Post-discharge nausea and vomiting after total intravenous anaesthesia and standardised PONV prophylaxis for ambulatory surgery.

BACKGROUND: The incidence of post-discharge nausea and vomiting (PDNV) after ambulatory anaesthesia using total intravenous anaesthesia with a risk-stratified anti-emetic approach is not well documented in the literature. In this study, we outline such an approach. The goal was to achieve an acceptably low rate of PDNV both immediately and the day after surgery. METHODS: With ethics committee approval, adult patients undergoing outpatient surgery received a Propofol-based general anaesthetic plus standardised PONV-prophylaxis corresponding to their Apfel risk-score (0-4); ondansetron (risk-score 2), additional dexamethasone (risk-score 3), and additional droperidol (risk-score 4). On post-operative days one and two, patients scored PDNV and pain (numeric rating scale (NRS); 0 = none at all; 10 = worst imaginable). On post-operative day two, patients indicated the level of interference of PDNV and/or pain with their quality of life. Data are descriptive (%) or mean. RESULTS: There were 222 patients included (age 43 years, 44% female, anaesthesia time 95 min). On the day of surgery, 69.4% of patients did not experience any nausea, 10.4% complained about severe (NRS > 6) nausea, 6.3% experienced vomiting or retching. On the first and second postoperative day, nausea was absent in 88.7% of patients and 97.3%, respectively. Quality of life was impacted (NRS ≥ 4) more by pain (32.8% of cases), than by PDNV (13.6%). CONCLUSION: Acceptably low rates of PDNV were achieved with the proposed standardised approach to PDNV prophylaxis. For almost 90% of patients, PDNV was not an issue the first day after surgery. Pain after discharge was a more common problem.

Development of Leptospira in vitro potency assays: EU/industry experience and perspectives.

Nobivac® Lepto (MSD Animal Health) is a non-adjuvanted canine leptospirosis vaccine containing inactivated whole cells of Leptospira interrogans serogroup Canicola serovar Portlandvere and L. interrogans serogroup Icterohaemorrhagiae serovar Copenhageni. The current standard in vivo potency test is a hamster challenge test associated with major drawbacks such as animal suffering and poor reproducibility. Here, the quantification of antigenic mass by ELISA as a new in vitro potency test is described, supporting the 3Rs concept (replacement, reduction, and refinement of animal tests) and in accordance with European Pharmacopoeia Monograph 0447 (Canine Leptospirosis Vaccine [Inactivated]). The two corresponding sandwich ELISAs are based on monoclonal antibodies specific for immunodominant leptospiral lipopolysaccharide epitopes. Protection in passive immunization experiments demonstrate that these monoclonal antibodies recognize key protective antigens in currently licensed human and veterinary whole cell Leptospira vaccines. The high precision and robustness renders the two ELISAs much more reliable correlates of potency in dogs than the hamster potency test. The recent approval of these assays for a new canine leptospirosis vaccine is an important contribution to the 3Rs in quality control testing of Leptospira vaccines.

Differentiating infection from vaccination in foot-and-mouth-disease: evaluation of an ELISA based on recombinant 3ABC.

Recent devastating outbreaks of foot-and-mouth disease (FMD) in Europe have reopened the discussion about the adequacy of the non-vaccination strategy implemented by the EU in 1991. Here we describe the evaluation of a new commercially available test kit for the discrimination between vaccination and infection. The test is based on the detection of antibodies against the recombinant non-structural (NS) protein 3ABC. In contrast to immunization with vaccines free of 3ABC, these antibodies are elicited as a consequence of infection. Testing more than 3600 negative sera from several countries revealed a specificity of > 99% for bovine, ovine, and porcine samples. Antibodies specific for 3ABC can be detected as soon as 10 days post-infection. As compared with the occurrence of antibodies against structural proteins of FMDV, anti-3ABC antibodies can be detected 5-10 days later, depending on the species. No anti-3ABC antibodies were detected in sera from vaccination experiments or in field sera from vaccinated animals. However, anti-3ABC antibodies can be detected in vaccinated animals upon challenge. These results provide evidence that this test can facilitate the use of vaccines in new strategies against FMD.

Detection of specific Mycoplasma conjunctivae antibodies in the sera of sheep with infectious keratoconjunctivitis.

The serological cross reactions between Mycoplasma conjunctivae, the etiological agent of infectious keratoconjunctivitis (IKC), and the antigenetically and phylogenetically closely related Mycoplasma ovipneumoniae, which is often found in sheep, were analysed. Cross reacting antigens were identified using sera from sheep with IKC and from sheep of herds known to be free of IKC, as well as rabbit hyperimmune serum specific to the two Mycoplasma species. Cross reactions were predominantly due to the strongly antigenic proteins of 42 kDa and 83 kDa. Serospecific antigens of M. conjunctivae could be separated from cross-reacting antigens by the extraction of Tween 20-soluble membrane proteins. The Tween 20-extracted proteins of the M. conjunctivae strain HRC/581T were used for the development of an indirect ELISA test. This ELISA test was shown to be a useful serological method for the diagnosis of M. conjunctivae infections and to identify infected sheep herds.

[The seroprevalence of Mycoplasma bovis in lactating cows in Switzerland, particularly in the republic and canton of Jura]. / Etude sur la séroprévalence de Mycoplasma bovis chez la vache laitière en Suisse, en particulier dans la République et Canton du Jura.

Sporadic cases of infection with Mycoplasma bovis have been observed in Switzerland since 1983. However, five severe outbreaks of endemic mastitis in a geographically distinct, small region (Canton du Jura) during the period 1995 to 1997 prompted the present investigation on the seroprevalence of infection with M. bovis among milking cows in Switzerland. A commercially prepared indirect enzyme immunoassay was used. Among a stratified random sample of 118 herds of milking cows in Switzerland, at least one positive animal was detected in 56 (47%) of the herds, whereas 6.1% of the 1816 individual animals tested positive. An epidemiological study was performed in the Canton du Jura region among 51 herds in order to assess the importance of management factors in the spread of M. bovis infection. The herd-level prevalence was 78%, and the seroprevalence at the level of the 1354 individual animals tested was 13.4%. A multivariate analysis of possible risk factors showed purchase of animals to be the only variable significantly associated with serological status of the herd with an "odds ratio" of 10.8.

Affinities of endotoxin-specific human monoclonal antibodies, their polyclonal counterparts and murine monoclonal antibodies.

Affinity as a measurement of the strength of binding is a crucial factor in biological significance. In general, high-affinity antibodies are most effective in mediating immunological effector mechanisms. Here, we compare the affinity distributions of corresponding polyclonal and monoclonal human antibodies specific for lipopolysaccharide determinants of the nosocomial pathogen Pseudomonas aeruginosa. The affinities of the 14 human mAb analysed ranged from 8.3 x 10(5) to 7.5 x 10(8). The average affinities of their polyclonal counterparts, assessed by analysing chromatographically separated antibody populations, ranged from 1.7 x 10(6) to 6.3 x 10(7). Furthermore, the affinities of murine mAb of the same specificity ranged from 3.7 x 10(5) to 1.4 x 10(7). These results suggest that the generated human monoclonal anti-carbohydrate antibodies exhibit affinities comparable to or higher than those of their human polyclonal counterparts and those of murine mAb of the same specificity.

Immunotherapy with human monoclonal antibodies. Fragment A specificity of polyclonal and monoclonal antibodies is crucial for full protection against tetanus toxin.

To investigate the feasibility of substituting human mAb (HmAb) for human polyclonal preparations in the treatment of infections, we employed anti-tetanus toxin (TT) as a model system. We established a large panel of hybridomas secreting anti-TT HmAb and compared their fine specificities and protectivity with those exhibited by tetanus immune globulin (TIG). Analysis of three different commercial TIG preparations indicated that the majority of anti-TT antibodies is directed against epitopes expressed by the A fragment, the L chain of TT. Absorption of TIG with purified A fragment completely abolished its protective capacity in mice. Absorption with C fragment, the carboxy-terminal portion of the H chain of TT, had no discernible effect, illustrating the crucial importance of anti-A fragment antibody. The vast majority of more than 100 generated TT-specific HmAb showed specificity for the A fragment. Six HmAb with significant neutralizing activity were identified and further characterized. Five of them recognized the A fragment, whereas one, ST12, bound to both the A fragment and the C fragment with equal affinity. ST12 by itself conferred long lasting protection against TT intoxication when singly administered, and the remainder mediated only a delayed death. ST12 conferred a protection of 13.2 IU/100 micrograms IgG. However, when individual HmAb were combined, synergistic effects were observed. Optimal potency (43 IU/100 micrograms IgG) was obtained with a combination of two HmAb. To obtain a 250-IU dose, only 0.7 mg of this mixture was required in contrast to 100 to 170 mg IgG for TIG.

Therapeutic human antibodies derived from PCR amplification of B-cell variable regions.

Despite advances in the in vitro immunization of human B cells (Borrebaeck et al. 1988) and the development of immunodeficient mice (McCune et al. 1988) for the reconstitution of the human immune system ex vivo, immortalization of antigen-specific human B cells remains the limiting step in the generation of human monoclonal antibodies. Typically this is performed with the aid of Epstein-Barr virus transformation followed by subcloning, confirmation of antigen binding and hybridization of the B lymphoblasts to a suitable fusion partner such as GLI-H7. This general approach is effective and widely used; however, it is time-consuming with erratic results. These were the immediate reasons we and others devised methods to directly obtain the variable regions from small numbers of human B cells (Larrick et al. 1987). The success of the PCR-based approach is illustrated above. In the present studies we successfully captured and stably produced antibodies from the V regions of two potent human anti-tetanus antibodies secreted by heteromyelomas that were too unstable for scale-up production. Although further preclinical evaluation of these antibodies is in progress, results to date indicate that the recombinant antibodies produced in myeloma-based cell lines or CHO cells are equivalent in binding specificity and activity to the native heteromyeloma-derived antibodies. Recent studies from this laboratory indicate that effective anti-tetanus protection will require a cocktail of anti-tetanus antibodies. Details of this work will be the subject of a future communication (Lang et al., in preparation).

Selective generation of antigen-specific human hybridomas optimized for large scale growth in serum-free medium.

The direct propagation of newly formed human hybridomas in serum-free medium selects for hybrids with a metabolism best suited to growth in this environment. Under optimal culture conditions, this procedure results in the generation of antigen-specific human hybridomas comparable in frequency, stability, and antibody secretion rate to that obtained with murine hybridomas. After a transient phase of a few days in the appropriate selection medium supplemented with 1% serum, hybridomas grow in serum-free medium in stationary cultures with a cell doubling time of 15-25 h and an antibody production rate averaging 12 micrograms/10(6) cells/day. Clones propagated in bioreactors exhibited a cell doubling time of 29-35 h and an antibody secretion rate of 10-21 micrograms/10(6) cells/day.

The developmental patterns of B cell precursors distinguishing between environmental and nonenvironmental forms of phosphocholine.

We have analyzed the developmental patterns of two groups of B cell precursors in nonimmunized BALB/c mice with respect to their relative proportions, absolute frequencies, V gene usage, fine specificity, and avidity for antigen. One group of B cells (group I) secretes antibodies specific for PC and PC-containing bacteria, whereas the other group (group II) produces antibodies recognizing only nonenvironmental PC-protein conjugates. A marked shift in the proportions of group I and group II occurs during ontogeny: while the group I B cells dominate (greater than 85%) the adult antibody repertoire, the group II B cells have equal representation in neonatal mice from Days 1 to 7, and remain as a significant portion until 2 weeks of age. Examination of the absolute frequencies of group I and group II B cells revealed that the frequency of group II B cells remained relatively stable throughout ontogeny, whereas group I B cells expanded rapidly after 7 days of age to predominate in the adult. Genetic analysis indicated that early group I antibodies were encoded by VH and VL genes different from adult group I antibodies which are mostly encoded by a single VH (S107) and VL (V kappa 22) gene combination (the T15 idiotype). On the other hand, early group II antibodies used VH genes comparable to their adult counterparts. The majority of early group I antibodies have lower avidity for PC than adult T15+ antibodies, whereas the avidity of neonatal group II antibodies varies considerably and is comparable with that of the adult group II antibodies. Our results suggest that the ontogeny of phosphocholine-specific B cells may be regulated according to their fine specificity rather than to their avidity or V gene usage.

Affinity constants of naturally acquired and vaccine-induced anti-Pseudomonas aeruginosa antibodies in healthy adults and cystic fibrosis patients.

Naturally acquired anti-Pseudomonas aeruginosa antibody fails to afford protection against repeated P. aeruginosa bronchopulmonary exacerbations in cystic fibrosis (CF) patients. In an effort to explain this phenomenon, the titer and affinity constants of serum anti-lipopolysaccharide (LPS) IgG were determined in five study groups: healthy adults before and after immunization with a polyvalent LPS-based vaccine, healthy noncolonized CF patients before and after immunization, nonimmunized CF patients with significantly elevated anti-LPS antibody titers without documented colonization, recently colonized CF patients before and after immunization, and nonimmunized CF patients chronically colonized with P. aeruginosa. Immunization elicited a significant rise in total anti-LPS immunoglobulin levels and affinity constants in both healthy adults and CF patients. Although chronically colonized patients had elevated levels of total anti-LPS antibody, these antibodies possessed affinities at least 100-fold less than those of vaccine-induced antibodies.

Analyses of affinity distributions within polyclonal populations of antigen-specific antibodies. Evaluation of their accuracy in population detection using monoclonal antibodies.

The potential of an ELISA based detection of affinity distributions within polyclonal populations of antigen-specific serum antibodies was assessed by analyzing defined probes composed of monoclonal antibodies (MAb). In a competitive binding ELISA in which the concentration of antigen in the liquid phase and the solid phase was varied, we analyzed mixtures containing defined percentage compositions of MAb exhibiting apparent affinity constants (aK) between 3 x 10(6) and 2 x 10(9) M-1 for Pseudomonas aeruginosa exotoxin A. Our results indicate that the detectability of antibody populations depends on the antigen concentrations in the solid phase and on the affinity distribution of the probe to be analyzed. In wells coated with high antigen concentrations, antibody titers reflected antibody concentrations, whereas at low antigen concentrations antibody titers primarily reflect antibody affinities. Independent of their affinities, subpopulations less than 10% could not be detected. Low affinity antibodies were preferentially underestimated. The degree of distortion depended on the composition of the probe to be analyzed. In general, the higher the absolute and the relative affinity of a population, the stronger was its capacity to interfere with the detection of other populations. As a consequence, the heterogeneity of affinity distributions in polyclonal samples may be substantially underestimated. The experiments reported provide guidelines for an optimal design and an adequate interpretation of ELISA based qualitative analyses of polyclonal antibody samples.

Characterization of the Shigella serotype D (S. sonnei) O polysaccharide and the enterobacterial R1 lipopolysaccharide core by use of mouse monoclonal antibodies.

In the course of developing a live vaccine, we generated three murine monoclonal antibodies (MAb) specific for Shigella sonnei. The specificities of these MAb were determined by enzyme-linked immunosorbent assay and immunoblot analyses with whole cells or purified lipopolysaccharides (LPSs) as antigens. Two of them are specific for the Shigella serotype D O-polysaccharide determinant, whereas one specifically binds to the core hexose region of R1-type LPSs. With these MAb, it was possible to analyze clinical isolates and a hybrid Salmonella typhi strain for their expression of the corresponding LPS moieties. In addition to their use in the screening of candidate vaccine strains, the new MAb provide a powerful tool for epidemiological and phylogenetic studies of natural enterobacterial populations.

Properties determining the potential of naturally occurring and vaccine-induced human antibodies to protect against lethal infection of Pseudomonas aeruginosa.

In order to characterize antibodies responsible for the protection against fatal infection with Pseudomonas aeruginosa we analysed the fine specificity, avidity and protective capacities of naturally occurring anti-lipopolysaccharide (LPS) antibodies in two standard human Ig preparations and of vaccine-induced anti-LPS antibodies in a hyperimmune Ig preparation. Applying competitive binding assays, immunoblotting and an in vivo protection assay, we provide evidence that only preparations from immunized volunteers contain significant amounts of antibodies which confer detectable protection in a murine burn-wound model. Supported by the parallel analysis of monoclonal antibodies, our data suggest that protection by passive immunization with anti-LPS antibodies is mediated by antibodies specific for the LPS O-chain moiety of the corresponding virulent bacterium. Furthermore, our results indicate that protectiveness is restricted to a small population of antibodies with high affinity for particular O-chain epitopes.

Influence of somatic cell hybridization and human serum on the generation and stability of human hybridomas.

We describe an approach that allows the generation of stable hybridomas secreting antigen specific human IgG antibodies with an efficiency comparable to that of the generation of IgM and IgA secreting hybridomas. This was achieved by evaluating means to increase the frequency of human hybridoma formation and the stability of the generated hybridoma cells when subjected to conditions for large scale growth. To this end, we generated new fusion lines with an increased human DNA content and modified the culture system. However, the application of these new fusion lines primarily resulted in unstable giant cells. As a consequence, we evaluated whether the viability of newly formed hybrids between existing fusion lines and lymphoblastoid cell lines might be improved. In an attempt to provide as many components necessary for the growth of antibody secreting hybridomas as possible, we propagated fused cells in medium supplemented with human serum. Our results show that with this approach the frequency of initially growing hybrids was significantly increased. Furthermore, only in culture medium supplemented with human serum was it possible to obtain stable IgG secreting clones.

Hapten conformation in the combining site of antibodies that bind phenylphosphocholine.

We have shown previously that anti-phenylphosphocholine antibodies elicited by phosphocholine-keyhole limpet hemocyanin can be divided into two populations according to their ability to recognize the two hapten analogues p-nitrophenylphosphocholine (NPPC) and p-nitrophenyl 3,3-dimethylbutyl phosphate (NPDBP). These analogues differ from each other in that NPPC has a positively charged nitrogen in the choline moiety, whereas NPDBP lacks the positively charged nitrogen. Group II-A antibodies bind only NPPC, whereas group II-B antibodies bind both ligands. Here, by infrared and nuclear magnetic resonance spectroscopic investigations, we find that when free in solution NPPC has a predominantly fixed structure in which the termini approach each other, probably due to electrostatic interactions within the molecule; this "bent" structural feature is retained when the ligand is bound by antibody. In contrast, the structure of unbound NPDBP is less fixed, being characterized by rapidly interchanging conformations corresponding to an open chain structure with less overall proximity of the termini compared to NPPC. The overall shape of NPPC is essentially unaltered by binding, whereas in the case of NPDBP what was a minor conformation in the unbound state becomes the predominate conformation of the bound ligand. Thus, our results are consistent with these antibodies providing a molecular template for stabilizing the conformation of the bound ligand.

Human monoclonal antibodies specific for capsular polysaccharides of Klebsiella recognize clusters of multiple serotypes.

We report the generation and the characterization of a set of human monoclonal antibodies (HmAb) specific for Gram-negative bacteria of Klebsiella pneumoniae. The eight human hybridomas secrete either IgM kappa, IgA1 kappa, or IgA2 kappa antibodies. One HmAb binds bacteria of only one serotype. Five HmAb recognize non-overlapping clusters of 2, 3, or 10 different serotypes. The remaining two HmAb both recognize three serotypes. Two serotypes are recognized by both HmAb, and in addition both HmAb bind one more nonidentical serotype. These results suggest that in man, epitopes are immunodominant, different from serotype-specific determinants detected by conventional rabbit antisera. Screening of clinical isolates revealed that the HmAb recognize not only representative typing strains but also most isolates of the corresponding serotype. In addition, most of the isolates that were non-typable by polyclonal antisera were recognized by one of the HmAb. Fine specificity analyses revealed that all HmAb are highly specific for the isolated capsular polysaccharides (CPS) of bacteria within the corresponding cluster of serotypes. However, the avidity of a HmAb for the different CPS can differ significantly. Taken together, our results suggest that the unequivocal interactions between HmAb and CPS offer the basis for an alternative, better defined classification system, and that passive immunization with a limited number of HmAb may provide a feasible strategy for the protection against the majority of fatal, nosocomial infections with multidrug-resistant strains of K. pneumoniae.

Qualitative analysis of antibody binding. An in vitro assay for the evaluation and development of vaccines.

We describe a rapid in vitro assay for the evaluation of in vivo properties of conjugate vaccines. Using human and murine monoclonal antibodies (mAb) specific for lipopolysaccharides (LPS), isolated from Pseudomonas aeruginosa, we determined in a competitive binding assay the amount of LPS or conjugate vaccine which was required to inhibit the antibody binding to LPS by 50% (I50 values). Furthermore, utilizing a murine burn wound sepsis model, we determined the potential of the same conjugates to induce protection in vivo against infection with the corresponding bacteria. Protective mAb have approximately 100-fold lower I50 values for preparations which are highly effective in inducing protection than for preparations which are ineffective. Furthermore, in the case of potent preparations it was noted that protective mAb exhibit similar I50 values for the conjugates and for the corresponding LPS. These results suggest that the fast and easily interpretable in vitro assay described may significantly facilitate the development and optimization of vaccines.

Antibody combining site heterogeneity within the response to phosphocholine-keyhole limpet hemocyanin.

The memory response to PC-KLH is dominated by two antibody populations differing in fine specificity. Group I antibodies show affinity for both phosphocholine (PC) and p-nitrophenyl phosphocholine (NPPC). Group II antibodies exhibit significant affinity only for NPPC. Here, we describe the binding site characteristics of Group II antibodies and show that in recognizing NPPC these antibodies have a common requirement for the phenyl moiety, a negatively charged phosphate, and the trimethyl structure of the choline. However, Group II antibodies were found to differ in their requirement for the positively charged nitrogen of choline and thus could be divided into two subgroups. In contrast to Group II-A, Group II-B antibodies recognize not only NPPC but also its analog p-nitrophenyl-3,3-dimethyl butyl phosphate (NPDBP), which differs from NPPC by substituting a carbon for the positively charged nitrogen of the choline moiety. These results suggest that Group II-B antibodies do not require the positive charge in order to bind, although the binding constant, Ka, was increased when the nitrogen was present. Furthermore, heterogeneity within Group II antibodies was characterized by differences in binding to dinitrophenyl phosphocholine which has an additional phenyl ring and aminophenyl phosphocholine which has an amino group in place of the nitro group of NPPC. The results indicate that diversity in the memory response to PC-KLH is reflected in the Group II antigen-binding phenotype by antibodies which differ appreciably in their recognition of various structural aspects of the hapten.