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Barth H, Worek F, Steinritz D, Papatheodorou P, Huber-Lang M. Trauma-toxicology: concepts, causes, complications. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2935-2948. [PMID: 37999755 PMCID: PMC11074020 DOI: 10.1007/s00210-023-02845-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023]
Abstract
Trauma and toxic substances are connected in several aspects. On the one hand, toxic substances can be the reason for traumatic injuries in the context of accidental or violent and criminal circumstances. Examples for the first scenario is the release of toxic gases, chemicals, and particles during house fires, and for the second scenario, the use of chemical or biological weapons in the context of terroristic activities. Toxic substances can cause or enhance severe, life-threatening trauma, as described in this review for various chemical warfare, by inducing a tissue trauma accompanied by break down of important barriers in the body, such as the blood-air or the blood-gut barriers. This in turn initiates a "vicious circle" as the contribution of inflammatory responses to the traumatic damage enhances the macro- and micro-barrier breakdown and often results in fatal outcome. The development of sophisticated methods for detection and identification of toxic substances as well as the special treatment of the intoxicated trauma patient is summarized in this review. Moreover, some highly toxic substances, such as the protein toxins from the pathogenic bacterium Clostridioides (C.) difficile, cause severe post-traumatic complications which significantly worsens the outcome of hospitalized patients, in particular in multiply injured trauma patients. Therefore, novel pharmacological options for the treatment of such patients are necessarily needed and one promising strategy might be the neutralization of the toxins that cause the disease. This review summarizes recent findings on the molecular and cellular mechanisms of toxic chemicals and bacterial toxins that contribute to barrier breakdown in the human body as wells pharmacological options for treatment, in particular in the context of intoxicated trauma patients. "trauma-toxicology" comprises concepts regrading basic research, development of novel pharmacological/therapeutic options and clinical aspects in the complex interplay and "vicious circle" of severe tissue trauma, barrier breakdown, pathogen and toxin exposure, tissue damage, and subsequent clinical complications.
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Affiliation(s)
- Holger Barth
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Center, Ulm, Germany.
| | - Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Dirk Steinritz
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Panagiotis Papatheodorou
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Center, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, University of Ulm Medical Center, Ulm, Germany.
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Niu Z, Wei G, Liang H, Wang X, Yang W, Wei G, Guo J, Chen Y, Tao R, Niu J. Bioinformatics-Led Identification of Potential Biomarkers and Inflammatory Infiltrates in Burn Injury. J Burn Care Res 2023; 44:1382-1392. [PMID: 37022972 DOI: 10.1093/jbcr/irad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Indexed: 04/07/2023]
Abstract
Burn injury is a life-threatening disease with a poor prognosis. The immune change and underlying mechanisms remain largely unknown. Thus, this study aims to find potential biomarkers and analyze the immune infiltrates after burn injury. Gene expression data of burn patients were obtained from the Gene Expression Omnibus database. Key immune-related genes (IRGs) were screened by differential and least absolute shrinkage and selection operator (LASSO) regression analysis. Based on key IRGs, patients were divided into two clusters by consensus cluster analysis. Immune infiltration was analyzed by the single sample gene set enrichment analysis (GSEA) method and the immune score was calculated by the principal component analysis method. A nomogram model was constructed based on the calculated immune score and clinical features. Finally, the expression of screened key genes was validated by an external cohort and quantitative polymerase chain reaction experiment. Fifty-nine IRGs were differently expressed in burn patients. After LASSO regression analysis, 12 key genes remained, namely AZU1, OLR1, RNASE2, FGF13, NR1D2, NR2E1, TLR5, CAMP, DEFA4, PGLYRP1, CTSG, and CCR3. Then, patients were divided into two clusters. Immune infiltration analysis revealed that more immune cells were infiltrated and more pathways were activated in cluster A, in which patients showed high immune scores. Finally, a nomogram model was constructed and showed high accuracy and reliability. The expression pattern of 12 key genes in an external cohort and clinical samples was in accordance with the theoretical analysis results. In conclusion, this research elucidated the key role of immune response in burns and could be used as a guide for burn treatment.
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Affiliation(s)
- Zehao Niu
- Department of Burns and Plastic surgery, The 83 Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
- Department of Plastic and Reconstructive Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guoxing Wei
- Department of Burns and Plastic surgery, The 83 Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Hao Liang
- Department of Burns and Plastic surgery, The 83 Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Xin Wang
- PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Wenjuan Yang
- Department of Burns and Plastic surgery, The 83 Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Gang Wei
- Department of Burns and Plastic surgery, The 83 Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Jiachang Guo
- Department of Burns and Plastic surgery, The 83 Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Yingen Chen
- Department of Cardiology, The First Affiliated Hospital of Xinxiang Medical University, Heart Center of Xinxiang Medical University, Xinxiang, China
| | - Ran Tao
- Department of Plastic and Reconstructive Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun Niu
- Department of Burns and Plastic surgery, The 83 Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
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Walrath T, Najarro KM, Giesy LE, Khair S, Frank DN, Robertson CE, Orlicky DJ, Quillinan N, Idrovo JP, McMahan RH, Kovacs EJ. REMOTE BURN INJURY IN AGED MICE INDUCES COLONIC LYMPHOID AGGREGATE EXPANSION AND DYSBIOSIS OF THE FECAL MICROBIOME WHICH CORRELATES WITH NEUROINFLAMMATION. Shock 2023; 60:585-593. [PMID: 37548929 PMCID: PMC10581426 DOI: 10.1097/shk.0000000000002202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/02/2023] [Accepted: 07/28/2023] [Indexed: 08/08/2023]
Abstract
ABSTRACT The Earth's population is aging, and by 2050, one of six people will be 65 years or older. Therefore, proper treatment of injuries that disproportionately impact people of advanced age will be more important. Clinical studies reveal people 65 years or older account for 16.5% of all burn injuries and experience higher morbidity, including neurocognitive decline, and mortality that we and others believe are mediated, in part, by heightened intestinal permeability. Herein, we used our clinically relevant model of scald burn injury in young and aged mice to determine whether age and burn injury cooperate to induce heightened colonic damage, alterations to the fecal microbiome, and whether resultant changes in the microbiome correlate with neuroinflammation. We found that aged, burn-injured mice have an increase in colonic lymphoid aggregates, inflammation, and proinflammatory chemokine expression when compared with young groups and sham-injured aged mice. We then performed fecal microbiota sequencing and found a striking reduction in gut protective bacterial taxa, including Akkermansia , in the aged burn group compared with all other groups. This reduction correlated with an increase in serum fluorescein isothiocyanate-Dextran administered by gavage, indicating heightened intestinal permeability. Furthermore, loss of Akkermansia was highly correlated with increased messenger RNA expression of neuroinflammatory markers in the brain, including chemokine ligand 2, TNF-α, CXC motif ligand 1, and S100 calcium-binding protein A8. Finally, we discovered that postburn alterations in the microbiome correlated with measures of strength in all treatment groups, and those that performed better on the rotarod and hanging wire tests had higher abundance of Akkermansia than those that performed worse. Taken together, these findings indicate that loss of protective bacteria after burn injury in aged mice contributes to alterations in the colon, gut leakiness, neuroinflammation, and strength. Therefore, supplementation of protective bacteria, such as Akkermansia , after burn injury in aged patients may have therapeutic benefit.
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Affiliation(s)
- Travis Walrath
- Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Kevin M. Najarro
- Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Lauren E. Giesy
- Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Shanawaj Khair
- Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Molecular Biology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Medical Scientist Training Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Daniel N. Frank
- Department of Medicine, Division of Infectious Disease, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Charles E. Robertson
- Department of Medicine, Division of Infectious Disease, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - David J. Orlicky
- Department of Pathology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Nidia Quillinan
- Department of Anesthesiology, Neuronal Injury Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Juan-Pablo Idrovo
- Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Rachel H. McMahan
- Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Elizabeth J. Kovacs
- Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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Horseman TS, Frank AM, Shupp JW, Burmeister DM. Meta-Analysis of Publicly Available Clinical and Preclinical Microbiome Data From Studies of Burn Injury. J Burn Care Res 2023; 44:1041-1050. [PMID: 37352011 DOI: 10.1093/jbcr/irad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 06/25/2023]
Abstract
Following burn injury, alterations in host commensal microbiota across body spaces may leave patients susceptible to opportunistic pathogens and serious sequelae such as sepsis. Generally, studies examining the microbiome postburn have had a limited sample size and lack of longitudinal data, which coupled with experimental and analytic variation, impacts overall interpretation. We performed a meta-analysis of publicly available sequencing data from preclinical and clinical burn studies to determine if there were consistent alterations in the microbiome across various anatomical sites and hosts. Ten human and animal 16S rRNA sequencing studies spanning respiratory, urinary, cutaneous, and gastrointestinal microbiomes were included. Taxonomic classification and alpha and beta diversity metrics were analyzed using QIIME2 v2021.8. Alpha diversity was consistently higher in control samples compared to burn-injured samples which were also different based on host and anatomical location; however, phylogenetic evaluation (ie, Faith PD) elucidated more significant differences compared to taxonomic metrics (ie, Shannon entropy). Beta diversity analysis based on weighted UniFrac showed that rodent specimens clustered less closely to humans than pig samples for both rectal and skin sources. Host species and performing institute were found to have a significant impact on community structure. In rectal samples, bacterial composition in pig and human burn samples included Bacteroidetes, Firmicutes, and Proteobacteria, while rodent samples were dominated by Firmicutes. Proteobacteria and Firmicutes increased on burned skin in each host species. Our results suggest that host species and the performing institute strongly influence microbiome structure. Burn-induced alterations in microbiome diversity and taxa exist across hosts, with phylogenetic metrics more valuable than others. Coordinated, multicenter studies, both clinical and preclinical, within the burn community are needed to more completely realize the diagnostic and therapeutic potential of the microbiome for improving outcomes postburn.
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Affiliation(s)
- Timothy S Horseman
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Andrew M Frank
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeffrey W Shupp
- The Burn Center, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - David M Burmeister
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Taylor JZ, Fong DL, Habenicht LM, Fink MK, Leszczynski JK, Frank DN, Kofonow JM, Robertson CE, Nicklawsky AG, Schurr MJ, Manuel CA. Effects of Extended Cage Component Sanitation Interval on the Microenvironment, Health, and Gastrointestinal Microbiome of Rats ( Rattus norvegicus). JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2023; 62:212-221. [PMID: 37072181 PMCID: PMC10230543 DOI: 10.30802/aalas-jaalas-22-000113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/10/2023] [Accepted: 02/20/2023] [Indexed: 04/20/2023]
Abstract
Washing and sanitizing rodent cage components requires costly equipment, significant personnel effort, and use of natural resources. The benchmark frequency for sanitation of individually ventilated caging (IVC) has traditionally been every 2 wk. In this study, we investigated the effects of extending this interval on the cage microenvironment, basic markers of health, and the gastrointestinal microbiota of rats. We compared our institutional standard of changing the sanitation interval for rat cage lids, box feeders, and enrichment devices from every 4 wk to an interval of 12 wk. The cage bottom and bedding continued to be changed every 2 wk for both groups. We hypothesized that we would find no significant difference between our current practice of 4 wks and continuous use for 12 wk. Our data showed that intracage ammonia levels remained below 5 ppm for most cages in both groups, with the exception of cages that experienced a cage flood. We found no significant difference between groups in bacterial colony forming units (CFU) on cage components. We used 3 novel methods of assessing cleanliness of enrichment devices and found no significant effect of continuous use for 12 wk on the number of CFU. In addition, we found no significant differences between groups for animal weight, routine blood work, or fecal and cecal microbiomes. These data indicate that a sanitation interval of up to 12 wk for components of rat IVC caging has no significant effects on the microenvironment or health of rats. Using the longer interval will improve efficiency, reduce the use of natural resources, and decrease costs while maintaining high-quality animal care.
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Affiliation(s)
- Jazmyne Z Taylor
- Office of Laboratory Animal Resources, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Derek L Fong
- Office of Laboratory Animal Resources, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Department of Pathology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Lauren M Habenicht
- Office of Laboratory Animal Resources, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Department of Pathology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Michael K Fink
- Office of Laboratory Animal Resources, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Department of Pathology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Jori K Leszczynski
- Office of Laboratory Animal Resources, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Department of Pathology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Daniel N Frank
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jennifer M Kofonow
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Charles E Robertson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Andrew G Nicklawsky
- University of Colorado Cancer Center Biostatistics Core, Aurora, Colorado; and
| | - Michael J Schurr
- Department of Immunology and Microbiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Christopher A Manuel
- Office of Laboratory Animal Resources, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Department of Pathology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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McMahan RH, Hulsebus HJ, Najarro KM, Giesy LE, Frank DN, Kovacs EJ. Changes in gut microbiome correlate with intestinal barrier dysfunction and inflammation following a 3-day ethanol exposure in aged mice. Alcohol 2023; 107:136-143. [PMID: 36150609 DOI: 10.1016/j.alcohol.2022.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/17/2022] [Accepted: 08/25/2022] [Indexed: 11/01/2022]
Abstract
Alcohol use among older adults is on the rise. This increase is clinically relevant as older adults are at risk for increased morbidity and mortality from many alcohol-related chronic diseases compared to younger patients. However, little is known regarding the synergistic effects of alcohol and age. There are intriguing data suggesting that aging may lead to impaired intestinal barrier integrity and dysbiosis of the intestinal microbiome, which could increase susceptibility to alcohol's negative effects. To study the effects of alcohol in age we exposed aged and young mice to 3 days of moderate ethanol and evaluated changes in gut parameters. We found that these levels of drinking do not have obvious effects in young mice but cause significant alcohol-induced gut barrier dysfunction and expression of the pro-inflammatory cytokine TNFα in aged mice. Ethanol-induced downregulation of expression of the gut-protective antimicrobial peptides Defa-rs1, Reg3b, and Reg3g was observed in aged, but not young mice. Analysis of the fecal microbiome revealed age-associated shifts in microbial taxa, which correlated with intestinal and hepatic inflammatory gene expression. Taken together, these data demonstrate that age drives microbiome dysbiosis, while ethanol exposure in aged mice induces changes in the expression of antimicrobial genes important for separating these potentially damaging microbes from the intestinal lumen. These changes highlight potential mechanistic targets for prevention of the age-related exacerbation of effects of ethanol on the gut.
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Affiliation(s)
- Rachel H McMahan
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States; GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States.
| | - Holly J Hulsebus
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States; Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Kevin M Najarro
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Lauren E Giesy
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Daniel N Frank
- GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States; GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States; Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States
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Colbert JF, Kirsch JM, Erzen CL, Langouët-Astrié CJ, Thompson GE, McMurtry SA, Kofonow JM, Robertson CE, Kovacs EJ, Sullivan RC, Hippensteel JA, Sawant NV, De Nisco NJ, McCollister BD, Schwartz RS, Horswill AR, Frank DN, Duerkop BA, Schmidt EP. Aging-associated augmentation of gut microbiome virulence capability drives sepsis severity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.10.523523. [PMID: 36711447 PMCID: PMC9882086 DOI: 10.1101/2023.01.10.523523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Prior research has focused on host factors as mediators of exaggerated sepsis-associated morbidity and mortality in older adults. This focus on the host, however, has failed to identify therapies that improve sepsis outcomes in the elderly. We hypothesized that the increased susceptibility of the aging population to sepsis is not only a function of the host, but also reflects longevity-associated changes in the virulence of gut pathobionts. We utilized two complementary models of gut microbiota-induced experimental sepsis to establish the aged gut microbiome as a key pathophysiologic driver of heightened disease severity. Further murine and human investigations into these polymicrobial bacterial communities demonstrated that age was associated with only subtle shifts in ecological composition, but an overabundance of genomic virulence factors that have functional consequence on host immune evasion. One Sentence Summary The severity of sepsis in the aged host is in part mediated by longevity-associated increases in gut microbial virulence.
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Huang Z, Huang Y, Chen J, Tang Z, Chen Y, Liu H, Huang M, Qing L, Li L, Wang Q, Jia B. The role and therapeutic potential of gut microbiome in severe burn. Front Cell Infect Microbiol 2022; 12:974259. [DOI: 10.3389/fcimb.2022.974259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/21/2022] [Indexed: 11/19/2022] Open
Abstract
Severe burn is a serious acute trauma that can lead to significant complications such as sepsis, multiple organ failure, and high mortality worldwide. The gut microbiome, the largest microbial reservoir in the human body, plays a significant role in this pathogenic process. Intestinal dysbiosis and disruption of the intestinal mucosal barrier are common after severe burn, leading to bacterial translocation to the bloodstream and other organs of the body, which is associated with many subsequent severe complications. The progression of some intestinal diseases can be improved by modulating the composition of gut microbiota and the levels of its metabolites, which also provides a promising direction for post-burn treatment. In this article, we summarised the studies describing changes in the gut microbiome after severe burn, as well as changes in the function of the intestinal mucosal barrier. Additionally, we presented the potential and challenges of microbial therapy, which may provide microbial therapy strategies for severe burn.
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Walrath T, McMahan RH, Idrovo JP, Quillinan N, Kovacs EJ. Cutaneous burn injury induces neuroinflammation and reactive astrocyte activation in the hippocampus of aged mice. Exp Gerontol 2022; 169:111975. [PMID: 36208823 DOI: 10.1016/j.exger.2022.111975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND By 2050, one in six people globally will be 65 or older. Confusion and delirium are significant complications after burn injury, especially in the elderly population. The etiology is still unknown, however complications may be driven by pro-inflammatory activation of astrocytes within the hippocampus (HPC) after burn injury. Reduced levels of phosphorylated cyclic-AMP response binding element (pCREB), caused by elevated systemic pro-inflammatory cytokines, could lead to cognitive decline and memory impairment. METHODS To examine the effects of remote injury on neuroinflammation in advanced age, young and aged mice were subjected to a 15 % total body surface area scald burn or sham injury, and euthanized after 24 h. Expression of ccl2 and tnfa were measured by qPCR in the whole brain and HPC. Astrocyte activation was measured by immunofluorescence within the HPC. pCREB was measured by immunohistochemistry in the dentate gyrus. RESULTS We saw an 80-fold increase in ccl2 and a 30-fold elevation in tnfa after injury in the whole brain of aged mice compared to young groups and aged sham mice (p < 0.05 and p < 0.05, respectively). Additionally, there was a 30-fold increase in ccl2 within isolated HPC of aged injured mice when compared to sham injured animals (p < 0.05). When investigating specific HPC regions, immunofluorescence staining showed a >20 % rise in glial fibrillary acidic protein (GFAP) positive astrocytes within the cornu ammonis 3 (CA3) of aged injured mice when compared to all other groups (p < 0.05). Lastly, we observed a >20 % decrease in pCREB staining by immunohistochemistry in the dentate gyrus of aged mice compared to young regardless of injury (p < 0.05). CONCLUSIONS These novel data suggest that remote injury in aged, but not young, mice is associated with neuroinflammation and astrocyte activation within the HPC. These factors, paired with an age related reduction in pCREB, could help explain the increased cognitive decline seen in burn patients of advanced age. To our knowledge, we are the first group to examine the impact of advanced age combined with burn injury on inflammation and astrocyte activation within the brain.
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Affiliation(s)
- Travis Walrath
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Rachel H McMahan
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Juan-Pablo Idrovo
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Nidia Quillinan
- Department of Anesthesiology, Neuronal Injury Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America.
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Manuel CA, Johnson LK, Pugazhenthi U, Fong DL, Fink M, Habenicht LM, Leszczynski JK, Diana IR, Schurr MJ, Frank DN. Effect of Antimicrobial Prophylaxis on Corynebacterium bovis Infection and the Skin Microbiome of Immunodeficient Mice. Comp Med 2022; 72:78-89. [PMID: 35379380 PMCID: PMC9084569 DOI: 10.30802/aalas-cm-21-000082] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/21/2021] [Accepted: 12/22/2021] [Indexed: 11/05/2022]
Abstract
Corynebacterium bovis is an opportunistic pathogen of the skin of immunodeficient mice and is sensitive to oral antibiotics that reach therapeutic blood concentrations. However, prophylactic antibiotics are considered to be ineffective at preventing C. bovis infection. In addition, the effect of C. bovis on the skin microbiome (SM) of common immunodeficient mouse strains has yet to be characterized. Consequently, we evaluated whether oral prophylactic antibiotics prevent C. bovis infection after inoculation. An infectious dose of C. bovis was applied to the skin of Hsd:Athymic Nude (nude) and NOD. Cg-Prkdcscid Il2rgtm1Wjl/SzJ (NSG) mice. Mice were then housed individually and assigned randomly to receive either untreated drinking water (Cb+Abx-group) or prophylactic amoxicillin-clavulanic acid in the drinking water (0.375 mg/mL) for 14 d (Cb+Abx+group). A third treatment group of each mouse strain was uninoculated and untreated (Cb-Abx-group). Mice from all groups were serially sampled by using dermal swabs to monitor C. bovis infection via quantitative real-time PCR and the SM via 16S rRNA sequence analysis. Fourteen days of prophylactic antibiotics prevented the perpetuation of C. bovis skin infection in both strains. Only the combination of C. bovis inoculation and oral antibiotics (Cb+Abx+) significantly affected the SM of NSG mice at day 14; this effect resolved by the end of the study (day 70). In mice that did not receive antibiotics, C. bovis significantly altered the SM of nude mice but not NSG mice at days 14 and 70. These findings demonstrate the potential benefit of prophylactic antibiotics for prevention of C. bovis infection. However, indirect effect of antibiotics on commensal bacteria and potential effects on xenograft models must be considered.
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Affiliation(s)
- Christopher A Manuel
- Office of Laboratory Animal Resources, University of Colorado Cancer Center, Aurora, CO; Department of Pathology, University of Colorado Cancer Center, Aurora, CO; University of Colorado Cancer Center, Aurora, CO;,
| | - Linda K Johnson
- Department of Pathology, University of Colorado Cancer Center, Aurora, CO; Deceased
| | - Uma Pugazhenthi
- Division of Endocrinology, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Derek L Fong
- Office of Laboratory Animal Resources, University of Colorado Cancer Center, Aurora, CO; Department of Pathology, University of Colorado Cancer Center, Aurora, CO
| | - Michaelk Fink
- Office of Laboratory Animal Resources, University of Colorado Cancer Center, Aurora, CO; Department of Pathology; University of Colorado Cancer Center, Aurora, CO
| | - Lauren M Habenicht
- Office of Laboratory Animal Resources, University of Colorado Cancer Center, Aurora, CO; Department of Pathology, University of Colorado Cancer Center, Aurora, CO
| | - Jori K Leszczynski
- Office of Laboratory Animal Resources, University of Colorado Cancer Center, Aurora, CO; Department of Pathology, University of Colorado Cancer Center, Aurora, CO
| | - I R Diana
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Michael J Schurr
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Daniel N Frank
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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11
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McMahan RH, Hulsebus HJ, Najarro KM, Giesy LE, Frank DN, Orlicky DJ, Kovacs EJ. Age-Related Intestinal Dysbiosis and Enrichment of Gut-specific Bacteria in the Lung Are Associated With Increased Susceptibility to Streptococcus pneumoniae Infection in Mice. FRONTIERS IN AGING 2022; 3:859991. [PMID: 35392033 PMCID: PMC8986162 DOI: 10.3389/fragi.2022.859991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 02/18/2022] [Indexed: 01/09/2023]
Abstract
The portion of the global population that is over the age of 65 is growing rapidly and this presents a number of clinical complications, as the aged population is at higher risk for various diseases, including infection. For example, advanced age is a risk factor for heightened morbidity and mortality following infection with Streptococcus pneumoniae. This increased vulnerability is due, at least in part, to age-related dysregulation of the immune response, a phenomenon termed immunosenescence. However, our understanding of the mechanisms influencing the immunosenescent state and its effects on the innate immune response to pneumonia remain incomplete. Recently, a role for the gut microbiome in age-specific alterations in immunity has been described. Here, we utilized a murine model of intranasal Streptococcus pneumoniae infection to investigate the effects of age on both the innate immune response and the intestinal microbial populations after infection. In aged mice, compared to their younger counterparts, infection with Streptococcus pneumoniae led to increased mortality, impaired lung function and inadequate bacterial control. This poor response to infection was associated with increased influx of neutrophils into the lungs of aged mice 24 h after infection. The exacerbated pulmonary immune response was not associated with increased pro-inflammatory cytokines in the lung compared to young mice but instead heightened expression of immune cell recruiting chemokines by lung neutrophils. Bacterial 16S-rRNA gene sequencing of the fecal microbiome of aged and young-infected mice revealed expansion of Enterobacteriaceae in the feces of aged, but not young mice, after infection. We also saw elevated levels of gut-derived bacteria in the lung of aged-infected mice, including the potentially pathogenic symbiote Escherichia coli. Taken together, these results reveal that, when compared to young mice, Streptococcus pneumoniae infection in age leads to increased lung neutrophilia along with potentially pathogenic alterations in commensal bacteria and highlight potential mechanistic targets contributing to the increased morbidity and mortality observed in infections in age.
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Affiliation(s)
- Rachel H. McMahan
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Aurora, CO, United States
- GI and Liver Innate Immune Program, University of Colorado Denver, Aurora, CO, United States
| | - Holly J. Hulsebus
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Aurora, CO, United States
- Immunology Graduate Program, University of Colorado Denver, Aurora, CO, United States
| | - Kevin M. Najarro
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Aurora, CO, United States
| | - Lauren E. Giesy
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Aurora, CO, United States
| | - Daniel N. Frank
- GI and Liver Innate Immune Program, University of Colorado Denver, Aurora, CO, United States
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, United States
| | - David J. Orlicky
- GI and Liver Innate Immune Program, University of Colorado Denver, Aurora, CO, United States
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elizabeth J. Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, Burn Research Program, University of Colorado Denver, Aurora, CO, United States
- GI and Liver Innate Immune Program, University of Colorado Denver, Aurora, CO, United States
- Immunology Graduate Program, University of Colorado Denver, Aurora, CO, United States
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12
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Najarro KM, Boe DM, Walrath TM, Mullen JE, Paul MT, Frankel JH, Hulsebus HJ, Idrovo JP, McMahan RH, Kovacs EJ. Advanced age exacerbates intestinal epithelial permeability after burn injury in mice. Exp Gerontol 2022; 158:111654. [PMID: 34915110 PMCID: PMC9188353 DOI: 10.1016/j.exger.2021.111654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Advanced age is an independent risk factor for morbidity and mortality after burn injury. Following burn, the intestines can become permeable leading to the leakage of bacteria and their products from the lumen of the ileum to the portal and systemic circulation. Here, we sought to determine the effects of advanced age on intestinal permeability post burn injury and assess intestinal inflammatory biomarkers. METHODS Young (4-5 months) and aged (18-22 months) female BALB/cBy mice were subjected to a 12-15% total body surface area (TBSA) sham or burn injury. 24 h after injury, mice were euthanized, and organs collected. Colony-forming units (CFU) were counted from plated mesenteric lymph nodes (MLN). Gene expression of ileal tight junctional proteins, occludin and zonula occludens 1 (ZO-1), in addition to ileal damage associated molecular pattern (DAMP) proteins, S100A8 and S100A9, as well as ileal inflammatory markers IL-6 and TNF-α were measured by qPCR. Intestinal cell death was measured by ELISA. Intestinal permeability was determined by FITC fluorescence in serum; 4kD FITC-dextran was given by oral gavage 3 h before euthanasia. RESULTS Aged mice subjected to burn injury had increased intestinal permeability as evidenced by a 5.8-fold higher level of FITC-dextran in their serum when compared to all other groups (p < 0.05). In addition, aged burn-injured mice exhibited heightened bacterial accumulation in the MLN with a 15.5-fold increase over all other groups (p < 0.05). Histology of ileum failed to show differences in villus length among all groups. Analysis of ileal tight junctional proteins and inflammatory marker gene expression revealed no difference in Ocln, Tjp1, Il6, or Tnf expression among all groups, but 2.3 and 2.9-fold upregulation of S100a8 and S100a9, respectively, in aged burn-injured mice relative to both young groups and aged sham-injured mice (p < 0.05). Lastly, cell death in the ileum was elevated more than two-fold in aged burn-injured mice relative to young animals regardless of injury (p < 0.05). CONCLUSIONS These data demonstrate that advanced age exacerbates intestinal epithelial permeability after burn injury. Heightened apoptosis may be responsible for the elevated intestinal leakiness and accumulation of bacteria in mesenteric lymph nodes. In addition, S100a8/9 may serve as a biomarker of elevated inflammation within the intestine.
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Affiliation(s)
- Kevin M. Najarro
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Devin M. Boe
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America,Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America,Medical Scientist Training Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States of America
| | - Travis M. Walrath
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Juliet E. Mullen
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Madison T. Paul
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - John H. Frankel
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Holly J. Hulsebus
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America,Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Juan-Pablo Idrovo
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Rachel H. McMahan
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America,GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Elizabeth J. Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Burn Research Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America,Immunology Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America,Medical Scientist Training Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, United States of America,GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, United States of America,Corresponding author at: Department of Surgery, GITES, University of Colorado Denver/Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, Aurora, CO 80045, United States of America. (E.J. Kovacs)
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13
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Dyamenahalli K, Choy K, Frank DN, Najarro K, Boe D, Colborn KL, Idrovo JP, Wagner AL, Wiktor AJ, Afshar M, Burnham EL, McMahan RH, Kovacs EJ. Age and Injury Size Influence the Magnitude of Fecal Dysbiosis in Adult Burn Patients. J Burn Care Res 2022; 43:1145-1153. [PMID: 35020913 PMCID: PMC9435505 DOI: 10.1093/jbcr/irac001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Clinical studies have demonstrated that age 50 years or older is an independent risk factor associated with poor prognosis after burn injury, the second leading cause of traumatic injuries in the aged population. While mechanisms driving age-dependent postburn mortality are perplexing, changes in the intestinal microbiome, may contribute to the heightened, dysregulated systemic response seen in aging burn patients. The fecal microbiome from 22 patients admitted to a verified burn center from July 2018 to February 2019 was stratified based on the age of 50 years and total burn surface area (TBSA) size of ≥10%. Significant differences (P = .014) in overall microbiota community composition (ie, beta diversity) were measured across the four patient groups: young <10% TBSA, young ≥10% TBSA, older <10% TBSA, and older ≥10% TBSA. Differences in beta diversity were driven by %TBSA (P = .013) and trended with age (P = .087). Alpha diversity components, richness, evenness, and Shannon diversity were measured. We observed significant differences in bacterial species evenness (P = .0023) and Shannon diversity (P = .0033) between the groups. There were significant correlations between individual bacterial species and levels of short-chain fatty acids. Specifically, levels of fecal butyrate correlated with the presence of Enterobacteriaceae, an opportunistic gut pathogen, when elevated in burn patients lead to worsen outcomes. Overall, our findings reveal that age-specific changes in the fecal microbiome following burn injuries may contribute to immune system dysregulation in patients with varying TBSA burns and potentially lead to worsened clinical outcomes with heightened morbidity and mortality.
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Affiliation(s)
| | | | - Daniel N Frank
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, USA,Gastrointestinal and Liver and Innate Immunity Program, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kevin Najarro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA,Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System Research Service, Aurora, USA
| | - Devin Boe
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Juan-Pablo Idrovo
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Anne L Wagner
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Arek J Wiktor
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Majid Afshar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Ellen L Burnham
- Department of Medicine, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Rachel H McMahan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, USA,Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System Research Service, Aurora, USA
| | - Elizabeth J Kovacs
- Address correspondence to Elizabeth J. Kovacs, PhD, Department of Surgery, GITES, University of Colorado Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, Aurora, CO 80045, USA.
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14
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McMahan RH, Najarro KM, Mullen JE, Paul MT, Orlicky DJ, Hulsebus HJ, Kovacs EJ. A novel murine model of multi-day moderate ethanol exposure reveals increased intestinal dysfunction and liver inflammation with age. IMMUNITY & AGEING 2021; 18:37. [PMID: 34556145 PMCID: PMC8459518 DOI: 10.1186/s12979-021-00247-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/08/2021] [Indexed: 12/23/2022]
Abstract
Background There are currently > 600 million people over the age of 65 globally and this number is expected to double by the year 2050. Alcohol use among this population is on the rise, which is concerning as aging is associated with increased risk for a number of chronic illnesses. As most studies investigating the effects of alcohol have focused on young/middle-aged populations, there is a dearth of information regarding the consequences of alcohol use in older consumers. In addition, most murine ethanol models have concentrated on exposure to very high levels of ethanol, while the vast majority of elderly drinkers do not consume alcohol in excess; instead, they drink on average 2 alcoholic beverages a day, 3–4 days a week. Methods We designed a murine model of aging and moderate ethanol consumption to determine if the deleterious effects of alcohol on the gut-liver axis are exacerbated in aged, relative to younger, animals. Aged and young mice were exposed to a multi-day moderate exposure ethanol regimen for 4 weeks and changes in gut permeability along with intestinal tight junction protein and antimicrobial peptide gene expression were measured. In addition, hepatic inflammation was assessed by histological analysis, inflammatory gene expression and flow cytometric analysis of inflammatory infiltrate. Results Our results reveal that in aged, but not young mice, moderate ethanol exposure yielded significantly worsened intestinal permeability, including increased bacterial translocation from the gut, elevated serum iFABP and leakage of FITC-dextran from the gut. Interestingly, moderate ethanol exposure in young animals led to gut protective transcriptional changes in the ileum while this protective response was blunted in aged mice. Finally, moderate ethanol exposure in aged mice also resulted in marked inflammatory changes in the liver. Conclusions These results demonstrate that aged mice are more susceptible to ethanol-induced gut barrier dysfunction and liver inflammation, even at moderate doses of ethanol. This increased vulnerability to ethanol’s gastrointestinal effects has important implications for alcohol use in the aging population. Future studies will explore whether improving intestinal barrier function can reverse these age-related changes.
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Affiliation(s)
- Rachel H McMahan
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, University of Colorado Denver, Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, CO, 80045, Aurora, USA. .,GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, 80045, USA.
| | - Kevin M Najarro
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, University of Colorado Denver, Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, CO, 80045, Aurora, USA
| | - Juliet E Mullen
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, University of Colorado Denver, Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, CO, 80045, Aurora, USA
| | - Madison T Paul
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, University of Colorado Denver, Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, CO, 80045, Aurora, USA
| | - David J Orlicky
- Department of Pathology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Holly J Hulsebus
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, University of Colorado Denver, Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, CO, 80045, Aurora, USA.,Department of Immunology and Microbiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, and Alcohol Research Program, University of Colorado Denver, Anschutz Medical Campus, 12700 East 19th Ave, RC2, Mail Stop #8620, CO, 80045, Aurora, USA.,GI and Liver Innate Immune Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, 80045, USA.,Department of Immunology and Microbiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, 80045, USA
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15
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Abstract
ABSTRACT Burn injuries are a common form of traumatic injury that leads to significant morbidity and mortality worldwide. Burn injuries are characterized by inflammatory processes and alterations in numerous organ systems and functions. Recently, it has become apparent that the gastrointestinal bacterial microbiome is a key component of regulating the immune response and recovery from burn and can also contribute to significant detrimental sequelae after injury, such as sepsis and multiple organ failure. Microbial dysbiosis has been linked to multiple disease states; however, its role in exacerbating acute traumatic injuries, such as burn, is poorly understood. In this article, we review studies that document changes in the intestinal microbiome after burn injury, assess the implications in post-burn pathogenesis, and the potential for further discovery and research.
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Affiliation(s)
- Marisa E. Luck
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Caroline J. Herrnreiter
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Biochemistry and Molecular Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Mashkoor A. Choudhry
- Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
- Biochemistry and Molecular Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
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16
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Abstract
INTRODUCTION While recent reports underscore the significance of the gut microbiome (GM) in health and disease, its importance in burn outcomes remains unclear. Moreover, aggressive intravenous (IV) fluid resuscitation of patients may alter intestinal flora. Herein, we describe GM changes following a large burn in swine randomized to different volumes of IV Lactated Ringers' (LR). METHODS Anesthetized Yorkshire swine sustained 40% total body surface area full-thickness burns and were randomized to different volumes of IV LR: none (n = 5), 15 mL/kg/d (low; n = 6), or 80 mL/kg/d (high; n = 6). At baseline and days 1 and 2, fecal swabs were collected for 16s rDNA sequencing. Proximal jejunum was collected immediately after euthanasia (day 2) for western blot, histopathology, and cytokine analyses. RESULTS Burns produced significant shifts in β-diversity and non-significant reductions in α-diversity that did not recover regardless of treatment group. Burn-induced increases in Proteobacteria and decreases in Firmicutes were attenuated by IV fluids in a dose-dependent manner, and also correlated with α-diversity. IV fluids caused a dose-dependent increase in Bacteroides and prevented a transient increase in the opportunistic pathogen Haemophilus parainfluenzae. While high volumes of IV fluids increased intestinal Hsp70 levels (P = 0.0464), they reduced SGLT1 (P = 0.0213) and caspase3 (P = 0.0139) levels. IV fluids elicited a non-specific cytokine response; however, Bacteroidetes levels correlated with intestinal IL18 levels (P = 0.0166, R = 0.4201). CONCLUSIONS We present the first report on the gut microbiome in a porcine burn model, and present data to suggest that IV fluids may influence GM and gut functional proteins following a burn. Overall, burn-induced GM diversity shifts may expose diagnostic and/or therapeutic targets to improve outcomes.
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17
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Idrovo JP, Boe DM, Kaahui S, Walrath T, McMahan RH, Kovacs EJ. Advanced age heightens hepatic damage in a murine model of scald burn injury. J Trauma Acute Care Surg 2021; 90:731-737. [PMID: 33306599 PMCID: PMC7979479 DOI: 10.1097/ta.0000000000003048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Elderly burn patients exhibit a lower survival rate compared with younger counterparts. The liver is susceptible to damage after burn injury, which predisposes to poor outcomes. Lipid homeostasis and the antioxidant glutathione system play fundamental roles in preserving liver integrity. Herein, we explored changes in these major pathways associated with liver damage in the aging animals after burn injury. METHODS We compared liver enzymes, histology, lipid-peroxidation, and glutathione-metabolism profiles from young and aged female mice after a 15% total body surface area burn. Mice were euthanized at 24 hours after injury, and livers and serum were collected. RESULTS Aged burn animals exhibited elevated (p < 0.05) aspartate aminotransferase and alanine aminotransferase levels and increased inflammatory cell infiltration, edema, and necrosis compared with their younger counterparts. The percentage of adipophilin-stained area in livers from young sham, young burn, aged sham, and aged burn groups was 10%, 44%, 16%, and 78% (p < 0.05), respectively. Liver malondialdehyde levels were 1.4 ± 0.5 nmol/mg, 2.06 ± 0.2 nmol/mg, 1.81 ± 0.12 nmol/mg, and 3.45 ± 0.2 nmol/mg (p < 0.05) in young sham, young burn, aged sham, and aged burn mice, respectively. Oxidized glutathione (GSSG) content increased 50% in the young burn, and 88% in aged burn animals compared with the young sham group (p < 0.05). The reduced glutathione GSH/GSSG ratio was significantly reduced by 54% in aged burn mice compared with young sham animals (p < 0.05). Furthermore, glutathione peroxidase gene expression showed a 96% decrease in the aged burn group compared with young sham mice (p < 0.05). CONCLUSION Aged burn animals exhibit severe liver damage from heightened lipid peroxidation and inadequate antioxidative response. The increased peroxidation is associated with abundant lipid deposits in hepatic tissue postburn and a weak antioxidative response due to hepatic glutathione peroxidase downregulation. Further studies will focus on the functional significance of these findings concerning hepatic homeostasis.
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Affiliation(s)
- Juan-Pablo Idrovo
- From the Division of G.I., Trauma, and Endocrine Surgery, (J.-P.I., D.M.B. S.K., T.W., R.H.M., E.J.K.), Division of Burn Research, Department of Surgery (D.M.B., T.W., R.H.M., E.J.K.), Department of Immunology and Microbiology (D.M.B., T.W., E.J.K.), Division of Alcohol Research, Department of Surgery (R.H.M., E.J.K.), University of Colorado, Aurora, Colorado
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18
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Mankowski RT, Thomas RM, Darden DB, Gharaibeh RZ, Hawkins RB, Cox MC, Apple C, Nacionales DC, Ungaro RF, Dirain ML, Moore FA, Leeuwenburgh C, Brakenridge SC, Clanton TL, Laitano O, Moldawer LL, Mohr AM, Efron PA. Septic Stability? Gut Microbiota in Young Adult Mice Maintains Overall Stability After Sepsis Compared to Old Adult Mice. Shock 2021; 55:519-525. [PMID: 32826817 PMCID: PMC7895866 DOI: 10.1097/shk.0000000000001648] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Older adults have worse outcomes after sepsis than young adults. Additionally, alterations of the gut microbiota have been demonstrated to contribute to sepsis-related mortality. We sought to determine if there were alterations in the gut microbiota with a novel sepsis model in old adult mice, which enter a state of persistent inflammation, immunosuppression, and catabolism (PICS), as compared with young adult mice, which recover with the sepsis model. METHODS Mixed sex old (∼20 mo) and young (∼4 mo) C57Bl/6J mice underwent cecal ligation and puncture with daily chronic stress (CLP+DCS) and were compared with naive age-matched controls. Mice were sacrificed at CLP+DCS day 7 and feces collected for bacterial DNA isolation. The V3-V4 hypervariable region was amplified, 16S rRNA gene sequencing performed, and cohorts compared. α-Diversity was assessed using Chao1 and Shannon indices using rarefied counts, and β-diversity was assessed using Bray-Curtis dissimilarity. RESULTS Naive old adult mice had significantly different α and β-diversity compared with naive adult young adult mice. After CLP+DCS, there was a significant shift in the α and β-diversity (FDR = 0.03 for both) of old adult mice (naive vs. CLP+DCS). However, no significant shift was displayed in the microbiota of young mice that underwent CLP+DCS in regards to α-diversity (FDR = 0.052) and β-diversity (FDR = 0.12), demonstrating a greater overall stability of their microbiota at 7 days despite the septic insult. The taxonomic changes in old mice undergoing CLP+DCS were dominated by decreased abundance of the order Clostridiales and genera Oscillospira. CONCLUSION Young adult mice maintain an overall microbiome stability 7 days after CLP+DCS after compared with old adult mice. The lack of microbiome stability could contribute to PICS and worse long-term outcomes in older adult sepsis survivors. Further studies are warranted to elucidate mechanistic pathways and potential therapeutics.
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Affiliation(s)
- Robert T. Mankowski
- Department of Aging and Geriatric Research; University of Florida College of Medicine; Gainesville, FL, USA
| | - Ryan M. Thomas
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
- Department of Molecular Genetics and Microbiology; University of Florida College of Medicine; Gainesville, FL, USA
- Section of General Surgery; North Florida/South Georgia Veterans Health System; Gainesville, FL, USA
| | - Dijoia B. Darden
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | | | - Russell B. Hawkins
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Michael C. Cox
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Camille Apple
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Dina C. Nacionales
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Ricardo F. Ungaro
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Marvin L. Dirain
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Fredrick A. Moore
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research; University of Florida College of Medicine; Gainesville, FL, USA
| | - Scott C. Brakenridge
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Thomas L. Clanton
- Department of Applied Physiology & Kinesiology; University of Florida College of Health and Human Performance; Gainesville, FL, USA
| | - Orlando Laitano
- Department of Applied Physiology & Kinesiology; University of Florida College of Health and Human Performance; Gainesville, FL, USA
| | - Lyle L. Moldawer
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Alicia M. Mohr
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
| | - Philip A. Efron
- Department of Aging and Geriatric Research; University of Florida College of Medicine; Gainesville, FL, USA
- Department of Surgery; University of Florida College of Medicine; Gainesville, FL, USA
- Department of Molecular Genetics and Microbiology; University of Florida College of Medicine; Gainesville, FL, USA
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Abstract
PURPOSE OF REVIEW Advances in the care of inhalational injuries have not kept pace with advances that have been seen in the treatment of cutaneous burns. There is not yet a standard of care for best outcomes for airway management of patients with known or suspected inhalational injuries. Clinicians must decide if to intubate the patient, and if so, whether to intubate early or late in their presentation. Unnecessary intubation affects morbidity and mortality. This review will summarize literature that highlights present practices in the treatment of patients with inhalation injuries. RECENT FINDINGS There have been promising investigations into biomarkers that can be used to quantify a patient's risk and better target therapies. Grading systems serve to better stratify the burn victim's prognosis and then direct their care. Special ventilator modes can assist in ventilating burn patients with inhalation injuries that experience difficulties in oxygenating. SUMMARY Inhalational injuries are a significant source of morbidity and mortality in thermally injured patients. Treatment modalities, such as modified ventilator settings, alteration in fluid resuscitation, and a standardized grading system may improve morbidity and mortality.
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Li X, Luck ME, Hammer AM, Cannon AR, Choudhry MA. 6-Formylindolo (3, 2-b) Carbazole (FICZ)-mediated protection of gut barrier is dependent on T cells in a mouse model of alcohol combined with burn injury. Biochim Biophys Acta Mol Basis Dis 2020; 1866:165901. [PMID: 32711051 PMCID: PMC7484351 DOI: 10.1016/j.bbadis.2020.165901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/14/2020] [Accepted: 07/17/2020] [Indexed: 12/22/2022]
Abstract
6-Formylindolo (3, 2-b) Carbazole (FICZ) is a ligand of aryl hydrocarbon receptor (AHR) which regulates Th17 release of IL-17 and IL-22 production. Earlier, we showed that ethanol combined with burn injury suppresses Th17 responses and disrupts intestinal barrier leading to increased gut bacterial growth and translocation. Since IL-22 is known for its role in intestinal barrier maintenance, we determined whether treatment of mice with FICZ restores T cell IL-22 release and protects intestine barrier following ethanol and burn injury. Wildtype and Rag1-/- mice were gavaged with ~2.9 g/kg ethanol or water, and given a ~12.5% total body surface area burn. Mice were given FICZ (5 μg) in resuscitation fluid. FICZ treatment of wildtype mice normalized IL-22 and IL-17 in lamina propria and spleen T cells, as well as increased CYP1A1 expression in spleen T cells. This was accompanied by improved gut motility, decreased copy number of small intestine total bacteria and Enterobacteriaceae, attenuation of intestinal tissue levels of IL-6, KC, IL-18, decreased apoptosis, and prevention of gut leakiness following ethanol and burn injury. However, FICZ treatment of Rag1-/- mice did not improve any of the parameters listed after ethanol and burn injury. Additional data generated using mice treated with recombinant IL-22 alone or in combination with anti-IL-18 antibody suggest that full protection of gut barrier integrity requires both IL-18 inhibition and IL-22 restoration following ethanol and burn injury. Together our findings suggest that AHR ligand FICZ may have better therapeutic potential for maintenance of gut barrier function after ethanol and burn injury.
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MESH Headings
- Animals
- Burns/drug therapy
- Burns/metabolism
- Carbazoles/therapeutic use
- Cytochrome P-450 CYP1A1/genetics
- Cytochrome P-450 CYP1A1/metabolism
- Cytokines/metabolism
- Disease Models, Animal
- Enzyme-Linked Immunosorbent Assay
- Ethanol/pharmacology
- Flow Cytometry
- Homeodomain Proteins/genetics
- Homeodomain Proteins/metabolism
- Interleukin-17/metabolism
- Interleukins/metabolism
- Intestinal Mucosa/drug effects
- Intestinal Mucosa/metabolism
- Intestinal Mucosa/microbiology
- Intestine, Small/drug effects
- Intestine, Small/metabolism
- Intestine, Small/microbiology
- Male
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Mucous Membrane/drug effects
- Mucous Membrane/metabolism
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Receptors, Aryl Hydrocarbon/genetics
- Receptors, Aryl Hydrocarbon/metabolism
- T-Lymphocytes/drug effects
- T-Lymphocytes/metabolism
- Interleukin-22
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Affiliation(s)
- Xiaoling Li
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Marisa E Luck
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Adam M Hammer
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Abigail R Cannon
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA
| | - Mashkoor A Choudhry
- Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Burn & Shock Trauma Research Institute, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Department of Surgery, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Department of Microbiology and Immunology, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA; Integrative Cell Biology Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL 60153, USA.
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21
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Corcione S, Lupia T, De Rosa FG. Microbiome in the setting of burn patients: implications for infections and clinical outcomes. BURNS & TRAUMA 2020; 8:tkaa033. [PMID: 32821744 PMCID: PMC7428410 DOI: 10.1093/burnst/tkaa033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/15/2020] [Indexed: 01/02/2023]
Abstract
Burn damage can lead to a state of immune dysregulation that facilitates the development of infections in patients. The most deleterious impact of this dysfunction is the loss of the skin’s natural protective barrier. Furthermore, the risk of infection is exacerbated by protracted hospitalization, urinary catheters, endotracheal intubation, inhalation injury, arterial lines and central venous access, among other mainstays of burn care. Currently, infections comprise the leading cause of mortality after major burn injuries, which highlights the improvements observed over the last 50 years in the care provided to burn victims. The need to implement the empirical selection of antibiotic therapy to treat multidrug-resistant bacteria may concomitantly lead to an overall pervasiveness of difficult-to-treat pathogens in burn centres, as well as the propagation of antimicrobial resistance and the ultimate dysregulation of a healthy microbiome. While preliminary studies are examining the variability and evolution of human and mice microbiota, both during the early and late phase burn injury, one must consider that abnormal microbiome conditions could influence the systemic inflammatory response. A better understanding of the changes in the post-burn microbiome might be useful to interpret the provenance and subsequent development of infections, as well as to come up with inferences on the prognosis of burn patients. This review aims to summarise the current findings describing the microbiological changes in different organs and systems of burn patients and how these alterations affect the risks of infections, complications, and, ultimately, healing.
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Affiliation(s)
- Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Italy
| | - Tommaso Lupia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Italy
| | - Francesco G De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, Italy
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22
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What's New in Shock, January 2020? Shock 2019; 53:1-4. [PMID: 31834257 DOI: 10.1097/shk.0000000000001447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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