Granulocyte adherence changes induced by hemodialysis, endotoxin, epinephrine, and glucocorticoids

Moderate to severe leukocytosis with vasopressor use is associated with increased mortality in trauma patients

Background

Leukocytosis is a rise in white blood cell (WBC) count and clinical outcomes of moderate to severe leukocytosis in trauma patients have not been described. We hypothesized that trauma patients with severe leukocytosis (SL; ≥40.0 × 109 leukocytes/L) have higher rates of in-hospital complications and mortality than those with moderate leukocytosis (ML; 25.0-39 × 109 leukocytes/L).

Methods

We performed a retrospective analysis (2010-2017) on trauma patients developing ML or SL at a single Level-I trauma center. A multivariable logistic regression analysis for risk factors were performed.

Results

From 15,807 trauma admissions, 332 (2.1%) had ML or SL. Of these, 308 (92.8%) were ML and 24 (7.2%) were SL. Patients with ML and SL reached their peak WBC count in 1 and 10 days after admission respectively (p < 0.001). SL patients suffered higher rates of in-hospital complications (p < 0.05) and mortality compared to those without ML or SL (14.5% vs. 3.3%, p < 0.001). Between ML and SL, mortality rates rose with leukocytosis severity (13.3% vs. 29.2%, p = 0.03). Among all patients with ML or SL, vasopressor use was the strongest independent risk factor for mortality (OR 12.61, p < 0.001).

Conclusion

Clinicians should be weary of the increased mortality rates and in-hospital complications in SL patients. Among patients with ML or SL, vasopressor use, rather than SL, was the strongest predictor of mortality. Patients with ML had a quicker time course to peak leukocytosis compared to SL, suggesting these two entities to be distinct in etiology and outcome, warranting future research.

Preserved Respiratory and Phagocytic Functions of Phagocytes Exposed to Flat Sheet Plasmapheresis Equipment

Monocytes and polymorphonuclear leukocytes (PMN) were tested for functional integrity after exposure to flat sheet plasmapheresis equipment. Purified PMN were tested for chemiluminescence activity in response to a variety of triggers of the respiratory burst. Monocytes were assessed for their capacity to ingest erythrocytes sensitized with varying amounts of IgG antibodies. Both assays were demonstrated to be sensitive hallmarks of functional modulation. However, no functional differences were noted between phagocytes from blood collected prior to pheresis and those exposed to flat sheet plasmapheresis cylinders. These data suggest that plasmapheresis with the Au-topheresis C system does not influence the respiratory and phagocytic function of phagocytes returned back to the donor and implies that contact of phagocytes with artificial surfaces and/or their exposure to surface-activated plasma factors generated in the collection cylinder are minimal when using this plasmapheresis method.

Kinetics of Pulmonary Leukocyte Sequestration in Man during Hemodialysis with Different Membrane-Types

Although it has been suggested that pulmonary sequestration of leukocytes could account for membrane-dependent white blood cell depletion in HD, direct evidence in patients is still lacking. Therefore a study was initiated to test whether and how leukocytes distribute in the lung circulation during HD with different membranes. Thirteen patients suffering from chronic renal failure underwent lung scintigraphy during HD with cuprophane (n = 3), hemophane (n = 8) and polysulfone (n = 2) lowflux capillary dialyzers. Isolated autologous leukocytes were labelled with 99m-Technetium and reinfused before starting HD. Distribution of leukocyte related activity was registered by lung scintigraphy. In comparison to normal lung scintigraphy performed without HD, an impressive redistribution peak was demonstrated 10-20 min after the start of HD with cuprophane and also to a lesser extent with hemophane. When HD was performed with polysulfone the decrease in activity was delayed but no real redistribution was obtained.

In accordance with other phenomena, such as peripheral leukopenia and changes in granulocyte oxidative metabolism, pulmonary sequestration of leukocytes takes place in man in the initial phase of HD and appears to be strongly dependent on the type of membrane. (Int J Artif Organs 1990; 13: 729-36)

Contrast Medium Induced Changes in Granulocyte Adherence in Vitro and during Angiography

The effect of ioxaglate and diatrizoate on per cent granulocyte adherence to nylon fibers was investigated in blood to which contrast medium was added in vitro and in blood from patients undergoing angiography. Very high concentrations of contrast medium, added to blood in vitro, directly abolished granulocyte adherence to nylon fibers. Intraaortic bolus injections of ioxaglate, but not of saline, transiently increased granulocyte concentrations in the femoral vein. Fractional granulocyte adherence to nylon fibers increased significantly above the baseline when angiographic dosages of contrast medium were diluted by circulation within the human body. On the other hand, dilute concentrations of contrast medium had no effect on per cent granulocyte adherence when added to whole blood in vitro. This indicates that the increased adherence produced in vivo is an indirect effect, which, usually, cannot be simulated in vitro.

Adrenal Insufficiency in the Intensive Care Setting

In the intensive care setting, the question of adrenal insufficiency arises most frequently in patients whose endogenous adrenal function may be suppressed by pre ceding glucocorticoid therapy or in patients with the acquired immunodeficiency syndrome. Less often the question arises in patients whose adrenal tissue may have been destroyed by autoimmune disease, tuber culosis, meningococcal or other infection, hemorrhage, or replacement by malignancy, or in patients whose adrenal function has been suppressed by certain drugs. Measurements of plasma adrenocorticotrophic hor mone (ACTH), cortisol, aldosterone, and renin levels and the response of cortisol and aldosterone to exoge nously administered ACTH form the basis for clinically evaluating the adequacy of a patient's adrenal function. The naturally occurring glucocorticoid, hydrocortisone, remains the cornerstone of adrenal replacement therapy along with appropriate fluid and electrolyte administra tion. In rare instances the addition of a mineralocor ticoid is necessary. A brief review of the use of mega- dose glucocorticoids in the treatment of sepsis, shock, and the adult respiratory distress syndrome is included.

Sympathoadrenal and immune system activation during the periparturient period and their association with bovine coliform mastitis. A review

Increased incidence of clinical mastitis in high-yielding cows during early lactation has been attributed to a depressed functional capacity of the immune system. Sympathoadrenal factors are known to play an important role in modulating the host susceptibility and resistance to infectious diseases. Of primary importance in combating acute intramammary infections are polymorphonuclear leukocytes (PMN), as they represent one of the early lines of immunological defense. The release of stress hormones at parturition and during the first weeks of lactation has been proposed to partly contribute to the impaired function of PMN. Here, we summarize the current understanding of the stress-induced peripheral effectors, i.e. the limbs of the sympathetic system and the hypothalamic-pituitary-adrenal axis, on PMN function around parturition and during coliform mastitis. The questions as to whether and how stress induced secretion of glucocorticoids and catecholamines might affect the lactating dairy cow's udder health will be addressed.

A retrospective study of canine and feline cutaneous vasculitis

Twenty-one cases of cutaneous vasculitis in small animals (dogs and cats) were reviewed, and cases were divided by clinical signs into five groups. An attempt was made to correlate clinical types of vasculitis with histological inflammatory patterns, response to therapeutic drugs and prognosis. Greater than 50% of the cases were idiopathic, whereas five were induced by rabies vaccine, two were associated with hypersensitivity to beef, one was associated with lymphosarcoma and two were associated with the administration of oral drugs (ivermectin and itraconazole). Only the cases of rabies vaccine-induced vasculitis in dogs had a consistent histological inflammatory pattern (mononuclear/nonleukocytoclastic) and were responsive to combination therapy with prednisone and pentoxifylline, or to prednisone alone. Most cases with neutrophilic or neutrophilic/eosinophilic inflammatory patterns histologically did not respond to pentoxifylline, but responded to sulfone/sulfonamide drugs, prednisone, or a combination of the two.

Effects of long-term hemofiltration on circulating mediators and superoxide production during continuous endotoxin administration

BACKGROUND

The purpose of this study was to test whether continuous hemofiltration eliminates cytokines and eicosanoids, or stimulates granulocyte function.

METHODS

Nineteen pigs were divided into a control group (n = 7), a hemofiltration group (n = 7), and an extracorporeal circuit only group (n = 5). All animals received the same amount of intravenous endotoxin and resuscitation fluid. Zero-balanced hemofiltration was started 30 minutes after initiation of endotoxemia and continued throughout the experiment. Plasma endotoxin, tumor necrosis factor-alpha, eicosanoids, superoxide production, and other physiologic parameters were measured before challenge and at scheduled intervals thereafter.

RESULTS

Eicosanoids were filtered but plasma concentrations were not reduced. Tumor necrosis factor-alpha was not filtered or adsorbed. There were no significant differences between groups in any measured parameters.

CONCLUSION

Continuous hemofiltration could not efficiently remove tumor necrosis factor-alpha or eicosanoids. Also, continuous hemofiltration did not stimulate production of the proinflammatory mediators measured, nor improve respiratory distress.

The role of leukocytes in the pathogenesis of vibration-induced white finger

Vibration white finger (VWF) is an occupational disorder associated with long-term exposure to hand-transmitted vibration. The condition exhibits features of secondary Raynaud's phenomenon. The etiology is unknown. The aim of this study was to examine the role of leukocyte rheology in the pathogenesis of VWF. Fifty-two male subjects divided into two groups were exposed to controlled acute hand-transmitted vibration. One group consisted of 29 workers who have all had occupational exposure to handheld vibration and all suffered from VWF (mean age 46.9 years, range 22-66). The second group consisted of 23 controls. Venous blood was analyzed from the dorsum of the hand before and after vibration to determine granulocyte deformability, granulocyte morphology, and white blood cell count with differential. There was a subpopulation of hard and poorly deformable granulocytes in the VWF group when compared with controls (p < 0.05). Acute hand-transmitted vibration had no in vitro effect on leukocyte rheology in either group. Leukocyte rheology may play a role in the pathogenesis of microvascular disease and tissue ischemia in VWF, although whether this is a cause or an effect of the disorder is not clear.

Glucocorticoid receptor regulates expression of L-selectin and CD11/CD18 on human neutrophils

BACKGROUND

Recent studies have raised the hypothesis that glucocorticoids could diminish the ability of endothelial cells to direct leukocyte traffic into inflamed tissues by inhibiting expression of the adhesion molecules endothelial-leukocyte adhesion molecule-1 and intercellular adhesion molecule-1. The aim of the present study was to investigate whether glucocorticoids also regulate the expression of L-selectin and CD11/CD18 integrins on human neutrophil granulocytes.

METHODS AND RESULTS

Incubation of human whole blood with platelet-activating factor (PAF, 1 mumol/L) evoked downregulation of L-selectin and upregulation of CD11/CD18 adhesion receptors on neutrophils as measured by flow cytometry. While dexamethasone (0.1 nmol/L to 100 mumol/L) did not affect expression of adhesion molecules on resting neutrophils, it attenuated the PAF-induced changes in L-selectin and CD18 expression in a time- and concentration-dependent fashion with IC50 values of 31 and 13 nmol/L, respectively. These effects of dexamethasone were completely aborted by RU-486 (10 mumol/L), which blocks transcriptional activation of the glucocorticoid receptor, and by the protein synthesis inhibitor cycloheximide (35.5 mumol/L). Dexamethasone, up to a concentration of 1 mumol/L, neither affected significantly the release of granule enzymes nor interfered with PAF binding to its membrane receptors.

CONCLUSIONS

Our results show that glucocorticoids at clinically relevant concentrations exert specific actions on expression of adhesion molecules on activated neutrophils, which are mediated through ligation of glucocorticoid receptors and induction of protein synthesis, and suggest a novel mechanism by which anti-inflammatory corticosteroids may inhibit leukocyte accumulation.

A major role for CD62P/CD15s interaction in leukocyte margination during hemodialysis

We investigated expression of several antigens on neutrophils and monocytes, involved in cell adhesion, from patients hemodialyzed with cellulosic and polyacrylonitrile membranes. Among the antigens tested only the expression of CD15s and CD11b was significantly increased on neutrophils and monocytes in patients dialyzed with cellulosic membranes. No changes occurred with polyacrylonitrile membranes. Leukocyte counts from patients dialyzed with cuprophane membranes decreased at the same time as expression of cellular CD15s increased, resulting in a significant negative correlation at all time points tested. No correlation was found between the drop of monocytes and their expression of CD11b. When CD15s expression increased on neutrophils and monocytes, we observed a concomitant increase of CD62P, a specific selectin of activated platelets. When whole blood cells were incubated with complement activated serum both antigens increased but not when cells were incubated with hrC5a. We also observed that CD61, a platelet phenotypic antigen, was present on leukocytes incubated with complement activated serum. At the time when platelet-leukocyte coaggregates decreased, CD62P expression remained stable on leukocytes, suggesting that both neutrophils and monocytes are able to trap either CD62P shed by activated platelets or soluble CD62P present in normal human serum. The present study documents a major role of P-selectin (CD62P)/sialyl-Lewis x (CD15s) interaction in the transient leukocyte margination during hemodialysis.

Role of bioincompatibility in dialysis morbidity and mortality

This review examines the mechanisms by which bioincompatibility in dialysis systems may have an effect on morbidity and mortality in the dialysis population. Direct toxic effects of membrane materials and various chemical substances have been well demonstrated in the chronic dialysis population. Activation of the complement cascade and stimulation of cytokine production may have autocrine effects on leukocyte function with sequelae such as enhanced rates of infection and the development of B2-microglobulin amyloidosis. The variable effect of different membrane materials on each of these effector systems is examined. Bioincompatibility may effect the incidence of infection, malignancy, cardiopulmonary disease, and malnutrition as well as induce novel disease processes. All these confounding variables must be considered when evaluating the effect of dialysis on mortality and morbidity.

Proton magnetic resonance imaging and spectroscopic studies of the pathogenesis and treatment of juvenile dermatomyositis

Juvenile dermatomyositis is an inflammatory disorder of muscle, skin, and connective tissue. Immune vasculopathy is central to the pathophysiology. We studied a 13-year-old boy with juvenile dermatomyositis using proton magnetic resonance imaging (MRI) with short tau inversion recovery (STIR), and proton magnetic resonance spectroscopy (MRS) to quantitate lipid and water in affected regions of muscle. Tissue perfusion was assessed by measuring tissue water concentration changes during isometric exercise of the tibialis anterior muscle. During sequential studies over 3 months of steroid treatment, STIR image abnormalities, resting water concentrations, and diminished perfusion returned to normal. Resting lipid concentrations increased during this period. MRI serves to guide muscle biopsy and monitor progress of the disease state. MRS demonstrates the vasculopathy and provides noninvasive assessment of steroid therapy in juvenile dermatomyositis.

Biocompatibility issues in hemodialysis

Hemodialysis, as a life-saving treatment modality for uremic patients, implies a repeated and compulsory contact of blood with foreign materials. As a consequence, biocompatibility problems are unavoidable. The same applies for the material used for the creation of vascular access, and for the alternative dialysis method, CAPD (continuous ambulatory peritoneal dialysis), although each system might cause its own and specific problems. Although in early dialysis the focus has been on maintenance of life and elimination of toxins, later on the important morbid implications of this lack of biocompatibility have been recognized. Eight major problems will be discussed, especially in the perspective of recent new findings in this field: (1) coagulation and clotting; (2) complement and leukocyte activation; (3) susceptibility to infection; (4) leaching or spallation; (5) surface alterations of solid materials; (6) allergic reactions; (7) shear; (8) transfer of compounds from contaminated dialysate. After description of the major biochemical and clinical implications of these problems, ways to prevent morbid events and future perspectives will be described.

Intestinal obstruction during shigellosis: incidence, clinical features, risk factors, and outcome

To determine the incidence and outcome of intestinal obstruction during shigellosis, the authors assessed 1211 consecutive patients with shigellosis admitted during a 15-month period to a diarrhea treatment center in Dhaka, Bangladesh. Obstruction was identified in 30 (2.5%) patients. Ten (33.3%) of these patients died, compared with 97 (8.2%) of the 1181 patients without obstructions (P less than 0.001; RR = 4.1). In a case-control study, patients with obstructions were compared with 30 control patients with shigellosis but without obstructions. Case and control patients were similar in age (median, 18 months vs. 24 months; NS). Before admission to the hospital, case patients had less often been breast-fed than control patients (33% vs. 85%; P = 0.006) and had more often received antimicrobial agents (53% vs. 13%; P = 0.001). Case patients more often had abdominal tenderness (73% vs. 13%; P less than 0.001), altered consciousness (50% vs. 17%; P = 0.006), and Shigella dysenteriae type 1 infection (73% vs. 27%, P = 0.001) and had a higher median blood leukocyte count (40 x 10(3)/microL vs. 14 x 10(3)/microL; P = 0.007) and serum potassium concentration (5.0 mmol/L vs. 4.3 mmol/L; P = 0.016), and lower median serum sodium (123 mmol/L vs. 131 mmol/L; P = 0.003) and total protein (52 g/L vs. 60 g/L; P = 0.025) concentrations than did control patients. Eight (27%) patients with obstructions developed the hemolytic-uremic syndrome, compared with none of the control patients (P = 0.003). It was concluded that obstruction is an ominous complication of shigellosis and that therapies in addition to provision of antimicrobial agents need to be evaluated.

Neutrophil-endothelial cell interaction in critical illness

Sepsis syndrome frequently results in endothelial injury in many organ systems. To evaluate neutrophil-pulmonary endothelial cell interaction in the sepsis syndrome, we studied 39 critically ill patients prospectively and 20 normal volunteers. Thirteen patients with sepsis (mean age, 71.4 years), 14 patients in an intensive care unit control group (mean age 65.4 years), and 12 patients admitted with acute myocardial infarction (mean age, 66.8 years) were evaluated. Blood samples were drawn from septic patients within 24 hours and from ICU and MI patients within 72 hours of admission. All sepsis patients were culture positive, 6 of 13 from the blood. Both renal failure and ARDS developed in 54 percent of septic patients. 51Cr-labelled neutrophils were prepared and added to bovine pulmonary endothelial cell monolayers with and without added phorbol myristate acetate. Endothelial cells with adherent PMA and nonadherent PMN's, were harvested and radioactivity in each fraction measured with a gamma scintillation counter. Baseline and maximally stimulated (PMA, 3.0 ng/ml) neutrophil adherence to endothelial cells were similar in all patients groups. However, in septic patients, PMA-stimulated PMN adherence was reduced at lower doses, most significantly in those who developed ARDS within 24 to 48 hours of admission (p less than 0.05). Seventy-one percent of patients who developed ARDS had reduced stimulated adherence (PMA 1.0 ng/ml) compared to 22 percent of critically ill patients who did not. We conclude that diminished adherence of neutrophils to endothelium in response to low-level PMA stimulation is significantly more common in patients with sepsis who develop ARDS. Our findings suggest that PMN-endothelial cell interaction is altered by the time sepsis is clinically recognized but before the development of ARDS. We speculate that the observed reduction in adherence of the PMN to endothelial cells may be a consequence of down-regulation by mediators generated in the inflammatory response to sepsis and/or the need for active participation of septic endothelium in this interaction.

Alterations in erythrocyte rheology in patients with severe peripheral vascular disease: 1. Cell volume dependence of erythrocyte rigidity

The erythrocyte rigidity of patients suffering from severe peripheral vascular disease (PVD) was measured by a filtration method using 3 microns pore size filters. Filtration pressures for both PVD patients and normal subjects showed a cell volume dependency, and patient filtration pressures were normalized to cell volume to evaluate intrinsic, ie, nonvolume dependent, abnormalities in erythrocyte deformability. A significant (p less than 0.001) increase in cell rigidity was found in 44 of 54 PVD patients in comparison with volume-matched normal controls. No significant difference was found between patient mean corpusculer hemoglobin (MCH) and normal MCH at any given mean corpuscular volume (MCV), indicating that observed increases in erythrocyte rigidity are not attributable to changes in patient MCH. Therefore, the mechanism of increase in erythrocyte rigidity for PVD patients still needs further investigation into such parameters as levels of adenosine triphosphate,2,3-DPG, and membrane fluidity (calcium- and/or protein-binding membrane, cholesterol and phospholipid content of membrane, etc), as well as other aspects of erythrocyte physiology.

The influence of flunixin on the response to Salmonella typhimurium endotoxin in calves

The effects of intravenous injection of 0.5 microgram/kg body weight of Salmonella typhimurium endotoxin were studied in calves. The injection was followed by ruminal stasis and general dullness. The clinical signs disappeared within 24 hours. The injection was followed by a tremendous increase in the plasma level of 15-ketodihydro-PGF2 alpha, the main metabolite of PGF2 alpha. The injection was also associated with a profound leukopenia and significant decreases in the serum levels of iron, zinc and calcium. In order to study the role of prostaglandin (PG) for the development of endotoxin-induced changes a group of calves was pretreated with flunixin, a potent cyclo-oxygenase inhibitor, at a dose of 2.2 mg/kg body weight. Flunixin inhibited the PG release completely, but did not influence the other responses to endotoxin. The pyrogenic response to endotoxin was very moderate and it was suggested that fever is not the most suitable parameter for monitoring endotoxin effects in calves. The studied blood parameters (15-ketodihydro-PGF2 alpha, iron, zinc, calcium and the number of leukocytes) appeared to be much more sensitive.

Some effects of gram-negative bacterial endotoxin and its importance as a contaminator of biological preparations

The purpose of this study was to establish a model which can be used to examine the biological response to Salmonella typhimurium endotoxin in both anaesthetized and unanaesthetized rabbits, and then compare this response to that of rabbits injected with an endotoxin-contaminated biological preparation. The parameters used to evaluate the biological response included total white blood cell and differential counts, 15-ketodihydro-PGF2 alpha concentration, and rectal temperature. Unanaesthetized groups of rabbits received 1000, 100, 10, or 1 ng/kg of the endotoxin via intravenous injection (i.v.); the anaesthetized group of rabbits received 100 ng/kg endotoxin i.v. (anaesthesia induced with Hypnorm). In addition, groups of rabbits were treated under anaesthesia with Pharmacia-Chiron's recombinant human Cu/Zn superoxide dismutase (SOD) (10 mg/kg body weight = 1.6 endotoxin units (EU)/kg) or Grünenthal's bovine SOD (two doses: 10 mg/kg = 400 EU/kg, or 50 mg/kg = 2000 EU/kg). Results demonstrated that at the lower doses of endotoxin (10 and 1 ng/kg) and r-hSOD (10 mg/kg), no leukopenia was observed. There was however a slight shift in the leukocyte population so that polymorphonucleocytes increased and monocytes decreased in number. Rabbits treated with higher doses of endotoxin (1000 and 100 ng/kg) showed many of the common signs of endotoxemia, including leukopenia, increased prostaglandin metabolite levels, and increased body temperature, as did the rabbits treated with endotoxin-contaminated bSOD. There was a definite dose-dependency, with the higher dose of bSOD giving a more marked rise in all parameters. These findings indicate that use of this or other endotoxin-contaminated biological preparations in live-animal experiments could produce erratic, and therefore unreliable, results.

A new stimulation of the interaction between neutrophils and pulmonary endothelial cells

To study the interaction between isolated homologous neutrophils and pulmonary endothelial cells under simulated in vivo conditions, we developed a model of the circulation in which neutrophils flow past endothelial cells. Endothelial cells from porcine pulmonary artery were grown on microcarriers, loaded into an elutriator chamber, and suspended (speed--300 rpm. flow--18 ml/min). Porcine neutrophils were labeled with 111In, mixed with a tracer dose of 125I-albumin, and injected into the elutriator inlet. Fractions were collected from the elutriator outlet and indicator dilution curves were plotted. Adherence of neutrophils was calculated by 1 - (area under 111In curve/area under 125I curve). In separate injections, neutrophils were preactivated with phorbol 12-myristate 13-acetate (100 ng/ml) or zymosan-activated plasma (10%, v/v). In three of eight lines of endothelial cells the adherence of activated neutrophils to cell-coated microcarriers was greater than that of nonactivated neutrophils. There was no difference in adherence to uncoated microcarriers or to the empty elutriator chamber between activated and nonactivated neutrophils. We conclude that this model will be useful for studying interactions between isolated neutrophils and endothelial cells because it incorporates flow in a physiologic milieu.

Screening of steroids in horse urine and plasma by using electron impact and chemical ionization gas chromatography-mass spectrometry

Gas chromatography with chemical ionization mass spectrometry and selected-ion monitoring provided a sensitive method for the screening and confirmation of steroids in horse urine and plasma. Chemical ionization mass spectrometry was more sensitive than the electron impact ionization mass spectrometry for most of the steroids except for testosterone, prednisone-metabolite-2 and prednisolone-metabolite-2. The chromatographic conditions used in this study provided clean separation of different natural and synthetic steroids. Approximately 75-85% of the steroids added to plasma and approximately 65-70% of the steroids added to urine were recovered by the extraction procedure used in this study.

Complement activation during hemodialysis

Hemodialysis, as other extracorporeal circulation treatments, determines activation of the complement system. In this paper molecular mechanism of complement activation by different hemodialysis membranes are reviewed as well as the biological consequences and clinical relevance of the activation.

Treatment of bullous pemphigoid with topical clobetasol propionate

The potent topical corticosteroid clobetasol propionate was evaluated in an open-label study for its safety and efficacy in the treatment of bullous pemphigoid. Ten patients admitted to the hospital with this diagnosis had clobetasol propionate cream applied twice daily to affected skin until all lesions were healed and for 2 weeks thereafter. Complete epithelialization was achieved in every case within 4 to 17 days of treatment. After discharge, patients received decreasingly less potent corticosteroid creams as maintenance therapy for between 5 weeks and 13 months. As of this report, 7 of the 10 patients remain in remission (range 1 to 10 months). In one patient the disease was exacerbated, and therapy with corticosteroids could not be discontinued. No local or systemic side effects were observed during the study, and plasma cortisol levels were within the normal range when measured during the early tapering-off period while patients were receiving less potent topical corticosteroids. We conclude that clobetasol propionate cream produced rapid healing of bullous lesions without adverse effects and that this treatment followed by maintenance therapy with less potent topical corticosteroids was highly effective in patients with bullous pemphigoid.

Comparative studies on the adhesiveness of granulocytes of guinea pig and man

The high affinity of granulocytes of guinea pig and man to glass surfaces is modified by serum. Native serum contains both an adherence-promoting activity, which is related to complement, and components which reduce the adhesiveness of granulocytes. These components are stable at 56 degrees C for 30 min and are tightly bound to the glass surface. beta-Lipoproteins are candidates for this adherence reducing ability of serum. Adherence promotion by native serum is mediated by coating the glass surface with C3b/C3bi. Human granulocytes from the peripheral blood adhered pig serum with C3b/C3bi to almost the same extent as in the presence of native serum, but on guinea pig granulocytes elicited in the peritoneal cavity, a cell surface metalloproteinase degraded the C3b/C3bi, thus reducing the adhesiveness of these cells. This proteinase was inhibited by MgEDTA, DTT, and 1,10-phenanthroline, whereby the high adhesiveness of granulocytes was restored to C3b/C3bi-coated glass.

Inhibition of the inflammatory action of interleukin-1 and tumor necrosis factor (alpha) on neutrophil function by pentoxifylline

Inflammatory cytokines, including interleukin-1 and tumor necrosis factor, are produced by monocytes and macrophages in response to microorganisms and microbial products such as endotoxins. The cytokines stimulate neutrophil adherence, degranulation, and superoxide production but inhibit neutrophil migration. We studied the modulation of cytokine-induced neutrophil activation by pentoxifylline and its principle metabolites. Lipopolysaccharide-stimulated mononuclear-leukocyte-conditioned medium containing inflammatory cytokines, purified human interleukin-1, or recombinant human tumor necrosis factor increased neutrophil adherence to nylon fiber, primed neutrophils for increased superoxide production in response to N-formyl-L-methionyl-L-leucyl-L-phenylalanine (FMLP), increased neutrophil lysozyme release stimulated by FMLP, and decreased directed migration of neutrophils to FMLP. Pentoxifylline and its principle metabolites at or near therapeutically achievable levels were able to counteract these effects. Pentoxifylline inhibited the increase in free intracellular calcium in polymorphonuclear leukocytes stimulated by FMLP and increased binding of FMLP to neutrophils at 37 degrees C but not at 4 degrees C. By blocking the inflammatory action of interleukin-1 and tumor necrosis factor on neutrophils, pentoxifylline may diminish the tissue damage caused by neutrophils in such conditions as septic shock, adult respiratory distress syndrome, cardiopulmonary bypass lung damage, and myocardial reperfusion injury.

Polymorphonuclear leucocytes in Crohn's disease and ulcerative proctocolitis: association between enhanced adherence to nylon fibre and disease variables

The adherence of polymorphonuclear leucocytes (PMN) to nylon fibre was investigated in patients with Crohn's disease, ulcerative proctocolitis, and anorexia nervosa, and compared with changes of circulating PMNs, C reactive protein concentrations, erythrocyte sedimentation rates, and clinical assessment of disease activity. PMN adherence was in excess of the maximum value detected for healthy subjects in 14 of 25 patients with Crohn's disease and two of 10 with proctocolitis, but it was within the normal range for all eight with anorexia nervosa. High adherence in Crohn's disease, however, was not associated with quantitative or qualitative changes of PMN populations, absolute concentrations of C reactive protein, erythrocyte sedimentation rates, disease severity, drug regimens, malnutrition, or zinc deficiency. High PMN adherence in Crohn's disease may therefore reflect the activation in vivo of normal PMN by humoral factors.

Impaired polymorphonuclear leukocyte function in chronically hemodialyzed patients with iron overload

Polymorphonuclear (PMN) leukoyte function tests and clinical data analyses were performed in 28 chronic renal failure (CRF) patients receiving regular hemodialysis. We divided them into two groups; 12 patients with normal serum ferritin were classified as group 1 and 16 patients with high serum ferritin as group 2. There was no difference in age, BUN, serum creatinine, complement (C3, C4), peripheral white blood cell count and the duration of dialysis between the two groups, but the serum iron level was higher in group 2 (129.1 ± 46.58 μg/dl) than in group 1 (74.3 ± 20.9 μg/dl) (p<0.001). The total iron binding capacity was lower in group 2 (p<0.05) and the number of transfusions was higher in group 2 (25 ± 16.1) than in group 1 (12 ± 8.7) (p<0.05). The nitroblue-tetrazolium (NBT) test showed no difference among groups 1, 2 and the healthy control group. In chemotaxis to fMLP (N-formylmethionylleucylphenylalanine), the mean number of migrated neutrophils to fMLP (10⁻⁶ M/L) per high power field was significantly decreased in group 2 (99.5 ± 37.6) compared with the healthy control group (140.1 ± 13.4) (p<0.005), but not in group 1 (155.8 ± 79.4). In the phagocytosis test using Staphylococcus aureus, the phagocytic index ratio compared to the healthy control group was significantly decreased in group 2 (0.59 ± 0.14), but not in group 1 (0.97 ± 0.18). These results suggest that iron overload due to multiple transfusions in patients receiving regular long term hemodialysis may play a part in causing susceptibility to infection by impairing PMN leukocyte functions, especially chemotaxis and phagocytosis.

Use of steroids to suppress vascular response to radiation

A quantitative measure of the vascular permeability surface area product (PS) for albumin has been made using a double isotope technique. PS was significantly elevated in irradiated rat lung, heart, skin, and muscle, between 19 and 26 days following 18 or 25 Gray thorax irradiation. Administration of dexamethasone from 2 days before irradiation through the day of measurement suppressed the expected increase in PS in lung, heart, and muscle, but not in skin. Shorter periods of steroid administration were not as effective in suppressing this response to radiation exposure. Increased vascular permeability following radiation may be an essential element in the development of radiation fibrosis. We hypothesize that the ability to suppress this response could result in a long term reduction in the incidence of fibrosis.

Neutrophil lysosomal enzyme release and complement activation during cardiopulmonary bypass

Complement activation and neutrophil degranulation were concomitantly studied during uncomplicated cardiopulmonary bypass (CPB). Plasma concentrations of complement factor C4, complement split product C3d, the neutrophil lysosomal enzyme elastase complexed with alpha 1-proteinase inhibitor (PI) and fibronectin were measured in 12 patients, C3d and elastase/PI increased significantly during CPB (volume-corrected results). The C3d rise was almost linear, whereas elastase/PI showed exponential increase. Mean elastase/PI and mean C3d concentrations at different times during CPB covaried closely. The study showed that during CPB neutrophil lysosomal enzyme release is intimately related to complement activation, although activation of the two systems may be caused by a common third activator within the extracorporeal circuit.

Restoration by levamisole of endotoxin-inhibited neutrophil migration, oedema and increased vascular permeability induced by carrageenin

Intravenous administration of E. coli lipopolysaccharide (LPS) inhibited the migration of neutrophils into the pleural cavity that occurs following challenge with intrapleural carrageenin. Treatment of animals with levamisole (10 mg/kg i.p.) 30 min after the intravenous administration of LPS almost restored carrageenin-induced neutrophil migration to control levels without affecting the number of circulating neutrophils. Intravenous administration of LPS (30 micrograms/kg) blocked neutrophil migration in vivo and significantly reduced the oedema and the increased vascular permeability induced by intraplantar administration of carrageenin. These LPS effects were partly counteracted by levamisole (10 mg/kg) given 30 min after LPS. Intravenous LPS did neither affect oedema nor the increase in vascular permeability induced by intraplantar administration of dextran. It is suggested that (a) the exudation and oedema formation induced by carrageenin partially depend upon migrating neutrophils and (b) inhibition of cell migration by circulating LPS may constitute an important contributing factor in septicaemia. Levamisole restores both cell migration and vascular inflammatory events inhibited by circulating LPS.

Methylprednisolone infusion therapy in rheumatoid arthritis patients. The effect on synovial fluid lymphocyte subsets and inflammatory indices

Paired samples of synovial fluid (SF) and blood were obtained prior to and at 4 and 24 hours following high-dose methylprednisolone infusion therapy in a group of patients with refractory rheumatoid arthritis. After therapy there was a significant decrease in numbers of polymorphonuclear leukocytes, lymphocytes, immune complexes, and C-reactive protein in the SF. Measurement of lymphocyte subsets, using monoclonal antibodies, revealed that at 4 hours postinfusion, there was a disproportionate decrease in the percentage of SF lymphocytes expressing class II antigens (HLA-DR or Ia-like). These data suggest that glucocorticoids induce rapid changes in SF indices of disease activity and may directly influence T cell activation within the rheumatoid joint.

Biocompatibility of haemodialysis membranes

Haemodialysis is widely used as a method of treatment for renal failure; it relies on diffusion across a semipermeable membrane. The exposure of blood to the membrane is associated with a rapid transient fall in white cells, activation of the complement system and a fall in arterial oxygenation. The interrelationship between these phenomena, their dependence on the type of membrane used and their clinical implications are reviewed and discussed.

Human polymorphonuclear leukocytes of the bone marrow, circulation, and marginated pool: function and granule protein content

Polymorphonuclear leukocytes (PMN) demonstrate altered function during acute infections and after administration of corticosteroids. We questioned whether or not such changes are due to population shifts from functionally different compartments of the granulocyte pool. Volunteers were given epinephrine to induce demargination or hydrocortisone (HC) to promote egress of PMN from the bone marrow. PMN obtained before and after drug administration were compared for adherence, chemotaxis, luminol-enhanced chemiluminescence, and total content and release of lactoferrin (LF), myeloperoxidase (MPO), and beta-glucuronidase (beta-glu). Epinephrine induced a significant neutrophilia of mature PMN (segmented neutrophils), but there were no changes in function or granule protein content. HC induced a significant neutrophilia with segmented neutrophils and immature PMN (bands). Circulating PMN obtained 4 hr after HC administration demonstrated less adherence, increased chemiluminescence, increased MPO release, and decreased MPO content. Band neutrophils, however, were more adherent than segmented PMN and showed a similar decrease in adherence following HC in vivo. Thus alteration of PMN adherence following intravenous corticosteroids is not due to an influx of immature neutrophils. On the other hand, it is possible that MPO content and release and capacity for oxidative metabolism change as PMN mature.

Hemodialysis membrane-induced activation of phagocyte oxidative metabolism detected in vivo and in vitro within microamounts of whole blood

The production of reactive oxygen species by phagocytes from uremic patients undergoing hemodialysis was monitored by chemiluminescence (CL) within microamounts of whole blood or isolated polymorphonuclear (PMN) cells, and compared on the basis of the dialysis membrane, cuprophane (CUP) or polyacrilonitrile (PAN). Compared to control subjects, resting and stimulated CL (with latex, zymosan, phorbol myristate acetate (PMA) but not formyl-methionyl-leucyl-phenylalanine (FMLP) were decreased in 10(-2) diluted blood sampled before dialysis. After 15 min of dialysis (ti), resting whole blood (10(-1) and 10(-2) diluted) CL increased sharply in patients dialyzed with the CUP but not the PAN membrane, while it returned to its predialysis level at the end of the session. This sharp resting CL increase found in whole blood at ti was not observed in isolated PMN cells except when tested with ti plasma from CUP dialyzed patients, suggesting that it was mediated via activated plasma compounds. In vitro treatment of normal blood, plasma, and isolated PMN cells with CUP membrane fragments reproduced this in vivo dialysis-induced activation of phagocyte oxidative metabolism strikingly and demonstrated additionally the requirement of complement for its induction. We propose this model as an effective means of evaluating dialysis membrane biocompatibility.

Increased expression of an adhesion-promoting surface glycoprotein in the granulocytopenia of hemodialysis

To identify the mechanisms accounting for hemodialysis-induced granulocytopenia, we undertook quantitative kinetic studies of a granulocyte-adhesion-promoting surface glycoprotein (Mo1). In eight patients undergoing maintenance hemodialysis, there was a fivefold increase in the mean cell-surface expression of Mo1 within 15 minutes after the start of dialysis with a new cuprophane membrane. The peak increase in surface Mo1 coincided with the maximal drop in neutrophil count and with the peak rise in the plasma levels of the complement-activation products C5a desArg and C3a desArg. During dialysis on a membrane being reused for the fifth time, no significant complement activation, no increase in Mo1 expression, and no change in neutrophil count were seen. C5a desArg (but not C3a desArg) induced a comparable increase in Mo1 expression on normal granulocytes in vitro at concentrations similar to those measured in vivo. Chemotactic peptide-induced granulocyte aggregation (a reflection of increased cell-to-cell adhesiveness) was specifically blocked by mouse monoclonal antibodies to Mo1 in vitro. These data suggest that the increased expression of Mo1 on granulocytes in vivo is in part mediated by C5a (and C5a desArg). The quantitative increase in granulocyte-surface Mo1 may provide a mechanism for initiating leukoaggregation, sequestration of granulocytes, and neutropenia during hemodialysis.

Chemotactic activity of plasma and lung lymph in sheep with endotoxemia: effect of hydroxyl radical scavengers

The formation and release of circulating chemoattractants has been considered to be responsible for the initial pulmonary leukostasis and subsequent pulmonary vascular injury seen with endotoxemia. Oxygen radicals released from granulocytes can produce these factors. Our purpose was (1) to determine whether chemotaxins are released with endotoxemia and whether the lung is the source of these factors and (2) if there is a cause and effect relationship between the release of chemoattractants and the lung injury. Lung lymph flow, QL, lymph protein clearance, and vascular pressures were used to monitor lung vascular integrity. Escherichia coli endotoxin was infused into 12 sheep. Six sheep were pretreated with dimethyl thiourea (DMTU), a scavenger of hydroxide ion radicals. Chemotactic activity (CA) of plasma and lung lymph was determined during baseline, the pulmonary hypertensive phase, and the permeability phase of the lung injury. It was found that endotoxemia was associated with generation of a granulocyte chemotactic factor in plasma but not in lung lymph. The peak increase in plasma CA occurred after the early pulmonary leukostasis. Pretreatment with DMTU eliminated the increased CA but had no effect on the initial leukopenia or the lung injury. It was concluded that (1) the lung is not the major source of increased CA after endotoxin and (2) increased plasma CA occurs but does not appear to be causative of the initial pulmonary leukostasis or the granulocyte-induced lung injury.