Hemolysis and suppression of neutrophil chemotaxis by a low molecular weight component of human burn patient sera

Pharmacological properties of cerium compunds

Cerium is a member of the lanthanide series or rare earth elements which exert diverse biological effects mainly by their resemblance to calcium. This similarity, which is particularly characteristic for the lighter members of the lanthanide series, enables these elements to replace calcium in biomolecules without necessarily substituting for it functionally. While the inhibitory effects on calcium-dependent physiological processes (such as those involved in the blood clotting cascade as well as in neuronal and muscular functions) are well-known, their relevance for the pharmacological properties of cerium are less clear. Historically, cerium oxalate was used as an antiemetic, especially in vomiting of pregnancy and kinetoses, although its mechanism of action has never been clarified. At present, cerium nitrate is available as an adjunct to silver sulfadiazine cream for the topical treatment of extensive burns not amenable to early wound excision. Apart from direct antiseptic effects, cerium helps to prevent postburn sepsis and systemic inflammatory response by fixing burn toxins. The antineoplastic potential of cerium compounds, which had fallen into oblivion, is currently being re-explored in experimental settings, though the mechanistic basis remains to be elucidated.

Lymphocyte function in wound healing and following injury

BACKGROUND

Injury activates a cascade of local and systemic immune responses.

METHODS

A literature review was undertaken of lymphocyte function in wound healing and following injury.

RESULTS

Lymphocytes are not required for the initiation of wound healing, but an intact cellular immune response is essential for a normal outcome of tissue repair. Injury affects lymphocyte immune mechanisms leading to generalized immunosuppression which, in turn, increases host susceptibility to infection and sepsis. Although the exact origin of post-traumatic immunosuppression remains unknown, stress hormones and immunosuppressive factors, such as inflammatory cytokines, prostaglandin E2 and nitric oxide, affect lymphocyte function adversely. Post-traumatic impairment of T lymphocyte immune function is reflected in decreased lymphocyte numbers, as well as altered T cell phenotype and activity. Antibody-producing B lymphocytes are variably affected by injury, probably secondary to alterations of T lymphocyte function, as a result of their close interaction with helper T cells. Therapeutic modulation of the host immune response may include non-specific and specific interventions to improve overall defence mechanisms.

CONCLUSION

Early resuscitation to restore lymphocyte function after injury is important for tissue repair and the prevention of immunosuppression.

Improved rapid photometric assay for quantitative measurement of PMN migration

We developed an improved quantitative method to measure in vitro polymorphonuclear leukocyte (PMN) migration using an assembly consisting of a 96-well chamber, polycarbonate filter membrane, and a 96-well microtiter plate. The convenience in setup and counting of migrated cells using this method allows processing of 80 samples and 16 controls in a short assay time of only 2 h. The peroxidase contained in PMNs was used as a marker enzyme to determine the number of migrated cells. Peroxidase released from lysed migrated cells was detected with an enzymatic method utilizing o-dianisidine as substrate. Photometric measurement was performed with a conventional microtiter plate reader at a wavelength of 405 nm. Optical density readings obtained using the enzymatic assay correlated with the number of migrated cells in a linear fashion up to 1 x 10(5) cells/well. The sensitivity of the enzymatic assay was sufficient to determine cell counts as low as 500 PMNs. PMNs lost no measurable amounts of peroxidase during the migration assay when ZAS was used as the chemoattractant. A calibration method was developed to make corrections for variations in the peroxidase content of different cell preparations and changes in the peroxidase content of cells exposed to the chemoattractant. High speed, convenient handling, and the use of standard laboratory equipment result in low cost per assay and make this migration assay ideally suited to research and clinical applications.

Effect of cerium nitrate-silver sulphadiazine on deep dermal burns: a histological hypothesis

Although there are excellent clinical results from using cerium nitrate plus silver sulphadiazine in the treatment of deep dermal burns in our burn centre, its mechanism of action remains unexplained. We set up a prospective study to establish a hypothesis which could explain the formation of the typical leathery crust. Burns treated with cerium nitrate plus silver sulphadiazine and silver sulphadiazine alone were compared histologically and metallurgically. Application of cerium nitrate plus silver sulphadiazine on deep dermal burns caused superficial connective tissue calcification with few deep dermal changes. Cerium penetration was low and silver was never detected intradermally. The precipitation of cerium and pyrophosphate destroys the calcification inhibitory function of the latter, creates multiple calcification nuclei and leads to superficial dermal calcification. No calcium was detectable in biopsies from silver sulphadiazine-treated wounds. No major toxicological side-effects were seen during this study. The clinical results were favourable, as have been reported previously.

Influence of burn-induced lipid-protein complex on IL1 secretion by PBMC in vitro

The lipid-protein complex (LPC) formed by thermal injury to skin, which has been shown to have a toxic effect on mice, and which suppresses the immune response, was tested for its specific influence on monocytes. Growth of bacterial endotoxin-stimulated peripheral blood mononuclear cells (PBMC) was inhibited in the presence of LPC, however, the inhibition was less at the time of the optimal rate of cell proliferation. Inhibition was proportional to LPC concentration. ConA-stimulated PBMC were also inhibited by LPC in a dose-related manner. PBMC, in the presence of LPC, secreted interleukin 1 (IL1) at an increasing rate as LPC concentration rose from 5 to 40 micrograms/ml, and the levels of IL1 which could be induced by endotoxin were increasingly amplified in the presence of LPC. In comparison to LPC, the native tissue proteins which were isolated from unburned skin by the same techniques which produced LPC from burned skin, were tested for their effect on PBMC. Native proteins had no effect on IL1 secretion, whether on background or endotoxin-stimulated levels. Thus, the thermally induced change in skin proteins has a specific effect on monocyte IL1 secretion which is not matched by the native proteins, indicating that burn injury to skin specifically affects the lymphokine cascade and consequent immune function.

Use of topically applied silver sulphadiazine plus cerium nitrate in major burns

All patients hospitalized between May 1987 and June 1988 suffering from burns covering over 50 per cent of the body surface area were treated by topical application of a cream containing cerium nitrate (0.05 M) and silver sulphadiazine (0.03 M) (CN + SSD). Eleven patients were included in this series, with a mean age of 35 years (range 22-65), a mean total burn size of 78 per cent (range 50-96 per cent) and full skin thickness covering a mean of 48 per cent (range 10-91 per cent). Eight patients survived (73 per cent) (mean age 36 years; mean total burn surface 73 per cent; mean full skin thickness burn surface, 38 per cent). These results are far better than those obtained in our Unit where a survival rate of 34 per cent was obtained in a comparable series of patients treated before 1987. Sixty positive blood cultures were obtained, which included a large variety of organisms with a slight predominance of Staph. aureus, Candida albicans and Ps. aeruginosa. Wound cultures were positive in 72 per cent of swabs and showed a predominance of Ps. aeruginosa (59 per cent of all the strains isolated). Even if CN + SSD appears in this series not to be very efficient in preventing wound colonization and septic complications, it permitted a very high survival rate in the treated patients, taking into account the extreme severity of the injuries. This beneficial effect is probably the consequence of the protective action of the yellow-green eschar formed by CN + SSD.(ABSTRACT TRUNCATED AT 250 WORDS)

Trauma peptide induction of lymphocyte changes predictive of sepsis

Post-trauma immunosuppression is characterized by T-cell subpopulation changes and the presence of a low molecular weight suppressive active peptide (SAP), which suppresses T-cell blastogenesis and neutrophil chemotaxis. This study evaluated post-trauma T-cell antigens and suppressive active peptide/T-cell interactions to determine if the suppressive active peptide concentrations predictive of sepsis can cause changes in antigen expression predictive of sepsis. Human lymphocyte markers and differentiation antigens were analyzed post-trauma using flow cytometry for markers predictive of sepsis. Changes induced by purified suppressive active peptide incubated with normal human lymphocytes were similarly analyzed by flow cytometry. SAP concentrations for incubation were chosen which correlated with concentrations in patients developing clinical sepsis. Significant T-cell changes in patients who developed sepsis include: decreased total T-cells, decreased helper cells, decreased natural killer cells, increased Ia expressing mononuclear cells, increased activated T-cells, (L22) and increased IL-2 expressing cells (TAC). Suppressive active peptide can activate T-cells and cause significant increased expression of IL-2 receptors and natural killer cells. Other T-cell changes following trauma predictive of sepsis seem to occur independent of in vitro incubation with suppressive active peptides. IL-2 expressing cells are known to be more readily suppressed by the suppressive peptide. Suppressive peptide activation and subsequent inhibition of T-cells suggests a potential way to explain suppressive peptide-induced immunosuppression following trauma.

Decreased reactivity of allosera against target lymphocytes obtained following thermal injury or long-term cyclosporine treatment

We speculated that two diverse causes of potent cell-mediated immune suppression, cyclosporine (CsA) and thermal trauma, may demonstrate some similar actions, and thus tested whether either could alter antisera reactivity against allogeneic target lymphocytes. Target splenocytes from 40% body surface area full-thickness burned Brown-Norway (BN) rats demonstrated significant (P = 0.004) decreased reactivity (agglutination) with antisera produced across a full allogeneic barrier (RT1 major histocompatibility complex (MHC) and non-MHC) compared to control splenocytes. Depression of allogeneic splenic target cell reactivity against Lewis (LEW)-anti-BN allosera was similarly observed using lymphocytes from long-term CsA-treated rats (P = 0.004). The decreased reactivity induced by burn trauma was transferable to pooled normal splenocytes or blood lymphocytes by preincubation with burn plasma (P less than 0.001), and was confirmed by a cellular enzyme-linked immunosorbent assay (CELISA) (P = 0.003). In summary, a similarity consisting of decreased antibody reactivity against lymphocytes from either burned or long-term CsA-treated animals was demonstrated. These results suggested that lymphocyte cell surface allogeneic determinants and their expression and/or availability were altered by either regimen.

Altered arachidonic acid metabolism in granulocytes of polytraumatized patients

The generation and metabolism of leukotrienes (LTs) from polymorphonuclear granulocytes of four polytraumatic patients on stimulation with the Ca-Ionophore A 23187 were studied by high performance liquid chromatography. In contrast to healthy donors the concentration of LTB4 within the supernatant of the stimulated granulocytes from these patients is reduced. The ratio of LTB4 versus the combined amounts of the biologically inactive 6-trans and 12-epi-6-trans-isomers is significantly decreased. In one patient who suffered from an Adult Respiratory Distress Syndrome (ARDS) a pronounced enhancement of LTC4 synthesis was observed.

Immunity of the burned patient. An overview

The study of mortality in severe burns shows very clearly that most patients die because of septic problems. Surgery and intensive care in burn patients are actually well established, but the fight against infection and septicemia is still difficult. The risk arises due to poor host defence, leading to an unfair struggle and very often ending in death. Today it has become necessary for every burn surgeon and plastic surgeon to understand why this immune depression occurs and how it can be prevented or treated.