United States

ABSTRACT 

Addisonian Crisis Exacerbation Secondary to COVID-19 Infection
Taylor L. Brewer, OMS III, Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL.; Hayley P. Nichols, OMS III, Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL.; Jordan S. Nolan, OMS III, Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL.; Heath W. Shelton, M.S., OMS III, Alabama College of Osteopathic Medicine, Dothan, AL.; Daniel C. Burnes, M.D., Crestwood Medical Center, Huntsville, AL. 

Addisonian Crisis, or adrenal crisis, is an uncommon condition characterized by severe hypotension, hypoglycemia, and hyperkalemia. If not treated promptly this condition can lead to organ failure or shock. It typically presents in patients who have had a prior diagnosis of Addison’s disease, or primary adrenal insufficiency (PAI). Manifestations of primary adrenal insufficiency include hyperpigmentation of skin, fatigue, nausea, vomiting, hypoglycemia, and hypotension. In this particular case a 55-year-old male with a past medical history significant for atrial fibrillation, hypothyroidism, and Addison’s disease was found unresponsive in his home. Upon presentation to the hospital the patient’s labs and vitals revealed an anion gap metabolic acidosis, fever of 103.2 degrees, altered mental status, an extremely hypotensive blood pressure of 69/49 mmHg, and was positive for COVID-19. He was given a bolus of normal saline IV fluids, ceftriaxone, ampicillin, and acyclovir as a prophylactic treatment regimen for possible meningitis that was later ruled out with a negative lumbar puncture. Cardizem was also initiated to combat tachycardia secondary to atrial fibrillation. Upon investigation into this patient’s prior hospitalizations, the electronic medical record revealed a previous diagnosis of primary adrenal insufficiency. At that time, IV hydrocortisone and fludrocortisone were initiated, followed by a rapid recovery and subsequent discharge from the hospital within 48 hours of admission. Since he was asymptomatic, COVID-19 directed therapy was never initiated. Upon discharge, fludrocortisone was reincorporated into the patient’s home medications. The purpose of this case report is to discuss an atypical presentation of Addison’s disease in a patient presenting in a crisis state due to COVID-19 infection.


2022 AMA Research Challenge

Addisonian Crisis Exacerbation Secondary to COVID-19 Infection

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poster

Hyposmia from chronic rhinosinusitis: Is a vitamin D3 derivative the cure?

Background: 
Autoimmune disease (AID) affects over 23 million Americans and is a leading cause of death among young and middle-aged women. Unfortunately, no cure exists for AID. Current therapies have limited efficacy and severe side effects, therefor new therapeutics utilizing the body’s immunoregulatory mechanisms are needed.
This study investigates CUE-401, an injectable fusion protein of cytokines IL-2 and TGF𝛽, designed to accomplish this by increasing regulatory immune cells known as Tregs. Previous studies demonstrated IL-2 and TGF𝛽 together induce new Tregs from naïve CD4+T-cells, whereas IL-2 alone expands existing Tregs. However, therapeutic use of these cytokines is limited by IL-2’s short half-life and TGF𝛽’s off-target effects. CUE-401 is designed to overcome these two challenges by fusing modified IL-2 and TGF𝛽 to an FC backbone.

Methods
Several in-vitro pilot assays using T-lymphocytes from a transgenic mouse model of autoimmune gastritis (TxA23) were completed to investigate this new molecule. First, naïve CD4+T-cells were co-cultured with CUE-401 and tested for Treg induction. Next, Foxp3+Tregs were isolated and co-cultured with titrating doses of CUE-401. Finally, proinflammatory cytokines released from mature T-cells co-cultured with CUE-401 were measured.
CUE-401 was then tested in-vivo with TxA23 mice modeling an environment of AID. A subcutaneous injection of CUE-401was given to TxA23 mice, then blood and lymphoid tissue was examined 7 days post-injection for cellular classification.

Results 
In-vitro studies revealed CUE-401’s ability to functionally induce and expand Tregs, while also suppressing effector cells. Naïve T-cells co-cultured with CUE-401 demonstrated significant Treg induction, while endogenous Tregs co-cultured with CUE-401 experienced significant expansion in a dose dependent manner. Effector cells co-cultured with CUE-401 released significantly less proinflammatory cytokines, revealing the molecule’s immunosuppressive capabilities.
Similarly, our in-vivo experiment revealed CUE-401 induced/expands Tregs, as tissue from mice treated with CUE-401 had significantly higher proportions of Tregs compared to untreated mice. Furthermore, CUE-401 also demonstrated immunosuppressive capabilities in-vivo by decreasing the proliferative index of disease mediating effector cells. 

Conclusion
Unlike current therapies for autoimmunity, CUE-401 acts directly on T-cells in-vivo to suppress autoreactivity by increasing Tregs and suppressing disease mediating effector cells. This unique mechanism of action may hold the key to a curative treatment for autoimmune disease.


Injectable Fusion Protein Expands Horizon of Autoimmune Disease Therapy

Background
COVID-19 vaccine production shed light on using mRNA vaccines to prevent chronic illness. Moderna recently announced their quest to manufacture an mRNA vaccine against HIV, a chronic illness affecting approximately 38 million people worldwide. In order to develop an HIV vaccine, two properties are essential: antibody dependent cellular cytotoxicity and long-lived antibody response. Multiple somatic hypermutations and long complementarity determining regions pose challenges to this. Key vaccine trials and a reflection on lessons learned for future vaccine development are discussed.

Methods
One study described an mRNA-LNP vaccine encoding clade C HIV-1 Env 1086C and tested tier 1, 2, and 3 neutralization capability. A second compared a gp160 mRNA vaccine with a SOSIP gp140 mRNA vaccine and SOSIP gp140 protein vaccine. SOSIPs are trimers that resemble HIV virions with a more soluble form due to the additions of a disulfide bond (SOS) and point substitution (IP). A third experiment compared an mRNA vaccine encoding HIV-1 Gag, Pol, and Nef proteins to another mRNA vaccine with an additional 1-methyl-3’-pseudouridylyl modified vector. Subjects were boosted with a poxvirus booster carrying the same antigen. A fourth experiment compared the efficacy of a trivalent versus tetravalent adjuvanted protein vaccine. The final experiment analyzed the efficacy of an mRNA vaccine that co-expressed HIV-1 426c.3dg Env and SIVmac239 Gag proteins.

Results
The first study failed to produce recall antibody response and recommended that future trials use next-generation SOSIPs. The second study incorporated SOSIPs but did not produce significant recall antibody responses. The third study showed promising results with vaccination with a poxvirus booster. The fourth study showed a higher antibody response and enhanced recall in tetravalent vaccines and is currently undergoing further testing. The final trial showed a 79% reduction in per-exposure risk for vaccinated subjects as compared to controls.

Conclusion
mRNA vaccines have a marked advantage compared to other vaccines – there are less manufacturing challenges and decreased cost. Incorporating several boosters, particularly utilizing different mechanisms and vehicles, shows promising results. The COVID-19 vaccine rollout provides a layout for arranging international rollout. Communities must be engaged early on and support the diversity and flexibility necessary in HIV vaccine development.

Lessons Learned from HIV mRNA Vaccine Development in the Age of COVID-19 Vaccines

Background: The Omicron Variant of Concern (VOC) recently originating from South Africa possesses a striking arrangement of mutations that distinguishes it from prior VOCs and which promotes greatly enhanced transmissibility and evasion from humoral immunity.

Methods: To better understand how these mutations have contributed to the “fourth wave” of the pandemic, we assessed 20 Omicron mutant isolates from South Africa against the immunogenetic profile of the South African population. Mutations contributing to innate immune evasion, antibody evasion, and T cell evasion were identified using the VaxiJenv2.0 and NetMHCpan immunoinformatic platforms were catalogued. 

Results: We characterized an unprecedented number of mutations predicted to cause evasion from innate and adaptive immune elements, including mutations occurring in immunodominant epitopes specific for the South African population. These findings suggest that Omicron’s success stems from its ability to simultaneously evade multiple arms of the immune system at the population level. 

Conclusion: We report that SARS-CoV variant Omicron appears to have evolved a comprehensive constellation of mutations, enabling it to escape all three arms of the immune system at once. We theorize that this mutational profile is a consequence of slowly adapting on a population with endemic HIV/AIDS, providing the virus the immunological opportunity to evolve more fastidiously on its host.


Mutational Analysis of SARS-CoV-2 Variant Omicron Reveals Profound Immunogenetic Adaptations: A Lesson on Antigenic Drift

Plasmodium spp., the causative pathogen of malaria infected over 200 million people in the past year and killed over 600,000 of those—mostly children and women in Sub-Saharan Africa. A malaria vaccine that can prevent both symptomatic disease and infection is desperately needed if we are to eradicate the disease. Current vaccine candidates that target the major surface protein CSP have proven unable to provide such infection-blocking protection. The Wilder lab has identified another antigen (UIS3), which when targeted by passive transfer (injection) of antibodies can reduce parasite burden during the multi-day intracellular liver stage. Although they do not completely block infection on their own, passively transferred anti-UIS3 polyclonal antibodies can work synergistically with anti-CSP antibodies to increase infection-blocking protection from 0% to 64% in a stringent murine challenge model. These results were not replicated when this combination was tested via active vaccination using RNA-based vaccines, which is likely due to the failure of this vaccine platform to elicit anti-UIS3 antibodies. In addition to understanding why UIS3 was not amenable to RNA-based vaccination, we will need understand how these antibodies are functioning mechanistically to better design future vaccines. To this end, we created a panel of monoclonal antibodies against UIS3 and found that 1 of 6 was able to reduce parasite liver burden in the mice. To determine if this function correlated with the ability of the antibody to the region of UIS3 known to sequester host autophagy protein LC3, we performed ELISA against the full-length UIS3 protein and simply the LC3 binding domain. We found that the one antibody with function in vivo bound for FL and BD the best, leaving open the possibility that either affinity and/or LC3 binding dictate function. Our next experiments include screening new monoclonals while also using the existing set to determine if the single functional antibody works by allowing autophagy-mediated killing of the parasite or other immune mechanisms.


Understanding the Mechanism of Action of Intracellularly acting anti-pyUIS3 Antibodies in Liver-stage Malaria Infection 

Background
COVID-19 has had severe impacts both in terms of human health and disruption to society since appearing in December 2019. Our project aims to look at changes in biophysical properties of the surface glycoprotein (S) of SARS-COV-2 to understand the evolution of variants within the human population. 

Methods
We obtained SARS-COV-2 amino acid sequences from the NIH NCBI Virus database and imported them into Microsoft Excel. Each amino acid residue within the full-length sequences was assigned a parametric value based on total accessible surface area (ASAtot), non-polar accessible surface area (ASAnp), polar accessible surface area (ASApol), and net charge at pH 7.0 (Charge). These values were used to quantify differences between these properties in sequences. PYMOL was then used to plot areas of interest onto the molecular structure in both the open (RBD – “Up”) and closed (RBD – “Down”) conformations. Furthermore, changes in parametric values observed in the sequences were compared to a random amino acid sequence data set using KaleidaGraph to determine statistical significance. 

Results
Our analysis revealed evidence of sporadic changes occurring at amino acids at the surface of S. Interestingly, different regions seem to be mutated in different variants. The S2 domain, particularly in Delta and Zeta lineages, appears to be inherently mutable. Despite the fact mutations are well-tolerated in many parts of S, very few of these become fixed in the population, indicating these individual changes do not provide a global selective advantage. In the Delta linage, for example, we observed numerous sporadic mutations occurring particularly in the N domain, whereas in the Omicron lineage, a greater proportion of mutations become fixed in the population.

Conclusion
We conclude that mutations in SARS-COV-2 S may confer fitness in the infected individual, but may not be advantageous in an outbred population. The biophysical property changes observed can be applied to predicting T- and B-cell interactions with S, helping us assess the effectiveness of current vaccines against circulating variants and help formulate future vaccine targets to protect against a wider range of SARS-COV-2 variants.

Using Biophysical Properties of SARS-COV-2 Surface Glycoprotein to Determine its Ongoing Structural Evolution

Anesthesiology - Effects of Electric Spinal Cord Stimulation on Post-Surgical Pain in Mice - Anesthesiology

Introduction: 
Propofol gains popularity (from 16.7% to 58.1% in the USA during the decade 2006-15) in anesthesia services for outpatient colonoscopy1. Recently, two randomized control trials (RCTs) with large study sizes show propofol’s positive impact in patient satisfaction in comparison to tradition sedation (midazolam) for elective colonoscopy.2,3 A recent review evaluated patient satisfaction but their study’s inclusion criteria omitted similar RCTs comparing propofol with midazolam in elective colonoscopy. This meta-analysis attempted to know the numerical effect size between propofol and midazolam, with or without opioids, to understand the magnitude of propofol’s impact in patient satisfaction compared to tradition sedatives such as midazolam. 
Methods:
We searched PubMed, EMBASE, and Web of Science (WOS) for publications that reported RCTs in which adults undergoing elective colonoscopy were randomly assigned to propofol with or without opioids or midazolam sedation with or without opioids. Male and female adults with ASA scores I-III having outpatient colonoscopy were included, while patients receiving patient-controlled anesthesia and ASA IV-V were excluded (Figure 1). The process of identifying study trials is summarized in the PRISMA flow diagram (Figure 2). Satisfaction scales were converted to 10-point scales with mean and standard deviation calculated. Validated data were transferred to specialized software (RevMan 5, www.cochrane.org) for statistical analysis and preparation of forrest plots. Mean difference i.e., difference in means, random-effects model with 95% confidence interval was calculated and compared with a larger and positive mean difference indicating more patient satisfaction to propofol. 
Results:
The patients with propofol sedation and midazolam sedation totaled (n=925 vs. n=939) n = 1,864. Patient satisfaction was significantly higher in propofol with mean difference 0.71 [0.41-1.01] CI 95% (Figure 3). The meta-analysis showed no publication bias, but statistical heterogeneity was high I2 = 88% (Figure 3,4).
Conclusion:
Anesthetists appreciate propofol’s rapid onset, ease of titration, and anti-emetic properties. This meta-analysis helps understand the magnitude of propofol’s impact in patient satisfaction compared to traditional sedatives such as midazolam. 


Anesthesiology - The Effect Size of Patient Satisfaction in a Meta-Analysis of Randomized Controlled Trials Between Propofol and Midazolam in Elective Colonoscopy - Anesthesiology

Background: Sinoatrial node (SAN) cells, the natural pacemakers of the heart, determine the rate and rhythm of the heart’s electrical conduction system. Damage to these cells can lead to conditions such as arrhythmias and Sick Sinus Syndrome. These conditions are commonly treated with electronic pacemaker implants which can lead to risks of complications, such as infection. A more biologically compatible therapeutic alternative that could reduce the risk of complications could eventually include cell transplantation with SAN cells derived from human pluripotent stem cells (hPSCs). However, a protocol for the generation of SAN cells from hPSCs in vitro has not been well-established, although there are well-established protocols for the generation of other cardiomyocytes, such as ventricular and atrial cells. Our study aims to generate SAN-like cells in vitro by using the hPSC model.

Methods: To generate the SAN-like cells, we combined aspects of protocols for the generation of ventricular and atrial cells from hPSCs with a newer, published, successful protocol by Protze et al. proposed for generating SAN-like cells from hPSCs. By incorporating these protocols, SAN-like cells were generated by selective induction of cardiac progenitors and controlled maturation of the SAN lineage by mimicking their in vivo development. The cells were then characterized via light and fluorescent microscopy, flow cytometry, and immunofluorescence, and viability was assessed via light microscopy and flow cytometry.

Results: We successfully generated SAN-like cells as demonstrated by their faster beating pattern on light and fluorescent microscopy and a lack of NKX2-5 expression on immunofluorescence, two characteristics that distinguish SAN cells from other cardiomyocytes. However, flow cytometry demonstrated a small proportion of live cells and light microscopy observations demonstrated increased cellular debris and cell death morphology of the SAN-like cells, suggesting that viability of these cells was greatly reduced compared to other cardiomyocytes generated in vitro.

Conclusion: The successful generation of SAN-like cells from hPSCs provides a promising avenue in the development of novel biologic therapies that could improve outcomes in the most susceptible populations for rhythm disorders. Future studies need to address the issue of reduced viability of these cells compared to other in vitro generated cardiomyocytes.

Cardiology - In vitro generation of sinoatrial node-like cardiomyocytes derived from human pluripotent stem cells - Cardiology

In this study we define a novel role for the SDF-1/CXCR4 axis in the hibernation and treatment of myocardial tissue in diabetic cardiomyopathy (DCM).
Wild-type and cardiac CXCR4 null (CM-CXCR4 null) mice were randomly assigned to low-fat diet (LFD) or high-fat diet (HFD) for 30 weeks. Serial echocardiography was used to assess cardiac function. SDF-1 plasmid (80 ug) was injected into the LV wall of half group of the HFD mice (27 weeks). SDF-1, CXCR4, SIRT1, SIRT3, and SIRT6 mRNA levels in the hearts were quantified by qPCR at different times.
Compared to age-matched LFD mice, 27-week-old HFD mice showed a 33% decrease in Ejection Fraction (EF). Direct myocardial injection of hSDF-1 plasmid led to a 15% and 30% improvement in EF 1 and 3 weeks later, respectively, compared to control. To determine if CM-CXCR4 expression induces CM hibernation as a mechanism of DCM, we quantified cardiac function in HFD CM-CXCR4 null mice. We observed an early loss of cardiac function in HFD CM-CXCR4 null mice compared to HFD control mice. Interestingly, SIRT1 and SIRT6 were statistically decreased in HFD mice, suggesting that SIRT signaling may be involved in blunted SDF-1 signaling in DCM.
Our data demonstrated that the SDF-1/CXCR4 axis has an important role in DCM. Our data suggests that cardiac myocyte over-expression of CXCR4 is involved in cardiac myocyte hibernation. These data suggest that modulation of SDF-1/CXCR4 expression will delay or alleviate DCM.

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Addisonian Crisis Exacerbation Secondary to COVID-19 Infection

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Hyposmia from chronic rhinosinusitis: Is a vitamin D3 derivative the cure?

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Lessons Learned from HIV mRNA Vaccine Development in the Age of COVID-19 Vaccines