Hemodialysis is Not Associated With Pre-prosthetic Inpatient Rehabilitation Outcomes After Dysvascular Lower Extremity Amputation: A Retrospective Cohort Study.

BACKGROUND: Lower extremity amputation due to complications from peripheral vascular disease and/or diabetes are common and these patients often have multiple comorbidities. Patients with end-stage renal disease receiving hemodialysis (ESRD/HD) are a particularly vulnerable group at risk for amputation. After lower extremity amputation (LEA) surgery, many patients undergo post-operative inpatient rehabilitation to improve their pre-prosthetic functional independence. Given the increased complexity of dysvascular patients living with ESRD/HD compared to those without ESRD/HD, the association of HD with pre-prosthetic inpatient functional outcomes warrants further study. OBJECTIVE: The objective of this study was to compare the pre-prosthetic functional outcomes and Length of Stay (LOS) among patients with recent dysvascular LEA with and without ESRD/HD. METHODOLOGY: A retrospective cohort design was used to analyze a group of 167 patients with unilateral, dysvascular limb loss who were admitted to inpatient rehabilitation with 24 of these patients in the ESRD/HD group. Age, gender, amputation level, amputation side, length of stay (LOS), time since surgery, Functional Independence Measure (FIM) scores (admission and discharge), and Charlson Comorbidity Index (CCI) were collected. FINDINGS: There was no difference between patients with dysvascular amputation with and without ESRD/HD in the association of functional outcomes or LOS in this cohort and rehabilitation model. The CCI score was higher in the ESRD/HD group. Multivariate analysis indicated an inverse relationship with age and FIM scores, where increased age was associated with lower Total and Motor FIM at admission and discharge. There were no associations with FIM change. Age was positively associated with LOS. Being female was inversely associated to motor FIM scores at admission and discharge. CONCLUSION: Among patients with recent dysvascular LEA, ESRD/HD is not associated with different functional outcomes or LOS in the pre-prosthetic inpatient rehabilitation setting. This suggests that despite added comorbidity that patients with ESRD/HD may still benefit from inpatient rehabilitation to optimize pre-prosthetic function.

Comorbidity and Non-prosthetic Inpatient Rehabilitation Outcomes After Dysvascular Lower Extremity Amputation.

BACKGROUND: Dysvascular amputations arising from peripheral vascular disease and/or diabetes are common. Patients who undergo amputation often have additional comorbidities that may impact their recovery after surgery. Many individuals undergo post-operative inpatient rehabilitation to improve their non-prosthetic functional independence. Thus far, our characterization of comorbidity in this population and how it is associated with non-prosthetic inpatient functional recovery remains relatively unexplored. OBJECTIVE: The objective of this study was to describe comorbidities, using the Charlson Comorbidity Index (CCI), and to examine associations between comorbidity and functional outcomes in a cohort of patients with dysvascular limb loss undergoing non-prosthetic inpatient rehabilitation. METHODOLOGY: A retrospective cohort design was used to analyze a group of 143 patients with unilateral, dysvascular limb loss who were admitted to inpatient rehabilitation. Age, sex, amputation level, amputation side, length of stay (LOS), time since surgery, Functional Independence Measure (FIM) scores (Total and Motor at admission and discharge), and CCI scores were collected. FINDINGS: The data showed that neither total or specific comorbidities were associated with functional outcomes or LOS in this cohort and rehabilitation model. Multivariate analysis demonstrated an inverse relationship with age and FIM scores, where increased age was associated with lower Total and Motor FIM at admission and discharge. Comorbidities were not associated with functional outcomes. Dementia was negatively associated with FIM scores, however this requires more study given the low number of patients with dementia in this cohort. CONCLUSION: These data suggest that regardless of burden of comorbidity or specific comorbidities that patients with dysvascular limb loss may derive similar functional benefit from post-operative non-prosthetic inpatient rehabilitation.

Recovering activity and illusion: the nephrology day care unit.

Day Care Units are an alternative to hospital care that improves more efficiency. The Nephrology, by its technical characteristics, would be benefit greatly from further development of this care modality. The objectives of this study are to present the process we have developed the Nephrology Day Care Unit in the Puerto Real University Hospital (Cádiz, Spain). For this project we followed the Deming Management Method of Quality improvement, selecting opportunities, analyzing causes, select interventions, implement and monitor results. The intervention plan includes the following points: 1) Define the place of the Day Care Unit in the organization of our Clinical Department of Nephrology, 2) Define the Manual of organization, 3) Define the structural and equipment resources, 4) Define the Catalogue of services and procedures, 5) Standards of Care Processes. Protocols and Clinical Pathways; and 6) Information and Registration System. In the first 8 months we have been performed nearly 2000 procedures, which corresponds to an average of about 10 procedures per day, and essentially related to Hemodialysis in critical or acute patients, the Interventional Nephrology, the Clinical Nephrology and Peritoneal Dialysis. The development of the Nephrology Day Care Units can help to increase our autonomy, our presence in Hospitals, recover the progressive loss of clinical activity (diagnostic and therapeutic skills) in the past to the benefit of other Specialties. It also contributes to: Promote and develop the Diagnostic and Interventional Nephrology; improve the clinical management of patients with Primary Health Level, promote the Health Education and Investigation, collaborate in the Resources Management, and finally, to make more attractive and exciting our Specialty, both for nephrologists to training specialists.

Estudio de prevalencia de infecciones nosocomiales en una unidad médica de alta especialidad / Study of prevalence of hospital-acquired infections in Medical unit of high speciality

Introducción: En unidades de atención médica de tercer nivel existen factores que propician mayor frecuencia de Infecciones Nosocomiales (IN). Por lo anterior; es fundamental; evaluar periódicamente la sensibilidad de los sistemas de vigilancia epidemiológica; para comprobar su funcionamiento y el logro de objetivos. Objetivo: Conocer la prevalencia puntual de IN de una Unidad Médica de Alta Especialidad; como indicador de las acciones implementadas por la Unidad de Vigilancia Epidemiológica Hospitalaria (UVEH). Así como conocer los factores de riesgo asociados a la prevalencia de IN. Metodología: Es un estudio observacional de tipo transversal. La población estuvo conformada por 383 pacientes hospitalizados. Resultados: Se encontró que el 73.9% tenían procedimientos invasivos terapéuticos. Se identificaron 68 casos con infección nosocomial; lo que corresponde a una prevalecía puntual de 17.8%. Los sitios de IN más frecuentes fueron las bacteremias (38.2%) y neumonías (20.6%). Los microorganismos identificados con mayor frecuencia fueron pseudomona sp; enterobacter aglomerans; serratia marcescens y staphylococo coagulasa negativa; así como Escherichia Coli. Además de ser neonato y lactante otros factores asociados a las IN por RM; fueron el estar inmunocomprometido; el tener catéter venoso por disección; diálisis peritoneal; sonda orogástrica; intubación orotraqueal; ventilación mecánica; nutrición parenteral y el tener una cirugía contaminada. Factores que están significativamente asociados (p = 0.05) al riesgo de IN. Conclusiones: El desarrollo del estudio permitió conocer la prevalencia puntual y caracterizar las IN; como un indicador del funcionamiento de la UVEH; para el establecimiento de medidas de control de infecciones.

Objective: The purpose of this research was to analyze the intIntroduction: Within third level medical attention units, there are factors which lead to a higher frequency of Hospital Infections (HI). Because of this, it is fundamental to assess periodically the epidemiologic surveillance systems sensibilities in order to verify their functionalities as well as the objective achievements. Objective: To assess the prevalence of HI in one high Specialty Medical Units, as an indicator of the actions taken by the Hospital Epidemiologic Surveillance Unit (HESU),and also to assess the risk factors associated with the prevalence of HI. Methodology: Basic observational study with a population of 383 hospitalized patients. Results: We found that 73.9% had invasive processes. We identified 68 cases with Hospital Infection (17.8).The most frequent HI were general bacterial invasions (38.2%) and pneumonias (20.6%).The most frequently identified microorganisms were pseudomona sp, enterobacter aglomerans, serratia marcescens, staphylococcus aureus, and Escherichia coli. Besides to be newborn and nursing other factors associated to IN bt RM they were inmunocomprometed to be, having venous catheter by dissection, peritoneal intubation, mechanical ventilation, parenteral nutrition and having a contaminated surgery, factors that are significantly (p ≤ 0.05) to the risk of IN. Conclusions: This study allowed us assesses and characterize the prevalence of HI as an indicator of the HESU functionality in order to establish infection control measurements.

Compartmentalisation between gut and lung mucosae in a model of secondary immunodeficiency: effect of thymomodulin.

UNLABELLED: Compartmentalisation of mucosal immune response seems to be the result mainly of the preferential migration of activated cells back to their inductive sites. The aim of this report was to demonstrate, in a model of secondary immunodeficiency in Wistar rats (severely protein deprived at weaning and refed with casein 20%; group R21), that the oral administration of Thymomodulin (group:R21TmB) has different effects on gut and BALT (Bronchus-associated lymphoid tissue). Tissue sections (5 mu) were studied by immunohistochemistry 1). The oral administration of Thymomodulin restores only in gut Lamina propria (LP) the IgA B and CD4 T cell populations to control levels. The CD8a and CD25 subpopulations do not vary in gut as they return to control levels when refed with 20% casein diet. All the populations mentioned above remained decreased even after receiving Thymomodulin by the oral route. However, the same behaviour was observed for the TCR delta T cells that were decreased and return to normal levels in both mucosae by the effect of the immunomodulator; 2) when studying the iIEL (intestinal intraepithelial lymphocytes) CD8 alpha, CD25 and TCR gamma delta T cells, that were increased in R21, return to control levels in R21TmB. In BALT intraepithelium CD8 alpha and CD25 T cells remained decreased, while only TCR gamma delta T cells (increased in R21) return to control values. CONCLUSIONS: 1) there exists a compartmentalisation between both mucosae, as T CD4+ and IgA B+ cells are restored by TmB only in gut; 2) only those iIEL involved in inflammation (CD8 alpha+/CD25+ and TCR gamma delta+/CD25+) are normalised by means of the Thymomodulin 3) however, in BALT,only TCR gamma delta+ T cells are restored 4) the oral administration of the present immunomodulator may be useful as a therapeutic agent, although the preferential survival in the tissue of initial stimulation is the major factor in the preferential distribution of activated cells.

Oral tolerance to dextrin mediated by specific suppressor T-cells induced in the intestinal intraepithelium and their systemic migration.

Antigens presented to the immune system through the oral route induce antigen specific secretory IgA and systemic unresponsiveness, termed oral tolerance (OT). We studied the induction of OT towards a diet antigen: dextrin (DEX) in rats that underwent protein deprivation and were further re-fed. Peyer's patches (PP), mesenteric lymph nodes (MLN) and spleen (Sp) cells from protein re-fed (R) rats mediated hyporesponsiveness after transfer into naïve recipient rats. Low numbers of MLN T cells transferred hyporesponsiveness while higher numbers transferred an enhancement of the delayed type hypersensitivity (DTH) reaction. MLN T cells were further separated based on their ability to bind Vicia villosa (VV). MLN VV- T cells, mainly CD8+, mediated hyporesponsiveness and MLN VV+ T cells (CD45RC+ CD4- CD8- cells) abrogated the hyporesponsiveness. Moreover, Sp DEX adherent T cells were mainly CD8+. Intestinal intraepithelial lymphocytes (iIELs) mainly CD8alpha+ gamma(delta)-TCR+ cells also inhibited the DTH response to DEX after transfer. The positive DTH response to another carbohydrate (levan) indicates the specificity of the suppression to dextrin. Therefore, our data indicate that after oral administration of DEX, two different populations of T cells were generated: one found only in the MLN that mediated DTH responses and the other one capable of migrating from the intestinal intraepithelium through PP and MLN to the Sp, mediating systemic tolerance.

Cytogenetic studies in bone marrow cells from Wistar rats in protein malnutrition.

The effect of severe protein deficiency at weaning has been studied in bone marrow, which is a primary lymphoid organ. Our experimental model of secondary immunodeficiency in Wistar rats has shown: (1) a decreased number of viable bone marrow cells (P <.0001); (2) diminished percentage of mitosis (P <.01); and (3) severe alteration in the percentage of chromosome pairs 3, 11, and 12 bearing nucleolar organizer regions (NORs) (P <.05). This last finding indicates a poor ribosomal gene activity. These alterations were reverted after the oral administration of a 20% casein diet during 5 to 9 days. However, there were no karyotype variations between the experimental groups. We conclude from these results that severe protein deficiency at weaning alters several aspects of bone marrow cell proliferation and ribosomal gene activity as determined by the number of silver stained nucleolus organizer regions.

Flow cytometric analysis of intestinal intraepithelial lymphocytes in a model of immunodeficiency in Wistar rats.

BACKGROUND: We have shown, in a rat model of immunodeficiency, permanent alterations in the thymus and in the gut-associated lymphoid tissues. We observed by immunohistochemistry an increase in the number of gamma/delta+ T cells in the gut lamina propria and in the number of CD8alpha/alpha+, CD25+, gamma/delta+ subpopulations of intestinal intraepithelial lymphocytes (iIEL). The aim of the present study was to analyze the isolated rat iIEL by flow cytometry. Materials and Methods Cells from mesenteric lymph nodes were examined in parallel with isolated iIEL. After staining with different antibodies, samples were run on a FACScan flow cytometer. Background staining was evaluated using isotype controls. Data analysis was performed using Lysys II software (Becton Dickinson) and WinMDI 2.3 software. RESULTS: 1) CD8alpha/beta populations do not express TCRgamma/delta, 2) CD8alpha/alpha+ populations express TCRgamma/delta, and its percentage is significantly increased in R21, 3) CD8alpha/beta and CD8alpha/alpha iIEL express TCRalpha/beta, being the percentage of CD8alpha/alpha+ TCRalpha/beta+ iIEL increased and the percentage of CD8alpha/beta+ TCRalpha/beta+ iIEL decreased in R21, and 4) CD8alpha/alpha as well as CD8alpha/beta iIEL do express CD25 only in R21. CONCLUSIONS: Considering the above results, we conclude that there exists an "in situ" origin and extrathymic maturation of the CD8alpha/alpha+ iIEL in the intestinal epithelium. The increase of TCRgamma/delta+ T cells may be triggered by the carbohydrate dextrin, to provide immune protection and control of inflammation at the intestinal level.

Developmental study of immunocompetent cells in the bronchus-associated lymphoid tissue (BALT) from Wistar rats.

The aim of the present report was to study in growing Wistar rats the development of immunocompetent cells in the bronchus-associated lymphoid tissue (BALT). We found at day 4 postpartum, a high number of TCRgamma/delta+ T cells and very few CD8alpha+, CD8beta+, CD5+, TCRalpha/beta+ T cells in BALT. The latter cells and CD4+ T cells increase with age. Even though T cells expressing TCRgamma/delta outnumber those expressing TCRalpha/beta early in development, until 45 days of age, alpha/beta+ predominate over gamma/delta+ T cells only in adult rats (60 days of age). Moreover, a predominance of suppressor/cytotoxic T cells over T-helper cells was found in 60 days old rats. Surprisingly, more CD8alpha+ than CD8beta+ T cells in BALT are observed. The number of IgA+ B and CD4+ T cells found in the BALT increases with age. The early appearance - 4 days of age - of all T-cell phenotypes in BALT especially of gamma/delta+ T cells may imply a benefit to respond to inhaled antigen soon after birth.

IgA B and T cells in the intestinal Villi of immunodeficient rats orally treated with thymomodulin.

Previous studies on the effect of the oral administration of bacterial immunomodulators (1M-104 and RN-301) during the protein free diet period, have shown an increase on B and T cell gut repopulation, accompanied by IgA antibody production. The usefulness of oral administration of the immunomodulator thymomodulin (TmB) during the protein refeeding period was investigated. TmB allowed the recovery of a normal repopulation of gut lamina propria with IgA B and CD5 T cells and decreases to control values the number of activated intraepithelial lymphocytes (CD25+ T cell subset). Therefore, the oral administration of TmB may be useful as a therapeutic agent as it seems to improve the repopulation of intestinal villi with immunocompetent cells. Also, it seems to regulate the immunosurveillance at the epithelium level as it increases the CD5+ T cells but decreases the activated ones.

Effect of RN-301 immunomodulator on bronchus-associated lymphoid tissue (BALT) in protein depleted rats at weaning.

It has been previously demonstrated in Wistar rats that severe protein deprivation at weaning, even after refeeding with a 20% casein diet for 21 days, provokes alterations in IgA+ B cell and T cell populations from gut and GALT (gut associated lymphoid tissue) that are reverted by immunomodulator IM-104. In the present report, we investigate the influence of RN-301 (quite similar to IM-104) given by the oral or subcutaneous route during the protein deprivation period, in the seeding of BALT with IgA+ B and CD5+ T cells. The immunomodulator RN-301 contains LPS from E. coli and membrane and ribosomal fractions of P. acne. Tissue sections of the lower respiratory tract were studied by immunohistochemistry. The immunomodulator RN-301 administered by the oral route favours the significant increase in the seeding of the BALT lamina propria with IgA+ B and CD5+ T cells (p < 0.001). However, the RN-301 given by the subcutaneous route does not favour the repopulation of the BALT lamina propria. The ribosomal fractions from P. acne associated with LPS from E. coli contained in the immunomodulator RN-301 administered by the oral route may rescue the small resting lymphocytes in the gut-associated lymphoid tissue (GALT). This event favours their proliferation and migration to the BALT.

The effect of testosterone on the immune response. 1. Mechanism of action on antibody-forming cells.

Sex hormones are known to be implicated in humoral and cellular immune responses. In this study we report the effects of orchidectomy and testosterone replacement on the immune response using T-dependent and T-independent antigens. It was found that the response was dependent on the nature of the antigen employed and on the presence of testosterone. The absence of testosterone receptors in spleen lymphocytes was also found. An hypothesis that testosterone regulates the immune system through the enhancement of suppressive activity is advanced.