The development of an outcomes management system for acute medical rehabilitation.

In 1993, Continental Medical Systems, Inc. (CMS), a provider of comprehensive medical rehabilitation, developed the Total Outcomes and Prediction Program (TOPP) to measure and evaluate key medical rehabilitation outcomes, quality indicators, and patient satisfaction at its 37 acute rehabilitation hospitals. The broad purposes of TOPP are to manage patient treatment, improve the cost-effectiveness of care, and provide outcomes reporting for managed care and other interested parties. The challenge was to develop a system which could measure, evaluate, and report medical rehabilitation patient outcomes in a way that could be easily understood by multiple audiences, including payers, accrediting organizations, physicians, patients and families, case managers, and CMS clinical staff. Using data from the Uniform Data System for Medical Rehabilitation database, CMS created descriptive outcomes reports for each hospital and for the corporation overall, including performance statistics, outcomes report cards, and quality report cards. These initial reports, as well as updates, quarterly reports, and special ad hoc requests, provide CMS corporate and hospital staff with statistically valid and reliable information to manage the outcomes of medical rehabilitation treatment. TOPP has assisted CMS with meeting accreditation standards for outcomes management and measurement and has been used in managed care contract negotiations. Future TOPP efforts will integrate resource use data, medical acuity and outcomes from acute, subacute, and outpatient rehabilitation levels into CMS' outcomes reporting system.

Effect of surgical trauma on splenocyte and peritoneal macrophage immune function.

Although previous studies have shown that simple laparotomy produces a depression in peritoneal macrophage (Mphi) antigen presentation capacity, it remains unknown whether the adverse effects of laparotomy are limited to peritoneal Mphi or whether such an insult also affects splenocyte immune function. To study this, mice were anesthetized and a 1-inch midline abdominal incision was made, followed by abdominal closure. At 2 and 24 hours after the surgical procedure, the animals were killed, splenocyte cultures established and stimulated for 48 hours with concanavalin A (2.5 micrograms/mL), while peritoneal macrophage cultures were stimulated with LPS (10 micrograms/mL). The proliferative capacity of the splenocytes, as well as their ability to release interleukin-2 and interleukin-3, was markedly decreased at 2 as well as 24 hours after laparotomy. Furthermore, the release of interleukin-6 by splenic and peritoneal macrophages from animals that underwent laparotomy were also significantly depressed at both 2 and 24 hours. These results support the concept that surgical stress in the form of midline laparotomy per se is sufficient to produce a significant impairment in cell-mediated immunity, thus setting the stage for increased incidence of postoperative complications.

PAF-antagonist administration after hemorrhage-resuscitation prevents splenocyte immunodepression.

A number of studies have suggested that the inflammatory and chemotactic autocoid platelet activating factor (PAF), together with various cytokines, plays an important role in the pathophysiology of trauma, sepsis, and shock. However, little is known about PAF's contribution to the immunosuppression associated with hemorrhage. The aim of our study was, therefore, to determine if the use of a PAF-antagonist following hemorrhage has any salutary effects on splenocyte lymphokine production. To study this, mice were bled to and maintained at a mean arterial pressure of 35 mm Hg for 60 min. The mice were then segregated into three groups and were resuscitated with shed blood plus lactated Ringer's solution (2x the volume of shed blood), containing either a potent PAF-antagonist (Ro 24-4736, a thienodiazepine) in dimethyl sulfoxide (DMSO) or DMSO-vehicle. Sham-operated mice received either DMSO-vehicle in saline or saline alone. Twenty-four hours thereafter the animals were sacrificed and splenocyte cultures established and stimulated for 48 hr with Con A (2.5 micrograms/ml). Supernatant lymphokine levels were determined by bioassay. The cellular release of interleukin-2 and -3 (IL-2 and IL-3) by splenocytes was significantly depressed in the nontreated or vehicle-treated hemorrhaged animals compared to shams. Treatment with the PAF-antagonist Ro 24-4736 restored IL-2 and IL-3 release values to levels comparable to those of the sham-operated animals. Thus, (1) PAF appears to play a significant role in hemorrhage-induced immunosuppression and (2) the use of a PAF-antagonist to uncouple the PAF-generated feedback loops prevents the depression in splenocyte function following hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypoxemia in the absence of blood loss or significant hypotension causes inflammatory cytokine release.

Although hemorrhagic shock causes a significant elevation of circulating levels of proinflammatory cytokines [tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1 beta, IL-6], it remains unknown whether hypoxemia per se in the absence of blood loss activates macrophages (Mø) to release increased amounts of these mediators. To study this, hypoxemia was induced in C3H/HeN mice by placing them in a plastic box that was flushed with a gas mixture containing 95% N2-5% O2 for 60 min, followed by return of the mice to room air. For control animals, the plastic box was flushed with room air. At 0, 2, or 24 h thereafter, blood samples were obtained, plasma was separated, and then peritoneal Mø (pMø) and Kupffer cells (KC) were isolated and incubated at 37 degrees C for 24 h with lipopolysaccharide. The Mø supernatants, as well as plasma samples, were assayed for TNF-alpha, IL-1 beta, and IL-6 with the use of specific bioassays. Hypoxemia induced a significant (P < 0.05) increase in plasma TNF-alpha levels during the entire study period while circulating IL-6 was elevated by 313% (P < 0.01) at 24 h after hypoxemia compared with shams. Moreover, the release of TNF-alpha, IL-1 beta, and IL-6 by pMø and KC was markedly increased after hypoxemia compared with shams. Thus, hypoxemia in itself, in the absence of any blood loss or tissue injury, induces release of proinflammatory cytokines, which may contribute to systemic inflammation following hypoxemia.

Effects of hydroxyethyl starch after trauma-hemorrhagic shock: restoration of macrophage integrity and prevention of increased circulating interleukin-6 levels.

OBJECTIVES: To determine the effects of resuscitation with the colloidal solution (hydroxyethyl starch) vs. crystalloid solution on cell-mediated immune functions after trauma-hemorrhage. DESIGN: Prospective, multiexperimental, randomized, controlled study. SETTING: University research laboratory. SUBJECTS: Thirty-six inbred male C3H/HEN (endotoxin-sensitive) mice, aged 6 to 7 wks, and weighing 18 to 23 g. INTERVENTIONS: Crystalloid (lactated Ringer's solution) with and without 6% hydroxyethyl starch after trauma-hemorrhage. MEASUREMENTS AND MAIN RESULTS: Mice underwent laparotomy, were bled to and maintained at a blood pressure of 40 mm Hg for 60 mins, then resuscitated with either 4x the shed blood volume as lactated Ringer's solution or 2x the shed blood volume as lactated Ringer's solution plus 1 x 6% hydroxyethyl starch. Sham mice were neither hemorrhaged nor resuscitated. At 2 or 24 hrs posthemorrhage, serum, splenocytes, peritoneal macrophages, and splenic macrophages were obtained. Bioassays were used to determine interleukin-2, interleukin-3, and interleukin-6 concentrations, while splenocyte proliferation was assessed by 3H-thymidine incorporation. Trauma-hemorrhage markedly depressed splenocyte proliferation, interleukin-6 release by macrophages, and lymphokine release at 2 and 24 hrs postresuscitation. The combination of lactated Ringer's solution and hydroxyethyl starch neither restored, nor exacerbated lymphocyte functions. Interleukin-6 release by peritoneal macrophages was restored 24 hrs after hydroxyethyl starch infusion; serum interleukin-6 concentrations remained at sham levels. CONCLUSIONS: Since the use of lactated Ringer's solution and hydroxyethyl starch after hemorrhage did not adversely affect cell-mediated immune functions, but produced salutary effects on macrophage functions, hydroxyethyl starch is a safe and beneficial resuscitation adjunct.

Dextran 70 administration after trauma-hemorrhagic shock does not impair cellular immune functions.

PURPOSE: Although the effects of the colloid dextran 70 on induction of anaphylactoid reactions or reticuloendothelial phagocytosis have been examined previously, its effects on specific cell-mediated immunity after trauma-hemorrhage shock remain unknown. METHODS: Nonheparinized C3H/HeN mice underwent a laparotomy, were bled, and then maintained at a blood pressure of 35 mm Hg for 60 minutes. Then they were resuscitated with either 4 x the shed blood volume as lactated Ringer's solution (LRS) or 2 x LRS + 1 x dextran 70. Control mice underwent all operative protocols but were neither hemorrhaged, nor resuscitated. At 2 or 24 hours posthemorrhage, serum, splenocytes (SPL), and peritoneal macrophages (pM phi, splenic Mo (sM phi) were obtained. Bioassays were used to determine interleukin-2 (IL-2), IL-3, IL-6, and SPL proliferation. RESULTS: Trauma-hemorrhage markedly depressed lymphokine release, splenocyte proliferation, and IL-6 release at 2 hours after the insult. The combination of LRS + dextran did not restore lymphocyte functions, but also did not further suppress them. The release of IL-6 by pM phi and sM phi at 2 and 24 hours after dextran infusion and serum IL-6 remained at the same level as in LRS-treated animals. CONCLUSIONS: The combination of LRS and colloid dextran 70 does not adversely affect ex vivo cell-mediated immune functions during the first 24 hours after its administration after trauma-hemorrhage. Thus, from the immunological standpoint, dextran is a safe resuscitation adjunct.

Peritoneal macrophages show increased cytokine gene expression following haemorrhagic shock.

Tumour necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), IL-1 and transforming growth factor-beta (TGF-beta) have been recognized as important mediators of pathophysiological and immunological events associated with shock. Previous studies have indicated that although peritoneal macrophage (PM phi) antigen presentation was depressed following haemorrhage, the cytokine release capacity in response to lipopolysaccharide (LPS) was not affected in vitro. To determine the effect of haemorrhagic shock on PM phi cytokine mRNA transcription, C3H/HeN male mice were bled to and maintained at a mean arterial blood pressure of 35 mmHg for 60 min, and then adequately resuscitated. PM phi were isolated at 1 or 24 hr after haemorrhage and were incubated without or with 10 micrograms LPS/ml for 1 hr. Total RNA was then extracted followed by Northern blot analysis, as well as semi-quantitative reverse transcription and polymerase chain reaction (RT-PCR). The results of Northern blot analysis indicated that haemorrhage markedly increased LPS-induced IL-1 beta, IL-6, and TNF-alpha mRNA accumulation in PM phi at both 1 and 24 hr after haemorrhage and resuscitation. Furthermore, competitive RT-PCR demonstrated that mRNA of IL-1 beta, IL-6, TNF-alpha, as well as TGF-beta, was increased in PM phi obtained 1 hr after haemorrhage either with or without LPS stimulation. The data from Northern blot analysis and semi-quantitative RT-PCR also revealed that LPS enhanced the effect of haemorrhage on PM phi cytokine gene expression. Thus, following haemorrhage, PM phi showed elevated cytokine mRNA accumulation which was not followed by an increased ability to release cytokines in response to LPS in vitro. These results, therefore, suggest that different mechanisms regulate gene expression and subsequent cytokine secretion by PM phi following haemorrhage.

Biological significance of elevated TNF levels: in vivo administration of monoclonal antibody against tnf following haemorrhage shock increases the capacity of macrophages to release TNF while restoring immunoresponsiveness.

Haemorrhagic shock results in a severe depression of the cellular and humoral immunity, thus rendering the host increasingly susceptible to sepsis. To study the effect of elevated TNF release following haemorrhagic shock on depressed macrophage and splenocyte functions, C3H/HeN mice were pretreated intraperitoneally with either anti-murine TNF-Ab or saline. Twenty hrs later, mice were bled to and maintained at a mean BP of 35 mmHg for 60 min followed by adequate fluid resuscitation. Pretreatment with anti-TNF-Ab completely neutralized elevated TNF plasma levels following haemorrhage. This was associated with an increased (P < 0.05) capacity of pMø isolated 24 h after haemorrhagic shock to release TNF, while the ability to secrete IL-6 and PGE2 was reduced. Haemorrhagic shock-induced suppression of pMø antigen presentation capacity and MHC class II antigen expression, as well as depression of splenocyte proliferation and lymphokine production was also attenuated (P < 0.05) by anti-TNF-Ab pretreatment. These data indicate that elevated circulating TNF levels play a pivotal role in the depression of essential macrophage and splenocyte functions following haemorrhagic shock.

Differential alterations in cyclic nucleotide levels in Kupffer cells and hepatocytes following trauma-hemorrhage and resuscitation.

Although cyclic nucleotides play an important role in regulating the control of metabolism, it is not known whether there are any differential alterations in cyclic nucleotides in Kupffer cells and hepatocytes after trauma-hemorrhage and resuscitation. To study this, rats underwent laparotomy (i.e., trauma-induced) and were rapidly bled to and maintained at a mean arterial pressure of 40 mmHg until 40% of maximum bleedout volume was returned in the form of Ringer's lactate. The animals were then resuscitated with Ringer's lactate, equivalent to four times the volume of shed blood. At the time of maximum bleedout or at 1.5 h postresuscitation, a portion of the liver was removed, and the levels of cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP) were determined by radioimmunoassay. Moreover, Kupffer cells and hepatocytes were isolated in additional groups of animals and cAMP and cGMP levels were measured. The results indicate that hepatic cAMP decreased, whereas hepatic cGMP increased significantly at the time of maximum bleedout. Although resuscitation normalized hepatic cyclic nucleotide levels, the levels of cAMP and cGMP in Kupffer cells increased significantly at 1.5 h after resuscitation. In contrast, cAMP and cGMP levels in hepatocytes were not significantly different from shams under such conditions. Thus, differential alterations in cyclic nucleotide levels in different liver cell populations occur following trauma-hemorrhage and resuscitation.

Aggressive fluid resuscitation following intestinal ischemia-reperfusion in immature rats prevents metabolic derangements and down regulates interleukin-6 release.

We have recently shown improved survival following intestinal ischemia-reperfusion in a model that utilized aggressive crystalloid resuscitation sufficient to eliminate reperfusion-induced cardiovascular instability. The aims of this study were to determine whether the salutary effects associated with this regimen were due to: 1) prevention of systemic metabolic derangements; 2) attenuation of secondary organ injury; or 3) modulation of the systemic immune response. Under anesthesia, 4-week-old (65-85 g) male Sprague-Dawley rats (N = 63) received crystalloids at either 15 or 65 ml.kg-1.h-1 intravenously and were subjected to 90 min of superior mesenteric artery occlusion followed by 90 min of reperfusion (IR15, IR65) or time-matched sham (SH) operation (SH15, SH65). Results indicate that inadequate fluid resuscitation following intestinal IR was associated with significant serum hyperkalemia and hyperphosphatemia, acute renal insufficiency, and enhanced serum interleukin-6 levels. Maintenance of cardiovascular stability with aggressive fluid resuscitation was associated with an attenuation of these alterations. Therefore, the prevention of circulatory shock and the attenuation of distant organ injury and inflammatory response are associated with improved survival when an aggressive crystalloid resuscitation regimen is applied after intestinal ischemiareperfusion in immature rats.

Role of Kupffer cells in interleukin-6 release following trauma-hemorrhage and resuscitation.

Although interleukin-6 (IL-6) plays an important role in the pathophysiology of trauma-hemorrhage and resuscitation, the cellular origin of this inflammatory cytokine remains unknown. This study was undertaken to determine whether Kupffer cells (KC) are a major source of IL-6 release following trauma-hemorrhage and resuscitation. KC numbers were significantly (p < .05) reduced in vivo with gadolinium chloride (GdCl3; 10 mg/kg IV). KC-reduced (KC(-)) and KC-normal (saline-treated; KC(+)) rats underwent laparotomy (i.e., trauma-induced), followed by either sham operation or hemorrhage. Hemorrhaged rats were bled to and maintained at a mean arterial pressure of 40 mmHg until 40% of the shed blood volume was returned as Ringer's lactate, and then resuscitated with Ringer's lactate (four times shed blood volume over 1 h). Results indicate that KC reduction per se had no effect on any measured parameter at any time. At 0.5 and 2.0 h postresuscitation, mean arterial pressure, heart rate, cardiac output, stroke volume, and hematocrit were reduced to a similar extent in both the KC(+) and KC(-) hemorrhage groups. KC reduction did, however, significantly reduce plasma IL-6 concentration (means +/- S.E.; U/ml) at both 0.5 h (KC(+) = 709 +/- 391 vs. KC(-) = 159 +/- 5) and at 2.0 h (KC(+) = 527 +/- 394 vs. KC(-) = 83 +/- 20) postresuscitation. In conclusion, this study demonstrates that KC are a major source of in vivo IL-6 release following trauma-hemorrhage and resuscitation.

Chloroquine inhibits macrophage tumour necrosis factor-alpha mRNA transcription.

Although chloroquine administration in vivo following haemorrhage in mice decreases tumour necrosis factor-alpha (TNF-alpha) release by macrophage (M phi), the mechanism remains unknown. To study this, peritoneal M phi (pM phi) from unmanipulated, sham-operated and post-haemorrhage mice were isolated, treated with 0.13 mg/ml chloroquine for 2 hr, and then stimulated with lipopolysaccharide (LPS) for 48 hr. Pretreatment of pM phi from various groups of mice with chloroquine resulted in 75-90% inhibition of TNF-alpha release, determined by bioassay. Total RNA was isolated from pM phi and murine M phi-derived cell lines (P388D1 and RAW 264.7), stimulated with LPS for 0.5 or 1 hr, respectively, and Northern blot analysis for TNF-alpha mRNA performed. Chloroquine inhibited TNF-alpha mRNA expression without interfering with mRNA stability, suggesting that this agent reduces M phi TNF-alpha release by disrupting TNF-alpha gene transcription.

Tumor necrosis factor depresses gut absorptive function.

Although recent studies have shown that gut absorptive function is significantly depressed even in the early hyperdynamic phase of sepsis, the mechanism responsible for this is unknown. Tumor necrosis factor (TNF-alpha) is a potent mediator of shock resulting in a marked inflammatory response leading to mucosal erosions of the gut and multiple organ failure. Although TNF is elevated in early sepsis, it remains unknown whether TNF plays any role in the depression of gut absorptive function under these conditions. To study this, we used the 1 hr D-xylose absorption test. C3H/HeN mice (n = 12) were lightly anesthetized, and a femoral artery and the portal vein were cannulated. After recovery from anesthesia, 125 micrograms recombinant murine TNF-alpha (rMuTNF-alpha)/kg body weight was given via the tail vein to one group of animals, while another group received an equivalent volume of saline (sham). One hour later, D-xylose was given orally. The systemic blood pressure was recorded 1 hr thereafter and D-xylose concentration in a sample of portal blood was determined colorimetrically. Results show that, while the systemic pressure was elevated 2 hr after administration of rMuTNF-alpha, D-xylose absorption was severely depressed. Thus the depressed gut absorptive function seen in the early stage of sepsis may be mediated directly or indirectly by TNF-alpha.

Chemically induced hypotension increases PGE2 release and depresses macrophage antigen presentation.

Hemorrhagic shock causes severe depression of macrophage functions and is associated with increased susceptibility to sepsis. Because hemorrhagic shock and resuscitation encompasses several pathophysiological conditions, such as hypotension, low-flow conditions, hypoxia, and reperfusion injury, it remains unknown whether severe hypotension in the absence of blood loss has any adverse effects on macrophage functions. To study this, systemic arterial hypotension was induced in C3H/HeN mice for 15 min by intravenous infusion of sodium nitroprusside or ATP-MgCl2. Peritoneal macrophages (PM) was harvested 20 h later with lavage. Antigen presentation was measured by coculturing PM with the D10.G4.1 Th cell clone. Tumor necrosis factor (TNF), interleukin (IL)-6, IL-1, and prostaglandin (PG) E2 levels in supernatants of PM stimulated with lipopolysaccharide were measured with bioassays or radioimmunoassay. Systemic arterial hypotension resulted in a significant decrease of PM capacity to present antigen. Although the release of TNF, IL-6, and IL-1 by PM was unaltered after hypotension, PGE2 release by PM was significantly elevated compared with the control group. These data indicate that chemically induced systemic arterial hypotension without blood loss leads to a depression of antigen presentation, which may be caused by elevated release of the immunosuppressive eicosanoid PGE2.

Modulation of macrophage membrane phospholipids by n-3 polyunsaturated fatty acids increases interleukin 1 release and prevents suppression of cellular immunity following hemorrhagic shock.

Studies have suggested that the significant suppression of cellular immunity following hemorrhage may be due to an increased release of prostaglandin E2 (PGE2) by macrophages. Since diets high in n-3 polyunsaturated fatty acids decrease PGE2 synthesis, we assessed whether hemorrhage-induced immunosuppression could be prevented by dietary manipulation. C3H/HeN mice were fed for 3 weeks with fat sources derived from corn oil, safflower oil, or fish oil, then bled to a mean blood pressure of 35 mm Hg maintained for 60 minutes. Following this, the animals were adequately resuscitated with fluids and killed 24 hours later. In the corn oil and safflower oil groups, hemorrhage resulted in a significant increase in PGE2 release by peritoneal macrophages, a marked suppression of peritoneal macrophage antigen presentation capacity, interleukin 1 release, splenocyte proliferation, and interleukin 2 secretion compared with shams. However, feeding mice with fish oil for 3 weeks prior to hemorrhage prevented the rise in PGE2 release and maintained normal macrophage and splenocyte functions following hemorrhage. Thus, the elevated release of PGE2 by peritoneal macrophages plays a pivotal role in hemorrhage-induced immunosuppression. Moreover, diets high in n-3 polyunsaturated fatty acids may offer a new therapeutic approach for preventing posthemorrhage immunosuppression and increased mortality from sepsis.

Role of interleukin 6 and transforming growth factor-beta in the induction of depressed splenocyte responses following sepsis.

We examined whether (1) there is an association between elevated circulating levels of transforming growth factor-beta (TGF-beta) and splenocyte dysfunction during sepsis, and (2) administration of monoclonal antibodies to interleukin 6 (an inducer of TGF-beta release) or TGF-beta could ablate these changes. Blood and splenocytes were obtained from C3H/HeN mice at 1, 4, or 24 hours following cecal ligation and puncture or sham operation. Only at 24 hours after cecal ligation and puncture was there an association between elevated blood TGF-beta value and depressed splenocyte interleukin 2 release. Administration of monoclonal antibodies against interleukin 6, but not against TGF-beta (intraperitoneally immediately following cecal ligation and puncture), significantly decreased the blood levels of TGF-beta at 24 hours following cecal ligation and puncture and improved splenocyte interleukin 2 release. Thus, the judicious use of monoclonal antibodies against interleukin 6 may block the subsequent elevation of TGF-beta, thereby attenuating host immunosuppression during sepsis.