Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Prominent Neutralizing Antibody Response Targeting the Ebolavirus Glycoprotein Subunit Interface Elicited by Immunization

The severe death toll caused by the recent outbreak of Ebola virus disease reinforces the importance of developing ebolavirus prevention and treatment strategies. Here, we have explored the immunogenicity of a novel immunization regimen priming with vesicular stomatitis virus particles bearing Sudan Ebola virus (SUDV) glycoprotein (GP) that consists of GP1 & GP2 subunits and boosting with soluble SUDV GP in macaques, which developed robust neutralizing antibody (nAb) responses following immunizations. Moreover, EB46, a protective nAb isolated from one of the immune macaques, is found to target the GP1/GP2 interface, with GP-binding mode and neutralization mechanism similar to a number of ebolavirus nAbs from human and mouse, indicating that the ebolavirus GP1/GP2 interface is a common immunological target in different species. Importantly, selected immune macaque polyclonal sera showed nAb specificity similar to EB46 at substantial titers, suggesting that the GP1/GP2 interface region is a viable target for ebolavirus vaccine.Importance: The elicitation of sustained neutralizing antibody (nAb) responses against diverse ebolavirus strains remains as a high priority for the vaccine field. The most clinically advanced rVSV-ZEBOV vaccine could elicit moderate nAb responses against only one ebolavirus strain, EBOV, among the five ebolavirus strains, which last less than 6 months. Boost immunization strategies are desirable to effectively recall the rVSV vector-primed nAb responses to prevent infections in prospective epidemics, while an in-depth understanding of the specificity of immunization-elicited nAb responses is essential for improving vaccine performance. Here, using non-human primate animal model, we demonstrated that booster immunization with a stabilized trimeric soluble form of recombinant glycoprotein derived from the ebolavirus Sudan strain following the priming rVSV vector immunization led to robust nAb responses that substantially map to the subunit interface of ebolavirus glycoprotein, a common B cell repertoire target of multiple species including primates and rodents.

BIKE regulates dengue virus infection and is a cellular target for broad-spectrum antivirals

Global health is threatened by emerging viruses, many of which lack approved therapies and effective vaccines, including dengue, Ebola, and Venezuelan equine encephalitis. We previously reported that AAK1 and GAK, two of the four members of the understudied Numb-associated kinases (NAK) family, control intracellular trafficking of RNA viruses. Nevertheless, the role of BIKE and STK16 in viral infection remained unknown. Here, we reveal a requirement for BIKE, but not STK-16, in dengue virus (DENV) infection. BIKE mediates both early (postinternalization) and late (assembly/egress) stages in the DENV life cycle, and this effect is mediated in part by phosphorylation of a threonine 156 (T156) residue in the μ subunit of the adaptor protein (AP) 2 complex. Pharmacological compounds with potent anti-BIKE activity, including the investigational anticancer drug 5Z-7-oxozeaenol and more selective inhibitors, suppress DENV infection both in vitro and ex vivo. BIKE overexpression reverses the antiviral activity, validating that the mechanism of antiviral action is, at least in part, mediated by BIKE. Lastly, 5Z-7-oxozeaenol exhibits antiviral activity against viruses from three unrelated RNA viral families with a high genetic barrier to resistance. These findings reveal regulation of poorly understood stages of the DENV life cycle via BIKE signaling and establish a proof-of-principle that pharmacological inhibition of BIKE can be potentially used as a broad-spectrum strategy against acute emerging viral infections.

Equivalence of Assurance® Gold Enzyme Immunoassay for Visual or Instrumental Detection of Motile and Nonmotile Salmonella in All Foods to AOAC Culture Method: Collaborative Study

Six foods representative of a wide variety of processed, dried powder processed, and raw food types were analyzed by the Assurance® Gold Salmonella Enzyme Immunoassay (EIA) and AOAC INTERNATIONAL culture method. Paired samples of each food type were simultaneously analyzed; one sample by the Assurance method and one by the AOAC culture method. The results for Assurance method were read visually and instrumentally with a microplate reader. A total of 24 laboratories representing federal government agencies and private industry, in the United States and Canada, participated in this collaborative study. Food types were inoculated with species of Salmonella with the exception of raw ground chicken, which was naturally contaminated. No statistical differences (p < 0.05) were observed between Assurance Gold Salmonella EIA with either visual or instrumental interpretation and the AOAC culture method for any inoculation level of any food type or naturally contaminated food. The Assurance visual and instrumental options of reading sample reactions produced the same results for 1277 of the 1296 sample and controls analyzed.

AAK1 and GAK inhibitors demonstrate activity against Filoviruses

Ebola virus (EBOV) and Marburg virus (MARV) are highly pathogenic members of the family filoviridae. The recent West Africa epidemic of Ebola virus disease was a grave reminder of the unmet need for post exposure therapeutics to combat filovirus infection. Our group has reported that multiple unrelated viruses, including EBOV, commandeer host kinases AP2-associated protein kinase-1 (AAK1) and cyclin G-associated kinase (GAK) during viral entry, assembly, and/or egress. This shared attribute makes AAK1 and GAK desirable broad-spectrum targets for the treatment of multiple viral infections without necessitating species identification. As the targets of these inhibitors are host cell factors, this may allow for the reduction in the likelihood that the virus will develop drug resistance. We have demonstrated that treatment with sunitinib and erlotinib, approved anticancer drugs with anti-AAK1 or GAK activity, is effective in inhibiting replication of Ebola, Hepatitis C and Dengue (DENV) viruses in vitro. Additionally, the combination of sunitinib and erlotinib has demonstrated efficacy in reducing morbidity and mortality following challenge with EBOV and DENV in the relevant mouse models. In an effort to improve toxicity and survival, we are developing novel, chemically distinct, more selective inhibitors of AAK1 and GAK. Here we describe the capability of these next generation AAK1 and GAK inhibitors to reduce in vitro infection of Ebola virus and Marburg virus.

Pan-filovirus monoclonal antibody cocktail protects against lethal challenge with Marburg virus in non-human primates

While disregarded in the past, the use of antibody therapeutics in the treatment of filovirus infection has been gaining traction in recent years. Early studies in our lab with the treatment of non-human primates (NHPs) with polyclonal antibodies from convalescent NHPs demonstrated protection against challenges with a lethal dose of Ebola virus (EBOV). Successes with monoclonal antibody (mAb) cocktails such as ZMapp™ have encouraged the development of a cocktail that may be protective against multiple species of filovirus. This may ultimately allow for the prepositioning of a single cocktail in filovirus prone locations, rather than storing and maintaining multiple cocktails at each location. We have previously described three antibodies, FVM04 and CA45, which can neutralize multiple species of ebolavirus, and MR191, which can neutralize marburgviruses, and have shown efficacy in rodent and NHP models of filovirus disease. In this study, we evaluated the efficacy of a pan-ebolavirus cocktail (FVM04+CA45) in combination with the Marburg virus specific mAb MR191 in a pan-filovirus cocktail (FVM04+CA45+MR191), in the NHP model of Marburg virus disease. Both the pan-ebolavirus and pan-filovirus cocktails have been shown to be efficacious against lethal challenge with Sudan virus (SUDV) or EBOV in the rhesus macaque model. These data are the first to demonstrate protective efficacy of MR191 as part of a pan-filovirus cocktail against MARV in the NHP model of disease.

Cytokine and chemokine profiles in a human respiratory disease model of Ebola virus

Category A agents, such as Ebola virus, pose a great risk to national security because of high rates of transmission and mortality and the gravity of impact to public health. The use of Ebola virus as a bioweapon is a significant concern, and rapid diagnostics, safe vaccines, and efficacious therapeutics are needed. The Mucosal Tissue Equivalent (MTE) component of the MIMIC™ lung mucosal model is an in vitro/ex vivo respiratory tissue model comprised of human lung epithelial cells that mimics the vascularized lower airway alveolar tissue micro-environment. The use of the MTE allows for the inclusion of human immune components, which may be a better predictor of the human immune response than animal models. In this study, Ebola virus was applied at the air-liquid interface of the differentiated human epithelium and expression of cytokines was measured. Peripheral blood mononuclear cells (PBMCs) were applied to apical layer of the MTEs prior to inoculation with Ebola virus (Kikwit). We quantified cytokines and chemokines using supernatants serially collected on days 0, 3, 6, 9, and 15 post infection. In the infected MTEs containing human PBMCs, we detected pro-inflammatory cytokines, colony stimulating factors and endothelial growth factors. This “cytokine storm” would be expected to play a role in inflammation, recruitment of cells to the site of infection, and induction of a specific immune response to acute viral infection in humans. This human lung infection model will be used to evaluate existing therapeutic antibody and vaccine candidates for Ebola virus. Going forward, this system may provide a more rapid, relevant and cost effective means to evaluate vaccine candidates than can be accomplished by using animal models.

An in vitro/ex vivo human lung infection model for studying the macrophage innate immune response to Ebola virus Kikwit

Ebola virus causes a severe and often fatal hemorrhagic fever in people, for which no approved vaccines or therapeutics are available. Disease pathogenesis and countermeasure studies are typically performed using animal models; however, ex vivo models recapitulating human immune responses may provide valuable information. We optimized engineered lung tissue constructs comprised of human lung epithelial cells and human endothelial cells that mimic the vascularized lower airway alveolar tissue micro-environment to study the human innate immune response to Ebola virus Kikwit (EBOV/Kik). Human lung tissue macrophages are difficult to obtain due to practical and ethical considerations, so macrophages were chemically derived from human monocytes. We inoculated the constructs, in the presence and absence of monocyte derived macrophages (MDM), and quantified cytokines/chemokines secreted on days 0, 3, 6, 9, and 15 post-infection using 29-plex and 1-plex human cytokine/chemokine kits. Prior to infection, MDM were secreting IL-13, MCP-1, MIP-1a, MIP-1b; however, these levels rapidly declined by day 3 post-infection (pi). The MDM secreted peak levels of IL-4, IFN-a2, Eotaxin, IL-12P40, and IFNg at day 6pi, and IL-1ra peaked at day 9 pi. In response to EBOV/Kik, the human lung epithelial cells in the engineered lung tissue construct secreted G-CSF, IL-1ra, IL-8, IP-10, and PDGF-AA/BB. G-CSF and IL-8, cytokines known to mobilize hematopoietic progenitors from bone marrow to blood and recruit neutrophils to sites of infection, were abundantly secreted by both endothelial cells and macrophages in response to infection. This model system may be a valuable resource to the field to study human immune responses during acute infections.

Anticancer kinase inhibitors impair intracellular viral trafficking and exert broad-spectrum antiviral effects

Global health is threatened by emerging viral infections, which largely lack effective vaccines or therapies. Targeting host pathways that are exploited by multiple viruses could offer broad-spectrum solutions. We previously reported that AAK1 and GAK, kinase regulators of the host adaptor proteins AP1 and AP2, are essential for hepatitis C virus (HCV) infection, but the underlying mechanism and relevance to other viruses or in vivo infections remained unknown. Here, we have discovered that AP1 and AP2 cotraffic with HCV particles in live cells. Moreover, we found that multiple viruses, including dengue and Ebola, exploit AAK1 and GAK during entry and infectious virus production. In cultured cells, treatment with sunitinib and erlotinib, approved anticancer drugs that inhibit AAK1 or GAK activity, or with more selective compounds inhibited intracellular trafficking of HCV and multiple unrelated RNA viruses with a high barrier to resistance. In murine models of dengue and Ebola infection, sunitinib/erlotinib combination protected against morbidity and mortality. We validated sunitinib- and erlotinib-mediated inhibition of AAK1 and GAK activity as an important mechanism of antiviral action. Additionally, we revealed potential roles for additional kinase targets. These findings advance our understanding of virus-host interactions and establish a proof of principle for a repurposed, host-targeted approach to combat emerging viruses.

A double blind clinical trial of Iloprost during cardiopulmonary bypass

Twenty patients undergoing elective coronary surgery were randomized to receive either the prostacyclin analogue Iloprost (Zk 36374) 5 ng/kg/min for 30 minutes before cardiopulmonary bypass (CPB) increasing to 10 ng/kg/min during CPB, or placebo, to investigate any beneficial effect on platelet preservation, or protection of the central nervous system during clinical CPB. Originally 50 patients were to have entered the trial, but unacceptable hypotensive effects occu rred in five patients who received Iloprost, lead i ng to early data analysis. No significant improvement in platelet number, volume or function; bleeding time; arterial line filter δ dry weight; retinal microembolism; or neuropsychological function, attributable to Iloprost, could be identified. The role and optimal dose of Iloprost in clinical CPB remains to be established.

Genetic, biochemical, and structural characterization of a new densovirus isolated from a chronically infected Aedes albopictus C6/36 cell line

We report the isolation, sequencing, biochemical, and structural characterization of a previously undescribed virus in a chronically infected Aedes albopictus C6/36 cell line. This virus is identified as a new densovirus under the Densovirinae subfamily of the Parvoviridae based on its biological and morphologic properties as well as sequence homologies, and is tentatively designated A. albopictus C6/36 cell densovirus (C6/36 DNV). Analysis of the 4094 nt of the C6/36 DNV genome revealed that the plus strand had three large open reading frames (ORFs): a left ORF, a right ORF, and a mid-ORF (within the left ORF), whose potential coding capacities are 91.0, 40.8, and 41.2 kDa, respectively. The left ORF likely encodes the nonstructural protein NS-1, which contains NTP-binding and helicase domains. The right ORF likely encodes structural proteins, VP1 and VP2. Our analyses revealed that C6/36 DNV has a similar genomic organization and shares very high homology in nucleotide sequence and amino acid sequences with Aedes aegypti densovirus (AaeDNV) and A. albopictus densovirus (AalDNV), members of the genus Brevidensovirus of the Densovirinae. Similar to other densoviruses, C6/36 DNV has a different genomic organization and no recognizable sequence homology with viruses in the Parvovirinae. The three-dimensional (3D) reconstruction of the C6/36 DNV at 15.6-A resolution by electron cryomicroscopy (cryoEM) revealed distinctive outer surface features not previously seen in other parvoviruses, indicating structural divergence of densoviruses, in addition to its genomic differences, while the inner surface of the C6/36 DNV capsid exhibits features that are conserved among parvoviruses.

A new method for bronchial-provocation testing in asthmatic subjects using a dry powder of mannitol

We developed a bronchial provocation test (BPT) with a dry powder preparation of mannitol. The mannitol was inhaled from gelatin capsules containing 5, 10, 20, or 40 mg to a cumulative dose of 635 mg, and was delivered via an inhalator, Halermatic, or Dinkihaler device. We studied the airway sensitivity to inhaled mannitol, the repeatability of the response, and the recovery after challenge in 43 asthmatic subjects 18 to 39 yr of age who had a 20% decrease in FEV1 in response to inhaling a 4.5% NaCl. We compared this with the airway response to methacholine in 25 subjects. The geometric mean (GM) for the dose of dry mannitol required to reduce the FEV1 by 15% of the baseline value (PD15) was 64 mg, with a 95% confidence interval (CI) of 45 to 91. Subjects responsive to mannitol had a PD20 to metacholine of < 7.8 mumol, with a GM of 0.7 mumol (CI: 0.4 to 1.2). For the first of two challenges to mannitol the PD15 was 59 mg (CI: 36 to 97) and for the second the PD15 was 58 mg (CI: 35 to 94) p = 0.91 (n = 23). Spontaneous recovery to within 5% of baseline occurred within 60 min and within 10 min after 0.5 mg terbutaline sulfate was inhaled. Arterial oxygen saturation (SaO2) remained at 93% or above during mannitol challenge. Subjects tolerated the inhalation of the mannitol well. A dry powder preparation of mannitol may be suitable to develop for bronchial provocation testing.

Survival and cause of death after mitral valve replacement in patients aged 80 years and over: collective results from the UK heart valve registry

OBJECTIVE

Over the last decade there has been an increasing number of patients aged 80 years and over undergoing heart valve replacement. However, literature on the outcome of mitral valve replacement (MVR) in this age group is still limited.

METHODS

We conducted the present study by analysing data extracted from the UK Heart Valve Registry. From January 1986 to December 1994, 86 patients underwent isolated MVR and 10 underwent combined MVR with aortic valve replacement (AVR) and were reported to the Registry.

RESULTS

The 30 day mortality was 10.4% (9/86) in the MVR group and 10% (1/10) in the MVR and AVR group. The actuarial survival was 79.8, 64.1 and 40.7% at 1, 3 and 5 years, respectively, in the MVR group. Of the 10 early (30 day) deaths, 8 were due to cardiac reasons and 19 of the 28 late deaths were due to non-cardiac reasons. A total of 55 (57.2%) patients received a bioprosthetic valve implant and 41 (42.8%) patients received a mechanical valve implant. There was no difference in survival between the two groups.

CONCLUSIONS

The above results suggest that MVR in octogenarians produces a satisfactory early postoperative outcome and moderate medium-term benefit. There is no difference in survival between patients receiving bioprosthetic and patients receiving mechanical valve implants.

Hypertonic saline challenge in an adult epidemiological survey

Bronchial provocation tests using pharmacological agents such as methacholine or histamine are used in epidemiological studies to identify asthma despite recognition of limitations in specificity, positive predictive value and availability of reagents. Hypertonic saline (4.5%) bronchial challenge (HSBC), although less sensitive than pharmacological challenges, is reportedly highly specific in diagnosing current asthma. Added advantages are that reagents are cheap, stable and recognized by participants. Thus, HSBC may offer benefits over pharmacological tests in epidemiological surveys. This paper reports on the second field survey using the test, a study of 99 adults from the timber industry in Western Australia. The test is described and critically appraised as a practical epidemiological tool for assessing asthma prevalence. At a cutoff point of 20% FEV, fall, HSBC was positive in 8% of subjects, appeared specific for asthma, was safe, well-accepted and easy to use in the field.

Genetically engineered serine protease inhibitor for hemostasis after cardiac operations

BACKGROUND

The serine protease inhibitor aprotinin has been widely reported for its beneficial action in limiting blood loss after cardiopulmonary bypass (CPB). A potent human serine protease inhibitor known as protease nexin II or amyloid precursor protein has been recently isolated. A recombinant protein known as recombinant Kunitz protease inhibitor (rKPI; Scios Nova, Mountain View, CA) with sequence homology to the protease nexin II-amyloid precursor protein molecule has been manufactured.

METHODS

Recombinant Kunitz protease inhibitor was assessed in an ovine model of CPB as a hemostatic agent after CPB. Sheep (n = 22) underwent CPB for 90 minutes. Two thoracic drains were sited and drain losses collected for a period of 3 hours after CPB. Wounds were subjectively assessed before closure for "dryness" using a visual analogue scale. Sheep were randomized to control (n = 8), aprotinin (n = 8), and rKPI (n = 6) groups.

RESULTS

Control animals had a drain loss of 409.4 +/- 39.4 mL/3 h, compared with 131.3 +/- 20.3 mL/3 h for the aprotinin group and 163.7 +/- 34.3 mL/3 h for the rKPI group (p = 0.16). Hemoglobin loss was 11.6 +/- 3.6, 6.02 +/- 2.1, and 4.6 +/- 1.2 g/3 h for the control, rKPI, and aprotinin groups respectively (p = 0.25). The subjective analysis of the wounds at the end of CPB found aprotinin (1.25 +/- 0.16; p < 0.05) and rKPI (1.17 +/- 0.17; p < 0.05) animals to score significantly lower than control animals (2.63 +/- 0.42).

CONCLUSIONS

On the basis of these in vivo findings, genetic modification may yield a more efficacious serine protease inhibitor with the inherent advantages of using a human-based protein.

Effects of cardiopulmonary bypass on gut blood flow, oxygen utilization, and intramucosal pH

Studies documenting rises in endotoxin after cardiopulmonary bypass (CPB) have postulated gut mucosal hypoperfusion. We have investigated alterations in jejunal blood flow by laser Doppler flow measurement, intramucosal pH (pHi) by tonometry, and oxygen utilization in a canine model of hypothermic CPB (n = 11 dogs). After 10 minutes of hypothermic CPB, despite no major reduction in superior mesenteric artery flow, mucosal laser Doppler flow decreased to -38.2% +/- 9.3% of levels obtained before bypass (p = 0.008) and serosal laser Doppler flow, to -47.3% +/- 11.4% (p = 0.006). During the hypothermic phase, mesenteric oxygen consumption fell from 0.18 +/- 0.01 to 0.098 +/- 0.01 mL.min-1.kg-1 (p = 0.005), and mesenteric oxygen delivery fell from 1.97 +/- 0.39 to 1.14 +/- 0.12 mL.min-1.kg-1 (p = 0.05). There was no change in jejunal pHi. During the rewarming phase, there was a substantial increase in mucosal laser Doppler flow, peaking at +69.8% +/- 15.2% (p = 0.03), whereas serosal laser Doppler flow returned to values seen prior to CPB (-16.4% +/- 21.5%; p = 0.25). These changes coincided with a surge in oxygen consumption (0.33 +/- 0.042 mL.min-1.kg-1; p = 0.009), while mesenteric oxygen delivery remained depressed at 1.09 +/- 0.12 mL.min-1.kg-1 (p = 0.04). Jejunal pHi fell from a value of 7.36 +/- 0.04 before CPB to 7.12 +/- 0.07 (p = 0.02), thus indicating mucosal hypoxia. During the rewarming phase of hypothermic CPB, there is a disparity between mesenteric oxygen consumption and oxygen delivery with villus tip ischemia; these findings may explain the pathophysiology of endotoxemia during CPB.

Retinal periphlebitis in multiple sclerosis

BACKGROUND

The ocular and visual manifestations of multiple sclerosis are varied. The most uncommon is sheathing of the veins, periphlebitis.

METHODS

A 39-year-old white female presented with primary visual complaints of contrast problems on a computer terminal. The patient was lost to follow up for 4 years, however, upon return a clinical diagnosis of multiple sclerosis was confirmed. Six years after the initial presentation, ophthalmoscopic exam of both eyes revealed marked focal sheathing of the retinal veins in the periphery, and associated hemorrhages in the right eye.

RESULTS

During follow-up, the left eye became further involved developing hemorrhages and a retinal hole, which was treated. The visual consequence of the multiple sclerosis as a result of further exacerbations were bilateral centrocecal scotomas and midly reduced visual acuity.

CONCLUSIONS

Multiple sclerosis should be considered in the differential diagnosis of patients with retinal periphlebitis.