Injury induces alterations in T-cell NFkappaB and AP-1 activation.

The immune dysfunction that occurs after severe injury involves major changes in T-cell-mediated immunity resulting in suppressed T-helper 1 (Th1) type responses and increased or persistent T-helper 2 (Th2) type cytokine production. Since little is known about what signaling pathways are responsible for this injury-induced phenotypic shift in T-cells, we undertook this study to address the molecular basis for injury effects on T-helper cell subset cytokine expression. Experiments were designed to test whether diminished IL-2 gene expression after thermal injury coincided with changes in the induction of IL-2 gene regulatory transcription factors. Electrophoretic mobility shift assays (EMSA) were used to screen for nuclear expression of changes of the IL-2 gene transcription factors. Our findings revealed that changes in mitogen-stimulated T-cell AP-1 and NFkappaB factor activation correlated directly with defective mitogen-induced IL-2 mRNA expression. We determined that there was a loss of nuclear AP-1 activation and changes in NFkappaB factor activation at 9 days after injury. T-cell nuclear extracts prepared from sham injured mice showed induction of NFkappaB2 (p52) and RelA (p65) containing NFkappaB EMSA complexes, while we detected no RelA or NFkappaB2 in EMSA complexes using T-cell nuclear extracts prepared from burn injured mice. Instead, these NFkappaB EMSA complexes contained mostly NFkappaB1 (p50). Western immunoblot analysis confirmed defective nuclear RelA translocation. Taken together, these results indicate that T-cell NFkappaB and AP-1 activation pathways may be involved in the injury-induced changes in T-cell cytokine production and the immune deviation that occurs after injury.

Infrainguinal bypass grafting in patients with end-stage renal disease: improving outcomes?

OBJECTIVE: This study was undertaken to examine recent trends in the outcomes of patients with end-stage renal disease (ESRD) undergoing infrainguinal bypass grafting (IBG) with autogenous vein. METHODS: A retrospective analysis of all IBGs performed on patients with ESRD at a single tertiary care institution during the interval 1993 to 1999 was undertaken. The comparison groups consisted of concurrent series of patients with elevated creatinine (creatinine level > 1.2 mg/dL) and patients with normal renal function undergoing IBG. Procedural variables, angiographic runoff scores, and extent of tissue necrosis at presentation were correlated with outcome. Categoric parameters were compared with chi(2) analysis; rates were computed with life-table analysis. RESULTS: Of an overall cohort of 622 IBGs performed during this interval, 78 IBGs (12.5%) were performed on 60 patients with ESRD, with a perioperative mortality rate of 1.3% that was comparable to controls. All reconstructions in the ESRD cohort were for limb salvage indications. Four-year survival, primary, assisted primary, and secondary patency rates for the ESRD group were 51% +/- 9%, 60% +/- 11%, 86% +/- 5%, and 86% +/- 5%, respectively; these were not statistically different from the control groups. Limb salvage in the ESRD group was 77% +/- 6% at 4 years and was significantly less then either the elevated creatinine (92% +/- 4%; P <.02) or the normal renal function group (90% +/- 2%: P <.02). Of 16 amputations in the ESRD group, nine were performed in limbs with patent grafts. The only absolute predictor of limb loss despite a patent graft was the presence of a heel ulcer more than 4 cm in diameter. Age, runoff score of the International Society for Cardiovascular Surgery/Society for Vascular Surgery, isolated tibial bypass graft, and location of distal anastomosis were not predictive of hemodynamic failure. CONCLUSIONS: Patients with ESRD constitute an increasing proportion of patients undergoing IBG in a tertiary care setting. Four-year survival, perioperative mortality, and graft patency rates are similar to patients with normal renal function and support an aggressive approach to this population. Major limb amputation despite a patent graft remains a problem of unique frequency in patients with ESRD. Adequate predictors of hemodynamic failure of IBG in this group do not exist, although a heel ulcer more than 4 cm may indicate an unsalvageable foot.

Impact of increasing comorbidity on infrainguinal reconstruction: a 20-year perspective.

OBJECTIVE: To examine trends in patient and procedural variables and outcomes associated with autogenous lower extremity arterial reconstruction (LER) in a single center during a period of two decades. SUMMARY BACKGROUND DATA: Surgical arterial reconstruction is of proven value in the therapy of patients with critical ischemia of the lower extremities. Changing demographics and increasing comorbidity are resulting in an increasing prevalence and associated complexity of peripheral vascular disease. The effect of these variables on the types and outcomes of surgical reconstructions is not known. METHODS: The authors performed a retrospective analysis of all autogenous LER procedures performed at their institution from 1978 to 1997. Procedures were divided into 5-year intervals: group 1, 1978 to 1982; group 2, 1983 to 1987; group 3, 1988 to 1992; group 4, 1993 to 1997. Categorical parameters were compared using chi-square analysis; rates were computed by the life-table method and compared using Mantel-Cox log-rank analysis. RESULTS: A total of 1,642 autogenous LER procedures were performed in 1,274 patients. A significant increase in age, female gender, diabetes mellitus, renal failure, and prior coronary artery bypass grafting was noted in group 4. Increased technical complexity in this group was reflected by a greater incidence of tissue necrosis as the indication for LER, the use of ectopic or composite vein, and more distal levels of outflow. The surgical death rate remained unchanged (2%) throughout. Patient survival, primary and secondary graft patency, and limb salvage at 5 years for the entire cohort were 70 +/- 2%, 63 +/- 2%, 73 +/- 1%, and 85 +/- 1%, respectively. Hospital length of stay was reduced 25% from a mean of 15.7 +/- 0.8 days in group 3 to 11.7 +/- 0.4 days in group 4. CONCLUSION: In a tertiary practice setting, patients requiring LER present an increasingly complex medical and surgical challenge compared with the previous decade. Excellent outcomes may still be achieved by an aggressive approach relying on autogenous vein conduit.

Autogenous composite vein bypass graft for infrainguinal arterial reconstruction.

PURPOSE: Lower extremity arterial reconstruction in the absence of adequate greater saphenous vein remains a challenging problem in contemporary vascular practice. The purpose of this review is to evaluate the long-term results of autogenous composite vein grafts used for infrainguinal arterial bypass grafting. METHODS: We retrospectively evaluated a prospective vascular registry and reviewed inpatient and office records. RESULTS: From June 1983 to September 1999, 165 autogenous composite vein infrainguinal bypass grafts were performed in 154 patients (87 men, 67 women; mean age, 69 years). The mean follow-up was 25 months (range, 3-147). Patients had the usual risk factors, including a 30% incidence of prior coronary bypass grafting. Forty-eight percent of bypass grafts were performed after failed previous reconstructions, and 90% were performed for limb salvage. The conduits were comprised of 2 segments (75%), 3 segments (23%), and 4 segments (2%). The distal anastomosis was at the popliteal level in 17% and the tibial/pedal level in 83%. The 30-day operative mortality rate was 1.8%. Perioperative graft failure (< 30 days) occurred in 18 bypass grafts (11%), resulting in early amputation (< 30 days) in 1.2%. The overall 5-year cumulative patency rates were 44% +/- 5% for primary patency, 63% +/- 5% for primary-assisted patency (PAP), and 65% +/- 5% for secondary patency (SP). A high revision rate for stenosis or thrombosis was required during follow-up to maintain patency of the grafts (27%). Limb salvage was 81% +/- 5% at 5 years. Primary reconstructions with composite vein fared significantly better than secondary reconstructions (SP 76% vs 54% at 5 years, P <.01). Arm vein composites showed superior patency compared with greater saphenous vein composites (SP 79% vs 61% at 5 years, P <.05). CONCLUSIONS: Infrainguinal reconstruction with autogenous composite vein results in durable graft patency and limb salvage rates in patients with few alternatives for revascularization. Intensive graft surveillance with aggressive graft revision is necessary to achieve these results.

A central role for CD95 (Fas) in T-cell reactivity after injury.

BACKGROUND: Recent findings indicate that severe injury primes the immune system for an enhanced and lethal proinflammatory cytokine response against bacterial-derived superantigens. This study asked whether this response to injury involves the CD95 (Fas) signaling pathway. METHODS: To assess superantigen-mediated mortality, wild-type (WT) C57BL/6 and Fas-deficient C57BL/6 lpr (-/-) (lpr) mice underwent burn or sham injury and were challenged 2 hours later with staphylococcal enterotoxin B (SEB). Spleen cells from sham and burn WT or lpr mice were stimulated in vitro with SEB to assess injury effects on IL-2, TNF-alpha, and IFN-gamma production. RESULTS: Lpr burn mice survived the SEB challenge (100% survival), while WT burn mice showed a high mortality (17% survival, P < 001, analysis of variance [ANOVA]). Sham lpr or WT mice suffered no mortality to the SEB challenge. In vitro studies demonstrated that burn lpr mice produced significantly less TNF-alpha, IFN-gamma, IL-2 than burn WT mice (P <.01, ANOVA). Burn injury markedly enhanced SEB-stimulated IFN-gamma production by WT spleen cells and CD8+ T cells, while this did not occur in SEB-stimulated lpr spleen cells. CONCLUSIONS: These findings support the hypothesis that the CD95 (Fas) signaling pathway plays an integral role in the injury-induced enhanced and lethal T-cell reactivity against bacterial superantigens.

Infrainguinal arterial reconstructions with vein grafts in patients with prior aortic procedures: the influence of aneurysm and occlusive disease.

PURPOSE: This study assessed whether infrainguinal reconstructions with autogenous vein (IR) performed in patients with prior abdominal aortic aneurysm (AAA) repairs have altered graft patency, compared with those in patients who have undergone prior aortobifemoral bypass grafting procedures (ABF) for aortoiliac occlusive disease. METHODS: From 1979 to 1998, 54 patients with prior aortic reconstructions underwent 64 autogenous single-segment saphenous IRs solely for infrainguinal occlusive disease. Included in this cohort were 30 IRs with an earlier AAA repair and 34 IRs with an earlier ABF repair. During the same period, 1274 patients underwent 1642 autogenous vein lower-extremity bypass grafting procedures (LEB). Lower-extremity native arterial (AAA, n = 6; ABF, n = 11) and vein graft diameters (AAA, n = 6; ABF, n = 6) were determined by means of angiography and duplex ultrasonography, respectively. The three reconstruction groups (AAA, ABF, LEB) were compared. RESULTS: The patients in the three groups were similar in sex, indication for operation, proximal and distal anastomotic site, and number of distal runoff vessels. The cumulative 5-year primary graft patency rate in the AAA group (92% +/- 5%) was significantly higher (P <. 001) than that in the LEB group (63% +/- 2%) and the ABF group (44% +/- 11%). Furthermore, cumulative 5-year primary patency was decreased in the ABF group compared with the LEB group (P =.05). A significant increase in both native arterial (P =.001) and vein graft diameter (P <.05) was demonstrated by using linear regression and a Student t test, respectively, in the AAA group compared with the ABF group. CONCLUSION: These data demonstrate that, compared with those in patients without a previous aortic procedure, IRs in patients with prior AAA repairs have significantly improved graft patency, and IRs in patients with prior ABF reconstructions for aortoiliac occlusive disease have significantly decreased graft patency. Larger arterial diameter and altered vein graft adaptation may contribute to the superior long-term outcomes of IRs in patients with prior AAA repairs.

Injury induces deficient interleukin-12 production, but interleukin-12 therapy after injury restores resistance to infection.

OBJECTIVE: To assess at serial intervals the production of interleukin-12 (IL-12) by monocytes/macrophages from the peripheral blood of injured patients and control subjects, and using a mouse model to confirm human findings and explore the effectiveness of low-dose IL-12 therapy in restoring resistance to infection after injury. SUMMARY BACKGROUND DATA: Serious injury is associated with loss of function of the T helper 1 lymphocyte phenotype, but little is known about IL-12 production in injured patients. The authors previously reported that early, moderate-dose IL-12 therapy in a mouse model of burn injury restored resistance to a later infectious challenge (cecal ligation and puncture, CLP). However, the efficacy of clinically relevant low-dose IL-12 therapy carried out to or beyond the time of septic challenge remains to be tested. METHODS: Peripheral blood mononuclear cells (PBMCs) and adherent cells were obtained from 27 patients with major burns or traumatic injury and 18 healthy persons and were studied at serial intervals for IL-12 production stimulated by bacterial lipopolysacharide (LPS). PBMCs from 18 of the same patients were studied for IL-10 production as well. IL-12 production by adherent cells from the spleens of burn or sham burn mice was studied at serial intervals after injury to confirm the human findings. Low-dose IL-12 or vehicle was given every other day to groups of burn and sham burn mice, which were then challenged with CLP on day 10, and survival was determined. Finally, spleens were harvested from burn or sham burn animals receiving low-dose IL-12 or vehicle after CLP. After splenic cellularity was determined by hemocytometer, splenocytes were cultured and production of tumor necrosis factor-alpha, interferon-gamma, and IL-10 were assessed by immunoassay. RESULTS: Adherent cells from patients' PBMCs produced significantly less IL-12 than normal PBMCs after injury, reaching a nadir 8 to 14 days after injury. Stimulation of whole PBMCs by LPS indicated that at 8 to 14 days after injury, IL-12 production by PBMCs was significantly lower and IL-10 production was significantly higher than that of PBMCs from healthy persons. Low-dose IL-12 therapy significantly increased survival after CLP. Splenocytes from burn mice treated with IL-12 had significantly increased production of TNF-alpha and IF-beta, both before and after CLP, when compared with vehicle-treated burn animals. IL-10 production by bum splenocytes remained high after IL-12 treatment. Splenic cellularity increased after IL-12 treatment in burn mice. CONCLUSION: The capacity to produce IL-12 by adherent cells of the monocyte/macrophage lineage is significantly reduced after serious injury in humans and in a mouse burn model. In humans, there is a reciprocal relation between diminished IL-12 production and increased IL-10 production at approximately 1 week after injury. Low-dose IL-12 therapy in the mouse burn model markedly increased survival after a septic challenge, even when treatment was carried beyond the onset of sepsis. Low-dose IL-12 treatment in the mouse increased production of proinflammatory mediators important in host defense and at the same time maintained or increased production of IL-10, an important antiinflammatory cytokine.

Protective effects of early interleukin 10 antagonism on injury-induced immune dysfunction.

HYPOTHESIS: Interleukin 10 (IL-10) plays a central role in the development of postinjury immune suppression, and early in vivo IL-10 antagonism can be protective. DESIGN: Male A/J mice underwent sham or burn injury and were treated with monoclonal anti-IL-10 antibody or control antibody at 1 day or 3 days after injury. Their ability to survive polymicrobial sepsis induced by the cecum ligation and puncture (CLP) technique was then tested. The response of sham- and burn-injured mice and burn-injured mice treated with anti-IL-10 to immunization with a T-cell-dependent antigen, trinitrophenyl (TNP)-haptenated ovalbumin (TNP-OVA) was also assessed. MAIN OUTCOME MEASURES: Mortality was monitored for a total of 7 days after CLP to assess the effect of anti-IL-10 therapy on the survival of burn-injured, immunecompromised mice. Serum antibody isotype formation was measured in sham- and burn-injured mice and burn-injured mice treated with anti-IL-10 to determine how IL-10 antagonism influenced helper T-cell responses in vivo. In vitro cytokine production by antigen-stimulated spleen cells was assessed to study the effect of blocking IL-10 activity at 1 day vs 3 days after burn injury. RESULTS: Treating mice with anti-IL-10 at 1 day after injury significantly improved CLP survival, whereas delaying treatment 3 days had no beneficial effect. The analysis of T-cell function in vivo as determined by serum antibody isotype formation indicated that anti-IL-10 treatment at 1 day or 3 days after injury increased T helper cell 1-type antibody formation to sham injury levels by day 10. Moreover, these treatments restored the injury-induced reduction of antigen-stimulated IL-2, interferon gamma, and IL-10 production. CONCLUSIONS: Interleukin 10 plays an early role in the development of burn injury-induced immune suppression. Its in vivo inhibition at 1 day after injury may be a useful approach toward preventing the development of injury-induced immune dysfunction and may do so by restoring T-cell function and cytokine production.

Severe injury triggers antigen-specific T-helper cell dysfunction.

Although it is established that post-injury immune dysfunction involves alterations in T-cell function, the effects of injury on T-cell function in vivo are poorly understood. This study uses a mouse injury model and an antigen immunization approach to investigate the influence of injury on antigen-specific T-helper cell function. We report here that injury triggered a significant reduction in antigen-specific T-helper-1 (Th1)-dependent IgG2a antibody formation, while IgM, IgG1, and IgE production was unchanged. In addition, injury caused a reduction in cytokine production (IL-2, IFNgamma and IL-10) by antigen-stimulated T-cells. We also demonstrate that interleukin 12 (IL-12), a cytokine that promotes Th1 cell differentiation, restored IgG2a antibody formation and corrected the injury-induced reduction in antigen-stimulated cytokine production. Taken together, these findings indicate that severe injury induces a dramatic reduction in Th1 cell function in vivo and suggest that therapies designed to restore Th1 cell function may be beneficial to the injured host.

Interleukin 10 is not essential for survival or for modulating T-cell function after injury.

BACKGROUND: Interleukin 10 (IL-10) is thought to be protective in injury and sepsis. However, we recently reported that IL-10 antagonism can be beneficial after burn injury. This study used IL-10-deficient (IL-10 [-/-]) mice to further define the role of IL-10 after injury. METHODS: Wild-type (WT) C57BL/6 or IL-10 (-/-) mice were anesthetized, sham or burn injured, and immunized subcutaneously with a T-cell-dependent protein antigen. Ten days later antigen-specific serum antibody isotype formation was measured by enzyme-linked immunosorbent assay. In addition, antigen-stimulated splenic T-cell proliferation and cytokine production (interleukin 2, interferon gamma, and tumor necrosis factor-alpha) were measured. RESULTS: Burn-injured IL-10 (-/-) mice survival (80%) was equivalent to that of burn-injured WT mice (74%). An injury-dependent loss of T-helper 1 (Th1)-type antibody isotype (IgG2a) formation occurred in both WT and IL-10 (-/-) mice. In vitro studies indicated that burn injury caused reduced antigen-stimulated splenic T-cell proliferation and Th1-type (interleukin 2 and interferon gamma) cytokine production in WT and IL-10 (-/-) mice, whereas burn-injured IL-10 (-/-) mice produced high levels of antigen-stimulated tumor necrosis factor-alpha. CONCLUSIONS: IL-10 is not essential for survival after burn injury or for several injury-induced changes in adaptive immune function, including Th1-type antibody isotype formation, T-cell proliferation, and Th1-type cytokine production.

The effects of injury on the adaptive immune response.

For more than thirty years it has been apparent that serious injury in humans and experimental animals is associated with a decrease in immune functions dependent upon T cells, the principal cells involved in initiating adaptive immune responses. This review focuses on more recent evidence that T helper cell function is altered after serious injury with loss of T helper 1 function and cytokine production and with preservation of T helper 2 function and an increased production of T helper 2 cytokines. Emphasis is placed on the importance of interactions between the innate and adaptive immune systems in the perturbed immune responses seen following injury. Immunomodulatory strategies are mentioned that have had success in animal models in ameliorating the diminished resistance to infection commonly seen after major traumatic or thermal injury. Finally, it is emphasized that immunomodulatory treatments that are successful in preventing infection may be contraindicated once infection is manifest.

Burn injury primes naive CD4+ T cells for an augmented T-helper 1 response.

BACKGROUND: The mechanisms responsible for altered T-cell responses and cytokine production after injury are not well understood. We used T-cell receptor (TCR) transgenic mice to study burn injury effects on naive versus antigen-activated CD4+ T cells in vivo. METHODS: One week after sham or burn injury, lymph node cells were prepared from TCR transgenic mice and stimulated with TCR transgene-specific antigens. T-cell proliferation was measured and culture supernatants were tested for interleukin-2 (IL-2), interferon-gamma (IFN-gamma), IL-4, and IL-10 by enzyme-linked immunosorbent assay (ELISA). Burn injury effects on antigen-activated T cells were studied by immunizing TCR transgenic or wild-type mice at the time of injury. RESULTS: The antigen-stimulated proliferation of native CD4+ T cells was unaffected by burn injury and no increase in T-helper 2 (Th2)-type cytokine production was observed. Instead, burn injury augmented INF-gamma production by naive CD4+ transgenic T cells, and IL-2 production was marginally reduced. Thus, burn injury primed native T cells for an enhanced Th1-type response. In contrast, antigen-specific proliferation, IL-2, and IFN-gamma production by T cells harvested from immunized wild-type mice were suppressed. Unexpectedly, high mortality was observed when burn-injured TCR transgenic mice were immunized. CONCLUSION: Our results show that burn injury has differential effects on naive and antigen-activated CD4+ T cells and can prime naive CD4+ T cells.

Early operative intervention after thrombolytic therapy for primary subclavian vein thrombosis: an effective treatment approach.

PURPOSE: Effective treatment of primary subclavian vein thrombosis focuses on restoration of venous patency, relief of intrinsic stenosis, and decompression of the thoracic inlet. The appropriate method and timing for surgery, however, have not been not well defined. We conducted a study to determine an acceptable treatment approach. METHODS: A retrospective review evaluated 11 patients seen at our institution in an 8-year period. Seven patients were male and four were female, with an average age of 30 years (range 15 to 54 years). Two patients who had symptomatic stenosis without occlusion were omitted from the study. All patients with occlusion received urokinase therapy and underwent surgical decompression within 5 days of thrombolytic therapy. Five percutaneous transluminal angioplasties were attempted before operative intervention. Eleven decompressions were performed, including nine first-rib resections and two scalenectomies. Five operative venous procedures, consisting of thrombectomy with patch closure (n = 3) and bypass (n = 2), and seven venolysis procedures were performed. All patients received coumadin for 3 to 6 months after the operation. RESULTS: Urokinase therapy established wide venous patency in nine of the 11 extremities treated, with the remaining two requiring thrombectomy for residual thrombus at the time of operation. One patient who underwent transluminal angioplasty before the operation had rethrombosis, and the remaining four showed no improvement in venous stenosis after the intervention. Eight of nine extremities treated by first-rib resection and one of two treated by scalenectomy were free of residual symptoms at follow-up. CONCLUSIONS: Preoperative use of percutaneous balloon angioplasty is ineffective and should be avoided in this setting. Surgical intervention within days of thrombolysis obviates the need for interim oral anticoagulation and enables patients to return to normal activity sooner.

Major injury induces increased production of interleukin-10 by cells of the immune system with a negative impact on resistance to infection.

OBJECTIVE: The purpose of this study was to compare the production of interleukin-10 (IL-10) by peripheral blood mononuclear cells (PBMC) from injured patients and control subjects to determine the responsible cell types and to relate IL-10 production to the occurrence of sepsis. A mouse model of burn injury was used to confirm the human findings and to assess the importance of IL-10 in the lowered resistance to infection after injury. SUMMARY BACKGROUND DATA: Severe injury is associated with depressed immune responses. Although IL-10 is known to inhibit several aspects of immune reactivity, the role of IL-10 in postinjury immune suppression remains controversial. METHODS: Peripheral blood mononuclear cells from 14 burn and 12 trauma patients and 16 healthy individuals were studied at serial intervals for IL-10 production stimulated by a T-cell mitogen, phytohemagglutinin, and by bacterial lipopolysaccharide. To determine the source of IL-10, CD4+ and CD8+ lymphocyte subsets were obtained by selective depletion of PBMC with antibody-coated magnetic beads and were stimulated by anti-CD3 antibody to induce IL-10 secretion. In addition, IL-10 production by patients' PBMC in the first 10 days after injury was assessed for correlation with subsequent septic events. Anti-CD3-stimulated IL-10 production also was determined for CD4- and CD8-enriched lymphocyte subsets obtained by antibody and complement depletion of splenocytes harvested from groups of burn and sham burn mice at day 10 after injury, the time of maximal susceptibility to a septic challenge, cecal ligation and puncture (CLP). Finally, to test the importance of IL-10 in immune suppression in vivo, groups of burn and sham burn mice were treated with anti-IL-10 monoclonal antibody or control immunoglobulin G (IgG) on days 1 and 3 postinjury and were observed for survival after CLP on day 10. RESULTS: Patients' PBMC produced significantly more IL-10 than did controls' PBMC 7 to 14 days after injury. Patients' CD4+ (T-helper) but not CD8+ (T-cytotoxic) lymphocytes also showed increased IL-10 production versus those of control subjects early after injury. Increased PBMC IL-10 production in the first 10 days postinjury correlated significantly (p < 0.05) with subsequent septic events. Burn mouse CD4-enriched but not CD8-enriched splenocytes produced more IL-10 than did sham burn splenocyte subsets on day 10 after injury. Burn mice treated with anti-IL-10 antibody but not with control IgG had significantly increased survival after CLP. CONCLUSION: Serious injury in humans and in a mouse burn model is followed by increased stimulated production of IL-10 by cells of the immune system. The CD4+ T-helper cells appear to be a major source of IL-10 after injury. In injured patients, increased IL-10 production is correlated with subsequent septic events, and in the burn mouse, IL-10 appears to induce decreased resistance to infection.

Optimal methods for autogenous bypass to the anterior tibial artery.

BACKGROUND: Autogenous bypass to the anterior tibial artery (AT) has been increasingly used for infrageniculate revascularization. The conduit may be routed through the interosseous membrane, a pretibial tunnel, or through a lateral thigh and calf tunnel. This study reviewed results of AT bypass to determine the optimal routing method. METHODS: One hundred thirty consecutive vein grafts to the AT were analyzed retrospectively to compare the experience with the interosseous (group I; n = 50), pretibial (group II; n = 51), and lateral (group III; n = 29) routing alternatives. RESULTS: Indications were claudication in 16 (12.3%) and critical ischemia in 114 (87.8%) procedures with no differences among routing subgroups. Ectopic nonreversed and composite conduits were more common in group III. Major operative morbidity occurred after 7 procedures (5.4%) with no differences in early graft failure (7.7% overall) among the three routing subgroups. Wound infections were more common among group I patients, but without predilection to the interosseous tunnel. During a mean follow-up of 24.9 months (0 to 111.2) overall 5-year secondary patency was 70% with no difference among routing technique. CONCLUSION: Optimal routing choice depends on the location of suitable AT, the length of adequate vein conduit, and the surgeon's preference rather than on factors inherent to the method used.

Anti-interleukin-10 antibody restores burn-induced defects in T-cell function.

BACKGROUND: Studies have shown that susceptibility to sepsis after severe injury correlated with reduced production of T-helper 1 (Th1) cytokines (interleukin-2 [IL-2] and interferon-gamma [IFN-gamma]) and a persistence of T-helper 2 (Th2) cytokines (IL-4 and IL-10). The mechanisms responsible for this effect are not clear. We used a T-dependent antigen to study both the effect of burn injury on antigen-specific Th functions in vivo and the effect of anti-IL-10 antibody on these functions. METHODS: Male A/J mice were anesthetized and given a 25% scald burn or a sham burn. On day 0 all mice were immunized with 100 micrograms trinitrobenzene sulfonic acid (TNP) haptenated ovalbumin (TNP-OVA) in complete Freund's adjuvant. Mice (10 per group) were given 250 micrograms monoclonal rat antimurine IL-10 antibody (anti-IL-10 MAB) or control rat immunoglobin G (IgG) on day 0 and 100 micrograms anti-IL-10 MAB or IgG on day 2. On day 10 the mice were killed to obtain serum and spleen cells. TNP-specific serum antibody isotype titers were determined by enzyme-linked immunosorbent assay (ELISA). Splenocyte proliferation and cytokine-production in response to TNP-OVA or to anti-CD3 MAB were determined by tritiated thymidine incorporation and by ELISA, respectively. RESULTS: Burn injury resulted in depressed levels of the TNP-specific IgG2a antibody isotype (Th1 dependent), whereas TNP-specific IgG1 and IgE (Th2 dependent) levels were not decreased in burn versus sham burn mice. Anti-IL-10 MAB but not IgG restored the IgG2a response. Burn injury also resulted in reduced TNP-OVA-specific proliferation of splenocytes, whereas anti-CD3 proliferation was equivalent in burn and sham mice. TNP-OVA-specific IL-2 and IFN-gamma production were significantly reduced by burn injury. Anti-IL-10 MAB restored TNP-OVA-specific proliferation and antigen-specific IL-2 and interferon-gamma production by splenocytes from burn mice. CONCLUSIONS: Burn injury induces the loss of antigen-specific Th1 cell function, and IL-10 acts as a trigger to down-regulate Th1 activity after injury.

Hemodynamic impact of vein graft stenoses and their prediction in the vascular laboratory.

PURPOSE: We undertook this prospective evaluation to define the direct hemodynamic impact of vein graft stenoses and to correlate intraoperative hemodynamic findings with the preoperative duplex scan. METHODS: Twelve consecutive isolated vein graft stenoses were identified in the vascular laboratory during our routine duplex scanning surveillance protocol over 10 months. Peak systolic flow velocity ratios (PSFVRs; velocity within stenosis/velocity proximal to the stenosis) at the stenoses ranged from 2.7 to 10 (mean, 5.5), and ankle-brachial indexes ranged from 0.47 to 0.94 (mean, 0.68) Preoperative arteriograms were obtained and confirmed the isolated stenoses, which radiographically ranged from 20% to 83% diameter reduction (mean, 64%). At the time of surgery the stenotic graft segment was isolated, and simultaneous pressure measurements proximal and distal to the graft stenosis were measured, along with ultrasound transit-time blood flow measurements. Pressure and flow wave forms were recorded for 10 seconds at 200 Hz and were stored on a personal computer-based digital acquisition system. The graft stenoses were then repaired with either a vein patch or short interposition graft, and the hemodynamic measurements were repeated. Fourier transformation of the pressure and flow curves was performed, and the resistance and longitudinal impedance were calculated for each graft segment. RESULTS: Before repair, mean pressure gradients across the stenotic graft segments (delta P) ranged from 1.0 to 74.6 mm Hg (mean, 20.4 mm Hg), and vein graft flow ranged from 4.9 to 140 ml/min (mean, 45.2 ml/min). After repair of the stenotic segments, the mean pressure gradient was decreased to a mean of 1.3 mm Hg, and vein graft flow increased to a mean of 104.8 ml/min. The PSFVR recorded in the vascular laboratory correlated significantly with delta P (r = 0.71; p = 0.01) and allowed prediction of delta P as: delta P = 7.4 (PSFVR) - 19.8. PSFVR also correlated with measured resistance across the stenosis (r = 0.79; p = 0.004). Conversely, the angiographic measurement of stenosis did not correlate significantly with these parameters. The angiographic measurement of stenosis showed a moderate correlation with the PSFVR (r = 0.58; p = 0.046). CONCLUSIONS: The PSFVR, as measured in the laboratory, is an accurate and useful indicator of the hemodynamic impact of vein graft stenosis. Revision of stenotic vein graft segments resulted in a significant improvement in graft hemodynamics.