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Jeschke M.G.,University of Texas Medical Branch | Jeschke M.G.,Ross Tilley Burn Center | Gauglitz G.G.,Ludwig Maximilians University of Munich | Finnerty C.C.,University of Texas Medical Branch | And 3 more authors.
Annals of Surgery | Year: 2014

OBJECTIVE:: To evaluate whether a panel of common biomedical markers can be utilized as trajectories to determine survival in pediatric burn patients. BACKGROUND:: Despite major advances in clinical care, of the more than 1 million people burned in the United States each year, more than 4500 die as a result of their burn injuries. The ability to predict patient outcome or anticipate clinical trajectories using plasma protein expression would allow personalization of clinical care to optimize the potential for patient survival. METHODS:: A total of 230 severely burned children with burns exceeding 30% of the total body surface, requiring at least 1 surgical procedure were enrolled in this prospective cohort study. Demographics, clinical outcomes, and inflammatory and acute-phase responses (serum cytokines, hormones, and proteins) were determined at admission and at 11 time points for up to 180 days postburn. Statistical analysis was performed using a 1-way analysis of variance, the Student t test, χ test, and Mann-Whitney test where appropriate. RESULTS:: Survivors and nonsurvivors exhibited profound differences in critical markers of inflammation and metabolism at each time point. Nonsurvivors had significantly higher serum levels of interleukin (IL)-6, IL-8, granulocyte colony-stimulating factor, monocyte chemoattractant protein-1, C-reactive protein, glucose, insulin, blood urea nitrogen, creatinine, and bilirubin (P < 0.05). Furthermore, nonsurvivors exhibited a vastly increased hypermetabolic response that was associated with increases in organ dysfunction and sepsis when compared with survivors (P < 0.05). CONCLUSIONS:: Nonsurvivors have different trajectories in inflammatory, metabolic, and acute phase responses allowing differentiation of nonsurvivors from survivors and now possibly allowing novel predictive models to improve and personalize burn outcomes. © 2013 by Lippincott Williams & Wilkins. Source

Abdullahi A.,Sunnybrook Research Institute | Jeschke M.G.,Sunnybrook Research Institute | Jeschke M.G.,University of Toronto | Jeschke M.G.,Ross Tilley Burn Center
Nutrition in Clinical Practice | Year: 2014

Thermal injury is a devastating injury that results in a number of pathological alterations in almost every system in the body. Hypermetabolism, muscle wasting, depressed immunity, and impaired wound healing are all clinical features of burns. Failure to address each of these specific pathological alterations can lead to increased mortality. Nutrition supplementation has been recommended as a therapeutic tool to help attenuate the hypermetabolism and devastating catabolism evident following burn. Despite the wide consensus on the need of nutrition supplementation in burn patients, controversy exists with regard to the type and amount of nutrition recommended. Nutrition alone is also not enough in these patients to halt and reverse some of the damage done by the catabolic pathways activated following severe burn injury. This has led to the use of anabolic pharmacologic agents in conjunction with nutrition to help improve patient outcome following burn injury. In this review, we examine the relevant literature on nutrition after burn injury and its contribution to the attenuation of the postburn hypermetabolic response, impaired wound healing, and suppressed immunological responses. We also review the commonly used anabolic agents clinically in the care of burn patients. Finally, we provide nutrition and pharmacological recommendations gained from prospective trials, retrospective analyses, and expert opinions based on our practice at the Ross Tilley Burn Center in Toronto, Canada. © 2014 American Society for Parenteral and Enteral Nutrition. Source

Stanojcic M.,Sunnybrook Research Institute | Chen P.,Sunnybrook Research Institute | Harrison R.A.,Sunnybrook Research Institute | Wang V.,Sunnybrook Research Institute | And 6 more authors.
Critical Care Medicine | Year: 2014

OBJECTIVES: Severe thermal injury is associated with extreme and prolonged inflammatory and hypermetabolic responses, resulting in significant catabolism that delays recovery or even leads to multiple organ failure and death. Burned patients exhibit many symptoms of stress-induced diabetes, including hyperglycemia, hyperinsulinemia, and hyperlipidemia. Recently, the nucleotide-binding domain, leucine-rich family (NLR), pyrin-containing 3 (NLRP3) inflammasome has received much attention as the sensor of endogenous "danger signals" and mediator of "sterile inflammation" in type II diabetes. Therefore, we investigated whether the NLRP3 inflammasome is activated in the adipose tissue of burned patients, as we hypothesize that, similar to the scenario observed in chronic diabetes, the cytokines produced by the inflammasome mediate insulin resistance and metabolic dysfunction. DESIGN: Prospective cohort study. SETTING: Ross Tilley Burn Centre & Sunnybrook Research Institute. PATIENTS: We enrolled 76 patients with burn sizes ranging from 1% to 70% total body surface area. All severely burned patients exhibited burn-induced insulin resistance and hyperglycemia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined the adipose tissue of control and burned patients and found, via flow cytometry and gene expression studies, increased infiltration of leukocytes -especially macrophages -and evidence of inflammasome priming and activation. Furthermore, we observed increased levels of interleukin-1β in the plasma of burned patients when compared to controls. CONCLUSIONS: In summary, our study is the first to show activation of the inflammasome in burned humans, and our results provide impetus for further investigation of the role of the inflammasome in burn-induced hypermetabolism and, potentially, developing novel therapies targeting this protein complex for the treatment of stress-induced diabetes. © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Source

Jeschke M.G.,Ross Tilley Burn Center | Jeschke M.G.,University of Toronto
Journal of Burn Care and Research | Year: 2016

Hypermetabolism is the ubiquitous response to a severe burn injury, which was first described in the nineteenth century. Despite identification of important components of this complex response, hypermetabolism is still not well understood in its entirety. This article describes this incredibly fascinating response and the understanding we have gained over the past 100 years. Additionally, this article describes novel insights and delineates treatment options to modulate postburn hypermetabolism with the goal to improve outcomes of burn patients. Copyright © 2014 by the American Burn Association 1559-047X/2014. Source

Li A.L.K.,Ross Tilley Burn Center | Gomez M.,Saint Johns Rehab Hospital | Fish J.S.,Ross Tilley Burn Center
Journal of Burn Care and Research | Year: 2010

The purpose of this study was to evaluate the effectiveness of pain management after electrical injury. A retrospective hospital chart review was conducted among electrically injured patients discharged from the outpatient burn clinic of a rehabilitation hospital (July 1, 1999, to July 31, 2008). Demographic data, numeric pain ratings (NPRs) at initial assessment and discharge, medications, nonpharmacologic modalities, and their effects before admission and after rehabilitation were collected. Pain management effects were compared between high (≥1000 v) and low (<1000 v) voltage, and between electrical contact and electrical flash patients, using Student's t-test and χ, with a P < .05 considered significant. Of 82 electrical patients discharged during the study period, 27 were excluded because of incomplete data, leaving 55 patients who had a mean age ±SD of 40.7 ± 11.3 years, TBSA of 19.2 ± 22.7%, and treatment duration of 16.5 ± 15.7 months. The majority were men (90.9%), most injuries occurred at work (98.2%), mainly caused by low voltage (n = 32, 58.2%), and the rest caused by high voltage (n = 18, 32.7%). Electrical contact was more common (54.5%) than electrical flash (45.5%). Pain was a chief complaint (92.7%), and hands were the most affected (61.8%), followed by head and neck (38.2%), shoulders (38.2%), and back torso (38.2%). Before rehabilitation, the most common medication were opioids (61.8%), relieving pain in 82.4%, followed by acetaminophen (47.3%) alleviating pain in 84.6%. Heat treatment was the most common nonpharmacologic modality (20.0%) relieving pain in 81.8%, followed by massage therapy (14.5%) alleviating pain in 75.0%. During the rehabilitation program, antidepressants were the most common medication (74.5%), relieving pain in 22.0%, followed by nonsteroidal antiinflammatory drugs (61.8%), alleviating pain in 70.6%. Massage therapy was the most common nonpharmacologic modality (60.0%), alleviating pain in 75.8%, and then cognitive behavioral therapy (54.5%), alleviating pain in 40.0%. There were pain improvements in all anatomic locations after rehabilitation except for the back torso, where pain increased 0.7 ± 2.9 points. Opioids were more commonly used in high voltage (P < .05), and cognitive behavioral therapy in low-voltage injuries (P < .05). Opioids were used in both electrical flash and electrical contact injuries. Pain in electrically injured patients remains an important issue and should continue to be addressed in a multimodal way. It is hoped that this study will guide us to design future interventions for pain control after electrical injury. © 2010 by the American Burn Association. Source

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