Curbing inflammation in burn patients

Smoke, Scars, and Survival: A Six-Year Analysis of Burn Mortality in a Resource-Limited Appalachian ICU

BACKGROUND

 Despite recent advances in burn management, burn injuries remain a major global cause of morbidity and mortality, with rural and underserved populations, such as those in Appalachia, being disproportionately affected. Contributing factors include limited access to specialized care and a high prevalence of comorbidities. Understanding the prognostic factors associated with mortality in adult burn patients is critical for guiding clinical care and resource allocation, particularly in resource-limited settings.

METHODS

 This retrospective study analyzed data from adult burn patients aged 18 to 65 admitted to the only Burn Intensive Care Unit (BICU) in West Virginia, located at Cabell Huntington Hospital, between January 2017 and January 2023. A total of 748 patients were included. Variables analyzed included demographics, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease (COPD), smoking history, home oxygen use), injury characteristics (inhalation injury, total body surface area burned (TBSA)), and clinical outcomes (total hospital duration (THD), total ventilation duration (TVD)). Categorical and continuous variables were compared between survivors and non-survivors using chi-square and t-tests, respectively. Multivariate logistic regression was used to identify independent predictors of mortality.

RESULTS

 The cohort consisted of 748 patients with a mortality rate of 3.6% (n = 27). Non-survivors were significantly older (mean age 56.1 vs. 40.2 years, p < 0.001), had higher mean TBSA (28.3% vs. 6.3%, p < 0.001), longer hospital stays (15.3 vs. 8.9 days, p = 0.012), and longer ventilation durations (18.5 vs. 6.7 days, p < 0.001). Inhalation injury was present in 66.7% of deceased patients compared to 14.1% of survivors (p < 0.001). Comorbidities such as diabetes (51.9% vs. 12.5%, p < 0.001), COPD (63.0% vs. 12.3%, p < 0.001), and home oxygen use (55.6% vs. 8.2%, p < 0.001) were significantly more prevalent in non-survivors. Smoking was also significantly associated with mortality (81.5% vs. 45.9%, p = 0.001). In the logistic regression analysis, independent predictors of mortality included TBSA (OR 1.15 per 1% increase, 95% CI: 1.10-1.21, p < 0.001), TVD (OR 1.08 per day, 95% CI: 1.02-1.14, p = 0.009), smoking history (OR 2.34, 95% CI: 1.15-4.78, p = 0.018), and inhalation injury (OR 6.82, 95% CI: 3.94-11.81, p < 0.001). THD was inversely associated with mortality (OR 0.93, 95% CI: 0.88-0.98, p = 0.008), possibly reflecting early deaths in more severe cases.

CONCLUSIONS

 In this Appalachian cohort of adult burn patients, mortality was significantly associated with larger burn size, prolonged ventilation, inhalation injury, smoking, and comorbidities such as diabetes, COPD, and home oxygen use. These findings highlight the need for individualized, multidisciplinary care strategies in resource-limited rural settings. Efforts to standardize inhalation injury diagnostics and enhance access to burn care may improve outcomes. Future studies should focus on scalable interventions and policy changes to reduce disparities in burn care and improve survival in underserved populations.

Dual-Action flavonol carbonized polymer dots spray: Accelerating burn wound recovery through immune responses modulation and EMT induction

Effective immune homeostasis modulation and re-epithelialization promotion are crucial for accelerating burn wound healing. Cell migration is fundamental to re-epithelialization, with epithelial-mesenchymal transition (EMT) as a key mechanism. A sustained inflammatory environment or impaired macrophage transition to M2 phenotype can hinder pro-resolving cytokine activation, further delaying the recruitment, migration, and re-epithelialization of epidermal cells to the injury site, ultimately compromising wound healing. Herein, the bioactive flavonol quercetin is transformed into pharmacologically active carbonized polymer dots (Qu-CDs) spray with high water dispersibility, permeability and biocompatibility for full-thickness skin burns treatment. Qu-CDs spray can efficiently initiate macrophage reprogramming and promote the transition of macrophages from M1 to M2 phenotype, modulating immune responses and facilitating the shift from the inflammatory phase to re-epithelialization. Additionally, Qu-CDs spray can promote cell migration and re-epithelialization of wound edge epithelial cells by inducing an EMT process without growth factors, further accelerating the reconstruction of the normal epidermal barrier. Mechanistically, Qu-CDs spray activates the smad1/5 signaling pathway for promoting the EMT phenotype of wound edge epithelial cells. Overall, this study facilitates the construction of novel spray dosage form of pharmacologically active carbonized polymer dots with desired bioactivities for effective wound healing.

Role of MLIP in burn-induced sepsis and insights into sepsis-associated cancer progression

Introduction

Burn-induced sepsis is a critical clinical challenge marked by systemic inflammation, immune dysregulation, and high mortality. Macrophage-driven inflammatory pathways are central to sepsis pathogenesis, while immune cell metabolic reprogramming plays a key role in both sepsis and cancer progression.

Methods

Bioinformatics analyses using GEO, TCGA, and GTEx datasets identified MLIP-modulated genes linked to immune responses and prognosis. In vitro, LPS-stimulated HUVEC cells were used to study MLIP's effects on inflammation and macrophage function through cell viability, ROS levels, cytokine expression, qRT-PCR, and immunofluorescence assays.

Results

MLIP-modulated genes were associated with immune-related metabolic pathways in both sepsis and cancer. Epigenetic analysis showed MLIP expression is regulated by promoter methylation and chromatin accessibility. Prognostic analyses revealed MLIP's impact on survival outcomes across cancer types. In vitro, MLIP reduced inflammation, oxidative stress, and macrophage hyperactivation.

Conclusions

MLIP regulates immune-metabolic dynamics in burn-induced sepsis, influencing macrophage activity and oxidative stress. Its role in metabolic reprogramming suggests MLIP as a potential therapeutic target linking immune modulation and cancer progression. Further research on MLIP's role in immune evasion and tumor metabolism may inform novel therapeutic strategies.

Admission neutrophil-to-lymphocyte ratio to predict mortality in burn patients: a meta-analysis

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) proves to be a convenient and cost-effective marker with studies showing that a high NLR can serve as a mortality indicator in burn cases. We conducted a meta-analysis aiming to explore whether on-admission NLR values could serve as predictors of mortality in burn patients.

METHODS

PubMed, Web of Science, Scopus and Embase were searched from inception until January 2024. We included all studies investigating burn patients that contain information on the NLR value at the time of hospital admission and mortality outcomes. The studies were critically appraised using the NIH Quality Assessment Tool.

RESULTS

Nine studies fulfilled our criteria with a total population of 1837 participants, including 1526 survivor Burn patients and 311 non-survivor Burn patients. The overall mean difference measured by random model showed a significant increase in NLR by 5.06 (95% CI 3.42, 6.68) p ≤ 0.001 for the non-survivor group over the survivors group with heterogeneity I2 = 67.33%, p ≤ 0.001. A meta-regression was done to investigate the potential source of heterogeneity among studies. The results showed that age (p = 0.394), gender (p = 0.164), and sample size (p = 0.099) did not contribute to the source of heterogeneity, however, the burn surface area contributed significantly (p = 0.002). A leave-one-out meta-analysis was done, showing that omitting Le Qui et al., leads to significantly decrease the heterogeneity to be I2 = 2.73%. Meta-regression repeated to assess the burn surface area again to be found noncontributing (p = 0.404).

CONCLUSIONS

Our findings support that elevated NLR values can serve as a mortality indicator in burn cases. This will have a great clinical impact by aiding in stratifying the burn patients on admission.

IL-8 Induces Neutrophil Extracellular Trap Formation in Severe Thermal Injury

Neutrophil extracellular traps (NETs) have a dual role in the innate immune response to thermal injuries. NETs provide an early line of defence against infection. However, excessive NETosis can mediate the pathogenesis of immunothrombosis, disseminated intravascular coagulation (DIC) and multiple organ failure (MOF) in sepsis. Recent studies suggest that high interleukin-8 (IL-8) levels in intensive care unit (ICU) patients significantly contribute to excessive NET generation. This study aimed to determine whether IL-8 also mediates NET generation in patients with severe thermal injuries. IL-8 levels were measured in serum samples from thermally injured patients with ≥15% of the total body surface area (TBSA) and healthy controls (HC). Ex vivo NET generation was also investigated by treating isolated neutrophils with serum from thermal injured patients or normal serum with and without IL-8 and anti-IL-8 antibodies. IL-8 levels were significantly increased compared to HC on days 3 and 5 (p < 0.05) following thermal injury. IL-8 levels were also significantly increased at day 5 in septic versus non-septic patients (p < 0.001). IL-8 levels were also increased in patients who developed sepsis compared to HC at days 3, 5 and 7 (p < 0.001), day 10 (p < 0.05) and days 12 and 14 (p < 0.01). Serum containing either low, medium or high levels of IL-8 was shown to induce ex vivo NETosis in an IL-8-dependent manner. Furthermore, the inhibition of DNase activity in serum increased the NET-inducing activity of IL-8 in vitro by preventing NET degradation. IL-8 is a major contributor to NET formation in severe thermal injury and is increased in patients who develop sepsis. We confirmed that DNase is an important regulator of NET degradation but also a potential confounder within assays that measure serum-induced ex vivo NETosis.

Update on Hypermetabolism in Pediatric Burn Patients

Despite advancements in pediatric burn care, the profound hypermetabolic response associated with severe burns remains a multifaceted challenge throughout the continuum of care. Understanding the various physiologic disturbances that constitute hypermetabolism is crucial for a thorough evaluation and for implementing appropriate surgical and nonsurgical interventions. In this article, we describe the pathophysiology and treatment of hypermetabolism in pediatric burn patients with a focus on reducing resting energy requirements, minimizing infection, and optimizing nutrition for patients undergoing frequent surgical intervention.

Coenzyme Q10 supplementation in burn patients: a double-blind placebo-controlled randomized clinical trial

BACKGROUND

Burn injuries are important medical problems that, aside from skin damage, cause a systemic response including inflammation, oxidative stress, endocrine disorders, immune response, and hypermetabolic and catabolic responses which affect all the organs in the body. The aim of this study was to determine the effect of coenzyme Q10 (CoQ10) supplementation on inflammation, oxidative stress, and clinical outcomes in burn patients.

METHODS

In a double-blind placebo-controlled randomized clinical trial, 60 burn patients were randomly assigned to receive 100 mg CoQ10 three times a day (total 300 mg/day) or a placebo for 10 days. Inflammatory markers including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), oxidative stress markers including total antioxidant capacity (TAC), malondialdehyde (MDA) and superoxide dismutase (SOD) activity, fasting blood glucose (FBG), blood urea nitrogen (BUN), creatinine, white blood cells (WBC), and body temperature were assessed as primary outcomes and albumin, prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), other hematological parameters, blood pressure, O2 saturation, ICU duration, and 28-mortality rate were assessed as secondary outcomes.

RESULTS

Fifty-two participants completed the trial. CRP and ESR levels were not significantly different between CoQ10 and placebo groups at the end of the study (P = 0.550 and P = 0.306, respectively). No significant differences between groups were observed for TAC (P = 0.865), MDA (P = 0.692), and SOD activity (P = 0.633) as well. Administration of CoQ10 resulted in a significant increase in albumin levels compared to placebo (P = 0.031). There was no statistically significant difference between the two groups in other measured outcomes (P > 0.05).

CONCLUSION

Results showed that in patients with burn injury, CoQ10 administration had no effect on inflammatory markers and oxidative stress, although serum albumin levels were improved after supplementation. Further studies with albumin as the primary outcome are needed to confirm this finding.

The effect of Wharton's jelly-derived stem cells seeded/boron-loaded acellular scaffolds on the healing of full-thickness burn wounds in the rat model

Burn wounds are the most destructive and complicated type of skin or underlying soft tissue injury that are exacerbated by a prolonged inflammatory response. Several cell-based therapeutic systems through the culturing of potent stem cells on modified scaffolds have been developed to direct the burn healing challenges. In this context, a new regenerative platform based on boron (B) enriched-acellular sheep small intestine submucosa (AOSIS) scaffold was designed and used as a carrier for mesenchymal stem cells derived from Wharton's jelly (WJMSCs) aiming to promote the tissue healing in burn-induced rat models. hWJMSCs have been extracted from human extra-embryonic umbilical cord tissue. Thereafter, 96 third-degree burned Wistar male rats were divided into 4 groups. The animals that did not receive any treatment were considered as group A (control). Then, group B was treated just by AOSIS scaffold, group C was received cell-seeded AOSIS scaffold (hWJMSCs-AOSIS), and group D was covered by boron enriched-cell-AOSIS scaffold (B/hWJMSCs-AOSIS). Inflammatory factors, histopathological parameters, and the expression levels of epitheliogenic and angiogenic proteins were assessed on 5, 14 and 21 d post-wounding. Application of the B/hWJMSCs-AOSIS on full-thickness skin-burned wounds significantly reduced the volume of neutrophils and lymphocytes at day 21 post-burning, whilst the number of fibroblasts and blood vessels enhanced at this time. In addition, molecular and histological analysis of wounds over time further verified that the addition of boron promoted wound healing, with decreased inflammatory factors, stimulated vascularization, accelerated re-epithelialization, and enhanced expression levels of epitheliogenic genes. In addition, the boron incorporation amplified wound closure via increasing collagen deposition and fibroblast volume and activity. Therefore, this newly fabricated hWJMSCs/B-loaded scaffold can be used as a promising system to accelerate burn wound reconstruction through inflammatory regulation and angiogenesis stimulation.

Fibrosis in burns: an overview of mechanisms and therapies

Scar development remains a common occurrence and a major healthcare challenge affecting the lives of millions of patients annually. Severe injuries to the skin, such as burns can lead to pathological wound healing patterns, often characterized by dermal fibrosis or excessive scarring, and chronic inflammation. The two most common forms of fibrotic diseases following burn trauma are hypertrophic scars (HSCs) and keloids, which severely impact the patient's quality of life. Although the cellular and molecular mechanisms are similar, HSC and keloids have several distinct differences. In this review, we discuss the different forms of fibrosis that occur postburn injury, emphasizing how the extent of burn influences scar development. Moreover, we highlight how a systemic response induced by a burn injury drives wound fibrosis, including both the role of the inflammatory response, as well as the fate of fibroblast during skin healing. Finally, we list potential therapeutics aimed at alleviating pathological scar formation. An understanding of the mechanisms of postburn fibrosis will allow us to effectively move studies from bench to bedside.

Procalcitonin in the Post-Operative Burn Patient

Serum procalcitonin (PCT) is a biomarker used to diagnose sepsis and infection. Following invasive bacterial infection, PCT is detectable in peripheral blood. The aim of our study was to determine if there is a relationship between serum PCT post-burn wound debridement and burn-related sepsis. In total, 34 participants were recruited from 1 November 2019 to 31 July 2020. Serum PCT levels were drawn on days 0, 1, 2, and 3, with day 0 being the day of the surgery. Blood culture samples were drawn on days 0 and 3. Statistical analyses were performed using STATA©. Descriptive statistics were presented as the median for continuous data and frequencies for categorical data. A two-sample Wilcoxon-Mann-Whitney test was performed to assess the correlation between the PCT values and blood culture positivity. In all, 33 burn debridement procedures were completed, and 1 patient demised before surgery. The median age was 35.5 years; 61.8% were male. Four patients had comorbidities. There was a trend of higher PCT values from day 0 to day 3. The median PCT on day 0 was 3.30 µg/L (IQR 0.78-15.10), compared to day 3 PCT which was 5.15 µg/L (IQR 1.35-18.55). The median values for serum PCT for days 0 to 3 were above the normal threshold regardless of BC positivity. There was a statistically significant difference in the PCT levels between positive and negative BC, with a p value of 0.0087 for day 3 serum PCT. The findings indicate an association of a high serum PCT level with a positive blood culture in a burn patient post-debridement surgery. A higher numerical threshold/cut-off of serum PCT should be used for this cohort of patients, to aid in the diagnosis of sepsis. A cut-off value could not be determined due to the small sample size.

[Analysis of the risk factors of persistent inflammation-immunosuppression-catabolism syndrome in patients with extensive burns]

Objective: To investigate the risk factors and treatment outcome of persistent inflammation-immunosuppression-catabolism syndrome (PICS) in patients with extensive burns. Methods: A retrospective case series study was conducted. From January 2017 to December 2021, 220 patients with extensive burns who were admitted to Guangzhou Red Cross Hospital of Jinan University met the inclusion criteria, including 168 males and 52 females, aged 18-84 (43±14) years. According to the occurrence of PICS, the patients were divided into PICS group (84 patients) and non-PICS group (136 patients). The general data such as sex, age, complication of underlying diseases and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score on admission, sepsis-related organ failure evaluation (SOFA) scores on admission and 14 days post admission, and proportion of patients with mechanical ventilation over 48 h during treatment, special conditions such as total burn area, full-thickness burn area, proportion of patients admitted within 48 h post injury, and exposed deep wound area at the 30th day post injury, outcome indicators such as hospitalization day, total cost of hospital stay, number of surgeries, and death of patients in the 2 groups were collected and analyzed. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, and chi-square test. The multivariate logistic regression analysis was performed on the indicators with statistically significant differences between the two groups except for outcome indicators, and the independent risk factors influencing secondary PICS in patients with extensive burns were screened. Results: The APACHE Ⅱ and SOFA scores on admission, and proportion of patients with mechanical ventilation over 48 h during treatment of patients in PICS group were significantly higher than those in non-PICS group (t=6.78, Z=-4.75, χ2=4.74, respectively, P<0.05). There were no statistically significant differences in the rest of general data of patients between the two groups (P>0.05). The total burn area, full-thickness burn area, and exposed deep wound area at the 30th day post injury in PICS group were significantly greater than those in non-PICS group (t=6.29, Z=-7.25, Z=-8.73, P<0.05), the exposed deep wound areas at the 30th day post injury in PICS group and non-PICS group were respectively 25% (15%, 35%) total body surface area (TBSA) and 8% (0, 13%) TBSA, while the proportion of patients admitted within 48 h post injury was significantly lower than that in non-PICS group (χ2=6.13, P<0.05). The hospitalization day, total cost of hospital stay, and number of surgeries of patients in PICS group were significantly higher than those in non-PICS group (with Z values of -7.12, -8.48, and -6.87, respectively, P<0.05), while the deaths of patients in the 2 groups were similar (P>0.05). The APACHE Ⅱ score on admission and exposed deep wound area at the 30th day post injury both were the independent risk factors for PICS in patients with extensive burns (with odds ratios of 1.15 and 1.07, 95% confidence intervals of 1.06-1.25 and 1.05-1.10, respectively, P<0.05). Conclusions: The APACHE Ⅱ score on admission and exposed deep wound area at the 30th day post injury are the independent risk factors for PICS in patients with extensive burns. The patients with secondary PICS had good prognosis with more surgical intervention and hospitalization day, and higher total cost of hospital stay.

The Role of Serum Albumin Level during Hospitalization as a Predictor of Complications and Mortality in Children with Burns

Background

Serum albumin can function as a potential biomarker to determine the severity of the injury and clinical staging of children with burns. Therefore, in this study, we investigated the association between serum albumin level and complications and mortality rate in children with burns.

Methods

In this descriptive-analytic cross-sectional study, 85 patients younger than 18 years with burns who were admitted to Shahid Motahari hospital between 2021 and 2022 were studied. Demographic information, including patients' age, sex, weight, underlying diseases, medical information, albumin level, and C-reactive protein (CRP), was obtained from patient records. Patients were observed until discharge. The independent t-test, chi-square, Pearson correlation, and logistic regression were used for analysis and to examine the predictive role of albumin.

Results

Out of 85 patients, 47 and 38 were boys and girls, respectively. The mean age of the participants was 3.69 ± 3.09 years. The mean length of hospital stay was 2.3 days, with a median of 1.5 days. The mean percentage of burns was 23.44 ± 16.50, and burn grade 2 was the most common. A total of 25 patients (29.41%) were admitted to the intensive care unit (ICU), and 13 deaths (15.29%) were observed among the patients. The mean albumin level was significantly lower than in other patients with outcomes of pulmonary infection, sepsis, renal failure, ICU admission, and death (P < 0.001).

Conclusion

Serum Albumin has a significant predictive value in death, pulmonary infection, sepsis, admission to the ICU, and renal failure. Serum albumin may be a good prognostic marker associated with morbidity and mortality.

Burn-injured skin is marked by a prolonged local acute inflammatory response of innate immune cells and pro-inflammatory cytokines

The systemic and local immune response in burn patients is often extreme and derailed. As excessive inflammation can damage healthy tissues and slow down the healing process, modulation of inflammatory responses could limit complications and improve recovery. Due to its complexity, more detailed information on the immune effects of thermal injury is needed to improve patient outcomes. We therefore characterized and quantified subsets of immune cells and mediators present in human burn wound tissue (eschar), sampled at various time points. This study shows that after burn injury, the number of immune cells were persistently increased, unlike the normal wound healing process. There was an immediate, strong increase in neutrophils and a moderate increase in monocytes/macrophages and lymphocytes, especially in the second and third week post burn. The percentage of classical (CD14highCD16-) monocytes/macrophages demonstrated a steady decrease over time, whereas the proportion of intermediate (CD14highCD16+) monocytes/macrophages slowly increased. The absolute numbers of T cells, NK cells and B cells increased up to week 3, while the fraction of γδ T cells was increased only in week 1. Secretome profiling revealed high levels of chemokines and an overall pro-inflammatory cytokine milieu in burn tissue. The local burn immune response shows similarities to the systemic immune reaction, but differs in neutrophil maturity and lymphocyte composition. Altogether, the neutrophil surges, high levels of pro-inflammatory cytokines and limited immunosuppression might be key factors that prolong the inflammation phase and delay the wound healing process in burns.

The Role of the Immune System in Pediatric Burns: A Systematic Review

Burns are one of the most common causes of home injuries, characterized by serious damage to the skin and causing the death of affected tissues. In this review, we intended to collect information on the pathophysiological effects of burns in pediatric patients, with particular emphasis on local and systemic responses. A total of 92 articles were included in the review, and the time range of the searched articles was from 2000 to 2021. The occurrence of thermal injuries is a problem that requires special attention in pediatric patients who are still developing. Their exposure to various burns may cause disturbances in the immune response, not only in the area of tissue damage itself but also by disrupting the systemic immune response. The aspect of immunological mechanisms in burns requires further research, and in particular, it is important to focus on younger patients as the existence of subtle differences in wound healing between adults and children may significantly influence the treatment of pediatric patients.

Employing Cellulose Nanofiber-Based Hydrogels for Burn Dressing

The aim of this research was to fabricate a burn dressing in the form of hydrogel films constructed with cellulose nanofibers (CNF) that has pain-relieving properties, in addition to wound healing. In this study, the hydrogels were prepared in the form of film. For this, CNF at weight ratios of 1, 2, and 3 wt.%, 1 wt.% of hydroxyethyl cellulose (HEC), and citric acid (CA) crosslinker with 10 and 20 wt.% were used. FE-SEM analysis showed that the structure of the CNF was preserved after hydrogel preparation. Cationization of CNF by C₆H₁₄NOCl was confirmed by FTIR spectroscopy. The drug release analysis results showed a linear relationship between the amount of absorption and the concentration of the drug. The MTT test (assay protocol for cell viability and proliferation) showed the high effectiveness of cationization of CNF and confirmed the non-toxicity of the resulting hydrogels.

Multicentre, longitudinal, observational cohort study to examine the relationship between neutrophil function and sepsis in adults and children with severe thermal injuries: a protocol for the Scientific Investigation of the Biological Pathways Following Thermal Injury-2 (SIFTI-2) study

INTRODUCTION

Burn-induced changes in the phenotype and function of neutrophils, cells which provide front-line protection against rapidly dividing bacterial infections, are emerging as potential biomarkers for the early prediction of sepsis. In a longitudinal study of adult burns patients, we recently demonstrated that a combined measurement of neutrophil phagocytic capacity, immature granulocyte (IG) count and plasma cell-free DNA (cfDNA) levels on the day of injury gave good discriminatory power for the prediction of later sepsis development. However, limited by a small sample size, single-centre design and focus on adult burns patients, these biomarkers require prospective validation in a larger patient cohort. The Scientific Investigation of the Biological Pathways Following Thermal Injury-2 study aims to prospectively validate neutrophil phagocytic activity, IG count and plasma cfDNA levels as early prognostic biomarkers of sepsis in thermally injured adult and paediatric patients.

METHODS AND ANALYSIS

This multicentre, longitudinal, observational cohort study will enrol 245 paediatric and adult patients with moderate to severe burns within 24 hours of injury. Blood samples will be obtained at 19 postinjury time points (days 1-14, day 28, months 3, 6, 12 and 24) and analysed for neutrophil phagocytic activity, IG count and cfDNA levels. Patients will be screened daily for sepsis using the 2007 American Burn Association diagnostic criteria for sepsis. In addition, daily multiple organ dysfunction syndrome and Sequential Organ Failure Assessment Scores will be recorded relationships between neutrophil phagocytic activity, IG count and plasma cfDNA levels on day 1 of injury and the development of sepsis will be examined using logistic regression models.

ETHICS AND DISSEMINATION

This study received ethics approval from the West Midlands, Coventry and Warwickshire Research Ethics Committee (REC reference:16/WM/0217). Findings will be presented at national and international conferences, and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04693442.

Diagnostic importance of serum C-reactive protein and procalcitonin in sepsis after burn

INTRODUCTION

In this study, we investigated the usefulness of blood white blood cell (WBC), C-reactive protein (CRP) and Procalcitonin (PCT) levels with a clinical diagnosis of infection in patients with severe burns, with a bacterial culture (+) wound site, in patients with SIRS and sepsis.

MATERIALS AND METHODS

In the study, 23 patients with (+) burn wound culture hospitalized in the intensive care unit of Gazi Yaşargil Training and Research Hospital Burn Center burn between January 2016 and January 2021 were analyzed. While five of these patients were showing symptoms of SIRS. Sepsis was observed in five patients.

RESULTS

From 23 patients, 18 (78.3%) were male, and 5 (21.7%) were female. The majority of our patients were lived in rural areas. The average age of patients was 1,061±17,273 years. The wound culture results of the 23 patients were (+), mostly due to Staphylococcus aureus in 21.7% (n=5) and Staphylococcus epidermidis in 21.7% (n=5). PCT and CRP results did not statistically differ in patients with sepsis, SIRS and (+) wound culture.

CONCLUSION

The laboratory biomarkers WBC, CRP and PCT do not have a superior value in determining and monitoring infection processes in patients with serious burns.

High-Voltage, Pulsed Electric Fields Eliminate Pseudomonas aeruginosa Stable Infection in a Mouse Burn Model

Objective: The incidence of severe infectious complications after burn injury increases mortality by 40%. However, traditional approaches for managing burn infections are not always effective. High-voltage, pulsed electric field (PEF) treatment shortly after a burn injury has demonstrated an antimicrobial effect in vivo; however, the working parameters and long-term effects of PEF treatment have not yet been investigated. Approach: Nine sets of PEF parameters were investigated to optimize the applied voltage, pulse duration, and frequency or pulse repetition for disinfection of Pseudomonas aeruginosa infection in a stable mouse burn wound model. The bacterial load after PEF administration was monitored for 3 days through bioluminescence imaging. Histological assessments and inflammation response analyses were performed at 1 and 24 h after the therapy. Results: Among all tested PEF parameters, the best disinfection efficacy of P. aeruginosa infection was achieved with a combination of 500 V, 100 μs, and 200 pulses delivered at 3 Hz through two plate electrodes positioned 1 mm apart for up to 3 days after the injury. Histological examinations revealed fewer inflammatory signs in PEF-treated wounds compared with untreated infected burns. Moreover, the expression levels of multiple inflammatory-related cytokines (interleukin [IL]-1α/β, IL-6, IL-10, leukemia inhibitory factor [LIF], and tumor necrosis factor-alpha [TNF-α]), chemokines (macrophage inflammatory protein [MIP]-1α/β and monocyte chemoattractant protein-1 [MCP-1]), and inflammation-related factors (vascular endothelial growth factor [VEGF], macrophage colony-stimulating factor [M-CSF], and granulocyte-macrophage colony-stimulating factor [G-CSF]) were significantly decreased in the infected burn wound after PEF treatment. Innovation: We showed that PEF treatment on infected wounds reduces the P. aeruginosa load and modulates inflammatory responses. Conclusion: The data presented in this study suggest that PEF treatment is a potent candidate for antimicrobial therapy for P. aeruginosa burn infections.

Mathematical Modeling, In-Human Evaluation, and Analysis of Volume Kinetics and Kidney Function after Burn Injury and Resuscitation

OBJECTIVE

Existing burn resuscitation protocols exhibit a large variability in treatment efficacy. Hence, they must be further optimized based on comprehensive knowledge of burn pathophysiology. A physics-based mathematical model that can replicate physiological responses in diverse burn patients can serve as an attractive basis to perform non-clinical testing of burn resuscitation protocols and to expand knowledge on burn pathophysiology. We intend to develop, optimize, validate, and analyze a mathematical model to replicate physiological responses in burn patients.

METHODS

Using clinical datasets collected from 233 burn patients receiving burn resuscitation, we developed and validated a mathematical model applicable to computer-aided in-human burn resuscitation trial and knowledge expansion. Using the validated mathematical model, we examined possible physiological mechanisms responsible for the cohort-dependent differences in burn pathophysiology between younger versus older patients, female versus male patients, and patients with versus without inhalational injury.

RESULTS

We demonstrated that the mathematical model can replicate physiological responses in burn patients associated with wide demographic characteristics and injury severity, and that an increased inflammatory response to injury may be a key contributing factor in increasing the mortality risk of older patients and patients with inhalation injury via an increase in the fluid retention.

CONCLUSION

We developed and validated a physiologically plausible mathematical model of volume kinetic and kidney function after burn injury and resuscitation suited to in-human application.

SIGNIFICANCE

The mathematical model may provide an attractive platform to conduct non-clinical testing of burn resuscitation protocols and test new hypotheses on burn pathophysiology.

Population Pharmacokinetic Modeling and Simulations of Imipenem in Burn Patients With and Without Continuous Venovenous Hemofiltration in the Military Health System

Continuous venovenous hemofiltration (CVVH) is a life‐sustaining procedure in patients with severe burns and acute kidney injury. Physiologic changes from burn injury and use of CVVH may alter imipenem pharmacokinetics (PK). We aimed to compare imipenem clearance (CL) in burn patients with and without CVVH, determine the effect of burn on imipenem volume of distribution (CVVH, n = 12; no CVVH, n = 11), in combination with previously published models. Model qualification was performed with standard diagnostics and comparing predicted PK parameters/time‐concentration profiles with those in the existing literature. Monte Carlo simulations were conducted to evaluate the probability of target attainment. A 2‐compartment model best described the data. Utilizing albumin as a covariate on volume parameters and leveraging the clearance model from prior literature, our model predicted imipenem central volume and CL within a 10% margin of error across healthy, renally impaired, and burn populations. We provide direct comparison of imipenem CL in burn patients with and without CVVH. Notably, there was no significant difference. Large imipenem V_d in patients with severe burns is likely explained by increased capillary permeability, for which serum albumin may be a reasonable surrogate. Dosing 500 mg every 6 hours is adequate for burn patients on renally dosed CVVH; however, suspicion of augmented renal clearance or patients placed on CVVH without renal impairment may necessitate dosing of 1000 mg every 6 hours.

Zinc Oxide Nanoparticles Protected with Terpenoids as a Substance in Redox Imbalance Normalization in Burns

Preliminary protection of zinc oxide nanoparticles (ZnO NPs) with terpenoids such as betulin, its derivatives, and essential oils components has been proposed to produce gel-like oleophilic and hydrophilic formulations. We studied the properties of gel-like dispersions of ZnO NPs with immobilized terpenoids and their effects on the activity of LDH, GR, G6PDH, restoration of redox balance of co-enzyme pairs NAD+/NADH and NADP+/NADPH, as well as the activity of SOD, catalase, AlDH in erythrocytes in the treatment of burns in rats. Hysteresis loops on the rheograms of studied dispersions characterize their thixotropic properties. ZnO NPs with betulin diphosphate in the water-ethanol medium lead to a 20-fold increase in the hydrodynamic radius at pH 7.3 compared to the initial ZnO NPs, and facilitate the formation of Zn2+ ions and their penetration into the viable epidermis, unlike oleophilic dispersions. All dispersions reduce the healing time by one and a half times compared with the untreated control group, increase the activity of LDH, GR, G6PDH, SOD, catalase, AlDH, and contribute to the normalization of coenzyme balance. Normalization of the redox balance and wound state was more effective using hydrophilic dispersions due to Zn2 + penetration.

Glucose Metabolism in Burns-What Happens?

Severe burns represent an important challenge for patients and medical teams. They lead to profound metabolic alterations, trigger a systemic inflammatory response, crush the immune defense, impair the function of the heart, lungs, kidneys, liver, etc. The metabolism is shifted towards a hypermetabolic state, and this situation might persist for years after the burn, having deleterious consequences for the patient's health. Severely burned patients lack energy substrates and react in order to produce and maintain augmented levels of glucose, which is the fuel "ready to use" by cells. In this paper, we discuss biological substances that induce a hyperglycemic response, concur to insulin resistance, and determine cell disturbance after a severe burn. We also focus on the most effective agents that provide pharmacological modulations of the changes in glucose metabolism.

Molecular Changes Underlying Hypertrophic Scarring Following Burns Involve Specific Deregulations at All Wound Healing Stages (Inflammation, Proliferation and Maturation)

Excessive connective tissue accumulation, a hallmark of hypertrophic scaring, results in progressive deterioration of the structure and function of organs. It can also be seen during tumor growth and other fibroproliferative disorders. These processes result from a wide spectrum of cross-talks between mesenchymal, epithelial and inflammatory/immune cells that have not yet been fully understood. In the present review, we aimed to describe the molecular features of fibroblasts and their interactions with immune and epithelial cells and extracellular matrix. We also compared different types of fibroblasts and their roles in skin repair and regeneration following burn injury. In summary, here we briefly review molecular changes underlying hypertrophic scarring following burns throughout all basic wound healing stages, i.e. during inflammation, proliferation and maturation.

A novel human ex vivo skin model to study early local responses to burn injuries

Burn injuries initiate numerous processes such as heat shock response, inflammation and tissue regeneration. Reliable burn models are needed to elucidate the exact sequence of local events to be able to better predict when local inflammation triggers systemic inflammatory processes. In contrast to other ex vivo skin culture approaches, we used fresh abdominal skin explants to introduce contact burn injuries. Histological and ultrastructural analyses confirmed a partial-thickness burn pathology. Gene expression patterns and cytokine production profiles of key mediators of the local inflammation, heat shock response, and tissue regeneration were analyzed for 24 h after burn injury. We found significantly increased expression of factors involved in tissue regeneration and inflammation soon after burn injury. To investigate purely inflammation-mediated reactions we injected lipopolysaccharide into the dermis. In comparison to burn injury, lipopolysaccharide injection initiated an inflammatory response while expression patterns of heat shock and tissue regeneration genes were unaffected for the duration of the experiment. This novel ex vivo human skin model is suitable to study the local, early responses to skin injuries such as burns while maintaining an intact overall tissue structure and it gives valuable insights into local mechanisms at the very beginning of the wound healing process after burn injuries.

Incidence of Laryngotracheal Stenosis after Thermal Inhalation Airway Injury

Inhalation injury is independently associated with burn mortality, yet little information is available on the incidence, risk factors, or functional outcomes of thermal injury to the airway. In patients with thermal inhalation injury, we sought to define the incidence of laryngotracheal stenosis (LTS), delineate risk factors associated with LTS development, and assess long-term tracheostomy dependence as a proxy for laryngeal function. Retrospective cohort study of adult patients treated for thermal inhalation injury at a single institution burn critical care unit from 2012 to 2017. Eligible patients' records were assessed for LTS (laryngeal, subglottic, or tracheal stenosis). Patient characteristics, burn injury characteristics, and treatment-specific covariates were assessed. Descriptive statistics, Mann-Whitney U-tests, odds ratio, and chi-square tests compared LTS versus non-LTS groups. Of 129 patients with thermal inhalation injury during the study period, 8 (6.2%) developed LTS. When compared with the non-LTS group, patients with LTS had greater mean TBSA (mean 30.3, Interquartile Range 7-57.5 vs 10.5, Interquartile Range 0-15.12, P = .01), higher grade of inhalation injury (mean 2.63 vs 1.80, P = .05), longer duration of intubation (12.63 vs 5.44; P < .001), and greater inflammatory response (mean white blood cell count on presentation 25.8 vs 14.9, P = .02, mean hyperglycemia on presentation 176.4 vs 136.9, P = .01). LTS patients had a significantly higher rate of tracheostomy dependence at last follow-up (50 vs 1.7%, P < .001). Six percent of patients with thermal inhalation injury develop LTS. LTS was associated with more severe thermal airway injury, longer duration of intubation, and more severe initial host inflammation. Patients with inhalation injury and LTS are at high risk for tracheostomy dependence. In burn patients with thermal inhalation injury, laryngeal evaluation and directed therapy should be incorporated early into multispecialty pathways of care.

Pirfenidone regulates LPS mediated activation of neutrophils

Excessive inflammation or its absence may result in impaired wound healing. Neutrophils are among the first innate immune cells to arrive at the injury site. They participate in infection control and debris removal to initiate healing. If not timely resolved, neutrophils can cause excessive tissue inflammation and damage. Drugs with anti-inflammatory and anti-fibrotic effects are of promise for improving healing by balancing the primary defensive functions and excessive tissue damage actions. Of interest, pirfenidone (Pf), an FDA approved anti-fibrotic drug to treat idiopathic pulmonary fibrosis, has been shown to ameliorate inflammation in several animal models including mouse deep partial-thickness burn wounds. However, there is a lack of mechanistic insights into Pf drug action on inflammatory cells such as neutrophils. Here, we examined the treatment effects of Pf on LPS-stimulated neutrophils as a model of non-sterile inflammation. Firstly, Pf reduced chemotaxis and production of pro-inflammatory ROS, cytokines, and chemokines by LPS-activated neutrophils. Secondly, Pf increased anti-inflammatory IL-1RA and reduced neutrophil degranulation, phagocytosis, and NETosis. Thirdly, Pf affected downstream signaling kinases which might directly or indirectly influence neutrophil responses to LPS. In conclusion, the results suggest that Pf lessens the inflammatory phenotypes of LPS-activated neutrophils.

Complete Blood Count and Derived Indices: Evolution Pattern and Prognostic Value in Adult Burned Patients

Certain parameters of complete blood count (CBC) such as red cell distribution width (RDW) and mean platelet volume, as well as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and RDW-to-platelet ratio (RPR) have been associated with inflammatory status and outcome in diverse medical conditions. The aim of this study was to describe the evolution pattern of these parameters in adult burned patients. Adult burned patients admitted to the National Burn Center in Uruguay between May 2017 and February 2018 (discovery cohort) and between March 2018 and August 2019 (validation cohort) were included. Patients' characteristics and outcomes were recorded, as well as CBC parameters on days 1, 3, 5, and 7 after thermal injury. Eighty-eight patients were included in the discovery cohort. Total body surface area burned was 14 [7-23]% and mortality was 15%. Nonsurvivors presented higher RDW and mean platelet volume (P < .01). NLR decreased after admission in all patients (P < .01), but was higher in nonsurvivors (P < .01). Deceased patients also presented higher RPR on days 3, 5, and 7 (P < .001). On the contrary, PLR was reduced in nonsurvivors (P < .05). There was a significant correlation between NLR on admission and burn extension and severity. Kaplan-Meier analysis revealed that NLR, PLR, and RPR could identify patients with increased mortality. These findings were confirmed in the validation cohort (n = 95). Basic CBC parameters and derived indices could be useful as biomarkers to determine prognosis in adults with thermal injuries.

Kefir Accelerates Burn Wound Healing Through Inducing Fibroblast Cell Migration In Vitro and Modulating the Expression of IL-1ß, TGF-ß1, and bFGF Genes In Vivo

Kefir is a natural probiotic compound with a long history of health benefits which can improve wound healing. This study investigated the regeneration potential of kefir in vitro scratch assay and in vivo burn wound in rat model. Cytotoxicity of different concentrations of kefir was evaluated by colorimetric methylthiazoltetrazolium assay. A scratch wound experiment was performed to investigate the ability of kefir in reducing the gap of wounds in a dose-dependent manner, in vitro. The standardized kefir was incorporated into silver sulfadiazine (SSD) and applied on burn wounds in vivo, and was compared with the SSD and negative control groups after 7, 14, and 28 days of treatment. The wound sites were then removed for histopathological and morphometric analyses, assessment of interleukin-1β (IL-1β), transforming growth factor-β1 (TGF-β1), basic fibroblast growth factor (bFGF), dry weight, and hydroxyproline contents. Kefir enhanced proliferation and migration of human dermal fibroblast (HDF) cells and 12.50, 6.25, and 3.12 μL/mL concentrations showed better effects on the scratch assay. Kefir resulted in reduction of IL-1β and TGF-β1 expression at day 7 compared to the negative control. Kefir also reduced the expression of IL-1β at days 14 and 28 and stimulated bFGF at day 28. It significantly improved the dry matter and hydroxyproline contents in the burn wounds. Kefir also resulted in enhanced angiogenesis and elevated migration and proliferation of fibroblasts and improved fibrous connective tissue formation in the wound area. The morphometric results indicated significant global contraction values in the kefir-treated wounds compared to other groups. Taken together, the findings suggest that kefir has considerable ability to accelerate healing of the burn wounds. Therefore, kefir may be a possible option to improve the outcomes of severe burns.

Comparison of botulinum toxin type A and aprotinin monotherapy with combination therapy in healing of burn wounds in an animal model

Burns are one of the most common injuries that are complicated by many challenges including infection, severe inflammatory response, excessive expression of proteases, and scar formation. The aim of this study was to investigate the effect of botulinum toxin type A (BO) and aprotinin (AP) separately or in combination (BO-AP) in healing process. Four burn wounds were created in each rat and randomly filled with silver sulfadiazine (SSD), BO, AP and BO-AP. The rats were euthanized after 7, 14, and 28 days, and their harvested wound samples were evaluated by gross pathology, histopathology, gene expression, biochemical testing, and scanning electron microscopy. Both BO and AP significantly reduced expression of interleukin-1β (IL-1β) and transforming growth factor-β1 (TGF-β1) at the 7th post wounding day. Moreover, they inhibited scar formation by reducing the TGF-β1 level and increasing basic fibroblast growth factor (bFGF) at the 28th day. AP by decreasing protease production showed more effective role than BO in wound regeneration. AP increased tissue organization and maturation and improved cosmetic appearance of wounds, at 28 days. The best results gained when combination of BO and AP were used in healing of burn wounds. Treatment by BO-AP significantly subsided inflammation compared to the BO, AP, and SSD treated wounds. Treatment with BO-AP also reduced collagen density and led to minimal scar formation. Combination of botulinum toxin type A and aprotinin considerably increased structural and functional properties of the healing wounds by reducing scar formation and decreasing production of proteases.

Burn-Induced Impairment of Ileal Muscle Contractility Is Associated with Increased Extracellular Matrix Components

INTRODUCTION

Severe burns lead to marked impairment of gastrointestinal motility, such as delayed gastric emptying and small and large intestinal ileus. However, the cellular mechanism of these pathologic changes remains largely unknown.

METHODS

Male Sprague Dawley rats approximately 3 months old and weighing 300-350 g were randomized to either a 60% total body surface area full-thickness scald burn or sham procedure and were sacrificed 24 h after the procedure. Gastric emptying, gastric antrum contractility ileal smooth muscle contractility, and colonic contractility were measured. Muscularis externa was isolated from the ileal segment to prepare smooth muscle protein extracts for Western blot analysis.

RESULTS

Compared with sham controls, the baseline rhythmic contractile activities of the antral, ileal, and colonic smooth muscle strips were impaired in the burned rats. Simultaneously, our data showed that ileal muscularis ECM proteins fibronectin and laminin were significantly up-regulated in burned rats compared with sham rats. TGF-β signaling is an important stimulating factor for ECM protein expression. Our results revealed that TGF-β signaling was activated in the ileal muscle of burned rats evidenced by the activation of Smad2/3 expression and phosphorylation. In addition, the total and phosphorylated AKT, which is an important downstream factor of ECM signaling in smooth muscle cells, was also up-regulated in burned rats' ileal muscle. Notably, these changes were not seen in the colonic or gastric tissues.

CONCLUSION

Deposition of fibrosis-related proteins after severe burn is contributors to decreased small intestinal motility.

Drug-specific differences in the ability of opioids to manage burn pain

Burn injury pain is a significant public health problem. Burn injury treatment has improved tremendously in recent decades. However, an unintended consequence is that a larger number of patients now survive more severe injuries, and face intense pain that is very hard to treat. Although many efforts have been made to find alternative treatments, opioids remain the most effective medication available. Burn patients are frequently prescribed opioids in doses and durations that are significantly higher and longer than standard analgesic dosing guidelines. Despite this, many continue to experience unrelieved pain. They are also placed at a higher risk for developing dependence and opioid use disorder. Burn injury profoundly alters the functional state of the immune system. It also alters the expression levels of receptor, effector, and signaling molecules within the spinal cord's dorsal horn. These alterations could explain the reduced potency of opioids. However, recent studies demonstrate that different opioids signal preferentially via differential signaling pathways. This ligand-specific signaling by different opioids implies that burn injury may reduce the antinociceptive potency of opioids to different degrees, in a drug-specific manner. Indeed, recent findings hint at drug-specific differences in the ability of opioids to manage burn pain early after injury, as well as differences in their ability to prevent or treat the development of chronic and neuropathic pain. Here we review the current state of opioid treatment, as well as new findings that could potentially lead to opioid-based pain management strategies that may be significantly more effective than the current solutions.

Hemocompatibility of different burn wound dressings

A variety of wound dressing are available for burns. Furthermore, although their impacts on wound healing have been studied sufficiently, their effects on blood remain unclear. Meanwhile, this aspect is extremely important, since blood interacts with the wound dressing, especially in extensive burn injuries. Therefore, the aim of this study is to evaluate the hemocompatibility and immunogenicity of different burn wound dressings. Accordingly, human whole blood (n = 5) was anticoagulated with heparin, treated with different wound dressings and incubated at 37°C for 30 minutes. Different parameters for coagulation and hemocompatibility were evaluated before and after incubation. Consequently, Jelonet, Xenoderm, and Matriderm showed higher TAT-III concentrations, Jelonet, Xenoderm, EZ Derm, and Matriderm were higher β-thromboglobulin; EZ Derm and Burntec showed higher SC5b-9 concentrations after incubation with whole blood. Our ex vivo study provided initial insights into the hemocompatibility and immunogenicity of different burn wound dressings. Moreover, Xenografts (Xenoderm and EZ Derm), Jelonet and Matriderm showed a hemostyptic effect, while EZ Derm and Burntec activated the complement system. Therefore, further studies must be conducted to analyze the possible effects in vivo.

Epidemiology, Bacteriological Profile, and Antibiotic Sensitivity Pattern of Burn Wounds in the Burn Unit of a Tertiary Care Hospital

INTRODUCTION

 Burn wounds are commonly infected by organisms which delay wound healing. Therefore, it is necessary to evaluate the flora obtained from wounds of burn patients in order to determine the most effective treatment. The aim of this study was to determine the frequencies of various bacteria isolated from burn wounds and to determine their antimicrobial susceptibility.  Materials and methods: This descriptive cross-sectional study was conducted from January 2018 to November 2018 which included consecutive samples of burn wounds from patients admitted to the burn ward of a tertiary care hospital. Bacteria and their antimicrobial susceptibility were determined by swab cultures and sensitivity tests by standard aseptic techniques. Data were analysed via the Statistical Package for Social Sciences (SPSS), v23.0 (IBM SPSS Statistics, Armonk, NY). Chi-square tests were applied between qualitative variables, while the Kruskal-Wallis test was applied to compare the means of asymmetrical data. Bacterial isolates and their susceptibility pattern were represented as frequencies and pie charts.

RESULTS

 A total of 178 samples were obtained from 109 patients from burn wounds. One hundred and twenty-two wounds (68.5%) showed growth and 56 (31.4%) showed no growth after 24 hours of incubation. Positive cultures were significantly more frequent in wounds of greater than one-week duration (p < 0.002). Out of 158 bacterial isolates, the most common isolate was Pseudomonas aeruginosa - 41 specimens (24.91%), followed by Staphylococcus aureus - 38 specimens (24.05%), Acinetobacter - 27 (17.09%), Klebsiella - 24 (15.19%), Escherichia coli - 13 (8.23%), Proteus - 7 (4.43%), other coliforms - 6 (3.8%), Enterococcus - 1 (0.63%), and Enterobacter - 1 (0.63%). Drug resistance to penicillin G, ampicillin, Augmentin, ceftazidime, cefotaxime, ceftriaxone, meropenem, and piperacillin+tazobactam was exceptionally high.

CONCLUSION

 The most common bacterial isolates are Pseudomonas aeruginosa and Staphylococcus aureus. Piperacillin+tazobactam against Pseudomonas aeruginosa and vancomycin and linezolid against Staphylococcus aureus are highly effective and can be used as empirical therapies.

Hyaluronic acid hydrogel loaded by adipose stem cells enhances wound healing by modulating IL-1β, TGF-β1, and bFGF in burn wound model in rat

Application of hydrogels can be an effective technique in transferring the adipose-derived stem cells (ASCs) to injured tissue and their protection from further complications. Besides, acellular dermal matrix (ADM) has successfully been used in treatment of wounds. In this study, a combination of hylauronic acid (HA) and ASCs (HA/ASCs) was applied on burn wounds and the injured area was then covered by an ADM dressing in a rat model (ADM-HA/ASCs). Wound healing was evaluated by histopathological, histomorphometrical, molecular, biochemical, and scanning electron microscopy assessments on days 7, 14, and 28 post-wounding. ADM-HA/ASCs stimulated healing significantly more than the ADM-HA and ADM treated wounds, as it led to reduced inflammation, and improved angiogenesis and enhanced granulation tissue formation. Expression of interleukin-1β (IL-1β) and transforming growth factor-β1 (TGF-β1) was lower in the ADM-HA/ASCs treated wounds than the ADM-HA and ADM groups, at the seventh post-wounding day. ADM-HA/ASCs also enhanced the expression level of TGF-β1 mRNA at 14 day post-wounding that was parallel to the experimental data from histological and biochemical assessments and confirmed the positive role of ASCs in repair of burn wounds. Additionally, increase in basic fibroblast growth factor (bFGF) expression and decreased TGF-β1 level on the 28th post-wounding day indicated the anti-scarring activity of ASCs. HA loaded by adipose stem cells can represent a promising strategy in accelerating burn wound healing.

Anti-IL-6 eluting immunomodulatory biomaterials prolong skin allograft survival

A primary goal in the management of burn wounds is early wound closure. The use of skin allografts represents a lifesaving strategy for severe burn patients, but their ultimate rejection limits their potential efficacy and utility. IL-6 is a major pleiotropic cytokine which critically links innate and adaptive immune responses. Here, we devised anti-IL-6 receptor eluting gelatin methacryloyl (GelMA) biomaterials (GelMA/anti-IL-6), which were implanted at the interface between the wound beds and skin allografts. Our visible light crosslinked GelMA/anti-IL-6 immunomodulatory biomaterial (IMB) demonstrated a stable kinetic release profile of anti-IL-6. In addition, the incorporation of anti-IL-6 within the GelMA hydrogel had no effect on the mechanical properties of the hydrogels. Using a highly stringent skin transplant model, the GelMA/anti-IL-6 IMB almost doubled the survival of skin allografts. The use of GelMA/anti-IL-6 IMB was far superior to systemic anti-IL-6 receptor treatment in prolonging skin allograft survival. As compared to the untreated control group, skin from the GelMA/anti-IL-6 IMB group contained significantly fewer alloreactive T cells and macrophages. Interestingly, the environmental milieu of the draining lymph nodes (DLNs) of the mice implanted with the GelMA/anti-IL-6 IMB was also considerably less pro-inflammatory. The percentage of CD4⁺ IFNγ⁺ cells was much lower in the DLNs of the GelMA/anti-IL-6 IMB group in comparison to the GelMA group. These data highlight the importance of localized immune delivery in prolonging skin allograft survival and its potential utility in treating patients with severe burns.

Topical delivery of chitosan-capped silver nanoparticles speeds up healing in burn wounds: A preclinical study

This study investigated the effects of topical application of chitosan-capped silver nanoparticles (Ch/AgNPs) on burn wound healing. The chitosan-capped silver nanoparticles were synthesized in one step from the silver nitrate, sodium borohydride, and chitosan and were characterized using transmission electron microscopy, fourier transform infrared spectroscopy, and X-ray diffraction methods. The antioxidant assay was performed to evaluate the scavenging rate. The effects of Ch/AgNPs on burn wound healing was also evaluated by histopathological, molecular, and biochemical evaluations after 7, 14 and 28 days of treatment in a rat model. In comparison to the negative control and silver sulfadiazine groups, the Ch/AgNPs treated wounds exhibited significantly lower inflammatory reaction as determined by the reduced level of interleukin-1β (IL-1β) and neutrophil counts. Treatment by Ch/AgNPs also significantly enhanced re-epithelialization, so that complete epithelialization was achieved in the lesions of the animals of this group, at the 7th day post-wounding. Rapid re-epithelialization, improved granulation tissue formation, reduced IL-1β expression, mild inflammation, and increased transforming growth factor-β1 and basic fibroblast growth factor, at 7 days post-wounding, are convincing reasons to confirm this idea that Ch/AgNPs are effective in speeding up the wound healing stages. Our histopathological findings are in agreement with the molecular and biochemical results and strongly demonstrate that Ch/AgNPs stimulate burn wound healing by decreasing the length of repair phases. Therefore, on the basis of our findings, Ch/AgNPs can be a promising candidate in stimulating wound repair and regeneration.

Mesenchymal Stromal Cell Preconditioning: The Next Step Toward a Customized Treatment For Severe Burn

Over the last century, the clinical management of severe skin burns significantly progressed with the development of burn care units, topical antimicrobials, resuscitation methods, early eschar excision surgeries, and skin grafts. Despite these considerable advances, the present treatment of severe burns remains burdensome, and patients are highly susceptible to skin engraftment failure, infections, organ dysfunction, and hypertrophic scarring. Recent researches have focused on mesenchymal stromal cell (MSC) therapy and hold great promises for tissue repair, as reported in several animal studies and clinical cases. In the present review, we will provide an up-to-date outlook of the pathophysiology of severe skin burns, clinical treatment modalities and current limitations. We will then focus on MSCs and their potential in the burn wound healing both in in vitro and in vivo studies. A specific attention will be paid to the cell preconditioning approach, as a means of improving the MSC efficacy in the treatment of major skin burns. In particular, we will debate how several preconditioning cues would modulate the MSC properties to better match up with the burn pathophysiology in the course of the cell therapy. Finally, we will discuss the clinical interest and feasibility of a MSC-based therapy in comparison to their paracrine derivatives, including microvesicles and conditioned media for the treatment of major skin burn injuries.

Antimicrobial peptide delivery: an emerging therapeutic for the treatment of burn and wounds

The management of wounds and burns is becoming difficult using conventional therapeutics available due to resistance development by microbes. Therefore, there is an utmost need to develop therapeutic alternatives to these agents. Antimicrobial peptides have emerged as a novel class of agents for the effective management of wounds and burns due to their potent nature along with minimal chances of resistance development against them. This article focuses on highlighting the importance of these antimicrobial peptides among the various therapeutic alternatives for burns and wounds. Further, effective delivery strategies for these agents that are being employed and investigated are reported along with an overview of the importance of these agents in the coming years.

Role of intestinal trefoil factor in protecting intestinal epithelial cells from burn-induced injury

Although intestinal trefoil factor (ITF) can alleviate the burn-induced intestinal mucosa injury, the underlying mechanisms remains elusive. In this study, we investigated if ITF alters glutamine transport on the brush border membrane vesicles (BBMVs) of the intestines in Sprague-Dawley rats inflicted with 30% TBSA and the underlying mechanisms. We found that ITF significantly stimulated intestinal glutamine transport in burned rats. Mechanistically, ITF enhanced autophagy, reduces endoplasmic reticulum stress (ERS), and alleviates the impaired PDI, ASCT2, and B0AT1 in IECs and BBMVs after burn injury likely through AMPK activation. Therefore, ITF may protect intestinal epithelial cells from burn-induced injury through improving glutamine transport by alleviating ERS.

[The expert evaluation of the cases of death from burn disease during the delayed post-traumatic period]

This article was designed to report the results of the comprehensive clinical and morphological analysis of the cases of death from the complications of burn disease based on the available medical documentation, the results of autopsies, and the data obtained in the histological and biochemical investigations. The study made it possible to reveal and identify the most typical, reliable, and stable intravital clinical and laboratory features of sepsis developing in burned individuals as well as postmortem pathomorphological and biochemical changes characterizing this condition supposed to be the immediate cause of death. The results of the study may be used to enhance the objectiveness and the level of evidence of expert conclusions concerning the cause of death of the patients presenting with burn disease and developing complications during its late period.

Treatment in the healing of burns with a cold plasma source

A cold plasma produced with helium gas was applied to two second-degree burns produced with boiling oil. These burns were located on a thigh and a shin of a 59-years-old male person. After the first treatment as benefit the patient neither presented itching nor pain and, after the second treatment, the patient presented new tissue. This result opens the possibilities of the application of a cold plasma source to health burns.

Development, Optimization and In Vitro/In Vivo Characterization of Collagen-Dextran Spongious Wound Dressings Loaded with Flufenamic Acid

The aim of this study was the development and optimization of some topical collagen-dextran sponges with flufenamic acid, designed to be potential dressings for burn wounds healing. The sponges were obtained by lyophilization of hydrogels based on type I fibrillar collagen gel extracted from calf hide, dextran and flufenamic acid, crosslinked and un-crosslinked, and designed according to a 3-factor, 3-level Box-Behnken experimental design. The sponges showed good fluid uptake ability quantified by a high swelling ratio. The flufenamic acid release profiles from sponges presented two stages—burst effect resulting in a rapid inflammation reduction, and gradual delivery ensuring the anti-inflammatory effect over a longer burn healing period. The resistance to enzymatic degradation was monitored through a weight loss parameter. The optimization of the sponge formulations was performed based on an experimental design technique combined with response surface methodology, followed by the Taguchi approach to select those formulations that are the least affected by the noise factors. The treatment of experimentally induced burns on animals with selected sponges accelerated the wound healing process and promoted a faster regeneration of the affected epithelial tissues compared to the control group. The results generated by the complex sponge characterization indicate that these formulations could be successfully used for burn dressing applications.

Procalcitonin as a diagnostic biomarker for septic shock and bloodstream infection in burn patients from the Formosa Fun Coast dust explosion

BACKGROUND/PURPOSE

Infection is the most common cause of death following burn injury. The study was conducted to compare the diagnostic value of serum procalcitonin (PCT) with the other current benchmarks as early predictors of septic shock and bloodstream infection in burn patients.

METHODS

We included 24 patients admitted to the Burn Unit of a medical center from June 2015 to December 2015 from the Formosa Fun Coast dust explosion. We categorized all patients at initial admission into either sepsis or septic shock groups. Laboratory tests including the worst PCT and C-reactive protein (CRP) levels, platelet (PLT), and white blood cell (WBC) count were performed at <48 h after admission. Patients were also classified in two groups with subsequent bacteremia and non-bacteremia groups during hospitalization.

RESULTS

Significantly higher PCT levels were observed among participants with septic shock compared to those with sepsis (47.19 vs. 1.18 ng/mL, respectively; p < 0.001). Patients with bacteremia had significantly elevated PCT levels compared to patients without bacteremia (29.54 versus 1.81 ng/mL, respectively, p < 0.05). No significant differences were found in CRP levels, PLT, and WBC count between the two groups. PCT levels showed reasonable discriminative power (cut-off: 5.12 ng/mL; p = 0.01) in predicting of bloodstream infection in burn patients and the area under receiver operating curves was 0.92.

CONCLUSIONS

PCT levels can be helpful in determining the septic shock and bloodstream infection in burn patients but CRP levels, PLT, and WBC count were of little diagnostic value.