Broad immunogenicity to prior SARS-CoV-2 strains and JN.1 variant elicited by XBB.1.5 vaccination in nursing home residents.

Background: SARS-CoV-2 vaccination has reduced hospitalization and mortality for nursing home residents (NHRs). However, emerging variants coupled with waning immunity, immunosenescence, and variability of vaccine efficacy undermine vaccine effectiveness. We therefore need to update our understanding of the immunogenicity of the most recent XBB.1.5 monovalent vaccine to variant strains among NHRs. Methods: The current study focuses on a subset of participants from a longitudinal study of consented NHRs and HCWs who have received serial blood draws to assess immunogenicity with each SARS-CoV-2 mRNA vaccine dose. We report data on participants who received the XBB.1.5 monovalent vaccine after FDA approval in Fall 2023. NHRs were classified based on whether they had an interval SARS-CoV-2 infection between their first bivalent vaccine dose and their XBB.1.5 monovalent vaccination. Results: The sample included 61 NHRs [median age 76 (IQR 68-86), 51% female] and 28 HCWs [median age 45 (IQR 31-58), 46% female). Following XBB.1.5 monovalent vaccination, there was a robust geometric mean fold rise (GMFR) in XBB.1.5-specific neutralizing antibody titers of 17.3 (95% confidence interval [CI] 9.3, 32.4) and 11.3 (95% CI 5, 25.4) in NHRs with and without interval infection, respectively. The GMFR in HCWs was 13.6 (95% CI 8.4,22). Similarly, we noted a robust GMFR in JN.1-specific neutralizing antibody titers of 14.9 (95% CI 7.9, 28) and 6.5 (95% CI 3.3, 13.1) among NHRs with and without interval infection, and a GMFR of 11.4 (95% CI 6.2, 20.9) in HCWs. NHRs with interval SARS-CoV-2 infection had higher neutralizing antibody titers across all analyzed strains following XBB.1.5 monovalent vaccination, compared to NHRs without interval infection. Conclusion: The XBB.1.5 monovalent vaccine significantly elevates Omicron-specific neutralizing antibody titers to XBB.1.5 and JN.1 strains in both NHRs and HCWs. This response was more pronounced in individuals known to be infected with SARS-CoV-2 since bivalent vaccination. Impact Statement: All authors certify that this work entitled " Broad immunogenicity to prior strains and JN.1 variant elicited by XBB.1.5 vaccination in nursing home residents " is novel. It shows that the XBB.1.5 monovalent vaccine significantly elevates Omicron-specific neutralizing antibody titers in both nursing home residents and healthcare workers to XBB and BA.28.6/JN.1 strains. This work is important since JN.1 increased from less than 0.1% to 94% of COVID-19 cases from October 2023 to February 2024 in the US. This information is timely given the CDC's latest recommendation that adults age 65 and older receive a Spring 2024 XBB booster. Since the XBB.1.5 monovalent vaccine produces compelling immunogenicity to the most prevalent circulating JN.1 strain in nursing home residents, our findings add important support and rationale to encourage vaccine uptake. Key Points: Emerging SARS-CoV-2 variants together with waning immunity, immunosenescence, and variable vaccine efficacy reduce SARS-CoV-2 vaccine effectiveness in nursing home residents.XBB.1.5 monovalent vaccination elicited robust response in both XBB.1.5 and JN.1 neutralizing antibodies in nursing home residents and healthcare workers, although the absolute titers to JN.1 were less than titers to XBB.1.5Why does this paper matter? Among nursing home residents, the XBB.1.5 monovalent SARS-CoV-2 vaccine produces compelling immunogenicity to the JN.1 strain, which represents 94% of all COVID-19 cases in the U.S. as of February 2024.

Nanotechnology-based theranostic and prophylactic approaches against SARS-CoV-2.

SARS-CoV-2 (COVID-19) pandemic has been an unpredicted burden on global healthcare system by infecting over 700 million individuals, with approximately 6 million deaths worldwide. COVID-19 significantly impacted all sectors, but it very adversely affected the healthcare system. These effects were much more evident in the resource limited part of the world. Individuals with acute conditions were also severely impacted. Although classical COVID-19 diagnostics such as RT-PCR and rapid antibody testing have played a crucial role in reducing the spread of infection, these diagnostic techniques are associated with certain limitations. For instance, drawback of RT-PCR diagnostics is that due to degradation of viral RNA during shipping, it can give false negative results. Also, rapid antibody testing majorly depends on the phase of infection and cannot be performed on immune compromised individuals. These limitations in current diagnostic tools require the development of nanodiagnostic tools for early detection of COVID-19 infection. Therefore, the SARS-CoV-2 outbreak has necessitated the development of specific, responsive, accurate, rapid, low-cost, and simple-to-use diagnostic tools at point of care. In recent years, early detection has been a challenge for several health diseases that require prompt attention and treatment. Disease identification at an early stage, increased imaging of inner health issues, and ease of diagnostic processes have all been established using a new discipline of laboratory medicine called nanodiagnostics, even before symptoms have appeared. Nanodiagnostics refers to the application of nanoparticles (material with size equal to or less than 100 nm) for medical diagnostic purposes. The special property of nanomaterials compared to their macroscopic counterparts is a lesser signal loss and an enhanced electromagnetic field. Nanosize of the detection material also enhances its sensitivity and increases the signal to noise ratio. Microchips, nanorobots, biosensors, nanoidentification of single-celled structures, and microelectromechanical systems are some of the most modern nanodiagnostics technologies now in development. Here, we have highlighted the important roles of nanotechnology in healthcare sector, with a detailed focus on the management of the COVID-19 pandemic. We outline the different types of nanotechnology-based diagnostic devices for SARS-CoV-2 and the possible applications of nanomaterials in COVID-19 treatment. We also discuss the utility of nanomaterials in formulating preventive strategies against SARS-CoV-2 including their use in manufacture of protective equipment, formulation of vaccines, and strategies for directly hindering viral infection. We further discuss the factors hindering the large-scale accessibility of nanotechnology-based healthcare applications and suggestions for overcoming them.

Epinephrine Stimulates Mycobacterium tuberculosis Growth and Biofilm Formation.

The human stress hormones catecholamines play a critical role in communication between human microbiota and their hosts and influence the outcomes of bacterial infections. However, it is unclear how M. tuberculosis senses and responds to certain types of human stress hormones. In this study, we screened several human catecholamine stress hormones (epinephrine, norepinephrine, and dopamine) for their effects on Mycobacterium growth. Our results showed that epinephrine significantly stimulated the growth of M. tuberculosis in the serum-based medium as well as macrophages. In silico analysis and molecular docking suggested that the extra-cytoplasmic domain of the MprB might be the putative adrenergic sensor. Furthermore, we showed that epinephrine significantly enhances M. tuberculosis biofilm formation, which has distinct texture composition, antibiotic resistance, and stress tolerance. Together, our data revealed the effect and mechanism of epinephrine on the growth and biofilm formation of M. tuberculosis, which contributes to the understanding of the environmental perception and antibiotic resistance of M. tuberculosis and provides important clues for the understanding of bacterial pathogenesis and the development of novel antibacterial therapeutics.

Role of Immunoglobulin A in COVID-19 and Influenza Infections.

Immunoglobulin A (IgA) is critical in the immune response against respiratory infections like COVID-19 and influenza [...].

Children's SARS-CoV-2 Infection and Their Vaccination.

SARS-CoV-2, a novel coronavirus, causes respiratory tract infections and other complications in affected individuals, and has resulted in numerous deaths worldwide. The unprecedented pace of its transmission worldwide, and the resultant heavy burden on healthcare systems everywhere, prompted efforts to have effective therapeutic strategies and vaccination candidates available to the global population. While aged and immunocompromised individuals form a high-risk group for COVID-19 and have severe disease outcome, the rate of infections among children has also increased with the emergence of the Omicron variant. In addition, recent reports of threatening SARS-CoV-2-associated complications in children have brought to the forefront an urgent necessity for vaccination. In this article, we discuss the current scenario of SARS-CoV-2 infections in children with a special focus on the differences in their immune system response as compared to adults. Further, we describe the various available COVID-19 vaccines, including the recent bivalent vaccines for children, in detail, intending to increase willingness for their acceptance.

Design and characterization of a recoil ion momentum spectrometer for investigating molecular fragmentation dynamics upon MeV energy ion impact ionization.

We present the development and performance of a newly built recoil ion momentum spectrometer to study the fragmentation dynamics of ionized molecules. The spectrometer is based on the two-stage Wiley-McLaren geometry and satisfies both time and velocity focusing conditions. An electrostatic lens has been introduced in the drift region to achieve velocity imaging and higher angular collection. The spectrometer is equipped with a 2D position-sensitive detector with multi-hit coincidence electronics. Ionic fragments with kinetic energy ∼8 eV can be detected with 4π collection. The overall performance of the spectrometer has been tested by carrying out three-dimensional ion imaging measurements for diatomic (N2) and polyatomic (CH2Cl2) molecules under the impact of 1 MeV protons. Three-dimensional momentum and kinetic energy release distributions were derived from the measured position and time-of-flight spectra. The observed features of the various fragmentation channels as well as the measured kinetic energy release distributions are in complete agreement with the available data.

Reprogramming Mycobacterium tuberculosis CRISPR System for Gene Editing and Genome-wide RNA Interference Screening.

Mycobacterium tuberculosis is the causative agent of tuberculosis (TB), which is still the leading cause of mortality from a single infectious disease worldwide. The development of novel anti-TB drugs and vaccines is severely hampered by the complicated and time-consuming genetic manipulation techniques for M. tuberculosis. Here, we harnessed an endogenous type III-A CRISPR/Cas10 system of M. tuberculosis for efficient gene editing and RNA interference (RNAi). This simple and easy method only needs to transform a single mini-CRISPR array plasmid, thus avoiding the introduction of exogenous protein and minimizing proteotoxicity. We demonstrated that M. tuberculosis genes can be efficiently and specifically knocked in/out by this system as confirmed by DNA high-throughput sequencing. This system was further applied to single- and multiple-gene RNAi. Moreover, we successfully performed genome-wide RNAi screening to identify M. tuberculosis genes regulating in vitro and intracellular growth. This system can be extensively used for exploring the functional genomics of M. tuberculosis and facilitate the development of novel anti-TB drugs and vaccines.

Distinct Persistence Fate of Mycobacterium tuberculosis in Various Types of Cells.

Mycobacterium tuberculosis can invade different cells with distinct persistence fates because cells are equipped with different host restriction factors. However, the underlying mechanisms remain elusive. Here, we infected THP1 and Raw264.7 macrophages cell lines, A549 epithelial cell line, and hBMEC and bEnd.3 endothelial cell lines with M. tuberculosis and demonstrated that M. tuberculosis significantly inhibited lysosome acidification in THP1, hBMEC, A549, and Raw264.7 cells, while, in bEnd.3 cells, M. tuberculosis was mainly delivered into acidified phagolysosomes and auto-lysosomes. The systematic gene profile analysis of different cells and intracellular M. tuberculosis showed that the phagosome autophagy-pathway-related genes itgb3 and atg3 were highly expressed in bEnd.3 cells. Knockdown of these genes significantly increased the number of viable intracellular M. tuberculosis bacilli by altering phagosomal trafficking in bEnd.3 cells. Treatment with itgb3 agonist significantly decreased M. tuberculosis survival in vivo. These findings could facilitate the identification of anti-M. tuberculosis host genes and guide M. tuberculosis-resistant livestock breeding. IMPORTANCE As an intracellular pathogen, Mycobacterium tuberculosis could avoid host cell immune clearance using multiple strategies for its long-term survival. Understanding these processes could facilitate the development of new approaches to restrict intracellular M. tuberculosis survival. Here, we characterized the detailed molecular events occurring during intracellular trafficking of M. tuberculosis in macrophage, epithelial, and endothelial cell lines and found that ITGB3 facilitates M. tuberculosis clearance in endothelial cells through altering phagosomal trafficking. Meanwhile, the treatment with ITGB3 agonist could reduce bacterial load in vivo. Our results identified new anti-M. tuberculosis restriction factors and illuminated a new anti-M. tuberculosis defense mechanism.

Rv3722c Promotes Mycobacterium tuberculosis Survival in Macrophages by Interacting With TRAF3.

Mycobacterium tuberculosis (M.tb) secretes numerous proteins to interfere with host immune response for its long-term survival. As one of the top abundant M.tb secreted proteins, Rv3722c was found to be essential for bacilli growth. However, it remains elusive how this protein interferes with the host immune response and regulates M.tb survival. Here, we confirmed that Rv3722c interacted with host TRAF3 to promote M.tb replication in macrophages. Knock-down of TRAF3 attenuated the effect of Rv3722c on the intracellular M.tb survival. The interaction between Rv3722c and TRAF3 hampered MAPK and NF-κB pathways, resulting in a significant increase of IFN-ß expression and decrease of IL-1ß, IL-6, IL-12p40, and TNF-α expression. Our study revealed that Rv3722c interacted with TRAF3 and interrupted its downstream pathways to promote M.tb survival in macrophages. These findings facilitate further understanding of the mechanism of M.tb secreted proteins in regulating the host cell immune response and promoting its intracellular survival.

Stealth Strategies of Mycobacterium tuberculosis for Immune Evasion.

Tuberculosis is a devastating disease causing high mortality all over the world, especially in the developing countries. Mycobacterium tuberculosis (M. tb) is the causative agent of tuberculosis which replicates in the intracellular environment of host macrophages. Although the host immune system is capable of completely eliminating the pathogen, co-evolution of M. tb with humans has resulted in its ability to hijack the host innate and adaptive immune systems in numerous ways. Limited recent progress has been made in the understanding of M. tb immune escape mechanisms, hence exploration of survival strategies of M. tb has been critically reviewed with an insight into understanding its pathogenesis. We summarized the recent studies regarding the modulation of innate immune response, adaptive immune response, epigenetics and the role of miRNA. All of these advancements suggest that M. tb is well-familiarize with the host immune system and possess the ability to hijack it for intracellular survival.

Cue-Reactivity Among Young Adults With Problematic Instagram Use in Response to Instagram-Themed Risky Behavior Cues: A Pilot fMRI Study.

BACKGROUND: Problematic Instagram use (PIGU), a specific type of internet addiction, is prevalent among adolescents and young adults. In certain instances, Instagram acts as a platform for exhibiting photos of risk-taking behavior that the subjects with PIGU upload to gain likes as a surrogate for gaining peer acceptance and popularity. AIMS: The primary objective was to evaluate whether addiction-specific cues compared with neutral cues, i.e., negative emotional valence cues vs. positive emotional valence cues, would elicit activation of the dopaminergic reward network (i.e., precuneus, nucleus accumbens, and amygdala) and consecutive deactivation of the executive control network [i.e., medial prefrontal cortex (mPFC) and dorsolateral prefrontal cortex (dlPFC)], in the PIGU subjects. METHOD: An fMRI cue-induced reactivity study was performed using negative emotional valence, positive emotional valence, and truly neutral cues, using Instagram themes. Thirty subjects were divided into PIGU and healthy control (HC) groups, based on a set of diagnostic criteria using behavioral tests, including the Modified Instagram Addiction Test (IGAT), to assess the severity of PIGU. In-scanner recordings of the subjects' responses to the images and regional activity of the neural addiction pathways were recorded. RESULTS: Negative emotional valence > positive emotional valence cues elicited increased activations in the precuneus in the PIGU group. A negative and moderate correlation was observed between PSC at the right mPFC with the IGAT scores of the PIGU subjects when corrected for multiple comparisons [r = -0.777, (p < 0.004, two-tailed)]. CONCLUSION: Addiction-specific Instagram-themed cues identify the neurobiological underpinnings of Instagram addiction. Activations of the dopaminergic reward system and deactivation of the executive control network indicate converging neuropathological pathways between Instagram addiction and other types of addictions.

Cumulative incidence of post-infection asthma or wheezing among young children clinically diagnosed with respiratory syncytial virus infection in the United States: A retrospective database analysis.

BACKGROUND: Respiratory syncytial virus (RSV) infection is implicated in subsequent development of asthma/wheezing (AW) among term and pre-term infants. We describe the cumulative incidence of AW among hospitalized and ambulatory neonates/infants/toddlers following RSV infection diagnosis over three independent follow-up periods. METHODS: Between January 1, 2007 and March 31, 2016, patients aged 0-2 years old with first clinical diagnosis of RSV infection were identified using the Optum® integrated electronic health records and claims database. Patients diagnosed with AW ≤ 30 days post-RSV diagnosis were excluded. Three cohorts with 1, 3, and 5 years of follow-up were stratified by presence or absence of specific RSV high-risk factors, including pre-term birth and pre-defined, pre-existing comorbidities. Descriptive statistics and logistic regression results were reported. RESULTS: Overall, 9811, 4524, and 1788 RSV-infected high-risk factor negative patients were included in 1, 3, and 5-year independent cohorts, respectively. Of these, 6.5%, 6.9%, and 5.8%, respectively had RSV-related hospitalization. By the end of follow-up, 14.9%, 28.2%, and 36.3% had AW events. Overall, 3030, 1378, and 552 RSV-infected high-risk factor positive patients were included in the respective cohorts. Of these, 11.4%, 11.1%, and 11.6%, respectively were hospitalized with initial RSV infection and 18.1%, 32.9%, and 37.9% had subsequent AW events within the follow-up period. Logistic regression confirmed RSV-related hospitalization significantly increased the likelihood of developing AW (P < .05) in high-risk factor positive and negative patients. CONCLUSIONS: In infants diagnosed with RSV infection, RSV-related hospitalization was associated with a significantly increased likelihood of AW development for at least 5 years, compared with non-hospitalized patients.

Purification and characterization of a novel, highly potent fibrinolytic enzyme from Bacillus subtilis DC27 screened from Douchi, a traditional Chinese fermented soybean food.

The highly fibrinolytic enzyme-producing bacterium was identified as Bacillus subtilis DC27 and isolated from Douchi, a traditional fermented soybean food. The DFE27 enzyme was purified from the fermentation broth of B. subtilis DC27 by using UNOsphere Q column chromatography, Sephadex G-75 gel filtration, and high-performance liquid chromatography. It was 29 kDa in molecular mass and showed the optimal reaction temperature and pH value of 45 °C and 7.0, respectively, with a stable fibrinolytic activity below 50 °C and within the pH range of 6.0 to 10.0. DFE27 was identified as a serine protease due to its complete inhibition by phenylmethysulfony fluoride. The first 24 amino acid residues of the N-terminal sequence of the enzyme were AQSVPYGVSQIKAPALHSQGFTGS. The enzyme displayed the highest specificity toward the substrate D-Val-Leu-Lys-pNA for plasmin and it could not only directly degrade but also hydrolyze fibrin by activating plasminogen into plasmin. Overall, the DFE27 enzyme was obviously different from other known fibrinolytic enzymes in the optimum substrate specificity or fibrinolytic action mode, suggesting that it is a novel fibrinolytic enzyme and may have potential applications in the treatment and prevention of thrombosis.

Treating Genetic Disorders Using State-Of-The-Art Technology.

CRISPR-Cas9 (clustered regularly interspaced short palindromic repeats-CRISPR associated Protein 9), basically a bacterial immune system is now widely applicable to engineer genomes of a number of cells and organisms because of its simplicity and robustness. In research avenue the system has been optimized to regulate gene expression, modify epigenome and edit target locus. These applications make CRISPR/Cas9, a technology of choice to edit disease causing mutations as well as the epigenome more efficiently than ever before. Meanwhile its application in in vivo and ex vivo cells is encouraging the scientific community for more vigorous gene therapy and in clinical setups for therapeutic genome editing. Here we review the recent advances that CRISPR-Cas9 mediated genome editing has achieved and is reported in previous studies and address the challenges associated with it.

Improving CRISPR-Cas9 On-Target Specificity.

The CRISPR-Cas9 has revolutionized the field of molecular biology, medical genetics and medicine. The technology is robust, facile and simple to achieve genome targeting in cells and organisms. However, to propagate these nucleases for therapeutic application, the on-target specificity is of paramount importance. Although the binding and cleavage of off-target sites by Cas9 is issue of concern, however the specificity of CRISPR technology is greatly improved in current research employing the use of engineer nucleases, improved gRNA selection, novel Cas9 orhtologs and the advancement in methods to detect and screen off-target sites and its effects. Here we summarize the advances in this state-of-the-art technology that will equip the genome editing tools to be applied in clinical research. The researcher should optimize these methods with emphasize to achieve perfection in the specificity.

Development and application of a recombination-based library versus library high- throughput yeast two-hybrid (RLL-Y2H) screening system.

Protein-protein interaction (PPI) network maintains proper function of all organisms. Simple high-throughput technologies are desperately needed to delineate the landscape of PPI networks. While recent state-of-the-art yeast two-hybrid (Y2H) systems improved screening efficiency, either individual colony isolation, library preparation arrays, gene barcoding or massive sequencing are still required. Here, we developed a recombination-based 'library vs library' Y2H system (RLL-Y2H), by which multi-library screening can be accomplished in a single pool without any individual treatment. This system is based on the phiC31 integrase-mediated integration between bait and prey plasmids. The integrated fragments were digested by MmeI and subjected to deep sequencing to decode the interaction matrix. We applied this system to decipher the trans-kingdom interactome between Mycobacterium tuberculosis and host cells and further identified Rv2427c interfering with the phagosome-lysosome fusion. This concept can also be applied to other systems to screen protein-RNA and protein-DNA interactions and delineate signaling landscape in cells.

Mycobacterium indicus pranii and Mycobacterium bovis BCG lead to differential macrophage activation in Toll-like receptor-dependent manner.

Mycobacterium indicus pranii (MIP) is an atypical mycobacterial species possessing strong immunomodulatory properties. It is a potent vaccine candidate against tuberculosis, promotes Th1 immune response and protects mice from tumours. In previous studies, we demonstrated higher protective efficacy of MIP against experimental tuberculosis as compared with bacillus Calmette-Guérin (BCG). Since macrophages play an important role in the pathology of mycobacterial diseases and cancer, in the present study, we evaluated the MIP in live and killed form for macrophage activation potential, compared it with BCG and investigated the underlying mechanisms. High levels of tumour necrosis factor-α, interleukin-12p40 (IL-12p40), IL-6 and nitric oxide were produced by MIP-stimulated macrophages as compared with BCG-stimulated macrophages. Prominent up-regulation of co-stimulatory molecules CD40, CD80 and CD86 was also observed in response to MIP. Loss of response in MyD88-deficient macrophages showed that both MIP and BCG activate the macrophages in a MyD88-dependent manner. MyD88 signalling pathway culminates in nuclear factor-κB/activator protein-1 (NF-κB/AP-1) activation and higher activation of NF-κB/AP-1 was observed in response to MIP. With the help of pharmacological inhibitors and Toll-like receptor (TLR) -deficient macrophages, we observed the role of TLR2, TLR4 and intracellular TLRs in MIP-mediated macrophage activation. Stimulation of HEK293 cells expressing TLR2 in homodimeric or heterodimeric form showed that MIP has a distinctly higher level of TLR2 agonist activity compared with BCG. Further experiments suggested that TLR2 ligands are well exposed in MIP whereas they are obscured in BCG. Our findings establish the higher macrophage activation potential of MIP compared with BCG and delineate the underlying mechanism.

Comparison of 'whoosh' and modified 'swoosh' test for identification of the caudal epidural space in children.

BACKGROUND: Caudal analgesia is widely used in pediatric anesthesia practice. The 'whoosh' test which uses air to identify the epidural space, has been recommended as a guide for successful needle placement. However, the use of air may be associated with an incidence of neurological complications. The 'swoosh' test avoids the injection of air and was originally performed using injection of a local anesthetic solution. A comparison was made between the 'whoosh' test and a modified 'swoosh' test using saline to identify the caudal epidural space in children. METHODS: We studied 60 children of either sex in the age group of 2-8 years undergoing inguinal herniotomy. During insertion of the caudal block, a stethoscope was placed over the lower lumbar spine to note the presence or absence of 'whoosh' or 'swoosh', by an independent observer who was blinded to the injection of 1 ml of air or saline which was given simultaneously by the operator into the caudal space. The operator's clinical impression of successful insertion of the needle was also recorded and correlated with the presence or absence of 'whoosh' or 'swoosh'. In addition, the need for supplemental intraoperative analgesia was noted. RESULTS: Overall success rate of caudal block using the 'whoosh' and modified 'swoosh' tests was found to be 96.6% and 93.3%, respectively as judged by the lack of supplementary perioperative analgesia. The sensitivity, specificity and positive predictive value of the 'whoosh' test and clinical predictors of caudal placement was found to be 100% whereas the modified 'swoosh' test had a sensitivity of 93%, specificity of 50% and a positive predictive value of 96%. However, statistically there was no significant difference between the clinical predictors, 'whoosh' and the modified 'swoosh' test for identification of the caudal epidural space. CONCLUSIONS: The modified 'swoosh' test is as reliable as the 'whoosh' test and we recommend it for identification of the caudal epidural space in children as it avoids injection of air into the caudal space.