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Imran P, Habib M, Fadlalla Ahmed TK, Shafique MA. Femoral blood gas analysis, a new promising tool to assess hemorrhagic shock status. Ann Med Surg (Lond) 2024; 86:4954-4956. [PMID: 39239025 PMCID: PMC11374263 DOI: 10.1097/ms9.0000000000002380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/05/2024] [Indexed: 09/07/2024] Open
Affiliation(s)
- Preet Imran
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Malaika Habib
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
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Duran I, Banerjee A, Flaherty PJ, Que YA, Ryan CM, Rahme LG, Tsurumi A. Development of a biomarker prediction model for post-trauma multiple organ failure/dysfunction syndrome based on the blood transcriptome. Ann Intensive Care 2024; 14:134. [PMID: 39198331 PMCID: PMC11358370 DOI: 10.1186/s13613-024-01364-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 08/09/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Multiple organ failure/dysfunction syndrome (MOF/MODS) is a major cause of mortality and morbidity among severe trauma patients. Current clinical practices entail monitoring physiological measurements and applying clinical score systems to diagnose its onset. Instead, we aimed to develop an early prediction model for MOF outcome evaluated soon after traumatic injury by performing machine learning analysis of genome-wide transcriptome data from blood samples drawn within 24 h of traumatic injury. We then compared its performance to baseline injury severity scores and detection of infections. METHODS Buffy coat transcriptome and linked clinical datasets from blunt trauma patients from the Inflammation and the Host Response to Injury Study ("Glue Grant") multi-center cohort were used. According to the inclusion/exclusion criteria, 141 adult (age ≥ 16 years old) blunt trauma patients (excluding penetrating) with early buffy coat (≤ 24 h since trauma injury) samples were analyzed, with 58 MOF-cases and 83 non-cases. We applied the Least Absolute Shrinkage and Selection Operator (LASSO) and eXtreme Gradient Boosting (XGBoost) algorithms to select features and develop models for MOF early outcome prediction. RESULTS The LASSO model included 18 transcripts (AUROC [95% CI]: 0.938 [0.890-0.987] (training) and 0.833 [0.699-0.967] (test)), and the XGBoost model included 41 transcripts (0.999 [0.997-1.000] (training) and 0.907 [0.816-0.998] (test)). There were 16 overlapping transcripts comparing the two panels (0.935 [0.884-0.985] (training) and 0.836 [0.703-0.968] (test)). The biomarker models notably outperformed models based on injury severity scores and sex, which we found to be significantly associated with MOF (APACHEII + sex-0.649 [0.537-0.762] (training) and 0.493 [0.301-0.685] (test); ISS + sex-0.630 [0.516-0.744] (training) and 0.482 [0.293-0.670] (test); NISS + sex-0.651 [0.540-0.763] (training) and 0.525 [0.335-0.714] (test)). CONCLUSIONS The accurate assessment of MOF from blood samples immediately after trauma is expected to aid in improving clinical decision-making and may contribute to reduced morbidity, mortality and healthcare costs. Moreover, understanding the molecular mechanisms involving the transcripts identified as important for MOF prediction may eventually aid in developing novel interventions.
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Affiliation(s)
- Ivan Duran
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 50 Blossom St., Their 340, Boston, MA, 02114, USA
| | - Ankita Banerjee
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 50 Blossom St., Their 340, Boston, MA, 02114, USA
| | - Patrick J Flaherty
- Department of Mathematics and Statistics, University of Massachusetts at Amherst, Amherst, MA, 01003, 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 and Harvard Medical School, 50 Blossom St., Their 340, Boston, MA, 02114, USA
- Shriners Hospitals for Children-Boston®, 51 Blossom St., Boston, MA, 02114, USA
| | - Laurence G Rahme
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 50 Blossom St., Their 340, Boston, MA, 02114, USA
- Shriners Hospitals for Children-Boston®, 51 Blossom St., Boston, MA, 02114, USA
- Department of Microbiology and Immunology, Harvard Medical School, 77 Ave. Louis Pasteur, Boston, MA, 02115, USA
| | - Amy Tsurumi
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 50 Blossom St., Their 340, Boston, MA, 02114, USA.
- Shriners Hospitals for Children-Boston®, 51 Blossom St., Boston, MA, 02114, USA.
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Buckley CT, Lee YL, Michele Schuler A, Langley RJ, Kutcher ME, Barrington R, Audia JP, Simmons JD. Deleterious effects of plasma-derived cellular debris in a porcine model of hemorrhagic shock. Injury 2024; 55:111300. [PMID: 38160196 DOI: 10.1016/j.injury.2023.111300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 11/20/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Recent studies identify large quantities of inflammatory cellular debris within Fresh Frozen Plasma (FFP). As FFP is a mainstay of hemorrhagic shock resuscitation, we used a porcine model of hemorrhagic shock and ischemia/reperfusion to investigate the inflammatory potential of plasma-derived cellular debris administered during resuscitation. METHODS The porcine model of hemorrhagic shock included laparotomy with 35 % hemorrhage (Hem), 45 min of ischemia from supraceliac aortic occlusion with subsequent clamp release (IR), followed by protocolized resuscitation for 6 h. Cellular debris (Debris) was added to the resuscitation phase in three groups. The four groups consisted of Hem + IR (n = 4), Hem + IR + Debris (n = 3), Hem + Debris (n = 3), and IR + Debris (n = 3). A battery of laboratory, physiologic, cytokine, and outcome data were compared between groups. RESULTS As expected, the Hem + IR group showed severe time dependent decrements in organ function and physiologic parameters. All animals that included both IR and Debris (Hem + IR + Debris or IR + Debris) died prior to the six-hour end point, while all animals in the Hem + IR and Hem + Debris survived. Cytokines measured at 30-60 min after initiation of resuscitation revealed significant differences in IL-18 and IL-1β between all groups. CONCLUSIONS Ischemia and reperfusion appear to prime the immune system to the deleterious effects of plasma-derived cellular debris. In the presence of ischemia and reperfusion, this model showed the equivalency of 100 % lethality when resuscitation included quantities of cellular debris at levels routinely administered to trauma patients during transfusion of FFP. A deeper understanding of the immunobiology of FFP-derived cellular debris is critical to optimize resuscitation for hemorrhagic shock.
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Affiliation(s)
- Colin T Buckley
- Department of Surgery, University of South Alabama, Mobile, AL, United States
| | - Yannleei L Lee
- Department of Surgery, University of South Alabama, Mobile, AL, United States
| | - A Michele Schuler
- Department of Comparative Medicine, University of South Alabama, United States; Department of Microbiology and Immunology, University of South Alabama, United States
| | - Raymond J Langley
- Department of Cellular & Molecular Pharmacology, University of South Alabama, United States
| | | | - Robert Barrington
- Department of Microbiology and Immunology, University of South Alabama, United States
| | - Jonathon P Audia
- Department of Microbiology and Immunology, University of South Alabama, United States
| | - Jon D Simmons
- Department of Surgery, University of South Alabama, Mobile, AL, United States; Department of Cellular & Molecular Pharmacology, University of South Alabama, United States.
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Velamuri SR, Ali Y, Lanfranco J, Gupta P, Hill DM. Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care. Clin Plast Surg 2024; 51:221-232. [PMID: 38429045 DOI: 10.1016/j.cps.2023.11.001] [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] [Indexed: 03/03/2024]
Abstract
Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.
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Affiliation(s)
- Sai R Velamuri
- Department of Surgery, College of Medicine, University of Tennessee, Health Science Center, Memphis, TN 38103, USA.
| | - Yasmin Ali
- Department of Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd floor Suite 217, Memphis, TN 38103, USA
| | - Julio Lanfranco
- Division of Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 Court Avenue Room H316B, Memphis, TN 38103, USA
| | - Pooja Gupta
- Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 court avenue, Room H316B, Memphis, TN 38103, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, University of Tennessee, 80 madison avenue, Memphis TN 38103, USA
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Sánchez-Arguiano MJ, Miñambres E, Cuenca-Fito E, Suberviola B, Burón-Mediavilla FJ, Ballesteros MA. Chronic critical illness after trauma injury: outcomes and experience in a trauma center. Acta Chir Belg 2023; 123:618-624. [PMID: 35881765 DOI: 10.1080/00015458.2022.2106626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 07/23/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To determine the prevalence, risk factors and functional results of chronic critical illness (CCI) in polytrauma patients. DESIGN Single-center observational retrospective study. SETTING ICU at a tertiary hospital in Santander, Spain, between 2015 and 2019. PATIENTS Adult trauma patients who survived beyond 48 h after injury. CCI was defined as the need for mechanical ventilation for at least 14 days or tracheostomy for difficult weaning. MEASUREMENTS AND MAIN RESULTS About 62/575 developed CCI. These patients were characterized by higher ISS score [17 (SD 10) vs. 13.8 (SD 8.2); p < 0.001] and higher NISS (26 (SD 11) vs. 19.2 (SD 10.5); p = 0.001). CCI group had greater proportion of hospital-acquired infections (100% vs. 18.1%; p < 0.001), and acute kidney failure (33.9% vs. 22.8% p < 0.001). During the first 24 h of admission, CCI group required in a greater proportion surgical intervention (50% vs. 29%; p = 0.001), and blood products (31.3% vs. 20.5%; p < 0.047). Hospital ward stay was longer in CCI patients [9.5 days (IQR 5-16.9) vs. 43.9 (IQR 30.3-53) p < 0.001]. The CCI mortality was higher (19.5% vs. 8.1%; p = 0.004). Surgical intervention in the first 24 h (OR 2.5 95% CI 1.1-4.1), age (> 55 years) (OR 2.1 95%CI 1.1-4.2), ISS score (OR 1.1 95%CI 1.02-1.3), GCS score (OR 0.8 95%CI 0.4-23.2) and multiple organ failure (OR 9.5 95%CI 3.9-23.2) were predictors of CCI in the multivariate analysis. CONCLUSIONS CCI after severe trauma appears in a considerable proportion of patients. Early identification and implementation of specific interventions could change the evolution of this process.
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Affiliation(s)
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Elena Cuenca-Fito
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | - María A Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
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Stern K, Aaltonen HL, Weykamp M, Gaskins D, Qui Q, O'Keefe G, Littman A, Linnau K, Rowhani-Rahbar A. Associations of Fatty Liver Disease With Recovery After Traumatic Injury. J Surg Res 2023; 291:270-281. [PMID: 37480755 DOI: 10.1016/j.jss.2023.06.014] [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: 11/28/2022] [Revised: 05/25/2023] [Accepted: 06/19/2023] [Indexed: 07/24/2023]
Abstract
INTRODUCTION Fatty liver disease (FLD) is associated with systemic inflammation, metabolic disease, and socioeconomic risk factors for poor health outcomes. Little is known on how adults with FLD recover from traumatic injury. METHODS We studied adults admitted to the intensive care unit of a level 1 trauma center (2016-2020), excluding severe head injury/cirrhosis (N = 510). We measured the liver-spleen attenuation difference in Hounsfield units (HUL-S) using virtual noncontrast computerized tomography scans: none (HUL-S>1), mild (-10≤HUL-S<1), moderate/severe (HUL-S < -10). We used Cox models to examine the "hazard" of recovery from systemic inflammatory response (SIRS score 2 or higher) organ dysfunction, defined as sequential organ failure assessment score 2 or higher, and lactate clearance (<2 mmol/L) in relation to FLD. RESULTS Fifty-one participants had mild and 29 had moderate/severe FLD. The association of FLD with recovery from SIRS differed according to whether an individual had shock on admission (hazard ratio [HR] = 0.76; 95% confidence interval [CI] 0.55-1.05 with shock; HR = 1.81; 95% CI 1.43-2.28 without shock). Compared to patients with no FLD, the hazard of lactate clearance was similar for mild FLD (HR = 1.04; 95% CI 0.63-1.70) and lower for moderate/severe FLD (HR = 0.40; 95% CI 0.18-0.89). CONCLUSIONS FLD is common among injured adults. Associations of FLD with outcomes after shock and critical illness warrant further study.
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Affiliation(s)
- Katherine Stern
- Division of Trauma, Burn & Critical Care, Department of Surgery, Harborview Medical Center, Seattle, Washington; Department of Surgery, University of Washington School of Medicine, Seattle, Washington; University of California San Francisco East Bay General Surgery Residency Program, Oakland, California; University of Washington School of Public Health, Seattle, Washington.
| | - H Laura Aaltonen
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Mike Weykamp
- Division of Trauma, Burn & Critical Care, Department of Surgery, Harborview Medical Center, Seattle, Washington; Department of Surgery, University of Washington School of Medicine, Seattle, Washington; University of Washington School of Public Health, Seattle, Washington
| | - Devin Gaskins
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Qian Qui
- Harborview Injury Prevention & Research Center, Seattle, Washington
| | - Grant O'Keefe
- Division of Trauma, Burn & Critical Care, Department of Surgery, Harborview Medical Center, Seattle, Washington; Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Harborview Injury Prevention & Research Center, Seattle, Washington
| | - Alyson Littman
- University of Washington School of Public Health, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Ken Linnau
- Division of Trauma, Burn & Critical Care, Department of Surgery, Harborview Medical Center, Seattle, Washington; Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Department of Radiology, University of Washington School of Medicine, Seattle, Washington
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Huang M, Atreya MR, Holder A, Kamaleswaran R. A MACHINE LEARNING MODEL DERIVED FROM ANALYSIS OF TIME-COURSE GENE-EXPRESSION DATASETS REVEALS TEMPORALLY STABLE GENE MARKERS PREDICTIVE OF SEPSIS MORTALITY. Shock 2023; 60:671-677. [PMID: 37752077 PMCID: PMC10662606 DOI: 10.1097/shk.0000000000002226] [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: 06/27/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/28/2023]
Abstract
ABSTRACT Sepsis is associated with significant mortality and morbidity among critically ill patients admitted to intensive care units and represents a major health challenge globally. Given the significant clinical and biological heterogeneity among patients and the dynamic nature of the host immune response, identifying those at high risk of poor outcomes remains a critical challenge. Here, we performed secondary analysis of publicly available time-series gene-expression datasets from peripheral blood of patients admitted to the intensive care unit to elucidate temporally stable gene-expression markers between sepsis survivors and nonsurvivors. Using a limited set of genes that were determined to be temporally stable, we derived a dynamical model using a Support Vector Machine classifier to accurately predict the mortality of sepsis patients. Our model had robust performance in a test dataset, where patients' transcriptome was sampled at alternate time points, with an area under the curve of 0.89 (95% CI, 0.82-0.96) upon 5-fold cross-validation. We also identified 7 potential biomarkers of sepsis mortality (STAT5A, CX3CR1, LCP1, SNRPG, RPS27L, LSM5, SHCBP1) that require future validation. Pending prospective testing, our model may be used to identify sepsis patients with high risk of mortality accounting for the dynamic nature of the disease and with potential therapeutic implications.
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Affiliation(s)
- Min Huang
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, Georgia
| | - Mihir R. Atreya
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andre Holder
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, Georgia
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
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Cohen MJ, Erickson CB, Lacroix IS, Debot M, Dzieciatkowska M, Schaid TR, Hallas MW, Thielen ON, Cralley AL, Banerjee A, Moore EE, Silliman CC, D'Alessandro A, Hansen KC. Trans-Omics analysis of post injury thrombo-inflammation identifies endotypes and trajectories in trauma patients. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.08.16.553446. [PMID: 37645811 PMCID: PMC10462097 DOI: 10.1101/2023.08.16.553446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Understanding and managing the complexity of trauma-induced thrombo-inflammation necessitates an innovative, data-driven approach. This study leveraged a trans-omics analysis of longitudinal samples from trauma patients to illuminate molecular endotypes and trajectories that underpin patient outcomes, transcending traditional demographic and physiological characterizations. We hypothesize that trans-omics profiling reveals underlying clinical differences in severely injured patients that may present with similar clinical characteristics but ultimately have very different responses to treatment and clinical outcomes. Here we used proteomics and metabolomics to profile 759 of longitudinal plasma samples from 118 patients at 11 time points and 97 control subjects. Results were used to define distinct patient states through data reduction techniques. The patient groups were stratified based on their shock severity and injury severity score, revealing a spectrum of responses to trauma and treatment that are fundamentally tied to their unique underlying biology. Ensemble models were then employed, demonstrating the predictive power of these molecular signatures with area under the receiver operating curves of 80 to 94% for key outcomes such as INR, ICU-free days, ventilator-free days, acute lung injury, massive transfusion, and death. The molecularly defined endotypes and trajectories provide an unprecedented lens to understand and potentially guide trauma patient management, opening a path towards precision medicine. This strategy presents a transformative framework that aligns with our understanding that trauma patients, despite similar clinical presentations, might harbor vastly different biological responses and outcomes.
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Li SR, Moheimani H, Herzig B, Kail M, Krishnamoorthi N, Wu J, Abdelhamid S, Scioscia J, Sung E, Rosengart A, Bonaroti J, Johansson PI, Stensballe J, Neal MD, Das J, Kar U, Sperry J, Billiar TR. High-dimensional proteomics identifies organ injury patterns associated with outcomes in human trauma. J Trauma Acute Care Surg 2023; 94:803-813. [PMID: 36787435 PMCID: PMC10205666 DOI: 10.1097/ta.0000000000003880] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Severe traumatic injury with shock can lead to direct and indirect organ injury; however, tissue-specific biomarkers are limited in clinical panels. We used proteomic and metabolomic databases to identify organ injury patterns after severe injury in humans. METHODS Plasma samples (times 0, 24, and 72 hours after arrival to trauma center) from injured patients enrolled in two randomized prehospital trials were subjected to multiplexed proteomics (SomaLogic Inc., Boulder, CO). Patients were categorized by outcome: nonresolvers (died >72 hours or required ≥7 days of critical care), resolvers (survived to 30 days and required <7 days of critical care), and low Injury Severity Score (ISS) controls. Established tissue-specific biomarkers were identified through a literature review and cross-referenced with tissue specificity from the Human Protein Atlas. Untargeted plasma metabolomics (Metabolon Inc., Durham, NC), inflammatory mediators, and endothelial damage markers were correlated with injury biomarkers. Kruskal-Wallis/Mann-Whitney U tests with false discovery rate correction assessed differences in biomarker expression across outcome groups (significance; p < 0.1). RESULTS Of 142 patients, 78 were nonresolvers (median ISS, 30), 34 were resolvers (median ISS, 22), and 30 were low ISS controls (median ISS, 1). A broad release of tissue-specific damage markers was observed at admission; this was greater in nonresolvers. By 72 hours, nine cardiac, three liver, eight neurologic, and three pulmonary proteins remained significantly elevated in nonresolvers compared with resolvers. Cardiac damage biomarkers showed the greatest elevations at 72 hours in nonresolvers and had significant positive correlations with proinflammatory mediators and endothelial damage markers. Nonresolvers had lower concentrations of fatty acid metabolites compared with resolvers, particularly acyl carnitines and cholines. CONCLUSION We identified an immediate release of tissue-specific biomarkers with sustained elevation in the liver, pulmonary, neurologic, and especially cardiac injury biomarkers in patients with complex clinical courses after severe injury. The persistent myocardial injury in nonresolvers may be due to a combination of factors including metabolic stress, inflammation, and endotheliopathy.
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Affiliation(s)
- Shimena R Li
- From the Department of Surgery (S.L., H.M., B.H., M.K., N.K., J.W., S.A., J. Scioscia, E.S., A.R., J.B., M.N., U.K., J. Sperry, T.R.B.) and Pittsburgh Transfusion and Trauma Research Center (S.L., H.M., B.H., M.K., N.K., J.W., S.A., J. Scioscia, E.S., A.R., J.B., M.N., U.K., J. Sperry, T.R.B.), University of Pittsburgh, Pittsburgh; Lake Erie College of Osteopathic Medicine (B.H.), Erie, Pennsylvania; Department of Cardiology (J.W.), The Third Xiangya Hospital, Central South University, Changsha, China; Section for Transfusion Medicine (P.I.J., J. Stensballe), Capital Region Blood Bank, Rigshospitalet and Department of Anesthesia and Trauma Center (J. Stensballe), Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen; Emergency Medical Services (J. Stensballe), The Capital Region of Denmark, Hillerød, Denmark; and Center for Systems Immunology, Departments of Immunology (J.D.) and Computational and Systems Biology (J.D.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Latif RK, Clifford SP, Baker JA, Lenhardt R, Haq MZ, Huang J, Farah I, Businger JR. Traumatic hemorrhage and chain of survival. Scand J Trauma Resusc Emerg Med 2023; 31:25. [PMID: 37226264 DOI: 10.1186/s13049-023-01088-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.
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Affiliation(s)
- Rana K Latif
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA.
- Paris Simulation Center, Office of Medical Education, University of Louisville School of Medicine, Louisville, KY, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sean P Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jeffery A Baker
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rainer Lenhardt
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Mohammad Z Haq
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
- Department of Cardiovascular & Thoracic Surgery, Cardiovascular Innovation Institute, University of Louisville, Louisville, KY, USA
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA
- Division of Infectious Diseases, Department of Medicine, Center of Excellence for Research in Infectious Diseases (CERID), University of Louisville, Louisville, KY, USA
| | - Ian Farah
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jerrad R Businger
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
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Elrod J, Lenz M, Kiwit A, Armbrust L, Schönfeld L, Reinshagen K, Pagerols Raluy L, Mohr C, Saygi C, Alawi M, Rohde H, Herrmann M, Boettcher M. Murine scald models characterize the role of neutrophils and neutrophil extracellular traps in severe burns. Front Immunol 2023; 14:1113948. [PMID: 36825027 PMCID: PMC9941538 DOI: 10.3389/fimmu.2023.1113948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/25/2023] [Indexed: 02/09/2023] Open
Abstract
Introduction Severe burns cause unique pathophysiological alterations especially on the immune system. A murine scald model was optimized as a basis for the understanding of immunological reactions in response to heat induced injury. The understanding of the roles of neutrophil extracellular traps (NETs) and DNases will support the development of new surgical or pharmacological strategies for the therapy of severe burns. Methods We studied C57BL/6 mice (n=30) and employed four scalding protocols with varying exposure times to hot water. An additional scald group with a shorter observational time was generated to reduce mortality and study the very early phase of pathophysiology. At 24h or 72h, blood was drawn and tissue (wound, liver, lung, spleen) was analyzed for the presence of NETs, oxidative stress, apoptosis, bacterial translocation, and extracellular matrix re-organization. In addition, we analyzed the transcriptome from lung and liver tissues. Results Exposure to hot water for 7s led to significant systemic and local effects and caused considerable late mortality. Therefore, we used an observation time of 24h in this groups. To study later phases of burns (72h) an exposure time of 6s is optimal. Both conditions led to significant disorganization of collagen, increased oxidative stress, NET formation (by immunodetection of H3cit, NE, MPO), apoptosis (cC3) and alterations of the levels of DNase1 and DNase1L3. Transcriptome analysis revealed remarkable alterations in genes involved in acute phase signaling, cell cohesion, extracellular matrix organization, and immune response. Conclusion We identified two scald models that allow the analysis of early (24h) or late (72h) severe burn effects, thereby generating reproducible and standardized scald injuries. The study elucidated the important involvement of neutrophil activity and the role of NETs in burns. Extensive transcriptome analysis characterized the acute phase and tissue remodeling pathways involved in the process of healing and may serve as crucial basis for future in-depth studies.
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Affiliation(s)
- Julia Elrod
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany,Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,*Correspondence: Julia Elrod,
| | - Moritz Lenz
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antonia Kiwit
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lina Armbrust
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lavinia Schönfeld
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laia Pagerols Raluy
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Mohr
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Ceren Saygi
- Bioinformatics Core, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malik Alawi
- Bioinformatics Core, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Herrmann
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany,Department of Medicine 3, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany,Deutsches Zentrum Immuntherapie DZI, Friedrich Alexander University Erlangen-Nuremberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany,Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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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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13
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Wen JJ, Mobli K, Radhakrishnan GL, Radhakrishnan RS. Regulation of Key Immune-Related Genes in the Heart Following Burn Injury. J Pers Med 2022; 12:jpm12061007. [PMID: 35743792 PMCID: PMC9224557 DOI: 10.3390/jpm12061007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/15/2022] Open
Abstract
Immune cascade is one of major factors leading to cardiac dysfunction after burn injury. TLRs are a class of pattern-recognition receptors (PRRs) that initiate the innate immune response by sensing conserved molecular patterns for early immune recognition of a pathogen. The Rat Toll-Like Receptor (TLR) Signaling Pathway RT² Profiler PCR Array profiles the expression of 84 genes central to TLR-mediated signal transduction and innate immunity, and is a validated tool for identifying differentially expressed genes (DEGs). We employed the PCR array to identify burn-induced cardiac TLR-signaling-related DEGs. A total of 38 up-regulated DEGs and 19 down-regulated DEGs were identified. Network analysis determined that all DEGS had 10 clusters, while up-regulated DEGs had 6 clusters and down-regulated DEGs had 5 clusters. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis showed that DEGs were involved in TLR signaling, the RIG-I-Like receptor signaling pathway, the IL-17 signaling pathway, and the NFkB signaling pathway. Function analysis indicated that DEGs were associated with Toll-like receptor 2 binding, Lipopeptide binding, Toll-like receptor binding, and NAD(P)+ nucleosidase activity. The validation of 18 up-regulated DEGs (≥10-fold change) and 6 down-regulated DEGs (≤5-fold change) demonstrated that the PCR array is a trusted method for identifying DEGs. The analysis of validated DEG-derived protein–protein interaction networks will guide our future investigations. In summary, this study not only identified the TLR-signaling-pathway-related DEGs after burn injury, but also confirmed that the burn-induced cardiac cytokine cascade plays an important role in burn-induced heart dysfunction. The results will provide the novel therapeutic targets to protect the heart after burn injury.
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Affiliation(s)
- Jake J. Wen
- Department of Surgery University of Texas Medical Branch, Galveston, TX 77550, USA;
- Correspondence: (J.J.W.); (R.S.R.); Tel.: +1-832-722-0348
| | - Keyan Mobli
- Department of Surgery University of Texas Medical Branch, Galveston, TX 77550, USA;
| | | | - Ravi S. Radhakrishnan
- Department of Surgery University of Texas Medical Branch, Galveston, TX 77550, USA;
- Correspondence: (J.J.W.); (R.S.R.); Tel.: +1-832-722-0348
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14
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Peng Y, Wu Q, Zhou Q, Yang Z, Yin F, Wang L, Chen Q, Feng C, Ren X, Liu T. Identification of Immune-Related Genes Concurrently Involved in Critical Illnesses Across Different Etiologies: A Data-Driven Analysis. Front Immunol 2022; 13:858864. [PMID: 35615364 PMCID: PMC9124755 DOI: 10.3389/fimmu.2022.858864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Severe trauma and sepsis can lead to multiple organ dysfunction syndrome, which is a leading cause of death in intensive care units with mortality rates in excess of 50%. In addition to infection, the degree of immuno-inflammatory response also influences the outcome. The genomic changes observed after a variety of pathophysiological insults, such as trauma, sepsis, burns are similar, and consist of innate immune activation and adaptive immunity suppression. However, the characteristics of the shared mechanisms of aforementioned critical illnesses and the clinical relevance remain less explored. In the present study, we performed a data analysis to identify functional genes concurrently involved in critical illnesses across differing etiologies (trauma and sepsis derived from community-acquired pneumonia/abdominal source) and explored the shared signaling pathways these common genes involved in to gain insight into the underlying molecular mechanisms. A number of immune-related biological functions were found to be dysregulated in both trauma and sepsis in the present study, so we continued to identify immune-related common genes, profiled the immune cell proportion, and explored the relationships between them. The diagnostic and prognostic value of the immune-related common genes was also evaluated to address their potential clinical utilization as novel biomarkers. Notably, we identified a list of 14 immune-related genes concurrently dysregulated in trauma and sepsis showing favorable diagnostic value, among which S100P can predict prognosis of sepsis patients. Moreover, a spectrum of immune cell subsets including naïve B cells, CD8+ T cells, CD4+ memory resting T cells, activated NK cells, resting dendritic cells, plasma cells, Tregs, macrophages M0 and macrophages M1 was found to be concurrently dysregulated in both trauma and sepsis, and a close relation between above identified immune-related genes and immune cell subsets was observed. Our data-driven findings lay a foundation for future research to elucidate the pathophysiology regarding the aspect of inflammatory and immune response in critical illnesses, and suggest future studies focus on interpreting the function roles of the identified immune-related genes, as well as the reactive immune cell subsets.
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Affiliation(s)
- Yaojun Peng
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Qiyan Wu
- Institute of Oncology, The Fifth Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Qing Zhou
- Department of Gastroenterology, The Second Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhanglin Yang
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Fan Yin
- Department of Oncology, The Second Medical Center & National Clinical Research Center of Geriatric Disease, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lingxiong Wang
- Institute of Oncology, The Fifth Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Qi Chen
- Department of Traditional Chinese Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Cong Feng
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- *Correspondence: Cong Feng, ; Xuewen Ren, ; Tianyi Liu,
| | - Xuewen Ren
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- *Correspondence: Cong Feng, ; Xuewen Ren, ; Tianyi Liu,
| | - Tianyi Liu
- Institute of Oncology, The Fifth Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- *Correspondence: Cong Feng, ; Xuewen Ren, ; Tianyi Liu,
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15
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Ballesteros MÁ, Sánchez‐Arguiano MJ, Chico‐Fernández M, Barea‐Mendoza JA, Serviá‐Goixart L, Sánchez‐Casado M, García Sáez I, Pino‐Sánchez FI, Antonio Llompart‐Pou J, Miñambres E. Chronic critical illness in polytrauma. Results of the Spanish trauma in ICU registry. Acta Anaesthesiol Scand 2022; 66:722-730. [PMID: 35332519 DOI: 10.1111/aas.14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/11/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Chronic critical illness after trauma injury has not been fully evaluated, and there is little evidence in this regard. We aim to describe the prevalence and risk factors of chronic critical illness (CCI) in trauma patients admitted to the intensive care unit. MATERIAL AND METHODS Retrospective observational multicenter study (Spanish Registry of Trauma in ICU (RETRAUCI)). Period March 2015 to December 2019. Trauma patients admitted to the ICU, who survived the first 48 h, were included. Chronic critical illness (CCI) was considered as the need for mechanical ventilation for a period greater than 14 days and/or placement of a tracheostomy. The main outcomes measures were prevalence and risk factors of CCI after trauma. RESULTS 1290/9213 (14%) patients developed CCI. These patients were older (51.2 ± 19.4 vs 49 ± 18.9); p < .01) and predominantly male (79.9%). They presented a higher proportion of infectious complications (81.3% vs 12.7%; p < .01) and multiple organ dysfunction syndrome (MODS) (27.02% vs 5.19%; p < .01). CCI patients required longer stays in the ICU and had higher ICU and overall in-hospital mortality. Age, injury severity score, head injury, infectious complications, and development of MODS were independent predictors of CCI. CONCLUSION CCI in trauma is a prevalent entity in our series. Early identification could facilitate specific interventions to change the trajectory of this process.
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Affiliation(s)
| | | | - Mario Chico‐Fernández
- UCI de Trauma y Emergencias Servicio de Medicina Intensiva, Hospital Universitario Madrid Spain
| | | | - Luis Serviá‐Goixart
- Servicio de Medicina Intensiva Hospital Universitario Arnau de Vilanova Lleida Spain
| | | | - Iker García Sáez
- Servicio de Medicina Intensiva Hospital Universitario Donostia Donostia‐San Sebastian Spain
| | | | - Juan Antonio Llompart‐Pou
- Servei de Medicina Intensiva Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa) Palma Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care University Hospital Marqués de Valdecilla‐IDIVAL School of Medicine University of Cantabria Santander Spain
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16
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A Multidimensional Bioinformatic Platform for the Study of Human Response to Surgery. Ann Surg 2022; 275:1094-1102. [PMID: 35258509 DOI: 10.1097/sla.0000000000005429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To design and establish a prospective biospecimen repository that integrates multi-omics assays with clinical data to study mechanisms of controlled injury and healing. SUMMARY BACKGROUND DATA Elective surgery is an opportunity to understand both the systemic and focal responses accompanying controlled and well-characterized injury to the human body. The overarching goal of this ongoing project is to define stereotypical responses to surgical injury, with the translational purpose of identifying targetable pathways involved in healing and resilience, and variations indicative of aberrant peri-operative outcomes. METHODS Clinical data from the electronic medical record combined with large-scale biological data sets derived from blood, urine, fecal matter, and tissue samples are collected prospectively through the peri-operative period on patients undergoing fourteen surgeries chosen to represent a range of injury locations and intensities. Specimens are subjected to genomic, transcriptomic, proteomic, and metabolomic assays to describe their genetic, metabolic, immunologic, and microbiome profiles, providing a multidimensional landscape of the human response to injury. RESULTS The highly multiplexed data generated includes changes in over 28,000 mRNA transcripts, 100 plasma metabolites, 200 urine metabolites, and 400 proteins over the longitudinal course of surgery and recovery. In our initial pilot dataset, we demonstrate the feasibility of collecting high quality multi-omic data at pre- and post-operative time points and are already seeing evidence of physiologic perturbation between timepoints. CONCLUSIONS This repository allows for longitudinal, state-of-the-art genomic, transcriptomic, proteomic, metabolomic, immunologic, and clinical data collection and provides a rich and stable infrastructure on which to fuel further biomedical discovery.
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17
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Wu J, Vodovotz Y, Abdelhamid S, Guyette FX, Yaffe MB, Gruen DS, Cyr A, Okonkwo DO, Kar UK, Krishnamoorthi N, Voinchet RG, Billiar IM, Yazer MH, Namas RA, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Zuckerbraun BS, Johansson PI, Stensballe J, Morrissey JH, Tracy RP, Wisniewski SR, Neal MD, Sperry JL, Billiar TR. Multi-omic analysis in injured humans: Patterns align with outcomes and treatment responses. Cell Rep Med 2021; 2:100478. [PMID: 35028617 PMCID: PMC8715070 DOI: 10.1016/j.xcrm.2021.100478] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 08/18/2021] [Accepted: 11/23/2021] [Indexed: 12/16/2022]
Abstract
Trauma is a leading cause of death and morbidity worldwide. Here, we present the analysis of a longitudinal multi-omic dataset comprising clinical, cytokine, endotheliopathy biomarker, lipidome, metabolome, and proteome data from severely injured humans. A "systemic storm" pattern with release of 1,061 markers, together with a pattern suggestive of the "massive consumption" of 892 constitutive circulating markers, is identified in the acute phase post-trauma. Data integration reveals two human injury response endotypes, which align with clinical trajectory. Prehospital thawed plasma rescues only endotype 2 patients with traumatic brain injury (30-day mortality: 30.3 versus 75.0%; p = 0.0015). Ubiquitin carboxy-terminal hydrolase L1 (UCHL1) was identified as the most predictive circulating biomarker to identify endotype 2-traumatic brain injury (TBI) patients. These response patterns refine the paradigm for human injury, while the datasets provide a resource for the study of critical illness, trauma, and human stress responses.
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Affiliation(s)
- Junru Wu
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Cardiology & Center of Pharmacology, The 3rd Xiangya Hospital, Central South University, Changsha, China
- Eight-Year Program of Medicine, Xiangya School of Medicine, Central South University, Changsha, China
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sultan Abdelhamid
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X. Guyette
- Department of Emergency Medicine, Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael B. Yaffe
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Danielle S. Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony Cyr
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Upendra K. Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Isabel M. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark H. Yazer
- The Institute for Transfusion Medicine, Pittsburgh, PA, USA
| | - Rami A. Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | | | | | - Jeffrey A. Claridge
- Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herbert A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Brian S. Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pär I. Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Emergency Medical Services, The Capital Region of Denmark, Hillerød, Denmark
| | - James H. Morrissey
- Departments of Biological Chemistry & Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Russell P. Tracy
- Department of Pathology & Laboratory Medicine and Biochemistry, University of Vermont Larner College of Medicine, Colchester, VT, USA
| | | | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy R. Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - PAMPer study group
- The PAMPer study group is detailed in Supplemental acknowledgments (Document S1)
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18
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Bonaroti J, Abdelhamid S, Kar U, Sperry J, Zamora R, Namas RA, McKinley T, Vodovotz Y, Billiar T. The Use of Multiplexing to Identify Cytokine and Chemokine Networks in the Immune-Inflammatory Response to Trauma. Antioxid Redox Signal 2021; 35:1393-1406. [PMID: 33860683 PMCID: PMC8905234 DOI: 10.1089/ars.2021.0054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Significance: The immunoinflammatory responses that follow trauma contribute to clinical trajectory and patient outcomes. While remarkable advances have been made in trauma services and injury management, clarity on how the immune system in humans responds to trauma is lagging. Recent Advances: Multiplexing platforms have transformed our ability to analyze comprehensive immune mediator responses in human trauma. In parallel, with the establishment of large data sets, computational methods have been adapted to yield new insights based on mediator patterns. These efforts have added an important data layer to the emerging multiomic characterization of the human response to injury. Critical Issues: Outcome after trauma is greatly affected by the host immunoinflammatory response. Excessive or sustained responses can contribute to organ damage. Hence, understanding the pathophysiology behind traumatic injury is of vital importance. Future Directions: This review summarizes our work in the study of circulating immune mediators in trauma patients. Our foundational studies into dynamic patterns of inflammatory mediators represent an important contribution to the concepts and computational challenges that these large data sets present. We hope to see further integration and understanding of multiomics strategies in the field of trauma that can aid in patient endotyping and in potentially identifiying certain therapeutic targets in the future. Antioxid. Redox Signal. 35, 1393-1406.
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Affiliation(s)
- Jillian Bonaroti
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sultan Abdelhamid
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Upendra Kar
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rami Ahmd Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Todd McKinley
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Timothy Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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19
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Haug VF, Tapking C, Panayi AC, Thiele P, Wang AT, Obed D, Hirche C, Most P, Kneser U, Hundeshagen G. Long-term sequelae of critical illness in sepsis, trauma and burns: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 91:736-747. [PMID: 34252062 DOI: 10.1097/ta.0000000000003349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sepsis, major trauma, and severe burn injury are life-threatening critical illnesses that remain significant contributors to worldwide morbidity and mortality. The three underlying etiologies share pathophysiological similarities: hyperinflammation, hypermetabolism, and acute immunomodulation. The aims of this study were to assess the current state of long-term outcome research and to identify key outcome parameters between the three forms of critical illness. METHODS This systematic review and meta-analysis (MA) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed was searched from January 1, 1975, to December 31, 2019. Studies were assessed for eligibility by independent reviewers. Inclusion criteria were studies reporting at least a 6-month follow-up of health-related quality of life and organ-specific sequelae within the three etiologies: severe burn injury, sepsis, and major trauma. RESULTS In total, 125 articles could be included in the systematic review and 74 in the MA. The mean follow-up time was significantly longer in burn studies, compared with sepsis and trauma studies. The majority of patients were from the sepsis group, followed by burns, and major trauma studies. In the overall health-related quality of life, as assessed by Short Form 36 and European Quality-of-Life Index, the three different etiologies were comparable with one another. CONCLUSION The effects of critical illness on survivors persist for years after hospitalization. Well-reported and reliable data on the long-term outcomes are imperative, as they can be used to determine the treatment choice of physicians and to guide the expectations of patients, improving the overall quality of care of three significant patient cohorts. LEVEL OF EVIDENCE Systematic review and MA, level III.
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Affiliation(s)
- Valentin F Haug
- From the Department of Hand, Plastic and Reconstructive Surgery (V.F.H., C.T., P.T., C.H., U.K., G.H.), Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Plastic, Hand and Reconstructive Microsurgery (C.H.), Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital to the Goethe-University Frankfurt am Main, Germany; German Center for Cardiovascular Research (DZHK) (P.M.), Partner site Heidelberg/Mannheim, Heidelberg; Division of Plastic Surgery, Department of Surgery (V.F.H., A.C.P., A.T.W., D.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Molecular and Translational Cardiology (P.T.), and Department of Internal Medicine III (P.M.), University Hospital, Heidelberg, Germany; and Division of Molecular and Translational Cardiology, Department of Internal Medicine III (P.M.), University Hospital, Heidelberg, Germany
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Viral Micro-RNAs Are Detected in the Early Systemic Response to Injury and Are Associated With Outcomes in Polytrauma Patients. Crit Care Med 2021; 50:296-306. [PMID: 34259445 DOI: 10.1097/ccm.0000000000005181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate early activation of latent viruses in polytrauma patients and consider prognostic value of viral micro-RNAs in these patients. DESIGN This was a subset analysis from a prospectively collected multicenter trauma database. Blood samples were obtained upon admission to the trauma bay (T0), and trauma metrics and recovery data were collected. SETTING Two civilian Level 1 Trauma Centers and one Military Treatment Facility. PATIENTS Adult polytrauma patients with Injury Severity Scores greater than or equal to 16 and available T0 plasma samples were included in this study. Patients with ICU admission greater than 14 days, mechanical ventilation greater than 7 days, or mortality within 28 days were considered to have a complicated recovery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Polytrauma patients (n = 180) were identified, and complicated recovery was noted in 33%. Plasma samples from T0 underwent reverse transcriptase-quantitative polymerase chain reaction analysis for Kaposi's sarcoma-associated herpesvirus micro-RNAs (miR-K12_10b and miRK-12-12) and Epstein-Barr virus-associated micro-RNA (miR-BHRF-1), as well as Luminex multiplex array analysis for established mediators of inflammation. Ninety-eight percent of polytrauma patients were found to have detectable Kaposi's sarcoma-associated herpesvirus and Epstein-Barr virus micro-RNAs at T0, whereas healthy controls demonstrated 0% and 100% detection rate for Kaposi's sarcoma-associated herpesvirus and Epstein-Barr virus, respectively. Univariate analysis revealed associations between viral micro-RNAs and polytrauma patients' age, race, and postinjury complications. Multivariate least absolute shrinkage and selection operator analysis of clinical variables and systemic biomarkers at T0 revealed that interleukin-10 was the strongest predictor of all viral micro-RNAs. Multivariate least absolute shrinkage and selection operator analysis of systemic biomarkers as predictors of complicated recovery at T0 demonstrated that miR-BHRF-1, miR-K12-12, monocyte chemoattractant protein-1, and hepatocyte growth factor were independent predictors of complicated recovery with a model complicated recovery prediction area under the curve of 0.81. CONCLUSIONS Viral micro-RNAs were detected within hours of injury and correlated with poor outcomes in polytrauma patients. Our findings suggest that transcription of viral micro-RNAs occurs early in the response to trauma and may be associated with the biological processes involved in polytrauma-induced complicated recovery.
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Gene Expression-Based Diagnosis of Infections in Critically Ill Patients-Prospective Validation of the SepsisMetaScore in a Longitudinal Severe Trauma Cohort. Crit Care Med 2021; 49:e751-e760. [PMID: 33883455 DOI: 10.1097/ccm.0000000000005027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Early diagnosis of infections is pivotal in critically ill patients. Innovative gene expression-based approaches promise to deliver precise, fast, and clinically practicable diagnostic tools to bedside. This study aimed to validate the SepsisMetaScore, an 11-gene signature previously reported by our study group, in a representative longitudinal cohort of trauma patients. DESIGN Prospective observational cohort study. SETTING Surgical ICUs of the University Medical Center Goettingen, Germany. PATIENTS Critically ill patients with severe traumatic injuries. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Paired box gene (PAXgene) RNA blood tubes were drawn at predefined time points over the course of disease. The performance of the SepsisMetaScore was tested using targeted polymerase chain reaction and compared with Procalcitonin using area under the receiver operating characteristics analyses. The SepsisMetaScore showed significant differences between infected and noninfected patients (n = 52). It was able to accurately discriminate infectious from noninfectious acute inflammation with an area under the receiver operating characteristics of 0.92 (95% CI, 0.85-0.99) and significantly outperformed Procalcitonin (area under the receiver operating characteristics curve = 0.53; 95% CI, 0.42-0.64) early in the course of infection (p = 0.014). CONCLUSIONS We demonstrated the clinical utility for diagnosis of infections with higher accuracy using the SepsisMetaScore compared with Procalcitonin in a prospective cohort of severe trauma patients. Future studies should assess whether the SepsisMetaScore may substantially improve clinical practice by accurate differentiation of infections from sterile inflammation and identification of patients at risk for sepsis. Our results support further investigation of the SepsisMetaScore for the development of tailored precision treatment of critically ill patients.
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Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. MEDICINES (BASEL, SWITZERLAND) 2021; 8:16. [PMID: 33805197 PMCID: PMC8064317 DOI: 10.3390/medicines8040016] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/15/2021] [Accepted: 03/07/2021] [Indexed: 12/17/2022]
Abstract
Coagulopathy induced by major trauma is common, affecting approximately one-third of patients after trauma. It develops independently of iatrogenic, hypothermic, and dilutive causes (such as iatrogenic cause in case of fluid administration), which instead have a pejorative aspect on coagulopathy. Notwithstanding the continuous research conducted over the past decade on Trauma-Induced Coagulopathy (TIC), it remains a life-threatening condition with a significant impact on trauma mortality. We reviewed the current evidence regarding TIC diagnosis and pathophysiological mechanisms and summarized the different iterations of optimal TIC management strategies among which product resuscitation, potential drug administrations, and hemostatis-focused approaches. We have identified areas of ongoing investigation and controversy in TIC management.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Iride Francesca Ceresa
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Luca Caneva
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Sebastiano Gerosa
- Emergency Department, IRCCS Policlinico San Matteo, PhD University of Pavia, 27100 Pavia, Italy; (I.F.C.); (S.G.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, 27100 Pavia, Italy;
- Saint Camillus International University of Health Sciences, 00152 Rome, Italy
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Brakenridge SC, Wang Z, Cox M, Raymond S, Hawkins R, Darden D, Ghita G, Brumback B, Cuschieri J, Maier RV, Moore FA, Mohr AM, Efron PA, Moldawer LL. Distinct immunologic endotypes are associated with clinical trajectory after severe blunt trauma and hemorrhagic shock. J Trauma Acute Care Surg 2021; 90:257-267. [PMID: 33214489 PMCID: PMC8194286 DOI: 10.1097/ta.0000000000003029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The genomic/cytokine "storm" after severe trauma is well described. However, the differing composition, magnitude and resolution of this response, and its relationship to clinical outcomes remain unclear. METHODS This is a secondary analysis of a prospective longitudinal cohort study of severely injured trauma patients in hemorrhagic shock. Peripheral blood sampling was performed at 0.5, 1, 4, 7, 14, and 28 days after injury for measurement of circulating immune biomarkers. K-means clustering using overall mean and trajectory slope of selected immunologic biomarkers were used to identify distinct temporal immunologic endotypes. Endotypes were compared with known clinical trajectories defined as early death (<14 days), chronic critical illness (CCI) (ICU length of stay of ≥14 days with persistent organ dysfunction), and rapid recovery (RAP) (ICU length of stay of <14 days with organ recovery). RESULTS The cohort included 102 subjects enrolled across 2 level 1 trauma centers. We identified three distinct immunologic endotypes (iA, iB, and iC), each with unique associations to clinical trajectory. Endotype iA (n = 47) exhibited a moderate initial proinflammatory response followed by a return to immunologic homeostasis, with a primary clinical trajectory of RAP (n = 44, 93.6%). Endotype iB (n = 44) exhibited an early hyperinflammatory response with persistent inflammation and immunosuppression, with the highest incidence of CCI (n = 10, 22.7%). Endotype iC (n = 11) exhibited a similar hyperinflammatory response, but with rapid return to immunologic homeostasis and a predominant trajectory of RAP (n = 9, 81.8%). Patients with endotype iB had the highest severity/duration of organ dysfunction and highest incidence of nosocomial infections (50%, p = 0.001), and endotype iB was the predominant endotype of patients who developed CCI (10 of 13 patients, 76.9%; p = 0.002). CONCLUSION We identified three distinct immunologic endotypes after severe injury differing the magnitude and duration of the early response. The clinical trajectory of CCI is characterized by an endotype (iB) defined by persistent alteration in inflammation/immunosuppression and is associated with poor clinical outcomes. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Scott C Brakenridge
- From the Department of Surgery (S.C.B.), University of Florida Health Science Center; Department of Surgery (S.C.B., M.C., S.R., R.H., D.D., F.A.M., A.M.M., P.A.E., L.L.M.), College of Medicine, and Department of Biostatistics (B.B., Z.W., G.G.), University of Florida, Gainesville, Florida; and Department of Surgery (J.C., R.V.M.), University of Washington, Seattle, Washington
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24
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Woodward KE, de Jesus P, Esser MJ. Neuroinflammation and Precision Medicine in Pediatric Neurocritical Care: Multi-Modal Monitoring of Immunometabolic Dysfunction. Int J Mol Sci 2020; 21:E9155. [PMID: 33271778 PMCID: PMC7730047 DOI: 10.3390/ijms21239155] [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: 10/22/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 11/17/2022] Open
Abstract
The understanding of molecular biology in neurocritical care (NCC) is expanding rapidly and recognizing the important contribution of neuroinflammation, specifically changes in immunometabolism, towards pathological disease processes encountered across all illnesses in the NCC. Additionally, the importance of individualized inflammatory responses has been emphasized, acknowledging that not all individuals have the same mechanisms contributing towards their presentation. By understanding cellular processes that drive disease, we can make better personalized therapy decisions to improve patient outcomes. While the understanding of these cellular processes is evolving, the ability to measure such cellular responses at bedside to make acute care decisions is lacking. In this overview, we review cellular mechanisms involved in pathological neuroinflammation with a focus on immunometabolic dysfunction and review non-invasive bedside tools that have the potential to measure indirect and direct markers of shifts in cellular metabolism related to neuroinflammation. These tools include near-infrared spectroscopy, transcranial doppler, elastography, electroencephalography, magnetic resonance imaging and spectroscopy, and cytokine analysis. Additionally, we review the importance of genetic testing in providing information about unique metabolic profiles to guide individualized interpretation of bedside data. Together in tandem, these modalities have the potential to provide real time information and guide more informed treatment decisions.
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Affiliation(s)
| | | | - Michael J. Esser
- Alberta Children’s Hospital, University of Calgary, Calgary, AB T3B 6A8, Canada; (K.E.W.); (P.d.J.)
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Barros-Becker F, Squirrell JM, Burke R, Chini J, Rindy J, Karim A, Eliceiri KW, Gibson A, Huttenlocher A. Distinct Tissue Damage and Microbial Cues Drive Neutrophil and Macrophage Recruitment to Thermal Injury. iScience 2020; 23:101699. [PMID: 33196024 PMCID: PMC7644964 DOI: 10.1016/j.isci.2020.101699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/17/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022] Open
Abstract
Tissue damage triggers a rapid innate immune response that mediates host defense. Previously we reported that thermal damage of the larval zebrafish fin disrupts collagen organization and induces a robust and potentially damaging innate immune response. The mechanisms that drive damaging versus protective neutrophil inflammation in interstitial tissues remain unclear. Here we identify distinct cues in the tissue microenvironment that differentially drive neutrophil and macrophage responses to sterile injury. Using live imaging, we found a motile zone for neutrophils, but not macrophages, in collagen-free regions and identified a specific role for interleukin-6 (IL-6) receptor signaling in neutrophil responses to thermal damage. IL-6 receptor mutants show impaired neutrophil recruitment to sterile thermal injury that was not present in tissues infected with Pseudomonas aeruginosa. These findings identify distinct signaling networks during neutrophil recruitment to sterile and microbial damage cues and provide a framework to limit potentially damaging neutrophil inflammation.
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Affiliation(s)
- Francisco Barros-Becker
- Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, WI, USA.,Cellular and Molecular Biology Doctoral Training Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Jayne M Squirrell
- Laboratory for Optical and Computational Instrumentation, Center for Quantitative Cell Imaging, University of Wisconsin-Madison, Madison, WI, USA
| | - Russell Burke
- Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, WI, USA
| | - Julia Chini
- Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, WI, USA.,School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | - Julie Rindy
- Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, WI, USA.,Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
| | - Aos Karim
- Department of Surgery, University of Wisconsin-Madison, Madison WI, USA
| | - Kevin W Eliceiri
- Laboratory for Optical and Computational Instrumentation, Center for Quantitative Cell Imaging, University of Wisconsin-Madison, Madison, WI, USA.,Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, USA
| | - Angela Gibson
- Department of Surgery, University of Wisconsin-Madison, Madison WI, USA
| | - Anna Huttenlocher
- Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, WI, USA.,Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
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Abstract
Sepsis in humans and experimental animals is characterized by an acute inflammatory response. glucocorticoids (GCs) are widely used for the treatment of many inflammatory disorders, yet their effectiveness in sepsis is debatable. One of the major anti-inflammatory proteins induced by GCs is glucocorticoid-induced leucine zipper (GILZ, coded by the TSC22D3 gene). We found that TSC22D3 mRNA expression is downregulated in white blood cells of human sepsis patients. Interestingly, transgenic GILZ-overexpressing mice (GILZ-tg) showed better survival rates in the cecal ligation and puncture (CLP) model of mouse sepsis. To our surprise, GILZ had only mild anti-inflammatory effects in this model, as the systemic proinflammatory response was not significantly reduced in GILZ-tg mice compared with control mice. During CLP, we observed reduced bacterial counts in blood of GILZ-tg mice compared with control mice. We found increased expression of Tsc22d3 mRNA specifically in peritoneal exudate cells in the CLP model, as well as increased capacity for bacterial phagocytosis of CD45 GILZ-tg cells compared with CD45 GILZ-wt cells. Hence, we believe that the protective effects of GILZ in the CLP model can be linked to a more efficient phagocytosis.
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Assessment of Coagulation Homeostasis in Blunt, Penetrating, and Thermal Trauma: Guidance for a Multicenter Systems Biology Approach. Shock 2020; 52:84-91. [PMID: 30339633 PMCID: PMC6472988 DOI: 10.1097/shk.0000000000001275] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Provisioning care for traumatically injured patients makes conducting research very proximal to injury difficult. These studies also inherently have regulatory barriers to overcome. Here we outline a protocol for acute-phase enrollment of traumatically injured patients into a prospective observational clinical trial with precise and comprehensive sample acquisition in support of a systems biology approach to a research study. METHODS Experts in trauma, burn, blood coagulation, computational biology, and integrative systems biology developed a prospective study that would capture the natural history of coagulation pathology after traumatic injury. Blood was sampled at admission and serial time points throughout hospitalization. Concurrently, demographic and outcomes data were recorded and on-site point-of-care testing was implemented. Protocols were harmonized across sites and sampling protocols validated through demonstration of feasibility and sample quality assurance testing. A novel data integration platform was developed to store, visualize, and enable large-scale analysis of empirical and clinical data. Regulatory considerations were also addressed in protocol development. RESULTS A comprehensive Manual of Operations (MOO) was developed and implemented at 3 clinical sites. After regulatory approval, the MOO was followed to collect 5,348 longitudinal samples from 1,547 patients. All samples were collected, processed, and stored per the MOO. Assay results and clinical data were entered into the novel data management platform for analyses. CONCLUSION We used an iterative, interdisciplinary process to develop a systematic and robust protocol for comprehensive assessment of coagulation in traumatically injured patients. This MOO can be a template for future studies in the acute setting.
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28
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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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Advancing Toward Precision Medicine in Trauma. Ann Surg 2020; 271:811-812. [PMID: 32301794 DOI: 10.1097/sla.0000000000003818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
OBJECTIVES Modern critical care amasses unprecedented amounts of clinical data-so called "big data"-on a minute-by-minute basis. Innovative processing of these data has the potential to revolutionize clinical prognostics and decision support in the care of the critically ill but also forces clinicians to depend on new and complex tools of which they may have limited understanding and over which they have little control. This concise review aims to provide bedside clinicians with ways to think about common methods being used to extract information from clinical big datasets and to judge the quality and utility of that information. DATA SOURCES We searched the free-access search engines PubMed and Google Scholar using the MeSH terms "big data", "prediction", and "intensive care" with iterations of a range of additional potentially associated factors, along with published bibliographies, to find papers suggesting illustration of key points in the structuring and analysis of clinical "big data," with special focus on outcomes prediction and major clinical concerns in critical care. STUDY SELECTION Three reviewers independently screened preliminary citation lists. DATA EXTRACTION Summary data were tabulated for review. DATA SYNTHESIS To date, most relevant big data research has focused on development of and attempts to validate patient outcome scoring systems and has yet to fully make use of the potential for automation and novel uses of continuous data streams such as those available from clinical care monitoring devices. CONCLUSIONS Realizing the potential for big data to improve critical care patient outcomes will require unprecedented team building across disparate competencies. It will also require clinicians to develop statistical awareness and thinking as yet another critical judgment skill they bring to their patients' bedsides and to the array of evidence presented to them about their patients over the course of care.
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Binnie A, Walsh CJ, Hu P, Dwivedi DJ, Fox-Robichaud A, Liaw PC, Tsang JLY, Batt J, Carrasqueiro G, Gupta S, Marshall JC, Castelo-Branco P, Dos Santos CC. Epigenetic Profiling in Severe Sepsis: A Pilot Study of DNA Methylation Profiles in Critical Illness. Crit Care Med 2020; 48:142-150. [PMID: 31939781 DOI: 10.1097/ccm.0000000000004097] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Epigenetic alterations are an important regulator of gene expression in health and disease; however, epigenetic data in sepsis are lacking. To demonstrate proof of concept and estimate effect size, we performed the first epigenome-wide methylation analysis of whole blood DNA samples from a cohort of septic and nonseptic critically ill patients. DESIGN A nested case-control study using genomic DNA isolated from whole blood from septic (n = 66) and nonseptic (n = 68) critically ill patients on "Day 1" of ICU admission. Methylation patterns were identified using Illumina 450K arrays with percent methylation expressed as β values. After quality control, 134 participants and 414,818 autosomal cytosine-phosphate-guanine sites were used for epigenome-wide methylation analyses. SETTING Tertiary care hospitals. SUBJECTS Critically ill septic and nonseptic patients. INTERVENTIONS Observational study. MEASUREMENTS AND MAIN RESULTS A total of 668 differentially methylated regions corresponding to 443 genes were identified. Known sepsis-associated genes included complement component 3; angiopoietin 2; myeloperoxidase; lactoperoxidase; major histocompatibility complex, class I, A; major histocompatibility complex, class II, isotype DR β I; major histocompatibility complex, class I, C; and major histocompatibility complex, class II, isotype DQ β I. When compared with whole blood gene expression data from seven external datasets containing septic and nonseptic patients, 81% of the differentially methylated region-associated genes were differentially expressed in one or more datasets and 31% in three or more datasets. Functional analysis showed enrichment for antigen processing and presentation, methyltransferase activity, cell adhesion, and cell junctions. Analysis by weighted gene coexpression network analysis revealed DNA comethylation modules that were associated with clinical traits including severity of illness, need for vasopressors, and length of stay. CONCLUSIONS DNA methylation marks may provide important causal and potentially biomarker information in critically ill patients with sepsis.
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Affiliation(s)
- Alexandra Binnie
- Department of Critical Care, William Osler Health System, Brampton, ON, Canada
| | - Christopher J Walsh
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Sciences and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Pingzhao Hu
- Department of Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, MB, Canada
| | - Dhruva J Dwivedi
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Alison Fox-Robichaud
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Patricia C Liaw
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jennifer L Y Tsang
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Niagara Health, St. Catharines, ON, Canada
| | - Jane Batt
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Sciences and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gabriela Carrasqueiro
- Centre for Biomedical Research, University of Algarve, Faro, Portugal
- Algarve Biomedical Center, Faro, Portugal
| | - Sahil Gupta
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Sciences and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John C Marshall
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Sciences and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Pedro Castelo-Branco
- Centre for Biomedical Research, University of Algarve, Faro, Portugal
- Algarve Biomedical Center, Faro, Portugal
- Regenerative Medicine Program, Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Claudia C Dos Santos
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
- Institute of Medical Sciences and Department of Medicine, University of Toronto, Toronto, ON, Canada
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Yu W, Guo Z, Liang P, Jiang B, Guo L, Duan M, Huang X, Zhang P, Zhang M, Ren L, Zeng J, Huang X. Expression changes in protein-coding genes and long non-coding RNAs in denatured dermis following thermal injury. Burns 2019; 46:1128-1135. [PMID: 31852616 DOI: 10.1016/j.burns.2019.11.016] [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: 06/10/2019] [Revised: 09/26/2019] [Accepted: 11/23/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Thermal injury repair is a complex process during which maintaining the proliferation of human dermis fibroblasts (HDFs) and synthesis of extracellular matrix (ECM) plays a critical role. In the present study, we analyzed potential molecular markers and the probable association between differentially-expressed lncRNAs and protein-coding genes within denatured dermis following thermal injury, attempting to provide further insights to thermal injury repair pathogenesis. METHODS AND MAIN RESULTS We found that the expression of 3940 lncRNAs was increased, while that of 1438 lncRNAs was reduced in the denatured dermis following thermal injury when compared to normal tissue. Of them, 338 were upregulated and 154 were downregulated by more than 128 times. Via cross-check with another microarray profile analysis on differentially-expressed lncRNAs after thermal injury, LINC00302 was found to be downregulated after thermal injury; more importantly, this skin-specially expressed lncRNA is located near a series of genes related to multiple skin inflammation and skin barrier-associated genomes. LINC00302 overexpression promoted the cell viability and the protein levels of α-SMA and Collagen I in HDFs. CONCLUSIONS In conclusion, mRNAs and lncRNAs could be differentially expressed in the denatured dermis following thermal injury. mRNA and lncRNA regulatory signaling pathways could participate in thermal injury repair pathogenesis. More importantly, LINC00302 may play a critical role in thermal injury repair.
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Affiliation(s)
- Wenchang Yu
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Zaiwen Guo
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China; Department of Burn and Plastic Surgery, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, Jiangsu 215002, PR China
| | - Pengfei Liang
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China.
| | - Bimei Jiang
- Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan 410008, PR China
| | - Le Guo
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Mengting Duan
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Xu Huang
- Department of Hyperbaric Oxygen, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Pihong Zhang
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Minghua Zhang
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Licheng Ren
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Jizhang Zeng
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
| | - Xiaoyuan Huang
- Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, PR China
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Early Achievement of Enteral Nutrition Protein Goals by Intensive Care Unit Day 4 is Associated With Fewer Complications in Critically Injured Adults. Ann Surg 2019; 274:e988-e994. [PMID: 33055581 DOI: 10.1097/sla.0000000000003708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications. BACKGROUND Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance. METHODS Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort. RESULTS There were 274 patients included (71.2% male). Mean age was 50.56 ± 19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001). CONCLUSIONS There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible.
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Microcirculatory Impairment Is Associated With Multiple Organ Dysfunction Following Traumatic Hemorrhagic Shock: The MICROSHOCK Study. Crit Care Med 2019; 46:e889-e896. [PMID: 29957708 DOI: 10.1097/ccm.0000000000003275] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To assess the relationship between microcirculatory perfusion and multiple organ dysfunction syndrome in patients following traumatic hemorrhagic shock. DESIGN Multicenter prospective longitudinal observational study. SETTING Three U.K. major trauma centers. PATIENTS Fifty-eight intubated and ventilated patients with traumatic hemorrhagic shock. INTERVENTIONS Sublingual incident dark field microscopy was performed within 12 hours of ICU admission (D0) and repeated 24 and 48 hours later. Cardiac output was assessed using oesophageal Doppler. Multiple organ dysfunction syndrome was defined as Serial Organ Failure Assessment score greater than or equal to 6 at day 7 post injury. MEASUREMENTS AND MAIN RESULTS Data from 58 patients were analyzed. Patients had a mean age of 43 ± 19 years, Injury Severity Score of 29 ± 14, and initial lactate of 7.3 ± 6.1 mmol/L and received 6 U (interquartile range, 4-11 U) of packed RBCs during initial resuscitation. Compared with patients without multiple organ dysfunction syndrome at day 7, patients with multiple organ dysfunction syndrome had lower D0 perfused vessel density (11.2 ± 1.8 and 8.6 ± 1.8 mm/mm; p < 0.01) and microcirculatory flow index (2.8 [2.6-2.9] and 2.6 [2.2-2.8]; p < 0.01) but similar cardiac index (2.5 [± 0.6] and 2.1 [± 0.7] L/min//m; p = 0.11). Perfused vessel density demonstrated the best discrimination for predicting subsequent multiple organ dysfunction syndrome (area under curve 0.87 [0.76-0.99]) compared with highest recorded lactate (area under curve 0.69 [0.53-0.84]), cardiac index (area under curve 0.66 [0.49-0.83]) and lowest recorded systolic blood pressure (area under curve 0.54 [0.39-0.70]). CONCLUSIONS Microcirculatory hypoperfusion immediately following traumatic hemorrhagic shock and resuscitation is associated with increased multiple organ dysfunction syndrome. Microcirculatory variables are better prognostic indicators for the development of multiple organ dysfunction syndrome than more traditional indices. Microcirculatory perfusion is a potential endpoint of resuscitation following traumatic hemorrhagic shock.
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Abstract
OBJECTIVES To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU. DATA SOURCES AND STUDY SELECTION A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord. DATA EXTRACTION AND DATA SYNTHESIS The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries. CONCLUSIONS The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.
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Weber B, Lackner I, Haffner-Luntzer M, Palmer A, Pressmar J, Scharffetter-Kochanek K, Knöll B, Schrezenemeier H, Relja B, Kalbitz M. Modeling trauma in rats: similarities to humans and potential pitfalls to consider. J Transl Med 2019; 17:305. [PMID: 31488164 PMCID: PMC6728963 DOI: 10.1186/s12967-019-2052-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 08/29/2019] [Indexed: 12/27/2022] Open
Abstract
Trauma is the leading cause of mortality in humans below the age of 40. Patients injured by accidents frequently suffer severe multiple trauma, which is life-threatening and leads to death in many cases. In multiply injured patients, thoracic trauma constitutes the third most common cause of mortality after abdominal injury and head trauma. Furthermore, 40-50% of all trauma-related deaths within the first 48 h after hospital admission result from uncontrolled hemorrhage. Physical trauma and hemorrhage are frequently associated with complex pathophysiological and immunological responses. To develop a greater understanding of the mechanisms of single and/or multiple trauma, reliable and reproducible animal models, fulfilling the ethical 3 R's criteria (Replacement, Reduction and Refinement), established by Russell and Burch in 'The Principles of Human Experimental Technique' (published 1959), are required. These should reflect both the complex pathophysiological and the immunological alterations induced by trauma, with the objective to translate the findings to the human situation, providing new clinical treatment approaches for patients affected by severe trauma. Small animal models are the most frequently used in trauma research. Rattus norvegicus was the first mammalian species domesticated for scientific research, dating back to 1830. To date, there exist numerous well-established procedures to mimic different forms of injury patterns in rats, animals that are uncomplicated in handling and housing. Nevertheless, there are some physiological and genetic differences between humans and rats, which should be carefully considered when rats are chosen as a model organism. The aim of this review is to illustrate the advantages as well as the disadvantages of rat models, which should be considered in trauma research when selecting an appropriate in vivo model. Being the most common and important models in trauma research, this review focuses on hemorrhagic shock, blunt chest trauma, bone fracture, skin and soft-tissue trauma, burns, traumatic brain injury and polytrauma.
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Affiliation(s)
- Birte Weber
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm Medical School, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Ina Lackner
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm Medical School, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Melanie Haffner-Luntzer
- Institute of Orthopedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany
| | - Annette Palmer
- Institute of Clinical and Experimental Trauma-Immunology, University of Ulm, Ulm, Germany
| | - Jochen Pressmar
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm Medical School, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | | | - Bernd Knöll
- Institute of Physiological Chemistry, University of Ulm, Ulm, Germany
| | - Hubert Schrezenemeier
- Institute of Transfusion Medicine, University of Ulm and Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg – Hessen and University Hospital Ulm, Ulm, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt, Germany
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm Medical School, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Affiliation(s)
- Idit Matot
- Division of Anesthesiology, Critical Care and Pain, Tel Aviv Medical Center, Tel Aviv, Israel,
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Anesthetics Influence Mortality in a Drosophila Model of Blunt Trauma With Traumatic Brain Injury. Anesth Analg 2019; 126:1979-1986. [PMID: 29596093 DOI: 10.1213/ane.0000000000002906] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Exposure to anesthetics is common in the majority of early survivors of life-threatening injuries. Whether and to what degree general anesthetics influence outcomes from major trauma is unknown. Potential confounding effects of general anesthetics on outcome measures are usually disregarded. We hypothesized that exposure to isoflurane or sevoflurane modulates the outcome from blunt trauma with traumatic brain injury (bTBI). METHODS We tested the hypothesis in a novel model of bTBI implemented in Drosophila melanogaster. Fruit flies of the standard laboratory strain w were cultured under standard conditions. We titrated the severity of bTBI to a mortality index at 24 hours (MI24) of approximately 20% under control conditions. We administered standard doses of isoflurane and sevoflurane before, before and during, or after bTBI and measured the resulting MI24. We report the MI24 as mean ± standard deviation. RESULTS Isoflurane or sevoflurane administered for 2 hours before bTBI reduced the MI24 from 22.3 ± 2.6 to 10.4 ± 1.8 (P < 10, n = 12) and from 19.3 ± 0.9 to 8.9 ± 1.1 (P < .0001, n = 8), respectively. In contrast, administration of isoflurane after bTBI increased the MI24 from 18.5% ± 4.3% to 25.3% ± 9.1% (P = .0026, n = 22), while sevoflurane had no effect (22.4 ± 7.1 and 21.5 ± 5.8, n = 22). CONCLUSIONS In a whole animal model of bTBI, general anesthetics were not indifferent with respect to early mortality. Therefore, collateral effects of general anesthetics should be considered in the interpretation of results obtained in vertebrate trauma models. Invertebrate model organisms can serve as a productive platform to interrogate anesthetic targets that mediate collateral effects and to inform trauma research in higher organisms about the potential impact of anesthetics on outcomes.
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Lamparello AJ, Namas RA, Constantine G, McKinley TO, Elster E, Vodovotz Y, Billiar TR. A conceptual time window-based model for the early stratification of trauma patients. J Intern Med 2019; 286:2-15. [PMID: 30623510 DOI: 10.1111/joim.12874] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Progress in the testing of therapies targeting the immune response following trauma, a leading cause of morbidity and mortality worldwide, has been slow. We propose that the design of interventional trials in trauma would benefit from a scheme or platform that could support the identification and implementation of prognostic strategies for patient stratification. Here, we propose a stratification scheme based on defined time periods or windows following the traumatic event. This 'time-window' model allows for the incorporation of prognostic variables ranging from circulating biomarkers and clinical data to patient-specific information such as gene variants to predict adverse short- or long-term outcomes. A number of circulating biomarkers, including cell injury markers and damage-associated molecular patterns (DAMPs), and inflammatory mediators have been shown to correlate with adverse outcomes after trauma. Likewise, several single nucleotide polymorphisms (SNPs) associate with complications or death in trauma patients. This review summarizes the status of our understanding of the prognostic value of these classes of variables in predicting outcomes in trauma patients. Strategies for the incorporation of these prognostic variables into schemes designed to stratify trauma patients, such as our time-window model, are also discussed.
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Affiliation(s)
- A J Lamparello
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - R A Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - G Constantine
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Mathematics, University of Pittsburgh, Pittsburgh, PA, USA
| | - T O McKinley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IU Health Methodist Hospital, Indianapolis, IN, USA
| | - E Elster
- Department of Surgery, University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Y Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - T R Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Chronic Critical Illness After Trauma: From Description to Treatment? Crit Care Med 2019; 45:2104-2105. [PMID: 29148989 DOI: 10.1097/ccm.0000000000002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Early Immunologic Response in Multiply Injured Patients With Orthopaedic Injuries Is Associated With Organ Dysfunction. J Orthop Trauma 2019; 33:220-228. [PMID: 31008819 DOI: 10.1097/bot.0000000000001437] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To quantify the acute immunologic biomarker response in multiply injured patients with axial and lower extremity fractures and to explore associations with adverse short-term outcomes including organ dysfunction and nosocomial infection (NI). DESIGN Prospective cohort study. SETTING Level 1 academic trauma center. PATIENTS Consecutive multiply injured patients, 18-55 years of age, with major pelvic and lower extremity orthopaedic injuries (all pelvic/acetabular fractures, operative femur and tibia fractures) that presented as a trauma activation and admitted to the intensive care unit from April 2015 through October 2016. Sixty-one patients met inclusion criteria. INTERVENTION Blood was collected upon presentation to the hospital and at the following time points: 8, 24, 48 hours, and daily during intensive care unit admission. Blood was processed by centrifugation, separation into 1.0-mL plasma aliquots, and cryopreserved within 2 hours of collection. MAIN OUTCOME MEASUREMENTS Plasma analyses of protein levels of cytokines/chemokines were performed using a Luminex panel Bioassay of 20 immunologic mediators. Organ dysfunction was measured by the Marshall Multiple Organ Dysfunction score (MODScore) and nosocomial infection (NI) was recorded. Patients were stratified into low (MODS ≤ 4; n = 34) and high (MODS > 4; n = 27) organ dysfunction groups. RESULTS The MODS >4 group had higher circulating levels of interleukin (IL)-6, IL-8, IL-10, monocyte chemoattractant protein-1 (MCP-1), IL-1 receptor antagonist (IL-1RA), and monokine induced by interferon gamma (MIG) compared with the MODS ≤4 group at nearly all time points. MODS >4 exhibited lower levels of IL-21 and IL-22 compared with MODS ≤4. Patients who developed NI (n = 24) had higher circulating concentrations of IL-10, MIG, and high mobility group box 1 (HMGB1) compared with patients who did not develop NI (n = 37). CONCLUSIONS Temporal quantification of immune mediators identified 8 biomarkers associated with greater levels of organ dysfunction in polytrauma patients with major orthopaedic injuries. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Uniquely human CHRFAM7A gene increases the hematopoietic stem cell reservoir in mice and amplifies their inflammatory response. Proc Natl Acad Sci U S A 2019; 116:7932-7940. [PMID: 30944217 PMCID: PMC6475388 DOI: 10.1073/pnas.1821853116] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The emergence of uniquely human genes during hominid speciation enabled numerous human-specific adaptations that presumably included changes in resilience to disease but potentially increased susceptibility as well. Here we show that the transgenic expression of one such gene, called CHRFAM7A, changes the mouse reservoir of hematopoietic stem cells in bone marrow and amplifies the mouse inflammatory response in a model of human systemic inflammatory response syndrome (SIRS). Because the CHRFAM7A gene is a dominant-negative inhibitor of ligand binding to α7 nicotinic acetylcholine receptor (α7nAChR), a neurotransmitter receptor implicated in immunity, inflammation, neurodegeneration, and cognitive function, the results underscore the importance of understanding the contribution of species-specific genes to human disease and the impact they may have on the fidelity of animal models for translational medicine. A subset of genes in the human genome are uniquely human and not found in other species. One example is CHRFAM7A, a dominant-negative inhibitor of the antiinflammatory α7 nicotinic acetylcholine receptor (α7nAChR/CHRNA7) that is also a neurotransmitter receptor linked to cognitive function, mental health, and neurodegenerative disease. Here we show that CHRFAM7A blocks ligand binding to both mouse and human α7nAChR, and hypothesized that CHRFAM7A-transgenic mice would allow us to study its biological significance in a tractable animal model of human inflammatory disease, namely SIRS, the systemic inflammatory response syndrome that accompanies severe injury and sepsis. We found that CHRFAM7A increased the hematopoietic stem cell (HSC) reservoir in bone marrow and biased HSC differentiation to the monocyte lineage in vitro. We also observed that while the HSC reservoir was depleted in SIRS, HSCs were spared in CHRFAM7A-transgenic mice and that these mice also had increased immune cell mobilization, myeloid cell differentiation, and a shift to inflammatory monocytes from granulocytes in their inflamed lungs. Together, the findings point to a pathophysiological inflammatory consequence to the emergence of CHRFAM7A in the human genome. To this end, it is interesting to speculate that human genes like CHRFAM7A can account for discrepancies between the effectiveness of drugs like α7nAChR agonists in animal models and human clinical trials for inflammatory and neurodegenerative disease. The findings also support the hypothesis that uniquely human genes may be contributing to underrecognized human-specific differences in resiliency/susceptibility to complications of injury, infection, and inflammation, not to mention the onset of neurodegenerative disease.
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Störmann P, Becker N, Künnemeyer L, Wutzler S, Vollrath JT, Lustenberger T, Hildebrand F, Marzi I, Relja B. Contributing factors in the development of acute lung injury in a murine double hit model. Eur J Trauma Emerg Surg 2019; 46:21-30. [PMID: 30937460 DOI: 10.1007/s00068-019-01121-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/27/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Blunt chest (thoracic) trauma (TxT) is known to contribute to the development of secondary pulmonary complications. Of these, acute lung injury (ALI) is common especially in multiply injured patients and might not only be due to the direct trauma itself, but seems to be caused by ongoing and multifactorial inflammatory changes. Nevertheless, the exact mechanisms and contributing factors of the development of ALI following blunt chest trauma are still elusive. METHODS 60 CL57BL/6N mice sustained either blunt chest trauma combined with laparotomy without further interventions or a double hit (DH) including TxT and cecal ligation puncture (CLP) after 24 h to induce ALI. Animals were killed either 6 or 24 h after the second procedure. Pulmonary expression of inflammatory mediators cxcl1, cxcl5, IL-1β and IL-6, neutrophil infiltration and lung tissue damage using the Lung Injury Score (LIS) were determined. RESULTS Next to a moderate increase in other inflammatory mediators, a significant increase in CXCL1, neutrophil infiltration and lung injury was observed early after TxT, which returned to baseline levels after 24 h. DH induced significantly increased gene expression of cxcl1, cxcl5, IL-1β and IL-6 after 6 h, which was followed by the postponed significant increase in the protein expression after 24 h compared to controls. Neutrophil infiltration was significantly enhanced 24 h after DH compared to all other groups, and exerted a slight decline after 24 h. LIS has shown a significant increase after both 6 and 24 h compared to both control groups as well the late TxT group. CONCLUSION Early observed lung injury with moderate inflammatory changes after blunt chest trauma recovered quickly, and therefore, may be caused by mechanical lung injury. In contrast, lung injury in the ALI group did not undergo recovery and is closely associated with significant changes of inflammatory mediators. This model may be used for further examinations of contributing factors and therapeutic strategies to prevent ALI.
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Affiliation(s)
- Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
| | - Nils Becker
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Leander Künnemeyer
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sebastian Wutzler
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.,Department of Trauma, Hand and Orthopedic Surgery, Helios Horst Schmidt Clinic, Wiesbaden, Germany
| | - Jan Tilmann Vollrath
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | | | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
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Perouansky M. In Response. Anesth Analg 2018; 127:e92-e93. [PMID: 30234541 DOI: 10.1213/ane.0000000000003769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Misha Perouansky
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,
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Galbraith NJ, O'Brien SJ, Walker SP, Gardner SA, Polk HC, Barnes SL. Temporal expression of circulating miRNA after severe injury. Surgery 2018; 164:665-672. [PMID: 30077391 DOI: 10.1016/j.surg.2018.05.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Severe injury can lead to immune dysfunction and predispose patients to infection and death. Micro-RNAs regulate gene expression and may act as biomarkers for susceptibility to infection. The aim of this study was to examine the temporal and differential expression of previously identified dysregulated micro-RNAs in patients with severe injury. METHODS Fourteen severely injured patients requiring transfusion were enrolled prospectively in this study approved by our institutional review board. Inclusion criteria consisted of adult patients deemed clinically to be in hemorrhagic shock necessitating transfusion in the acute phase of their injury care. Peripheral blood samples were obtained after admission to the surgical intensive care unit and again at 6, 12, 24, and 48 hours after admission. The samples obtained at arrival to the intensive care unit and 24 and 48 hours later were analyzed in this data set. Fourteen healthy volunteers served as controls. The 10 dysregulated micro-RNAs identified in a prior study at the 12-hour time point and important genes in innate immunity were measured using quantitative reverse transcription-polymerase chain reaction. RESULTS The participants were 21-77 years old (median, 42), 78% were male, and their Injury Severity Score ranged from 11 to 43 (median, 27); 11 had blunt and 3 had penetrating injuries. Three were intubated and 5 had received blood products before arrival at the hospital. Base deficit on hospital admission was 3-20 (median, 9). All patients required blood transfusion secondary to blood loss sustained during injury. Eleven of the 14 patients went directly to the operating room from the emergency department for control of the source of hemorrhage. Survival to discharge was 93%. Seven patients developed infection. Compared with healthy controls, miR-106a was downregulated at all time points compared with controls (P < .05). miR-618 was upregulated in initial blood draws (P < .05) and at 24 and 48 hours (P < .06). Tumor necrosis factor α and human leukocyte antigen-DR (HLA-DR) were downregulated, and interleukin-10 and PD-L1 were upregulated (P < .05). In patients who developed infection, miR-106a levels appeared more downregulated than those who did not develop infection. CONCLUSION miR-106a was downregulated in trauma patients after major injury for up to 48 hours after intensive care unit admission. Tumor necrosis factor α and interleukin-10 are targeted by miR-106a, which are regulators of the immune response. Manipulation of micro-RNA expression may be a therapeutic target for immune dysfunction.
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Affiliation(s)
- Norman J Galbraith
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Stephen J O'Brien
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Samuel P Walker
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Sarah A Gardner
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Hiram C Polk
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Stephen L Barnes
- Department of Surgery, University of Missouri Hospital, Columbia, MO.
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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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48
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Farinas AF, Bamba R, Pollins AC, Cardwell NL, Nanney LB, Thayer WP. Burn wounds in the young versus the aged patient display differential immunological responses. Burns 2018; 44:1475-1481. [PMID: 29895402 DOI: 10.1016/j.burns.2018.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/12/2018] [Accepted: 05/17/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Individuals in the geriatric age range are more prone than younger individuals to convert their partial thickness thermal burns into full thickness injuries. We hypothesized that this often observed clinical phenomenon is strongly related to differential local injury responses mediated by the immune system. MATERIALS & METHODS Skin samples from areas with partial thickness thermal burns were obtained during routine excision and grafting procedures between post burn days 2-6. Tissue samples were grouped by age ranges with young patients defined as <30 years of age or aged patients defined as >65. Formalin fixed samples were used to confirm depth of burn injury and companion sections were homogenized for multiplex analysis using a Luminex platform. Immunohistochemical staining was used to quantify total macrophage numbers as well as the M1 and M2 subpopulations. RESULTS Our analysis includes samples derived from 11 young subjects (mean age=23) and 3 aged subjects (mean age=79.2). Our initial survey of analytes examined 31 cytokines/chemokines. Twelve were excluded from consideration as they were present in concentrations either above or below the optimal detection range. Two analytes emerged as candidate molecules with significant differences between the young and the aged patient responses to burn injury. EGF levels were on average 21.69pg/ml in young vs 14.87pg/ml in aged (p=0.032). RANTES/CCL5 levels were on average 14.86pg/ml in young vs 4.26pg/ml in aged (p=0.026). Elevated macrophage numbers were present within wounds of younger patients compared to the old (p<0.01), with a higher concentration of the M1 type in the elderly (p>0.05). CONCLUSION Our study has identified at least 2 well known cytokines, CCL5 (RANTES) and EGF, which are differentially regulated in response to burn injury by young versus aged burn victims. Evidence suggests that a proinflammatory environment can explain the high conversion rate from partial to full thickness burns. Our data suggest the need for future studies at the point of injury (cutaneous targets) that may be modulated by post burn release of cytokines/chemokines.
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Affiliation(s)
- Angel F Farinas
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN, United States
| | - Ravinder Bamba
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN, United States; Georgetown University, Department of Surgery, Washington, DC, United States
| | - Alonda C Pollins
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN, United States
| | - Nancy L Cardwell
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN, United States
| | - Lillian B Nanney
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN, United States; Department of Cell & Developmental Biology, Vanderbilt University, Nashville, TN, United States
| | - Wesley P Thayer
- Vanderbilt University Medical Center, Department of Plastic Surgery, Nashville, TN, United States; Vanderbilt University Medical Center, Department of Biomedical Engineering, Nashville, TN, United States; VA Tennessee Healthcare System, Nashville, TN, United States.
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49
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Affiliation(s)
- Jeremy W Cannon
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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50
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Machado-Aranda D. [The Use Of Pulmonary Gene Therapy In The Treatment Of Experimental Models Of Pneumonia And Septicemia]. GACETA MEDICA DE CARACAS 2018; 126:5-14. [PMID: 30100668 PMCID: PMC6086359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- David Machado-Aranda
- Laboratorio del Estudio de la Biología y Terapia Molecular para el Manejo del Trauma Pulmonar
- División de Cirugía de Trauma, Quemados y Urgencias - Terapia Intensiva Quirúrgica, Universidad de Michigan, Ann Arbor, Michigan, Estados Unidos de América
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