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Schieffelers DR, Dombrecht D, Lafaire C, De Cuyper L, Rose T, Vandewal M, Meirte J, Gebruers N, van Breda E, Van Daele U. Effects of exercise training on muscle wasting, muscle strength and quality of life in adults with acute burn injury. Burns 2023; 49:1602-1613. [PMID: 37188565 DOI: 10.1016/j.burns.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/23/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Exercise training during the acute phase of burns is difficult to implement but offers potential benefits. This multicenter trial explored the effects of an exercise program on muscular changes and quality of life during burn center stay. METHODS Fifty-seven adults with burns ranging between 10% and 70% TBSA were allocated to receive either standard of care (n = 29), or additionally exercise (n = 28), consisting of resistance and aerobic training, commenced as early as possible according to safety criteria. Muscle wasting (primary outcome), quantified by ultrasound-derived quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA), muscle strength and quality of life (Burn Specific Health Scale-Brief (BSHS-B) and EQ-5D-5L) were assessed at baseline, four and eight weeks later, or hospital discharge. Mixed models were used to analyze between-group changes over time with covariates of interest added in stepwise forward modeling. RESULTS The addition of exercise training to standard of care induced significant improvements in QMLT, RF-CSA, muscle strength and the BSHS-B subscale hand function (ß-coefficient. 0.055 cm/week of QMLT, p = 0.005). No added benefit was observed for other quality-of-life measures. CONCLUSIONS Exercise training, administered during the acute phase of burns, reduced muscle wasting, and improved muscle strength throughout burn center stay.
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Affiliation(s)
- David R Schieffelers
- Multidisciplinary Metabolic Research Unit (M2RUN), MOVANT Research Group, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium.
| | - Dorien Dombrecht
- Multidisciplinary Metabolic Research Unit (M2RUN), MOVANT Research Group, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Cynthia Lafaire
- Burn Unit, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium; OSCARE, Organization for Burns, Scar After-care and Research, Van Roiestraat 18, 2170 Antwerp, Belgium
| | - Lieve De Cuyper
- Burn Unit, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium; OSCARE, Organization for Burns, Scar After-care and Research, Van Roiestraat 18, 2170 Antwerp, Belgium
| | - Thomas Rose
- Burn Unit, Military Hospital Queen Astrid, Rue Bruyn 1, 1120 Brussels, Belgium
| | - Martijn Vandewal
- Burn Unit, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium
| | - Jill Meirte
- Multidisciplinary Metabolic Research Unit (M2RUN), MOVANT Research Group, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium; OSCARE, Organization for Burns, Scar After-care and Research, Van Roiestraat 18, 2170 Antwerp, Belgium
| | - Nick Gebruers
- Multidisciplinary Metabolic Research Unit (M2RUN), MOVANT Research Group, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium; Multidisciplinary Edema Clinic, Antwerp University Hospital, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Eric van Breda
- Multidisciplinary Metabolic Research Unit (M2RUN), MOVANT Research Group, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium.
| | - Ulrike Van Daele
- Multidisciplinary Metabolic Research Unit (M2RUN), MOVANT Research Group, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Wilrijk, Belgium; OSCARE, Organization for Burns, Scar After-care and Research, Van Roiestraat 18, 2170 Antwerp, Belgium.
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Prabhakaran HS, Hu D, He W, Luo G, Liou YC. Mitochondrial dysfunction and mitophagy: crucial players in burn trauma and wound healing. BURNS & TRAUMA 2023; 11:tkad029. [PMID: 37465279 PMCID: PMC10350398 DOI: 10.1093/burnst/tkad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/10/2023] [Accepted: 04/28/2023] [Indexed: 07/20/2023]
Abstract
Burn injuries are a significant cause of death worldwide, leading to systemic inflammation, multiple organ failure and sepsis. The progression of burn injury is explicitly correlated with mitochondrial homeostasis, which is disrupted by the hyperinflammation induced by burn injury, leading to mitochondrial dysfunction and cell death. Mitophagy plays a crucial role in maintaining cellular homeostasis by selectively removing damaged mitochondria. A growing body of evidence from various disease models suggest that pharmacological interventions targeting mitophagy could be a promising therapeutic strategy. Recent studies have shown that mitophagy plays a crucial role in wound healing and burn injury. Furthermore, chemicals targeting mitophagy have also been shown to improve wound recovery, highlighting the potential for novel therapeutic strategies based on an in-depth exploration of the molecular mechanisms regulating mitophagy and its association with skin wound healing.
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Affiliation(s)
- Harshini Sheeja Prabhakaran
- Department of Biological Sciences, Faculty of Science, National University of Singapore, 14 Science drive 4, 117543 Singapore, Singapore
| | - Dongxue Hu
- Department of Biological Sciences, Faculty of Science, National University of Singapore, 14 Science drive 4, 117543 Singapore, Singapore
| | - Weifeng He
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Gao Tan Yan Zheng Street, Sha Ping Ba District, Chongqing, 400038, People's Republic of China
- Chongqing Key Laboratory for Disease Proteomics, Gao Tan Yan Zheng Street, Sha Ping Ba District, Chongqing, 400038, People's Republic of China
| | - Gaoxing Luo
- State Key Laboratory of Trauma, Burn and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Gao Tan Yan Zheng Street, Sha Ping Ba District, Chongqing, 400038, People's Republic of China
- Chongqing Key Laboratory for Disease Proteomics, Gao Tan Yan Zheng Street, Sha Ping Ba District, Chongqing, 400038, People's Republic of China
| | - Yih-Cherng Liou
- Department of Biological Sciences, Faculty of Science, National University of Singapore, 14 Science drive 4, 117543 Singapore, Singapore
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Robles MC, Heard TC, Chao T, Alcover K, Wagner A, Akers KS, Burmeister DM. DIAGNOSTIC VALUE OF MITOCHONDRIAL DNA AND PERIPHERAL BLOOD MONONUCLEAR CELL RESPIROMETRY FOR BURN-RELATED SEPSIS. Shock 2023; 59:294-299. [PMID: 36730861 DOI: 10.1097/shk.0000000000002025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Background: Sepsis is the leading cause of mortality among burn patients that survive acute resuscitation. Clinical criteria have poor diagnostic value for burn-induced sepsis, making it difficult to diagnose. Protein biomarkers (e.g., procalcitonin) have been examined with limited success. We aimed to explore other biomarkers related to mitochondria (mitochondrial DNA [mtDNA]) and mitochondrial function of peripheral blood mononuclear cells (PBMCs) for sepsis diagnosis in burn patients. Methods: We conducted a follow-up analysis of a single center, prospective observational study of subjects (n = 10 healthy volunteers, n = 24 burn patients) to examine the diagnostic value of mtDNA and PBMC respirometry. Patients were enrolled regardless of sepsis status and followed longitudinally. Patient samples were classified as septic or not based on empiric clinical criteria. Isolated PBMCs were loaded into a high-resolution respirometer, and circulating mtDNA was measured with a PCR-based assay. Sequential Organ Failure Assessment (SOFA) criteria were also compared. Results: The SOFA criteria comparing septic versus before/nonseptic patients revealed significantly higher heart rate ( P = 0.012) and lower mean arterial pressure ( P = 0.039) in burn sepsis. MtDNA was significantly elevated in septic burn patients compared with healthy volunteers ( P < 0.0001) and nonseptic patients ( P < 0.0001), with no significant difference between healthy volunteers and nonseptic burn patients ( P = 0.187). The area under the ROC curve (AUC) for mtDNA was 0.685 (95% confidence interval = 0.50-0.86). For PBMC respirometry, burn patients exhibited increased routine and maximal respiration potential compared with healthy volunteers. However, no difference was found between nonseptic and septic patient samples. A subanalysis revealed a significant mortality difference in PBMC respirometry after sepsis diagnosis, wherein survivors had higher routine respiration ( P = 0.003) and maximal respiration ( P = 0.011) compared with nonsurvivors. Conclusion: Our findings reveal that mtDNA may have diagnostic value for burn sepsis, whereas PBMC respirometry is nonspecifically elevated in burns, but may have value in mortality prognosis. A larger, multisite study is warranted for further validity of the diagnostic value of mtDNA and PBMC respirometry as biomarkers for prognosis of sepsis and outcomes in burn patients.
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Affiliation(s)
| | - Tiffany C Heard
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Tony Chao
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | | | - Amanda Wagner
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Kevin S Akers
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
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Santos SS, Brunialti MKC, Soriano FG, Szabo C, Salomão R. Repurposing of Clinically Approved Poly-(ADP-Ribose) Polymerase Inhibitors for the Therapy of Sepsis. Shock 2021; 56:901-909. [PMID: 34115723 DOI: 10.1097/shk.0000000000001820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Sepsis' pathogenesis involves multiple mechanisms that lead to a dysregulation of the host's response. Significant efforts have been made in search of interventions that can reverse this situation and increase patient survival. Poly (ADP-polymerase) (PARP) is a constitutive nuclear and mitochondrial enzyme, which functions as a co-activator and co-repressor of gene transcription, thus regulating the production of inflammatory mediators. Several studies have already demonstrated an overactivation of PARP1 in various human pathophysiological conditions and that its inhibition has benefits in regulating intracellular processes. The PARP inhibitor olaparib, originally developed for cancer therapy, paved the way for the expansion of its clinical use for nononcological indications. In this review we discuss sepsis as one of the possible indications for the use of olaparib and other clinically approved PARP inhibitors as modulators of the inflammatory response and cellular dysfunction. The benefit of olaparib and other clinically approved PARP inhibitors has already been demonstrated in several experimental models of human diseases, such as neurodegeneration and neuroinflammation, acute hepatitis, skeletal muscle disorders, aging and acute ischemic stroke, protecting, for example, from the deterioration of the blood-brain barrier, restoring the cellular levels of NAD+, improving mitochondrial function and biogenesis and, among other effects, reducing oxidative stress and pro-inflammatory mediators, such as TNF-α, IL1-β, IL-6, and VCAM1. These data demonstrated that repositioning of clinically approved PARP inhibitors may be effective in protecting against hemodynamic dysfunction, metabolic dysfunction, and multiple organ failure in patients with sepsis. Age and gender affect the response to PARP inhibitors, the mechanisms underlying the lack of many protective effects in females and aged animals should be further investigated and be cautiously considered in designing clinical trials.
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Affiliation(s)
- Sidnéia Sousa Santos
- Division of Infectious Diseasses, Paulista School of Medicine, Federal University of Sao Paulo, Brazil
| | | | - Francisco Garcia Soriano
- Laboratory of Medical Research, Faculty of Medicine of the University of São Paulo-USP, São Paulo, Brazil
| | - Csaba Szabo
- Chair of Pharmacology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Reinaldo Salomão
- Division of Infectious Diseasses, Paulista School of Medicine, Federal University of Sao Paulo, Brazil
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Palackic A, Suman OE, Porter C, Murton AJ, Crandall CG, Rivas E. Rehabilitative Exercise Training for Burn Injury. Sports Med 2021; 51:2469-2482. [PMID: 34339042 DOI: 10.1007/s40279-021-01528-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2021] [Indexed: 11/29/2022]
Abstract
Due to improvements in acute burn care over the last few decades, most patients with severe burns (up to 90% of the total body surface) survive. However, the metabolic and cardiovascular complications that accompany a severe burn can persist for up to 3 years post injury. Accordingly, there is now a greater appreciation of the need for strategies that can hasten recovery and reduce long-term morbidity post burn. Rehabilitation exercise training (RET) is a proven effective treatment to restore lean body mass, glucose and protein metabolism, cardiorespiratory fitness, and muscle strength in burn survivors. Despite this, very few hospitals incorporate RET in programs to aid the rehabilitation of patients with severe burns. Given that RET is a safe and efficacious treatment that restores function and reduces post-burn morbidity, we propose that a long-term exercise prescription plan should be considered for all patients with severe burns. In this literature review, we discuss the current understanding of burn trauma on major organ systems, and the positive benefits of incorporating RET as a part of the long-term rehabilitation of severely burned individuals. We also provide burn-specific exercise prescription guidelines for clinical exercise physiologists.
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Affiliation(s)
- Alen Palackic
- Department of Surgery, Division of Surgical Sciences, Medical Branch, University of Texas, Galveston, TX, USA.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Oscar E Suman
- Department of Surgery, Division of Surgical Sciences, Medical Branch, University of Texas, Galveston, TX, USA
| | - Craig Porter
- Department of Pediatrics, Division of Developmental Nutrition, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Andrew J Murton
- Department of Surgery, Division of Surgical Sciences, Medical Branch, University of Texas, Galveston, TX, USA
| | - Craig G Crandall
- Southwestern Medical Center, University of Texas, Dallas, TX, USA
| | - Eric Rivas
- KBR, Human Physiology, Performance, Protection and Operations Laboratory, NASA Johnson Space Center, 2101 NASA Parkway, Houston, TX, 77058, USA.
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Abstract
Trauma, burn injury, sepsis, and ischemia lead to acute and chronic loss of skeletal muscle mass and function. Healthy muscle is essential for eating, posture, respiration, reproduction, and mobility, as well as for appropriate function of the senses including taste, vision, and hearing. Beyond providing support and contraction, skeletal muscle also exerts essential roles in temperature regulation, metabolism, and overall health. As the primary reservoir for amino acids, skeletal muscle regulates whole-body protein and glucose metabolism by providing substrate for protein synthesis and supporting hepatic gluconeogenesis during illness and starvation. Overall, greater muscle mass is linked to greater insulin sensitivity and glucose disposal, strength, power, and longevity. In contrast, low muscle mass correlates with dysmetabolism, dysmobility, and poor survival. Muscle mass is highly plastic, appropriate to its role as reservoir, and subject to striking genetic control. Defining mechanisms of muscle growth regulation holds significant promise to find interventions that promote health and diminish morbidity and mortality after trauma, sepsis, inflammation, and other systemic insults. In this invited review, we summarize techniques and methods to assess and manipulate muscle size and muscle mass in experimental systems, including cell culture and rodent models. These approaches have utility for studies of myopenia, sarcopenia, cachexia, and acute muscle growth or atrophy in the setting of health or injury.
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7
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Quintana HT, Baptista VIDA, Lazzarin MC, Antunes HKM, Le Sueur-Maluf L, de Oliveira CAM, de Oliveira F. Insulin Modulates Myogenesis and Muscle Atrophy Resulting From Skin Scald Burn in Young Male Rats. J Surg Res 2020; 257:56-68. [PMID: 32818785 DOI: 10.1016/j.jss.2020.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 06/18/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Burn injuries (BIs) due to scalding are one of the most common accidents among children. BIs greater than 40% of total body surface area are considered extensive and result in local and systemic response. We sought to assess morphological and myogenic mechanisms through both short- and long-term intensive insulin therapies that affect the skeletal muscle after extensive skin BI in young rats. MATERIALS AND METHODS Wistar rats aged 21 d were distributed into four groups: control (C), control with insulin (C + I), scald burn injury (SI), and SI with insulin (SI + I). The SI groups were submitted to a 45% total body surface area burn, and the C + I and SI + I groups received insulin (5 UI/Kg/d) for 4 or 14 d. Glucose tolerance and the homeostatic model assessment of insulin resistance index were determined. Gastrocnemius muscles were analyzed for histopathological, morphometric, and immunohistochemical myogenic parameters (Pax7, MyoD, and MyoG); in addition, the expression of genes related to muscle atrophy (MuRF1 and MAFbx) and its regulation (IGF-1) were also assessed. RESULTS Short-term treatment with insulin favored muscle regeneration by primary myogenesis and decreased muscle atrophy in animals with BIs, whereas the long-term treatment modulated myogenesis by increasing the MyoD protein. Both treatments improved histopathological parameters and secondary myogenesis by increasing the MyoG protein. CONCLUSIONS Treatment with insulin benefits myogenic parameters during regeneration and modulates MuRF1, an important mediator of muscle atrophy.
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Affiliation(s)
| | | | | | | | | | | | - Flavia de Oliveira
- Departamento de Biociências, Universidade Federal de São Paulo, Santos, SP, Brazil.
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Berlanga-Acosta J, Iglesias-Marichal I, Rodríguez-Rodríguez N, Mendoza-Marí Y, García-Ojalvo A, Fernández-Mayola M, Playford RJ. Review: Insulin resistance and mitochondrial dysfunction following severe burn injury. Peptides 2020; 126:170269. [PMID: 32045621 DOI: 10.1016/j.peptides.2020.170269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/06/2020] [Accepted: 02/07/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Jorge Berlanga-Acosta
- Tissue Repair and Cytoprotection Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Ave 31 e/158 and 190. Playa, Havana, 10600, Cuba
| | | | - Nadia Rodríguez-Rodríguez
- Tissue Repair and Cytoprotection Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Ave 31 e/158 and 190. Playa, Havana, 10600, Cuba
| | - Yssel Mendoza-Marí
- Tissue Repair and Cytoprotection Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Ave 31 e/158 and 190. Playa, Havana, 10600, Cuba
| | - Ariana García-Ojalvo
- Tissue Repair and Cytoprotection Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Ave 31 e/158 and 190. Playa, Havana, 10600, Cuba
| | - Maday Fernández-Mayola
- Tissue Repair and Cytoprotection Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Ave 31 e/158 and 190. Playa, Havana, 10600, Cuba
| | - Raymond J Playford
- University of Plymouth, Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
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Clemens MG. What's New in Shock, August 2018? Shock 2018; 50:129-131. [DOI: 10.1097/shk.0000000000001176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Yang F, Wang Y. Systemic bioinformatics analysis of skeletal muscle gene expression profiles of sepsis. Exp Ther Med 2018; 15:4637-4642. [PMID: 29805480 PMCID: PMC5952067 DOI: 10.3892/etm.2018.6026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/10/2017] [Indexed: 11/06/2022] Open
Abstract
Sepsis is a type of systemic inflammatory response syndrome with high morbidity and mortality. Skeletal muscle dysfunction is one of the major complications of sepsis that may also influence the outcome of sepsis. The aim of the present study was to explore and identify potential mechanisms and therapeutic targets of sepsis. Systemic bioinformatics analysis of skeletal muscle gene expression profiles from the Gene Expression Omnibus was performed. Differentially expressed genes (DEGs) in samples from patients with sepsis and control samples were screened out using the limma package. Differential co-expression and coregulation (DCE and DCR, respectively) analysis was performed based on the Differential Co-expression Analysis package to identify differences in gene co-expression and coregulation patterns between the control and sepsis groups. Gene Ontology terms and Kyoto Encyclopedia of Genes and Genomes pathways of DEGs were identified using the Database for Annotation, Visualization and Integrated Discovery, and inflammatory, cancer and skeletal muscle development-associated biological processes and pathways were identified. DCE and DCR analysis revealed several potential therapeutic targets for sepsis, including genes and transcription factors. The results of the present study may provide a basis for the development of novel therapeutic targets and treatment methods for sepsis.
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Affiliation(s)
- Fang Yang
- Department of Critical Care Medicine, Central Hospital of Weihai, Weihai, Shandong 264400, P.R. China
| | - Yumei Wang
- Department of Critical Care Medicine, Central Hospital of Weihai, Weihai, Shandong 264400, P.R. China
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