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Hundeshagen G, Blears E, Mertin V, Day AG, Palackic A, Tapking C, Haug V, Kneser U, Bliesener B, Panayi AC, Aballay A, Depret F, Stoppe C, Heyland DK. Administration and effects of beta blockers and oxandrolone in severely burned adults: a post hoc analysis of the RE-ENERGIZE trial. BURNS & TRAUMA 2024; 12:tkad063. [PMID: 38650969 PMCID: PMC11033841 DOI: 10.1093/burnst/tkad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/15/2023] [Accepted: 12/13/2023] [Indexed: 04/25/2024]
Abstract
Background Prospective randomized trials in severely burned children have shown the positive effects of oxandrolone (OX), beta blockers (BB) and a combination of the two (BBOX) on hypermetabolism, catabolism and hyperinflammation short- and long-term post-burn. Although data on severely burned adults are lacking in comparison, BB, OX and BBOX appear to be commonly employed in this patient population. In this study, we perform a secondary analysis of an international prospective randomized trial dataset to provide descriptive evidence regarding the current utilization patterns and potential treatment effects of OX, BB and BBOX. Methods The RE-ENERGIZE (RandomizEd Trial of ENtERal Glutamine to minimIZE Thermal Injury, NCT00985205) trial included 1200 adult patients with severe burns. We stratified patients according to their receipt of OX, BB, BBOX or none of these drugs (None) during acute hospitalization. Descriptive statistics describe the details of drug therapy and unadjusted analyses identify predisposing factors for drug use per group. Association between OX, BB and BBOX and clinical outcomes such as time to discharge alive and 6-month mortality were modeled using adjusted multivariable Cox regressions. Results More than half of all patients in the trial received either OX (n = 138), BB (n = 293) or BBOX (n = 282), as opposed to None (n = 487, 40.6%). Per study site and geographical region, use of OX, BB and BBOX was highly variable. Predisposing factors for the use of OX, BB and BBOX included larger total body surface area (TBSA) burned, higher acute physiology and chronic health evaluation (APACHE) II scores on admission and younger patient age. After adjustment for multiple covariates, the use of OX was associated with a longer time to discharge alive [hazard ratio (HR) 0.62, confidence interval (CI) (0.47-0.82) per 100% increase, p = 0.001]. A higher proportion of days on BB was associated with lower in-hospital-mortality (HR: 0.5, CI 0.28-0.87, p = 0.015) and 6-month mortality (HR: 0.44, CI 0.24-0.82, p = 0.01). Conclusions The use of OX, BB and BBOX is common within the adult burn patient population, with its use varying considerably across sites worldwide. Our findings found mixed associations between outcomes and the use of BB and OX in adult burn patients, with lower acute and 6-month-mortality with BB and longer times to discharge with OX. Further research into these pharmacological modulators of the pathophysiological response to severe burn injury is indicated.
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Affiliation(s)
- Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Elisabeth Blears
- Department of Plastic Surgery, Bayview Medical Center, Johns Hopkins University, 4940 Eastern Ave, Baltimore 21224, MD, USA
| | - Viktoria Mertin
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Andrew G Day
- Kingston General Health Research Institute, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, K7L 2V7, Canada
| | - Alen Palackic
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Björn Bliesener
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Adriana C Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ariel Aballay
- Department of Plastic Surgery, Bayview Medical Center, Johns Hopkins University, 4940 Eastern Ave, Baltimore 21224, MD, USA
| | - Francois Depret
- Department of Anaesthesiology, Intensive Care Medicine and Burn center, Saint-Louis Hospital, 1 avenue Claude-Vellefaux, 75010, Asistance Publique Hôpitaux de Paris, Paris Cité University, France
| | - Christian Stoppe
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, Germany
- University Hospital, Würzburg, Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080 Würzburg, Germany
- Departments of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Augustenburger Platz 1 | 13353, Berlin, Germany
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen’s University, 76 Stuart Street, Kingston, K7L 2V7 Ontario, Canada
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Radzikowska-Büchner E, Łopuszyńska I, Flieger W, Tobiasz M, Maciejewski R, Flieger J. An Overview of Recent Developments in the Management of Burn Injuries. Int J Mol Sci 2023; 24:16357. [PMID: 38003548 PMCID: PMC10671630 DOI: 10.3390/ijms242216357] [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: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.
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Affiliation(s)
- Elżbieta Radzikowska-Büchner
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Inga Łopuszyńska
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Wojciech Flieger
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4 Street, 20-090 Lublin, Poland;
| | - Michał Tobiasz
- Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Krasnystawska 52 Street, 21-010 Łęczna, Poland;
| | - Ryszard Maciejewski
- Faculty of Medicine, University of Warsaw, Żwirki i Wigury 101 Street, 02-089 Warszawa, Poland;
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A Street, 20-093 Lublin, Poland
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Jalkh APC, Eastmond AK, Shetty C, Rizvi SMHA, Sharaf J, Williams KAD, Tariq M, Acharekar MV, Guerrero Saldivia SE, Unnikrishnan SN, Chavarria YY, Akindele AO, Hamid P. Oxandrolone Efficacy in Wound Healing in Burned and Decubitus Ulcer Patients: A Systematic Review. Cureus 2022; 14:e28079. [PMID: 36127967 PMCID: PMC9477554 DOI: 10.7759/cureus.28079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/15/2022] [Indexed: 11/18/2022] Open
Abstract
Wounds with delayed or impaired healing represent a considerable challenge in medical practice. These patients develop a sustained hypermetabolic and catabolic state, directly impacting the wound healing process. The use of oxandrolone has been studied to control this metabolic imbalance and protect lean body mass as a beneficial resource in wound healing. This systematic review aims to analyze previously conducted randomized controlled trials to evaluate the evidence of the applicability of oxandrolone therapy. We compared its use in adult patients with burns and adult patients with pressure ulcers in terms of wound healing and healing time of the skin graft donor site in days. The digital searches were done from March 23-28, 2022, within the databases: Google Scholar, PubMed/MEDLINE, and EBSCO (Elton B. Stephens Company). Data from six studies were analyzed and included in this review. Analysis of the available data demonstrated a significant advantage in skin healing using oxandrolone in adult burn patients as an adjunct. For adult patients with pressure ulcers, the drug showed no benefit on wound healing and skin graft site healing. Importantly, we found only one study evaluating the use of oxandrolone in patients with decubitus ulcers that met our eligibility criteria, and the certainty of the evidence was low. Thus, further prospective randomized studies with larger samples and standard wound care protocols are needed to produce more solid results, allowing more definitive conclusions to be made on this theme.
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4
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Kopel J, Sorensen G, Griswold J. A Reappraisal of Oxandrolone in Burn Management. J Pharm Technol 2022; 38:232-238. [PMID: 35832568 PMCID: PMC9272491 DOI: 10.1177/87551225221091115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Burn injuries remain among the most severe traumatic injuries globally. With the discovery of cortisol, the use of steroids has become an essential therapy for the management of inflammatory and metabolic conditions. Several studies have shown the steroid oxandrolone improves burn injuries through stimulating anabolic and reducing catabolic processes. In this review, we examine the efficacy and applications of oxandrolone with regard to burn management and treatment. Data Sources: A literature search was performed using the PubMed database from January 1990 to May 2020 to identify articles on oxandrolone and burn management. A total of 18 studies were included in our review. Study Selection and Criteria: The keywords used in our search strategy for PubMed included “oxandrolone” and “burns.” Data Synthesis: The main benefit of oxandrolone is the improved long-term lean body, protein, and bone mineral mass of burn patients. In addition, 3 separate meta-analyses showed oxandrolone shortened length of hospital stay, donor-site healing time, reduced weight loss, and net protein loss. However, oxandrolone therapy did not affect mortality, infection, or liver function. Conclusion: Oxandrolone remains an effective therapy for reducing the hypermetabolic response and comorbidities from burn injuries. Future clinical trials are needed using larger sample sizes and long-term follow-up to determine whether oxandrolone in the context of rehabilitation programs can reduce mortality, lower treatment costs, and improve function outcomes among burn patients.
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Affiliation(s)
- Jonathan Kopel
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Grant Sorensen
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Gala K, Desai V, Liu N, Omer EM, McClave SA. How to Increase Muscle Mass in Critically Ill Patients: Lessons Learned from Athletes and Bodybuilders. Curr Nutr Rep 2021; 9:369-380. [PMID: 33098051 DOI: 10.1007/s13668-020-00334-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Decades of research on nutrition and exercise on athletes and bodybuilders has yielded various strategies to promote anabolism and improve muscle health and growth. We reviewed these interventions in the context of muscle loss in critically ill patients. RECENT FINDINGS For critically ill patients, ensuring optimum protein intake is important, potentially using a whey-containing source and supplemented with vitamin D and leucine. Agents like hydroxyl β-methylbutyrate and creatine can be used to promote muscle synthesis. Polyunsaturated fatty acids stimulate muscle production as well as have anti-inflammatory properties that may be useful in critical illness. Adjuncts like oxandralone promote anabolism. Resistance training has shown mixed results in the ICU setting but needs to be explored further with specific outcomes. Critically ill patients suffer from severe proteolysis during hospitalization as well as persistent inflammation, immunosuppression, and catabolism syndrome after discharge. High protein supplementation, ergogenic aids, anti-inflammatories, and anabolic adjuncts have shown potential in alleviating muscle loss and should be used in intensive care units to optimize patient recovery.
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Affiliation(s)
- Khushboo Gala
- Department of Internal Medicine, University of Louisville, 550 S Jackson Street, 3rd Floor, Ambulatory Care Building, Louisville, KY, 40202, USA.
| | - Viral Desai
- Department of Internal Medicine, University of Louisville, 550 S Jackson Street, 3rd Floor, Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Nanlong Liu
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Endashaw M Omer
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Stephen A McClave
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
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Ring J, Heinelt M, Sharma S, Letourneau S, Jeschke MG. Oxandrolone in the Treatment of Burn Injuries: A Systematic Review and Meta-analysis. J Burn Care Res 2021; 41:190-199. [PMID: 31504621 DOI: 10.1093/jbcr/irz155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Severe burns induce a profound hypermetabolic response, leading to a prolonged state of catabolism associated with organ dysfunction and delay of wound healing. Oxandrolone, a synthetic testosterone analog, may alleviate the hypermetabolic catabolic state thereby decreasing associated morbidity. However, current literature has reported mixed outcomes on complications following Oxandrolone use, specifically liver and lung function. We conducted an updated systematic review and meta-analysis studying the effects of Oxandrolone on mortality, length of hospital stay, progressive liver dysfunction, and nine secondary outcomes. We searched Pubmed, EMBASE, Web of Science, CINAHL, and Cochrane Databases of Systematic Reviews and Randomized Controlled Trials. Thirty-one randomized control trials and observational studies were included. Basic science and animal studies were excluded. Only studies comparing Oxandrolone to standard of care, or placebo, were included. Oxandrolone did not affect rates of mortality (relative risk [RR]: 0.72; 95% confidence interval [CI]: 0.47 to 1.08; P = .11) or progressive liver dysfunction (RR: 1.04; 95% CI: 0.59 to 1.85; P = .88), but did decrease length of stay in hospital. Oxandrolone significantly increased weight regain, bone mineral density, percent lean body mass, and decreased wound healing time for donor graft sites. Oxandrolone did not change the incidence of transient liver dysfunction or mechanical ventilation requirements. There is evidence to suggest that Oxandrolone is a beneficial adjunct to the acute care of burn patients; shortening hospital stays and improving several growth and wound healing parameters. It does not appear that Oxandrolone increases the risk of progressive or transient liver injury, although monitoring liver enzymes is recommended.
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Affiliation(s)
- Justine Ring
- School of Medicine, Queen's University, Kingston, Ontario, Canada.,Undergraduate Medical Education, Kingston, Ontario, Canada
| | - Martina Heinelt
- School of Medicine, Queen's University, Kingston, Ontario, Canada.,Undergraduate Medical Education, Kingston, Ontario, Canada
| | - Shubham Sharma
- School of Medicine, Queen's University, Kingston, Ontario, Canada.,Undergraduate Medical Education, Kingston, Ontario, Canada
| | - Sasha Letourneau
- School of Medicine, Queen's University, Kingston, Ontario, Canada.,Undergraduate Medical Education, Kingston, Ontario, Canada
| | - Marc G Jeschke
- Biological Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Ross Tilley Burn Centre, Sunnybrook Hospital, Toronto, Ontario, Canada.,Department of Surgery, Division of Plastic Surgery and Department of Immunology, University of Toronto, Ontario, Canada
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Shi H, Cheer K, Simanainen U, Lesmana B, Ma D, Hew JJ, Parungao RJ, Li Z, Cooper MS, Handelsman DJ, Maitz PK, Wang Y. The contradictory role of androgens in cutaneous and major burn wound healing. BURNS & TRAUMA 2021; 9:tkaa046. [PMID: 33928173 PMCID: PMC8058007 DOI: 10.1093/burnst/tkaa046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/31/2020] [Indexed: 01/25/2023]
Abstract
Wound healing is a complex process involving four overlapping phases: haemostasis, inflammation, cell recruitment and matrix remodeling. In mouse models, surgical, pharmacological and genetic approaches targeting androgen actions in skin have shown that androgens increase interleukin-6 and tumor necrosis factor-α production and reduce wound re-epithelization and matrix deposition, retarding cutaneous wound healing. Similarly, clinical studies have shown that cutaneous wound healing is slower in men compared to women. However, in major burn injury, which triggers not only local wound-healing processes but also systemic hypermetabolism, the role of androgens is poorly understood. Recent studies have claimed that a synthetic androgen, oxandrolone, increases protein synthesis, improves lean body mass and shortens length of hospital stay. However, the possible mechanisms by which oxandrolone regulates major burn injury have not been reported. In this review, we summarize the current findings on the roles of androgens in cutaneous and major burn wound healing, as well as androgens as a potential therapeutic treatment option for patients with major burn injuries.
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Affiliation(s)
- Huaikai Shi
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Kenny Cheer
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Ulla Simanainen
- Andrology, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Brian Lesmana
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Duncan Ma
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Jonathan J Hew
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Roxanne J Parungao
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Zhe Li
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia.,Burns and Reconstructive Surgery Unit, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Mark S Cooper
- Adrenal Steroid Laboratory, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - David J Handelsman
- Andrology, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Peter K Maitz
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia.,Burns and Reconstructive Surgery Unit, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
| | - Yiwei Wang
- Burns Research Group, ANZAC Research Institute, University of Sydney, Concord Hospital, Gate, 3 Hospital road, Concord, NSW 2139, Australia
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Smalley MC, Olivi J, Causa KA, Pathak M, Austin CL, Thompson SJ. Post-burn temporal dynamics of blood plasma histamine during the initial 6 days from injury. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2020; 10:68-75. [PMID: 32714630 PMCID: PMC7364418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/08/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Burn injuries can induce distinct, systemic inflammatory and immunological responses which occur acutely up to 72 hrs or chronically after 24 hrs. Previously published literature showed a dramatic increase in whole blood histamine values within 24 hrs of a thermal injury. However, the data is limited due to infrequent monitoring, resulting in statistically insignificant findings. The goal of this study was to determine localized histamine fluctuations for 6 consecutive days in a successive group of patients admitted immediately after a burn. METHOD Using blood plasma from 7 patients (average total burn surface area 24.7%), we examined histamine within an average 4.1 (± 0.3) hrs from burn injury, by means of a monoclonal-based competitive binding enzyme immunoassay. Histamine values were normalized to patient baselines prior to determining overall averages. Patient vitals and electrolyte values were extracted from the electronic health record. A two-tailed student t-test was used to compare values with p-value ≤ 0.05 considered statistically significant using statistical software R. RESULTS The histamine values were significantly higher than patient baseline values up to 48 hrs (p-value ≤ 0.05), followed by a return to baseline values from approximately 3 days post-injury. Heart rates were within normal values up until 72 hrs. Hematocrit and hemoglobin began within normal values, dropped at 72 hrs, and reduced significantly from 96 hrs post-injury. The electrolyte calcium began within the normal range, and then was significantly less than the baseline value from 96 hrs post-injury. CONCLUSIONS We have shown a distinct and significant increase in histamine plasma levels within 48 hrs after a moderate burn injury.
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Affiliation(s)
- Miles C Smalley
- Mercy Hospital-Springfield, Burn ICU1235 E Cherokee, Springfield, MO 65804, USA
| | - Joe Olivi
- Northwest Physicians, Surgical Services601 W Maple Ave, Springdale, AR 72764, USA
| | - Krisi A Causa
- Mercy Hospital-Springfield, General & Trauma Surgery1965 S Fremont, Springfield, MO 65804, USA
| | - Manoj Pathak
- Murray State University, Department of Mathematics and Statistics102 Curris Center, Murray, KY 42071, USA
| | - Cindy L Austin
- Mercy Hospital-Springfield, Trauma & Burn Research1235 E Cherokee, Springfield, MO 65804, USA
| | - Simon J Thompson
- Mercy Hospital-Springfield, Trauma & Burn Research1235 E Cherokee, Springfield, MO 65804, USA
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Linakis MW, Rower JE, Sorenson S, Reilly CA, Lambert LM, Williams RV, Burch PT. Stability of Oxandrolone in Medium-Chain Triglyceride Oil and Pharmacokinetics Following Buccal Administration of the Extemporaneous Formulation in Neonates and Adults. J Pediatr Pharmacol Ther 2020; 25:220-227. [DOI: 10.5863/1551-6776-25.3.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Growth failure following surgical palliation of complex congenital heart defects (CHDs) is a prognosticator of poor outcomes. Many strategies for improving weight gain have been implemented in this population, with limited success. We recently described the potential of the anabolic steroid oxandrolone to improve weight gain following surgical repair of CHD when administered via a medium-chain triglyceride (MCT) oil suspension to the buccal mucosa. The current study evaluates the stability of oxandrolone in the MCT oil formulation, as well as the pharmacokinetics of oxandrolone when administered via buccal mucosa in both neonates and adults.METHODS Stability was assessed by long-term storage of the preparation 1) at ambient conditions and 2) under photodegradative conditions for 3 days. Neonatal pharmacokinetic parameters were determined in a cohort of neonates following surgical CHD repair, whereas adult pharmacokinetics parameters were collected as part of a prospective study to evaluate the relative bioavailability of the oxandrolone in MCT oil formulation.RESULTS We found that oxandrolone was stable in the MCT oil formulation for at least 1 month, although exposure to light hastened drug degradation. Both neonatal and adult oxandrolone pharmacokinetics were variable; however, oxandrolone in MCT oil was relatively well absorbed through the buccal mucosa (mean bioavailability = 62.5%).CONCLUSIONS These data suggest that the variability in oxandrolone exposures is inherent to the drug, and not the formulation or route of administration. Combined, these data support further study of this novel oxandrolone in MCT oil formulation and its impact on growth following complex surgical repair of CHD in neonates.
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Polychronopoulou E, Herndon DN, Porter C. The Long-Term Impact of Severe Burn Trauma on Musculoskeletal Health. J Burn Care Res 2020; 39:869-880. [PMID: 30010999 DOI: 10.1093/jbcr/iry035] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/15/2018] [Indexed: 12/13/2022]
Abstract
Severe burn injury causes a profound stress response that leads to muscle and bone cachexia. Evidence suggests that these deficits persist for several months or even years after injury and are associated with growth delay, increased incidence of fractures, and increased hospital admissions for musculoskeletal disorders. Thus, there is an overwhelming need to determine the optimal acute and rehabilitative strategies to mitigate these deficits and improve quality of life for burn survivors. To date, there is limited research on the long-term impact of cachexia on functional performance and overall health, as well as on the lasting impact of pharmacological, nutritional, and exercise interventions. The aim of this review is to emphasize the long-term consequences of musculoskeletal cachexia and determine the best evidence-based strategies to attenuate it. We also underline important knowledge gaps that need to be addressed in order to improve care of burn survivors.
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Affiliation(s)
- Efstathia Polychronopoulou
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas.,Shriners Hospitals for Children - Galveston, Galveston, Texas
| | - David N Herndon
- Shriners Hospitals for Children - Galveston, Galveston, Texas.,Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Craig Porter
- Shriners Hospitals for Children - Galveston, Galveston, Texas.,Department of Surgery, University of Texas Medical Branch, Galveston, Texas
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11
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Gus EI, Shahrokhi S, Jeschke MG. Anabolic and anticatabolic agents used in burn care: What is known and what is yet to be learned. Burns 2019; 46:19-32. [PMID: 31852612 DOI: 10.1016/j.burns.2018.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/17/2018] [Accepted: 03/18/2018] [Indexed: 12/15/2022]
Abstract
Major thermal injury induces profound metabolic derangements secondary to an inflammatory "stress-induced" hormonal environment. Several pharmacological interventions have been tested in an effort to halt the hypermetabolic response to severe burns. Insulin, insulin growth factor 1, insulin growth factor binding protein 3, metformin, human growth hormone, thyroid hormones, testosterone, oxandrolone, and propranolol, among others, have been proposed to have anabolic or anticatabolic effects. The aim of this broad analysis of pharmacological interventions was to raise awareness of treatment options and to help establishing directions for future clinical research efforts. A PubMed search was conducted on the anabolic and anticatabolic agents used in burn care. One hundred and thirty-five human studies published between 1999 and 2017 were included in this review. The pharmacological properties, rationale for the treatments, efficacy considerations and side effect profiles are summarized in the article. Many of the drugs tested for investigational purposes in the severely thermally injured are not yet gold-standard therapies in spite of their potential benefit. Propranolol and oxandrolone have shown great promise but further evidence is still needed to clarify their potential use for anabolic and anticatabolic purposes.
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Affiliation(s)
- Eduardo I Gus
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada
| | - Shahriar Shahrokhi
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada; Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Marc G Jeschke
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada; Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Department of Immunology, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada.
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Church DD, Gwin JA, Wolfe RR, Pasiakos SM, Ferrando AA. Mitigation of Muscle Loss in Stressed Physiology: Military Relevance. Nutrients 2019; 11:nu11081703. [PMID: 31344809 PMCID: PMC6724061 DOI: 10.3390/nu11081703] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/15/2019] [Accepted: 07/22/2019] [Indexed: 12/14/2022] Open
Abstract
Military personnel may be exposed to circumstances (e.g., large energy deficits, sleep deprivation, cognitive demands, and environmental extremes) of external stressors during training and combat operations (i.e., operational stressors) that combine to degrade muscle protein. The loss of muscle protein is further exacerbated by frequent periods of severe energy deficit. Exposure to these factors results in a hypogonadal state that may contribute to observed decrements in muscle mass. In this review, lessons learned from studying severe clinical stressed states and the interventions designed to mitigate the loss of muscle protein are discussed in the context of military operational stress. For example, restoration of the anabolic hormonal status (e.g., testosterone, insulin, and growth hormone) in stressed physiological states may be necessary to restore the anabolic influence derived from dietary protein on muscle. Based on our clinical experiences, restoration of the normal testosterone status during sustained periods of operational stress may be advantageous. We demonstrated that in severe burn patients, pharmacologic normalization of the anabolic hormonal status restores the anabolic stimulatory effect of nutrition on muscle by improving the protein synthetic efficiency and limiting amino acid loss from skeletal muscle. Furthermore, an optimal protein intake, and in particular essential amino acid delivery, may be an integral ingredient in a restored anabolic response during the stress state. Interventions which improve the muscle net protein balance may positively impact soldier performance in trying conditions.
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Affiliation(s)
- David D Church
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, Center for Translational Research in Aging & Longevity, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Jess A Gwin
- Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
- Oak Ridge Institute for Science and Education Supporting the Military Nutrition Division of the US Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Robert R Wolfe
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, Center for Translational Research in Aging & Longevity, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Stefan M Pasiakos
- Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Arny A Ferrando
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, Center for Translational Research in Aging & Longevity, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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Kaewboonchoo O, Sung FC, Lin CL, Hsu HC, Kuo CT. Risk of osteoporosis and fracture in victims with burn injury. Osteoporos Int 2019; 30:837-843. [PMID: 30734067 DOI: 10.1007/s00198-018-04818-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 12/17/2018] [Indexed: 12/31/2022]
Abstract
UNLABELLED Osteoporosis is a well-known bone disorder affecting people worldwide. Patients with osteoporosis have an increased risk of bone fracture. This study provides new information on the risk of developing osteoporosis post burn injury and the risk of fracture among those with osteoporosis developed. INTRODUCTION The relationship between burn injury and hip fracture risk is unclear. Population-based evaluation on relationships between burn injury and osteoporosis development and subsequent fractures is limited. We conducted a retrospective cohort study as the investigation. METHODS From the insurance data of Taiwan, we established a cohort of 43,532 patients with a burn injury in 2000-2012 and a comparison cohort of 174,124 individuals without such an injury, frequency matched by sex, age, and diagnosis date. Both cohorts were followed up to the end of 2013 to evaluate the occurrence of osteoporosis and hip fracture. RESULTS The incidence of osteoporosis was greater in the burn cohort than in the comparison cohort (6.40 vs. 4.75 per 1,000 person-years) with an adjusted IRR of 1.35 (95% confidence interval = 1.32-1.39). The incidence rates in both cohorts were greater in women than in men, increased with age, income, and Charlson comorbidity index. Patients with burns involving 20%-49% of total body surface area and with burns confined to the lower/upper limbs had the greatest incidence rates, 8.32 and 8.58 per 1,000 person-years, respectively. Osteoporosis incidence increased further to 22.7 per 1,000 person-years for burn victims with comorbid diabetes. The risk of fracture was over five-fold greater for burn victims with osteoporosis developed than for comparisons without osteoporosis. CONCLUSION Patients who have a burn injury deserve prevention intervention to reduce the risk of osteoporosis and fracture.
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Affiliation(s)
- O Kaewboonchoo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Bangkok, Thailand
| | - F C Sung
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Bangkok, Thailand
- Department of Health Services Administration, China Medical University College of Public Health, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C L Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - H C Hsu
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - C T Kuo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Bangkok, Thailand.
- Department of Public Health, China Medical University College of Public Health, 91 Hseuh Shis Road, Taichung, 404, Taiwan.
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Ahmad A, Herndon DN, Szabo C. Oxandrolone protects against the development of multiorgan failure, modulates the systemic inflammatory response and promotes wound healing during burn injury. Burns 2018; 45:671-681. [PMID: 31018913 DOI: 10.1016/j.burns.2018.10.006] [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: 07/14/2018] [Accepted: 10/04/2018] [Indexed: 12/14/2022]
Abstract
Oxandrolone is a synthetic oral non-aromatizable testosterone derivative. This drug has been used successfully for several decades to safely treat growth delays in various diseases including Turner's syndrome. Currently the use of oxandrolone is under clinical testing in children with burn injury; the available data indicate that the anabolic steroid increases net muscle protein balance, maintains lean body mass, and reduces intensive care unit stay. Although oxandrolone is already in clinical trials in burn patients, preclinical burn-related studies with oxandrolone - especially those that go beyond muscle-related parameters and focus on burn-associated organ dysfunction, inflammatory response and wound healing - remain to be conducted. In the current project, using a well-characterized murine model of third-degree burn, we have tested the effect of oxandrolone on indices of organ injury, clinical chemistry parameters and plasma levels of inflammatory mediators. In oxandrolone-treated mice (1mg/kg/day for up to 21 days) there was a significant amelioration of burn-induced accumulation of myeloperoxidase levels in heart and lung (but not the liver and kidney) and significantly lower degree of malon dialdehyde accumulation in the liver (but not the heart, lung and kidney). Oxandrolone-treated mice showed a significant attenuation of the burn-induced elevation in circulating alkaline aminotransferase and amylase levels, while blood urea nitrogen and creatinine levels remained unaffected, indicative of protective effects of the anabolic hormone against burn-induced hepatic and pancreatic (but not renal) functional impairment. Multiple burn-induced inflammatory mediators (TNF-α, IL-1α, IL-1β, IL-4, IL-6, IL-10, IL-12, IP-10, G-CSF, GM-CSF and interferon-γ) were significantly lower in the plasma of oxandrolone-treated animals after burn injury than in the plasma of controls subjected to burns. Finally, oxandrolone significantly accelerated burn wound healing. We conclude that oxandrolone improves organ function, modulates the systemic inflammatory response and accelerates wound healing in a murine model of burn injury.
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Affiliation(s)
- Akbar Ahmad
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - David N Herndon
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA,; Shriners Hospital for Children, Galveston, TX, USA
| | - Csaba Szabo
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospital for Children, Galveston, TX, USA.
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Oxandrolone Coadministration Does Not Alter Plasma Propranolol Concentrations in Severely Burned Pediatric Patients. J Burn Care Res 2018; 38:243-250. [PMID: 28240622 PMCID: PMC5507814 DOI: 10.1097/bcr.0000000000000494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The systemic impact of severe burn injury results in a variety of disorders that require therapeutic intervention. Propranolol, a nonselective β1, β2-adrenergic receptor antagonist, reduces resting heart rate and cardiac work caused by elevated circulating catecholamines. Oxandrolone, a testosterone mimetic, promotes protein synthesis and anabolism to counter muscle wasting. Coadministration of these drugs is expected to synergistically improve patient outcomes. Testosterone administration is known to alter β-adrenergic receptor-mediated signaling. Here, we determined whether the coadministration of oxandrolone alters plasma propranolol concentrations. Ninety-two pediatric patients with burns covering ≥30% of the TBSA were enrolled in this institutional review board-approved study and randomized to receive propranolol (n = 49) or oxandrolone + propranolol (n = 43). Plasma propranolol concentrations were determined following two dosing strategies: Q6 (liquid formulation; n = 86) and Q24 (extended-release capsule; n = 22). Samples were drawn before drug administration and at regular intervals throughout the next two dosing periods. Heart rate and blood pressure were recorded throughout the study. Propranolol half-life was 3.3 hours for the Q6 drug dosing frequency (P < .0001) and 11.2 hours for the Q24 strategy (P < .0001). Percentage of predicted heart rate declined by 2.8% for each doubling of the propranolol concentration in the Q6 dosing schedule (P < .0001). Percentage of predicted heart rate declined by 2.5% for each doubling of propranolol concentration on the Q24 dosing schedule (P < .0001). Maximum and minimum propranolol plasma concentrations were similar with either dosing regimen. The addition of oxandrolone did not affect any of the measured parameters. Oxandrolone coadministration does not alter propranolol’s plasma concentration, half-life, or effect on heart rate. This study is registered at clincialtrials.gov: NCT00675714.
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Thakkar RK, Diltz Z, Drews JD, Wheeler KK, Shi J, Devine R, Fabia R, Hall M. Abnormal lymphocyte response after pediatric thermal injury is associated with adverse outcomes. J Surg Res 2018; 228:221-227. [PMID: 29907215 DOI: 10.1016/j.jss.2018.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/07/2018] [Accepted: 03/15/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Burns are a leading cause of morbidity in children, with infections representing the most common group of complications. Severe thermal injuries are associated with a profound inflammatory response, but the utility of laboratory values to predict infections in pediatric burn patients is poorly understood. MATERIALS AND METHODS Our institutional burn database was queried for patients aged 18 y and younger with at least 10% total body surface area burns. Demographics, mechanism, laboratory results, and outcomes were extracted from the medical record. Patients were classified as having an abnormal or normal total white blood cell count, neutrophil percentage, and lymphocyte percentage using the first complete blood count drawn 72 or more hours postinjury. Outcomes were compared between groups. RESULTS White blood cell data were available for 90 patients, 84 of whom had neutrophil and lymphocyte percentages. Abnormal lymphocyte percentage 72 h or more after burn injury was associated with a significant increase in infections (67.9% versus 32.3%, P = 0.003), length of stay (33.1 versus 18.8 d, P = 0.02), intensive care unit length of stay (13.1 versus 3.7 days, P = 0.01), and ventilator days (5.8 versus 2.3, P = 0.02). It was also an independent predictor of infection (odds ratio 7.2, 95% confidence interval 2.1-24.5). CONCLUSIONS Abnormal lymphocyte percentage at or after 72 h after burn injury is associated with adverse outcomes, including increased infectious risk.
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Affiliation(s)
- Rajan K Thakkar
- The Ohio State University College of Medicine, Columbus, Ohio; Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Burn Center, Nationwide Children's Hospital, Columbus, Ohio; Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
| | - Zachary Diltz
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Drews
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Krista K Wheeler
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Junxin Shi
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Racheal Devine
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Renata Fabia
- The Ohio State University College of Medicine, Columbus, Ohio; Department of Pediatric Surgery, Burn Center, Nationwide Children's Hospital, Columbus, Ohio; Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Mark Hall
- The Ohio State University College of Medicine, Columbus, Ohio; Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Screening of Key Genes in Severe Burn Injury at Different Stages via Analyzing Gene Expression Data. J Burn Care Res 2018; 37:e254-62. [PMID: 25412053 DOI: 10.1097/bcr.0000000000000179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Microarray analysis was performed to investigate the changes in gene expression profiles after severe burn injury at the early and middle stages, further discovering therapeutic targets for severe burn injury. Microarray data (GSE19743) were downloaded from Gene Expression Omnibus. First, differentially expressed genes (DEGs) at different stages were screened using limma package. Gene Ontology (GO) functional annotation and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis of DEGs were then performed using DAVID. Protein-protein interaction (PPI) networks were also constructed using String database. Additionally, transcription factor binding site was detected using the Whole-Genome rVISTA. Compared with the healthy controls, 160 DEGs were identified in patients with early-stage burn injury and 261 DEGs were obtained in patients with middle-stage burn injury. Only 10 genes showed differential expression between the early and middle stages. KEGG functional analysis indicated that DEGs detected at the early stage were mainly enriched in the immune response, kinase activity, and signaling pathways and DEGs detected at the middle stage were involved in the immune response, protein and fat metabolism, and programmed cell death pathways. Three PPI networks were constructed and hub proteins with high degrees of connection were screened, such as lactotransferrin, interleukin 8, and perforin-1. Additionally, many transcription factor binding sites that may be involved in the regulation of these DEGs were also detected. A number of DEGs were identified in patients with early- and middle-stage burn injury, which helps to deepen the understanding about the molecular mechanism underlying severe burn injury.
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Kaewboonchoo O, Sung FC, Lin CL, Hsu HC, Kuo CT. Hip fracture risk in patients with burn injury: a retrospective cohort study in Taiwan. Osteoporos Int 2017; 28:3415-3420. [PMID: 28875313 DOI: 10.1007/s00198-017-4209-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED This work aimed to evaluate the hip fracture risk for patients with burn injury. A total of 16,430 patients with burn injury had an adjusted hazard ratio of 1.54 to encounter a hip fracture, compared with controls without the injury. These results encourage future studies focusing on mechanisms leading to fracture associated with burn injury. INTRODUCTION The relationship between burn injury and hip fracture risk is unclear. We conducted a retrospective cohort study to investigate this relationship. METHODS From insurance data of Taiwan, we identified a cohort with 16,430 burn patients in 2000-2010 and a comparison cohort of 65,716 persons without the history of burn, frequency matched by sex, age, and diagnosis date. Both cohorts were followed up to the end of 2011 to evaluate the risk of hip fracture. RESULTS Patients with burn injury were 1.62-fold more likely than comparisons to encounter a hip fracture (6.95 vs. 4.28 per 1000 person-years), with an adjusted hazard ratio (aHR) of 1.54 (95% confidence interval (CI) = 1.40-1.68). The fracture incidence increased with age and is slightly greater for women than for men in both cohorts. The fracture risk was greater for patients with burn in the eyes, face, and head with an incidence of 7.14 per 1000 person-years, or an aHR of 2.09 (95% CI = 1.53, 2.86). Diabetes and osteoporosis were also associated with an increased hip fracture risk. CONCLUSION Burn injury is associated with an increased risk of hip fracture. Diabetes and osteoporosis are associated with an enhanced risk.
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Affiliation(s)
- O Kaewboonchoo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand
| | - F C Sung
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand
- Department of Health Services Administration, China Medical University College of Public Health, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C L Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - H C Hsu
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - C T Kuo
- Department of Public Health Nursing, Mahidol University Faculty of Public Health, Khet Ratchathewi, Thailand.
- Department of Public Health, China Medical University College of Public Health, 91 Hseuh Shih Road, Taichung, 404, Taiwan.
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The P50 Research Center in Perioperative Sciences: How the investment by the National Institute of General Medical Sciences in team science has reduced postburn mortality. J Trauma Acute Care Surg 2017; 83:532-542. [PMID: 28697015 DOI: 10.1097/ta.0000000000001644] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since the inception of the P50 Research Center in Injury and Peri-operative Sciences (RCIPS) funding mechanism, the National Institute of General Medical Sciences has supported a team approach to science. Many advances in critical care, particularly burns, have been driven by RCIPS teams. In fact, burns that were fatal in the early 1970s, prior to the inception of the P50 RCIPS program, are now routinely survived as a result of the P50-funded research. The advances in clinical care that led to the reduction in postburn death were made by optimizing resuscitation, incorporating early excision and grafting, bolstering acute care including support for inhalation injury, modulating the hypermetabolic response, augmenting the immune response, incorporating aerobic exercise, and developing antiscarring strategies. The work of the Burn RCIPS programs advanced our understanding of the pathophysiologic response to burn injury. As a result, the effects of a large burn on all organ systems have been studied, leading to the discovery of persistent dysfunction, elucidation of the underlying molecular mechanisms, and identification of potential therapeutic targets. Survival and subsequent patient satisfaction with quality of life have increased. In this review article, we describe the contributions of the Galveston P50 RCIPS that have changed postburn care and have considerably reduced postburn mortality.
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Impact of ghrelin on body composition and muscle function in a long-term rodent model of critical illness. PLoS One 2017; 12:e0182659. [PMID: 28796827 PMCID: PMC5552127 DOI: 10.1371/journal.pone.0182659] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 07/22/2017] [Indexed: 01/14/2023] Open
Abstract
Background Patients with multiple injuries or sepsis requiring intensive care treatment invariably develop a catabolic state with resultant loss of lean body mass, for which there are currently no effective treatments. Recovery can take months and mortality is high. We hypothesise that treatment with the orexigenic and anti-inflammatory gastric hormone, ghrelin may attenuate the loss of body mass following critical illness and improve recovery. Methods Male Wistar rats received an intraperitoneal injection of the fungal cell wall derivative zymosan to induce a prolonged peritonitis and consequent critical illness. Commencing at 48h after zymosan, animals were randomised to receive a continuous infusion of ghrelin or vehicle control using a pre-implanted subcutaneous osmotic mini-pump, and continued for 10 days. Results Zymosan peritonitis induced significant weight loss and reduced food intake with a nadir at Day 2 and gradual recovery thereafter. Supra-physiologic plasma ghrelin levels were achieved in the treated animals. Ghrelin-treated rats ate more food and gained more body mass than controls. Ghrelin increased adiposity and promoted carbohydrate over fat metabolism, but did not alter total body protein, muscle strength nor muscle morphology. Muscle mass and strength remained significantly reduced in all zymosan-treated animals, even at ten days post-insult. Conclusions Continuous infusion of ghrelin increased body mass and food intake, but did not increase muscle mass nor improve muscle function, in a long-term critical illness recovery model. Further studies with pulsatile ghrelin delivery or additional anabolic stimuli may further clarify the utility of ghrelin in survivors of critical illness.
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Abstract
Severe burn injury is followed by a profound hypermetabolic response that persists up to 2 years after injury. It is mediated by up to 50-fold elevations in plasma catecholamines, cortisol, and glucagon that lead to whole-body catabolism, elevated resting energy expenditures, and multiorgan dysfunction. Modulation of the response by early excision and grafting of burn wounds, thermoregulation, control of infection, early and continuous enteral nutrition, and pharmacologic treatments aimed at mitigating physiologic derangements have markedly decreased morbidity.
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Affiliation(s)
- Felicia N Williams
- Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina, Chapel Hill, 3007D Burnett Womack Building, CB 7206, Chapel Hill, NC 27599-7206, USA
| | - David N Herndon
- Department of Surgery, Shriners Hospital of Children, University of Texas Medical Branch, 815 Market Street, Galveston, TX 77550, USA.
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FIVE-YEAR OUTCOMES AFTER LONG-TERM OXANDROLONE ADMINISTRATION IN SEVERELY BURNED CHILDREN: A RANDOMIZED CLINICAL TRIAL. Shock 2016; 45:367-74. [PMID: 26506070 DOI: 10.1097/shk.0000000000000517] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Administration of oxandrolone, a nonaromatizable testosterone analog, to children for 12 months following severe burn injury has been shown to improve height, increase bone mineral content (BMC), reduce cardiac work, and augment muscle strength. Surprisingly, the increase in BMC persists well beyond the period of oxandrolone administration. This study was undertaken to determine if administration of oxandrolone for 2 years yields greater effects on long-term BMC and bone mineral density (BMD). Patients between 0 and 18 years of age with ≥30% of total body surface area burned were consented to an IRB-approved protocol and randomized to receive either placebo (n = 84) or 0.1 mg/kg oxandrolone orally twice daily for 24 months (n = 35). Patients were followed prospectively from the time of admission until 5 years postburn in a single-center, intent-to-treat setting. Height, weight, BMC, and BMD were recorded annually through 5 years postinjury. The long-term administration of oxandrolone for 16 ± 1 months postburn (range, 12.1-25.2 months) significantly increased whole-body (WB) BMC (p < 0.02) and lumbar spine (LS) BMC (p < 0.05); these effects were significantly pronounced for a longer time in patients who were in growth spurt years (7-18 years). When adjusted for height, sex, and age, LS BMD was found to significantly increase with long-term oxandrolone administration (p < 0.0009). Fewer patients receiving oxandrolone exhibited LS BMD z scores below -2.0 as compared with controls, indicating a significantly reduced risk for future fracture with oxandrolone administration. Long-term oxandrolone patients had significantly greater height velocity than controls throughout the first 2-year postburn (p < 0.05). No adverse side effects were attributed to the long-term administration of oxandrolone. A comparison of the current patients receiving long-term oxandrolone to previously described patients receiving 12 months of oxandrolone revealed that long-term oxandrolone administration imparted significantly greater increases in WB-BMC, WB-BMD, and LS-BMD (p < 0.05). In conclusion, the administration of oxandrolone for up to 24 months to severely burned pediatric patients significantly improves WB BMC, LS BMC, LS BMD, and height velocity. The administration of long-term oxandrolone was more efficacious than administration for 12 months. Additionally, fewer patients in the oxandrolone cohort met the diagnostic criteria for pediatric osteoporosis, pointing to a reduced risk for future bone fracture. This study demonstrates that administering oxandrolone for up to 2 years following severe burn injury results in greater improvements in BMC, BMD, and height velocity.
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Are we creating survivors…or victims in critical care? Delivering targeted nutrition to improve outcomes. Curr Opin Crit Care 2016; 22:279-84. [DOI: 10.1097/mcc.0000000000000332] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Burch PT, Spigarelli MG, Lambert LM, Loftus PD, Sherwin CM, Linakis MW, Sheng X, LuAnn Minich L, Williams RV. Use of Oxandrolone to Promote Growth in Neonates following Surgery for Complex Congenital Heart Disease: An Open-Label Pilot Trial. CONGENIT HEART DIS 2016; 11:693-699. [PMID: 27257953 DOI: 10.1111/chd.12376] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Malnutrition and poor weight gain, common in neonates following repair of complex congenital heart disease (CHD), are associated with increased morbidity and mortality. Oxandrolone, an anabolic steroid, improves weight gain in older children at high-risk for growth failure. We sought to determine feasibility, safety, and efficacy of oxandrolone therapy in neonates following surgery for complex CHD. DESIGN Neonates with RACHS-1 score >3 were eligible to receive open-label oxandrolone for 28 days in this prospective pilot trial. There were 3 cohorts of 5 subjects receiving oxandrolone therapy under 3 specified dosage and preparation protocols: 0.1 mg/kg/day aqueous solution, 0.2 mg/kg/day aqueous solution, and 0.1 mg/kg/day preparation in medium chain triglyceride (MCT) oil. Age- and diagnosis-matched neonates who underwent surgery, but received no oxandrolone, served as a control cohort. Anthropometric measurements, physical examination for virilization, safety labs, and adverse events were monitored. RESULTS Of 25 eligible patients, 15 consented (60%, 13/15 with Norwood procedure). There was no evidence of virilization, no changes in safety labs, and no serious adverse events related to oxandrolone among subjects receiving therapy. No subject met criteria for termination of study drug. There was a significant difference in change in weight-for-age z-score among the four cohorts, with subjects receiving 0.1 mg/kg/day in MCT oil having the lowest decline during the study period (-1.8 ± 0.5 for controls, -1.7 ± 0.4 for 0.1 mg/kg/day aqueous, -1.0 ± 0.4 for 0.2 mg/kg/day aqueous, and -0.6 ± 0.7 for 0.1 mg/kg/day MCT oil, P = .012). CONCLUSIONS Oxandrolone therapy at the doses studied appears safe in neonates after surgery for complex CHD. The decline in weight-for-age z-score was lowest in those receiving the MCT oil preparation suggesting better bioavailability of this preparation and a potential growth benefit with oxandrolone therapy. Further investigation is needed to define optimal dosing and assess efficacy.
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Affiliation(s)
- Phillip T Burch
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Michael G Spigarelli
- Adolescent Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA.,Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Linda M Lambert
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Patrick D Loftus
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Catherine M Sherwin
- Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Matthew W Linakis
- Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - L LuAnn Minich
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Richard V Williams
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
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The efficacy and safety of oxandrolone treatment for patients with severe burns: A systematic review and meta-analysis. Burns 2016; 42:717-27. [DOI: 10.1016/j.burns.2015.08.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 11/23/2022]
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Cardiovascular Dysfunction Following Burn Injury: What We Have Learned from Rat and Mouse Models. Int J Mol Sci 2016; 17:ijms17010053. [PMID: 26729111 PMCID: PMC4730298 DOI: 10.3390/ijms17010053] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/14/2015] [Accepted: 12/23/2015] [Indexed: 12/11/2022] Open
Abstract
Severe burn profoundly affects organs both proximal and distal to the actual burn site. Cardiovascular dysfunction is a well-documented phenomenon that increases morbidity and mortality following a massive thermal trauma. Beginning immediately post-burn, during the ebb phase, cardiac function is severely depressed. By 48 h post-injury, cardiac function rebounds and the post-burn myocardium becomes tachycardic and hyperinflammatory. While current clinical trials are investigating a variety of drugs targeted at reducing aspects of the post-burn hypermetabolic response such as heart rate and cardiac work, there is still a paucity of knowledge regarding the underlying mechanisms that induce cardiac dysfunction in the severely burned. There are many animal models of burn injury, from rodents, to sheep or swine, but the majority of burn related cardiovascular investigations have occurred in rat and mouse models. This literature review consolidates the data supporting the prevalent role that β-adrenergic receptors play in mediating post-burn cardiac dysfunction and the idea that pharmacological modulation of this receptor family is a viable therapeutic target for resolving burn-induced cardiac deficits.
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Bone Mineral Density After Burn Injury and Its Relation to the Characteristics of Scar Tissue. J Burn Care Res 2016; 37:e263-7. [DOI: 10.1097/bcr.0000000000000241] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nong Q, Li S, Liu D. A comprehensive bioinformatics method to screen key genes for severe burn. EUR J INFLAMM 2015. [DOI: 10.1177/1721727x15622459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Severe burn is a kind of traumatic injury, which can lead to serious financial burden, high morbidity and mortality following inflammatory response and complications. Microarray analysis has emerged as a popular tool for generating gene expression data and revealing the complex gene expression patterns. The Gene Expression Omnibus (GEO) repository at the National Center for Biotechnology Information has become the leading public repository of microarray data. This study aimed to study the mechanisms of severe burn. Microarray of GSE37069 was downloaded from GEO including blood samples from 244 severe burn patients and blood samples from 35 healthy controls. The differentially expressed genes (DEGs) between blood samples from healthy controls and patients were identified by t-test in the LIMMA package of R. Their interaction relationships were searched using STRING online software and then protein-protein interaction (PPI) network was constructed by Cytoscape. Using DAVID online tool, underlying functions of the DEGs involved in the PPI network were analyzed by functional and pathway enrichment analyses. We screened 541 DEGs in blood samples from severe burns patients compared with blood samples from healthy controls. Meanwhile, DEGs including MMP9, TIMP1, GZMK, GZMA, and GZMB showed higher degrees in the PPI networks. Moreover, they may function in severe burn through interacting with others. According to functional enrichment analysis, these DEGs were mainly involved in BP categories associated with inflammatory responses. MMP9, TIMP1, HGF, GZMA, GZMB, and GZMK might play important roles in severe burns.
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Affiliation(s)
- Qingwen Nong
- Burns & Plastic Surgery, the First Affiliate Hospital of Guangxi Medical University, Nanning, Guangxi, PR China
| | - Shuntang Li
- Burns & Plastic Surgery, the First Affiliate Hospital of Guangxi Medical University, Nanning, Guangxi, PR China
| | - Daen Liu
- Burns & Plastic Surgery, the First Affiliate Hospital of Guangxi Medical University, Nanning, Guangxi, PR China
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Wischmeyer PE, San-Millan I. Winning the war against ICU-acquired weakness: new innovations in nutrition and exercise physiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19 Suppl 3:S6. [PMID: 26728966 PMCID: PMC4699141 DOI: 10.1186/cc14724] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the last 10 years we have significantly reduced hospital mortality from sepsis and critical illness. However, the evidence reveals that over the same period we have tripled the number of patients being sent to rehabilitation settings. Further, given that as many as half of the deaths in the first year following ICU admission occur post ICU discharge, it is unclear how many of these patients ever returned home. For those who do survive, the latest data indicate that 50-70% of ICU "survivors" will suffer cognitive impairment and 60-80% of "survivors" will suffer functional impairment or ICU-acquired weakness (ICU-AW). These observations demand that we as intensive care providers ask the following questions: "Are we creating survivors ... or are we creating victims?" and "Do we accomplish 'Pyrrhic Victories' in the ICU?" Interventions to address ICU-AW must have a renewed focus on optimal nutrition, anabolic/anticatabolic strategies, and in the future employ the personalized muscle and exercise evaluation techniques utilized by elite athletes to optimize performance. Specifically, strategies must include optimal protein delivery (1.2-2.0 g/kg/day), as an athlete would routinely employ. However, as is clear in elite sports performance, optimal nutrition is fundamental but alone is often not enough. We know burn patients can remain catabolic for 2 years post burn; thus, anticatabolic agents (i.e., beta-blockers) and anabolic agents (i.e., oxandrolone) will probably also be essential. In the near future, evaluation techniques such as assessing lean body mass at the bedside using ultrasound to determine nutritional status and ultrasound-measured muscle glycogen as a marker of muscle injury and recovery could be utilized to help find the transition from the acute phase of critical illness to the recovery phase. Finally, exercise physiology testing that evaluates muscle substrate utilization during exercise can be used to diagnose muscle mitochondrial dysfunction and to guide a personalized ideal heart rate, assisting in recovery of muscle mitochondrial function and functional endurance post ICU. In the end, future ICU-AW research must focus on using a combination of modern performance-enhancing nutrition, anticatabolic/anabolic interventions, and muscle/exercise testing so we can begin to create more "survivors" and fewer victims post ICU care.
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Increased admissions for musculoskeletal diseases after burns sustained during childhood and adolescence. Burns 2015; 41:1674-1682. [DOI: 10.1016/j.burns.2015.08.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/19/2015] [Accepted: 08/23/2015] [Indexed: 11/19/2022]
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Randall SM, Fear MW, Wood FM, Rea S, Boyd JH, Duke JM. Long-term musculoskeletal morbidity after adult burn injury: a population-based cohort study. BMJ Open 2015; 5:e009395. [PMID: 26362668 PMCID: PMC4567662 DOI: 10.1136/bmjopen-2015-009395] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate if adults who are hospitalised for a burn injury have increased long-term hospital use for musculoskeletal diseases. DESIGN A population-based retrospective cohort study using linked administrative health data from the Western Australian Data Linkage System. SUBJECTS Records of 17,753 persons aged at least 20 years when hospitalised for a first burn injury in Western Australia during the period 1980-2012, and 70,758 persons who were age and gender-frequency matched with no injury admissions randomly selected from Western Australia's electoral roll. MAIN OUTCOME MEASURES Admission rates and cumulative length of stay for musculoskeletal diseases. Negative binomial and Cox proportional hazards regression modelling were used to generate incidence rate ratios (IRR) and HRs with 95% CIs, respectively. RESULTS After adjustment for pre-existing health status and demographic characteristics, the burn cohort had almost twice the hospitalisation rate for a musculoskeletal condition (IRR, 95% CI 1.98, 1.86 to 2.10), and spent 3.70 times as long in hospital with a musculoskeletal diagnosis (95% CI 3.10 to 4.42) over the 33-year period, than the uninjured comparison cohort. Adjusted survival analyses of incident post-burn musculoskeletal disease admissions found significant increases for the 15-year post burn discharge period (0-6 months: HR, 95% CI 2.51, 2.04 to 3.11; 6 months-2 years: HR, 95% CI 1.77, 1.53 to 2.05; 2-15 years: HR, 95% CI 1.32, 1.23 to 1.42). Incident admission rates were significantly elevated for 20 years post-burn for minor and severe burn injury for a range of musculoskeletal diseases that included arthropathies, dorsopathies, osteopathies and soft tissue disorders. CONCLUSIONS Minor and severe burn injuries were associated with significantly increased post-burn incident admission rates, long-term hospital use and prolonged length of stay for a range of musculoskeletal diseases. Further research is required that facilitates identification of at-risk patients and appropriate treatment pathways, to reduce the long-term morbidity associated with burns.
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Affiliation(s)
- Sean M Randall
- Centre for Data Linkage, Curtin University, Perth, Western Australia, Australia
| | - Mark W Fear
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
- Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Suzanne Rea
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
- Burns Service of Western Australia, Royal Perth Hospital and Princess Margaret Hospital, Perth, Western Australia, Australia
| | - James H Boyd
- Centre for Data Linkage, Curtin University, Perth, Western Australia, Australia
| | - Janine M Duke
- Burn Injury Research Unit, School of Surgery, University of Western Australia, Perth, Western Australia, Australia
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Nieschlag E, Vorona E. Doping with anabolic androgenic steroids (AAS): Adverse effects on non-reproductive organs and functions. Rev Endocr Metab Disord 2015; 16:199-211. [PMID: 26373946 DOI: 10.1007/s11154-015-9320-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Since the 1970s anabolic androgenic steroids (AAS) have been abused at ever increasing rates in competitive athletics, in recreational sports and in bodybuilding. Exceedingly high doses are often consumed over long periods, in particular by bodybuilders, causing acute or chronic adverse side effects frequently complicated by additional polypharmacy. This review summarizes side effects on non-reproductive organs and functions; effects on male and female reproduction have been recently reviewed in a parallel paper. Among the most striking AAS side effects are increases in haematocrit and coagulation causing thromboembolism, intracardiac thrombosis and stroke as well as other cardiac disturbances including arrhythmias, cardiomyopathies and possibly sudden death. 17α-alkylated AAS are liver toxic leading to cholestasis, peliosis, adenomas and carcinomas. Hyperbilirubinaemia can cause cholemic nephrosis and kidney failure. AAS abuse may induce exaggerated self-confidence, reckless behavior, aggressiveness and psychotic symptoms. AAS withdrawal may be accompanied by depression and suicidal intentions. Since AAS abuse is not or only reluctantly admitted physicians should be aware of the multitude of serious side effects when confronted with unclear symptoms.
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Affiliation(s)
- Eberhard Nieschlag
- Centre of Reproductive Medicine and Andrology, University of Münster, Münster, Germany.
- Center of Excellence in Genomic Medicine Research, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Elena Vorona
- Centre of Endocrinology, Diabetology and Rheumatology, Dortmund, Germany
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Jewo P, Fadeyibi I. Progress in burns research: a review of advances in burn pathophysiology. ANNALS OF BURNS AND FIRE DISASTERS 2015; 28:105-15. [PMID: 27252608 PMCID: PMC4837486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 05/15/2014] [Accepted: 11/04/2014] [Indexed: 06/05/2023]
Abstract
Severe burns trigger a wide range of responses in the victim. Initial vascular changes are followed by hypermetabolic, inflammatory and immunologic changes. The prolonged hypermetabolic response is associated with an elevated resting rate of energy consumption, tissue wasting and altered substrate kinetics. There is increased blood glucose though insulin levels are above normal. The cortisol level is raised and, together with catecholamine, drives the metabolic response. The immune system is typically weakened. There is elevation in blood levels of a wide range of cytokines from activated cells. These agents drive a prolonged inflammatory response which can lead to tissue damage and multiple organ failure. Dynamic fluid resuscitation regimens have cut down mortality from shock in the early post-burn period. However, unbalanced activity of pro- and anti-inflammatory cytokines can leave patients in an immuno-suppressed state that affects outcomes. So far, many treatments, such as propranolol, a cardio-protector, and anabolic agents, such as oxandrolone and growth hormone, have been tried with mixed results. This review focuses on research that elucidated burn pathophysiology. Some clinical areas in which treatment centred on correcting altered physiology were also included. We have highlighted both the challenges and significant findings. Finally, this paper draws attention to the gaps between progress in basic research and clinical application and suggests areas where further research and funding could be focused.
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Affiliation(s)
- P.I. Jewo
- Department of Anatomy, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - I.O. Fadeyibi
- Burns and Plastic Surgery Unit, Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
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Abstract
BACKGROUND Recombinant human growth hormone (rhGH) increases protein synthesis, therefore it is used in burns with a total body surface area (TBSA) greater than 40%, where there is frequently an increase in protein breakdown and a decrease in protein synthesis. This change in protein metabolism correlates with poor wound healing of the burn and donor sites. OBJECTIVES To determine the effects of rhGH on the healing rate of burn wounds and donor sites in people with burns. SEARCH METHODS For this first update we searched the Cochrane Wounds Group Specialised Register (searched 04 September 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 8); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2014, Issue 3); Ovid MEDLINE (1950 to September Week 4 2014); Ovid MEDLINE (In-Process & Other Non-Indexed Citations September 8, 2014); Ovid EMBASE (1980 to 2014 Week 35); and EBSCO CINAHL (1982 to 8 September 2014). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing rhGH with any comparator intervention, e.g. oxandrolone or placebo, in adults or children with burns. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed trial quality and extracted data. The primary outcomes were the healing of the burn wound and donor sites and the occurrence of wound infections. The secondary outcomes were mortality rate, length of hospital stay, scar assessment, and adverse events: hyperglycaemia and septicaemia. MAIN RESULTS We included 13 RCTs (701 people). Six of the RCTs included only children aged 1 to 18 years and seven involved only adults (from 18 to 65 years of age). The mean TBSA of the included participants was greater than 49%. Twelve studies compared rhGH with placebo and one study compared rhGH with oxandrolone. Two trials found that compared with placebo, burn wounds in adults treated with rhGH healed more quickly (by 9.07 days; 95% confidence interval (CI) 4.39 to 13.76, I² = 0%). The donor site healing time was significantly shorter in rhGH-treated adults compared with placebo-treated participants (by 3.15 days; 95% CI 1.54 to 4.75, I² = 0%). Two studies in children with the outcome of donor site healing time could be pooled and the donor site healing time was shorter in the rhGH-treated children (by 1.70 days; 95% CI 0.87 to 2.53, I² = 0%). No studies reporting the outcome of wound infection were found. The incidence of hyperglycaemia was higher in adults during rhGH treatment compared with placebo (risk ratio (RR) 2.43; 95% CI 1.54 to 3.85), but not in children. Pooling the studies of adults and children yielded a significantly higher incidence of hyperglycaemia in the rhGH-treated participants (RR 2.65; 95% CI 1.68 to 4.16). AUTHORS' CONCLUSIONS There is some evidence that using rhGH in people with large burns (more than 40% of the total body surface area) could result in more rapid healing of the burn wound and donor sites in adults and children, and in reduced length of hospital stay, without increased mortality or scarring, but with an increased risk of hyperglycaemia. This evidence is based on studies with small sample sizes and risk of bias and requires confirmation in higher quality, adequately powered trials.
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Affiliation(s)
- Roelf S Breederveld
- Red Cross HospitalSurgery and Burn CentreVondellaan 13BeverwijkNHNetherlands1942 LE
| | - Wim E Tuinebreijer
- Red Cross HospitalSurgery and Burn CentreVondellaan 13BeverwijkNHNetherlands1942 LE
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Faienza MF, Luce V, Lonero A, Ventura A, Colaianni G, Colucci S, Cavallo L, Grano M, Brunetti G. Treatment of osteoporosis in children with glucocorticoid-treated diseases. Expert Rev Endocrinol Metab 2014; 9:525-534. [PMID: 30736214 DOI: 10.1586/17446651.2014.936384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Glucocorticoid induced osteoporosis (GIO) is the most frequent form of drug induced osteoporosis. Glucocorticoids affect osteoblastogenesis, osteoclastogenesis and promote the apoptosis of osteoblasts and osteocytes. A decrease of bone mineral density has been described in several pediatric diseases that require glucocorticoids, both as long-term replacement therapy, such as Congenital Adrenal Hyperplasia, and as treatment of acute phase or relapses, such as asthma, juvenile rheumatoid arthritis, inflammatory bowel diseases, systemic lupus erythematosus, organ transplantation and Steroid Sensitive Nephrotic Syndrome. The increasing number of children with GIO and at risk of fractures reflects the complex nature of this condition, and the need of development of anti-osteoporotic drugs. In this review, we focus on the mechanisms of GIO in some pediatric diseases and on treatment of osteoporosis. We also report data on new signaling pathways as potential targets for future anti-osteoporotic drugs.
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Affiliation(s)
- Maria Felicia Faienza
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Vincenza Luce
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Antonella Lonero
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Annamaria Ventura
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Graziana Colaianni
- b Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Silvia Colucci
- b Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Luciano Cavallo
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Maria Grano
- b Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Giacomina Brunetti
- b Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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Atiyeh B, Janom H. Physical rehabilitation of pediatric burns. ANNALS OF BURNS AND FIRE DISASTERS 2014; 27:37-43. [PMID: 25249846 PMCID: PMC4158448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Indexed: 06/03/2023]
Abstract
Significant improvements have been made in the acute treatment of pediatric burn injuries over the past 3 decades which have significantly decreased mortality. Each year, more burned children are necessitating serious medical attention during their convalescence. For children with serious consequences resulting from burns that can persist from childhood through adolescence into adulthood, the value of long-term rehabilitation cannot be over stated. Burn injury management should not focus only on the immediate treatment. Long-term functional outcome and the required rehabilitation that burn victims must go through should be given equal if not more attention. The present is a review of the available modalities utilized for the physical rehabilitation of convalescent pediatric burns in order to overcome the catabolic state, improve muscle power and fitness, reduce disfiguring scars and prevent contractures.
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Affiliation(s)
- B. Atiyeh
- Euro-Mediterranean Council for Burns and Fire Disasters, MBC
- Department of Surgery, Division of Plastic, Reconstructive and Aesthetic Surgery, American University of Beirut Medical Center Beirut, Lebanon
| | - H.H. Janom
- Department of Surgery, Division of Plastic, Reconstructive and Aesthetic Surgery, American University of Beirut Medical Center Beirut, Lebanon
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Rose SR, Kim MO, Korbee L, Wilson KA, Ris MD, Eyal O, Sherafat-Kazemzadeh R, Bollepalli S, Harris R, Jeng MR, Williams DA, Smith FO. Oxandrolone for the treatment of bone marrow failure in Fanconi anemia. Pediatr Blood Cancer 2014; 61:11-9. [PMID: 24019220 DOI: 10.1002/pbc.24617] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 05/03/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND A majority of Fanconi anemia (FA) patients will experience bone marrow failure (BMF) and androgen therapy (most often oxymetholone) may be utilized as a treatment to improve BMF-related cytopenias. However, oxymetholone is associated with toxicities making identification of other agents of interest. In this study we aimed to evaluate the toxicity profile and hematologic response in patients with FA who are treated with low-dose oxandrolone, a synthetic non-fluorinated anabolic steroid, similar to oxymetholone, with known dosing thresholds for virilization. PROCEDURE A single arm, Phase I/II study was designed to treat patients on low-dose oxandrolone. If no toxicity or hematologic response was noted at 16 weeks, a single dose escalation was offered. Subjects were regularly assessed for toxicity, including determinations of virilization, behavioral changes, and liver and kidney function. At 32 weeks, those who demonstrated hematologic response were allowed to continue study treatment, and those without improvement were deemed non-responsive. RESULTS Nine subjects completed the study and were followed for a median of 99 weeks (46-136 weeks). Three (33.3%) subjects developed mild sub-clinical virilization and continued treatment with a dose reduction. None (0%) had adverse behavioral changes. Two (22.2%) developed elevated liver function tests at 42 and 105 weeks. Seven (77.8%) subjects had a hematologic response. CONCLUSION Oxandrolone appears to be well-tolerated, has limited toxicities at the administered doses in FA with patients, and may be an alternative androgen for the treatment of BMF in FA.
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Affiliation(s)
- Susan R Rose
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Endocrinology, Stanford University School of Medicine, Stanford, California
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D'Asta F, Cianferotti L, Bhandari S, Sprini D, Rini GB, Brandi ML. The endocrine response to severe burn trauma. Expert Rev Endocrinol Metab 2014; 9:45-59. [PMID: 30743738 DOI: 10.1586/17446651.2014.868773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The endocrine system is frequently altered after a major burn trauma. Besides the endocrine response to stress characterized by hypercortisolism, several hypothalamus-hypophysis-target gland axes are rapidly perturbed within a few days. These alterations can persist in the long term and deserve an appropriate treatment. Disturbances in water clearance and glucidic metabolism are also common and need to be diagnosed and corrected to decrease morbidity in such patients. Bone and mineral metabolism is deeply compromised and requires correction of mineral abnormalities in order to improve symptoms and prevent bone loss. No large prospective and/or intervention trials are available to date to elaborate age-related, evidence-based recommendations to monitor and treat burn-related endocrine alterations.
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Affiliation(s)
- Federica D'Asta
- a Department of Neuroscience, Psychology, Drug, Research and Child Health, University of Florence, Viale Pieraccini 24, 50139 Florence, Italy
| | - Luisella Cianferotti
- b Department of Surgery and Translational Medicine, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
| | - Sahil Bhandari
- c Manchester Medical School, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Delia Sprini
- d Department of Internal Medicine, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Giovam Battista Rini
- d Department of Internal Medicine, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Maria Luisa Brandi
- b Department of Surgery and Translational Medicine, Unit of Bone and Mineral Metabolism, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
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ESPEN endorsed recommendations: Nutritional therapy in major burns. Clin Nutr 2013; 32:497-502. [DOI: 10.1016/j.clnu.2013.02.012] [Citation(s) in RCA: 196] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 02/15/2013] [Accepted: 02/17/2013] [Indexed: 11/23/2022]
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Abstract
The trauma of a severe burn injury induces a hypermetabolic response that increases morbidity and mortality. Previously, our group showed that insulin resistance after burn injury is associated with endoplasmic reticulum (ER) stress. Evidence suggests that c-Jun N-terminal kinase (JNK) 2 may be involved in ER stress-induced apoptosis. Here, we hypothesized that JNK2 contributes to the apoptotic response after burn injury downstream of ER stress. To test this, we compared JNK2 knockout mice (-/-) with wild-type mice after inducing a 30% total body surface area thermal injury. Animals were killed after 1, 3, and 5 days. Inflammatory cytokines in the blood were measured by multiplex analysis. Hepatic ER stress and insulin signaling were assessed by Western blotting, and insulin resistance was measured by a peritoneal glucose tolerance test. Apoptosis in the liver was quantified by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining. Liver function was quantified by aspartate aminotransferase and alanine aminotransferase activity assays. Endoplasmic reticulum stress increased after burn in both JNK2 and wild-type mice, indicating that JNK2 activation is downstream of ER stress. Knockout of JNK2 did not affect serum inflammatory cytokines; however, the increase in interleukin 6 mRNA expression was prevented in the knockouts. Serum insulin did not significantly increase in the JNK2 group. On the other hand, insulin signaling (PI3K/Akt pathway) and glucose tolerance tests did not improve in JNK2. As expected, apoptosis in the liver increased after burn injury in wild-type mice but not in JNK2. Aspartate aminotransferase/alanine aminotransferase activity revealed that liver function recovered more quickly in JNK2. This study indicates that JNK2 is a central mediator of hepatic apoptosis after a severe burn.
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Abstract
BACKGROUND Recombinant human growth hormone (rhGH) increases protein synthesis, therefore it is used in burns with a total body surface area (TBSA) greater than 40%, where there is frequently an increase in protein breakdown and a decrease in protein synthesis. This change in protein metabolism correlates with poor wound healing of the burn and donor sites. OBJECTIVES To determine the effects of rhGH on the healing rate of burn wounds and donor sites in people with burns. SEARCH METHODS We searched the Cochrane Wounds Group Specialised Register (searched 28 June 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (1950 to June Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations June 27, 2012); Ovid EMBASE (1980 to 2012 Week 25); and EBSCO CINAHL (1982 to 21 June 2012). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing rhGH with any comparator intervention, e.g. oxandrolone or placebo, in adults or children with burns. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed trial quality and extracted data. The primary outcomes were the healing of the burn wound and donor sites and the occurrence of wound infections. The secondary outcomes were mortality rate, length of hospital stay, scar assessment, and adverse events: hyperglycaemia and septicaemia. MAIN RESULTS We included 13 RCTs (701 people). Six of the RCTs included only children aged 1 to 18 years and seven involved only adults (from 18 to 65 years of age). The mean TBSA of the included participants was greater than 49%. Twelve studies compared rhGH with placebo and one study compared rhGH with oxandrolone. Two trials found that compared with placebo, burn wounds in adults treated with rhGH healed more quickly (by 9.07 days; 95% confidence interval (CI) 4.39 to 13.76, I² = 0%). The donor site healing time was significantly shorter in rhGH-treated adults compared with placebo-treated participants (by 3.15 days; 95% CI 1.54 to 4.75, I² = 0%). Two studies in children with the outcome of donor site healing time could be pooled and the donor site healing time was shorter in the rhGH-treated children (by 1.70 days; 95% CI 0.87 to 2.53, I² = 0%). No studies reporting the outcome of wound infection were found. The incidence of hyperglycaemia was higher in adults during rhGH treatment compared with placebo (risk ratio (RR) 2.43; 95% CI 1.54 to 3.85), but not in children. Pooling the studies of adults and children yielded a significantly higher incidence of hyperglycaemia in the rhGH-treated participants (RR 2.65; 95% CI 1.68 to 4.16). AUTHORS' CONCLUSIONS There is some evidence that using rhGH in people with large burns (more than 40% of the total body surface area) could result in more rapid healing of the burn wound and donor sites in adults and children, and in reduced length of hospital stay, without increased mortality or scarring, but with an increased risk of hyperglycaemia. This evidence is based on studies with small sample sizes and risk of bias and requires confirmation in higher quality, adequately powered trials.
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Rojas Y, Finnerty CC, Radhakrishnan RS, Herndon DN. Burns: an update on current pharmacotherapy. Expert Opin Pharmacother 2012; 13:2485-94. [PMID: 23121414 DOI: 10.1517/14656566.2012.738195] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The worldwide occurrence of burn injuries remains high despite efforts to reduce injury incidence through public awareness campaigns and improvements in living conditions. In 2004, almost 11 million people experienced burns severe enough to warrant medical treatment. Advances over the past several decades in aggressive resuscitation, nutrition, excision and grafting have reduced morbidity and mortality. Incorporation of pharmacotherapeutics into treatment regimens may further reduce complications of severe burn injuries. AREAS COVERED Severe burn injuries, as well as other forms of stress and trauma, trigger a hypermetabolic response that, if left untreated, impedes recovery. In the past two decades, use of anabolic agents, β-adrenergic receptor antagonists and anti-hyperglycemic agents has successfully counteracted post-burn morbidities including catabolism, the catecholamine-mediated response and insulin resistance. Here, the authors review the most up-to-date information on currently used pharmacotherapies in the treatment of these sequelae of severe burns and the insights that have expanded the understanding of the pathophysiology of severe burns. EXPERT OPINION Existing drugs offer promising advances in the care of burn injuries. Continued gains in the understanding of the molecular mechanisms driving the hypermetabolic response will enable the application of additional existing drugs to be broadened to further attenuate the hypermetabolic response.
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Affiliation(s)
- Yesenia Rojas
- Shriners Hospitals for Children, Galveston, TX 77550, USA
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Porro LJ, Herndon DN, Rodriguez NA, Jennings K, Klein GL, Mlcak RP, Meyer WJ, Lee JO, Suman OE, Finnerty CC. Five-year outcomes after oxandrolone administration in severely burned children: a randomized clinical trial of safety and efficacy. J Am Coll Surg 2012; 214:489-502; discussion 502-4. [PMID: 22463890 DOI: 10.1016/j.jamcollsurg.2011.12.038] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 12/15/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Oxandrolone, an anabolic agent, has been administered for 1 year post burn with beneficial effects in pediatric patients. However, the long-lasting effects of this treatment have not been studied. This single-center prospective trial determined the long-term effects of 1 year of oxandrolone administration in severely burned children; assessments were continued for up to 4 years post therapy. STUDY DESIGN Patients 0 to 18 years old with burns covering >30% of the total body surface area were randomized to receive placebo (n = 152) or oxandrolone, 0.1 mg/kg twice daily for 12 months (n = 70). At hospital discharge, patients were randomized to a 12-week exercise program or to standard of care. Resting energy expenditure, standing height, weight, lean body mass, muscle strength, bone mineral content (BMC), cardiac work, rate pressure product, sexual maturation, and concentrations of serum inflammatory cytokines, hormones, and liver enzymes were monitored. RESULTS Oxandrolone substantially decreased resting energy expenditure and rate pressure product, increased insulin-like growth factor-1 secretion during the first year after burn injury, and, in combination with exercise, increased lean body mass and muscle strength considerably. Oxandrolone-treated children exhibited improved height percentile and BMC content compared with controls. The maximal effect of oxandrolone was found in children aged 7 to 18 years. No deleterious side effects were attributed to long-term administration. CONCLUSIONS Administration of oxandrolone improves long-term recovery of severely burned children in height, BMC, cardiac work, and muscle strength; the increase in BMC is likely to occur by means of insulin-like growth factor-1. These benefits persist for up to 5 years post burn.
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Affiliation(s)
- Laura J Porro
- Shriners Hospitals for Children-Galveston, Galveston, TX 77550, USA
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Jeschke MG, Williams FN, Finnerty CC, Rodriguez NA, Kulp GA, Ferrando A, Norbury WB, Suman OE, Kraft R, Branski LK, Al-mousawi AM, Herndon DN. The effect of ketoconazole on post-burn inflammation, hypermetabolism and clinical outcomes. PLoS One 2012; 7:e35465. [PMID: 22606232 PMCID: PMC3350497 DOI: 10.1371/journal.pone.0035465] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 03/19/2012] [Indexed: 11/19/2022] Open
Abstract
Background Hypercortisolemia has been suggested as a primary hormonal mediator of whole-body catabolism following severe burn injury. Ketoconazole, an anti-fungal agent, inhibits cortisol synthesis. We, therefore, studied the effect of ketoconazole on post-burn cortisol levels and the hyper-catabolic response in a prospective randomized trial (block randomization 2∶1). Methodology/Principal Findings Fifty-five severely burned pediatric patients with >30% total body surface area (TBSA) burns were enrolled in this trial. Patients were randomized to receive standard care plus either placebo (controls, n = 38) or ketoconazole (n = 23). Demographics, clinical data, serum hormone levels, serum cytokine expression profiles, organ function, hypermetabolism measures, muscle protein synthesis, incidence of wound infection sepsis, and body composition were obtained throughout the acute hospital course. Statistical analysis was performed using Fisher’s exact test, Student’s t-test, and parametric and non-parametric two-way repeated measures analysis of variance where applicable. Patients were similar in demographics, age, and TBSA burned. Ketoconazole effectively blocked cortisol production, as indicated by normalization of the 8-fold elevation in urine cortisol levels [F(1, 376) = 85.34, p<.001] with the initiation of treatment. However, there were no significant differences in the inflammatory response, acute-phase proteins, body composition, muscle protein breakdown or synthesis, or organ function between groups. Conclusions Both groups were markedly hypermetabolic and catabolic throughout the acute hospital stay. Normalization of hypercortisolemia with ketoconazole therapy had no effect on whole-body catabolism or the post-burn inflammatory or hypermetabolic response, suggesting that hypercortisolemia does not play a central role in the post-burn hypermetabolic catabolic response. Trial Registration ClinicalTrials.gov NCT00675714; and NCT00673309
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Affiliation(s)
- Marc G. Jeschke
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Felicia N. Williams
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Celeste C. Finnerty
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
- Institute for Translational Sciences and the Sealy Center for Molecular Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Noe A. Rodriguez
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Gabriela A. Kulp
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Arny Ferrando
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - William B. Norbury
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Oscar E. Suman
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Robert Kraft
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Ludwik K. Branski
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Ahmed M. Al-mousawi
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - David N. Herndon
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
- * E-mail:
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Jeschke MG, Gauglitz GG, Kulp GA, Finnerty CC, Williams FN, Kraft R, Suman OE, Mlcak RP, Herndon DN. Long-term persistance of the pathophysiologic response to severe burn injury. PLoS One 2011; 6:e21245. [PMID: 21789167 PMCID: PMC3138751 DOI: 10.1371/journal.pone.0021245] [Citation(s) in RCA: 408] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 05/24/2011] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Marc G Jeschke
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America.
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Tuvdendorj D, Chinkes DL, Zhang XJ, Suman OE, Aarsland A, Ferrando A, Kulp GA, Jeschke MG, Wolfe RR, Herndon DN. Long-term oxandrolone treatment increases muscle protein net deposition via improving amino acid utilization in pediatric patients 6 months after burn injury. Surgery 2011; 149:645-53. [PMID: 21333314 DOI: 10.1016/j.surg.2010.12.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 12/07/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND We recently showed that mechanisms of protein turnover in skeletal muscle are unresponsive to amino acid (AA) infusion in severely burned pediatric patients at 6 months postinjury. In the current study, we evaluated whether oxandrolone treatment affects mechanisms of protein turnover in skeletal muscle and whole-body protein breakdown in pediatric burn patients 6 months postinjury. METHODS At the time of admission, patients were randomized to control or oxandrolone treatments. The treatment regimens were continued until 6 months postinjury, at which time patients (n = 26) underwent study with a stable isotope tracer infusion to measure muscle and whole-body protein turnover. RESULTS Protein kinetics in leg muscle were expressed in nmol/min per 100 mL leg volume (mean ± SE). During AA infusion, rates of protein synthesis in leg muscle were increased (P < .05) in both groups (basal vs AA: control, 51 ± 8 vs 86 ± 21; oxandrolone, 56 ± 7 vs 96 ± 12). In the control group, there was also a simultaneous increase in breakdown (basal vs AA: 65 ± 10 vs 89 ± 25), which resulted in no change in the net balance of leg muscle protein (basal vs AA: -15 ± 4 vs -2 ± 10). In the oxandrolone group, protein breakdown did not change (basal vs AA: 80 ± 12 vs 77 ± 9), leading to increased net balance (basal vs AA: -24 ± 7 vs 19 ± 7; P < .05). Protein breakdown at the whole-body level was not different between the groups. CONCLUSION Long-term oxandrolone treatment increased net deposition of leg muscle protein during AA infusion by attenuating protein breakdown, but did not affect whole-body protein breakdown.
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Affiliation(s)
- Demidmaa Tuvdendorj
- Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555-1220, USA
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Jeschke MG, Kulp GA, Kraft R, Finnerty CC, Mlcak R, Lee JO, Herndon DN. Intensive insulin therapy in severely burned pediatric patients: a prospective randomized trial. Am J Respir Crit Care Med 2010; 182:351-9. [PMID: 20395554 DOI: 10.1164/rccm.201002-0190oc] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Hyperglycemia and insulin resistance have been shown to increase morbidity and mortality in severely burned patients, and glycemic control appears essential to improve clinical outcomes. However, to date no prospective randomized study exists that determines whether intensive insulin therapy is associated with improved post-burn morbidity and mortality. OBJECTIVES To determine whether intensive insulin therapy is associated with improved post-burn morbidity. METHODS A total of 239 severely burned pediatric patients with burns over greater than 30% of their total body surface area were randomized (block randomization 1:3) to intensive insulin treatment (n = 60) or control (n = 179). MEASUREMENTS AND MAIN RESULTS Demographics, clinical outcomes, sepsis, glucose metabolism, organ function, and inflammatory, acute-phase, and hypermetabolic responses were determined. Demographics were similar in both groups. Intensive insulin treatment significantly decreased the incidence of infections and sepsis compared with controls (P < 0.05). Furthermore, intensive insulin therapy improved organ function as indicated by improved serum markers, DENVER2 scores, and ultrasound (P < 0.05). Intensive insulin therapy alleviated post-burn insulin resistance and the vast catabolic response of the body (P < 0.05). Intensive insulin treatment dampened inflammatory and acute-phase responses by deceasing IL-6 and acute-phase proteins compared with controls (P < 0.05). Mortality was 4% in the intensive insulin therapy group and 11% in the control group (P = 0.14). CONCLUSIONS In this prospective randomized clinical trial, we showed that intensive insulin therapy improves post-burn morbidity. Clinical trial registered with www.clinicaltrials.gov (NCT00673309).
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Affiliation(s)
- Marc G Jeschke
- Shriners Hospitals for Children, Galveston, TX 77550, USA.
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Williams FN, Herndon DN, Jeschke MG. The hypermetabolic response to burn injury and interventions to modify this response. Clin Plast Surg 2009; 36:583-96. [PMID: 19793553 PMCID: PMC3776603 DOI: 10.1016/j.cps.2009.05.001] [Citation(s) in RCA: 141] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Severe burn injury is followed by a profound hypermetabolic response that persists up to 24 months after injury. It is mediated by up to 50-fold elevations in plasma catecholamines, cortisol, and inflammatory cells that lead to whole-body catabolism, elevated resting energy expenditures, and multiorgan dysfunction. All of these metabolic and physiologic derangements prevent full rehabilitation and acclimatization of burn survivors back into society. Modulation of the response by early excision and grafting of burn wounds, thermoregulation, early and continuous enteral feeding with high-protein high-carbohydrate feedings, and pharmacologic treatments have markedly decreased morbidity.
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Affiliation(s)
- Felicia N Williams
- NIH Research Fellow, Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - David N Herndon
- Professor, Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
- Shriners Hospitals for Children, Galveston, Texas
| | - Marc G Jeschke
- Associate Professor, Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
- Shriners Hospitals for Children, Galveston, Texas
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The hepatic response to thermal injury: is the liver important for postburn outcomes? Mol Med 2009; 15:337-51. [PMID: 19603107 DOI: 10.2119/molmed.2009.00005] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 04/03/2009] [Indexed: 12/11/2022] Open
Abstract
Thermal injury produces a profound hypermetabolic and hypercatabolic stress response characterized by increased endogenous glucose production via gluconeogenesis and glycogenolysis, lipolysis, and proteolysis. The liver is the central body organ involved in these metabolic responses. It is suggested that the liver, with its metabolic, inflammatory, immune, and acute phase functions, plays a pivotal role in patient survival and recovery by modulating multiple pathways following thermal injury. Studies have evaluated the role and function of the liver during the postburn response and showed that liver integrity and function are essential for survival, and that hepatic acute phase proteins are strong predictors for postburn survival. This review discusses these studies and delineates the pivotal role of the liver in patients following severe thermal injury.
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Williams FN, Jeschke MG, Chinkes DL, Suman OE, Branski LK, Herndon DN. Modulation of the hypermetabolic response to trauma: temperature, nutrition, and drugs. J Am Coll Surg 2009; 208:489-502. [PMID: 19476781 PMCID: PMC3775552 DOI: 10.1016/j.jamcollsurg.2009.01.022] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 01/14/2009] [Indexed: 12/21/2022]
Affiliation(s)
- Felicia N Williams
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
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