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Pérez-Torres D, Martín-Luengo AI, Cuenca-Rubio C, Berezo-García JÁ, Díaz-Rodríguez C, Canas-Pérez I, Fernández-Rodríguez ML, Colmenero-Calleja C, Sánchez-Ballesteros J, Blanco-Schweizer P, Ticona-Espinoza TG, Piqueras-Pérez JM. Selective decontamination of the digestive tract in a burns unit reduces the incidence of hospital-acquired infections: A retrospective before-and-after cohort study. Med Intensiva 2024:S2173-5727(24)00139-5. [PMID: 38897897 DOI: 10.1016/j.medine.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To evaluate the effect of selective decontamination of the digestive tract (SDD) on hospital-acquired infections (HAIs) in patients with acute burn injury requiring admission to a Burns Unit (BU). DESIGN Retrospective before-and-after cohort study, between January 2017 and June 2023. SDD was implemented in March 2019, dividing patients into two groups. SETTING Four-bed BU, in a referral University Hospital in Spain. PATIENTS All the patients admitted during the study period were eligible for analysis. Patients who died or were discharged within 48hours of admission, and patients with an estimated survival less than 10% not considered for full escalation of therapy were excluded. INTERVENTION SDD comprised the administration of a 4-day course of an intravenous antibiotic, and an oral suspension and oral topical paste of non-absorbable antibiotics during the stay in the BU. MAIN VARIABLE OF INTEREST Incidence of HAIs during the stay in the BU. SECONDARY OUTCOMES incidence of specific types of infections by site (bacteremia, pneumonia, skin and soft tissue infection) and microorganism (Gram-positive, Gram-negative, fungi), and safety endpoints. RESULTS We analyzed 72 patients: 27 did not receive SDD, and 45 received SDD. The number of patients who developed HAIs were 21 (77.8%) and 21 (46.7%) in the non-SDD and the SDD groups, respectively (p=0.009). The number of hospital-acquired infectious episodes were 2.52 (1.21-3.82) and 1.13 (0.54-1.73), respectively (p=0.029). CONCLUSIONS SDD was associated with a reduced incidence of bacterial HAIs and a decrease in the number of infectious episodes per patient.
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Affiliation(s)
- David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Programa de Optimización del Uso de Antimicrobianos (PROA), Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain.
| | - Ana Isabel Martín-Luengo
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Cristina Cuenca-Rubio
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - José Ángel Berezo-García
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Cristina Díaz-Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Isabel Canas-Pérez
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - María Lorena Fernández-Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Cristina Colmenero-Calleja
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Jesús Sánchez-Ballesteros
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Pablo Blanco-Schweizer
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Thalia Gloria Ticona-Espinoza
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - José María Piqueras-Pérez
- Unidad de Quemados, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain; Servicio de Cirugía Plástica, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
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2
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Macedo-Viñas M, Lucas A. Evolution of Microbial Flora Colonizing Burn Wounds during Hospitalization in Uruguay. Biomedicines 2023; 11:2900. [PMID: 38001901 PMCID: PMC10669172 DOI: 10.3390/biomedicines11112900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
(1) Background: Infections are a main cause of morbidity and mortality among burn patients. The spectrum of microorganisms depends on the epidemiological context and treatment practices. We aimed to describe the evolution of microbial flora colonizing burn wounds among patients hospitalized during 15 or more days at the National Burn Center in 2015. (2) Methods: Demographic data, length of stay, total body surface area burn, and status at discharge were collected from electronic records and culture results from the laboratory database. (3) Results: Among 98 included patients, 87 were colonized. The mean length of stay was 39 days overall and 16 days in the ICU. Acinetobacter spp., Enterococcus spp., and Staphylococcus aureus predominated. Fifty-six patients harbored multidrug-resistant bacteria and had a significantly greater TBSA. The mean time to colonization was 6 days overall and 14 days for multidrug-resistant bacteria; it was significantly longer for methicillin-resistant S. aureus than for methicillin-susceptible S. aureus. (4) Conclusions: This is the first report describing the dynamics of microbial colonization of burn wounds in Uruguay. Similarities were found with reports elsewhere, but early colonization with yeasts and the absence of Streptococcus pyogenes were unique. Each burn center needs to monitor its microbial ecology to tailor their antimicrobial strategies effectively.
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Affiliation(s)
- Marina Macedo-Viñas
- Centro Nacional de Quemados, Hospital de Clínicas, Piso 13, Avenida Italia s/n, Montevideo 11600, Uruguay;
- Molecular Biology and Flow Citometry Laboratory, Pasteur Hospital, Administration of the State Health Services, Larravide 2458, Montevideo 11400, Uruguay
| | - Andrea Lucas
- Centro Nacional de Quemados, Hospital de Clínicas, Piso 13, Avenida Italia s/n, Montevideo 11600, Uruguay;
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3
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Song J, Chowdhury IH, Choudhuri S, Ayadi AEI, Rios LE, Wolf SE, Wenke JC, Garg NJ. Acute muscle mass loss was alleviated with HMGB1 neutralizing antibody treatment in severe burned rats. Sci Rep 2023; 13:10250. [PMID: 37355693 PMCID: PMC10290662 DOI: 10.1038/s41598-023-37476-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/22/2023] [Indexed: 06/26/2023] Open
Abstract
Burn injury is associated with muscle wasting, though the involved signaling mechanisms are not well understood. In this study, we aimed to examine the role of high mobility group box 1 (HMGB1) in signaling hyper-inflammation and consequent skeletal muscle impairment after burn. Sprague Dawley rats were randomly assigned into three groups: (1) sham burn, (2) burn, (3) burn/treatment. Animals in group 2 and group 3 received scald burn on 30% of total body surface area (TBSA) and immediately treated with chicken IgY and anti-HMGB1 antibody, respectively. Muscle tissues and other samples were collected at 3-days after burn. Body mass and wet/dry weights of the hind limb muscles (total and individually) were substantially decreased in burn rats. Acute burn provoked the mitochondrial stress and cell death and enhanced the protein ubiquitination and LC3A/B levels that are involved in protein degradation in muscle tissues. Further, an increase in muscle inflammatory infiltrate associated with increased differentiation, maturation and proinflammatory activation of bone marrow myeloid cells and αβ CD4+ T and γδ T lymphocytes was noted in in circulation and spleen of burn rats. Treatment with one dose of HMGB1 neutralizing antibody reduced the burn wound size and preserved the wet/dry weights of the hind limb muscles associated with a control in the markers of cell death and autophagy pathways in burn rats. Further, anti-HMGB1 antibody inhibited the myeloid and T cells inflammatory activation and subsequent dysregulated inflammatory infiltrate in the muscle tissues of burn rats. We conclude that neutralization of HMGB1-dependent proteolytic and inflammatory responses has potential beneficial effects in preventing the muscle loss after severe burn injury.
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Affiliation(s)
- Juquan Song
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA.
| | - Imran H Chowdhury
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Subhadip Choudhuri
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Amina E I Ayadi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Lizette E Rios
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Joseph C Wenke
- Department of Orthopedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA
| | - Nisha J Garg
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA.
- Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX, USA.
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4
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Bagheri M, von Kohout M, Zoric A, Fuchs PC, Schiefer JL, Opländer C. Can Cold Atmospheric Plasma Be Used for Infection Control in Burns? A Preclinical Evaluation. Biomedicines 2023; 11:biomedicines11051239. [PMID: 37238910 DOI: 10.3390/biomedicines11051239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/28/2023] Open
Abstract
Wound infection with Pseudomonas aeruginosa (PA) is a serious complication and is responsible for higher rates of mortality in burn patients. Because of the resistance of PA to many antibiotics and antiseptics, an effective treatment is difficult. As a possible alternative, cold atmospheric plasma (CAP) can be considered for treatment, as antibacterial effects are known from some types of CAP. Hence, we preclinically tested the CAP device PlasmaOne and found that CAP was effective against PA in various test systems. CAP induced an accumulation of nitrite, nitrate, and hydrogen peroxide, combined with a decrease in pH in agar and solutions, which could be responsible for the antibacterial effects. In an ex vivo contamination wound model using human skin, a reduction in microbial load of about 1 log10 level was observed after 5 min of CAP treatment as well as an inhibition of biofilm formation. However, the efficacy of CAP was significantly lower when compared with commonly used antibacterial wound irrigation solutions. Nevertheless, a clinical use of CAP in the treatment of burn wounds is conceivable on account of the potential resistance of PA to common wound irrigation solutions and the possible wound healing-promoting effects of CAP.
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Affiliation(s)
- Mahsa Bagheri
- Plastic Surgery, Hand Surgery, Burn Center, Cologne-Merheim Hospital, Witten/Herdecke University, Ostmerheimer Str. 200, 51109 Cologne, Germany
- Institute for Research in Operative Medicine (IFOM), Cologne-Merheim Hospital, Witten/Herdecke University, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Maria von Kohout
- Plastic Surgery, Hand Surgery, Burn Center, Cologne-Merheim Hospital, Witten/Herdecke University, Ostmerheimer Str. 200, 51109 Cologne, Germany
- Institute for Research in Operative Medicine (IFOM), Cologne-Merheim Hospital, Witten/Herdecke University, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Andreas Zoric
- Institute for Research in Operative Medicine (IFOM), Cologne-Merheim Hospital, Witten/Herdecke University, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Paul C Fuchs
- Plastic Surgery, Hand Surgery, Burn Center, Cologne-Merheim Hospital, Witten/Herdecke University, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Jennifer L Schiefer
- Plastic Surgery, Hand Surgery, Burn Center, Cologne-Merheim Hospital, Witten/Herdecke University, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Christian Opländer
- Institute for Research in Operative Medicine (IFOM), Cologne-Merheim Hospital, Witten/Herdecke University, Ostmerheimer Str. 200, 51109 Cologne, Germany
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5
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Abraham P, Monard C, Schneider A, Rimmelé T. Extracorporeal Blood Purification in Burns: For Whom, Why, and How? Blood Purif 2023; 52:17-24. [PMID: 35738240 PMCID: PMC9909620 DOI: 10.1159/000525085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
Patients with serious thermal burn injuries require immediate and specialized care in order to minimize morbidity and mortality. Optimal fluid resuscitation, nutritional support, pulmonary care, burn wound care, and infection control practices represent key aspects of patient care in burn centers. When severely burned, the patient usually presents a systemic inflammatory response syndrome, soon balanced by a counter anti-inflammatory response syndrome. These may lead to immune dysregulation/exhaustion favoring infectious complications that dramatically impair the prognosis of burn patients. This narrative review provides an overview of the main concepts, current understanding, and potential applications of extracorporeal blood purification techniques for burn patient management. Current understanding of burn patients' immune responses is reported. Hypotheses and data on the potential value of immunoregulation are reviewed. Finally, how extracorporeal blood purification may be of interest in this specific population is discussed.
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Affiliation(s)
- Paul Abraham
- Adult Intensive Care Unit and Burn Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland,*Paul Abraham,
| | - Céline Monard
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France,EA 7426, Pathophysiology of Injury-Induced Immunosuppression (P13), Claude Bernard University Lyon 1-Biomérieux-Hospices Civils de Lyon, Lyon, France
| | - Antoine Schneider
- Adult Intensive Care Unit and Burn Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thomas Rimmelé
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France,EA 7426, Pathophysiology of Injury-Induced Immunosuppression (P13), Claude Bernard University Lyon 1-Biomérieux-Hospices Civils de Lyon, Lyon, France
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6
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Leder MCD, Bagheri M, Plattfaut I, Fuchs PC, Brüning AKE, Schiefer JL, Opländer C. Phototherapy of Pseudomonas aeruginosa-Infected Wounds: Preclinical Evaluation of Antimicrobial Blue Light (450-460 nm) Using In Vitro Assays and a Human Wound Skin Model. Photobiomodul Photomed Laser Surg 2022; 40:800-809. [PMID: 36306523 DOI: 10.1089/photob.2022.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: To determine effective treatment strategies against bacterial infections of burn wounds with Pseudomonas aeruginosa, we tested different treatment regimens with antibacterial blue light (BL). Background: Infections of burn wounds are serious complications and require effective and pathogen-specific therapy. Hereby, infections caused by P. aeruginosa pose a particular challenge in clinical practice due to its resistance to many antibiotics and topical antiseptics. Methods: LED-based light sources (450-460 nm) with different intensities and treatment times were used. Antibacterial effects against P. aeruginosa were determined by colony-forming unit (CFU) assays, human skin wound models, and fluorescence imaging. Results: In suspension assays, BL (2 h, 40 mW/cm2, 288 J/cm2) reduced bacterial number (>5 log10 CFU/mL). Applying 144 J/cm2, using 40 mW/cm2 for 1 h was more effective (>4 log10 CFU) than using 20 mW/cm2 for 2 h (>1.5 log10 CFU). BL with low irradiance (24 h, 3.5 mW/cm2, 300 J/cm2) only revealed bacterial reduction in thin bacteria-containing medium layers. In infected in vitro skin wounds only BL irradiation (2 h, 40 mW/cm2, 288 J/cm2) exerted a significant antimicrobial efficacy (2.94 log10 CFU/mL). Conclusions: BL treatment may be an effective therapy for P. aeruginosa-infected wounds to avoid radical surgical debridement. However, a significant antibacterial efficacy can only be achieved with higher irradiances and longer treatment times (min. 40 mW/cm2; >1 h), which cannot be easily integrated into regular clinical treatment protocols, for example, during a dressing change. Further studies are necessary to establish BL therapy for infected burns among tissue compatibility and interactions with previous therapeutic agents.
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Affiliation(s)
- Marie-Charlotte D Leder
- Centre for Biomedical Education and Research (ZBAF), Witten/Herdecke University, Witten, Germany
| | - Mahsa Bagheri
- Plastic Surgery, Hand Surgery, Burn Center, Cologne-Merheim Hospital, Witten/Herdecke University, Cologne, Germany
| | - Isabell Plattfaut
- Centre for Biomedical Education and Research (ZBAF), Witten/Herdecke University, Witten, Germany
| | - Paul C Fuchs
- Plastic Surgery, Hand Surgery, Burn Center, Cologne-Merheim Hospital, Witten/Herdecke University, Cologne, Germany
| | - Anne K E Brüning
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Jennifer L Schiefer
- Plastic Surgery, Hand Surgery, Burn Center, Cologne-Merheim Hospital, Witten/Herdecke University, Cologne, Germany
| | - Christian Opländer
- Institute for Research in Operative Medicine (IFOM), Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
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Chen X, Wang K, Li D, Zhao M, Huang B, Su W, Yu D. Genetic and immune crosstalk between severe burns and blunt trauma: A study of transcriptomic data. Front Genet 2022; 13:1038222. [PMID: 36246590 PMCID: PMC9561827 DOI: 10.3389/fgene.2022.1038222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Severe burns and blunt trauma can lead to multiple organ dysfunction syndrome, the leading cause of death in intensive care units. In addition to infection, the degree of immune inflammatory response also affects prognosis. However, the characteristics and clinical relevance of the common mechanisms of these major diseases are still underexplored. Methods: In the present study, we performed microarray data analysis to identify immune-related differentially expressed genes (DEGs) involved in both disease progression in burns and blunt trauma. Six analyses were subsequently performed, including gene enrichment analysis, protein‐protein interaction (PPI) network construction, immune cell infiltration analysis, core gene identification, co-expression network analysis, and clinical correlation analysis. Results: A total of 117 common immune-related DEGs was selected for subsequent analyses. Functional analysis emphasizes the important role of Th17 cell differentiation, Th1 and Th2 cell differentiation, Cytokine-cytokine receptor interaction and T cell receptor signaling pathway in these two diseases. Finally, eight core DEGs were identified using cytoHubba, including CD8A, IL10, CCL5, CD28, LCK, CCL4, IL2RB, and STAT1. The correlation analysis showed that the identified core DEGs were more or less significantly associated with simultaneous dysregulation of immune cells in blunt trauma and sepsis patients. Of these, the downregulation of CD8A and CD28 had a worse prognosis. Conclusion: Our analysis lays the groundwork for future studies to elucidate molecular mechanisms shared in burns and blunt trauma. The functional roles of identified core immune-related DEGs and dysregulated immune cell subsets warrant further in-depth study.
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Affiliation(s)
- Xiaoming Chen
- Department of Plastic and burns Surgery, The Second Affiliated Hospital of Chengdu Medical College (China National Nuclear Corporation 416 Hospital), Chengdu, China
| | - Kuan Wang
- Department of Cosmetic Plastic and burns Surgery, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Dazhuang Li
- Department of Orthopedics, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Mingyue Zhao
- Department of Periodontology, Affiliated Stomatological Hospital of Zunyi MedicalUniversity, Zunyi, China
| | - Biao Huang
- Department of Plastic and burns Surgery, The Second Affiliated Hospital of Chengdu Medical College (China National Nuclear Corporation 416 Hospital), Chengdu, China
- *Correspondence: Biao Huang, ; Wenxing Su, ; Daojiang Yu,
| | - Wenxing Su
- Department of Plastic and burns Surgery, The Second Affiliated Hospital of Chengdu Medical College (China National Nuclear Corporation 416 Hospital), Chengdu, China
- *Correspondence: Biao Huang, ; Wenxing Su, ; Daojiang Yu,
| | - Daojiang Yu
- Department of Plastic and burns Surgery, The Second Affiliated Hospital of Chengdu Medical College (China National Nuclear Corporation 416 Hospital), Chengdu, China
- *Correspondence: Biao Huang, ; Wenxing Su, ; Daojiang Yu,
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8
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Thompson MA, Zuniga K, Sousse L, Christy R, Gurney J. The Role of Vitamin E in Thermal Burn Injuries, Infection, and Sepsis: A Review. J Burn Care Res 2022; 43:1260-1270. [PMID: 35863690 PMCID: PMC9629418 DOI: 10.1093/jbcr/irac100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Thermal burn injuries are still a serious public health concern in the United States, due to the initial insult and resulting comorbidities. Burned patients are increasingly susceptible to colonization by endogenous and exogenous microorganisms after having lost skin, which acts as the primary protective barrier to environmental contaminants. Furthermore, the onset of additional pathophysiologies, specifically sepsis, becomes more likely in burned patients compared to other injuries. Despite improvements in the early care of burn patients, infections, and sepsis, these pathophysiologies remain major causes of morbidity and mortality and warrant further investigation of potential therapies. Vitamin E may be one such therapy. We aimed to identify publications of studies that evaluated the effectiveness of vitamin E as it pertains to thermal burn injuries, infection, and sepsis. Several investigations ranging from in vitro bench work to clinical studies have examined the impact on, or influence of, vitamin E in vitro, in vivo, and in the clinical setting. To the benefit of subjects it has been shown that enteral or parenteral vitamin E supplementation can prevent, mitigate, and even reverse the effects of thermal burn injuries, infection, and sepsis. Therefore, a large-scale prospective observational study to assess the potential benefits of vitamin E supplementation in patients is warranted and could result in clinical care practice paradigm changes.
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Affiliation(s)
- Marc A Thompson
- US Army Institute of Surgical Research, JBSA Ft Sam Houston, San Antonio, TX
| | - Kameel Zuniga
- US Army Institute of Surgical Research, JBSA Ft Sam Houston, San Antonio, TX
| | - Linda Sousse
- US Army Institute of Surgical Research, JBSA Ft Sam Houston, San Antonio, TX
| | - Robert Christy
- US Army Institute of Surgical Research, JBSA Ft Sam Houston, San Antonio, TX
| | - Jennifer Gurney
- Burn Center, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, USA
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van Zuijlen PPM, Korkmaz HI, Sheraton VM, Haanstra TM, Pijpe A, de Vries A, van der Vlies CH, Bosma E, de Jong E, Middelkoop E, Vermolen FJ, Sloot PMA. The future of burn care from a complexity science perspective. J Burn Care Res 2022; 43:1312-1321. [PMID: 35267022 DOI: 10.1093/jbcr/irac029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Healthcare is undergoing a profound technological and digital transformation and has become increasingly complex. It is important for burns professionals and researchers to adapt to these developments which may require new ways of thinking and subsequent new strategies. As Einstein has put it: 'We must learn to see the world anew'. The relatively new scientific discipline "Complexity science" can give more direction to this and is the metaphorical open door that should not go unnoticed in view of the burn care of the future. Complexity sciences studies 'why the whole is more than the sum of the parts'. It studies how multiple separate components interact with each other and their environment and how these interactions lead to 'behavior of the system'. Biological systems are always part of smaller and larger systems and exhibit the behavior of adaptivity, hence the name complex adaptive systems. From the perspective of complexity science, a severe burn injury is an extreme disruption of the 'human body system'. But this disruption also applies to the systems at the organ and cellular level. All these systems follow principles of complex systems. Awareness of the scaling process at multilevel helps to understand and manage the complex situation when dealing with severe burn cases. The aim of this paper is to create awareness of the concept of complexity and to demonstrate the value and possibilities of complexity science methods and tools for the future of burn care through examples from preclinical, clinical, and organizational perspective in burn care.
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Affiliation(s)
- Paul P M van Zuijlen
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands.,Department of Plastic and Reconstructive Surgery, Red Cross Hospital, Beverwijk, The Netherlands.,Department of Plastic Reconstructive and Hand Surgery, Amsterdam Movement Sciences (AMS) Institute, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Paediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - H Ibrahim Korkmaz
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands.,Department of Plastic Reconstructive and Hand Surgery, Amsterdam Movement Sciences (AMS) Institute, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Department of Molecular Cell Biology and Immunology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Association of Dutch Burn Centres (ADBC), Beverwijk, The Netherlands
| | - Vivek M Sheraton
- Institute for Advanced Study, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Anouk Pijpe
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands
| | - Annebeth de Vries
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands.,Paediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.,Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - Cornelis H van der Vlies
- Burn Centre, Maasstad Ziekenhuis, Rotterdam, The Netherlands.,Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Eelke Bosma
- Burn Centre and Department of Surgery, Martini Ziekenhuis, Groningen, The Netherlands
| | - Evelien de Jong
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands.,Intensive Care Unit, Red Cross Hospital, Beverwijk, The Netherlands
| | - Esther Middelkoop
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands.,Department of Plastic Reconstructive and Hand Surgery, Amsterdam Movement Sciences (AMS) Institute, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Association of Dutch Burn Centres (ADBC), Beverwijk, The Netherlands
| | - Fred J Vermolen
- Delft Institute of Applied Mathematics, Delft University of Technology, Delft, The Netherlands.,Computational Mathematics, Hasselt University, Diepenbeek, Belgium
| | - Peter M A Sloot
- Institute for Advanced Study, University of Amsterdam, Amsterdam, The Netherlands.,Complexity Institute, Nanyang Technological University, Singapore.,ITMO University, Saint Petersburg, Russian Federation
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10
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Kunwar A, Shrestha P, Shrestha S, Thapa S, Shrestha S, Amatya NM. Detection of biofilm formation among Pseudomonas aeruginosa isolated from burn patients. BURNS OPEN 2021. [DOI: 10.1016/j.burnso.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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11
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Korkmaz HI, Ulrich MMW, Wieringen WNV, Doǧan H, Vlig M, Emmens RW, Meyer KW, Sinnige P, Zeerleder S, Wouters D, Ham MSV, Zuijlen PPMV, Krijnen PAJ, Niessen HWM. C1 Inhibitor Administration Reduces Local Inflammation and Capillary Leakage, Without Affecting Long-term Wound Healing Parameters, in a Pig Burn Wound Model. Antiinflamm Antiallergy Agents Med Chem 2021; 20:150-160. [PMID: 32614753 DOI: 10.2174/1871523019666200702101513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/07/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Burns induce a boost in local and systemic complement levels as well as immune cell infiltration in the burn wound, which may negatively affect wound healing. OBJECTIVE In this study, the effects of long-term treatment with complement inhibitor C1 esterase inhibitor (C1inh) on post-burn inflammation and wound healing parameters were analyzed in time up to 60 days post-burn. METHODS Burned pigs were treated either with or without C1inh up to 15 days post-burn. Burn wound biopsies and blood were collected at different time points up to 60 days post-burn. Thereafter, complement in blood as well as complement and immune cells in the wound, capillary leakage, necrosis, reepithelialization and wound contraction were quantified. RESULTS No significant differences in complement C3 blood levels were observed at any time point between C1inh-treated and control pigs. In the wound, complement C4 levels were significantly lower in the C1inh group than in controls at day 3-6 and 21-30 post-burn. Similarly, C3 levels, neutrophil and macrophage infiltration in the wound were, although not statistically significant, reduced in C1inh-treated pigs at day 9-14 post-burn. No differences in lymphocyte infiltration in the wound were found between C1inh and control pigs. C1inh-treated pigs also showed reduced capillary leakage. Despite these effects, no significant differences in the long-term wound healing parameters necrosis, reepithelialization and wound contraction were observed between C1inh and control pigs. CONCLUSION In pigs, 15 days of C1inh treatment after burn, leads to a reduction in local inflammation and capillary leakage in the burn wound without affecting long-term wound healing parameters.
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Affiliation(s)
| | - Magda M W Ulrich
- Department of Pathology, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Wessel N Van Wieringen
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Hatice Doǧan
- Department of Pathology, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Marcel Vlig
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - Reindert W Emmens
- Department of Pathology, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Klaas W Meyer
- Amsterdam Animal Research Center (AARC), Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Paul Sinnige
- Amsterdam Animal Research Center (AARC), Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Sacha Zeerleder
- Sanquin Research, Department of mmunopathology and Landsteiner Laboratory, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Diana Wouters
- Sanquin Research, Department of mmunopathology and Landsteiner Laboratory, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Marieke S Van Ham
- Sanquin Research, Department of mmunopathology and Landsteiner Laboratory, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Paul P M Van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - Paul A J Krijnen
- Department of Pathology, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Hans W M Niessen
- Department of Pathology, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
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12
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Zhang P, Zou B, Liou YC, Huang C. The pathogenesis and diagnosis of sepsis post burn injury. BURNS & TRAUMA 2021; 9:tkaa047. [PMID: 33654698 PMCID: PMC7901709 DOI: 10.1093/burnst/tkaa047] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/20/2020] [Indexed: 02/05/2023]
Abstract
Burn is an under-appreciated trauma that is associated with unacceptably high morbidity and mortality. Although the survival rate after devastating burn injuries has continued to increase in previous decades due to medical advances in burn wound care, nutritional and fluid resuscitation and improved infection control practices, there are still large numbers of patients at a high risk of death. One of the most common complications of burn is sepsis, which is defined as “severe organ dysfunction attributed to host's disordered response to infection” and is the primary cause of death in burn patients. Indeed, burn injuries are accompanied by a series of events that lead to sepsis and multiple organ dysfunction syndrome, such as a hypovolaemic state, immune and inflammatory responses and metabolic changes. Therefore, clear diagnostic criteria and predictive biomarkers are especially important in the prevention and treatment of sepsis and septic shock. In this review, we focus on the pathogenesis of burn wound infection and the post-burn events leading to sepsis. Moreover, the clinical and promising biomarkers of burn sepsis will also be summarized.
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Affiliation(s)
- Pengju Zhang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, and West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, and Collaborative Innovation Center for Biotherapy, No.17 People's South Road, Chengdu, 610041, China
| | - Bingwen Zou
- Department of Thoracic Oncology and Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu, 610041, China
| | - Yih-Cherng Liou
- Department of Biological Sciences, Faculty of Science, National University of Singapore, 14 Science Drive 4, 117543, Singapore
| | - Canhua Huang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, and West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, and Collaborative Innovation Center for Biotherapy, No.17 People's South Road, Chengdu, 610041, China
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13
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Tapking C, Houschyar KS, Rontoyanni VG, Hundeshagen G, Kowalewski KF, Hirche C, Popp D, Wolf SE, Herndon DN, Branski LK. The Influence of Obesity on Treatment and Outcome of Severely Burned Patients. J Burn Care Res 2020; 40:996-1008. [PMID: 31294797 DOI: 10.1093/jbcr/irz115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Obesity and the related medical, social, and economic impacts are relevant multifactorial and chronic conditions that also have a meaningful impact on outcomes following a severe injury, including burns. In addition to burn-specific difficulties, such as adequate hypermetabolic response, fluid resuscitation, and early wound coverage, obese patients also present with common comorbidities, such as arterial hypertension, diabetes mellitus, or nonalcoholic fatty liver disease. In addition, the pathophysiologic response to severe burns can be enhanced. Besides the increased morbidity and mortality compared to burn patients with normal weight, obese patients present a challenge in fluid resuscitation, perioperative management, and difficulties in wound healing. The present work is an in-depth review of the current understanding of the influence of obesity on the management and outcome of severe burns.
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Affiliation(s)
- Christian Tapking
- Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas.,Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Khosrow S Houschyar
- Department of Plastic Surgery, Hand Surgery, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
| | - Victoria G Rontoyanni
- Department of Surgery, University of Texas Medical Branch, Galveston.,Metabolism Unit, Shriners Hospitals for Children, Galveston, Texas
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | | | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Daniel Popp
- Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas.,Department of Urology, University Medical Center Mannheim, University of Heidelberg, Germany
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston
| | - Ludwik K Branski
- Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
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14
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Abstract
Background: Viral infections after burns are less common than bacterial infections but usually occur in the more severely burned patients and have been associated with poor outcomes. Methods: Retrospective reviews and case series were examined to provide an overview of the management of viral infections in the burn patient. Results: The most common viral pathogens in these patients are the herpesviruses, which include herpes simplex, varicella zoster, cytomegalovirus, and human herpesvirus 6. Established viral infections that may complicate patient management include human immunodeficiency virus, hepatitis B and C, and, more recently, the novel coronavirus SARS-CoV-2. Herpesvirus infections can occur as primary or nosocomial pathogens but clinical manifestations most commonly are re-activation of latent viral infection. Because of the paucity of data in the burn population, much of the evidence for specific treatments is extrapolated from patients with severe immunosuppression or critical illness. Antiviral therapy is employed for the burn patient with herpesvirus infections. This is an area of active study, and further research is needed to better understand the risks, clinical manifestations, and attributable morbidity and mortality of viral infections. Conclusions: Major burn injury results in immunosuppression and viral infection in a small number of patients. Recognition and antiviral therapy are employed, but additional studies are necessary to improve outcomes in these patients.
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Affiliation(s)
- John L Kiley
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Dana M Blyth
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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15
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Abstract
Background: Infection is the most common complication and cause of death in patients suffering burn injuries. These patients are susceptible to infection and burn wound sepsis secondary to the alterations in their physiology. Diagnosis and management of infections rely on physical examination, cultures, and the pathology of the burn wound. Method: We performed an electronic search for articles in the Google Scholar and PubMed databases using the search terms "burn sepsis," "burn infection," and "burn critical care." Results: Multiple factors increase burn patients' risk of invasive infection and sepsis, including underlying factors and co-morbidities, the percent total body surface area of the burn, delays in burn wound excision, and microbial virulence/bacterial count. Organisms causing burn wound infection differ, depending on the time since injury and its location; and diagnosis is multi-factorial. The most common pathogens remain Staphylococcus and Pseudomonas spp. Conclusion: Overall, the recognition of burn sepsis is based on clinical findings. Treatment consists of a combination of local dressings, early burn excision, and systemic antimicrobial therapy. The mortality rate has decreased significantly over the past 10 years, but continued efforts at timely management and infection prevention are essential.
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Affiliation(s)
- Josephine A D'Abbondanza
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shahriar Shahrokhi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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16
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Vinaik R, Barayan D, Shahrokhi S, Jeschke MG. Management and prevention of drug resistant infections in burn patients. Expert Rev Anti Infect Ther 2019; 17:607-619. [PMID: 31353976 DOI: 10.1080/14787210.2019.1648208] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Despite modern advances, the primary cause of death after burns remains infection and sepsis. A key factor in determining outcomes is colonization with multi-drug resistant (MDR) organisms. Infections secondary to MDR organisms are challenging due to lack of adequate antibiotic treatment, subsequently prolonging hospital stay and increasing risk of adverse outcomes. Areas covered: This review highlights the most frequent organisms colonizing burn wounds as well as the most common MDR bacterial infections. Additionally, we discuss different treatment modalities and MDR infection prevention strategies as their appropriate management would minimize morbidity and mortality in this population. We conducted a search for articles on PubMed, Web of Science, Embase, Cochrane, Scopus and UpToDate with applied search strategies including a combination of: "burns, 'thermal injury,' 'infections,' 'sepsis,' 'drug resistance,' and 'antimicrobials.' Expert opinion: Management and prevention of MDR infections in burns is an ongoing challenge. We highlight the importance of preventative over therapeutic strategies, which are easy to implement and cost-effective. Additionally, targeted, limited use of antimicrobials can be beneficial in burn patients. A promising future area of investigation within this field is post-trauma microbiome profiling. Currently, the best treatment strategy for MDR in burn patients is prevention.
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Affiliation(s)
- Roohi Vinaik
- a Sunnybrook Research Institute , Toronto , Canada
| | | | - Shahriar Shahrokhi
- b Department of Surgery, Division of Plastic Surgery, University of Toronto , Toronto , Canada.,c Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Marc G Jeschke
- a Sunnybrook Research Institute , Toronto , Canada.,b Department of Surgery, Division of Plastic Surgery, University of Toronto , Toronto , Canada.,c Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre , Toronto , Canada.,d Department of Immunology, University of Toronto , Toronto , Canada
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17
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Pujji OJS, Nakarmi KK, Shrestha B, Rai SM, Jeffery SLA. The Bacteriological Profile of Burn Wound Infections at a Tertiary Burns Center in Nepal. J Burn Care Res 2019; 40:838-845. [DOI: 10.1093/jbcr/irz096] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AbstractIn Nepal, burn is the third most common injury after falls and road traffic accidents. Infection is the leading cause of mortality in burn injury. A profile exploring predominant flora and antimicrobial sensitivity is important to facilitate treatment ahead of microbiology results and to aid prevention of multidrug-resistant organisms. The aim of this study was to document epidemiological and bacteriological data of burn wound infections at a tertiary level burns center in Nepal. Samples were collected from January 2017 to May 2017, over a period of 5 months. Patient notes were referred to and information regarding baseline characteristics and burn wound infection data was collected. A total of 76 patients were included in the study during the 5-month period, which resulted in 113 samples being included for review. Females were injured most with burns 70% (n = 53) compared with males 30% (n = 23). Only 6 (8%) of 77 patients lived locally in Kathmandu. The average distance traveled by patients was 233 km (median 208, range 0–765, SD 181). Average TBSA% of burn was 22% (median 20, range 3–50, SD 12). Gram-negative organisms predominated, with Acinetobacter spp. in 42 cases (55%), Pseudomonas aeruginosa in 26 cases (34%), and Enterobacter spp. in 16 cases (21%). Colistin, polymyxin B, and tigecycline were found to be most sensitive covering 108, 98, and 94 organisms. Gram-negative bacteria colonized the majority of burn wounds. Colistin, polymyxin B, and tigecycline were the most sensitive to gram-negative bacteria. Gram-positive Staphylococcus aureus was sensitive most to vancomycin and tigecycline.
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Affiliation(s)
| | - Kiran Kishor Nakarmi
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
| | | | - Shankar Man Rai
- Department of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Nepal
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18
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A Rare Extraskeletal Osteosarcoma Appearing After 55 Years on a Large Stage 3 Burn Scar. Case Rep Dermatol Med 2018; 2018:5185604. [PMID: 29971170 PMCID: PMC6008689 DOI: 10.1155/2018/5185604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/22/2018] [Indexed: 12/14/2022] Open
Abstract
It is widely accepted that chronic burn wounds may lead to the development of various malignant skin tumors. Deep stage 3 burned areas may facilitate deeper carcinogenesis. Deep tissues are probably less subject to severe insult than is the epithelial layer during physical insult, suggesting that soft tissues transform to a lesser extent during the late stages of tumoral development as in an immunocompromised district with altered local immune defense with both cellular and humoral defense affected. Most authors claim that tumors are almost squamous cell carcinomas, although other types of malignancies such as basal cell carcinoma and, to a lesser extent, melanoma can also be seen. However, malignant transformation of cutaneous soft tissue in a burn insult area has rarely been described. Similarly, burn-induced tumors of histiocytic origin have been reported in few cases and osteosarcoma only in two case reports. Here, we report a patient case suffering from severe large stage 3 burn after-effects on the leg. Fifty-five years after the injury, this patient developed a large extraosseous osteosarcoma on the scar.
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19
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Zhou J, Yao D, Qian Z, Hou S, Li L, Jenkins ATA, Fan Y. Bacteria-responsive intelligent wound dressing: Simultaneous In situ detection and inhibition of bacterial infection for accelerated wound healing. Biomaterials 2018; 161:11-23. [DOI: 10.1016/j.biomaterials.2018.01.024] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/13/2018] [Accepted: 01/13/2018] [Indexed: 11/30/2022]
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20
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Stanojcic M, Vinaik R, Jeschke MG. Status and Challenges of Predicting and Diagnosing Sepsis in Burn Patients. Surg Infect (Larchmt) 2018; 19:168-175. [PMID: 29327977 DOI: 10.1089/sur.2017.288] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Burns are a common form of trauma that account for more than 300,000 deaths each year worldwide. Survival rates have improved over the past decades because of improvements in nutritional and fluid support, burn wound care, and infection control practices. Death, however, remains unacceptably high. The primary cause of death has changed over the last decades from anoxic causes to now predominantly infections and sepsis. Sepsis and septic complications are not only major contributors to poor outcomes, but they further result in longer hospital stay and higher healthcare costs. Despite the importance of infections and sepsis, the diagnosis and prediction remain a major challenge. To date, no clear diagnostic criteria or predictive formula exist that can predict reliably the occurrence of sepsis and infections. This review will highlight and discuss current definitions and criteria for diagnosis as well as predictive biomarkers of sepsis in patients with burns. It will also present the diagnostic tools employed, such as procalcitonin, C-reactive protein, and cytokines. We will discuss the benefits and shortcomings of different treatment modalities in the context of sepsis prevention. Last, we identify new therapeutic strategies for sepsis prediction and present future considerations to prevent sepsis in patients with burns. Minimizing and preventing septic complications through early detection would significantly benefit patients and necessitate continued research to unravel new biomarkers and mechanisms. Subsequent studies need to take a fresh perspective and consider the implementation of patient-centered therapeutic strategies.
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Affiliation(s)
- Mile Stanojcic
- 1 Sunnybrook Research Institute , Toronto, Ontario, Canada
| | - Roohi Vinaik
- 1 Sunnybrook Research Institute , Toronto, Ontario, Canada
| | - Marc G Jeschke
- 1 Sunnybrook Research Institute , Toronto, Ontario, Canada .,2 Department of Surgery, Division of Plastic Surgery, University of Toronto , Toronto, Ontario, Canada .,3 Department of Immunology, University of Toronto , Toronto, Ontario, Canada .,4 Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre , Toronto, Ontario, Canada
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21
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Udy AA, Roberts JA, Lipman J, Blot S. The effects of major burn related pathophysiological changes on the pharmacokinetics and pharmacodynamics of drug use: An appraisal utilizing antibiotics. Adv Drug Deliv Rev 2018; 123:65-74. [PMID: 28964882 DOI: 10.1016/j.addr.2017.09.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/31/2017] [Accepted: 09/22/2017] [Indexed: 12/13/2022]
Abstract
Patients suffering major burn injury represent a unique population of critically ill patients. Widespread skin and tissue damage causes release of systemic inflammatory mediators that promote endothelial leak, extravascular fluid shifts, and cardiovascular derangement. This phase is characterized by relative intra-vascular hypovolaemia and poor peripheral perfusion. Large volume intravenous fluid resuscitation is generally required. The patients' clinical course is then typically complicated by ongoing inflammation, protein catabolism, and marked haemodynamic perturbation. At all times, drug distribution, metabolism, and elimination are grossly distorted. For hydrophilic agents, changes in volume of distribution and clearance are marked, resulting in potentially sub-optimal drug exposure. In the case of antibiotics, this may then promote treatment failure, or the development of bacterial drug resistance. As such, empirical dose selection and pharmaceutical development must consider these features, with the application of strategies that attempt to counter the unique pharmacokinetic changes encountered in this setting.
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22
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Korkmaz HI, Krijnen PAJ, Ulrich MMW, de Jong E, van Zuijlen PPM, Niessen HWM. The role of complement in the acute phase response after burns. Burns 2017; 43:1390-1399. [PMID: 28410933 DOI: 10.1016/j.burns.2017.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/03/2017] [Accepted: 03/08/2017] [Indexed: 12/11/2022]
Abstract
Severe burns induce a complex systemic inflammatory response characterized by a typical prolonged acute phase response (APR) that starts approximately 4-8h after-burn and persists for months up to a year after the initial burn trauma. During this APR, acute phase proteins (APPs), including C-reactive protein (CRP) and complement (e.g. C3, C4 and C5) are released in the blood, resulting amongst others, in the recruitment and migration of inflammatory cells. Although the APR is necessary for proper wound healing, a prolonged APR can induce local tissue damage, hamper the healing process and cause negative systemic effects in several organs, including the heart, lungs, kidney and the central nervous system. In this review, we will discuss the role of the APR in burns with a specific focus on complement.
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Affiliation(s)
- H Ibrahim Korkmaz
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; Institute of Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands.
| | - Paul A J Krijnen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; Institute of Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Magda M W Ulrich
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands; Association of Dutch Burn Centres (ADBC), Beverwijk, The Netherlands
| | - E de Jong
- Department of Intensive Care, Red Cross Hospital, Beverwijk, The Netherlands
| | - Paul P M van Zuijlen
- Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, VU University Medical Center, Amsterdam, The Netherlands; Burn Center and Department of Plastic and Reconstructive Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Association of Dutch Burn Centres (ADBC), Beverwijk, The Netherlands
| | - Hans W M Niessen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; Department of Cardiac Surgery, VU University Medical Center, Amsterdam, The Netherlands; Institute of Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
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23
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Manzano-Nunez R, García-Perdomo HA, Ferrada P, Ordoñez Delgado CA, Gomez DA, Foianini JE. Safety and effectiveness of propranolol in severely burned patients: systematic review and meta-analysis. World J Emerg Surg 2017; 12:11. [PMID: 28265298 PMCID: PMC5335497 DOI: 10.1186/s13017-017-0124-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this systematic review was to determine the effectiveness and safety of propranolol compared to placebo or usual care for improving clinical relevant outcomes in severely burned patients (TBSA >20%). METHODS Relevant articles from randomized controlled trials were identified by a literature search in MEDLINE, EMBASE, and CENTRAL. We included trials involving patients with a severe burn (>20% of total body surface area affected). Trials were eligible if they evaluated propranolol and compared to usual care or placebo. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for the final analysis. We conducted a meta-analysis using a random-effects model. RESULTS We included ten studies in our systematic review. These studies randomized a total of 1236 participants. There were no significant differences between propranolol and placebo with respect to mortality (RD -0.02 [95% CI -0.06 to 0.02]), sepsis (RD -0.03 [95% CI -0.09 to 0.04]), and the overall hospital stay (MD -0.37 [-4.52 to 3.78]). Propranolol-treated adults had a decrease in requirements of blood transfusions (MD -185.64 [95% CI -331.06 to -40.43]) and a decreased heart rate (MD -26.85 [95% CI -39.95 to -13.75]). CONCLUSIONS Our analysis indicates that there were no differences in mortality or sepsis in severely burned patients treated with propranolol compared with those who had usual care or placebo. However, the use of propranolol in these patients resulted in lower requirements of blood transfusion and lower values of heart rate. The evidence synthesized in this systematic review is limited to conclude that propranolol reduces the length of hospital stay among severely burned patients. Future trials should assess the impact of propranolol on clinically relevant outcomes such as mortality and adverse events.
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Affiliation(s)
- Ramiro Manzano-Nunez
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
- UROGIV Research Group, Universidad Del Valle, Cali, Colombia
| | | | - Paula Ferrada
- Surgical Critical Care, Virginia Commonwealth University, Richmond, VA USA
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24
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Rose LF, Chan RK. The Burn Wound Microenvironment. Adv Wound Care (New Rochelle) 2016; 5:106-118. [PMID: 26989577 PMCID: PMC4779284 DOI: 10.1089/wound.2014.0536] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/13/2014] [Indexed: 01/27/2023] Open
Abstract
Significance: While the survival rate of the severely burned patient has improved significantly, relatively little progress has been made in treatment or prevention of burn-induced long-term sequelae, such as contraction and fibrosis. Recent Advances: Our knowledge of the molecular pathways involved in burn wounds has increased dramatically, and technological advances now allow large-scale genomic studies, providing a global view of wound healing processes. Critical Issues: Translating findings from a large number of in vitro and preclinical animal studies into clinical practice represents a gap in our understanding, and the failures of a number of clinical trials suggest that targeting single pathways or cytokines may not be the best approach. Significant opportunities for improvement exist. Future Directions: Study of the underlying molecular influences of burn wound healing progression will undoubtedly continue as an active research focus. Increasing our knowledge of these processes will identify additional therapeutic targets, supporting informed clinical studies that translate into clinical relevance and practice.
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Affiliation(s)
- Lloyd F. Rose
- United States Army Institute of Surgical Research, Brook Army Medical Center, Joint Base San Antonio, Ft. Sam Houston, Texas
| | - Rodney K. Chan
- United States Army Institute of Surgical Research, Brook Army Medical Center, Joint Base San Antonio, Ft. Sam Houston, Texas
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Salibian AA, Rosario ATD, Severo LDAM, Nguyen L, Banyard DA, Toranto JD, Evans GRD, Widgerow AD. Current concepts on burn wound conversion-A review of recent advances in understanding the secondary progressions of burns. Burns 2016; 42:1025-1035. [PMID: 26787127 DOI: 10.1016/j.burns.2015.11.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/16/2015] [Accepted: 11/24/2015] [Indexed: 01/27/2023]
Abstract
Burn wound conversion describes the process by which superficial partial thickness burns convert into deeper burns necessitating surgical intervention. Fully understanding and thus controlling this phenomenon continues to defy burn surgeons. However, potentially guiding burn wound progression so as to obviate the need for surgery while still bringing about healing with limited scarring is the major unmet challenge. Comprehending the pathophysiologic background contributing to deeper progression of these burns is an essential prerequisite to planning any intervention. In this study, a review of articles examining burn wound progression over the last five years was conducted to analyze trends in recent burn progression research, determine changes in understanding of the pathogenesis of burn conversion, and subsequently examine the direction for future research in developing therapies. The majority of recent research focuses on applying therapies from other disease processes to common underlying pathogenic mechanisms in burn conversion. While ischemia, inflammation, and free oxygen radicals continue to demonstrate a critical role in secondary necrosis, novel mechanisms such as autophagy have also been shown to contribute affect significantly burn progression significantly. Further research will have to determine whether multiple mechanisms should be targeted when developing clinical therapies.
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Affiliation(s)
- Ara A Salibian
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Orange, CA, 92868-3298, United States
| | - Angelica Tan Del Rosario
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Orange, CA, 92868-3298, United States
| | - Lucio De Almeida Moura Severo
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Orange, CA, 92868-3298, United States
| | - Long Nguyen
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Orange, CA, 92868-3298, United States
| | - Derek A Banyard
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Orange, CA, 92868-3298, United States
| | - Jason D Toranto
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Orange, CA, 92868-3298, United States
| | - Gregory R D Evans
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Orange, CA, 92868-3298, United States
| | - Alan D Widgerow
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Orange, CA, 92868-3298, United States.
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Duke JM, Bauer J, Fear MW, Rea S, Wood FM, Boyd J. Burn injury, gender and cancer risk: population-based cohort study using data from Scotland and Western Australia. BMJ Open 2014; 4:e003845. [PMID: 24441050 PMCID: PMC3902327 DOI: 10.1136/bmjopen-2013-003845] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To investigate the risk of cancer and potential gender effects in persons hospitalised with burn injury. DESIGN Population-based retrospective cohort study using record-linkage systems in Scotland and Western Australia. PARTICIPANTS Records of 37 890 and 23 450 persons admitted with a burn injury in Scotland and Western Australia, respectively, from 1983 to 2008. Deidentified extraction of all linked hospital morbidity records, mortality and cancer records were provided by the Information Service Division Scotland and the Western Australian Data Linkage Service. MAIN OUTCOME MEASURES Total and gender-specific number of observed and expected cases of total ('all sites') and site-specific cancers and standardised incidence ratios (SIRs). RESULTS From 1983 to 2008, for female burn survivors, there was a greater number of observed versus expected notifications of total cancer with 1011 (SIR, 95% CI 1.3, 1.2 to 1.4) and 244 (SIR, 95% CI 1.12, 1.05 to 1.30), respectively, for Scotland and Western Australia. No statistically significant difference in total cancer risk was found for males. Significant excesses in observed cancers among burn survivors (combined gender) in Scotland and Western Australian were found for buccal cavity, liver, larynx and respiratory tract and for cancers of the female genital tract. CONCLUSIONS Results from the Scotland data confirmed the increased risk of total ('all sites') cancer previously observed among female burn survivors in Western Australia. The gender dimorphism observed in this study may be related to the role of gender in the immune response to burn injury. More research is required to understand the underlying mechanism(s) that may link burn injury with an increased risk of some cancers.
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Affiliation(s)
- Janine M Duke
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Crawley, Western Australia, Australia
| | - Jacqui Bauer
- Population Health Research Network, Centre for Data Linkage, Curtin University, Perth, Western Australia, Australia
| | - Mark W Fear
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Crawley, Western Australia, Australia
| | - Suzanne Rea
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Crawley, Western Australia, Australia
- Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Crawley, Western Australia, Australia
- Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Western Australia, Australia
- Fiona Wood Foundation, Crawley, Western Australia, Australia
| | - James Boyd
- Population Health Research Network, Centre for Data Linkage, Curtin University, Perth, Western Australia, Australia
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Duke J, Rea S, Semmens J, Edgar DW, Wood F. Burn and cancer risk: A state-wide longitudinal analysis. Burns 2012; 38:340-7. [DOI: 10.1016/j.burns.2011.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 09/06/2011] [Accepted: 10/11/2011] [Indexed: 01/06/2023]
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Huzar TF, Cross JM. Ventilator-associated pneumonia in burn patients: a cause or consequence of critical illness? Expert Rev Respir Med 2012; 5:663-73. [PMID: 21955236 DOI: 10.1586/ers.11.61] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Infectious complications are a constant threat to thermally injured patients during hospitalizations and are a predominant cause of death. Most of the infections that develop in burn patients are nosocomial and of a pulmonary etiology. The bacteria that cause ventilator associated pneumonia (VAP) take advantage of the fact that uniquely among intensive care unit patients endotracheal intubation allows them a 'free' passage to the sterile lower airways; however, the combination of severe thermal injury (systemic immunosuppression) and inhalation injury (local immunosuppression and tissue injury) create an ideal environment for development of VAP. Thus, strategies directed at preventing and treating VAP in burn patients must address not only rapid extubation and VAP prevention bundles known to work in other intensive care unit populations, but therapies directed to more rapid wound healing and restoration of pulmonary patency.
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Affiliation(s)
- Todd F Huzar
- Department of Surgery, University of Texas Medical School, Houston, TX, USA.
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Prolonged C1 Inhibitor Administration Improves Local Healing of Burn Wounds and Reduces Myocardial Inflammation in a Rat Burn Wound Model. J Burn Care Res 2012; 33:544-51. [DOI: 10.1097/bcr.0b013e31823bc2fc] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Orman MA, Ierapetritou MG, Berthiaume F, Androulakis IP. The dynamics of the early inflammatory response in double-hit burn and sepsis animal models. Cytokine 2011; 56:494-502. [PMID: 21824784 DOI: 10.1016/j.cyto.2011.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 06/22/2011] [Accepted: 07/01/2011] [Indexed: 12/22/2022]
Abstract
Severe burn trauma is generally associated with bacterial infections, which causes a more persistent inflammatory response with an ongoing hypermetabolic and catabolic state. This complex biological response, mediated by chemokines and cytokines, can be more severe when excessive interactions between the mediators take place. In this study, the early inflammatory response following the cecum ligation and puncture (CLP) or its corresponding control treatment (sham-CLP or SCLP) in burn (B) male rats was analyzed by measuring 23 different cytokines and chemokines. Cytokines and chemokines, including MCP-1, IP-10, leptin, TNF-α, MIP-1α, IL-18, GMCSF, RANTES and GCSF were significantly altered in both B+CLP and B+SCLP groups. IL-10 and IL-6 were significantly up-regulated in the B+CLP group when compared to the B+SCLP group. Down regulation of leptin and IP-10 concentrations were found to be related to surgery and/or infection. IL-18 and MCP-1 were elevated in all groups including previously published single injury models receiving similar treatments. In this study, insult-specific mediators with their characteristic temporal patterns were elucidated in double hit models.
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Affiliation(s)
- Mehmet A Orman
- Department of Chemical and Biochemical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA
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Comparison of silver-coated dressing (Acticoat®), chlorhexidine acetate 0.5% (Bactigrass®) and nystatin for topical antifungal effect in Candida albicans-contaminated, full-skin-thickness rat burn wounds. Burns 2011; 37:882-5. [DOI: 10.1016/j.burns.2011.01.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 12/10/2010] [Accepted: 01/24/2011] [Indexed: 11/22/2022]
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Lee JH, Jin GY, Jin ZW, Yu HC, Cho BH. Ramification of Glisson's sheath peripheral branches and clinical implications in the era of local ablation therapy. Surg Radiol Anat 2010; 32:911-7. [PMID: 20204636 DOI: 10.1007/s00276-010-0643-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 02/18/2010] [Indexed: 12/21/2022]
Abstract
PURPOSE Classical anatomical resection does not always guarantee tumor-free margins when the tumor overrides traditional anatomical planes. Surgeons and interventionists frequently need to focus on the peripheral branches of Glisson's sheath in patients with poor hepatic reserves, particularly when the tumor is deep seated. The present study used anatomical liver dissection to investigate the spatial distribution of the branches of Glisson's sheath in each of four liver sectors. METHODS Sixty-four adult human liver specimens were dissected. The size and ramification patterns of Glisson's sheath in each sector were analyzed in terms of bilateral homology within two paramedian sectors and within two lateral sectors. RESULTS Each liver sector had a characteristic Glisson's sheath in terms of trunk shape and ramification pattern. The two paramedian sectors showed point symmetry. Most of the branches of the two paramedian sectors emerged from the top of a short stout trunk. Although the two paramedian sectors were similar in terms of basic configuration, the ramification axes were almost perpendicular to each other. Unlike the paramedian sectors, the two lateral sectors showed not much homology. CONCLUSIONS The peripheral branches of Glisson's sheath were generally longer (approximately 5 cm) and thicker than anticipated. Extirpation strategies should take into account that each liver sector has a characteristic Glisson's sheath ramification pattern.
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Affiliation(s)
- Jung Hun Lee
- Department of Surgery and Research Institute of Clinical Medicine, Chonbuk National University Medical School, San 2-20 Geumam-dong, Deokjin-gu, Jeonju, Jeonbuk, 561-180, Republic of Korea
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Abstract
One of the most complicated issues that surgeons face, in the care of burn patients, is infection. This includes both superficial and systemic infections. Systemic infection is the leading cause of death in this population. This article will look to review the microbiology of burn wound infections with particular emphasis on classification, host response to burn wound infections, antimicrobial agents, and modern treatment practices.
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Harper A, Rea S, Wood F. Hepatocellular carcinoma in a young survivor of major burns. Burns 2007; 34:572-4. [PMID: 18082962 DOI: 10.1016/j.burns.2007.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Accepted: 02/22/2007] [Indexed: 10/22/2022]
Affiliation(s)
- A Harper
- Burns Service of Western Australia, Royal Perth Hospital, Mc Comb Foundation, School of Paediatrics University of Western Australia, WA, Australia
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Mellemkjaer L, Hölmich LR, Gridley G, Rabkin C, Olsen JH. Risks for skin and other cancers up to 25 years after burn injuries. Epidemiology 2007; 17:668-73. [PMID: 17028504 DOI: 10.1097/01.ede.0000239651.06579.a4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Malignant degeneration of chronic ulcers such as nonhealed burn wounds has been described in the literature, but this phenomenon has never been quantified in an epidemiologic study. We investigated the risks for skin and other cancers among patients with a prior burn. METHODS We identified 16,903 patients from the Danish Hospital Discharge Register who had been admitted to a hospital with a thermal or chemical burn during 1978 to 1993. The cohort was followed for cancer in the Danish Cancer Registry through 2002, and the cancer incidence in the cohort was compared with that in the general population of Denmark. RESULTS Patients with burn had 139 skin cancers, with 189 expected, yielding a standardized incidence ratio of 0.7 (95% confidence interval = 0.6-0.9). This reduced risk was due mainly to deficits of basal cell carcinoma and malignant melanoma, whereas the number of squamous cell carcinomas observed was close to expected. We saw no consistent increases in risk for skin cancer in the subgroups of patients with the most severe injuries or with the longest periods of follow up. CONCLUSIONS The tendency to malignant degeneration of burn scars, described in previous reports of case series, did not result in an excess of squamous cell carcinoma of the skin or of any other type of skin cancer during up to 25 years' follow up of a large unselected cohort of patients hospitalized for burn injuries.
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Affiliation(s)
- Lene Mellemkjaer
- Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark.
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Denman PK, McElwain DLS, Harkin DG, Upton Z. Mathematical modelling of aerosolised skin grafts incorporating keratinocyte clonal subtypes. Bull Math Biol 2006; 69:157-79. [PMID: 17054001 DOI: 10.1007/s11538-006-9082-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Accepted: 01/18/2006] [Indexed: 12/14/2022]
Abstract
Severe burns can be very traumatic for the patient, and while burns caused by industrial or domestic accidents are common, there are also increasing numbers of burns associated with terrorism. A novel technique to assist in the healing process is to spray skin cells, keratinocytes, that are cultured from the patient's own tissue, directly onto the burn site. This process involves taking some undamaged skin from the patient, allowing the skin cells to proliferate rapidly in the laboratory over a period of 5-10 days, harvesting and separating the cells and then spraying them onto the burn. This paper deals with keratinocytes that have been cultured in vitro for a short period of time (early passage cultured cells). The spraying process has yet to be optimised with respect to the seeding density required for fastest re-epithelisation and thus there is a need for this process to be modelled. In this paper, we review some of the skin biology and develop a mathematical model of the growth patterns of cell colonies after they have been applied using a aerosolised technique. The model allows us to predict coverage over time and can be used as a decision support tool for clinicians.
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Affiliation(s)
- Paula K Denman
- School of Mathematical Sciences, Queensland University of Technology, GPO Box 2434, Brisbane 4001, Australia.
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Abstract
Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.
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Affiliation(s)
- Deirdre Church
- Calgary Laboratory Services, 9-3535 Research Rd. N.W., Calgary, Alberta, Canada T2L 2K8.
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Abstract
Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.
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Yu HC, Moon JI, Jin ZW, Lee DY, Kim CY, Song CH, Cho BH. Effect of radiofrequency ablation of the liver on cell-mediated immunity in rats. World J Surg 2005; 29:739-43. [PMID: 15880280 DOI: 10.1007/s00268-005-7728-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We investigated the effect of radiofrequency ablation (RFA) of the liver on cell-mediated immunity in rats. Sprague-Dawley rats were divided into five groups: control group that did not have any procedure, a sham-operation group that underwent laparotomy, a lobectomy group that had left lateral lobectomy of the liver, a one-lobe RFA group that had RFA on the left lateral lobe of the liver, and a two-lobe RFA group that had RFA on the left lateral and left median lobe of the liver. Delayed-type hypersensitivity (DTH) was induced by challenging the ears of previously sensitized rats with 2,4-dinitro-1-fluorobenzene. Cell-mediated immunity was evaluated by direct measurement of the ear thickness and quantitative analysis of leukocytic infiltration of the tissue. The increased ear thickness was 42.0%, 69.2%, 61.8%, 46.7%, and 39.8% from the baseline one day after each procedure, and the mean leukocytic infiltration into the ear tissue was 3136.7, 3895.0, 3913.3, 2803.3, and 2316.7/mm(2) seven days after each procedure in the control, sham-operation, lobectomy, one-lobe RFA, and two-lobe RFA groups, respectively. In conclusion, RFA of the liver tissue can partially abolish the augmentation of DTH and leukocytic infiltration those were seen in the hepatic lobectomy and sham-operation groups. The procedure had a negative effect on cell-mediated immunity in rats, and the intensity of RFA showed a reverse correlation with cell-mediated immunity.
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Affiliation(s)
- Hee Chul Yu
- Department of Surgery, Chonbuk National University Medical School, 634-18 Keumam-dong, Dukjin-gu, Jeonju, Jeonbuk, 561-180, Korea
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Lehnhardt M, Jafari HJ, Druecke D, Steinstraesser L, Steinau HU, Klatte W, Schwake R, Homann HH. A qualitative and quantitative analysis of protein loss in human burn wounds. Burns 2005; 31:159-67. [PMID: 15683686 DOI: 10.1016/j.burns.2004.08.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2004] [Indexed: 11/17/2022]
Abstract
INTRODUCTION It is well known that in patients suffering from major burn injuries of more than 15% of total body surface area (TBSA), capillary leak and loss of proteins including immunoglobulins (Ig) lead to cardiovascular failure and significantly elevated risk of infections. However, knowledge of the resulting protein profiles is limited. In order to elucidate quantitative and qualitative protein loss in human burn wounds we compared wound fluid (WF) protein content with serum protein levels. MATERIAL AND METHODS Eleven patients suffering from second degree burns of 18-68% TBSA were enrolled in the study. Immediately after admission burn wounds were enclosed in cutaneous vinyl wound chambers covering a 2.25 cm(2) wound surface area. WF and serum samples were harvested every 8 h with a follow up of 48 h and analyzed for total protein content, albumin and the immunoglobulins A, E, G and M. RESULTS Protein levels in serum were significantly lower as compared to physiological levels while WF protein levels were elevated and remained high. Total protein (TP) and albumin (AL) accumulated in high concentrations on the wound surface (average accumulation on 10% burnt TBSA within 8 h: TP=16.59+/-8.86 g; AL=12.39+/-5.87 g). The albumin fraction in WF showed increasing values (24 h: 69%; 32 h: 86%) although the serum albumin fraction remained nearly unchanged (55%). Peak values were initially found for all immunoglobulins both in serum and WF. IgA, E and M reached a steady state 32 h post-trauma, whereas IgG continuously decreased until 40 h. IgG values in serum were significantly below physiological levels at all time points. CONCLUSIONS This study qualifies and quantifies a significant protein loss in second degree burn wounds. Protein concentrations in wound fluid correlate highly with serum concentrations until 48 h post-burn. A patient's entire amount of serum proteins accumulates in wound fluid in a 20% TBSA burn within approximately 24h. In contrast to capillary leak theory proteins and immunoglobulins extravasate to wound fluid even after 48 h post-trauma.
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Affiliation(s)
- M Lehnhardt
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany.
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Nomoto S, Shibata M, Iriki M, Riedel W. Role of afferent pathways of heat and cold in body temperature regulation. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2004; 49:67-85. [PMID: 15549421 DOI: 10.1007/s00484-004-0220-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2003] [Revised: 05/22/2004] [Accepted: 05/22/2004] [Indexed: 05/24/2023]
Abstract
The detection of surface and internal temperatures is achieved by axons terminating at lamina I of the spinal dorsal horn, otherwise approached only by nociceptive afferents. Recent advances in thermal physiology research have disclosed that temperature-sensitive ion channels belonging to the "transient receptor potential" family exist in the peripheral sensory neurons and in the brain. Thermosensory, nociceptive and polymodal afferents project to different thalamic nuclei, and specific pathways to the insular cortex evoke the conscious experience of thermal sensation. The posterior insular region represents discriminative thermal sensation, while the largest correlation with subjective ratings of temperature is located in the orbitofrontal and anterior insular cortex. The insular cortex forms an integrative part of the limbic system and is closely tied with the hypothalamus, the amygdala, the anterior cingulate cortex and the orbitofrontal cortex and emerges as the main coordinator of behavioral, autonomic and endocrine responses to both non-noxious and noxious thermal stimuli. The firing rate of warm and cold receptors is not altered by pyrogens. A strong correlation between the onset of fever and production of superoxide by macrophages following the injection of pyrogens implicates reactive oxygen species as elicitors of fever, a hypothesis strengthened by the observation that oxygen radical scavengers or thiol reductants act as antipyretics. Oxidative stress appears to be sensed by the brain and a likely structure for its detection may be the redox-sensitive site of the N-methyl-D-aspartate (NMDA) receptor for glutamate, in that oxidation of this site causes fever while its reduction lowers body temperature, effects which are abrogated by specific NMDA receptor blockers.
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Affiliation(s)
- Shigeki Nomoto
- Tokyo Metropolitan Institute of Gerontology, 173-0015 Tokyo, Japan.
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Sachse C, Wolterink G, Pallua N. Neutrophil intracellular pH and phagocytosis after thermal trauma. Clin Chim Acta 2000; 295:13-26. [PMID: 10767391 DOI: 10.1016/s0009-8981(00)00189-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Severe burn trauma induces an acquired dysfunction of neutrophil granulocytes. As neutrophil function is considerably influenced by intracellular pH (pH(i)), the pH(i) of blood neutrophils was longitudinally determined in 19 patients with major burns. pH(i) was measured by a flow cytometric method using the pH-sensitive fluoroprobe carboxy-semi-naphthorhodafluor-1; mechanisms influencing the pH(i) were examined by addition of amiloride (inhibition of Na(+)/H(+) countertransport), diphenylene iodonium (inhibition of NADPH oxidase) and N-formyl-methionyl-leucyl-phenylalanine (activation of H(+) extrusion). The neutrophil phagocytic activity was measured in parallel. Patients showed distinct alterations of neutrophil pH(i), depending on whether they developed sepsis in the postburn period or not. In the sepsis patients pH(i) did not deviate from the values found in healthy volunteers in the first days after injury, but rose afterwards, with significant intracellular alkalinization in the second postburn week (P<0.05). In contrast, patients without sepsis had increased pH(i) in the first (P<0.01 at days 1-2), but not in the second week after burn trauma. Inhibition studies showed that postburn intracellular alkalinization is not solely caused by activation of Na(+)/H(+) countertransport. A clear relation between pH(i) changes and phagocytosis could not be established.
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Affiliation(s)
- C Sachse
- Department of Clinical Chemistry II, Medical School Hannover, Podbielskistrasse 380, 30659, Hannover, Germany.
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Sachse C, Prigge M, Cramer G, Pallua N, Henkel E. Association between reduced human leukocyte antigen (HLA)-DR expression on blood monocytes and increased plasma level of interleukin-10 in patients with severe burns. Clin Chem Lab Med 1999; 37:193-8. [PMID: 10353460 DOI: 10.1515/cclm.1999.036] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Severe thermal injury causes an immune dysfunction which includes a decrease of monocyte human leukocyte antigen DR (HLA-DR) expression. Interleukin-10 exerts a negative influence on this parameter in vitro. In this study we determined the prognostic value of reduced monocyte HLA-DR expression with regard to infectious complications, and the in vivo association between monocyte HLA-DR and plasma interleukin-10 concentration. Both quantities were measured serially in 19 patients with severe burns. HLA-DR expression was determined by direct immunofluorescence on a flow cytometer, and interleukin-10 was measured by ELISA. After burn trauma the percentage of HLA-DR expressing monocytes fell markedly (median: 53% at day 2, 36% at day 4, 31% at day 7, 28% at day 9, 35% at day 12, and 42% at day 14; compared to 93% for healthy volunteers). Moreover, patients who became septic showed lower monocyte HLA-DR expression than non-septic patients; the differences were significant at day 2 (p < 0.01) and day 7 (p < 0.05). Plasma concentrations of interleukin-10 increased after thermal injury (median: 40 ng/l at day 2, 43 ng/l at day 4, 77 ng/l at day 7, 120 ng/l at day 9, 63 ng/l at day 12, and 82 ng/l at day 14). Individual HLA-DR expression and interleukin-10 concentration were negatively correlated, the association reaching statistical significance at day 4 (p=0.006) and day 7 (p=0.031). Thus, after severe burn injury monocyte HLA-DR expression has prognostic value and is negatively associated with interleukin-10 plasma concentration.
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Affiliation(s)
- C Sachse
- Institut für Klinische Chemie II, Medizinische Hochschule Hannover, Germany
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