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Nachman, MD, is the chief of pediatric infectious diseases at Stony Brook Children's Hospital.

Pediatrician Sharon Nachman, MD, discusses the potential effects of the new policy including how things like vaccine access, incidence rates, and participation in placebo-controlled trials may change. 

How Will the New FDA COVID-19 Vaccine Policy Affect the Pediatric Population?

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

Alexander Laurenson presents T cell-focused tool at 2025 Vaccinology Conference using data from 18 countries and 748 HLA alleles to address immune diversity in Africa.

Computational Model Maps Over 67,000 Malaria Epitopes to Improve Vaccine Targeting

A new computational pipeline developed at the University of Maryland School of Medicine may help improve malaria vaccine development by addressing two major challenges: the genetic diversity of 

 and variability in human immune genes across African populations. The model was presented at the 2025 Annual Conference on Vaccinology Research.

The approach uses mixed-integer linear programming to identify T cell epitopes that are conserved, immunogenic, and broadly recognizable across a range of human leukocyte antigen (HLA) alleles. The tool evaluates parasite sequences from 18 African countries and 748 unique HLA alleles from 24 African nations. It then selects combinations of epitopes that maximize population-level immune coverage while reducing the likelihood of immune escape.

From a set of 42 candidate proteins, the model identified more than 65,000 class I and nearly 2,000 class II epitopes. The most promising liver-stage antigens included HSP70-2, ROM1, and LISP1. Blood-stage antigens included RON2, PfRh5, and EBA-175. Among the most optimized results, five MHC class I epitopes independently covered 100 percent of HLA-A, -B, and -C alleles. MHC class II coverage ranged from 98.5 to 100 percent when epitopes from multiple parasite stages were combined.

Alexander Laurenson, a second-year MD/PhD student and lead investigator, said the pipeline aims to help researchers narrow their focus before entering more costly stages of vaccine testing. “What I think we’re experiencing right now in a lot of the malaria vaccine development pipeline is a bottleneck in determining what exactly to target,” Laurenson said. “Plasmodium falciparum is a eukaryote, so it has an enormous genome. That means there are a lot of components that allow for redundancy in how the pathogen invades, causes disease, and survives in the host.”

Laurenson noted that by using this tool early in the vaccine development pipeline, researchers can reduce time spent on expensive laboratory assays.“We’re hoping this tool is integrated effectively so we can at least generate a shortlist of potential antigens or epitopes to target before moving on to that expensive and tedious step,” he said.

The tool also focuses on enhancing HLA coverage, a factor tied to the ability to activate T cells, which support longer-lasting and more durable immune responses.“When we talk about HLA coverage, we’re covering a much more complicated concept related to the activation of T cells,” Laurenson said. “This is something that’s often less emphasized in vaccinology, where the focus is usually on generating a robust antibody response—which is, rightfully, considered highly protective.”

“But in this case, we’re focusing on what I sometimes call the ‘middle child’ of the immune response—T cells—that help do a few important things. CD8 T cells go after infected host cells to kill them and squash the infection when it’s hiding inside our cells. CD4 T cells, when activated, fully activate B cells, which is key for those B cells to become memory B cells and produce long-lasting antibodies.”

By improving T cell engagement, the model may contribute to longer-lasting immunity and potentially reduce the frequency of booster doses needed in the field. Laurenson said the tool was designed to be scalable and adaptable to other vaccine targets. 

“We’re not just in the business of designing malaria vaccines—we’re also interested in designing tools that could be used for other understudied, neglected, or elusive pathogens,” he said. “We’re looking at applying this work to pathogens that have been difficult to target with vaccines due to high antigenic diversity, or where there’s variability in immune response between individuals.”

He noted that this includes diseases like influenza, COVID-19, and hepatitis B, where breakthrough infections remain common and vaccine coverage varies.“We really want to figure out how this overall strategy could be used not just for malaria, but for other emerging or elusive pathogens,” Laurenson said. Next steps include experimental validation of the model’s epitope predictions and integration into vaccine platforms that support durable immune responses.

Laurenson A, Laurens MB. A novel computational approach to 

 vaccine design to address human leukocyte antigen restriction and parasite diversity. Poster #1 presented at the 2025 Annual Conference on Vaccinology Research. May 5-7, 2025; Washington, DC.

Alexander Laurenson presents T-cell-focused tool at the 2025 Vaccinology Conference using data from 18 countries and 748 HLA alleles to address immune diversity in Africa.

Conferences

Last month, the World Health Organization (WHO) published its first-ever global guidelines for meningitis diagnosis, treatment and care, aiming to speed up detection, ensure timely treatment, and improve long-term care for those affected. By bringing together the latest evidence-based recommendations, the guidelines provide a tool for reducing mortality and disability caused by the disease.

The guidelines contribute to the broader Defeating Meningitis by 2030 Global Roadmap, adopted by WHO Member States in 2020, which aims to: eliminate bacterial meningitis epidemics, reduce cases of vaccine-preventable bacterial meningitis by 50% and deaths by 70%, and reduce disability and improve quality of life after meningitis.

Achieving these goals requires coordinated action across 5 key areas:

Faster detection and optimal clinical management.

: Developing new affordable vaccines, achieving high immunization and coverage, and improving outbreak preparedness and response.

Strengthening monitoring systems to guide prevention and control.

4.Care and support for those affected by meningitis: 

Ensuring early recognition and improved access to care and support for after-effects from meningitis.

Increasing political commitment and inclusion in country plans, better public understanding of meningitis, and increased awareness of right to prevention, care and after-care services.

Despite effective treatments and vaccines against some forms of meningitis, the disease remains a significant global health threat. Bacterial meningitis is the most dangerous form and can become fatal within 24 hours. Many pathogens can cause meningitis with an estimated 2.5 million cases reported globally in 2019. This includes 1.6 million cases of bacterial meningitis which resulted in approximately 240 000 deaths.

Approximately, 20% of people who contract bacterial meningitis develop long-term complications, including disabilities that impact quality of life. The disease also carries heavy financial and social costs for individuals, families, and communities.

“Bacterial meningitis kills 1 in six of the people it strikes, and leaves many others with lasting health challenges," Tedros Adhanom Ghebreyesus, PhD, WHO Director-General said in a statement. "Implementing these new guidelines will help save lives, improve long-term care for those affected by meningitis, and strengthen health systems."

Here in the US, the impact is smaller but for those afflicted with the infection it can be quite severe. According to the Centers for Disease Control and Prevention, approximately 1,400 to 3,000 people in the US, or 1 in 100,000 are diagnosed with bacterial meningitis each year. Typically it affects mostly infants, children, college students, and the elderly.

Initial presentation can often look like flu-like symptoms such as fever, headache, and a stiff neck. However, patients’ condition can worsen rapidly, and it is important to consider additional symptoms, such as altered mental status, like confusion, nausea, photophobia, and vomiting.

A first line of treatment is intravenous antibiotics. Sometimes corticosteroids are part of the treatment to reduce swelling in the brain. Anti-seizure medication can be used and supportive care such as intravenous fluids are given to prevent dehydration and support other vital functions.

For those who want to read the guidelines, interested parties can go 

References
1.WHO launches first-ever guidelines on meningitis diagnosis, treatment and care. WHO press release. April 10, 2025. Accessed May 19, 2025.


https://www.who.int/news/item/10-04-2025-who-launches-first-ever-guidelines-on-meningitis-diagnosis--treatment-and-care


2.Meningitis. Mayo Clinic. Accessed May 19,2025.


https://www.mayoclinic.org/diseases-conditions/meningitis/diagnosis-treatment/drc-20350514

.
3.Meningococcal Disease Symptoms and Complications. CDC. August 30,2024. Accessed May 19, 2025.
https://www.cdc.gov/meningococcal/symptoms/index.html
4. Clinical Guidance for Meningococcal Disease. CDC. August 21,2024. Accessed May 19, 2025.
https://www.cdc.gov/meningococcal/hcp/clinical-guidance

The international organization’s first set of guidelines for this serious condition are looking to reduce mortality and morbidity.

With Its Global Bacterial Meningitis Guidelines, WHO Aims to Speed Up Diagnosis, Treatment

Today, Innoviva Specialty Therapeutics, which is a subsidiary of Innoviva, announced its antibiotic, ceftobiprole (Zevtera), is available for prescribing in the US. The antibiotic was approved in April 2024, and now marks the first cephalosporin indicated to treat SAB.

“The availability of Zevtera in the US marks the introduction of our second novel therapy in 2 years, addressing drug-resistant pathogens that pose significant health risks, particularly in hospitals and out-patient settings,” said Innoviva CEO Pavel Raifeld, said in a statement.

In addition to being indicated for treating adults with 

bloodstream infections, including those with right-sided infective endocarditis, it can be prescribed for adults with acute bacterial skin and skin structure infections (ABSSSI), and adult and pediatric patients 3 months to less than 18 years old with community-acquired bacterial pneumonia (CABP).

In the phase 3 ERADICATE study, ceftobiprole met the primary endpoint by demonstrating non-inferiority versus daptomycin, with or without aztreonam for SAB. The overall success rate was 69.8% with ceftobiprole, compared to 68.7% with daptomycin, in the Modified Intention-to-Treat (mITT) population at 70 days post-randomization. Both treatments were well tolerated. The overall rate of adverse events was similar between the ceftobiprole and daptomycin groups.

In the trial, researchers randomly assigned 390 subjects to receive Zevtera (192 subjects) or daptomycin plus optional aztreonam [the comparator] (198 subjects). The primary measure of efficacy for this trial was the overall success (defined as survival, symptom improvement, 

 bacteremia bloodstream clearance, no new 

bacteremia complications and no use of other potentially effective antibiotics) at the post-treatment evaluation visit, which occurred 70 days after being randomly assigned an antibiotic.

 Ceftobiprole’s efficacy in treating ABSSSI was evaluated in a randomized, controlled, double-blind, multinational trial. In the trial, researchers randomly assigned 679 subjects to receive either ceftobiprole (335 subjects) or vancomycin plus aztreonam [the comparator] (344 subjects).

The primary measure of efficacy was early clinical response 48-72 hours after start of treatment. Early clinical response required a reduction of the primary skin lesion by at least 20%, survival for at least 72 hours and the absence of additional antibacterial treatment or unplanned surgery. Of the subjects who received ceftobiprole, 91.3% achieved an early clinical response within the necessary timeframe compared to 88.1% of subjects who received the comparator.

Ceftobiprole’s efficacy in treating adult patients with CABP was evaluated in a randomized, controlled, double-blind, multinational, multicenter trial. In the trial, researchers randomly assigned 638 adults hospitalized with CABP and requiring IV antibacterial treatment for at least 3 days to receive either ceftobiprole (314 subjects) or ceftriaxone with optional linezolid [the comparator] (324 subjects). The primary measurement of efficacy were clinical cure rates at test-of-cure visit, which occurred 7-14 days after end-of-treatment. Of the subjects who received Zevtera, 76.4% achieved clinical cure compared to 79.3% of subjects who received the comparator. An additional analysis considered an earlier timepoint of clinical success at day 3, which was 71% in patients receiving ceftobiprole and 71.1% in patients receiving the comparator.

Outside the US, the brand is currently approved and marketed in several European countries and beyond as Zevtera and Mabelio for the treatment of adult patients with hospital-acquired bacterial pneumonia (HABP), excluding ventilator-associated bacterial pneumonia (VABP), and for the treatment of CABP. Basilea has entered into license and distribution agreements covering more than 80 countries.

References
1. ZEVTERA (ceftobiprole), an Advanced-Generation Cephalosporin Antibiotic Now Commercially Available in the U.S. to Treat Three Types of Bacterial Infections. Innoviva press release. May 20, 2025. Accessed May 20, 2025. 
https://investor.inva.com/news-releases/news-release-details/zevterar-ceftobiprole-advanced-generation-cephalosporin

2.FDA News Release. FDA Approves New Antibiotic for Three Different Uses. Published April 3, 2024. Accessed April 3, 2024. 

https://www.fda.gov/news-events/press-announcements/fda-approves-new-antibiotic-three-different-uses

Innoviva Specialty Therapeutics’ antibiotic is the first and only FDA-approved cephalosporin indicated to treat Staphylococcus aureus bacteremia, including right-sided endocarditis, caused by the methicillin-resistant Staphylococcus aureus. 

 Ceftobiprole Launches Commercially in US  

Lyme disease is typically treated with antibiotics, and most people experience a resolution of symptoms. However, the disease can become chronic and debilitating for some individuals. This condition has been named Lyme infection-associated chronic illness (IACI). Approximately 5% to 10% of patients go on to experience prolonged symptoms—often including fatigue, pain, and cognitive impairment—that can last for years and significantly limit function and quality of life.¹

Charting a Path Toward New Treatments for Lyme Infection-Associated Chronic Illnesses

, from the National Academies of Sciences, Engineering, and Medicine

 aims to prioritize research into treatments that improve function and quality of life for people living with IACI.¹

“There is an urgent need to identify and develop safe and effective treatments for Lyme IACI that can restore functionality and quality of life, and it is possible for that work to start now,” Kent Kester, chair of the committee that wrote the report and executive director of research and development at the Coalition for Epidemic Preparedness Innovations, said in a statement. “People living with this condition deserve to have information that allows them to both make informed decisions about their own health and to have safe and effective treatments available to them.”

The report highlights an unrealized opportunity for researchers, clinicians, and people living with other infection-associated chronic illnesses—such as myalgic encephalomyelitis/chronic fatigue syndrome or Long COVID—to share knowledge to better understand common mechanistic pathways or treatments that may be applicable across these diseases. Pooling research efforts to examine the pathogenesis and treatment of persistent symptoms could streamline discovery and maximize the impact of funding.

The report recommends that the department of Health and Human Services develop an integrated strategic plan for research on infection-associated chronic illnesses to facilitate collaboration across different disease research efforts. This plan should improve understanding of commonalities across diseases and help advance effective interventions.

According to the National Academies, they convened a committee of experts to assess the evidence for disease mechanisms, diagnoses, and treatments of Lyme IACI, and to chart a pathway for the development of new treatments. Contributors to the report include the National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Board on Health Sciences Policy; and the Committee on the Evidence Base for Lyme Infection-Associated Chronic Illnesses Treatment.

The report again emphasizes the potential for cross-condition collaboration among researchers and patients facing chronic illnesses like ME/CFS or long COVID, aiming to identify shared biological mechanisms and therapeutic approaches. By coordinating research and funding, the impact of scientific discovery could be enhanced.

Named after the town of Lyme, Connecticut, where a small cluster of cases in both adults and children occurred in 1975, the disease had existed for years before being officially identified. Today, several factors are contributing to Lyme disease becoming the most common vector-borne disease in the US.

In 2023, more than 89,000 cases of Lyme disease were reported to the Centers for Disease Control and Prevention (CDC) by state health departments and the District of Columbia. However, these numbers come from routine national surveillance and may underrepresent the actual burden. The CDC estimates that approximately 476,000 people in the US are diagnosed with Lyme disease each year using other data collection methods.This number likely includes patients who are treated based on clinical suspicion but do not actually have Lyme disease, according to the federal agency.

To view the report, interested parties can go 



References
1. Research Funders Should Prioritize Finding Treatments to Ease Symptoms of Chronic Illnesses Associated with Lyme Disease, Not Wait for Certainty on Cause, Says New Report. National Academies of Sciences, Engineering, and Medicine. May 8, 2025. Accessed May 14, 2025.
https://www.nationalacademies.org/news/2025/05/research-funders-should-prioritize-finding-treatments-to-ease-symptoms-of-chronic-illnesses-associated-with-lyme-disease-not-wait-for-certainty-on-cause-says-new-report
 2. Lyme Disease Surveillance and Data. CDC March 13, 2025 Accessed May 14, 2025.
https://www.cdc.gov/lyme/data-research/facts-stats/index.html

A small percentage of people who contract the tick-borne illness have lingering symptoms and health issues after the acute infection has been treated, but there are no FDA-approved therapies to deal with prolonged symptoms. A new report looks to address this issue.  

New Report Calls For Funding Treatments, Greater Emphasis on Chronic Lyme Disease

More than 80% of adults support COVID-19 vaccination, but hesitancy linked to side effects, geopolitics, and misinformation remains a challenge, says lead researcher Mahmud Sheku, MPH, MSc.

More than 80% of adults in Sierra Leone said they would accept COVID-19 vaccines for themselves or their families, according to a study presented at the 2025 Annual Conference on Vaccinology Research. The study surveyed 2,146 adults to assess vaccine awareness, acceptance, and hesitancy.

Researchers from the University of Siena, the Sierra Leone Ministry of Health, and other institutions found that 75.2% of respondents were aware of COVID-19 vaccines, and acceptance rose to 85% when vaccination was required. Main reasons for acceptance included beliefs in safety, immunity, and trust in vaccines.

Although, hesitancy was also reported. It was linked to concerns about side effects, doubts about effectiveness, and skepticism about the pandemic itself, often influenced by social media and misinformation.

Mahmud Sheku, MPH, MSc, a PhD student at Emory University and lead investigator on the study, explained the origins of the work, “I conducted this study around December or January, during the COVID-19 pandemic, just as the vaccines were about to hit the market. I had just graduated from my master’s program in vaccinology. I was listening to people from different backgrounds and wanted to get a deeper understanding of what was happening.” What Sheku found was a deep undercurrent of distrust in vaccines depending on their country of origin,even when those vaccines were locally approved.

“There was a buildup of social media narratives and misinformation within communities. These narratives framed vaccines from certain countries as experimental and unsafe compared to others,” he said. “That developed into geopolitical perceptions. People came to believe that the vaccine manufacturing processes were uncertain or risky, and that taking such vaccines might harm them.”

According to the survey, while 32.4% of respondents were willing to accept vaccines from any country as long as they were approved locally, 15.1% said they would reject vaccines from China, 12.6% from India, and 11.4% from the United States. Smaller but notable percentages expressed distrust in vaccines originating in Germany, Russia, the United Kingdom, and Belgium.

To overcome such biases, Sheku emphasized the role of trusted local messengers, “We have to look at community leaders and professionals as trusted messengers. They can re-emphasize the importance of vaccines, how safe they are, and the rigorous approval processes they go through before being released to the public,” he said. “Each country has a national regulatory authority that independently reviews vaccine data before granting a local license. And vaccines approved by the WHO’s Emergency Use Listing have met all international safety and development standards.”

The study also revealed a widespread preference for vaccines with fewer side effects, reported by 55.7% of participants, even when this meant lower efficacy, “This reflects limited understanding in some communities about how vaccines work,” Sheku noted. “People need to understand the difference between protective efficacy and the reactogenic profile of vaccines.”

According to Sheku, vaccine education efforts must go beyond slogans and address the root of people’s concerns, “We should tailor messaging to specific populations using locally relevant content. Translate vaccine development concepts into local languages. Use targeted campaigns for communities with high hesitancy. Explain the stages of development and the role of all the agencies involved in ensuring vaccines are safe.”

The study’s findings, he believes, can support vaccine developers as well, “Safety is paramount. Developers should aim to minimize side effects where possible. But public trust also depends on education. People need to know that a side effect doesn’t mean the vaccine is unsafe—it’s just the immune system responding.”

Sheku M, Clemens R, Clemens SAC, Kargbo I, Swaray IB. COVID-19 vaccine acceptability: a cross-sectional mixed-methods study in Sierra Leone. Poster #25 presented at the 2025 Annual Conference on Vaccinology Research. May 5–7, 2025; Washington, DC.

Sharon Nachman, MD

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