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Isitt CE, McCloskey KA, Caballo A, Sharma P, Williams A, Leon-Villapalos J, Vizcaychipi MP. An analysis of surgical and anaesthetic factors affecting skin graft viability in patients admitted to a Burns Intensive Care Unit. Scars Burn Heal 2016; 2:2059513116642089. [PMID: 29799557 PMCID: PMC5965314 DOI: 10.1177/2059513116642089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
After large burns injuries, patients require fluid to be given via an IV drip.
This is often very large volumes of fluid, much higher than would normally be
required in other medical conditions. When the area of burn is very large
multiple operations are often required and during these operations, IV fluids
are again used to keep the blood pressure normal and keep the patient hydrated.
We looked at the hospital records of 35 patients to see if there was any link
between the drugs and fluids given during these operations and the success of
the skin grafts performed in these operations. We found that using a particular
type of fluid called a colloid fluid, which allows smaller volumes to be given
for the same effect on blood pressure and hydration, was more common in patients
whose skin grafts subsequently required further surgery due to poor healing. A
larger study would now be required to see if this type of fluid is causing poor
healing or whether it is a coincidental finding only.
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Affiliation(s)
- Catherine E Isitt
- Department of Anaesthetics and Intensive Care, Chelsea and Westminster Hospital NHS Trust, London SW10 9NH, UK
| | - Kayleigh A McCloskey
- Department of Anaesthetics and Intensive Care, Chelsea and Westminster Hospital NHS Trust, London SW10 9NH, UK
| | - Alvaro Caballo
- Department of Plastics and Burns Surgery, Chelsea and Westminster Hospital NHS Trust, London SW10 9NH, UK
| | - Pranev Sharma
- Department of Anaesthetics and Intensive Care, Chelsea and Westminster Hospital NHS Trust, London SW10 9NH, UK
| | - Andrew Williams
- Department of Plastics and Burns Surgery, Chelsea and Westminster Hospital NHS Trust, London SW10 9NH, UK
| | - Jorge Leon-Villapalos
- Department of Plastics and Burns Surgery, Chelsea and Westminster Hospital NHS Trust, London SW10 9NH, UK
| | - Marcela P Vizcaychipi
- Department of Anaesthetics and Intensive Care, Chelsea and Westminster Hospital NHS Trust, London SW10 9NH, UK.,Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
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Muschitz GK, Schwabegger E, Kocijan R, Baierl A, Moussalli H, Fochtmann A, Nickl S, Tinhofer I, Haschka J, Resch H, Rath T, Pietschmann P, Muschitz C. Early and Sustained Changes in Bone Metabolism After Severe Burn Injury. J Clin Endocrinol Metab 2016; 101:1506-15. [PMID: 26789778 DOI: 10.1210/jc.2015-3575] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Severe burn injury causes a massive stress response, consecutively heightened serum levels of acute phase proteins, cortisol, and catecholamines with accompanying disturbance in calcium metabolism. OBJECTIVE Evaluation of early and prolonged changes of serum bone turnover markers (BTMs) and regulators of bone metabolism. DESIGN Longitudinal observational design. SETTING University clinic. PATIENTS A total of 32 male patients with a median age of 40.5 years and a median burned total body surface area of 40% (83% patients with full thickness burn injury). INTERVENTIONS None. MAIN OUTCOME MEASURES Comparison of changes of BTM/regulators of bone metabolism in the early (d 2–7) and prolonged (d 7–56) phases after trauma. RESULTS All investigated BTM/regulators significantly changed. During the early phase, pronounced increases were observed for serum type 1 collagen cross-linked C-telopeptide, intact N-terminal propeptide of type I procollagen, sclerostin, Dickkopf-1, bone-specific alkaline phosphatase, fibroblast growth factor 23, and intact parathyroid hormone levels, whereas 25-hydroxyvitamin D, albumin, serum, and ionized calcium levels decreased. Changes of osteoprotegerin, osteocalcin, and phosphate were less pronounced but remained significant. In the prolonged phase, changes of intact N-terminal propeptide of type I procollagen were most pronounced, followed by elevated sclerostin, osteocalcin, bone-specific alkaline phosphatase, and lesser changes for albumin levels. Calcium and ionized calcium levels tardily increased and remained within the limit of normal. In contrast, levels of intact parathyroid hormone, fibroblast growth factor 23, C-reactive protein, and to a lesser extent serum type 1 collagen cross-linked C-telopeptide and phosphate levels declined significantly during this phase of investigation. CONCLUSIONS Ongoing changes of BTM and regulators of bone metabolism suggest alterations in bone metabolism with a likely adverse influence on bone quality and structure in male patients with severe burn injuries.
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Affiliation(s)
- Gabriela Katharina Muschitz
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Elisabeth Schwabegger
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Roland Kocijan
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Andreas Baierl
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Hervé Moussalli
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Alexandra Fochtmann
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Stefanie Nickl
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Ines Tinhofer
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Judith Haschka
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Heinrich Resch
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Thomas Rath
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Peter Pietschmann
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
| | - Christian Muschitz
- Division of Plastic and Reconstructive Surgery (G.K.M., A.F., S.N., I.T., T.R.), Department of Surgery, and Department of Pathophysiology and Allergy Research (P.P.), Center for Pathophysiology, Infectiology and Immunology, The Medical University of Vienna, and Department of Statistics and Operations Research (A.B.), The University of Vienna, 1090 Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery (E.S.), The Medical University Innsbruck, 6020 Innsbruck, Austria; St. Vincent Hospital (R.K., H.M., J.H., H.R., C.M.), Medical Department II, Academic Teaching Hospital of The Medical University of Vienna, and Karl Landsteiner Institute for Gastroenterology and Rheumatology (H.R.), 1060 Vienna, Austria
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153
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Kim JB, Cho YS, Jang KU, Joo SY, Choi JS, Seo CH. Effects of sustained release growth hormone treatment during the rehabilitation of adult severe burn survivors. Growth Horm IGF Res 2016; 27:1-6. [PMID: 26843473 DOI: 10.1016/j.ghir.2015.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 12/17/2015] [Accepted: 12/31/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The catabolic phase following burn injuries increases caloric imbalance and results in substantial weight loss because of hypermetabolism; energy expenditures as high as twice the normal limit have been documented during the first 3 weeks. Furthermore, the wound size and healing duration seem to be related to the length of stay in the intensive care unit, which results in the loss of muscle mass, the so-called sarcopenia; weakness; and physical frailty. Possible therapeutic strategies include exercises, use of anabolic steroids, or replacement with human growth hormone (hGH). To determine the clinical effects of hGH on sarcopenia after burn injuries, we compared patients who received subcutaneous hGH injections during rehabilitation with control patients who received placebo treatment. METHODS A total of 33 patients with third degree burn injuries covering a total body surface area of >20% were randomly divided into a test group (n=18), which received 2-mg injections of sustained release hGH (SR-hGH) weekly for 3 months during rehabilitation, and a control group (n=15), which followed the same rehabilitation protocol with placebo injections. Muscular strength, cardiopulmonary function, body composition, and body weight were measured at baseline and 1 and 3 months after SR-hGH or placebo administration. RESULTS The mean age of patients was 37.67 ± 7.64 years in the SR-hGH group and 37.22 ± 8.19 years in the control group, while the interval between injury and SR-hGH or placebo injection was 123.7 ± 53.6 and 126.6 ± 43.5 days, respectively. The oxygen consumption at the lactate threshold, maximum oxygen consumption, lean body mass, knee extensor peak torque, and insulin-like growth factor 1 (IGF-1) and adiponectin levels were significantly higher in the SR-hGH group than in the control group at 3 months. There were no differences in the body weight, systolic and diastolic blood pressure (BP), bone mineral content, percentage body fat, and burn scar characteristics between groups. CONCLUSION Our results suggest that SR-hGH treatment during the rehabilitation of adult burn survivors positively affects physical fitness levels, muscle power, and metabolic processes, although further confirmation through research of metabolic pathways in burn survivors is required.
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Affiliation(s)
- June-Bum Kim
- Department of Pediatrics, Hallym University, College of Medicine, 94-200 Yeongdeungpo-Dong Yeongdeungpo-Ku, Seoul 150-030, South Korea.
| | - Yun Soo Cho
- Department of Rehabilitation Medicine, Hallym University, College of Medicine, 94-200 Yeongdeungpo-Dong Yeongdeungpo-Ku, Seoul 150-030, South Korea.
| | - Ki Un Jang
- Department of Rehabilitation Medicine, Hallym University, College of Medicine, 94-200 Yeongdeungpo-Dong Yeongdeungpo-Ku, Seoul 150-030, South Korea.
| | - So Young Joo
- Department of Rehabilitation Medicine, Hallym University, College of Medicine, 94-200 Yeongdeungpo-Dong Yeongdeungpo-Ku, Seoul 150-030, South Korea.
| | - Ji Soo Choi
- Department of Rehabilitation Medicine, Hallym University, College of Medicine, 94-200 Yeongdeungpo-Dong Yeongdeungpo-Ku, Seoul 150-030, South Korea.
| | - Cheong Hoon Seo
- Department of Rehabilitation Medicine, Hallym University, College of Medicine, 94-200 Yeongdeungpo-Dong Yeongdeungpo-Ku, Seoul 150-030, South Korea.
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154
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Cardiovascular Dysfunction Following Burn Injury: What We Have Learned from Rat and Mouse Models. Int J Mol Sci 2016; 17:ijms17010053. [PMID: 26729111 PMCID: PMC4730298 DOI: 10.3390/ijms17010053] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/14/2015] [Accepted: 12/23/2015] [Indexed: 12/11/2022] Open
Abstract
Severe burn profoundly affects organs both proximal and distal to the actual burn site. Cardiovascular dysfunction is a well-documented phenomenon that increases morbidity and mortality following a massive thermal trauma. Beginning immediately post-burn, during the ebb phase, cardiac function is severely depressed. By 48 h post-injury, cardiac function rebounds and the post-burn myocardium becomes tachycardic and hyperinflammatory. While current clinical trials are investigating a variety of drugs targeted at reducing aspects of the post-burn hypermetabolic response such as heart rate and cardiac work, there is still a paucity of knowledge regarding the underlying mechanisms that induce cardiac dysfunction in the severely burned. There are many animal models of burn injury, from rodents, to sheep or swine, but the majority of burn related cardiovascular investigations have occurred in rat and mouse models. This literature review consolidates the data supporting the prevalent role that β-adrenergic receptors play in mediating post-burn cardiac dysfunction and the idea that pharmacological modulation of this receptor family is a viable therapeutic target for resolving burn-induced cardiac deficits.
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155
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Diao L, Patsouris D, Sadri AR, Dai X, Amini-Nik S, Jeschke MG. Alternative Mechanism for White Adipose Tissue Lipolysis after Thermal Injury. Mol Med 2015; 21:959-968. [PMID: 26736177 DOI: 10.2119/molmed.2015.00123] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 12/29/2015] [Indexed: 12/18/2022] Open
Abstract
Extensively burned patients often suffer from sepsis, a complication that enhances postburn hypermetabolism and contributes to increased incidence of multiple organ failure, morbidity and mortality. Despite the clinical importance of burn sepsis, the molecular and cellular mechanisms of such infection-related metabolic derangements and organ dysfunction are still largely unknown. We recently found that upon endoplasmic reticulum (ER) stress, the white adipose tissue (WAT) interacts with the liver via inflammatory and metabolic signals leading to profound hepatic alterations, including hepatocyte apoptosis and hepatic fatty infiltration. We therefore hypothesized that burn plus infection causes an increase in lipolysis of WAT after major burn, partially through induction of ER stress, contributing to hyperlipidemia and profound hepatic lipid infiltration. We used a two-hit rat model of 60% total body surface area scald burn, followed by intraperitoneal (IP) injection of Pseudomonas Aeruginosa-derived lipopolysaccharide (LPS) 3 d postburn. One day later, animals were euthanized and liver and epididymal WAT (EWAT) samples were collected for gene expression, protein analysis and histological study of inflammasome activation, ER stress, apoptosis and lipid metabolism. Our results showed that burn plus LPS profoundly increased lipolysis in WAT associated with significantly increased hepatic lipid infiltration. Burn plus LPS augmented ER stress by upregulating CHOP and activating ATF6, inducing NLRP3 inflammasome activation and leading to increased apoptosis and lipolysis in WAT with a distinct enzymatic mechanism related to inhibition of AMPK signaling. In conclusion, burn sepsis causes profound alterations in WAT and liver that are associated with changes in organ function and structure.
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Affiliation(s)
- Li Diao
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | | | - Xiaojing Dai
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Saeid Amini-Nik
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Surgery, Division of Plastic Surgery, Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Surgery, Division of Plastic Surgery, Department of Immunology, University of Toronto, Toronto, Ontario, Canada.,Ross Tilley Burn Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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156
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Szczesny B, Brunyánszki A, Ahmad A, Oláh G, Porter C, Toliver-Kinsky T, Sidossis L, Herndon DN, Szabo C. Time-Dependent and Organ-Specific Changes in Mitochondrial Function, Mitochondrial DNA Integrity, Oxidative Stress and Mononuclear Cell Infiltration in a Mouse Model of Burn Injury. PLoS One 2015; 10:e0143730. [PMID: 26630679 PMCID: PMC4668069 DOI: 10.1371/journal.pone.0143730] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 11/08/2015] [Indexed: 01/11/2023] Open
Abstract
Severe thermal injury induces a pathophysiological response that affects most of the organs within the body; liver, heart, lung, skeletal muscle among others, with inflammation and hyper-metabolism as a hallmark of the post-burn damage. Oxidative stress has been implicated as a key component in development of inflammatory and metabolic responses induced by burn. The goal of the current study was to evaluate several critical mitochondrial functions in a mouse model of severe burn injury. Mitochondrial bioenergetics, measured by Extracellular Flux Analyzer, showed a time dependent, post-burn decrease in basal respiration and ATP-turnover but enhanced maximal respiratory capacity in mitochondria isolated from the liver and lung of animals subjected to burn injury. Moreover, we detected a tissue-specific degree of DNA damage, particularly of the mitochondrial DNA, with the most profound effect detected in lungs and hearts of mice subjected to burn injury. Increased mitochondrial biogenesis in lung tissue in response to burn injury was also observed. Burn injury also induced time dependent increases in oxidative stress (measured by amount of malondialdehyde) and neutrophil infiltration (measured by myeloperoxidase activity), particularly in lung and heart. Tissue mononuclear cell infiltration was also confirmed by immunohistochemistry. The amount of poly(ADP-ribose) polymers decreased in the liver, but increased in the heart in later time points after burn. All of these biochemical changes were also associated with histological alterations in all three organs studied. Finally, we detected a significant increase in mitochondrial DNA fragments circulating in the blood immediately post-burn. There was no evidence of systemic bacteremia, or the presence of bacterial DNA fragments at any time after burn injury. The majority of the measured parameters demonstrated a sustained elevation even at 20–40 days post injury suggesting a long-lasting effect of thermal injury on organ function. The current data show that there are marked time-dependent and tissue-specific alterations in mitochondrial function induced by thermal injury, and suggest that mitochondria-specific damage is one of the earliest responses to burn injury. Mitochondria may be potential therapeutic targets in the future experimental therapy of burns.
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Affiliation(s)
- Bartosz Szczesny
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States of America.,Shriners Hospitals for Children, Galveston, TX, United States of America
| | - Attila Brunyánszki
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Akbar Ahmad
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Gabor Oláh
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Craig Porter
- Shriners Hospitals for Children, Galveston, TX, United States of America.,Department of Surgery, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Tracy Toliver-Kinsky
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States of America.,Department of Biochemistry and Molecular Biology, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Labros Sidossis
- Shriners Hospitals for Children, Galveston, TX, United States of America.,Department of Surgery, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - David N Herndon
- Shriners Hospitals for Children, Galveston, TX, United States of America.,Department of Surgery, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Csaba Szabo
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States of America.,Shriners Hospitals for Children, Galveston, TX, United States of America
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157
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Duke JM, Boyd JH, Randall SM, Wood FM. Long term mortality in a population-based cohort of adolescents, and young and middle-aged adults with burn injury in Western Australia: A 33-year study. ACCIDENT; ANALYSIS AND PREVENTION 2015; 85:118-124. [PMID: 26432064 DOI: 10.1016/j.aap.2015.09.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 06/03/2015] [Accepted: 09/13/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Advances in the treatment and management of burn patients over the past decades have resulted in a decline of in-hospital mortality rates. Current estimates of burn-related mortality are usually in the context of deaths occurring during the admission or within a short time period after the incident burn. Limited data are available that examine long term mortality after burn injury. This study aimed to assess the impact of burn injury on long-term mortality and quantify any increased risk of death attributable to burn injury. METHODS A population-based cohort study of persons 15-44 years of age hospitalised for burn injury (n=14,559) in Western Australia (1980-2012) and a matched non-injured comparison group (n=56,822) using linked health administrative data was used. Hospital morbidity and death data were obtained from the Western Australian Hospital Morbidity Data System and Death Register. De-identified extraction of all linked hospital morbidity and death records for the period 1980-2012 were provided by the Western Australian Data Linkage System. Survival analysis was conducted using the Kaplan-Meier method and Cox proportional hazards modelling. RESULTS The adjusted all-cause Mortality Rate Ratio (MRR) for burn injury was 1.8 (95%CI: 1.7-2.0); those with burn injury had a 1.8 times greater rate of mortality than those with no injury. The index burn injury was estimated to account for 44% of all recorded deaths in the burn injury cohort during the study period after discharge. Increased risk of mortality was observed for both severe (MRR, 95%CI: 1.9, 1.3-2.9) and minor (MRR, 95%CI: 2.5, 2.2-3.0) burns. CONCLUSIONS An increased risk of long-term all-cause mortality is associated with both minor and severe burn injury. Estimates of total mortality burden based on the early in-patient period alone, significantly underestimates the true burden of burn injury in adolescents, and young and middle aged adults. These results have significant implications for burn injury prevention.
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Affiliation(s)
- Janine M Duke
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Western Australia, Perth, Australia.
| | - James H Boyd
- Population Health Research Network, Centre for Data Linkage, Curtin University, Western Australia, Perth, Australia
| | - Sean M Randall
- Population Health Research Network, Centre for Data Linkage, Curtin University, Western Australia, Perth, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Western Australia, Perth, Australia; Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Western Australia, Perth, Australia
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158
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Nakamura K, Inokuchi R, Hiruma T, Omura T, Ohshima K, Tokunaga K, Ueda A, Doi K. Continuous veno-venous hemodialysis and filtration for extensive burn with severe hypernatremia. Acute Med Surg 2015; 3:260-264. [PMID: 29123794 DOI: 10.1002/ams2.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 08/31/2015] [Indexed: 11/12/2022] Open
Abstract
Case A 51-year-old man presented with severe burns, with a burn index of 33.5. Relaxation incisions were made in the trunk and right arm. Ringer's solution (12,000 mL) was used as initial fluid therapy for the first 24 h. The patient's serum Na level gradually increased to 170 mEq/L; infusion was carried out to correct the hypernatremia. Continuous veno-venous hemodialysis and filtration succeeded in maintaining the serum Na level at approximately 145 mEq/L. Outcome After the initiation of continuous veno-venous hemodialysis and filtration, the skin graft survival rate improved markedly with the normalization of the Na level, and the patient recovered smoothly. He was discharged on foot. Conclusion Hypernatremia, frequently observed in patients with extensive burns, is considered to be markedly disadvantageous for the survival of skin grafts. Continuous veno-venous hemodialysis and filtration may be one of the options for the treatment of refractory hypernatremia in severe burns.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine Hitachi General Hospital Ibaraki Japan
| | - Ryota Inokuchi
- Department of Emergency and General Medicine JR General Hospital Tokyo Japan
| | - Takahiro Hiruma
- Department of Emergency and Critical Care Medicine The University of Tokyo Hospital Tokyo Japan
| | - Takaki Omura
- Department of Emergency and Critical Care Medicine Hitachi General Hospital Ibaraki Japan
| | - Kazuma Ohshima
- Department of Emergency and Critical Care Medicine Hitachi General Hospital Ibaraki Japan
| | - Kurato Tokunaga
- Department of Emergency and Critical Care Medicine Hitachi General Hospital Ibaraki Japan
| | - Atsushi Ueda
- Department of Nephrology Hitachi General Hospital Ibaraki Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine The University of Tokyo Hospital Tokyo Japan
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159
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Abdullahi A, Jeschke MG. Nutrition and anabolic pharmacotherapies in the care of burn patients. Nutr Clin Pract 2015; 29:621-30. [PMID: 25606644 DOI: 10.1177/0884533614533129] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Thermal injury is a devastating injury that results in a number of pathological alterations in almost every system in the body. Hypermetabolism, muscle wasting, depressed immunity, and impaired wound healing are all clinical features of burns. Failure to address each of these specific pathological alterations can lead to increased mortality. Nutrition supplementation has been recommended as a therapeutic tool to help attenuate the hypermetabolism and devastating catabolism evident following burn. Despite the wide consensus on the need of nutrition supplementation in burn patients, controversy exists with regard to the type and amount of nutrition recommended. Nutrition alone is also not enough in these patients to halt and reverse some of the damage done by the catabolic pathways activated following severe burn injury. This has led to the use of anabolic pharmacologic agents in conjunction with nutrition to help improve patient outcome following burn injury. In this review, we examine the relevant literature on nutrition after burn injury and its contribution to the attenuation of the postburn hypermetabolic response, impaired wound healing, and suppressed immunological responses. We also review the commonly used anabolic agents clinically in the care of burn patients. Finally, we provide nutrition and pharmacological recommendations gained from prospective trials, retrospective analyses, and expert opinions based on our practice at the Ross Tilley Burn Center in Toronto, Canada.
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Affiliation(s)
- Abdikarim Abdullahi
- Sunnybrook Health Sciences Centre, Ross Tilley Burn Centre, Rm D7-04B, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
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160
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Release of insulin from PLGA-alginate dressing stimulates regenerative healing of burn wounds in rats. Clin Sci (Lond) 2015; 129:1115-29. [PMID: 26310669 DOI: 10.1042/cs20150393] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/26/2015] [Indexed: 12/21/2022]
Abstract
Burn wound healing involves a complex set of overlapping processes in an environment conducive to ischaemia, inflammation and infection costing $7.5 billion/year in the U.S.A. alone, in addition to the morbidity and mortality that occur when the burns are extensive. We previously showed that insulin, when topically applied to skin excision wounds, accelerates re-epithelialization and stimulates angiogenesis. More recently, we developed an alginate sponge dressing (ASD) containing insulin encapsulated in PLGA [poly(D,L-lactic-co-glycolic acid)] microparticles that provides a sustained release of bioactive insulin for >20 days in a moist and protective environment. We hypothesized that insulin-containing ASD accelerates burn healing and stimulates a more regenerative, less scarring healing. Using heat-induced burn injury in rats, we show that burns treated with dressings containing 0.04 mg insulin/cm(2) every 3 days for 9 days have faster closure, a higher rate of disintegration of dead tissue and decreased oxidative stress. In addition, in insulin-treated wounds, the pattern of neutrophil inflammatory response suggests faster clearing of the burned dead tissue. We also observe faster resolution of the pro-inflammatory macrophages. We also found that insulin stimulates collagen deposition and maturation with the fibres organized more like a basket weave (normal skin) than aligned and cross-linked (scar tissue). In summary, application of ASD-containing insulin-loaded PLGA particles on burns every 3 days stimulates faster and more regenerative healing. These results suggest insulin as a potential therapeutic agent in burn healing and, because of its long history of safe use in humans, insulin could become one of the treatments of choice when repair and regeneration are critical for proper tissue function.
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161
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Results of a pilot multicenter genotype-based randomized placebo-controlled trial of propranolol to reduce pain after major thermal burn injury. Clin J Pain 2015; 31:21-9. [PMID: 25084070 DOI: 10.1097/ajp.0000000000000086] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Results of previous studies suggest that β-adrenoreceptor activation may augment pain, and that β-adrenoreceptor antagonists may be effective in reducing pain, particularly in individuals not homozygous for the catechol-O-methyltransferase (COMT) high-activity haplotype. MATERIALS AND METHODS Consenting patients admitted for thermal burn injury at participating burn centers were genotyped; those who were not high-activity COMT homozygotes were randomized to propranolol 240 mg/d or placebo. Primary outcomes were study feasibility (consent rate, protocol completion rate) and pain scores on study days 5 to 19. Secondary outcomes assessed pain and posttraumatic stress disorder symptoms 6 weeks postinjury. RESULTS Seventy-seven percent (61/79) of eligible patients were consented and genotyped, and 77% (47/61) were genotype eligible and randomized. Ninety-one percent (43/47) tolerated study drug and completed primary outcome assessments. In intention-to-treat and per-protocol analyses, patients randomized to propranolol had worse pain scores on study days 5 to 19. CONCLUSIONS Genotype-specific pain medication interventions are feasible in hospitalized burn patients. Propranolol is unlikely to be a useful analgesic during the first few weeks after burn injury.
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162
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Porter C, Hardee JP, Herndon DN, Suman OE. The role of exercise in the rehabilitation of patients with severe burns. Exerc Sport Sci Rev 2015; 43:34-40. [PMID: 25390300 DOI: 10.1249/jes.0000000000000029] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Severe burn trauma results in persistent skeletal muscle catabolism and prolonged immobilization. We hypothesize that structured rehabilitative exercise is a safe and efficacious strategy to restore lean body mass and physical function in burn victims. Here, we review the evidence for the utility of rehabilitative exercise training in restoring physiological function in burn survivors.
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Affiliation(s)
- Craig Porter
- 1Shriners Hospitals for Children; 2Department of Surgery, University of Texas Medical Branch, Galveston, TX; and 3Department of Exercise Science, University of South Carolina, Columbia, SC
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163
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Corrick KL, Stec MJ, Merritt EK, Windham ST, Thomas SJ, Cross JM, Bamman MM. Serum from human burn victims impairs myogenesis and protein synthesis in primary myoblasts. Front Physiol 2015; 6:184. [PMID: 26136691 PMCID: PMC4468386 DOI: 10.3389/fphys.2015.00184] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/03/2015] [Indexed: 11/30/2022] Open
Abstract
The pathophysiological response to a severe burn injury involves a robust increase in circulating inflammatory/endocrine factors and a hypermetabolic state, both of which contribute to prolonged skeletal muscle atrophy. In order to characterize the role of circulating factors in muscle atrophy following a burn injury, human skeletal muscle satellite cells were grown in culture and differentiated to myoblasts/myotubes in media containing serum from burn patients or healthy, age, and sex-matched controls. While incubation in burn serum did not affect NFκB signaling, cells incubated in burn serum displayed a transient increase in STAT3 phosphorlyation (Tyr705) after 48 h of treatment with burn serum (≈ + 70%; P < 0.01), with these levels returning to normal by 96 h. Muscle cells differentiated in burn serum displayed reduced myogenic fusion signaling (phospho-STAT6 (Tyr641), ≈−75%; ADAM12, ≈-20%; both P < 0.01), and reduced levels of myogenin (≈−75%; P < 0.05). Concomitantly, myotubes differentiated in burn serum demonstrated impaired myogenesis (assessed by number of nuclei/myotube). Incubation in burn serum for 96 h did not increase proteolytic signaling (assessed via caspase-3 and ubiquitin levels), but reduced anabolic signaling [p-p70S6k (Ser421/Thr424), −30%; p-rpS6 (Ser240/244), ≈-50%] and impaired protein synthesis (−24%) (P < 0.05). This resulted in a loss of total protein content (−18%) and reduced cell size (−33%) (P < 0.05). Overall, incubation of human muscle cells in serum from burn patients results in impaired myogenesis and reduced myotube size, indicating that circulating factors may play a significant role in muscle loss and impaired muscle recovery following burn injury.
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Affiliation(s)
- Katie L Corrick
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham Birmingham, AL, USA
| | - Michael J Stec
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham Birmingham, AL, USA ; UAB Center for Exercise Medicine, University of Alabama at Birmingham Birmingham, AL, USA
| | - Edward K Merritt
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham Birmingham, AL, USA ; UAB Center for Exercise Medicine, University of Alabama at Birmingham Birmingham, AL, USA
| | - Samuel T Windham
- UAB Center for Exercise Medicine, University of Alabama at Birmingham Birmingham, AL, USA ; Department of Surgery, University of Alabama at Birmingham Birmingham, AL, USA
| | - Steven J Thomas
- Department of Surgery, University of Alabama at Birmingham Birmingham, AL, USA
| | - James M Cross
- Department of Surgery, University of Texas Health Science Center Houston, TX, USA
| | - Marcas M Bamman
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham Birmingham, AL, USA ; UAB Center for Exercise Medicine, University of Alabama at Birmingham Birmingham, AL, USA ; Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center Birmingham, AL, USA
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164
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Rowan MP, Cancio LC, Elster EA, Burmeister DM, Rose LF, Natesan S, Chan RK, Christy RJ, Chung KK. Burn wound healing and treatment: review and advancements. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:243. [PMID: 26067660 PMCID: PMC4464872 DOI: 10.1186/s13054-015-0961-2] [Citation(s) in RCA: 467] [Impact Index Per Article: 51.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Burns are a prevalent and burdensome critical care problem. The priorities of specialized facilities focus on stabilizing the patient, preventing infection, and optimizing functional recovery. Research on burns has generated sustained interest over the past few decades, and several important advancements have resulted in more effective patient stabilization and decreased mortality, especially among young patients and those with burns of intermediate extent. However, for the intensivist, challenges often exist that complicate patient support and stabilization. Furthermore, burn wounds are complex and can present unique difficulties that require late intervention or life-long rehabilitation. In addition to improvements in patient stabilization and care, research in burn wound care has yielded advancements that will continue to improve functional recovery. This article reviews recent advancements in the care of burn patients with a focus on the pathophysiology and treatment of burn wounds.
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Affiliation(s)
- Matthew P Rowan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.
| | - Leopoldo C Cancio
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Eric A Elster
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - David M Burmeister
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Lloyd F Rose
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Shanmugasundaram Natesan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Rodney K Chan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.,Brooke Army Medical Center, 3551 Roger Brook Dr, Fort Sam Houston, TX, 78234, USA
| | - Robert J Christy
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Kevin K Chung
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
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165
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Chi Y, Chai J, Xu C, Luo H, Zhang Q. Apelin inhibits the activation of the nucleotide-binding domain and the leucine-rich, repeat-containing family, pyrin-containing 3 (NLRP3) inflammasome and ameliorates insulin resistance in severely burned rats. Surgery 2015; 157:1142-52. [DOI: 10.1016/j.surg.2015.01.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/13/2015] [Accepted: 01/20/2015] [Indexed: 02/07/2023]
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166
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Prelack K, Yu YM, Sheridan RL. Nutrition and metabolism in the rehabilitative phase of recovery in burn children: a review of clinical and research findings in a speciality pediatric burn hospital. BURNS & TRAUMA 2015; 3:7. [PMID: 27574653 PMCID: PMC4964101 DOI: 10.1186/s41038-015-0004-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 04/06/2015] [Indexed: 11/10/2022]
Abstract
During the rehabilitation phase of burn injury, patient care transitions from critical care medicine to restorative treatment strategies that encompass physical and occupational therapies, nutrition repletion, and psychosocial support for community reintegration. As pediatric burn patients undergo rehabilitation, nutrition assessment remains ongoing to define nutritional status and any alterations in metabolism that may take place. For some, a persistent hypermetabolic state appears evident, and weight loss may continue. The severity and duration however varies among patients. Many patients enter their rehabilitative phase with visible lean body mass depletion, and the focus of nutritional therapy for them shifts to replenishing nutritional status, while supporting rehabilitative efforts. Over the past decade, we have conducted studies on energy and protein metabolism, body composition, including bone mineralization, and general wellness in over 130 patients to better understand changes in metabolism and nutritional status during the rehabilitative phase of recovery. This abstract summarizes our findings.
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Affiliation(s)
- Kathy Prelack
- Shriners Hospitals For Children, Boston, Massachusetts USA
| | - Yong Ming Yu
- Shriners Hospitals For Children, Boston, Massachusetts USA
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167
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Modeling Fluid Resuscitation by Formulating Infusion Rate and Urine Output in Severe Thermal Burn Adult Patients: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:508043. [PMID: 26090415 PMCID: PMC4442020 DOI: 10.1155/2015/508043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 04/24/2015] [Indexed: 11/17/2022]
Abstract
Acute burn injuries are among the most devastating forms of trauma and lead to significant morbidity and mortality. Appropriate fluid resuscitation after severe burn, specifically during the first 48 hours following injury, is considered as the single most important therapeutic intervention in burn treatment. Although many formulas have been developed to estimate the required fluid amount in severe burn patients, many lines of evidence showed that patients still receive far more fluid than formulas recommend. Overresuscitation, which is known as “fluid creep,” has emerged as one of the most important problems during the initial period of burn care. If fluid titration can be personalized and automated during the resuscitation phase, more efficient burn care and outcome will be anticipated. In the present study, a dynamic urine output based infusion rate prediction model was developed and validated during the initial 48 hours in severe thermal burn adult patients. The experimental results demonstrated that the developed dynamic fluid resuscitation model might significantly reduce the total fluid volume by accurately predicting hourly urine output and has the potential to aid fluid administration in severe burn patients.
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168
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Ali A, Herndon DN, Mamachen A, Hasan S, Andersen CR, Grogans RJ, Brewer JL, Lee JO, Heffernan J, Suman OE, Finnerty CC. Propranolol attenuates hemorrhage and accelerates wound healing in severely burned adults. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:217. [PMID: 25936635 PMCID: PMC4432824 DOI: 10.1186/s13054-015-0913-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/08/2015] [Indexed: 12/03/2022]
Abstract
Introduction Propranolol, a nonselective β-blocker, exerts an indirect effect on the vasculature by leaving α-adrenergic receptors unopposed, resulting in peripheral vasoconstriction. We have previously shown that propranolol diminishes peripheral blood following burn injury by increasing vascular resistance. The purpose of this study was to investigate whether wound healing and perioperative hemodynamics are affected by propranolol administration in severely burned adults. Methods Sixty-nine adult patients with burns covering ≥30% of the total body surface area (TBSA) were enrolled in this IRB-approved study. Patients received standard burn care with (n = 35) or without (control, n = 34) propranolol. Propranolol was administered within 48 hours of burns and given throughout hospital discharge to decrease heart rate by approximately 20% from admission levels. Wound healing was determined by comparing the time between grafting procedures. Blood loss was determined by comparing pre- and postoperative hematocrit while factoring in operative graft area. Data were collected between first admission and first discharge. Results Demographics, burn size, and mortality were comparable in the control and propranolol groups. Patients in the propranolol group received an average propranolol dose of 3.3 ± 3.0 mg/kg/day. Daily average heart rate over the first 30 days was significantly lower in the propranolol group (P <0.05). The average number of days between skin grafting procedures was also lower in propranolol patients (10 ± 5 days) than in control patients (17 ± 12 days; P = 0.02), indicative of a faster donor site healing time in the propranolol group. Packed red blood cell infusion was similar between groups (control 5.3 ± 5.4 units vs. propranolol 4.4 ± 3.1 units, P = 0.89). Propranolol was associated with a 5 to 7% improvement in perioperative hematocrit during grafting procedures of 4,000 to 16,000 cm2 compared to control (P = 0.002). Conclusions Administration of propranolol during the acute hospitalization period diminishes blood loss during skin grafting procedures and markedly improves wound healing in severely burned adults. As burn patients require serial surgical interventions for motor and cosmetic repair, restricting blood loss during operative intervention is optimal.
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Affiliation(s)
- Arham Ali
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Ashish Mamachen
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Samir Hasan
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Clark R Andersen
- Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Ro-Jon Grogans
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Jordan L Brewer
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Jong O Lee
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Jamie Heffernan
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA. .,Institute for Translational Sciences and the Sealy Center for Molecular Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
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169
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Duke JM, Boyd JH, Rea S, Randall SM, Wood FM. Long-term mortality among older adults with burn injury: a population-based study in Australia. Bull World Health Organ 2015; 93:400-6. [PMID: 26240461 PMCID: PMC4450710 DOI: 10.2471/blt.14.149146] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 02/10/2015] [Accepted: 02/16/2015] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To assess if burn injury in older adults is associated with changes in long-term all-cause mortality and to estimate the increased risk of death attributable to burn injury. METHODS We conducted a population-based matched longitudinal study - based on administrative data from Western Australia's hospital morbidity data system and death register. A cohort of 6014 individuals who were aged at least 45 years when hospitalized for a first burn injury in 1980-2012 was identified. A non-injury comparison cohort, randomly selected from Western Australia's electoral roll (n = 25 759), was matched to the patients. We used Kaplan-Meier plots and Cox proportional hazards regression to analyse the data and generated mortality rate ratios and attributable risk percentages. FINDINGS For those hospitalized with burns, 180 (3%) died in hospital and 2498 (42%) died after discharge. Individuals with burn injury had a 1.4-fold greater mortality rate than those with no injury (95% confidence interval, CI: 1.3-1.5). In this cohort, the long-term mortality attributable to burn injury was 29%. Mortality risk was increased by both severe and minor burns, with adjusted mortality rate ratios of 1.3 (95% CI: 1.1-1.9) and 2.1 (95% CI: 1.9-2.3), respectively. CONCLUSION Burn injury is associated with increased long-term mortality. In our study population, sole reliance on data on in-hospital deaths would lead to an underestimate of the true mortality burden associated with burn injury.
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Affiliation(s)
- Janine M Duke
- Burn Injury Research Unit, School of Surgery, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, M318 35 Stirling Highway, Crawley, 6009, Perth, Western Australia, Australia
| | - James H Boyd
- Centre for Data Linkage, Curtin University, Perth, Australia
| | - Suzanne Rea
- Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Australia
| | - Sean M Randall
- Centre for Data Linkage, Curtin University, Perth, Australia
| | - Fiona M Wood
- Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Australia
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170
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Duke JM, Rea S, Boyd JH, Randall SM, Wood FM. Mortality after burn injury in children: a 33-year population-based study. Pediatrics 2015; 135:e903-10. [PMID: 25802351 DOI: 10.1542/peds.2014-3140] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess the impact of burn injury sustained during childhood on long-term mortality and to quantify any increased risk of death attributable to burn injury. METHODS A population-based cohort study of children younger than 15 years hospitalized for burn injury in Western Australia (1980-2012) and a matched noninjured comparison group. Deidentified extraction of linked hospital morbidity and death records for the period 1980-2012 were provided by the Western Australian Data Linkage System. An inception cohort (1980-2012) of burn cases younger than 15 years of age when hospitalized for a first burn injury (n = 10,426) and a frequency matched noninjured comparison cohort (n = 40,818) were identified. Survival analysis was conducted by using the Kaplan-Meier method and Cox proportional hazards regression. Mortality rate ratios and attributable risk percent adjusted for sociodemographic and preexisting heath factors were generated. RESULTS The median follow-up time for the pediatric burn cohort was 18.1 years after discharge. The adjusted all-cause mortality rate ratios for burn injury was 1.6 (95% confidence interval: 1.3-2.0); children with burn injury had a 1.6 times greater rate of mortality than those with no injury. The index burn injury was estimated to account for 38% (attributable risk percent) of all recorded deaths in the burn injury cohort during the study period. CONCLUSIONS Burn injury sustained by children is associated with an increased risk of long-term all-cause mortality. Estimates of the total mortality burden based on in-hospital deaths alone underestimates the true burden from burn injury.
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Affiliation(s)
- Janine M Duke
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Australia;
| | - Suzanne Rea
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Australia; Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Australia; and
| | - James H Boyd
- Population Health Research Network Centre for Data Linkage, Curtin University, Perth, Australia
| | - Sean M Randall
- Population Health Research Network Centre for Data Linkage, Curtin University, Perth, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Australia; Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Australia; and
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Abstract
Burn injuries pose complex biopsychosocial challenges to recovery and improved comprehensive care. The physical and emotional sequelae of burns differ, depending on burn severity, individual resilience, and stage of development when they occur. Most burn survivors are resilient and recover, whereas some are more vulnerable and have complicated outcomes. Physical rehabilitation is affected by orthopedic, neurologic, and metabolic complications and disabilities. Psychiatric recovery is affected by pain, mental disorders, substance abuse, and burn stigmatization. Individual resilience, social supports, and educational or occupational achievements affect outcomes.
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Affiliation(s)
- Frederick J Stoddard
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1st Avenue, Boston, MA 02129, USA.
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172
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Revisión sistemática del efecto del propranolol sobre el hipermetabolismo del quemado. Med Intensiva 2015; 39:101-13. [DOI: 10.1016/j.medin.2014.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/30/2014] [Accepted: 08/01/2014] [Indexed: 02/05/2023]
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Leto Barone AA, Mastroianni M, Farkash EA, Mallard C, Albritton A, Torabi R, Leonard DA, Kurtz JM, Sachs DH, Cetrulo CL. Genetically modified porcine split-thickness skin grafts as an alternative to allograft for provision of temporary wound coverage: preliminary characterization. Burns 2014; 41:565-74. [PMID: 25406888 DOI: 10.1016/j.burns.2014.09.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 08/29/2014] [Accepted: 09/02/2014] [Indexed: 01/28/2023]
Abstract
Temporary coverage of severely burned patients with cadaver allograft skin represents an important component of burn care, but is limited by availability and cost. Porcine skin shares many physical properties with human skin, but is susceptible to hyperacute rejection due to preformed antibodies to α-1,3-galactose (Gal), a carbohydrate on all porcine cells. Our preliminary studies have suggested that skin grafts from α-1,3-galactosyltransferase knock out (GalT-KO) miniature swine might provide temporary wound coverage comparable to allografts, since GalT-KO swine lack this carbohydrate. To further evaluate this possibility, eight non-human primates received primary autologous, allogeneic, GalT-KO, and GalT+xenogeneic skin grafts. Additionally, secondary grafts were placed to assess whether sensitization would affect the rejection time course of identical-type grafts. We demonstrate that both GalT-KO xenografts and allografts provide temporary coverage of partial- and full-thickness wounds for up to 11 days. In contrast, GalT+xenografts displayed hyperacute rejection, with no signs of vascularization and rapid avulsion from wounds. Furthermore, secondary GalT-KO transplants failed to vascularize, demonstrating that primary graft rejection sensitizes the recipient. We conclude that GalT-KO xenografts may provide temporary coverage of wounds for a duration equivalent to allografts, and thus, could serve as a readily available alternative treatment of severe burns.
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Affiliation(s)
- Angelo A Leto Barone
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Melissa Mastroianni
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Evan A Farkash
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher Mallard
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alexander Albritton
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Radbeh Torabi
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - David A Leonard
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Josef M Kurtz
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Department of Biology, Emmanuel College, Boston, MA, United States
| | - David H Sachs
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Curtis L Cetrulo
- Transplant Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
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174
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Xi P, Kaifa W, Yong Z, Hong Y, Chao W, Lijuan S, Hongyu W, Dan W, Hua J, Shiliang W. Establishment and assessment of new formulas for energy consumption estimation in adult burn patients. PLoS One 2014; 9:e110409. [PMID: 25330180 PMCID: PMC4199722 DOI: 10.1371/journal.pone.0110409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 09/05/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE An accurate knowledge of energy consumption in burn patients is a prerequisite for rational nutrition therapy. This study sought to create a formula that accounts for the metabolic characteristics of adult burn patients to accurately estimate energy consumption of patients with different areas and extents of burn and at different times after injury. METHODS Resting energy expenditure (REE) data on 66 burn patients, with total body surface area (TBSA) of burns ranging from 4% to 96%, were evaluated at different times after injury. REE values were determined in patients using indirect calorimetry at days 1, 2, 3, 7, 14, 21, and 28 after injury. We then constructed a mathematical model of REE changes post-burn. Next, established two new formulas (one non-linear and the other linear) for energy consumption estimation using model-based analytical solution and regression analysis. The new formulas were compared with measured REE and commonly used formulas including those of Carlson, Xie, Curreri, and Milner to determine accuracy and reliability. RESULTS Comparative analysis showed that the new formulas offered significantly higher accuracy and reliability than the Milner formula, which is considered the most accurate of commonly used burn energy consumption estimate formulas. The accuracy of the new nonlinear formula (94.29%) and that of the linear formula (91.43%) were significantly higher than that of Milner formula (72.86%) when compared to measured REE (χ2 = 11.706, P = 0.001; χ2 = 8.230, P = 0.004, respectively). The reliabilities of the new estimation formulas were both 100% and that of Milner formula was 74.24% (χ2 = 19.513, P = 0.000). CONCLUSION The new formulas constructed in this study provide reliable simulation of the impact of the degree of burn and post-burn days on energy consumption and offer notably higher accuracy and reliability than other formulas. These formulas will help determine nutritional needs of burn patients. TRIAL REGISTRATION The study was registered on Chinese Clinical Trial Registry as ChiCTR-TRC-13003806.
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Affiliation(s)
- Peng Xi
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Wang Kaifa
- Department of Mathematics, School of Biomedical Engineering, Third Military Medical University, Chongqing, P.R. China
| | - Zhang Yong
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Yan Hong
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Wang Chao
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Song Lijuan
- Department of Mathematics, School of Biomedical Engineering, Third Military Medical University, Chongqing, P.R. China
| | - Wang Hongyu
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Wu Dan
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Jiang Hua
- Department of Computational Mathematics and Biostatistics, Metabolomics and Multidisciplinary Laboratory for Trauma Research, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdu, China
| | - Wang Shiliang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
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175
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Abstract
Burn injuries pose complex biopsychosocial challenges to recovery and improved comprehensive care. The physical and emotional sequelae of burns differ, depending on burn severity, individual resilience, and stage of development when they occur. Most burn survivors are resilient and recover, whereas some are more vulnerable and have complicated outcomes. Physical rehabilitation is affected by orthopedic, neurologic, and metabolic complications and disabilities. Psychiatric recovery is affected by pain, mental disorders, substance abuse, and burn stigmatization. Individual resilience, social supports, and educational or occupational achievements affect outcomes.
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Affiliation(s)
- Frederick J Stoddard
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey C Schneider
- Trauma, Burn and Orthopedic Program, Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 125 Nashua Street, Boston, MA 02114, USA.
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176
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Abstract
BACKGROUND Recombinant human growth hormone (rhGH) increases protein synthesis, therefore it is used in burns with a total body surface area (TBSA) greater than 40%, where there is frequently an increase in protein breakdown and a decrease in protein synthesis. This change in protein metabolism correlates with poor wound healing of the burn and donor sites. OBJECTIVES To determine the effects of rhGH on the healing rate of burn wounds and donor sites in people with burns. SEARCH METHODS For this first update we searched the Cochrane Wounds Group Specialised Register (searched 04 September 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 8); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2014, Issue 3); Ovid MEDLINE (1950 to September Week 4 2014); Ovid MEDLINE (In-Process & Other Non-Indexed Citations September 8, 2014); Ovid EMBASE (1980 to 2014 Week 35); and EBSCO CINAHL (1982 to 8 September 2014). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing rhGH with any comparator intervention, e.g. oxandrolone or placebo, in adults or children with burns. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed trial quality and extracted data. The primary outcomes were the healing of the burn wound and donor sites and the occurrence of wound infections. The secondary outcomes were mortality rate, length of hospital stay, scar assessment, and adverse events: hyperglycaemia and septicaemia. MAIN RESULTS We included 13 RCTs (701 people). Six of the RCTs included only children aged 1 to 18 years and seven involved only adults (from 18 to 65 years of age). The mean TBSA of the included participants was greater than 49%. Twelve studies compared rhGH with placebo and one study compared rhGH with oxandrolone. Two trials found that compared with placebo, burn wounds in adults treated with rhGH healed more quickly (by 9.07 days; 95% confidence interval (CI) 4.39 to 13.76, I² = 0%). The donor site healing time was significantly shorter in rhGH-treated adults compared with placebo-treated participants (by 3.15 days; 95% CI 1.54 to 4.75, I² = 0%). Two studies in children with the outcome of donor site healing time could be pooled and the donor site healing time was shorter in the rhGH-treated children (by 1.70 days; 95% CI 0.87 to 2.53, I² = 0%). No studies reporting the outcome of wound infection were found. The incidence of hyperglycaemia was higher in adults during rhGH treatment compared with placebo (risk ratio (RR) 2.43; 95% CI 1.54 to 3.85), but not in children. Pooling the studies of adults and children yielded a significantly higher incidence of hyperglycaemia in the rhGH-treated participants (RR 2.65; 95% CI 1.68 to 4.16). AUTHORS' CONCLUSIONS There is some evidence that using rhGH in people with large burns (more than 40% of the total body surface area) could result in more rapid healing of the burn wound and donor sites in adults and children, and in reduced length of hospital stay, without increased mortality or scarring, but with an increased risk of hyperglycaemia. This evidence is based on studies with small sample sizes and risk of bias and requires confirmation in higher quality, adequately powered trials.
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Affiliation(s)
- Roelf S Breederveld
- Red Cross HospitalSurgery and Burn CentreVondellaan 13BeverwijkNHNetherlands1942 LE
| | - Wim E Tuinebreijer
- Red Cross HospitalSurgery and Burn CentreVondellaan 13BeverwijkNHNetherlands1942 LE
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177
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Relationship between zolpidem concentrations and sleep parameters in pediatric burn patients. J Burn Care Res 2014; 36:137-44. [PMID: 25185933 DOI: 10.1097/bcr.0000000000000164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Zolpidem is a short-acting non-benzodiazepine hypnotic that is used to improve sleep architecture in patients with burn injuries. This study evaluated the relationship between zolpidem administration and sleep parameters in a cohort of children with severe burn injuries. Standard age-based zolpidem dosing practices were employed. Polysomnography data were recorded at 30-second intervals throughout the night. Serum concentrations of zolpidem were measured at 0, 1, 2, 4, 5, 6, and 8 hours after administration of the first dose. The relationship between zolpidem concentrations and sleep parameters was evaluated using Markov mixed-effects pharmacodynamic models. Ten children received two doses of zolpidem at 22:00 and 02:00 hours. The median total amount of sleep was 361.0 (interquartile range [IQR]: 299.0-418.5) minutes; approximately 65% of the normal reference value for an 8-hour period. Slow-wave and rapid eye movement (REM) sleep were also dramatically reduced (18-37% of normal). With two doses of zolpidem, stage 2 sleep was 99% of normal levels. Higher peak zolpidem concentrations were associated with increased stage 2 sleep (r = .54; P = .04). Despite this, a median of 120.0 (IQR: 99.5-143.5) transitions between nocturnal sleep stages were recorded, with a median of 55.5 (IQR: 36-75) night-time awakenings per patient. In pediatric burn patients, higher zolpidem serum concentrations were associated with restoration of stage 2 sleep to normal levels. Nonetheless, slow-wave and REM sleep were profoundly depressed with frequent transitions between sleep stages, suggesting that alternative hypnotic agents may be required to restore normal sleep architecture in severely burned children.
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178
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Linden K, Stewart IJ, Kreyer SF, Scaravilli V, Cannon JW, Cancio LC, Batchinsky AI, Chung KK. Extracorporeal blood purification in burns: A review. Burns 2014; 40:1071-8. [DOI: 10.1016/j.burns.2014.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 11/15/2022]
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Joshi R, Kadeer N, Sheriff S, Friend LA, James JH, Balasubramaniam A. Phosphodiesterase (PDE) inhibitor torbafylline (HWA 448) attenuates burn-induced rat skeletal muscle proteolysis through the PDE4/cAMP/EPAC/PI3K/Akt pathway. Mol Cell Endocrinol 2014; 393:152-63. [PMID: 24973766 DOI: 10.1016/j.mce.2014.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 06/02/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
Treatment of rats after burn-injury with the cyclic AMP phosphodiesterase (PDE) inhibitor, torbafylline (also known as HWA 448) significantly reversed changes in rat skeletal muscle proteolysis, PDE4 activity, cAMP concentrations and mRNA expression of TNFα, IL-6, ubiquitin and E3 ligases. Torbafylline also attenuated muscle proteolysis during in vitro incubation, and this effect was blocked by the inhibitor Rp-cAMPS. Moreover, torbafylline significantly increased phospho-Akt levels, and normalized downregulated phospho-FOXO1 and phospho-4E-BP1 in muscle of burn rats. Similarly, torbafylline also normalized phosphorylation levels of Akt and its downstream elements in TNFα+IFNγ treated C2C12 myotubes. Torbafylline enhanced protein levels of exchange protein directly activated by cAMP (Epac) both in skeletal muscle of burn rats and in TNFα+IFNγ treated C2C12 myotubes. Pretreatment with a specific antagonist of PI3K or Epac significantly reversed the inhibitory effects of torbafylline on TNFα+IFNγ-induced MAFbx mRNA expression and protein breakdown in C2C12 myotubes. Torbafylline inhibits burn-induced muscle proteolysis by activating multiple pathways through PDE4/cAMP/Epac/PI3K/Akt.
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Affiliation(s)
- Rashika Joshi
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Nijiati Kadeer
- Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Sulaiman Sheriff
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
| | - Lou Ann Friend
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - J Howard James
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Ambikaipakan Balasubramaniam
- Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229, USA; Cincinnati Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220, USA.
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180
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Zhang Y, Cai B, Jiang H, Yan H, Yang H, Peng J, Wang W, Ma S, Wu X, Peng X. Use of 1H-nuclear magnetic resonance to screen a set of biomarkers for monitoring metabolic disturbances in severe burn patients. Crit Care 2014; 18:R159. [PMID: 25059459 PMCID: PMC4220088 DOI: 10.1186/cc13999] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 07/01/2014] [Indexed: 12/04/2022] Open
Abstract
Introduction To establish a plasma metabolomics fingerprint spectrum for severe burn patients and to use it to identify a set of biomarkers that could be used for clinical monitoring. Methods Twenty-one severe burn patients and three healthy control individuals were enrolled in this study, and the plasma samples from patients and healthy individuals were collected for nuclear magnetic resonance (NMR) measurements. The NMR spectra were analyzed using principal component analysis (PCA) and partial least squares (PLS) in order to establish the metabolomics fingerprint representing the changes in metabolism and to select the major biomarkers. Results NMR spectra of the plasma samples showed significant differences between burn patients and healthy individuals. Using metabolomics techniques, we found an Eigen-metabolome that consists of 12 metabolites, which are regulated by 103 enzymes in a global metabolic network. Among these metabolites, α-ketoisovaleric acid, 3-methylhistidine, and β-hydroxybutyric acid were the most important biomarkers that were significantly increased during the early stage of burn injury. These results suggest that the mitochondrial damage and carbohydrate, protein and fatty acid metabolism disturbances occur after burn injury. Our analysis also show that histone deacetylases, which are protein transcription suppressors, were remarkably increased and indicate that protein transcription was inhibited and anabolism was restrained during the early stage of burn injury. Conclusions Metabolomics techniques based on NMR can be used to monitor metabolism in severe burn patients. Our study demonstrates that integrated 1H-NMR metabolome and global metabolic network analysis is useful for visualizing complex metabolic disturbances after severe burn injury and may provide a new quantitative injury severity evaluation for future clinical use. Trial registration Chinese Clinical Trial Registry ChiCTR-OCC-12002145. Registered 25 April 2012.
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181
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Abstract
Exercise programs capable of contributing positively to the long-term rehabilitation of burn patients should be included in outpatient rehabilitation programs. However, the extent and intensity of the resistance and cardiopulmonary exercise prescribed are unclear. This study was conducted to investigate the existence, design, content, and prescription of outpatient cardiopulmonary and resistance exercise programs within outpatient burn rehabilitation. A survey was designed to gather information on existing exercise programs for burn survivors and to assess the extent to which these programs are included in overall outpatient rehabilitation programs. Three hundred and twenty-seven surveys were distributed in the licensed physical and occupational therapists part of the American Burn Association Physical Therapy/Occupational Therapy Special Interest Group. One hundred and three surveys were completed. Eighty-two percent of respondents indicated that their institutions offered outpatient therapy after discharge. The frequency of therapists' contact with patients during this period varied greatly. Interestingly, 81% of therapists stated that no hospital-based cardiopulmonary endurance exercise programs were available. Patients' physical function was infrequently determined through the use of cardiopulmonary parameters (oxygen consumption and heart rate) or muscle strength. Instead, more subjective parameters such as range of motion (75%), manual muscle testing (61%), and quality of life (61%) were used. Prescription and follow-up assessment of cardiopulmonary endurance training are inconsistent among institutions, underscoring the need for greater awareness of the importance of exercise in any burn rehabilitation program. Identification of cardiopulmonary and progressive resistance parameters for establishing and tracking exercise training is also needed to maximize exercise-induced benefits.
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182
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Abstract
As a result of continuous development in the treatment of burns, the LD50 (the burn size lethal to 50% of the population) for thermal injuries has risen from 42% total body surface area (TBSA) during the 1940s and 1950s to more than 90% TBSA for young thermally injured patients. This vast improvement in survival is due to simultaneous developments in critical care, advancements in resuscitation, control of infection through early excision, and pharmacologic support of the hypermetabolic response to burns. This article reviews these recent advances and how they influence modern intensive care of burns.
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Affiliation(s)
- Shawn P Fagan
- Sumner Redstone Burn Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Mary-Liz Bilodeau
- Sumner Redstone Burn Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Jeremy Goverman
- Sumner Redstone Burn Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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183
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Survivors versus nonsurvivors postburn: differences in inflammatory and hypermetabolic trajectories. Ann Surg 2014; 259:814-23. [PMID: 23579577 DOI: 10.1097/sla.0b013e31828dfbf1] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate whether a panel of common biomedical markers can be utilized as trajectories to determine survival in pediatric burn patients. BACKGROUND Despite major advances in clinical care, of the more than 1 million people burned in the United States each year, more than 4500 die as a result of their burn injuries. The ability to predict patient outcome or anticipate clinical trajectories using plasma protein expression would allow personalization of clinical care to optimize the potential for patient survival. METHODS A total of 230 severely burned children with burns exceeding 30% of the total body surface, requiring at least 1 surgical procedure were enrolled in this prospective cohort study. Demographics, clinical outcomes, and inflammatory and acute-phase responses (serum cytokines, hormones, and proteins) were determined at admission and at 11 time points for up to 180 days postburn. Statistical analysis was performed using a 1-way analysis of variance, the Student t test, χ test, and Mann-Whitney test where appropriate. RESULTS Survivors and nonsurvivors exhibited profound differences in critical markers of inflammation and metabolism at each time point. Nonsurvivors had significantly higher serum levels of interleukin (IL)-6, IL-8, granulocyte colony-stimulating factor, monocyte chemoattractant protein-1, C-reactive protein, glucose, insulin, blood urea nitrogen, creatinine, and bilirubin (P < 0.05). Furthermore, nonsurvivors exhibited a vastly increased hypermetabolic response that was associated with increases in organ dysfunction and sepsis when compared with survivors (P < 0.05). CONCLUSIONS Nonsurvivors have different trajectories in inflammatory, metabolic, and acute phase responses allowing differentiation of nonsurvivors from survivors and now possibly allowing novel predictive models to improve and personalize burn outcomes.
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184
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Poranki DR, Van Dyke ME. The effect of gamma keratose on cell viability in vitro after thermal stress and the regulation of cell death pathway-specific gene expression. Biomaterials 2014; 35:4646-55. [DOI: 10.1016/j.biomaterials.2014.02.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 02/23/2014] [Indexed: 11/27/2022]
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185
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Pidcoke HF, Baer LA, Wu X, Wolf SE, Aden JK, Wade CE. Insulin effects on glucose tolerance, hypermetabolic response, and circadian-metabolic protein expression in a rat burn and disuse model. Am J Physiol Regul Integr Comp Physiol 2014; 307:R1-R10. [PMID: 24760998 DOI: 10.1152/ajpregu.00312.2013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Insulin controls hyperglycemia after severe burns, and its use opposes the hypermetabolic response. The underlying molecular mechanisms are poorly understood, and previous research in this area has been limited because of the inadequacy of animal models to mimic the physiological effects seen in humans with burns. Using a recently published rat model that combines both burn and disuse components, we compare the effects of insulin treatment vs. vehicle on glucose tolerance, hypermetabolic response, muscle loss, and circadian-metabolic protein expression after burns. Male Sprague-Dawley rats were assigned to three groups: cage controls (n = 6); vehicle-treated burn and hindlimb unloading (VBH; n = 11), and insulin-treated burn and hindlimb unloading (IBH; n = 9). With the exception of cage controls, rats underwent a 40% total body surface area burn with hindlimb unloading, then IBH rats received 12 days of subcutaneous insulin injections (5 units·kg(-1)·day(-1)), and VBH rats received an equivalent dose of vehicle. Glucose tolerance testing was performed on day 14, after which blood and tissues were collected for analysis. Body mass loss was attenuated by insulin treatment (VBH = 265 ± 17 g vs. IBH = 283 ± 14 g, P = 0.016), and glucose clearance capacity was increased. Soleus and gastrocnemius muscle loss was decreased in the IBH group. Insulin receptor substrate-1, AKT, FOXO-1, caspase-3, and PER1 phosphorylation was altered by injury and disuse, with levels restored by insulin treatment in almost all cases. Insulin treatment after burn and during disuse attenuated the hypermetabolic response, increased glucose clearance, and normalized circadian-metabolic protein expression patterns. Therapies aimed at targeting downstream effectors may provide the beneficial effects of insulin without hypoglycemic risk.
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Affiliation(s)
| | - Lisa A Baer
- University of Texas Health Science Center at Houston, Houston, Texas; and
| | - Xiaowu Wu
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Steven E Wolf
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - James K Aden
- U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Charles E Wade
- University of Texas Health Science Center at Houston, Houston, Texas; and
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186
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Abstract
Outcomes of patients with burns have improved substantially over the past two decades. Findings from a 2012 study in The Lancet showed that a burn size of more than 60% total body surface area burned (an increase from 40% a decade ago) is associated with risks and mortality. Similar data have been obtained in adults and elderly people who have been severely burned. We discuss recent and future developments in burn care to improve outcomes of children.
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Affiliation(s)
- Marc G Jeschke
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Surgery, Division of Plastic Surgery, Department of Immunology, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada.
| | - David N Herndon
- Shriners Hospitals for Children and Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
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187
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Occurrence of multiorgan dysfunction in pediatric burn patients: incidence and clinical outcome. Ann Surg 2014; 259:381-7. [PMID: 23511841 DOI: 10.1097/sla.0b013e31828c4d04] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the incidence of single or multiple organ failure postburn and its resultant clinical outcomes during acute hospitalization. BACKGROUND Patient outcomes are inherently dependent on intact organ function; however, burn injury affects the structure and function of almost every organ, but especially lung, liver, kidney, and heart. Therefore, single-organ failure and/or multiorgan failure (MOF) are thought to contribute significantly to postburn morbidity and mortality, but to date no large trial examining the effects of MOF on postburn outcomes exists. METHODS Incidence of MOF was monitored in 821 pediatric burn patients during acute hospitalization. Patients were divided into groups on the basis of the incidence of single-organ-specific failure, MOF, and non-MOF. The DENVER2 score was used to assess organ-specific scores for lung, liver, kidney, and heart. The patient's demographics, injury characteristics, and outcome parameters were recorded. RESULTS Respiratory failure has the highest incidence in the early phase of postburn injury and decreases starting 5 days postburn. Cardiac failure was noted to have the highest incidence throughout hospital stay. Incidence of hepatic failure increases with the hospital length of stay and is associated with a high mortality during the late phase of the acute hospital stay. Renal failure has an unexpectedly low incidence but is associated with a high mortality during the first 3 weeks postburn injury. Three or more organ failure is associated with very high mortality. CONCLUSIONS This is the first large study in burn patients to determine the incidence of organ-specific failure and outcome. The results of this study confirmed the expected chronologic incidence of organ-specific failure and yield the long-term mortality from liver and renal failure.
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188
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Gabriel VA, McClellan EA, Scheuermann RH. Response of human skin to esthetic scarification. Burns 2014; 40:1338-44. [PMID: 24582755 DOI: 10.1016/j.burns.2014.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 11/01/2013] [Accepted: 01/11/2014] [Indexed: 10/25/2022]
Abstract
This study was undertaken to investigate changes in RNA expression in previously healthy adult human skin following thermal injury induced by contact with hot metal that was undertaken as part of esthetic scarification, a body modification practice. Subjects were recruited to have pre-injury skin and serial wound biopsies performed. 4 mm punch biopsies were taken prior to branding and 1 h, 1 week, and 1, 2 and 3 months after injury. RNA was extracted and quality assured prior to the use of a whole-genome based bead array platform to describe expression changes in the samples using the pre-injury skin as a comparator. Analysis of the array data was performed using k-means clustering and a hypergeometric probability distribution without replacement and corrections for multiple comparisons were done. Confirmatory q-PCR was performed. Using a k of 10, several clusters of genes were shown to co-cluster together based on Gene Ontology classification with probabilities unlikely to occur by chance alone. OF particular interest were clusters relating to cell cycle, proteinaceous extracellular matrix and keratinization. Given the consistent expression changes at 1 week following injury in the cell cycle cluster, there is an opportunity to intervene early following burn injury to influence scar development.
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Affiliation(s)
- Vincent A Gabriel
- Division of Physical Medicine and Rehabilitation, Departments of Clinical Neurosciences, Surgery and Pediatrics, Alberta Children's Hospital Research Institute, Firefighters' Burn Treatment Centre, University of Calgary, Canada.
| | - Elizabeth A McClellan
- Department of Mathematical and Computer Sciences, Metropolitan State University of Denver, Denver, CO, USA.
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189
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Joyce C, Kelly J, Sugrue C. A bibliometric analysis of the 100 most influential papers in burns. Burns 2014; 40:30-7. [DOI: 10.1016/j.burns.2013.10.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 10/19/2013] [Accepted: 10/21/2013] [Indexed: 10/25/2022]
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190
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Finnerty CC, Ali A, McLean J, Benjamin N, Clayton RP, Andersen CR, Mlcak RP, Suman OE, Meyer W, Herndon DN. Impact of stress-induced diabetes on outcomes in severely burned children. J Am Coll Surg 2014; 218:783-95. [PMID: 24655871 DOI: 10.1016/j.jamcollsurg.2014.01.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND Post-burn hyperglycemia leads to graft failure, multiple organ failure, and death. A hyperinsulinemic-euglycemic clamp is used to keep serum glucose between 60 and 110 mg/dL. Because of frequent hypoglycemic episodes, a less-stringent sliding scale insulin protocol is used to maintain serum glucose levels between 80 and 160 mg/dL after elevations >180 mg/dL. STUDY DESIGN We randomized pediatric patients with massive burns into 2 groups, patients receiving sliding scale insulin to lower blood glucose levels (n = 145) and those receiving no insulin (n = 98), to determine the differences in morbidity and mortality. Patients 0 to 18 years old with burns covering ≥ 30% of the total body surface area and not randomized to receive anabolic agents were included in this study. End points included glucose levels, infections, resting energy expenditure, lean body mass, bone mineral content, fat mass, muscle strength, and serum inflammatory cytokines, hormones, and liver enzymes. RESULTS Maximal glucose levels occurred within 6 days of burn injury. Blood glucose levels were age dependent, with older children requiring more insulin (p < 0.05). Daily maximum and daily minimum, but not 6 am, glucose levels were significantly different based on treatment group (p < 0.05). Insulin significantly increased resting energy expenditure and improved bone mineral content (p < 0.05). Each additional wound infection increased incidence of hyperglycemia (p = 0.004). There was no mortality in patients not receiving insulin, only in patients who received insulin (p < 0.004). Muscle strength was increased in patients receiving insulin (p < 0.05). CONCLUSIONS Burn-induced hyperglycemia develops in a subset of severely burned children. Length of stay was reduced in the no insulin group, and there were no deaths in this group. Administration of insulin positively impacted bone mineral content and muscle strength, but increased resting energy expenditure, hypoglycemic episodes, and mortality. New glucose-lowering strategies might be needed.
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Affiliation(s)
- Celeste C Finnerty
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX; Sealy Center for Molecular Medicine, University of Texas Medical Branch, Galveston, TX.
| | - Arham Ali
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Josef McLean
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Nicole Benjamin
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Robert P Clayton
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Clark R Andersen
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Ronald P Mlcak
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX
| | - Oscar E Suman
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Walter Meyer
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX
| | - David N Herndon
- Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX
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191
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Affiliation(s)
- Celeste C Finnerty
- Shriners Hospitals for Children, 815 Market Street, Galveston, TX 77550, USA
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192
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D'Asta F, Cianferotti L, Bhandari S, Sprini D, Rini GB, Brandi ML. The endocrine response to severe burn trauma. Expert Rev Endocrinol Metab 2014; 9:45-59. [PMID: 30743738 DOI: 10.1586/17446651.2014.868773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The endocrine system is frequently altered after a major burn trauma. Besides the endocrine response to stress characterized by hypercortisolism, several hypothalamus-hypophysis-target gland axes are rapidly perturbed within a few days. These alterations can persist in the long term and deserve an appropriate treatment. Disturbances in water clearance and glucidic metabolism are also common and need to be diagnosed and corrected to decrease morbidity in such patients. Bone and mineral metabolism is deeply compromised and requires correction of mineral abnormalities in order to improve symptoms and prevent bone loss. No large prospective and/or intervention trials are available to date to elaborate age-related, evidence-based recommendations to monitor and treat burn-related endocrine alterations.
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Affiliation(s)
- Federica D'Asta
- a Department of Neuroscience, Psychology, Drug, Research and Child Health, University of Florence, Viale Pieraccini 24, 50139 Florence, Italy
| | - Luisella Cianferotti
- b Department of Surgery and Translational Medicine, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
| | - Sahil Bhandari
- c Manchester Medical School, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Delia Sprini
- d Department of Internal Medicine, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Giovam Battista Rini
- d Department of Internal Medicine, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Maria Luisa Brandi
- b Department of Surgery and Translational Medicine, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
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193
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Mandell SP, Gibran NS. Early Enteral Nutrition for Burn Injury. Adv Wound Care (New Rochelle) 2014; 3:64-70. [PMID: 24761346 DOI: 10.1089/wound.2012.0382] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 12/12/2012] [Indexed: 11/13/2022] Open
Abstract
Significance: Nutrition has been recognized as a critical component of acute burn care and ultimate wound healing. Debate remains over the appropriate timing of enteral nutrition and the benefit of supplemental trace elements, antioxidants, and immunonutrition for critically ill burn patients. Pharmacotherapy to blunt the metabolic response to burn injury plays a critical role in effective nutritional support. Recent Advances: Further evidence is demonstrating long-term benefits from pharmacologic immunomodulation given the prolonged metabolic response to injury that may last for over a year following the initial insult. Critical Issues: The majority of evidence regarding early enteral feeding comes from mixed populations and smaller studies. However, on balance, available evidence favors early feeding. Data regarding immunonutrition does not support the routine use of these products. Limited data regarding use of antioxidants and trace elements support their use. Future Directions: Further evaluation of anti-inflammatory mediators of the immune response, such as statins, will likely play a role in the future. Further data are needed on the dosing and route of micronutrients as well as the utility of immunonutrition. Finally, little is known about nutrition in the obese burn patient making this an important area for investigation.
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Affiliation(s)
- Samuel P. Mandell
- Department of Surgery, University of Washington Burn Center, Harborview Medical Center, Seattle, Washington
| | - Nicole S. Gibran
- Department of Surgery, University of Washington Burn Center, Harborview Medical Center, Seattle, Washington
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Abstract
PURPOSE Severely burned patients frequently experience sleep fragmentation and insomnia. This study evaluated the population pharmacokinetics of the sleep-enhancing agent zolpidem among burned children. METHODS Zolpidem was administered according to the following age-based dosing schedule: 2.5 mg per dose for 2-4 year olds, 5.0 mg per dose for 5-10 year olds, and 10 mg per dose for older than 10 years. Serum samples were collected before and 1, 2, 4, 5, 6, and 8 hours after dosing. The population pharmacokinetic analysis modeled zolpidem concentrations using nonlinear mixed effects models. RESULTS Eleven patients with a mean (±SD) age of 8.3 ± 4.0 years and a mean total burn surface area of 56% ± 22% were recruited. Seventy-three zolpidem concentrations were measured with a mean Cmax of 291 ± 140 ng/mL. A 2-compartment model with first-order absorption best described the data. Zolpidem clearance was estimated at 0.03 L·h(-1)·kg(-1) (relative standard error, 55%) and increased with body weight (P < 0.05). The central compartment volume of distribution was estimated at 0.05 L/kg (relative standard error, 25%), which was inversely related to the proportion of the body surface with third-degree burns (P < 0.001). CONCLUSIONS A population pharmacokinetic model has been developed that reliably characterized the pharmacokinetic parameters of zolpidem when used as a sleep-enhancing agent among pediatric burn patients. Additional studies are needed to link this pharmacokinetic model with pharmacodynamic data, which may include an assessment of the effects of higher zolpidem doses and/or more frequent administration upon sleep architecture.
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195
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Gene expression profile of cytokines and receptors of inflammation from cultured keratinocytes of burned patients. Burns 2013; 40:947-56. [PMID: 24331407 DOI: 10.1016/j.burns.2013.11.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 11/05/2013] [Accepted: 11/24/2013] [Indexed: 11/21/2022]
Abstract
INTRODUCTION At all stages of wound healing, growth factors and cytokines play a particularly important role in the interaction with keratinocytes cellular receptors. Keratinocytes have received little attention about their potential to act as a source and target of cytokines. Changes in the cytokine levels after the burning occur prior to the metabolic abnormalities. Thus, it may be possible to develop therapeutic interventions that can mitigate the acute inflammatory response and modulating expression of these cytokines. The objective was to evaluate the expression of 84 genes mediators of the inflammatory response by using PCR array in a primary human epidermal cultured keratinocytes from patients with burns. METHODS Keratinocytes cultured from normal skin around injury from small and large burn patient were treated for DNA synthesis. The samples were analyzed by the PCR Superarray(®) assay and curve analyses were performed for 84 relevant human genes and their involvement in the inflammatory cytokines pathway and receptors. These genes were checked for the up or down regulation. And it was used MetaCore™ for the analysis of networks and Gene Ontology (GO) processes. RESULTS Chemokines of the CXC family were more expressed in the large burn group, except CXCL12. The C, CC and CX3C chemokine family were downregulated, especially in the small burn group. The interleukins IL8 and IL1B were more expressed in large burn than in small burn; except IL13RA1, IL13 and IL5RA that were downregulated, mainly in the small burn group. CONCLUSIONS The cytokine profile showed some important differences between the large and small burn patients, and from this original database, we can create new interventional trials in acute inflammation in burns.
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Ebid AA, El-Shamy SM, Draz AH. Effect of isokinetic training on muscle strength, size and gait after healed pediatric burn: a randomized controlled study. Burns 2013; 40:97-105. [PMID: 24074720 DOI: 10.1016/j.burns.2013.05.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 05/14/2013] [Accepted: 05/21/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the effects of isokinetic training program on muscle strength, muscle size and gait parameters after healed pediatric burn. DESIGN Randomized controlled trial. SUBJECTS Thirty three pediatric burned patients with circumferential lower extremity burn with total body surface area (TBSA) ranging from 36 to 45%, and ages from 10 to 15 years participated in the study and were randomized into isokinetic group and a control group. Non-burned healthy pediatric subjects were assessed similarly to burned subjects and served as matched healthy controls. METHODS Patients in the isokinetic group (n=16) participated in the isokinetic training program for 12 weeks for quadriceps dominant limb, 3 times per week, at angular velocity 150°/s, concentric mode of contraction, time rest between each set for 3 min, 3 sets/day and control group (n=17) participated in home based physical therapy exercise program without isokinetic. MAIN MEASURES Assessment of quadriceps strength by isokinetic dynamometer, quadriceps size and gait parameters were performed at baseline and at the end of the training period for both groups. RESULTS Patients in isokinetic group showed a significant improvement in quadriceps strength, quadriceps size and gait parameters as compared with those in the control group. Quadriceps strength and percentage of improvement was 79.25 ± 0.93 Nm (68.40%) for isokinetic group and 51.88 ± 1.31 Nm (9.84%) for the control group. Quadriceps size and percentage of improvement was 31.50 ± 0.89 cm (7.47%) for isokinetic group and 29.26 ± 1.02 cm (1.02%) for the control group. Stride length, step length, velocity and cadence and percentage of improvement for isokinetic group was 135.50 ± 2.82 (53.97%), 63.25 ± 2.97 (63.77%), 135.94 ± 1.65 (81.42%), 137.63 ± 1.36 (66.96%) and for the control group was 94.00 ± 2.69 (6.68%), 43.76 ± 1.34 (15.15%), 81.11 ± 1.91 (8.6%), 90.35 ± 1.32 (9.01%) respectively. CONCLUSIONS Participation in the isokinetic training program resulted in a greater improvement in quadriceps muscle strength, size and gait parameters in pediatric burn.
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Affiliation(s)
| | - Shamekh Mohamed El-Shamy
- Department of Growth and Developmental Disorders in Children and its Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Amira Hussin Draz
- Department of Basic Science, Faculty of Physical Therapy, Cairo University, Giza, Egypt
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197
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Effect of acute thermal injury in status of serum vitamins, inflammatory markers, and oxidative stress markers: preliminary data. J Burn Care Res 2013; 34:e87-91. [PMID: 23370992 DOI: 10.1097/bcr.0b013e31826fc506] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to evaluate the vitamin status, inflammatory markers, and oxidative stress markers in adult patients up to 3 days after thermal injury. This prospective study was conducted with 11 patients 24 to 72 hours after thermal injury (Burn Group), total surface area ranging from 10 to 41%, 34.3 ± 9.3 years, 82% of males, body mass index of 22.3 ± 2.9 kg/m(2). We included 11 healthy adults (Control Group), 36.5 ± 7.6 years, 73% of males, and body mass index of 23.8 ± 2.5 kg/m(2). Laboratory data were measured (plasma total protein, albumin, transferrin, lymphocyte counts, zinc, and iron), as well as serum vitamins (folic acid, vitamin B12, and vitamins A, C, and E), inflammatory stress markers (C-reactive protein, ferritin, and acid α1-glycoprotein) and oxidative stress markers such as glutathione peroxidase (GPx) and thiobarbituric acid reactive substances. The inflammatory stress was characterized by lower levels of total protein (median difference 1.2 g/dL, 95% CI: 0.4-2.1) and albumin (median difference 0.9 g/dL, 95% CI: 0.5-1.5), and higher levels of C-reactive protein (median difference -8.12 mg/dL, 95% CI: -11.62 to 4.61) and α-1 glycoprotein acid (median difference -28.56 mg/dL, 95% CI: -51.57 to -5.07) in burn patients. Decreased serum levels of vitamin A (median difference 1.10 μmol/L, 95% confidence interval [CI]: 0.42-1.66) and vitamin C (median difference 0.82 mg/dL, 95% CI: 0.50-1.04) were also detected. There was no statistical evidence of difference in the serum levels of glutathione peroxidase and thiobarbituric acid reactive substances between burn patients and controls, respectively. Even though there is an inflammatory stress, the obtained data showed that oxidative stress markers are normal 24 to 72 hours after burn injury. The decrease in negative acute phase protein may account for the diminished serum levels of vitamin A, which seems to be related to inflammatory stress. The marked decrease in the serum levels of vitamin C can be justified by augmented cutaneous loss and consumption in the regeneration of vitamin E.
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McClave SA, Kozar R, Martindale RG, Heyland DK, Braga M, Carli F, Drover JW, Flum D, Gramlich L, Herndon DN, Ko C, Kudsk KA, Lawson CM, Miller KR, Taylor B, Wischmeyer PE. Summary Points and Consensus Recommendations From the North American Surgical Nutrition Summit. JPEN J Parenter Enteral Nutr 2013; 37:99S-105S. [DOI: 10.1177/0148607113495892] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | - Daren K. Heyland
- Kingston General Hospital, Queens University, Kingston, Ontario, Canada
| | | | | | - John W. Drover
- Kingston General Hospital, Queens University, Kingston, Ontario, Canada
| | | | - Leah Gramlich
- Royal Alexandra Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | - Clifford Ko
- UCLA School of Medicine, Los Angeles, California
| | | | | | | | - Beth Taylor
- Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
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D'Cruz R, Martin HCO, Holland AJA. Medical management of paediatric burn injuries: best practice part 2. J Paediatr Child Health 2013; 49:E397-404. [PMID: 23551985 DOI: 10.1111/jpc.12179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2012] [Indexed: 12/16/2022]
Abstract
Burns remain a leading cause of injury in the paediatric population in Australia despite efforts in prevention. Advances in surgical management include novel debridement methods and blood conserving techniques. Patients with severe burns (>20%) remain significantly more complex to manage as a result of extensive alterations in metabolic processes. There appears increasing evidence to support the use of pharmacological modulators of the hyper-metabolic state in these patients. The management of a child with burns involves acute, subacute and long-term planning. This holistic approach seems optimally co-ordinated by a Burns Unit in which each discipline required to provide care to these children in order to achieve optimal outcomes is represented.
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Affiliation(s)
- Rachel D'Cruz
- Burns Unit, The Children's Hospital at Westmead Burns Research Institute, Sydney, New South Wales, Australia; Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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The heat is on: a case of hyperthermia-induced posterior reversible encephalopathy syndrome (PRES). Neurol Sci 2013; 35:127-30. [PMID: 23959533 DOI: 10.1007/s10072-013-1525-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 08/07/2013] [Indexed: 10/26/2022]
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