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Lindenmann J, Porubsky C, Okresa L, Klemen H, Mykoliuk I, Roj A, Koutp A, Kink E, Iberer F, Kovacs G, Krause R, Smolle J, Smolle-Juettner FM. Immediate and Long-Term Effects of Hyperbaric Oxygenation in Patients with Long COVID-19 Syndrome Using SF-36 Survey and VAS Score: A Clinical Pilot Study. J Clin Med 2023; 12:6253. [PMID: 37834897 PMCID: PMC10573231 DOI: 10.3390/jcm12196253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
(1) Background: Long COVID syndrome (LCS) is a heterogeneous long-standing condition following COVID-19 infection. Treatment options are limited to symptomatic measures, and no specific medication has been established. Hyperbaric oxygenation (HBO) has been found to have a positive impact on the treatment of COVID-19 infection. This study evaluates both the feasibility and outcome of supportive HBO in patients with LCS. (2) Methods: Within 17 months, 70 patients with proven LCS were prospectively included. Each patient underwent a cycle of 10 subsequent HBO treatment sessions administered for 75 min at 2.2 atmospheres. Evaluation of the patients was performed before the first and after the last HBO session and 3 months afterwards. Statistical evaluation was based on an intention-to-treat analysis using Fisher's exact test and Student's t-test for paired samples. (3) Results: In total, 59 patients (33 females, 26 males; mean age: 43.9 years; range: 23-74 years; median: 45.0) were evaluable. After HBO, a statistically significant improvement of physical functioning (p < 0.001), physical role (p = 0.01), energy (p < 0.001), emotional well-being (p < 0.001), social functioning (p < 0.001), pain (p = 0.01) and reduced limitation of activities (p < 0.001) was confirmed. (4) Conclusions: Physical functioning and both the physical and emotional role improved significantly and sustainably, suggesting HBO as a promising supportive therapeutic tool for the treatment of LCS.
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Affiliation(s)
- Joerg Lindenmann
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria (F.M.S.-J.)
| | - Christian Porubsky
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria (F.M.S.-J.)
| | - Lucija Okresa
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria (F.M.S.-J.)
| | - Huberta Klemen
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria (F.M.S.-J.)
| | - Iurii Mykoliuk
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria (F.M.S.-J.)
| | - Andrej Roj
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria (F.M.S.-J.)
| | - Amir Koutp
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria (F.M.S.-J.)
| | - Eveline Kink
- Department of Internal and Respiratory Medicine, Hospital Graz II, Academic Teaching Hospital of the Medical University of Graz, 8036 Graz, Austria
| | - Florian Iberer
- Department of Internal and Respiratory Medicine, Hospital Graz II, Academic Teaching Hospital of the Medical University of Graz, 8036 Graz, Austria
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Medical University of Graz, 8036 Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Josef Smolle
- Institute of Medical Informatics, Statistics and Documentation, Medical University of Graz, 8036 Graz, Austria
| | - Freyja Maria Smolle-Juettner
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria (F.M.S.-J.)
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Chi W, Pang P, Luo Z, Liu X, Cai W, Li W, Hao J. Risk factors for hypoxaemia following hip fracture surgery in elderly patients who recovered from COVID-19: a multicentre retrospective study. Front Med (Lausanne) 2023; 10:1219222. [PMID: 37497272 PMCID: PMC10366448 DOI: 10.3389/fmed.2023.1219222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023] Open
Abstract
Objectives To explore the risk factors associated with postoperative hypoxaemia in elderly patients who have recovered from coronavirus disease (COVID-19) and underwent hip fracture surgery in the short term. Design Multicentre retrospective study. Setting The study was performed in three first 3A-grade hospitals in China. Participants A sequential sampling method was applied to select study participants. Medical records of 392 patients aged ≥65 years who had recovered from COVID-19 and underwent hip fracture surgery at three hospitals in China between 1 November, 2022, and 15 February, 2023, were reviewed. Interventions Patients were assigned to hypoxaemia or non-hypoxaemia groups, according to whether hypoxaemia occurred after surgery. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for postoperative hypoxaemia. Results The incidence of postoperative hypoxaemia was 38.01%. Statistically significant differences were found between the two groups in terms of age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, presence of expectoration symptoms, preoperative hypoxaemia, chronic obstructive pulmonary disease, pulmonary inflammation, time between recovery from COVID-19 and surgery, anaesthetic mode, surgical procedure, intraoperative blood loss, intraoperative infusion, duration of surgery, and length of hospital stay (p < 0.05). Furthermore, patients with BMI ≥28.0 kg/m2, expectoration symptoms, presence of preoperative hypoxaemia, ASA classification III, time between recovery from COVID-19 and surgery ≤2 weeks, and general anaesthesia were potential risk factors for postoperative hypoxaemia. Conclusion Obesity, expectoration symptoms, preoperative hypoxaemia, ASA classification III, time between recovery from COVID-19 and surgery ≤2 weeks, and general anaesthesia were potential risk factors for postoperative hypoxaemia in elderly patients who recovered from COVID-19 and underwent hip fracture surgery in the short term.
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Affiliation(s)
- Wen Chi
- Department of Operating Room, HongHui Hospital, Xi’an JiaoTong University, Xi’an, China
| | - Peng Pang
- Department of Anaesthesiology, Binzhou Medical College Affiliated Hospital, Binzhou, China
| | - Zhenguo Luo
- Department of Anaesthesiology, HongHui Hospital, Xi’an JiaoTong University, Xi’an, China
| | - Xiaobing Liu
- Department of Anaesthesiology, HongHui Hospital, Xi’an JiaoTong University, Xi’an, China
| | - Wenbo Cai
- Department of Anaesthesiology, HongHui Hospital, Xi’an JiaoTong University, Xi’an, China
| | - Wangyang Li
- Department of Orthopedic, Linfen Hospital Affiliated to Shanxi Medical University, Linfen, China
| | - Jianhong Hao
- Department of Anaesthesiology, HongHui Hospital, Xi’an JiaoTong University, Xi’an, China
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3
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Siewiera J, Brodaczewska K, Jermakow N, Lubas A, Kłos K, Majewska A, Kot J. Effectiveness of Hyperbaric Oxygen Therapy in SARS-CoV-2 Pneumonia: The Primary Results of a Randomised Clinical Trial. J Clin Med 2022; 12:jcm12010008. [PMID: 36614808 PMCID: PMC9820955 DOI: 10.3390/jcm12010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Mortality in COVID-19 is mainly associated with respiratory failure, cytokine storm, and macrophage activation. Oxygenation and anti-inflammatory effects of Hyperbaric Oxygen Therapy (HBOT) suggest that it is a promising adjunct treatment for COVID-19. Repeated sessions of HBO with standard COVID-19 therapy were used to reduce the inflammation and increase oxygenation. We evaluated the safety and efficacy of HBOT in avoiding the replacement ventilation and/or ECMO and its effect on the inflammatory process. Twenty-eight moderate-to-severe COVID-19 patients were randomized into control or HBOT group. HBOT patients participated in 5 hyperbaric sessions (60 min). Before and after each session blood gas levels and vital parameters were monitored. Blood samples were collected for extended biochemical tests, blood morphology and immunological assays. There were 3 deaths in the control, no deaths in the HBOT group. No adverse events leading to discontinuation of HBOT were observed and patients receiving HBOT required lower oxygen delivery. We observed decrease in CRP, ferritin and LDH and increase in CD3 in HBOT group compared to control. This study confirmed the feasibility and safety of HBOT in patients with COVID-19 and indicated HBOT can lead to alleviation of inflammation and partial restoration of T cell responses.
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Affiliation(s)
- Jacek Siewiera
- Department of Hyperbaric Medicine, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland
| | - Klaudia Brodaczewska
- Laboratory of Molecular Oncology and Innovative Therapies, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland
| | - Natalia Jermakow
- Department of Hyperbaric Medicine, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland
| | - Arkadiusz Lubas
- Department of Internal Diseases Nephrology and Dialysis, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland
| | - Krzysztof Kłos
- Department of Infectious Diseases and Allergology, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland
| | - Aleksandra Majewska
- Laboratory of Molecular Oncology and Innovative Therapies, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland
- Postgraduate School of Molecular Medicine (SMM), Warsaw Medical University, 02-091 Warsaw, Poland
- Correspondence:
| | - Jacek Kot
- National Centre for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine, Medical University of Gdansk, 81-519 Gdynia, Poland
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Prevention and Treatment of Life-Threatening COVID-19 May Be Possible with Oxygen Treatment. Life (Basel) 2022; 12:life12050754. [PMID: 35629421 PMCID: PMC9142938 DOI: 10.3390/life12050754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/22/2022] [Accepted: 05/12/2022] [Indexed: 01/08/2023] Open
Abstract
Most SARS CoV-2 infections probably occur unnoticed or cause only cause a mild common cold that does not require medical intervention. A significant proportion of more severe cases is characterized by early neurological symptoms such as headache, fatigue, and impaired consciousness, including respiratory distress. These symptoms suggest hypoxia, specifically affecting the brain. The condition is best explained by primary replication of the virus in the nasal respiratory and/or the olfactory epithelia, followed by an invasion of the virus into the central nervous system, including the respiratory centers, either along a transneural route, through disruption of the blood-brain barrier, or both. In patients, presenting with early dyspnea, the primary goal of therapy should be the reversal of brain hypoxia as efficiently as possible. The first approach should be intermittent treatment with 100% oxygen using a tight oronasal mask or a hood. If this does not help within a few hours, an enclosure is needed to increase the ambient pressure. This management approach is well established in the hypoxia-related diseases in diving and aerospace medicine and preserves the patient’s spontaneous breathing. Preliminary research evidence indicates that even a small elevation of the ambient pressure might be lifesaving. Other neurological symptoms, presenting particularly in long COVID-19, suggest imbalance of the autonomous nervous system, i.e., dysautonomia. These patients could benefit from vagal nerve stimulation.
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Elahi R, Karami P, Heidary AH, Esmaeilzadeh A. An updated overview of recent advances, challenges, and clinical considerations of IL-6 signaling blockade in severe coronavirus disease 2019 (COVID-19). Int Immunopharmacol 2022; 105:108536. [PMID: 35074571 PMCID: PMC8747952 DOI: 10.1016/j.intimp.2022.108536] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/01/2022] [Accepted: 01/07/2022] [Indexed: 02/07/2023]
Abstract
Since 2019, COVID-19 has become the most important health dilemma around the world. The dysregulated immune response which results in ARDS and cytokine storm has an outstanding role in the progression of pulmonary damage in COVID-19. IL-6, through induction of pro-inflammatory chemokines and cytokines, is the pioneer of the hyperinflammatory condition and cytokine storm in severe COVID-19. Therefore, IL-6 pathway blockade is considered an emerging approach with high efficacy to reduce lung damage in COVID-19. This article aims to review the pleiotropic roles of the IL-6 pathway in lung damage and ARDS in severe COVID-19, and the rationale for IL-6 signaling blockade at different levels, including IL-6 soluble and membrane receptor pathways, IL-6 downstream signaling (such as JAK-STAT) inhibition, and non-specific anti-inflammatory therapeutic approaches. Recent clinical data of each method, with specific concentration on tocilizumab, along with other new drugs, such as sarilumab and siltuximab, have been discussed. Challenges of IL-6 signaling inhibition, such as the risk of superinfection and hepatic injury, and possible solutions have also been explained. Moreover, to achieve the highest efficacy, ongoing clinical trials and special clinical considerations of using different IL-6 inhibitors have been discussed in detail. Special considerations, including the appropriate timing and dosage, monotherapy or combination therapy, and proper side effect managment must be noticed regarding the clinical administration of these drugs. Future studies are still necessary to improve the productivity and unknown aspects of IL-6 signaling blockade for personalized treatment of severe COVID-19.
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Affiliation(s)
- Reza Elahi
- Zanjan University of Medical Sciences, Zanjan, Iran
| | - Parsa Karami
- School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | | | - Abdolreza Esmaeilzadeh
- Department of Immunology, Zanjan University of Medical Sciences, Zanjan, Iran; Cancer Gene Therapy Research Center (CGRC), Zanjan University of Medical Sciences, Zanjan, Iran.
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Possible Applications of Hyperbaric Oxygen Therapy-Narrative Review. POLISH HYPERBARIC RESEARCH 2021. [DOI: 10.2478/phr-2021-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Abstract
Hyperbaric oxygen therapy is a method supporting the treatment of many diseases. Oxygen therapy treatments are conducted in hyperbaric chambers, in which patients breathe pure, 100% oxygen with higher than atmospheric pressure. This allows to increase the amount of oxygen supplied to all cells of the body many times over. The treatment with hyperbaric oxygen therapy enables the patient to recover faster and be fully active, and also reduces the costs of standard treatment.
The aim of the study was to summarize the possible applications of hyperbaric oxygen therapy. The available literature in the PUBMED database was reviewed in September 2022 with the use of the phrases ‘hyperbaric oxygen therapy’, ‘therapeutic applications’. The indications for therapy in a hyperbaric chamber are all kinds of diseases, both acute and chronic. The method supports the nourishment and regeneration of cells and tissues of the organism, and also slows down the aging process. However, due to the possible side effects of such therapy, patients should be qualified for its use after a careful analysis of their clinical condition and coexisting diseases. To sum up: hyperbaric oxygen therapy is most often used in the treatment of skin diseases and injuries, burns, and peripheral vascular diseases.
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7
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Gottfried I, Schottlender N, Ashery U. Hyperbaric Oxygen Treatment-From Mechanisms to Cognitive Improvement. Biomolecules 2021; 11:biom11101520. [PMID: 34680155 PMCID: PMC8533945 DOI: 10.3390/biom11101520] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/19/2022] Open
Abstract
Hyperbaric oxygen treatment (HBOT)—the medical use of oxygen at environmental pressure greater than one atmosphere absolute—is a very effective therapy for several approved clinical situations, such as carbon monoxide intoxication, incurable diabetes or radiation-injury wounds, and smoke inhalation. In recent years, it has also been used to improve cognition, neuro-wellness, and quality of life following brain trauma and stroke. This opens new avenues for the elderly, including the treatment of neurological and neurodegenerative diseases and improvement of cognition and brain metabolism in cases of mild cognitive impairment. Alongside its integration into clinics, basic research studies have elucidated HBOT’s mechanisms of action and its effects on cellular processes, transcription factors, mitochondrial function, oxidative stress, and inflammation. Therefore, HBOT is becoming a major player in 21st century research and clinical treatments. The following review will discuss the basic mechanisms of HBOT, and its effects on cellular processes, cognition, and brain disorders.
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Affiliation(s)
- Irit Gottfried
- School of Neurobiology, Biochemistry and Biophysics, Life Sciences Faculty, Tel Aviv University, Tel Aviv 6997801, Israel; (I.G.); (N.S.)
| | - Nofar Schottlender
- School of Neurobiology, Biochemistry and Biophysics, Life Sciences Faculty, Tel Aviv University, Tel Aviv 6997801, Israel; (I.G.); (N.S.)
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Uri Ashery
- School of Neurobiology, Biochemistry and Biophysics, Life Sciences Faculty, Tel Aviv University, Tel Aviv 6997801, Israel; (I.G.); (N.S.)
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-3-6409827
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Ortega MA, Fraile-Martinez O, García-Montero C, Callejón-Peláez E, Sáez MA, Álvarez-Mon MA, García-Honduvilla N, Monserrat J, Álvarez-Mon M, Bujan J, Canals ML. A General Overview on the Hyperbaric Oxygen Therapy: Applications, Mechanisms and Translational Opportunities. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:864. [PMID: 34577787 PMCID: PMC8465921 DOI: 10.3390/medicina57090864] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/09/2021] [Accepted: 08/20/2021] [Indexed: 12/17/2022]
Abstract
Hyperbaric oxygen therapy (HBOT) consists of using of pure oxygen at increased pressure (in general, 2-3 atmospheres) leading to augmented oxygen levels in the blood (Hyperoxemia) and tissue (Hyperoxia). The increased pressure and oxygen bioavailability might be related to a plethora of applications, particularly in hypoxic regions, also exerting antimicrobial, immunomodulatory and angiogenic properties, among others. In this review, we will discuss in detail the physiological relevance of oxygen and the therapeutical basis of HBOT, collecting current indications and underlying mechanisms. Furthermore, potential areas of research will also be examined, including inflammatory and systemic maladies, COVID-19 and cancer. Finally, the adverse effects and contraindications associated with this therapy and future directions of research will be considered. Overall, we encourage further research in this field to extend the possible uses of this procedure. The inclusion of HBOT in future clinical research could be an additional support in the clinical management of multiple pathologies.
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Affiliation(s)
- Miguel A. Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Cancer Registry and Pathology Department, Hospital Universitario Principe de Asturias, 28806 Alcala de Henares, Spain
| | - Oscar Fraile-Martinez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Cielo García-Montero
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Enrique Callejón-Peláez
- Underwater and Hyperbaric Medicine Service, Central University Hospital of Defence—UAH Madrid, 28801 Alcala de Henares, Spain;
| | - Miguel A. Sáez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Pathological Anatomy Service, Central University Hospital of Defence—UAH Madrid, 28801 Alcala de Henares, Spain
| | - Miguel A. Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Jorge Monserrat
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Immune System Diseases—Rheumatology, Oncology Service an Internal Medicine, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcala de Henares, Spain
| | - Julia Bujan
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcala de Henares, Spain; (C.G.-M.); (M.A.S.); (M.A.Á.-M.); (N.G.-H.); (J.M.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - María Luisa Canals
- ISM, IMHA Research Chair, Former of IMHA (International Maritime Health Association), 43001 Tarragona, Spain;
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Oliaei S, SeyedAlinaghi S, Mehrtak M, Karimi A, Noori T, Mirzapour P, Shojaei A, MohsseniPour M, Mirghaderi SP, Alilou S, Shobeiri P, Azadi Cheshmekabodi H, Mehraeen E, Dadras O. The effects of hyperbaric oxygen therapy (HBOT) on coronavirus disease-2019 (COVID-19): a systematic review. Eur J Med Res 2021; 26:96. [PMID: 34412709 PMCID: PMC8374420 DOI: 10.1186/s40001-021-00570-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/10/2021] [Indexed: 02/08/2023] Open
Abstract
Background Oxygenation serves as a cornerstone in the treatment of COVID-19, and several methods have been extensively studied so far. Herein, we aimed to systematically review the studies discussing hyperbaric oxygen therapy (HBOT) to examine its reported efficacy and adverse events in patients with COVID-19. Methods We systematically searched and retrieved the relevant articles using keywords on the online databases, including PubMed, Scopus, Embase, Web of Science, and Cochrane databases up to April 11th, 2021. The retrieved records underwent a two-step title/abstract and full-text screening process, and the eligible papers were identified. National Institutes of health (NIH) quality assessment tool was used for this study. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with ID CRD42021269821. Results Eight articles from three countries were included. All the included studies had good and fair quality scores, with no poor studies included in this systematic review (Good: n = 5, Fair: n = 3). Studies were divided into clinical trials and case reports/series. Most of the studies used HBOT less than 1.5–2 absolute atmospheres (ATA) for 90 min sessions and thereafter sessions were decreased to 60 min. Trials demonstrated most of the patients recovered after receiving HBOT, and blood oxygen saturation increased after several sessions of HBOT. Conclusion Overall, HBOT seems to be a safe and effective oxygenation method in patients with COVID-19. However, there is limited knowledge and evidence regarding the effects and mechanism of HBOT in COVID-19 treatment, and further evaluations require extensive well-designed studies.
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Affiliation(s)
- Shahram Oliaei
- HBOT Research Center, Golestan Hospital, Islamic Republic of Iran, Navy and AJA Medical University, Tehran, Iran
| | - SeyedAhmad SeyedAlinaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehrtak
- Healthcare Services Management, School of Medicine and Allied Medical Sciences, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Amirali Karimi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Tayebeh Noori
- Department of Health Information Technology, Zabol University of Medical Sciences, Zabol, Iran
| | - Pegah Mirzapour
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Shojaei
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrzad MohsseniPour
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Sanam Alilou
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Parnian Shobeiri
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hadiseh Azadi Cheshmekabodi
- Health Information Technology, School of Health Information Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Esmaeil Mehraeen
- AMAD Research Institute, Supreme National Defense University, Tehran, Iran. .,Department of Health Information Technology, Khalkhal University of Medical Sciences, 1419733141, Khalkhal, Iran.
| | - Omid Dadras
- Department of Global Health and Socioepidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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10
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COVID-19 associated mucormycosis: Staging and management recommendations (Report of a multi-disciplinary expert committee). J Oral Biol Craniofac Res 2021; 11:569-580. [PMID: 34395187 PMCID: PMC8354814 DOI: 10.1016/j.jobcr.2021.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/28/2021] [Accepted: 08/04/2021] [Indexed: 12/26/2022] Open
Abstract
Even before the onslaught of COVID-19 pandemic could settle, the unprecedented rise in cases with COVID-19 associated mucormycosis pushed the medical health to the fringe. Hyperglycaemia and corticosteroids appear to be the most consistent associations leading to the commonest manifestation of mucormycosis, Rhino-Orbito-Cerebral Mucormycosis. To address challenges right from categorisation and staging of the disease to the management of relentless progression, a multi-disciplinary expert committee was formed to handle the task in an evidence-based format to enforce best practices. The report of the committee on one hand attempts to succinctly present the currently available evidence while at the other also attempts to bridge the evidence-deficient gaps with the specialty-specific virtuosity of experts.
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11
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Yanagawa Y. Current status of hyperbaric oxygen therapy for COVID-19. Acute Med Surg 2021; 8:e678. [PMID: 34262779 PMCID: PMC8264955 DOI: 10.1002/ams2.678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/03/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Youichi Yanagawa
- Department of Acute Critical Care Medicine Shizuoka Hospital Juntendo University Izunokuni City Japan
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12
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Kjellberg A, Douglas J, Pawlik MT, Kraus M, Oscarsson N, Zheng X, Bergman P, Frånberg O, Kowalski JH, Nyren SP, Silvanius M, Skold M, Catrina SB, Rodriguez-Wallberg KA, Lindholm P. Randomised, controlled, open label, multicentre clinical trial to explore safety and efficacy of hyperbaric oxygen for preventing ICU admission, morbidity and mortality in adult patients with COVID-19. BMJ Open 2021; 11:e046738. [PMID: 34226219 PMCID: PMC8260306 DOI: 10.1136/bmjopen-2020-046738] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION COVID-19 may cause severe pneumonitis and trigger a massive inflammatory response that requires ventilatory support. The intensive care unit (ICU)-mortality has been reported to be as high as 62%. Dexamethasone is the only of all anti-inflammatory drugs that have been tested to date that has shown a positive effect on mortality. We aim to explore if treatment with hyperbaric oxygen (HBO) is safe and effective for patients with severe COVID-19. Our hypothesis is that HBO can prevent ICU admission, morbidity and mortality by attenuating the inflammatory response. The primary objective is to evaluate if HBO reduces the number of ICU admissions compared with best practice treatment for COVID-19, main secondary objectives are to evaluate if HBO reduces the load on ICU resources, morbidity and mortality and to evaluate if HBO mitigates the inflammatory reaction in COVID-19. METHODS AND ANALYSIS A randomised, controlled, phase II, open label, multicentre trial. 200 subjects with severe COVID-19 and at least two risk factors for mortality will be included. Baseline clinical data and blood samples will be collected before randomisation and repeated daily for 7 days, at days 14 and 30. Subjects will be randomised with a computer-based system to HBO, maximum five times during the first 7 days plus best practice treatment or only best practice treatment. The primary endpoint, ICU admission, is defined by criteria for selection for ICU. We will evaluate if HBO mitigates the inflammatory reaction in COVID-19 using molecular analyses. All parameters are recorded in an electronic case report form. An independent Data Safety Monitoring Board will review the safety parameters. ETHICS AND DISSEMINATION The trial is approved by The National Institutional Review Board in Sweden (2020-01705) and the Swedish Medical Product Agency (5.1-2020-36673). Positive, negative and any inconclusive results will be published in peer-reviewed scientific journals with open access. TRIAL REGISTRATION NCT04327505. EudraCT number: 2020-001349-37.
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Affiliation(s)
- Anders Kjellberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Douglas
- Department of Anaesthesia and Intensive Care, Blekinge Hospital Karlskrona, Karlskrona, Sweden
| | - Michael T Pawlik
- Department of Anaesthesiology and Intensive Care Medicine, Catholic Charities Hospital, St. Josef, Regensburg, Germany
| | - Michael Kraus
- Department of Anaesthesiology and Intensive Care Medicine, Bergmannsheil und Kinderklinik Buer GmbH, Gelsenkirchen, Germany
| | - Nicklas Oscarsson
- Department of Anesthesiology and Intensive Care, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
| | - Xiaowei Zheng
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Peter Bergman
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institute, Stockholm, Sweden
| | - Oskar Frånberg
- Department of Mathematics and Natural Science, Blekinge Institute of Technology, Karlskrona, Sweden
| | | | - Sven Paul Nyren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Mårten Silvanius
- Department of Mathematics and Natural Sciences, TIMN, Blekinge Institute of Technology, Karlskrona, Sweden
- SwAF Diving and Naval Medicine Centre, Swedish Armed Forces, Karlskrona, Sweden
| | - Magnus Skold
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Sergiu-Bogdan Catrina
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Center for Diabetes, Academic Specialist Center, Stockholm, Sweden
| | - Kenny A Rodriguez-Wallberg
- Department of Reproductive Medicine, Division of Gynecology and Reproduction, Karolinska Universitetssjukhuset, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency Medicine, UCSD, La Jolla, California, USA
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13
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Hyperbaric Oxygen Therapy in Covid-19 Treatment: Efficacy and Safety. POLISH HYPERBARIC RESEARCH 2021. [DOI: 10.2478/phr-2021-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Introduction: New effective treatments are sought to eliminate COVID-19-related hypoxia. Hyperbaric oxygen therapy is an effective method in the treatment of many diseases accompanied by hypoxia.
Aim: The aim of this study was to analyse the literature on the use of hyperbaric oxygen in the treatment of COVID-19 and to evaluate the effectiveness and safety of this method.
Materials and methods: Medical databases (Medline and PBL) and websites were reviewed using the terms hyperbaric oxygen and COVID-19. 25 works were qualified for the analysis.
Conclusions: The analysed literature shows that hyperbaric oxygen therapy is an effective and safe method of treating patients with COVID-19. Due to the limited amount of scientific evidence assessing the use of HBOT in COVID-19, there is a need for further research to confirm the effectiveness and safety of this method.
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14
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El Hawa AAA, Charipova K, Bekeny JC, Johnson-Arbor KK. The evolving use of hyperbaric oxygen therapy during the COVID-19 pandemic. J Wound Care 2021; 30:S8-S11. [PMID: 33573494 DOI: 10.12968/jowc.2021.30.sup2.s8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Sars-CoV-2 (COVID-19) pandemic has resulted in significant and unprecedented shifts in the delivery of health care services in the United States. Although wound care remains an essential service during the COVID-19 pandemic, the financial consequences and infectious disease ramifications of the pandemic have resulted in closure or limitation of hours in many outpatient wound and hyperbaric oxygen therapy (HBOT) centers. As HBOT patients often require daily treatment sessions for a period of months, it is necessary for facilities providing HBOT services to adjust to the COVID-19 pandemic while still maintaining availability of this important service. Modification of HBOT session timing and chamber decontamination procedures, utilisation of telehealth services for initial patient evaluations, and acceptance of novel patient populations and diagnoses are mechanisms by which HBOT centers can adapt to the evolving model of health care delivery throughout a pandemic. While COVID-19 is not a currently accepted indication for HBOT, patients may be referred for HBOT consultation due to the post-infectious sequelae of the virus, and thus HBOT facilities must be aware of the potential uses of this treatment for post-viral complications. By redefining paradigms for health care delivery during the COVID-19 pandemic, HBOT and wound centers can continue to provide high-quality and uninterrupted care to vulnerable patient populations.
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Affiliation(s)
| | - Karina Charipova
- Georgetown University School of Medicine; Washington, District of Columbia
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
| | - Kelly K Johnson-Arbor
- Georgetown University School of Medicine; Washington, District of Columbia.,Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
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15
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Criado PR, Miot HA, Pincelli TPH, Fabro AT. From dermatological conditions to COVID-19: Reasoning for anticoagulation, suppression of inflammation, and hyperbaric oxygen therapy. Dermatol Ther 2020; 34:e14565. [PMID: 33219572 PMCID: PMC7744832 DOI: 10.1111/dth.14565] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/24/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Abstract
COVID‐19 generates a complex systemic inflammatory response that can lead to death due to wide macrophage activation, endothelial damage, and coagulation in critically ill patients. SARS‐CoV‐2‐induced lung injury due to inflammatory mediated thrombosis could be similar to the livedoid vasculopathy in the skin, supporting a translational comparison of these clinical settings. In this article, we discuss anticoagulation, suppression of inflammatory response, and hyperbaric oxygen therapy in the context of severe COVID‐19 and livedoid vasculopathy.
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Affiliation(s)
- Paulo Ricardo Criado
- Department of Dermatology, Centro Universitário Saúde ABC, Santo André, São Paulo, Brazil
| | - Hélio Amante Miot
- Department of Dermatology and Radiotherapy, Faculdade de Medicina da Unesp, Botucatu, São Paulo, Brazil
| | | | - Alexandre Todorovic Fabro
- Department of Pathology and Forensic Medicine, Faculdade de Medicina de Ribeirão Preto da USP, São Paulo, Brazil
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16
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Kjellberg A, De Maio A, Lindholm P. Can hyperbaric oxygen safely serve as an anti-inflammatory treatment for COVID-19? Med Hypotheses 2020; 144:110224. [PMID: 33254531 PMCID: PMC7456590 DOI: 10.1016/j.mehy.2020.110224] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/07/2020] [Accepted: 08/27/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION SARS-CoV-2 affects part of the innate immune response and activates an inflammatory cascade stimulating the release of cytokines and chemokines, particularly within the lung. Indeed, the inflammatory response during COVID-19 is likely the cause for the development of acute respiratory distress syndrome (ARDS). Patients with mild symptoms also show significant changes on pulmonary CT-scan suggestive of severe inflammatory involvement. HYPOTHESIS The overall hypothesis is that HBO2 is safe and reduces the inflammatory response in COVID-19 pneumonitis by attenuation of the innate immune system, increase hypoxia tolerance and thereby prevent organ failure and reduce mortality. EVALUATION OF THE HYPOTHESIS HBO2 is used in clinical practice to treat inflammatory conditions but has not been scientifically evaluated for COVID-19. Experimental and empirical data suggests that HBO2 may reduce inflammatory response in COVID-19. However, there are concerns regarding pulmonary safety in patients with pre-existing viral pneumonitis. EMPIRICAL DATA Anecdotes from "compassionate use" and two published case reports show promising results. CONSEQUENCES OF THE HYPOTHESIS AND DISCUSSION Small prospective clinical trials are on the way and we are conducting a randomized clinical trial.
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Affiliation(s)
- Anders Kjellberg
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden.
| | - Antonio De Maio
- Division of Trauma, Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego, La Jolla, CA 92093, USA; Department of Neurosciences, School of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Department of Emergency Medicine, University of California San Diego, La Jolla, CA 92093, USA
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17
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Senniappan K, Jeyabalan S, Rangappa P, Kanchi M. Hyperbaric oxygen therapy: Can it be a novel supportive therapy in COVID-19? Indian J Anaesth 2020; 64:835-841. [PMID: 33437070 PMCID: PMC7791429 DOI: 10.4103/ija.ija_613_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/23/2020] [Accepted: 09/02/2020] [Indexed: 12/21/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) is a pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Although 85% of infected patients remain asymptomatic, 5% show severe symptoms such as hypoxaemic respiratory failure and multiple end organ dysfunction (MODS) requiring intensive care unit (ICU) admission with a mortality rate of about 2.8%. Since a definitive treatment is yet to be identified, preventive and supportive strategies remain the mainstay of management. Supportive measures such as oxygen therapy with nasal cannula, face mask, noninvasive ventilation, mechanical ventilation and even extreme measures such as extracorporeal membrane oxygenation (ECMO) fail to improve oxygenation in some patients. Hence, hyperbaric oxygen therapy (HBOT) has been proposed as a supportive strategy to improve oxygenation in COVID-19 patients. HBOT is known to increase tissue oxygenation by increasing the amount of dissolved oxygen in plasma. HBOT also mitigates tissue inflammation thus reducing the ill effects of cytokine storm in COVID-19 patients. Though there is limited literature available on HBOT in COVID-19 patients, considering the present need for additional supportive therapy to improve oxygenation, HBOT has been proposed as a novel supportive treatment in COVID-19 patients.
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Affiliation(s)
- Kirubanand Senniappan
- Department of Anaesthesia, Narayana Institute of Cardiac Sciences, Narayana Health, Bangalore, Karnataka, India
| | - Salome Jeyabalan
- Department of Anaesthesia, Narayana Institute of Cardiac Sciences, Narayana Health, Bangalore, Karnataka, India
| | - Pradeep Rangappa
- Department of Intensive Care, Columbia Asia Hospitals, Bangalore, Karnataka, India
| | - Muralidhar Kanchi
- Department of Anaesthesia and Intensive Care, Narayana Institute of Cardiac Sciences, Narayana Health, Bangalore, Karnataka, India
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18
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Paganini M, Bosco G, Perozzo FAG, Kohlscheen E, Sonda R, Bassetto F, Garetto G, Camporesi EM, Thom SR. The Role of Hyperbaric Oxygen Treatment for COVID-19: A Review. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1289:27-35. [PMID: 32696443 DOI: 10.1007/5584_2020_568] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The recent coronavirus disease 2019 (COVID-19) pandemic produced high and excessive demands for hospitalizations and equipment with depletion of critical care resources. The results of these extreme therapeutic efforts have been sobering. Further, we are months away from a robust vaccination effort, and current therapies provide limited clinical relief. Therefore, several empirical oxygenation support initiatives have been initiated with intermittent hyperbaric oxygen (HBO) therapy to overcome the unrelenting and progressive hypoxemia during maximum ventilator support in intubated patients, despite high FiO2. Overall, few patients have been successfully treated in different locations across the globe. More recently, less severe patients at the edge of impending hypoxemia were exposed to HBO preventing intubation and obtaining the rapid resolution of symptoms. The few case descriptions indicate large variability in protocols and exposure frequency. This summary illustrates the biological mechanisms of action of increased O2 pressure, hoping to clarify more appropriate protocols and more useful application of HBO in COVID-19 treatment.
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Affiliation(s)
- Matteo Paganini
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Gerardo Bosco
- Department of Biomedical Sciences, University of Padova, Padova, Italy.
| | - Filippo A G Perozzo
- Plastic and Reconstructive Surgery Unit, Padova University Hospital, Padova, Italy
| | - Eva Kohlscheen
- Plastic and Reconstructive Surgery Unit, Padova University Hospital, Padova, Italy
| | - Regina Sonda
- Plastic and Reconstructive Surgery Unit, Padova University Hospital, Padova, Italy
| | - Franco Bassetto
- Plastic and Reconstructive Surgery Unit, Padova University Hospital, Padova, Italy
| | | | - Enrico M Camporesi
- Teamhealth Anesthesia Attending, Emeritus Professor of Surgery, USA, Tampa, FL, USA
| | - Stephen R Thom
- Emergency Medicine, University of Maryland, Baltimore, MD, USA
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