Anthony C. Antonacci

Peripheral blood leukocyte kinetics following in vivo lipopolysaccharide (LPS) administration to normal human subjects. Influence of elicited hormones and cytokines.

Lipopolysaccharide (LPS, endotoxin) administration to human subjects elicits significant elevations in plasma cachectin/TNF, epinephrine, and cortisol. This study examined the temporal relationship between changes in blood leukocyte subsets and plasma mediators following endotoxin administration to normal human subjects. A five-minute intravenous infusion of purified LPS (20 units/kg Escherichia coli) was administered to 12 healthy volunteers. Blood samples were obtained at varying intervals after infusion and analyzed for differential cell counts and lymphocyte subsets (CD2, CD3, CD4, CD8, CD20, and HLA-DR) by flow microfluorimetry, and also assayed for plasma cachectin/TNF, epinephrine, and cortisol. Plasma cachectin/TNF was significantly elevated at 75 and 90 minutes after infusion with a peak concentration of 261 +/- 115 pg/ml noted 75 minutes after infusion. A significant plasma epinephrine elevation of 181 +/- 75 pg/ml was demonstrated one hour after infusion, while significant elevations in plasma cortisol were noted from one to five hours after infusion with a peak level of 34 +/- 3 micrograms/dl three hours after infusion. A profound monocytopenia (p less than 0.01) was noted one hour after infusion. Temporally associated with the rise in plasma cortisol was a reversal of the early granulocytopenia to a significant granulocytosis (p less than 0.01 versus preinfusion mean), whereas a marked lymphocytopenia (p less than 0.01) was observed from one to six hours after infusion. During the period of hypercortisolemia, CD2, CD3, and CD4 lymphocyte percentages were decreased (p less than 0.01) while CD20 and HLA-DR lymphocyte percentages were increased (p less than 0.01). There was a small percentage decrease in CD8 lymphocytes from one to 24 hours after infusion (p less than 0.01), although relative to the one-hour nadir, there was a significant rise in the percentage during the time of elevated plasma cortisol concentrations. A six-hour infusion of epinephrine (30 ng/kg/min) administered to six healthy volunteers resulted in a monocytosis (p less than 0.05) and granulocytosis (p less than 0.01) without a change in lymphocyte number or lymphocyte subset percentage. Previous reports have shown that in vivo corticosteroid infusion causes a prominent granulocytosis, monocytopenia, and lymphocytopenia with a decrease in the percentages of CD3 and CD4 lymphocytes. The peripheral blood leukocyte dynamics documented in the current study are similar to patterns observed following in vivo corticosteroid administration. This study suggests that the acute adrenocortical response to endotoxemia primarily mediates the subsequent changes in leukocyte subsets.

Autologous and allogeneic mixed-lymphocyte responses following thermal injury in man: The immunomodulatory effects of interleukin 1, interleukin 2, and a prostaglandin inhibitor, WY-18251☆

A group of 30 burn patients with 36-87% total body surface area (TBSA) burns was studied at 24-48 hr postburn. These included studies of (1) autologous and allogeneic mixed-lymphocyte reactions (MLR); (2) the immunoregulatory influence of mitomycin C-treated T cells, non-T cells, and unfractionated peripheral blood lymphocytes (PBL) on allogeneic MLR; and (3) correlation between the proportions of T-cell subsets defined with monoclonal antibodies (OKT4 and OKT8) and autologous MLR. Studies concerning adherent cell production of thromboxane, prostaglandin E2, and prostaglandin F2a and the immunomodulatory effects of Interleukin 1 (IL-1), Interleukin 2 (IL-2), and a prostaglandin inhibitor, WY-18251, on autologous MLR are presented. The autologous mixed-lymphocyte reaction was depressed in 60% of the burn patients tested. This depressed response correlated closely to the extent of third-degree injury (P less than 0.025) and to TBSA injury greater than 60% (P less than 0.025). A linear correlation was observed between the depression in autologous MLR and a decrease in both the percentage of OKT4+ T cells and the OKT4+/OKT8+ ratio. The response of T cells from burn patients in allogeneic MLR was normal. Age, sex, TBSA of the burn, and size of second-degree burn did not correlate with the abnormalities observed in MLR. Mitomycin C-treated mononuclear cells, purified T cells, or non-T cells from burned patients did not demonstrate any suppressive influence on MLR in normals. Monocyte number and arachidonic acid metabolism were investigated. In addition to increased numbers of monocytes following thermal injury, adherent cells produced increased quantities of thromboxane, prostaglandin E2, and prostaglandin F2a. The effects of Interleukin 1, Interleukin 2, and a prostaglandin inhibitor, WY-18251, were studied in autologous MLR (AMLR) of burned and normal patients. Interleukin 1 and WY-18251 did not induce any significant changes in proliferation in burned patients or normal controls. When compared to cultures without exogenous IL-2, an increase in AMLR was observed following the addition of IL-2 to burn patient cultures at Day 6 and Day 7 of culture. Although the addition of IL-2 did increase proliferation in AMLR of normal controls at Day 6 and Day 7, the enhancement observed for the burn patient cultures represented a restoration to the level of normal control cultures without IL-2. A dose-dependent increase in AMLR was observed in T cells isolated from normal and burned patients in the presence of purified Interleukin 2.(ABSTRACT TRUNCATED AT 400 WORDS)

A Report Card System Using Error Profile Analysis and Concurrent Morbidity and Mortality Review: Surgical Outcome Analysis, Part II

BACKGROUND An effective report card system for adverse outcome error analysis following surgery is lacking. We hypothesized that a memorialized database could be used in conjunction with error analysis and management evaluation at Morbidity & Mortality conference to generate individualized report cards for Attending Surgeon and System performance. STUDY DESIGN Prospectively collected data from September 2000 through April 2005 were reported following Morbidity & Mortality review on 1618 adverse outcomes, including 219 deaths, following 29,237 operative procedures, in a complete loop to approximately 60 individual surgeons and responsible system personnel. RESULTS A 40% reduction of gross mortality (P < 0.001) and 43% reduction of age-adjusted mortality were achieved over 4 years at the Academic Center. Quality issues were identified at a rate three times greater than required by New York State regulations and increased from a baseline 4.96% to 32.7% (odds ratio 1.94; P < 0.03) in cases associated with mortality. A detailed review demonstrated a significant increase (P < 0.001) in system errors and physician-related diagnostic and judgment errors associated with mortality highlighted those practices and processes involved, and contrasted the results between academic (43% mortality improvement) and community (no improvement) hospitals. CONCLUSIONS The findings suggest that structured concurrent data collection combined with non-punitive error-based case review and individualized report cards can be used to provide detailed feedback on surgical performance to individual surgeons and possibly improve clinical outcomes.

A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis: part I.

BACKGROUND We hypothesized that an archive database in conjunction with Morbidity and Mortality (M&M) review could be used to define a systematic list of post-surgical adverse events and identify areas for performance improvement. STUDY DESIGN Adverse event data following surgery were prospectively collected at the Beth Israel Medical Center in NYC from academic, specialty, community hospital, and ambulatory care settings over a 5-year period from September 2000 through April 2005. A classification system and analysis methodology was developed to guide and maximize the effectiveness of M&M review. RESULTS A total of 1618 adverse events, including 219 deaths, were analyzed following 29,237 operative procedures according to the analysis method described. A list of 245 adverse events was classified among 15 groups, and a subgroup of 25 adverse events accounted for over 80% of total adverse events. Five categories of adverse events were associated with death in surgical patients and 4 of 5 categories were post-operative events. Used in conjunction with M&M review, data derived from this analysis highlighted those adverse events with the greatest clinical frequency to the departments quality profile. CONCLUSIONS We present a classification system for surgical adverse events and propose a specific analysis method which may be used in conjunction with Morbidity and Mortality Conference to standardize the profiling of surgical performance.

The decrease in peripheral blood CD4+ T cells following thermal injury in humans can be accounted for by a concomitant decrease in suppressor-inducer CD4+ T cells as assessed using anti-CD45R

Using single- and two-color fluorescence flow cytometry, 10 thermally injured human subjects were assessed over time for both percentages and absolute numbers of lymphocytes comprising peripheral blood lymphocyte subpopulations. The CD3+ lymphocyte percentage decreased significantly in the early postburn period, and this decrease could be accounted for entirely by a concomitant decrease in the CD4+ lymphocyte percentage. Further, the decline in CD4+ percentage was due to a specific decrease in the suppressor-inducer subset of CD4 as defined using anti-CD45R. No change in the helper-effector subset of CD4 was noted. The percentage of CD8+ lymphocytes did not change significantly at any time postburn nor did subsets of CD8 as defined using anti-CD11. Numerical changes in lymphocyte subsets were dominated by a general lymphopenia occurring on Day 4 following injury. However, suppressor-inducer (CD4+/CD45R+) T cells also decreased significantly on postburn Day 1. These results further elucidate phenotypic changes in immunoregulatory subsets following major injury and suggest a possible basis for depressed autologous mixed lymphocyte responsiveness of burn patient T cells, one of the functional immunologic defects associated with severe injury.

Chronic pathophysiologic elevation of corticosterone after thermal injury or thermal injury and burn wound infection adversely affects body mass, lymphocyte numbers, and outcome.

The purpose of the present studies was to investigate the effect of glucocorticoids on catabolism and lymphocyte numbers in a rat model of thermal injury or thermal injury plus burn wound infection. Thermal injury alone caused only an acute increase in plasma corticosterone concentrations. Furthermore, body weight declined moderately (5%), and lymphocyte numbers in lymph nodes draining the burn wound and blood increased markedly, whereas splenic lymphocyte numbers declined by about 60%. By contrast uninjured rats subjected to chronic elevation of corticosterone by corticosterone pellet implantation showed large decreases in body weight and lymphocyte numbers in all tissues examined. The combination of injury and chronic corticosterone elevation resulted in body weight and lymphocyte changes intermediate between injury alone and corticosterone treatment alone. Chronic elevation of corticosterone for 4 days before burn wound infection significantly decreased survival time and survival. Burn wound infection immediately after injury caused chronic elevation of endogenous plasma corticosterone and body weight and numeric lymphocyte changes that were remarkably similar to those of uninjured rats treated with corticosterone. Finally, the glucocorticoid receptor antagonist RU 486 significantly increased survival time in thermally injured, burn wound-infected rats. These results lend support to a hypothesis that chronic elevation of plasma cortisol concentrations as observed in patients with burns may be deleterious.

Changes in Free and Total Levels of Plasma Cortisol and Thyroxine Following Thermal Injury in Man

Changes in endocrine status are known to occur following thermal injury. Therefore, the effect of burn injury on plasma corticosteroid and and thyroid hormones and their respective binding proteins was examined. Thirty-one subjects with 18%-99% TBSA burn were compared to 50 normal controls with respect to plasma levels of total cortisol, free cortisol, total thyroxine (T4), free thyroxine index (FTI), corticosteroidbinding globulin capacity ICBGC), tri-iodothyronine uptake (T3U), and albumin. Compared to controls, plasma concentrations of total and free cortisol in thermally injured patients were elevated at all time points tested. However, there was no significant difference in total or free cortisol values for survivors and nonsurvivors. Both total T4 and the FTI were significantly decreased compared to normal, and nonsurvivors in turn had significantly lower T4 and FTI values than did survivors. In nonsurviving patients, values of T4 and the FTI were about 50% of the mean value for normal controls, and these levels showed only a slight increase by postburn day (PBD) 21. For both survivors and nonsurvivors, CBGC was decreased relative to normals in the 48-hour period following burn, but by PBD 7 survivors and nonsuivivors had mean levels of CBGC within the normal range. Plasma albumin was uniformly decreased throughout, and there was no difference in levels for survivors and nonsurvivors. These data confirm that thermally injured human beings have increased levels of free and total corticosteroids and decreased levels of T4, and that these changes are more extreme in patients with greater illness who eventually die.

Granulocyte contamination of Ficoll-Hypaque preparations of mononuclear cells following thermal injury may lead to substantial overestimation of lymphocyte recovery

During ongoing flow cytometric studies of burned patient blood leukocytes, it was noted frequently that large numbers of granulocytes were present along with the mononuclear cells at the plasma/Ficoll-Hypaque (F-H) interface following centrifugation over F-H. Since differential WBC counts are not routinely performed on F-H interface cells, it is possible that many previous immunologic studies of burned patients have greatly overestimated numbers of lymphocytes recovered. The present study sought to quantify the extent to which granulocyte contamination of F-H separated cells occurs following burn injury. Blood from 15 thermally injured patients (7-55% total body surface area burn) was studied serially at 24 hr, 48 hr, and weekly thereafter through 6 weeks postburn (PB). Controls were age-matched normals (No. of control bloods = 59). Three-part differential cell counts (lymphocytes, monocytes, and granulocytes) were performed on both F-H interface cells and RBC-lysed whole blood. Counts were performed by light scatter analysis on a flow cytometer. Except at 48 hr, at every time studied through 4 weeks PB, there was significant contamination of F-H interface cells with granulocytes. At 24 hr PB, 41 +/- 9% of the interface cells were granulocytes while at 4 weeks, PB 24 +/- 8% of the interface cells were granulocytes. The data did not support the interpretation that this increase in F-H interface granulocytes was simply reflective of the granulocytosis commonly observed after burn. Thus artificial generation of granulocytosis by addition of extra normal leukocytes to normal blood resulted in complete separation of granulocytes from mononuclear cells following centrifugation over F-H.(ABSTRACT TRUNCATED AT 250 WORDS)

Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes.

OBJECTIVE To study the profile of incidents affecting quality outcomes after surgery by developing a usable operating room and perioperative clinical incident report database and a functional electronic classification, triage, and reporting system. Previously, incident reports after surgery were handled on an individual, episodic basis, which limited the ability to perceive actuarial patterns and meaningfully improve outcomes. DESIGN, SETTING, AND PARTICIPANTS Clinical incident reports were experientially generated in the second largest health care system in New York City. Data were entered into a functional classification system organized into 16 categories, and weekly triage meetings were held to electronically review and report summaries on 40 to 60 incident reports per week. System development and deployment reviewed 1041 reports after 19,693 operative procedures. During the next 4 years, 3819 additional reports were generated from 83,988 operative procedures and were reported electronically to the appropriate departments. MAIN OUTCOME MEASURES Number of incident reports generated annually. RESULTS A significant decrease in volume-adjusted clinical incident reports occurred (from 53 to 39 reports per 1000 procedures) from 2001 to 2005 (P < .001). Reductions in incident reports were observed for ambulatory conversions (74% reduction), wasted implants (65%), skin breakdown (64%), complications in the operating room (42%), laparoscopic conversions (32%), and cancellations (23%) as a result of data-focused process and clinical interventions. Six of 16 categories of incident reports accounted for more than 88% of all incident reports. CONCLUSION These data suggest that effective review, communication, and summary feedback of clinical incident reports can produce a statistically significant decrease in adverse outcomes.

Monoclonal antibodies directed at human T lymphocyte activation antigens cross react with concanaval in a-stimulated canine and baboon peripheral blood lymphocytes

Abstract A panel of 10 monoclonal antibodies directed at activation antigens on human T lymphocytes were tested for cross reactivity with canine and baboon resting and ConA stimulated peripheral blood lymphocytes. Monoclonal antibodies anti-OKT19, anti-OKT-21, and anti-OKT22 labeled a high percentage of both resting and stimulated canine and baboon cells. Anti-OKT24 labeled activated but not resting baboon lymphocytes and did not label canine lymphocytes. Anti-HLA-DR labeled a small percentage of resting baboon lymphocytes (presumably B cells) and a high percentage of activated baboon and resting and activated canine lymphocytes. Anti-OKT14, anti-OKT20, and anti-OKT23 did not label canine or baboon lymphocytes. Anti-OKT9 did not label baboon lymphocytes, but labeled a low percentage of lymphocytes in one dog. Anti-TAC labeled activated but not resting canine and baboon cells