Comparison of replicating and nonreplicating vaccines against SARS-CoV-2

Most gene-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines are nonreplicating vectors. They deliver the gene or messenger RNA to the cell to express the spike protein but do not replicate to amplify antigen production. This study tested the utility of replication in a vaccine by comparing replication-defective adenovirus (RD-Ad) and replicating single-cycle adenovirus (SC-Ad) vaccines that express the SARS-CoV-2 spike protein. SC-Ad produced 100 times more spike protein than RD-Ad and generated significantly higher antibodies against the spike protein than RD-Ad after single immunization of Ad-permissive hamsters. SC-Ad-generated antibodies climbed over 14 weeks after single immunization and persisted for more than 10 months. When the hamsters were challenged 10.5 months after single immunization, a single intranasal or intramuscular immunization with SC-Ad-Spike reduced SARS-CoV-2 viral loads and damage in the lungs and preserved body weight better than vaccination with RD-Ad-Spike. This demonstrates the utility of harnessing replication in vaccines to amplify protection against infectious diseases.

Unlocking loxP to Track Genome Editing In Vivo

The development of CRISPR-associated proteins, such as Cas9, has led to increased accessibility and ease of use in genome editing. However, additional tools are needed to quantify and identify successful genome editing events in living animals. We developed a method to rapidly quantify and monitor gene editing activity non-invasively in living animals that also facilitates confocal microscopy and nucleotide level analyses. Here we report a new CRISPR "fingerprinting" approach to activating luciferase and fluorescent proteins in mice as a function of gene editing. This system is based on experience with our prior cre recombinase (cre)-detector system and is designed for Cas editors able to target loxP including gRNAs for SaCas9 and ErCas12a. These CRISPRs cut specifically within loxP, an approach that is a departure from previous gene editing in vivo activity detection techniques that targeted adjacent stop sequences. In this sensor paradigm, CRISPR activity was monitored non-invasively in living cre reporter mice (FVB.129S6(B6)-Gt(ROSA)26Sortm1(Luc)Kael/J and Gt(ROSA)26Sortm4(ACTB-tdTomato,-EGFP)Luo/J, which will be referred to as LSL-luciferase and mT/mG throughout the paper) after intramuscular or intravenous hydrodynamic plasmid injections, demonstrating utility in two diverse organ systems. The same genome-editing event was examined at the cellular level in specific tissues by confocal microscopy to determine the identity and frequency of successfully genome-edited cells. Further, SaCas9 induced targeted editing at efficiencies that were comparable to cre, demonstrating high effective delivery and activity in a whole animal. This work establishes genome editing tools and models to track CRISPR editing in vivo non-invasively and to fingerprint the identity of targeted cells. This approach also enables similar utility for any of the thousands of previously generated loxP animal models.

Retargeting adenoviruses for therapeutic applications and vaccines

Adenoviruses (Ads) are robust vectors for therapeutic applications and vaccines, but their use can be limited by differences in their in vitro and in vivo pharmacologies. This review emphasizes that there is not just one Ad, but a whole virome of diverse viruses that can be used as therapeutics. It discusses that true vector targeting involves not only retargeting viruses, but importantly also detargeting the viruses from off-target cells.

Comparison of Gene Delivery to the Kidney by Adenovirus, Adeno-Associated Virus, and Lentiviral Vectors After Intravenous and Direct Kidney Injections

There are many kidney diseases that might be addressed by gene therapy. However, gene delivery to kidney cells is inefficient. This is due, in part, to the fact that the kidney excludes molecules above 50 kDa and that most gene delivery vectors are megaDaltons in mass. We compared the ability of adeno-associated virus (AAV), adenovirus (Ad), and lentiviral (LV) vectors to deliver genes to renal cells. When vectors were delivered by the intravenous (IV) route in mice, weak luciferase activity was observed in the kidney with substantially more in the liver. When gene delivery was observed in the kidney, expression was primarily in the glomerulus. To avoid these limitations, vectors were injected directly into the kidney by retrograde ureteral (RU) and subcapsular (SC) injections in mice. Small AAV vectors transduced the kidney, but also leaked from the organ and mediated higher levels of transduction in off-target tissues. Comparison of AAV2, 6.2, 8, and rh10 vectors by direct kidney injection demonstrated highest delivery by AAV6.2 and 8. Larger Ad and LV vectors transduced kidney cells and mediated less off-target tissue transduction. These data demonstrate the utility of direct kidney injections to circumvent the kidney size exclusion barrier. They also identify the effects of vector size on on-target and off-target transduction. This lays the foundation for the use of different vector platforms for gene therapy of diverse kidney diseases.

Expanding the diversity of mycobacteriophages: insights into genome architecture and evolution

Mycobacteriophages are viruses that infect mycobacterial hosts such as Mycobacterium smegmatis and Mycobacterium tuberculosis. All mycobacteriophages characterized to date are dsDNA tailed phages, and have either siphoviral or myoviral morphotypes. However, their genetic diversity is considerable, and although sixty-two genomes have been sequenced and comparatively analyzed, these likely represent only a small portion of the diversity of the mycobacteriophage population at large. Here we report the isolation, sequencing and comparative genomic analysis of 18 new mycobacteriophages isolated from geographically distinct locations within the United States. Although no clear correlation between location and genome type can be discerned, these genomes expand our knowledge of mycobacteriophage diversity and enhance our understanding of the roles of mobile elements in viral evolution. Expansion of the number of mycobacteriophages grouped within Cluster A provides insights into the basis of immune specificity in these temperate phages, and we also describe a novel example of apparent immunity theft. The isolation and genomic analysis of bacteriophages by freshman college students provides an example of an authentic research experience for novice scientists.

Determination of the analgesic dose-response relationship for epidural fentanyl and sufentanil with bupivacaine 0.125% in laboring patients

STUDY OBJECTIVE

To establish the analgesic effective doses as defined as a visual analog pain scale (VAS) of at least 10 for 95% of parturients (ED95) receiving either epidural fentanyl or sufentanil with bupivacaine 0.125% for labor analgesia.

DESIGN

Double-blind, randomized controlled study.

SETTING

Two tertiary-care teaching hospitals.

PATIENTS

100 female patients, at full-term pregnancy, in active early labor (< 5 cm cervical dilation) and requesting obstetric anesthesia services for labor analgesia.

INTERVENTIONS

Patients were randomized and equally distributed to receive one of ten epidural dosing regimens of bupivacaine 0.125% alone or with either fentanyl 25, 50, 75, or 100 micrograms or sufentanil 5, 10, 15, 20, or 25 micrograms in a 10-ml bolus after a 3-ml test dose of bupivacaine 0.25%.

MEASUREMENTS AND MAIN RESULTS

VAS scores were obtained from each parturient using a 10-cm plastic VAS slide rule at times 0, 1, 5, 10, 15, 20, 25, and 30 minutes, and then again when the patient requested additional analgesia. Analgesic duration and demographic and obstetric data also were obtained. Using a log-probit dose-response analysis, analgesic success as defined as a VAS of at least 10 with each opioid dose was plotted and an ED95 value of 8 micrograms and 50 micrograms was established for sufentanil and fentanyl, respectively, in bupivacaine 0.125%. No statistical difference was detected for analgesic duration or incidence of side effects between analgesic groups.

CONCLUSIONS

Epidural analgesia with fentanyl and sufentanil in bupivacaine 0.125% behaves in a dose-response fashion allowing for the determination of equipotent dose of each.

The use of infrared ear thermometers in pediatric and family practice offices

OBJECTIVE

To describe the use of infrared (IR) ear thermometers in pediatric and family practice offices.

METHODS

The authors mailed a questionnaire to 350 randomly selected members of the American Academy of Pediatrics and to 355 randomly selected members of the American Academy of Family Physicians.

RESULTS

Of respondents in clinical practice, 78% had used IR ear thermometers at least once in the past; 65% of pediatricians and 64% of family practice physicians were current users. Seventeen percent of pediatric offices and 18% of family practice offices that had used IR ear thermometers had discontinued use, most citing inaccuracy or lack of staff trust in the device. Pediatric offices were less likely than family practice offices to use the device in well neonates and sick neonates and more likely to use it in sick children. Advantages cited included rapid readings, ease of use, and accuracy. Seventy-five percent of current users reported at least one problem, including low readings and lack of staff trust.

CONCLUSIONS

IR ear thermometers are widely used in pediatric and family practice offices. Some offices limit use of these devices to older children and adults, and most of the offices surveyed report using other devices as a check on the accuracy of IR thermometers. Statements by professional organizations that provide user guidelines and establish appropriate age cut-offs would be helpful.

Child health care in Charles County, Maryland: a needs assessment

In response to the perception of community leaders in Charles County, Maryland, that more health care services should be available for disadvantaged infants and young children in the county, an informal needs assessment was carried out. First, available public health statistical data were used to estimate the number of children under 10 years of age residing in low-income households without health insurance. Next, a household survey and a physician survey were used to determine community and professional attitudes regarding unmet child health care needs, barriers to care, and possible solutions. Survey results validate the existence of unmet health care needs of county children as well as support for a volunteer clinic to address these needs.

Cough and cold medicine use in young children: a survey of Maryland pediatricians

Among 307 Maryland pediatricians responding to a mail survey, recommendation or prescription of cough and cold medicines for children under 36 months of age was found to be related to the patient's age, as well as to the physician's year of graduation and type of practice.

Use of prescription and non-prescription drugs in pregnancy. The Baltimore-Washington Infant Study Group

We analyzed use of therapeutic drugs during pregnancy by 2752 mothers of infants without major congenital malformations. During pregnancy, 68% of the women used at least one prescription or non-prescription drug. Drug use in pregnancy was significantly more common for women who were white, older, married, better educated, of higher income and occupational status, receiving private prenatal care and not living in urban areas. Number of maternal illnesses, higher socioeconomic status, white race, multiparity and use of recreational drugs explained 26% of reported drug use. The mean number of drugs reported (1.2) underestimates total drug exposure due to exclusion of some drug categories including multivitamins and illicit drugs. Since the majority of women giving birth to normal infants report use of at least one pharmacologic agent during pregnancy, attribution of adverse outcome to drug use in an individual case is rarely justified.

Effectiveness of family notification efforts and compliance with measles post-exposure prophylaxis

Exposures to measles in medical settings have contributed to the recent resurgence of the disease in the United States. Following a measles exposure in two pediatric medical facilities serving an inner-city population, we investigated the effectiveness of a disease notification strategy and compliance of the exposed population with recommendations for post-exposure prophylaxis, two requirements of a successful intervention program. Of 106 families with children eligible for a prophylactic vaccination by standard guidelines, 64% were notified of exposure by telephone. Compliance was assessed by a brief telephone questionnaire based upon the Health Belief Model, and verified by medical records. Forty-six families were interviewed regarding their decisions to comply with the recommendations. Most (75%) families were compliant. Compliant parents perceived measles to be severe and their children to be in excellent health. In a multiple logistic regression analysis, only the perceived severity of measles significantly contributed to the model. We conclude that: infection control outreach may need to extend beyond telephone notification for an inner-city population, and that once notified, most people will comply with recommendations. The Health Belief Model explains compliance with infection control measures and may be useful in guiding public health interventions.

Tetralogy of Fallot. The spectrum of severity in a regional study, 1981-1985

The combined medical and surgical mortality rate for 125 infants with tetralogy of Fallot registered in the Baltimore-Washington Infant Study from 1981 to 1985 was 28% (mean age at follow-up for living infants, 40 months). Despite early diagnosis and successful early repair in many infants, significant risk factors for death included pulmonary atresia, major additional cardiac anomalies, major noncardiac malformations, low birth weight, and prematurity. There is a wide spectrum of severity, ranging from infants with isolated tetralogy and no risk factors who have an excellent prognosis to infants with three or more risk factors and a high probability of neonatal death. Further treatment advances will improve outcome in some, but not all, infants. A regional all-inclusive study of a specific cardiac defect can define research and treatment challenges not obvious from selected clinical series.

Iodinated radiographic contrast media: comparison of low-osmolar with conventional ionic agents [corrected]

A large number of reports on radiographic contrast media have appeared over the past year. The majority of these compared various properties of the new, nonionic low-osmolar agents with those of conventional ionic contrast media, including types and rates of adverse reactions, nephrotoxicity, anticoagulant effects, degree of subcutaneous injury resulting from extravasation, and gastrointestinal tolerance. In this review, recent developments in each of these areas are discussed. Although, in general, the newer agents are safer and better tolerated than ionic contrast media, their greatly increased cost prevents them from completely replacing these media. In this time of increasingly cost-conscious health care, even expert opinion concerning indications for nonionic low-osmolar contrast media use (also summarized here) is widely divided.

Maternal diabetes and cardiovascular malformations: predominance of double outlet right ventricle and truncus arteriosus

Most studies on the relationship of maternal diabetes to cardiovascular malformations (CVM) have been prospective investigations of pregnancy outcome and therefore could not identify associations with rare cardiac lesions. The results of a retrospective study shed new light on the risks of specific cardiac defects in diabetic pregnancies. The Baltimore-Washington Infant Study, a population-based case-control investigation of CVM, provides information on maternal diabetes reported in personal interviews. Among 2259 mothers of cases, 35 (1.5%) reported diabetes present before pregnancy (called "overt") and 95 (4.2%) reported diabetes only during pregnancy (called "gestational"). Among 2,801 mothers of controls, 14 (0.5%) had overt diabetes and 83 (3.0%) had gestational diabetes. Malformation-specific risks were expressed as odds ratios (OR) with 99.5% confidence intervals (CI). The strongest associations with overt maternal diabetes were found with double outlet right ventricle (OR 21.33; 99.5% CI 3.34, 136.26), and truncus arteriosus (OR 12.81; 99.5% CI 1.43, 114.64). No significant diagnosis-specific associations were found with gestational diabetes. Non-cardiac malformations were present in 23% of infants with CVM whose mothers had overt diabetes and in 26% of infants with CVM whose mother had gestational diabetes, in 32% of infants with CVM whose mothers did not have diabetes, and in 4% of controls. Double outlet right ventricle and truncus arteriosus are malformations dependent upon neural-crest-cell-derived ectomesenchymal tissues; these are precisely the conotruncal abnormalities that result from experimental ablation of the neural crest in chick embryos. The association with diabetes suggests a further etiologic link between these two lesions.

Health promotion beliefs and practices of fourth-year medical students

Little is known about medical student beliefs about health promotion issues or about their prevention practices with patients. We administered a questionnaire about health promotion beliefs and practices to fourth-year medical students in a required course, "Preventive Medicine in Clinical Practice," at the University of Maryland School of Medicine. During a three-year period we surveyed 343 students. A majority of students believed that most of 23 health behaviors were of some importance to health promotion, and their responses were similar to those of practicing physicians in prior studies. Most students reported that they assessed preventive practices in their patients but did not feel well prepared to counsel patients about health issues. Students reported they were currently unsuccessful in modifying patient health behaviors and expressed limited optimism about future success in helping patients change health promotion behaviors with further training and support. There were no differences between students entering primary care specialties and other students. Information about medical student health promotion and disease prevention beliefs and practices can be applied in curriculum development.

Congenital cardiovascular malformations associated with chromosome abnormalities: an epidemiologic study

The Baltimore-Washington Infant Study is a population-based case-control study that seeks to identify risk factors for cardiovascular malformations. Between 1981 and 1986, a total of 2102 infants with cardiovascular malformations were ascertained, among whom 271 (12.9%) also had a chromosome abnormality. Among 2328 random control subjects, only two had a chromosome abnormality. Down syndrome with cardiovascular malformations had a maternal age-adjusted regional prevalence of 4.33/10,000 for the white population and 3.70/10,000 for the nonwhite population. Endocardial cushion defect, the predominant cardiac abnormality in Down syndrome (60.1%), rarely occurred as an isolated cardiac lesion (2.8%). The absence of transpositions and the rarity of heterotaxias and of right- and left-sided obstructive lesions in trisomies indicate that there may be a genetic influence on specific embryologic mechanisms. Alimentary tract lesions were more common in Down syndrome than among euploid patients with heart disease and more severe than in control subjects. Urinary tract lesions also occurred in excess of the rate in control subjects. The coexistence of these major malformations with heart disease raises the possibility of incomplete expression of the VA(C)TER (vertebral, anal, cardiac, tracheal, esophageal renal) association. The selective association of chromosome abnormalities with certain cardiovascular defects is now beginning to be explained by reported embryologic studies on cellular characteristics. An explanation of the negative association with transposition and obstructive lesions requires further multidisciplinary studies on genetic and epigenetic factors.

Early detection of congenital cardiovascular malformations in infancy

In an ongoing population-based study of congenital cardiovascular malformations in the Baltimore-Washington, DC, area, 1527 affected infants were ascertained from multiple sources during the years 1981 to 1984. Ninety-eight percent were evaluated at a regional pediatric cardiology center. Among the unreferred cases, in which the cardiac defect was diagnosed only at autopsy, most infants died in the first week of life and had associated problems, such as low birth weight, major noncardiac malformations, or other life-threatening illnesses, but a few infants with potentially remediable heart disease escaped clinical detection. Until preventive measures become available, reduction of infant mortality due to congenital cardiovascular malformations will continue to depend on early recognition of signs of serious heart disease in infants and on effective community-wide use of specialized cardiac services.

Cardiac and noncardiac malformations: observations in a population-based study

A regional case-control study of congenital cardiovascular malformations (CCVMs) searches for all live-born infants in the community in whom the cardiac diagnosis has been confirmed by echocardiography, cardiac catheterization, surgery, or autopsy. Their families are studied in comparison to those of a representative sample of resident live-born infants. Detailed descriptions of noncardiac abnormalities are obtained from physician reports and maternal interviews expanded by medical record and death certificate data. Among 1,494 cases and 1,572 controls, chromosomal abnormalities, syndromes, heritable disorders, and suspect syndromes occurred with an overwhelming excess in cases (chromosomes, P less than 10(-4); syndromes/heritable disorders, P less than .005). Abnormalities affecting chromosomes 13, 18, and 21 constituted 93% of the cytogenetic defects. Syndromes and heritable disorders were of 39 types. Nonsyndromic abnormalities were three times more frequent in cases than in controls (P less than .005). Case excesses occurred for central nervous system malformations, eye disorders, major abdominal wall defects, and abnormalities of the alimentary and urinary tracts. Severe anomalies frequent among cases were those which also occur in certain recognized syndromes, and it is suggested that paired combinations of cardiac and other midline anomalies may represent "formes frustes" of syndromes with similar though variable phenotypic expressions. Cleft lip and palate, inguinal hernia, and lower limb anomalies occurred with equal frequency, suggesting their association with CCVMs by chance alone.

Familial risks of congenital heart defect assessed in a population-based epidemiologic study

Congenital heart defects (CHD) represent a heterogeneous group of disorders caused by chromosome abnormalities, mendelian disorders, teratogenic exposures, and unknown etiologic mechanisms. A large group of various isolated defects is presumably multifactorial in origin. Previous studies of familial risks for specific anatomic defects obtained from clinical series may include significant biases and obscured pathogenic relationships. In this population-based study we analyzed all cases of CHD in infants and a control birth cohort in the Baltimore-Washington area. The rates of CHD were defined for first-degree relatives of cases with isolated defects, grouped by a pathogenic classification scheme. Precurrence risks were found to vary among the groups, and risks for flow lesions were higher than previously reported. The sibling precurrence risk for hypoplastic left heart syndrome (13.5%) was not significantly different from that expected for an autosomal recessive mechanism; the risks for different types of ventricular septal defects (VSD) varied among mechanistic groups. The results indicate that the additive multifactorial model does not adequately account for the risks in all forms of isolated CHD of unknown etiology.

Subsequent pregnancy in mothers of infants with congenital heart disease

Pregnancy rates for mothers of infants with conotruncal cardiac malformations and mothers of healthy control infants were compared for a 3-year period. Mothers of infants who died of congenital heart disease had the highest pregnancy rates, followed by control mothers, and then by mothers of surviving infants with congenital heart disease. Comparison in relation to the number of living children showed similar subsequent pregnancy rates for mothers of deceased infants with congenital heart disease and mothers of control infants, but lower rates for mothers of surviving infants with congenital heart disease. "Replacement" of a deceased infant occurs frequently, apparently in order to achieve a desired family size, whereas decreased reproduction in families of living infants with congenital heart disease may reflect the psychosocial and economic impact of the continuing care of a child with severe heart disease.

Congenital heart disease: prevalence at livebirth. The Baltimore-Washington Infant Study

The Baltimore-Washington Infant Study is a regional epidemiologic study of congenital heart disease. Among Infants born in the study area in 1981 and 1982, 664 had a diagnosis of congenital heart disease confirmed in the first year of life by echocardiography, cardiac catheterization, cardiac surgery, or autopsy. The prevalence rate was 3.7/1,000 livebirths for all cases and 2.4/1,000 livebirths for cases confirmed by invasive methods only. Diagnosis-specific prevalence rates of congenital heart disease are compared with those of eight previous case series. Changing diagnostic categorizations in the time span covered and methodological differences resulted in great variation of the data. However, the data of the New England Infant Cardiac Program which used the same case discovery methods showed similar occurrences of major morphologic abnormalities, suggesting that these are stable basic estimates in the eastern United States. For all case series, the rate of confirmed congenital heart disease was approximately 4/1,000 livebirths over the 40-year time span.

Maternal hormone therapy and congenital heart disease

Exogenous female sex hormone exposure was studied in the mothers of 110 infants with conotruncal malformations of the heart, born in the years 1972-75. Cases were ascertained throughout the referral area of the Maryland State Intensive Care Neonatal Program. For each case, three normal controls were chosen from the birth population: Two matched on eight characteristics related to the likelihood of hormone-taking (race, maternal age, parity, fetal losses, gestational age, delivery mode, time of prenatal registration, private/service), and one also on the infant's sex and birthweight; the third control was chosen at random. In personal interviews, information was obtained on the mother's general health, family history, reproductive characteristics, pregnancy health, and environmental exposures. Identification of hormonal products was aided by a display of pills and packages. Maternal recall was examined in comparison to the responses of a group of mothers of infants with hypoplastic left heart ("disease controls"). Regression analysis on time elapsed since the infant's birth revealed no difference in recall between the mothers of cases and of controls. Multilogistic regression analysis, controlling for confounding variables and for scores constructed for reproductive, malformation, and exposure risks, showed no increase in relative risk for cases when compared with matched controls. When compared to random controls, the analysis suggested a possible increase in relative risk with increased environmental exposure scores; components of the risk score were excess smoking and alcohol intake, exposure to X-ray, drugs, paints, insecticides, and chemicals. The possible significance of this finding needs to be further investigated.

Implications of central retinal artery occlusion

The purpose of this paper, was to discuss central retinal artery occlusion and its role in the patient's overall health. Several different causes of occlusion such as cardiovascular diseases, carotid artery disease, aortic arch disease and giant cell arteritis are discussed along with their symptomatology and clinical manifestations. Because of the importance of a proper diagnosis, the more common ophthalmoscopic pictures that are confused with the central retinal artery occlusions are also included. A case report of a central retinal artery occlusion secondary to a carotid artery stenosis is presented to acquaint the optometrist to the need of further testing after a vascular accident to the eye.