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Barillo DJ, Croutch CR, Barillo AR, Thompson CK, Roseman J, Reid F. Debridement of Sulfur Mustard Skin Burns: A Comparison of Three Methods. J Burn Care Res 2021; 41:159-166. [PMID: 31504620 DOI: 10.1093/jbcr/irz140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Sulfur mustard burns are characterized by delayed symptoms, slow healing, and recurrence after closure. Incomplete debridement at the level of the basement membrane is the postulated cause. Graham pioneered laser debridement of mustard burns. For field or mass-casualty use, saline wet-to-wet or antibiotic-soak debridement is more practical. In this study, we compared laser, saline, and antibiotic debridement in a porcine model of deep partial-thickness injury. Deep-dermal sulfur mustard burns were produced in 18 anesthetized Gottingen minipigs using 10-μl saturated vapor cap exposure time of 90 minutes. Debridement was started 48 hours postinjury and consisted of a single laser treatment; 5 days of 5% aqueous mafenide acetate wet-to-wet dressings; or 7 to 12 days of saline wet-to-wet dressings. Wounds were treated with daily silver sulfadiazine for 30 days and, then, assessed by histopathology, silver-ion analysis, colorimetry, and evaporimetry. All wounds healed well with no sign of infection. Antibiotic debridement showed no advantage over saline debridement. There were no significant differences between groups for colorimetry or evaporimetry. Histopathology was graded on a mustard-specific scale of 1 to 15 where higher values indicate better healing. Mean histology scores were 13.6 for laser, 13.9 for mafenide, and 14.3 for saline. Saline debridement statistically outperformed laser (P < .05) but required the longest debridement time. Laser debridement had the benefit of requiring a single treatment rather than daily dressing changes, significantly decreasing need for wound care and personnel resources. Development of a ruggedized laser for field use is a countermeasures priority.
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Affiliation(s)
- David J Barillo
- Disaster Response/Critical Care Consultants LLC, Mt Pleasant, South Carolina
| | - Claire R Croutch
- MRIGlobal Medical Countermeasures Division, Kansas City, Missouri
| | - Anthony R Barillo
- Disaster Response/Critical Care Consultants LLC, Mt Pleasant, South Carolina
| | - Charles K Thompson
- Disaster Response/Critical Care Consultants LLC, Mt Pleasant, South Carolina
| | - Julie Roseman
- MRIGlobal Medical Countermeasures Division, Kansas City, Missouri
| | - Frances Reid
- MRIGlobal Medical Countermeasures Division, Kansas City, Missouri
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Hassanpour M, Hajihassani F, Abdollahpourasl M, Cheraghi O, Aghamohamadzade N, Rahbargazi R, Nouri M, Pilehvar-Soltanahmadi Y, Zarghami N, Akbarzadeh A, Panahi Y, Sahebkar A. Pathophysiological Effects of Sulfur Mustard on Skin and its Current Treatments: Possible Application of Phytochemicals. Comb Chem High Throughput Screen 2020; 24:3-19. [PMID: 32679016 DOI: 10.2174/1386207323666200717150414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/21/2020] [Accepted: 06/03/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sulfur-(SM) and nitrogen (NM)-based mustards are the mutagenic incapacitating compounds which are widely used in vesicating the chemical warfare and cause toxicity in many organs, especially skin. SM, as a potent vesicating agent, contributes to the destruction of skin in dermis and epidermis layers. The progression of the lesion depends on the concentration of SM and the duration of exposure. Body responses start with pruritus, erythema, edema and xerosis, which lead to the accumulation of immune cells in the target sites and recruitment of mast cells and paracrine-mediated activity. Pro-inflammatory effectors are accumulated in the epidermis, hair follicles, and sebaceous glands resulting in the destruction of the basement membrane beneath the epidermis. There is still no satisfactory countermeasure against SM-induced lesions in clinical therapy, and the symptomatic or supportive treatments are routine management approaches. OBJECTIVE The current review highlights the recent progression of herbal medicines application in SM-induced injuries through the illustrative examples and also demonstrates their efficacies, properties and mechanism of actions as therapeutic agents. CONCLUSION Phytochemicals and herbal extracts with anti-bacterial, anti-inflammatory and antioxidant properties have been recently shown to hold therapeutic promise against the SM-induced cutaneous complications. The present review discusses the possible application of herbal medicines in the healing of SM-induced injuries.
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Affiliation(s)
- Mehdi Hassanpour
- Department of Clinical Biochemistry and Laboratory Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fateme Hajihassani
- Department of Health Management, School of Management and Medical informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Omid Cheraghi
- Department of Biochemistry, Faculty of Biological Science, Tarbiat Modares University, Tehran, Iran
| | - Nasser Aghamohamadzade
- Endocrine and Metabolism Section, Department of Internal Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Rahbargazi
- Department of Applied Cell Sciences, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Nouri
- Department of Clinical Biochemistry and Laboratory Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Younes Pilehvar-Soltanahmadi
- Department of Applied Cell Sciences, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nosratollah Zarghami
- Department of Applied Cell Sciences, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abolfazl Akbarzadeh
- Department of Applied Cell Sciences, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yunes Panahi
- Pharmacotherapy Department, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Abstract
Sulfur mustard (SM) is a blistering chemical warfare agent that was used during the World War I and in the Iraq-Iran conflict. The aim of this paper is to discuss and critically review the published results of experiments on the treatment of SM poisoning based on our clinical and research experience. The victims must remove from the contaminated zone immediately. The best solution for decontamination is large amounts of water, using neutral soap and 0.5% sodium hypochlorite. Severely intoxicated patients should be treated according to advanced life support protocols and intensive care therapy for respiratory disorders and the chemical burn. Sodium thiosulfate infusion (100-500 mg/kg/min) should be started up to 60 min after SM exposure. However, N-acetyle cysteine (NAC) is recommended, none of them acts as specific or effective antidote. The important protective and conservative treatment of SM-induced pulmonary injuries include humidified oxygen, bronchodilators, NAC as muculytic, rehydration, mechanical ventilation, appropriate antibiotics and respiratory physiotherapy as clinically indicated. Treatment of acute SM ocular lesions start with topical antibiotics; preferably sulfacetamide eye drop, continue with lubricants, and artificial tears. Treatment for cutaneous injuries include: moist dressing; preferably with silver sulfadiazine cream, analgesic, anti-pruritic, physically debridement, debridase, Laser debridement, followed by skin autologous split-thickness therapy as clinically indicated. The new suggested medications and therapeutic approaches include: anti-inflammatory agents, Niacinamide, Silibinin, Calmodulin antagonists, Clobetasol, full-thickness skin grafting for skin injuries; Doxycycline; Bevacizumab, and Colchicine for ocular injuries. Recommended compounds based on animal studies include Niacinamide, Aprotinin, des-aspartate-angiotensin-I, Gamma-glutamyltransferase, vitamin E, and vitamin D. In vitro studies revealed that Dimethylthiourea, L-nitroarginine, Methyl-ester, Sodium pyruvate, Butylated hydroxyanisole, ethacrynic acid, and macrolide antibiotics are effective. However, none of them, except macrolide antibiotics have been proved clinically. Avoidance of inappropriate polypharmacy is advisable.
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Affiliation(s)
- Leila Etemad
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences , Mashhad , Iran
| | - Mohammad Moshiri
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences , Mashhad , Iran
| | - Mahdi Balali-Mood
- Medical Toxicology and Drug Abuse Research Center, Birjand University of Medical Sciences , Birjand , Iran
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Abstract
The transient receptor potential ankyrin 1 (TRPA1) ion channel is a sensor for irritant chemicals, has ancient lineage, and is distributed across animal species including humans, where it features in many organs. Its activation by a diverse panel of electrophilic molecules (TRPA1 agonists) through electrostatic binding and/or covalent attachment to the protein causes the sensation of pain. This article reviews the species differences between TRPA1 channels and their responses, to assess the suitability of different animals to model the effects of TRPA1-activating electrophiles in humans, referring to common TRPA1 activators (exogenous and endogenous) and possible mechanisms of action relating to their toxicology. It concludes that close matching of in vitro and in vivo models will help optimise the identification of relevant biochemical and physiological responses to benchmark the efficacy of potential therapeutic drugs, including TRPA1 antagonists, to counter the toxic effects of those electrophiles capable of harming humans. The analysis of the species issue provided should aid the development of medical treatments to counter poisoning by such chemicals.
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Affiliation(s)
- C D Lindsay
- Chemical, Biological and Radiological (CBR) Division, Defence Science and Technology Laboratory (Dstl), Salisbury, UK
| | - C M Timperley
- Chemical, Biological and Radiological (CBR) Division, Defence Science and Technology Laboratory (Dstl), Salisbury, UK
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Rose D, Schmidt A, Brandenburger M, Sturmheit T, Zille M, Boltze J. Sulfur mustard skin lesions: A systematic review on pathomechanisms, treatment options and future research directions. Toxicol Lett 2017; 293:82-90. [PMID: 29203275 DOI: 10.1016/j.toxlet.2017.11.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 12/13/2022]
Abstract
Sulfur mustard (SM) is a chemical warfare, which has been used for one hundred years. However, its exact pathomechanisms are still incompletely understood and there is no specific therapy available so far. In this systematic review, studies published between January 2000 and July 2017 involving pathomechanisms and experimental treatments of SM-induced skin lesions were analyzed to summarize current knowledge on SM pathology, to provide an overview on novel treatment options, and to identify promising targets for future research to more effectively counter SM effects. We suggest that future studies should focus on (I) systemic effects of SM intoxication due to its distribution throughout the body, (II) removal of SM depots that continuously release active compound contributing to chronic skin damage, and (III) therapeutic options that counteract the pleiotropic effects of SM.
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Affiliation(s)
- Dorothee Rose
- Department of Translational Medicine and Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell Technology, Mönkhofer Weg 239a, 23562, Lübeck, Germany; Institute of Medical and Marine Biotechnology, University of Lübeck, Ratzeburger Allee 160, 23652, Lübeck, Germany
| | - Annette Schmidt
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstraße 11, 80937, Munich, Germany; Universität der Bundeswehr, Fakultät für Humanwissenschaften, Department für Sportwissenschaft, Werner-Heisenberg-Weg 39, 85577, Neubiberg, Germany.
| | - Matthias Brandenburger
- Department of Translational Medicine and Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell Technology, Mönkhofer Weg 239a, 23562, Lübeck, Germany; Institute of Medical and Marine Biotechnology, University of Lübeck, Ratzeburger Allee 160, 23652, Lübeck, Germany
| | - Tabea Sturmheit
- Department of Translational Medicine and Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell Technology, Mönkhofer Weg 239a, 23562, Lübeck, Germany; Institute of Medical and Marine Biotechnology, University of Lübeck, Ratzeburger Allee 160, 23652, Lübeck, Germany
| | - Marietta Zille
- Department of Translational Medicine and Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell Technology, Mönkhofer Weg 239a, 23562, Lübeck, Germany; Institute of Medical and Marine Biotechnology, University of Lübeck, Ratzeburger Allee 160, 23652, Lübeck, Germany; Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Johannes Boltze
- Department of Translational Medicine and Cell Technology, Fraunhofer Research Institution for Marine Biotechnology and Cell Technology, Mönkhofer Weg 239a, 23562, Lübeck, Germany; Institute of Medical and Marine Biotechnology, University of Lübeck, Ratzeburger Allee 160, 23652, Lübeck, Germany
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Jenner J, Graham SJ. Treatment of sulphur mustard skin injury. Chem Biol Interact 2013; 206:491-5. [DOI: 10.1016/j.cbi.2013.10.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 10/09/2013] [Accepted: 10/10/2013] [Indexed: 01/16/2023]
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Poursaleh Z, Ghanei M, Babamahmoodi F, Izadi M, Harandi AA, Emadi SE, Taghavi NOS, Sayad-Nouri SS, Emadi SN. Pathogenesis and treatment of skin lesions caused by sulfur mustard. Cutan Ocul Toxicol 2011; 31:241-9. [DOI: 10.3109/15569527.2011.636119] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Graham JS, Stevenson RS, Mitcheltree LW, Hamilton TA, Deckert RR, Lee RB, Schiavetta AM. Medical management of cutaneous sulfur mustard injuries. Toxicology 2009; 263:47-58. [DOI: 10.1016/j.tox.2008.07.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 07/25/2008] [Accepted: 07/28/2008] [Indexed: 10/21/2022]
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Abstract
Sulfur mustard is a member of the vesicant class of chemical warfare agents that causes blistering to the skin and mucous membranes. There is no specific antidote, and treatment consists of systematically alleviating symptoms. Historically, sulfur mustard was used extensively in inter-governmental conflicts within the trenches of Belgium and France during World War I and during the Iran-Iraq conflict. Longitudinal studies of exposed victims show that sulfur mustard causes long-term effects leading to high morbidity. Given that only a small amount of sulfur mustard is necessary to potentially cause an enormous number of casualties, disaster-planning protocol necessitates the education and training of first-line healthcare responders in the recognition, decontamination, triage, and treatment of sulfur mustard-exposed victims in a large-scale scenario.
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Abstract
Tangential excision in burns serves to preserve uninjured tissue in order to maximise cosmesis and function. Excision of all necrotic tissue remains absolutely necessary prior to reconstruction, and the choice of debridement method will depend on the injury, the condition of the patient and the experience of the surgeon. A problem with tangential excision has been that the amount of tissue excised is often greater than the amount of necrotic tissue. Techniques of tangential excision are described. Those using a guard, such as the Goulian or Watson knife, allow the depth of the gap between the blade and the guard to be varied. However, there remains the issue of precision, and a variance between the shape of the blade and of certain parts of the body. "Shelving" can occur as variances in the depth of excision slopes conflict with the uniform thickness of split thickness grafts or Integra, and may lead to an excess of tissue at the periphery of a wound, or "stuck on" appearance. Dermatome debridement may result in less loss of tissue, but this technique can difficult to perform due to the amount of blood loss. The Versajet (Smith & Nephew, Hull, UK) hydrosurgery system enables a more precise removal of unhealthy tissue, as it allows the narrowest excision margin currently available. As with many new techniques, the debridement may take longer at first, but the improved results will justify the extra time. In addition to greater precision in tangential excision, a better and smoother surface for future grafting may be created.
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Affiliation(s)
- S L A Jeffery
- Consultant Plastic Surgeon, The Royal Centre for Defence Medicine, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham, UK.
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