with abnormal baseline ALT or AST results.

Ion-Implantation of Reactive Elements in Improving the Adhesion of Thermally Grown Cr2O3 Sales

The high temperature oxidation behavior of Al, Y and Hf ion-implantation in Ni-25wtCr alloy with dosages ranging from 1015-1017 ions/cm2 has been studied. Results are compared with the unimplanted alloy, a Xe-implanted alloy and alloys with 0.2wt% Y or lwt% Al additions. Oxidation tests were carried out at 1000°C and 1100°C in 1 atm. O2. It is found that the ion-implantation of Y and Hf greatly reduced oxidation rate and improved scale adherence after a critical implantation dosage, ∼ l×1016 ions/cm2, has been reached. The improved scale adhesion is attributed to both a reduction in growth stress and a strengthened scale/alloy interface, which all developed as a result of a modified scale growth process.

Myths and misconceptions about cervical cancer among Zambian women: rapid assessment by peer educators

OBJECTIVE

To make a rapid assessment of the common myths and misconceptions surrounding the causes of cervical cancer and lack of screening among unscreened low-income Zambian women.

METHODS

We initiated a door-to-door community-based initiative, led by peer educators, to inform unscreened women about the existence of a new see-and-treat cervical cancer prevention program. During home visits peer educators posed the following two questions to women: 1. What do you think causes cervical cancer? 2. Why haven't you been screened for cervical cancer? The most frequent types of responses gathered in this exercise were analyzed thematically.

RESULTS

Peer educators contacted over 1100 unscreened women over a period of two months. Their median age was 33 years, a large majority (58%) were not educated beyond primary school, over two-thirds (71%) did not have monthly incomes over 500,000 Zambian Kwacha (US$100) per month, and just over half (51%) were married and cohabiting with their spouses. Approximately 75% of the women engaged in discussions had heard of cervical cancer and had heard of the new cervical cancer prevention program in the local clinic. The responses of unscreened low-income Zambian women to questions posed by peer educators in urban Lusaka reflect the variety of prevalent 'folk' myths and misconceptions surrounding cervical cancer and its prevention methods.

CONCLUSION

The information in our rapid assessment can serve as a basis for developing future educational and intervention campaigns for improving uptake of cervical cancer prevention services in Zambia. It also speaks to the necessity of ensuring that programs addressing women's reproductive health take into account societal inputs at the time they are being developed and implemented. Taking a community-based participatory approach to program development and implementation will help ensure sustainability and impact.

Structural studies of biomaterials using double-quantum solid-state NMR spectroscopy

Proteins directly control the nucleation and growth of biominerals, but the details of molecular recognition at the protein-biomineral interface remain poorly understood. The elucidation of recognition mechanisms at this interface may provide design principles for advanced materials development in medical and ceramic composites technologies. Here, we describe both the theory and practice of double-quantum solid-state NMR (ssNMR) structure-determination techniques, as they are used to determine the secondary structures of surface-adsorbed peptides and proteins. In particular, we have used ssNMR dipolar techniques to provide the first high-resolution structural and dynamic characterization of a hydrated biomineralization protein, salivary statherin, adsorbed to its biologically relevant hydroxyapatite (HAP) surface. Here, we also review NMR data on peptides designed to adsorb from aqueous solutions onto highly porous hydrophobic surfaces with specific helical secondary structures. The adsorption or covalent attachment of biological macromolecules onto polymer materials to improve their biocompatibility has been pursued using a variety of approaches, but key to understanding their efficacy is the verification of the structure and dynamics of the immobilized biomolecules using double-quantum ssNMR spectroscopy.

Urinary incontinence in familial dysautonomia

The aim of this study was to determine the prevalence of urinary incontinence in women with familial dysautonomia (FD). A telephone survey was conducted on 68 known surviving female FD patients over 13 years of age registered with the Dysautonomia Centers in the USA and Israel. The mean age of the surveyed group was 27.1+/-9.8 years and 99% of the patients were nulliparous. The overall reported prevalence of urinary incontinence was 82% (n=56). Of the patients with incontinence, 59% (n=33) reported stress incontinence, 11% (n=6) reported urge incontinence, and 30% (n=17) reported symptoms of both, or mixed incontinence. In most women urinary loss was both small and infrequent, but 36% of women (n=20) with incontinence experienced a loss sufficient to necessitate the use of protection (panty liners, pads or diapers); in 7% (n=4) such loss occurred daily. Twelve per cent of all women with FD surveyed experienced primary nocturnal enuresis and 26% experienced nocturia. The prevalence of urinary incontinence is high in young female patients with familial dysautonomia. Neurophysiologic testing in this population may provide a better understanding of the role of the autonomic nervous system in urinary incontinence.

Two Japanese variants of the absolute transvestite film

This essay compares two Japanese transvestite films from different generations-Black Lizard of 1968 and Summer Vacation 1999 of 1988. While Western transvestite conventions are usually exploited only to climactically reinforce heterosexual coupling, what binds these two films is their divergent tradition of what I call "permanent transvestism." That is, the films employ a cross-dressing which occurs extra-diegetically, is unnecessary to the plot, and which an audience may or may not be aware of depending on their geo-historical position. However, it is this non-Western tradition of cross-dressing that nevertheless imparts an aestheticization of sexual desire beyond fixed categories of "gay," "lesbian," or even our conventional ideas of transsexualism.

Gastric cancer and metastasis to the brain

BACKGROUND

Metastasis of gastric carcinoma to the brain is very uncommon. At The University of Texas M. D. Anderson Cancer Center (M. D. Anderson), less than 1% of patients with primary gastric carcinoma are found to have brain metastases. Little has been published regarding the evaluation and treatment of these patients. The purpose of this study was to review our experience with gastric cancer metastatic to the brain and to describe the efficacy of the treatment used.

METHODS

Between 1957 and 1997, a total of 218,690 patients were seen for evaluation of malignant tumors at M. D. Anderson. Of these patients, 3320 (1.5%) had a diagnosis of gastric cancer; however, only 24 patients (0.7%) were found to have brain metastases on imaging studies or at autopsy. We performed a retrospective review of these 24 patients and divided them into three groups on the basis of the treatment they received.

RESULTS

Group 1 included patients who received steroids alone (16 mg of dexamethasone, daily). Group 2 patients received 3000 cGy of whole-brain radiation therapy (WBRT) delivered in 10 fractions in addition to steroids. Group 3 patients were managed with surgical resection, WBRT, and steroids. There were 18 male and 6 female patients, with a median age of 53 years. The most common presenting symptoms were weakness, difficulty with balance, and headache. Of the 19 patients diagnosed antemortem, 11 patients developed neurological symptoms after the primary diagnosis of gastric carcinoma, whereas 8 patients developed neurological symptoms before the diagnosis of gastric cancer. Forty-five percent of patients had a single brain metastasis, whereas 55% had multiple lesions. All patients had systemic disease, with bone, liver, and lung involvement seen in 46%, 42%, and 29%, respectively. Nineteen of 24 patients received treatment after diagnosis of brain metastases. Four patients received steroids only (group 1), 11 patients received WBRT and steroids (group 2), and 4 patients were treated with surgery, WBRT, and steroids (group 3). Median survival was approximately 2 months for patients in groups 1 and 2, whereas group 3 patients had a median survival of slightly greater than I year.

CONCLUSIONS

Our results suggest that the overall prognosis of patients with brain metastases from gastric cancer is extremely poor (median survival, 9 weeks). WBRT, as an adjuvant to steroid treatment, was not effective in improving outcome in our series. In selected patients, most of whom were relatively young and had less advanced systemic disease, surgical resection followed by WBRT was associated with relatively long survival times (median survival, 54 weeks).

Chromosomal breakpoint positions suggest a direct role for radiation in inducing illegitimate recombination between the ELE1 and RET genes in radiation-induced thyroid carcinomas

The RET/PTC3 rearrangement is formed by fusion of the ELE1 and RET genes, and is highly prevalent in radiation-induced post-Chernobyl papillary thyroid carcinomas. We characterized the breakpoints in the ELE1 and RET genes in 12 post-Chernobyl pediatric papillary carcinomas with known RET/PTC3 rearrangement. We found that the breakpoints within each intron were distributed in a relatively random fashion, except for clustering in the Alu regions of ELE1. None of the breakpoints occurred at the same base or within a similar sequence. There was also no evidence of preferential cleavage in AT-rich regions or other target DNA sites implicated in illegitimate recombination in mammalian cells. Modification of sequences at the cleavage sites was minimal, typically involving a 1-3 nucleotide deletion and/or duplication. Surprisingly, the alignment of ELE1 and RET introns in opposite orientation revealed that in each tumor the position of the break in one gene corresponded to the position of the break in the other gene. This tendency suggests that the two genes may lie next to each other but point in opposite directions in the nucleus. Such a structure would facilitate formation of RET/PTC3 rearrangements because a single radiation track could produce concerted breaks in both genes, leading to inversion due to reciprocal exchange via end-joining.

Mitotic and post mitotic consequences of genomic instability induced by oncogenic Ha-ras

Induced expression of a mutant human Ha-ras oncogene in NIH3T3 cells leads to the rapid production of multicentric chromosomes, acentric chromosome fragments, double minute chromosomes, increased heteroploidy, and increased capacity to undergo gene amplification. In this study we have used fluorescent-in-situ hybridization (FISH) to demonstrate that induction of the Ha-ras oncogene also leads to disruption of the mitotic machinery, resulting in aberrant mitoses and abnormal daughter cells. Cells induced to express an oncogenic Ha-ras transgene accumulate chromosomes that lag outside of the rest of the chromosomal architecture, chromosomes that form bridges between daughter nuclei at anaphase, and that form micronuclei. Many of these mitotic aberrations contain structurally abnormal chromosomes. These ras-induced changes were suppressed by the introduction of a gene encoding the dominant negative effector of ras, raf 301. Expression of raf301 in cells induced to express Ha-ras reduced the level of growth in soft agar, chromosome aberrations, mitotic aberrations, and frequency of gene amplification. These data provide evidence for an association between Ha-ras induced transformation, chromosome aberrations and gene amplification. Furthermore they offer insight into how the cell responds to the formation of aberrant chromosomes, and how disrupting chromosomal architecture could lead to further imbalances in the distribution of genetic material between daughter cells.

Epidemiology of group B streptococci: one year's experience in an obstetric and special care baby unit

The epidemiology of group B streptococci (GBS) was studied in an obstetric unit and the related special care baby unit (SCBU). In 1 year 53 (77%) of 69 babies who acquired GBS from their mothers were colonized within 24 h of birth, compared with only 9 (35%) of 38 who acquired GBS from non-maternal sources. While 38 (36%) of 107 GBS colonized babies in the obstetric unit derived the organism from a non-maternal source, the value for the SCBU was only 2 (9%) of 23. In babies rectal and umbilical swabs gave the highest GBS isolation rates. Phage-typing and serotyping suggested that colonized mother baby pairs, rather than staff, were the primary source of hospital acquired GBS. This mode of GBS acquisition did not result in long-term carriage once babies had left hospital. Nosocomial transmission can play an important part in GBS epidemiology, but can be minimized by attention to infection control procedures.

Carriage and transmission of group B streptococci among STD clinic patients

High rates of carriage of group B streptococci were found among men (38%) and women (42.3%) attending a clinic for sexually transmitted diseases. Swabs from the perineal/anorectal area gave the highest isolation rate and those from the urethra the lowest. The subpreputial sac was an important site for carriage of the organism, and there was a strong association between streptococcal isolation and balanitis. Of 92 couples studied, neither partner was colonised with group B streptococci in 36. In a further 36 one or other was colonised and in 20 both were colonised. Serotyping and phage typing showed that only three of these 20 couples were colonised with similar strains of the organism.

Colonisation of babies and their families by group B streptococci

A high incidence of group B streptococcal disease of the newborn in West Berkshire led to a prospective study of the condition. Cultures taken from 1090 babies shortly after birth showed that 65 (6%) were colonised with the streptococcus. Thirty of these babies were assigned to group 1. Bacteriological samples were taken from babies and mothers at birth and at four, eight, and 12 weeks, and also from fathers and siblings. Fifty uncolonised babies and their families were similarly studied and served as controls (group 2). In group 1,28 of the 30 mothers and 14 of the 28 fathers examined were colonised by group B streptococci. In group 2 the streptococci were isolated from three babies, 12 mothers, and 11 out of 45 fathers during follow-up. These findings suggest that group B streptococci are carried predominantly in the lower gastrointestinal and genitourinary tracts. Most families are lightly colonised, but in others maternal colonisation is stable and heavy and the incidence of paternal colonisation high. Results of serotyping suggest that sexual transmission occurs, which may explain the difficulty in eradicating the organism during pregnancy.

Nosocomial transmission of group B streptococci

The acquisition of group B streptococci by babies in a special-care baby unit and two postnatal wards was investigated over a six-month period using serology and phage typing. Sixty-three culture-positive babies were identified in the postnatal wards, one-third of whom had been born to mothers who were not carrying the organism in the genital tract or anorectal area during labour. A non-maternal source was identified for 14 of these 21 infants: either colonised mothers and babies in the same ward or, on one occasion, a member of the hospital staff. In the special-care baby unit, however, only one instance of nosocomial acquisition of group B streptococci was recorded despite a high prevalence of colonisation in the staff on the unit and the presence of heavily colonised babies. The results of this survey suggest that although sepsis caused by group B streptococci may be the result of nosocomial transmission, this may be prevented by careful attention to hygiene.

Transmission of group B streptococci. Traced by use of multiple epidemiologic markers

During a three-week period, septicemia caused by group B Streptococcus, serotype III, developed in four infants born at a community hospital. The first infant had early-onset disease; late-onset disease that appeared, from epidemiologic data, to be nosocomial developed in the other three infants. Bacteriophage typing and antimicrobial susceptibility testing confirmed the relatedness of the isolates. A prospective study designed to differentiate between vertical and nosocomial transmission of group B Streptococcus showed that of 82 infants, 21 (26%) were culture-positive during their hospitalization, and nine of these infants (43%) had been culture-negative at birth. Although serotype III strains were recovered from four of nine infants with apparently nosocomial acquisition, none of the isolates displayed an antibiogram or bacteriophage type similar to that of the isolates involved in the recent cluster. Bacteriophage typing and antimicrobial susceptibility testing in addition to the use of serotyping may be helpful in epidemiologic studies of group B Streptococcus.

Source of group B streptococci in the female genital tract

Swabs were taken from the posterior fornix, perineum, and anorectum of 135 patients on three occasions during their pregnancy. Multiple isolates of beta-haemolytic streptococci of group B were obtained from 24 women, in 21 of whom the strains were examined by a highly discriminative serotyping and phage typing method. In 18 of these patients their own isolates were indistinguishable but different from those of other women with multiple isolates. Women yielding group B streptococci from the posterior fornix usually carried an indistinguishable strain in the anorectum.

Integration of viral DNA sequences in cells transformed by adenovirus 2 or SV40

We have cloned and propagated in prokaryotic vectors the viral DNA sequences that are integrated in a variety of cells transformed by adenovirus 2 or SV40. Analysis of the clones reveals that the viral DNA sequences sometimes are arranged in a simple fashion, collinear with the viral genome; in other cell lines there are complex arrangements of viral sequences in which tracts of the viral genome are inverted with respect to each other. In several cases the nucleotide sequences at the joints between cell and viral sequences have been determined: usually there is a sharp transition between cellular and viral DNAs. The viral sequences are integrated at different locations within the genomes of different cell lines; likewise there is no specific site on the viral genomes at which integration occurs. Sometimes the viral sequences are integrated within repetitive cellular DNA, and sometimes within unique sequences. In some cases there is evidence that the viral sequences along with the flanking cell DNA have been amplified after integration. The sequences that flank the viral insertion in the line of SV40-transformed rat cells known as 14B have been used as probes to isolate, from untransformed rat cells, clones that carry the region of the chromosome in which integration occurred. Analysis of the structure of these clones by restriction endonculease digestion and heteroduplex formation shows that a rearrangement of cellular sequences has occurred, presumably as a consequence of integration.

Nosocomial transmission of bacteriophage type 7/11/12 group B streptococci in a special care nursery

Two premature infants in a special care nursery acquired late-onset group B streptococcal (GBS) sepsis within a 24-hour period. The infecting strains were serotype III organisms with bacteriophage type 7/11/12. Cultures of the mothers of the two affected infants were negative for GBS, implying nosocomial acquisition of infection. Although 32% of nursery personnel had mucosal carriage of GBS, none of the seven isolates of GBS type III was the same bacteriophage type as the two infecting strains. Of the other infants hospitalized in the nursery, five were asymptomatically colonized with GBS. These infants were in bassinets adjacent to the affected infants; all five of their isolates were identical to the two infecting strains. We conclude that infant-to-infant transmission may result in nosocomial late-onset GBS septicemia.

The development of a phage-typing system for group-B streptococci

A typing system for group-B streptococci, based on the use of 24 phages, has been evaluated. Used in conjunction with serotyping, it gave highly discriminating and reproducible results.

Very early termination of pregnancy (menstrual extraction)

Very early termination of pregnancy was performed on 424 women in three London teaching hospitals. Altogether 90% of the women were no more than 14 days overdue, and 67% of these had histological evidence of pregnancy. The procedure differed little in technique or its acceptability to the patient from termination done later in the first trimester. The similar incidence of complications suggested that it is not an alternative to conventional contraception. The response of patients, general practitioners, and referral agencies, however, indicated that there is a definite need in the community for a very early termination service.