Marc G. Jeschke

Survivors versus nonsurvivors postburn: Differences in inflammatory and hypermetabolic trajectories

Objective:To evaluate whether a panel of common biomedical markers can be utilized as trajectories to determine survival in pediatric burn patients. Background:Despite major advances in clinical care, of the more than 1 million people burned in the United States each year, more than 4500 die as a result of their burn injuries. The ability to predict patient outcome or anticipate clinical trajectories using plasma protein expression would allow personalization of clinical care to optimize the potential for patient survival. Methods:A total of 230 severely burned children with burns exceeding 30% of the total body surface, requiring at least 1 surgical procedure were enrolled in this prospective cohort study. Demographics, clinical outcomes, and inflammatory and acute-phase responses (serum cytokines, hormones, and proteins) were determined at admission and at 11 time points for up to 180 days postburn. Statistical analysis was performed using a 1-way analysis of variance, the Student t test, &khgr;2 test, and Mann-Whitney test where appropriate. Results:Survivors and nonsurvivors exhibited profound differences in critical markers of inflammation and metabolism at each time point. Nonsurvivors had significantly higher serum levels of interleukin (IL)-6, IL-8, granulocyte colony-stimulating factor, monocyte chemoattractant protein-1, C-reactive protein, glucose, insulin, blood urea nitrogen, creatinine, and bilirubin (P < 0.05). Furthermore, nonsurvivors exhibited a vastly increased hypermetabolic response that was associated with increases in organ dysfunction and sepsis when compared with survivors (P < 0.05). Conclusions:Nonsurvivors have different trajectories in inflammatory, metabolic, and acute phase responses allowing differentiation of nonsurvivors from survivors and now possibly allowing novel predictive models to improve and personalize burn outcomes.

Burns in children: standard and new treatments

Outcomes of patients with burns have improved substantially over the past two decades. Findings from a 2012 study in The Lancet showed that a burn size of more than 60% total body surface area burned (an increase from 40% a decade ago) is associated with risks and mortality. Similar data have been obtained in adults and elderly people who have been severely burned. We discuss recent and future developments in burn care to improve outcomes of children.

Predictive Value of IL-8 for Sepsis and Severe Infections After Burn Injury: A Clinical Study.

ABSTRACT The inflammatory response induced by burn injury contributes to increased incidence of infections, sepsis, organ failure, and mortality. Thus, monitoring postburn inflammation is of paramount importance but, so far, there are no reliable biomarkers available to monitor and/or predict infectious complications after burn. As interleukin 8 (IL-8) is a major mediator for inflammatory responses, the aim of our study was to determine whether IL-8 expression can be used to predict postburn sepsis, infections, and mortality. Plasma cytokines, acute-phase proteins, constitutive proteins, and hormones were analyzed during the first 60 days after injury from 468 pediatric burn patients. Demographics and clinical outcome variables (length of stay, infection, sepsis, multiorgan failure [MOF], and mortality) were recorded. A cutoff level for IL-8 was determined using receiver operating characteristic analysis. Statistical significance is set at P < 0.05. Receiver operating characteristic analysis identified a cutoff level of 234 pg/mL for IL-8 for survival. Patients were grouped according to their average IL-8 levels relative to this cutoff and stratified into high (H) (n = 133) and low (L) (n = 335) groups. In the L group, regression analysis revealed a significant predictive value of IL-8 to percent of total body surface area burned and incidence of MOF (P < 0.001). In the H group, IL-8 levels were able to predict sepsis (P < 0.002). In the H group, elevated IL-8 was associated with increased inflammatory and acute-phase responses compared with the L group (P < 0.05). High levels of IL-8 correlated with increased MOF, sepsis, and mortality. These data suggest that serum levels of IL-8 may be a valid biomarker for monitoring sepsis, infections, and mortality in burn patients.

Leukocyte infiltration and activation of the NLRP3 inflammasome in white adipose tissue following thermal injury.

ObjectivesSevere thermal injury is associated with extreme and prolonged inflammatory and hypermetabolic responses, resulting in significant catabolism that delays recovery or even leads to multiple organ failure and death. Burned patients exhibit many symptoms of stress-induced diabetes, including hyperglycemia, hyperinsulinemia, and hyperlipidemia. Recently, the nucleotide-binding domain, leucine-rich family (NLR), pyrin-containing 3 (NLRP3) inflammasome has received much attention as the sensor of endogenous “danger signals” and mediator of “sterile inflammation” in type II diabetes. Therefore, we investigated whether the NLRP3 inflammasome is activated in the adipose tissue of burned patients, as we hypothesize that, similar to the scenario observed in chronic diabetes, the cytokines produced by the inflammasome mediate insulin resistance and metabolic dysfunction. DesignProspective cohort study. SettingRoss Tilley Burn Centre & Sunnybrook Research Institute. PatientsWe enrolled 76 patients with burn sizes ranging from 1% to 70% total body surface area. All severely burned patients exhibited burn-induced insulin resistance and hyperglycemia. InterventionsNone. Measurements and Main Results:We examined the adipose tissue of control and burned patients and found, via flow cytometry and gene expression studies, increased infiltration of leukocytes—especially macrophages—and evidence of inflammasome priming and activation. Furthermore, we observed increased levels of interleukin-1&bgr; in the plasma of burned patients when compared to controls. Conclusions:In summary, our study is the first to show activation of the inflammasome in burned humans, and our results provide impetus for further investigation of the role of the inflammasome in burn-induced hypermetabolism and, potentially, developing novel therapies targeting this protein complex for the treatment of stress-induced diabetes.

Effect of Human Wharton’s Jelly Mesenchymal Stem Cell Paracrine Signaling on Keloid Fibroblasts

Keloid scars are abnormal benign fibroproliferative tumors with high recurrence rates and no current efficacious treatment. Accumulating evidence suggests that human umbilical cord Whartons jelly‐derived mesenchymal stem cells (WJ‐MSCs) have antifibrotic properties. Paracrine signaling is considered one of the main underlying mechanisms behind the therapeutic effects of mesenchymal stem cells. However, the paracrine signaling effects of WJ‐MSCs on keloids have not yet been reported. The aim of this study is to investigate paracrine signaling effects of human WJ‐MSCs on keloid fibroblasts in vitro. Human umbilical cords and keloid skin samples were obtained, and WJ‐MSCs and keloid fibroblasts were isolated and cultured. One‐way and two‐way paracrine culture systems between both cell types were investigated. Plasminogen activator inhibitor‐I and transforming growth factor‐β2 (TGF‐β2) transcripts were upregulated in keloid fibroblasts cultured with WJ‐MSC‐conditioned medium (WJ‐MSC‐CM) and cocultured with inserts, while showing lower TGF‐β3 gene expression. Interleukin (IL)‐6, IL‐8, TGF‐β1, and TGF‐β2 protein expression was also enhanced. The WJ‐MSC‐CM‐treated keloid fibroblasts showed higher proliferation rates than their control keloid fibroblasts with no significant change in apoptosis rate or migration ability. In our culture conditions, the indirect application of WJ‐MSCs on keloid fibroblasts may enhance their profibrotic phenotype.

Perturbed mononuclear phagocyte system in severely burned and septic patients

Burn is one of the most common and devastating forms of trauma. Major burn injury disturbs the immune system, resulting in marked alterations in bone marrow hematopoiesis and a progressive suppression of the immune response, which are thought to contribute to increased susceptibility to secondary infections and the development of sepsis. Immunosuppression in patients with severe burn and sepsis leads to high morbidity and mortality in these patients. mononuclear phagocytes system (MPS) is a critical component of the innate immune response and plays key roles in burn immunity. These phagocytes are the first cellular responders to severe burn injury after acute disruption of the skin barrier. They are not only able to internalize and digest bacteria and dead cells and scavenge toxic compounds produced by metabolism, but also able to initiate an adaptive immune response. Severe burn and sepsis profoundly inhibit the functions of dendritic cells, monocytes, and macrophages. Adoptive transfer of MPS or stem cells to patients with severe burn and sepsis that aim to restore MPS function is promising. A better understanding of the roles played by MPS in the pathophysiology of severe burn and sepsis will guarantee a more rational and effective immunotherapy of patients with severe burn and sepsis.

Norepinephrine Inhibits Macrophage Migration by Decreasing CCR2 Expression

Increased incidences of infectious and septic complications during post-burn courses represent the main contributor to burn injury mortality. Sustained increases in catecholamine levels, especially norepinephrine (NE), contribute to immune disturbances in severely burned patients. The precise mechanisms underlying NE-mediated immunoregulation are not fully understood. Here we hypothesize that persistently elevated NE levels are associated with immunodysfunctions. We examined the effects of NE on the phenotype and functions of bone marrow-derived macrophages (BMMs). Whole mouse bone marrow cells were treated in vitro with 40 ng/mL of M-CSF and with 1 x 10-6 M or 1 x 10-8 M of NE or without NE for 7 days; cells were collected and stained with antibodies for CD11b, F4/80, MHC II and the inflammatory CC chemokine receptor 2 (CCR2). We found 1 x 10-6 M of NE inhibited MHC II and CCR2 expression on CD11b+/F4/80+ BMM cells. It also inhibited BMM proliferation by inhibiting CSF-1R expression. On the contrary, 1 x 10-8 M of NE slightly increased both MHC II and CCR2 expression on CD11b+/F4/80+ BMM cells but inhibited CD11b+/F4/80+ BMM proliferation. MCP-1 based migration assay showed that the migration of 1 x 10-6 M of NE-treated BMM toward MCP-1 was significantly decreased compared to BMM without NE treatment. Both 1 x 10-8 M and 1 x 10-6 M of NE enhanced TNF-α production and phagocytosis of FITC-Dextran. Intracellular staining of transcriptional factor MafB showed that 1 x 10-6 M of NE treatment enhanced its expression, whereas 1 x 10-8 M of NE decreased expression. Stimulation with LPS in the last 24-hours of BMM culture further decreased CCR2 and MHC II expression of these BMM, suggesting the synergistic effect of LPS and NE on macrophage. Our results demonstrate that NE regulates macrophage differentiation, proliferation and function, and may play a critical role in the dysfunctional immune response post-burn.

Endoplasmic reticulum stress in adipose tissue augments lipolysis.

The endoplasmic reticulum (ER) is an organelle important for protein synthesis and folding, lipid synthesis and Ca2+ homoeostasis. Consequently, ER stress or dysfunction affects numerous cellular processes and has been implicated as a contributing factor in several pathophysiological conditions. Tunicamycin induces ER stress in various cell types in vitro as well as in vivo. In mice, a hallmark of tunicamycin administration is the development of fatty livers within 24–48 hrs accompanied by hepatic ER stress. We hypothesized that tunicamycin would induce ER stress in adipose tissue that would lead to increased lipolysis and subsequently to fatty infiltration of the liver and hepatomegaly. Our results show that intraperitoneal administration of tunicamycin rapidly induced an ER stress response in adipose tissue that correlated with increased circulating free fatty acids (FFAs) and glycerol along with decreased adipose tissue mass and lipid droplet size. Furthermore, we found that in addition to fatty infiltration of the liver as well as hepatomegaly, lipid accumulation was also present in the heart, skeletal muscle and kidney. To corroborate our findings to a clinical setting, we examined adipose tissue from burned patients where increases in lipolysis and the development of fatty livers have been well documented. We found that burned patients displayed significant ER stress within adipose tissue and that ER stress augments lipolysis in cultured human adipocytes. Our results indicate a possible role for ER stress induced lipolysis in adipose tissue as an underlying mechanism contributing to increases in circulating FFAs and fatty infiltration into other organs.

Anabolic and anticatabolic agents in critical care

Purpose of reviewA complex network of hormones and other effectors characterize the hypermetabolic response in critical illness; these mediators work together to induce numerous pathophysiologic alterations. Increased incidence of infection, multiorgan failure, long-term debilitation, delays in rehabilitation, and death result from an inability to meet the prohibitively elevated protein and energy requirements, which occur during illness and can persist for several years. Pharmacologic interventions have been successfully utilized to attenuate particular aspects of the hypermetabolic response; these modalities are a component of managing critically ill patients – including those patients with severe burns. Here, we review recent advances in pharmacologically attenuating the hypermetabolic and catabolic responses. Recent findingsPropranolol, a nonspecific &bgr;-adrenergic receptor antagonist, is one of the most widely used anticatabolic therapies. Oxandrolone, testosterone, and intensive insulin therapy represent anabolic pharmacological strategies. Promising therapies, such as metformin, glucagon-like peptide 1, peroxisome proliferator-activated receptor agonists, are currently being investigated. SummaryProfound metabolic derangements occur in critically ill patients; this hypermetabolic response is a major contributor to adverse outcomes. Despite the pharmacological therapies currently available to counteract this devastating cascade, future studies are warranted to explore new multimodality agents that will counteract these effects while maintaining glycemic control and preventing unfavorable complications.

Keloids: what do we know and what do we do next?

I t is believed that the knowledge of excessive scarring and keloids as a pathologic consequence of cutaneous injury was first described in approximately 1700 BCE as outlined in the Edwin Smith Papyrus. Keloids represent a pathologic response to dermal injuries resulting in firm, rubbery tumors with a shiny surface appearance that grow beyond initial wound boundaries. Keloid scarring is unique to human beings, and it occurs predominantly on the chest, back, shoulders, and earlobes, whereas it rarely occurs on the soles or palms. One plausible explanation stems from the fact that humans have different sebaceous glands than other mammals and that these higher risk areas of the human body may have higher concentrations of sebaceous glands. The so-called ‘‘sebum hypothesis’’ proposes that the sebum released by the sebaceous glands onto the skin surface may come into contact with T-cells after cutaneous injury and cause an inflammatory reaction that leads to keloid progression, but more in-depth studies to prove this hypothesis are warranted. Fibroblasts derived from keloids are marked by an overproduction of fibronectin and type I procollagen, a high expression of transforming growth factor (TGF)-