Inducible nitric oxide synthase is critical for immune-mediated liver injury in mice.

Concanavalin A (Con A) causes severe TNF-alpha-mediated and IFN-gamma-mediated liver injury in mice. In addition to their other functions, TNF-alpha and IFN-gamma both induce the inducible nitric oxide (NO) synthase (iNOS). Using different models of liver injury, NO was found to either mediate or prevent liver damage. To further elucidate the relevance of NO for liver damage we investigated the role of iNOS-derived NO in the Con A model. We report that iNOS mRNA was induced in livers of Con A-treated mice within 2 hours, with iNOS protein becoming detectable in hepatocytes as well as in Kupffer cells within 4 hours. iNOS-/- mice were protected from liver damage after Con A treatment, as well as in another TNF-alpha-mediated model that is inducible by LPS in D-galactosamine-sensitized (GalN-sensitized) mice. iNOS-deficient mice were not protected after direct administration of recombinant TNF-alpha to GalN-treated mice. Accordingly, pretreatment of wild-type mice with a potent and specific inhibitor of iNOS significantly reduced transaminase release after Con A or GalN/LPS, but not after GalN/TNF-alpha treatment. Furthermore, the amount of plasma TNF-alpha and of intrahepatic TNF-alpha mRNA and protein was significantly reduced in iNOS-/- mice. Our results demonstrate that iNOS-derived NO regulates proinflammatory genes in vivo, thereby contributing to inflammatory liver injury in mice by stimulation of TNF-alpha production.

Trends in length of stay, mortality and readmission among patients with community-acquired bacteraemia.

In patients hospitalized with severe infection, premature discharge may lead to increased risk of readmission and death. We conducted this population-based cohort study to examine trends in length of stay (LOS) and 30-day mortality and hospital readmission rates after bacteraemia from 1994 through 2013. We used Cox regression to compute hazard ratios (HRs) for 30-day mortality and 30-day postdischarge readmission rates by calendar period and quintiles of LOS, adjusting for age, sex and comorbidity. Among 7618 patients hospitalized with community-acquired bacteraemia during the study period, median LOS decreased from 12 days (quartiles 7-21 days) in 1994-1998 to 9 days (quartiles 6-16 days) in 2009-2013 (25% relative reduction). The 30-day mortality fell from 16.7% to 15.0%, yielding an adjusted 30-day HR of 0.80 (95% confidence interval (CI) 0.68-0.95). Almost one fifth (19.4%) of patients discharged alive were readmitted within 30 days. Concurrently, the adjusted HR of readmission tended to increase (adjusted HR 1.09, 95% CI 0.93-1.28) in 2009-2013 compared with 1994-1998. Compared with the middle quintile of LOS (9-12 days), the risk of readmission was slightly higher for patients discharged within 5 days (adjusted HR 1.12, 95% CI 0.92-1.37), especially for readmission due to infection (adjusted HR 1.38, 95% CI 1.03-1.85). Readmission risk was lowest for 6 to 8 days LOS (adjusted HR 0.80, 95% CI 0.67-0.95) and highest for LOS ≥23 days (adjusted HR 1.30, 95% CI 1.11-1.53). The declining LOS after community-acquired bacteraemia between 1994 and 2013 was not accompanied by increased 30-day mortality but by slightly increased readmission rates.

Cyclophilin-A is a zinc-dependent DNA binding protein in macrophages.

The association of cyclosporin A (CsA) immunosuppression with inhibition of transcription factor-dependent lymphokine gene activation formed the basis of our decision to investigate nuclear-associated Cyp isoforms. Immunofluorescence microscopy of mouse macrophages cell line with a monoclonal antibody mAb7F1 raised against CypA shows a co-localisation of CypA in the nucleus and in the cytosol. Nuclear CypA binds to DNA in a zinc ion-dependent manner, in contrast to recombinant CypB. Peptidyl-prolyl cisltrans isomerase (PPIase) activity of nuclear CypA is inhibited by zinc ions. The zinc inhibited CypA does not bind cyclosporin A (CsA). We suggest that nuclear Cyp in complex with zinc ions recognizes DNA sequences and is involved in transcription modulating processes.

Requirement of peptidergic sensory innervation for disease activity in murine models of immune hepatitis and protection by beta-adrenergic stimulation.

To investigate the interaction between the peripheral nervous and the immune system in vivo, we used two mouse models of T cell and TNF-alpha dependent liver injury inducible by either concanavalin A or a combination of D-galactosamine and staphylococcal enterotoxin B. Mice depleted of peptidergic sensory nerve fibres by capsaicin were protected from liver injury. Moreover, TNF-alpha production was significantly reduced. Examination of the effect of catecholamines on liver injury showed that the beta2-adrenergic agonist salbutamol prevented, whereas chemical sympathectomy by 6-hydroxydopamine, deteriorated the disease. Hence, strategies reducing the activity of peptidergic sensory nerve fibres or stimulating beta2-adrenoreceptors, may be of benefit in immune-mediated liver disease.

Localization and regulation of cyclo-oxygenase-1 and -2 and neuronal nitric oxide synthase in mouse spinal cord.

Prostaglandins are important mediators in spinal nociceptive processing. They are produced by cyclo-oxygenase isoforms, cyclo-oxygenase-1 and -2, which are both constitutively expressed in the central nervous system. The present immunohistochemical study details localization and regulation of cyclo-oxygenase-1 and -2 and neuronal nitric oxide synthase in lumbar spinal cord before and after induction of a painful paw inflammation in mice. Cyclo-oxygenase-1 immunoreactivity was found in glial cells of the dorsal and ventral horns, but not in neurons. In unstimulated mice, cyclo-oxygenase-2 immunoreactivity was found in motoneurons of the ventral horns and in lamina X, but not in dorsal horn neurons. After induction of a paw inflammation with zymosan, cyclo-oxygenase-2 immunoreactivity increased dramatically in dorsal horn neurons of laminae I-VI and X, paralleled by a significant increase in prostaglandin E(2) release from lumbar spinal cord. Cyclo-oxygenase-2 was co-localized with neuronal nitric oxide synthase immunoreactivity in several neurons in superficial laminae of the dorsal horns and in the area surrounding the central canal. Nitric oxide synthase was distributed in the cytoplasm and extended to processes of some neurons. In contrast, electron microscopy revealed that cyclo-oxygenase-2 immunoreactivity was restricted to the nuclear membrane and rough endoplasmic reticulum. It is shown in the present study that both cyclo-oxygenase isoforms are constitutively expressed in the spinal cord, cyclo-oxygenase-1 in glial cells of the dorsal and ventral horns and cyclo-oxygenase-2 in motoneurons. After induction of a hindpaw inflammation, several dorsal horn neurons express cyclo-oxygenase-2. Some of them are also positive for neuronal nitric oxide synthase, which is also induced following peripheral inflammation. Intracellularly, cyclo-oxygenase-2 is bound to the membranes of the nucleus and endoplasmic reticulum, whereas neuronal nitric oxide synthase is found in the cytoplasm.

Keloid and hypertrophic scars: trace element alteration.

The state of excessive fibroblastic proliferation for wound healing results in hypertrophic and keloid scars. It has been well established that some of the trace elements (such as zinc) are essential in wound healing, and there are appreciable changes in trace elements in various disease states. The levels of zinc (Zn), copper (Cu), manganese (Mn), and selenium (Se) in serum, normal skin and scar of 40 keloid and hypertrophic scar patients were assessed. There was a significant increase of manganese (Mn) level in skin of burn, trauma, and surgical incision patients compared to controls with p < 0.0013, p < 0.0001, and p < 0.046, respectively. Furthermore, the zinc, copper, and selenium contents of the skin in incision patients were decreased significantly when compared to other groups. No significant changes occurred regarding serum levels of zinc, copper, manganese, and selenium in the different groups. From this study, no relationships between the hypertrophic and keloid scar to trace elements were found; however, because of the limited numbers of patients, a definite conclusion could not be drawn.

Mortality from burns in Kuwait.

There were 96 deaths among 1433 burns patients admitted to the Plastic Surgery and Burns Unit at Ibn Sina Hospital and Plastic Surgery Unit at Mubarak Al-Kabeer Hospital from January 1982 to December 1987. This represents an overall mortality of 6.7 per cent; 74 per cent of the patients who died had sustained more than 50 per cent body surface area (BSA) burns. A large number of deaths occurred in two age groups, 0-5 years (21 deaths) and 21-30 years (24 deaths). The male to female ratio of burn-induced deaths was 1.18:1. Flame burns due to domestic accidents were the aetiological factors in the majority of patients; 84 (87.5 per cent) of those who died sustained flame burns, although flame burns were only responsible for 46.6 per cent of all burns cases admitted. The mean survival period was 16.8 days postburn, the longest period being 79 days for a patient with 60 per cent BSA burns. Forty-seven patients (49.9 per cent) died of septicaemia which, with its related complications, remains the most important cause of death in our burns patients.

Epidemiology and mortality of 162 major burns in Kuwait.

The burns intensive care unit at IBN Sina Hospital reopened in July 1991, following the Iraqi occupation of Kuwait and the Gulf War. Epidemiology and mortality of 162 burn patients with 30 per cent and over total body surface area (TBSA) burns, treated from July 1991 to December 1994, is presented. There were 91 males and 71 females with a ratio of 1.3 to 1. The median age was 30 years (range 4 months to 93 years) and 44 per cent of the patients were 15-40 years of age. 124 (76.5 per cent) accidents occurred at home and the flame burn was the commonest involving 131 (80.9 per cent) patients. The median burn surface area was 45.5 per cent and the majority of them sustained deep burns. The hospital stay of the surviving patients ranged from 11 to 174 days (median 38 days), while the day of the death was from 1 to 134 days. Forty-six deaths represent an overall mortality rate of 28.4 per cent amongst our patients. All the patients whose Baux score was 130 and above died. Burn shock was responsible for 10 deaths, and out of them eight were not actively resuscitated due to high Baux score. Sixteen deaths occurred within 48 h postburn. Septicaemia and its related effects were responsible for the majority of the deaths.

Caecal perforation in a burn patient.

A 30-year-old female with a 38 per cent TBSA flame burn developed caecal perforation due to non-specific colonic ulceration. Only one such case has so far been reported in the literature by Still et al. (Burns 1994; 20: 85). The caecal perforation in our patient was treated using a right hemicolectomy. She deteriorated postoperatively and died day 21 postburn due to septicaemia, the perforation of the caecum contributed to the mortality.

Scald accidents during water aerosol inhalation in infants.

A study of 193 infants admitted for burns over a 4-year period revealed 11 infants (5.7 per cent) had sustained scalds during the process of water aerosol inhalation. The water aerosol inhalation therapy was prescribed for respiratory tract infection and carried out at home using either an electric kettle or a saucepan. It appears that infants are prone to this type of injury because of the difficulty of keeping them still during therapy and their inquisitiveness to explore their surroundings. The resulting scalds added to the morbidity of those children already suffering from respiratory tract infections. These accidents can easily be prevented by the alternative use of a humidifier.

An analysis of childhood burns in Kuwait.

A prospective study of 394 burned children (in-patients) up to the age of 12 years old was carried out for the period from January 1984 to December 1986. They were categorized into three age groups, the infants and toddlers 0-2 years, early childhood 3-6 years and late childhood 7-12 years. In the first two groups scalding was the predominant cause of injury, while in late childhood there were many more flame burns. Ninety-five per cent of the accidents occurred at home and the majority happened in the presence of parents. The presence of parents was not a deterrent to the accident but ensured speedy transport to the hospital. In our review 3 per cent of patients sustained more than 50 per cent BSA burns, there were 12 deaths with a mortality rate of 3 per cent. An intense campaign to make parents aware of the risk factors and their avoidance is required to reduce the number of burn accidents.

Acute thrombocytopenic crisis following burns complicated by staphylococcal septicaemia.

The pathophysiological changes in a burn patient can at times manifest as severe complications, the management of which can be extremely challenging to the burn surgeon. A case report of an adult male with burns (18% total body surface area) who developed an acute unexpected thrombocytopenia crisis (2x10(9) l(-1)) on day 3 followed by disseminated intravascular coagulation is presented. The various etiological factors and possible mechanisms leading to thrombocytopenia in burns are discussed. Minor burns may present acute major complications in the presence of other thrombocytopenic factors like trauma and sepsis and thrombocytopenia by it self can be a good indicator of sub-clinical infection.

Minor [correction of Mi1nor] burns and pneumatocoeles: a case report.

Minor burns in children need to be cautiously managed as they may manifest with life threatening complications especially in the presence of staphylococcal infection. A one and a half year old child with minor burns (12% TBSA), who developed large pneumatocoeles and peumomediastinum following Staphylococcus aureus pneumonia causing severe respiratory distress and needing ventilatory support is presented. Most of the pneumatocoeles were spontaneously absorbed over a period of 10 days while surgical interference was being contemplated. A conservative approach to pneumatocoeles as in non-burn patients may help prevent unnecessary surgery. An extensive English literature search (since 1966) did not reveal any report of pneumatocoeles in association with burns and therefore we believe this to be the first report of its kind.

Staphylococcal septicaemia in burns.

This study analyses staphylococcal septicaemia in a series of 1516 burn patients who were admitted to the burn unit of the Al-Babtain Centre for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait over a period of 6.5 years (1 June 1992-31 December 1998). One hundred and nine patients (7.2%) developed clinically and microbiologically proven septicaemia, of which 80 (73.4%) showed one or the other type of Staphylococcus in their blood. Fifty (62.5%) of them were males and 30 (37.5%) females, with a mean age of 26 years and the mean total body surface area of burns (TBSA) of 45% (range 1-93%). Preschool age children comprised 27.5% of the patients. Flame was the dominant (80%) cause of burn. Of the 80 patients who had 91 episodes of septicaemia, 52 (65%) had MRSA, 8 (10%) MSSA, 11 (13.8%) MRSE and 5 (6.2%) MSSE and 4 (5%) others had mixed organisms. Only the patients with MRSA had multiple episodes. Eight patients (10%) showed septicaemic episodes within only 48 h of admission; however, the majority of the patients (77.5%) had a septicaemic attack within 2 weeks postburn. Of the 52 MRSA septicaemic cases, 39 (75%) survived and 13 (25%) died. Four patients with septicaemia due to mixed infections died. A total of 19 patients were intubated, 14 due to inhalation injury and 5 because of septicaemia; all in the former group died. Glycopeptide therapy (vancomycin/teicoplanin) was instituted immediately following the detection of staphylococci in the blood. No significant difference was noted in relation to mortality amongst the septicaemic patients, whether or not on prophylactic antibiotic. Fifty-six (70%) of the 80 patients had 139 sessions of skin grafting and survived. Of the 52 MRSA patients, 40 had 101 sessions of skin grafting and 33 of them survived. The apparent low mortality was probably due to early detection of the organism, appropriate antibiotic therapy, care for nutrition and early wound cover. This study indicates a high incidence of staphylococcal septicaemia (especially due to MRSA) in the burn unit. A surface wound is the likely source of entry to the blood stream in these immunocompromised patients. The organism could be detected in blood as early as 48 h postburn and in as little TBSA burn as 1% in this MRSA endemic unit. Inhalation injury with major burns and added staphylococcal septicaemia invariably proved to be fatal.

Liquid ammonia injury.

The toxic effects of a gas depend on the time of exposure, concentration and its chemical nature. Pressurized liquids and gases exert an additional cold thermal injury and this may complicate the clinical picture. A patient who had an accidental exposure to liquid ammonia over a prolonged period, manifesting in cutaneous, respiratory and ocular damage in addition to a severe cold thermal injury (frostbite) with a fatal outcome is presented. The patient had flaccid quadriparesis and episodes of bradycardia, which has not been reported previously. These manifestations raise the possibility of the systemic toxicity in patients with prolonged exposure to ammonia.

Beta-haemolytic Streptococcus infection in burns.

Group A beta haemolytic Streptococcus has been one of the most serious infections in the burn patients resulting in severe cellulitis and sepsis. Penicillin has been used ever since its introduction as prophylaxis against these conditions. Penicillin prophylaxis was used in our burn unit as well without any serious evaluation until December 1992. This prospective study was therefore, undertaken to evaluate the incidence of beta haemolytic Streptococcus infection in burn patients, and its clinical outcome over a period of 5 years in the absence of prophylaxis with penicillin. 14 of the 1213 burn patients admitted to the Al-Babtain Centre for Plastic Surgery and Burns from January 1993 to December 1997 had either colonization or infection with Streptococcus spp. Their mean age was 15 years (range 1 month to 52 years) and the mean burn surface area was 20% (range 5 to 90%). Streptococci were isolated from burn wounds in 10 patients, throat in 3 and blood culture in 1. Group A Streptococcus was found in 5, group C in 3 and group D in 6 patients. In all patients except one the organisms were isolated > or =72 h post burn. The infections were successfully controlled by antibiotic and no detrimental effect was observed either on wound healing or skin graft take. There was no mortality amongst these 14 patients. The study showed that only 1.1% of the burn patients in our unit acquired Streptococcus of which only one third comprised of group A. This study thus demonstrates that the practice of penicillin prophylaxis during the first five post burn days may not be of any value and therefore, deserves discontinuation in units where the incidence of this organism is minuscule.

Burn septicaemia: an analysis of 79 patients.

Out of 943 patients treated from June 92 to May 96 at the burns unit of the Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, 280 (30%) required admission to the burns intensive care unit (ICBU) and were studied retrospectively. Seventy-nine (28.2%) developed clinically and microbiologically proven septicaemia. Forty-four (56%) were males, 35 (44%) females with a mean age of 26 years (range 45 days to 75 years) and mean total body surface area burn (TBSA) of 46% (range 10-90%). Sixty-two had flame burns, 16 a scald and one had an electric burn. These 79 patients had a total of 118 septicaemic episodes. Sixty (76%) had only one and 19 (24%) had multiple episodes of septicaemia. Fifty-four (68%) had their first episode within 2weeks, though the maximum number of episodes was between 6 and 10 days postburn. Septicaemia was also observed in 13% of patients within 3 days postburn. Out of the 118 episodes, 48 were due to methicillin resistant Staphylococcus aureus (MRSA), 17 due to methicillin resistant Staphylococcus epidemidis (MRSE), 15 to Pseudomonas, 12 to Acinetobacter, four to Streptococcus, another four to Enterococci, two to Klebsiella, one due to Serratia and 15 to more than one organism. Once the septicaemia was diagnosed appropriate therapy was instituted. Fifty-six (71%) patients had 143 sessions of skin grafting and the mortality was low in operated patients. Twenty-three (29.1%) patients died. The low mortality rate was probably due to factors such as continuous clinical and microbiological surveillance leading to quick detection of aetiology, appropriate antibiotic therapy, care for nutrition and early wound cover. This study suggests that flame burn patients are more vulnerable to sepsis. Onset of septicaemia may be as early as 3 days and commonly within 2 weeks. A surface wound is the likely source of entry to the blood stream. Gram positive organisms are dominant in the aetiology. Early detection and appropriate treatment including wound coverage result in a better outcome.

Pseudomonas aeruginosa septicaemia in burns.

Out of 1415 patients treated as inpatients at Al-Babtain Center for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait spanning over a period of 6 years from June 1992 to June 1998, 102 developed clinically and microbiologically proven septicaemia. Only 15 out of them had either single or multiple episodes of septicaemia due to Pseudomonas aeruginosa and were studied during their stay in the hospital. Five of them were males and 10 females, with a mean age of 26 years (range 3-51 years) and mean total body surface area of burns (TBSA) of 66% (range 25-90%). All of them had flame burns and resuscitation was found to be difficult in eight patients either due to delayed hospitalization or accompanied inhalation injury. Seven patients were intubated, four due to inhalation injury and three for septicaemic complications. Among the 15 patients under study, a total of 36 septicaemic episodes were detected of which 21 were due to P. aeruginosa. This organism was found in the first episodes in nine patients, in second episodes in six, in third episodes in three and fourth, fifth and sixth episodes in one patient, each at a variable postburn day. Ten patients had 38 sessions of excision and skin grafting, six of them survived. Nine of the 15 patients under study died due to septicaemia, but only six of them had P. aeruginosa as the last isolate. Except for one, all patients had > 40% TBSA burn, two had difficult resuscitation and four were intubated. The day of death varied between 3 to 52 days postburn (mean 19 days). This study showed that females with flame burns are susceptible to P. aeruginosa septicaemia. Difficult resuscitation and intubation also proved to be important risk factors. Septicaemia could occur quite early in the postburn days and the mortality due to this organism was quite high. Early excision and grafting with other effective management may result in a better outcome.

Case report: Use of skin grafting to keep a scleroderma patient ambulant.

A case of scleroderma is presented in which there was extensive skin involvement with contractures, but without any systemic manifestation. This patient has been kept ambulatory by repeated skin grafting. The grafts were taken from the few areas which were not involved with the disease. The grafting was successful, and so far the skin grafts have remained free of disease.