Serial Monitoring and Hyperimmunoglobulin versus Standard of Care to Prevent Congenital Cytomegalovirus Infection: A Phase III Randomized Trial.

INTRODUCTION: Nonrandomized studies support the potential of cytomegalovirus hyperimmunoglobulin (CMV-HyperIg) in preventing maternofetal CMV transmission, but prospective interventional studies show equivocal results. We pre-sent a prospective phase-III international randomized open-label trial on the potential effect of CMV-HyperIg following serial monitoring of CMV serostatus. METHODS: CMV-seronegative pregnant women (gestational age [GA] <14 weeks) were 1:1 randomized to monthly CMV-serostatus monitoring and CMV-HyperIg upon seroconversion (treatment), or routine prenatal care with CMV-serostatus testing at end of pregnancy (control). Ethical considerations required that control subjects with confirmed seroconversion be offered Cytotect®. The primary endpoint was the proportion of fetuses/newborns with congenital CMV infection. Secondary endpoints included neonatal CMV disease and safety during the 24-month follow-up. RESULTS: The treatment arm counted 4,800 randomized subjects: 52 seroconverted (median GA 24 [11-35] weeks), of which 45 completed follow-up. The control arm counted 4,735 randomized subjects: 42 seroconverted, of which 34 completed follow-up (evaluable data for 28 newborns) and 8 subjects chose off-label Cytotect®. Congenital CMV rates were 13/28 newborns (46.4% [CI 27.51; 66.13]) vs. 16/45 newborns (35.6% [CI 21.87; 51.22]) in control and treated arms, respectively (p = 0.46). Newborn CMV disease was mostly mild and spontaneously resolving. There were no major safety concerns. The target sample was not reached within an acceptable time frame. CONCLUSIONS: Serial monitoring of CMV serostatus with CMV-HyperIg treatment was associated with a mild nonsignificant reduction in the vertical CMV transmission rate. Studies on the optimal preventive strategy are hampered by epidemiological and ethical challenges and should focus on GA-dependent transmission rates and accurate dating of infection.

Induction of (2'-5')oligoadenylate synthetase in the marine sponges Suberites domuncula and Geodia cydonium by the bacterial endotoxin lipopolysaccharide.

Recent studies have shown that the Porifera, with the examples of the demosponges Suberites domuncula and Geodia cydonium, comprise a series of pathways found also in the immune system of Deuterostomia, such as vertebrates, but are absent in Protostomia, with insects or nematodes as examples. One pathway is the (2'-5')oligoadenylate synthetase [(2-5)A synthetase] system. In the present study we show that crude extracts from tissue of S. domuncula collected from the sea display a considerable amount of (2-5)A synthetase activity; 16% of the ATP substrate is converted to the (2-5)A product, while tissue from specimens which were kept for 6 months in an aquarium shows only 1% of conversion. As aquarium animals show a lower bacterial load, those specimens were treated for the experiments with the bacterial endotoxin lipopolysaccharide (LPS); they responded to LPS with a stimulation of the (2-5)A synthetase activity. To monitor if this effect can be obtained also on the in vitro level, primmorphs which comprise proliferating and differentiating cells, were incubated with LPS. Extracts obtained from LPS-treated primmorphs also convert ATP to the (2-5)A products mediated by the synthetase. In parallel to this effect on protein level, LPS causes after an incubation period of 12 h also an increase in the steady-state level of the transcripts encoding the putative (2-5)A synthetase. It is postulated that in sponges the (2-5)A synthetase is involved in antimicrobial defense of the animals.