Comparison of simulation and predictive efficacy for hemorrhagic fever with renal syndrome incidence in mainland China based on five time series models

Background

Hemorrhagic fever with renal syndrome (HFRS) is a zoonotic infectious disease commonly found in Asia and Europe, characterized by fever, hemorrhage, shock, and renal failure. China is the most severely affected region, necessitating an analysis of the temporal incidence patterns in the country.

Methods

We employed Autoregressive Integrated Moving Average (ARIMA), Long Short-Term Memory (LSTM), Convolutional Neural Network (CNN), Nonlinear AutoRegressive with eXogenous inputs (NARX), and a hybrid CNN-LSTM model to model and forecast time series data spanning from January 2009 to November 2023 in the mainland China. By comparing the simulated performance of these models on training and testing sets, we determined the most suitable model.

Results

Overall, the CNN-LSTM model demonstrated optimal fitting performance (with Root Mean Square Error (RMSE), Mean Absolute Percentage Error (MAPE), and Mean Absolute Error (MAE) of 93.77/270.66, 7.59%/38.96%, and 64.37/189.73 for the training and testing sets, respectively, lower than those of individual CNN or LSTM models).

Conclusion

The hybrid CNN-LSTM model seamlessly integrates CNN's data feature extraction and LSTM's recurrent prediction capabilities, rendering it theoretically applicable for simulating diverse distributed time series data. We recommend that the CNN-LSTM model be considered as a valuable time series analysis tool for disease prediction by policy-makers.

Spatial and temporal patterns of haemorrhagic fever with renal syndrome (HFRS) and the impact of environmental drivers in a border area of the Russian Far East

AIMS

Haemorrhagic fever with renal syndrome (HFRS) is a significant zoonotic disease transmitted by rodents. The distribution of HFRS in the European part of Russia has been studied quite well; however, much less is known about the endemic area in the Russian Far East. The mutual influence of the epidemic situation in the border regions and the possibility of cross-border transmission of infection remain poorly understood. This study aims to identify the spatiotemporal hot spots of the incidence and the impact of environmental drivers on the HFRS distribution in the Russian Far East.

METHODS AND RESULTS

A two-scale study design was performed. Kulldorf's spatial scan statistic was used to conduct spatiotemporal analysis at a regional scale from 2000 to 2020. In addition, an ecological niche model based on maximum entropy was applied to analyse the contribution of various factors and identify spatial favourability at the local scale. One spatiotemporal cluster that existed from 2002 to 2011 and located in the border area and one pure temporal cluster from 2004 to 2007 were revealed. The best suitability for orthohantavirus persistence was found along rivers, including those at the Chinese-Russian border, and was mainly explained by land cover, NDVI (as an indicator of vegetation density and greenness) and elevation.

CONCLUSIONS

Despite the stable incidence in recent years in, targeted prevention strategies are still needed due to the high potential for HRFS distribution in the southeast of the Russian Far East.

A case of hemorrhagic fever with renal syndrome and abnormal serum levels of ferritin, vitamin B12, and folic acid

INTRODUCTION

Hemorrhagic fever with renal syndrome (HFRS) is a globally prevalent infectious disease caused by the hantavirus in rodents.

CASE STUDY

This report describes a case of a 36-year-old male presenting with elevated ferritin, vitamin B12, and folic acid deficiency during the early onset phase of HFRS. Despite normal renal function at admission, the patient exhibited persistent fever and thrombocytopenia, leading to a potential misdiagnosis of an atypical HFRS presentation. Abnormal serum levels of ferritin, vitamin B12, and folic acid served as early indicators of renal dysfunction in patients with HRFS. The patient's condition improved rapidly with a combination of vitamin B6, methyl cobalamin, and folic acid, as evidenced by a subsequent decrease in the ferritin levels, from 3000 to 600 ng/mL, on days 4 and 24, respectively, and an increase in the vitamin B12 and folic acid levels to 200 pg/mL and 36.7 ng/mL, separately.

CONCLUSIONS

These findings suggest that ferritin, vitamin B12, and folic acid have the potential to serve as biomarkers for HFRS and play a predictive role in the diagnosis and treatment of the disease.

Corrigendum: Hantavirus: an overview and advancements in therapeutic approaches for infection

[This corrects the article DOI: 10.3389/fmicb.2023.1233433.].

Pathogenicity of novel hantavirus isolate and antigenicity and immunogenicity of novel strain-based inactivated vaccine

BACKGROUND

Hantaan virus (HTNV, Orthohantavirus hantanensae species, Hantaviridae family) is the main etiological agent responsible for hemorrhagic fever with renal syndrome (HFRS). The novel HTNV may pose a potential danger to the control and prevention of HFRS in China, which highlights the importance of vaccine development in public health management. In previous studies, our laboratory discovered and successfully isolated a new HTNV strain, HV004 strain, from Apodemus agrarius captured in an epidemic area in Hubei, China.

METHODS

An initial biological and pathogenicity characterization of HTNV 76-118 (standard train), HV114 strain (a clinical isolate from Hubei province in 1986), and the novel isolate HV004 strain from the epidemic areas of Hubei province were performed in susceptible cells and in vivo. An experimental HV004 strain inactivated vaccine was prepared, and its corresponding immunogenicity was analyzed in BALB/c mice.

RESULTS

HV004 strain had a similar but higher pathogenicity than HTNV 76-118 and HV114 in suckling mice. A subcutaneous vaccination (s.c.) with the inactivated HTNV vaccine adjuvanted with aluminum, followed by a challenge intraperitoneally with 106 FFU/ml HTNV, afforded full protection against an HTNV challenge. All immunized mice in every group elicited serum neutralizing antibodies with increasing dosages, which may protect mice from HTNV infection. A dose-dependent stimulation index of splenocytes was also observed in immunized mice. The percentage of IFN-γ-producing CD3+CD8+ T cells was significantly higher in the spleens of immunized mice than in those of control mice.

CONCLUSIONS

These findings suggest that the inactivated HTNV vaccine may stimulate mice to produce high levels of antibodies with neutralization activity and elicit specific anti-HTNV humoral and cellular immune responses in BALB/c mice against the prevalent strain of HTNV in south central China.

Hemorrhagic Fever with Renal Syndrome Patients Exhibit Increased Levels of Lipocalin-2, Endothelin-1 and NT-proBNP

Hemorrhagic fever with renal syndrome (HFRS) is an acute zoonotic disease caused by viruses of the Orthohantavirus genus. This syndrome is characterized by renal and cardiopulmonary implications detectable with different biomarkers. Here, we explored the role of serum and urine levels of lipocalin-2, endothelin-1 and N-terminal pro-brain natriuretic peptide (NT-proBNP) in HFRS pathology. A total of twenty-eight patients hospitalized due to a Puumala orthohantavirus infection were included, with serum and urine samples collected on patient admission (acute phase) and discharge (convalescent phase). In comparison to healthy individuals, patients exhibited significantly higher acute-phase serum and urine levels of lipocalin-2, serum levels of endothelin-1 and serum and urine levels of NT-proBNP. Patients in the convalescent phase showed a significant decrease in urine lipocalin-2, serum endothelin-1 and serum and urine NT-proBNP levels. We recorded a strong correlation between serum levels of lipocalin-2 and endothelin-1 and urine levels of lipocalin-2 with several kidney injury markers, such as serum creatinine, urea, urine white blood cell count and proteinuria. We also demonstrated an independent correlation of serum and urine lipocalin-2 levels with acute kidney injury in HFRS. All in all, our results show an involvement of NT-proBNP, lipocalin-2 and endothelin-1 in the renal and cardiac pathology of HFRS.

A framework for understanding and predicting orthohantavirus functional traits

Orthohantaviruses present a global public health threat; there are 58 distinct viruses currently recognized and case fatality of pathogenic orthohantaviruses ranges from <0.1% to 50%. An Old World versus New World dichotomy is frequently applied to distinguish human diseases caused by orthohantaviruses. However, this geographic grouping masks the importance of phylogeny and virus-host ecology in shaping orthohantavirus traits, especially since related arvicoline rodents and their orthohantaviruses are found in both regions. We argue that orthohantaviruses can be separated into three phylogenetically based rodent host groups with differences in key functional traits, including human disease, transmission route, and virus-host fidelity. This framework can help understand and predict traits of under-studied and newly discovered orthohantaviruses and guide public health and biosafety policy.

Hantavirus: an overview and advancements in therapeutic approaches for infection

Hantaviruses are a significant and emerging global public health threat, impacting more than 200,000 individuals worldwide each year. The single-stranded RNA viruses belong to the Hantaviridae family and are responsible for causing two acute febrile diseases in humans: Hantavirus pulmonary syndrome (HPS) and hemorrhagic fever with renal syndrome (HFRS). Currently, there are no licensed treatments or vaccines available globally for HTNV infection. Various candidate drugs have shown efficacy in increasing survival rates during the early stages of HTNV infection. Some of these drugs include lactoferrin, ribavirin, ETAR, favipiravir and vandetanib. Immunotherapy utilizing neutralizing antibodies (NAbs) generated from Hantavirus convalescent patients show efficacy against HTNV. Monoclonal antibodies such as MIB22 and JL16 have demonstrated effectiveness in protecting against HTNV infection. The development of vaccines and antivirals, used independently and/or in combination, is critical for elucidating hantaviral infections and the impact on public health. RNA interference (RNAi) arised as an emerging antiviral therapy, is a highly specific degrades RNA, with post-transcriptional mechanism using eukaryotic cells platform. That has demonstrated efficacy against a wide range of viruses, both in vitro and in vivo. Recent antiviral methods involve using small interfering RNA (siRNA) and other, immune-based therapies to target specific gene segments (S, M, or L) of the Hantavirus. This therapeutic approach enhances viral RNA clearance through the RNA interference process in Vero E6 cells or human lung microvascular endothelial cells. However, the use of siRNAs faces challenges due to their low biological stability and limited in vivo targeting ability. Despite their successful inhibition of Hantavirus replication in host cells, their antiviral efficacy may be hindered. In the current review, we focus on advances in therapeutic strategies, as antiviral medications, immune-based therapies and vaccine candidates aimed at enhancing the body's ability to control the progression of Hantavirus infections, with the potential to reduce the risk of severe disease.

Potential clinical biomarkers in monitoring the severity of Hantaan virus infection

Hantavirus, which causes hemorrhagic fever with renal syndrome (HFRS) is almost prevalent worldwide. While Hantaan virus (HTNV) causes the most severe form of HFRS with typical clinical manifestations of thrombocytopenia, increased vascular permeability, and acute kidney injury. Although the knowledge of the pathogenesis of HFRS is still limited, immune dysfunction and pathological damage caused by disorders of immune regulation are proposed to play a vital role in the development of the disorder, and the endothelium is considered to be the primary target of hantaviruses. Here, we reviewed the production and function of multiple molecules, mainly focusing on their role in immune response, endothelium, vascular permeability regulation, and platelet and coagulation activation which are closely related to the pathogenesis of HTNV infection. meanwhile, the relationship between these molecules and characteristics of HTNV infection including the hospital duration, immune dysfunction, thrombocytopenia, leukocytosis, and acute kidney injury are also presented, to provide a novel insight into the potential role of these molecules as monitoring markers for HTNV infection.

Predictive value of CD4+CD8+ double positive T cells for the severity of hemorrhagic fever with renal syndrome

PURPOSES

We aimed to investigate the levels of CD4+CD8+ double positive (DP) T cells in patients with various severities of hemorrhagic fever with renal syndrome (HFRS), and the predictive capacity of DP T cells for the severity of this disorder.

METHODS

The levels of DP T cells in 213 patients and 48 healthy donors were measured by flow cytometry, as were the levels of CD4+ T cells, CD8+ T cells, B lymphocytes, and natural killer (NK) cells. In each type of HFRS patient, we tested the basic clinical reference values for leukocytes, platelets, creatinine (Cr), uric acid (UA), and urea, and the values for activated partial thromboplastin time, prothrombin time, and fibrinogen, using conventional methods. The colloidal gold method was used to measure HFRS antibody levels in the patients.

RESULTS

The frequency of DP T cells increased with disease severity and peaked in patients with critical disease. Furthermore, the level of DP T cells proportionally correlated with the levels of Cr, UA, and urea in the serum. In contrast, there was an inverse correlation between DP T cells and platelets. Interestingly, the pattern of change in DP T cell frequency was similar to those of CD8+ T cells, B cells, and NK cells, but an inverse tendency was observed for CD4+ T cells. DP T cells demonstrated significant predictive value for the severity of HFRS.

CONCLUSIONS

The level of DP T cells is associated with HFRS severity, suggesting that it may be a potent indicator for the course of this disorder.

Investigation of a subunit protein vaccine for HFRS based on a consensus sequence between envelope glycoproteins of HTNV and SEOV

Due to the global resurgence of hemorrhagic fever with renal syndrome (HFRS), more attention is being focused on this dangerous illness. In China and Korea, the only vaccines available are the virus-inactivated vaccine against Hantaan virus (HTNV) or Seoul virus (SEOV), but their efficacy and safety are inadequate. Therefore, it is important to develop new vaccines that are safer and more efficient to neutralize and regulate areas with a high prevalence of HFRS. We employed bioinformatics methods to design a recombinant protein vaccine based on conserved regions of protein consensus sequences in HTNV and SEOV membranes. The S2 Drosophila expression system was utilized to enhance protein expression, solubility and immunogenicity. After the Gn and Gc proteins of HTNV and SEOV were successfully expressed, mice were immunized, and the humoral immunity, cellular immunity, and in vivo protection of the HFRS universal subunit vaccine were systematically evaluated in mouse models. These results indicated that the HFRS subunit vaccine generated elevated levels of binding and neutralizing antibodies, particularly IgG1, compared to that of the traditional inactivated HFRS vaccine. Additionally, the spleen cells of immunized mice secreted IFN-r and IL-4 cytokines effectively. Moreover, the HTNV-Gc protein vaccine successfully protected suckling mice from HTNV infection and stimulated GC responses. In this research, a new scientific approach is investigated to develop a universal HFRS subunit protein vaccine that is capable of producing effective humoral and cellular immunity in mice. The results suggest that this vaccine could be a promising candidate for preventing HFRS in humans.

Validation of Frail Scale and comparison with hospital frailty risk score to predict hospital use in a cohort of older Australian women

INTRODUCTION

With no standard frailty tool for clinical care, research and policymaking, identifying frail older people is a challenge.

AIMS

This study aimed to compare two validated scales, which are the Frail Scale and Hospital Frailty Risk Score (HFRS) for their ability in identifying frailty in older Australian women and predicting hospital use.

METHODS

This study included older Australian women aged 75-95 years, who had unplanned overnight hospital admission as an index admission between 2001 and 2016. Data from the Australian Longitudinal Study on Women's Health (ALSWH) were linked with administrative hospital data to calculate HFRS (using the International Statistical Classification of Diseases, Australia Modification (ICD-10-AM) diagnostic codes) and the Frail Scale (using the ALSWH self-reported survey).

RESULTS

The Frail Scale identified a higher proportion of older frail women (30.54%) compared to the HFRS (23.0%). Frail older women, classified by Frail Scale, were at higher risk of long hospital stay (adjusted odds ratio = 1.28, 95% CI = 1.02-1.60), repeated admission (adjusted hazard ratio [AHR] = 1.30, 95% CI = 1.03-1.41) and death (AHR = 1.70, 95% CI = 1.45-2.01). HFRS was associated with longer hospital stay and mortality.

CONCLUSIONS

The proportion of older women classified as frail by the Frail Scale tool was higher than women classified as frail by HFRS. The Frail Scale and HFRS were not significantly associated with each other. While both tools were associated with the risk of long hospital stay and mortality, only the Frail Scale predicted the risk of repeated admission.

Co-circulation and co-infection of hantaviruses and Wenzhou mammarenavirus in small mammals and humans in Jiangxi, China

Both Orthohantaviruses (HV) and Whenzhou Mammarenaviruses (WENV) are rodents borne viruses, allowing them to spread simultaneously in the same area and infect humans. To explore the potential threat of HV and WENV to public health safety, an environmental and laboratory investigation was conducted in 2020-2021, in Jiangxi province, China. A total of 461 small mammals of 7 species and paired sera from 43 suspected HFRS cases were collected from Jiangxi Province, China. Viral genomic RNA and specific antibodies against HV and WENV were detected to evaluate the epidemic situation of the two viruses. Hantaan virus (HTNV), seoul virus (SEOV) and WENV RNA were detected in the lungs of the captured mammals, which resulted 4.1% and 7.4% of HV and WENV RNA positive respectively. Co-infections of WENV and SEOV were detected from Rattus norvegicus, Mus musculus and Rattus flavipectus with an overall co-infection rate of 0.65%. The detection rates of antibodies in the blood against HV and WENV were 11.9% (55/461), and 13.2% (61/461) respectively. The prevalence of viral infection and viral genetic characters varied among the selected areas. In the paired sera of 43 suspected HFRS cases, 38 were with HV infection, 11 were with WENV IgG, and 7 with a 4-fold or more of WENV IgG titer elevation. These results revealed the fact of the co-circulating and coinfection of HV and WENV in the same area at the same time, which might impact on public health safety.

The Spatiotemporal Pattern and Its Determinants of Hemorrhagic Fever With Renal Syndrome in Northeastern China: Spatiotemporal Analysis

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS) is a significant zoonotic disease mainly transmitted by rodents. However, the determinants of its spatiotemporal patterns in Northeast China remain unclear.

OBJECTIVE

This study aimed to investigate the spatiotemporal dynamics and epidemiological characteristics of HFRS and detect the meteorological effect of the HFRS epidemic in Northeastern China.

METHODS

The HFRS cases of Northeastern China were collected from the Chinese Center for Disease Control and Prevention, and meteorological data were collected from the National Basic Geographic Information Center. Times series analyses, wavelet analysis, Geodetector model, and SARIMA model were performed to identify the epidemiological characteristics, periodical fluctuation, and meteorological effect of HFRS in Northeastern China.

RESULTS

A total of 52,655 HFRS cases were reported in Northeastern China from 2006 to 2020, and most patients with HFRS (n=36,558, 69.43%) were aged between 30-59 years. HFRS occurred most frequently in June and November and had a significant 4- to 6-month periodicity. The explanatory power of the meteorological factors to HFRS varies from 0.15 ≤ q ≤ 0.01. In Heilongjiang province, mean temperature with a 4-month lag, mean ground temperature with a 4-month lag, and mean pressure with a 5-month lag had the most explanatory power on HFRS. In Liaoning province, mean temperature with a 1-month lag, mean ground temperature with a 1-month lag, and mean wind speed with a 4-month lag were found to have an effect on HFRS, but in Jilin province, the most important meteorological factors for HFRS were precipitation with a 6-month lag and maximum evaporation with a 5-month lag. The interaction analysis of meteorological factors mostly showed nonlinear enhancement. The SARIMA model predicted that 8,343 cases of HFRS are expected to occur in Northeastern China.

CONCLUSIONS

HFRS showed significant inequality in epidemic and meteorological effects in Northeastern China, and eastern prefecture-level cities presented a high risk of epidemic. This study quantifies the hysteresis effects of different meteorological factors and prompts us to focus on the influence of ground temperature and precipitation on HFRS transmission in future studies, which could assist local health authorities in developing HFRS-climate surveillance, prevention, and control strategies targeting high-risk populations in China.

HTNV infection induces activation and deficiency of CD8+MAIT cells in HFRS patients

Hantaan virus (HTNV) infection causes an epidemic of hemorrhagic fever with renal syndrome (HFRS) mainly in Asia. Mucosal-associated invariant T (MAIT) cells are innate-like T lymphocytes known to play an important role in innate host defense during virus infection. However, their roles and phenotypes during HTNV infection have not yet been explored. We characterized CD8+MAIT cells from HFRS patients based on scRNA-seq data combined with flow cytometry data. We showed that HTNV infection caused the loss and activation of CD8+MAIT cells in the peripheral blood, which were correlated with disease severity. The production of granzyme B and IFN-γ from CD8+MAIT cells and the limitation of HTNV replication in endothelia cells indicated the anti-viral property of CD8+MAIT cells. In addition, in vitro infection of MAIT cells by HTNV or HTNV-exposed monocytes showed that the activation of MAIT cells was IL-18 mediated. In conclusion, this study identified, for the first time, gene expression profiles of MAIT cells, provided underlying molecular mechanisms for activation of MAIT cells during HTNV infection, and suggested a potential anti-viral role of MAIT cells in HFRS.

Dual seasonal pattern for hemorrhagic fever with renal syndrome and its potential determinants in China

Hemorrhagic fever with renal syndrome (HFRS) continued to affect human health across Eurasia, which complicated by climate change has posed a challenge for the disease prevention measures. Nation-wide surveillance data of HFRS cases were collected during 2008-2020.The seasonality and epidemiological features were presented by combining the HFRS incidence and the endemic types data. Factors potentially involved in affecting incidence and shaping disease seasonality were investigated by generalized additive mixed model, distributed lag nonlinear model and multivariate meta-analysis. A total of 76 cities that reported totally 111,054 cases were analyzed. Three endemic types were determined, among them the Type I cities (Hantaan virus-dominant) were related to higher incidence level, showing one spike every year in Autumn-Winter season; Type II (Seoul virus-dominant) cities were related to lower incidence, showing one spike in Spring, while Type III (Hantaan/Seoul-mixed type) showed dual peaks with incidence lying between. Persistently heavy rainfall had significantly negative influence on HFRS incidence in Hantaan virus-dominant endemic area, while a significantly opposite effect was identified when continuously heavy rainfall induced floods, where temperature and relative humidity affected HFRS incidence via an approximately parabolic or linear manner, however few or no such effects was shown in Seoul virus-dominant endemic areas, which was more vulnerable to temperature variation. Dual seasonal pattern of HFRS was depended on the dominant genotypes of hantavirus, and impact of climate on HFRS was greater in Hantaan virus-dominant endemic areas, than in Seoul virus-dominant areas.

Spatial-temporal dynamics and time series prediction of HFRS in mainland China: A long-term retrospective study

Hemorrhagic fever with renal syndrome (HFRS) is highly endemic in mainland China. The current study aims to characterize the spatial-temporal dynamics of HFRS in mainland China during a long-term period (1950-2018). A total of 1 665 431 cases of HFRS were reported with an average annual incidence of 54.22 cases/100 000 individuals during 1950-2018. The joint regression model was used to define the global trend of the HFRS cases with an increasing-decreasing-slightly increasing-decreasing-slightly increasing trend during the 68 years. Then spatial correlation analysis and wavelet cluster analysis were used to identify four types of clusters of HFRS cases located in central and northeastern China. Lastly, the prophet model outperforms auto-regressive integrated moving average model in the HFRS modeling. Our findings will help reduce the knowledge gap on the transmission dynamics and distribution patterns of the HFRS in mainland China and facilitate to take effective preventive and control measures for the high-risk epidemic area.

Increased CD4+CD8+ Double Positive T Cells during Hantaan Virus Infection

Hantaan virus (HTNV) infection causes an epidemic of hemorrhagic fever with renal syndrome (HFRS) mainly in Asia. It is well known that T cells mediated anti-viral immune response. Although previous studies showed that double positive T (DP T) cells, a little portion of T lymphocytes, were involved in adaptive immune response during virus infection, their kinetic changes and roles in HTNV infection have not yet been explored. In this study, we characterized DP T cells from HFRS patients based on flow cytometry data combined with scRNA-seq data. We showed that HTNV infection caused the upregulation of DP T cells in the peripheral blood, which were correlated with disease stage. The scRNA-seq data clustered DP T cells, unraveled their gene expression profile, and estimated the ordering of these cells. The production of granzyme B and CD107a from DP T cells and the abundant TCR distribution indicated the anti-viral property of DP T cells. In conclusion, this study identified, for the first time, an accumulation of DP T cells in the peripheral blood of HFRS patients and suggested these DP T cells belonging to CD8+T cells lineage. The DP T cells shared the similar characteristics with cytotoxic T cells (CTL) and exerted an anti-viral role in HFRS.

Factors associated with hemorrhagic fever with renal syndrome based maximum entropy model in Zhejiang Province, China

Background

Hemorrhagic fever with renal syndrome (HFRS) is a serious public health problem in China. The geographic distribution has went throughout China, among which Zhejiang Province is an important epidemic area. Since 1963, more than 110,000 cases have been reported.

Methods

We collected the meteorological factors and socioeconomic indicators of Zhejiang Province, and constructed the HFRS ecological niche model of Zhejiang Province based on the algorithm of maximum entropy.

Results

Model AUC from 2009 to 2018, is 0.806–0.901. The high incidence of epidemics in Zhejiang Province is mainly concentrated in the eastern, western and central regions of Zhejiang Province. The contribution of digital elevation model ranged from 2009 to 2018 from 4.22 to 26.0%. The contribution of average temperature ranges from 6.26 to 19.65%, Gross Domestic Product contribution from 7.53 to 21.25%, and average land surface temperature contribution with the highest being 16.73% in 2011. In addition, the average contribution of DMSP/OLS, 20-8 precipitation and 8-20 precipitation were all in the range of 9%. All-day precipitation increases with the increase of rainfall, and the effect curve peaks at 1,250 mm, then decreases rapidly, and a small peak appears again at 1,500 mm. Average temperature response curve shows an inverted v-shape, where the incidence peaks at 17.8^°C. The response curve of HFRS for GDP and DMSP/OLS shows a positive correlation.

Conclusion

The incidence of HFRS in Zhejiang Province peaked in areas where the average temperature was 17.8^°C, which reminds that in the areas where temperature is suitable, personal protection should be taken when going out as to avoid contact with rodents. The impact of GDP and DMSP/OLS on HFRS is positively correlated. Most cities have good medical conditions, but we should consider whether there are under-diagnosed cases in economically underdeveloped areas.

Adenosine Deaminase is a Potential Molecular Marker for Diagnosis and Prognosis of Haemorrhagic Fever with Renal Syndrome

Objective

Haemorrhagic fever with renal syndrome (HFRS) is a serious zoonotic disease which seriously endangers physical health and mainly occurs in China. To date, there is still a lack of early and novel biomarkers to detect the severity of disease and prognosis of HFRS. This study was aimed to examine the value of the serum Adenosine deaminase (ADA) concentrations in the patients with HFRS.

Methods

The clinical and laboratory data of 124 adult patients with HFRS and 131 patients with similar clinical symptoms to HFRS were analyzed. A receiver operating characteristic (ROC) curve was used to analyze the diagnostic value of ADA in HFRS.

Results

The ADA levels in the serum of HFRS patients were significantly higher than those in control patients (P < 0.001), and ADA has a strong positive correlation with HFRS (r = 0.785, P < 0.001). The optimal cut-off value of ADA for diagnosis of HFRS was 18 U/L and the area under the curve (AUC) was 0.953 (95% CI: 0.925, 0.981). The sensitivity was 84.8%, the specificity was 93.1%, the positive predictive value was 92.2%, the negative predictive value was 86.5% and the Youden index was 77.9%. Serum ADA levels in patients with HFRS tended to decrease at discharge compared with those at admission.

Conclusion

ADA could be a potential molecular marker for diagnosis and prognosis of HFRS patients.

Epidemiology, virology and clinical aspects of hantavirus infections: an overview

At the end of 2019 and 2020s, a wave of coronavirus disease 19 (COVID-19) epidemics worldwide has catalyzed a new era of 'communicable infectious diseases'. However, the world is not currently prepared to deal with the growing burden of COVID-19, with the unexpected arrival of Hantavirus infection heading to the next several healthcare emergencies in public. Hantavirus is a significant class of zoonotic pathogens of negative-sense single-stranded ribonucleic acid (RNA). Hemorrhagic renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS) are the two major clinical manifestations. Till date, there is no effective treatments or vaccines available, public awareness and precautionary measures can help to reduce the spread of hantavirus disease. In this study, we outline the epidemiology, virology, clinical aspects, and existing HFRS and HCPS management approaches. This review will give an understanding of virus-host interactions and will help for the early preparation and effective handling of further outbreaks in an ever-changing environment.

A fatal case of haemorrhagic fever with renal syndrome in Kursk Region, Russia, caused by a novel Puumala virus clade

Haemorrhagic fever with renal syndrome (HFRS) is the most widespread natural-focal human disease in the Russian Federation. In this study, we report virological assessment of a fatal case of HFRS-PUUV (Puumala virus) in the Kursk Region. The infection caused severe multiorgan failure and the maximum viral load was detected in the tissue of the spleen. Viral sequences were obtained from the patient's autopsy material and lung tissues of bank voles captured in the region. These sequences formed a new clade in the PUUV phylogenetic tree, an outgroup to all known Russian (RUS) lineage sequences. On the other hand viruses collected in the Kursk Region grouped with the RUS lineage and are separated from all other PUUV linages. We propose to nominate this novel group as W-RUS as the identified viruses were collected near the western Russian boundary. The recombination signals between their ancestors and RUS lineage representatives from the Volga region were revealed. The strain Samara_94/CG/2005 suggestively emerged as the result of reassortment between the ancestors of W-RUS and DTK-Ufa-97.

Hospital frailty risk score predicts adverse events in spine surgery

PURPOSE

The Hospital Frailty Risk Score (HFRS) is derived from routinely collected data and validated as a geriatric risk stratification tool. This study aimed to evaluate the utility of the HFRS as a predictor for postoperative adverse events in spine surgery.

METHODS

In this retrospective analysis of 2042 patients undergoing spine surgery at a university spine center between 2011 and 2019, HFRS was calculated for each patient. Multivariable logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events. Adverse events were compared between patients with high or low frailty risk.

RESULTS

Patients with intermediate or high frailty risk showed a higher rate of reoperation (19.7% vs. 12.2%, p < 0.01), surgical site infection (3.4% vs. 0.4%, p < 0.001), internal complications (4.1% vs. 1.1%, p < 0.01), Clavien-Dindo IV complications (8.8% vs. 3.4%, p < 0.001) and transfusion (10.9% vs. 1.5%, p < 0.001). Multivariable logistic regression analyses revealed a high HFRS as independent risk factor for reoperation [odds ratio (OR) = 1.1; 95% confidence interval (CI) 1.0-1.2], transfusion (OR = 1.3; 95% CI 1.2-1.4), internal complications (OR = 1.2; 95% CI 1.1-1.3), surgical site infections (OR = 1.3; 95% CI 1.2-1.5) and other complications (OR = 1.3; 95% CI 1.2-1.4).

CONCLUSION

The HFRS can predict adverse events and is an easy instrument, fed from routine hospital data. By identifying risk patients at an early stage, the individual patient risk could be minimized, which leads to less complications and lower costs.

LEVEL OF EVIDENCE

Level III - retrospective cohort study TRIAL REGISTRATION: The study was approved by the local ethics committee (20-1821-104) of the University of Regensburg in February 2020.

Comparison of the predictive ability of clinical frailty scale and hospital frailty risk score to determine long-term survival in critically ill patients: a multicentre retrospective cohort study

BACKGROUND

The Clinical Frailty Scale (CFS) is the most commonly used frailty measure in intensive care unit (ICU) patients. The hospital frailty risk score (HFRS) was recently proposed for the quantification of frailty. We aimed to compare the HFRS with the CFS in critically ill patients in predicting long-term survival up to one year following ICU admission.

METHODS

In this retrospective multicentre cohort study from 16 public ICUs in the state of Victoria, Australia between 1st January 2017 and 30th June 2018, ICU admission episodes listed in the Australian and New Zealand Intensive Care Society Adult Patient Database registry with a documented CFS, which had been linked with the Victorian Admitted Episode Dataset and the Victorian Death Index were examined. The HFRS was calculated for each patient using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes that represented pre-existing conditions at the time of index hospital admission. Descriptive methods, Cox proportional hazards and area under the receiver operating characteristic (AUROC) were used to investigate the association between each frailty score and long-term survival up to 1 year, after adjusting for confounders including sex and baseline severity of illness on admission to ICU (Australia New Zealand risk-of-death, ANZROD).

RESULTS

7001 ICU patients with both frailty measures were analysed. The overall median (IQR) age was 63.7 (49.1-74.0) years; 59.5% (n = 4166) were male; the median (IQR) APACHE II score 14 (10-20). Almost half (46.7%, n = 3266) were mechanically ventilated. The hospital mortality was 9.5% (n = 642) and 1-year mortality was 14.4% (n = 1005). HFRS correlated weakly with CFS (Spearman's rho 0.13 (95% CI 0.10-0.15) and had a poor agreement (kappa = 0.12, 95% CI 0.10-0.15). Both frailty measures predicted 1-year survival after adjusting for confounders, CFS (HR 1.26, 95% CI 1.21-1.31) and HFRS (HR 1.08, 95% CI 1.02-1.15). The CFS had better discrimination of 1-year mortality than HFRS (AUROC 0.66 vs 0.63 p < 0.0001).

CONCLUSION

Both HFRS and CFS independently predicted up to 1-year survival following an ICU admission with moderate discrimination. The CFS was a better predictor of 1-year survival than the HFRS.

LncRNA NEAT1 Potentiates SREBP2 Activity to Promote Inflammatory Macrophage Activation and Limit Hantaan Virus Propagation

As the global prototypical zoonotic hantavirus, Hantaan virus (HTNV) is prevalent in Asia and is the leading causative agent of severe hemorrhagic fever with renal syndrome (HFRS), which has profound morbidity and mortality. Macrophages are crucial components of the host innate immune system and serve as the first line of defense against HTNV infection. Previous studies indicated that the viral replication efficiency in macrophages determines hantavirus pathogenicity, but it remains unknown which factor manipulates the macrophage activation pattern and the virus-host interaction process. Here, we performed the transcriptomic analysis of HTNV-infected mouse bone marrow-derived macrophages and identified the long noncoding RNA (lncRNA) nuclear enriched abundant transcript 1 (NEAT1), especially the isoform NEAT1-2, as one of the lncRNAs that is differentially expressed at the early phase. Based on coculture experiments, we revealed that silencing NEAT1-2 hinders inflammatory macrophage activation and facilitates HTNV propagation, while enhancing NEAT1-2 transcription effectively restrains viral replication. Furthermore, sterol response element binding factor-2 (SREBP2), which controls the cholesterol metabolism process, was found to stimulate macrophages by promoting the production of multiple inflammatory cytokines upon HTNV infection. NEAT1-2 could potentiate SREBP2 activity by upregulating Srebf1 expression and interacting with SREBP2, thus stimulating inflammatory macrophages and limiting HTNV propagation. More importantly, we demonstrated that the NEAT1-2 expression level in patient monocytes was negatively correlated with viral load and HFRS disease progression. Our results identified a function and mechanism of action for the lncRNA NEAT1 in heightening SREBP2-mediated macrophage activation to restrain hantaviral propagation and revealed the association of NEAT1 with HFRS severity.

Hospital Frailty Risk Score and healthcare resource utilization after surgery for metastatic spinal column tumors

OBJECTIVE

The Hospital Frailty Risk Score (HFRS) was developed utilizing ICD-10 diagnostic codes to identify frailty and predict adverse outcomes in large national databases. While other studies have examined frailty in spine oncology, the HFRS has not been assessed in this patient population. The aim of this study was to examine the association of HFRS-defined frailty with complication rates, length of stay (LOS), total cost of hospital admission, and discharge disposition in patients undergoing spine surgery for metastatic spinal column tumors.

METHODS

A retrospective cohort study was performed using the years 2016 to 2019 of the National Inpatient Sample (NIS) database. All adult patients (≥ 18 years old) undergoing surgical intervention for metastatic spinal column tumors were identified using the ICD-10-CM diagnostic codes and Procedural Coding System. Patients were categorized into the following three cohorts based on their HFRS: low frailty (HFRS < 5), intermediate frailty (HFRS 5-15), and high frailty (HFRS > 15). Patient demographics, comorbidities, treatment modality, perioperative complications, LOS, discharge disposition, and total cost of hospital admission were assessed. A multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, nonroutine discharge, and increased cost.

RESULTS

Of the 11,480 patients identified, 7085 (61.7%) were found to have low frailty, 4160 (36.2%) had intermediate frailty, and 235 (2.0%) had high frailty according to HFRS criteria. On average, age increased along with progressively worsening frailty scores (p ≤ 0.001). The proportion of patients in each cohort who experienced ≥ 1 postoperative complication significantly increased along with increasing frailty (low frailty: 29.2%; intermediate frailty: 53.8%; high frailty: 76.6%; p < 0.001). In addition, the mean LOS (low frailty: 7.9 ± 5.0 days; intermediate frailty: 14.4 ± 13.4 days; high frailty: 24.1 ± 18.6 days; p < 0.001), rate of nonroutine discharge (low frailty: 40.4%; intermediate frailty: 60.6%; high frailty: 70.2%; p < 0.001), and mean total cost of hospital admission (low frailty: $48,603 ± $29,979; intermediate frailty: $65,271 ± $43,110; high frailty: $96,116 ± $60,815; p < 0.001) each increased along with progressing frailty. On multivariate regression analysis, intermediate and high frailty were each found to be significant predictors of both prolonged LOS (intermediate: OR 3.75 [95% CI 2.96-4.75], p < 0.001; high: OR 7.33 [95% CI 3.47-15.51]; p < 0.001) and nonroutine discharge (intermediate: OR 2.05 [95% CI 1.68-2.51], p < 0.001; high: OR 5.06 [95% CI 1.93-13.30], p = 0.001).

CONCLUSIONS

This study is the first to use the HFRS to assess the impact of frailty on perioperative outcomes in patients with metastatic bony spinal tumors. Among patients with metastatic bony spinal tumors, frailty assessed using the HFRS was associated with longer hospitalizations, more nonroutine discharges, and higher total hospital costs.

Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients

BACKGROUND

Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration.

AIMS

To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients.

METHODS

This was a single-centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72-h between frail (HFRS ≥ 5) and non-frail (HFRS < 5) patients. Exploratory secondary outcomes included in-hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28-day readmission rates.

RESULTS

Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non-frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio = 1.28; 95% confidence interval = 1.01-163; P = 0.041). In univariable analyses, timely GOC was associated with greater in-hospital mortality, RRC, and hospital LOS in both frail and non-frail patients (all P < 0.05) and greater 28-day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in-hospital mortality in both frail and non-frail patients, independent of age and gender.

CONCLUSION

Older frail hospitalised patients were more likely to have timely GOC than older non-frail patients. Timely GOC in such patients may avoid burdensome treatments.

Development and design of the Hantavirus registry - HantaReg - for epidemiological studies, outbreaks and clinical studies on hantavirus disease

Background

Frequent outbreaks around the globe and endemic appearance in different parts of the world emphasize the substantial risk of hantavirus diseases. Increasing incidence rates, trends of changing distribution of hantavirus species and new insights into clinical courses of hantavirus diseases call for multinational surveillance. Furthermore, evidence-based guidelines for the management of hantavirus diseases and scoring systems, which allow stratification of patients into risk categories, are lacking.

Methods

Hantavirus registry (HantaReg) is a novel registry platform facilitating multinational research of hantavirus-caused diseases, such as haemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS). HantaReg provides an electronic case report form and uses the General Data Protection Regulation compliant platform clinicalsurveys.net, which can be accessed from any internet browser in the world. Having a modular structure, the registry platform is designed to display or hide questions and items according to the documented case (e.g. patient with HFRS versus HCPS) to facilitate fast, but standardized, data entry. Information categories documented in HantaReg are demographics, pre-existing diseases, clinical presentation, diagnostic and therapeutic approaches, as well as outcome.

Conclusions

HantaReg is a novel, ready-to-use platform for clinical and epidemiological studies on hantavirus diseases and facilitates the documentation of the disease course associated with hantavirus infections. HantaReg is expected to promote international collaboration and contributes to improving patient care through the analysis of diagnostic and treatment pathways for hantavirus diseases, providing evidence for robust treatment recommendations. Moreover, HantaReg enables the development of prognosis-indicating scoring systems for patients with hantavirus disease.

Estimating the Long-Term Epidemiological Trends and Seasonality of Hemorrhagic Fever with Renal Syndrome in China

OBJECTIVE

We aim to examine the adequacy of an innovation state-space modeling framework (called TBATS) in forecasting the long-term epidemic seasonality and trends of hemorrhagic fever with renal syndrome (HFRS).

METHODS

The HFRS morbidity data from January 1995 to December 2020 were taken, and subsequently, the data were split into six different training and testing segments (including 12, 24, 36, 60, 84, and 108 holdout monthly data) to investigate its predictive ability of the TBATS method, and its forecasting performance was compared with the seasonal autoregressive integrated moving average (SARIMA).

RESULTS

The TBATS (0.27, {0,0}, -, {<12,4>}) and SARIMA (0,1,(1,3))(0,1,1)12 were selected as the best TBATS and SARIMA methods, respectively, for the 12-step ahead prediction. The mean absolute deviation, root mean square error, mean absolute percentage error, mean error rate, and root mean square percentage error were 91.799, 14.772, 123.653, 0.129, and 0.193, respectively, for the preferred TBATS method and were 144.734, 25.049, 161.671, 0.203, and 0.296, respectively, for the preferred SARIMA method. Likewise, for the 24-, 36-, 60-, 84-, and 108-step ahead predictions, the preferred TBATS methods produced smaller forecasting errors over the best SARIMA methods. Further validations also suggested that the TBATS model outperformed the Error-Trend-Seasonal framework, with little exception. HFRS had dual seasonal behaviors, peaking in May-June and November-December. Overall a notable decrease in the HFRS morbidity was seen during the study period (average annual percentage change=-6.767, 95% confidence intervals: -10.592 to -2.778), and yet different stages had different variation trends. Besides, the TBATS model predicted a plateau in the HFRS morbidity in the next ten years.

CONCLUSION

The TBATS approach outperforms the SARIMA approach in estimating the long-term epidemic seasonality and trends of HFRS, which is capable of being deemed as a promising alternative to help stakeholders to inform future preventive policy or practical solutions to tackle the evolving scenarios.

Hormonal Defects Are Common during Puumala Hantavirus Infection and Associate with Disease Severity and Biomarkers of Altered Haemostasis

Central and peripheral hormone deficiencies have been documented during and after acute hantavirus infection. Thrombocytopenia and coagulation abnormalities are common findings in haemorrhagic fever with renal syndrome (HFRS). The associations between coagulation and hormonal abnormalities in HFRS have not been studied yet. Forty-two patients diagnosed with Puumala virus (PUUV) infection were examined during the acute phase and on a follow-up visit approximately one month later. Hormonal defects were common during acute PUUV infection. Overt (clinical) hypogonadism was identified in 80% of the men and approximately 20% of the patients had overt hypothyroidism. At the one-month follow-up visit, six patients had central hormone deficits. Acute peripheral hormone deficits associated with a more severe acute kidney injury (AKI), longer hospital stay and more severe thrombocytopenia. Half of the patients with bleeding symptoms had also peripheral hormonal deficiencies. Patients with free thyroxine levels below the reference range had higher D-dimer level than patients with normal thyroid function, but no thromboembolic events occurred. Acute phase hormonal abnormalities associate with severe disease and altered haemostasis in PUUV infection.

Nlrc3 Knockout Mice Showed Renal Pathological Changes After HTNV Infection

Hantaan virus (HTNV) infects humans and causes hemorrhagic fever with renal syndrome (HFRS). The development of well-characterized animal models of HFRS could accelerate the testing of vaccine candidates and therapeutic agents and provide a useful tool for studying the pathogenesis of HFRS. Because NLRC3 has multiple immunoregulatory roles, we investigated the susceptibility of Nlrc3-/- mice to HTNV infection in order to establish a new model of HFRS. Nlrc3-/- mice developed weight loss, renal hemorrhage, and tubule dilation after HTNV infection, recapitulating many clinical symptoms of human HFRS. Moreover, infected Nlrc3-/- mice showed higher viral loads in serum, spleen, and kidney than wild type C57BL/6 (WT) mice, and some of them manifested more hematological disorders and significant pathological changes within multiple organs than WT mice. Our results identify that HTNV infected Nlrc3-/- mice can develop clinical symptoms and pathological changes resembling patients with HFRS, suggesting a new model for studying the pathogenesis and testing of candidate vaccines and therapeutics.

The Presence of Circulating Nucleated Red Blood Cells Is Associated With Disease Severity in Patients of Hemorrhagic Fever With Renal Syndrome

Hemorrhagic fever with renal syndrome (HFRS) is a regional infectious disease of epidemic potential caused by the Hantaan virus (HTNV). Red blood cells (RBCs) are the major components of peripheral blood. However, pathological changes in RBCs and the underlying mechanisms during HTNV infection remain largely unclear. Therefore, this study sought to explore changes in RBCs in the peripheral blood of HFRS patients. We isolated PBMCs from HFRS patients and performed single-cell RNA sequencing. The results showed that clusters of RBCs in the peripheral blood of HFRS could be classified as nucleated red blood cells (NRBC) based on their cellular components, gene expression profiles and cell surface markers. In addition, it was shown that the higher the count of NRBC in peripheral blood, the more severe the disease status was. Moreover, hematological indices related to RBCs were analyzed and the results showed that impairment in the folate pathway might be the possible reason behind the presence of NRBCs. This study, for the first time showed that the presence of NRBCs in the peripheral blood of HFRS patients was associated with disease severity. This was also the first study to show that infection with the HTNV virus hindered the maturation of RBCs. Therefore, this work provides further insights on the role of and pathological changes in RBCs during HTNV infection.

New class of hantaan virus inhibitors based on conjugation of the isoindole fragment to (+)-camphor or (-)-fenchone hydrazonesv

This work presents the design and synthesis of camphor, fenchone, and norcamphor N-acylhydrazone derivatives as a new class of inhibitors of the Hantaan virus, which causes haemorrhagic fever with renal syndrome (HFRS). A cytopathic model was developed for testing chemotherapeutics against the Hantaan virus, strain 76-118. In addition, a study of the antiviral activity was carried out using a pseudoviral system. It was found that the hit compound possesses significant activity (IC₅₀ = 7.6 ± 2 µM) along with low toxicity (CC₅₀ > 1000 µM). Using molecular docking procedures, the binding with Hantavirus nucleoprotein was evaluated and the correlation between the structure of the synthesised compounds and the antiviral activity was established.

Serological Evidence of Human Orthohantavirus Infections in Barbados, 2008 to 2016

Background: Hantavirus pulmonary syndrome (HPS) is well-known in South and North America; however, not enough data exist for the Caribbean. The first report of clinical orthohantavirus infection was obtained in Barbados, but no other evidence of clinical orthohantavirus infections among adults in the Caribbean has been documented. Methods: Using enzyme linked immunosorbent assay (ELISA) tests followed by confirmatory testing with immunofluorescent assays (IFA), immunochromatographic (ICG) tests, and pseudotype focus reduction neutralization tests (pFRNT), we retrospectively and prospectively detected orthohantavirus-specific antibodies among patients with febrile illness in Barbados. Results: The orthohantavirus prevalence rate varied from 5.8 to 102.6 cases per 100,000 persons among febrile patients who sought medical attention annually between 2008 and 2016. Two major orthohantavirus epidemics occurred in Barbados during 2010 and 2016. Peak orthohantavis infections were observed observed during the rainy season (August) and prevalence rates were significantly higher in females than males and in patients from urban parishes than rural parishes. Conclusions: Orthohantavirus infections are still occurring in Barbados and in some patients along with multiple pathogen infections (CHIKV, ZIKV, DENV and Leptospira). Orthohantavirus infections are more prevalent during periods of high rainfall (rainy season) with peak transmission in August; females are more likely to be infected than males and infections are more likely among patients from urban rather than rural parishes in Barbados.

Hospital Frailty Risk Score Outperforms Current Risk Stratification Models in Primary Total Hip and Knee Arthroplasty

BACKGROUND

Models for risk stratification and prediction of outcome, such as the Charlson Comorbidity Index (CCI), the Elixhauser Comorbidity Method (ECM), the 5-factor modified Frailty Index (mFI-5), and the Hospital Frailty Risk Score (HFRS) have been validated in orthopedic surgery. The aim of this study is to compare the predictive power of these models in total hip and knee replacement.

METHODS

In a retrospective analysis of 8250 patients who had undergone total joint replacement between 2011 and 2019, CCI, ECM, mFI-5, and HFRS were calculated for each patient. Receiver operating characteristic curve plots were generated and the area under the curve (AUC) was compared between each score with regard to adverse events such as transfusion, surgical, medical, and other complications. Multivariate logistic regression models were used to assess the relationship among risk stratification models, demographic factors, and postoperative adverse events.

RESULTS

In prediction of surgical complications, HFRS performed best (AUC: 0.719, P < .001), followed by ECM (AUC: 0.578, P < .001), mFI-5 (AUC: 0.564, P = .003), and CCI (AUC: 0.555, P = .012). With regard to medical complications, other complications, and transfusion, HFRS also was superior to ECM, mFI-5, and CCI. Multivariate logistic regression analyses revealed HFRS as an independent risk stratification model associated with all captured adverse events (P ≤ .001).

CONCLUSION

The HFRS is superior to current risk stratification models in the context of total joint replacement. As the HRFS derives from routinely collected administrative data, healthcare providers can identify at-risk patients without additional effort or expense.

Hospital Frailty Risk Score predicts adverse events in revision total hip and knee arthroplasty

Introduction

The Hospital Frailty Risk Score (HFRS) is a validated risk stratification model referring to the cumulative deficits model of frailty. The purpose of this study was to evaluate the HFRS as a predictor of 90-day readmission and complications after revision total hip (rTHA) and knee (rTKA) arthroplasty.

Methods

In a retrospective analysis of 565 patients who had undergone rTHA or rTKA between 2011 and 2019, the HFRS was calculated for each patient. Rates of adverse events were compared between patients with low and intermediate or high frailty risk. Multivariable logistic regression models were used to assess the relationship between the HFRS and post-operative adverse events.

Results

Patients with intermediate or high frailty risk showed higher rates of readmission (30days: 23.8% vs. 9.9%, p = 0.006; 90days: 26.2% vs. 13.0%, p < 0.018), surgical complications (28.6% vs. 7.8%, p < 0.001), medical complications (11.9% vs. 1.0%, p < 0.001), other complications (28.6% vs. 2.3%, p < 0.001), Clavien-Dindo grade IV complications (14.3% vs. 4.8%, p = 0.009), and transfusion (33.3% vs. 6.1%, p < 0.001). Multivariable logistic regression analyses revealed a high HFRS as independent risk factor for surgical complications (OR = 3.45, 95% CI 1.45-8.18, p = 0.005), medical complications (OR = 7.29, 95% CI 1.72-30.97, p = 0.007), and other complications (OR = 14.15, 95% CI 5.16-38.77, p < 0.001).

Conclusion

The HFRS predicts adverse events after rTHA and rTKA. As it derives from routinely collected data, the HFRS could be implemented automated in hospital information systems to facilitate identification of at-risk patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-021-05038-w.

[The potential role of mirnas in the pathogenesis of hemorrhagic fever with renal syndrome]

Hemorrhagic fever with renal syndrome (HFRS) is an acute natural focal viral disease caused by viruses of the genus hantavirus, characterized by damage to small blood vessels, kidneys, lungs and other organs of a person. MicroRNAs (miRNAs) are 18-22 nucleotide endogenously expressed RNA molecules that inhibit gene expression at the post-transcriptional level by binding to the 3-untranslated region of the target mRNA. It has been proven that miRNAs play a significant role in various biological processes, including the cell cycle, apoptosis, cell proliferation and differentiation. It has been proven that miRNAs may be involved in the pathogenesis of infectious diseases, including HFRS. Hantavirus infection predominantly affects endothelial cells and causes dysfunction of the endothelium of capillaries and small vessels. It is known that the immune response induced by Hantavirus infection plays an important role in disrupting the endothelial barrier. In a few studies, both in vitro and in vivo, it has been shown that endothelial dysfunction and the immune response after infection with Hantavirus can be partially regulated by miRNAs by acting on certain genes. Most of the miRNAs is expressed within the cells themselves. However, in some biological fluids of the human body, for example, plasma or blood serum, numerous miRNAs, called circulating miRNAs, have been found. Circulating miRNAs can be secreted by cells into human biological fluids as part of extracellular vesicles as exosomes or be part of an RNA-bound protein complex as miRNA-Argonaute 2 (Ago2). These miRNAs are resistant to nucleases, which makes them attractive as potential biomarkers in various human diseases. There is no specific antiviral therapy for HFRS, and the determination of laboratory parameters that are used to diagnose, assess the severity, and predict the course of the disease remains a challenge due to the peculiarities of the pathophysiology and clinical course of the disease. Studying the role of miRNAs in HFRS seems to be expedient for the development of specific and effective therapy, as well as for use as diagnostic and prognostic biomarkers (in relation to circulating miRNAs).

Hospital Frailty Risk Score Predicts Adverse Events in Primary Total Hip and Knee Arthroplasty

BACKGROUND

The Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.

METHODS

In a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.

RESULTS

Patients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001).

CONCLUSION

The HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Utility of the Hospital Frailty Risk Score for Predicting Adverse Outcomes in Degenerative Spine Surgery Cohorts

BACKGROUND

As spine surgery becomes increasingly common in the elderly, frailty has been used to risk stratify these patients. The Hospital Frailty Risk Score (HFRS) is a novel method of assessing frailty using International Classification of Diseases, Tenth Revision (ICD-10) codes. However, HFRS utility has not been evaluated in spinal surgery.

OBJECTIVE

To assess the accuracy of HFRS in predicting adverse outcomes of surgical spine patients.

METHODS

Patients undergoing elective spine surgery at a single institution from 2008 to 2016 were reviewed, and those undergoing surgery for tumors, traumas, and infections were excluded. The HFRS was calculated for each patient, and rates of adverse events were calculated for low, medium, and high frailty cohorts. Predictive ability of the HFRS in a model containing other relevant variables for various outcomes was also calculated.

RESULTS

Intensive care unit (ICU) stays were more prevalent in high HFRS patients (66%) than medium (31%) or low (7%) HFRS patients. Similar results were found for nonhome discharges and 30-d readmission rates. Logistic regressions showed HFRS improved the accuracy of predicting ICU stays (area under the curve [AUC] = 0.87), nonhome discharges (AUC = 0.84), and total complications (AUC = 0.84). HFRS was less effective at improving predictions of 30-d readmission rates (AUC = 0.65) and emergency department visits (AUC = 0.60).

CONCLUSION

HFRS is a better predictor of length of stay (LOS), ICU stays, and nonhome discharges than readmission and may improve on modified frailty index in predicting LOS. Since ICU stays and nonhome discharges are the main drivers of cost variability in spine surgery, HFRS may be a valuable tool for cost prediction in this specialty.

Hantavirus Infections-Treatment and Prevention

Purpose of review

Hantavirus infection is an emerging zoonosis and there are two main clinical presentations, hemorrhagic fever with renal syndrome (HFRS) and Hantavirus pulmonary syndrome (HPS). Although Hantavirus infections have a worldwide distribution with a high mortality rate, a safe and effective vaccine or an antiviral drug against the Hantavirus disease is yet to be available. This review summarizes all the efforts undertaken to develop medical countermeasures in vitro, in vivo, and human clinical trials against Hantavirus infections.

Recent findings

Multiple antivirals are shown to be effective with limited evidence and recent studies on immunotherapy were not very conclusive. There are multiple vaccine candidates with evidence of conferring long protective immunity against Hantaviruses. Some of these had been already trialed on humans.

Summary

At present, severe HPS or HFRS case management is purely based on supportive treatments, often in an intensive care unit. Rodent control and public health education and promotion play a major role in preventing Hantavirus infection.

Hantavirus Infection during Pregnancy

Hantavirus infection is a global health challenge, causing widespread public concern. In recent years, cases of hantavirus infection in pregnant women have been reported in many countries. The infected pregnant women and their fetuses appear to have more severe clinical symptoms and worse clinical outcomes. Hence, to study the prevalence of hantavirus infection in pregnant women, this study will focus on the epidemiological distribution of the virus, different virus species penetrating the placental barrier, and factors affecting the incidence and clinical outcome of the infection in pregnant women and their fetuses. In addition, this review will also discuss the diagnostic tools and treatments for pregnant patients and provide an overview of the relevant future research.

Flash-Like Albuminuria in Acute Kidney Injury Caused by Puumala Hantavirus Infection

Transient proteinuria and acute kidney injury (AKI) are characteristics of Puumala virus (PUUV) infection. Albuminuria peaks around the fifth day and associates with AKI severity. To evaluate albuminuria disappearance rate, we quantified albumin excretion at different time points after the fever onset. The study included 141 consecutive patients hospitalized due to acute PUUV infection in Tampere University Hospital, Finland. Timed overnight albumin excretion (cU-Alb) was measured during the acute phase in 133 patients, once or twice during the convalescent phase within three months in 94 patients, and at six months in 36 patients. During hospitalization, 30% of the patients had moderately increased albuminuria (cU-Alb 20-200 μg/min), while 57% presented with severely increased albuminuria (cU-Alb >200 μg/min). Median cU-Alb was 311 μg/min (range 2.2-6460) ≤7 days after fever onset, 235 μg/min (range 6.8-5479) at 8-13 days and 2.8 μg/min (range 0.5-18.2) at 14-20 days. After that, only one of the measurements showed albuminuria (35.4 μg/min at day 44). At six months, the median cU-Alb was 2.0 μg/min (range 0.6-14.5). Albuminuria makes a flash-like appearance in PUUV infection and returns rapidly to normal levels within 2-3 weeks after fever onset. In the case of AKI, this is a unique phenomenon.

Molecular and epidemiological characteristics of human Puumala and Dobrava-Belgrade hantavirus infections, Germany, 2001 to 2017

Introduction

Two hantavirus species, Puumala (PUUV) and Dobrava-Belgrade (DOBV) virus (genotype Kurkino), are endemic in Germany. Recent PUUV outbreaks raised questions concerning increasing frequency of outbreaks and expansion of PUUV endemic areas.

Aims

To describe the epidemiology of human PUUV and DOBV infections in Germany.

Methods

We conducted an observational retrospective study analysing national hantavirus surveillance data notified to the national public health institute and hantavirus nucleotide sequences from patients collected at the national consultation laboratory between 2001 and 2017. Matching molecular sequences with surveillance data, we conducted epidemiological, phylogenetic and phylogeographic analyses.

Results

In total, 12,148 cases of symptomatic hantavirus infection were notified 2001–17 (mean annual incidence: 0.87/100,000; range: 0.09–3.51). PUUV infections showed a highly variable space-time disease incidence pattern, causing large outbreaks every 2–3 years with peaks in early summer and up to 3,000 annually reported cases. Sex-specific differences in disease presentation were observed. Of 202 PUUV nucleotide sequences obtained from cases, 189 (93.6%) fall into well-supported phylogenetic clusters corresponding to different endemic areas in Germany. DOBV infections caused few, mostly sporadic cases in autumn and winter in the north and east of Germany.

Conclusions

The frequency of PUUV outbreaks increased between 2001 and 2017 but our data does not support the suggested expansion of endemic areas. The epidemiology of PUUV and DOBV-Kurkino infections differs in several aspects. Moreover, the latter are relatively rare and combining efforts and data of several countries to identify risk factors and develop specific recommendations for prevention could be worthwhile.

HTNV Sensitizes Host Toward TRAIL-Mediated Apoptosis-A Pivotal Anti-hantaviral Role of TRAIL

Hantaviruses can cause hemorrhagic fever with renal syndrome (HFRS) in Eurasia and have led to public health threat in China. The pathogenesis of HFRS is complex and involves capillary leakage due to the infection of vascular endothelial cells. Accumulating evidence has demonstrated that hantavirus can induce apoptosis in many cells, but the mechanism remains unclear. Our studies showed that Hantaan virus (HTNV) infection could induce TNF-related apoptosis-inducing ligand (TRAIL) expression in primary human umbilical vein endothelial cells (HUVECs) and sensitize host cells toward TRAIL-mediated apoptosis. Furthermore, TRAIL interference could inhibit apoptosis and enhance the production of HTNV as well as reduce IFN-β production, while exogenous TRAIL treatment showed reverse outcome: enhanced apoptosis and IFN-β production as well as a lower level of viral replication. We also observed that nucleocapsid protein (NP) and glycoprotein (GP) of HTNV could promote the transcriptions of TRAIL and its receptors. Thus, TRAIL was upregulated by HTNV infection and then exhibited significant antiviral activities in vitro, and it was further confirmed in the HTNV-infected suckling mice model that TRAIL treatment significantly reduced viral load, alleviated virus-induced tissue lesions, increased apoptotic cells, and decreased the mortality. In conclusion, these results demonstrate that TRAIL-dependent apoptosis and IFN-β production could suppress HTNV replication and TRAIL treatment might be a novel therapeutic target for HTNV infection.

Anti-HFRS Human IgG Produced in Transchromosomic Bovines Has Potent Hantavirus Neutralizing Activity and Is Protective in Animal Models

We explored an emerging technology to produce anti-Hantaan virus (HTNV) and anti-Puumala virus (PUUV) neutralizing antibodies for use as pre- or post-exposure prophylactics. The technology involves hyperimmunization of transchomosomic bovines (TcB) engineered to express human polyclonal IgG antibodies with HTNV and PUUV DNA vaccines encoding G_nG_c glycoproteins. For the anti-HTNV product, TcB was hyperimmunized with HTNV DNA plus adjuvant or HTNV DNA formulated using lipid nanoparticles (LNP). The LNP-formulated vaccine yielded fivefold higher neutralizing antibody titers using 10-fold less DNA. Human IgG purified from the LNP-formulated animal (SAB-159), had anti-HTNV neutralizing antibody titers >100,000. SAB-159 was capable of neutralizing pseudovirions with monoclonal antibody escape mutations in G_n and G_c demonstrating neutralization escape resistance. SAB-159 protected hamsters from HTNV infection when administered pre- or post-exposure, and limited HTNV infection in a marmoset model. An LNP-formulated PUUV DNA vaccine generated purified anti-PUUV IgG, SAB-159P, with a neutralizing antibody titer >600,000. As little as 0.33 mg/kg of SAB-159P protected hamsters against PUUV infection for pre-exposure and 10 mg/kg SAB-159P protected PUUV-infected hamsters post-exposure. These data demonstrate that DNA vaccines combined with the TcB-based manufacturing platform can be used to rapidly produce potent, human, polyclonal, escape-resistant anti-HTNV, and anti-PUUV neutralizing antibodies that are protective in animal models.

A case-control study on the risk factors for hemorrhagic fever with renal syndrome

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS) is an endemic communicable disease in China, accounting for 90% of total reported cases worldwide. In this study, the authors want to investigate the risk factors for HFRS in recent years to provide the prevention and control advices.

METHODS

A community-based, 1:2 matched case-control study was carried out to investigate the risk factors for HFRS. Cases were defined as laboratory-confirmed cases that tested positive for hantavirus-specific IgM antibodies. Two neighbourhood controls of each case were selected by sex, age and occupation. Standardized questionnaires were used to collect information and identify the risk factors for HFRS.

RESULTS

Eighty-six matched pairs were investigated in the study. The median age of the cases was 55.0 years, 72.09% were male, and 73.26% were farmers. In the multivariate logistic regression analysis, cleaning spare room at home (OR = 3.310, 95%CI 1.335-8.210) was found to be risk factor for infection; storing food and crops properly (OR = 0.279 95%CI 0.097-0.804) provided protection from infection.

CONCLUSION

Storing food and crops properly seemed to be protective factor, which was important for HFRS prevention and control. More attention should be paid to promote comprehensive health education and behaviour change among high-risk populations in the HFRS endemic area.

Vaccines and Therapeutics Against Hantaviruses

Hantaviruses (HVs) are rodent-transmitted viruses that can cause hantavirus cardiopulmonary syndrome (HCPS) in the Americas and hemorrhagic fever with renal syndrome (HFRS) in Eurasia. Together, these viruses have annually caused approximately 200,000 human infections worldwide in recent years, with a case fatality rate of 5–15% for HFRS and up to 40% for HCPS. There is currently no effective treatment available for either HFRS or HCPS. Only whole virus inactivated vaccines against HTNV or SEOV are licensed for use in the Republic of Korea and China, but the protective efficacies of these vaccines are uncertain. To a large extent, the immune correlates of protection against hantavirus are not known. In this review, we summarized the epidemiology, virology, and pathogenesis of four HFRS-causing viruses, HTNV, SEOV, PUUV, and DOBV, and two HCPS-causing viruses, ANDV and SNV, and then discussed the existing knowledge on vaccines and therapeutics against these diseases. We think that this information will shed light on the rational development of new vaccines and treatments.

Heterogeneous Puumala orthohantavirus situation in endemic regions in Germany in summer 2019

Puumala orthohantavirus (PUUV) causes most human hantavirus disease cases in Europe. PUUV disease outbreaks are usually synchronized Germany-wide driven by beech mast-induced irruptions of its host (bank vole, Myodes glareolus). Recent data indicate high vole abundance, high PUUV prevalence and high human incidence in summer 2019 for some regions, but elsewhere values were low to moderate. This significant lack of synchrony among regions in Germany is in contrast to previous studies. Health institutions need to be informed about the heterogeneous distribution of human PUUV infection risk to initiate appropriate actions.

Elevated plasma interleukin 34 levels correlate with disease severity-reflecting parameters of patients with haemorrhagic fever with renal syndrome

Background: Haemorrhagic fever with renal syndrome (HFRS) is characterized by an uncontrolled cytokine storm that causes vascular leakage and kidney injury. The cytokine interleukin 34 (IL-34) enhances proliferation and differentiation of myeloid cells and secretion of pro-inflammatory cytokines, which is involved in the pathogenesis of some inflammatory and infectious diseases, including acute kidney injury. To date, however, the role of IL-34 in patients with HFRS is unclear. This study aims to determine the plasma IL-34 levels of HFRS patients and discuss the possible effects of IL-34 in the pathogenesis of HFRS. Methods: Plasma levels of IL-34 in 52 HFRS patients and 20 healthy controls were quantified using enzyme-linked immunosorbent assay. Results: Compared with healthy controls, the plasma IL-34 levels in HFRS patients were significantly elevated in acute phase [37.92 (0-215.45) pg/ml vs. 7.13 (0-19.44) pg/ml, p < .0001], and then decreased to the normal levels in convalescent phase. Importantly, IL-34 levels correlated positively with white blood cell counts and mononuclear cell counts (r = 0.592, p < .0001 and r = 0.458, p < .0001, respectively), and correlated negatively with platelet counts and serum albumin levels (r = -0.430, p < .0001 and r = -0.479, p = .0001, respectively). Conclusions: Plasma levels of IL-34 in HFRS patients were significantly elevated in acute phase and correlated with disease severity-reflecting parameters, which suggests a potential role of IL-34 in HFRS and should be future explored.