Factors Affecting Functional Impairment among Elderly Germans - Results of a Longitudinal Study.

OBJECTIVE: To investigate causal factors of functional impairment in old age in a longitudinal approach. DESIGN: A population-based prospective cohort study. SETTING: Elderly individuals were recruited via GP offices at six study centers in Germany. They were observed every 1.5 years over six waves. PARTICIPANTS: Three thousand two hundred fifty-six people aged 75 years and older at baseline. MEASUREMENTS: Functional impairment was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale (IADL) and the Barthel-Index (BI). RESULTS: Fixed effects regressions revealed that functional impairment (IADL; BI) increased significantly with ageing (ß=-.2; ß=-1.1), loss of a spouse (ß= .5; ß=-3.1), not living alone in private household (ß=-1.2; ß=-5.5), depression (solely significant for IADL: ß= .6) and dementia (ß=-2.3; ß=-18.2). The comorbidity score did not affect functional impairment. CONCLUSION: Our findings underline the relevance of changes in sociodemographic variables as well as the occurrence of depression or dementia for functional impairment. While several of these causal factors for functional decline in the oldest old are inevitable, some may not be, such as depression. Therefore, developing interventional strategies to prevent depression might be a fruitful approach in order to delay functional impairment in old age.

Evaluation of dengue virus strains for human challenge studies.

Discordance between the measured levels of dengue virus neutralizing antibody and clinical outcomes in the first-ever efficacy study of a dengue tetravalent vaccine (Lancet, Nov 2012) suggests a need to re-evaluate the process of pre-screening dengue vaccine candidates to better predict clinical benefit prior to large-scale vaccine trials. In the absence of a reliable animal model and established correlates of protection for dengue, a human dengue virus challenge model may provide an approach to down-select vaccine candidates based on their ability to reduce risk of illness following dengue virus challenge. We report here the challenge of flavivirus-naïve adults with cell culture-passaged dengue viruses (DENV) in a controlled setting that resulted in uncomplicated dengue fever (DF). This sets the stage for proof-of-concept efficacy studies that allow the evaluation of dengue vaccine candidates in healthy adult volunteers using qualified DENV challenge strains well before they reach field efficacy trials involving children. Fifteen flavivirus-naïve adult volunteers received 1 of 7 DENV challenge strains (n=12) or placebo (n=3). Of the twelve volunteers who received challenge strains, five (two DENV-1 45AZ5 and three DENV-3 CH53489 cl24/28 recipients) developed DF, prospectively defined as ≥2 typical symptoms, ≥48h of sustained fever (>100.4°F) and concurrent viremia. Based on our study and historical data, we conclude that the DENV-1 and DENV-3 strains can be advanced as human challenge strains. Both of the DENV-2 strains and one DENV-4 strain failed to meet the protocol case definition of DF. The other two DENV-4 strains require additional testing as the illness approximated but did not satisfy the case definition of DF. Three volunteers exhibited effusions (1 pleural/ascites, 2 pericardial) and 1 volunteer exhibited features of dengue (rash, lymphadenopathy, neutropenia and thrombocytopenia), though in the absence of fever and symptoms. The occurrence of effusions in milder DENV infections counters the long-held belief that plasma leakage syndromes are restricted to dengue hemorrhagic fever/dengue shock syndromes (DHF/DSS). Hence, the human dengue challenge model may be useful not only for predicting the efficacy of vaccine and therapeutic candidates in small adult cohorts, but also for contributing to our further understanding of the mechanisms behind protection and virulence.

A human challenge model for dengue infection reveals a possible protective role for sustained interferon gamma levels during the acute phase of illness.

Dengue has recently been defined by the World Health Organization as a major international public health concern. Although several vaccine candidates are in various stages of development, there is no licensed vaccine available to assist in controlling the further spread of this mosquito borne disease. The need for a reliable animal model for dengue disease increases the risk to vaccine developers as they move their vaccine candidates into large-scale phase III testing. In this paper we describe the cellular immune responses observed in a human challenge model for dengue infection; a model that has the potential to provide efficacy data for potential vaccine candidates in a controlled setting. Serum levels of sIL-2Rα and sTNF-RII were increased in volunteers who developed illness. Supernatants from in vitro stimulated PBMC were tested for cytokines associated with a T(H)1 or T(H)2 T-cell response (IL-2, TNF-α, IFN-γ, IL-4, IL-10, IL-5) and only IFN-γ was associated with protection against fever and/or viremia. Interestingly, IFN-γ levels drop to 0 pg/mL for volunteers who develop illness after challenge suggesting that some mechanism of immunosuppression may play a role in dengue illness. The human challenge model provides an opportunity to test potential vaccine candidates for efficacy prior to large-scale phase III testing, and hints at a possible mechanism for immune suppression by dengue.

Presymptomatic prediction of sepsis in intensive care unit patients.

Postoperative or posttraumatic sepsis remains one of the leading causes of morbidity and mortality in hospital populations, especially in populations in intensive care units (ICUs). Central to the successful control of sepsis-associated infections is the ability to rapidly diagnose and treat disease. The ability to identify sepsis patients before they show any symptoms would have major benefits for the health care of ICU patients. For this study, 92 ICU patients who had undergone procedures that increased the risk of developing sepsis were recruited upon admission. Blood samples were taken daily until either a clinical diagnosis of sepsis was made or until the patient was discharged from the ICU. In addition to standard clinical and laboratory parameter testing, the levels of expression of interleukin-1beta (IL-1beta), IL-6, IL-8, and IL-10, tumor necrosis factor-alpha, FasL, and CCL2 mRNA were also measured by real-time reverse transcriptase PCR. The results of the analysis of the data using a nonlinear technique (neural network analysis) demonstrated discernible differences prior to the onset of overt sepsis. Neural networks using cytokine and chemokine data were able to correctly predict patient outcomes in an average of 83.09% of patient cases between 4 and 1 days before clinical diagnosis with high sensitivity and selectivity (91.43% and 80.20%, respectively). The neural network also had a predictive accuracy of 94.55% when data from 22 healthy volunteers was analyzed in conjunction with the ICU patient data. Our observations from this pilot study indicate that it may be possible to predict the onset of sepsis in a mixed patient population by using a panel of just seven biomarkers.

Anomalous changes in forward scatter of lymphocytes with loosely packed membranes.

BACKGROUND: Forward scatter (FSC) is generally associated with cell size and has been suggested as a way to differentiate apoptotic from viable cells. Among spleen cells cultured for 48 h, a population of cells (population B) was found to have decreased forward and increased side scatter relative to freshly purified cells (population A). Interestingly, population B was not present early in analysis; this report explores the change in FSC of population B. METHODS: Using a Coulter (Hialeah, FL) Epics Elite ESP flow cytometer, changes in forward scatter and lipid packing of spleen cells were measured. RESULTS: Over time, the FSC of unfixed cells in population B increased from that of the debris field, to reach a stable value by 30 sec (population A's FSC remained constant). When fixed, populations A and B exhibited constant FSC. Population B cells displayed altered lipid packing as reported by MC540, and the FSC changes were mimicked by Nonidet P-40 treatment of freshly purified spleen cells. CONCLUSIONS: Data emphasize the importance of delaying measurements on unfixed cells until FSC readings have stabilized, and suggest that flow cytometry may be a useful tool in studying lipid packing.

The triggering signal dictates the effect of docosahexaenoic acid on lymphocyte function in vitro.

Docosahexaenoic acid (DHA) is an n-3 fatty acid beneficial to several human conditions including inflammation and autoimmune disease. To better understand the effect of DHA on immunity, we monitored the rise in cytosolic free calcium, interleukin 2 receptor (IL2R) expression, and proliferation of splenic lymphocytes triggered with three different stimuli in the presence or absence of DHA. We found that 10 microg DHA/mL suppressed concanavalin A-induced mitogenesis and the mixed lymphocyte reaction while concurrently enhancing proliferation stimulated with anti-Thy-1 antibodies. Proliferation, as measured by [3H]thymidine incorporation after 2 to 5 d of culture, was affected by DHA, but earlier activation effects such as elevation of cytosolic free calcium and IL2R expression were not altered. These results imply that DHA incorporated into membrane phospholipids differentially affects the activity of distinct membrane-bound receptors and signaling molecules. This result suggests that DHA may be used to modulate immune responses selectively, e.g., to suppress undesired autoimmunity while maintaining protective immunity.

Spleen cell survival and proliferation are differentially altered by docosahexaenoic acid.

Omega-3 fatty acids have diverse health benefits that are not clearly understood. In this study we have examined the effects of the omega-3 fatty acid docosahexaenoic acid (DHA) on mitogen-activated and resting splenic lymphocytes. DHA inhibited lymphocyte proliferation, producing an apparent block or prolongation of S phase, without evidence for direct cytotoxicity. In contrast, DHA enhanced the survival of resting lymphocytes in culture without inducing cell cycling. When DHA was added at the start of culture, the survival advantage was apparent for 2 to 3 days, after which time typical lymphocyte attrition occurred. Using flow cytometry we observed that both T and B cell recoveries were increased by DHA, but there were DHA dose-dependent alterations of forward- and side-scatter characteristics, with some preference for B cells, perhaps indicating altered membrane properties. Our data imply that DHA may check ongoing immune response while concurrently preserving resting lymphocytes needed for subsequent immune responses.