Investigation of an mpox outbreak affecting many vaccinated persons in Chicago, IL-March 2023-June 2023

BACKGROUND

After months of few mpox cases, an increased number of cases were reported in Chicago during May 2023; predominantly among fully vaccinated patients. We investigated the outbreak scope, differences between vaccinated and unvaccinated patients, and hypotheses for monkeypox virus (MPXV) infection after vaccination.

METHODS

We interviewed patients and reviewed medical records to assess demographic, behavioral, and clinical characteristics, mpox vaccine status, and vaccine administration routes. We evaluated serum antibody levels after infection and compared patient viral genomes with MPXV sequences in available databases. We discussed potential vaccine compromise with partners who manufactured, handled, and administered vaccine associated with breakthrough infections.

RESULTS

During March 18-June 27, 2023, we identified 49 mpox cases; 57% of these mpox patients were fully vaccinated (FV). FV patients received both JYNNEOS doses subcutaneously (57%), intradermally (7%), or via heterologous administration (36%). FV patients had more median sex partners (3, IQR=1-4) versus not fully vaccinated (NFV) patients (1, IQR=1-2). Thirty-six of 37 sequenced specimens belonged to lineage B.1.20 of clade IIb MPXV, which did not demonstrate any amino acid changes relative to B.1, the predominant lineage from May 2022. Vaccinated patients demonstrated expected humoral antibody responses; none were hospitalized. No vaccine storage excursions were identified. Approximately 63% of people at risk for mpox in Chicago were FV during this period.

CONCLUSIONS

Our investigation indicated cases were likely due to frequent behaviors associated with mpox transmission, even with relatively high vaccine effectiveness and vaccine coverage. Cases after vaccination might occur in similar populations.

Experimental studies on performance of ventilators stored in the Strategic National Stockpile

BACKGROUND

The Center for Devices and Radiological Health, Food and Drug Administration (FDA) launched a collaborative initiative with Centers for Disease Control and Prevention (CDC) to gain a better understanding of ventilators that are used during national emergencies. This initiative was intended to test reliability of ventilator devices stored long term in the CDC Strategic National Stockpile (SNS) and also used by the Department of Defense. These ventilators are intended to be used by trained operators to provide ventilatory support to adult and pediatric populations under diverse environmental conditions. The authors evaluated device performance and possible effects of long-term storage.

METHODS

Three SNS ventilator models: Impact Uni-Vent 754 Eagle™, Covidien (Puritan Bennett) LP10, and CareFusion LTV 1200 were used in this study. A total of 36 ventilators, 12 per model, were evaluated for performance in simulated adult populations using a test lung. The parameters evaluated included battery charge status and capability, battery longevity, positive end expiratory pressure consistency, device performance on AC and DC (battery) power, and device durability testing.

RESULTS

The out-of-the-box run time was equal to or higher than the manufacturer's specifications for fully charged batteries for all ventilators except 58 percent of the Impact 754 ventilators. No significant ventilator performance issues were observed in terms of tidal volume consistency, proximal pressure, oxygen consumption, and a 2000-hour run test in LP10 models.

CONCLUSIONS

These findings provide information about the long-term storage of ventilators that have regular maintenance, and their ability to perform reliably during a public health emergency.

Contraceptive availability during an emergency response in the United States

This article provides the evidence for contraceptive need to prevent unintended pregnancy during an emergency response, discusses the most appropriate types of contraceptives for disaster situations, and details the current provisions in place to provide contraceptives during an emergency response.

UV inhibits allergic airways disease in mice by reducing effector CD4 T cells

BACKGROUND

In human asthma, and experimental allergic airways disease in mice, antigen-presenting cells and CD4(+) effector cells at the airway mucosa orchestrate, and CD4(+)CD25(+) regulatory T cells attenuate, allergen immunity. UV irradiation of skin before sensitization with ovalbumin (OVA) causes significantly reduced asthma-like responses in respiratory tissues.

OBJECTIVE

To determine whether UV-induced changes in CD11c(+) cells, CD4(+)CD25(+) effector cells or CD4(+)CD25(+) regulatory cells in the trachea and airway draining lymph nodes (ADLNs) were responsible for reduced allergic airways disease.

METHODS

The phenotype and function of CD11c(+) cells and CD4(+)CD25(+) cells in the trachea and ADLNs of UV- and non-irradiated, OVA-sensitized mice was examined 24 h after a single exposure to aerosolized OVA.

RESULTS

No changes in the function of CD11c(+) cells from UV-irradiated mice were observed. CD4(+)CD25(+) cells from UV-irradiated, OVA-sensitized mice harvested 24 h after OVA aerosol proliferated less in response to OVA in vitro and were unable to suppress the proliferation of OVA-sensitized responder cells. This result suggested reduced activation of effector T cells in the airway mucosa of UV-irradiated, OVA-sensitized mice. To exclude regulatory cells of any type, there was similar proliferation in vivo to aerosolized OVA by CFSE-loaded, OVA-TCR-specific CD4(+) cells adoptively transferred into UV- and non-irradiated, OVA-sensitized mice. In addition, there was no difference in the expression of regulatory T cell markers (Foxp3, IL-10, TGF-beta mRNA). To examine effector T cells, ADLN cells from UV-irradiated, OVA-sensitized and -challenged mice were cultured with OVA. There was reduced expression of the early activation marker CD69 by CD4(+)CD25(+) cells, and reduced proliferation in the absence of the regulatory cytokine, IL-10.

CONCLUSION

Reduced allergic airways disease in UV-irradiated mice is due to fewer effector CD4(+)CD25(+) cells in the trachea and ADLNs, and not due to UV-induced regulatory cells.

Pandemic influenza planning: addressing the needs of children

Children represent one quarter of the US population. Because of its enormous size and special needs, it is critically important to address this population group in pandemic influenza planning. Here we describe the ways in which children are vulnerable in a pandemic, provide an overview of existing plans, summarize the resources available, and, given our experience with influenza A(H1N1), outline the evolving lessons we have learned with respect to planning for a severe influenza pandemic. We focus on a number of issues affecting children-vaccinations, medication availability, hospital capacity, and mental health concerns-and emphasize strategies that will protect children from exposure to the influenza virus, including infection control practices and activities in schools and child care programs.

Suppression of the asthmatic phenotype by ultraviolet B-induced, antigen-specific regulatory cells

BACKGROUND

Over recent decades, there has been a significant global increase in the prevalence of asthma, an inflammatory disease of the respiratory system. While ultraviolet radiation (UV) has been used successfully in the treatment of inflammatory conditions such as psoriasis, studies of UV-induced regulation of allergic respiratory responses have been rare, and have not analysed in vivo measurements of airway hyperresponsiveness (AHR) or the antigen specificity of the UV-induced effects.

OBJECTIVE

To investigate the regulatory properties of erythemal ultraviolet B (UVB) irradiation of the skin and the induction of allergen-induced airway immunity in a murine asthma model, and to examine the mechanisms involved.

METHODS

BALB/c mice were exposed to a single erythemal dose of UV 3 days before intraperitonial sensitization (day 0) and boost (day 14) with the antigen, ovalbumin (OVA). Airway-associated, asthma-like responses to aerosolized OVA at day 21 were analysed including (a) AHR measured in vivo, (b) OVA-specific proliferative responses and cytokine production by cells from the lung-draining lymph nodes (LDLN), and (c) inflammatory cells and cytokines in the bronchoalveolar lavage fluid. To determine UVB-induced mechanisms of regulation, LDLN cells from UVB irradiated, OVA-sensitized mice were adoptively transferred into naïve BALB/c mice that were subsequently sensitized and challenged with OVA, or a non-specific antigen.

RESULTS

UVB irradiation of skin significantly suppressed AHR to methacholine and OVA-specific responses in the LDLN and in the lung compartment. Reduced OVA-specific responses by LDLN cells from both UVB irradiated mice and mice that received 5 x 10(6) LDLN cells from UVB irradiated, but not from non-irradiated, OVA-sensitized mice suggested that UVB-induced regulatory cells are responsible for many of the asthma-reducing effects of dorsal UVB exposure.

CONCLUSION

UVB irradiation of skin suppresses AHR and cellular responses of the airways to respiratory allergens. Further, this study implicates UVB or its downstream mediators as a potential approach to reducing the severity of asthma.

Transmission of two Australian strains of murine cytomegalovirus (MCMV) in enclosure populations of house mice (Mus domesticus)

To control plagues of free-living mice (Mus domesticus) in Australia, a recombinant murine cytomegalovirus (MCMV) expressing fertility proteins is being developed as an immunocontraceptive agent. Real-time quantitative PCR was used to monitor the transmission of two genetically variable field strains of MCMV through mouse populations after 25% of founding mice were infected with the N1 strain, followed by the G4 strain 6 weeks later. Pathogen-free wild-derived mice were released into outdoor enclosures located in northwestern Victoria (Australia). Of those mice not originally inoculated with virus, N1 DNA was detected in more than 80% of founder mice and a third of their offspring and similarly, G4 DNA was detected in 13% of founder mice and in 3% of their offspring. Thus, prior immunity to N1 did not prevent transmission of G4. This result is promising for successful transmission of an immunocontraceptive vaccine through Australian mouse populations where MCMV infection is endemic.

Characterization of gabapentin overdose using a poison center case series

BACKGROUND

Gabapentin is an anticonvulsant that is being used for an increasing number of off-label indications. The purpose of this study is to document the clinical manifestations and outcomes of gabapentin exposures reported to poison centers.

METHODS

A multicenter prospective observational study of all gabapentin exposures reported to three poisoncenters was conducted between 4/1/98 and 4/1/2000. Cases involving gabapentin only were evaluated.

RESULTS

There were 20 cases with gabapentin as the sole substance in doses ranging from 50 mg to 35 g. Ten of the 20 cases involved children and adolescents. Clinical effects developed early and resolved within 10 hours in most patients. Seven cases were managed in the home with only observation. Four of these patients remained asymptomatic. Effects reported in the three symptomatic patients were drowsiness (3) and ataxia (1). Thirteen patients were managed in a health care facility. Nine were symptomatic with reported effects of drowsiness (6), dizziness (3), nausea/vomiting (2), tachycardia (2), and hypotension (2). None of the patients were admitted for medical care.

CONCLUSION

In this cases series, gabapentin exposures caused no or minimal toxicity.

Mutation of a nuclear receptor gene, NR2E3, causes enhanced S cone syndrome, a disorder of retinal cell fate

Hereditary human retinal degenerative diseases usually affect the mature photoreceptor topography by reducing the number of cells through apoptosis, resulting in loss of visual function. Only one inherited retinal disease, the enhanced S-cone syndrome (ESCS), manifests a gain in function of photoreceptors. ESCS is an autosomal recessive retinopathy in which patients have an increased sensitivity to blue light; perception of blue light is mediated by what is normally the least populous cone photoreceptor subtype, the S (short wavelength, blue) cones. People with ESCS also suffer visual loss, with night blindness occurring from early in life, varying degrees of L (long, red)- and M (middle, green)-cone vision, and retinal degeneration. The altered ratio of S- to L/M-cone photoreceptor sensitivity in ESCS may be due to abnormal cone cell fate determination during retinal development. In 94% of a cohort of ESCS probands we found mutations in NR2E3 (also known as PNR), which encodes a retinal nuclear receptor recently discovered to be a ligand-dependent transcription factor. Expression of NR2E3 was limited to the outer nuclear layer of the human retina. Our results suggest that NR2E3 has a role in determining photoreceptor phenotype during human retinogenesis.

Cloning and characterization of T-cell lymphoma invasion and metastasis 2 (TIAM2), a novel guanine nucleotide exchange factor related to TIAM1

TIAM1 is a guanine nucleotide exchange factor that was identified in a screen for genes that increase the invasiveness of T lymphoma cell lines (Habets et al., 1994, Cell 77(4): 537-549). We have identified a gene, T-cell lymphoma invasion and metastasis 2 (HGMW-approved symbol TIAM2), with significant identity to the carboxyl-terminal region of the TIAM1 and mapped it to 6q25. TIAM2 is expressed as an approximately 3.3-kb transcript in cerebrum and as an approximately 4.4-kb transcript in the cerebellum and testis. The approximately 4. 4-kb message encodes a longer form of the approximately 3.3-kb mRNA predicted protein, and both contain homology to the Dbl-homologous region (70%) and Pleckstrin-homologous (54%) regions of TIAM1. We have purified TIAM2 and shown it to have GDP-GTP exchange activity. In situ hybridizations demonstrate TIAM2 expression in the E13.5 telencephalon of mouse embryos and in the cerebral cortex, hippocampus, and ependyma of adult mouse brains.

Open-label, single-dose pharmacokinetic study of modafinil tablets: influence of age and gender in normal subjects

An open-label, single-center, single-dose, parallel-group study was performed in healthy young males and females as well as healthy elderly males to examine the influence of age and gender on the pharmacokinetics of modafinil following administration of a single 200 mg oral dose. Twelve subjects were enrolled in each of the following three groups: young males, young females, and elderly males. Each fasted (overnight) subject received 2 x 100 mg modafinil tablets. Blood and urine samples were collected at various times up to 72 hours postdose for the determination of plasma and urine levels of modafinil as well as the acid and sulfone metabolites. The plasma concentrations of the individual isomers, d- and l-modafinil, were also determined. Pharmacokinetic parameters were determined by noncompartmental methods. Modafinil was well tolerated at a single oral dose of 200 mg. The most commonly reported adverse events were headache, fever, pharyngitis, and asthenia. There were no clinically meaningful differences with respect to the incidence rate of treatment-emergent adverse events among the young female, young male, and old male groups. Modafinil was rapidly absorbed after oral dosing and slowly cleared (t1/2 approximately 11-14 hr) from the body. Modafinil acid was the major urinary metabolite, which accounted for 35% to 60% of the dose. Results from this study indicated that there were age and gender effects on modafinil clearance processes. In this regard, the clearance rate of modafinil in males decreased with age while young females cleared modafinil at a faster rate than young males. Stereospecific pharmacokinetics of modafinil were also demonstrated. The d-modafinil was eliminated three times faster than the l-modafinil.

The affliction of Job: poisoned!

The story of Job has been an inspiration for centuries to those familiar with the story. It has also been a source of curiosity as to what affliction he suffered. A critical reappraisal of the clinical manifestations of his illness support the contention that he was a victim of poisoning. There is historical evidence to support that the poison was available in his time and already in use for poisoning. Finally, there is even documentation in the story of Job as to the identity of his poisoner.

A recombinant adenovirus that directs secretion of biologically active kappa-bungarotoxin from mammalian cells

A novel Cre-lox system was used to construct an adenovirus encoding kappa-bungarotoxin (kappa-Bgt), modified to be secreted by attachment of a bovine prolactin signal sequence at the N-terminus of the toxin. Western blot of medium from HEK-293 cells infected with the virus demonstrated that recombinant kappa-Bgt (R-kappa-Bgt) was secreted. The biological activity of the secreted R-kappa-Bgt was investigated in Xenopus oocytes that expressed neuronal nicotinic acetylcholine receptor (nAChR) subtypes alpha3beta2 and alpha2beta2. The recombinant toxin inhibited the response of alpha3beta2 type AChRs to ACh, but did not inhibit the response of alpha2beta2 type AChRs. These data demonstrated that the recombinant adenovirus directs the secretion of biologically active kappa-Bgt from a mammalian cell line. Because adenovirus can be used to infect post-mitotic cells, recombinant adenoviruses encoding biologically active peptides may be of use as delivery vehicles for in vivo experiments where repeated application of the purified peptide is unfeasible.

Influence of selective decontamination of the digestive tract on microbial biofilm formation on endotracheal tubes from artificially ventilated patients

The effect of selective decontamination of the digestive tract on the nature and incidence of microbial biofilm formation on endotracheal tubes was assessed. Thirty endotracheal tubes were obtained post-extubation from patients in the intensive care unit who had been ventilated for a 1 to 15 day period and who did or did not receive the antibiotic regimen. Extensive biofilm formation was identified by scanning electron microscopy on 97% of tubes examined. Endotracheal tube biofilm in tubes obtained from patients who received selective decontamination of the digestive tract showed a high prevalence of colonization with yeast (4 of 15 tubes) and gram-positive bacteria (streptococci, staphylococci and diphtheroids) (14 of 15 tubes). Staphylococcus aureus was isolated only from this group. Pseudomonas spp. were isolated from 2 of 15 tubes in both patient groups. Enteric gram-negative organisms (coliforms, Klebsiella and Proteus spp.) were isolated only from tubes of patients who did not receive the antibiotic regimen (4 of 15 tubes). Yeasts, however, were not isolated from these tubes. Group D streptococcal isolates were resistant to tobramycin as were half of the Staphylococcus aureus isolates. For gram-negative bacteria, the MIC of tobramycin was in the range 1-64 micrograms/ml and the MIC of polymyxin in the range 0.5-16 micrograms/ml. Although a reduction was observed in the incidence of gram-negative microorganisms, this antibiotic regimen does not inhibit biofilm formation on the endotracheal tube by other pathogens associated with pneumonia in ventilated patients. This persistent nidus may be a factor in the pathogenesis of nosocomial pneumonia.

Case report: tuberculous colitis mimicking Crohn's disease

Although intestinal tuberculosis is rare in this country, increasing numbers of patients are now being seen, particularly in the immigrant population. We present the history of a lady who had acute diarrhoea and in whom the radiological and endoscopic findings looked very similar to those seen in Crohn's disease. The radiological presentation included widespread aphthous ulceration, a feature that has rarely been reported in tuberculous colitis.

Psychological morale and job satisfaction among homecare workers who care for persons with AIDS

This paper reports the findings of a study of 103 home care workers who have cared for PWAs. It investigated degree of "exposure" to AIDS cases, perception of risk of occupational contagion, client/worker relationships, attitudes toward homosexuality and drug abuse and other work related factors for their relationship with psychological morale and job satisfaction. Multivariate analyses found sociodemographic characteristics and physical health to be the strongest predictors of morale. The quality of client/worker relationships and risk perception were the strongest predictors of job satisfaction. These findings, and that of the relative lack of importance of exposure to AIDS cases and attitudes toward the risk groups in accounting for job satisfaction, are discussed in terms of qualitative data collected from respondents during informal small group discussions.

Value of lymph node biopsy in the treatment of patients with the human immunodeficiency virus

The indications and value of lymph node biopsy in patients infected with the human immunodeficiency virus (HIV) are not clearly defined. We reviewed 29 consecutive lymph node biopsies performed on 24 patients with the HIV over a 4-year period. Indications for biopsy included: (1) new or worsening medical symptoms with no detectable etiology in patients with lymphadenopathy, (2) disproportionately larger or enlarging lymph node in patients with generalized adenopathy, and (3) exclusion of concomitant disease in patients with previously defined infectious or neoplastic processes. The biopsy samples exhibited a diversity of histologic appearances including atypical and reactive hyperplasia, malignancy, and infection. Nineteen biopsies (64%) resulted in the institution or alteration of treatment. The absolute number of T-helper cells prior to biopsy was significantly lower in patients with a diagnosis of malignancy or infection (p < 0.05), as well as in those who eventually died (p < 0.05). Four (14%) minor complications resulted from lymph node biopsy. Based on our results, we conclude that lymph node biopsy is indicated in the above three subsets of HIV-infected patients. Biopsy can be performed with minimal morbidity and significantly alters therapy in the majority of patients.

Plasma catecholamine concentration during sedation in ventilated patients requiring intensive therapy

The effects of isoflurane and midazolam sedation on the catecholamine responses of ventilated patients were studied over a 24-h period. Sixty ventilated patients admitted to our intensive therapy unit were allocated randomly to receive either isoflurane or midazolam sedation. Arterial blood samples for plasma catecholamine concentrations were taken at baseline, 6 h after starting sedation and at the end of the study period. Patients sedated with isoflurane showed a progressive reduction in both adrenaline and noradrenaline concentrations during the period of sedation which reached statistical significance for adrenaline at 6 h (p less than 0.02) and at the end of the study (p less than 0.001). Patients sedated with midazolam showed no significant changes of adrenaline or noradrenaline concentrations. Overall, a more satisfactory degree of sedation was achieved with isoflurane.

Power and effective nursing practice

Underlying the Nursing Knowledge Program were the beliefs that professionals can be prepared to function more effectively in organizations and that organizations can be designed to promote better use of professional skills. The training program, therefore, included both educational and structural solutions for the problems of powerlessness experienced by nurses in the hospital setting. Educationally, the program was designed to empower the participating nurses by teaching them the analytic and interpersonal skills they needed to develop and implement plans for change. Structurally, it established new lines of communication between staff nurses and nurse administrators, linked the nurses to needed resources, and gave the nurses more control over working conditions. Due to the quasi-experimental nature of the research design used in the project, the findings cannot be generalized to all nurses in all hospitals. There is no question, however, that each of the four strategies can be a valuable administrative approach for increasing nursing power. Confirming the strategies and moving groups of nurses through a series of activities specifically designed to use the strategies can bring significant change in the perceptions of nurses about themselves and their profession. For the administrator, the strategies are a way to develop a more effective and satisfied nursing staff, to encourage new leadership, and to create a stronger constituency among staff members. They also create a new source of energy and ideas for resolving the very real problems of professional practice.

Superoxide dismutase in Didymium iridis: characterization and changes in activity during senescence and sporulation

The myxomycete Didymium iridis displays a single cytoplasmic superoxide dismutase in the diploid plasmodial stage. The enzyme was purified and appears to be a manganese-containing protein of approximately 32000 molecular weight. Superoxide dismutase specific activity was constant throughout the cell cycle and showed no significant change over the majority of plasmodial life span. Elevated superoxide dismutase activity, relative to that of other cytoplasmic enzymes, occurred during necrosis of senescent plasmodia, staling, and starvation-induced sporulation.