Burn-induced nitric oxide release in humans

Extracorporeal Blood Purification in Burns: For Whom, Why, and How?

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.

Intradermal methylene blue administration on the progression of burn injuries

OBJECTIVE

A burn injury has two defined areas: central necrosis and an adjacent area of ischaemia, which may or may not progress to necrosis. The concentration of nitric oxide (NO) increases after burn injury and may originate from potent oxidising agents. Methylene blue (MB) may act as an antioxidant and is supposed to reduce burn progression. This investigation was carried out to evaluate the effects of intradermal MB on necrosis progression in burns.

METHODS

Full-thickness burn injuries were performed by applying a heated metal comb on the shaved back of male Wistar rats. The animals were divided into three groups: Control (C, n=7); MB (2mg/kg) one hour after burn injury (MB1h, n=11); and MB (2mg/kg) six hours after burn injury (MB6h, n=8). After seven days the lesions were photographed for visual assessment of burn necrosis; full-thickness cuts of lesions were dyed with Masson and Giemsa for microscopic histopathology; and tissue fragments of unburned interspaces were processed for chemiluminescence with nitrite/nitrate (NOX) and malondialdehyde (MDA) as oxidative stress markers.

RESULTS

No statistically significant differences between groups were observed during visual analysis and NOX dosage. However, in microscopic analysis, the MB1h and MB6h groups showed smaller areas of necrosis, less inflammatory infiltration, and a more significant extension of interspaces. Furthermore, the dosage of MDA revealed that the MB1h group showed lower values when compared with the control group (p=0.001).

CONCLUSIONS

The study provided good evidence that MB intradermal injection can reduce necrosis progression in ischaemic perilesional areas and suggests an alternative to treating burns.

Methylene blue reduces progression of burn and increases skin survival in an experimental rat model

Following burn, increased nitric oxide (NO) combine with superoxide anion forming peroxynitrite. Methylene blue (MB) has NO blocking and antioxidant effects. Male Wistar rats (250g) were burned bilaterally in dorsum with a comb metal plate heated inside boiling water and applied during 30s, creating four rectangular 10×20mm full-thickness burned areas separated by three 5×20mm unburned interspaces (stasis zone). 30 rats were randomized into three groups (n=10): treated groups received one dose of intraperitoneal (IP) MB injections (2mg/kg), one or six hours after injury, and control group received saline. Seven days after injury, wounds were visually analyzed for interspaces necrosis; full-thickness sections were evaluated with Masson staining; tissue fragments were processed for nitrite/nitrate (NOx) and malondialdehyde (MDA) dosages. Photographic analysis: interspaces progression to necrosis were higher in control (64.8%) than in one (44.7%) and six (13.3%) hours MB groups (P=0.0060). Histopathology showed lower necrosis percentage in one (34.85%) and six (41.62%) hours MB groups than control (77.03%) (P=0.0034) and higher normal skin percentage in one (25.33%) and six (26.85%) hours MB groups than control (8.32%) (P=0.0037). Re-epithelialization skin areas were higher in both MB groups (39.94% for one and 31.89% for six hours) than control (14.63%) (P=0.0210). Interspace's NOx increased in both MB groups (P=0.0130) with no difference in burned areas. No MDA difference was observed. IP MB injection one or six hours after injury reduced necrosis progression in stasis area in the rat comb burn model suggesting an antioxidant effect reducing oxidative stress.

Guanylate cyclase inhibition by methylene blue as an option in the treatment of vasoplegia after a severe burn. A medical hypothesis

Today it is known that severe burns can be accompanied by the phenomenon of vasoplegic syndrome (VS), which is manifested by persistent and diffuse vasodilation, hypotension and low vascular resistance, resulting in circulatory and respiratory failure. The decrease in systemic vascular resistance observed in VS is associated with excessive production of nitric oxide (NO). In the last 2 decades, studies have reported promising results from the administration of an NO competitor, methylene blue (MB), which is an inhibitor of the soluble guanylate cyclase (sGC), in the treatment of refractory cases of vasoplegia. This medical hypothesis rationale is focused on the tripod of burns/vasoplegia catecholamine resistant/methylene blue. This article has 3 main objectives: 1) to study the guanylate cyclase inhibition by MB in burns; 2) to suggest MB as a viable, safe and useful co-adjuvant therapeutic tool of fluid resuscitation, and; 3) to suggest MB as burns hypotensive vasoplegia amine-resistant treatment.

Gamma delta (γδ) T-cells are critical in the up-regulation of inducible nitric oxide synthase at the burn wound site

BACKGROUND

The high incidence of morbidity and mortality following major burn can in part be attributed to immune derangements and wound healing complications. Inflammation plays an important role in wound healing, of which inducible nitric oxide synthase (iNOS) derived nitric oxide is a central mediator. T-cells of the γδ TCR lineage have also been shown to be important in healing of the burn wound site. Nonetheless, the role of γδ T-cells in the regulation of the burn wound iNOS expression is unknown.

METHODS

Wildtype (WT) and δ TCR(-/-) male C57BL/6 mice were subjected to burn (3rd degree, 12.5% TBSA) or sham treatment. Three days after injury, skin samples from non-injured and the burn wound were collected and analyzed for the expression of iNOS and cytokines and chemokine levels. In a second series of experiments, WT mice were subjected to burn and left untreated or treated with the iNOS inhibitor, L-Nil. Skin cytokine and chemokine levels were assessed 3days thereafter.

RESULTS

Burn induced an 18-fold increase in iNOS expression at the wound site as compared to the uninjured skin of WT sham mice. In δ TCR(-/-) mice iNOS expression at the wound site was significantly lower than that of the WT group. Burn also induced increased levels of IL-1β, IL-6, G-CSF, TNF-α, KC, MCP-1, MIP-1α and MIP-1β at the wound site in WT and δ TCR(-/-) mice, but G-CSF, TNF-α, and MIP-1β levels were greater in δ TCR(-/-) mice. Inhibition of iNOS activity in WT mice with L-Nil suppressed burn wound levels of IL-1β, G-CSF, and MIP-1α, whereas IL-6, TNF-α, KC, MCP-1 and MIP-1β were unaffected.

CONCLUSIONS

T-cells of the γδ TCR lineage significantly contribute to the up-regulation of iNOS expression which contributes to wound inflammation.

Estrogen treatment following severe burn injury reduces brain inflammation and apoptotic signaling

Background

Patients with severe burn injury experience a rapid elevation in multiple circulating pro-inflammatory cytokines, with the levels correlating with both injury severity and outcome. Accumulations of these cytokines in animal models have been observed in remote organs, however data are lacking regarding early brain cytokine levels following burn injury, and the effects of estradiol on these levels. Using an experimental animal model, we studied the acute effects of a full-thickness third degree burn on brain levels of TNF-α, IL-1β, and IL-6 and the protective effects of acute estrogen treatment on these levels. Additionally, the acute administration of estrogen on regulation of inflammatory and apoptotic events in the brain following severe burn injury were studied through measuring the levels of phospho-ERK, phospho-Akt, active caspase-3, and PARP cleavage in the placebo and estrogen treated groups.

Methods

In this study, 149 adult Sprague-Dawley male rats received 3rd degree 40% total body surface area (TBSA) burns. Fifteen minutes following burn injury, the animals received a subcutaneous injection of either placebo (n = 72) or 17 beta-estradiol (n = 72). Brains were harvested at 0.5, 1, 2, 4, 6, 8, 12, 18, and 24 hours after injury from the control (n = 5), placebo (n = 8/time point), and estrogen treated animals (n = 8/time point). The brain cytokine levels were measured using the ELISA method. In addition, we assessed the levels of phosphorylated-ERK, phosphorylated-Akt, active caspase-3, and the levels of cleaved PARP at the 24 hour time-point using Western blot analysis.

Results

In burned rats, 17 beta-estradiol significantly decreased the levels of brain tissue TNF-α (~25%), IL-1β (~60%), and IL-6 (~90%) when compared to the placebo group. In addition, we determined that in the estrogen-treated rats there was an increase in the levels of phospho-ERK (p < 0.01) and Akt (p < 0.05) at the 24 hour time-point, and that 17 beta-estradiol blocked the activation of caspase-3 (p < 0.01) and subsequent cleavage of PARP (p < 0.05).

Conclusion

Following severe burn injury, estrogens decrease both brain inflammation and the activation of apoptosis, represented by an increase in the levels of phospho-Akt and inhibition of caspase-3 activation and PARP cleavage. Results from these studies will help further our understanding of how estrogens protect the brain following burn injury, and may provide a novel, safe, and effective clinical treatment to combat remote secondary burn injury in the brain and to preserve cognition.

Bench-to-bedside review: Burn-induced cerebral inflammation--a neglected entity?

Severe burn injury remains a major burden on patients and healthcare systems. Following severe burns, the injured tissues mount a local inflammatory response aiming to restore homeostasis. With excessive burn load, the immune response becomes disproportionate and patients may develop an overshooting systemic inflammatory response, compromising multiple physiological barriers in the lung, kidney, liver, and brain. If the blood–brain barrier is breached, systemic inflammatory molecules and phagocytes readily enter the brain and activate sessile cells of the central nervous system. Copious amounts of reactive oxygen species, reactive nitrogen species, proteases, cytokines/chemokines, and complement proteins are being released by these inflammatory cells, resulting in additional neuronal damage and life-threatening cerebral edema. Despite the correlation between cerebral complications in severe burn victims with mortality, burn-induced neuroinflammation continues to fly under the radar as an underestimated entity in the critically ill burn patient. In this paper, we illustrate the molecular events leading to blood–brain barrier breakdown, with a focus on the subsequent neuroinflammatory changes leading to cerebral edema in patients with severe burns.

Gammadelta T-cells: potential regulators of the post-burn inflammatory response

Severe burn induces an immunopathological response that contributes to the development of a systemic inflammatory response (SIRS) and subsequent multiple organ failure. While, multiple immune cells type (T-cells, macrophages, neutrophils) are involved in this response, recent evidence suggests that a unique T-cell subset, gammadelta T-cells are central in the response to injury. While gammadelta T-cells represent only a small percentage of the total T-cell population, they display specific functional characteristics that uniquely position them in the immune/inflammatory axis to influence a number of important aspects of the body's response to burn. This review will focus on the potential regulator role of gammadelta T-cells in immunopathological response following burn and thereby their potential as therapeutic targets for affecting inflammation and healing.

Polydeoxyribonucleotide improves angiogenesis and wound healing in experimental thermal injury

OBJECTIVE

Polydeoxyribonucleotide contains a mixture of nucleotides and interacts with adenosine receptors, stimulating vascular endothelial growth factor expression and wound healing. The purpose of this study was to investigate the effect of polydeoxyribonucleotide on experimental burn wounds.

DESIGN

Randomized experiment.

SETTING

Research laboratory at a university hospital.

SUBJECTS

Thermal injury in mice.

INTERVENTIONS

Mice were immersed in 80 degrees C water for 10 secs to achieve a deep-dermal second-degree burn. Animals were randomized to receive either polydeoxyribonucleotide (8 mg/kg/day intraperitoneally for 14 days) or its vehicle alone (0.9% NaCl solution at 100 microL/day intraperitoneally). On days 7 and 14 the animals were killed. Blood was collected for tumor necrosis factor-alpha measurement; burn areas were used for histologic and immunohistochemical examination, for the evaluation of vascular endothelial growth factor and nitric oxide synthases by Western blot, and for the determination of wound nitric oxide products.

MEASUREMENTS AND MAIN RESULTS

Polydeoxyribonucleotide increased burn wound re-epithelialization and reduced the time to final wound closure. Polydeoxyribonucleotide improved healing of burn wound through increased epithelial proliferation and maturation of the extracellular matrix as confirmed by fibronectin and laminin immunostaining. Polydeoxyribonucleotide also improved neoangiogenesis as suggested by the marked increase in microvessel density and by the robust expression of platelet-endothelial cell adhesion molecule-1. Furthermore, polydeoxyribonucleotide blunted serum tumor necrosis factor-alpha and enhanced inducible nitric oxide synthase and vascular endothelial growth factor expression and the wound content of nitric oxide products.

CONCLUSIONS

Our study suggests that polydeoxyribonucleotide may be an effective therapeutic approach to improve clinical outcomes after thermal injury.

Inhibition of p38 MAP kinase improves survival of cardiac myocytes with hypoxia and burn serum challenge

This study was aimed to investigate the effects of SB203580, the specific p38 mitogen-activated protein (MAP) kinase inhibitor, on cardiac myocyte survival and secretion of cytokines in an in vitro model of hypoxia and burn serum challenge. Results demonstrated that hypoxia and burn serum induced a persistent activation of p38 MAP kinase in primary cultured neonatal rat cardiomyocytes during the 12h period of stimulation, concomitant with a time-dependent increased expression of tumor necrosis factor (TNF)-alpha and inducible nitric oxide (iNOS), a progressively developed oxidative stress reflected by malondialdehyde (MDA) production, and myocytes injury evidenced by the increased levels of released lactate dehydrogenase (LDH) and the decreased myocyte viability. Furthermore, hypoxia and burn serum resulted in a significant increase in myocyte apoptosis, which may account for the impairment of myocyte viability as observed. SB203580 abolished p38 MAP kinase activation, blunted the upregulation of TNF-alpha, iNOS and the subsequent nitric oxide (NO) production, reduced oxidative stress, and alleviated hypoxia and burn serum-induced myocytes injury or apoptosis. These results demonstrated for the first time that inhibition of p38 MAP kinase improves survival of cardiac myocytes with hypoxia and burn serum challenge possibly via reducing the production of cytokines, such as TNF-alpha and NO, and the subsequent oxidative stress, providing strong evidence that the excessive inflammatory cytokines produced by cardiomyocytes themselves may be sufficient to cause myocardial injury after burn.

Quality Assurance Assessment of the Use of Linezolid in the Treatment of Thermal Injury Patients at a Community Teaching Hospital

We sought to evaluate the adverse effect profile of linezolid among thermal injury patients requiring treatment for Enterococcus species or other Gram-positive infection warranting treatment with linezolid. Seventy-six inhalation injury and/or thermal injury patients experiencing 94 exposures to linezolid for 48 hours or longer (range, 2-83 days) were included. We evaluated leukocyte count and platelet count for the time period preceding, during, and after therapy with linezolid based on specified time periods of exposure for evaluation of specific adverse effects. Sixty-three of 76 (83%) patient admissions were complicated by inhalation injury. The average TBSA involvement was 34.4% (range, 0-98%). The onset of thrombocytopenia before linezolid therapy was noted in 21 of 57 patients (36.8%), which was attributable to fluid resuscitation and acute platelet consumption. After they were exposure to linezolid, 12 patients developed thrombocytopenia. Platelet counts recovered in 7 of these 12 patients with continued exposure to linezolid; however, thrombocytopenia persisted for more than 9 days after therapy in 9 patients, of whom 6 patients succumbed to sepsis. On average, thrombocytes increased by 102,000/mm3 during linezolid treatment. Leucopenia was rare in thermal injury patients, and persisting thrombocytopenia in this population was associated with sepsis and mortality. Continuing linezolid therapy after the onset of thrombocytopenia among survivors almost always resulted in recovery from thrombocytopenia.

Screening for the formation of reactive oxygen species and of NO in muscle tissue and remote organs upon mechanical trauma to the mouse hind limb

BACKGROUND

Until now, no systematic surveys exist in the literature on the early local and systemic generation of reactive oxygen species and of nitric oxide in response to muscle crush injury. Therefore, this study aims to evaluate the formation of reactive oxygen species and nitric oxide in different tissues (injured and contralateral muscle, liver, kidney, spleen and blood) that is induced by closed muscle trauma.

METHODS

5, 45 and 180 min after induction of blunt trauma to the mouse gastrocnemius muscle, animals were sacrificed, tissues harvested and homogenized, and analyzed for their content of glutathione, nitrate and thiobarbituric acid-reactive substances.

RESULTS

The local formation of reactive oxygen species in the injured muscle started immediately upon induction of the mechanical trauma as indicated by changes in the glutathione redox balance. Liver and kidney did not show any response to trauma; however, a marked and immediate increase in the splenic nitrate content was detected, thus suggesting a specific nitric oxide-dependent response of splenic cells to injury.

CONCLUSION

We conclude that immediately after the induction of trauma a formation of reactive oxygen species takes place at the site of crush injury. This might constitute the basis of further damage to the injured tissue by free radical-dependent mechanisms. The immediate formation of nitric oxide within the spleen upon muscle crush appears to represent a specific signalling mechanism of the body in response to distant organ injury.

Recombinant human erythropoietin improves angiogenesis and wound healing in experimental burn wounds

OBJECTIVE

Erythropoietin interacts with vascular endothelial growth factor (VEGF) and stimulates endothelial cell mitosis and motility; thus it may be of importance in the complex phenomenon of wound healing. The purpose of this study was to investigate the effect of recombinant human erythropoietin (rHuEPO) on experimental burn wounds.

DESIGN

Randomized experiment.

SETTING

Research laboratory.

SUBJECTS

C57BL/6 male mice weighing 25-30 g.

INTERVENTIONS

Mice were immersed in 80 degrees C water for 10 secs to achieve a deep-dermal second degree burn. Animals were randomized to receive either rHuEPO (400 units/kg/day for 14 days in 100 microL subcutaneously) or its vehicle alone (100 microl/day distilled water for 14 days subcutaneously). On day 14 the animals were killed. Burn areas were used for histologic examination, evaluation of neoangiogenesis by immunohistochemistry, and expression (Western blot) of the specific endothelial marker CD31 as well as quantification of microvessel density, measurement of VEGF wound content (enzyme-linked immunosorbent assay), expression (Western blot) of endothelial and inducible nitric oxide synthases, and determination of wound nitric oxide (NO) products.

MEASUREMENTS AND MAIN RESULTS

rHuEPO increased burn wound reepithelialization and reduced the time to final wound closure. These effects were completely abated by a passive immunization with specific antibodies against erythropoietin. rHuEPO improved healing of burn wound through increased epithelial proliferation, maturation of the extracellular matrix, and angiogenesis. The hematopoietic factor augmented neoangiogenesis as suggested by the marked increase in microvessel density and by the robust expression of the specific endothelial marker CD31. Furthermore, rHuEPO enhanced the wound content of VEGF caused a marked expression of endothelial and inducible nitric oxide synthases and increased wound content of nitric oxide products.

CONCLUSIONS

Our study suggests that rHuEPO may be an effective therapeutic approach to improve clinical outcomes after thermal injury.

The immunological consequences of injury

Immediate and early trauma death rates are determined by "first hits" such as hypoxia, hypotension and organ injury, while late mortality correlates closely with "second hits" such as infection. An imbalance between the early systemic inflammatory response (SIRS), and the later compensatory counter-inflammatory response (CARS), is considered to be responsible for much post-traumatic morbidity and mortality. From a clinical perspective, this remains a significant healthcare problem, which has stimulated decades of experimental and clinical research aimed at understanding the functional effects of injury on the immune system. This review describes the impact of injury on the innate and adaptive immune systems. Though it is worth noting that the features of the immune response to injury overlap in many areas with immune dysregulation in sepsis, we attempt here to elucidate the mechanism by which injury predisposes to infection rather than to describe the alterations in host immunity consequent to established sepsis.

Nitric oxide contributes to the development of a post-injury Th2 T-cell phenotype and immune dysfunction

Severe injury induces immune dysfunction resulting in increased susceptibility to opportunistic infections. Previous studies from our laboratory have demonstrated that post-burn immunosuppression is mediated by nitric oxide (NO) due to the increased expression of macrophage inducible nitric oxide synthase (iNOS). In contrast, others suggest that injury causes a phenotypic imbalance in the regulation of Th1- and Th2 immune responses. It is unclear whether or not these apparently divergent mediators of immunosuppression are interrelated. To study this, C57BL/6 mice were subjected to major burn injury and splenocytes were isolated 7 days later and stimulated with antiCD3. Burn injury induced NO-mediated suppression of proliferative responses that was reversed in the presence of the NOS inhibitor L-monomethyl-L-arginine and subsequently mimicked by the addition of the NO donor, S-nitroso-N-acetyl-penicillamine (SNAP). SNAP also dose-dependently suppressed IFN-gamma and IL-2 (Th1), but not IL-4 and IL-10 (Th2) production. Delaying the addition of SNAP to the cultures by 24 h prevented the suppression of IFN-gamma production. The Th2 shift in immune phenotype was independent of cGMP and apoptosis. The addition of SNAP to cell cultures also induced apoptosis, attenuated mitochondrial oxidative metabolism and induced mitochondrial membrane depolarization. However, these detrimental cellular effects of NO were observed only at supra-physiologic concentrations (>250 microM). In conclusion, these findings support the concept that NO induces suppression of cell-mediated immune responses by selective action on Th1 T cells, thereby promoting a Th2 response.

Opiate Analgesics Contribute to the Development of Post-Injury Immunosuppression1

BACKGROUND

Immune dysfunction and post-injury infections are complications associated with thermal injury. Opiates, the analgesic of choice for the treatment of post-burn pain, can also induce similar immune complications. However, the impact of therapeutic opiates on post-burn immune dysfunction is unknown.

MATERIALS AND METHODS

C57BL/6 mice were subjected to a small 6.25% total body surface area (TBSA) burn or sham procedure. The mice were left untreated or treated with morphine sulfate by subcutaneous implantation of an Alzet pump that administered morphine sulfate at a rate of 2 mg/kg body weight/day. Plasma, splenocytes and splenic macrophages were isolated for in vitro analysis 1, 4, or 7 days later.

RESULTS

Neither burn injury nor morphine treatment alone significantly altered splenic T-cell proliferation at 1, 4, or 7 days post-injury/treatment. In contrast, morphine treatment of injured mice suppressed splenic T-cell proliferation at 4 and 7 days post-injury/treatment. The suppressed proliferation of T-cells correlated with increased levels of the nitric oxide and an immunosuppressive Th-2 type phenotype. In contrast morphine treatment did not accentuate the suppressed T-cell proliferative responses associated with larger injuries covering 12.5% and 25% TBSA. Splenic macrophage function was unaffected with the exception that LPS-induced nitric oxide production was elevated in the injured mice treated with morphine.

CONCLUSIONS

These findings demonstrate that those mice treated with a clinically relevant dose of morphine sulfate after an "immunologically insignificant" burn displayed immunosuppression and a Th-2 cytokine profile. Thus, the therapeutic administration of exogenous opiates appears to contribute to the development of post-burn immune dysfunction.

LIPID PEROXIDATION INHIBITION BY RAXOFELAST IMPROVES ANGIOGENESIS AND WOUND HEALING IN EXPERIMENTAL BURN WOUNDS

We investigated the effects of raxofelast, a lipid peroxidation inhibitor, in an experimental model of burn wounds. C57BL/6 male mice of 25-30 g were immersed in 80 degrees C water for 10 seconds to achieve a partial-thickness scald burn. Animals received intraperitoneally either raxofelast (20 mg/kg/day for 14 days in 100 microL) or its vehicle alone (100 microL/day for 14 days). On day 14, burn areas were used for measuring conjugated dienes, reduced glutathione levels, histological damage, neoangiogenesis by immunohistochemistry and expression (Western blot) of the specific endothelial marker CD31 as well as quantification of microvessel density, VEGF wound content, endothelial and inducible nitric oxide synthase (eNOS and iNOS) expression and wound nitrite content. Raxofelast decreased tissue conjugated dienes (vehicle 6.1 +/- 1.4 DeltaABS/mg protein; raxofelast 3.7 +/- 0.8 DeltaABS/mg protein), prevented tissue glutathione consumption (vehicle 3.2 +/- 0.9 micromol/g protein; raxofelast 6.7 +/- 1.8 mumol/g protein), increased epithelial proliferation, extracellular matrix maturation, and augmented neoangiogenesis as suggested by the marked increase in microvessel density and by the robust expression of the specific endothelial marker CD31 (vehicle 9.4 +/- 1.1 integrated intensity; raxofelast 14.8 +/- 1.8 integrated intensity). Furthermore, raxofelast enhanced VEGF wound content (vehicle 1.4 +/- 0.4 pg/mg protein; raxofelast 2.4 +/- 0.6 pg/mg protein), caused a marked expression of eNOS (vehicle 16.1 +/- 3 integrated intensity; raxofelast 26.2 +/- 4 integrated intensity) and iNOS (vehicle 9.1 +/- 1.8 integrated intensity; raxofelast 16.2 +/- 3.5 integrated intensity) and increased wound nitrite content. Lipid peroxidation inhibition by raxofelast may be an effective therapeutic approach to improve clinical outcomes after thermal injury.

EFFECTS OF BURN SERUM ON MYOCARDIAL INFLAMMATION AND FUNCTION

Large cutaneous burns are clearly recognized to produce acute myocardial contractile dysfunction. This study used a model of burn serum challenge in either primary cardiomyocyte cultures or isolated perfused hearts to examine several aspects of burn-serum-related contractile dysfunction as well as myocardial inflammatory responses. Despite the absence of detectable LPS in burn serum, pretreating isolated cells or perfused hearts with recombinant bactericidal permeability-increasing protein (rBPI21) prevented both the inflammatory cytokine cascade and the cardiac contractile dysfunction induced by burn serum treatment of myocytes or ventricular muscle preparations. Our finding that anti-TNF strategies applied to isolated myocytes or hearts before burn serum challenge prevented myocardial inflammation and contractile dysfunction suggested that LPS or LPS-like factors may require the action of second messengers such as TNF-alpha and IL-1beta to mediate LPS-related myocardial depressant effects. Our finding that experimental approaches neutralizing circulating LPS provided cardioprotection suggested that bacterial endotoxin or LPS-like molecules contribute, in part, to burn-related myocardial contractile dysfunction.

MAP kinases differentially regulate the expression of macrophage hyperactivity after thermal injury

Thermal injury increases the capacity of macrophages (Mphi) to produce various inflammatory mediators, (i.e., Mphi hyperactivity), which is believed to be involved in the development of subsequent immunosuppression, sepsis, and multiple organ failure. The signal transduction pathways involved in the expression of Mphi hyperactivity post-burn, however, remain to be clearly elucidated. To study this C57BL/6 female mice were subjected to a 25% TBSA burn and splenic Mphis were isolated 7 days later. LPS-stimulated inflammatory mediator production and MAPK expression (P38 ERK 1/2 and JNK) were determined. Burn injury increased LPS-induced P38 MAPK, suppressed JNK activation and ERK 1/2 activation was unaltered. These changes in MAPK activation were paralleled by the increased production of PGE(2), TNF-alpha, IL-1beta, IL-6, and IL-10. Differential sensitivity to the inhibition of the MAPK pathways was observed with regard to the mediator evaluated and the presence or absence of burn injury. In general cytokine production in the burn group was in part resistant to the inhibition of a single MAPK pathway as compared with shams. Thus, burn injury increases cross-talk between the MAPKs pathways, suggesting that alterations MAPK activation and signal transduction contribute to the development Mphi hyperactivity post-injury.

Nitric oxide, inflammation and acute burn injury

Nitric oxide (NOz.rad;) is a diatomic mediator liberated on oxidation of L-arginine by the nitric oxide synthase (NOS) family of enzymes. It has complex and wide ranging functions in vivo and has been implicated in the development of the profound inflammatory response that occurs as a result of cutaneous burn injury. In addition, dysregulation of NOS activity has been associated with multiple organ failure in human burn patients and may therefore represent a novel therapeutic target in such circumstances. This review focuses on the role of NOz.rad; in inflammation, with particular emphasis on the acute post-burn inflammatory response. Specific areas of discussion include the maintenance of microvascular haemostasis, leukocyte recruitment and remote organ dysfunction following thermal injury.

Effects of a thermal injury on brain and blood nitric oxide (NO) content in the rat

In the present study, the effects of a thermal injury on the nitric oxide (NO)-ergic system was investigated in freely moving rats. Using a voltammetric method allowing direct and in situ NO measurements, a significant decrease in cortical NO concentration was observed during the 24h following burning procedure. Since in the burning procedure halothane was employed, it was verified that this anaesthetic did not induce significant effect on cortical NO level. Experiments conducted in ex vivo conditions showed that blood NO and nitrites (NO(2)(-)) + nitrates (NO(3)(-)) concentrations increased strongly after burn injury while hypothalamic inducible NO-synthase (NOS(2)) mRNA level decreased significantly. A thermal injury was thus accompanied by a rapid impairment of the NO-ergic pathways, which might partly have been responsible for numerous changes occurring after burn injury.

Functional significance of inducible nitric oxide synthase induction and protein nitration in the thermally injured cutaneous microvasculature

Increased nitric oxide (NO) production after burn injury is well established. However, there is little information relating to the reactions that occur as a consequence of NO generation under such circumstances. We have investigated the synthesis and function of NO in a rat model of local cutaneous thermal injury. We show that NO levels are elevated from 3 hours after injury with a concomitant increase in protein nitration. A selective inducible nitric oxide synthase (iNOS) inhibitor (1400W) significantly attenuated NO synthesis, protein nitration, and neutrophil accumulation in this model, but had no effect on edema formation. The results also indicate that NO synthesis and protein nitration occurred independently of neutrophil accumulation because these parameters were unaffected by depletion of circulating neutrophils. 3-Chlorotyrosine, a marker of neutrophil/myeloperoxidase-mediated protein damage was significantly increased from 1 hour after burn. Our observations provide evidence for the involvement of reactive species in the inflammatory response after burn. The use of selective iNOS inhibitors may represent a novel approach for the management of human burn injuries.

Effect of recombinant adeno-associated virus vector-mediated vascular endothelial growth factor gene transfer on wound healing after burn injury

OBJECTIVE

The purpose of this study was to investigate the effect of recombinant adeno-associated viral (rAAV) vector-mediated human vascular endothelial growth factor (VEGF165) transfer on experimental burn wounds.

DESIGN

Randomized experiment.

SETTING

Research laboratory.

SUBJECTS

C57BL/6 male mice weighing 25-30 g.

INTERVENTIONS

Mice were immersed in 80 degrees C water for 10 secs to achieve a partial-thickness scald burn. Animals were randomized to receive at two injection sites on the edge of the burn either 1011 copies of the rAAV-VEGF165 or the vector carrying the control and inert gene beta-galactosidase (rAAV-LacZ). On day 14 the animals were killed. Burn areas were used for histologic examination, evaluation of VEGF expression (immunohistochemistry) and VEGF wound content (enzyme-linked immunosorbent assay), determination of wound nitrite, and measurement of messenger RNA (mRNA) for endothelial and inducible nitric oxide synthase (eNOS and iNOS).

MEASUREMENTS AND MAIN RESULTS

rAAV-VEGF165 increased epithelial proliferation, angiogenesis, and maturation of the extracellular matrix. Furthermore, gene transfer enhanced VEGF expression, studied by immunohistochemistry, and the wound content of the mature protein (rAAV-LacZ, 11 +/- 5 pg/wound; rAAV-VEGF165, 104 +/- 7 pg/wound). Moreover, VEGF165 gene transfer increased wound content of nitrate. Finally, rAAV-VEGF165 administration enhanced the messenger RNA for eNOS (rAAV-VEGF165, 1.1 +/- 0.2 relative amount of eNOS mRNA; rAAV-LacZ, 0.66 +/- 0.3 relative amount of eNOS mRNA) and iNOS (rAAV-VEGF165, 0.8 +/- 0.09 relative amount of iNOS mRNA; rAAV-LacZ, 0.45 +/- 0.05 relative amount of iNOS mRNA).

CONCLUSION

Our study suggests that rAAV-VEGF gene transfer may be an effective therapeutic approach to improve clinical outcomes after thermal injury.

Nitric oxide suppression triggers apoptosis through the FKHRL1 (FOXO3A)/ROCK kinase pathway in human breast carcinoma cells

BACKGROUND

The winged helix/forkhead transcriptional factor FKHRL1 (FOXO3a) triggers apoptosis, but its mode of action is not well understood. ROCK kinase is an effector molecule in human breast carcinoma cell apoptosis, but its relation to FKHRL1 is unknown. Because the human breast carcinoma T47D cell line releases a great amount of nitric oxide (NO), I investigated signaling of FKHRL1/ROCK [corrected] kinase during NO suppression.

METHODS

Expression of phosphorylated FKHRL1 in T47D cells was analyzed using Western blotting. Apoptosis was evaluated by flow cytometry. Transfection of FKHRL1-HA wild-type and mutant FKHRL1-HA T32A constructs were performed by lipofectamine plus reagent. Measurement of NO generation was performed by Griess reaction.

RESULTS

Nitric oxide suppression promotes FKHRL1 thr-32-enhanced phosphorylation, which was significantly (P < 0.005) sensitive to Y-27632, a specific inhibitor of the ROCK kinase, but not to capase-3 inhibitor or wortnannin, a specific inhibitor of phosphoinositol-3-OH kinase (PI3K). Nitric oxide suppression by N-(G)-monomethyl-L-arginine, an inhibitor of NO synthase, causes a significant (P < 0.001) increase in the apoptosis of T47D cells. However, a significant decrease (P < 0.01) in NO generation and a significant (P < 0.01) increase in apoptosis were observed when FKHRL1-HA wild-type cells were transfected, which caused increased FKHRL1 thr-32 phosphorylation.

CONCLUSIONS

This novel unknown phenomenon of breast carcinoma cell apoptosis was triggered by NO suppression, which promotes FKHRL1 thr-32-enhanced phosphorylation and initiates signaling of FKHRL1 to ROCK kinase as an effector molecule. This apoptotic signalling process is caspase-3 as well as PI3K/Akt independent.

Macrophages and post-burn immune dysfunction

The activation of a pro-inflammatory cascade after burn injury appears to be important in the development of subsequent immune dysfunction, susceptibility to sepsis and multiple organ failure. Macrophages are major producers of pro-inflammatory mediators and their productive capacity for these mediators is markedly enhanced following thermal injury. Thus, macrophage hyperactivity (as defined by increased productive capacity for pro-inflammatory mediators) appears to be of critical importance in the development of post-burn immune dysfunction. This review will focus on the current state of knowledge with regards to the role of macrophages in the development of post-burn immune dysfunction. Particular areas of discussion include: nitric oxide synthase (NOS) and cyclooxygenase (COX) enzyme systems, macrophages and the T-helper (Th)-1/Th-2 cytokine responses, alterations in macrophages signal transduction and a potential role for gamma/delta T-cells in the development of macrophage hyperactivity following thermal injury. A more comprehensive understanding of the relationship between macrophage activity and post-burn immune dysfunction will hopefully provide the basis for improved therapeutic regimes in the treatment of burn patients.

Nitric oxide inhibits spleen cell proliferative response after burn injury by inducing cytostasis, apoptosis, and necrosis of activated T lymphocytes: role of the guanylate cyclase

We previously showed that an overproduction of nitric oxide (NO) by macrophages was responsible for the collapse of lymphoproliferative responses after burn injury in rats. First, we demonstrate here that 10 days post-burn, the inhibition of splenocyte response to concanavalin-A results from cytostatic, apoptotic, and necrotic effects of NO on activated T cells. This was evidenced by various criteria at the levels of DNA, mitochondria, and plasma membrane. Inhibition of NO synthase by S-methylisothiourea (10 microM) normalized all the parameters. Second, we show that two soluble guanylate cyclase (sGC) inhibitors, LY83583 and ODQ, restored the proliferative response in a concentration-dependent manner. LY83583 (0.5 microM) rescued T cells from apoptosis. Similar results were obtained with KT5823 (5 microM) a specific inhibitor of protein kinase G (PKG). In contrast, neither LY83583 nor KT5823 inhibited NO-induced necrosis. These results suggest that NO blocked T cells in the G1 phase and induced apoptosis through a sGC-PKG-dependent pathway and necrosis through an independent one.

Nitric oxide directly impairs intestinal barrier function

Excess production of nitric oxide (NO) has been implicated in endotoxin-induced loss of gut barrier function in vivo. Thus, we tested the direct effect of NO on the barrier function of intestinal mucosal membranes suspended ex vivo in Ussing chambers and on IEC-6 enterocyte monolayers. In these experiments, ex vivo-mounted ileal membranes or IEC-6 cell enterocyte monolayers were exposed to the NO donor, S-nitroso-N-acetyl-penicillamine (SNAP) over a dose range (10 microm to 2 mM) or medium. SNAP at concentrations of 1 or 2 mM, but not 10 or 100 microM, increased the rates of bacterial translocation (BT) across both the ileal membranes and the IEC-6 monolayers by >1 log (P < 0.05), as well as the permeability of the IEC-6 monolayers to phenol red (P < 0.05). The ileal membranes exposed to 1 or 2 mM SNAP for 3 h manifested histologic evidence of mucosal injury and decreases in electrical resistance and potential difference values (P < 0.05), while the IEC-6 cells exposed to SNAP for 18 h had increased levels of cell death (P < 0.05). Since NO produced locally by stimulated enterocytes could contribute to barrier dysfunction, NO production, iNOS mRNA levels, and monolayer permeability were measured in enterocytes (IEC-6 and Caco-2) exposed to medium, endotoxin (lipopolysaccharide [25 microg/mL]) or a cytokine mixture (IL-1beta 10 ng/mL, TNF-alpha 10 ng/mL, and INF-gamma 250 U/mL) for 6 or 24 h. Endotoxin increased NO production, iNOS mRNA expression, and monolayer permeability in the IEC-6, but not the Caco-2 cells, while exposure to the cytokine mixture increased both NO production, iNOS mRNA expression, and monolayer permeability in both the IEC-6 and Caco-2 cell lines. Based on the results of these studies it appears that NO can directly increase ileal mucosal membrane and enterocyte monolayer permeability and BT and that increased NO production and iNOS mRNA expression is associated with endotoxin- and/or cytokine-induced loss of enterocyte monolayer barrier function.

Resistance of macrophages to the suppressive effect of interleukin-10 following thermal injury

The activation of a macrophage (Mphi)-dependent proinflammatory cascade following thermal injury plays an important role in the development of immunosuppression and increased susceptibility to subsequent sepsis in burn patients. In contrast, although interleukin (IL)-10, an anti-inflammatory cytokine that can downregulate M phi activity, has also been implicated in postburn immune dysfunction, its role in the regulation of M phi function postburn remains unclear. To study this, C57BL/6 female mice were subjected to a 25% total body surface area third-degree scald burn, and splenic Mphis were isolated 7 days later. Lipopolysaccharide (LPS)-stimulated IL-10, IL-6, tumor necrosis factor (TNF)-alpha, and nitric oxide (NO) production were significantly increased in the burn group compared with shams. Blockade of endogenous IL-10 activity enhanced IL-6 and TNF-alpha release, but not NO release, in both groups. The addition of exogenous IL-10 to the M phi cultures dose dependently suppressed production of these inflammatory mediators in both groups. The timing of IL-10 addition to the cultures in relation to LPS stimulation, however, was critical. The suppressive effect of exogenous IL-10 was attenuated in both groups when the cells were exposed to IL-10 at 4-6 h after LPS stimulation; however, Mphis from injured mice were significantly better able to maintain inflammatory mediator-productive capacity. The resistance of Mphis from injured mice to IL-10-mediated suppression correlated with decreased IL-10 receptor (IL-10R) expression and increased CD11b expression. These findings suggest that Mphis, following thermal injury, display resistance to suppression by IL-10 due in part to downregulation of IL-10R expression.

Effects of nitric oxide synthase inhibitors on vascular hyperpermeability with thermal injury in mice

The role of nitric oxide and related synthase in thermal injury was investigated by using models of experimental burn to evaluate severity from the aspect of vascular permeability. Thermal injuries were produced in the murine right ear by pinching with a pair of preheated tweezers. Immediately thereafter, Evans blue dye was intravenously administered, and the mice injured with burns were sacrificed at various times. The burned ears were collected and hydrolyzed, and the level of extracted dye was measured as an indicator of inflammation. Vascular hyperpermeability was suppressed by the administration of nitric oxide synthase inhibitors. LNAME not only suppressed vascular hyperpermeability in thermal injuries in a dose-dependent manner but was also effective with either prophylactic or therapeutic administration. Although aminoguanidine also suppressed the inflammatory response, it had no effect on the early inflammatory phase. Nitric oxide synthase is well known to have two types of isozymes. Aminoguanidine, an inhibitor specific to inducible nitric oxide synthase, suppressed the late phase 6 h after injury, suggesting that inducible nitric oxide synthase is involved in inflammatory responses of thermal injuries. These results also demonstrated that inducible nitric oxide synthase-like protein stained the burned region immunohistochemically. Therefore, both types of enzymes mediating nitric oxide affect inflammatory responses, i.e., vascular hyperpermeability, and their regulation may lead to the development of new therapy for thermal injuries.

Analysis of plasma nitrite/nitrate in human thermal injury

The aim of this study is to examine the characteristics of nitrite/nitrate (NOx), the final metabolite of nitric oxides, in plasma after burn injury. A total of 83 blood samples were collected from 19 patients on arrival, day 1, day 3, and day 5 after suffering burn injuries and from 7 non-burned volunteers. We measured the NOx levels in plasma using the Griess method, and analyzed the relationships among plasma the NOx levels, the burn-magnitude, and the blood examination data using a stepwise multivariate regression analysis. The plasma NOx levels at hospital-arrival after burns significantly exceeded those of non-burned volunteers, and the NOx levels in the plasma returned to normal range after day 1. Based on the findings of a multivariate analysis, the plasma NOx levels at admission to the hospital were not found to be related to the total burn surface area, the burn index or inhalation injury, but they were significantly related to age. Furthermore, these plasma NOx levels were also related to the platelet count, neutrophil count and blood urea nitrogen. The increase in the plasma NOx level may therefore play an important role in the pathophysiology of elderly burned patients, while the nitric oxide levels in the plasma might also play a role in inhibiting the constriction of microvascular smooth muscle in extensively burned patients.

Effect of nitric oxide synthase inhibitor on experimentally induced burn wounds

BACKGROUND

Nitric oxide (NO) may have an important role in the healing of burn wounds. This study investigated the effect of NO on experimentally induced burn wounds by preventing NO synthesis.

METHODS

A total of 40 mice weighing 25 to 30 g were used in this study. The shaved skin on the back of the mice was immersed in 100 degrees C water for 10 seconds to achieve a partial-thickness scald burn. The mice were divided into two groups of 20. In group I (control group), 17.5 mg/kg of serum physiologic (placebo) was injected intraperitoneally two times a day for 15 days. In group II (study group), 17.5 mg/kg of aminoguanidine (NO synthase inhibitor) was injected intraperitoneally two times a day for 15 days. On day 15 of the burn, the animals were killed and the burn areas were investigated histologically. Histologic changes such as epithelial proliferation, abscess, collagen, and granulation tissue were evaluated.

RESULTS

Epithelial proliferation, formation of collagen, and granulation tissue with rich capillaries observed in the control group were statically significantly higher than those observed in the study group (z = -2.022, p < 0.05; z = -2.02, p < 0.05; and z = -2.022, p < 0.05; respectively).

CONCLUSION

We concluded that healing of the burn wound is delayed by preventing NO synthesis.

Vascular endothelial growth factor up-regulates ICAM-1 expression via the phosphatidylinositol 3 OH-kinase/AKT/Nitric oxide pathway and modulates migration of brain microvascular endothelial cells

Endothelium of the cerebral blood microvessels, which constitutes the major component of the blood-brain barrier, controls leukocyte and metastatic cancer cell adhesion and trafficking into the brain parenchyma. In this study, using rat primary brain microvascular endothelial cells (BMEC), we demonstrate that the vascular endothelial growth factor (VEGF), a potent promoter of angiogenesis, up-regulates the expression of the intracellular adhesion molecule-1 (ICAM-1) through a novel pathway that includes phosphatidylinositol 3 OH-kinase (PI3K), AKT, and nitric oxide (NO), resulting in the migration of BMEC. Upon VEGF treatment, AKT is phosphorylated in a PI3K-dependent manner. AKT activation leads to NO production and release and activation-deficient AKT attenuates NO production stimulated by VEGF. Transfection of the constitutive myr-AKT construct significantly increased basal NO release in BMEC. In these cells, VEGF and the endothelium-derived NO synergistically up-regulated the expression of ICAM-1, which was mediated by the PI3K pathway. This activity was blocked by the PI3K-specific inhibitor, wortmannin. Furthermore, VEGF and NO significantly increased BMEC migration, which was mediated by the up-regulation of ICAM-1 expression and was dependent on the integrity of the PI3K/AKT/NO pathway. This effect was abolished by wortmannin, by the specific ICAM-1 antibody, by the specific inhibitor of NO synthase, N(G)-l-monomethyl-arginine (l-NMMA) or by a combination of wortmannin, ICAM-1 antibody, and l-NMMA. These findings demonstrate that the angiogenic factor VEGF up-regulates ICAM-1 expression and signals to ICAM-1 as an effector molecule through the PI3K/AKT/NO pathway, which leads to brain microvessel endothelial cell migration. These observations may contribute to a better understanding of BMEC angiogenesis and the physiological as well as pathophysiological function of the blood-brain barrier, whose integrity is crucial for normal brain function.

Role of nitric oxide in wound healing

Nitric oxide is a short-lived free radical, that is capable of multiple effects at the molecular, cellular, and physiologic levels. Over the past several years, nitric oxide has been proved to play an important role in the healing of various types of wounds. The present review examines some of the recently defined roles of nitric oxide in normal and pathologic healing.

The effect of heat on cytokine production in rat endotoxemia

OBJECTIVE

To determine whether heat stress protects the endotoxemic rat by up-regulation of the counterinflammatory cytokine interleukin (IL)-10, thereby attenuating the inflammatory response.

DESIGN

A total of 16 rats were assigned to either the heat stress group (n = 8) or the control group (n = 8). The heat stress group was warmed to a temperature of >42 degrees C (107.6 degrees F) rectally for 10-15 mins; 20 hrs later, all rats were intubated, paralyzed, and ventilated. After jugular venous and arterial catheterization, endotoxin was given intravenously. Arterial blood was removed at 0, 2, 4, and 5 hrs for blood gases, tumor necrosis factor (TNF)-alpha, nitric oxide metabolites (NO), IL-10, and macrophage inflammatory protein (MIP)-2. The alveolar macrophages were removed, counted, and then incubated for 24 hrs. The supernatant was analyzed for TNF-alpha, NO, IL-10, and MIP-2.

SETTING

University research laboratory.

SUBJECTS

Male Sprague-Dawley rats (n = 16).

INTERVENTIONS

Administration of heat before endotoxin infusion.

MEASUREMENTS AND MAIN RESULTS

Alveolar-arterial oxygen gradient was lower in the heat stress group at 4 and 5 hrs after endotoxemia. Plasma and alveolar macrophage supernatant concentrations of TNF-alpha, NO, and IL-10 were not affected by heat. Plasma and alveolar macrophage supernatant MIP-2 concentrations were higher in endotoxemic rats receiving heat pretreatment compared with controls.

CONCLUSIONS

Our study demonstrates that heat leads to pulmonary protection of short duration in severe endotoxemia. This protection was not mediated by plasma TNF-alpha, IL-10, or NO. Contrary to our hypothesis, pretreatment with heat increased rather than decreased the plasma MIP-2 concentration and alveolar macrophage production of MIP-2 in endotoxemia. The mechanism of heat-conferred pulmonary protection in endotoxemia remains unclear. Alveolar macrophages do not produce IL-10 in endotoxemia. The increased MIP-2 production by heated alveolar macrophages was not attributable to alterations in production of either TNF-alpha or IL-10. The significance of increased MIP-2 by endotoxin-exposed alveolar macrophages in heated rats is unknown.

Effects of short-term nitrogen monoxide inhalation on leukocyte adhesion molecules, generation of reactive oxygen species, and cytokine release in human blood

Increased nitrogen monoxide (NO) concentrations change leukocyte function under a multitude of experimental conditions. NO inhalation is an experimental treatment for lung failure and exposes leukocytes to increased NO concentrations during passage through the lungs. To investigate whether short-term NO inhalation induces lasting changes in the function of circulating human leukocytes, venous blood samples were drawn from eight healthy male volunteers before and at the end of a 35-min period of breathing 40 ppm NO in 30% O(2). The leukocytes in the samples were subsequently analyzed for NO-induced changes in expression of cell surface molecules, generation of reactive oxygen species (ROS), and cytokine production by flow cytometry and ELISA techniques. The results were (1) NO inhalation changed neither the baseline nor the Escherichia coli lipopolysaccharide (LPS)-induced expression of the cell adhesion molecules CD11a, CD11b, CD11c, and CD62L (l-selectin) on neutrophilic granulocytes (PMN) or monocytes (Mo). The expression of CD14 and HLA-DR was also unchanged. (2) The generation of ROS in response to activation with phorbol myristate acetate increased in PMN after NO inhalation; an increase in Mo did not reach significance. (3) Baseline and LPS-stimulated production of IL-1beta decreased after NO inhalation, while the LPS-stimulated production of TNF-alpha increased. No changes in IL-6 production were detected.

The effects of human burn injury on urinary nitrate excretion

Different studies have demonstrated both an increase and a decrease in the biosynthesis of nitric oxide (NO) during the first 2 days following experimental and human burn trauma. This study investigated changes in urinary nitrate excretion in humans following thermal injury in order to determine the temporal relationship between NO release and the initial injury. Urinary nitrate was measured in daily 24-h urine collections taken on days 1-7 following burn injury from 15 patients. The control group consisted of 11 healthy, age- and sex-matched patients who kept a nitrate-restricted diet for five days prior to collection of a single 24-h urine sample. The burns group had a mean age of 41.9 +/- 19.4 (mean +/- S.D.) years and a mean total burn surface area (TBSA) of 30.2 +/- 24.9% (mean +/- S.D.). In the burn injured patients, urinary nitrate levels peaked at day 4 and a 2-fold increase relative to day 1 was observed. Urinary nitrate levels were significantly higher in the burns group than the control group on days 4 and 5 only (p < 0.05 for both days). There was no correlation between TBSA and the measured urinary nitrate levels. This study confirms that the biosynthesis of NO is increased during the first week following burn trauma and establishes that the renal elimination of the by-products of NO metabolism is not increased during the first three days after injury. Notwithstanding the potential effects of burns on nitrate distribution, our findings may reflect a delay in the release of NO following the initial insult.

Acetylcholine-induced and nitric oxide-mediated vasodilation in burns

Microvascular endothelial cells actively participate in local regulation of blood flow and blood-tissue exchange by producing various vasoactive substances including nitric oxide (NO). This study examined microcirculatory changes in the early stage of thermal injury and the NO-related mechanisms. Resistance arterioles of rat cremaster muscle were observed using intravital microscopy. Arteriolar diameter and flow velocity were measured and flow rate was calculated after administration of various vasoactive agonists in burns. In fluid-resuscitated rats with stable systemic blood pressure, microvascular caliber and blood flow were not significantly altered in the first hour following a 25% total body surface area full-thickness scald burn. Topical application of acetylcholine (ACh), an endothelium-dependent vasodilator, increased arteriolar diameter and flow rate in a dose-dependent fashion. The dose-responsive effects of ACh were significantly greater in burned rats than in sham-burned rats, and the augmentation was blocked by inhibition of NO production with NG-monomethyl-l-arginine (L-NMMA). Topical application of adenosine, an endothelium-independent vasodilator, and sodium nitroprusside, an exogenous NO donor, markedly increased arteriolar diameter and flow rate. The effects were not significantly different in burned and sham-burned animals, and the adenosine-induced vasodilation was not blocked by L-NMMA. These data suggest that endothelium-dependent and NO-mediated arteriolar dilation is enhanced in the early stage of thermal injury. This effect may play an important role in the pathophysiological events of microcirculation and blood-tissue exchange in burns.

Pathophysiology of nitric oxide and related species: free radical reactions and modification of biomolecules

Since its initial discovery as an endogenously produced bioactive mediator, nitric oxide (.NO) has been found to play a critical role in the cellular function of nearly all organ systems. Furthermore, aberrant production of .NO or reactive nitrogen species (RNS) derived from .NO, has been implicated in a number of pathological conditions, such as acute lung disease, atherosclerosis and septic shock. While .NO itself is fairly non-toxic, secondary RNS are oxidants and nitrating agents that can modify both the structure and function of numerous biomolecules both in vitro, and in vivo. The mechanisms by which RNS mediate toxicity are largely dictated by its unique reactivity. The study of how reactive nitrogen species (RNS) derived from .NO interact with biomolecules such as proteins, carbohydrates and lipids, to modify both their structure and function is an area of active research, which is lending major new insights into the mechanisms underlying their pathophysiological role in human disease. In the context of .NO-dependent pathophysiology, these biochemical reactions will play a major role since they: (i) lead to removal of .NO and decreased efficiency of .NO as an endothelial-derived relaxation factor (e.g. in hypertension, atherosclerosis) and (ii) lead to production of other intermediate species and covalently modified biomolecules that cause injury and cellular dysfunction during inflammation. Although the physical and chemical properties of .NO and .NO-derived RNS are well characterised, extrapolating this fundamental knowledge to a complicated biological environment is a current challenge for researchers in the field of .NO and free radical research. In this review, we describe the impact of .NO and .NO-derived RNS on biological processes primarily from a biochemical standpoint. In this way, it is our intention to outline the most pertinent and relevant reactions of RNS, as they apply to a diverse array of pathophysiological states. Since reactions of RNS in vivo are likely to be vast and complex, our aim in this review is threefold: (i) address the major sources and reactions of .NO-derived RNS in biological systems, (ii) describe current knowledge regarding the functional consequences underlying .NO-dependent covalent modification of specific biomolecules, and (iii) to summarise and critically evaluate the available evidence implicating these reactions in human pathology. To this end, three areas of special interest have been chosen for detailed description, namely, formation and role of S-nitrosothiols, modulation of lipid oxidation/nitration by RNS, and tyrosine nitration mechanisms and consequences.

Nitrite and nitrate analyses: a clinical biochemistry perspective

OBJECTIVE

To review the assays available for measurement of nitrite and nitrate ions in body fluids and their clinical applications.

DESIGN AND METHODS

Literature searches were done of Medline and Current Contents to November 1997.

RESULTS

The influence of dietary nitrite and nitrate on the concentrations of these ions in various body fluids is reviewed. An overview is presented of the metabolism of nitric oxide (which is converted to nitrite and nitrate). Methods for measurement of the ions are reviewed. Reference values are summarized and the changes reported in various clinical conditions. These include: infection, gastroenterological conditions, hypertension, renal and cardiac disease, inflammatory diseases, transplant rejection, diseases of the central nervous system, and others. Possible effects of environmental nitrite and nitrate on disease incidence are reviewed.

CONCLUSIONS

Most studies of changes in human disease have been descriptive. Diagnostic utility is limited because the concentrations in a significant proportion of affected individuals overlap with those in controls. Changes in concentration may also be caused by diet, outside the clinical investigational setting. The role of nitrite and nitrate assays (alongside direct measurements of nitric oxide in breath) may be restricted to the monitoring of disease progression, or response to therapy in individual patients or subgroups. Associations between disease incidence and drinking water nitrate content are controversial (except for methemoglobinemia in infants).

Nitric oxide and human thermal injury short term outcome

Nitric oxide (NO) is an important mediator in numerous physiological and pathophysiological events. After thermal injury an increase in plasma and urinary levels has been observed. The real importance of this fact is unknown. The stable NO derivatives (NO2-/NO3-) plasma concentrations were determined in 27 burned patients admitted to the Burn Unit at Santa Maria Hospital in Lisbon at first, third, fifth, seventh, ninth and 15th days and the values were compared with healthy controls (n=9). A significant increase (P<0.05) in burn patient determinations upon admission was found. The patients with inhalation injury revealed greater values compared to the other patients with statistical significance at 5th day (P<0.05). The patients who died showed a NO increase (0.397+/-0.138 vs. 0.267+/-0.017, P> 0.1, day 1) with significance at day 5 (0.615+/-0.223 vs. 0.154+/-0.048, P<0.05). The determinations in patients with sepsis were higher than in the other patients (P<0.01) at day 3. No relation with total burned surface area (TBSA) was found. For the first time, considering burned patients, a significant increase of NO was found in patients who died, in patients with inhalation injury and in patients in sepsis. The possible role of NO in burn injury is discussed. The authors suggest the possible role of NO determination as an indicator of sepsis. The role of NO synthesis inhibitors is discussed. Further studies are needed to clarify these questions.

Prolonged decreases in plasma nitrate levels at early postoperative phase after hepato-pancreato-biliary surgery

Nitric oxide (.NO) is known to influence circulatory, neural, immunologic, and metabolic alterations. To evaluate the clinical significance of .NO production under surgical stress, serial measurements of plasma nitrite plus nitrate levels were performed in 45 surgical patients. Group A included 19 patients who underwent major surgery with uneventful postoperative courses. Group B included 18 patients who underwent laparoscopic cholecystectomy. Group C included 8 patients whose surgery was complicated by intra-abdominal abscesses. Eight healthy volunteers served as controls. Plasma nitrate levels were determined with a redox chemiluminescence .NO analyzer and coincided with measurements made by high-performance liquid chromatography (r = 0.868, p < 0.0001, 58 samples). During laparotomy, arterial nitrate levels correlated well with peripheral, portal, and hepatic venous nitrate levels (r = 0.966, 0.938, and 0.949, respectively; p < 0.0001). A significant decrease in nitrate from preoperative levels in groups A (postoperative day (POD) 1 and 3; p < 0.0005) and B (POD 1, p < 0.0001) was observed; nitrate levels in group C did not decrease for 14 days after surgery. Plasma nitrate levels in groups A and B were significantly different (POD 1 through 6, p < 0.05) and at POD 3 were significantly lower in group A (p < 0.005). Plasma nitrate levels measured before and after fasting or food intake were not significantly different. These results suggest that surgical stress leads to a decrease in the end product of .NO in the whole body, and that the greater the surgical stress the longer the duration of decreased .NO production.

Nitric oxide production in burns: plasma nitrate levels are not increased in patients with minor thermal injuries

BACKGROUND

Recent studies have suggested that adults who sustain burns of less than 15% total body surface area display elevated plasma nitrate levels, indicating increased production of nitric oxide. The present study was initiated to confirm whether plasma nitrate is elevated in minor burn injury and, if so, whether it heralds the onset of a systemic inflammatory response to that injury.

METHODS

Plasma samples were taken from 98 control and 10 burns patients.

RESULTS

The mean plasma nitrate level for nine burns patients with a mean total body surface area burnt of 7.65% (range, 4-15%) was 42.83 micromol/L on day 1. This was not significantly different from that of a control population of 98 preoperative plastic surgery patients: 36.91 micromol/L (p = 0.162). Eight of 10 burns patients showed a decrease in plasma nitrate to 27.47 micromol/L by day 3 (p = 0.046). Elevated nitrate levels were seen in 2 of 10 burns patients. One had concurrent smoke-inhalation injury preceding multiple organ dysfunction, and one was treated with a cream containing cerium nitrate (Flammacerium, Duphar Laboratories, Southhampton, United Kingdom).

CONCLUSIONS

For patients who sustain minor burns, plasma levels of nitrate decrease from those of mean normal controls with time unless there is multiple organ dysfunction or the patient receives extraneous nitrate.