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Hoisington AJ, Choy K, Khair S, Dyamenahalli KU, Najarro KM, Wiktor AJ, Frank DN, Burnham EL, McMahan RH, Kovacs EJ. Recent alcohol intake impacts microbiota in adult burn patients. Alcohol 2024; 118:25-35. [PMID: 38604285 PMCID: PMC11179986 DOI: 10.1016/j.alcohol.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/26/2024] [Accepted: 04/04/2024] [Indexed: 04/13/2024]
Abstract
Alcohol use is associated with an increased incidence of negative health outcomes in burn patients due to biological mechanisms that include a dysregulated inflammatory response and increased intestinal permeability. This study used phosphatidylethanol (PEth) in blood, a direct biomarker of recent alcohol use, to investigate associations between a recent history of alcohol use and the fecal microbiota, short chain fatty acids, and inflammatory markers in the first week after a burn injury for nineteen participants. Burn patients were grouped according to PEth levels of low or high and differences in the overall fecal microbial community were observed between these cohorts. Two genera that contributed to the differences and had higher relative abundance in the low PEth burn patient group were Akkermansia, a mucin degrading bacteria that improves intestinal barrier function, and Bacteroides, a potentially anti-inflammatory bacteria. There was no statistically significant difference between levels of short chain fatty acids or intestinal permeability across the two groups. To our knowledge, this study represents the first report to evaluate the effects of burn injury and recent alcohol use on early post burn microbiota dysbiosis, inflammatory response, and levels of short chain fatty acids. Future studies in this field are warranted to better understand the factors associated with negative health outcomes and develop interventional trials.
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Affiliation(s)
- Andrew J Hoisington
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, CO, USA; Department of Systems Engineering and Management, Air Force Institute of Technology, Wright-Patterson Air Force Base, OH, USA
| | - Kevin Choy
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Shanawaj Khair
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Graduate Program in Molecular Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kiran U Dyamenahalli
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kevin M Najarro
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Veterans Health Administration, Eastern Colorado Health Care System, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA
| | - Arek J Wiktor
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel N Frank
- GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ellen L Burnham
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Alcohol Research Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rachel H McMahan
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Veterans Health Administration, Eastern Colorado Health Care System, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA
| | - Elizabeth J Kovacs
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Graduate Program in Molecular Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Veterans Health Administration, Eastern Colorado Health Care System, Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Alcohol Research Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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2
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Zhou YY, Wang Y, Wang L, Jiang H. The efficacy of Omega-3 polyunsaturated fatty acids for severe burn patients: A systematic review and trial sequential meta-analysis of randomized controlled trials. Clin Nutr ESPEN 2024; 59:126-134. [PMID: 38220365 DOI: 10.1016/j.clnesp.2023.11.019] [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: 06/13/2023] [Revised: 08/03/2023] [Accepted: 11/26/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND & AIMS Severe burns lead to metabolic changes, systemic inflammatory response syndrome, and multiple organ dysfunction syndrome. Omege-3 polyunsaturated fatty acids (PUFAs) have anti-inflammatory properties. In the absence of substantial evidence for use on major burns, we systematically reviewed the efficacy of omega-3 PUFAs for patients with severe burns. METHODS We comprehensively searched MEDLINE, Web of Science, Embase, Cochrane Library, China National Knowledge Internet, Wang Fang Data, Chinese Biomedicine Database, and Science Direct databases to collect randomised controlled trials of omega-3 PUFAs administered to patients with burns from January 2000 to June 2023. Two researchers independently screened the literatures, extracted the data, and assessed the risk of bias in the included studies. The outcomes were mortality, the risk of severe sepsis, septic shock, and multiple organ dysfunction syndrome. Data synthesis was conducted using Review Manager. Trial sequential analyses (TSA) for outcomes were performed. RESULTS Three randomised controlled trials involving 140 patients were included. Of these, 71 patients received omega-3 PUFAs. The results showed that omega-3 PUFAs significantly reduced the incidence of severe sepsis, septic shock, multiple organ dysfunction syndrome (RR = 0.38, 95 % CI [0.19, 0.75], P = 0.005), C-reactive protein levels (MD = -39.70[-81.63, 2.23], P = 0.06), and improved respiratory outcomes. However, there was no difference in 14-day mortality (RR = 1.10, 95%CI [0.59, 2.05], P = 0.75). TSA showed that the results for the incidence of severe sepsis, septic shock, multiple organ dysfunction syndrome are insufficient and inconclusive. CONCLUSIONS Omega-3 PUFAs may reduce inflammatory response and risk of sepsis, septic shock, and multiple organ dysfunction syndrome in severe burns patients and may shorten hospital stay but cannot reduce risk of death. Due to the limitation of the quantity and quality of the included studies, the evidence level is low, and the conclusions need to be verified by larger scale and higher quality randomised controlled trials.
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Affiliation(s)
- Yi-Yue Zhou
- Department of Biology (life sciences), Sorbonne University, 4 Pl. Jussieu, Paris 75005, France.
| | - Yu Wang
- Department of Clinical Nutrition, Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai fu yuan Wang fu jing, Dong cheng District, Beijing 100730, China.
| | - Lu Wang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, Yi Huan Lu Xi Er Duan, Chengdu 610072, China; Sichuan Clinical Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, Yi Huan Lu Xi Er Duan, Chengdu 610072, China.
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, Yi Huan Lu Xi Er Duan, Chengdu 610072, China; Sichuan Clinical Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No.32, Yi Huan Lu Xi Er Duan, Chengdu 610072, China.
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Choy K, Dyamenahalli KU, Khair S, Colborn KL, Wiktor AJ, Idrovo JP, McMahan RH, Burnham EL, Kovacs EJ. Aberrant inflammatory responses in intoxicated burn-injured patients parallel impaired cognitive function. Alcohol 2023; 109:35-41. [PMID: 36690221 PMCID: PMC10175175 DOI: 10.1016/j.alcohol.2023.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
Burn-injured patients with alcohol use disorder (AUD) have increased morbidity and mortality compared to alcohol-abstaining individuals with similar injuries. It is hypothesized that this is due, in part, to alcohol-induced dysregulation of the systemic inflammatory response, leading to worsened clinical outcomes, including increased susceptibility to infection, and heightened cognitive impairment. To examine the effects of alcohol on inflammatory markers after burn injury, we used multiplex assays to measure a panel of 48 cytokines, chemokines, and growth factors in the plasma of burn patents within 24 h of admission to the University of Colorado Burn Center. Thirty patients were enrolled between July 2018 to February 2020 and were stratified based on presence of AUD and total body surface area (TBSA) burn of ≥20% into four groups: [AUD-, TBSA <20%, N = 12], [AUD+, TBSA <20%, N = 3], [AUD-, TBSA ≥20%, N = 8], [AUD+, TBSA ≥20%, N = 7]. In addition, Confusion Assessment Method (CAM) scores were collected to evaluate patient delirium during the course of hospitalization. Multivariate statistical analysis demonstrated a number of cytokines and other factors that were significantly different between the groups. For example, the anti-inflammatory cytokine interleukin 1 receptor antagonist (IL-1ra) was dampened in the AUD+, TBSA ≥20% cohort with a 75.2% decrease compared to AUD-, TBSA ≥20%, and an 83.9% decrease compared to AUD-, TBSA <20% (p = 0.008). Additionally, plasma levels of the pro-inflammatory mediator CXCL12 (C-X-C motif chemokine ligand 12, also known as stromal cell-derived factor 1, SDF-1) was higher in the AUD + groups (p = 0.03) and similarly, IL-18 levels were greater in AUD+, TBSA ≥20% (p = 0.009). Eotaxin (also known as cytokine CC motif ligand 11, CCL11) was markedly elevated in the AUD+, TBSA ≥20% cohort with a 2.4-fold increase over the AUD-, TBSA ≥20%, and a 1.7-fold rise compared to the AUD-, TBSA <20% cohorts (p = 0.04). Interestingly, there was also a marked rise in CAM + delirium scores (85.7%) among the AUD + patients with TBSA ≥20% (p = 0.02). Not surprisingly, we found that hospital stays increased with AUD+ and larger burns (p = 0.0009). Our findings reveal that burn patients who misuse alcohol have aberrant inflammatory responses that may lead to greater immune dysregulation and worse clinical outcomes.
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Affiliation(s)
- Kevin Choy
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kiran U Dyamenahalli
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Shanawaj Khair
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Graduate Program in Molecular Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Arek J Wiktor
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Juan-Pablo Idrovo
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Rachel H McMahan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Rocky Mountain Regional Veterans Administration Medical Center, Veterans Administration Eastern Colorado Health Care System Research Service, Aurora, CO, United States
| | - Ellen L Burnham
- Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elizabeth J Kovacs
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Graduate Program in Molecular Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Rocky Mountain Regional Veterans Administration Medical Center, Veterans Administration Eastern Colorado Health Care System Research Service, Aurora, CO, United States; Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
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4
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Schaffrick L, Ding J, Kwan P, Tredget E. The dynamic changes of monocytes and cytokines during wound healing post-burn injury. Cytokine 2023; 168:156231. [PMID: 37247448 DOI: 10.1016/j.cyto.2023.156231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Burn injury is a sudden and traumatic injury that affects a large part of the population worldwide, who are placed at high risk of developing hypertrophic scars (HTS). HTS are a fibrotic scar resulting in painful contracted and raised scarring, affecting mobility in joints and work life, as well as cosmetically. The aim of this research was to enhance our understanding of the systematic response of monocytes and cytokines in wound healing after burn injury, in order to develop novel approaches to prevention and treatment of HTS. METHODS Twenty-seven burn patients and thirteen healthy individuals were recruited in this study. Burn patients were stratified by burn total body surface area (TBSA). Peripheral blood samples were taken post-burn injury. Serum and peripheral blood mononuclear cells (PBMCs) were separated from the blood samples. This research investigated cytokines IL-6, IL-8, IL1RA, IL-10, and chemokine pathways SDF-1/CXCR4, MCP-1/CCR2, RANTES/CCR5 during the wound healing process in burn patients with varying severity of injuries by using enzyme-linked immunosorbent assays. PBMCs were stained for monocytes and the chemokine receptors by flow cytometry. Statistical analysis was done by one-way ANOVA with a Tukey correction, and regression analysis was performed using Pearson's Correlation analysis. RESULTS The CD14+CD16- monocyte subpopulation is larger in patients who developed HTS at 4-7 days. The CD14+CD16+ monocyte subpopulation is smaller in the first week of injury, where it is similar after 8 days. Burn injury increased CXCR4, CCR2, and CCR5 expressions in CD14+ CD16+ monocytes. Increases in MCP-1 at 0-3 days after burn injury was positively correlated with burn severity. IL-6, IL-8, RANTES, and MCP-1 significantly increased with increasing burn severity. CONCLUSIONS Monocytes and their chemokine receptors, as well as systemic levels of cytokines in wound healing of burn patients and scar development will require ongoing assessment to enhance our understanding of the abnormal wound healing after burn injury.
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Affiliation(s)
- Lindy Schaffrick
- Wound Healing Research Group, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Jie Ding
- Wound Healing Research Group, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Peter Kwan
- Wound Healing Research Group, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Division of Critical Care, University of Alberta, Edmonton, Alberta, Canada
| | - Edward Tredget
- Wound Healing Research Group, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Division of Critical Care, University of Alberta, Edmonton, Alberta, Canada.
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5
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Osborne T, Wall B, Edgar DW, Fairchild T, Wood F. Current understanding of the chronic stress response to burn injury from human studies. BURNS & TRAUMA 2023; 11:tkad007. [PMID: 36926636 PMCID: PMC10013650 DOI: 10.1093/burnst/tkad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/26/2022] [Accepted: 01/17/2023] [Indexed: 03/15/2023]
Abstract
There is a marked inflammatory and hypermetabolic response following a burn injury. The interlinked responses are more pronounced than for other forms of trauma and can persist for ≥3 years post-injury in burned patients. After a burn, patients have an increased risk of diseases of ageing including cancer, diabetes and cardiovascular disease, highlighting the need for effective long-term strategies to ameliorate the stress response post-burn. Current therapeutic strategies for post-burn recovery include removal of damaged tissue with surgical excision and wound repair, nutritional supplementation and rehabilitative exercise. These strategies aim to minimize the hypermetabolic and inflammatory responses, as well as reducing the loss of lean body mass. This review briefly summarises the inflammatory and hypermetabolic responses and provides an update on the current therapeutic strategies for burned patients. The review examines the persistent nutritional challenge of ensuring sufficient energy intake of each macronutrient to fuel the hypermetabolic and counteract the catabolic response of burn injury, whilst reducing periods of hyperglycaemia and hypertriglyceridemia. Patients require individualized treatment options tailored to unique systemic responses following a burn, facilitated by a precision medicine approach to improve clinical and physiological outcomes in burned patients. Thus, this review discusses the utility of metabolic flexibility assessment to aid clinical decision making and prescription relating to nutritional supplementation and rehabilitative exercise in the burned patient.
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Affiliation(s)
- Tyler Osborne
- Discipline of Exercise Science, Murdoch University, Murdoch 6150, Western Australia.,Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Murdoch 6150, Western Australia
| | - Bradley Wall
- Discipline of Exercise Science, Murdoch University, Murdoch 6150, Western Australia.,Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Murdoch 6150, Western Australia
| | - Dale W Edgar
- State Adult Burns Unit, Government of Western Australia South Metropolitan Health Service, Fiona Stanley Hospital, Murdoch 6150, Western Australia.,Fiona Wood Foundation, Fiona Stanley Hospital, Murdoch 6150, Western Australia.,Burn Injury Research Node, Institute for Health Research, The University of Notre Dame Australia, Murdoch 6160, Western Australia.,Burn Injury Research Unit, University of Western Australia, Murdoch 6009, Western Australia
| | - Timothy Fairchild
- Discipline of Exercise Science, Murdoch University, Murdoch 6150, Western Australia.,The Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch 6150, Western Australia
| | - Fiona Wood
- State Adult Burns Unit, Government of Western Australia South Metropolitan Health Service, Fiona Stanley Hospital, Murdoch 6150, Western Australia.,Fiona Wood Foundation, Fiona Stanley Hospital, Murdoch 6150, Western Australia.,Burn Injury Research Unit, University of Western Australia, Murdoch 6009, Western Australia
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6
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Zhong C, Liang G, Li P, Shi K, Li F, Zhou J, Xu D. Inflammatory response: The target for treating hyperpigmentation during the repair of a burn wound. Front Immunol 2023; 14:1009137. [PMID: 36817442 PMCID: PMC9929571 DOI: 10.3389/fimmu.2023.1009137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Hyperpigmentation is a common complication in patients with burn injuries during wound healing; however, the mechanisms underlying its occurrence and development remain unclear. Recently, postinflammatory hyperpigmentation (PIH) was found to result from overproduction of melanin. Local or systemic inflammatory responses are often observed in patients who develop hyperpigmentation. However, we lack studies on the relationship between PIH and burn injury. Therefore, we comprehensively reviewed the existing literature on the melanogenesis of the skin, inflammatory mechanisms in pigmentation, and local or systemic alteration in inflammatory cytokines in patients suffering from burn trauma to elucidate the relationship between PIH and burn injury. We believe that this review will guide further research on regulating melanin production in the burn management process.
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Affiliation(s)
- Chi Zhong
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Geao Liang
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Peiting Li
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ke Shi
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Fuyin Li
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jianda Zhou
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Dan Xu
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
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Hall HR, Mahung C, Dunn JLM, Kartchner LM, Seim RF, Cairns BA, Wallet SM, Maile R. Characterization of the Basal and mTOR-Dependent Acute Pulmonary and Systemic Immune Response in a Murine Model of Combined Burn and Inhalation Injury. Int J Mol Sci 2022; 23:8779. [PMID: 35955914 PMCID: PMC9368856 DOI: 10.3390/ijms23158779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 11/17/2022] Open
Abstract
Severe burn injury leads to a cascade of local and systemic immune responses that trigger an extreme state of immune dysfunction, leaving the patient highly susceptible to acute and chronic infection. When combined with inhalation injury, burn patients have higher mortality and a greater chance of developing secondary respiratory complications including infection. No animal model of combined burn and inhalation injury (B+I) exists that accurately mirrors the human clinical picture, nor are there any effective immunotherapies or predictive models of the risk of immune dysfunction. Our earlier work showed that the mechanistic/mammalian target of rapamycin (mTOR) pathway is activated early after burn injury, and its chemical blockade at injury reduced subsequent chronic bacterial susceptibility. It is unclear if mTOR plays a role in the exacerbated immune dysfunction seen after B+I injury. We aimed to: (1) characterize a novel murine model of B+I injury, and (2) investigate the role of mTOR in the immune response after B+I injury. Pulmonary and systemic immune responses to B+I were characterized in the absence or presence of mTOR inhibition at the time of injury. Data describe a murine model of B+I with inhalation-specific immune phenotypes and implicate mTOR in the acute immune dysfunction observed.
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Affiliation(s)
- Hannah R. Hall
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Cressida Mahung
- North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Julia L. M. Dunn
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Laurel M. Kartchner
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Roland F. Seim
- North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Bruce A. Cairns
- North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Shannon M. Wallet
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Division of Oral and Craniofacial Health Sciences, University of North Carolina Adams School of Dentistry, Chapel Hill, NC 27599, USA
| | - Robert Maile
- North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Characteristics and prognosis of Herpesviridae-related pneumonia in critically ill burn patients. Burns 2022; 48:1155-1165. [PMID: 34823946 DOI: 10.1016/j.burns.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/25/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of this study was to describe the prevalence, characteristics and outcome of critically burn patients with pulmonary HSV reactivation. METHODS Retrospective, single-center cohort study in a burn critical care unit in a tertiary center, including all consecutive severely burn patients with bronchoalveolar lavage performed for pneumoniae suspicion and screened for HSV from January 2013 and April 2017. We used logistic regression to identify factors associated with HSV reactivation and outcomes. RESULTS 94 patients were included, mean age was 51 (39-64) years; median total body surface area burned was 36 (25-54)% and ICU mortality 38%. Fifty-five patients (59%) had pulmonary HSV reactivation and 30 (55%) were treated with acyclovir. Patients with HSV reactivation were more severely ill with higher SOFA score at admission compared to patient without HSV reactivation (6 [3-8] vs. 2 [1-4], p < 0.0001 respectively). In multivariate analysis, sex, SOFA score at admission and smoke inhalation were significantly associated with HSV reactivation. Only septic shock was associated with 90-day mortality when HSV reactivation was not. CONCLUSIONS Pulmonary HSV reactivation is frequent among severely ill burn patients. Initial severity and smoke inhalation are risk factors. Antiviral treatment was not associated with outcome.
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9
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Li X, Luck ME, Herrnreiter CJ, Cannon AR, Choudhry MA. IL-23 Promotes Neutrophil Extracellular Trap Formation and Bacterial Clearance in a Mouse Model of Alcohol and Burn Injury. Immunohorizons 2022; 6:64-75. [PMID: 35058308 DOI: 10.4049/immunohorizons.2100109] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 12/17/2023] Open
Abstract
Our previous studies have shown that ethanol intoxication combined with burn injury increases intestinal bacterial growth, disrupts the intestinal barrier, and enhances bacterial translocation. Additionally, studies show that Th17 effector cytokines IL-17 and IL-22, which are dependent on IL-23, play important roles in maintaining intestine mucosal barrier integrity. Recent findings suggest neutrophils are a significant source of IL-17 and IL-22. We determined the effect of ethanol and burn injury on neutrophil IL-17 and IL-22 production, as well as their ability to phagocytose and in bacterial clearance, and whether these effects are modulated by IL-23. Mice were given ethanol 4 h prior to receiving ∼12.5% total body surface area burn and were euthanized day 1 after injury. We observed that intoxication combined with burn injury significantly decreases blood neutrophil phagocytosis and bacteria killing, as well as their ability to produce IL-17 and IL-22, compared with sham vehicle mice. The treatment of neutrophils with rIL-23 significantly increases IL-22 and IL-17 release and promotes expression of IL-23R, retinoic acid-related orphan receptor γt, Lipocalin2, and Nod-like receptor 2 following ethanol and burn injury. Furthermore, IL-22- and IL-17-producing neutrophils have enhanced neutrophil extracellular trap formation and bacterial killing ability, which are dependent on IL-23. Finally, although we observed that peritoneal neutrophils harvested after casein treatment are functionally different from blood neutrophils, both blood and peritoneal neutrophils exhibited the same response to rIL-23 treatment. Together these findings suggest that IL-23 promotes neutrophil IL-22 and IL-17 production and their ability to kill bacteria following ethanol and burn injury.
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Affiliation(s)
- Xiaoling Li
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
| | - Marisa E Luck
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
| | - Caroline J Herrnreiter
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Biochemistry and Molecular Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL; and
| | - Abigail R Cannon
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
| | - Mashkoor A Choudhry
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL;
- Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
- Biochemistry and Molecular Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL; and
- Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL
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10
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Dyamenahalli K, Choy K, Frank DN, Najarro K, Boe D, Colborn KL, Idrovo JP, Wagner AL, Wiktor AJ, Afshar M, Burnham EL, McMahan RH, Kovacs EJ. Age and Injury Size Influence the Magnitude of Fecal Dysbiosis in Adult Burn Patients. J Burn Care Res 2022; 43:1145-1153. [PMID: 35020913 PMCID: PMC9435505 DOI: 10.1093/jbcr/irac001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Clinical studies have demonstrated that age 50 years or older is an independent risk factor associated with poor prognosis after burn injury, the second leading cause of traumatic injuries in the aged population. While mechanisms driving age-dependent postburn mortality are perplexing, changes in the intestinal microbiome, may contribute to the heightened, dysregulated systemic response seen in aging burn patients. The fecal microbiome from 22 patients admitted to a verified burn center from July 2018 to February 2019 was stratified based on the age of 50 years and total burn surface area (TBSA) size of ≥10%. Significant differences (P = .014) in overall microbiota community composition (ie, beta diversity) were measured across the four patient groups: young <10% TBSA, young ≥10% TBSA, older <10% TBSA, and older ≥10% TBSA. Differences in beta diversity were driven by %TBSA (P = .013) and trended with age (P = .087). Alpha diversity components, richness, evenness, and Shannon diversity were measured. We observed significant differences in bacterial species evenness (P = .0023) and Shannon diversity (P = .0033) between the groups. There were significant correlations between individual bacterial species and levels of short-chain fatty acids. Specifically, levels of fecal butyrate correlated with the presence of Enterobacteriaceae, an opportunistic gut pathogen, when elevated in burn patients lead to worsen outcomes. Overall, our findings reveal that age-specific changes in the fecal microbiome following burn injuries may contribute to immune system dysregulation in patients with varying TBSA burns and potentially lead to worsened clinical outcomes with heightened morbidity and mortality.
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Affiliation(s)
| | | | - Daniel N Frank
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, USA,Gastrointestinal and Liver and Innate Immunity Program, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kevin Najarro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA,Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System Research Service, Aurora, USA
| | - Devin Boe
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Juan-Pablo Idrovo
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Anne L Wagner
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Arek J Wiktor
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Majid Afshar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Ellen L Burnham
- Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Rachel H McMahan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA,Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System Research Service, Aurora, USA
| | - Elizabeth J Kovacs
- Address correspondence to Elizabeth J. Kovacs, PhD, Department of Surgery, GITES, University of Colorado Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, Aurora, CO 80045, USA.
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11
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Abstract
ABSTRACT Burn injuries are a common form of traumatic injury that leads to significant morbidity and mortality worldwide. Burn injuries are characterized by inflammatory processes and alterations in numerous organ systems and functions. Recently, it has become apparent that the gastrointestinal bacterial microbiome is a key component of regulating the immune response and recovery from burn and can also contribute to significant detrimental sequelae after injury, such as sepsis and multiple organ failure. Microbial dysbiosis has been linked to multiple disease states; however, its role in exacerbating acute traumatic injuries, such as burn, is poorly understood. In this article, we review studies that document changes in the intestinal microbiome after burn injury, assess the implications in post-burn pathogenesis, and the potential for further discovery and research.
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Affiliation(s)
- Marisa E. Luck
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Caroline J. Herrnreiter
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Biochemistry and Molecular Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Mashkoor A. Choudhry
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Biochemistry and Molecular Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
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12
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Keyloun JW, Le TD, Brummel-Ziedins KE, Mclawhorn MM, Bravo MC, Orfeo T, Johnson LS, Moffatt LT, Pusateri AE, Shupp JW. Inhalation Injury is Associated with Endotheliopathy and Abnormal Fibrinolytic Phenotypes in Burn Patients: A Cohort Study. J Burn Care Res 2021; 43:432-439. [PMID: 34089618 PMCID: PMC8946676 DOI: 10.1093/jbcr/irab102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Burn injury is associated with endothelial dysfunction and coagulopathy and concomitant inhalation injury increases morbidity and mortality. The aim of this work is to identify associations between inhalation injury (IHI), coagulation homeostasis, vascular endothelium, and clinical outcomes in burn patients. One-hundred and twelve patients presenting to a regional burn center were included in this retrospective cohort study. Whole blood was collected at set intervals from admission through 24 hours and underwent viscoelastic assay with rapid TEG (rTEG). Syndecan-1 (SDC-1) on admission was quantified by ELISA. Patients were grouped by the presence (n=28) or absence (n=84) of concomitant IHI and rTEG parameters, fibrinolytic phenotypes, SDC-1, and clinical outcomes were compared. Of the 112 thermally injured patients, 28 (25%) had IHI. Most patients were male (68.8%) with a median age of 40 (IQR, 29-57) years. Patients with IHI had higher overall mortality (42.68% vs. 8.3%; p<0.0001). rTEG LY30 was lower in patients with IHI at hours 4 and 12 (p<0.05). There was a pattern of increased abnormal fibrinolytic phenotypes among IHI patients. There was a greater proportion of IHI patients with endotheliopathy (SDC-1 > 34 ng/mL) (64.7% vs. 26.4%; p=0.008). There was a pattern of increased mortality among patients with inhalation injury and endotheliopathy (0% vs. 72.7%; p=0.004). Significant differences between patients with and without IHI were found in measures assessing fibrinolytic potential and endotheliopathy. Mortality was associated with abnormal fibrinolysis, endotheliopathy, and inhalation injury. However, the extent to which IHI associated dysfunction is independent of TBSA burn size remains to be elucidated.
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Affiliation(s)
- John W Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Tuan D Le
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX.,Department of Epidemiology and Biostatistics, University of Texas Health Science Center, Tyler, TX
| | | | - Melissa M Mclawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Maria C Bravo
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT
| | - Thomas Orfeo
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT
| | - Laura S Johnson
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC.,Department of Biochemistry Georgetown University, Washington, DC
| | | | - Jeffrey W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC.,Department of Biochemistry Georgetown University, Washington, DC
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13
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Zhao R, Lang TC, Kim A, Wijewardena A, Vandervord J, McGrath R, Fulcher G, Xue M, Jackson C. Early protein C activation is reflective of burn injury severity and plays a critical role in inflammatory burden and patient outcomes. Burns 2021; 48:91-103. [PMID: 34175158 DOI: 10.1016/j.burns.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/17/2021] [Accepted: 03/09/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Navigating the complexities of a severe burn injury is a challenging endeavour where the natural course of some patients can be difficult to predict. Straddling both the coagulation and inflammatory cascades that feature strongly in the burns systemic pathophysiology, we propose the pleiotropic protein C (PC) system may produce a viable biomarker to assist traditional evaluation methods for diagnostic and prognostic purposes. METHODS We enrolled 86 patients in a prospective observational cohort study. Over three weeks, serial blood samples were taken and measured for PC, activated (A)PC, their receptor endothelial protein C receptor (EPCR), and a panel of inflammatory cytokines including C-reactive protein (CRP), tumour necrosis factor-α, interleukin (IL)-1β, IL-6, IL-8, and IL-17. Their temporal trends were analysed alongside clinical factors including burn size, burn depth, presence of inhalational injury, and a composite outcome of requiring increased support. RESULTS (i) APC increased from a nadir on Day 3 (2.3±2.1ng/mL vs 4.1±2.5ng/mL by Day 18, p<0.0005), only becoming appropriately correlated to PC from Day 6 onwards (r=0.412-0.721, p<0.05 for all Days 6-21). (ii) This early disturbance in the PC system was amplified in the more severe burns (≥30% total body surface area, predominantly full thickness, or with inhalational injury), which were characterised by a marked fall in PC activation (approximated by APC/PC ratio) and APC levels during Days 0-3 with low unchanged PC levels. Critically low levels of this cytoprotective agent was associated with greater inflammatory burden, as reflected by significantly elevated CRP, IL-6, and IL-8 levels in the more severe compared to less severe burns, and by negative correlations between both PC and APC with most inflammatory cytokines. (iii) Alongside clinical markers of severity at admission (burn size, burn depth, and presence of inhalational injury), only Day 0 APC/PC ratio (OR 1.048 (1.014-1.083), p=0.006), APC (OR 1.364 (1.032-1.803), p=0.029), PC (OR 0.899 (0.849-0.953), p<0.0005), and not any inflammatory cytokines were predictive markers of requiring increased support. Uniquely, decreased Day 0 PC was further individually associated with each increased total length of stay, ICU length of stay, intravenous fluid resuscitation, and total surgeries, as well as possibly mortality. CONCLUSION An early functional depletion of the cytoprotective PC system provides a physiological link between severe burns and the cytokine storm, likely contributing to worse outcomes. Our findings on the changes in APC, PC and PC activation during this pathological state support APC and PC as early diagnostic and prognostic biomarkers, and provides a basis for their therapeutic potential in severe burn injuries.
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Affiliation(s)
- Ruilong Zhao
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
| | - Thomas Charles Lang
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Albert Kim
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | | | - John Vandervord
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Rachel McGrath
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Gregory Fulcher
- Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Meilang Xue
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Christopher Jackson
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney at Royal North Shore Hospital, St Leonards, NSW 2065, Australia
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14
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Dyamenahalli K, Garg G, Shupp JW, Kuprys PV, Choudhry MA, Kovacs EJ. Inhalation Injury: Unmet Clinical Needs and Future Research. J Burn Care Res 2020; 40:570-584. [PMID: 31214710 DOI: 10.1093/jbcr/irz055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pulmonary and systemic insults from inhalation injury can complicate the care of burn patients and contribute to significant morbidity and mortality. However, recent progress in diagnosis and treatment of inhalation injury has not kept pace with the care of cutaneous thermal injury. There are many challenges unique to inhalation injury that have slowed advancement, including deficiencies in our understanding of its pathophysiology, the relative difficulty and subjectivity of bronchoscopic diagnosis, the lack of diagnostic biomarkers, the necessarily urgent manner in which decisions are made about intubation, and the lack of universal recommendations for the application of mucolytics, anticoagulants, bronchodilators, modified ventilator strategies, and other measures. This review represents a summary of critical shortcomings in our understanding and management of inhalation injury identified by the American Burn Association's working group on Cutaneous Thermal Injury and Inhalation Injury in 2018. It addresses our current understanding of the diagnosis, pathophysiology, and treatment of inhalation injury and highlights topics in need of additional research, including 1) airway repair mechanisms; 2) the airway microbiome in health and after injury; and 3) candidate biomarkers of inhalation injury.
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Affiliation(s)
- Kiran Dyamenahalli
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, University of Colorado School of Medicine, Aurora
| | - Gaurav Garg
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Jeffrey W Shupp
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Paulius V Kuprys
- Department of Surgery, Burn & Shock Trauma Research Institute, Health Sciences Division, Loyola University, Maywood, Illinois
| | - Mashkoor A Choudhry
- Department of Surgery, Burn & Shock Trauma Research Institute, Health Sciences Division, Loyola University, Maywood, Illinois
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, University of Colorado School of Medicine, Aurora
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15
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Li X, Luck ME, Hammer AM, Cannon AR, Choudhry MA. 6-Formylindolo (3, 2-b) Carbazole (FICZ)-mediated protection of gut barrier is dependent on T cells in a mouse model of alcohol combined with burn injury. Biochim Biophys Acta Mol Basis Dis 2020; 1866:165901. [PMID: 32711051 PMCID: PMC7484351 DOI: 10.1016/j.bbadis.2020.165901] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/14/2020] [Accepted: 07/17/2020] [Indexed: 12/22/2022]
Abstract
6-Formylindolo (3, 2-b) Carbazole (FICZ) is a ligand of aryl hydrocarbon receptor (AHR) which regulates Th17 release of IL-17 and IL-22 production. Earlier, we showed that ethanol combined with burn injury suppresses Th17 responses and disrupts intestinal barrier leading to increased gut bacterial growth and translocation. Since IL-22 is known for its role in intestinal barrier maintenance, we determined whether treatment of mice with FICZ restores T cell IL-22 release and protects intestine barrier following ethanol and burn injury. Wildtype and Rag1-/- mice were gavaged with ~2.9 g/kg ethanol or water, and given a ~12.5% total body surface area burn. Mice were given FICZ (5 μg) in resuscitation fluid. FICZ treatment of wildtype mice normalized IL-22 and IL-17 in lamina propria and spleen T cells, as well as increased CYP1A1 expression in spleen T cells. This was accompanied by improved gut motility, decreased copy number of small intestine total bacteria and Enterobacteriaceae, attenuation of intestinal tissue levels of IL-6, KC, IL-18, decreased apoptosis, and prevention of gut leakiness following ethanol and burn injury. However, FICZ treatment of Rag1-/- mice did not improve any of the parameters listed after ethanol and burn injury. Additional data generated using mice treated with recombinant IL-22 alone or in combination with anti-IL-18 antibody suggest that full protection of gut barrier integrity requires both IL-18 inhibition and IL-22 restoration following ethanol and burn injury. Together our findings suggest that AHR ligand FICZ may have better therapeutic potential for maintenance of gut barrier function after ethanol and burn injury.
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MESH Headings
- Animals
- Burns/drug therapy
- Burns/metabolism
- Carbazoles/therapeutic use
- Cytochrome P-450 CYP1A1/genetics
- Cytochrome P-450 CYP1A1/metabolism
- Cytokines/metabolism
- Disease Models, Animal
- Enzyme-Linked Immunosorbent Assay
- Ethanol/pharmacology
- Flow Cytometry
- Homeodomain Proteins/genetics
- Homeodomain Proteins/metabolism
- Interleukin-17/metabolism
- Interleukins/metabolism
- Intestinal Mucosa/drug effects
- Intestinal Mucosa/metabolism
- Intestinal Mucosa/microbiology
- Intestine, Small/drug effects
- Intestine, Small/metabolism
- Intestine, Small/microbiology
- Male
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Mucous Membrane/drug effects
- Mucous Membrane/metabolism
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Receptors, Aryl Hydrocarbon/genetics
- Receptors, Aryl Hydrocarbon/metabolism
- T-Lymphocytes/drug effects
- T-Lymphocytes/metabolism
- Interleukin-22
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Affiliation(s)
- Xiaoling Li
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Marisa E Luck
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Adam M Hammer
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Abigail R Cannon
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Mashkoor A Choudhry
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA.
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16
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Ruiz-Castilla M, Dos Santos B, Vizcaíno C, Baena J, Guilabert P, Marin-Corral J, Masclans JR, Roca O, Barret JP. Soluble suppression of tumorigenicity-2 predicts pneumonia in patients with inhalation injury: Results of a pilot study. Burns 2020; 47:906-913. [PMID: 33143991 DOI: 10.1016/j.burns.2020.10.010] [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: 01/28/2020] [Revised: 08/25/2020] [Accepted: 10/08/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Several mechanisms play a role in the development of pneumonia after inhalation injury. Our aim was to analyze whether higher concentrations of inflammatory markers or of biomarkers of epithelial injury are associated with a higher incidence of pneumonia in patients with inhalation injury. MATERIAL AND METHODS Secondary analysis of a single-center prospective observational cohort pilot study, performed over a two-year period (2015-2017) at the Burns Unit of the Plastic and Reconstructive Surgery Department of Vall d'Hebron University Hospital. All patients aged 18 with suspected inhalation injury undergoing admission to the Burns Unit were included. Plasma biomarkers of the lung epithelium (RAGE and SP-D), inflammation markers (IL6, IL8), and IL33, as well as soluble suppression of tumorigenicity-2 (sST2) levels, were measured within the first 24 h of admission. RESULTS Twenty-four patients with inhalation injury were included. Eight (33.3%) developed pneumonia after a median of 7 (4-8) days of hospital stay. Patients with pneumonia presented higher plasma concentrations of sST2 (2853 [2356-3351] ng/mL vs 1352 [865-1839] ng/mL; p < 0.001), IL33 (1.95 [1.31-2.59] pg/mL vs 1.26 [1.07-1.45] pg/mL; p = 0.002) and IL8 (325.7 [221.6-430.0] pg/mL vs 174.1 [95.2-253.0] pg/mL; p = 0.017) on day 1 of inclusion. Plasma sST2 concentration in the first 24 h demonstrated excellent diagnostic accuracy for predicting the occurrence of pneumonia in patients with smoke inhalation (AUROC 0.929 [95%CI 0.818-1.000]). A cutoff point of ≥2825 ng/mL for sST2 had a sensitivity of 75% and a specificity of 100%. The risk ratio of pneumonia in patients with sST2 ≥ 2825 ng/mL was 7.14 ([95% CI 1.56-32.61]; p = 0.016). CONCLUSIONS Plasma sST2 in the first 24 h of admission predicts the occurrence of pneumonia in patients with inhalation injury.
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Affiliation(s)
- Mireia Ruiz-Castilla
- Plastic and Reconstructive Surgery Department, Hospital Quirónsalud Barcelona, Barcelona, Spain; Plastic and Reconstructive Surgery Department and Burns Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.
| | - Bruce Dos Santos
- Plastic and Reconstructive Surgery Department and Burns Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Claudia Vizcaíno
- Critical Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Jacinto Baena
- Critical Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Patricia Guilabert
- Anesthesiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Judith Marin-Corral
- Critical Care Department, Parc de Salut Mar (Hospital del Mar) de Barcelona, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Joan R Masclans
- Critical Care Department, Parc de Salut Mar (Hospital del Mar) de Barcelona, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Roca
- Critical Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain; Ciber Enfermedades Respiratorias (Ciberes), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan P Barret
- Plastic and Reconstructive Surgery Department and Burns Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
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17
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Kowal-Vern A, Dennis AJ, Bourdon P, Casey LE, Latenser BA. Bronchoalveolar lavage and plasma Antithrombin and cytokines in inhalation and burn injury: a pilot study. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2020; 10:255-262. [PMID: 33224614 PMCID: PMC7675199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 08/25/2020] [Indexed: 06/11/2023]
Abstract
Systemic inflammatory response syndrome (SIRS) is initiated during the acute phase of thermal injury. The objective was to determine the SIRS impact on cytokine and Antithrombin (AT) levels in smoke inhalation and burn injury. This observational pilot study compared plasma and bronchoalveolar lavage fluid (BAL) cytokine and AT levels in the first six days post smoke inhalation and burn injury. Twenty-five patients, 14 with inhalation + burn injury > 10% total body surface area (TBSA) and 11 with inhalation injury and ≤ 10% TBSA participated. Human Th1/Th2 cytometric bead array kit from BD Biosciences Pharmingen determined cytokine levels; AT levels with Sigma Diagnostics and spectrophotometry. Results indicated no significant age difference between the two groups (42.1 ± 7.2) versus 49.6 ± 6.4 years. On admission, the inhalation group had 5.4 ± 3.9% TBSA compared to 35.0 ± 22.2% TBSA in the inhalation + burn group, P < 0.001. Comparing groups, AT plasma levels were significantly decreased (P = 0.025) and IL-2 levels significantly increased (P = 0.025) in the inhalation + burn group compared to the inhalation group; there was no significant difference in BAL AT or cytokine levels. Combined group plasma AT levels (65.41 ± 4.44%) were significantly increased compared to BAL AT levels (1.06 ± 0.71%), P < 0.001. In contrast, BAL TNF-α levels (35.61 ± 16.01 pg/ml) were significantly increased in relation to the plasma levels (4.68 ± 1.27 pg/ml), P = 0.02. On days 1-2, AT plasma levels were significantly decreased in the inhalation + burn group (41.01 ± 5.24%) compared to the inhalation group (81.02 ± 10.99%), P = 0.002. IL-6 plasma levels were higher in the inhalation + burn group compared to the inhalation group on admission, but both levels decreased by days 3-6. IL-6 BAL levels were elevated in both groups on days 1-2 and decreased by days 3-6. In the first six days of resuscitation, all plasma cytokines were increased in the two groups compared to controls. AT plasma and BAL levels were significantly reduced in both groups, contributing to the coagulopathy. Increased BAL TNF-α and IL-6 levels may have contributed to the pulmonary perturbations during the initial SIRS response in both groups.
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Affiliation(s)
- Areta Kowal-Vern
- Department of Research, Arizona Burn Center, Valleywise Health Medical CenterPhoenix, AZ, USA
| | - Andrew J Dennis
- Burn Center, Department of Trauma, John H. Stroger Hospital of Cook CountyChicago, IL, USA
| | - Paul Bourdon
- Department of Mathematics, University of VirginiaCharlottesville, VA, USA
| | | | - Barbara A Latenser
- Burn Center, Department of Trauma, John H. Stroger Hospital of Cook CountyChicago, IL, USA
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18
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Tsai SY, Lio CF, Shih SC, Lin CJ, Chen YT, Yu CM, Sun FJ, Kuo CF, Jia X. The predisposing factors of AKI for prophylactic strategies in burn care. PeerJ 2020; 8:e9984. [PMID: 33072437 PMCID: PMC7537615 DOI: 10.7717/peerj.9984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 08/27/2020] [Indexed: 01/22/2023] Open
Abstract
Background Acute kidney injury (AKI) is one of the most severe complications of burn injury. AKI with severe burn injury causes high mortality. This study aims to investigate the incidence of and predisposing factors for AKI in burn patients. Methods This is a single-center, retrospective, descriptive criterion standard study conducted from June 27, 2015, to March 8, 2016. We used Kidney Disease Improving Global Outcomes criteria to define and select patients with AKI. The study was conducted by recruiting in hospital patients who suffered from the flammable cornstarch-based powder explosion and were treated under primary care procedures. A total of 49 patients who suffered from flammable dust explosion-related burn injury were enrolled and admitted on June 27, 2015. The patients with more than 20% total body surface area of burn were transferred to the intensive care unit. Patients received fluid resuscitation in the first 24 hours based on the Parkland formula. The primary measurements were the incidence of and predisposing factors for AKI in these patients. Demographic characteristics, laboratory data, and inpatient outcomes were also evaluated. The incidence of AKI in this cohort was 61.2% (n = 30). The mortality rate was 2.0% (n = 1) during a 59-day follow-up period. The multivariate analysis revealed inhalation injury (adjusted OR = 22.0; 95% CI [1.4–358.2]) and meeting ≥3 American Burn Association (ABA) sepsis criteria (adjusted OR = 13.7; 95% CI [1.7–110.5]) as independent risk factors for early advanced AKI. Conclusions The incidence rate of AKI was higher in this cohort than in previous studies, possibly due to the flammable dust explosion-related burn injury. However, the mortality was lower than that expected. In clinical practice, indicators of inflammation, including ABA sepsis criteria may help in predicting the risk of AKI in patients with burn injury.
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Affiliation(s)
- Shin-Yi Tsai
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan.,Graduate Institute of Biomedical Sciences; Graduate Institute of Long- Term Care, Mackay Medical College, New Taipei City, Taiwan.,Department of Health Policy and Management, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, United States of America
| | - Chon-Fu Lio
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shou-Chuan Shih
- Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Cheng-Jui Lin
- Department of Nephrology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yu-Tien Chen
- Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chia-Meng Yu
- Department of Plastic Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chien-Feng Kuo
- Institute of Infectious Disease, Mackay Memorial Hospital, Taipei, Taiwan
| | - Xiaofeng Jia
- Biomedical Engineering, Anesthesiology & Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, United States of America.,Department of Neurosurgery, Orthopaedics, Anatomy & Neurobiology, University of Maryland at Baltimore, Baltimore, MD, United States of America
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19
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Coulter MJ, Mickelson RC, Dye JL, Shannon KB, Ambrosio AA. Serious Inhalation Injuries From Military Operations in Afghanistan, Iraq, and Syria. J Intensive Care Med 2020; 36:1061-1065. [PMID: 32914702 DOI: 10.1177/0885066620956618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize serious inhalation injuries seen during recent military operations, and assess whether bronchoscopic severity findings were associated with clinical presentation and outcomes. METHODS Service members who suffered inhalation injuries while deployed to Iraq, Afghanistan, or Syria from 2001-2018 were identified using ICD-9 and 10 codes from the Expeditionary Medical Encounter Database (EMED), which is abstracted from patient records in forward-deployed medical facilities. Further information including demographics, mechanism of injury, mortality, total burn surface area (TBSA), degree of facial burn, total Injury Severity Score (ISS), and first post-injury bronchoscopy notes were collected. Patients were excluded with ISS less than 16 or without sufficient details regarding bronchoscopy. Injuries were grouped based on bronchoscopic Abbreviated Injury Scores (AIS) into low-grade (AIS of 1), moderate-grade (AIS of 2), or high-grade (AIS of 3 or 4). RESULTS 91 patients met inclusion criteria, with no significant differences in age, gender, paygrade, or service branch between degrees of injury. There were no statistical correlations between grade of injury and battle versus non-battle injury, blast versus non-blast mechanism, TBSA, or degree of facial burn. High-grade injuries had significantly higher ISS than low or moderate-grade injuries. After adjusting for ISS, the odds ratio of death was 10.4 (95% CI 1.47 to 74.53) for those with high-grade and 3.7 (95% CI 0.45 to 32.30) for those with moderate-grade compared to low-grade injuries. CONCLUSION In this cohort of deployed military members with inhalation injuries, initial bronchoscopic severity findings are strongly associated with mortality even after adjusting for ISS. The AIS may be an important prognostic tool in all of those with serious inhalation injuries.
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Affiliation(s)
- Michael J Coulter
- Department of Otolaryngology/Head and Neck Surgery, 19938Naval Medical Center, San Diego, CA, USA
| | - Roxanne C Mickelson
- Department of Otolaryngology/Head and Neck Surgery, 19938Naval Medical Center, San Diego, CA, USA
| | - Judy L Dye
- Leidos, San Diego, CA, USA.,Naval Health Research Center, San Diego, CA, USA
| | - Kaeley B Shannon
- Naval Health Research Center, San Diego, CA, USA.,Axiom Resource Management, Inc, Falls Church, VA, USA
| | - Art A Ambrosio
- Department of Otolaryngology/Head and Neck Surgery, 19938Naval Medical Center, San Diego, CA, USA.,Virtual Medical Center Indo-Pacific, 19938Naval Medical Center San Diego, CA, USA
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20
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Mercel AI, Gillis DC, Sun K, Dandurand BR, Weiss JM, Tsihlis ND, Maile R, Kibbe MR. A comparative study of a preclinical survival model of smoke inhalation injury in mice and rats. Am J Physiol Lung Cell Mol Physiol 2020; 319:L471-L480. [PMID: 32697601 DOI: 10.1152/ajplung.00241.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Smoke inhalation injury increases morbidity and mortality. Clinically relevant animal models are necessary for the continued investigation of the pathophysiology of inhalation injury and the development of therapeutics. The goal of our research was threefold: 1) to develop a reproducible survival model of smoke inhalation injury in rats that closely resembled our previous mouse model, 2) to validate the rat smoke inhalation injury model using a variety of laboratory techniques, and 3) to compare and contrast our rat model with both the well-established mouse model and previously published rat models to highlight our improvements on smoke delivery and lung injury. Mice and rats were anesthetized, intubated, and placed in custom-built smoke chambers to passively inhale woodchip-generated smoke. Bronchoalveolar lavage fluid (BALF) and lung tissue were collected for confirmatory tests. Lung sections were hematoxylin and eosin stained, lung edema was assessed with wet-to-dry (W/D) ratio, and inflammatory cell infiltration and cytokine elevation were evaluated using flow cytometry, immunohistochemistry, and ELISA. We confirmed that our mouse and rat models of smoke inhalation injury mimic the injury seen after human burn inhalation injury with evidence of pulmonary edema, neutrophil infiltration, and inflammatory cytokine elevation. Interestingly, rats mounted a more severe immunological response compared with mice. In summary, we successfully validated a reliable and clinically translatable survival model of lung injury and immune response in rats and mice and characterized the extent of this injury. These animal models allow for the continued study of smoke inhalation pathophysiology to ultimately develop a better therapeutic.
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Affiliation(s)
- Alexandra I Mercel
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - David C Gillis
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kui Sun
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brooke R Dandurand
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jenna M Weiss
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nick D Tsihlis
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rob Maile
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Curriculum of Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Melina R Kibbe
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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21
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Modified abbreviated burn severity index as a predictor of in-hospital mortality in patients with inhalation injury: development and validation using independent cohorts. Surg Today 2020; 51:242-249. [PMID: 32691141 DOI: 10.1007/s00595-020-02085-5] [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: 05/10/2020] [Accepted: 07/05/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The ability to accurately evaluate the severity of inhalation injury can help to optimize patient care. However, there is no accepted severity grading system, especially for inhalation injury. METHODS We screened a multicenter burn registry and included adult patients who required oxygen treatment or mechanical ventilation. After the patient data were divided into development and validation cohorts, missing values were replaced with multiple imputation. Twelve potential predictors were analyzed using multivariate logistic regression to identify prognostic variables for in-hospital mortality and scores were assigned to each predictor based on odds ratios to develop the Modified Abbreviated Burn Severity Index, mABSI. The mABSI was validated using c-statistics and calibration curves. RESULTS We randomly assigned 1377 and 919 patients to the development and validation cohorts, respectively. Age, self-inflicted injury, cutaneous burn area, and mechanical ventilation requirement were identified as independent predictors, and the mABSI (1-17 scale) was, thus, developed. The mABSI has a high discriminatory power (c-statistic = 0.94; 95% CI 0.92-0.97), and both estimated and observed in-hospital mortalities increased from 1% at score ≤ 5 to almost 100% at score ≥ 14 with linear calibration plots. CONCLUSIONS We developed and validated the mABSI which accurately predicts in-hospital mortality.
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22
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Klein HJ, Rittirsch D, Buehler PK, Schweizer R, Giovanoli P, Cinelli P, Plock JA, Reding T, Graf R. Response of routine inflammatory biomarkers and novel Pancreatic Stone Protein to inhalation injury and its interference with sepsis detection in severely burned patients. Burns 2020; 47:338-348. [PMID: 33272743 DOI: 10.1016/j.burns.2020.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Inhalation of thermal and chemical products of combustion evokes an immune response measurable at a systemic level. Inhalation injury related kinetics of currently available inflammatory biomarkers and novel Pancreatic Stone Protein (PSP) as well as their interference with septic events has not been addressed to literature yet. METHODS Analysis of the influence of inhalation injury and ARDS on biomarker kinetics (PSP, procalcitonin (PCT), C-reactive Protein (CRP), white blood cells (WBC)) in 90 patients admitted to Zurich Burn Center between May 2015 and October 2018 with burns ≥15% total body surface area (TBSA) over 14 days. RESULTS Twenty-five (27%) of 90 included patients presented with inhalation injury (median age 52 years [IQR 27], median TBSA 31.5% [IQR 21], mean ABSI-Score 7±3). At admission, only WBC demonstrated significantly higher values in the inhalation injury group (p=0.011). Acute respiratory distress syndrome (ARDS) was present in 32% without association to the severity of inhalation injury (p=0.11). WBC, CRP and PCT failed to delineate inhalation injury related inflammation from septic progression at most time points. PSP was the strongest marker to identify septic patients both by its higher values and steeper increase over time (p<0.001). CONCLUSION Inhalation injury leads to an inflammatory response at a systemic level with alterations of biomarkers. While routine inflammatory markers demonstrated strong interferences between inhalation injury with its associated ARDS and evolving sepsis, PSP reliably identified septic patients in a setting of inflammatory turbulences secondary to inhalation injury.
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Affiliation(s)
- Holger J Klein
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland; Regenerative and Reconstructive Plastic Surgery Research Laboratory, University of Zurich, Zurich, Switzerland.
| | - Daniel Rittirsch
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland
| | - Philipp K Buehler
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Riccardo Schweizer
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland; Regenerative and Reconstructive Plastic Surgery Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland
| | - Paolo Cinelli
- Center for Surgical Research, University and University Hospital Zurich, Zurich, Switzerland
| | - Jan A Plock
- Department of Plastic Surgery and Hand Surgery, Burn Center, University Hospital Zurich, Zurich, Switzerland; Regenerative and Reconstructive Plastic Surgery Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Theresia Reding
- Pancreas Research Laboratory, Department of Visceral Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Rolf Graf
- Pancreas Research Laboratory, Department of Visceral Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
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23
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Moffatt LT, Madrzykowski D, Gibson ALF, Powell HM, Cancio LC, Wade CE, Choudhry MA, Kovacs EJ, Finnerty CC, Majetschak M, Shupp JW. Standards in Biologic Lesions: Cutaneous Thermal Injury and Inhalation Injury Working Group 2018 Meeting Proceedings. J Burn Care Res 2020; 41:604-611. [PMID: 32011688 PMCID: PMC7195554 DOI: 10.1093/jbcr/irz207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
On August 27 and 28, 2018, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn and inhalation injury in Washington, DC. The goal of the meeting was to identify and discuss the existing knowledge, data, and modeling gaps related to understanding cutaneous thermal injury and inhalation injury due to exposure from a fire environment, and in addition, address two more areas proposed by the American Burn Association Research Committee that are critical to burn care but may have current translational research gaps (inflammatory response and hypermetabolic response). Representatives from the Underwriters Laboratories Firefighter Safety Research Institute and the Bureau of Alcohol, Tobacco, Firearms and Explosives Fire Research Laboratory presented the state of the science in their fields, highlighting areas that required further investigation and guidance from the burn community. Four areas were discussed by the full 24 participant group and in smaller groups: Basic and Translational Understanding of Inhalation Injury, Thermal Contact and Resulting Injury, Systemic Inflammatory Response and Resuscitation, and Hypermetabolic Response and Healing. A primary finding was the need for validating historic models to develop a set of reliable data on contact time and temperature and resulting injury. The working groups identified common areas of focus across each subtopic, including gaining an understanding of individual response to injury that would allow for precision medicine approaches. Predisposed phenotype in response to insult, the effects of age and sex, and the role of microbiomes could all be studied by employing multi-omic (systems biology) approaches.
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Affiliation(s)
- Lauren T Moffatt
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC
| | | | - Angela L F Gibson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Heather M Powell
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH
- Research Department, Shriners Hospitals for Children, Cincinnati, OH
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Charles E Wade
- Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Mashkoor A Choudhry
- Department of Surgery, Burn & Shock Trauma Research Institute, Health Sciences Division, Loyola University, Maywood, IL
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora CO
| | - Celeste C Finnerty
- Departments of Surgery and Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch and Shriners Burns Hospital, Galveston TX
| | - Matthias Majetschak
- Departments of Surgery and Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Jeffrey W Shupp
- Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University School of Medicine, Washington, DC
- The Burn Center, MedStar Washington Hospital Center, Washington DC
- Department of Surgery, Georgetown University School of Medicine, Washington, DC
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24
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Yin HN, Hao JW, Chen Q, Li F, Yin S, Zhou M, Zhang QH, Yao YM, Chai JK. Plasma glucagon-like peptide 1 was associated with hospital-acquired infections and long-term mortality in burn patients. Surgery 2020; 167:1016-1022. [PMID: 32295709 DOI: 10.1016/j.surg.2020.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/19/2019] [Accepted: 01/07/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although glucagon-like peptide 1 levels have been closely associated with inflammation and mortality in septic patients, the clinical importance of glucagon-like peptide 1 on hospital-acquired infections and long-term mortality after burn injury remains unexplored. METHODS Plasma samples from 144 burn patients were collected on admission to determine total glucagon-like peptide 1, interleukin 6, and monocyte chemotactic protein-1 levels. Hospital-acquired infections were determined by positive microbial culture. One-year mortality was assessed by telephone interview. Factors associated with glucagon-like peptide 1 were determined by multivariable linear logistic regression. Predicting the clinical importance of glucagon-like peptide 1 on the development of hospital-acquired infections and mortality were determined by Cox proportional hazards models and further by receiver operating characteristic curve analysis. Kaplan-Meier analyses were performed to examine whether the mean glucagon-like peptide 1 level of the cohort could discriminate the hospital-acquired infections-free survival. RESULTS Median burn size was 41% (19%-70%) of total body surface area. Hospital-acquired infections developed in 36 (25%) patients after a mean of 10 ± 1 days after injury. Interleukin 6, monocyte chemotactic protein-1, and blood urea nitrogen levels and thrombin time were independently associated with increased glucagon-like peptide 1 levels. Levels of glucagon-like peptide 1 (median, interquartile range) were greater in patients who developed hospital-acquired infections than in those who did not (237 pmol/L, 76-524 vs 80 pmol/L, 51-158; P < .001) and in patients who died (536 pmol/L, interquartile range: 336-891 pmol vs 98 pmol/L, 47-189; P < .001). Although the glucagon-like peptide 1 level could not predict hospital-acquired infections-free survival in individual patients, it could predict 1-year mortality independently (P = .021). Moreover, a glucagon-like peptide 1 level of 200 pmol/L could discriminate hospital-acquired infections-free survival (P < .001). CONCLUSION Admission glucagon-like peptide 1 level can discriminate hospital-acquired infections-free survival and predict long-term mortality in a group of patients with burn injury. Our data suggests that glucagon-like peptide 1 may be a predictive biomarker for hospital-acquired infections and mortality in burn patients.
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Affiliation(s)
- Hui-Nan Yin
- Department of Burn and Plastic Surgery, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Ji-Wei Hao
- Trauma Repairment and Tissue Regeneration Center, Department of Medical Innovation Study, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Qi Chen
- Department of Burn and Plastic Surgery, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Feng Li
- Department of Burn and Plastic Surgery, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Song Yin
- Department of Outpatient Service, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Min Zhou
- Neurocritical Care Unit, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, Hefei, Anhui, People's Republic of China
| | - Qing-Hong Zhang
- Trauma Repairment and Tissue Regeneration Center, Department of Medical Innovation Study, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.
| | - Yong-Ming Yao
- Trauma Repairment and Tissue Regeneration Center, Department of Medical Innovation Study, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Jia-Ke Chai
- Department of Burn and Plastic Surgery, Fourth Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
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25
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Matsuura H, Matsumoto H, Osuka A, Ogura H, Shimizu K, Kang S, Tanaka T, Ueyama M, Shimazu T. Clinical Importance of a Cytokine Network in Major Burns. Shock 2020; 51:185-193. [PMID: 29621119 DOI: 10.1097/shk.0000000000001152] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Major burns elicit an acute inflammatory response including various inflammatory cytokines. Cytokines play mutual interacting roles in inflammatory diseases. There is little evidence of the clinical significance of the cytokine network in patients with major burns. This study aimed to investigate the clinical significance of the cytokine network in patients with major burn. This prospective observational study comprising 38 patients with major burns (total body surface area (%TBSA) ≥ 20%) and 12 healthy controls was conducted from April 2014 to December 2016. Blood samples were collected from patients at six points: day 1, day 2, days 3-5, 1 week, 2 weeks, and 1 month after the burn injury. Inflammatory cytokines (interferon [IFN]-α, IFN-γ, interleukin [IL]-1β, IL-6, IL-8, IL-12/IL-23p40, IL-17A, monocyte chemotactic protein-1 [MCP-1], TNF-α), and anti-inflammatory cytokines (IL-4, IL-10) were measured. Twenty-eight-day mortality, %TBSA, prognostic burn index (PBI) and Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were evaluated. Hierarchical clustering analysis and network visualization showed one cluster and network, respectively. Both were formed by four cytokines including IL-6, IL-8, IL-10, and MCP-1 on days 1 and 2, suggesting the presence of a cytokine network in the early hospital phase. Each cytokine showed significant associations with the SOFA score within 5 days and 1 month after burn injury. Cox regression analysis highlighting days 1 and 2 showed significant correlation of IL-6, IL-8, and IL-10 with 28-day mortality. We showed a cytokine network and its relation with prognosis and injury severity on days 1 and 2 and suggest that this cytokine network may play a role in major burns.
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Affiliation(s)
- Hiroshi Matsuura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hisatake Matsumoto
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Akinori Osuka
- Department of Trauma, Critical Care Medicine and Burn Center, Japan Community Health Care Organization Chukyo Hospital, Minami-ku, Nagoya, Aichi, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Sujin Kang
- Department of Clinical Application of Biologics, Osaka University Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Toshio Tanaka
- Department of Clinical Application of Biologics, Osaka University Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine and Burn Center, Japan Community Health Care Organization Chukyo Hospital, Minami-ku, Nagoya, Aichi, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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26
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Ogura A, Tsurumi A, Que YA, Almpani M, Zheng H, Tompkins RG, Ryan CM, Rahme LG. Associations between clinical characteristics and the development of multiple organ failure after severe burns in adult patients. Burns 2019; 45:1775-1782. [PMID: 31690472 DOI: 10.1016/j.burns.2019.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 01/07/2019] [Accepted: 02/14/2019] [Indexed: 11/24/2022]
Abstract
To determine the association between potential risk factors and multiple organ failure (MOF) in severe burn adult patients, we performed a secondary analysis of data from the "Inflammation and the Host Response to Injury" database, which included patients from six burn centers in the United States between 2003 and 2009. Three hundred twenty-two adult patients (aged ≥16 years) with severe burns (≥20.0% total body surface area [TBSA]) were included. MOF was defined according to the Denver score. Potential risk factors were analyzed for their association with MOF. Models were built using multivariable logistic regression analysis. Eighty-eight patients (27.3%) developed MOF during the study period. We found that TBSA, age, and inhalation injury were significant risk factors for MOF. This predictive model showed good performance, with the total area under the receiver operating characteristic curve being 0.823. Moreover, among patients who developed MOF, inhalation injury was significantly associated with the development of MOF in the acute phase (within three days of injury) (adjusted odds ratio 3.1; 95% confidence interval 1.1-8.3). TBSA, age, lactate, and Denver score within 24h were associated with the late phase development of MOF. Thus, we have identified key risk factors for the onset of MOF after severe burn injury. Our findings contribute to the understanding of individualized treatment and will potentially allow for efficient allocation of resources and a lower threshold for admission to an intensive care unit, which can prevent the development of MOF and eventually reduce mortality.
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Affiliation(s)
- Asako Ogura
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA
| | - Amy Tsurumi
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA; Shriners Hospitals for Children, 51 Blossom St., Boston, MA 02114, USA
| | - Yok-Ai Que
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Marianna Almpani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA; Shriners Hospitals for Children, 51 Blossom St., Boston, MA 02114, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, and Harvard Medical School, 50 Staniford St., Boston, MA 02114, USA
| | - Ronald G Tompkins
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA; Shriners Hospitals for Children, 51 Blossom St., Boston, MA 02114, USA
| | - Laurence G Rahme
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 340 Thier Research Building, 50 Blossom Street, Boston MA 02114, USA; Shriners Hospitals for Children, 51 Blossom St., Boston, MA 02114, USA; Department of Microbiology and Immunobiology, Harvard Medical School, 77 Ave. Louis Pasteur, Boston, MA 02114, USA.
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27
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Xiao P, Sun S, Cao J, Wang J, Li H, Hou S, Ding H, Liu Z, Fang Y, Bai S, Qin X, Yu F, Liu J, Wang X, Lv Q, Fan H. Expression profile of microRNAs in bronchoalveolar lavage fluid of rats as predictors for smoke inhalation injury. Burns 2018; 44:2042-2050. [DOI: 10.1016/j.burns.2018.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 06/08/2018] [Accepted: 07/19/2018] [Indexed: 02/08/2023]
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Bergquist M, Hästbacka J, Glaumann C, Freden F, Huss F, Lipcsey M. The time-course of the inflammatory response to major burn injury and its relation to organ failure and outcome. Burns 2018; 45:354-363. [PMID: 30274808 DOI: 10.1016/j.burns.2018.09.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/24/2018] [Accepted: 09/05/2018] [Indexed: 12/11/2022]
Abstract
Burn injury causes major inflammatory activation and cytokine release, however, the temporal resolution of the acute and sub-acute inflammatory response has not yet been fully delineated. To this end, we have quantified 20 inflammatory mediators in plasma from 44 adult patients 0-21 days after burn injury and related the time course of these mediators to % total body surface area (TBSA) burned, clinical parameters, organ failure and outcome. Of the cytokines analyzed in these patients, interleukin 6 (IL-6), IL-8, IL-10 and monocyte chemoattractant protein 1 (MCP-1) correlated to the size of the injury at 24-48h after burn injury. In our study, the concentration of IL-10 had prognostic value in patients with burn injury both measured at admission and at 24-48h after injury. However, simple demographic data such as age, % burned TBSA, inhalation injury and their combination, the Baux score and modified Baux score, outperform most of the cytokines, with the exception of IL-8 and MCP-1 levels on admission, in predicting death.
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Affiliation(s)
- Maria Bergquist
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden; Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Johanna Hästbacka
- Intensive Care Medicine, Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Christian Glaumann
- Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Filip Freden
- Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden; Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Fredrik Huss
- Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden; Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
| | - Miklos Lipcsey
- The Hedenstierna Laboratory, CIRRUS, Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
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29
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Deutsch C, Tan A, Smailes S, Dziewulski P. The diagnosis and management of inhalation injury: An evidence based approach. Burns 2018; 44:1040-1051. [DOI: 10.1016/j.burns.2017.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 10/03/2017] [Accepted: 11/20/2017] [Indexed: 10/28/2022]
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30
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Peluso H, Abougergi MS, Caffrey J. Impact of primary payer status on outcomes among patients with burn injury: A nationwide analysis. Burns 2018; 44:1973-1981. [PMID: 30005990 DOI: 10.1016/j.burns.2018.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/24/2018] [Accepted: 06/15/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the relationship between insurance provider and important outcomes among patients with burn injury. METHODS Adults with burn injury were selected from the National Inpatient Sample. The primary outcome was inpatient mortality. Secondary outcomes were morbidity (septic shock and prolonged mechanical ventilation (PMV)), treatment metrics (time to surgery and parenteral or enteral nutrition (P/E-nutrition)) and resource utilization (length of stay (LOS) and total hospitalization costs and charges). Confounders were adjusted for using multivariate regression analysis. RESULTS Insurance did not affect in-hospital mortality rate. Compared with private insurance, Medicaid was associated with higher septic shock rate (aOR: 2.14 (1.04-4.39), longer LOS (adjusted mean difference (aMD): 2.79 (0.50-5.08) days) and higher costs (aMD: $16,161 ($4789-$27,534) while uninsured patients has shorter LOS (aMD: -2.57 (-4.59--0.55) days), lower charges (aMD: $-37,792 $(-65,550-$-10,034) and costs (aMD: $-8563 ($15,581-$-1544)). Insurance did not affect PMV rates or time to surgery or P/E-nutrition. CONCLUSIONS Primary payer does not affect in-hospital mortality or treatment metrics among patients admitted for burn injury. However, compared with private insurance, Medicaid was associated with both higher morbidity and resource utilization, whereas uninsured patients had lower resource utilization.
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Affiliation(s)
- Heather Peluso
- Department of surgery, University of South Carolina, Greenville Health System, 701 Grove Road, Greenville, SC, 29605, USA.
| | - Marwan S Abougergi
- Catalyst Medical Consulting, 722 Elmbrook Drive, Simpsonville, SC, 29681, USA; Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, 5 Medical Park Road, Columbia, SC, 29203, USA
| | - Julie Caffrey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University Medical Center, Johns Hopkins Adult Burn Unit, Johns Hopkins Bayview Medical Center, 4900 Eastern Avenue, Baltimore, MD, 21224, USA
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31
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Jayaraman SP, Anand RJ, DeAntonio JH, Mangino M, Aboutanos MB, Kasirajan V, Ivatury RR, Valadka AB, Glushakova O, Hayes RL, Bachmann LM, Brophy GM, Contaifer D, Warncke UO, Brophy DF, Wijesinghe DS. Metabolomics and Precision Medicine in Trauma: The State of the Field. Shock 2018; 50:5-13. [PMID: 29280924 PMCID: PMC5995639 DOI: 10.1097/shk.0000000000001093] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Trauma is a major problem in the United States. Mortality from trauma is the number one cause of death under the age of 45 in the United States and is the third leading cause of death for all age groups. There are approximately 200,000 deaths per year due to trauma in the United States at a cost of over $671 billion in combined healthcare costs and lost productivity. Unsurprisingly, trauma accounts for approximately 30% of all life-years lost in the United States. Due to immense development of trauma systems, a large majority of trauma patients survive the injury, but then go on to die from complications arising from the injury. These complications are marked by early and significant metabolic changes accompanied by inflammatory responses that lead to progressive organ failure and, ultimately, death. Early resuscitative and surgical interventions followed by close monitoring to identify and rescue treatment failures are key to successful outcomes. Currently, the adequacy of resuscitation is measured using vital signs, noninvasive methods such as bedside echocardiography or stroke volume variation, and other laboratory endpoints of resuscitation, such as lactate and base deficit. However, these methods may be too crude to understand cellular and subcellular changes that may be occurring in trauma patients. Better diagnostic and therapeutic markers are needed to assess the adequacy of interventions and monitor responses at a cellular and subcellular level and inform clinical decision-making before complications are clinically apparent. The developing field of metabolomics holds great promise in the identification and application of biochemical markers toward the clinical decision-making process.
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Affiliation(s)
- Sudha P Jayaraman
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Rahul J Anand
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Jonathan H DeAntonio
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Martin Mangino
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Michel B Aboutanos
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Vigneshwar Kasirajan
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Rao R Ivatury
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Alex B Valadka
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Olena Glushakova
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ronald L Hayes
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
- Center of Innovative Research, Banyan Biomarkers, Inc., Alachua, Florida
| | - Lorin M Bachmann
- Department of Pathology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel Contaifer
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Urszula O Warncke
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Dayanjan S Wijesinghe
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
- da Vinci Center, Virginia Commonwealth University, Richmond, Virginia
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32
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Aung MT, Garner D, Pacquola M, Rosenblum S, McClure J, Cleland H, Pilcher DV. The use of a simple three-level bronchoscopic assessment of inhalation injury to predict in-hospital mortality and duration of mechanical ventilation in patients with burns. Anaesth Intensive Care 2018; 46:67-73. [PMID: 29361258 DOI: 10.1177/0310057x1804600110] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Major burn centres in Australia use bronchoscopy to assess severity of inhalation injuries despite limited evidence as to how best to classify severity of inhalational injury or its relationship to patient outcomes. All patients with burns who were admitted to the intensive care unit (ICU) at The Alfred Hospital between February 2010 and July 2014 and underwent bronchoscopy to assess inhalational injury, were reviewed. Age, total body surface area burnt, severity of illness indices and mechanisms of injury were extracted from medical histories and local ICU and burns registries. Inhalational injury was classified based on the Abbreviated Injury Score and then grouped into three categories (none/mild, moderate, or severe injury). Univariable and multivariable analyses were undertaken to examine the relationship between inhalational injury and outcomes (in-hospital mortality and duration of mechanical ventilation). One hundred and twenty-eight patients were classified as having none/mild inhalational injury, 81 moderate, and 13 severe inhalation injury. Mortality in each group was 2.3% (3/128), 7.4% (6/81) and 30.7% (4/13) respectively. Median (interquartile range) duration of mechanical ventilation in each group was 26 (11-82) hours, 84 (32-232) hours and 94 (21-146) hours respectively. After adjusting for age, total body surface area burnt and severity of illness, only the severe inhalation injury group was independently associated with increased mortality (odds ratio 20.4 [95% confidence intervals {CI} 1.74 to 239.4], <i>P</i>=0.016). Moderate inhalation injury was independently associated with increased duration of ventilation (odds ratio 2.25 [95% CI 1.53 to 3.31], <i>P</i> <0.001), but not increased mortality. This study suggests that stratification of bronchoscopically-assessed inhalational injury into three categories can provide useful prognostic information about duration of ventilation and mortality. Larger multicentre prospective studies are required to validate these findings.
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Affiliation(s)
| | | | | | | | | | - H Cleland
- Department of Surgery, Central and Eastern Clinical School, Monash University, Melbourne, Victoria
| | - D V Pilcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria
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33
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Abstract
This article summarizes research conducted over the last decade in the field of inhalation injury in thermally injured patients. This includes brief summaries of the findings of the 2006 State of the Science meeting with regard to inhalation injury, and of the subsequent 2007 Inhalation Injury Consensus Conference. The reviewed studies are categorized in to five general areas: diagnosis and grading; mechanical ventilation; systemic and inhalation therapy; mechanistic alterations; and outcomes.
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34
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Frankel JH, Boe DM, Albright JM, O'Halloran EB, Carter SR, Davis CS, Ramirez L, Burnham EL, Gamelli RL, Afshar M, Kovacs EJ. Age-related immune responses after burn and inhalation injury are associated with altered clinical outcomes. Exp Gerontol 2017; 105:78-86. [PMID: 29080833 DOI: 10.1016/j.exger.2017.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 10/20/2017] [Accepted: 10/23/2017] [Indexed: 12/20/2022]
Abstract
This prospective study aimed to address changes in inflammatory response between different aged populations of patients who sustained burn and inhalation injury. Plasma and bronchoalveolar lavage (BAL) samples were collected from 104 patients within 15h of their estimated time of burn injury. Clinical variables, laboratory parameters, and immune mediator profiles were examined in association with clinical outcomes. Older patients were at higher odds for death after burn injury (odds ratio (OR)=7.37 per 10years, p=0.004). In plasma collected within 15h after burn injury, significant increases in the concentrations of interleukin 1 receptor antagonist (IL-1RA), interleukin 2 (IL-2), interleukin 4 (IL-4), interleukin 6 (IL-6), granulocyte colony-stimulating factor (G-CSF), interferon-gamma-induced protein 10 (IP-10) and monocyte chemoattractant protein 1 (MCP-1) (p<0.05 for all) were observed in the ≥65 group. In the BAL fluid, MCP-1 was increased three-fold in the ≥65 group. This study suggests that changes in certain immune mediators were present in the older cohort, in association with in-hospital mortality.
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Affiliation(s)
- John H Frankel
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Devin M Boe
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Joslyn M Albright
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Eileen B O'Halloran
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Stewart R Carter
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Christopher S Davis
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA
| | - Luis Ramirez
- Department of Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Ellen L Burnham
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Colorado Alcohol Pulmonary Research Collaborative, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | | | - Majid Afshar
- Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, IL, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA; Division of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
| | - Elizabeth J Kovacs
- Burn Research Program, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Loyola University Chicago, Maywood, IL, USA; Colorado Alcohol Pulmonary Research Collaborative, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA; Alcohol Research Program, Burn and Shock Trauma Research Institute, Department of Surgery, Loyola University Chicago Health Sciences Campus, Maywood, IL, USA.
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35
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Afshar M, Netzer G, Mosier MJ, Cooper RS, Adams W, Burnham EL, Kovacs EJ, Durazo-Arvizu R, Kliethermes S. The Contributing Risk of Tobacco Use for ARDS Development in Burn-Injured Adults With Inhalation Injury. Respir Care 2017; 62:1456-1465. [PMID: 28900039 DOI: 10.4187/respcare.05560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study aims to determine the relationship between tobacco use, inhalation injury, and ARDS in burn-injured adults. METHODS This study was an observational cohort of 2,485 primary burn admissions to a referral burn center between January 1, 2008 and March 15, 2015. Subjects were evaluated by methods used to account for mediation and traditional approaches (multivariable logistic regression and propensity score analysis). Mediation analysis examined both the (1) indirect effect of tobacco use via inhalation injury as the mediator on ARDS development and (2) the direct effect of tobacco use alone on ARDS development. RESULTS ARDS development occurred in 6.8% (n = 170) of the cohort. Inhalation injury occurred in 5.0% (n = 125) of the cohort, and ARDS developed in 48.8% (n = 83) of the subjects with inhalation injury. Tobacco use was 2-fold more common in subjects with ARDS. In the mediated model, the direct effect of tobacco use on ARDS, including interaction between tobacco use and inhalation injury, was not significant (odds ratio [OR] 1.63, 95% CI 0.91-2.92, P = .10). However, the indirect effect of tobacco use via inhalation injury as the mediator was significant (OR 1.61, 95% CI 1.25-2.07, P < .001), and the proportion of the total effect of tobacco use operating through the mediator was 55.6%. In the non-mediation models (multivariable logistic regression and propensity score analysis), which controlled for inhalation injury and other covariables, the OR for the association between tobacco use and ARDS was 1.84 (95% CI 1.22-2.81, P < .001) and 1.69 (95% CI 1.04-2.75, P = .03), respectively. CONCLUSIONS In mediation analysis, inhalation injury was the overwhelming predictor for ARDS development, whereas tobacco use has its strongest effect indirectly through inhalation injury. Patients with at least moderate inhalation injury are at greatest risk for ARDS development despite baseline risk factors like tobacco use.
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Affiliation(s)
- Majid Afshar
- Burn and Shock Trauma Research Institute .,Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, Illinois
| | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore Maryland
| | | | - Richard S Cooper
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - William Adams
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine
| | - Elizabeth J Kovacs
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ramon Durazo-Arvizu
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - Stephanie Kliethermes
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin
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36
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Li X, Cannon AR, Hammer AM, Morris NL, Choudhry MA. IL-23 restoration of Th17 effector function is independent of IL-6 and TGF-β in a mouse model of alcohol and burn injury. J Leukoc Biol 2017; 102:915-923. [PMID: 28684599 DOI: 10.1189/jlb.3a1216-527r] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/22/2017] [Accepted: 06/11/2017] [Indexed: 12/26/2022] Open
Abstract
T cells play a critical role in host defense against intestinal bacteria. We have shown that ethanol combined with burn injury suppresses Peyer's patch (PP) Th17 cytokines 1 d after injury. We assessed the mechanism of suppressed Th17 effector functions. Mice were gavaged with ethanol 4 h before burn injury and euthanized 1, 3, and 7 d after injury. Mesenteric lymph nodes (MLNs), PPs, and spleen Th1 and Th17 cytokines were assessed. A significant decrease in IL-17, IL-22, IL-2, and IFN-γ were observed in all 3 lymphoid organs 1 and 3 d after injury. We used splenic cells to study the role of IL-6, IL-23, TGF-β, and aryl hydrocarbon receptor (AHR) in suppressing Th17 cytokines. We also assessed whether the AHR agonist 6-formylindolo (3, 2-b) carbazole (FICZ) modulates Th17 cytokines. We found a significant decrease in IL-6 and TGF-β after ethanol and burn; IL-23 was undetectable. The reconstitution of IL-23 in culture medium increased IL-17 by 2-fold and IL-22 by 20-fold in cells from burn ethanol mice. The restoration of IL-6 and TGF-β combined did not influence the release of Th17 cytokines. We observed that AHR was necessary for IL-23 restoration of IL-22 after ethanol and burn injury. The AHR agonist FICZ enhanced IL-22, but not IL-17. None of these treatments influenced the release of Th1 cytokines. Together, these results suggest that IL-23 plays a critical role in regulation of Th17 cytokines. Furthermore, IL-6 and TGF-β do not appear to influence IL-23-mediated restoration of Th17 cytokines after ethanol and burn injury.
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Affiliation(s)
- Xiaoling Li
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA.,Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Illinois, USA.,Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA
| | - Abigail R Cannon
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA.,Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Illinois, USA.,Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA.,Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA; and.,Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA
| | - Adam M Hammer
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA.,Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Illinois, USA.,Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA
| | - Niya L Morris
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA.,Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Illinois, USA.,Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA
| | - Mashkoor A Choudhry
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA; .,Burn and Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Illinois, USA.,Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA.,Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA; and.,Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, Illinois, USA
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37
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Jones SW, Williams FN, Cairns BA, Cartotto R. Inhalation Injury: Pathophysiology, Diagnosis, and Treatment. Clin Plast Surg 2017; 44:505-511. [PMID: 28576239 DOI: 10.1016/j.cps.2017.02.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The classic determinants of mortality from severe burn injury are age, size of injury, delays of resuscitation, and the presence of inhalation injury. Of the major determinants of mortality, inhalation injury remains one of the most challenging injuries for burn care providers. Patients with inhalation injury are at increased risk for pneumonia (the leading cause of death) and multisystem organ failure. There is no consensus among leading burn care centers in the management of inhalation injury. This article outlines the current treatment algorithms and the evidence of their efficacy.
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Affiliation(s)
- Samuel W Jones
- Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina at Chapel Hill, 3007D Burnett Womack Building, CB 7206, Chapel Hill, NC 27599-7206, USA.
| | - Felicia N Williams
- Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina at Chapel Hill, 3007D Burnett Womack Building, CB 7206, Chapel Hill, NC 27599-7206, USA
| | - Bruce A Cairns
- Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina at Chapel Hill, 3007D Burnett Womack Building, CB 7206, Chapel Hill, NC 27599-7206, USA
| | - Robert Cartotto
- Department of Surgery, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, Room D712, 1075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
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38
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Burmeister DM, McIntyre MK, Beely B, Jordan B, Walker KP, Aden JK, Batchinsky A, Chung KK, Cancio LC, Christy RJ. A model of recovery from inhalation injury and cutaneous burn in ambulatory swine. Burns 2017; 43:1295-1305. [PMID: 28410931 DOI: 10.1016/j.burns.2017.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 12/22/2022]
Abstract
Inhalation injury commonly accompanies thermal injury, increasing the likelihood of mortality and multiple organ dysfunction (MOD). Large animal models have given important insight into the pathophysiology of this injury; however recapitulating late MOD has remained difficult. The current report describes experiments using a smoke inhalation and burn model, with follow-up of ambulatory swine for 14days with bronchoscopy, CT scanning, and bronchoalveolar lavage fluid (BALF)/blood collection. Clinically, animals cleared airway damage in the first several days after-injury. This was mirrored with erythematous airways on day 2 after-injury, which resolved by the end of the experiment, as did parenchymal damage seen on CT. An initial rise in the protein content of BALF immediately after-injury was followed by a dramatic increase in the concentration of leukocytes. Circulating neutrophils increased while lymphocytes decreased; both correlated with cell counts in BALF. IL8 levels in BALF increased 30-fold and remained elevated throughout the experiment. IL1ra increased circulation immediately after-injury, and afterwards in BALF. Other cytokines (TNFα, IL12) transiently increased in BALF (and decreased in circulation) on day 2. Taken together, these results display a remarkable capability for the lungs to recover in the absence of intubation, with further evidence of the role of cytokines such as IL8 and IL1ra. The possible exacerbating effects of clinical practices such as ventilation and bronchoscopies should be considered.
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Affiliation(s)
| | | | - Brendan Beely
- United States Army Institute of Surgical Research, United States; The Geneva Foundation, Tacoma WA, United States
| | - Bryan Jordan
- United States Army Institute of Surgical Research, United States
| | - Kerfoot P Walker
- United States Army Institute of Surgical Research, United States
| | - James K Aden
- United States Army Institute of Surgical Research, United States
| | - Andriy Batchinsky
- United States Army Institute of Surgical Research, United States; The Geneva Foundation, Tacoma WA, United States
| | - Kevin K Chung
- United States Army Institute of Surgical Research, United States
| | | | - Robert J Christy
- United States Army Institute of Surgical Research, United States.
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39
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Tsurumi A, Que YA, Ryan CM, Tompkins RG, Rahme LG. TNF-α/IL-10 Ratio Correlates with Burn Severity and May Serve as a Risk Predictor of Increased Susceptibility to Infections. Front Public Health 2016; 4:216. [PMID: 27761434 PMCID: PMC5050217 DOI: 10.3389/fpubh.2016.00216] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 09/16/2016] [Indexed: 11/13/2022] Open
Abstract
Severe burn injury renders patients susceptible to multiple infection episodes; however, identifying specific patient groups at high risk remains challenging. Burn-induced inflammatory response dramatically modifies the levels of various cytokines. Whether these changes could predict susceptibility to infections remains unknown. The aim of this study was to determine the early changes in the pro- to anti-inflammatory cytokine ratio and investigate its ability to predict susceptibility to repeated infections after severe burn trauma. The patient population consisted of 34 adult patients having early (≤48 h since injury) blood draws following severe (≥20% total burn surface area (TBSA)) burn injury and suffering from a first infection episode at least 1 day after blood collection. Plasma TNF-α and IL-10 levels were measured to explore the association between the TNF-α/IL-10 ratio, hypersusceptibility to infections, burn size (TBSA), and common severity scores (Acute Physiology and Chronic Health Evaluation II (APACHEII), Baux, modified Baux (R-Baux), Ryan Score, and Abbreviated Burn Severity Index (ABSI)). TNF-α/IL10 plasma ratio measured shortly after burn trauma was inversely correlated with burn size and the injury severity scores investigated, and was predictive of repeated infections (≥3 infection episodes) outcome (AUROC [95%CI] of 0.80 [0.63-0.93]). Early measures of circulating TNF-α/IL10 ratio may be a previously unidentified biomarker associated with burn injury severity and predictive of the risk of hypersusceptibility to repeated infections.
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Affiliation(s)
- Amy Tsurumi
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA; Department of Microbiology and Immunology, Harvard Medical School, Boston, MA, USA; Shriners Hospitals for Children-Boston®, Boston, MA, USA
| | - Yok-Ai Que
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA; Shriners Hospitals for Children-Boston®, Boston, MA, USA
| | - Ronald G Tompkins
- Department of Surgery, Massachusetts General Hospital , Boston, MA , USA
| | - Laurence G Rahme
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA; Department of Microbiology and Immunology, Harvard Medical School, Boston, MA, USA; Shriners Hospitals for Children-Boston®, Boston, MA, USA
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Hazeldine J, Hampson P, Lord JM. The diagnostic and prognostic value of systems biology research in major traumatic and thermal injury: a review. BURNS & TRAUMA 2016; 4:33. [PMID: 27672669 PMCID: PMC5030723 DOI: 10.1186/s41038-016-0059-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/09/2016] [Indexed: 01/12/2023]
Abstract
As secondary complications remain a significant cause of morbidity and mortality amongst hospitalised trauma patients, the need to develop novel approaches by which to identify patients at risk of adverse outcome is becoming increasingly important. Centred on the idea that patients who experience “poor” outcome post trauma elicit a response to injury that is distinct from those who experience “good” outcome, tailored therapeutics is an emerging concept aimed at improving current treatment regimens by promoting patient-specific therapies. Making use of recent advancements in the fields of genomics, proteomics and metabolomics, numerous groups have undertaken a systems-based approach to analysing the acute immune and inflammatory response to major traumatic and thermal injury in an attempt to uncover a single or combination of biomarkers that can identify patients at risk of adverse outcome. Early results are encouraging, with all three approaches capable of discriminating patients with “good” outcome from those who develop nosocomial infections, sepsis and multiple organ failure, with differences apparent in blood samples acquired as early as 2 h post injury. In particular, genomic data is proving to be highly informative, identifying patients at risk of “poor” outcome with a higher degree of sensitivity and specificity than statistical models built upon data obtained from existing anatomical and physiological scoring systems. Here, focussing predominantly upon human-based research, we provide an overview of the findings of studies that have investigated the immune and inflammatory response to major traumatic and thermal injury at the genomic, protein and metabolite level, and consider both the diagnostic and prognostic potential of these approaches.
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Affiliation(s)
- Jon Hazeldine
- NIHR Surgical Reconstruction and Microbiology Research Centre, Institute of Inflammation and Ageing, Birmingham University Medical School, Birmingham, B15 2TT UK
| | - Peter Hampson
- NIHR Surgical Reconstruction and Microbiology Research Centre, Institute of Inflammation and Ageing, Birmingham University Medical School, Birmingham, B15 2TT UK ; Healing Foundation Centre for Burns Research, Queen Elizabeth Hospital, Birmingham, B15 2WB UK
| | - Janet M Lord
- NIHR Surgical Reconstruction and Microbiology Research Centre, Institute of Inflammation and Ageing, Birmingham University Medical School, Birmingham, B15 2TT UK
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Mécanismes de toxicité des fumées d’incendie (monoxyde de carbone et cyanures exclus). MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1212-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Early leukocyte gene expression associated with age, burn size, and inhalation injury in severely burned adults. J Trauma Acute Care Surg 2016; 80:250-7. [PMID: 26517785 DOI: 10.1097/ta.0000000000000905] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the patient with burn injury, older age, larger percentage of total body surface area (TBS) burned, and inhalation injury are established risk factors for death, which typically results from multisystem organ failure and sepsis, implicating burn-induced immune dysregulation as a contributory mechanism. We sought to identify early transcriptomic changes in circulating leukocytes underlying increased mortality associated with these three risk factors. METHODS We performed a retrospective analysis of the Glue Grant database. From 2003 to 2010, 324 adults with 20% or greater TBS burned were prospectively enrolled at five US burn centers, and 112 provided blood samples within 1 week after burn. RNA was extracted from pooled leukocytes for hybridization onto Affymetrix HU133 Plus 2.0 GeneChips. A multivariate regression model was constructed to determine risk factors for mortality. Testing for differential gene association associated with age, burn size, and inhalation injury was based on linear models using a fold change threshold of 1.5 and false discovery rate of 0.05. RESULTS After adjusting for potential confounders, age greater than 60 years (relative risk [RR], 4.53; 95% confidence interval [CI], 2.93-6.99), burn size greater than 40% TBS (RR, 4.24; 95% CI, 2.61-6.91), and inhalation injury (RR, 2.08; 95% CI, 1.35-3.21) were independently associated with mortality. No genes were differentially expressed in association with age greater than 60 years or inhalation injury. Fifty-one probe sets representing 39 unique genes were differentially expressed in leukocytes from patients with burn size greater than 40% TBS; these genes were associated with platelet activation and degranulation/exocytosis, and gene-set enrichment analysis suggested increased cellular proliferation and down-regulation of proinflammatory cytokines. CONCLUSION Among adults with large burns, older age, increasing burn size, and inhalation injury have a modest effect on the leukocyte transcriptome in the context of the "genomic storm" induced by a 20% or greater than TBS burned. The 39-gene signature we identified may provide novel targets for the development of therapies to reduce morbidity and mortality associated with burns greater than 40% TBS. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Abstract
Traumatic injury remains one of the most prevalent reasons for patients to be hospitalized. Burn injury accounts for 40,000 hospitalizations in the United States annually, resulting in a large burden on both the health and economic system and costing millions of dollars every year. The complications associated with postburn care can quickly cause life-threatening conditions including sepsis and multiple organ dysfunction and failure. In addition, alcohol intoxication at the time of burn injury has been shown to exacerbate these problems. One of the biggest reasons for the onset of these complications is the global suppression of the host immune system and increased susceptibility to infection. It has been hypothesized that infections after burn and other traumatic injury may stem from pathogenic bacteria from within the host's gastrointestinal tract. The intestine is the major reservoir of bacteria within the host, and many studies have demonstrated perturbations of the intestinal barrier after burn injury. This article reviews the findings of these studies as they pertain to changes in the intestinal immune system after alcohol and burn injury.
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Alteration of Leukocyte Count Correlates With Increased Pulmonary Vascular Permeability and Decreased PaO2:FiO2 Ratio Early After Major Burns. J Burn Care Res 2016; 36:484-92. [PMID: 25501784 DOI: 10.1097/bcr.0000000000000211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Leukocytes are activated systemically and their numbers increase soon after a burn followed by a rapid decline to low normal or subnormal levels, possibly by increased extravasation. Experimental data support that an important target for such extravasation is the lungs and that leukocytes when they adhere to endothelial cells cause an increase in vascular permeability. The authors investigated a possible relation between early increased pulmonary vascular permeability or a decreased PaO2:FiO2 ratio and the dynamic change in concentration of blood leukocytes after a burn. This is a prospective, exploratory, single-center study. The authors measured the dynamic changes of leukocytes in blood starting early after the burn, pulmonary vascular permeability index by thermodilution, and PaO2:FiO2-ratios in 20 patients during the first 21 days after a major burn (>20% TBSA%). Median TBSA was 40% interquartile range (IQR, 25-52) and full thickness burn 28% (IQR, 2-39). There was a correlation between the early (<24 hours) alteration in white blood cell count and both early increased pulmonary vascular permeability (r = .63, P = .004) and the decreased oxygenation index defined as PaO2:FiO2 < 27 kPa (P = .004). The authors have documented a correlation between dynamic change of blood leukocytes and pulmonary failure early after burns.
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Ruiz-Castilla M, Roca O, Masclans JR, Barret JP. Recent Advances in Biomarkers in Severe Burns. Shock 2016; 45:117-25. [DOI: 10.1097/shk.0000000000000497] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Walker PF, Buehner MF, Wood LA, Boyer NL, Driscoll IR, Lundy JB, Cancio LC, Chung KK. Diagnosis and management of inhalation injury: an updated review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:351. [PMID: 26507130 PMCID: PMC4624587 DOI: 10.1186/s13054-015-1077-4] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this article we review recent advances made in the pathophysiology, diagnosis, and treatment of inhalation injury. Historically, the diagnosis of inhalation injury has relied on nonspecific clinical exam findings and bronchoscopic evidence. The development of a grading system and the use of modalities such as chest computed tomography may allow for a more nuanced evaluation of inhalation injury and enhanced ability to prognosticate. Supportive respiratory care remains essential in managing inhalation injury. Adjuncts still lacking definitive evidence of efficacy include bronchodilators, mucolytic agents, inhaled anticoagulants, nonconventional ventilator modes, prone positioning, and extracorporeal membrane oxygenation. Recent research focusing on molecular mechanisms involved in inhalation injury has increased the number of potential therapies.
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Affiliation(s)
- Patrick F Walker
- Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20889, USA
| | - Michelle F Buehner
- Department of General Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA.
| | - Leslie A Wood
- Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA
| | - Nathan L Boyer
- Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA
| | - Ian R Driscoll
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Jonathan B Lundy
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Kevin K Chung
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Building A, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
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Yamamura H, Morioka T, Hagawa N, Yamamoto T, Mizobata Y. Computed tomographic assessment of airflow obstruction in smoke inhalation injury: Relationship with the development of pneumonia and injury severity. Burns 2015; 41:1428-34. [PMID: 26187056 DOI: 10.1016/j.burns.2015.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 06/13/2015] [Accepted: 06/17/2015] [Indexed: 01/07/2023]
Abstract
PURPOSE The prediction of pulmonary deterioration in patients with smoke inhalation injury is important because this influences the strategy for patient management. We hypothesized that narrowing of the luminal bronchus due to bronchial wall thickening correlates to respiratory deterioration in smoke inhalation injury patients. METHODS In a prospective observational study, all patients were enrolled at a single tertiary trauma and critical care center. In 40 patients, chest computed tomographic images were obtained within a few hours after smoke inhalation injury. We assessed bronchial wall thickness and luminal area % on chest computed tomographic images. Airway wall thickness to total bronchial diameter (T/D) ratio, percentage of luminal area, and clinical indices were compared between patients with smoke inhalation injury and control patients. RESULTS The T/D ratio of patients with smoke inhalation was significantly higher than that of control patients (p<0.001), and the luminal area of these patients was significantly smaller than that of control patients (p<0.001). The number of mechanical ventilation days correlated with the initial infusion volume, T/D ratio, and luminal area %. ROC analysis showed a cut-off value of 0.26 for the T/D ratio, with a sensitivity of 79.0% and specificity of 73.7%, and a value of 23.4% for luminal area %, with a sensitivity of 68.4% and specificity of 84.2%. CONCLUSIONS These data revealed the utility of computed tomography scanning on admission to show that the patients with smoke inhalation injury had airway wall thickening compared to control patients without smoke inhalation injury. Airflow narrowing due to airway wall thickening was related to the development of pneumonia and the number of mechanical ventilation days in patients with smoke inhalation injury. Airflow narrowing is one important factor of respiratory deterioration in smoke inhalation injury.
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Affiliation(s)
- Hitoshi Yamamura
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan.
| | - Takasei Morioka
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan
| | - Naohiro Hagawa
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan
| | - Tomonori Yamamoto
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan
| | - Yasumitsu Mizobata
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan
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Blet A, Benyamina M, Legrand M. Manifestations respiratoires précoces d’un patient brûlé grave. MEDECINE INTENSIVE REANIMATION 2015; 24:433-443. [PMID: 32288740 PMCID: PMC7117817 DOI: 10.1007/s13546-015-1084-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/08/2015] [Indexed: 11/29/2022]
Affiliation(s)
- A. Blet
- Département d’anesthésie-réanimation et centre de traitement des brûlés, AP–HP, groupe hospitalier Saint-Louis-Lariboisière, F-75010 Paris, France
- Université Paris-Diderot, F-75475 Paris, France
- UMR Inserm 942, Institut national de la santé et de la recherche médicale (Inserm), hôpital Lariboisière, F-75010 Paris, France
| | - M. Benyamina
- Département d’anesthésie-réanimation et centre de traitement des brûlés, AP–HP, groupe hospitalier Saint-Louis-Lariboisière, F-75010 Paris, France
- Université Paris-Diderot, F-75475 Paris, France
| | - M. Legrand
- Département d’anesthésie-réanimation et centre de traitement des brûlés, AP–HP, groupe hospitalier Saint-Louis-Lariboisière, F-75010 Paris, France
- Université Paris-Diderot, F-75475 Paris, France
- UMR Inserm 942, Institut national de la santé et de la recherche médicale (Inserm), hôpital Lariboisière, F-75010 Paris, France
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