Unplanned decannulation of tracheotomy tube in massive burn patients: a retrospective case series study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Unplanned extubation is associated with adverse outcomes in intensive care unit. The massive burn patient differs from other critically ill patients in many ways. However, little is known about the unplanned decannulation (UD) in Burn Intensive Care Unit. This paper describes the special features of the circumstances and outcome of UD of tracheotomy tube in massive burn patients.</p><p><b>METHODS</b>A case series study was performed between January 1999 and December 2008 and UD of tracheotomy tube was analyzed retrospectively. A total of 21 patients with 29 UD events were identified. Demographic data, diagnosis, intervention, UD events and outcome of UD patients were collected. Differences in proportions were compared using the chi-square (χ(2)) or Fisher's exact test.</p><p><b>RESULTS</b>Patients with UD were often burned with head and neck (67%) and combined with inhalation injury (62%). The majority of them (76%) were transferred patients, occurred early (55%) and were accidental UD (79%). UD events tended to happen in day shift (90%) and to be associated with the medical procedure that was performing by caregivers at besides (79%). Loose of the stabilizing rope, medical procedure and tracheotomy malposition were the main causes of UD. Early UD and reintubation failure were associated with patients' death.</p><p><b>CONCLUSIONS</b>UD happened to massive burn patients can lead to patient death. Careful management of respiratory tract was essential for massive burn patients.</p>

Repair of deep burn and traumatic wounds in lower extremities with combined transplantation of multiple pedicled skin flaps / 中华烧伤杂志

<p><b>OBJECTIVE</b>To summarize the clinical experience in repair of deep burn and traumatic wounds with combined transplantation of different types of pedicled skin flaps in lower extremities.</p><p><b>METHODS</b>Two hundred and thirty-six patients with 271 deep wounds in lower extremities after burn or trauma were repaired with muscular skin flaps, local fascial flaps and island flaps with vascular pedicle (more than 20 types) in our department from Jan. 1998 to Sept. 2008.</p><p><b>RESULTS</b>Complete necrosis of skin flaps occurred in 1 case, congestion and necrosis over the edge of skin flaps occurred in 3 cases, which were healed after grafting, and other skin flaps survived well with soft texture. Skin flaps were too bulky in 26 cases, among them 17 cases were thinned, and the appearance of other skin flaps were satisfactory. In 68 patients with functional region injury were recovered to certain extent without contracture.</p><p><b>CONCLUSIONS</b>Skin flaps with pedicles, multiple transplantations if necessary, can repair deep wounds satisfactorily in lower extremities after deep burn or trauma injury.</p>

Treatment of severe crush syndrome caused by earthquake: a report of 35 cases / 中国骨伤

<p><b>OBJECTIVE</b>To discuss the diagnosis and treatment of the crush syndrome in the earthquake.</p><p><b>METHODS</b>Thirty-five patients with crush syndrome caused by earthquake were involved the retrospective study. The role of nutritional support, active wound treatment and hemodialysis on the patients' recovery was observed.</p><p><b>RESULTS</b>The function of the heart and kidneys were gradually improved by the planned removal of the necrotic tissue, which laid a foundation for the further repair of the wound.</p><p><b>CONCLUSION</b>The removal of necrotic tissue, which can decrease the toxic absorption, will improve the success rate for treatment of the crush syndrome patients when being assisted with the hemodialysis.</p>

Role of c-Jun NH (2)-terminal kinase in insulin resistance after burn / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the role of c-Jun NH (2)-terminal kinase (JNk) in insulin resistance after burn and its mechanism.</p><p><b>METHODS</b>Twenty-four Sprague-Dawley rats were randomized to control, burn and burn + anisomycin groups. The rats in control group received sham burn trauma, and burn and burn + anisomycin groups received 30% total body surface area (TBSA) full thickness burn injury. Anisomycin (5 mg/kg) together with 250 microl dimethyl sulfoxide (DMSO) was injected to the rats in anisomycin group intravenously, and only 250 microl DMSO in the other two groups. Euglycemic-hyperinsulinemic glucose clamps was performed 2 hours after the injection. The changes of phospho-serine 307, phospho-tyrosine of insulin receptor substrate (IRS)-1 and phospho-JNK in muscle tissues were determined and compared using immunoprecipitation and Western blot analysis or immunohistochemistry in the three groups.</p><p><b>RESULTS</b>The infusing rates of total 10% glucose (mg x kg(-1) x min(-1)) in control, burn and burn + anisomycin group were 12.3 +/- 0.4, 6.6 +/- 0.3, 6.5 +/- 0.4, respectively. The level of IRS-1 Serine 307 phosphorylation and phospho-JNK in muscle increased significantly, while insulin-induced tyrosine phosphorylation of IRS-1 decreased markedly after burn.</p><p><b>CONCLUSIONS</b>The activation of JNK elevates the level of IRS-1 phospho-serine 307 and might play a role in insulin resistance after burn in rats.</p>

Interaction between p38 mitogen-activated protein kinase signal transduction pathway and NF-kappaB/IkappaB system on the proinflammatory cytokines release after burn trauma / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the interaction between p38 mitogen-activated protein kinase signal transduction pathway and nuclear factor (NF)-kappaB/IkappaB system on the proinflammatory cytokines release after burn trauma.</p><p><b>METHODS</b>Human monocyte line THP-1 were incubated with serum from eight healthy controls, burn sera, burn sera pretreatment with SB203580, and burn sera pretreatment with pyrrolidine dithiocarbamate (PDTC). After 24 hours incubation with serum, tumor necrosis factor (TNF)-alpha and interleukin-1beta (IL-1beta) levels in THP-1 culture supernatants were measured by ELISA. The activities of p38 MAPK and expressions of IkappaBalpha in THP-1 were measured by Western blot analysis. The EMSA method was used to characterize the binding activities of NF-kappaB and activating protein (AP)-1 in THP-1.</p><p><b>RESULTS</b>In comparison with normal controls, burn sera resulted in a significant higher level release of TNF-alpha and IL-1beta in THP-1 [(7.30 +/- 0.84) ng/ml vs (2.20 +/- 0.28) ng/ml, P < 0.05; (2.88 +/- 0.38) ng/ml vs (0.81 +/- 0.14) ng/ml, P < 0.05], which were significantly inhibited by pretreatment with SB203580 or PDTC. Burn sera showed increased activities of p38 MAPK and AP-1 in THP-1 (4728 +/- 582 vs 1291 +/- 163, P < 0.05; 946 +/- 137 vs 361 +/- 40, P < 0.05), which were abolished by pretreatment with SB203580 but not PDTC. The expression of IkappaBalpha in THP-1 incubated with burn sera was significantly decreased than those incubated with control sera (1211 +/- 115 vs 2658 +/- 318, P < 0.05), which were abolished by pretreatment with PDTC but not SB203580. Burn sera also leaded to an increased activity of NF-kappaB in THP-1 (1636 +/- 170 vs 317 +/- 32, P < 0.05), which were abolished by pretreatment with PDTC but not SB203580.</p><p><b>CONCLUSIONS</b>There are no direct interaction between p38 MAPK signal transduction pathway and NF-kappaB/IkappaB pathway. These two pathways, which regulate the production of TNF-alpha and IL-1beta in monocyte following burn trauma, are parallel and independent.</p>

Amelioration of insulin resistance after scald by c-Jun N-terminal kinase inhibitor in rat / 中华烧伤杂志

<p><b>OBJECTIVE</b>To investigate the role and mechanism of c-Jun N-terminal kinase (JNk) inhibitor (SP600125) in amelioration of insulin resistance after scald.</p><p><b>METHODS</b>Twenty-four Sprague-Dawley rats were randomized into sham (the process of scald was mimicked by water at room temperature) , scald, scald and SP600125 groups. The rats were inflicted with 30% TBSA full-thickness scald in the latter two groups. Euglycemic-hyperinsulinemic glucose clamp experiment was carried out 4 days after scald. SP600125 was administered to the rats in scald and SP600125 2 hrs before Euglycemic-hyperinsulinemic glucose clamp was performed. Changes in the phospho-Serine307 and phospho-tyrosine of IRS-1 activity, as well as expression of phospho-JNK in muscles were determined.</p><p><b>RESULTS</b>Euglycemic-Hyperinsulinemic Glucose Clamps experiment showed that the infusion rate of 100 g/L glucose in sham, scald, scald and SP600125 groups were (12. 33 +/-0. 42) , (6. 61 +/-0. 27) , (11. 11 +/-0. 68) mgx kg(-1) x min(-1) , respectively ( P <0.01). The level of IRS-1 Serine307 phosphorylation and JNK activity in muscles were significantly increased, while insulin-induced tyrosine phosphorylation of IRS-1 decreased markedly after scald. Compared with scald group, the level of IRS-1 Serine307 phosphorylation and JNK activity in scald and SP600125 group were decreased but tyrosine phosphorylation was elevated.</p><p><b>CONCLUSION</b>SP600125 can partially ameliorate insulin resistance after scald by inhibition of JNK activation, and decrease the level of IRS-1 phospho-serine307.</p>

Role of p38MAPK signal transduction pathway in Kupffer cells production of TNF-alpha and IL-1beta in severely burned rats / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the role of p38 mitogen-activated protein kinase (MAPK) signal transduction pathway in the Kupffer cells production of tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta in severely burns rats.</p><p><b>METHODS</b>Male health adult Sprague-Dawley rats were randomized into four groups: sham burn rats given vehicle, sham burn rats given the p38 MAP kinase inhibitor SB203580, rats given a 30% total body surface area (TBSA) full-thickness burn and fluid resuscitation plus vehicle, and burn rats given injury and fluid resuscitation plus SB203580. Rats from each group were killed at 24 h after burn or sham burn and Kupffer cells (KCs) were isolated. After 18 h incubation, KCs next were stimulated with 50 ng/ml of LPS for 18 h. After stimulation, supernatants were removed for analysis of TNF-alpha and IL-1beta levels by ELISA. The TNF-alpha and IL-1beta mRNA expressions (by quantitative real-time RT-PCR) and the activities of p38 MAPK and JNK (by Western blot analysis) in KCs were examined.</p><p><b>RESULTS</b>Eighteen hours after 50 ng/ml LPS stimulation, KCs from burn rats released significantly higher levels of TNF-alpha and IL-1beta than did shams. The mRNA levels of TNF-alpha and IL-1beta in KCs increased significantly postburn. Western blot analysis suggested that expression of phosphorylated p38 MAPK and JNK were increased in KCs harvested from burn group after stimulation with LPS compared with those from sham group. In vivo administration of SB203580 markedly suppressed both the release of TNF-alpha and IL-1beta and the mRNA expressions of TNF-alpha and IL-1beta in KCs from both sham and burn rats. p38 MAPK activity in KCs was abolished by administration with SB203580, whereas JNK was not.</p><p><b>CONCLUSIONS</b>p38 MAPK signal transduction pathway mediates KCs production of proinflammatory cytokines TNF-alpha and IL-1beta in severely burned rats.</p>

The modulating role of p38 mitogen-activated protein kinase in the expression of tumor necrosis factor-alpha in hepatic cells and its role in hepatic injury in severely burned rats / 中华烧伤杂志

<p><b>OBJECTIVE</b>To investigate The modulating role of p38 mitogen-activated protein kinase (MAPK) in the expression of tumor necrosis factor-alpha in hepatic cells and its role in hepatic injury in severely burned rats.</p><p><b>METHODS</b>Twenty-four adult healthy male SD rats were randomly divided into three groups (8 rats in each group): sham group, burn group, and burn with SB203580 group. A rat model of full-thickness burn injury covering 30% total body surface area (TBSA) was reproduced. The specific inhibitor of p38MAPK (SB203580 in 10 mg/kg) was given to the rats in the burn with SB203580 group at 15 minutes and 12 hours after burn. The serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were measured at 24 postburn hours (PBHs). The TNF-alpha mRNA expression in the liver was determined by real-time reverse transcription polymerase chain reaction, and the expression levels of p38MAPK and phosphor-p38MAPK in the liver were determined by Western blot analysis.</p><p><b>RESULTS</b>The serum levels of AST and ALT, and the expression of TNF-alpha mRNA in liver cells were significantly higher in burn group than those in sham and SB203580 groups (P < 0.05 or 0.01), but there was no difference between the two latter groups. It was indicated by Western blot results that there was no difference of p38MAPK expression in rat liver among the three groups (P > 0.05). The phospho-p38MAPK expression ratio among sham, burn and burn with SB203580 groups was 1.00:3.90:1.10. The phospho-p38MAPK expression was significantly lower in burn with SB203580 group than that in burn group (P < 0.01), but there was no significant difference compared with that in sham group (P > 0.05).</p><p><b>CONCLUSION</b>The postburn activated p38MAPK in rat liver after severe burn injury enhances the expression of TNF-alpha mRNA and participates in the development of postburn hepatic injury.</p>

Activation of p38 MAPK signal transduction pathway by burn serum and the expression of VCAM-1 in HUVECs induced by NF-kappaB / 中华烧伤杂志

<p><b>OBJECTIVE</b>To investigate the influence of burn serum on the expression of vascular cell adhesion molecule-1 (VCAM-1) of human umbilical vein endothelial cells (HUVECs) andits signal transduction mechanism.</p><p><b>METHODS</b>HUVECs cultured in vitro were employed for the experiment, and were divided into normal control (NC, with addition of normal serum), burn serum (BS, with addition of burn serum), SB203580 (with addition of 10 micromol/L SB203580 treatment 1 hour before burn serum treatment) and PDTC [with 10 mmol/L pyrrolidine dithiocarbamate (PDTC) 1 hour before burn serum treatment] groups. Protein and mRNA expression of VCAM-1 in HUVECs was measured by flow cytometry and reverse transcription polymerase chain reaction (RT-PCR) respectively at 0, 6, 12, 24 and 36 hours after burn serum treatment. The expression of VCAM-1 on HUVEC surface and the soluble VCAM-1 (sVCAM-1) content in HUVECs culture supernatants were measured by ELISA at 24 hours after the serum stimulation. Adherence of peripheral blood mononuclear leukocytes (PBMC) adherence to HUVECs was also observed in vitro.</p><p><b>RESULTS</b>The expression of VCAM-1 mRNA increased obviously in BS group after the burn serum stimulation and reached peak level at 24 post stimulation hour (PSH), and it decreased thereafter. The above expression was significantly decreased in SB203580 and PDTC groups at 24 PSH, but there was no difference compared with normal control (P > 0.05). The VCAM-1 expression on the membrane of HUVEC was evidently higher in BS group (66.5 +/- 6.2) than that in NC group (19.1 +/- 1.9, P < 0.05) at 24 PSH, but it was decreased significantly in SB203580 (21.7 +/- 2.3) and PDTC (23.1 +/- 2.4) groups and there was no significant difference compared with NC group (P > 0.05), and which was evidently lower than that in BS group (P < 0.05). The VCAM-1 content in the supernatant of BS group (125 +/- 10 ng/L) was obviously higher than that in NC (23 +/- 3 ng/L), SB203580 (27 +/- 5 ng/L) and PDTC (29 +/- 5 ng/L) groups. (P < 0.05). The number of PBMCs adherent to HUVECs in BS group [(197 +/- 11)%] was much larger than that in NC group [(100 +/- 4)%], SB203580 group [(113 +/- 7)%] or PDTC group [(97 +/- 112)%] at 24 PSH (P < 0.05), but no difference between NC group and SB203580, PDTC groups (P > 0.05).</p><p><b>CONCLUSION</b>Burn serum can enhance the expression of VCAM-1 in HUVECs through p38 MAPK signaling pathway, and the activation of NF-kappaB was also involved in this process.</p>

Role of p38 mitogen-activated protein kinase signal transduction pathway in the acute lung injury of severely burned rats / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the role of p38 mitogen-activated protein kinase (MAPK) signal transduction pathway in the acute lung injury of severely burned rats.</p><p><b>METHODS</b>Forty-eight adult healthy rats were randomly divided into three groups: sham group, burn control group, and burn + SB203580 group. A third-degree burns over 30% total body surface area rat model was used and pulmonary capillary permeability, lung water content, pulmonary histology and p38 MAPK activity were measured at 24 hours postburn.</p><p><b>RESULTS</b>Burn trauma resulted in increased pulmonary capillary leakage permeability (42.5 +/- 4.7 vs. 12.1 +/- 1.4, P < 0.01), elevated lung water content (P < 0.05), and worsen histologic condition. There was a significant activation of p38 MAPK at 24 hours postburn compared with control. SB203580 inhibited the activation of p38 MAPK, reduced the pulmonary capillary leakage permeability (24.7 +/- 2.9 vs. 42.5 +/- 4.7, P < 0.01), decreased lung water content, and prevented burn-mediated lung injury.</p><p><b>CONCLUSION</b>The activation of p38 MAPK is one important aspect of the signaling event that contributes to burn-induced lung injury.</p>

Mechanism of p38 mitogen-activated protein kinase in postburn acute pulmonary injury in scalded rats / 中华烧伤杂志

<p><b>OBJECTIVE</b>To investigate the role of p38 mitogen-activated protein kinase (MAPK) signal transduction pathway in the production of the proinflammatory factors such as tumor necrosis factor (TNF-alpha) and interleukin 1beta (IL-1beta) in lungs and in the pulmonary endothelial cell injury in severely scalded rats.</p><p><b>METHODS</b>Forty eight adult healthy SD rats were randomly divided into three groups with 16 rats in each group, i.e. sham, burn and burn with SB203580 treatment groups. The changes in the TNF-alpha and IL-1beta contents in serum and bronchoalveolar lavage fluid (BALF), the von Willebrand factor (vWF) contents in plasma and pulmonary microvessels and pulmonary activating protein (AP-1) activity were determined at 24 postburn hours (PBH).</p><p><b>RESULTS</b>Compared with those in sham group, the TNF-alpha and IL-1beta contents in serum and BALF and the vWF content in plasma (194.2% +/- 28.3% vs 93.2% +/- 14.3%) at 24 PBH in burn group increased significantly (P < 0.01), whereas vWF content in pulmonary microvessel decreased obviously (1.1 +/- 0.3 vs 3.3 +/- 0.4, P < 0.01). In addition, the pulmonary AP-1 activity also increased at 24 PBH. Nevertheless, all the above indices improved obviously in burn with SB203580 (inhibitor of p38 MAPK signal transduction pathway) treatment group when compared with those in burn group.</p><p><b>CONCLUSION</b>AP-1 might mediate the production of proinflammatory factors, such as TNF-alpha and IL-1beta in lungs leading to pulmonary vascular endothelial injury, after being activated by activated p38 MAPK.</p>