Outcomes comparison in patients admitted to low complexity rural and urban intensive care units in the Veterans Health Administration.

PURPOSE: To evaluate mortality, length of stay, and inter-hospital transfer in the Veteran Health Administration (VHA) among low complexity Intensive Care Unit (ICU) patients. MATERIALS AND METHOD: Retrospective study of adult ICU admissions identified in VHA Medical SAS®; 2010-2015 at Veterans Affairs (VA) Medical Centers. Facilities classified by the Rural Urban Commuting Area code algorithm as large rural (referred to as rural) (N = 6) or urban (N = 33). RESULTS: In rural hospitals, patients (N = 9665) were less likely to have a respiratory (12.9% v. 18.9%; p < .001) diagnosis, more likely diagnosed with sepsis (17.6% v. 4.9%), and had a higher illness severity score (42.0 vs. 41.4; p = .01) compared to urban (N = 65,846) counterparts. Mortality within ICU did not vary across facility rurality. In unadjusted analyses, facility rurality (rural vs. urban) was associated with reduced inter-hospital transfers (OR = 0.74; 95% CI = [0.69, 0.80]; p < .001) and a shorter ICU length of stay (RR = 0.82; 95% CI = [0.74, 0.91]; p < .001). This did not hold when the hierarchical data was accounted for. CONCLUSIONS: Despite challenges, low complexity ICUs in rural VA facilities fare similarly to urban counterparts. Being part of a national healthcare system may have benefits to explore in sustaining critical care access in rural areas outside the VA healthcare system.

Inhibition of lymphokine-activated killer cells by human pulmonary macrophages: discordance between up-regulation of the beta chain (p75) of the interleukin-2 receptor on CD56+ cells and limited response to interleukin-2.

Previous studies have demonstrated that interaction of interleukin-2 (IL-2) with the beta chain (p75) of the IL-2 receptor on CD56+ cells is necessary for the development of lymphokine-activated killer (LAK) activity and proliferation of CD56+ LAK cells in response to IL-2. Human pulmonary macrophages (PM) are potent inhibitors of LAK cells in vitro, and purified resident human lung lymphocytes show limited LAK activity in response to IL-2, suggesting that IL-2-p75 interactions may be altered locally in vivo. In the current study, human PM or anti-p75 inhibited LAK activity and proliferation of CD56+ cells in response to IL-2. This effect was produced by either live or paraformaldehyde-fixed PM, but not peripheral blood monocytes, suggesting that a membrane signal on PM was responsible for inhibition. Suppression of LAK function and proliferation in response to IL-2 occurred despite a rapid up-regulation of p75 on CD56+ cells after 24 h of incubation with PM. Greater than 70% of CD56+ cells expressed p75 after culture with either live or fixed PM, compared with 10 to 15% at 0 h or after 24 h of incubation in IL-2 alone. p75 dim and p75 bright cells increased equally, suggesting that p75 was being up-regulated on previously p75- cells rather than an overexpansion of one subset of p75+ cells. The increase in p75 expression in the presence of PM paralleled with an increase in IL-2 binding to these lymphocytes. These results suggest that PM inhibit the activation of LAK cells at a point distal to IL-2-p75 binding.

Effect of interstitial lung disease macrophages on T-cell signal transduction.

Some types of interstitial lung disease (ILD) are characterized by an abnormal proliferation and activation of lymphocytes in the alveolus and interstitium. Recent data have suggested that membrane signals on alveolar macrophages (AM) in normal lung play a crucial role in limiting lymphocyte activation by altering early events in receptor-mediated signal transduction in lymphocytes. In the current study fixed AM from normal volunteers and from patients with either sarcoidosis or idiopathic pulmonary fibrosis were compared for the ability to inhibit CD3-mediated increases in intracellular calcium concentration [(Ca2+)i]. All normal AM inhibited CD3-mediated increases in (Ca2+)i, whereas seven of 10 ILD AM were permissive of this early event in T-lymphocyte activation. Patients with ILD and permissive AM displayed significantly greater mean BAL lymphocytes than did those with suppressive AM (42 versus 12%, respectively). The inhibitory effect of normal AM could be partially duplicated by incubation of lymphocytes with surfactant (SF) obtained from normal lungs. Analysis of one SF component, SF protein A, in normal and in ILD AM membranes disclosed reduced SF protein A in ILD AM. These results demonstrate alterations in AM in patients with ILD and a lymphocytic alveolitis that renders AM permissive for early events in T-cell activation.

Human alveolar macrophages inhibit immunoglobulin production in response to direct B cell mitogen.

B lymphocytes are crucial participants in pulmonary immune defense. However, excess local antibody production is associated with accelerated lung destruction in several types of lung disease. The purpose of the current study was to study the potential role of alveolar macrophages (AM) in the local regulation of immunoglobulin (Ig) production in the lung in response to a direct B cell mitogen, Staphylococcus aureus Cowan strain (SAC). AM, when added to peripheral blood mononuclear cells, caused a dose-dependent inhibition of IgG and IgM, while not affecting IgA production in response to SAC. The mechanism of the AM-induced inhibition included both membrane-bound and soluble signals. The inhibition was not abrogated by indocin and catalase, or reversed by blocking antibodies to transforming growth factor-beta or interferon-gamma. Mononuclear cells isolated from human lung parenchyma displayed a reduced response to SAC compared with blood cells. However, depletion of macrophages from the parenchymal cells was associated with a restoration of IgG production in response to SAC. The results demonstrate that AM inhibit B cell responses to direct B cell mitogen and suggest that the effect of AM is selective for IgM and IgG.

Human alveolar macrophages inhibit receptor-mediated increases in intracellular calcium concentration in lymphocytes.

Prior studies have demonstrated that human alveolar macrophages (AM) are suppressive of lymphocyte function, through the mechanism of inhibition is unclear. In the current study, human AM inhibited receptor-mediated increases in intracellular calcium concentration ([Ca2+]i) in T cells, natural killer cells, and B cells. This effect was produced by either live or fixed AM, while peripheral blood monocytes caused a minimal reduction in [Ca2+]i. The inhibitory effect of AM was seen following 1 to 2 h of incubation with lymphocytes, was complete at 16 h, and did not affect ionomycin-mediated [Ca2+]i. Inhibition of [Ca2+]i by AM correlated with suppression of T-lymphocyte proliferation and cytotoxic T-lymphocyte activity in response to alloantigen and Staphylococcus A-induced immunoglobulin production. Our findings suggest that a membrane signal on AM is capable of inhibiting receptor-mediated signal transduction in lymphocytes and that this is likely a major mechanism by which immune responses are downregulated in the alveolus.

Cytolytic human lung lymphocytes: characterization of intragranular protease content and response to interleukin-2.

Cytolytic lymphocytes play an important role in defense against viral and neoplastic disease. Integral to the function of these cells is the content of lysosomal granules. Recent attention has focused on a family of proteases present in the granules of natural killer (NK) cells, interleukin-2 (IL-2)-activated NK cells (LAK cells), and cytotoxic T lymphocytes (CTL). In the current investigation, lymphocytes were obtained from human lung parenchyma and peripheral blood. Following activation with IL-2, both groups of lymphocytes exhibited comparable cytolytic activity against K562 targets. Lysosomal granules obtained from these cells contained two serine proteases with molecular weights of 30 and 28 kD. These proteases were capable of hydrolyzing benzyloxycarbonyl-L-lysine thiobenzyl ester (BLT-ester), a substrate of cytolytic lymphocyte proteases. When compared to blood, unactivated lung lymphocytes contained significantly higher levels of protease content. Although IL-2 produced a significant increase in blood lymphocyte protease content, no change in lung lymphocyte granule protease activity was observed. We conclude that cytolytic lung lymphocytes contain high levels of lysosomal granule protease but differ from blood lymphocytes in the ability to increase protease content following activation with IL-2. The high level of protease content in cytolytic lung lymphocytes suggests that these cells could produce local tissue injury during the release of lysosomal granules.

A comparison of the effects of intact and deacylated lipopolysaccharide on human polymorphonuclear leukocytes.

Enzymatic deacylation of LPS markedly reduces its activity in the dermal Shwartzman reaction. Inasmuch as polymorphonuclear leukocytes (PMN) are involved in the genesis of tissue injury in Shwartzman reactions, we have investigated the effects of deacylated LPS (dLPS) on PMN. Compared to LPS, dLPS was ineffectual as a stimulus of both PMN adherence and release of secondary granule enzymes, and dLPS inhibited specific LPS-induced adherence. Neither LPS nor dLPS caused release of the primary granule enzymes, myeloperoxidase, and elastase. Unlike LPS, dLPS failed to prime PMN for superoxide release when a second stimulus (FMLP, 10(-6) M was given. The mechanism of the LPS induced increase in PMN adherence was investigated, and we found that LPS significantly increased the amount of the adhesive glycoprotein CD11b on the surface of the PMN. dLPS had no effect on CD11b expression. Our results suggest that enzymatic deacylation of LPS profoundly alters its ability to stimulate PMN and deacylation of LPS by inflammatory cells in vivo might be an important mechanism limiting the toxic effects of LPS.

Human pulmonary natural killer (NK) cells exhibit limited lymphokine-activated killer (LAK) activity.

The spontaneous activity of natural killer (NK) cells against most solid tumor targets is low but can be increased by incubation with interleukin 2 (IL-2). This phenomenon, termed lymphokine-activated killer (LAK) activity, has been used in recent clinical trials against some pulmonary malignancies. We compared the LAK activity of blood and lung lymphocytes after activation with IL-2. Lung lymphocytes did not develop LAK activity despite demonstrating a significant increase in NK activity against K562 targets after incubation with IL-2. This functional difference correlated with a reduced expression of Leu-19, a marker present on virtually all LAK cells derived from peripheral blood, on lung NK cells. Because pulmonary macrophages (PM) are important regulators of NK function, we next investigated whether PM could be responsible for the functional and phenotypic differences noted. Measuring NK and LAK activity in parallel, we found that the addition of PM to IL-2-activated lymphocytes resulted in a preferential suppression of LAK activity and a loss of Leu-19 expression from IL-2-activated blood lymphocytes as well as a Leu-19+ T cell clone. We conclude that pulmonary NK cells are phenotypically and functionally different from peripheral blood NK cells and that this likely reflects local regulation, perhaps by PM.

Human natural killer cells enhance a mixed leukocyte reaction.

Natural killer cells (NK) have been reported to down-regulate the initiation of T cell responses in animal models. In the current study, highly purified CD16+ human NK cells were obtained by cell sorting and their effect on the stimulation of allogeneic T cells (MLR) determined. NK cells did not directly stimulate T cell proliferation. However, when added to a population of loosely adherent mononuclear cells (LAM), NK enhanced the ability of these accessory cells to stimulate T proliferation. This effect was not reproduced by the addition of sorted CD5 + T cells, sorted CD16- cells, or control lymphocytes to the MLR. The effect of NK on the MLR was not restricted by class II antigens and was similar to the effect of adding IL-1 to MLR cultures. These results demonstrate that human NK cells are capable of enhancing a T cell response.