Salvaging the Zone of Stasis By Simvastatin: An

Experimental Study in Rats

Fatih Uygur, MD,* Rahmi Evinc, MD,* Muammer Urhan, MD,†
Bahattin Celikoz, MD,* Aptullah Haholu, MD‡

Salvaging the zone of stasis is important for burn researchers because this can prevent an
increase in the depth and width of the injured area. Statin analogues have many pleiotropic
effects on the vessel walls and the coagulation and fibrinolytic systems. In this study, we
investigated the effects of simvastatin, a statin analogue, administered to rats burned with a
metal comb. No treatment was given to the control group (n ⴝ 10). Simvastatin was given
at a dose of 5 mg/kg/d by intraperitoneal injection in treatment group (n ⴝ 10) for 7
days. Phosphate-buffered saline was given 1 mg/kg/d by intraperitoneal injection in sham
group (n ⴝ 10). The groups were randomly divided into two subgroups (n ⴝ 5) for evalua-
tion at 24 hours and 7 days. It was observed that there were necrotic areas and viable in-
terspaces in both the experimental and control groups at 24 hours. The interspaces pro-
gressed to necrotic areas in the control and sham groups at 7 days. However, viable
interspaces were separated from necrotic areas clearly in the treatment group at 7 days. In
the samples taken from interspaces at 24 hours, positive staining for thrombomodulin (TM)
for all groups was noted. In the samples taken from the control and phosphate-buffered saline
groups at 7 days, there was negative staining for TM. However, in the samples taken from
interspaces of the treatment group, positive staining for TM was observed. The conclusion
of this study was that simvastatin potently increased endothelial TM expression in the zone
of stasis and preserved the zone. (J Burn Care Res 2009;30:872– 879)

Analyzing the pathophysiology of a burn and salvag-
ing the zone of stasis is of clinical importance for burn
specialists because saving this zone prevents the po-
tential increase in the depth and width of the burned
area thereby decreasing mortality and morbidity.1– 4
The vascular system has a prominent role in con-
verting the zone of stasis to the zone of coagulation.
Thermal injuries cause endothelial damage, an in-
crease in vascular permeability, coagulation of the
blood, and a plugging of capillaries that results in
pathological processes such as thrombosis, hyperco-
From the *Department of Plastic and Reconstructive Surgery and
Burn Unit; †Department of Nuclear Medicine; and
‡Department of Pathology, Gülhane Military Academy and
Medical Faculty, Haydarpaşa Training Hospital, Istanbul,
Turkey.
Address correspondence to Fatih Uygur, MD, Department of
Plastic and Reconstructive Surgery and Burn Unit, Gülhane
Military Medical Academy and Medical Faculty, Haydarpaşa
Training Hospital, Selimiye Mahallesi Tibbiye Caddesi 34#668,
Üsküdar, Istanbul, Turkey.
Copyright © 2009 by the American Burn Association.
1559-047X/2009
DOI: 10.1097/BCR.0b013e3181b47eb8
agulation, luminal obstruction, and progressive isch-
emia.5–10 von Bülow et al11 reported that thermal
injury affected the dermal endothelial surfaces and
caused shedding of thrombomodulin (TM), an im-
portant anticoagulating and antifibrinolytic glycop-
rotein expressed on the surface of vascular endothelial
cells. They suggested that it was important to convert
the zone of stasis to a zone of coagulation.
Statins are potent inhibitors of cholesterol synthesis
and widely used clinically in the treatment of hyperlip-
idemia, atherosclerosis, and coronary artery disease.
They decrease the cholesterol levels in the blood inhib-
iting the conversion of 3-hydroxy-3-methylglutaryl co-
enzyme A (HMG-CoA) to mevalonic acid, which is the
rate-limiting step in cholesterol biosynthesis.12 Statins
have many nonlipid-related (pleiotropic) effects on the
vascular wall: they up-regulate endothelial cell TM ex-
pression and activity, alter endothelial dysfunction, reg-
ulate angiogenesis, reduce inflammation, and increase
antithrombotic responses.13–18 It was the aim of this
study to investigate if treatment with an HMG-CoA
reductase inhibitor would have a favorable effect on re-
ducing the shed of TM from the endothelium and on

872
Journal of Burn Care & Research
Volume 30, Number 5
salvaging the zone of stasis. To address these questions,
we used simvastatin, a statin analogue in an experimen-
tal analysis to reveal its effect on the healing process of
the dorsal skin of the rats that had been burned using the
comb model.
MATERIALS AND METHODS
Burn Model
The study was performed after approval of the exper-
imental protocol by the Ethical Committee of the
Haydarpasa Training Hospital. Male Sprague-Dawley
rats (n ⫽ 30) weighing 350 to 400 g were used. They
were housed under standard conditions at an ambient
room temperature and given laboratory chow and
water ad libitum throughout the study. The dorsal
skins of the rats were shaved after intraperitoneal an-
esthesia (pentobarbital 35 mg/kg) and an additional
dose of 10 mg/kg pentobarbital was administered as
necessary. The back of the rats was injured according
to the comb-burn model, which was described by Isik
et al.19 The comb that was made of brass contained
four brass rows (1 ⫻ 2 cm) and three interspaces
(0.5 ⫻ 1 cm). It was immersed in boiling water for 5
minutes and left to achieve thermal equilibrium be-
tween the comb and the hot water. A full-thickness
burn injury was produced by applying the hot brass
probes to the back of the animal 0.5 cm lateral and
parallel to the midline for more than 20 seconds. The
same burn injury was repeated after a period of 10 min-
utes, on the other side of the back of the rat, 0.5 cm
lateral and parallel to the midline. The rats were kept
under anesthesia for 2 hours for pain control. Postop-
erative analgesia was ensured by administering 0.025
mg/kg of buprenorphine subcutaneously every 12
hours for 2 more days. Fluid resuscitation with an intra-
peritoneal injection of 4 ml of lactated Ringer’s solution
was administered to all the rats.
The vital interspaces regarded as the zone of stasis
were clearly separate from the necrotic areas at the
beginning of the study. After burn injury, the in-
terspaces progressed to necrotic areas regarded as the
zone of coagulation.
The rats were randomly grouped into three groups
(n ⫽ 10), and the groups were then randomly divided
into two subgroups (n ⫽ 5) for evaluation at 24 hours or
7 days. They were named Control-24 hours, Control-7
day, phosphate-buffered saline (PBS)-24 hours, PBS-7
day, Simvastatin-24 hours, and Simvastatin-7 day. No
treatment was given to the control group. Thirty min-
utes after burn injury, the treatment group was treated
with simvastatin (Merck, Sharp and Dohme West Point,
Uygur et al 873
PA) at a dose of 5 mg/kg/d by daily intraperitoneal
injection, and the sham group was treated with 1 mg/
kg/d with a PBS for 7 days.
Treatment
Simvastatin was chemically activated by alkaline hy-
drolysis before administration by intraperitoneal in-
jection according to a protocol reported previously
because it needs to be metabolized by hepatic lacto-
nases to obtain its pharmacologically active form.20,21
Preactivated simvastatin was diluted with PBS to a
concentration of 0.4 mg/mL.
To determine an effective dose, a preliminary study
was performed using test doses of 5 and 10 mg/kg
i.p. simvastatin. The dose of 5 mg/kg i.p. was found
to be effective in preventing the zone of stasis from
becoming a zone of necrosis.
Laser Doppler Flowmetry
All measurements were made by individuals blinded
to the rat treatment group. Perfusion of the tissue was
evaluated by a laser Doppler flowmetry. Blood flow of
the full-thickness burn area, the stasis zone, and the
unburned area that was 2 cm caudal from the burned
area were individually measured using a Laser Dopp-
ler (Laserflo BPM, Vasamedics, St Paul, MN) and a
skin probe (Vasamedics, cat. No: P440). After the
animal was anesthetized with pentobarbital, the out-
put was recorded in milliliters per minute per 100 g
and was a relative measurement of microvascular nu-
trient perfusion. The blood flow was measured at
three different points on each side of the dorsal sec-
tion of the rats. The average values calculated were
accepted as the blood flow value of the corresponding
area. Blood flow measurements were performed pre-
injury, immediately post thermal injury, and 30 min-
utes after drug or PBS injection. The measurements
were performed until 7th day of injury.
Scintigraphic Imaging
Twenty-four hours after the burn injury with a hot
metal comb, the rats in the experimental (n ⫽ 5) and
control groups (n ⫽ 5) were injected with 3 mCi of
technetium-99m methoxyisobutylsonitril (Tc-99m
MIBI) in the tail vein. All the rats from these groups
were sacrificed by decapitation 30 minutes after being
injected with ketamine anesthesia and their dorsal
skin including the panniculus corneous muscle layer
was removed. The specimen was laid on a translucent
film layer to prevent extravasations of the radioactiv-
ity and distortion of the specimen. The activity ob-
tained from the burned areas and the interspaces was
detected using a gamma camera with pin-hole colli-
mation (Forte, Philips, Eindhoven, the Netherlands)

874 Uygur et al
by 256 ⫻ 256 matrix. The same scintigraphic proce-
dure was repeated on the 7th day after burn trauma.
The perfusion and the viability between the in-
terspaces and burned area in the control and treat-
ment groups were expressed as the percentages of
radioactivity.
Histological Analysis
The rats in the first (n ⫽ 5) and second subgroup (n ⫽
5) were sacrificed 24 hours and 7 days after burn
injury, respectively, after the last treatment. After
scintigraphic evaluation of the rats in the sub-groups,
skin biopsies were taken from the zone of stasis, full
thickness burns, and from unburned areas.
Samples were fixed in a neutral-buffered formalin
and embedded in paraffin media. Micron sections
were deparaffinized and processed for immunoperox-
idase staining. Standard immunohistochemical tech-
niques using a monoclonal mouse anti-rabbit anti-
body specifically binding to TM (Thermo Scientific,
Fremont, CA, Clone 141C01) was performed.
Zymed DAB Plus Substrat Kit (Zymed Laboratories
Inc., San Francisco, CA) was used as the detection
system. For counterstaining, Mayer’s Hematoxylin
was used for 2 minutes. To prevent interpretation and
misdiagnosis two blinded pathologists, who were in-
dependent examiners, evaluated the slides in our
study. The evaluation of the specimen was performed
according to procedure described by von Bülow et
al.11 Ten randomly chosen areas on the histological
slices were evaluated for vascular endothelial TM ex-
pression. The slices were judged based on the number
of dermal capillaries and on whether they showed
positive staining for thrombomdulin at 100 times en-
largement. A quantitative injury score (QIS) was de-
termined to compare the two groups. The QIS (0 –3
points) consists of three major elements: 1) intravas-
cular fibrin collection (0 –3); 2) tissue inflammation
(0 –3); and 3) tissue coagulation (0 –3) (Table 1).
Statistical Analysis
Average blood flow measurements and radioactive
agent uptake percentages were expressed in mean ⫾
SD (standard deviation) and P values ⬍.05 were as-
signed as statistically significant. These values were
statistically compared using one-way analysis of vari-
ance and unpaired two-tailed Student’s t-test.
RESULTS
No deaths occurred during this study. Twenty-four
hours after burn injury, it was revealed that there were
necrotic areas and vital interspaces in both the exper-
imental and control groups. During the evaluation 7
Journal of Burn Care & Research
September/October 2009
Table 1. The quantitative injury scores (QIS)
1. Intravascular fibrin collection (0–3)
0—No intravascular fibrin collection.
1—Mild intravascular fibrin collection.
2—Moderate intravascular fibrin collection.
3—Severe intravascular fibrin collection.
2. Tissue inflammation (0–3)
0—No tissue inflammation.
1—Mild tissue inflammation.
2—Moderate tissue inflammation.
3—Severe tissue inflammation.
3. Tissue coagulation (0–3)
0—No tissue coagulation.
1—Mild tissue coagulation.
2—Moderate tissue coagulation.
3—Severe tissue coagulation.
days after burn injury, it was revealed that the in-
terspaces had progressed to necrotic areas in the con-
trol groups. In the simvastatin-7 day group, the vital
interspaces were clearly separated from the necrotic
areas (Figure 1).
Laser Doppler Flowmetry
The skin blood flow was measured as 17.1 ⫾ 1.8
(mean ⫾ SD) ml LD/min/100 g tissue in the burned
rows immediately before thermal injury in all groups.
Blood flow decreased to 11.3 ⫾ 1.2 and 9.8 ⫾ 0.8
(mean ⫾ SD) in the interspaces immediately and 24
hours after injury, respectively, in all groups. There
was a statistically, significant difference by the second
day of injury between the simvastatin group and the
other groups according to blood flow measurements
in the interspaces (P ⫽ .04). On the 7th day postburn
injury, blood flow measurements in the interspaces
significantly differed between the simvastatin group
(P ⫽ .036), by 6.2 ⫾ 1.6 and 1.6 ⫾ 0.5 (mean ⫾ SD)
Figure 1. The appearance of the skin surface of groups on
day 7 postburn; control (A), sham (B), and statin (C)
groups.
Journal of Burn Care & Research
Volume 30, Number 5
Figure 2. Blood flow measurements in interspace areas
showed that there was statistically difference second day of
injury between simvastatine and other groups (P ⫽ .04).
There was no difference between control and sham groups
in any days (P ⬎ .05).
and control-PBS groups (Figure 2). There was no
difference noted between control and PBS groups on
any other day (P ⬎ .05).
Nuclear Images
The mean percentages of survived interspaced areas
were higher in the experimental groups than the con-
trol groups at both 24 hours and on the 7th day (P ⫽
.042 for 24th hour and .039 for 7th day). The ratio of
the radioactivity between the burned and interspaces
regions on the first day of injury in the control group
was 82.3 ⫾ 2.54% mean. There was no statistical
difference between groups on the first day of injury
(P ⬎ .05). The ratio of the radioactivity on the 7th
day of injury in the control group was 18.6 ⫾ 12.06%
and 19.2 ⫾ 8.27 mean. There was no statistical dif-
ference between these groups (P ⬎ .05). It was
65.9 ⫾ 6.2% mean in the simvastatin-7 day group.
There was a statistical difference between groups on
the 7th day of injury (P ⫽ .039) (Table 2).
Table 2. The percentages of the radioactivity for three
groups at 1st and 7th days of injury
Group 24th Hour (IS/B) 7th Day (IS/B)
Control 82.3 ⫾ 2.54 18.6 ⫾ 12.06
PBS 81.3 ⫾ 2.57 19.2 ⫾ 8.27
Simvastatin 84.2 ⫾ 3.21 65.9 ⫾ 6.2
IS/B, burned-interspace ratio.
There was higher radioactivity than other groups in statin group at both 24
hours and on the 7th day (P ⫽ .042 for 24th hour) and (P ⫽.039 for 7th
day), and there was statistically difference between groups. According to the
ratio of the radioactivity between the burned and interspaces regions at first
day of injury in control group, there was no statistically difference between
groups at 1st day of injury (P ⬎ .05). According to the ratio of the radioac-
tivity at 7th day of injury in control group there was no statistically difference
between these groups (P ⬎ .05). However, there was statistically difference
between groups at 7th day of injury (P ⫽ .039).
Uygur et al 875
Histological Findings
Positive immunoperoxidase staining specific for TM
was detected in all specimens taken from unburned
skin biopsies. Dermal capillary vessels in these samples
showed a brown color in the cytoplasm of the endo-
thelial cells. Samples taken from the burned area at
day 1 postburn showed negative staining for TM in all
groups. Similar appearances were seen on samples
that were taken from the burned area at day 7 post-
burn for all groups. The tissue was infiltrated by in-
flammatory cells. In specimens taken from full thick-
ness burned areas, no specific peroxidase activity was
detectable. These samples showed a homogeneous
blue color. Protein content and fiber of the extracel-
lular matrix were coagulated. Most cellular structures
were disintegrated. The capillary vessels appeared as
empty holes in the necrotic tissue. Endothelial cells
were absent or showed a deep blue color.
In the samples taken from interspaces at day 1 post-
burn positive staining for TM for all groups was noted
TM expression (Figure 3). In the samples taken from
the control and PBS groups at day 7 postburn, histo-
logical findings were similar to burned areas showing
negative staining for TM. However, in the whole
samples taken from interspaces at simvastatine-7 day,
positive staining for TM showed TM expression (Fig-
ure 4).
QIS were generated to compare the groups. The
QIS was determined to be 1.7 ⫾ 0.7 (mean ⫾ SD) in
the interspaces at 24 hours in the control group. In
the sham group and statin group, it was 1.5 ⫾ 0.83
(mean ⫾ SD) and 1.6 ⫾ 0.54 (mean ⫾ SD), respec-
tively. There was no significant difference between
the statin group and the other groups according to
Figure 3. Specimen taken from the stasis zone at first day
after injury (100⫻). Positive immunoperoxidase staining
for thrombomodulin in dermal capillary endothelial cells
revealed in all groups.
 Journal of Burn Care & Research
876 Uygur et al September/October 2009

Figure 4. Specimen taken from the stasis zone at seventh day after injury (100⫻). Negative immunoperoxidase staining for
thrombomodulin in dermal capillary endothelial cells for control (A) and sham groups (B). Positive immunoperoxidase staining
for thrombomodulin in dermal capillary endothelial cells for statin group (C).

QIS in the interspaces (P ⬎ .05). On the 7th day of postulated that the output showed large differences
burn injury, QIS measurements in the interspaces sig- among the rats, even at the same position before the
nificantly differed between the groups, in the statin operation. These differences were influenced by the
(1.9 ⫾ 0.83), control (8.3 ⫾ 0.54), and sham (7.9 ⫾ individual conditions of the sampling tissue volume.
0.54) groups (P ⬍ .05). There was no difference Therefore, we did not use the absolute value of out-
noted between the control and sham groups on any put voltage, but preferred to use the blood flow
other day (P ⬎ .05) (Table 3). change rate as the parameter in assessing the extent of
ischemia because it gave more accurate results to ob-
serve the changes. The histological examination was
DISCUSSION used to determine the level of the damage and the
viability of the cells as well as the vascular obstruction
In the present experimental burn model, the injured represented in the zone of coagulation. Ischemia,
sites represented the zone of coagulation showing partial ischemia, and normal viability could be seen in
irreversible tissue loss with vascular thrombosis and
tissue biopsy specimens obtained from the zone of
tissue necrosis. The spaces between the burned areas
stasis and coagulation. We used immunostaining as the
were assumed to be equivalent to the zone of stasis
primary technique to investigate TM expression and ap-
and exhibited the expected pattern of initial hyper-
plied monoclonal antibodies against to TM. Our tech-
emia followed by reduced perfusion.19 We investi-
nique might not be sufficiently sensitive enough to
gated the effect of simvastatin on these areas because
record TM, however, it can be used to determine the
it is one of the most common agents used in daily
clinical practice. endothelial TM expression effectively.11
In evaluation procedures, the macroscopic method In our study, a final decrease in intravascular coag-
is a reliable method for investigating the long-term ulation and an increase in blood flow prevented tissue
changes in injured tissues. The laser Doppler flow necrosis in the zone of stasis was confirmed by laser
meter was used to detect tissue perfusion. It can be Doppler flowmetry. Blood flow did not decrease in
the group progressively in contrary to the control
group after the burn injury, and it was significantly
greater in the treated group compared with the con-
Table 3. Quantitative injury scores and thrombomodulin trol groups. Preventing the extension of the zone of
expressions for all groups stasis was confirmed by nuclear imaging and clinical
Full-Thickness findings. The injured area in the treated groups ex-
Stasis Zone Burn Area tended less than that of in the control group up to 48
hours. As healing commenced, the zone of the stasis
Group TM QIS TM QIS
became significantly smaller than that of the control
Control 24 hr ⫹ 1.7 ⫾ 0.7 ⫺ 7.5 ⫾ 0.83 group.
Control 7 day ⫺ 8.3 ⫾ 0.54 ⫺ 8.7 ⫾ 1.0 Under normal circumstances, the vascular endo-
PBS 24 hr ⫹ 1.5 ⫾ 0.83 ⫺ 7.8 ⫾ 1.09 thelium exhibits a number of regulatory mechanisms
PBS 7 day ⫺ 7.9 ⫾ 0.54 ⫺ 8.4 ⫾ 0.89 to modulate coagulation, inflammation, and vascular
Simvastatin 24 hr ⫹ 1.6 ⫾ 0.54 ⫺ 7.9 ⫾ 1.09
function to maintain homeostatic balance.22 Among
Simvastatin 7 day ⫹ 1.9 ⫾ 0.83 ⫺ 7.8 ⫾ 1.09
the endothelial surface receptors, TM plays a critical
Journal of Burn Care & Research
Volume 30, Number 5
role in maintaining the normal endothelial function.
Its role is prominent as an anticoagulant and antifi-
brinolytic agent by inhibiting thrombin and acceler-
ating protein-C activation. Activated protein C, in
concert with protein S, inactivates activated factor-V
and factor-VIII, thus limits thrombin generation fur-
ther.23,24 Moreover, TM has an anti-inflammatory ac-
tivity directly and minimizes the cytokine formation in
the endothelium decreasing leukocyte– endothelial cell
adhesion.25,26 TM is transcriptionally down regulated
by shear stress, hemodynamic forces, hypoxia, oxi-
dized low-density lipoprotein, and transforming
growth factor.27–32 After burn injury, the direct effect
of the damage of the endothelium and the indirect
effect of associated inflammatory reaction causes
shedding of TM from endothelial surfaces that results
in disturbed dermal flow in the zone of stasis and
necrosis.11 When TM is shedded from endothelial
surfaces thrombosis, hypercoagulopaties, and lumen
obstruction take place.33
Statins potently reduce serum cholesterol levels,
however, in several recent studies it was reported that,
restoration of endothelial functions occurred before
significant reduction in serum cholesterol level. It was
suggested that there were additional effects of endo-
thelial cells other than reducing the serum choles-
terol. Statins exert pleiotropic effects such as anti-
inflammatory, immunomodulatory, antioxidant effects
on the vascular wall, coagulation and fibrinolytic sys-
tem.13–17 In a considerable amount of studies, re-
searchers focused on the mechanisms by which statins
enhance endothelial anticoagulation and fibrinolytic
features. These studies revealed that statins cause an
increase in the activity of endothelial nitric oxide synthe-
sis, prostocyclin upregulation, and tissue-type plasmin-
ogen activator levels while a decrease in oxidative stress,
down-regulating tissue factors, endothelin-1 and plas-
minogen activation.34 –38 Shi et al13 demonstrated that
statin treatment caused an up-regulation in endothe-
lial cell TM expression and reduced shedding of TM
significantly. We concluded that administration of
simvastatin caused an increase in endothelial TM ex-
pression and contributed to saving the zone of stasis
in our study.
It is clear that the underlying mechanisms of the
positive effects of simvastatin on the vascular lining
are various and can not be attributed only to endo-
thelial TM stabilization. Other pleiotropic effects of
simvastatin on the vascular wall such as the alteration
of endothelial dysfunction and regulation of angio-
genesis may contribute to the salvage of the zone of
stasis and should be taken into account.
Uygur et al 877
Furthermore, thermal injury causes various dy-
namic processes such as inflammation, immune de-
pletion, etc. Simvastatin has other systemic effects
such as reduction of the inflammatory response, isch-
emia/reperfusion injury associated with increased
blood flow, leukocyte adherence, immunomodula-
tory, and antioxidant effects. These may support heal-
ing during the many steps in the healing process of
the burn injury.16,39 – 43
Several agents used to salvage the zone of stasis
have some features in controlling the pathological
processes.44 – 48 An ideal pharmacological agent for
saving the zone of stasis should have the following
features: safety, clinical availability, easy administra-
tion, reproducibility of effective results, feasibility of
postburn treatment, cost-effectiveness, known mech-
anism of action, established bioavailability, and pro-
tective effects on the zone of stasis. According to the
analysis of the literature published, statins have a rel-
atively safe profile and fulfill most of the requi-
sites.49,50 Upregulation of TM in response to simva-
statin is robust, consistent with the notion that their
effect on TM may be biologically relevant compared
with the effect of simvastatin on other agents in na-
ture involved in the regulation of coagulation and
fibrinolysis.
CONCLUSION
Our results provide a basis for preclinical investiga-
tions of simvastatin in burn model. In the present
study, we concluded that simvastatin increased TM
expression potently and was efficient in saving the
zone of stasis. It is inexpensive, can be used in the
patients safely to prevent or reverse endothelial dys-
function by upregulating TM effectively. We recom-
mend using simvastatin because it can decrease the
mortality and the morbidity by acting on the zone of
stasis.
ACKNOWLEDGMENTS
We thank Mrs. Lana Neufeld Yılmaz for her help in
correcting the manuscript.
REFERENCES
1. Jackson DM. The diagnosis of the depth of burning. Br J Surg
1953;40:588 –96.
2. Hineshaw RJ. Early changes in the depth of burns. Arch Surg
1963;87:131–5.
3. deCamara DL, Raine TJ, London MD, Robson MC, Heg-
gers JP. Progression of thermal injury: a morphological study.
Plast Reconstr Surg 1982;69:491–9.

878 Uygur et al
4. Arturson G. Pathophysiology of the burn wound and phar-
macological treatment: the Rudi Hermans Lecture, 1995.
Burns 1996;22:255–74.
5. Regas FC, Ehrlich HP. Elucidating the vascular response to
burns with a new rat model. J Trauma 1992;32:557– 63.
6. Aggarwal SJ, Da Costa R, Diller KR, Hinich MJ. The effects
of burn injury on vasoactivity in hamster peripheral microcir-
culation. Microvasc Res 1990;40:73– 87.
7. Nozaki ML, Guest MM, Bond TP, Larson DL. Permeabil-
ity of blood vessels after thermal injury. Burns 1979;6:
213–21.
8. Branemark PI, Breine U, Joshi M. Microvascular pathophys-
iology of burned tissue. Ann N Y Acad Sci 1968;150:
474 –94.
9. Basse P, Hovgaard DJB, Lohmann M, Alsbjom BF. Micro-
circulation flow alterations in burn wounds. Acta Chir Plast
1993;35:86 –90.
10. Noble HGS, Robson MC, Krizek TJ. Dermal ischemia in the
burn wound. J Surg Res 1977;23:117–25.
11. von Bülow S, Hartmann T, Fuchs PC, Schrimpf C, Pallua N.
Endothelial thrombomodulin (CD 141) in a rabbit burn
model. Burns 2005;314:459 – 64.
12. Ide H, Fujiya S, Aanuma Y, Agishi Y. Effects of simvastatin, an
HMG-CoA reductase inhibitor, on plasma lipids and steroid
hormones. Clin Ther 1990;12:410 –20.
13. Shi J, Wang J, Zheng H, et al. Statins increase thrombo-
modulin expression and function in human endothelial
cells by a nitric oxide-dependent mechanism and counter-
act tumor necrosis factor alpha-induced thrombomodulin
downregulation. Blood Coagul Fibrinolysis 2003;146:
575– 85.
14. Takemoto M, Liao JK. Pleiotropic effects of 3-hydroxy-3-
methylglutaryl coenzyme a reductase inhibitors. Arterioscler
Thromb Vasc Biol 2001;21:1712–9.
15. Ii M, Losordo DW. Statins and the endothelium. Vascul
Pharmacol 2007;46:1–9.
16. Weitz-Schmidt G. Statins as anti-inflammatory agents.
Trends Pharmacol Sci 2002;23:482– 6.
17. Schonbeck U, Libby P. Inflammation, immunity, and HMG-
CoA reductase inhibitors: statins as antiinflammatory agents?
Circulation 2004;109(suppl 1):II18 –26.
18. Kureishi Y, Luo Z, Shiojima I, et al. The HMG-CoA reduc-
tase inhibitor simvastatin activates the protein kinase Akt and
promotes angiogenesis in normocholesterolemic animals.
Nat Med 2000;6:1004 –10.
19. Isik S, Sahin U, Ilgan S, Guler M, Gunalp B, Selmanpakoglu
N. Saving the zone of stasis in burns with recombinant tissue-
type plasminogen activator (r-tPA): an experimental study in
rats. Burns 1998;24:217–23.
20. Endres M, Laufs U, Huang Z, et al. Stroke protection by
3-hydroxy-3-methylglutaryl (HMG)-CoA reductase inhibi-
tors mediated by endothelial nitric oxide synthase. Proc Natl
Acad Sci U S A 1998;95:8880 –5.
21. Laufs U, Marra D, Node K, Liao JK. 3-Hydroxy-3-
methylglutaryl-CoA reductase inhibitors attenuate vascular
smooth muscle proliferation by preventing rho GTPase-
induced down-regulation of p27(Kip1). J Biol Chem 1999;
274:21926 –31.
22. Becker BF, Heindl B, Kupatt C, Zahler S. Endothelial func-
tion and hemostasis. Z Kardiol 2000;89:160 –7.
23. Esmon CT. The roles of protein C and thrombomodulin in
the regulation of blood coagulation. J Biol Chem 1987;264:
4743– 6.
24. Maruyama I. Thrombomodulin, an endothelial anticoagulant;
its structure, function and expression. Jpn Circ J 1992;56:
187–91.
25. Sadler JE. Thrombomodulin structure and function. Thromb
Haemost 1997;78:392–5.
26. Grey ST, Hancock WW. A physiologic anti-inflammatory
pathway based on thrombomodulin expression and genera-
Journal of Burn Care & Research
September/October 2009
tion of activated protein C by human mononuclear phago-
cytes. J Immunol 1996;156:2256 – 63.
27. Malek AM, Jackman R, Rosenberg RD, Izumo S. Endothelial
expression of thrombomodulin is reversibly regulated by fluid
shear stress. Circ Res 1994;74:852– 60.
28. Sperry JL, Deming CB, Bian C, et al. Wall tension is a potent
negative regulator of in vivo thrombomodulin expression.
Circ Res 2003;92:41–7.
29. Ohji T, Urano H, Shirahata A, et al. Transforming growth
factor ␤1 and ␤2 induce down-modulation of thrombo-
modulin in human umbilical vein endothelial cells. Thromb
Haemost 1995;73:812– 8.
30. Ishii H, Tezuka T, Ishikawa H, Takada K, Oida K, Horie S.
Oxidized phospholipids in oxidized low-density lipopro-
tein down-regulate thrombomodulin transcription in vas-
cular endothelial cells through a decrease in the binding of
RARbeta-RXRalpha heterodimers and Sp1 and Sp3 to
their binding sequences in the TM promoter. Blood 2003;
101:4765–74.
31. Sandusky G, Berg DT, Richardson MA, Myers L, Grinnell
BW. Modulation of thrombomodulin-dependent activation
of human protein C through differential expression of endo-
thelial Smads. J Biol Chem 2002;277:49815–9.
32. Grey ST, Csizmadia V, Hancock WW. Differential effect of
tumor necrosis factor-alpha on thrombomodulin gene ex-
pression by human monocytoid (THP-1) cell versus endo-
thelial cells. Int J Hematol 1998;67:53– 62.
33. Van de Wouwer M, Collen D, Conway EM. Thrombomodulin-
Protein C-EPCR System: integrated to regulate coagulation
and inflammation. Arterioscler Thromb Vasc Biol 2004;24:
1374 – 83.
34. Laufs U, La Fata V, Plutzky J, Liao JK. Upregulation of
endothelial nitric oxide synthase by HMG CoA reductase
inhibitors. Circulation 1998;97:1129 –35.
35. Seeger H, Mueck AO, Lippert TH. Fluvastatin increases
prostacyclin and decreases endothelin production by human
umbilical vein endothelial cells. Int J Clin Pharmacol Ther
2000;38:270 –2.
36. Essig M, Nguyen G, Prie D, Escoubet B, Sraer JD, Fried-
lander G. 3-hydroxy-3-methylglutaryl coenzyme A reductase
inhibitors increase fibrinolytic activity in rat aortic endothelial
cells. Role of geranylgeranylation and Rho proteins. Circ Res
1998;83:683–90.
37. Rikitake Y, Kawashima S, Takeshita S, et al. Anti-oxidant
properties of fluvastatin, an HMG-CoA reductase inhibitor,
contribute to prevention of atherosclerosis in cholesterol-fed
rabbits. Atherosclerosis 2001;154:87–96.
38. Hernandez-Perera O, Perez-Sala D, Navarro-Antolin J, et al.
Effects of the 3-hydroxy-3-methylglutaryl-CoA reductase in-
hibitors, atorvastatins and simvastatin, on the expression of
endothelin-1 and endothelial nitric oxide synthase in vascular
endothelial cells. J Clin Invest 1998;101:2711–9.
39. Kwak B, Mulhaupt F, Myit S, Mach F. Statins as a newly
recognized type of immunomodulator. Nat Med 2000;6:
1399 – 402.
40. Carneado J, Alvarez de Sotomayor M, Perez-Guerrero C et
al. Simvastatin improves endothelial function in spontane-
ously hypertensive rats through a superoxide dismutase
mediated antioxidant effect. J Hypertens 2002;20:
429 –37.
41. Morikawa S, Takabe W, Mataki C, et al. The effect of statins
on mRNA levels of genes related to inflammation, coagula-
tion, and vascular constriction in HUVEC. J Atheroscler
Thromb 2002;9:178 – 83.
42. Masamura K, Oida K, Kanehara H, et al. Pitavastatin-induced
thrombomodulin expression by endothelial cells acts via in-
hibition of small G proteins of the Rho family. Arterioscler
Thromb Vasc Biol 2003;23:512–3.
43. Kiliçcoglu SS, Erdemli E. New addition to the statin’s effect.
J Trauma 2007;63:187–91.
44. Choi M, Ehrlich HP. U75412E, a lazaroid, prevents progres-
Journal of Burn Care & Research
Volume 30, Number 5
sive burn ischemia in a rat burn model. Am J Pathol 1993;
142:519 –28.
45. Bucky LP, Vedder NB, Hong HZ, et al. Reduction of burn
injury by inhibiting CD18-mediated leukocyte adherence in
rabbits. Plast Reconstr Surg 1994;93:1473– 80.
46. Choi M, Rabb H, Arnaout MA, Ehrlich HP. Preventing the
infiltration of leukocytes by monoclonal antibody blocks the
development of progressive ischemia in rat burns. Plast Re-
constr Surg 1995;96:1177– 85.
Uygur et al 879
47. Cetinkale O, Demir M, Sayman HB, Ayan F, Onsel C. Effects of
allopurinol ibuprofen and cyclosporin A on local microcircula-
tory disturbances due to burn injuries. Burns 1997;23:43–9.
48. Ehrlich HP. Promotion of vascular patency in dermal burns
with ibuprofen. Am J Med 1984;77:107–13.
49. Davidson MH. Safety profiles for HMG-CoA reductase
inhibitors: treatment and trust. Drugs 2001;61:197–206.
50. Law M, Rudnicka AR. Statin safety: a systematic review. Am J
Cardiol 2006;97:52C– 60C.