The raccoon an emerging rabies host

The geographic distribution of enzootic rabies in raccoons is currently limited to Florida and Georgia. The enzootic area has steadily expanded northward into Georgia during the 1960's. An epizootic in a population of raccoons closely associated with the human residents of a small, off-shore island was investigated. Forty-seven raccoons from the island were confirmed rabies positive by the State Laboratory from January 22 to May 20, 1969. About 10 percent of the raccoons trapped during the peak of the epizootic were positive and all of these had high titers of virus in their salivary glands but were asymptomatic in behavior. Human exposure typically resulted from close approach to a "sick" raccoon. Similar outbreaks may occur elsewhere when humans live in close contact with a semi-domesticated raccoon population. Rabies vaccination of raccoons should be considered as an alternative to population reduction in such situations.

Comparison of new clinical and scintigraphic algorithms for the diagnosis of pulmonary embolism

Since the publication of the modified Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) criteria for the diagnosis of pulmonary embolism (PE), new clinical and scintigraphic diagnostic algorithms (the McMaster clinical criteria, the PisaPED simplified scintigraphic grading and the Miettinen logistic regression analysis) have been reported although the results have not been reproduced in other sites. Ventilation-perfusion lung scintigraphy was performed in 238 consecutive patients with a provisional diagnosis of PE. Scans were reported as normal/very low, low, intermediate or high probability for PE using standardized criteria. Each patient received a clinical grading of probability of PE as low, moderate or high using the McMaster clinical criteria. Using the PisaPED criteria (an alternate simplified scintigraphic grading system using the perfusion scan alone) each scan was also graded as normal/near normal, abnormal but not PE, or abnormal and PE. Using the logistic regression algorithm of Miettinen each scan received a numerical probability of PE. Frequencies for differing levels of probability of PE varied widely between the various algorithms. Cross tabulations revealed correlation of the standardized criteria with the Miettinen grading but not with the McMaster or the PisaPED gradings. We were unable to reproduce similar results using the McMaster clinical grading or the PisaPED simplified scintigraphic grading although the Miettinen logistic regression formula gave comparable results. New algorithms are not automatically transferable to new environments.

West Nile virus in livestock and wildlife

WN virus is one of the most ubiquitous arboviruses occurring over a broad geographical range and in a wide diversity of vertebrate host and vector species. The virus appears to be maintained in endemic foci on the African continent and is transported annually to temperate climates to the north in Europe and to the south in South Africa. Reports of clinical disease due to natural WN virus infection in wild or domestic animals were much less common than reports of infection (virus isolation or antibody detection). Until recently, records of morbidity and mortality in wild birds were confined to a small number of cases and infections causing encephalitis, sometimes fatal, in horses were reported infrequently. In the period 1996-2001, there was an increase in outbreaks of illness due to WN virus in animals as well as humans. Within the traditional range of WN virus, encephalitis was reported in horses in Italy in 1998 and in France in 2000. The first report of disease and deaths caused by WN virus infection in domestic birds was reported in Israel in 1997-1999, involving hundreds of young geese. In 1999 WN virus reached North America and caused an outbreak of encephalitis in humans in the New York area at the same time as a number of cases of equine encephalitis and deaths in American crows and a variety of other bird species, both North American natives and exotics. Multi-state surveillance for WN virus has been in place since April 2000 and has resulted in the detection of WN virus in thousands of dead birds from an increasing number of species in North America, and also in several species of mammals. The surveillance system that has developed in North America because of the utility of testing dead birds for the rapid detection of WN virus presence has been a unique integration of public health and wildlife health agencies. It has been suggested that the recent upsurge in clinical WN virus infection in wild and domestic animals as well as in humans may be related to the emergence of one or more new strains of WN virus. Virus isolated in New York in 1999 was found to be identical to that from Israel. It was alarming for WN virus to so easily invade the United States and surprising that it became established so quickly in the temperature climate of New York. Its persistence and rapid expansion in the United States leave a number of unanswered questions. New disease characteristics and patterns have occurred and more are evolving as WN virus further invades the western hemisphere. Additional animal research is needed to answer these questions. Some of the research needs include bird migration as a mechanism of virus dispersal, vector and vertebrate host relationships, virus persistence mechanisms, laboratory diagnosis, viral pathogenesis, risk factor studies, vaccine development, and WN virus impact on wildlife (CDC 2001a). Determination of the primary reservoir host species that are involved in the epidemiology of WN virus and the suitable sentinel species for active surveillance are also important research areas.

West Nile virus transmission and ecology in birds

The ecology of the strain of West Nile virus (WNV) introduced into the United States in 1999 has similarities to the native flavivirus, St. Louis encephalitis (SLE) virus, but has unique features not observed with SLE virus or with WNV in the old world. The primary route of transmission for most of the arboviruses in North America is by mosquito, and infected native birds usually do not suffer morbidity or mortality. An exception to this pattern is eastern equine encephalitis virus, which has an alternate direct route of transmission among nonnative birds, and some mortality of native bird species occurs. The strain of WNV circulating in the northeastern United States is unique in that it causes significant mortality in exotic and native bird species, especially in the American crow (Corvus brachyrhynchos). Because of the lack of information on the susceptibility and pathogenesis of WNV for this species, experimental studies were conducted at the USGS National Wildlife Health Center. In two separate studies, crows were inoculated with a 1999 New York strain of WNV, and all experimentally infected crows died. In one of the studies, control crows in regular contact with experimentally inoculated crows in the same room but not inoculated with WNV succumbed to infection. The direct transmission between crows was most likely by the oral route. Inoculated crows were viremic before death, and high titers of virus were isolated from a variety of tissues. The significance of the experimental direct transmission among captive crows is unknown.

Experimental infection of nontarget species of rodents and birds with Brucella abortus strain RB51 vaccine

The Brucella abortus vaccine strain RB51 (SRB51) is being considered for use in the management of bnucellosis in wild bison (Bison bison) and elk (Cervus elaphus) populations in the Greater Yellowstone Area (USA). Evaluation of the vaccines safety in non-target species was considered necessary prior to field use. Between June 1998 and December 1999, ground squirrels (Spermophilus richardsonii, n = 21), deer mice (Peromyscus maniculatus, n = 14), prairie voles (Microtus ochrogaster, n = 21), and ravens (Corvus corax, n = 13) were orally inoculated with SRB51 or physiologic saline. Oral and rectal swabs and blood samples were collected for bacteriologic evaluation. Rodents were necropsied at 8 to 10 wk and 12 to 21 wk post inoculation (PI), and ravens at 7 and 11 wk PI. Spleen, liver and reproductive tissues were collected for bacteriologic and histopathologic evaluation. No differences in clinical signs, appetite, weight loss or gain, or activity were observed between saline- and SRB51-inoculated animals in all four species. Oral and rectal swabs from all species were negative throughout the study. In tissues obtained from SRB51-inoculated animals, the organism was isolated from six of seven (86%) ground squirrels, one of six (17%) deer mice, none of seven voles, and one of five (20%) ravens necropsied at 8, 8, 10, and 7 wk PI, respectively. Tissues from four of seven (57%) SRB51-inoculated ground squirrels were culture positive for the organism 12 wk PI; SRB51 was not recovered from deer mice, voles. or ravens necropsied 12, 21, or 11 wk, respectively, PI. SRB51 was not recovered from saline-inoculated ground squirrels, deer mice, or voles at any time but was recovered from one saline-inoculated raven at necropsy, 7 wk PI, likely attributable to contact with SRB51-inoculated ravens in an adjacent aviary room. Spleen was time primary tissue site of colonization in ground squirrels, followed by the liver and reproductive organs. The results indicate oral exposure to SRB51 does not produce morbidity or mortality in ravens, ground squirrels, deer mice, or prairie voles.

Serologic survey for selected infectious disease agents in swift and kit foxes from the western United States

A serologic survey of swift fox (Vulpes velox) and kit fox (V. macrotis) from the western USA was conducted for 12 infectious diseases. Samples from swift fox were collected between 1987 and 1992 from Colorado (n = 44), Kansas (n = 10), and Wyoming (n = 9). Samples from kit fox were collected in California (n = 86), New Mexico (n = 18), Utah (n = 9), and Arizona (n = 6). Overall antibody prevalence rates were 33 of 110 (30%) for canine parvovirus (CPV), 9 of 72 (13%) for canine distemper virus (CDV), 23 of 117 (20%) for vesicular stomatitis New Jersey, 16 of 117 (14%) for vesicular stomatitis Indiana, six of 117 (5%) for Cache Valley virus, five of 117 (4%) for Jamestown Canyon virus, one of 97 (1%) for rabies virus, one of 117 (1%) for Colorado tick fever virus, and one of 117 (1%) for western equine encephalitis virus. In addition, antibodies were not found to Yersinia pestis, Francisella tularensis, and Borrelia burgdorferi in serum from 25 Colorado swift fox. Adult swift fox from Colorado had serologic evidence of exposure to CPV more often than juveniles. No juvenile swift fox from Colorado had serum antibodies to CDV. There were season-specific differences in serum antibody prevalence for CPV for swift fox from Colorado. No viruses were isolated from ectoparasites or fox from Colorado.

The utilization of colon transit scintigraphy in the diagnostic algorithm for patients with chronic constipation

We performed a retrospective utilization study covering a four-year period to determine how physicians familiar with colon transit scintigraphy (CTS) use it to manage patients with chronic constipation. Following CTS, there was a change is both frequency and likelihood of diagnosis. The diagnosis was changed in 51% of patients-37% of those considered to have slow transit constipation (STC) before CTS, 43% with obstructed defecation, and 64% with functional bowel disease (FBD). CTS increased the diagnostic likelihood in all groups. Of patients with the diagnosis of STC, 16% were considered "almost certain" before CTS while 83% were considered "almost certain" after CTS. For FBD comparable percentages were 13% and 62%. CTS may play a major role in the diagnostic work-up of patients with chronic constipation, both altering diagnosis and increasing diagnostic certainty.

Screening for prostate cancer: estimating the magnitude of overdetection

BACKGROUND

No randomized controlled trial of prostate cancer screening has been reported and none is likely to be completed in the near future. In the absence of direct evidence, the decision to screen must therefore be based on estimates of benefits and risks. The main risk of screening is overdetection--the detection of cancer that, if left untreated, would not cause death. In this study the authors estimate the level of overdetection that might result from annual screening of men aged 50-70.

METHODS

The annual rate of lethal screen-detectable cancer (detectable cancer that would prove fatal before age 85 if left untreated) was calculated from the observed prostate cancer mortality rate in Quebec; the annual rate of all cases of screen-detectable prostate cancer was calculated from 2 recent screening studies.

RESULTS

The annual rate of lethal screen-detectable prostate cancer was estimated to be 1.3 per 1000 men. The annual rate of all cases of screen-detectable prostate cancer was estimated to be 8.0 per 1000 men. The estimated case-fatality rate among men up to 85 years of age was 16% (1.3/8.0) (sensitivity analysis 13% to 22%).

INTERPRETATION

Of every 100 men with screen-detected prostate cancer, only 16 on average (13 to 22) could have their lives extended by surgery, since the prostate cancer would not cause death before age 85 in the remaining 84 (78 to 87).

Epidemic leptospirosis associated with pulmonary hemorrhage-Nicaragua, 1995

In October 1995, epidemic "hemorrhagic fever," without jaundice or renal manifestations, was reported in rural Nicaragua following heavy flooding; 2259 residents were evaluated for nonmalarial febrile illnesses (cumulative incidence, 6.1%) and 15 (0.7%) died with pulmonary hemorrhage. A case-control study found that case-patients were more likely than controls to have ever walked in creeks (matched odds ratio [MOR], 15.0; 95% confidence interval [CI], 1.7-132.3), have household rodents (MOR, 10.4; 95% CI, 1.1-97.1), or own dogs with titers >/=400 to Leptospira species (MOR, 23.4; 95% CI, 3.6-infinity). Twenty-six of 51 case-patients had serologic or postmortem evidence of acute leptospirosis. Leptospira species were isolated from case-patients and potential animal reservoirs. This leptospirosis epidemic likely resulted from exposure to flood waters contaminated by urine from infected animals, particularly dogs. Leptospirosis should be included in the differential diagnosis for nonmalarial febrile illness, particularly during periods of flooding or when pulmonary hemorrhage occurs.

Ticks, Lyme disease spirochetes, trypanosomes, and antibody to encephalitis viruses in wild birds from coastal Georgia and South Carolina

Ticks and blood samples were collected from wild birds mist-netted on St. Catherine's Island, Georgia, and at the Wedge Plantation in coastal South Carolina in 1994 and 1995. Immature stages of 5 species of ixodid ticks were recovered from 10 of 148 (7%) birds belonging to 6 species in Georgia, whereas 6 ixodid species were recovered from 45 of 259 (17%) birds representing 10 avian species in South Carolina. Borrelia burgdorferi sensu lato was isolated from 27 of 120 (23%) screened ticks (Ixodes scapularis and Ixodes minor) recovered from South Carolina birds, but from none of 16 screened ticks removed from Georgia birds. This spirochete was also isolated from 1 of 97 (1%) birds in South Carolina. In 1995, neither eastern equine encephalitis (EEE) virus nor St. Louis encephalitis (SLE) virus was isolated from any of 218 bird sera screened, but serum neutralizing antibodies were found to EEE virus in 4 of 121 (3%) sera and to SLE virus in 2 of 121 (2%) sera from South Carolina. No antibody to either virus was detected in 51 avian sera screened from Georgia. Trypanosomes (probably Trypanosoma avium) were isolated from 1 of 51 (2%) birds from Georgia and from 13 of 97 (13%) birds from South Carolina. Our data suggest that some wild birds may be reservoir hosts for the Lyme disease spirochete and for encephalitis viruses in coastal Georgia and South Carolina and that migrating birds can disperse immature ticks infected with B. burgdorferi.

The role of deer as a possible reservoir host of potosi virus, a newly recognized arbovirus in the United States

Potosi (POT) virus (Bunyaviridae) was isolated from Aedes albopictus, an introduced Asian mosquito species, collected at a used tire yard in Potosi, Missouri (USA), in August and September, 1989. In September, 1990, small animals were trapped at the tire yard and six cattle were sampled at an adjacent farm; in November 1990 and 1991, blood samples were collected with filter paper strips from 364 hunter-killed, white-tailed deer (Odocoileus virginianus) in the region to determine the possible reservoir hosts of the virus. Deer specimens from Arkansas (n = 70), Colorado (n = 29), and Iowa (n = 763) (USA) were also analyzed. Specimens from 33 small vertebrates captured at the tire yard were negative for viruses. Only one eastern chipmunk (Tamias striatus) and none of six cattle had neutralizing (N) antibody against POT virus by the plaque-reduction serum neutralization test in Vero cell culture but 45 (25%) of 178 deer specimens in 1990 and 55 (30%) of 186 in 1991 were antibody positive. The 186 deer sera from 1991 were tested further and 29 (16%) were also N antibody positive to Cache Valley (CV) virus. From the 763 deer specimens tested from Iowa in 1993, 114 (15%) had N antibody to POT virus. Of 70 serum specimens from Arkansas deer in 1990, 33 (47%) had N antibody to POT and 15 (21%) to CV viruses; two (7%) of 29 CV negative serum specimens from Colorado deer in 1981 were serologically positive to POT virus. Three eastern chipmunks were experimentally inoculated with POT virus to determine their reservoir potential; none became viremic but all developed N antibody. Thus we propose that POT virus may be another virus regularly infecting wild deer populations but its impact on the health of these animals is unknown.

Susceptibility of selected rodent species from Colorado to Borrelia burgdorferi

To determine the susceptibility of some common Colorado (USA) rodent species to Borrelia burgdorferi, pregnant Peromyscus maniculatus, Tamias minimus, and Spermophilus lateralis were trapped in May 1990 and kept in quarantine until their young were old enough to be used in the experiment. Six to eight 8-wk-old individuals of each of the Colorado species and, for comparison, eight laboratory raised P. leucopus were subcutaneously inoculated with > or = 10(5) spirochetes in 0.1 ml in July 1990. Tissue specimens were collected for isolation from these animals through April 1991. Spirochetes were isolated from blood, ear, bladder, kidney, spleen, liver, and eye in Barbour-Stoener-Kelly (BSK) medium from P. maniculatus, P. leucopus and T. minimus. Spirochetes were isolated from at least one tissue from all of these animals and no isolations were obtained from any of the S. lateralis. Thus, three of the four rodent species tested are susceptible to, and could harbor, B. burgdorferi.

Borrelia burgdorferi-infected Ixodes scapularis (Acari: Ixodidae) and Peromyscus leucopus in northeastern Wisconsin

Populations of the blacklegged tick, Ixodes scapularis Say, are established in western and central Wisconsin in the upper midwestern United States, but appear to be expanding geographically there. Here, we report a previously unknown population in northeastern Wisconsin. Questing I. scapularis nymphs and adults were collected by flagging vegetation from a riverine site in Marinette County, Wisconsin, in spring of 1993 and 1994. Dissection and culture of tick guts in modified Barbour-Stoenner-Kelley II medium showed that some of the ticks were infected with Borrelia burgdorferi Johnson, Schmid, Hyde, Steigerwald & Brenner, causative agent of Lyme disease. Fifteen of 30 white-footed mice, Peromyscus leucopus (Rafinesque), live-trapped at the site on 23-24 August 1994 were infested with immature I. scapularis, and ear-punch biopsies yielded B. burgdorferi cultures from 2 of the mice. However, none of 50 white-tailed deer, Odocoileus virginianus (Zimmermann), shot by hunters in Marinette County in November 1994 had I. scapularis on them, probably because no deer were shot at the same site where the tick population is located. These findings document existence of an established population of I. scapularis and a focus of Lyme disease in northeastern Wisconsin.

Experimental infection of wading birds with eastern equine encephalitis virus

To study the susceptibility of wading birds to eastern equine encephalitis (EEE) virus and to determine their potential as reservoir or amplifying hosts, fledgling glossy ibises (Plegadis falcinellus) and snowy egrets (Egretta thula) were captured in New Jersey (USA) and shipped to Colorado (USA) where they were experimentally inoculated with EEE virus. All 16 snowy egrets and 14 (93%) of 15 of the glossy ibises inoculated became viremic with moderate titers, and all survivors developed neutralizing antibody. Six ibises and two egrets died during the first week after inoculation, and EEE virus was isolated from the tissues of three birds. Our experimental results support field evidence about the relative involvement of glossy ibises and snowy egrets in the epizootiology of EEE virus in New Jersey.

Serologic survey of neotropical bats in Guatemala for virus antibodies

Neotropical bats were collected from different life zones in Guatemala in 1983 and 1984 to determine the presence and distribution of antibody against 10 viruses. Bats were collected with mist nets at 13 sites in eight departments and 332 serum specimens were obtained for testing for neutralizing (N) antibody by the plaque-reduction neutralization test. Eighty-seven (26%) of the 332 bats from 16 (38%) of 42 bat species sampled were serologically positive for five of six arboviruses and for two other viruses tested. Antibodies against Venezuelan equine encephalitis (VEE) variant I-A/B, eastern equine encephalitis, western equine encephalitis, St. Louis encephalitis, vesicular stomatitis, Tacaribe, and Rio Bravo viruses were detected in resident species of bats. However, N antibodies against the enzootic strain of VEE (Mena II, variant I-E) or Nepuyo viruses were not detected.

Vector competence of Aedes albopictus from Pine Bluff, Arkansas, for a St. Louis encephalitis virus strain isolated during the 1991 epidemic

The vector competence of Aedes albopictus from Pine Bluff, AR, was assessed for a St. Louis encephalitis (SLE) virus strain isolated during the 1991 epidemic. Aedes albopictus were fed on hamsters with viremia levels of 10(4.6)-10(4.9) Vero cell plaque-forming units (PFU)/ml. At 7 and 15 days postbloodfeeding, transmission trials were conducted using individual suckling mice. Three of 313 Ae. albopictus were determined to be infected with SLE virus with titers of 10(6.3)-10(7.0) PFU/mosquito. At 15 days postbloodfeeding, one of 209 Ae. albopictus that refed transmitted virus resulting in a 15-day population transmission rate of 0.5%. The infection threshold (i.e., the amount of virus required to infect from 1 to 5% of mosquitoes) was determined to be approximately 10(2.3) PFU/mosquito. Virus inoculated intracoelomically into Ae. albopictus replicated and reached mean titers above 10(6.0) PFU/mosquito on day 6. The combination of low susceptibility to infection and a mammalophilic bloodfeeding pattern suggests that Ae. albopictus is unlikely to play a significant role in SLE transmission.

Distribution of Borrelia burgdorferi in host mice in Pennsylvania

Host mice (Peromyscus leucopus and Peromyscus maniculatus) were sampled throughout the state of Pennsylvania to determine the geographical and ecological distribution of the Lyme disease spirochete Borrelia burgdorferi. All 67 counties of the state were sampled. A total of 1,619 mice were captured from a total of 157 sites during the period 1990 to 1993 for an overall capture rate of 29.69%. A total of 112 (6.92%) isolations of B. burgdorferi were made. The distribution of isolations revealed the reason for the correlated distribution of human cases of Lyme disease in the state. Significantly more mice were captured and significantly more isolations were made from hemlock (Tsuga canadensis) habitat than from deciduous species forest. Nevertheless, high isolation rates from counties of the southeastern corner of the state illustrate well that hemlock habitat is not essential. Evidence suggests that in some areas, transmission between mice is occurring in some way other than through ticks as vectors. Host mice proved useful for determining the geographical and ecological distribution of B. burgdorferi.

Prevalence of Borrelia burgdorferi in host-seeking ticks (Acari: Ixodidae) from a Lyme disease endemic area in northern Michigan

The Lyme disease spirochete, Borrelia burgdorferi Johnson, Schmid, Hyde, Steigerwalt & Brenner, was recovered from the guts of questing Ixodes scapularis Say adults and nymphs and adult Dermacentor variabilis (Say), collected in Menominee County, Michigan, in 1992. Spirochetes were cultured successfully from guts placed in modified Barbour-Stoenner-Kelly II medium held in 5-ml cultures tubes or in 0.3-ml wells of microtiter plates. Most isolates were recovered within 2 wk of culturing at an incubation temperature of 34 degrees C. Spirochetes were recovered more rapidly in culture tubes than in microtiter plates. For determination of tick infection with B. burgdorferi, culturing was equivalent to examination of gut smears by immunofluorescence. We found the following infection rates: 57/179 I. scapularis females (31.8%), 62/204 I. scapularis males (30.4%), 9/54 I. scapularis nymphs (16.7%), and 5/383 D. variabilis adults (1.3%).

Isolation of pseudorabies (Aujeszky's disease) virus from a Florida panther

Pseudorabies virus was isolated in cell culture from the brain tissue of a 3.5-year-old male Florida panther (Felis concolor coryi). The virus was not isolated from other tissues collected at necropsy. Based upon a nested polymerase chain reaction (PCR), the virus was determined to have the classical wild-type virulent genotype, glycoprotein I+ (gI+) and thymidine kinase+ (TK+).

Arboviruses in water birds (Ciconiiformes, Pelecaniformes) from Florida

Sera from 360 ciconiform and pelecaniform birds collected in Florida (USA) from 1974 to 1990 were tested for serum neutralizing (SN) antibodies to eastern equine encephalitis (EEE), St. Louis encephalitis (SLE), and Everglades (EVE) viruses. Serum neutralizing antibodies to EEE virus were detected in 2%, to SLE virus in 7%, and to EVE virus in none of the samples. Pelecaniform birds (16%) had a higher antibody prevalence (P < 0.02) for SLE virus than did ciconiform birds (5%). Virus could not be isolated from 67 samples. Nestling birds with SN antibodies to both EEE and SLE viruses were found in both fresh water and marine colonies. Antibodies were more prevalent in adult and fledged juvenile birds than in nestlings.

Serologic surveillance for the Lyme disease spirochete, Borrelia burgdorferi, in Minnesota by using white-tailed deer as sentinel animals

To determine the effectiveness of white-tailed deer as sentinel animals in serologic surveillance programs for Borrelia burgdorferi, we performed enzyme-linked immunosorbent assay (ELISA) and Western immunoblotting analyses on 467 deer serum samples. The seropositivity rate in the ELISA was 5% for the 150 samples collected at the three sites in which the tick Ixodes scapularis was absent. The three sites with established I. scapularis populations had a seropositivity rate of 80% for 317 samples. Results were similar for two closely situated sites, one with an established I. scapularis population and one without; these sites were only 15 km apart. Rates of seropositivity were significantly higher in yearling and adult deer than in fawns. The mean numbers of bands seen on Western immunoblots were 3.0 for samples negative in the ELISA and 13.8 for samples positive in the ELISA; all of these samples were collected from sites in which I. scapularis was established. At sites in which I. scapularis was absent, the mean numbers of bands seen were 1.6 for samples negative in the ELISA and 8.2 for samples positive in the ELISA. There were 14 different B. burgdorferi antigens that reacted with more than 50% of the ELISA-positive samples from areas with I. scapularis. A 19.5-kDa antigen reacted with 94% of the ELISA-positive samples. Reactivity against OspA and OspB was weak a infrequent (2%). Serologic analysis of white-tailed deer sera appears to be an accurate and sensitive surveillance method for determining whether B. burgdorferi is present in specific geographic locations.

Experimental infection of the eastern chipmunk (Tamias striatus) with the Lyme disease spirochete (Borrelia burgdorferi)

Lyme disease, caused by the spirochete Borrelia burgdorferi, is endemic in the northeast, north-central, and Pacific coastal states of the United States. The eastern chipmunk (Tamias striatus) is found throughout the disease-enzootic regions except along the Pacific coast, and may serve as an important reservoir host in some locations. To characterize their potential as a host, 11 adult chipmunks were inoculated with 10(5) spirochetes from strains of B. burgdorferi isolated from Peromyscus leucopus and Ixodes scapularis in a hyperendemic area of Westchester County, New York (USA). All inoculated chipmunks became infected. Spirochetemias were detected by isolating spirochetes in Barbour-Stoenner-Kelly media in eight of eight chipmunks, and lasted for 2 to 5 days. Spirochetes were isolated from the ears of all animals, starting at 1 wk and for < or = 4 mo, and from various internal organs at 133 days post-inoculation. Laboratory-reared larval I. scapularis ticks became infected with spirochetes after feeding on two of the inoculated chipmunks.

Isolation and characterization of Borrelia burgdorferi from blood of a bird captured in the Saint Croix River Valley

Field investigations were conducted to further evaluate the role of birds in the maintenance and dissemination of Borrelia burgdorferi. Blood specimens were taken from 39 passerine birds of 17 species captured during June 1991 at the Saint Croix National Riverway in Wisconsin, and one isolate, WI91-23, was cultured from an adult song sparrow (Melospiza melodia). This isolate was shown to be infectious for Peromyscus leucopus and Mesocricetus auratus (golden hamster). Isolate WI91-23 was confirmed as B. burgdorferi by immunofluorescence assay by using species-specific anti-OspA monoclonal antibodies H3TS and H5332 and anti-OspB antibody H5TS. Isolate WI91-23 was compared with Borrelia anserina Es, Borrelia hermsii MAN-1, and other B. burgdorferi strains (ATCC 53210, CT-1, and Catharus fuscescens [veery] liver 10293). Pulsed-field gel electrophoresis of in situ-lysed spirochetes revealed that the DNA plasmid profile of WI91-23 was most similar to those of plasmids from B. burgdorferi and most different from those of plasmids from B. anserina and B. hermsii. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis indicated that the protein profile of WI91-23 was like that of other B. burgdorferi strains studied, with dominant proteins corresponding to OspA and OspB, and that it differed from the protein profiles of B. anserina and B. hermsii. These findings indicate that passerine birds may serve as reservoirs for B. burgdorferi.

Avian hosts of St. Louis encephalitis virus in Pine Bluff, Arkansas, 1991

An investigation of the extent of St. Louis encephalitis (SLE) virus activity in the avian population in Pine Bluff, Arkansas was conducted from August 30, 1991 through September 5, 1991, following an SLE epidemic that resulted in 25 human cases. A total of 363 birds of 33 species were captured with ground-level mist nets at four sites along the northern edge of the city. No viruses were isolated from the serum of these birds, but 91 birds (25%) of 11 species had detectable neutralizing antibody against the TBH-28 strain of SLE virus in the constant-virus, serum-dilution, plaque-reduction neutralization test in Vero cell culture. No antibody to eastern equine encephalitis virus was detected. The prevalence of antibody to SLE virus varied among the sites from 11% to 44%, but the prevalence at each site was influenced by the avian species composition. The two most abundant species captured in the city, the American robin (43%) and house sparrow (42%), also had the highest prevalence of antibody. Nine other bird species were serologically positive but at significantly lower rates than for the abundant species. The antibody prevalence was higher in immature birds (27%) than in adult birds (15%), but the antibody titers were higher in adult birds than in immature ones. The overall SLE antibody prevalence and the prevalence for house sparrows were significantly higher than the average prevalence for avian hosts studied during previous SLE epidemics. Therefore, house sparrows would be a good choice for a local sentinel species.

Serologic analysis of white-tailed deer sera for antibodies to Borrelia burgdorferi by enzyme-linked immunosorbent assay and western immunoblotting

White-tailed deer serum samples were collected in the Minneapolis-St. Paul, Minn., metropolitan area during the fall and winter months from 1989 to 1992 and analyzed for antibodies to Borrelia burgdorferi, the etiologic agent of Lyme borreliosis. Ninety-eight percent of the serum samples were collected from regions where currently the vector tick, Ixodes dammini, is nonexistent. Antibodies to B. burgdorferi were detected in 2.2% of 508 samples by enzyme-linked immunosorbent assay, and their presence was confirmed by Western immunoblot analysis. Western immunoblotting yielded mean numbers of reactive bands of 0.1 and 6.0 for samples that were negative and positive for antibodies by enzyme-linked immunosorbent assay, respectively. The molecular weights of the antigens in many of the reactive bands from positive samples were similar to the molecular weights of antigens reactive with samples from humans with Lyme borreliosis. An antibody response to the major outer surface proteins A and B was not detected. Serologic analysis of deer sera may provide a valuable method for surveillance programs designed to monitor the spread of B. burgdorferi in nature.

Ecology of porcupines (Erethizon dorsatum) and Colorado tick fever virus in Rocky Mountain National Park, 1975-1977

The involvement of porcupines, Erethizon dorsatum (L.), in the ecology of Colorado tick fever (CTF) virus in Rocky Mountain National Park was investigated from 1975 to 1977. Porcupine dens and feeding activity were found mostly on rocky knolls or on south-facing slopes within open stands of the montane coniferous forest, and 20 adult porcupines were trapped or captured by hand at those locations. An average of 24.6 +/- 5.4 adult Dermacentor andersoni Stiles ticks were found per animal (annual range, 17.5-31.4 ticks). The minimum CTF virus infection rate of the ticks removed from porcupines varied from 129 to 257, whereas for questing adult D. andersoni ticks from the same geographic area was 205 in 1976. No virus was isolated from the 20 animals, but 85% had neutralizing antibody against CTF virus. Porcupines utilize the same habitats described for the CTF ecosystem in Rocky Mountain National Park and appear to be an important host for adult D. andersoni.

Susceptibility parameters of Aedes albopictus to per oral infection with eastern equine encephalitis virus

Aedes albopictus (Skuse) mosquitoes were fed on snowy egrets, Egretta thula (Thayer and Bangs), that had been infected by subcutaneous inoculation of eastern equine encephalitis (EEE) virus. Freshly fed mosquitoes were frozen and tested to determine how much virus they had ingested. Other fed mosquitoes from the same lots were incubated for 7 d at 27 degrees C before testing. Seven lots of Ae. albopictus fed on viremic birds. Based on average amounts of virus ingested and day 7 virus infection rates in mosquitoes from the same lots, the amount of virus required to infect 50% of the mosquitoes was calculated to be 10(2.8) Vero cell plaque-forming units (PFU). The infection threshold (i.e., the amount of virus required to infect from 1 to 5% of mosquitoes) was determined to be < or = 10 PFU per blood meal. These parameters indicate that Ae. albopictus is sufficiently susceptible to infection with EEE virus to enable it to acquire infectious doses from a wide variety of viremic birds and possibly from equines.

Oral colon transit scintigraphy using indium-111 DTPA: variability in healthy subjects

Oral colon transit scintigraphy using indium-111 diethylene-triamine-pentaacetic acid was performed in 41 healthy subjects (22 females, 19 males) to determine variability with age and sex and to define normal ranges. Repeat studies were performed in 10 females and 9 males to assess intra-subject variability. Females showed slightly but significantly slower colonic transit than men and slightly greater intra-subject variability. There was no correlation between age and colonic transit. The results have implications for the definition of normal ranges.

Experimental inoculation of three arboviruses in black-bellied whistling ducks (Dendrocygna autumnalis)

Wild-caught, immature black-bellied whistling ducks (Dendrocygna autumnalis) were inoculated with eastern equine encephalitis (EEE), St. Louis encephalitis (SLE), or western equine encephalitis (WEE) virus. Susceptibility, duration and titer of viremia, and antibody response to these arboviruses were determined. Birds from all inoculated groups became viremic. Higher virus titers occurred in the EEE group but overall mean titers were not significantly different among experimental groups. All birds inoculated with EEE and SLE viruses developed antibodies, and six of seven ducks receiving WEE virus were seropositive. All seropositive ducks had antibodies for at least 59 days, when the study was terminated. The EEE group had significantly more seropositive ducks during more days than the WEE and SLE groups. Geometric mean antibody titers were significantly smaller in the WEE group when compared to the EEE and SLE groups. Control ducks did not develop viremia or antibodies. Gross and histopathologic lesions compatible with viral encephalitis were absent in all of nine ducks necropsied. Black-bellied whistling ducks can develop low and short-term levels of viremia sufficient to infect mosquitoes, but probably cannot contribute significantly to the transmission of EEE and SLE. They may serve as good indicators of virus activity.

Serologic survey for selected arboviruses and other potential pathogens in wildlife from Mexico

During 1988 and 1989, a serologic survey of wildlife was conducted in northeastern Mexico to determine the presence, prevalence, and distribution of arboviruses and other selected disease agents. Eighty mammal specimens were tested. Antibodies to vesicular stomatitis-Indiana, Venezuelan equine encephalitis-Mena II, Rio Grande virus, and vesicular stomatitis-New Jersey were detected predominantly in small mammals. Deer and mouflon (Ovis musimon) had antibodies to bluetongue and epizootic hemorrhagic disease. Two species had serologic evidence of recent exposure to Francisella tularensis. A white-tailed deer (Odocoileus virginianus) had antibodies to Anaplasma marginale. All specimens tested for antibodies against Yersinia pestis and Brucella abortus were negative. Sera from 315 birds were tested for antibody against five equine encephalitis viruses and six avian pathogens. During 1988, antibodies to Venezuelan equine encephalitis-Mena II, Venezuelan equine encephalitis-TC83, St. Louis encephalitis, eastern equine encephalitis, and western equine encephalitis were detected in birds of several species. Antibodies to Pasteurella multocida and Newcastle disease virus were also detected. Birds from five species presented antibodies to Mycoplasma meleagridis. Specimens tested for M. gallisepticum, M. synoviae, and Chlamydia psittaci were negative. To the best of our knowledge, this survey represents the first serologic evidence of bluetongue, Cache Valley virus, epizootic hemorrhagic disease, Jamestown Canyon virus, vesicular stomatitis-Indiana, vesicular stomatitis-New Jersey, Rio Grande virus, and tularemia reported among wildlife in Mexico.

Borrelia burgdorferi infection in white-footed mice (Peromyscus leucopus) in hemlock (Tsuga canadensis) habitat in western Pennsylvania

White-footed mice (Peromyscus leucopus) were captured and their tissues sampled from 27 sites in seven counties of western Pennsylvania in 1990 for isolation and identification of Borrelia burgdorferi. Two hundred sixty mice were captured from which there were 27 isolations. Significantly more mice were captured and significantly more isolations made from hemlock (Tsuga canadensis) habitat than from deciduous species forest. Hemlock habitat is sparse and focal but evidently increases winter survival of mice, and thus possibly results in increased infection rates in mice.

Cloacal flora isolated from wild black-bellied whistling ducks (Dendrocygna autumnalis) in Laguna La Nacha, Mexico

Cloacal swabs from 110 adult black-bellied whistling ducks trapped at Laguna La Nacha, Tamaulipas, Mexico, were cultured to determine the prevalence of normal and potentially pathogenic bacteria. Twenty-five gram-negative enterobacteria and four gram-positive cocci were isolated. The most common isolates included Escherichia coli (54%), Staphylococcus spp. (29%), Streptococcus spp. (22%), Aeromonas hydrophila (15%) Enterobacter cloacae (14%), and Micrococcus sp. (14%). The implications of whistling ducks as possible reservoirs of pathogenic bacteria are discussed.

Comparison of oral iodine-131-cellulose and indium-111-DTPA as tracers for colon transit scintigraphy: analysis by colon activity profiles

In 11 normal subjects and 11 patients with a clinical diagnosis of constipation, oral 131I-cellulose and 111In-DTPA were compared simultaneously as tracers for radionuclide colon transit scintigraphy. Visual assessment of the images revealed no differences between tracers. Quantitation was performed using total and segmental percent retention and the derived value of clearance half-time. In addition, profiles of the activity distribution along the length of the colon were generated and the mean position of the activity in the colon calculated. For all indices, the results were similar in both normal subjects and constipated patients when comparing tracers, although marked differences were present between normal subjects and constipated patients for each tracer. Indium-111-DTPA was easy to administer and dosimetry was more acceptable than for 131I-cellulose, especially in constipated patients. It is concluded that 111In-DTPA is the preferred tracer for oral colon transit scintigraphy.

Isolation of Tete serogroup bunyaviruses from Ceratopogonidae collected in Colorado

Two viruses were isolated from ceratopogonid midges collected in northern Colorado. Electron microscopy indicated that both isolates were bunyavirus-like. Indirect fluorescent antibody and serum dilution-plaque reduction neutralization tests showed that these isolates were members of the Tete serogroup, most closely related antigenically to Tete and Batama viruses but distinguishable from both and from each other. We suggest the name Weldona virus for these isolates. Antibody in both waterfowl and passerine birds in northern Colorado indicates the enzootic presence of these viruses in northern Colorado and raises unanswered questions about the introduction and establishment of Tete serogroup viruses in the Americas.

Colon transit scintigraphy in health and constipation using oral iodine-131-cellulose

The purpose of the study was to assess if a new scintigraphic method for noninvasive assessment of colonic transit could differentiate between subjects with normal bowel transit and those with constipation. Eleven normal subjects and 29 constipated patients were given 4 MBq iodine-131-cellulose (131I-cellulose) orally and sequential abdominal scans were performed at 6, 24, 48, 72, and 96 hr from which total and segmental percent retentions were calculated. There were clear differences between the normal subjects and the constipated patients for the total percent retention at all time intervals, on a segmental basis in the right colon at 24 hr, and in all segments at 48 and 72 hr. Three-day urinary excretion of radioiodine was minimal; 2.4% +/- 1.2% (mean +/- s.d.) in constipated patients and 3.1% +/- 0.8% in normals, with approximately 75% occurring in the first day. The use of oral radiotracers in the investigation of constipation appears promising.

Western equine encephalitis in avian populations in North Dakota, 1975

The involvement of wild birds in western equine encephalitis (WEE) and St. Louis encephalitis (SLE) virus activity in the Red River valley area of North Dakota (USA) during a WEE epidemic was investigated in August 1975. Free-ranging birds were captured with mist nets and nestlings by hand. Virologic and serologic results indicated that a similar rate of WEE virus activity occurred throughout Richland County and between permanent and summer resident birds. The rate of SLE virus activity in the birds of Richland County was lower than for WEE virus, but the SLE antibody prevalence was greater in rural areas than within urban locations. Seven of the nine WEE virus isolations were from nestling birds of four different species; the remaining two from adults of two different species. Overall prevalence of neutralizing (N) antibody against WEE virus was 5% in nestling and 14% in adult birds but was the opposite for N antibody against SLE virus, 17% in nestling and 5% in adult birds. Differences between the two viruses in the presence and persistence of maternal N antibody or differential mortality in nestling birds may have caused the disparity in antibody prevalences.

Characterization of five new phleboviruses recently isolated from sand flies in tropical America

Five new phlebotomus fever virus serotypes (Bunyaviridae: Phlebovirus) are described. These viruses, designated Ambe, Ixcanal, Mariquita, Armero, and Durania, were isolated from sand flies (Diptera: Psychodidae) collected in Brazil, Colombia, and Guatemala. Two of the agents were recovered from pools of male sand flies. The new viruses are antigenically related to other members of the phlebotomus fever serogroup by immunofluorescence, but are distinct from the other 39 members of this serogroup by plaque reduction neutralization test.

Co-circulation of multiple Colorado tick fever virus genotypes

Colorado tick fever (CTF) virus, family Reoviridae, genus Orbivirus, contains 12 genes distinguishable by polyacrylamide gel electrophoresis (PAGE). Multiple genotypes of CTF virus were isolated at 3 field sites in Colorado in 1985. Five genotypes were found at Campos Cabin, 2 at Drake, and 6 at Rocky Mountain National Park. Virus isolations were made in 1985 from 6 patients with CTF. These isolates were distinct from each other and the field isolates. Although the CTF isolates were different by PAGE profile, the majority of the 12 genes were highly conserved among the 1985 isolates and a Florio isolate (FMA). Only genes 4 and 6 were variant among the 1985 CTF isolates and FMA, and no unique genes were identified. In 1986, a follow-up field survey was done at the Campos Cabin site. Of the 3 CTF PAGE genotypes obtained, 2 exhibited PAGE profiles which were different from the 1985 isolates. One isolate may have resulted from the reassortment of genes from 2 of the isolates circulating at Campos Cabin in 1985.

The ecology of Colorado tick fever in Rocky Mountain National Park in 1974. III. Habitats supporting the virus

Ecologic studies of small mammals in Rocky Mountain National Park (RMNP) were conducted in 1974 in order to identify the specific habitats within the Lower Montane Forest that support Colorado tick fever (CTF) virus. Data was collected on the abundance and distribution of 4 primary rodent species, tick infestation, CTF virus, and neutralizing antibody prevalence. Rodents were captured along transects crossing different habitats. Open stands of ponderosa pine and shrubs on dry, rocky surfaces were found to be important for maintaining CTF virus.

A plague epizootic in the white-tailed prairie dogs (Cynomys leucurus) of Meeteetse, Wyoming

Surveillance for sylvatic plague (Yersinia pestis) was conducted near Meeteetse, Wyoming (USA) from 24 May to 14 June 1985. Ten species of fleas were collected from white-tailed prairie dogs (Cynomys leucurus), and from their burrows and associated rodents. Five of these flea species and two adult prairie dogs were positive for plague. The progression of this plague epizootic appeared to be slower and the intensity was less than in previous epizootics in other prairie dog colonies. The plague epizootic occurred within the only known colony of black-footed ferrets (Mustela nigripes) and was a potential threat to the food source of this endangered species.

Isolation of Cache Valley virus and detection of antibody for selected arboviruses in Michigan horses in 1980

Blood samples collected in September and November 1980 from 87 horses in southwestern Michigan were examined for virus isolation and for plaque-reduction neutralizing antibody against selected arboviruses. Cache Valley virus was isolated from the blood of a clinically normal horse in St Joseph County in September. The age-specific antibody prevalence for Cache Valley virus indicated enzootic transmission in the study area. The high antibody prevalence and the lack of age-specific antibody prevalence indicated sporadic, but intense, exposure to Jamestown Canyon virus. Low prevalences of antibody were detected for Highlands J, snowshoe hare, St Louis encephalitis, and trivittatus viruses.

Epizootic vesicular stomatitis in Colorado, 1982: some observations on the possible role of wildlife populations in an enzootic maintenance cycle

Sera obtained from wild ungulates, carnivores, and rodents in Colorado were tested for neutralizing (N) antibody against vesicular stomatitis, New Jersey serotype (VSNJ), virus to determine their involvement in the 1982 Colorado VSNJ epizootic in domestic animals. Viremic and N antibody responses of two local rodent species to a 1982 Colorado isolate of VSNJ were determined in the laboratory. The rodents produced only weak viremias, but all developed N antibody. N antibody prevalences for VSNJ in sera from wild ungulates was sufficiently high to indicate their involvement during the epizootic. In addition, the demonstration of N antibody in elk (Cervus elaphus) and mule deer (Odocoileus hemionus) prior to the epizootic in cattle and horses suggests that an enzootic cycle may exist in Colorado.

Viremic enhancement due to transovarially acquired antibodies to St. Louis encephalitis virus in birds

Adult house sparrows (Passer domesticus) were captured and experimentally inoculated with St. Louis encephalitis (SLE) virus to produce high concentrations of circulating antiviral antibody. Nestlings, 5-7 and 14-16 days of age, from SLE immune adult females and challenged with SLE virus, exhibited viremic enhancement by producing viremias of greater duration and magnitude than did controls. Nestlings possessing maternal antibody and challenged with SLE virus between 8 and 13 days of age did not produce viremias differing significantly from controls in magnitude, duration, or temporal appearance. Experimental nestling sparrows possessed detectable amounts of maternally derived passive antibody to SLE virus prior to challenge with this virus. Passive geometric mean antibody titers ranged from a high of 1:34.5 in nestlings tested 5-7 days posthatching, to a low of 1:11.2 in 14-16-day-old birds. Results presented imply that enhancement of SLE virus infections could lead to increased viral amplification and dissemination rates during natural disease cycles.

Prognostic value of axillary lymphoscintigraphy in breast carcinoma patients

Axillary lymphoscintigraphy (AxLS) with bilateral interdigital injection of [99mTc]antimony sulfide colloid carried out concurrently with internal mammary lymphoscintigraphy in 488 patients with breast carcinoma was evaluated. Patterns of radiocolloid distribution within the ipsilateral axilla and supraclavicular fossa were compared with similar features on the contralateral side to determine whether image characteristics are significantly disrupted by prior surgery, reflect the presence of metastases, and can predict treatment failure. Interpretive criteria for AxLS were refined after correlation of the identified image components with clinical parameters including axillary surgery, lymph node histology and relapse within a follow-up period of 2 years from the study. Results indicate that AxLS is at least as accurate as clinical assessment and provides data predictive of relapse to complement axillary lymph node status although the technique cannot presently replace lymph node sampling for patient staging.

Distribution of Bunyamwera serogroup viruses in North America, 1956-1984

We attempted to tabulate all Bunyamwera serogroup (family Bunyaviridae, genus Bunyavirus) isolates from North America. By summarizing information from the laboratories of the Centers for Disease Control, data generously shared by other laboratories, and the published literature, we were able to accumulate data regarding 1,372 Bunyamwera serogroup viruses. These were: Tensaw (664, including 8 from vertebrates), Cache Valley (396, including 6 from vertebrates), Main Drain (160, including 14 from vertebrates), Lokern (69, including 8 from vertebrates), Northway (13, including 5 from vertebrates), Tlacotalpan (7), Santa Rosa (2), Santa Cruz (1 from a horse), and 60 of undetermined serotype. Virus isolation rates by month of collection were correlated with collection efforts, but associations of viruses and arthropod vectors varied by location, vertebrate host, and arthropod distribution. Tensaw virus was isolated principally from Anopheles crucians mosquitoes (466/656 isolates from arthropods) in the southeastern United States; Cache Valley virus principally from An. quadrimaculatus (94), Coquillettidia perturbans (59), Culiseta inornata (45), Aedes sollicitans (30), Psorophora columbiae (23), An. punctipennis (18), and Ae. vexans and trivittatus (18 each) mosquitoes (total = 305/382 isolates from arthropods from all of the United States and Canada, except the southeastern United States); Main Drain virus from Culicoides variipennis (31), Culicoides (Selfia) sp. (65), and Psorophora (23) and Aedes (21) species mosquitoes in the western United States; Lokern virus from Culicoides species (55/61 isolates from arthropods) in the western United States. Relationships between vector and vertebrate host distributions are discussed briefly in regard to geographic distribution of the Bunyamwera serogroup viruses.

Late cardiac, thyroid, and pulmonary sequelae of mantle radiotherapy for Hodgkin's disease

Cardiac, thyroid and pulmonary function were evaluated in 25 patients aged 35 years or under, treated for Hodgkin's disease by mantle radiotherapy 5-16 years previously. No patient had symptoms of heart disease. Although thallium myocardial perfusion scintigraphy was normal in all patients, abnormalities of myocardial function were detected in 6 (24%) patients using gated equilibrium rest and exercise radionuclide ventriculography. Resting left ventricular ejection fraction (LVEF) was abnormal in 1 patient, and in 3 patients there was an abnormal LVEF response to exercise. All 6 patients had right ventricular dilatation. Apical hypokinesia was present in 4 of these patients. A small asymptomatic pericardial effusion was detected by M-Mode echocardiography in only 2 (8%) patients. Twenty-three (92%) patients had evidence of abnormal thyroid function. Two (8%) patients had become clinically hypothyroid. Serum TSH was elevated in 13 (52%) patients and TRH stimulation test was abnormal in a further 10 (40%) patients in whom TSH was normal. Pulmonary function studies showed a moderate decrease in diffusing capacity (72% of predicted) and a minor reduction in lung volume. Although a high incidence of cardiac, thyroid and pulmonary abnormalities was detected, only the 2 patients who had become hypothyroid were symptomatic. Modification of the irradiation technique may reduce the incidence of cardiac abnormalities, but is unlikely to alter significantly the thyroid or pulmonary sequelae.