Teaching Incision and Drainage: Perceived Educational Value of Abscess Models.

OBJECTIVES: Incision and drainage (I&D) of skin abscesses is an important procedural skill for pediatric emergency medicine providers. Practical skills training using simulation provides an opportunity to learn and gain confidence with this invasive procedure. Our objective was to assess the perceived educational value of 2 versions of an abscess model as part of an educational workshop for teaching I&D. METHODS: A combined didactic and practical skills workshop was developed for use at 2 national conferences. The didactic content was created through an iterative process. To facilitate hands-on training, 2 versions of an abscess model were created: 1 constructed from a negative mold and the other using a 3-dimensional printer. Participants were surveyed regarding prior experience with I&D, procedural confidence, and perceptions of the educational utility of the models. RESULTS: Seventy physicians and 75 nurse practitioners participated in the study. Procedural confidence improved after training using each version of the model, with the greatest improvements noted among novice learners. Ninety-four percent of physicians, and 99% of nurse practitioners rated the respective models as either "educational" or "very educational," and 97% and 100%, respectively, would recommend the abscess models to others. CONCLUSIONS: A combined didactic and practical skills educational workshop using novel abscess models was effective at improving learners' confidence. Our novel models provide an effective strategy for teaching procedural skills such as I&D and demonstrate a novel use of 3-dimensional printers in medical education. Further study is needed to determine if these educational gains translate into improvement in clinical performance or patient outcomes.

Peritoneal fluid localization on FAST examination in the pediatric trauma patient.

OBJECTIVE: To determine the location of intraperitoneal free fluid on FAST exam in pediatric patients undergoing evaluation for trauma. METHODS: Retrospective review of all FAST exams positive for intraperitoneal free fluid performed in patients sustaining trauma between August 2009 and February 2016 in an urban pediatric emergency department. Positive results were categorized into one of nine potential intraperitoneal locations; 4 each in the right and left upper quadrants, and the pelvis. RESULTS: One hundred and three complete positive studies were reviewed. The median age of patients was 10years (IQR 7-14) with 66% being male. Ninety-five percent had fluid present in the pelvis, 35% had fluid present in the RUQ, and 16.5% had fluid present in the LUQ. Overall, the most frequent location of fluid outside of the pelvis was found at the inferior tip of the liver, present in 83.3% of patients with fluid in the RUQ and 29% of all patients with a positive FAST. CONCLUSIONS: The majority of pediatric trauma patients with a positive FAST exam will exhibit free fluid in the pelvis. Particular attention should be directed to the inferior tip of the liver in children as this represents the most common location for fluid collection outside the pelvis.

Point-of-Care Ultrasonography for the Diagnosis of Pediatric Soft Tissue Infection.

OBJECTIVES: To determine the test characteristics of point-of-care ultrasonography for the identification of a drainable abscess and to compare the test characteristics of ultrasonography with physical examination. In addition, we sought to measure the extent to which ultrasonography impacts clinical management of children with skin and soft tissue infections (SSTIs). STUDY DESIGN: We performed a prospective study of children with SSTIs evaluated in a pediatric emergency department. Treating physicians recorded their initial impression of whether a drainable abscess was present based on physical examination. Another physician, blinded to the treating physician's assessment, performed an ultrasound study and conveyed their interpretation and recommendations to the treating physician. Any management change was recorded. An abscess was defined as a lesion from which purulent fluid was expressed during a drainage procedure in the emergency department or during the 2- to 5-day follow-up period. We defined a change in management as correct when the ultrasound diagnosis was discordant from physical examination and matched the ultimate lesion classification. RESULTS: Of 151 SSTIs evaluated among 148 patients, the sensitivity and specificity of point-of-care ultrasonography for the presence of abscess were 96% (95% CI 90%-99%) and 87% (74%-95%), respectively. The sensitivity and specificity of physical examination for the presence of abscess were 84% (75%-90%) and 60% (44%-73%), respectively. For every 4 ultrasound examinations performed, there was 1 correct change in management. CONCLUSIONS: Point-of-care ultrasonography demonstrates excellent test characteristics for the identification of skin abscess and has superior test characteristics compared with physical examination alone.

Dermocystidium sp. Infection in Blue Ridge Sculpin Captured in Maryland.

Raised pale cysts were observed on Blue Ridge Sculpin Cottus caeruleomentum during stream fish community surveys in Catoctin Mountain Park, Maryland. When examined histologically, preserved sculpin exhibited multiple cysts containing spherical endospores with a refractile central body characteristic of Dermocystidium spp. Cysts were not observed on the gills or internally. The portion of the watershed in which affected sculpin were observed contained lower than expected numbers of sculpin, raising concerns about the population effects of this infection. A nearby stream lacked sculpin even though they are common in this region, further suggesting the possibility of regional effects. This is the first report of a Dermocystidium infecting any fish species in the eastern United States. Received October 16, 2015; accepted February 14, 2016.

Evaluating the child with acute hip pain ("irritable hip") in a Lyme endemic region.

OBJECTIVES: To estimate the prevalence of Lyme infection among children presenting with acute, nontraumatic hip pain in a Lyme endemic region and to investigate predictors of Lyme disease among children with suspected transient synovitis. STUDY DESIGN: Retrospective cross-sectional study of children with unilateral hip pain who were brought to an academic pediatric emergency department. Cases were identified by specific discharge diagnoses or radiologic imaging. Lyme infection was determined by serologic criteria, and a minimum prevalence was estimated for the entire study population; maximum estimate was determined for those who had Lyme testing. Multivariate regression was used to identify discriminating clinical findings for Lyme disease among those with nonseptic arthritis. RESULTS: Three hundred eighty-five children with a median age of 5.4 years were studied; 15% of children had fever ≥38.0°C and 40% had pain for less than 24 hours at evaluation. Lyme infection was identified in 5.2% (95% CI 3.2%-7.9%). A maximum estimate of Lyme disease was calculated to be 8.0% (95% CI 4.9%-12.0%). Regression analysis did not identify any practical clinical predictors of Lyme infection. CONCLUSIONS: Lyme infection occurred in approximately 5% of children with acute, nontraumatic hip pain who were evaluated in a pediatric emergency department in a Lyme endemic region. Based on this estimate, we do not recommend routine Lyme testing when transient synovitis is suspected; however, Lyme testing should be considered in children having laboratory studies obtained for alternative diagnoses such as septic/pyogenic arthritis and for those with an atypical clinical course for transient synovitis.

Preclinical assessment of a novel human antibody VH domain targeting mesothelin as an antibody-drug conjugate.

Mesothelin (MSLN) has been a validated tumor-associated antigen target for several solid tumors for over a decade, making it an attractive option for therapeutic interventions. Novel antibodies with high affinity and better therapeutic properties are needed. In the current study, we have isolated and characterized a novel heavy chain variable (VH) domain 3C9 from a large-size human immunoglobulin VH domain library. 3C9 exhibited high affinity (KD [dissociation constant] <3 nM) and binding specificity in a membrane proteome array (MPA). In a mouse xenograft model, 3C9 fused to human IgG1 Fc was detected at tumor sites as early as 8 h post-infusion and remained at the site for over 10 days. Furthermore, 3C9 fused to a human Fc domain drug conjugate effectively inhibited MSLN-positive tumor growth in a mouse xenograft model. The X-ray crystal structure of full-length MSLN in complex with 3C9 reveals interaction of the 3C9 domains with two distinctive residue patches on the MSLN surface. This newly discovered VH antibody domain has a high potential as a therapeutic candidate for MSLN-expressing cancers.

Yeast Mating as a Tool for Highly Effective Discovery and Engineering of Antibodies via Display Methodologies.

Yeast surface display (YSD) is a powerful methodology for discovery and engineering of antibodies, and the yeast mating has been used to overcome low transformation efficiency of yeast in antibody library generation. We developed an optimized method of yeast mating for generating a large, combinatorial antibody fragment library and heterodimeric protein library by cellular fusion between two haploid cells carrying different library each other. This method allows for increased diversity in screening of target-specific fragment antigen-binding (Fab) antibodies as well as in the development of heterodimeric Fc variants for bi-specific antibody generation and T-cell receptor (TCR). Here we describe the efficient isolation of human antibodies against the activated GTP-bound form of the oncogenic Ras mutant (KRasG12D-GTP) by sequential isolation of their heavy chains (HCs) followed by combination with light chains (LCs) via the yeast mating process. This strategy facilitates guided selection of the antigen-specific HC with either a fixed functional LC, which has cytosol penetrating ability, or an LC library to generate the Fab. It also allows for deeper exploration of a sequence space with fixed diversity, leading to a higher probability of successful isolation of human antibodies with high specificity and affinity.

Developing a Statewide Research Compendium: Key Points and Steps for Success.

Engaging clinical nurses in nursing research requires value for the nurses and a structured process. One way to involve nurses in research is through development of a research compendium. A professional development specialist can lead the creation of a research compendium. Identifying key stakeholders, developing a technologic infrastructure, piloting the compendium, gaining feedback, and identifying outcomes that will be evaluated are key. [J Contin Educ Nurs. 2022;53(3):106-108.].

A highly-specific fully-human antibody and CAR-T cells targeting CD66e/CEACAM5 are cytotoxic for CD66e-expressing cancer cells in vitro and in vivo.

Neuro-endocrine prostate cancer (NEPC) accounts for about 20% of lethal metastatic castration-resistant prostate cancer (CRPC). NEPC has the most aggressive biologic behavior of all prostate cancers and is associated with poor patient outcome. Effective treatment for NEPC is not available because NEPC exhibit distinct cell-surface expression profiles compared to other types of prostate cancer. Recently, the carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5) (known as CEA or CD66e) was suggested to be a specific surface protein marker for NEPC. Therefore, we identified a new, fully-human anti-CEACAM5 monoclonal antibody, 1G9, which bound to the most proximal membrane domains, A3 and B3, of CEACAM5 with high affinity and specificity. It shows no off-target binding to other CEACAM family members, membrane distal domains of CEACAM5, or 5800 human membrane proteins. IgG1 1G9 exhibited CEACAM5-specific ADCC activity toward CEACAM5-positive prostate cancer cells in vitro and in vivo. Chimeric antigen receptor T cells (CAR-T) based on scFv 1G9 induced specific and strong antitumor activity in a mouse model of prostate cancer. Our results suggest that IgG1 and CAR-T cells based on 1G9 are promising candidate therapeutics for CEACAM5-positive NEPC and other cancers.

Potent and broad neutralization of SARS-CoV-2 variants of concern (VOCs) including omicron sub-lineages BA.1 and BA.2 by biparatopic human VH domains.

The emergence of SARS-CoV-2 variants of concern (VOCs) requires the development of next-generation biologics with high neutralization breadth. Here, we characterized a human VH domain, F6, which we generated by sequentially panning large phage-displayed VH libraries against receptor binding domains (RBDs) containing VOC mutations. Cryo-EM analyses reveal that F6 has a unique binding mode that spans a broad surface of the RBD and involves the antibody framework region. Attachment of an Fc region to a fusion of F6 and ab8, a previously characterized VH domain, resulted in a construct (F6-ab8-Fc) that broadly and potently neutralized VOCs including Omicron. Additionally, prophylactic treatment using F6-ab8-Fc reduced live Beta (B.1.351) variant viral titers in the lungs of a mouse model. Our results provide a new potential therapeutic against SARS-CoV-2 variants including Omicron and highlight a vulnerable epitope within the spike that may be exploited to achieve broad protection against circulating variants.

Potent Neutralization of Omicron and other SARS-CoV-2 Variants of Concern by Biparatopic Human VH Domains.

The emergence of SARS-CoV-2 variants of concern (VOCs) requires the development of next-generation biologics that are effective against a variety of strains of the virus. Herein, we characterize a human V H domain, F6, which we generated by sequentially panning large phage displayed V H libraries against receptor binding domains (RBDs) containing VOC mutations. Cryo-EM analyses reveal that F6 has a unique binding mode that spans a broad surface of the RBD and involves the antibody framework region. Attachment of an Fc region to a fusion of F6 and ab8, a previously characterized V H domain, resulted in a construct (F6-ab8-Fc) that neutralized Omicron pseudoviruses with a half-maximal neutralizing concentration (IC 50 ) of 4.8 nM in vitro . Additionally, prophylactic treatment using F6-ab8-Fc reduced live Beta (B.1.351) variant viral titers in the lungs of a mouse model. Our results provide a new potential therapeutic against SARS-CoV-2 VOCs - including the recently emerged Omicron variant - and highlight a vulnerable epitope within the spike protein RBD that may be exploited to achieve broad protection against circulating variants.

Effective killing of cells expressing CD276 (B7-H3) by a bispecific T cell engager based on a new fully human antibody.

The pancaner molecule CD276 (B7-H3) is an attractive target for antibody based therapy. We identified from a large (1011) phage-displayed single-chain variable fragment (scFv) library, a fully human antibody, B11, which bound with high avidity (KD=0.4 nM) to CD276. B11 specifically bound to the V1/V2 domain of CD276 and competed with the antibody 8H9 (Omburtamab). It was used to design an IgG-format bispecific T cell engager B11-BiTE, which was more effective than 8H9-BiTE in 14 different cancer cell lines. B11-BiTE also exhibited strong ADCC/ADCP. Therefore, the fully human B11-BiTE is a promising candidate for treatment of tumors expressing CD276.

Phylogeographic Genetic Diversity in the White Sucker Hepatitis B Virus across the Great Lakes Region and Alberta, Canada.

Hepatitis B viruses belong to a family of circular, double-stranded DNA viruses that infect a range of organisms, with host responses that vary from mild infection to chronic infection and cancer. The white sucker hepatitis B virus (WSHBV) was first described in the white sucker (Catostomus commersonii), a freshwater teleost, and belongs to the genus Parahepadnavirus. At present, the host range of WSHBV and its impact on fish health are unknown, and neither genetic diversity nor association with fish health have been studied in any parahepadnavirus. Given the relevance of genomic diversity to disease outcome for the orthohepadnaviruses, we sought to characterize genomic variation in WSHBV and determine how it is structured among watersheds. We identified WSHBV-positive white sucker inhabiting tributaries of Lake Michigan, Lake Superior, Lake Erie (USA), and Lake Athabasca (Canada). Copy number in plasma and in liver tissue was estimated via qPCR. Templates from 27 virus-positive fish were amplified and sequenced using a primer-specific, circular long-range amplification method coupled with amplicon sequencing on the Illumina MiSeq. Phylogenetic analysis of the WSHBV genome identified phylogeographical clustering reminiscent of that observed with human hepatitis B virus genotypes. Notably, most non-synonymous substitutions were found to cluster in the pre-S/spacer overlap region, which is relevant for both viral entry and replication. The observed predominance of p1/s3 mutations in this region is indicative of adaptive change in the polymerase open reading frame (ORF), while, at the same time, the surface ORF is under purifying selection. Although the levels of variation we observed do not meet the criteria used to define sub/genotypes of human and avian hepadnaviruses, we identified geographically associated genome variation in the pre-S and spacer domain sufficient to define five WSHBV haplotypes. This study of WSHBV genetic diversity should facilitate the development of molecular markers for future identification of genotypes and provide evidence in future investigations of possible differential disease outcomes.

Genome Sequences of 26 White Sucker Hepatitis B Virus Isolates from White Sucker, Catostomus commersonii, Inhabiting Transboundary Waters from Alberta, Canada, to the Great Lakes, USA.

We report 26 genome sequences of the white sucker hepatitis B virus (WSHBV) from the white sucker, Catostomus commersonii The genome length ranged from 3,541 to 3,543 bp, and nucleotide identity was 96.7% or greater across genomes. This work suggests a geographical range of this virus that minimally extends from the Athabasca River, Alberta, Canada, to the Great Lakes, USA.

Draft Genome Sequence of an Adomavirus Associated with Raised Mucoid Skin Lesions on Smallmouth Bass (Micropterus dolomieu).

Raised mucoid skin lesions have been observed on smallmouth bass (Micropterus dolomieu) for years. Here, we report the draft genome of a novel adomavirus (Micropterus dolomieu adomavirus 2) associated with this disease. The circular genome is 17,561 bp and most similar to that of alpha-adomaviruses.

Enhanced elicitation of potent neutralizing antibodies by the SARS-CoV-2 spike receptor binding domain Fc fusion protein in mice.

The development of an effective vaccine against SARS-CoV-2 is urgently needed. We generated SARS-CoV-2 RBD-Fc fusion protein and evaluated its potency to elicit neutralizing antibody response in mice. RBD-Fc elicited a higher neutralizing antibodies titer than RBD as evaluated by a pseudovirus neutralization assay and a live virus based microneutralization assay. Furthermore, RBD-Fc immunized sera better inhibited cell-cell fusion, as evaluated by a quantitative cell-cell fusion assay. The cell-cell fusion assay results correlated well with the virus neutralization potency and could be used for high-throughput screening of large panels of anti-SARS-CoV-2 antibodies and vaccines without the requirement of live virus infection in BSL3 containment. Moreover, the anti-RBD sera did not enhance the pseudotyped SARS-CoV-2 infection of K562 cells. These results demonstrate that Fc fusion can significantly improve the humoral immune response to recombinant RBD immunogen, and suggest that RBD-Fc could serve as a useful component of effective vaccines against SARS-CoV-2.

Anxiolytic effects of L-theanine--a component of green tea--when combined with midazolam, in the male Sprague-Dawley rat.

The purpose of the study was to investigate the anxiolytic effects of L-theanine and its potential interaction with the GABAA receptor in Sprague-Dawley rats. L-theanine is a major component of green tea, which has traditionally been used as an herbal remedy in the treatment of many medical conditions, including anxiety. Herbals and supplements and their potential interactions perioperatively are a concern to anesthetists. Fifty-five rats were divided into 5 groups: control (saline); L-theanine (positive control); flumazenil (a known benzodiazepine receptor antagonist) and L-theanine; and midazolam and L-theanine. The behavioral component of anxiety was evaluated using the elevated plus-maze and calculated by the time spent in the open arm of the maze divided by total time in the maze. Data were analyzed using a 2-tailed multivariate analysis of variance and Sheffé posthoc test. The data suggest that L-theanine does not produce anxiolysis by modulation of the GABAA receptor; however, in combination with midazolam, a synergistic or additive effect was demonstrated by decreased anxiety and both fine and basic motor movements. These data may provide direction for further studies examining L-theanine and its effects on anxiety and motor activity.

Newly Described Coccidia Goussia bayae from White Perch Morone americana: Morphology and Phylogenetics Support Emerging Taxonomy of Goussia within Piscine Hosts.

In March and April 2016, 150 white perch ( Morone americana) were collected from various localities in Chesapeake Bay and examined for coccidia. A previously undescribed species of coccidia was observed in the hepatic bile ducts and gallbladder of all white perch (100%) examined. We describe this species using morphological characteristics, histology, and gene sequences of the small-subunit ribosomal DNA ( rDNA), large-subunit rDNA, and mitochondrial genes cytochrome oxidase 1 ( COI), cytochrome oxidase b ( Cytb), and cytochrome oxidase 3 ( COIII). Oocysts of Goussia bayae n. sp. were subspherical with a single-layered smooth wall and measured (length [L] × width [W]) 26.2 × 21.8 µm, with a L/W ratio of 1.2. A micropyle was present but a micropyle cap, polar granules, and oocyst residuum were absent. Each oocyst contained 4 sporocysts that were ellipsoidal and measured (L × W) 12.6 × 7.8 µm, with a L/W ratio of 1.6. A pair of sporozoites was present, but sporocysts lacked a Stieda body and residuua. Meronts and gamonts were epicellular in biliary epithelial cells and oocysts were coelozoic in hepatic and common bile ducts and gallbladder. This is the first report of Goussia spp. from white perch and the first mitochondrial DNA sequence reported from a Goussia species. Phylogenetic analysis indicates basal placement of G. bayae to Eimeriidae, Choleoeimeria, and Sarcocystidae.