The History and Development of Hyperbaric Oxygenation (HBO) in Thermal Burn Injury.

Background and Objectives: Hyperbaric oxygenation (HBO) denotes breathing of 100% oxygen under elevated ambient pressure. Since the initiation of HBO for burns in 1965, abundant experimental and clinical work has been done. Despite many undisputedly positive and only a few controversial results on the efficacy of adjunctive HBO for burn injury, the method has not yet been established in clinical routine. Materials and Methods: We did a retrospective analysis of the literature according to PRISMA-guidelines, from the very beginning of HBO for burns up to present, trying to elucidate the question why HBO is still sidelined in the treatment of burn injury. Results: Forty-seven publications (32 animal experiments, four trials in human volunteers and 11 clinical studies) fulfilled the inclusion criteria. Except four investigators who found little or no beneficial action, all were able to demonstrate positive effects of HBO, most of them describing less edema, improved healing, less infection or bacterial growth and most recently, reduction of post-burn pain. Secondary enlargement of burn was prevented, as microvascular perfusion could be preserved, and cells were kept viable. The application of HBO, however, concerning pressure, duration, frequency and number of treatment sessions, varied considerably. Authors of large clinical studies underscored the intricate measures required when administering HBO in severe burns. Conclusions: HBO unquestionably has a positive impact on the pathophysiological mechanisms, and hence on the healing and course of burns. The few negative results are most likely due to peculiarities in the administration of HBO and possibly also to interactions when delivering the treatment to severely ill patients. Well-designed studies are needed to definitively assess its clinical value as an adjunctive treatment focusing on relevant outcome criteria such as wound healing time, complications, length of hospital stay, mortality and scar quality, while also defining optimal HBO dosage and timing.

Safety of enzymatic debridement in extensive burns larger than 15% total body surface area.

OBJECTIVES: Bromelain-based enzymatic debridement has emerged as an alternative to surgical eschar removal. Indications include partial thickness, mixed pattern, and full-thickness burns. Enzymatic debridement has been approved by the European Medicines Agency for treating burn wounds affecting <15% total body surface area (TBSA). Data and evidence for the treatment of areas >15% TBSA in one session is scarce. The aim of this retrospective study was to retrospectively analyze off-label use of enzymatic debridement in a single burn center for large TBSA burns. METHODS: Between 01/2017 and 12/2018, 59 patients with partial- to full-thickness burns underwent enzymatic debridement in a single center study. Patients were categorized into two groups: the regular use group with a treated area less than 15% TBSA and the off-label group (OG) with larger TBSA debrided in one session. Treatment was evaluated for systemic inflammatory reaction, bleeding, hemodynamic instability and electrolyte shifts. RESULTS: In total, 49 patients were treated in the regular use group with a median application area of 6% (IQR 2.5-9.5) and 10 patients were treated in the off-label group with a median application area of 18% (IQR 15-19) TBSA. We found no significant differences regarding blood pressure, body temperature or hemodynamic stability during and after enzymatic debridement. No treatment-related serious adverse events were observed in either group. Catecholamine use was similar in both groups. No differences in leukocyte counts, CRP, PCT and lactate prior to application and during the following three days were observed. Sodium, potassium, chloride and phosphate levels did not differ. We found no evidence of an electrolyte shift. Survival was 49 of 49 patients (100%) in the RG and 7 of 10 patients (70%) in the OG (p = 0.004). CONCLUSION: Enzymatic debridement did not result in any expected or unexpected side effects in the patient groups investigated. These preliminary results indicate the potential safety of bromelain-based enzymatic debridementin the treatment of burns greater than 15% TBSA.

Esophageal Hematoma Associated with the Bolus Ingestion of Hot Coffee.

A 59-year-old woman presented with pharyngeal discomfort and dysphagia starting the previous day. Esophagogastroduodenoscopy revealed a longitudinal reddish area and hematoma mainly on the left wall of the esophagus. On the previous day, she had felt a piece of meat sticking in her throat while eating; she therefore rapidly gulped down some hot coffee to hasten the passage of the meat. Based on the history, we diagnosed her endoscopic findings as esophageal hematoma and thermal injury associated with hot coffee. We herein describe a case of an acute esophageal hematoma and thermal injury and the clinical course following endoscopy.

Seeds of Zizyphus lotus: In Vivo Healing Properties of the Vegetable Oil.

The present study has been undertaken in order to highlight the healing effect of Zizyphus lotus vegetable oil. The seeds of this plant contain an oil rate of 30%. The obtained results on the main elements composing the vegetable oil have shown that Zizyphus lotus vegetable oil has a low value of acidity index and it presents a not negligible degree of unsaturation. The value of the peroxide index of Zizyphus lotus vegetable oil is less than 10 which characterizes the most of conventional oils. Furthermore, the spectral analysis by gas chromatography has shown the presence of 53 majority and minority molecules. Thus, the evaluation of the healing activity of Z. lotus seed vegetable oil has demonstrated a highly significant effect against the negative control and silver sulfadiazine was used as conventional treatment for burns. Based on the obtained results, we can suggest that the oil extracted from the seeds of the studied plant could be used to cure wounds.

A comparison of two scar massage protocols in pediatric burn survivors.

The current evidence to support the use of massage for scar management is conflicting in the literature. The purpose of this study was to compare two scar massage protocols administered with pediatric burn survivors to determine if a more structured and standardized approach to scar massage could improve outcome. A retrospective review of the medical records of 100 children who received massage during the time period when two different protocols were implemented was conducted and data that was collected as part of the clinical exam regarding scar height, vascularity, pliability, itch and pain were extracted. Comparisons were made within subject for scar changes from baseline to follow up and between subjects receiving Protocol A and those receiving Protocol B for the same scar characteristics. Versions of the Vancouver Scar Scale were used to assess scars, while visual analogue scale, Itch Man Scale and Wong-Baker Faces Pain Scale were used to assess itch and pain. Results demonstrated improvements in itch and vascularity over time with both scar massage protocols. However, when comparing patients who received Protocol A to those who received Protocol B, there was no difference found in scar height, vascularity, pliability, itch or pain. Using commonly applied subjective scar assessment tools, we did not find clinically meaningful changes in scar characteristics with the implementation of a structured scar massage program compared to a general approach to massage. Further research is needed to better define the impact of massage on the recovery experience for burn survivors.

Role of 904 nm superpulsed laser-mediated photobiomodulation on nitroxidative stress and redox homeostasis in burn wound healing.

BACKGROUND: Burn wound healing is delayed due to several critical factors such as sustained inflammation, vascular disorder, neuropathy, enhanced proteolysis, infection, and oxidative stress. Burn wounds have limited oxygen supply owing to compromised blood circulation. Hypoxic burn milieu leads to free radicals overproduction incurring oxidative injury, which impedes repair process causing damage to cell membranes, proteins, lipids, and DNA. Photobiomodulation (PBM) with 904 nm superpulsed laser had shown potent healing efficacy via attenuating inflammation while enhancing proliferation, angiogenesis, collagen accumulation, and bioenergetic activation in burn wounds. METHODS: This study investigated the effects of 904 nm superpulsed laser at 0.4 mW/cm2 average power density, 0.2 J/cm2 total energy density, 100 Hz frequency, and 200 ns pulse width for 10 min daily for seven days postburn injury on nitroxidative stress, endogenous antioxidants status, and redox homeostasis. RESULTS: Photobiomodulation treatment significantly decreased reactive oxygen species, nitric oxide, and lipid peroxidation levels as compared to non-irradiated control. Further, protective action of PBM against protein oxidative damage was evidenced by reduced protein carbonylation and advanced oxidation protein product levels along with significantly enhanced endogenous antioxidants levels of SOD, catalase, GPx, GST, reduced glutathione, and thiol (T-SH, Np-SH, P-SH). Biochemical changes aid in reduction of oxidative stress and maintenance of redox homeostasis, which further well corroborated by significantly up-regulated protein expression of Nrf 2, hemeoxygenase (HO-1), and thioredoxin reductase 2 (Txnrd2). CONCLUSION: Photobiomodulation with 904 nm superpulsed laser led to reduction of nitroxidative stress, induction of endogenous antioxidants, and maintenance of redox homeostasis that could play a vital role in augmentation of burn wound healing.

Impact of the implementation of a therapy dog program on burn center patients and staff.

Animal-assisted interventions have been implemented in both inpatient and outpatient settings and have demonstrated positive outcomes on patients and hospital staff. Animal-assisted interventions have not been previously reported in any burn center. A therapy dog program was established at our burn center with the intent of improving duration and quality of rehabilitation sessions and physical therapy. Satisfaction surveys were distributed to patients and staff. After one year, 14 patient surveys and 23 staff surveys were collected. Implementation of this program was feasible and patients worked with the therapy dogs in all environments of the burn center: outpatient, ward, and ICU. Most patients reported improved pain and anxiety after working with the therapy dogs. All patients reported that they would like more sessions with the therapy dogs. All staff members were satisfied or very satisfied with their therapy dog visit and all enjoyed having the therapy dogs present. Most reported an improved mood after seeing the therapy dogs and wanted that additional therapy dog visits. One year after the implementation of the therapy dog program, we have demonstrated feasibility, acceptability, and desirability of this type of program at our burn center. Given the paramount importance of rehabilitation in the recovery of burn patients, further investigation into therapy should be performed and longer term outcomes assessed.

The effect of aromatherapy massage with lavender and chamomile oil on anxiety and sleep quality of patients with burns.

INTRODUCTION: Regarding the importance of anxiety management and improvement of the quality of sleep in patients with burn injuries, this study aimed to determine the effect of aromatherapy massage (using aromatic oils of lavender and chamomile) on the anxiety and sleep quality of the patients with burn injuries. METHOD: In a quasi-experimental study, 105 patients with burns were recruited by convenience sampling method and then assigned into three groups (control, placebo massage, and combined aromatic oil massage). The study intervention was performed 20min before bedtime in three sessions, within a week. The control group was only under daily routine care. The study data were collected using the Persian version of Spielberg's anxiety scale and the Pittsburgh Sleep Quality Inventory. Descriptive and inferential statistical tests were used to analyze the data in SPSS version 20. RESULTS: The results showed a significant difference among the three groups in terms of anxiety score (P<0.001) and in terms of sleep quality after the intervention (P=0.027). CONCLUSION: Since the aromatherapy massage as a non-pharmacological and simple method can improve the anxiety and quality of sleep in patients with burns, it is suggested that nurses and burn medical care team apply it to reduce burn patients' anxiety and promote their sleep quality. Applying massage alone also reduces anxiety in burn survivors.

The impact of assault by vitriolage on quality of life: Integrative review.

AIMS: To analyse quality of life post vitriolage and explore factors affecting an individual's everyday functioning after an acid attack. DESIGN: Integrative review. DATA SOURCES: Articles (N = 570) retrieved from Medline, CINAHL Embase and Psychinfo between 2004-2017. Reference chaining and hand-searching yielded 12 further articles. A total 12 articles were reviewed. REVIEW METHODS: Whittemore and Knalf (2005) Journal of Advanced Nursing, 52, 546-553. RESULTS: Five themes were identified; contextual factors, physical wounds, psychological wounds, social wounds, and legal factors, as demonstrated by a conceptual model exploring traumatic events experienced by survivors. CONCLUSION: The event, the burn injury itself, scarring and ocular damage are core factors that impair quality of life. Patients find it difficult to reintegrate into society following the assault and discrepancies between medico-legal and social services further prevent them from achieving their pre-morbid level of functioning. Nurses can use the biopsychosocial findings of this review to provide effective care for those assaulted by acid. It also provides a basis of discussion and application to other permanently disfiguring conditions and intentional injuries. IMPACT: This review has found survivors of acid assaults experience legal, physical, psychological, and social problems. Findings suggest that no single person will have the same experiences since the burden of injury is dependent on socio-cultural and contextual factors rather than the degree of injury alone. Inadequate coordination between multidisciplinary services hinders reintegration into society; causing permanent traumatization for some survivors. This review can assist nurses in understanding how acid assaults impact on quality of life to enable more holistic care provision.

Involvement of brain-derived neurotrophic factor (BDNF) in chronic intermittent stress-induced enhanced mechanical allodynia in a rat model of burn pain.

BACKGROUND: Reports show that stressful events before injury exacerbates post-injury pain. The mechanism underlying stress-induced heightened thermal pain is unclear. Here, we examined the effects of chronic intermittent stress (CIS) on nociceptive behaviors and brain-derived nerve growth factor (BDNF) system in the prefrontal cortex (PFC) and hypothalamus of rats with and without thermal injury. RESULTS: Unstressed rats showed transient mechanical allodynia during stress exposure. Stressed rats with thermal injury displayed persistent exacerbated mechanical allodynia (P < 0.001). Increased expression of BDNF mRNA in the PFC (P < 0.05), and elevated TrkB and p-TrkB (P < 0.05) protein levels in the hypothalamus were observed in stressed rats with thermal injury but not in stressed or thermally injured rats alone. Furthermore, administration of CTX-B significantly reduced stress-induced exacerbated mechanical allodynia in thermally injured rats (P < 0.001). CONCLUSION: These results indicate that BDNF-TrkB signaling in PFC and hypothalamus contributes to CIS-induced exacerbated mechanical allodynia in thermal injury state.

Photobiomodulation associated to cellular therapy improve wound healing of experimental full thickness burn wounds in rats.

Adipose derived stromal vascular fraction (SVF) is a method of cell therapy potentially applicable for treatment of full thickness burns. Here we investigated if the association of photobiomodulation (PBM) with SVF therapy could improve wound healing in experimentally induced full thickness burn wounds in rats compared to the topical agent 2% silver sulfadiazine in a dose-dependent manner. Sixty-six male Wistar rats were divided in 4 groups containing 5 animals each which received the following treatments: 2% sulfadiazine (SD), SVF, SVF plus PBM at 30 mW (SVFL30), and SVF plus PBM at 100 mW (SVFL100). Two donor animals were used for each experimental series with 3, 7 and 30 days. Digital photography, microscopic analysis with Hematoxilin and Eosin (H&E), quantification of collagen type I by picrosirius red staining analysis and wound contraction evaluation were performed in order to quantify the results. At day 3 SVF alone or combined with PBM promoted increased early inflammatory response compared to SD. At day 7 SVFL30 and SVFL100 enhanced inflammatory cells infiltration, angiogenesis and fibroblast content compared to SVF and SD groups. At day 30 collagen concentration and wound contraction were higher in SVFL30 when compared to the other groups. In conclusion PBM promotes a synergistic outcome with SVF therapy with a dose dependent effect potentializing wound healing of experimental full thickness burns in rats through amplification of early inflammatory response, enhanced angiogenesis, fibroblast content, accentuated wound contraction and collagen concentration.

Evaluation of leap motion control for hand rehabilitation in burn patients: An experience in the dust explosion disaster in Formosa Fun Coast.

Hand burns cause functional impairment. Leap motion control (LMC), a kind of virtual reality games, employs a novel system that provides biofeedback and training of fine motor function and functional skills. In this study, we hypothesized that LMC would improve burned hand function. Sixteen participants were allocated to either the LMC group or the control group. The LMC group played 20min identical leap motion video games after 40min traditional occupational therapy (OT). The control group received traditional OT for 60min. Both groups received interventions 2 days a week for 4 months. A series of questionnaires were administered, including BSHS-B, QuickDASH, iADL, and Barthel index. Data on baseline characteristics including joint range of motion (ROM), grip and pinch strength, and scar thickness were obtained. Furthermore, we used the Mann-Whitney U test and Wilcoxon signed-rank test for comparison, as appropriate. We found improvements in BSHS-B, QuickDASH, and iADL in the LMC group (all p<0.05) compared to those in the control group. In the LMC-trained hand, the ROM of the thumb IP joint and pinch strength increased, whereas the scar thickness over the first dorsal interossei muscle decreased (p<0.05). In conclusion, leap motion training could help patients with hand burns to increase finger ROM, decrease scar thickness, and improve hand function.

Kefir Accelerates Burn Wound Healing Through Inducing Fibroblast Cell Migration In Vitro and Modulating the Expression of IL-1ß, TGF-ß1, and bFGF Genes In Vivo.

Kefir is a natural probiotic compound with a long history of health benefits which can improve wound healing. This study investigated the regeneration potential of kefir in vitro scratch assay and in vivo burn wound in rat model. Cytotoxicity of different concentrations of kefir was evaluated by colorimetric methylthiazoltetrazolium assay. A scratch wound experiment was performed to investigate the ability of kefir in reducing the gap of wounds in a dose-dependent manner, in vitro. The standardized kefir was incorporated into silver sulfadiazine (SSD) and applied on burn wounds in vivo, and was compared with the SSD and negative control groups after 7, 14, and 28 days of treatment. The wound sites were then removed for histopathological and morphometric analyses, assessment of interleukin-1ß (IL-1ß), transforming growth factor-ß1 (TGF-ß1), basic fibroblast growth factor (bFGF), dry weight, and hydroxyproline contents. Kefir enhanced proliferation and migration of human dermal fibroblast (HDF) cells and 12.50, 6.25, and 3.12 µL/mL concentrations showed better effects on the scratch assay. Kefir resulted in reduction of IL-1ß and TGF-ß1 expression at day 7 compared to the negative control. Kefir also reduced the expression of IL-1ß at days 14 and 28 and stimulated bFGF at day 28. It significantly improved the dry matter and hydroxyproline contents in the burn wounds. Kefir also resulted in enhanced angiogenesis and elevated migration and proliferation of fibroblasts and improved fibrous connective tissue formation in the wound area. The morphometric results indicated significant global contraction values in the kefir-treated wounds compared to other groups. Taken together, the findings suggest that kefir has considerable ability to accelerate healing of the burn wounds. Therefore, kefir may be a possible option to improve the outcomes of severe burns.

Comparing isolated soy protein with flaxseed oil vs isolated soy protein with corn oil and wheat flour with corn oil consumption on muscle catabolism, liver function, blood lipid, and sugar in burn patients: a randomized clinical trial.

BACKGROUND: There is controversy regarding whether increasing isolated soy protein (ISP) with or without flaxseed oil (FO), as functional foods, would lead to reduce muscle catabolism and cachexia in burn patients. METHODS: One hundred and eighty-eight patients were assessed for eligibility in this randomized controlled trial. Of these, seventy-three eligible patients (total burn surface area 20-50%) were randomly assigned to three groups, labeled as Control (wheat flour [WF] + corn oil [CO]), ISP + FO, and ISP + CO, to receive these nutrients for three weeks. Weight, body mass index (BMI), serum hepatic enzymes (alanine transaminase [ALT], aspartate transaminase [AST], alkaline phosphatase [ALP]), systemic inflammatory response syndrome (SIRS), 24-h urinary urea nitrogen excretion (UUN), serum creatinine, 24-h urinary creatinine (UUC) excretion, fasting blood sugar (FBS), triglyceride (TG), and cholesterol were measured. RESULTS: Using analysis of covariance models in the intention-to-treat population (n = 73), we found that at three weeks, patients in the ISP groups had lost significantly less in weight and BMI compared to those in the control group (all P < 0.01). Nitrogen retention and serum creatinine (primary outcomes) increased significantly in the ISP groups compared with the control group. Even after controlling for potential covariates in ANCOVA models, changes in these indices were still statistically significant (P = 0.008 and P = 0.005 for nitrogen balance and serum creatinine, respectively). However, no such significant differences were found between the ISP groups. On the other hand, 24-h UUN, and UUC excretion, serum hepatic enzymes, FBS, TG, and cholesterol were not significant between the groups (P > 0.05). CONCLUSION: ISP and FO compared to WF and CO reduced muscle catabolism and increased body weight in burn patients. TRIAL REGISTRATION: Iranian Registry of Clinical Trials, IRCT2014051817740N1 . Registered on 27 June 2014.

Effectiveness of a Crocus sativus Extract on Burn Wounds in Rats.

Crocus sativus is a spice with various pharmacological properties. Crocin, picrocrocin, and safranal are the main compositions of saffron that have recently been considered in the therapy of many diseases. High-performance liquid chromatography analysis revealed presence of these compounds in our saffron extract. This study was carried out to evaluate the effect of saffron on burn wound healing at an in vivo model. Saffron was topically applied on burn wounds in rats; the percentage of wound closure, wound contraction, and the levels of main cytokines and growth factors were measured. The saffron extract was also applied to evaluate the proliferation and migration of human dermal fibroblast (HDF) cells using in vitro scratch assay and resulted in active proliferation and migration of the HDF cells in a dose-dependent manner. A clear enhanced healing was observed in the saffron-treated wounds compared to the silver sulfadiazine and negative control groups. Decreased expression of interleukin-1ß and transforming growth factor-ß1 (TGF-ß1) during the inflammatory phase demonstrated the role of saffron in promoting wound healing. In addition, enhanced TGF-ß1 expression during the proliferative phase and basic fibroblast growth factor during the remodeling phase represented regenerative and anti-scarring role of saffron, respectively. Our histological and biochemical findings also confirmed that saffron significantly stimulated burn wound healing by modulating healing phases. Therefore, saffron can be an optimal option in promoting skin repair and regeneration. Application of this herbal medicinal drug should be encouraged because of its availability and negligible side effects.

[Advances in the research of effects of glutamine on immune function of burn patients].

Glutamine is the most abundant amino acid found in plasma and cells. It is the preferred fuel for enterocytes in the small intestine, macrophages, and lymphocytes. After serious burn, increased requirement of glutamine by the gastrointestinal tract, kidney and lymphocytes, and relatively insufficient self synthesis likely contribute to the rapid decline of glutamine in circulation and cells. Glutamine supplementation can not only protect intestinal mucosa, maintain normal intestinal barrier function, reduce bacterial translocation, and enhance the intestinal immune function, but also increase the number of lymphocytes, enhance the phagocytic function of macrophage, promote the synthesis of immunoglobulin, and reduce the body's inflammatory response, so as to enhance the immune function. Therefore, glutamine supplementation can improve and enhance the immune function, reduce complications and promote the prognosis of severely burned patients.

Metformin adapts its cellular effects to bioenergetic status in a model of metabolic dysfunction.

Thermal injury induces a complex immunometabolic response, characterized by hyperglycemia, extensive inflammation and persistent hypermetabolism. It has been suggested that attenuation of the hypermetabolic response is beneficial for patient wellbeing. To that effect, metformin represents an attractive therapeutic agent, as its effects on glycemia, inflammation and bioenergetics can improve outcomes in burn patients. Therefore, we studied metformin and its effects on mitochondrial bioenergetics in a murine model of thermal injury. We set out to determine the impact of this agent on mitochondrial hypermetabolism (adult mice) and mitochondrial dysfunction (aged mice). Seahorse respirometry complimented by in-gel activity assays were used to elucidate metformin's cellular mechanism. We found that metformin exerts distinctly different effects, attenuating the hypermetabolic mitochondria of adult mice while significantly improving mitochondrial bioenergetics in the aged mice. Furthermore, we observed that these changes occur both with and without adenosine monophosphate kinase (AMPK) activation, respectively, and analyzed damage markers to provide further context for metformin's beneficial actions. We suggest that metformin has a dual role following trauma, acting via both AMPK-dependent and independent pathways depending on bioenergetic status. These findings help further our understanding of metformin's biomolecular effects and support the continued use of this drug in patients.

Emergency department management of smoke inhalation injury in adults.

Smoke inhalation injury portends increased morbidity and mortality in fire-exposed patients. Upper airway thermal burns, inflammation from lower airway irritants, and systemic effects of carbon monoxide and cyanide can contribute to injury. A standardized diagnostic protocol for inhalation injury is lacking, and management remains mostly supportive. Clinicians should maintain a high index of suspicion for concomitant traumatic injuries. Diagnosis is mostly clinical, aided by bronchoscopy and other supplementary tests. Treatment includes airway and respiratory support, lung protective ventilation, 100% oxygen or hyperbaric oxygen therapy for carbon monoxide poisoning, and hydroxocobalamin for cyanide toxicity. Due to its progressive nature, many patients with smoke inhalation injury warrant close monitoring for development of airway compromise.

Clinician's Guide to Nutritional Therapy Following Major Burn Injury.

This article provides a clinician's guide to nutritional support of the burn patient. The authors review the assessment and management of the needs of the thermally injured patient and provide recommendations on replacement and supplementation with calories, protein, carbohydrates, lipids, fluids, and minerals. Furthermore, the authors compare and contrast enteral versus parenteral delivery of nutrition.