Clinical, Demographic, and Oral Presentations of COVID-19 Associated Mucormycosis from a Tertiary Care Hospital in India: A Cross-Sectional Study

Background

The black fungus, mucormycosis, is on the list of lethal complications reported in recent times in COVID patients.

Methodology

This cross-sectional study included all cases of post-COVID-19 mucormycosis. Patients' demographics, clinical presentations, and general health information were collected using a pre-designed form.

Results

The study included 171 participants with the mean (SD) age as 49 (10) years with the sex distribution as 71% (122/171) male and 29% (49/122) females. About half of the admitted patients (47%) were known cases of Diabetes Mellitus type II with a median (IQR) Glycosylated Haemoglobin (HbA1c) of 9.1% (7-11.1%). Only 28% (48/171) had received the first COVID vaccination, and 2.9% (5/171) were fully vaccinated with two doses. During COVID-19, 76% (130/171) required hospitalisation for a mean (SD) stay of 11 (6.4) days. Eighty percent of the patients (136/171) received steroids during therapy, while 87% (150/171) and 51% (88/171) received antibiotics and antivirals, respectively. Oxygen was administered to 71% of hospitalised patients (120/171), with 39.1% (47/120) receiving it for more than 7 days. About the development of the first symptoms of mucormycosis (headache, nasal congestion, black crusts in the nose, facial pain, swelling in cheeks and eyes, and loss of vision) after being diagnosed with COVID-19, 16% (28/171) reported it within 7 days, 75% (127/171) between 8 and 30th days and 9% (16/171) after a month. On examination, 20% of mucor patients had hard palate findings, eschars, fistulas, and perforations, 38% had periodontal abscesses, and 5% reported tenderness to percussion.

Conclusion

Generally, oral manifestations involved the palate and included varying degrees of mucosal discolouration, swelling, ulcers, superficial necrotic areas, and bone exposure and necrosis with dark eschars.

Burden of Childhood Injuries in India and Possible Public Health Interventions: A Systematic Review

Childhood injuries are a major public health challenge in India and globally. This systematic review was conducted to understand the burden and spectrum of childhood injuries, with a focus on unintentional injuries, among children 5-14 years of age and to suggest approaches to prevention that can be adopted in the Indian context. This systematic review was conducted with the standard approach and use of keywords. A total of 33 studies which were found to be relevant were analyzed. Road traffic accidents (RTAs) contribute to nearly 85% of all unintentional injuries and related deaths and 90% of disability-adjusted life years (DALYs) lost in developing countries. Poor traffic regulation, heavy traffic load, and poor skill of identifying the dangerous road crossing sites make the children's age group vulnerable and prone to RTA. Children with poor skill of identification and response to dangerous road crossing sites, along with heavy unregulated traffic were found to be the major reasons for such accidents and make this age group more vulnerable. Public health-based prevention approaches need to be based upon legislation, regulation, and enforcement, as well as environmental modification, education and skill development, emergency medical care using levels of prevention, and principles of targeted prevention to effectively address child health challenges. Addressing child injuries should be a key component of all endeavors aimed at enhancing child mortality and morbidity rates, as well as the overall welfare of children, both at the national and global levels. It is imperative to prioritize policies focused on preventing unintentional injuries across all age groups, with particular attention to children.

Undiagnosed hypertension and associated factors among adults in the urban field practice area of AIIMS Raipur: A community-based screening survey

Introduction

Undiagnosed hypertension (HTN) increases the risk of severe consequences such as chronic kidney disease (CKD), hypertensive retinopathy, heart failure, and stroke. Population-based screening can be used to expose the hidden diseased mass with active disease. Thus, a screening survey was conducted to estimate the proportion of people with HTN among apparently healthy adults of age ≥30 years residing at the urban field practice area (UHTC) of AIIMS, Raipur, and also determine the predictors of undiagnosed HTN among the study participants.

Methodology

This was a community-based cross-sectional study conducted over 2 months duration in the Ramnagar area, which comes under the urban field practice area of AIIMS Raipur using the STEPS tool is an acronym of study tool provided by WHO i.e. STEPwise approach to NCD risk factor surveillance consisting of three steps viz. questionnaire for behavioural risk factors, physical measurements and biochemical measurements.

Results

In this study, 24.2% (95%, confidence interval [CI]: 20.1-28.2) of participants screened positive for HTN. The proportion of males who screened positive for HTN was 28.8% (95% CI: 22.6-35), whereas the proportion of females who screened positive for HTN was 19.6% (95% CI: 14.3-25). In this study, elderly (>60 years), male gender, daily tobacco use, greater waist circumference (male >90 cm and female >80 cm), and daily salt intake of more than 5 g were found to have higher odds of having HTN.

Conclusion

The prevalence of undiagnosed HTN in the UHTC of AIIMS Raipur was quite high.

Predictors of Out-of-Pocket Expenditure on Health Incurred by Elderly Persons Residing in a Rural Area of Faridabad District

BACKGROUND

A significant portion of India's 1.2 billion population consists of elderly individuals, accounting for approximately 8.6%, who incur substantial out-of-pocket (OOP) healthcare expenses. Any policy for the elderly should encompass financial protection from illness-related expenditures. However, the lack of comprehensive information on OOP expenditure and its determinants precludes such action.

METHODS

We conducted a cross-sectional study of 400 elderly persons residing in the rural town of Ballabgarh. The participants were randomly selected using the health demographic surveillance system. We utilized questionnaires and tools to assess the costs associated with outpatient and inpatient services in the previous year, as well as gather information on socio-demographics (individual characteristics), morbidity (motivation for seeking care), and social engagement (health-seeking).

RESULTS

A total of 396 elderly persons participated, with a mean (SD) age of 69.4 (6.7), and 59.4% females. Nearly 96% and 50% of the elderly availed of outpatient and inpatient services, respectively, in the preceding year. The mean (IQR) annual OOP expenditure, as per the consumer price index 2021, was INR 12,543 (IQR, INR 8,288-16,787), with a median of INR 2,860 (IQR, INR 1,458-7,233), explained significantly by sex, morbidity status, social engagement, and mental health.

CONCLUSION

In low-middle-income countries like India, policymakers may consider pre-payment mechanisms like health insurance for the elderly, using such prediction scores.

Viral Hepatitis as a Public Health Concern: A Narrative Review About the Current Scenario and the Way Forward

Viral hepatitis is one of the emerging public health problems, which urgently needs special attention. The disease has a varied presentation at the time of diagnosis, and it can progress from an accidental finding to life-threatening conditions like liver cirrhosis. It belongs to the rare group of diseases that can cause chronic inflammation inside the body, and it can have a delayed presentation. It contributes substantially to the global burden on healthcare. In terms of mortality, the burden due to viral hepatitis is similar to that of HIV and tuberculosis. It is among the major global public health challenges along with other communicable diseases, such as HIV, malaria, and tuberculosis; the major difference is that there are very limited preventive models in place for viral hepatitis, especially in developing countries like India. With limited resources for diagnosis and treatment, varied levels of presentation, and a rapidly increasing burden, it can become the next silent pandemic. In the current review, the authors aimed to compile the available global strategies for combating hepatitis, protocols available for disease surveillance, and the salient points from the national program for hepatitis control in India [National Viral Hepatitis Control Program (NVHCP)], and propose some recommendations. Ensuring a health facility equipped with a rapid diagnostic kit for screening, proper lab for the confirmation, robust Health Management Information System (HMIS) portal for the data management, and organizing regular workshops for physicians and lab technicians are some of the recommendations that we put forward.

COVID-19 reinfection: Linked Possibilities and future outlook

SARS-CoV-2 is the third major coronavirus epidemic to affect humans. There had been multiple instances of patients turning positive after recovering from SARS-2-CoV infection. Though many different theories emerge, false positive RT-PCR is logically the foremost cause and there is a general consensus that during quarantine re-infection from outside seems unlikely when strictly adhered to. As many new strains emerge worldwide during the course of on-going pandemic, the chances of re-infection cannot be ignored as it may contribute to false negative RT-PCR test results. SARS-2-CoV though a novel virus, is phylogenetically similar to SARS-like CoV with around 79% similarity. Studies on immunological response to these infections suggest that antibodies formed after infection confers immunity only for a short period of time before it starts to wane. Also studies on SARS-CoV-2 suggest that antibody formation and longevity of immunity in an individual is dependent on the strain of coronavirus, its severity and age of the person infected. All these considerations demand reviewing the treatment duration, discharge criteria, appropriate use of imaging techniques and importance of risk communication and health education to those recovered.

Tribal population in India: A public health challenge and road to future

India with 8.6% of tribal population is finding it difficult to bridge the gap that exists between tribal and non-tribal population in regards to healthcare. Tribal population suffers triple burden of disease; in fact it is quadruple, namely, communicable diseases, non-communicable diseases, malnutrition, mental health, and addictions complicated by poor health seeking behavior. With increasing needs, an Expert committee on Tribal health has given recommendations with the goal to bridge the current gap in the health status of tribal people latest by the year 2027. An entirely parallel health system has been proposed with key focus areas, governance, and financing. To summarize and report the present scenario in terms of disease burden, health-seeking behavior, healthcare delivery system, and a roadmap for the future along the importance of primary healthcare in achieving it. Mere establishment of more health facilities cannot overcome the poor health of tribal population and so the role of trained manpower to deliver quality healthcare, in which case the role of traditional healers, local Tribal boys and girls comes in handy. It is high time and states should act swiftly to assess the needs, priorities of their own tribal population and set goals, targets to achieve the same through proven public health strategies.

Vaccination coverage and vaccine hesitancy among vulnerable population of India

Vaccination coverage in India has improved from 44% to 62%, an increase of 19% over a span of 10 y (2006-2016), the inequity continues among the vulnerable people belonging to tribal groups and migrant population. In order to leave no one behind strategy, their vaccination coverage, reasons for low coverage were analyzed from available literary sources through this review article. A systematic search for relevant articles was conducted and articles published in various journals over the past 5 y were included. The vaccine coverage among the vulnerable population ranged from 31% to 89% from various studies. It was found that parents' education status, income of the family and lack of awareness of the schedule were the most important reasons for vaccine hesitancy. Introduction of cash assistance integrated into other national program, digitalizing vaccination cards, involvement of local healers are few strategies suggested in this article.

Immune status with empyema thoracis

OBJECTIVE

To evaluate the humoral and cell mediated immune status of children with empyema thoracis.

METHODS

Serum IgG, IgA, IgM, Complement C3 assay and cell mediated immunity (CMI) tests were performed in 33 patients of empyema thoracis, and 14 healthy age matched controls.

RESULTS

The mean serum IgG and IgA levels in empyema thoracis and its subgroups were significantly raised as compared to controls. The overall values of IgG and IgA were 104% (p<0.001) and 114% (p<0.01) of normal mean, respectively. The mean serum IgM and complement C3 levels did not differ significantly in both the groups. The frequency of negative skin reaction to purified protein derivative (PPD) was significantly higher in children with empyema thoracis as compared to controls (p<0.05). The mean absolute lymphocyte count (ALC) was significantly decreased and serum adenosine deaminase (ADA) activity was significantly raised in empyema thoracis in comparison to controls. The overall ALC was 76.1% (p<0.01) and serum ADA activity was 169.4% (p<0.001) of normal mean, respectively. No significant differences were observed in the mean levels of immunoglobulins, complement C3 and CMI tests between pyothorax and pyopneumothorax and pleural fluid culture positive and negative cases.

CONCLUSIONS

Thus, both humoral and cell mediated immunity were affected in empyema thoracis patients. However, CMI demonstrated more pronounced change in comparison to humoral immunity.

Dynamic copy choice: steady state between murine leukemia virus polymerase and polymerase-dependent RNase H activity determines frequency of in vivo template switching

We recently proposed a dynamic copy-choice model for retroviral recombination in which a steady state between the rates of polymerization and RNA degradation determines the frequency of reverse transcriptase (RT) template switching. The relative contributions of polymerase-dependent and polymerase-independent RNase H activities during reverse transcription and template switching in vivo have not been determined. We developed an in vivo trans-complementation assay in which direct repeat deletion through template switching reconstitutes a functional green fluorescent protein gene in a retroviral vector. Complementation in trans between murine leukemia virus Gag-Pol proteins lacking polymerase and RNase H activities restored viral replication. Because only polymerase-independent RNase H activity is present in this cell line, the relative roles of polymerase-dependent and -independent RNase H activities in template switching could be determined. We also analyzed double mutants possessing polymerase and RNase H mutations that increased and decreased template switching, respectively. The double mutants exhibited low template switching frequency, indicating that the RNase H mutations were dominant. Trans-complementation of the double mutants with polymerase-independent RNase H did not restore the high template switching frequency, indicating that polymerase-dependent RNase H activity was essential for the increased frequency of template switching. Additionally, trans-complementation of RNase H mutants in the presence and absence of hydroxyurea, which slows the rate of reverse transcription, showed that hydroxyurea increased template switching only when polymerase-dependent RNase H activity was present. This is, to our knowledge, the first demonstration of polymerase-dependent RNase H activity in vivo. These results provide strong evidence for a dynamic association between the rates of DNA polymerization and polymerase-dependent RNase H activity, which determines the frequency of in vivo template switching.

Design of retroviral vectors and helper cells for gene therapy

During the past decade, gene therapy has been applied to the treatment of disease in hundreds of clinical trials. Various tools have been developed to deliver genes into human cells; among them, genetically engineered retroviruses are currently the most popular tool for gene delivery. Most of the systems contain vectors that are capable of accommodating genes of interest and helper cells that can provide the viral structural proteins and enzymes to allow for the generation of vector-containing infectious viral particles. Retroviridae is a family of retroviruses that differs in nucleotide and amino acid sequence, genome structure, pathogenicity, and host range. This diversity provides opportunities to use viruses with different biological characteristics to develop different therapeutic applications. Currently, a variety of retroviruses that provide distinct advantages for gene delivery has been modified and used in clinical trials. In this review, the genome structures of oncoviruses, lentiviruses, and spumaviruses are reviewed and examples of vectors derived from these viruses are described. As with any delivery tool, the efficiency, the ability to target certain tissue or cell type, the expression of the gene of interest, and the safety of retroviral-based systems are important for successful application of gene therapy. Significant efforts have been dedicated to these areas of research in recent years. Various modifications have been made to retroviral-based vectors and helper cells to alter gene expression, target delivery, improve viral titers, and increase safety. The principles and design of these modifications are discussed in this review.

Role of murine leukemia virus reverse transcriptase deoxyribonucleoside triphosphate-binding site in retroviral replication and in vivo fidelity

Retroviral populations exhibit a high evolutionary potential, giving rise to extensive genetic variation. Error-prone DNA synthesis catalyzed by reverse transcriptase (RT) generates variation in retroviral populations. Structural features within RTs are likely to contribute to the high rate of errors that occur during reverse transcription. We sought to determine whether amino acids within murine leukemia virus (MLV) RT that contact the deoxyribonucleoside triphosphate (dNTP) substrate are important for in vivo fidelity of reverse transcription. We utilized the previously described ANGIE P encapsidating cell line, which expresses the amphotropic MLV envelope and a retroviral vector (pGA-1). pGA-1 expresses the bacterial beta-galactosidase gene (lacZ), which serves as a reporter of mutations. Extensive mutagenesis was performed on residues likely to interact with the dNTP substrate, and the effects of these mutations on the fidelity of reverse transcription were determined. As expected, most substitution mutations of amino acids that directly interact with the dNTP substrate significantly reduced viral titers (>10,000-fold), indicating that these residues played a critical role in catalysis and viral replication. However, the D153A and A154S substitutions, which are predicted to affect the interactions with the triphosphate, resulted in statistically significant increases in the mutation rate. In addition, the conservative substitution F155W, which may affect interactions with the base and the ribose, increased the mutation rate 2.8-fold. Substitutions of residues in the vicinity of the dNTP-binding site also resulted in statistically significant decreases in fidelity (1. 3- to 2.4-fold). These results suggest that mutations of residues that contact the substrate dNTP can affect viral replication as well as alter the fidelity of reverse transcription.

Utilization of nonviral sequences for minus-strand DNA transfer and gene reconstitution during retroviral replication

Minus-strand DNA transfer, an essential step in retroviral reverse transcription, is mediated by the two repeat (R) regions in the viral genome. It is unclear whether R simply serves as a homologous sequence to mediate the strand transfer or contains specific sequences to promote strand transfer. To test the hypothesis that the molecular mechanism by which R mediates strand transfer is based on homology rather than specific sequences, we examined whether nonviral sequences can be used to facilitate minus-strand DNA transfer. The green fluorescent protein (GFP) gene was divided into GF and FP fragments, containing the 5' and 3' portions of GFP, respectively, with an overlapping F fragment (85 bp). FP and GF were inserted into the 5' and 3' long terminal repeats, respectively, of a murine leukemia virus-based vector. Utilization of the F fragment to mediate minus-strand DNA transfer should reconstitute GFP during reverse transcription. Flow cytometry analyses demonstrated that GFP was expressed in 73 to 92% of the infected cells, depending on the structure of the viral construct. This indicated that GFP was reconstituted at a high frequency; molecular characterization further confirmed the accurate reconstitution of GFP. These data indicated that nonviral sequences could be used to efficiently mediate minus-strand DNA transfer. Therefore, placement and homology, not specific sequence context, are the important elements in R for minus-strand DNA transfer. In addition, these experiments demonstrate that minus-strand DNA transfer can be used to efficiently reconstitute genes for gene therapy applications.

Structural determinants of murine leukemia virus reverse transcriptase that affect the frequency of template switching

Retroviral reverse transcriptases (RTs) frequently switch templates within the same RNA or between copackaged viral RNAs to generate mutations and recombination. To identify structural elements of murine leukemia virus RT important for template switching, we developed an in vivo assay in which RT template switching within direct repeats functionally reconstituted the green fluorescent protein gene. We quantified the effect of mutations in the YXDD motif, the deoxynucleoside triphosphate binding site, the thumb domain, and the RNase H domain of RT and hydroxyurea treatment on the frequencies of template switching. Hydroxyurea treatment and some mutations in RT increased the frequency of RT template switching up to fivefold, while all of the mutations tested in the RNase H domain decreased the frequency of template switching by twofold. Based on these results, we propose a dynamic copy choice model in which both the rate of DNA polymerization and the rate of RNA degradation influence the frequency of RT template switching.

Effect of the murine leukemia virus extended packaging signal on the rates and locations of retroviral recombination

Reverse transcriptase (RT) switches templates frequently during DNA synthesis; the acceptor template can be the same RNA (intramolecular) or the copackaged RNA (intermolecular). Previous results indicated that intramolecular template switching occurred far more frequently than intermolecular template switching. We hypothesized that intermolecular template-switching events (recombination) occurred at a lower efficiency because the copackaged RNA was not accessible to the RT. To test our hypothesis, the murine leukemia virus (MLV) extended packaging signal (Psi(+)) containing a dimer linkage structure (DLS) was relocated from the 5' untranslated region (UTR) to between selectable markers, allowing the two viral RNAs to interact closely in this region. It was found that the overall maximum recombination rates of vectors with Psi(+) in the 5' UTR or Psi(+) between selectable markers were not drastically different. However, vectors with Psi(+) located between selectable markers reached a plateau of recombination rate at a shorter distance. This suggested a limited enhancement of recombination by Psi(+). The locations of the recombination events were also examined by using restriction enzyme markers. Recombination occurred in all four regions between the selectable markers; the region containing 5' Psi(+) including DLS did not undergo more recombination than expected from the size of the region. These experiments indicated that although the accessibility of the copackaged RNA was important in recombination, other factors existed to limit the number of viruses that were capable of undergoing intermolecular template switching. In addition, recombinants with multiple template switches were observed at a frequency much higher than expected, indicating the presence of high negative interference in the MLV-based system. This extends our observation with the spleen necrosis virus system and suggests that high negative interference may be a common phenomenon in retroviral recombination.

Wild-type and YMDD mutant murine leukemia virus reverse transcriptases are resistant to 2',3'-dideoxy-3'-thiacytidine

The antiretroviral nucleoside analog 2',3'-dideoxy-3'-thiacytidine (3TC) is a potent inhibitor of wild-type human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT). A methionine-to-valine or methionine-to-isoleucine substitution at residue 184 in the HIV-1 YMDD motif, which is located at the RT active site, leads to a high level of resistance to 3TC. We sought to determine whether 3TC can inhibit the replication of wild-type murine leukemia virus (MLV), which contains V223 at the YVDD active site motif of the MLV RT, and of the V223M, V223I, V223A, and V223S mutant RTs. Surprisingly, the wild type and all four of the V223 mutants of MLV RT were highly resistant to 3TC. These results indicate that determinants outside the YVDD motif of MLV RT confer a high level of resistance to 3TC. Therefore, structural differences among similar RTs might result in widely divergent sensitivities to antiretroviral nucleoside analogs.

Development of an in vivo assay to identify structural determinants in murine leukemia virus reverse transcriptase important for fidelity

Error-prone DNA synthesis by retroviral reverse transcriptases (RTs) is a major contributor to variation in retroviral populations. Structural features of retroviral RTs that are important for accuracy of DNA synthesis in vivo are not known. To identify structural elements of murine leukemia virus (MLV) RT important for fidelity in vivo, we developed a D17-based encapsidating cell line (ANGIE P) which is designed to express the amphotropic MLV envelope. ANGIE P also contains an MLV-based retroviral vector (GA-1) which encodes a wild-type bacterial beta-galactosidase gene (lacZ) and a neomycin phosphotransferase gene. Transfection of ANGIE P cells with wild-type or mutated MLV gag-pol expression constructs generated GA-1 virus that was able to undergo only one cycle of viral replication upon infection of D17 cells. The infected D17 cell clones were characterized by staining with 5-bromo-4-chloro-3-indolyl-beta-D-galactopyranoside (X-Gal), and the frequencies of inactivating mutations in lacZ were quantified. Three mutations in the YVDD motif (V223M, V223S, and V223A) and two mutations in the RNase H domain (S526A and R657S) exhibited frequencies of lacZ inactivation 1.2- to 2.3-fold higher than that for the wild-type MLV RT (P < 0.005). Two mutations (V223I and Y598V) did not affect the frequency of lacZ inactivation. These results establish a sensitive in vivo assay for identification of structural determinants important for accuracy of DNA synthesis and indicate that several structural determinants may have an effect on the in vivo fidelity of MLV RT.

Development of murine leukemia virus-based self-activating vectors that efficiently delete the selectable drug resistance gene during reverse transcription

Expression of the selectable drug resistance gene in retroviral vectors used for gene therapy can lead to a decreased expression of the gene of interest and may induce a host immune response, resulting in a decreased efficiency of gene therapy. In this study, we demonstrate that high-frequency deletion of direct repeats, an inherent property of reverse transcriptases, can be used to efficiently excise the drug resistance gene during reverse transcription. One retroviral vector containing a direct repeat deleted the neomycin resistance expression cassette during a single replication cycle at >99% efficiency.

Effect of distance between homologous sequences and 3' homology on the frequency of retroviral reverse transcriptase template switching

Deletion of direct repeats in retroviral genomes provides an in vivo system for analysis of reverse transcriptase (RT) template switching. The effect of distance between direct repeats on the rate of deletion was determined for 16 murine leukemia virus (MLV)-based vectors containing a 701-bp direct repeat of overlapping fragments of the herpes simplex virus thymidine kinase gene (HTK). The direct repeats were separated by spacer fragments of various lengths (0.1 to 3.5 kb). Southern analysis of infected cells after one replication cycle indicated that all vectors in which the distance between homologous sequences was >1,500 bp deleted at very high rates (>90%). In contrast, vectors containing <1,500 bp between homologous sequences exhibited lower frequencies of deletion (37 to 82%). To analyze the pattern of locations at which RT switched templates, restriction site markers were introduced to divide the downstream direct repeat into five regions. RT switched templates within all five regions of the 701-bp direct repeat and the frequency of template switching was greater within the 5' regions in comparison to the 3' regions. The probability of RT switching templates within the 5' regions doubled when the MLV packaging sequence (Psi) was placed between the 701-bp direct repeats. However, Psi did not increase the rate of template switching for shorter direct repeats. These results indicate that linear distance between homologous sequences increases the rate of template switching and suggest that duplex formation between nascent DNA and homologous template sequences 3' of RT promote template switching.

Deoxyribonucleoside triphosphate pool imbalances in vivo are associated with an increased retroviral mutation rate

Deoxyribonucleoside triphosphate (dNTP) pool imbalances are associated with an increase in the rate of misincorporation and hypermutation during in vitro reverse transcription reactions. However, the effects of in vivo dNTP pool imbalances on the accuracy of reverse transcription are unknown. We sought to determine the effects of in vivo dNTP pool imbalances on retroviral mutation rates and to test our hypothesis that 3'-azido-3'-deoxythymidine (AZT) increases the retroviral mutation rates through induction of dNTP pool imbalances. D17 cells were treated with thymidine, hydroxyurea (HU), or AZT, and the effects on in vivo dNTP pools were measured. Thymidine and HU treatments induced significant dNTP pool imbalances. In contrast, AZT treatment had very little effect on the dNTP pools. The effects of in vivo dNTP pool imbalances induced by thymidine and HU treatments on the retroviral mutation rates were also determined. Spleen necrosis virus (SNV)-based and murine leukemia virus (MLV)-based retroviral vectors that expressed the lacZ mutant reporter gene were used. The frequencies of inactivating mutations introduced in the lacZ gene in a single replication cycle provided a measure of the retroviral mutation rates. Treatment of D17 target cells with 500 microM thymidine increased the SNV and MLV mutant frequencies 4.7- and 4-fold, respectively. Treatment of D17 target cells with 2 mM HU increased the SNV and MLV mutant frequencies 2.1- and 2.7-fold, respectively. These results demonstrate that dNTP pool imbalances are associated with an increase in the in vivo retroviral mutation rates, but AZT treatment results in an increase in the retroviral mutation rates by a mechanism not involving alterations in dNTP pools.

Relative rates of retroviral reverse transcriptase template switching during RNA- and DNA-dependent DNA synthesis

Retroviral reverse transcriptases (RTs) frequently switch templates during DNA synthesis, which can result in mutations and recombination. The relative rates of in vivo RT template switching during RNA- and DNA-dependent DNA synthesis are unknown. To determine the relative rates of RT template switching during copying of RNA and DNA templates, we constructed spleen necrosis virus-based retroviral vectors containing a 400-bp direct repeat. The directly repeated sequences were upstream of the polypurine tract (PPT) in the RB-LLP vector; the same direct repeats flanked the PPT and attachment site (att) in the RB-LPL vector. RT template switching events could occur during either RNA- or DNA-dependent DNA synthesis and delete one copy of the direct repeat plus the intervening sequences. RB-LLP vectors that underwent direct repeat deletions during RNA- and DNA-dependent DNA synthesis generated viral DNA that could integrate into the host genome. However, any deletion of the direct repeats in the RB-LPL vector that occurred during RNA-dependent DNA synthesis resulted in deletion of the essential PPT and att site and generated a dead-end viral DNA product. Thus, only RB-LPL vectors that underwent direct repeat deletions during DNA-dependent DNA synthesis could integrate to form proviruses. The RB-LLP and RB-LPL vectors were permitted to undergo a single replication cycle, and the frequencies of direct repeat deletions were determined by PCR and Southern analysis of the resulting proviruses. A comparison of the frequency of direct repeat deletions in the RB-LLP and RB-LPL vectors indicated that the in vivo rates of RT template switching during RNA- and DNA-dependent DNA synthesis are nearly identical.

Homologous recombination occurs in a distinct retroviral subpopulation and exhibits high negative interference

Homologous recombination and deletions occur during retroviral replication when reverse transcriptase switches templates. While recombination occurs solely by intermolecular template switching (between copackaged RNAs), deletions can occur by an intermolecular or an intramolecular template switch (within the same RNA). To directly compare the rates of intramolecular and intermolecular template switching, two spleen necrosis virus-based vectors were constructed. Each vector contained a 110-bp direct repeat that was previously shown to delete at a high rate. The 110-bp direct repeat was flanked by two different sets of restriction site markers. These vectors were used to form heterozygotic virions containing RNAs of each parental vector, from which recombinant viruses were generated. By analyses of the markers flanking the direct repeats in recombinant and nonrecombinant proviruses, the rates of intramolecular and intermolecular template switching were determined. The results of these analyses indicate that intramolecular template switching is much more efficient than intermolecular template switching and that direct repeat deletions occur primarily through intramolecular template switching events. These studies also indicate that retroviral recombination occurs within a distinct viral subpopulation and exhibits high negative interference, whereby the selection of one recombination event increases the probability that a second recombination event will be observed.

Psi- vectors: murine leukemia virus-based self-inactivating and self-activating retroviral vectors

We have developed murine leukemia virus (MLV)-based self-inactivating and self-activating vectors to show that the previously demonstrated high-frequency direct repeat deletions are not unique to spleen necrosis virus (SNV) or the neomycin drug resistance gene. Retroviral vectors pKD-HTTK and pKD-HTpTK containing direct repeats composed of segments of the herpes simplex virus type 1 thymidine kinase (HTK) gene were constructed; in pKD-HTpTK, the direct repeat flanked the MLV packaging signal. The generation of hypoxanthine-aminopterin-thymidine-resistant colonies after one cycle of retroviral replication demonstrated functional reconstitution of the HTK gene. Quantitative Southern analysis indicated that direct repeat deletions occurred in 57 and 91% of the KD-HTTK and KD-HTpTK proviruses, respectively. These results demonstrate that (i) deletion of direct repeats occurs at similar high frequencies in SNV and MLV vectors, (ii) MLV psi can be efficiently deleted by using direct repeats, (iii) suicide genes can be functionally reconstituted during reverse transcription, and (iv) the psi region may be a hot spot for reverse transcriptase template switching events.

The antiretrovirus drug 3'-azido-3'-deoxythymidine increases the retrovirus mutation rate

It was previously observed that the nucleoside analog 5-azacytidine increased the spleen necrosis virus (SNV) mutation rate 13-fold in one cycle of retrovirus replication (V. K. Pathak and H. M. Temin, J. Virol. 66:3093-3100, 1992). Based on this observation, we hypothesized that nucleoside analogs used as antiviral drugs may also increase retrovirus mutation rates. We sought to determine if 3'-azido-3'-deoxythymidine (AZT), the primary treatment for human immunodeficiency virus type 1 (HIV-1) infection, increases the retrovirus mutation rate. Two assays were used to determine the effects of AZT on retrovirus mutation rates. The strategy of the first assay involved measuring the in vivo rate of inactivation of the lacZ gene in one replication cycle of SNV- and murine leukemia virus-based retroviral vectors. We observed 7- and 10-fold increases in the SNV mutant frequency following treatment of target cells with 0.1 and 0.5 microM AZT, respectively. The murine leukemia virus mutant frequency increased two- and threefold following treatment of target cells with 0.5 and 1.0 microM AZT, respectively. The second assay used an SNV-based shuttle vector containing the lacZ alpha gene. Proviruses were recovered as plasmids in Escherichia coli, and the rate of inactivation of lacZ alpha was measured. The results indicated that treatment of target cells increased the overall mutation rate two- to threefold. DNA sequence analysis of mutant proviruses indicated that AZT increased both the deletion and substitution rates. These results suggest that AZT treatment of HIV-1 infection may increase the degree of viral variation and alter virus evolution or pathogenesis.

Utilization of nonhomologous minus-strand DNA transfer to generate recombinant retroviruses

During reverse transcription, minus-strand DNA transfer connects the sequences located at the two ends of the viral RNA to generate a long terminal repeat. It is thought that the homology in the repeat (R) regions located at the two ends of the viral RNA sequences facilitate minus-strand DNA transfer. In this report, the effects of diminished R-region homology on DNA synthesis and virus titer were examined. A retrovirus vector, PY31, was constructed to contain the 5' and 3' cis-acting elements from Moloney murine sarcoma virus and spleen necrosis virus. These two viruses are genetically distinct, and the two R regions contain little homology. In one round of replication, the PY31 titer was approximately 3,000-fold lower than that of a control vector with highly homologous R regions. The molecular characteristics of the junctions of minus-strand DNA transfer were analyzed in both unintegrated DNA and integrated proviruses. Short stretches of homology were found at the transfer junctions and were likely to be used to facilitate minus-strand DNA transfer. Both minus-strand strong-stop DNA and weak-stop DNA were observed to mediate strand transfer. The ability of PY31 to complete reverse transcription indicates that minus-strand DNA transfer can be used to join sequences from two different viruses to form recombinant viruses. These results suggest the provocative possibility that genetically distinct viruses can interact through this mechanism.

Retroviral mutation rates and A-to-G hypermutations during different stages of retroviral replication

Retroviruses mutate at a high rate in vivo during viral replication. Mutations may occur during proviral transcription by RNA polymerase II, during minus-strand DNA synthesis (RNA template) by viral reverse transcriptase, or during plus-strand DNA synthesis (DNA template) by reverse transcriptase. To determine the contributions of different stages of replication to the retroviral mutation rates, we developed a spleen necrosis virus-based in vivo system to selectively identify mutations occurring during the early stage (RNA transcription plus minus-strand synthesis) and the late stage (plus-strand synthesis plus DNA repair). A lacZalpha reporter gene was inserted into the long terminal repeat (LTR) of a spleen necrosis virus shuttle vector, and proviruses were recovered from infected cells as plasmids containing either one or both LTRs. Plasmids containing both LTRs generated a mutant phenotype only if the lacZalpha genes in both LTRs were mutated, which is most likely to occur during the early stage. Mutant phenotypes were identified from plasmids containing one LTR regardless of the stage at which the mutations occurred. Thus, mutant frequencies obtained after recovery of plasmids containing both LTRs or one LTR provided early-stage and total mutation rates, respectively. Analysis of 56,409 proviruses suggested that the retroviral mutation rates during the early and late stages of replication were equal or within twofold of each other. In addition, two mutants with A-to-G hypermutations were discovered, suggesting a role for mammalian double-stranded RNA adenosine deaminase enzyme in retroviral mutations. These experiments provide a system to selectively identify mutations in the early stage of retroviral replication and to provide upper and lower limits to the in vivo mutation rates during minus-strand and plus-strand synthesis, respectively.

Efficient initiation and strand transfer of polypurine tract-primed plus-strand DNA prevent strand transfer of internally initiated plus-strand DNA

A critical step in retroviral reverse transcription is the initiation of plus-strand DNA synthesis at the polypurine tract (PPT) and strand transfer of the PPT-primed strong-stop DNA to the 5' end of the viral DNA. An attachment site (att) immediately 3' to the PPT is essential for proper integration of proviral DNA into the host chromosome. Plus-strand DNA synthesis is discontinuous in many retroviruses, indicating that sequences upstream of the PPT are also used to initiate plus-strand DNA synthesis (internally initiated DNA). Strand transfer of internally initiated DNA would result in "dead" viral DNA that lacks the att site needed for integration. Strand transfer of the internally initiated DNA could occur if DNA synthesis failed to initiate at the PPT or if the PPT-primed DNA was displaced before strand transfer. We sought to determine the efficiency of DNA synthesis initiating at the PPT and the proportions of PPT-primed DNA and internally initiated DNAs that are utilized for strand transfer. We constructed spleen necrosis virus-based retroviral vectors containing an internal PPT and an att site 5' of the normal PPT and att site. After one replication cycle of the retroviral vectors, the structures of the resulting proviruses were determined by Southern blotting. The analysis suggested that the PPT is an efficient and rapid initiator of plus-strand DNA synthesis and that internally initiated DNAs are rarely utilized for strand transfer. We hypothesize that efficient synthesis and strand transfer of PPT-primed DNA evolved to prevent lethal strand transfers of internally initiated DNAs.

E- vectors: development of novel self-inactivating and self-activating retroviral vectors for safer gene therapy

We have developed novel self-inactivating and self-activating retroviral vectors based on the previously observed high-frequency deletion of direct repeats. We constructed spleen necrosis virus (SNV)-based viral vectors that contained large direct repeats flanking the viral encapsidation sequence (E). A large proportion of the proviruses in the target cells had E and one copy of the direct repeat deleted. Direct repeats of 1,333 and 788 bp were deleted at frequencies of 93 and 85%, respectively. To achieve a 100% deletion efficiency in target cells after ex vivo infection and drug selection, we constructed a self-activating vector that simultaneously deleted E and reconstituted the neomycin phosphotransferase gene. Selection of the target cells for resistance to G418 (a neomycin analog) ensured that all integrated proviruses had E deleted. The proviruses with E deleted were mobilized by a replication-competent virus 267,000-fold less efficiently than proviruses with E. We named these self-inactivating vectors E- (E-minus) vectors. These vectors should increase the safety of retroviral vector-mediated gene therapy by preventing the spread of vector sequences to nontarget cells in the event of coinfection with helper virus. We propose that direct-repeat deletions occur during RNA-dependent DNA synthesis and suggest that template switches occur without a requirement for RNA breaks. The minimum template dissociation frequency was estimated as 8%/100 bp per replication cycle. These vectors demonstrate that large direct repeats and template-switching properties of reverse transcriptase can be utilized to delete any sequence or reconstitute genes during retroviral replication.

5-Azacytidine and RNA secondary structure increase the retrovirus mutation rate

A broad spectrum of mutations occurs at a high rate during a single round of retrovirus replication (V.K. Pathak and H. M. Temin, Proc. Natl. Acad. Sci. USA 87:6019-6023, 1990). We have now determined that this high rate of spontaneous mutation can be further increased by 5-azacytidine (AZC) treatment or by regions of potential RNA secondary structure. We found a 13-fold increase in the mutation rate after AZC treatment of retrovirus-producing cells and target cells. The AZC-induced substitutions were located at the same target sites as previously identified spontaneous substitutions. The concordance of the AZC-induced and spontaneous substitutions indicates the presence of reverse transcription "pause sites," where the growing point is error prone. An analysis of nucleotides that neighbored substitutions revealed that transversions occur primarily by transient template misalignment, whereas transitions occur primarily by misincorporation. We also introduced a 34-bp potential stem-loop structure as an in-frame insertion within a lacZ alpha gene that was inserted in the long terminal repeat (LTR) U3 region and determined whether this potential secondary structure increased the rate of retrovirus mutations. We found a threefold increase in the retrovirus mutation rate. Fifty-seven of 96 mutations were deletions associated with the potential stem-loop. We also determined that these deletion mutations occurred primarily during minus-strand DNA synthesis by comparing the frequencies of mutations in recovered provirus plasmids containing both LTRs and in provirus plasmids containing only one LTR.

Broad spectrum of in vivo forward mutations, hypermutations, and mutational hotspots in a retroviral shuttle vector after a single replication cycle: deletions and deletions with insertions

In the preceding paper we described an experiment that determined the in vivo forward mutation rate in a single replication cycle for spleen necrosis virus. In addition to substitutions, frameshifts, and hypermutations, the mutated proviruses contained two classes of deletions. One class of deletions contained short direct repeats at the deletion junctions. Another class of deletions had short stretches of sequences inserted at the deletion junctions. In this report, we describe the deletion mutations, and we present models for their generation. Detailed analysis of two deletions with insertions indicates that these mutations occurred as a result of template switching during plus-strand DNA synthesis. The analysis also indicates that fragments of viral RNA generated by the viral RNase H endonuclease are used as templates and contribute to the sequences inserted at the deletion junctions.

Broad spectrum of in vivo forward mutations, hypermutations, and mutational hotspots in a retroviral shuttle vector after a single replication cycle: substitutions, frameshifts, and hypermutations

We determined the in vivo forward mutation rate in a single replication cycle for spleen necrosis virus (SNV). A method was developed to clone integrated proviruses of retroviral shuttle vectors by exploiting the tight binding of the lac operator to the lac repressor protein. The vectors contained the lacZ alpha gene as a reporter of mutations. Thirty-seven of the 16,867 proviruses recovered contained five classes of mutations, including substitutions and frameshifts. Runs of 9 and 10 identical base pairs and a direct repeat of 110 base pairs were mutational hotspots. In addition, two copies of a provirus contained 15 G-to-A substitutions. Such proviruses, which we name hypermutants, may arise through the action of an error-prone polymerase and could significantly contribute to the genetic variation in retroviral populations.

Effect of corticosteroids on carbohydrate metabolism in Bufo melanostictus (Schneider)

A single injection of corticosterone (1 or 5 micrograms/50 g body weight) produced a significant elevation in plasma glucose, liver and muscle glycogen contents of B. melanostictus. Single but identical doses of aldosterone had no effect on plasma glucose concentration. Liver and muscle glycogen contents were however significantly augmented. Administration of 1 or 5 micrograms corticosterone and 1 microgram or 200 ng aldosterone/50 g body weight, for 15 days, caused no change in plasma glucose concentration. In all the groups receiving corticosterone or aldosterone for 15 days, liver and muscle glycogen contents significantly increased. The magnitude of increase in liver and muscle glycogen by aldosterone was marginally greater than that by corticosterone. The results suggest that both the corticosteroids may be gluconeogenic in B. melanostictus.

Iopanoic acid prevents spring premigratory increase in body weight of redheaded bunting Emberiza bruniceps

Effects of long term administration of iopanoic acid (IOP), a potent inhibitor of peripheral conversion of thyroxine (T4) into triiodothyronine (T3), on body weight and gonad development in intact and in thyroidectomized (Thx) redheaded bunting that received replacement therapy with T4 were studied. IOP prevented the premigratory increase in body weight observed in intact bunting (during March/April). In contrast to the Thx birds receiving T4 only, IOP administration in combination with T4 caused a significant decrease in body weight of Thx birds. The gonad development in intact and Thx birds that received IOP was significantly inhibited. Results suggest that IOP through an effective inhibition of peripheral T4-monodeiodination may prevent the spring premigratory fattening. Emphasis is given for an important role of T3 in the physiological preparations associated with migration.

The phosphorylation state of eucaryotic initiation factor 2 alters translational efficiency of specific mRNAs

Phosphorylation of the alpha subunit of the eucaryotic translation initiation factor (eIF-2 alpha) by the double-stranded RNA-activated inhibitor (DAI) kinase correlates with inhibition of translation initiation. The importance of eIF-2 alpha phosphorylation in regulating translation was studied by expression of specific mutants of eIF-2 alpha in COS-1 cells. DNA transfection of certain plasmids could activate DAI kinase and result in poor translation of plasmid-derived mRNAs. In these cases, translation of the plasmid-derived mRNAs was improved by the presence of DAI kinase inhibitors or by the presence of a nonphosphorylatable mutant (serine to alanine) of eIF-2 alpha. The improved translation mediated by expression of the nonphosphorylatable eIF-2 alpha mutant was specific to plasmid-derived mRNA and did not affect global mRNA translation. Expression of a serine-to-aspartic acid mutant eIF-2 alpha, created to mimic the phosphorylated serine, inhibited translation of the mRNAs derived from the transfected plasmid. These results substantiate the hypothesis that DAI kinase activation reduces translation initiation through phosphorylation of eIF-2 alpha and reinforce the importance of phosphorylation of eIF-2 alpha as a way to control initiation of translation in intact cells.

Structure of the beta subunit of translational initiation factor eIF-2

A human liver cDNA encoding the beta subunit of protein synthesis initiation factor 2 (eIF-2) was isolated and sequenced. The 1416 bp cDNA encodes a protein of 333 amino acids (38,404 daltons) with characteristics that resemble authentic purified eIF-2 beta. De novo synthesized eIF-2 beta from cDNA transcripts incorporates into endogenous rabbit eIF-2 complexes. The protein possesses putative GTP-binding sites, a zinc finger motif, and a highly charged N-terminal region composed of three basic polylysine blocks separated by acidic domains. The polylysine blocks and the zinc finger motif suggest that eIF-2 beta interacts with RNA. A yeast protein, Sui3, isolated as an extragenic suppressor of his4 initiation codon mutations, exhibits extensive sequence identity with human eIF-2 beta, especially in the polylysine and zinc finger domains, thereby reinforcing the view that these elements are important for function.

Generation of a mutant form of protein synthesis initiation factor eIF-2 lacking the site of phosphorylation by eIF-2 kinases

The phosphorylation of the alpha-subunit of initiation factor eIF-2 leads to an inhibition of protein synthesis in mammalian cells. We have performed site-directed mutagenesis on a cDNA encoding the alpha-subunit of human eIF-2 and have replaced the candidate sites of phosphorylation, Ser-48 and Ser-51, with alanines. The cDNAs were expressed in vitro by SP6 polymerase transcription and rabbit reticulocyte lysate translation, and the radiolabeled protein products were analyzed by high-resolution two-dimensional gel electrophoresis. The wild-type and Ser-48 mutant proteins became extensively phosphorylated by eIF-2 kinases present in the reticulocyte lysate, and when additional heme-controlled repressor or double-stranded RNA-activated kinase was present, phosphorylation of the proteins was enhanced. The Ser-51 mutant showed little covalent modification by the endogenous enzymes and showed no increase in the acidic variant with additional eIF-2 kinases, thereby suggesting that Ser-51 is the site of phosphorylation leading to repression of protein synthesis.

Survey of int region DNA rearrangements in C3H and BALB/cfC3H mouse mammary tumor system

Rearrangement of the int-1 and int-2 regions of mouse chromosomes was compared in the C3H and BALB/cfC3H hyperplastic alveolar nodule and its hyperplastic outgrowth (HPO) model systems by examining the DNA of the different stages of the neoplastic progression, with use of the Southern blot technique. Rearrangement of int region DNAs associated with proviral amplification occurred more frequently in spontaneous tumors (19 of 27) than in tumors from HPOs (7 of 37) and rarely occurred in HPOs (1 of 29). However, the int-1 rearrangement maintained in 1 BALB/cfC3H HPO line through 11 transplant generations suggests that the int-1 rearrangement is neither sufficient nor necessary for progression to mouse mammary carcinoma.

Variations in circulating thyroxine and triiodothyronine concentration in relation to spring migration in rosy pastor, Sturnus roseus

In rosy pastor, Sturnus roseus, the spring premigratory fattening observed during April was preceded by a significant increase in circulating thyroxine (T4) and triiodothyronine (T3) concentrations. Plasma T4 and T3 both declined significantly by May when in nature the migrating conspecifics had departed for their breeding ground. A possible role of thyroid hormones in the migratory disposition of this bird is, therefore, suggested.

Sensitive radiochemical assay for inosine 5'-monophosphate dehydrogenase and determination of activity in murine tumor and tissue extracts

Crude tissue or tumor extracts either do not contain sufficient inosine 5'-monophosphate dehydrogenase (IMPD) activity to be measured spectrophotometrically, or interfering enzyme activities prevent the use of a more sensitive radiochemical assay. A modified assay system which incorporates alpha, beta-methylene adenosine 5'-diphosphate, an inhibitor of 5'-nucleotidase; allopurinol, an inhibitor of xanthine oxidase; and ethylenediaminetetraacetate, an inhibitor of alkaline phosphatase, has been developed. [14C]Xanthine monophosphate produced during the assay was separated from [14C]hypoxanthine monophosphate by thin-layer chromatography on flexible diethylaminoethyl-cellulose sheets. Xanthine monophosphate formation was linear for at least 40 min and was inhibited by greater than 95% in the presence of mycophenolic acid, a specific IMPD inhibitor. Partial purified IMPD from murine EMT6 tumors was used to compare assay rates obtained with the radiochemical and spectrophotometric assays under identical conditions. The reaction rate of the radiochemical assay was 0.92 +/- 0.07 (S.E.) of the rate of xanthine monophosphate formation as determined spectrophotometrically at 290 nm, indicating that both assays are measuring product formation with an equal degree of accuracy. The improved radiochemical assay was used to determine IMPD specific activity in supernatants from EMT6 tumors and several normal mouse tissues. The observed activities (nmol/min/mg protein) were: EMT6 tumor, 0.303; spleen, 0.029; brain, 0.022; kidney, 0.015; lung, 0.009; liver, 0.008; and heart and skeletal muscle, less than 0.004.