The COVID-19 Army Rapid Assessment Tool (CARAT) for Management of COVID-19 in the Deployed Setting.

The COVID-19 pandemic poses unique challenges within the austere clinical setting, and the time between patient presentation and deterioration is a critical opportunity for intervention. In some cases, this may be a life-saving transfer to a higher level of care. US Central Command (CENTCOM) has provided valuable guidance for COVID-19 management in the operational environment,1 and has proposed the National Early Warning System 2 (NEWS2) scoring tool as a useful adjunct to gauging illness severity. NEWS2, however, does not consider co-morbidities, such as diabetes or chronic cardiac disease, which could worsen the clinical course of SARS-CoV-2 patients. Thus, NEWS2 fails to address such factors during the risk stratification of patients to a higher level of care. To address this concern, June 2020, 3rd Medical Brigade, Operation Spartan Shield (OSS) developed the COVID-19 Army Rapid Assessment Tool (CARAT) with inputs from clinicians and researchers (The Team). The CARAT is a clinical scoring system, modified from the NEWS2, which combines the effects of co-morbid disease with the current physiological condition of a COVID-19 patient. The Team obtained clinical data for 105 patients from the CENTCOM area of responsibility (AOR), who presented to a military treatment facility (MTF) symptomatic for, and testing positive for SARS-CoV-2, during the time period of June to mid-August 2020. Each patient was retrospectively assigned a CARAT score based on his or her initial presentation. Preliminary review of data suggested a CARAT value of 4 or greater was an indicator for risk of further deterioration. Patients were then grouped into two categories: patients who received transfer to a higher level of care, versus "stay-in-place" supportive care. Results showed that 100% of patients with a score ≥4 had been transferred to a higher echelon of care, compared to 2% of patients with scores less than 4. A Fisher's exact test demonstrated a statistically significant difference between these two groups (p is less than 0.001). Interestingly, when compared with the NEWS2 score, the CARAT identified 9 individuals for transfer to a higher level of care, of whom only one patient was identified by the NEWS2, clearly underscoring the significance of CARAT despite small sample size. We therefore recommend that CARAT be further validated in predicting disease severity and need for emergent evacuation in larger patient settings.

Intraoperative core temperature and infectious complications after colorectal surgery: A registry analysis.

STUDY OBJECTIVE: Moderate hypothermia (e.g., 34.5 °C) causes surgical site infections, but it remains unknown whether mild hypothermia (34.6 °C-35.9 °C) causes infection. Therefore, the objective of this study was to evaluate the relationship between intraoperative time-weighted average core temperature and a composite of serious wound and systemic infections in adults having colorectal surgery over a range of near-normal temperatures. DESIGN: Retrospective, single center study. SETTING: The operating rooms of the Cleveland Clinic Foundation from January 2005 to December 2014. PATIENTS: Adult patients having colorectal surgery at least 1 h in length who received both general anesthesia and esophageal core temperature monitoring. INTERVENTION(S): Time weighted average intraoperative core temperature. MEASUREMENTS: Our primary outcome was a composite of serious infections obtained from a surgical registry and billing codes. Average intraoperative esophageal temperatures and the composite of serious 30-day complications were assessed with logistic regression, adjusted for potential confounding factors. MAIN RESULTS: A total of 7908 patients were included in the analysis. A 0.5 °C decrease in time-weighted average intraoperative core temperature ≤ 35.4 °C was associated with an increased odds of serious infection (OR = 1.38, P = .045); that is, hypothermia below 35.4 °C progressively worsened infection risk. Additionally, at higher core temperatures, the odds of serious infection increased slightly with each 0.5 °C increase in average temperature (OR = 1.10, P = .047). CONCLUSIONS: Below 35.5 °C, hypothermia was associated with increased risk of serious infectious complications. Why composite complications increased at higher temperatures remains unclear, but the highest temperatures may reflect febrile patients who had pre-existing infections. Avoiding time-weighted average core temperatures <35.5 °C appears prudent from an infection perspective, but higher temperatures may be needed to prevent other hypothermia-related complications.

Aggregatibacter actinomycetemcomitans leukotoxin utilizes a cholesterol recognition/amino acid consensus site for membrane association.

Aggregatibacter actinomycetemcomitans produces a repeats-in-toxin (RTX) leukotoxin (LtxA) that selectively kills human immune cells. Binding of LtxA to its ß2 integrin receptor (lymphocyte function-associated antigen-1 (LFA-1)) results in the clustering of the toxin·receptor complex in lipid rafts. Clustering occurs only in the presence of LFA-1 and cholesterol, and LtxA is unable to kill cells lacking either LFA-1 or cholesterol. Here, the interaction of LtxA with cholesterol was measured using surface plasmon resonance and differential scanning calorimetry. The binding of LtxA to phospholipid bilayers increased by 4 orders of magnitude in the presence of 40% cholesterol relative to the absence of cholesterol. The affinity was specific to cholesterol and required an intact secondary structure. LtxA contains two cholesterol recognition/amino acid consensus (CRAC) sites; CRAC(336) ((333)LEEYSKR(339)) is highly conserved among RTX toxins, whereas CRAC(503) ((501)VDYLK(505)) is unique to LtxA. A peptide corresponding to CRAC(336) inhibited the ability of LtxA to kill Jurkat (Jn.9) cells. Although peptides corresponding to both CRAC(336) and CRAC(503) bind cholesterol, only CRAC(336) competitively inhibited LtxA binding to this sterol. A panel of full-length LtxA CRAC mutants demonstrated that an intact CRAC(336) site was essential for LtxA cytotoxicity. The conservation of CRAC(336) among RTX toxins suggests that this mechanism may be conserved among RTX toxins.

Mechanistic roles of lipoprotein lipase and sphingomyelinase in low density lipoprotein aggregation.

The initiation of atherosclerosis involves retention of colloidal atherogenic lipoproteins, primarily low density lipoprotein (LDL), in the arterial intima. This retention occurs when LDL binds to smooth muscle cell extracellular matrix (SMC ECM), and is enhanced by lipoprotein lipase (LpL) and sphingomyelinase (Smase). Here we use a fluorescence assay and dynamic light scattering to study the individual and combined effects of these two enzymes on LDL aggregation. Our results show: (1) LpL is self-sufficient to induce LDL aggregation with aggregate sizes up to ~400 nm; (2) Smase induces LDL aggregation due to generation of ceramide and subsequent hydrophobic interactions; (3) Smase hydrolysis of LpL-induced LDL aggregates does not cause further aggregation and results in a ~3-fold diminished production of ceramide, while LpL treatment of Smase-induced aggregates does enhance aggregation; (4) The simultaneous addition of LpL and Smase causes increased variability in aggregation with final sizes ranging from 50 to 110 nm. Our data suggest a new proatherogenic function for LpL, namely, bridging between LDL particles causing their aggregation and consequently enhanced retention by SMC ECM. The mechanism of LpL-and-Smase-mediated LDL aggregation and binding to SMC ECM provides specific points of intervention to design novel effective antiatherogenic therapeutics.

Size-selective uptake of colloidal low density lipoprotein aggregates by cultured white blood cells.

This paper illustrates how principles of colloid science are useful in studying atherosclerosis. Accumulation of foam cells in the arterial intima is a key step in atherogenesis. The extent of foam cell formation is enhanced by low density lipoprotein (LDL) aggregates, and we have previously shown that the size of sphingomyelinase (Smase)-hydrolysis-induced aggregates depends directly on the concentration of ceramide generated in the LDL phospholipid monolayer, mediated by the hydrophobic effect. Here, we focus on the effect of LDL aggregate particle sizes on their subsequent uptake by macrophages. Our data show the first direct measurement of uptake as a function of aggregate size and the first direct comparison of uptake after Smase-catalyzed and vortex-mixing-mediated aggregation. Vortex-mixed aggregates with radii 20-77 nm showed maximal uptake approximately 118 microg sterol/mg protein at a 53 nm intermediate size, consistent with a mathematical model describing competition between aggregate surface area and volume. Smase-treated aggregates with radii 25-211 nm also showed maximal uptake at an intermediate size, approximately 58 microg sterol/mg protein for 132 nm particles, and fit a modified model that incorporated ceramide concentration expressed as aggregate size. This study shows that particle size is significant and composition may also be a factor in LDL uptake.

Effect of sphingomyelinase-mediated generation of ceramide on aggregation of low-density lipoprotein.

This study addresses the response-to-retention hypothesis, which states that the subendothelial retention of atherogenic lipoproteins is the necessary and sufficient condition for the initiation of atherosclerosis. Here we focus on the relationship between the generation of ceramide in the low-density lipoprotein (LDL) phospholipid monolayer and the resulting aggregation of LDL particles. This study provides the first measurement of neutral, Mg (2+)-dependent Sphingomyelinase (Smase)-mediated ceramide formation from LDL-sphingomyelin and does so for a range of enzyme concentrations (0-0.22 units Smase/mL). The kinetics of ceramide generation was measured using a fluorescence assay for the above enzyme concentrations with a fixed substrate concentration (0.33 mg LDL/mL). The kinetics of LDL aggregate formation was measured by dynamic light scattering (DLS, method of cumulants) for identical enzyme concentrations. Ceramide concentration profiles were fit with a modification of the Michaelis-Menten model ( k a = 1.11 x 10 (-1) microM (-1) min (-1), k -a = 6.54 x 10 (2) microM (-1) min (-1), k 1 = 3.33 x 10 (1) microM (-1) min (-1), k -1 = 1.41 x 10 (-2) min (-1), k cat = 8.05 x 10 (1) min (-1), K M = 2.418 microM, k deact = 4.66 x 10 (-2) microM (-1) min (-1)) that accounts for the effects of enzyme attachment to the LDL monolayer and for deactivation of Smase due to product inhibition. LDL aggregation is described by a mass action model as explained in previous studies. A key result of this work is the finding that LDL aggregate size depends directly on ceramide concentration and is independent of enzyme concentration. This study demonstrates how principles of colloid science are relevant to important biomedical problems.