Adjunctive hyperbaric oxygen therapy in severe burns: Experience in Taiwan Formosa Water Park dust explosion disaster

Reactive Oxygen Species (ROS)-Mediated Antibacterial Oxidative Therapies: Available Methods to Generate ROS and a Novel Option Proposal

The increasing emergence of multidrug-resistant (MDR) pathogens causes difficult-to-treat infections with long-term hospitalizations and a high incidence of death, thus representing a global public health problem. To manage MDR bacteria bugs, new antimicrobial strategies are necessary, and their introduction in practice is a daily challenge for scientists in the field. An extensively studied approach to treating MDR infections consists of inducing high levels of reactive oxygen species (ROS) by several methods. Although further clinical investigations are mandatory on the possible toxic effects of ROS on mammalian cells, clinical evaluations are extremely promising, and their topical use to treat infected wounds and ulcers, also in presence of biofilm, is already clinically approved. Biochar (BC) is a carbonaceous material obtained by pyrolysis of different vegetable and animal biomass feedstocks at 200-1000 °C in the limited presence of O2. Recently, it has been demonstrated that BC's capability of removing organic and inorganic xenobiotics is mainly due to the presence of persistent free radicals (PFRs), which can activate oxygen, H2O2, or persulfate in the presence or absence of transition metals by electron transfer, thus generating ROS, which in turn degrade pollutants by advanced oxidation processes (AOPs). In this context, the antibacterial effects of BC-containing PFRs have been demonstrated by some authors against Escherichia coli and Staphylococcus aureus, thus giving birth to our idea of the possible use of BC-derived PFRs as a novel method capable of inducing ROS generation for antimicrobial oxidative therapy. Here, the general aspects concerning ROS physiological and pathological production and regulation and the mechanism by which they could exert antimicrobial effects have been reviewed. The methods currently adopted to induce ROS production for antimicrobial oxidative therapy have been discussed. Finally, for the first time, BC-related PFRs have been proposed as a new source of ROS for antimicrobial therapy via AOPs.

Risks of mental disorders among inpatients with burn injury: A nationwide cohort study

OBJECTIVE

This investigation identified the association between burn injuries and the risk of mental disorders in patients with no documented pre-existing psychiatric comorbidities. We also examined the relationship of injury severity and the types of injury with the likelihood of receiving new diagnoses of mental disorders.

METHODS

This population-based retrospective cohort study used administrative data extracted from the Taiwanese National Health Insurance Research Database (NHIRD) between 2000 and 2013. In total, 10,045 burn survivors were matched with a reference cohort of 40,180 patients without burn injuries and were followed to determine if any mental disorder was diagnosed. Patients diagnosed with mental disorders in the five years before study initiation were excluded to ensure incident diagnoses throughout the research duration. Generalized estimating equations in Cox proportional hazard regression models were used for data analysis.

RESULTS

In general, burn injury survivors have a 1.21-fold risk of being diagnosed with new mental disorders relative to patients without burn injuries. Total body surface area (TBSA) of ≧ 30% (aHR: 1.49, 95% CI: 1.36-1.63) and third- or fourth-degree burns (aHR: 1.49, 95% CI: 1.37-1.63) had a significantly greater risk of being diagnosed with mental disorders in comparison to the reference cohort. Patients TBSA 10-29% (aHR: 0.85, 95% CI: 0.77-0.93) and first- or second-degree burn victims (aHR: 0.89, 95% CI: 0.81-0.97) had relatively lower risk of mental disorders than the reference cohort.

CONCLUSION

Burn injuries were associated with an increased risk of mental disorders. Additional research in this field could elucidate this observation, especially if the inherent limitations of the NHIRD can be overcome.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Therapeutic Outcome of Burn Patients Treated With Hyperbaric Oxygen

Amongst various interventions for burns and inhalation injuries, hyperbaric oxygen therapy (HBOT) has recently been widely integrated as an adjunctive management of care due to its therapeutic properties in reducing tissue hypoxia, pathological inflammation, and augmenting neovascularization. However, the limitation of human clinical trials and data undermines its efficacy to be implemented as an adjunctive therapeutic modality in burns. The purpose of the literature review is to determine the efficacy of HBOT as an adjunct to standard management in burns. A review of the literature was done by searching PubMed, Cochrane, Medline, EMBASE, and Google Scholar for papers addressing the comparison of therapeutic outcomes between HBOT and non-HBOT in burns. Current research findings are conflicting, and the use of HBOT as an adjunct in burns management is still controversial. Therefore there is still a need for more data and research on the therapeutic benefits of HBOT in burn management.

The Effects of Hyperbaric Oxygenation on Oxidative Stress, Inflammation and Angiogenesis

Hyperbaric oxygen therapy (HBOT) is commonly used as treatment in several diseases, such as non-healing chronic wounds, late radiation injuries and carbon monoxide poisoning. Ongoing research into HBOT has shown that preconditioning for surgery is a potential new treatment application, which may reduce complication rates and hospital stay. In this review, the effect of HBOT on oxidative stress, inflammation and angiogenesis is investigated to better understand the potential mechanisms underlying preconditioning for surgery using HBOT. A systematic search was conducted to retrieve studies measuring markers of oxidative stress, inflammation, or angiogenesis in humans. Analysis of the included studies showed that HBOT-induced oxidative stress reduces the concentrations of pro-inflammatory acute phase proteins, interleukins and cytokines and increases growth factors and other pro-angiogenesis cytokines. Several articles only noted this surge after the first HBOT session or for a short duration after each session. The anti-inflammatory status following HBOT may be mediated by hyperoxia interfering with NF-κB and IκBα. Further research into the effect of HBOT on inflammation and angiogenesis is needed to determine the implications of these findings for clinical practice.

Hyperbaric Oxygen Therapy Attenuates Burn-Induced Denervated Muscle Atrophy

Background: Neuronal apoptosis and inflammation in the ventral horn of the spinal cord contribute to denervated muscle atrophy post-burn. Hyperbaric oxygen therapy (HBOT) exerts anti-inflammation and neuroprotection. Furthermore, hypoxia-inducible factor (HIF)-1α has been reported to promote inflammation and apoptosis. We investigated the therapeutic potential of HBOT and the role of HIF-1α post-burn. Methods: Sprague-Dawley rats were divided into three groups: a control group, an untreated burn group receiving burn and sham treatment, and a HBOT group receiving burn injury and HBOT. The burn injury was induced with 75ºC ± 5ºC at the right hindpaw. HBOT (100% oxygen at 2.5 atmosphere, 90 min/day) and sham HBOT (21% oxygen at 1 atmosphere, 90 min/day) was started on day 28 after burn injury and continued for 14 treatments (days 28-41). Incapacitance (hind limb weight bearing) testing was conducted before burn and weekly after burn. At day 42 post-burn, the gastrocnemius muscle and the spinal cord ventral horn were analyzed. Results: HBOT improved burn-induced weight bearing imbalance. At day 42 post-burn, less gastrocnemius muscle atrophy and fibrosis were noted in the HBOT group than in the untreated burn group. In the ventral horn, HBOT attenuated the neuronal apoptosis and glial activation post-burn. The increases in phosphorylated AKT/mTOR post-burn were reduced after HBOT. HBOT also inhibited HIF-1α signaling, as determined by immunofluorescence and western blot. Conclusions: HBOT reduces burn-induced neuronal apoptosis in the ventral horn, possibly through HIF-1α signaling.

A Critical Update of the Assessment and Acute Management of Patients with Severe Burns

Significance: Burns are debilitating, life threatening, and difficult to assess and manage. Recent advances in assessment and management have occurred since a comprehensive review of the care of patients with severe burns was last published, which may influence research and clinical practice. Recent Advances: Recent advances have occurred in the understanding of burn pathophysiology, which has led to the identification of potential biomarkers of burn severity, such as protein C. There is new evidence about the potential superiority of natural colloids over crystalloids during fluid resuscitation, and new evidence about components of initial and perioperative management, including an improved understanding of pain following burns. Critical Issues: The limitations of the clinical examination highlight the need for imaging and biomarkers to assist in estimations of burn severity. Fluid resuscitation reduces mortality, although there is conjecture over the ideal method. The subsequent perioperative period is associated with significant morbidity and the evidence for preventing and treating pain, infection, and fluid overload while maximizing wound healing potential is described. Future Directions: Promising developments are ongoing in imaging technology, histopathology, biomarkers, and wound healing adjuncts such as hyperbaric oxygen therapy, topical negative pressure therapy, stem cell treatments, and skin substitutes. The greatest benefit from further research on management of patients with burns would most likely be derived from the elucidation of optimal fluid resuscitation protocols, pain management protocols, and surgical techniques from randomized controlled trials.

Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion

OBJECTIVE

The study provides a comprehensive insight into how an initial receiving hospital without adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast Dust Explosion (FFCDE).

METHODS

Data collection was via in-depth interviews with 11 key participants. This was combined with information from medical records of FFCDE patients and admission logs from the emergency department (ED) to build a detailed timeline of patients flow and ED workload changes. Process tracing analysis focused on how the ED and other units adapted to coping with the difficulties created by the patient surge.

RESULTS

The hospital treated 30 victims with 36.3% average total body surface area burn for over 5 hours alongside 35 non-FFCDE patients. Overwhelming demand resulted in the saturation of ED space and intensive care unit beds, exhaustion of critical materials, and near-saturation of clinicians. The hospital reconfigured human and physical resources differently from conventional drills. Graphical timelines illustrate anticipatory or reactive adaptations. The hospital's ability to adapt was based on anticipation during uncertainty and coordination across roles and units to keep pace with varying demands.

CONCLUSION

Adapting to beyond-surge capacity incident is essential to effective disaster response. Building organizational support for effective adaptation is critical for disaster planning.

Hyperbaric oxygen therapy: Antimicrobial mechanisms and clinical application for infections

Hyperbaric oxygen therapy (HBOT) is a treatment procedure that involves breathing 100% O₂ for a certain time and under a certain pressure. HBOT is commonly administrated as a primary or alternative therapy for different diseases such as infections. In this paper, we reviewed the general aspect of HBOT procedures, the mechanisms of antimicrobial effects and the application in the treatment of infections. Parts of the antimicrobial effects of HBOT are believed to result of reactive from the formation of reactive oxygen species (ROS). It is also said that HBOT enhances the antimicrobial effects of the immune system and has an additive or synergistic effect with certain antimicrobial agents. HBOT has been described as a useful procedure for different infections, particularly in deep and chronic infections such as necrotizing fasciitis, osteomyelitis, chronic soft tissue infections, and infective endocarditis. The anti-inflammation property of HBOT has demonstrated that it may play a significant role in decreasing tissue damage and infection expansion. Patients treated by HBOT need carful pre-examination and monitoring. If safety standards are strictly tracked, HBOT can be considered a suitable procedure with an apt rate of complication.

Response of a local hospital to a burn disaster: Contributory factors leading to zero mortality outcomes

OBJECTIVE

To investigate the outcomes of a local healthcare system in managing a burn mass casualty incident (BMCI).

METHODS

Thirty-three victims admitted to the National Taiwan University Hospital within 96h of the explosion were included in the study. Data were recorded on: patient demographics, Baux score, laboratory data, management response, treatment strategies, and outcomes. Case notes from June 27, 2015 to November 2015 were reviewed with a focus on fluid resuscitation, ventilation support, nutrition, infection control, sepsis treatment, and wound closure plan.

RESULTS

Female predominance (mean age: 21.7 years) and lower extremity circumferential flame burns were the characteristics of the burn injury. The mean Baux score was 70±18. The mean burn area was 42% of the total body surface area (TBSA). A total of 79% patients arrived at the hospital within 24h of sustaining injuries. Intensive care unit (ICU) admission criteria were modified to accommodate patients with 40% TBSA of burns, facilities were expanded from 4 ICU beds to 18 beds, and new staff was recruited. A total of 36% patients (n=12/33, 62±13 TBSA of burns) required fluid resuscitation. The mean volume of Lactate Ringer administered in the first 24h of burns was 3.34±2.18ml/kg/%TBSA, while the mean volume of fresh frozen plasma administered was 0.60±0.63ml/kg/h. Forty-two percent patients were intubated on the day of admission, and 71% of the intubated patients had inhalation injuries that were confirmed by diagnostic bronchoscopy. The mean intubation period was 17±9 days. The incidence of pulmonary edema was 58% (n=7/12), possibly due to sub-optimal monitoring. Of these, 57% (n=4/7) patients progressed to adult respiratory distress syndrome, but were successfully treated with early strict fluid restriction, systemic antibiotics, ventilation support, and bronchial lavage. A total of 94% patients received grafting. The mean grafted area was 4432.3±3891cm². Tube feeding was provided to patients with burns >40% TBSA. All patients tolerated gastric tube feeding without conversion to duodenal switch. On admission, all patients received prophylactic antibiotics. Septic shock was noted in 12 patients, but no mortality occurred. The mean hospital stay was 1.5 days per percent burn.

CONCLUSIONS

This article highlights the value of precise triage, traffic control, and effective resource allocation in treating a BMCI. Effective supporting systems for facility expansion, staff recruitment, medical supplies and clear-cut treatment strategies for severely burned patients are contributory factors leading to zero mortalities in our series, in addition to young age and minimal inhalation injuries. The need for reevaluation of the safety of cornstarch powder in festival activities is clear.