Metabolic and Endocrine Considerations After Burn Injury

Dexmedetomidine on the interplay of IL-6 and STAT3 pathways in adrenal gland damage-induced scalding burns in rats

Scalding burns are a common form of thermal injury that often leads to systemic complications. Pro-inflammatory cytokines like interleukin-6 (IL-6) and the activation of signal transducer and activator of transcription 3 (STAT3) pathways have been linked to the pathophysiology of organ damage caused by burns. This study aimed to investigate the potential therapeutic effects of dexmedetomidine, an α2-adrenergic receptor agonist with anti-inflammatory properties, on the interplay of IL-6 and STAT3 pathways in adrenal gland damage following scalding burns in rats. Twenty-eight rats were divided randomly into four groups. Rats in group 1 (n=7, control) were given only 0.9% intraperitoneal (i.p.) NaCl. Rats in group 2 (n=7, DEX) were exposed to 25°C water for 17 s on day 1 and received 100 mcg/kg/day dexmedetomidine i.p. for 3 days; for rats in group 3 (n=7, Burn), boiling water of 94°C was applied inside for 17 s. Rats in group 4 (n=7, Burn+DEX) were exposed to 94°C water for 17 s and received 100 mcg/kg/day dexmedetomidine i.p. for 3 days. Adrenal gland tissues were histopathological examined, and STAT3, IL-6, and TUNEL staining were performed using immunohistochemically. Our results revealed that scalding burns increased IL-6 and STAT3 expression in the adrenal glands of rats. Histological analysis demonstrated that dexmedetomidine administration ameliorated adrenal gland damage and reduced inflammatory cell infiltration. Our findings suggest that dexmedetomidine protects the adrenal glands in scalding burns. This protection appears to be mediated, at least in part, by its modulation of IL-6 and STAT3 pathways.

Speeding up the Production of Clinical-Grade Skin Substitutes Using Off-the-shelf Decellularized Self-Assembled Dermal Matrices

Patients with deep and extensive wounds need urgent skin coverage to re-establish the cutaneous barrier that prevents life-threatening infections and dehydration. However, the current clinically-available skin substitutes intended for permanent coverage are limited in number, and a trade-off between production time and quality must be made. Here, we report the use of decellularized self-assembled dermal matrices to reduce by half the manufacturing process time of clinical-grade skin substitutes. These decellularized matrices can be stored for over 18 months and recellularized with patients' cells in order to generate skin substitutes that show outstanding histological and mechanical properties in vitro. Once grafted in mice, these substitutes persist over weeks with high graft take, few contraction events, and high stem cell content. These next-generation skin substitutes constitute a substantial advancement in the treatment of major burn patients, combining, for the first time, high functionality, rapid manufacturability and easy handling for surgeons and healthcare practitioners. Future clinical trials will be conducted to assess the advantages of these substitutes over existing treatments. STATEMENT OF SIGNIFICANCE: The number of patients in need for organ transplantation is ever-growing and there is a shortage in tissue and organ donors. In this study, we show for the first time that we can preserve decellularized self-assembled tissues and keep them in storage. Then, in only three weeks we can use them to produce bilayered skin substitutes that have properties very close to those of the native human skin. These findings therefore represent a major step forward in the field of tissue engineering and organ transplantation, paving the way toward a universal off-the-shelf biomaterial for tissue reconstruction and surgery that will be beneficial for many clinicians and patients.

Infections in Burn Patients

Infections are the leading cause of mortality in burn patients who survive their initial resuscitation. Burn injury leads to immunosuppression and a dysregulated inflammatory response which can have a prolonged impact. Early surgical excision along with support of the multidisciplinary burn team has improved mortality in burn patients. The authors review diagnostic and therapeutic challenges as well as strategies for management of burn related infections.

The Complexity of the Post-Burn Immune Response: An Overview of the Associated Local and Systemic Complications

Burn injury induces a complex inflammatory response, both locally and systemically, and is not yet completely unravelled and understood. In order to enable the development of accurate treatment options, it is of paramount importance to fully understand post-burn immunology. Research in the last decades describes insights into the prolonged and excessive inflammatory response that could exist after both severe and milder burn trauma and that this response differs from that of none-burn acute trauma. Persistent activity of complement, acute phase proteins and pro- and anti-inflammatory mediators, changes in lymphocyte activity, activation of the stress response and infiltration of immune cells have all been related to post-burn local and systemic pathology. This "narrative" review explores the current state of knowledge, focusing on both the local and systemic immunology post-burn, and further questions how it is linked to the clinical outcome. Moreover, it illustrates the complexity of post-burn immunology and the existing gaps in knowledge on underlying mechanisms of burn pathology.

Surgical Repair of the Acute Burn Wound: Who, When, What Techniques? What Is the Future?

Modern burns surgery is multidisciplinary, multimodal and includes a dermal preservation approach. The management of the surgical wound starts in the pre-hospital environment with stabilization and assessment of the burn injured patient according to protocols of trauma resuscitation with special emphasis in the assessment of the burn depth and surface area. A large burn requires fluid resuscitation and physiological support, including counterbalancing hyper metabolism, fighting infection and starting a long burns intensive care journey. A deep burn may impose the need for surgical debridement and cover through a staged approach of excision of devitalized tissue depending on its extension and patient circumstances. These methodologies warrant patients survivability and require professionals integrated in a multidisciplinary team sharing decisions and directing management. Burns Multimodality involves multiple techniques used according to patient's needs, wound environment, operators experience and available resources. Traditional practices used together with new techniques may reduce morbidity and operative time but also challenge stablished practice. The concept of using the best teams with the best techniques combines with the need for selective and judicious surgery that preserves tissue architecture and spares as much as possible dermal component, therefore reducing the possibility of functional impairment and cosmetic embarrassment caused by pathological scars. Who is best placed to perform these tasks, the appropriate or best timing of surgery and the different practices used to achieve best results will be discussed, together with a reflection on what the future holds for these fundamental steps in the management of the burn injured patient turning into a functional burn survivor.

Spinal Irisin Gene Delivery Attenuates Burn Injury-Induced Muscle Atrophy by Promoting Axonal Myelination and Innervation of Neuromuscular Junctions

Muscle loss and weakness after a burn injury are typically the consequences of neuronal dysregulation and metabolic change. Hypermetabolism has been noted to cause muscle atrophy. However, the mechanism underlying the development of burn-induced motor neuropathy and its contribution to muscle atrophy warrant elucidation. Current therapeutic interventions for burn-induced motor neuropathy demonstrate moderate efficacy and have side effects, which limit their usage. We previously used a third-degree burn injury rodent model and found that irisin-an exercise-induced myokine-exerts a protective effect against burn injury-induced sensory and motor neuropathy by attenuating neuronal damage in the spinal cord. In the current study, spinal irisin gene delivery was noted to attenuate burn injury-induced sciatic nerve demyelination and reduction of neuromuscular junction innervation. Spinal overexpression of irisin leads to myelination rehabilitation and muscular innervation through the modulation of brain-derived neurotrophic factor and glial-cell-line-derived neurotrophic factor expression along the sciatic nerve to the muscle tissues and thereby modulates the Akt/mTOR pathway and metabolic derangement and prevents muscle atrophy.

Effects of enteral nutrition with different energy supplies on metabolic changes and organ damage in burned rats

BACKGROUND

Enteral nutrition (EN) is an important treatment for burn patients. However, severe gastrointestinal damage caused by major burns often leads to EN intolerance. Trophic EN solves this problem basically, but how to transition from trophic EN to standard EN smoothly is still a challenge in burn clinical nutrition. The aim of this study is to investigate the effects of EN with different energy supplies on metabolic changes, organ damage and prognosis in burned rats.

METHODS

Different feeding regimens were designed based on the continuous monitoring of resting energy expenditure in rats. Thirty-two Sprague-Dawley rats were randomly divided into a normal control group, burn +50% REE group, burn +75% REE group and burn +100% REE group. At the end of a nutritional treatment cycle (14th day), nuclear magnetic resonance spectroscopy, blood biochemistry analysis and quantification of subscab bacteria were performed to explore the differences in metabolic changes, degrees of organ damage and prognoses between the groups.

RESULTS

Sixteen metabolites involving seven metabolic pathways were identified from the different energy supply groups. After burn injury, resting energy consumption and body weight loss increased obviously. Meanwhile, weight loss was inversely related to energy supply. The greatest changes in the degree of organ damage, the level of plasma proteins, lipids and endotoxins, as well as the quantification of subscab bacteria were observed in the 50% REE group, followed by the 75 and 100% groups.

CONCLUSIONS

Achieving an early balance between energy supply and expenditure is conducive to mitigating metabolic disorders and improving prognosis after burn injury.

Transcriptomic analysis of mRNA expression in giant congenital melanocytic nevi

BACKGROUND AND OBJECTIVE

GCMN is a sporadic disease with an incidence ranging from 1/20,000 to 1/500000. So far, several studies have found that GCMN is related to somatic mutations, but most of them have focused on known pathogenic genes, and transcriptome sequencing based on large datasets is relatively uncommon. At present, the use of next-generation sequencing technologies and bioinformatics platforms makes genomic information study more comprehensive and efficient. In this study, the transcriptome differences between GCMN lesions and surrounding normal skin tissues were investigated using high-throughput transcriptome sequencing, and hub genes and pathways related to pathogenesis were identified, providing a theoretical foundation for further research into the pathogenesis of GCMN.

METHODS

Pathological skin tissue and surrounding normal skin tissue from GCMN patients, namely the pathological group (PG) and the control group (CG), were obtained. 1. All specimens were stained with HE to ensure that the samples met the experimental requirements. 2. Ten pairs of specimens were selected for high-throughput transcriptome sequencing, and the differentially expressed genes (DEGs) between the PG and the CG were obtained. The DEGs were analyzed by clusterProfiler R software for Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. The function of the subnetwork was analyzed and the hub genes were identified by the STRING database and Cytoscape software. 3. The expression differences of hub genes PTGS2, EGF, and SOX10 in pathological skin tissues and normal skin tissues were verified by qRT-PCR and immunofluorescence staining.

RESULTS

1. HE staining revealed a lot of melanocytes in the dermis and subcutaneous tissues. They were found around the hair follicles, sweat glands, sebaceous glands, and blood vessel walls, or in a specific pattern. 2. The screening threshold was set at p<0.01 and |log2fc|<1, and a total of 1163 DEGs were discovered between the PG and CG, with 519 genes up-regulated and 644 genes down-regulated in the pathological tissues. According to the GO functional analysis, 29 biological processes, 18 cell compositions, and 17 molecular functions were significantly enriched, with the majority of them being related to keratinocytes and the extracellular matrix. There were 779 nodes and 2359 interactions in the protein interaction network. Using the MCODE plug-in, the network was divided into 25 functional clusters. According to ClueGO results, Cluster5 was involved in melanin biosynthesis and melanocyte proliferation. Using 11 operation methods in the Cytohubba plug-in, PTGS2, EGF, and SOX10 in Cluster5 were chosen as hub genes. 3. qRT-PCR and immunofluorescent staining revealed that compared to normal skin tissue, the expression of SOX10 was significantly up-regulated, and the expression of PTGS2 and EGF was significantly down-regulated in pathological skin tissue(P<0.001).

CONCLUSIONS

In GCMN, keratinocytes and extracellular matrix may directly and indirectly affect melanocyte activity. PTGS2, EGF, and SOX10 are important genes and significantly differentially expressed in pathological and normal skin tissues. These findings may serve as a springboard for future research.

Efficacy of dexmedetomidine versus midazolam when combined with butorphanol for sedation and analgesia during burn dressing changes: A randomized clinical trial

Objective: The aim of this study was to compare dexmedetomidine-butorphanol (DB) and midazolam-butorphanol (MB) combinations for sedation, and analgesia in burn patients undergoing dressing changes.

Methods: A total of 56 ASA I–II burn patients were included in this single-center randomized clinical trial. The ages of these patients were between 20 and 60 years. TBSA ranged from 10% to 50%. They were randomized to group DB and group MB during dressing change. In the DB group, each patient received a bolus dose of dexmedetomidine (0.5 μg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). In the MB group, each patient received a bolus dose of midazolam (0.05 mg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). The primary outcomes were sedation scores and pain scores. The second outcomes were vital signs, side effects, and butorphanol consumption.

Results: The sedation scores of these two groups did not differ significantly (p &gt; 0.05), and the pain scores of these groups were not significantly different (p &gt; 0.05). More patients had hypotension in the DB group than in the MB group (6 versus 0, p = 0.01), but the number of patients who had respiratory depression was higher in the MB group compared with the DB group (4 versus 0, p = 0.038). Butorphanol consumption in the MB group was higher than in the DB group (p = 0.025).

Conclusion: Dexmedetomidine is comparable to midazolam when combined with butorphanol in burn patients during dressing change. Compared with midazolam, it has the advantage of opioid-sparing effect.

Clinical Trial Registration: [http://www.chictr.org.cn/showproj.aspx&amp;proj=130622], identifier [ChiCTR2100049325].

Ameliorative effect of bone marrow-derived mesenchymal stem cells on burn-induced hepatic and metabolic derangements in rats

AIMS

The current study aims to investigate the therapeutic potential of bone marrow-derived mesenchymal stem cells (MSCs) as a solo therapy in ameliorating both skin lesions and liver injury induced by cutaneous severe burn injury (SBI) in rats.

MAIN METHODS

In anesthetized male adult Wistar albino rats, 30 % total burn surface area and established hepatic injury was achieved via direct contact of each experimental animal's dorsum with heated metal rod (100 °C) for 10 s. On the next day following burn, human MSCs or mouse MSCs was administered locally around the burn site and intraperitonially (0.5 × 10⁶ cells/rat for each route) and outcomes were investigated at 4 and 14 days following burn induction.

KEY FINDINGS

Both types of MSCs significantly improved skin and liver histology, decreased liver enzymes, and ameliorated oxidative stress in hepatocytes of SBI-rats. Further, SBI-induced rises in hepatic apoptotic marker (caspase-3, Bax) and serum inflammatory markers (TNF-α, IL-1β, and IL-6) were reduced following either human or mouse MSC administration. In addition, MSCs augmented insulin receptor substrate-1, phosphorylated protein kinase-B (phospho-Akt), while alleviating serum glucose levels in SBI-rats. These previous effects persisted even at the 14-day time point.

SIGNIFICANCE

Following single administration, bone marrow-derived MSCs is capable of counteracting SBI-induced skin lesions as well as related hepatic complications, specifically via mitigating postburn hyperglycemia and hyperinflammation.

LYTIC COCKTAIL ATTENUATES CATECHOLAMINE SURGE AFTER SEVERE BURNS BY BLOCKING HISTAMINE H1 RECEPTOR/PKA/CREB/TYROSINE HYDROXYLASE SIGNALING IN CHROMAFFIN CELLS

ABSTRACT

Severe burns develop a catecholamine surge, inducing severe damage to the organism, raising the possibility of multisystem organ failure, and even death. The mechanisms of catecholamine surge have not been fully elucidated, and few strategies are generally acceptable to reduce catecholamine surge postburn. Thus, it is valuable to investigate the underlying mechanisms of catecholamine surge postburn to develop targeted interventions to attenuate it. We have found that the lytic cocktail alleviates the surge of catecholamine and organ injury after severe burn; however, the underlying mechanisms were still unclear. Moreover, the lytic cocktail has side effects, such as significant arterial hypotension and breathing depression, limiting its clinical application. This study aims to investigate the therapeutic mechanism of the lytic cocktail in regulating catecholamine levels postburn. We find that promethazine, a classic histamine H1 receptor blocker and a component of the lytic cocktail, can effectively reduce catecholamine surge and organ injury postburn. Our study confirms that blood histamine levels increase after severe burns. We find that histamine can amplify the catecholamine surge by elevating tyrosine hydroxylase expression and catecholamine synthesis in chromaffin cells through the histamine H1 receptor/Protein Kinase A /cAMP-response element binding protein signaling pathway. In summary, for the first time, we find that histamine plays a vital role in catecholamine surge postburn. We also confirm that the lytic cocktail effectively alleviates catecholamine surge and organ injury postburn through promethazine.

The use of propranolol in adult burn patients: Safety and outcome influence

OBJECTIVES

This study investigated safety and effect of propranolol on adult patients with severe burn.

METHODS

A prospective study was conducted on 124 severely adult burn patients who were randomly divided into propranolol and non-propranolol group. Propranolol was given by nasogastric tube to achieve the target of lowering 15-20% of initial heart rate.

RESULTS

Average dose of propranolol was 1.9 ± 0.5 mg/kg/day ranging from 0.9 to 3.3 mg/kg/day and was not affected by burn extent and inhalation injury. Mean heart rate reduced by 21.2% during the 28 day period. Recorded adverse events included hypotension (11.9%), bradycardia (1.6%), hypoglycemia (17.7%) and total number of held events was 8 occurring in 7 (11.3%) patients. Serum levels of glucose, total protein, albumin, cholesterol and triglyceride at different times were not significantly different between the two groups. Significantly lower resting energy expenditure on the 7^th and 14^th day were seen in propranolol group (p < 0.05). After 3 weeks, liver size in the propranolol group did not change significantly from admission, while in the non-propranolol group, liver size increased significantly (p < 0.05). The complete healing time of partial-thickness burns and donor sites were significantly shorter in propranolol group (p < 0.01). Duration of ventilation, length of stay in intensive care unit and in hospital, number of operations, rate of multiple organ failure, and death were not different between the two groups (p > 0.05).

CONCLUSION

For severely burned adults, propranolol was safe and effective on reducing energy expenditure, limited hepatomegaly, and accelerated partial burn wound and donor site closure, but does not affect length of stay in ICU, hospitalization, complication ormortality rate.

Identification of Novel Biomarkers With Diagnostic Value and Immune Infiltration in Burn Injury

Burn injury is an intractable problem in the field of surgery where screening relevant target genes and exploring pathological mechanisms through bioinformatic methods has become a necessity. Herein, we integrated three burn injury mRNA microarray datasets from the Gene Expression Omnibus database to analyze the hub differentially expressed genes (DEGs) between burn injury patient samples and healthy human samples; we conducted multiple functional enrichment analyses and constructed the protein-protein interaction (PPI) network. Finally, we evaluated the immune infiltration in the burn injury microenvironment. A total of 84 intersection DEGs (32 upregulated and 52 downregulated) were screened in burn injury patients via integrated analyses. Upregulated genes were primarily enriched in regulation of T cell activation, regulation of response to DNA damage stimulus, positive regulation of innate immune response, positive regulation of defense response. We also identified 10 hub genes from the PPI network (CCNB2, MYO10, TTK, POLQ, VASP, TIMP1, CDK16, MMP1, ZYX, and PKMYT1). Next, we found that 22 immune cells were substantially changed during the burn injury by CIBERSORT. In addition, we verified that VASP and POLQ are two novel diagnostic markers in burn processes with high diagnostic efficacy via immunohistochemistry. In summary, we identified several key genes involved in burn injury and provided a favorable basis for elucidating the molecular mechanisms of burn injury through comprehensive bioinformatic analysis.

Integrated analysis of dysregulated microRNA and mRNA expression in intestinal epithelial cells following ethanol intoxication and burn injury

Gut barrier dysfunction is often implicated in pathology following alcohol intoxication and burn injury. MicroRNAs (miRNAs) are negative regulators of gene expression that play a central role in gut homeostasis, although their role after alcohol and burn injury is poorly understood. We performed an integrated analysis of miRNA and RNA sequencing data to identify a network of interactions within small intestinal epithelial cells (IECs) which could promote gut barrier disruption. Mice were gavaged with ~ 2.9 g/kg ethanol and four hours later given a ~ 12.5% TBSA full thickness scald injury. One day later, IECs were harvested and total RNA extracted for RNA-seq and miRNA-seq. RNA sequencing showed 712 differentially expressed genes (DEGs) (padj < 0.05) in IECs following alcohol and burn injury. Furthermore, miRNA sequencing revealed 17 differentially expressed miRNAs (DEMs) (padj < 0.1). Utilizing the miRNet, miRDB and TargetScan databases, we identified both validated and predicted miRNA gene targets. Integration of small RNA sequencing data with mRNA sequencing results identified correlated changes in miRNA and target expression. Upregulated miRNAs were associated with decreased proliferation (miR-98-3p and miR-381-3p) and cellular adhesion (miR-29a-3p, miR-429-3p and miR3535), while downregulated miRNAs were connected to upregulation of apoptosis (Let-7d-5p and miR-130b-5p) and metabolism (miR-674-3p and miR-185-5p). Overall, these findings suggest that alcohol and burn injury significantly alters the mRNA and miRNA expression profile of IECs and reveals numerous miRNA–mRNA interactions that regulate critical pathways for gut barrier function after alcohol and burn injury.

Vascularized Composite Allotransplantation in Burn Reconstruction: Systematic Review and Meta-analysis

Vascularized composite allotransplantation has been successfully employed for burn reconstruction since 2003. However, its safety in this population has been questioned due to high levels of alloimmunization from burn care-related tissue exposures. To investigate this, a systematic review of vascularized composite allotransplantation employed for burn reconstruction was conducted, evaluating literature from January 2000 to September 2019. Articles containing vascularized composite allotransplantation, composite tissue allotransplantation, and burn reconstructive surgery were included; articles without published outcomes were excluded. Observational meta-analysis of pooled mortality and acute rejection episodes relative to allograft type (face vs extremity) and reconstruction type (burn vs non-burn) was performed. Twenty-four of the 63 identified articles met the criteria for inclusion, with 5 more articles added after secondary review. To date, 152 allotransplantations have been performed in 117 patients: 45 face transplants and 107 extremity transplants. Of these, 34 (22%) were performed for burn reconstruction in 25 patients (21%) with an overall higher 1-year mortality rate (12.0% vs 1.1%, P  = .030). Of these deaths, 75% received three or more simultaneous allografts. Additionally, more episodes of acute rejection occurred compared to non-burn patients (4.4 vs 2.4, P  = .035). Vascularized composite allotransplantation performed for burn reconstruction was found to be associated with a greater risk of 1-year mortality and nearly twice the number of episodes of acute rejection. Future studies should seek to identify unique risk factors of burn patients undergoing this operation and evaluate the relationship between antigenic burden and surgical outcomes.

Mesenchymal stem cell-based therapy for burn wound healing

Burns, with their high incidence and mortality rates, have a devastating effect on patients. There are still huge challenges in the management of burns. Mesenchymal stem cells (MSCs), which have multidirectional differentiation potential, have aroused interest in exploring the capacity for treating different intractable diseases due to their strong proliferation, tissue repair, immune tolerance and paracrine abilities, among other features. Currently, several animal studies have shown that MSCs play various roles and have beneficial effects in promoting wound healing, inhibiting burn inflammation and preventing the formation of pathological scars during burn healing process. The substances MSCs secrete can act on peripheral cells and promote burn repair. According to preclinical research, MSC-based treatments can effectively improve burn wound healing and reduce pain. However, due to the small number of patients and the lack of controls, treatment plans and evaluation criteria vary widely, thus limiting the value of these clinical studies. Therefore, to better evaluate the safety and effectiveness of MSC-based burn treatments, standardization of the application scheme and evaluation criteria of MSC therapy in burn treatment is required in the future. In addition, the combination of MSC pretreatment and dressing materials are also conducive to improving the therapeutic effect of MSCs on burns. In this article, we review current animal research and clinical trials based on the use of stem cell therapy for treating burns and discuss the main challenges and coping strategies facing future clinical applications.

A Randomized Controlled Trial on the Effectiveness of Epidermal Growth Factor-Containing Ointment on the Treatment of Solar Lentigines as Adjuvant Therapy

Background and Objective: Little is known about the anti-pigmentation effects of whitening agents on solar lentigines. Epidermal growth factor (EGF) has been used as a booster for wound healing in the skin, and it has been suggested to have anti-pigmentation effects. This study aimed to evaluate the effect and safety of EGF-containing ointment for treating solar lentigines with a Q-switched (QS) 532 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (Bluecore company, Seoul, Republic of Korea). Materials and Methods: Subjects who underwent QS 532 nm Nd:YAG laser treatment of solar lentigines were randomly assigned to treatment with an EGF ointment or petrolatum. After the laser procedure, the subjects were administered the test ointment twice a day for 4 weeks. The physician's assessment of the degree of pigment clearance and patient's satisfaction were assessed after 4 and 8 weeks. Additionally, the melanin index (MI), erythema index (EI), transepidermal water loss (TEWL), and post-inflammatory hyperpigmentation (PIH) were evaluated. This trial was registered with ClinicalTrials.gov (NCT04704245). Results: The blinded physician's assessment using 5-grade percentage improvement scale and patient's satisfaction were significantly higher in the study group than in the control group at the 4th and 8th weeks. The MI was significantly higher in the control group than in the study group at the 4th and 8th weeks. The EI and TEWL did not differ significantly between the two groups at either time point. The incidence of PIH was higher in the control group (37.5%) than in the EGF group (7.14%) at the 8th week. Conclusions: The application of EGF-containing ointment on facial solar lentigines with a QS 532 nm Nd:YAG laser showed efficient and safe therapeutic effects, with less PIH. Thus, EGF-containing ointment could be suggested as the promising adjuvant treatment strategy with a QS laser for solar lentigines.

Application of critical care scores in severely burned patients

Early detection of sepsis is of crucial importance in patients with severe burn injuries. However, according to the S1-guideline , based on SIRS criteria, the early diagnosis of sepsis in severely burned patients is difficult. The value of the new definition of sepsis based on sequential organ failure assessment (SOFA) according to S3-guidelines for patients with severe burn injuries is not described in detail in literature.We analyzed retrospectively all data during the period 2014-2018 from the electronic patient information system. Using Receiver operating characteristic (ROC) curve the area under the curve (AUC) was calculated for diagnostic value of procalcitonin (PCT), SIRS and SOFA score according to the burned total body surface area (TBSA). 651 patients with burn injuries were admitted to our burn unit, 315 of them had burn injuries affecting more than 10% body surface area with partial to full thickness burn (grade 2-4) . In this group, 59 patients showed one or more septic events in the course of the intensive care treatment, defined by positive blood stream infection. Both S1- and S3- guidelines were inappropriate to diagnose sepsis in patients with severe burn injuries. Due to pathophysiological changes of the body function in severely burned patients, that show features of both SIRS and pathological SOFA scores (> 2 points) at the outset of burn injury, the diagnosis of sepsis associated with burns is intricate in this patient group. Assessing data for potential hallmarks of sepsis in burn patients we found PCT to show significant correlation with sepsis.

An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation

On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.

The effect of trauma care systems on the mortality of injured adult patients: A protocol for systematic review and meta-analysis

PURPOSE

The aim of this study was to have a comprehensive evaluation of the effect of trauma care systems on the mortality of injured adult patients.

MATERIALS AND METHODS

This protocol established in this study has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Web of Science, PubMed, EMBASE, Scopus, and the Cochrane Library were searched for all clinical trials evaluating the effect of trauma care systems on the mortality of injured adult patients until July 31, 2020. We will use a combination of Medical Subject Heading and free-text terms with various synonyms to search based on the eligibility criteria. Two investigators independently reviewed the included studies and extracted relevant data. The odds ratio (OR) and 95% confidence intervals (CIs) were used as effect estimate. I-square (I) test, substantial heterogeneity, sensitivity analysis, and publication bias assessment will be performed accordingly. Stata 15.0 and Review Manger 5.3 are used for meta-analysis and systematic review.

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

The results of this review will be widely disseminated through peer-reviewed publications and conference presentations. This evidence may also provide a comprehensive evaluation of the effect of trauma care systems on the mortality of injured adult patients.

REGISTRATION NUMBER

INPLASY202080058.

Multiorgan Metabolomics and Lipidomics Provide New Insights Into Fat Infiltration in the Liver, Muscle Wasting, and Liver-Muscle Crosstalk Following Burn Injury

Burn injury mediated hypermetabolic syndrome leads to increased mortality among severe burn victims, due to liver failure and muscle wasting. Metabolic changes may persist up to 2 years following the injury. Thus, understanding the underlying mechanisms of the pathology is crucially important to develop appropriate therapeutic approaches. We present detailed metabolomic and lipidomic analyses of the liver and muscle tissues in a rat model with a 30% body surface area burn injury located at the dorsal skin. Three hundred and thirty-eight of 1587 detected metabolites and lipids in the liver and 119 of 1504 in the muscle tissue exhibited statistically significant alterations. We observed excessive accumulation of triacylglycerols, decreased levels of S-adenosylmethionine, increased levels of glutamine and xenobiotics in the liver tissue. Additionally, the levels of gluconeogenesis, glycolysis, and tricarboxylic acid cycle metabolites are generally decreased in the liver. On the other hand, burn injury muscle tissue exhibits increased levels of acyl-carnitines, alpha-hydroxyisovalerate, ophthalmate, alpha-hydroxybutyrate, and decreased levels of reduced glutathione. The results of this preliminary study provide compelling observations that liver and muscle tissues undergo distinctly different changes during hypermetabolism, possibly reflecting liver-muscle crosstalk. The liver and muscle tissues might be exacerbating each other's metabolic pathologies, via excessive utilization of certain metabolites produced by each other.

Actionable Risk Model for the Development of Surgical Site Infection after Emergency Surgery

Background: Surgical site infections (SSIs) increase mortality and the economic burden associated with emergency surgery (ES). A reliable and sensitive scoring system to predict SSIs can help guide clinician assessment and patient counseling of post-operative SSI risk. We hypothesized that after quantifying the ES post-operative SSI incidence, readily abstractable parameters can be used to develop an actionable risk stratification scheme. Patients and Methods: We reviewed retrospectively all patients who underwent ES operations at an urban academic hospital system (2005-2013). Comorbidities and operative characteristics were abstracted from the electronic health record (EHR) with a primary outcome of post-operative SSIs. Risk of SSI was calculated using logistic regression modeling and validated using bootstrapping techniques. Beta-coefficients were calculated to correlate risk. A simplified clinical risk assessment tool was derived by assigning point values to the rounded β-coefficients. Results: A total of 4,783 patients with a 13.2% incidence of post-operative SSIs were identified. The strongest risk factors associated with SSIs included acute intestinal ischemia, weight loss, intestinal perforation, trauma-related laparotomy, radiation exposure, previous gastrointestinal surgery, and peritonitis. The assessment tool defined three patient groups based on SSI risk. Post-operative SSI incidence in high-risk patients (34%; score = 6-10) exceeded that of medium- (11.1%; score = 3-5) and low-risk patients (1.5%; score = 1-2) (C statistic = 0.802). Patients with a risk score ≥10 points evidenced the highest post-operative SSI risk (71.9%). Conclusion: Pre-operative identification of ES patient risk for post-operative SSI may inform pre-operative patient counseling and operative planning if the proposed procedure includes medical device implantation. A clinically relevant seven-factor risk stratification model such as this empirically derived one may be suitable to incorporate into the EHR as a decision-support tool.

Review: Insulin resistance and mitochondrial dysfunction following severe burn injury

The insulin signaling pathway plays a pivotal role in glucose metabolism and metabolic homeostasis. Disruption of this pathway is commonly seen in critical illness such as following severe burn injuries where homeostatic control is lost, leading to "insulin resistance" with poor blood glucose control. The aberrant signaling pathways involved in insulin resistance following burn injury include increases in hyperglycemic stress hormones, pro-inflammatory cytokines and free radical production. Leakage of mitochondrial sequestered self-antigens and signaling between mitochondria and endoplasmic reticulum also contribute to insulin resistance. Greater understanding of molecular processes involved in burn-related insulin resistance could potentially lead to the development of novel therapeutic approaches to improve patient management.

Evaluating the Safety and Efficacy of Intraoperative Enteral Nutrition in Critically Ill Burn Patients: A Systematic Review and Meta-analysis

Major burn injuries incite a hypermetabolic response, and the initiation of early enteral nutrition is the standard of care in patients with large burns and contributes to improved outcomes. Perioperative fasting is a common cause of caloric deficits in burn patients and can be obviated with intraoperative enteral nutrition. However, the risks and benefits of this practice are unknown, and there is a concern for aspiration. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of intraoperative enteral nutrition. We performed a systematic literature search using PubMed, Scopus, and OvidSP MEDLINE databases. We identified studies that evaluated the effects of intraoperative enteral nutrition in adult burn patients compared to those undergoing routine perioperative fasting. We performed a meta-analysis on the incidence of mortality, pneumonia, wound infections, and aspiration in burn patients receiving intraoperative enteral nutrition. We identified seven articles for qualitative review and four for quantitative review (N = 83 patients). There were no statistically significant increases in the risk of mortality (odds ratio [OR] = 1.28, 95% confidence interval [CI]: 0.49, 3.31), wound infections (OR = 0.71, 95% CI: 0.16, 3.24), pneumonia (OR = 2.1, 95% CI: 0.7, 6.1), and aspiration (OR = 1.14, 95% CI: 0.07, 18.75) in patients receiving intraoperative enteral nutrition. Within individual studies, intraoperative enteral nutrition patients received significantly more calories than standard fasting patients. Intraoperative enteral nutrition may increase nutritional intake in burn patients without an increase in complications; however, this is based on limited studies. Randomized controlled trials are needed before recommendations on intraoperative enteral nutrition practice can be made.

Inducible nitric oxide synthase contributes to insulin resistance and cardiac dysfunction after burn injury in mice

AIMS

Cardiac dysfunction is a major cause of multi-organ dysfunction in critical care units following severe burns. The purpose of this study was to investigate the role of inducible nitric oxide synthase (iNOS) in cardiac dysfunction in burned mice.

MATERIALS AND METHODS

Wild-type and iNOS-knockout mice were subjected to 30% total body surface area burns. Next, the expression of iNOS was measured at 1, 3 and 7 days post-burn. Cardiac function, insulin sensitivity, inflammation, oxidative stress, and apoptosis in the hearts of the mice were assessed at 3 days post-burn.

KEY FINDINGS

Compared to control mice, iNOS expression was increased and reached a maximum in the heart of burned mice at 3 days post-burn. iNOS deficiency significantly alleviated the cardiac dysfunction and insulin resistance in burned mice. In addition, burn-induced inflammation, oxidative stress, and apoptosis in the heart were markedly reduced in iNOS-knockout burned mice when compared to corresponding values in wild-type burned mice.

SIGNIFICANCE

Our study demonstrates that iNOS contributes to insulin resistance in the hearts of mice following burn injury, and iNOS deficiency protects cardiac function against burn injury in mice, suggesting iNOS as a potential therapeutic target to treat burn injuries.

Systemic translation of locally infiltrated epidermal growth factor in diabetic lower extremity wounds

Diabetic foot ulcer is one of the most frightened diabetic complications leading to amputation disability and early mortality. Diabetic wounds exhibit a complex networking of inflammatory cytokines, local proteases, and reactive oxygen and nitrogen species as a pathogenic polymicrobial biofilm, overall contributing to wound chronification and host homeostasis imbalance. Intralesional infiltration of epidermal growth factor (EGF) has emerged as a therapeutic alternative to diabetic wound healing, reaching responsive cells while avoiding the deleterious effect of proteases and the biofilm on the wound's surface. The present study shows that intralesional therapy with EGF is associated with the systemic attenuation of pro-inflammatory markers along with redox balance recovery. A total of 11 diabetic patients with neuropathic foot ulcers were studied before and 3 weeks after starting EGF treatment. Evaluations comprised plasma levels of pro-inflammatory, redox balance, and glycation markers. Pro-inflammatory markers such as erythrosedimentation rate, C-reactive protein, interleukin-6, soluble FAS, and macrophage inflammatory protein 1-alpha were significantly reduced by EGF therapy. Oxidative capacity, nitrite/nitrate ratio, and pentosidine were also reduced, while soluble receptor for advanced glycation end-products significantly increased. Overall, our results indicate that the local intralesional infiltration of EGF translates in systemic anti-inflammatory and antioxidant effects, as in attenuation of the glycation products' negative effects.

Epidermis-Activated Gasdermin-A3 Enhances Thermogenesis of Brown Adipose Tissue through IL-6/Stat3 Signaling

Missense mutations in the gasdermin-A3 (Gsdma3) gene are associated with skin inflammation and hair loss in mice. However, the physiological function of Gsdma3 remains unclear. Herein, we reported that mice carrying the Gsdma3 Y344H mutation that encodes a presumptive activated form of Gsdma3 show increased heat production along with lower body fat percentages. Detailed analysis indicated that this metabolic phenotype is mediated by serum IL-6-induced up-regulation of thermogenesis in brown adipose tissue. The mutant form of Gsdma3 promotes the expression of IL-6 in the epidermis in a c-Jun N-terminal kinase (JNK) signaling-dependent manner. The higher whole-body heat production in alopecia and excoriation mice could be suppressed by an IL-6 receptor/GP130 inhibitor. Our results uncovered Gsdma3/IL-6-dependent cross talk between the skin and brown adipose tissue.

Novel pharmacotherapy for burn wounds: what are the advancements

INTRODUCTION

The prognosis for severe burns has improved significantly over the past 50 years. Meanwhile, burns have become an affliction mainly affecting the less well-developed regions of the world. Early excision and skin grafting has led to major improvements in therapeutic outcomes.

AREAS COVERED

The purpose of this article is to survey the use of pharmacotherapy to treat different pathophysiological complications of burn injury. The author, herein, discusses the use of drug treatments for a number of systemic metabolic disturbances including hyperglycemia, elevated catabolism, and gluconeogenesis.

EXPERT OPINION

Advancements in personalized and molecular medicine will make an impact on burn therapy. Similarities between severe burns and other critically ill patients will lead to cross-fertilization between different medical specialties. Furthermore, advances in stem cells and tissue regeneration will lead to improved healing and less lifelong disability. Indeed, research in new drug therapy for burns is actively progressing for many different complications.

Oxandrolone protects against the development of multiorgan failure, modulates the systemic inflammatory response and promotes wound healing during burn injury

Oxandrolone is a synthetic oral non-aromatizable testosterone derivative. This drug has been used successfully for several decades to safely treat growth delays in various diseases including Turner's syndrome. Currently the use of oxandrolone is under clinical testing in children with burn injury; the available data indicate that the anabolic steroid increases net muscle protein balance, maintains lean body mass, and reduces intensive care unit stay. Although oxandrolone is already in clinical trials in burn patients, preclinical burn-related studies with oxandrolone - especially those that go beyond muscle-related parameters and focus on burn-associated organ dysfunction, inflammatory response and wound healing - remain to be conducted. In the current project, using a well-characterized murine model of third-degree burn, we have tested the effect of oxandrolone on indices of organ injury, clinical chemistry parameters and plasma levels of inflammatory mediators. In oxandrolone-treated mice (1mg/kg/day for up to 21 days) there was a significant amelioration of burn-induced accumulation of myeloperoxidase levels in heart and lung (but not the liver and kidney) and significantly lower degree of malon dialdehyde accumulation in the liver (but not the heart, lung and kidney). Oxandrolone-treated mice showed a significant attenuation of the burn-induced elevation in circulating alkaline aminotransferase and amylase levels, while blood urea nitrogen and creatinine levels remained unaffected, indicative of protective effects of the anabolic hormone against burn-induced hepatic and pancreatic (but not renal) functional impairment. Multiple burn-induced inflammatory mediators (TNF-α, IL-1α, IL-1β, IL-4, IL-6, IL-10, IL-12, IP-10, G-CSF, GM-CSF and interferon-γ) were significantly lower in the plasma of oxandrolone-treated animals after burn injury than in the plasma of controls subjected to burns. Finally, oxandrolone significantly accelerated burn wound healing. We conclude that oxandrolone improves organ function, modulates the systemic inflammatory response and accelerates wound healing in a murine model of burn injury.

Mesenchymal Stromal Cell Preconditioning: The Next Step Toward a Customized Treatment For Severe Burn

Over the last century, the clinical management of severe skin burns significantly progressed with the development of burn care units, topical antimicrobials, resuscitation methods, early eschar excision surgeries, and skin grafts. Despite these considerable advances, the present treatment of severe burns remains burdensome, and patients are highly susceptible to skin engraftment failure, infections, organ dysfunction, and hypertrophic scarring. Recent researches have focused on mesenchymal stromal cell (MSC) therapy and hold great promises for tissue repair, as reported in several animal studies and clinical cases. In the present review, we will provide an up-to-date outlook of the pathophysiology of severe skin burns, clinical treatment modalities and current limitations. We will then focus on MSCs and their potential in the burn wound healing both in in vitro and in vivo studies. A specific attention will be paid to the cell preconditioning approach, as a means of improving the MSC efficacy in the treatment of major skin burns. In particular, we will debate how several preconditioning cues would modulate the MSC properties to better match up with the burn pathophysiology in the course of the cell therapy. Finally, we will discuss the clinical interest and feasibility of a MSC-based therapy in comparison to their paracrine derivatives, including microvesicles and conditioned media for the treatment of major skin burn injuries.