Normothermic ex vivo perfusion of the limb allograft depletes donor leukocytes prior to transplantation.

INTRODUCTION: The donor immune compartment plays a central role in graft rejection of the vascularised composite allograft (VCA) by contributing to 'direct presentation'. Using our limb ex vivo normothermic machine perfusion (EVNP) protocol designed for prolonged allograft preservation, this study aimed to assess whether donor leukocytes responsible for allograft rejection are mobilised from the donor compartment. METHODS: Five genetically different pig forelimbs underwent perfusion via the brachial and radial collateral artery for 6 h after 2 h of cold storage. Oxygenated haemodilute leucocyte-deplete blood was recirculated at normothermia using an extracorporeal perfusion system. Tissue perfusion was evaluated clinically and biochemically via blood perfusate. The temporal kinetics of donor leucocyte extravasation, cytokine secretion and cell-free DNA was characterised in the circulating perfusate. RESULTS: Flow cytometry revealed increasing populations of viable leukocytes over time, reaching 49 billion leukocytes by 6 h. T (3.0 × 109 cells) and B cells (3.1 × 108 cells) lymphocytes, monocytes (2.7 × 109 cells), granulocytes (8.1 × 109 cells), NK (6.3 × 108) and γδ (8.1 × 108) cells were all identified. Regulatory T cells comprised a minor population (1.6 × 107 cells). There was a cumulative increase in pro-inflammatory cytokines suggesting that the donor limb has the capacity to elicit significant inflammatory responses that could contribute to leucocyte activation and diapedesis. CONCLUSION: EVNP not only acts as a preservation tool, but could also be utilized to immunodeplete the VCA allograft prior to transplantation. This has clinical implications to mitigate acute rejection and prevent graft dysfunction and supports the future application of machine perfusion in graft preservation and immune modulation.

Peri-partum posture and behaviour of gilts and the location of their piglets in lines selected for components of efficient lean growth.

Peri-partum posture and behaviour of gilts from lines selected for different components of efficient lean growth were studied to determine if behavioural changes may have been associated with the observed responses in reproductive performance. The proportions of time that gilts expressed defined posture and behaviour traits and the locations of their piglets were determined from video recordings of observations made at 5min intervals in the period extending from 2h pre-farrowing to 2h post-farrowing. The 137 gilts studied were from four pairs of Large White lines which had been divergently (high and low) selected for either daily food intake (DFI), lean food conversion efficiency (LFC), lean growth rate on ad libitum feeding (LGA) or lean growth rate on a restricted feeding scale (LGS).Almost all the significant (P<05) changes occurred in the LGS pair of lines. In the pre-farrowing period, relative to the low LGS gilts, high LGS gilts spent a higher proportion of their time lying on their sides (0.92 versus 0.69), and less time in the upright postures of standing, sitting or lying on their bellies (0.08 versus 0.33) and engaging in nesting behaviour (0.02 versus 0.10). During farrowing, high LGS gilts again lay on their sides more often than low LGS gilts (0.96 versus 0.80) and were upright less often (0.04 versus 0.20). High LGS gilts changed posture less often than low LGS gilts (0.05 versus 0.31) but were more often alert (0.79 versus 0.61). During farrowing, high LGS piglets were seen less often at their mother's head, back and vulva or at the creep than low LGS piglets (0.06 versus 0.15). Post-farrowing, there were no significant differences between the lines, almost all gilts lying on their sides with their piglets at the udder. Divergent selection for components of efficient lean growth rate on ad libitum feeding was not associated with consistent responses in gilt posture and behaviour or in piglet location. Selection for high lean growth on restricted feeding had effects on gilt posture and behaviour which may have been beneficial to her welfare and that of her piglets.

Health promotion and senior women with limited incomes.

Health promotion is increasingly being recognized as making an important contribution to the well-being of Canada's seniors. Most research relating to this topic, however, has focused on middle-income senior men and women. An exploratory study using ethnographic methods was conducted to explore and describe the health promotion experience of senior women living on limited incomes. Interviews with a total of 11 urban senior women living on limited incomes were analyzed. A major finding of this study was that the women utilized a wide variety of "ways of living" that are presented in the model, Health Promotion as Self Nurturance. Health promotion was perceived to be influenced by living on a limited income by most participants; however, 3 of the participants believed that their health status and income level were unrelated. Findings are discussed and implications for community health nurses are offered.

Impact of an instructional program on nurses' accuracy in capillary blood glucose monitoring.

This experiment examined the accuracy of capillary blood glucose monitoring using the visual glucose oxidase strip (Chemstrip) procedure. Also, the effects of a certification program for nurses on the accuracy of glucose oxidase strip monitoring by registered nurses were analyzed. Seventy nurses and 123 patients participated. Data were collected from nurses' recordings of visual Chemstrip procedure results and from the concurrent laboratory blood glucose determinations for 3 months. The data included 70 Chemstrip recordings and 70 concurrent laboratory blood glucose recordings in the experimental group and 68 Chemstrip and 68 concurrent laboratory glucose recordings in the control group. Data analysis revealed that the accuracy of the nurses' performance of the glucose oxidase strip procedure was inadequate. A certification program did, however, dramatically improve the accuracy of the procedure. Proximity of time between the certification program and the performance of the glucose oxidase strip procedure did not affect accuracy.

Utilization of hospital services by the elderly: geriatric crisis in one Canadian single payer system.

As the number and proportion of elderly persons in the Canadian population increase, utilization of health services by the elderly becomes a growing concern for health service insurers, financial managers and policy makers, as well as for care providers. The purpose of this paper is to present the results of a study to analyse the use of hospital services by the elderly in Alberta since the introduction of a universal single payer health care insurance system in 1970. The study period coincides with the implementation of publicly-financed comprehensive medical and hospital insurance programmes for all Alberta residents, making it possible to perform historical and population-based utilization analyses. Thus the data used for the study included all hospital discharge abstracts generated by all Alberta hospitals from 1971 to 1991. Trends in hospital service utilization by the elderly in terms of total number of separations, patient-days, and per case measures such as average length of stay as well as per capita utilization rates were reviewed to identify utilization patterns over the study period. Further, relative per capita utilization measures, in comparison with the base year (1971), age group 15-44, male, metropolitan residents, were derived and historical trends identified. A series of regression analyses were carried out to estimate the effects of age, sex and origin on utilization rates. In addition, for the period of 1984-1991, Diagnosis Related Groups (DRG) case weights were used to measure per capita and per case rates and to analyse historical relative utilization rates over the 8-year period. In general, there has been a significant decline in hospital utilization by Albertans under the publicly-financed single payer system, but utilization rates for elderly have remained high, resulting in high relative utilization rates in comparison with other age groups. It was also noted that per capita utilization rates for rural residents were substantially higher than urban residents. It appears that these higher utilization rates by the elderly and rural residents in combination with tight bed and financial control by the government have been causing significant bed shortage problems for non-elderly elective patients in urban areas.

Visions realized and dreams dashed: Helen Penhale and the first basic integrated baccalaureate program in nursing in the west, at the University of Alberta 1952-1956.

The first basic degree program in nursing in Canada was established at the University of British Columbia in 1919. This program and those that followed elsewhere were of the non-integrated form, wherein a diploma program offered by a hospital was supplemented by university courses in the arts, humanities, and sciences. In 1942 an innovative basic baccalaureate program in nursing was established at the University of Toronto; courses in nursing, given by the university, were offered in conjunction with university courses in other subjects. Only two other attempts were made to set up integrated programs in Canada prior to release of the Report of the Royal Commission on Health Services of 1964; McMaster University established a program in 1946, and, in an attempt that was ultimately unsuccessful, a program was established at the University of Alberta in 1952. The purpose of this study was to examine the conditions surrounding the initiation and termination of a basic degree program in the 1950s at the University of Alberta, in order to understand the key issues in the movement to establish basic university degree programs for nurses, and the gender discrimination relative to nurses and nursing students that has prevailed in health and education. Although the conflict at the University of Alberta was a very difficult one for the nurses involved, and although the Director who had the temerity to establish the program relinquished her position when the program was summarily terminated, this episode in Canadian nursing history provides insight into the climate in which baccalaureate nursing education existed and into some of the issues relative to its development.

Acute ischemia-reperfusion injury in the canine hindlimb.

A canine arterial ligation preparation was used to produce whole limb ischemia-reperfusion injury. Alterations in the distribution of arterial blood flow as well as the morphology of skeletal muscle ischemia-reperfusion have not been investigated completely in this setting. Five anesthetized adult mongrel dogs underwent multiple infrarenal aortic branch ligations; one randomly selected hindlimb was subjected to six hours of ischemia and two hours of reperfusion, while the opposite limb served as control. Distribution of arterial blood flow was analyzed by injection of radiolabeled microspheres. Electromagnetically measured femoral arterial blood flow was 92 +/- 10 ml/min during control, and increased significantly (p less than 0.05) to 254 +/- 94 ml/min during reperfusion. Flow distribution to skin, muscle, and bone was 9 +/- 2%, 68 +/- 7%, and 8 +/- 1% during control, and 7 +/- 3%, 65 +/- 8%, and 9 +/- 4% after reperfusion, which did not represent significant changes. Arteriovenous shunting was 11 +/- 4% during control, and was 13 +/- 5% during reperfusion, which was not significantly different. Subcellular injury in the ischemic and reperfused hindlimb was demonstrated by light and electron microscopy. These findings further characterize whole limb ischemia-reperfusion injury in the canine hindlimb.

Technetium 99m pyrophosphate quantitation of skeletal muscle ischemia and reperfusion injury.

The study of ischemia and reperfusion injury in the extremity has been hampered by lack of an accurate method of measuring skeletal muscle injury. We used a bilateral isolated in vivo canine gracilis muscle model in 15 anesthetized dogs. The experimental muscles had 4, 6, or 8 hours of ischemia and 1 hour of reperfusion. The contralateral gracilis muscle served as a control. Technetium 99m pyrophosphate (99mTc-PYP), an agent which localizes in injured muscle cells, was used to quantitate canine skeletal muscle damage. After 6 hours of ischemia and 1 hour of reperfusion, there was a significant increase of 215% of 99mTc-PYP uptake in the experimental vs the control muscle. Experimental muscle uptake was 8% greater than control after 4 hours and 405% more after 8 hours of ischemia and reperfusion. Segmental distribution of 99mTc-PYP uptake showed localization to be greatest in the middle of the muscle at the entry site of the gracilis artery. Electron microscopic evaluation also documented this area to have undergone the most severe injury. Distal portions of the muscle did not show increased damage. Our results show that 99mTc-PYP effectively quantitates skeletal muscle ischemia and reperfusion injury. The pattern of 99mTc-PYP uptake suggests that considerable injury is caused during reperfusion.

Effectiveness of a program of information and support for myocardial infarction patients recovering at home.

The impact of patient education follow-up by telephone on the knowledge of the postmyocardial infarction (MI) patient was investigated in this study. On the basis of Orem's self-care framework, subjects' levels of knowledge in six criterion areas were assessed according to measurement criteria developed by Horn and Swain. Fifty-one subjects from the total population of MI patients admitted to the coronary care unit of the study hospital during the period of research who met study criteria were randomly assigned to experimental and control groups. Statistically significant differences (p less than 0.05) were found in the knowledge level of the experimental group in the areas of the disease, its effects, related self-care measures, recommended exercises, and all teaching areas together. Although significant differences were not found in the teaching areas of therapeutic diet, medications, physical activity restrictions, and recommended rest, a higher mean was produced for the experimental group in all but one area. These findings demonstrate that a telephone teaching program for MI patients 6 to 8 weeks after hospital discharge can be effective in increasing knowledge relative to the disease, self-care, and therapeutic regimen.

Regional hypothermia protects against ischemia-reperfusion injury in isolated canine gracilis muscle.

Regional hypothermia is known to protect many tissues from ischemic injury. We investigated the relationship between regional hypothermia and skeletal muscle ischemia-reperfusion injury in a bilateral in vivo isolated canine gracilis muscle model. In five anesthetized dogs, one gracilis muscle was subjected to 6 hours of ischemia followed by 1 hour of reperfusion while the contralateral muscle served as a nonischemic control. Localization and quantitation of skeletal muscle injury was determined by histochemical staining with triphenyl tetrazolium chloride (TTC) followed by computerized planimetry of the infarct size. Muscle pH and temperature were monitored continuously in the proximal, middle, and distal segments by using pH electrodes and needle thermistors. Muscle pH was calculated by use of the Nernst equation with temperature correction, and hydrogen ion washout rates (H+) were derived from the observed change in muscle pH during reperfusion. A significant (p less than 0.05) regional hypothermia was observed in the distal third of the muscle. The preischemic temperature in the distal muscle was 27 +/- 2 degrees (SEM) C, compared to 34 +/- 1 degree and 32 +/- 2 degrees C in the proximal and middle segments of muscle, respectively. This temperature gradient was sustained throughout the experiment. The distal third of the ischemic muscle demonstrated significantly less (p less than 0.05) injury than the proximal and middle thirds as measured by TTC infarct size (31 +/- 10%, compared to 71 +/- 3% and 78 +/- 6%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Rate of reperfusion blood flow modulates reperfusion injury in skeletal muscle.

The mechanisms of ischemia-reperfusion (I-R) injury in skeletal muscle remain controversial. We investigated the effect of the rate of reperfusion blood flow on I-R injury in an isolated in vivo canine gracilis muscle model in six anesthetized dogs. In all animals, both gracilis muscles were subjected to 6 hr of ischemia followed by 1 hr of reperfusion. During reperfusion, one gracilis artery was partially occluded to limit the rate of reperfusion blood flow to its preischemic rate (limited reperfusion, LR), while the contralateral artery was allowed to perfuse freely at a normal rate (normal reperfusion, NR). Muscle injury was quantified by histochemical staining (triphenyltetrazolium chloride, TTC) with computerized planimetry of the infarct size, and by spectrophotometric determination of technetium-99m pyrophosphate uptake. Endothelial permeability was quantified by measurement of gracilis muscle weight gain and 125I-albumin radioactivity after intravenous injection. Results are presented as the means +/- SEM, and differences are considered to be statistically significant if P less than 0.05 by Student's t test for paired data. LR resulted in significantly less blood flow (9.7 +/- 1.7 cc/min/100 g) when compared to NR (55.7 +/- 11.6 cc/min/100 g). I-R injury was significantly reduced by LR as evidenced by a decrease in TTC infarct size from 41 +/- 7% to 11 +/- 5%, and a decrease in technetium-99m pyrophosphate uptake from 512 +/- 20 to 163 +/- 44 X 10(3) counts/min/g. LR also significantly decreased the postreperfusion edema formation as evidenced by a reduction in the muscle weight gain from 27 +/- 6 to 9 +/- 1 g, and a reduction in the 125I-albumin radioactivity from 45 +/- 14 to 32 +/- 8 counts/min/g. These data suggest that the hyperemic rate of reperfusion blood flow is a significant factor in the pathophysiology of postreperfusion edema and that clinical control of reperfusion injury in skeletal muscle may be achieved by limiting the rate of reperfusion blood flow.

Heparin decreases ischemia-reperfusion injury in isolated canine gracilis model.

The mechanisms of ischemia-reperfusion injury in skeletal muscle remain controversial. Some investigators have demonstrated that heparin can ameliorate ischemic injury to heart, brain, and renal tissue. We investigated the ability of heparin sodium to decrease ischemia-reperfusion injury in an isolated gracilis muscle model in ten anesthetized mongrel dogs. One gracilis muscle was perfused normally while the contralateral muscle was subjected to six hours of ischemia followed by one hour of reperfusion. Five dogs were given a preischemic bolus of heparin sodium (200 U/kg, intravenously followed by a continuous infusion (15 U/kg/h, intravenously), and five control dogs received no heparin. Quantitation of skeletal muscle ischemia-reperfusion injury was determined by histochemical staining with triphenyl tetrazolium-chloride and computerized planimetry of the infarct size. Results from the ischemic muscle demonstrate a significant beneficial effect of heparinization. The nonheparinized dogs had a 72% +/- 5% infarct size, which was significantly reduced to 24% +/- 8% in the heparinized dogs. The mechanism of this protective effect may be due to heparin's anticoagulant, antiplatelet, or anti-inflammatory action.

Heparinization reduces endothelial permeability and hydrogen ion accumulation in a canine skeletal muscle ischemia-reperfusion model.

Skeletal muscle injury after revascularization (ischemia-reperfusion) continues to be a major clinical problem. Although heparinization has been recommended, its action in an experimental model of I-R has not been evaluated. We investigated the ability of heparinization to decrease I-R injury in 10 anesthetized dogs (nonheparinized, n = 5; heparinized, n = 5), subjecting one gracilis muscle to 6 hours of ischemia followed by 1 hour of reperfusion while the identically prepared contralateral muscle served as a nonischemic control. Skeletal muscle infarction was determined by Tc-PYP uptake. Endothelial permeability was quantified by measurement of skeletal muscle 125I-Alb activity after intravenous injection. Interstitial hydrogen ion (H+) accumulation was determined by a miniature pH electrode inserted into the gracilis muscle. Isotopic activities from the ischemic muscle were calculated as a percentage of the contralateral nonischemic muscle (mean +/- SEM). Nonheparinized ischemic muscles had an increase in the activities of Tc-PYP and 125I-Alb of 684% +/- 149% and 742% +/- 130%, which were reduced to 218% +/- 54% and 378% +/- 85% by heparinization, respectively (p less than 0.05). During ischemia, the nonheparinized muscles accumulated 1223 +/- 121 nmol of H+ compared with 785 +/- 95 nmol in the heparinized animals (p less than 0.01). This significant reduction in I-R injury may be causally related to diminished endothelial permeability and H+ accumulation.

Doppler ultrasound, laser Doppler, and perfusion fluorometry in bowel ischemia.

Improved accuracy and objectivity in the evaluation of intestinal viability has been reported by some investigators using Doppler ultrasound, and more recently laser Doppler velocimetry and perfusion fluorometry. To compare the sensitivity and clinical applicability of these techniques, intestinal viability was evaluated by each method in nine 15- to 50-cm loops of small bowel prepared by division of the mesenteric vasculature in five anesthetized dogs. The sensitivity of Doppler ultrasound was 86%, of laser Doppler flow velocity 85%, of laser Doppler index 94%, and of perfusion fluorometry 95%. Though the sensitivity of Doppler ultrasound is significantly less than that of laser Doppler and perfusion fluorometry, this is not unexpected since the latter two techniques are more quantitative than Doppler ultrasound. Clinically, Doppler ultrasound compares favorably with laser Doppler and perfusion fluorometry, and its low cost and simplicity suggest its adjunctive use in the operative setting.

Quantitative histochemical evaluation of skeletal muscle ischemia and reperfusion injury.

Acute arterial obstruction to the extremities is associated with significant morbidity and mortality. The evaluation of accompanying skeletal muscle injury has thus far been indirect and imprecise. Triphenyltetrazolium chloride (TTC) is an oxidation-reduction indicator which allows for the histochemical quantitation of skeletal muscle injury. In 21 anesthetized nonheparinized adult mongrel dogs, the isolated in vivo gracilis muscle underwent 4, 6, or 8 hr of ischemia with and without reperfusion. The muscles were excised and cut into 1-cm segments, representative muscle biopsies for electron microscopy were taken, each segment was stained in 1% TTC, and the total area of staining was measured with computerized planimetry. All control muscles stained completely with a dark red color. After 4, 6, or 8 hr of ischemia, quantitative measurements of muscle staining indicative of normal tissue were present in 98 +/- 1%, 59 +/- 5%, and 23 +/- 9% of the total muscle areas, respectively. Six hours of ischemia followed by reperfusion was associated with only 36 +/- 9% of the muscle being stained. Segmental TTC staining demonstrated that reperfusion was associated with greater injury, and less TTC staining, in the proximal portion of the gracilis muscle at the site of entry of the major arterial pedicle. The distal muscle did not demonstrate increased damage with reperfusion. It is hypothesized that protection of the distal muscle from reperfusion injury may be due to an absence of reflow farther away from the artery.