Temporal cytokine profiles in severely burned patients: a comparison of adults and children

A severe burn leads to hypermetabolism and catabolism resulting in compromised function and structural changes of essential organs. The release of cytokines has been implicated in this hypermetabolic response. The severity of the hypermetabolic response following burn injury increases with age, as does the mortality rate. Due to the relationship between the hypermetabolic and inflammatory responses, we sought to compare the plasma cytokine profiles following a severe burn in adults and in children. We enrolled 25 adults and 24 children who survived a flame burn covering more than 20% of total body surface area (TBSA). The concentrations of 22 cytokines were measured using the Linco multiplex array system (St. Charles, MO, USA). Large perturbations in the expression of pro- and anti-inflammatory cytokines were seen following thermal injury. During the first week following burn injury, IFN-gamma, IL-10, IL-17, IL-4, IL-6, and IL-8 were detected at significantly higher levels in adults compared with children, P < 0.05. Significant differences were measured during the second week post-burn for IL-1beta (higher in children) and IL-5 (higher in adults), P < 0.05. IL-18 was more abundant in children compared with adults during the third week post-burn, P < 0.05. Between post-burn d 21 and d 66, IL-1alpha was detected at higher concentrations in pediatric compared with adult patients, P < 0.05. Only GM-CSF expression was significantly different at all time points; it was detected at lower levels in pediatric patients, P < 0.05. Eotaxin, G-CSF, IL-13, IL-15, IP-10, MCP-1, and MIP-1alpha were detected at significantly different concentrations in adult compared with pediatric patients at multiple time points, P < 0.05. There were no differences in IL-12, IL-2, IL-7, or TNF levels in adult compared with pediatric burn patients at any of these time points. Following severe flame burns, the cytokine profiles in pediatric patients differ compared with those in adult patients, which may provide insight with respect to the higher morbidity rate in adults. Furthermore, the dramatic discrepancies observed in plasma cytokine detection between children and adults suggest that these two patient populations may benefit from different therapeutic interventions to achieve attenuation of the post-burn inflammatory response.     

Long-term persistance of the pathophysiologic response to severe burn injury

Background

Main contributors to adverse outcomes in severely burned pediatric patients are profound and complex metabolic changes in response to the initial injury. It is currently unknown how long these conditions persist beyond the acute phase post-injury. The aim of the present study was to examine the persistence of abnormalities of various clinical parameters commonly utilized to assess the degree hypermetabolic and inflammatory alterations in severely burned children for up to three years post-burn to identify patient specific therapeutic needs and interventions.

Methodology/Principal Findings

Patients: Nine-hundred seventy-seven severely burned pediatric patients with burns over 30% of the total body surface admitted to our institution between 1998 and 2008 were enrolled in this study and compared to a cohort non-burned, non-injured children. Demographics and clinical outcomes, hypermetabolism, body composition, organ function, inflammatory and acute phase responses were determined at admission and subsequent regular intervals for up to 36 months post-burn. Statistical analysis was performed using One-way ANOVA, Student''s t-test with Bonferroni correction where appropriate with significance accepted at p<0.05. Resting energy expenditure, body composition, metabolic markers, cardiac and organ function clearly demonstrated that burn caused profound alterations for up to three years post-burn demonstrating marked and prolonged hypermetabolism, p<0.05. Along with increased hypermetabolism, significant elevation of cortisol, catecholamines, cytokines, and acute phase proteins indicate that burn patients are in a hyperinflammatory state for up to three years post-burn p<0.05.

Conclusions

Severe burn injury leads to a much more profound and prolonged hypermetabolic and hyperinflammatory response than previously shown. Given the tremendous adverse events associated with the hypermetabolic and hyperinflamamtory responses, we now identified treatment needs for severely burned patients for a much more prolonged time.     

In situ metabolic flux analysis to quantify the liver metabolic response to experimental burn injury

Trauma such as burns induces a hypermetabolic response associated with altered central carbon and nitrogen metabolism. The liver plays a key role in these metabolic changes; however, studies to date have evaluated the metabolic state of liver using ex vivo perfusions or isotope labeling techniques targeted to specific pathways. Herein, we developed a unique mass balance approach to characterize the metabolic state of the liver in situ, and used it to quantify the metabolic changes to experimental burn injury in rats. Rats received a sham (control uninjured), 20% or 40% total body surface area (TBSA) scald burn, and were allowed to develop a hypermetabolic response. One day prior to evaluation, all animals were fasted to deplete glycogen stores. Four days post-burn, blood flow rates in major vessels of the liver were measured, and blood samples harvested. We combined measurements of metabolite concentrations and flow rates in the major vessels entering and leaving the liver with a steady-state mass balance model to generate a quantitative picture of the metabolic state of liver. The main findings were: (1) Sham-burned animals exhibited a gluconeogenic pattern, consistent with the fasted state; (2) the 20% TBSA burn inhibited gluconeogenesis and exhibited glycolytic-like features with very few other significant changes; (3) the 40% TBSA burn, by contrast, further enhanced gluconeogenesis and also increased amino acid extraction, urea cycle reactions, and several reactions involved in oxidative phosphorylation. These results suggest that increasing the severity of injury does not lead to a simple dose-dependent metabolic response, but rather leads to qualitatively different responses.     

Hormonal regulation of protein degradation in skeletal and cardiac muscle

A number of hormones produce either anabolic or catabolic effects on protein degradation in muscle. These effects can account for the changes in muscle proteolysis associated with a variety of physiological and pathological states. Thus the balance of hormones within the organism seems to play an important role in the overall regulation of this process. In the fed state, insulin may be the single most important factor maintaining low rates of proteolysis, whereas the catabolic effects of the glucocorticoid hormones in fasting seem to predominate. The proportions of these hormones may be important not only during starvation, but also in trauma and in diseases associated with their altered production and secretion (e.g., diabetes, Cushing's syndrome). Hyperthyroidism too causes catabolic effects on muscle proteolysis.     

Central alpha-MSH infusion in rats: disparate anorexic vs. metabolic changes with aging

Changes of the anorexigenic and hypermetabolic components of the overall catabolic effect of alpha-MSH were studied in rats as a function of age. In male Wistar rats a 7 day-long intracerebroventricular infusion of alpha-MSH suppressed food intake and caused a fall in body weight in 2 and 3-4 month-old (young) groups, but it was most effective in the 24 month-old group and had hardly any effect in the 12 month-old (middle-aged) animals. In contrast, metabolic rate as well as biotelemetric measurements of core temperature and heart rate revealed the most pronounced hypermetabolic effects of such infusions at age 12 months. The hypermetabolic effect was still high in the oldest group, but low in the younger groups. In conclusion: Changes of the anorexigenic and hypermetabolic effects in the course of aging are not concordant. The overall catabolic activity of alpha-MSH is smallest in the middle-aged and highest in the oldest group.     

Nutritional support for burn injuries

There are approximately 2,000,000 burns each year in the United States that require medical treatment. Fortunately, most of these can be treated on an outpatient basis; however, 100,000 patients are hospitalized yearly. The mortality rate is higher in patients with large burns or smoke inhalation injury or both, or in patients otherwise compromised by age or concomitant disease. Thermal injury leads to suppression of the immune response, and infectious morbidity is common in all burn patients. In addition, the injury and recovery processes are attended by tremendous catabolism of host tissues, leaving patients debilitated and functionally impaired. Medical nutrition therapy plays a key role in the support of the burn patient, supporting the immune system and blunting the hypermetabolic response.     

Trace element requirements in critically ill burned patients

Critically ill burned patients are characterized by a strong oxidative stress, an intense inflammatory response, and months-long hypermetabolism, all of which are proportional to the severity of injury. Trace element (TE) deficiencies have repeatedly been described. The clinical course is complicated by organ failures, infections, and delayed wound healing, which can be partly attributed to TE deficiencies.Among critically ill patients, TE deficiencies are the most severe in major burns, who suffer a specific copper deficiency. Plasma TE concentrations are low during any critical illness, as a result of TE losses in biological fluids, low intakes, dilution by fluid resuscitation, and redistribution from plasma to tissues mediated by the inflammatory response. The large exudative losses cause negative TE balances. Intravenous supplementation trials show that early substitution improves recovery, reduces infectious complications (particularly nosocomial pneumonia), normalize thyroid function, normalize skin tissue levels, improve wound healing and shorten hospital stay.Nevertheless, prolonged high dose delivery may be deleterious, as TE have potential for toxicity. In major burns, supplements up to 4 mg of Cu/day, 500 mg Se/day and 40 mg Zn/day for 3 weeks have been found to be safe and effective. The intravenous route appears the only way to deliver the doses required to achieve antioxidant and clinical effects. Further research is required to determine the optimal combination and doses for different severities of injury.     

Transforming growth factor-beta(1), -beta(2), -beta(3), basic fibroblast growth factor and vascular endothelial growth factor expression in keratinocytes of burn scars

Keratinocytes are increasingly recognized as key regulators of skin inflammation and remodeling, as they are capable of producing growth factors and cytokines that are important mediators in the wound healing process. We investigated the expression and distribution of TGF-beta 1 mRNA by mRNA in situ hybridization and of TGF-beta 1, TGF-beta 2, TGF-beta 3, bFGF and VEGF protein expression using immunohistochemistry in spontaneously healed, partial-thickness burns and compared this with the expression of these markers in matched unburned skin. This was done to assess their role in the remodeling phase of burn wound healing. Punch biopsies were taken from both partial-thickness burns after re-epithelialization and from matched, unburned skin. At 4 and 7 months post-burn, biopsies were taken of normotrophic and hypertrophic scars that had developed in these wounds. We observed a higher expression of all mentioned growth factors in keratinocytes in scars at 1 month post-burn compared with matched unburned skin. At 4 months, keratinocytes still displayed a higher expression of TGF-beta 3 and bFGF, but the expression of TGF-beta 1, TGF-beta 2 and VEGF was normalized. The expression of TGF-beta 3 in the epidermis of hypertrophic scars was slightly higher than in normotrophic scars. At 7 months post-burn, all growth factors studied showed a normal expression on keratinocytes. Our results suggest that keratinocytes are not only involved in re-epithelialization, but also in the scar maturation. The data support the idea that keratinocytes not only respond to cytokines and growth factors in an autocrine fashion, but also exert regulatory paracrine effects on contiguous cells.     

Immunoregulation after thermal injury: sequential appearance of I-J+, Ly-1 T suppressor inducer cells and Ly-2 T suppressor effector cells following thermal trauma in mice

Immunoregulation as a consequence of thermal injury was investigated by using a murine model involving a 30% surface area full thickness burn. Both allogeneic mixed lymphocyte reaction (MLR) and in vitro anti-SRBC responses were depressed from days 3 to 25 post-burn. Suppressor T cells could be identified in both systems between days 5 and 15. On day 5 post-burn, an Ly-1+,2-, I-J+ T cell is responsible for the majority of the suppression observed. This cell behaves like a T suppressor inducer T cell in that it must interact with an Ly-2+ cyclophosphamide-sensitive cell to manifest suppression. On day 7 post-burn, only Ly-1-,2+ suppressor T cells are found which can directly suppress the activity of Ly-1+,2- helper T cells. Thus, these cells behave as T suppressor effector cells. We suggest that feedback suppression is in operation after thermal injury, with functional suppressor inducer cells appearing on day 5 post-burn, leading to the appearance of T suppressor effector cells by 7 days post-burn. Recovery from post-burn immunosuppression occurs by day 25 post-burn and is associated with the appearance of V. villosa-adherent T cells, whose activity antagonizes that of the day 7 post-burn suppressor effector. These cells may represent contrasuppressor T cells, which could play a role in the restoration of immunocompetence after burn injury.     

The effects of fire on grassland bird communities of Barberspan,North West Province,South Africa

Considering the frequent nature of fires and resultant drastic change in habitat following fire, research on the effects of fire on birds in the grasslands of South Africa is surprisingly scarce. For at least five months after burns we followed the changes in bird species composition, species richness and densities of two controlled burns and one accidental fire at the Barberspan Nature Reserve in grasslands that had not been burned or grazed in 10 years. Compared with the control areas, species richness and densities increased in the burned areas immediately following the burns, with more species and birds recruited to the burned areas than were lost. Immediate post-burn opportunists tended to be larger species, and the biomass increase mirrored the increases in species richness and densities in burned areas. Avian species richness, densities and biomass tended to return to the initial conditions after a number of months. Although the bird communities from two controlled-burns differed before the burns, they converged to a characteristic immediate post-burn composition. Five months after the burns however, the bird communities reflected a pre-burn composition. Indications were that birds in an area larger than that burned were affected. Mosaic burning, with shifting large and small patches, should be considered on a landscape scale.     

Melatonin prevents oxidative kidney damage in a rat model of thermal injury

Animal models of thermal trauma implicate oxygen radicals as causative agents in local wound response and distant organ injury following burn. This study was designed to determine the effect of melatonin treatment on levels of glutathione (GSH), malondialdehyde (MDA), protein oxidation (PO) and myeloperoxidase (MPO) activity in the kidney tissues of rats with thermal injury. Under ether anaesthesia, shaved dorsum of the rats was exposed to 90 degrees C bath for 10 s to induce burn injury. Rats were decapitated either 3 h or 24 h after burn injury. Melatonin was administered i.p. immediately after burn injury. In the 24-h burn group melatonin injections were repeated for two more occasions. In the sham group the same protocol was applied except that the dorsum was dipped in a 25 degrees C water bath for 10 s. Severe skin scald injury (30% of total body surface area) caused a significant decrease in GSH level, and significant increases in MDA and PO levels, and MPO activity at post-burn 3 and 24 hours. Treatment of rats with melatonin (10 mg/kg) significantly elevated the reduced GSH levels while it decreased MDA and PO levels as well as MPO activity.     

Effects of burn wound excision on bacterial colonization and invasion

Rates of survival after thermal injury have improved in the past two decades, and rates of wound infections and sepsis have decreased during the same period. Early excision has been advocated as one of the major factors, but its safety and efficacy and the exact timing of burn excision are still under debate. It was hypothesized that acute burn wound excision (in the first 24 hours after burning) would be superior to conservative treatment and delayed excision in preventing bacterial colonization and invasion. Twenty consecutive patients with thermal injuries were studied. Twelve patients underwent acute burn wound excision, and eight patients underwent conservative treatment and delayed excision. The second group of patients received topical treatments in another facility and underwent delayed excision after transfer to our service, on postburn day 6. Quantitative bacteriological assessments of the excised wound and biopsy samples of the wound bed, obtained before autografting and/or homografting, were performed. The effects of time on bacterial counts, differences between superficial and deep biopsy samples, and the effects of early versus late debridement were studied. Patients admitted early exhibited bacterial counts of less than 10 bacteria per gram of tissue. Patients in this group did not experience infection or graft loss. Patients admitted late exhibited counts of more than 10 bacteria (p = 0.001, compared with early admission). Three patients in the late excision group experienced infection and graft loss (p < 0.05, compared with the early excision group). Burn wound excision significantly decreased bacterial colonization for all patients (p < 0.001). Greater bacterial colonization and higher rates of infection were correlated with topical treatment and late excision (p < 0.001). It is concluded that burn wound excision significantly reduces bacterial colonization. Patients who undergo topical treatment and delayed burn wound excision exhibit greater bacterial colonization and increased rates of infection. Acute burn wound excision should be considered for all full-thickness burns.     

Skeletal muscle apoptosis after burns is associated with activation of proapoptotic signals

Critical illness is associated with muscle wasting and muscle weakness. Using burn injury as a model of local and systemic inflammatory response, we tested the hypothesis that thermal injury causes apoptosis in muscle. After a 40% body surface area burn to rats, abdominal muscles beneath the burn and limb muscles distant from the burn were examined for apoptosis at varying times after burn. Ladder assay, ELISA, and histological methods showed evidence of apoptosis in the abdominal muscles within 4-12 h with peak changes occurring at 3-7 days. Maximal apoptosis was also evident at distant limb muscles at 3-7 days. Investigation of proapoptotic pathways indicated mitochondrial membrane potential to be altered by 1 h after burn. Starting at 15 min after burn, cytochrome c was released from the mitochondria into the cytosol, followed by increased activity of caspase-3, starting at 6 h after burn. These studies suggest that mitochondria and caspase-mediated apoptotic pathways may be an additional mechanism of muscle weight loss in burns and may be potential therapeutic targets for prevention of muscle wasting.     

Down-regulation of glutatione S-transferase α 4 (hGSTA4) in the muscle of thermally injured patients is indicative of susceptibility to bacterial infection

Patients with severe burns are highly susceptible to bacterial infection. While immunosuppression facilitates infection, the contribution of soft tissues to infection beyond providing a portal for bacterial entry remains unclear. We showed previously that glutathione S-transferase S1 (gstS1), an enzyme with conjugating activity against the lipid peroxidation byproduct 4-hydroxynonenal (4HNE), is important for resistance against wound infection in Drosophila muscle. The importance of the mammalian functional counterpart of GstS1 in the context of wounds and infection has not been investigated. Here we demonstrate that the presence of a burn wound dramatically affects expression of both human (hGSTA4) and mouse (mGsta4) 4HNE scavengers. hGSTA4 is down-regulated significantly within 1 wk of thermal burn injury in the muscle and fat tissues of patients from the large-scale collaborative Inflammation and the Host Response to Injury multicentered study. Similarly, mGsta4, the murine GST with the highest catalytic efficiency for 4HNE, is down-regulated to approximately half of normal levels in mouse muscle immediately postburn. Consequently, 4HNE protein adducts are increased 4- to 5-fold in mouse muscle postburn. Using an open wound infection model, we show that deletion of mGsta4 renders mice more susceptible to infection with the prevalent wound pathogen Pseudomonas aeruginosa, while muscle hGSTA4 expression negatively correlates with burn wound infection episodes per patient. Our data suggest that hGSTA4 down-regulation and the concomitant increase in 4HNE adducts in human muscle are indicative of susceptibility to infection in individuals with severely thermal injuries.     

烧烫伤创面感染的小鼠模型构建

目的探讨一种简单、稳定的烧烫伤创面感染的小鼠模型构建方法,以便进行相关烧烫伤创面修复研究。方法取30只BALB/c小鼠,采用自制木质烫伤板,沸水浴法烫取直径8 mm的圆形创面,烫伤时间分别为5 s、10 s、15 s。伤后48 h,取创面组织进行HE染色观察,筛选最佳创面烫伤时间。另取72只小鼠制成深Ⅱ度烫伤创面,采用擦刮法分别接种20μL菌浓度为1×106、l×107、1×108CFU/mL金黄色葡萄球菌标准菌株ATCC 25923的菌液。接种细菌后72 h,取创面组织HE染色观察创面炎症反应情况,并测定3、7、14 d的皮肤菌负荷,筛选最佳的细菌接种浓度。最后,按最佳条件建模后,观察创面的完全愈合时间以及创面愈中、愈后的组织学变化,以确定此创面感染模型是否建立成功。结果组织学结果表明,10 s为深Ⅱ度创面的理想致伤时间,最佳接种菌浓度为l×108CFU/mL,此时期,14 d内菌负荷均高于l×105CFU/g。该模型的创面愈合时间(21±0.95 d)较正常创面愈合时间(15.92±0.34 d)明显延长(P<0.01),炎性反应明显,愈后不佳。结论烧烫伤创面感染的小鼠模型构建成功,可作为感染创面防治研究的实验动物模型。     

Increases in plasma beta-endorphin and tail flick latency in the rat following burn injury

In children with burn injuries we found, in earlier studies, an inverse association of plasma beta-endorphin immunoactivity (iB-EP) and pain levels. To further explore the effects of burn trauma on the peripheral release of beta-endorphin and the occurrence of centrally mediated stress analgesia, plasma iB-EP levels and tail flick latency (TFL) were measured in rats subjected (while anesthetized) to scald injury. In comparison to sham burn (dip in tepid water), burn injury increased plasma iB-EP and TFL; both the duration and magnitude of these effects were directly proportional to the extent of burns. In rats receiving no treatment, TFLs were unchanged throughout the time of the burn experiments. At 2 days post-burn TFLs were invariably back to pre-burn levels. Administration of the long-acting opioid antagonist naltrexone prior to burn injury prevented the rise in TFL. Thus the trauma of burns appeared to bring about a stress-induced analgesia (SIA). The marked increase in iB-EP during this SIA and its antagonism by naltrexone suggest that it was opioid and hormonal in character.