Recent alcohol intake impacts microbiota in adult burn patients.

Alcohol use is associated with an increased incidence of negative health outcomes in burn patients due to biological mechanisms that include a dysregulated inflammatory response and increased intestinal permeability. This study used phosphatidylethanol (PEth) in blood, a direct biomarker of recent alcohol use, to investigate associations between a recent history of alcohol use and the fecal microbiota, short chain fatty acids, and inflammatory markers in the first week after a burn injury for nineteen participants. Burn patients were grouped according to PEth levels of low or high and differences in the overall fecal microbial community were observed between these cohorts. Two genera that contributed to the differences and had higher relative abundance in the low PEth burn patient group were Akkermansia, a mucin degrading bacteria that improves intestinal barrier function, and Bacteroides, a potentially anti-inflammatory bacteria. There was no statistically significant difference between levels of short chain fatty acids or intestinal permeability across the two groups. To our knowledge, this study represents the first report to evaluate the effects of burn injury and recent alcohol use on early post burn microbiota dysbiosis, inflammatory response, and levels of short chain fatty acids. Future studies in this field are warranted to better understand the factors associated with negative health outcomes and develop interventional trials.

Aberrant inflammatory responses in intoxicated burn-injured patients parallel impaired cognitive function.

Burn-injured patients with alcohol use disorder (AUD) have increased morbidity and mortality compared to alcohol-abstaining individuals with similar injuries. It is hypothesized that this is due, in part, to alcohol-induced dysregulation of the systemic inflammatory response, leading to worsened clinical outcomes, including increased susceptibility to infection, and heightened cognitive impairment. To examine the effects of alcohol on inflammatory markers after burn injury, we used multiplex assays to measure a panel of 48 cytokines, chemokines, and growth factors in the plasma of burn patents within 24 h of admission to the University of Colorado Burn Center. Thirty patients were enrolled between July 2018 to February 2020 and were stratified based on presence of AUD and total body surface area (TBSA) burn of ≥20% into four groups: [AUD-, TBSA <20%, N = 12], [AUD+, TBSA <20%, N = 3], [AUD-, TBSA ≥20%, N = 8], [AUD+, TBSA ≥20%, N = 7]. In addition, Confusion Assessment Method (CAM) scores were collected to evaluate patient delirium during the course of hospitalization. Multivariate statistical analysis demonstrated a number of cytokines and other factors that were significantly different between the groups. For example, the anti-inflammatory cytokine interleukin 1 receptor antagonist (IL-1ra) was dampened in the AUD+, TBSA ≥20% cohort with a 75.2% decrease compared to AUD-, TBSA ≥20%, and an 83.9% decrease compared to AUD-, TBSA <20% (p = 0.008). Additionally, plasma levels of the pro-inflammatory mediator CXCL12 (C-X-C motif chemokine ligand 12, also known as stromal cell-derived factor 1, SDF-1) was higher in the AUD + groups (p = 0.03) and similarly, IL-18 levels were greater in AUD+, TBSA ≥20% (p = 0.009). Eotaxin (also known as cytokine CC motif ligand 11, CCL11) was markedly elevated in the AUD+, TBSA ≥20% cohort with a 2.4-fold increase over the AUD-, TBSA ≥20%, and a 1.7-fold rise compared to the AUD-, TBSA <20% cohorts (p = 0.04). Interestingly, there was also a marked rise in CAM + delirium scores (85.7%) among the AUD + patients with TBSA ≥20% (p = 0.02). Not surprisingly, we found that hospital stays increased with AUD+ and larger burns (p = 0.0009). Our findings reveal that burn patients who misuse alcohol have aberrant inflammatory responses that may lead to greater immune dysregulation and worse clinical outcomes.

Age and Injury Size Influence the Magnitude of Fecal Dysbiosis in Adult Burn Patients.

Clinical studies have demonstrated that age 50 years or older is an independent risk factor associated with poor prognosis after burn injury, the second leading cause of traumatic injuries in the aged population. While mechanisms driving age-dependent postburn mortality are perplexing, changes in the intestinal microbiome, may contribute to the heightened, dysregulated systemic response seen in aging burn patients. The fecal microbiome from 22 patients admitted to a verified burn center from July 2018 to February 2019 was stratified based on the age of 50 years and total burn surface area (TBSA) size of ≥10%. Significant differences (P = .014) in overall microbiota community composition (ie, beta diversity) were measured across the four patient groups: young <10% TBSA, young ≥10% TBSA, older <10% TBSA, and older ≥10% TBSA. Differences in beta diversity were driven by %TBSA (P = .013) and trended with age (P = .087). Alpha diversity components, richness, evenness, and Shannon diversity were measured. We observed significant differences in bacterial species evenness (P = .0023) and Shannon diversity (P = .0033) between the groups. There were significant correlations between individual bacterial species and levels of short-chain fatty acids. Specifically, levels of fecal butyrate correlated with the presence of Enterobacteriaceae, an opportunistic gut pathogen, when elevated in burn patients lead to worsen outcomes. Overall, our findings reveal that age-specific changes in the fecal microbiome following burn injuries may contribute to immune system dysregulation in patients with varying TBSA burns and potentially lead to worsened clinical outcomes with heightened morbidity and mortality.

Age-related changes in intestinal immunity and the microbiome.

The gastrointestinal (GI) tract is a vitally important site for the adsorption of nutrients as well as the education of immune cells. Homeostasis of the gut is maintained by the interplay of the intestinal epithelium, immune cells, luminal Ags, and the intestinal microbiota. The well-being of the gut is intrinsically linked to the overall health of the host, and perturbations to this homeostasis can have severe impacts on local and systemic health. One factor that causes disruptions in gut homeostasis is age, and recent research has elucidated how critical systems within the gut are altered during the aging process. Intestinal stem cell proliferation, epithelial barrier function, the gut microbiota, and the composition of innate and adaptive immune responses are all altered in advanced age. The aging population continues to expand worldwide, a phenomenon referred to as the "Silver Tsunami," and every effort must be made to understand how best to prevent and treat age-related maladies. Here, recent research about changes observed in the intestinal epithelium, the intestinal immune system, the microbiota, and how the aging gut interacts with and influences other organs such as the liver, lung, and brain are reviewed. Better understanding of these age-related changes and their impact on multi-organ interactions will aid the development of therapies to increase the quality of life for all aged individuals.

Triage and Transfer to a Regional Burn Center-Impact of a Mobile Phone App.

Telemedicine technology can be used to facilitate consultations from nonburn-trained referring providers. However, there is a paucity of evidence indicating these technologies influence transfer decisions and follow-up care. In 2016, our regional burn center implemented a mobile phone app, which allows a referring provider to send photos of the wound along with basic demographic and clinical data to the burn specialist. A retrospective review was performed on consults to our regional burn center from a Level I trauma center approximately 70 miles away with a shared electronic medical record. Patients were considered to be "down-triaged" if they could be managed locally or if the transfer could occur via personal vehicle instead of ground or air ambulance transport. During the 2-year study period, 126 consultations were made for thermal injuries. Eighty-seven patients (69%) were referred using the Burn App. Overall, 49 patients (39%) were transferred. When the subset of intermediate size (1-10% TBSA) burns were considered (n = 48), the Burn App allowed for successful "down-triage" of 12 patients (33%) referred through the app. No patient referred without the app could be "down-triaged" (P = .02). Although 57 patients (44%) were recommended for outpatient follow-up, only 42% followed up. A mobile app can be used to successfully triage patients with intermediate size burn injuries to a lower acuity of follow-up and transfer mode. However, only a minority of patients triaged to outpatient management actually follow up with a regional burn center. Telemedicine efforts should focus on improving not only initial triage, but also aftercare.

"Bedside Anatomy": A Tool to Contextualize Learning and Introduce Surgical Careers.

BACKGROUND: Many medical students cite an unwelcoming culture in surgery and perceive surgeons as arrogant or unfriendly. These perceptions have been reported as factors discouraging medical students from applying to surgical residency programs. This highlights an opportunity early in medical education to address these negative stereotypes and create opportunities for positive interactions with surgeons. We hypothesize that positive experiences with surgical residents and introduction to representative surgical cases early in the medical school curriculum can provide a real-world context for learning anatomy and encourage students to consider a surgical career. METHODS: We developed and implemented a series of structured, one-hour, cadaver-based sessions cofacilitated by anatomists and surgical residents for medical students during their anatomy didactics. Sessions included common surgical cases and focused on critical thinking and problem-solving skills, while offering opportunities to review cadaver anatomy. Students completed a postcourse survey. RESULTS: Nine sessions were implemented with involvement of eight surgical residents and 185 students; 83 students completed a postcourse survey (response rate of 45%). A majority of students rated the sessions "very helpful" in terms of highlighting the importance of anatomy in medical education (n = 52, 63%) and providing clinical context (n = 59, 71%). 54% (n = 45) indicated interest in a surgical career and 64% (n = 53) agreed that session participation had increased their interest in surgery. CONCLUSIONS: Overall, students agreed that sessions provided clinical context for their learning and increased interest in a surgical career. Surgical faculty and residents should engage in preclinical medical education to bridge the basic science and clinical years and introduce positive surgical role models early during medical training.

Inhalation Injury: Unmet Clinical Needs and Future Research.

Pulmonary and systemic insults from inhalation injury can complicate the care of burn patients and contribute to significant morbidity and mortality. However, recent progress in diagnosis and treatment of inhalation injury has not kept pace with the care of cutaneous thermal injury. There are many challenges unique to inhalation injury that have slowed advancement, including deficiencies in our understanding of its pathophysiology, the relative difficulty and subjectivity of bronchoscopic diagnosis, the lack of diagnostic biomarkers, the necessarily urgent manner in which decisions are made about intubation, and the lack of universal recommendations for the application of mucolytics, anticoagulants, bronchodilators, modified ventilator strategies, and other measures. This review represents a summary of critical shortcomings in our understanding and management of inhalation injury identified by the American Burn Association's working group on Cutaneous Thermal Injury and Inhalation Injury in 2018. It addresses our current understanding of the diagnosis, pathophysiology, and treatment of inhalation injury and highlights topics in need of additional research, including 1) airway repair mechanisms; 2) the airway microbiome in health and after injury; and 3) candidate biomarkers of inhalation injury.

Controlled two-photon photodegradation of PEG hydrogels to study and manipulate subcellular interactions on soft materials.

Cell adhesion and detachment to and from the extracellular matrix (ECM) are critical regulators of cell function and fate due to the exchange of mechanical signals between the cell and its microenvironment. To study this cell mechanobiology, researchers have developed several innovative methods to investigate cell adhesion in vitro; however, most of these culture platforms are unnaturally stiff or static. To better capture the soft, dynamic nature of the ECM, we present a PEG-based hydrogel in which the context and geometry of the extracellular space can be precisely controlled in situ via two-photon induced erosion. Here, we characterize the two-photon erosion process, demonstrate its efficacy in the presence of cells, and subsequently exploit it to induce subcellular detachment from soft hydrogels. A working space was established for a range of laser powers required to induce complete erosion of the gel, and these data are plotted with model predictions. From this working space, two-photon irradiation parameters were selected for complete erosion in the presence of cells. Micron-scale features were eroded on and within a gel to demonstrate the resolution of patterning with these irradiation conditions. Lastly, two-photon irradiation was used to erode the material at the cell-gel interface to remove cell adhesion sites selectively, and cell retraction was monitored to quantify the mesenchymal stem cell (MSC) response to subcellular detachment from soft materials.

The motif of SPARC that inhibits DNA synthesis is not a nuclear localization signal.

SPARC (secreted protein acidic and rich in cysteine), although primarily known as a secreted, matricellular protein, has also been identified in urothelial cell nuclei. Many biological activities, including inhibition of cell adhesion and repression of DNA synthesis, have been ascribed to SPARC, but the influence of its intracellular localization on each of these activities is unknown. When exposed by epitope retrieval and nuclear matrix unmasking techniques, endogenous SPARC was found to localize strongly to the nuclei and the nuclear matrix of cultured urothelial cells. Live-cell time-lapse imaging revealed that exogenous fluorescently labeled recombinant (r) SPARC was taken up from medium over a 16 h period and accumulated inside cells. Two variants of rSPARC with alterations in its putative nuclear localization signal (NLS) were generated to investigate the existence and effects of the NLS. These variants demonstrated similar biophysical characteristics as the wild-type protein. Visualization by a variety of techniques, including live-cell imaging, deconvolution microscopy, and cell fractionation, all concurred that exogenous rSPARC was not able to localize to cell nuclei, but instead accumulated as perinuclear clusters. Localization of the rSPARC NLS variants was no different than wild-type, arguing against the presence of an active NLS in rSPARC. Imaging experiments showed that only permeabilized, dead cells avidly took up rSPARC into their nuclei. The rSPARC(no NLS) variant proved ineffective at inhibiting DNA synthesis, whereas the rSPARC(strong NLS) variant was a more potent inhibitor of DNA synthesis than was wild-type rSPARC. The motif of SPARC that inhibits the synthesis of urothelial cell DNA is therefore not a nuclear localization signal, but its manipulation holds therapeutic potential to generate a "Super-SPARC" that can quiesce proliferative tissues.

Translocation of fibroblast growth factor-10 and its receptor into nuclei of human urothelial cells.

Fibroblast growth factor-10 (FGF-10), a mitogen for the epithelial cells lining the lower urinary tract, has been identified inside urothelial cells, despite its acknowledged role as an extracellular signaling ligand. Recombinant (r)FGF-10 was determined by fluorescence microscopy optical sectioning to localize strongly to nuclei inside cultured urothelial cells. To clarify the possible role of a nuclear localization signal (NLS) in this translocation, a variant of rFGF-10 was constructed which lacked this sequence. rFGF-10(no NLS) was found in cytoplasm to a far greater degree than rFGF-10, identifying this motif as a possible NLS. Furthermore, this variant displayed poor or non-existent bioactivity compared to the wild-type protein in triggering mitogenesis in quiescent urothelial cells. The presence of rFGF-10(no NLS) in the nucleus suggested that additional interactions were also responsible for the nuclear accumulation of rFGF-10. The FGF-10 receptor was observed in cell nuclei regardless of the presence or concentration of exogenous rFGF-10 ligand. Co-localization studies between rFGF-10 and the FGF-10 receptor revealed a strong intracellular relationship between the two. This co-localization was seen in nuclei for both rFGF-10 and for rFGF-10(no NLS), although the correlation was weaker for rFGF-10(no NLS). These data show that an NLS-like motif of rFGF-10 is a partial determinant of its intracellular distribution and is necessary for its mitogenic activity. These advancements in the understanding of the activity of FGF-10 present an opportunity to engineer the growth factor as a therapeutic agent for the healing of damaged urothelial tissue.