Trauma results in immune cell-induced intestinal epithelial damage with subsequently increased sepsis rate.

BACKGROUND: The detrimental effect of trauma on the immune system has been a subject of interest for decades. The gut-associated lymphoid tissue (GALT) of the bowel that encompasses different lymphocyte subpopulations may be an important pillar of human immunity in the context of trauma. Neither the short-term histological trauma-induced changes in the GALT nor its impact on the outcome after trauma surgery has been investigated. METHODS: This prospective, longitudinal proof-of-concept study included patients who required damage-control surgery after abdominal gunshot wounds with small bowel involvement. Bowel specimens were obtained during the index and relook operations, and the T-lymphocytic quantity therein was analyzed via immunohistochemistry. We scrutinized how the lymphocyte structure and numbers of the GALT altered, and whether the extent and nature of these changes had an impact on the postoperative outcome with regard to septic and surgical complications. RESULTS: A total of 31 damage-control patients were recruited for the study. The main histological changes between the index and relook specimen was a shift of CD8+ T cells from the lamina propria (LP) into the epithelium and a decrease of T lymphocytes in the LP. The significant increase of the intraepithelial CD8+ T cells was associated with a more extensive enterocyte apoptosis, and correlated significantly, positively with the number of postoperative septic complications. CONCLUSION: Our data support that trauma induces an immune cell-driven impairment of the intestinal epithelium, as well as an increased apoptosis of lymphocytes in the LP, which is associated with a worse clinical outcome. The underlying mechanism suggests that a therapeutic approach to minimize apoptosis in the intestine may impact the outcome of severely injured trauma patients. LEVEL OF EVIDENCE: Therapeutic/care/management, level lV.

Severe gunshot injuries in a porcine model: impact on central markers of innate immunity.

BACKGROUND: the mechanisms behind lipopolysaccharide (LPS) tolerance remain obscure. LPS signals through Toll-like receptor 4 (TLR4) and severe trauma/haemorrhage may influence binding and signalling through this receptor, e.g. by changing membrane expression or by releasing endogenous ligands like High Mobility Group Box 1 (HMGB1). The aim of this study was to examine these relations further in a porcine model with standardized trauma. METHODS: nine anaesthetized pigs sustained one gunshot through the femur and one pistol shot through the upper abdomen. Blood was sampled before and 90 min after shooting. The samples were stimulated for 4 h with LPS 10 ng/ml or an equivalent amount of normal saline. The leucocyte response was evaluated by measuring the tumour necrosis factor-α (TNF-α) and CXC ligand 8 (CXCL8) in the supernatant. Flow cytometry was used to measure the surface expression of TLR4 on CD14+ monocytes. HMGB1 concentrations were measured in the plasma. RESULTS: trauma and treatment caused a significant decline in the LPS-stimulated concentrations of TNF-α [4.53 ± 0.24 pg/ml (ln) at 0 min, 3.54 ± 0.35 pg/ml (ln) at 90 min, P=0.026], but did not modify the release of CXCL8. Monocyte TLR4 expression was unchanged. Plasma HMGB1 increased significantly [<0.92 vs. 3.02 ± 0.19 ng/ml (ln), P<0.001]. The concentrations of TNF-α and CXCL8 did not correlate with TLR4 expression or HMGB1 concentrations. CONCLUSION: the results suggest that trauma-induced LPS tolerance is not primarily regulated by TLR4 expression on circulating CD14+ monocytes or by the release of HMGB1 from damaged tissues.

[Immune disorders in extended peritonitis of gunshot origin].

The dynamics of changes of the immune homeostasis indices in a gun-shot peritonitis in 45 military service persons was studied. The patients were 27.6 years old at average. Progressive reduction of T-lymphocytes quantity, the ratio disorder in T-lymphocytes inductors/helpers and suppressors/killers subclasses as well as poorly differentiated precursors of T-lymphocytes and pre-T-supressors/killers constitute prognostically unfavourable signs.

Acute and delayed neuroinflammatory response following experimental penetrating ballistic brain injury in the rat.

BACKGROUND: Neuroinflammation following acute brain trauma is considered to play a prominent role in both the pathological and reconstructive response of the brain to injury. Here we characterize and contrast both an acute and delayed phase of inflammation following experimental penetrating ballistic brain injury (PBBI) in rats out to 7 days post-injury. METHODS: Quantitative real time PCR (QRT-PCR) was used to evaluate changes in inflammatory gene expression from the brain tissue of rats exposed to a unilateral frontal PBBI. Brain histopathology was assessed using hematoxylin and eosin (H&E), silver staining, and immunoreactivity for astrocytes (GFAP), microglia (OX-18) and the inflammatory proteins IL-1beta and ICAM-1. RESULTS: Time course analysis of gene expression levels using QRT-PCR indicated a peak increase during the acute phase of the injury between 3-6 h for the cytokines TNF-alpha (8-11 fold), IL-1beta (11-13 fold), and IL-6 (40-74 fold) as well as the cellular adhesion molecules VCAM (2-3 fold), ICAM-1 (7-15 fold), and E-selectin (11-13 fold). Consistent with the upregulation of pro-inflammatory genes, peripheral blood cell infiltration was a prominent post-injury event with peak levels of infiltrating neutrophils (24 h) and macrophages (72 h) observed throughout the core lesion. In regions of the forebrain immediately surrounding the lesion, strong immunoreactivity for activated astrocytes (GFAP) was observed as early as 6 h post-injury followed by prominent microglial reactivity (OX-18) at 72 h and resolution of both cell types in cortical brain regions by day 7. Delayed thalamic inflammation (remote from the primary lesion) was also observed as indicated by both microglial and astrocyte reactivity (72 h to 7 days) concomitant with the presence of fiber degeneration (silver staining). CONCLUSION: In summary, PBBI induces both an acute and delayed neuroinflammatory response occurring in distinct brain regions, which may provide useful diagnostic information for the treatment of this type of brain injury.

Capacity of glycine to modulate early inflammatory disturbances after serious gunshot injuries in the pig.

OBJECTIVE: Perturbation of immune homeostasis is an important determinant for organ dysfunction following multiple injuries. The aim of this study was to investigate the ability of glycine to influence the immediate post-traumatic inflammatory environment and altered reactivity of circulating leucocytes. MATERIAL AND METHODS: Twenty pigs were subjected to two standardized gunshots to the abdomen and thigh. Treatment was started immediately. The animals were randomized to receive either glycine 180 mg/kg i.v. over 30 min (n=10) or normal saline (n=10). Blood samples were drawn at baseline and 75 min after injury. In a follow-up study 12 pigs were exposed to an identical trauma. Blood was drawn at the same time-points and stimulated with lipopolysaccharide (LPS) or LPS plus glycine for 2 h in an ex vivo whole blood model. RESULTS: Selected physiologic variables and organ injury did not differ between groups 75 min after trauma. Reactive oxygen species decreased to 82.7+/-5.5 % of baseline (p<0.05) in the glycine group (unaltered in the controls). Liver glutathione concentrations decreased in parallel in both groups. In vivo production of TNF-alpha and IL-1-beta increased to the same extent regardless of treatment. Trauma induced a strong LPS tolerance. In whole blood challenged with LPS, glycine inhibited cytokine synthesis, but only in samples drawn at baseline. CONCLUSIONS: Post-traumatic infusion of glycine only modestly influenced the early post-traumatic inflammatory environment. Our ex vivo results confirm previous reports on the anti-inflammatory potential of glycine, but restricted to pre-trauma conditions.

Penetrating ballistic-like brain injury in the rat: differential time courses of hemorrhage, cell death, inflammation, and remote degeneration.

Acute and delayed cerebral injury was assessed in a recently developed rat model of a penetrating ballistic-like brain injury (PBBI). A unilateral right frontal PBBI trajectory was used to induce survivable injuries to the frontal cortex and striatum. Three distinct phases of injury progression were observed. Phase I (primary injury, 0-6 h) began with immediate (<5 min) intracerebral hemorrhage (ICH) that reached maximal volumetric size at 6 h (27.0 +/- 2.9 mm(3)). During Phase II (secondary injury, 6-72 h), a core lesion of degenerate neurons surrounding the injury track expanded into peri-lesional areas to reach a maximal volume of 69.9 +/- 6.1 mm(3) at 24 h. The core lesion consisted of predominately necrotic cell death and included marked infiltration of both neutrophils (24 h) and macrophages (72 h). Phase III (delayed degeneration, 3-7 days) involved the degeneration of neurons and fiber tracts remote from the core lesion including the thalamus, internal capsule, external capsule, and cerebral peduncle. Overall, different time courses of hemorrhage, lesion evolution, and inflammation were consistent with complementary roles in injury development and repair, providing key information about these mediators of primary, secondary, and delayed brain injury development. The similarities/differences of PBBI to other focal brain injury models are discussed.

Response of circulating immune cells to major gunshot injury, haemorrhage, and acute surgery.

PURPOSE: The purpose of this study was to use an established porcine model to investigate the effects on immune function of severe gunshot injury. METHODS: Twelve pigs sustained two standardised rounds, one through right femur and one through left upper abdomen. First aid treatment and acute surgery was started immediately. Blood samples were drawn before shooting and after 75 min. Circulating neutrophils were isolated and reactive oxygen species (ROS) measured. Serum levels of tumour necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6, and IL-10 were determined at 0, 75 min, as well as 2h after incubation with 1 microg/ml endotoxin in an ex vivo whole blood model. RESULTS: TNF-alpha, IL-1beta, and IL-6 significantly increased at 75 min. ROS in circulating granulocytes tended to increase (NS). Incubation with endotoxin led to a more than 100-fold increase of TNF-alpha pre-trauma, compared to a three-fold increase post-trauma (p<0.0001 between groups). A similar pattern was obtained for IL-1beta, and IL-6. IL-10 was below detection in all samples. The granulocytes maintained their ability to react to the protein kinase C activator phorbol myristate acetate (PMA) after trauma. CONCLUSION: Severe gunshot injury and peritraumatic stress rapidly activate circulating immune cells, but reduce their capacity to react to a subsequent challenge to endotoxin.

[Proinflammatory cytokines in wound discharge and peripheral blood in patients with gunshot osteomyelitis of extremities]. / Provovospalitel'nye tsitokiny v ranevom otdeliaemom i perifericheskoi krovi pri ognestrel'nom osteomielite konechnostei.

Examination of 36 patients with gunshot osteomyelitis of extremities having the disease during 1-5 years has established that in acute gunshot osteomyelitis the concentration of antiinflammatory cytokines was rapidly increasing both in the blood serum and in the wound discharge. In the chronic course of the process the concentration of antiinflammatory cytokines in blood is a little higher than normal and only an analysis of the wound discharge can reflect the dynamics of the inflammatory (suppuration) process.

[Bioelectrostimulation in the rehabilitation of patients with gunshot wounds of the peripheral nervous system (a clinico-immunological study)]. / Bioélektrostimuliatsiia v reabilitatsii bol'nykh s ognestrel'nymi raneniiami perifericheskoi nervnoi sistemy (kliniko-immunologicheskoe issledovanie).

Immune homeostasis was studied in 35 patients with gunshot injuries of the peripheral nerves in the process of rehabilitation using bioelectrostimulation of the muscles impaired. Parameters of cellular and humoral immunity were determined. Bioelectrostimulation resulted in the regression of preexisting motor, sensitive, vegetovascular and trophic disorders. Cellular and humoral immunity improved: the number of T-lymphocytes, T-helpers, T-suppressors increased, the immunoregulatory index normalized, levels of B-lymphocytes, immunoglobulins G, circulating immune complexes reduced. Thus, bioelectrostimulation in patients with gunshot injuries of the peripheral nerves corrects the disturbed homeostasis and promotes recovery of the functions lost.

Patterns of injury and white cell response in critically ill trauma patients who present with leucopenia.

The outcome of critically ill trauma patients who presented to the intensive care unit with leucopenia (total peripheral white cell count < 4 x 10(9)/1) was studied prospectively with respect to the total white cell and neutrophil response. A total of 105 patients, of whom 30 were leucopenic, were admitted to the ICU during a 4-month period. The prevalence of leucopenia was significantly higher in patients with gunshot wounds (P < 0.05) and hollow visceral intra-abdominal injury (P < 0.001). Eight (27%) of the leucopenic patients died. No significant difference was found in initial mean total white cell or neutrophil count, or in the differential percentages, between survivors and non-survivors. The total peripheral white cell count increased significantly in survivors compared with non-survivors (P < 0.001), and significant differences were found in absolute neutrophil counts and differential percentages by days 5 and 10 (counts P = 0.01, P < 0.02; differentials P < 0.01, P < 0.01). These results suggest that granulocyte colony-stimulating factor may have a role in the treatment of trauma patients with persistent neutropenia following intra-abdominal hollow visceral injury.

[Possible role of the immune system in lead peripheral polyneuropathy. Case report]. / Possível intermediação do sistema imune na polineuropatia periférica plúmbica. Relato de caso.

This is a case report of a twenty-five years old man who developed, due to lead intoxication, a severe axonal peripheral predominantly motor neuropathy, after a shotgun injury. The projectile was retained in the right hip. Before this diagnosis had been done he was treated with corticosteroids in immunosuppressive doses and showed an improvement, but he had worsened at each attempt to interrupt the drug. Because he had also other signs of lead intoxication, such as abdominal cramps, severe anemia and seizures it was search for the blood levels of lead that was 101.2 micrograms/dl. The patient was treated with calcium disodium edetate and surgical removal of lead fragments. After that he had a good outcome with no need of corticosteroids. It is emphasized the possible relevance of the immune system on the mechanism of plumbic intoxication and the importance of the withdrawal of the lead material retained in joints.

Possível intermediaçäo do sistema imune na polineuropatia periférica plúmbica: relato de caso / Possible role of the immune system in lead neuropathy: case report

Relata-se o caso de paciente de 25 anos com ferimento porarma de fogo na articulacao coxofemural esquerda que desenvolveu, entre outros sinais de intoxicacao plumbica, polineuropatia periferica axonal predominantemente motora. Tratado inicialmente com corticosteroides em doses imunossupressoras obteve melhora, mas apresentava recidiva a cada tentativa de retirada da medicacao. Demonstrados laboratorialmente niveis sericos toxicos de chumbo, foi submetido a quelacao com EDTA e a retirada cirurgica do projetil, com boa recuperacao dapolineuropatia, sem necessidade ulterior de corticosteroides. Enfatiza-se: 1) o possivel papel do sistema imune na fisiopatogenia da intoxicacao por chumbo, podendo ser um dos motivos das diferentes apresentacoes clinicas das neuropatias plumbicas na infancia e no adulto; 2) a importancia da retirada do material plumbeo quando alojado em articulacoes.

[The immune reactions of the cerebrospinal fluid in victims of gunshot wounds of the skull and brain in relation to the treatment procedure and outcome]. / Immunnye reaktsii tserebrospinal'noi zhidkosti u postradavshikh s ognestrel'nymi raneniiami cherepa i golovnogo mozga v zavisimosti ot taktiki i iskhoda lecheniia.

The paper shows the formation of immunopathological syndromes in the cerebrospinal fluid in the victims with gunshot wounds in relation to the policy and outcome of treatment. Suturing the dura mater during a primary surgical treatment should be regarded as a protective process to limit antigen release, the development of immunological paralysis and autoimmunization. Deaths are caused by the neurogenic immune dysfunction induced by the inadequate functioning of the psychoneuroimmunoendocrine connections of the whole body.

[The treatment of soft-tissue wounds by using sorbent bandages]. / Lechenie ran miagkikh tkanei s ispol'zovaniem sorbiruiushchikh poviazok.

On the basis of experimental and clinical researches the authors has found out that the sorption via wound using activated carbonic fibrous material if started at an early post shock period could be considered as an effective method of treatment of severe mechanic injuries with a vast wound surface. This method contributes to the favourable outcome of local wound healing and diminishes the number of complications mainly of purulent-septic nature. The positive influence of sorbent applied directly on wound after surgical treatment consists in promoting tissue metabolism, and reducing the risk of inflammatory processes. There are straight manifestations of general detoxicating effect: diminishing of catabolism processes, reducing of toxic metabolite concentration, stimulating of immune system, falling the rate of toxemia. As a result the number of complications has diminished 40%, and the number of lethal cases--15%.

[Gunshot wound sepsis]. / Ognestrelnyi sepsis.

The authors emphasize that the origin of gunshot sepsis has specific features which are due to the peculiar effect of modern gunshot injury on the organism, the development of primary and secondary polyorganic deficiency, immunodeficiency among others. According to the authors, gunshot sepsis is encountered in 3.6% of cases among various infectious-purulent complications of gunshot wounds, usually in injuries to the lower extremities and pelvis, with 52.3% lethality. Improvement of the outcomes of gunshot sepsis is connected with refined organization of medical aid to the injured on the stages of medical evacuation, monitoring operative control over the course of the wound process, the use of medicinal agents which raise the viability of the damaged tissues and the organism's immunoresistance, improvement of the methods of surgical debridement of gunshot wounds and detoxification of the organism.

[Wound healing as affected by constitutional immunity factors]. / Zazhivlenie ran v zavisimosti ot faktorov konstitutsional'nogo immuniteta.

The authors examined 52 patients with gunshot wounds of various localization. Besides the type of wound healing, they determined the ABO system blood groups, the value of phagocytosis intensity and the value of connective tissue saturation with ascorbic acid, which, as it was shown earlier, are unrelated to the current condition of the wound process and may serve for predicting the risk of wound purulent complications. The distribution features of the studied values in patients with gunshot wounds were compared with those in individuals with gunshot-inflicted wounds. It is shown that such signs of constitutional immunity as the B blood group, weak phagocytosis intensity, and low saturation of the connective tissue with ascorbic acid are risk factors of purulent complications in both traumatic and gunshot wounds.

Immunoassay of macrophage stimulating alpha 2 SB (surface binding) glycoprotein in pig plasma following missile trauma.

Pigs were subjected to a standardized missile trauma in the thigh and plasma samples were collected at various times after trauma. The plasma level of an opsonic alpha 2 SB (surface binding) glycoprotein related to macrophage phagocytosis was determined by an agglutination assay using 125I-labelled gelatin particles. The results indicated a transient but significance decrease (p less than 0.01) in the plasma agglutination activity after trauma reflecting a deficiency in plasma alpha 2 SB glycoprotein. One non-surviving animal showed a persistent decrease in the plasma level of alpha 2 SB glycoprotein, while the surviving animals showed a normalization indicating that this agglutination assay may have prognostic value during the course of posttraumatic therapy.