Recombinant human thrombin: safety and immunogenicity in pediatric burn wound excision

BACKGROUND

Previous studies of recombinant human thrombin (rThrombin) enrolled adult and adolescent patients. This phase 4, open-label, single-group study was conducted in pediatric patients undergoing synchronous burn wound excision and skin grafting to provide information regarding the safety and immunogenicity of rThrombin (primary and secondary endpoints) in this population.

METHODS

Topical rThrombin was applied as a hemostatic aid during a surgical procedure (day 1). Adverse events and clinical laboratory abnormalities were recorded during the study. Immunogenicity samples were collected on days 1 and 29 (study end). Study results were summarized with descriptive statistics.

RESULTS

Thirty patients enrolled and 28 completed the study. Mean age was 6.9 years (range, 0.9-17.8 years); 40.0% of patients were girls. Flame and scald were the most common burn types (33.3% each, n = 10/30). Mean graft size was 3.6% total body surface area. Procedural pain (50.0% patients), pruritus (43.3%), and anemia (30.0%) were the most commonly reported adverse events. All adverse events and clinical laboratory abnormalities were considered unrelated to treatment. No patients developed anti-rThrombin product antibodies at day 29.

CONCLUSIONS

In pediatric patients undergoing burn wound excision and skin grafting, rThrombin was well tolerated and did not lead to the formation of anti-rThrombin product antibodies.

Identification of a unique library of complex, but ordered, arrays of repetitive elements in the human genome and implication of their potential involvement in pathobiology

Approximately 2% of the human genome is reported to be occupied by genes. Various forms of repetitive elements (REs), both characterized and uncharacterized, are presumed to make up the vast majority of the rest of the genomes of human and other species. In conjunction with a comprehensive annotation of genes, information regarding components of genome biology, such as gene polymorphisms, non-coding RNAs, and certain REs, is found in human genome databases. However, the genome-wide profile of unique RE arrangements formed by different groups of REs has not been fully characterized yet. In this study, the entire human genome was subjected to an unbiased RE survey to establish a whole-genome profile of REs and their arrangements. Due to the limitation in query size within the bl2seq alignment program (National Center for Biotechnology Information [NCBI]) utilized for the RE survey, the entire NCBI reference human genome was fragmented into 6206 units of 0.5M nucleotides. A number of RE arrangements with varying complexities and patterns were identified throughout the genome. Each chromosome had unique profiles of RE arrangements and density, and high levels of RE density were measured near the centromere regions. Subsequently, 175 complex RE arrangements, which were selected throughout the genome, were subjected to a comparison analysis using five different human genome sequences. Interestingly, three of the five human genome databases shared the exactly same arrangement patterns and sequences for all 175 RE arrangement regions (a total of 12,765,625 nucleotides). The findings from this study demonstrate that a substantial fraction of REs in the human genome are clustered into various forms of ordered structures. Further investigations are needed to examine whether some of these ordered RE arrangements contribute to the human pathobiology as a functional genome unit.

Prevalent de novo somatic mutations in superantigen genes of mouse mammary tumor viruses in the genome of C57BL/6J mice and its potential implication in the immune system

Background

Superantigens (SAgs) of mouse mammary tumor viruses (MMTVs) play a crucial role in T cell selection in the thymus in a T cell receptor (TCR) Vβ-specific manner and SAgs presented by B cells activate T cells in the periphery. The peripheral T cell repertoire is dynamically shaped by the steady induction of T cell tolerance against self antigens throughout the lifespan. We hypothesize that de novo somatic mutation of endogenous MMTV SAgs contributes to the modulation of the peripheral T cell repertoire.

Results

SAg coding sequences were cloned from the genomic DNAs and/or cDNAs of various tissues of female C57BL/6J mice. A total of 68 unique SAg sequences (54 translated sequences) were identified from the genomic DNAs of liver, lungs, and bone marrow, which are presumed to harbor only three endogenous MMTV loci (Mtv-8, Mtv-9, and Mtv-17). Similarly, 69 unique SAg sequences (58 translated sequences) were cloned from the cDNAs of 18 different tissues. Examination of putative TCR Vβ specificity suggested that some of the SAg isoforms identified in this study have Vβ specificities different from the reference SAgs of Mtv-8, Mtv-9, or Mtv-17.

Conclusion

The pool of diverse SAg isoforms, generated by de novo somatic mutation, may play a role in the shaping of the peripheral T cell repertoire including the autoimmune T cell population.

Lipopolysaccharide stress induces cell-type specific production of murine leukemia virus type-endogenous retroviral virions in primary lymphoid cells

Some murine-endogenous retroviruses, making up ∼10 % of the mouse genome, are induced during the course of experimental sepsis in which lipopolysaccharide (LPS), a pathogenic component of gram-negative bacteria, often plays a critical role. In this study, we investigated whether LPS stress induces the production of murine leukemia virus type-endogenous retrovirus (MuLV-ERV) virions in primary lymphoid cells. LPS treatment of cells (single-cell suspensions and sorted B- and T-cells) isolated from seven lymphoid organs of C57BL/6J mice resulted in a differential increase in the production of MuLV-ERV virions in most cells examined. Interestingly, among the 34 unique MuLV-ERV U3 sequences cloned from the viral genomic RNAs, the nuclear respiratory factor 1 (transcription factor) element was present only in the 20 U3 sequences that were derived from the LPS-induced MuLV-ERV U3 bands. Using the U3 sequences as a probe, 55 putative MuLV-ERV loci were mapped onto the C57BL/6J mouse genome and 15 of them retained full coding potential. Furthermore, one full-length recombinant MuLV-ERV originating from a locus on chromosome 13 was determined to be responsive to LPS stress. The findings from this study suggest that LPS stress differentially activates MuLV-ERV virion production in lymphoid organs in a cell type- and MuLV-ERV-specific manner. Further investigation is needed to define the role of MuLV-ERVs in the LPS signalling pathway(s) in general, as well as in the pathogenesis of sepsis.

Topical antimicrobial agents for burn wounds

Because burns destroy the barrier against invading bacteria, topical antimicrobial agents have been developed to minimize the proliferation of bacteria and other microorganisms. The topical treatment depends on the depth of burns. The goal for superficial burns is to optimize re-epithelialization. For deep burns, topical antimicrobial agents should be used to minimize microbial growth until the wound is grafted. This article introduces a strategy for the rational use of these agents.

Burn resuscitation: the results of the ISBI/ABA survey

INTRODUCTION

There are valid concerns that burn shock resuscitation is inadequate; a tendency to over-resuscitate the patient seems to exist which may increase complications such as compartment syndrome. The purpose of this study was to survey members of the ISBI and ABA to determine current practices of burn resuscitation.

METHODS

A survey asking for practices of burn shock resuscitation was provided to all participants of a recent ABA meeting. Around the same time, the survey was sent to all members of the ISBI through the internet. The results of the 101 respondents (ABA--59, ISBI--42, approximately a 15% response rate) are described.

RESULTS

Surveys were returned from all the continents except Africa. Respondents included directors (48%), staff physicians (19%), nurses (23%) and others. Most programs admitted adults (87%) and children (75%) with a mean of 289 admissions per year. The cut off to initiate resuscitation was 15% TBSA and most preferred peripheral IVs (70%) and central lines (47.5%). The Parkland formula was preferred (69.3%) while others were used: Brooke--6.9%, Galveston--8.9%, Warden--5.9%, and colloid 11.9%. Lactated Ringer's (LR) was the preferred solution (91.9%), followed by normal saline--5%, hypertonic saline--4%, albumin--20.8%, FFP--13.9%, and LR/NaHCO(3)--12.9%. Approximately half (49.5%) added colloid before 24h. Urine output is the major indicator of success (94.9%) while 22.7% use other monitors. Most (88.8%) feel their protocols work well, with 69.8% feel that it provides the right amount of fluid (24%--too much, 7%--too little). Despite this feeling, they still feel that they give more fluid than the formula in 55.1%, less than formula in 12.4% and the right amount in 32.6%. Approximately 1/3 use an oral resuscitation formula and 81.8% feel that an oral formula works for burns<15% TBSA.

CONCLUSION

Large variations exist in resuscitation protocols but the Parkland formula using LR is still the dominant method. Most feel that their resuscitation protocol works well.

Stress-mediated increases in systemic and local epinephrine impair skin wound healing: potential new indication for beta blockers

BACKGROUND

Stress, both acute and chronic, can impair cutaneous wound repair, which has previously been mechanistically ascribed to stress-induced elevations of cortisol. Here we aimed to examine an alternate explanation that the stress-induced hormone epinephrine directly impairs keratinocyte motility and wound re-epithelialization. Burn wounds are examined as a prototype of a high-stress, high-epinephrine, wound environment. Because keratinocytes express the beta2-adrenergic receptor (beta2AR), another study objective was to determine whether beta2AR antagonists could block epinephrine effects on healing and improve wound repair.

METHODS AND FINDINGS

Migratory rates of normal human keratinocytes exposed to physiologically relevant levels of epinephrine were measured. To determine the role of the receptor, keratinocytes derived from animals in which the beta2AR had been genetically deleted were similarly examined. The rate of healing of burn wounds generated in excised human skin in high and low epinephrine environments was measured. We utilized an in vivo burn wound model in animals with implanted pumps to deliver beta2AR active drugs to study how these alter healing in vivo. Immunocytochemistry and immunoblotting were used to examine the up-regulation of catecholamine synthetic enzymes in burned tissue, and immunoassay for epinephrine determined the levels of this catecholamine in affected tissue and in the circulation. When epinephrine levels in the culture medium are elevated to the range found in burn-stressed animals, the migratory rate of both cultured human and murine keratinocytes is impaired (reduced by 76%, 95% confidence interval [CI] 56%-95% in humans, p < 0.001, and by 36%, 95% CI 24%-49% in mice, p = 0.001), and wound re-epithelialization in explanted burned human skin is delayed (by 23%, 95% CI 10%-36%, p = 0.001), as compared to cells or tissues incubated in medium without added epinephrine. This impairment is reversed by beta2AR antagonists, is absent in murine keratinocytes that are genetically depleted of the beta2AR, and is reproduced by incubation of keratinocytes with other beta2AR-specific agonists. Activation of the beta2AR in cultured keratinocytes signals the down-regulation of the AKT pathway, accompanied by a stabilization of the actin cytoskeleton and an increase in focal adhesion formation, resulting in a nonmigratory phenotype. Burn wound injury in excised human skin also rapidly up-regulates the intra-epithelial expression of the epinephrine synthesizing enzyme phenylethanolamine-N-methyltransferase, and tissue levels of epinephrine rise dramatically (15-fold) in the burn wounded tissue (values of epinephrine expressed as pg/ug protein +/- standard error of the mean: unburned control, 0.6 +/- 0.36; immediately postburn, 9.6 +/- 1.58; 2 h postburn, 3.1 +/- 1.08; 24 h post-burn, 6.7 +/- 0.94). Finally, using an animal burn wound model (20% body surface in mice), we found that systemic treatment with betaAR antagonists results in a significant increase (44%, 95% CI 27%-61%, p < 0.00000001) in the rate of burn wound re-epithelialization.

CONCLUSIONS

This work demonstrates an alternate pathway by which stress can impair healing: by stress-induced elevation of epinephrine levels resulting in activation of the keratinocyte beta2AR and the impairment of cell motility and wound re-epithelialization. Furthermore, since the burn wound locally generates epinephrine in response to wounding, epinephrine levels are locally, as well as systemically, elevated, and wound healing is impacted by these dual mechanisms. Treatment with beta adrenergic antagonists significantly improves the rate of burn wound re-epithelialization. This work suggests that specific beta2AR antagonists may be apt, near-term translational therapeutic targets for enhancing burn wound healing, and may provide a novel, low-cost, safe approach to improving skin wound repair in the stressed individual.

Genome-wide expression profiles of endogenous retroviruses in lymphoid tissues and their biological properties

Endogenous retroviruses (ERVs) constitute approximately 8-10% of the human and mouse genome. Some autoimmune diseases are attributed to the altered expression of ERVs. In this study, we examined the ERV expression profiles in lymphoid tissues and analyzed their biological properties. Tissues (spleen, thymus, and lymph nodes [axillary, inguinal, and mesenteric]) from C57BL/6J mice were analyzed for differential murine ERV (MuERV) expression by RT-PCR examination of polymorphic U3 sequences. Each tissue had a unique profile of MuERV expression. A genomic map identifying 60 putative MuERVs was established using 22 unique U3s as probes and their biological properties (primer binding site, coding potential, transcription regulatory element, tropism, recombination event, and integration age) were characterized. Interestingly, 12 putative MuERVs retained intact coding potentials for all three polypeptides essential for virus assembly and replication. We suggest that MuERV expression is differentially regulated in conjunction with the transcriptional environment of individual lymphoid tissues.

Comparison of fibrin sealant and staples for attaching split-thickness autologous sheet grafts in patients with deep partial- or full-thickness burn wounds: a phase 1/2 clinical study

We undertook a multicenter, randomized, controlled, phase 1/2 clinical study to investigate the safety and efficacy of a fibrin sealant containing 4 IU/ml thrombin (FS 4IU) for the attachment of autologous sheet grafts in patients with deep partial-thickness or full-thickness burn wounds. Fibrin sealant (FS 4IU) was compared with staples for adherence of sheet grafts in 40 patients. Patients had to have burn wounds measuring 40% TBSA or less with two comparable test sites measuring between 1% and 4% TBSA each. Wound beds were prepared before treatment assignment, which was randomized. Percent area of hematoma/seroma at Day 1 (P = .0138) and questionable viability at Day 5 (P = .0182) were significantly less for FS 4IU-treated sites. Median percent area of graft survival on Day 14 was 100% for both treatments (P = .3525). The percentage of completely closed sites generally was greater for FS 4IU-sites on Days 5 to 91; the maximum difference occurred at Day 28 (79.5% vs 59%; P = .0215). The safety profile of FS 4IU was excellent as indicated by the lack of any related serious adverse experiences. These findings indicate that FS 4IU is safe and effective for fixation of skin grafts, with outcomes similar to or better than staple fixation. The data suggest that FS 4IU is a promising candidate for further clinical studies focusing on skin graft adhesion and burn wound healing.

Consequences of excessive scar formation: dealing with the problem and aiming for the future

Scarring is the major hindrance to the healing of all tissues. Unfortunately, our knowledge about the factors that regulate scarring is quite limited. Even worse is the fact that there have been few gains in the treatment of pathologic scarring. This review sets the stage for the supplement on scar formation that provides the latest knowledge on the pathophysiology and treatment of scar formation.

Central venous catheter infections in burn patients with scheduled catheter exchange and replacement

INTRODUCTION

Consensus in the general critical care patient population is that routine central venous catheter change is not necessary, and that central lines should not be rewired in the setting of possible infection. This concept has not carried over into the burn realm. In burn patients the rewiring of lines may lead to increased infection rates.

METHODS

Fifty-nine consecutive critically ill burn patients requiring central line placement were included: 277 central lines and 1691 catheter days. Standard care protocol was followed in all patients, with lines being placed initially by new site insertion, changed over a guidewire on day 6, and moved to a new site on day 12. New sites were used for all suspected or documented line infections. All other care was the same. New site placements were compared to guidewire exchanges. Pediatric patients (under the age of 18) were considered with and separate from adults.

RESULTS

There was no difference in the incidence of catheter-related bloodstream infections (CRBSI) between lines placed by new site access (15.4/1000 catheter days) or by guidewire exchange (15.4/1000). Considering the 979 pediatric line days, there was a distinct difference, with new sites having 16.6/1000, and rewires 25.2/1000. Adults revealed the opposite trend, rewires having no occurrences of CRBSI, and new sites 13.7/1000. Children had a higher rate of CRBSI, 19.4/1000 days, compared to adults at 9.8/1000 days. Children had larger burns (P < 0.0001), more femoral lines (P = 0.0003), and lines closer to the burn wound (P = 0.001).

CONCLUSIONS

In pediatric patients guidewire exchange increased the incidence of infection. This was not noted in adult patients. The utility of guidewire exchange needs to be further investigated in adults, although this data would imply that it may be safe to use routine rewire of lines in adult burn patients. Pediatric patients require an increase in vigilance to minimize CRBSI. Central venous catheters should be removed as soon as not needed and routine change of lines in burn patients needs continued evaluation.