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McIntosh SE, Freer L, Grissom CK, Rodway GW, Giesbrecht GG, McDevitt M, Imray CH, Johnson EL, Pandey P, Dow J, Hackett PH. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update. Wilderness Environ Med 2024; 35:183-197. [PMID: 38577729 DOI: 10.1177/10806032231222359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2019.
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Affiliation(s)
- Scott E McIntosh
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Luanne Freer
- Everest ER, Himalayan Rescue Association, Kathmandu, Nepal
| | - Colin K Grissom
- Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - George W Rodway
- Department of Family Medicine - Sports Medicine, School of Medicine, University of Nevada, Reno, NV
| | - Gordon G Giesbrecht
- Faculty of Kinesiology and Recreation Management, Departments of Anesthesia and Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marion McDevitt
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Christopher H Imray
- Warwick Medical School, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Eric L Johnson
- Community Faculty, Family Medicine, University Nevada-Reno, Reno, NV
| | | | - Jennifer Dow
- Denali National Park and Preserve, Denali Park, AK
| | - Peter H Hackett
- Altitude Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO
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Wibbenmeyer L, Lacey AM, Endorf FW, Logsetty S, Wagner ALL, Gibson ALF, Nygaard RM. American Burn Association Clinical Practice Guidelines on the Treatment of Severe Frostbite. J Burn Care Res 2024; 45:541-556. [PMID: 37045447 DOI: 10.1093/jbcr/irad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
This Clinical Practice Guideline addresses severe frostbite treatment. We defined severe frostbite as atmospheric cooling that results in a perfusion deficit to the extremities. We limited our review to adults and excluded cold contact or rapid freeze injuries that resulted in isolated devitalized tissue. After developing population, intervention, comparator, outcomes (PICO) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations based on the available scientific evidence were formulated through consensus of a multidisciplinary committee. We conditionally recommend the use of rapid rewarming in a 38 to 42°C water bath and the use of thrombolytics for fewer amputations and/or a more distal level of amputation. We conditionally recommend the use of "early" administration of thrombolytics (≤12 hours from rewarming) compared to "later" administration of thrombolytics for fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of vascular imaging studies to determine the use of and/or the time to initiate thrombolytic therapy. No recommendation could be formed on the use of intravenous thrombolytics compared to the use of intra-arterial thrombolytics on fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of iloprost resulting in fewer amputations and/or more distal levels of amputation. No recommendation could be formed on the use of diagnostic imaging modalities for surgical planning on fewer amputations, a more distal level of amputation, or earlier timing of amputation.
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Affiliation(s)
- Lucy Wibbenmeyer
- Department of Surgery, University of Iowa, Iowa City, IA 52242, USA
| | | | | | - Sarvesh Logsetty
- Departments of Surgery, Psychiatry, and Children's Health, University of Manitoba, Winnipeg, Manitoba R3E 3P5, Canada
| | - Anne L L Wagner
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, USA
| | - Angela L F Gibson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - Rachel M Nygaard
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN 55415, USA
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Ma X, Pouoh JT, Hogue BT, Bougie E. Frostbite in the Pediatric Population: A Comprehensive Review and a Prospective Canadian Survey. Pediatr Emerg Care 2024:00006565-990000000-00372. [PMID: 38206303 DOI: 10.1097/pec.0000000000003109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Frostbite in the pediatric population, where skeletal maturity has not been achieved, can have important repercussions on subsequent growth. Yet, the optimal management of frostbite injuries in children remains vague. This review aims to summarize the current evidence for frostbite management in children and understand Canadian practice trends on this topic. METHODS A review using Medline, Scopus, Web of Science, and gray literature was performed to identify relevant literature on the clinical manifestations, diagnostic methods, and treatment options in pediatric frostbite. An online survey was sent to plastic surgeons through the Canadian Society of Plastic Surgeons (CSPS) mailing list to further identify national practices and trends for pediatric frostbite management. RESULTS A total of 109 articles were reviewed. No article provided a specific algorithm for pediatric frostbite, with existing recommendations suggesting the use of adult guidelines for treating children. Our survey yielded 9 responses and highlighted the rarity of pediatric frostbite cases, with no responder treating more than 10 cases per year. Most (55.6%) do not use a pediatric-specific treatment algorithm, whereas 30% apply adult guidelines. A conservative approach focusing on rewarming (55.6%), limb elevation (50%), and tetanus status verification (66.7%) was predominant. Imaging and surgical interventions seem to be reserved for severe cases. CONCLUSIONS The current literature for pediatric frostbite management lacks specificity. Canadian practices vary, with a trend toward a conservative approach. The limited evidence and rarity of experience highlight the need for further research, ideally in a collaborative multicentric manner, to create a consensus for pediatric frostbite care.
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Affiliation(s)
- Xiya Ma
- From the Division of Plastic Surgery, Université de Montréal, Montreal, Quebec, Canada
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Poole A, Ahmed Y, Davidson M. The Occasional frostbite. CANADIAN JOURNAL OF RURAL MEDICINE 2024; 29:30-36. [PMID: 38358103 DOI: 10.4103/cjrm.cjrm_2_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/11/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Alexander Poole
- Whitehorse General Hospital, Yukon Hospital Corporation, Whitehorse, Yukon, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yousuf Ahmed
- Department of Emergency Medicine, Dalhousie University, Saint John, Canada
- Department of Family Medicine, Dalhousie University, Saint John, Canada
| | - Malcolm Davidson
- Temerty School of Medicine, University of Toronto, Toronto, ON, Canada
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Regli IB, Oberhammer R, Zafren K, Brugger H, Strapazzon G. Frostbite treatment: a systematic review with meta-analyses. Scand J Trauma Resusc Emerg Med 2023; 31:96. [PMID: 38072923 PMCID: PMC10712146 DOI: 10.1186/s13049-023-01160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Our objective was to perform a systematic review of the outcomes of various frostbite treatments to determine which treatments are effective. We also planned to perform meta-analyses of the outcomes of individual treatments for which suitable data were available. MAIN BODY We performed a systematic review and meta-analyses in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched PubMed, Cochrane Trials, and EMBase to identify primary references from January 1, 1900, to June 18, 2022. After eliminating duplicates, we screened abstracts to identify eligible studies containing information on treatment and outcomes of Grade 2 to 4 frostbite. We performed meta-analyses of groups of articles that provided sufficient data. We registered our review in the prospective registry of systematic reviews PROSPERO (Nr. 293,693). We identified 4,835 potentially relevant studies. We excluded 4,610 studies after abstract screening. We evaluated the full text of the remaining 225 studies, excluding 154. Ultimately, we included 71 articles with 978 cases of frostbite originating from 1 randomized controlled trial, 20 cohort studies and 51 case reports. We found wide variations in classifications of treatments and outcomes. The two meta-analyses we performed both found that patients treated with thrombolytics within 24 h had better outcomes than patients treated with other modalities. The one randomized controlled trial found that the prostacyclin analog iloprost was beneficial in severe frostbite if administered within 48 h. CONCLUSIONS Iloprost and thrombolysis may be beneficial for treating frostbite. The effectiveness of other commonly used treatments has not been validated. More prospective data from clinical trials or an international registry may help to inform optimal treatment.
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Affiliation(s)
- Ivo B Regli
- Institute of Mountain Emergency Medicine, EURAC Research, Viale Druso 1, 39100, Bolzano, BZ, Italy.
- Dr. Regli's Alpine Medical Services and Research, Unterägeri, ZG, Switzerland.
- Department of Internal and Emergency Medicine, Bürgerspital, Solothurn, SO, Switzerland.
| | - Rosmarie Oberhammer
- Department of Anesthesia and Intensive Care, Hospital of Brunico, Brunico, BZ, Italy
| | - Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK, USA
- Department of Emergency Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC Research, Viale Druso 1, 39100, Bolzano, BZ, Italy
- Department of Anesthesia and Intensive Care, Medical University Innsbruck, Innsbruck, Tyrol, Austria
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, EURAC Research, Viale Druso 1, 39100, Bolzano, BZ, Italy
- Department of Anesthesia and Intensive Care, Medical University Innsbruck, Innsbruck, Tyrol, Austria
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Wang XH, Li M, Cheng Y, Wang GJ, Lin GL, Liu WN. Comprehensive treatment of deep frostbite of multiple fingers after trauma: A case report. World J Clin Cases 2023; 11:8219-8227. [PMID: 38130784 PMCID: PMC10731172 DOI: 10.12998/wjcc.v11.i34.8219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/27/2023] [Accepted: 11/29/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Frostbite is becoming increasingly common in urban environments, and severe cases can lead to tissue loss. The treatment goal is to preserve tissue and function; the sooner appropriate treatment is administered, the more tissue can be saved. However, not every patient with deep frostbite seeks medical care promptly. CASE SUMMARY We report the case of a 73-year-old male patient who was lost in the wilderness for 2 d due to trauma and confusion. He experienced deep frostbite on multiple fingers. Treatment should not be discontinued for patients with deep frostbite who present after the optimum treatment timing. Bullae that no longer form (bloody) blisters within 24 h of aspiration should be removed. Mucopolysaccharide polysulfate cream has clinical value in frostbite treatment. The patient was transferred to Chinese Academy of Medical Sciences and Peking Union Medical College Hospital 12 h after being rescued. The patient had contraindications for thrombolysis, the most effective treatment, due to intracranial hemorrhage and presenting past the optimum treatment timing. We devised a comprehensive treatment plan, which involved delayed use vasodilators and high-pressure oxygen therapy at day 49 post-injury. We experimented with mucopolysaccharide polysulfate cream to treat the frostbite. The aim of the treatment was to safeguard as much tissue as possible. In the end, the fingers that suffered from frostbite were able to be partially preserved. CONCLUSION The case indicated that patients with severe frostbite who missed the optimal treatment time and had contraindications for thrombolysis could still partially preserve the affected limbs through comprehensive treatment.
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Affiliation(s)
- Xi-Hua Wang
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Min Li
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yue Cheng
- Department of Nursing, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Guang-Jian Wang
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Guo-Le Lin
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Nan Liu
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
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Lowe J, Warner M. Can iloprost be used for treatment of cold weather injury at the point of wounding in a forward operating environment? A literature review. Int J Circumpolar Health 2023; 82:2210340. [PMID: 37154780 PMCID: PMC10167884 DOI: 10.1080/22423982.2023.2210340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION Cold Weather Injury (CWI) represents a spectrum of pathology, the two main divisions being Freezing Cold Injury (FCI) and Non-Freezing Cold Injury (NFCI). Both are disabling conditions associated with microvascular and nerve injury often treated hours after initial insult when presenting to a healthcarestablishment. Given that iloprost is used for the treatment of FCI, could it be used in a forward operating environment to mitigate treatment delay? Is there a role for its use in the forward treatment of NFCI? This review sought to evaluate the strength of evidence for the potential use of iloprost in a forward operating environment. METHODS Literature searches were undertaken using the following question for both FCI and NFCI: in [patients with FCI/NFCI] does [the use of iloprost] compared to [standard care] reduce the incidence of [long-term complications]. Medline, CINAHL and EMBASE databases were searched using the above question and relevant alternative terminology. Abstracts were reviewed before full articles were requested. RESULTS The FCI search yielded 17 articles that were found to refer to the use of iloprost and FCI. Of the 17, one referred to pre-hospital treatment of frostbite at K2 base camp; however, this was utilising tPA. No articles referred to pre-hospital use in either FCI or NFCI. DISCUSSION Although evidence exists to support the use of iloprost in the treatment of FCI, its use to date has been in hospital. A common theme is delayed treatment due to the challenges of evacuating casualties from a remote location. There may be a role for iloprost in the treatment of FCI; however, further study is required to better understand the risk of its use.
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Affiliation(s)
- Jonathon Lowe
- British Antarctic Survey Medical Unit, Emergency Department, Derriford Hospital, Plymouth, UK
| | - Matthew Warner
- British Antarctic Survey Medical Unit, Emergency Department, Derriford Hospital, Plymouth, UK
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Gauthier J, Morris-Janzen D, Poole A. Iloprost for the treatment of frostbite: a scoping review. Int J Circumpolar Health 2023; 82:2189552. [PMID: 36966492 PMCID: PMC10044161 DOI: 10.1080/22423982.2023.2189552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023] Open
Abstract
We performed a scoping review to identify the extent of the literature describing the use of iloprost in the treatment of frostbite. Iloprost is a stable synthetic analog of prostaglandin I2. As a potent inhibitor of platelet aggregation and vasodilator, it has been used to address the post-rewarming reperfusion injury in frostbite. The search using iloprost and frostbite as key words and MeSH terms yielded 200 articles. We included in our review the literature examining iloprost for the treatment of frostbite in humans in the form of primary research, conference proceedings and abstracts. Twenty studies published from 1994 to 2022 were selected for analysis. The majority were retrospective case series consisting of a homogeneous population of mountain sport enthusiasts. A total of 254 patients and over 1000 frostbitten digits were included among the 20 studies. The larger case series demonstrated a decrease in amputation rates relative to untreated patients. Primary gaps in the literature include a paucity of randomised trials and relatively limited study populations to date. While the case evidence is promising, a multi-centre collaboration would be crucial to adequately power prospective randomised studies to definitively determine if iloprost has a role in the treatment of frostbite.
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Affiliation(s)
- Josianne Gauthier
- Whitehorse General Hospital, Yukon Hospital Corporation, Whitehorse, Yukon, Canada
| | - Dunavan Morris-Janzen
- Northern Medical Program, University of British Columbia, Prince George, British Columbia, Canada
| | - Alexander Poole
- Whitehorse General Hospital, Yukon Hospital Corporation, Whitehorse, Yukon, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Norheim AJ, Sullivan-Kwantes W, Steinberg T, Castellani J, Friedl KE. The classification of freezing cold injuries - a NATO research task group position paper. Int J Circumpolar Health 2023; 82:2203923. [PMID: 37083565 PMCID: PMC10124983 DOI: 10.1080/22423982.2023.2203923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
INTRODUCTION Freezing cold injuries (FCI) are a common risk in extreme cold weather operations. Although the risks have long been recognised, injury occurrences tend to be sparse and geographically distributed, with relatively few cases to study in a systematic way. The first challenge to improve FCI medical management is to develop a common nomenclature for FCI classification. This is critical for the development of meaningful epidemiological reports on the magnitude and severity of FCI, for the standardisation of patient inclusion criteria for treatment studies, and for the development of clinical diagnosis and treatment algorithms. METHODOLOGY A scoping review of the literature using PubMed and cross-checked with Google Scholar, using search terms related to freezing cold injury and frostbite, highlighted a paucity of published clinical papers and little agreement on classification schemes. RESULTS A total of 74 papers were identified, and 28 were included in the review. Published reports and studies can be generally grouped into four different classification schemes that are based on (1) injury morphology; (2) signs and symptoms; (3) pathophysiology; and (4) clinical outcome. The nomenclature in the different classification systems is not coherent and the discrete classification limits are not evidence based. CONCLUSIONS All the classification systems are necessary and relevant to FCI medical management for sustainment of soldier health and performance in cold weather operations and winter warfare. Future FCI reports should clearly characterise the nature of the FCI into existing classification schemes for surveillance (morphology, symptoms, and appearance), identifying risk-factors, clinical guidelines, and agreed inclusion/exclusion criteria for a future treatment trial.
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Affiliation(s)
- Arne Johan Norheim
- National Research Center in Complementary and Alternative Medicine (NAFKAM), Institute of Community Medicine, UiT- The Arctic University of Norway, Tromsø, Norway
| | - Wendy Sullivan-Kwantes
- Joint medical services, Defence Research and Development Canada-Toronto Research Center, Sessvollmoen
| | - Tuva Steinberg
- National Research Center in Complementary and Alternative Medicine (NAFKAM), Institute of Community Medicine, UiT- The Arctic University of Norway, Tromsø, Norway
- Norwegian Armed Forces - Joint Medical Service, Norway
| | - John Castellani
- U.S. Army Research Institute of Environmental Medicine, Natick MA USA
| | - Karl E Friedl
- U.S. Army Research Institute of Environmental Medicine, Natick MA USA
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Klammer L, Ollier M, Gauthier J, Allen LR, Davidson M, Ahmed Y, Smith-Turchyn J, Hansen-Jaumard D, Hebert S, Logsetty S, Morris-Jantzen D, Peet R, Poole AJ, Champion C. Exploring the Development of a Canadian Frostbite Care Network and the Future of Frostbite Care in Canada Using a Qualitative Approach. Wilderness Environ Med 2023; 34:427-434. [PMID: 37479605 DOI: 10.1016/j.wem.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/08/2023] [Accepted: 06/08/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION The Canadian Frostbite Collaborative project is exploring frostbite patient care needs and current practices in Canada to inform the development of a Canadian frostbite care network (CFCN) as a national quality improvement initiative. METHODS Using a quantitative and qualitative approach, this study aimed to define the landscape of current frostbite practices, challenges, and interest in future work. RESULTS Current frostbite care practices were initially assessed through semistructured phone interviews of Canadian healthcare providers. Canadian healthcare providers managing frostbite in a range of health disciplines and contexts then participated in focus group sessions discussing the potential roles and opportunities as well as potential challenges in developing a CFCN. Roles and opportunities for a network in advancing frostbite care included facilitating research, educating stakeholders, facilitating collaboration, standardizing care, and advocating for frostbite care. Challenges identified in frostbite care and network development included managing resources, navigating the Canadian healthcare system, overcoming low numbers, and communicating with policymakers and frontline providers. CONCLUSIONS Formalizing a CFCN may provide important opportunities and support in overcoming critical barriers to providing high-quality frostbite care across Canada.
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Affiliation(s)
- Lauren Klammer
- College of Medicine University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mary Ollier
- University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Josianne Gauthier
- Whitehorse General Hospital, Yukon Hospital Corporation, Yukon, Canada
| | - Lisa R Allen
- Muskoka Algonquin Healthcare, Huntsville and Bracebridge, Ontario, Canada.
| | - Malcolm Davidson
- University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Yousuf Ahmed
- Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada; Department of Family Medicine, Dalhousie University, Saint John, New Brunswick, Canada
| | | | - Delphine Hansen-Jaumard
- Department of Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada; Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | | | - Sarvesh Logsetty
- Departments of Surgery and Psychiatry, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Rachel Peet
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Alex J Poole
- Whitehorse General Hospital, Yukon Hospital Corporation, Yukon, Canada; University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Caitlin Champion
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada; West Parry Sound Health Center, Parry Sound, Ontario, Canada
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Zhang XH, Cui CL, Zhu HY, Wang J, Xue Y, Zhang N, Sun ZA, Gao XX, Zhou X, Yu JA, Chen XX. The Effects of Recombinant Human Granulocyte-Macrophage Colony-Stimulating Factor Gel on Third-Degree Frostbite Wounds in Northeastern China: A Randomized Controlled Trial. J Burn Care Res 2023; 44:715-722. [PMID: 32006002 DOI: 10.1093/jbcr/iraa019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Indexed: 12/12/2022]
Abstract
The aim of the study was to investigate the effects of the rhGM-CSF gel on third-degree frostbite wounds. Sixty-two patients who had suffered third-degree frostbite on their hand or foot (91 wounds in total) were selected using a convenience sampling method and randomly allocated to two groups: the rhGM-CSF group(31patients,45 frostbite wounds) received the rhGM-CSF gel when wound dressing change daily; however, the control group (31patients, 46 frostbite wounds) received aloe glue. The wound healing time, the score of inflammation about the wound and the positive bacterial culture of wound secretions were used to measure outcomes, respectively. Data were analyzed using SPSS (25.0), Student's t test or Mann-Whitney U test and chi-square test or Fisher exact test were selected, as appropriate. The healing time of the rhGM-CSF group was (12.2 ± 5.0) days, which was significantly shorter than that of the control group (15.5 ± 4.7) days (P < .0001). The rhGM-CSF group's wound inflammation scores on the 7th and 14th day of treatment were (0.96 ± 0.21) and (1.88 ± 0.29), respectively, which were better than those of the control group (1.12 ± 0.24) and (1.38 ± 0.15) (both P < .0001). The positive bacterial culture of wound secretions in the rhGM-CSF group was also better than that in the control group on the 3rd, 7th, and 14th day after treatment (P = .027, .004, .030, respectively). According to the results, using rhGM-CSF gel considerably increases the speed of frostbite wounds healing, and have an effect on protecting third-degree frostbite wounds regarding the positive effects. Trial Registration: This trial was registered in the Chinese Clinical Trial Register, ChiCTR1900021299.
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Affiliation(s)
- Xiu-Hang Zhang
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
| | - Chang-Lei Cui
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun, China
| | - Hao-Yue Zhu
- Clinical medicine department, Shandong University of Traditional Chinese Medicine, Jinan City, China
| | - Jian Wang
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yan Xue
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
| | - Nan Zhang
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
| | - Zhan-Ao Sun
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
| | - Xin-Xin Gao
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
| | - Xin Zhou
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
| | - Jia-Ao Yu
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
| | - Xin-Xin Chen
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, China
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Patel P, Handa M, Jain K, Shukla R. Recent pharmaceutical engineered approaches as prophylaxis and management of frostbite. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Affiliation(s)
- Robert L Sheridan
- From the Departments of Surgery (R.L.S., J.M.G.) and Radiology (T.G.W.), Massachusetts General Hospital, and Boston Shriners Hospital for Children (R.L.S., J.M.G.) - both in Boston
| | - Jeremy M Goverman
- From the Departments of Surgery (R.L.S., J.M.G.) and Radiology (T.G.W.), Massachusetts General Hospital, and Boston Shriners Hospital for Children (R.L.S., J.M.G.) - both in Boston
| | - T Gregory Walker
- From the Departments of Surgery (R.L.S., J.M.G.) and Radiology (T.G.W.), Massachusetts General Hospital, and Boston Shriners Hospital for Children (R.L.S., J.M.G.) - both in Boston
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Drinane J, Heiman AJ, Ricci JA, Patel A. Thrombolytic Salvage of the Frostbitten Upper Extremity: A Systematic Review. Hand (N Y) 2022; 17:397-404. [PMID: 32935578 PMCID: PMC9112743 DOI: 10.1177/1558944720940065] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Vascular thrombosis secondary to frostbite can lead to ischemic tissue damage in severe cases. Threatened extremities may be salvaged with thrombolytics to restore perfusion; however, current data are limited to single institution case series. The authors performed a systematic review to determine the efficacy of thrombolytic therapy in treating upper extremity frostbite. METHODS PubMed, EBSCO, and Google Scholar were queried using the keywords "thrombolytics," "frostbite," "fibrinolytics," and "tPA." Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as intraarterial (IA) or intravenous (IV) administration of tissue plasminogen activator (tPA), alteplase, urokinase, streptokinase, or any tPA derivative. RESULTS A total of 42 studies were identified, with 13 satisfying inclusion criteria. Eight studies reported catheter-directed IA thrombolysis, four reported systemic IV administration, and 1 reported both methods. A total of 157 patients received thrombolytics. In all, 73 upper extremity digits were treated by IA route and 136 digits were treated by IV route. Overall upper extremity digit salvage rate was 59%. There was a significantly higher salvage rate in digits treated by the IA route compared to the IV route. CONCLUSIONS Thrombolytics, particularly when administered by the intra-arterial route, are emerging as a promising treatment of severe frostbite of the upper extremity, increasing digit salvage rates.
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Affiliation(s)
| | | | - Joseph A. Ricci
- Montefiore Medical Center, Bronx, NY, USA,Joseph A. Ricci, Division of Plastic Surgery, Department of Surgery, Montefiore Medical Center, 1776 Eastchester Road, Suite 200, Second Floor, Bronx, NY 10461, USA.
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Extracellular vesicles from human hepatic progenitor cells accelerate deep frostbite wound healing by promoting fibroblasts proliferation and inhibiting apoptosis. J Tissue Viability 2021; 31:286-293. [PMID: 34906420 DOI: 10.1016/j.jtv.2021.10.009] [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: 09/20/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 11/24/2022]
Abstract
Frostbites are cold tissue damages frequently observed at high altitudes and under extremely cold conditions. Though their incidence rate is low, the resulting impact in affected patients can be very serious, often leading to amputations. Clinical management and the prediction of outcome can be of utmost importance to frostbite patients. A possible use of stem cell-derived extracellular vesicles (EVs) has been suggested for cutaneous wound healing and we, therefore, tested their use for the treatment of deep frostbite wound. To this end, the impacts of hHPC-derived EVs were evaluated in an in vivo animal model comprising of Kunming female mice as well as studied in vitro for the mechanism. We first characterized the EVs and these hHPC-derived EVs, when applied to treat frostbite wounds, accelerated wound healing in the in vivo animal model, as assessed by wound closure, re-epithelization thickness, collagen density and the expression of Collagen I and α-SMA. The proliferation and migration of human skin fibroblasts was also found to be increased by EVs in the in vitro experiments. The H2O2-induced apoptosis cell model, established to simulate the post-frostbite injury, was inhibited by EVs, with concomitant increase in the expression of Bcl-2 and decreased expression of Bax, further confirming the findings. Our novel results indicate that the application of EVs might be a promising strategy for deep frostbite wound healing.
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Hyperbaric Oxygen Therapy with Iloprost Improves Digit Salvage in Severe Frostbite Compared to Iloprost Alone. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111284. [PMID: 34833502 PMCID: PMC8620371 DOI: 10.3390/medicina57111284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 12/13/2022]
Abstract
Background and Objectives: Frostbite is a freezing injury that can lead to amputation. Current treatments include tissue rewarming followed by thrombolytic or vasodilators. Hyperbaric oxygen (HBO) therapy might decrease the rate of amputation by increasing cellular oxygen availability to the damaged tissues. The SOS-Frostbite study was implemented in a cross-border program among the hyperbaric centers of Geneva, Lyon, and the Mont-Blanc hospitals. The objective was to assess the efficacy of HBO + iloprost among patients with severe frostbite. Materials and Methods: We conducted a multicenter prospective single-arm study from 2013 to 2019. All patients received early HBO in addition to standard care with iloprost. Outcomes were compared to a historical cohort in which all patients received iloprost alone between 2000 and 2012. Inclusion criteria were stage 3 or 4 frostbite and initiation of medical care <72 h from frostbite injury. Outcomes were the number of preserved segments and the rate of amputated segments. Results: Thirty patients from the historical cohort were eligible and satisfied the inclusion criteria, and 28 patients were prospectively included. The number of preserved segments per patient was significantly higher in the prospective cohort (mean 13 ± SD, 10) compared to the historical group (6 ± 5, p = 0.006); the odds ratio was significantly higher by 45-fold (95%CI: 6-335, p < 0.001) in the prospective cohort compared to the historical cohort after adjustment for age and delay between signs of freezing and treatment start. Conclusions: This study demonstrates that the combination of HBO and iloprost was associated with higher benefit in patients with severe frostbite. The number of preserved segments was two-fold higher in the prospective cohort compared to the historical group (mean of 13 preserved segments vs. 6), and the reduction of amputation was greater in patients treated by HBO + iloprost compared with the iloprost only.
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Heard J, Shamrock A, Galet C, Pape KO, Laroia S, Wibbenmeyer L. Thrombolytic Use in Management of Frostbite Injuries: Eight Year Retrospective Review at a Single Institution. J Burn Care Res 2021; 41:722-726. [PMID: 32030427 DOI: 10.1093/jbcr/iraa028] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Frostbite injuries are uncommon, understudied, and lack standardized treatment protocols. Although thrombolytics are commonly used, their efficacy remains controversial. Herein, we report the results of a retrospective review of frostbite treatment practices at a single institution. The impact of thrombolytics on outcomes was evaluated. Medical records of frostbite patients admitted between January 2010 and April 2018 were reviewed. Demographics, injury details, treatment, and outcomes were collected. Descriptive statistics were obtained. A case-control analysis comparing patients who received tissue plasminogen activator (tPA) with those who did not was performed. A total of 102 patients were included. The mean age was 43 ± 17.7; 82.4% were male. About 13% of patients were presented with first-degree, 54% with second-degree, 29% with third-degree, and 5% with fourth-degree frostbite. Toes (69%), fingers (53%), and feet (43%) were most commonly affected. Thirteen patients had angiograms. Twelve patients received tPA: three systemic tPA and nine catheter-directed tPA. Overall, 32 patients (31%) required surgery and 27 (26.5%) patients required amputation with an average of 6.5 digits amputated. Digit salvage rate based on angiography was 84.7%. Length of stay (P = .046), number of operations (P = .037), and need for surgery (P = .030) were significantly lower for patients who received thrombolytics. Two patients had bleeding complications but did not require intervention or interruption of therapy. Despite its small sample size, our study suggests benefits from thrombolytic therapy. Prospective, well designed, and multi-institutional studies are warranted to establish evidence-based treatment guidelines for the management of frostbite injuries.
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Affiliation(s)
| | | | | | - Kate O Pape
- Department of Pharmaceutical Care.,College of Pharmacy
| | - Sandeep Laroia
- Department of Radiology, The University of Iowa, Iowa City, Iowa
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Quality of Reporting on Guideline, Protocol, or Algorithm Implementation in Adult Trauma Centers: A Systematic Review. Ann Surg 2021; 273:e239-e246. [PMID: 30985368 DOI: 10.1097/sla.0000000000003313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). BACKGROUND At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines. METHODS A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0. RESULTS Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report. CONCLUSIONS Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes.
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Poole A, Gauthier J, MacLennan M. Management of severe frostbite with iloprost, alteplase and heparin: a Yukon case series. CMAJ Open 2021; 9:E585-E591. [PMID: 34021017 PMCID: PMC8177911 DOI: 10.9778/cmajo.20200214] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We identified the need to modernize frostbite management in our northern centre and implemented a treatment protocol in 2015. Our aim was to describe the clinical course of patients presenting to the hospital since the implementation of the protocol. METHODS This was a retrospective case series from Whitehorse General Hospital, Whitehorse, Yukon Territory, Canada. We reviewed the charts of patients who presented to the hospital with grade 2-4 frostbite and were treated as per our protocol between Feb. 9, 2015, and Feb. 8, 2020. Patients with grade 2-4 frostbite received iloprost; in addition, those with grade 4 frostbite received alteplase and heparin. We determined the number of digits affected and salvaged, and the time from presentation to the emergency department to treatment initiation. We also examined patients' demographic characteristics, predisposing events, frostbite severity and adverse drug reactions. RESULTS In 22 patients treated for grade 2-4 frostbite, 142 digits were affected: 59 with grade 2 frostbite, 25 with grade 3 frostbite and 58 with grade 4 frostbite; of the 142, 113 (79.6%) were salvaged. All 29 digits amputated had grade 4 frostbite. The mean time from presentation to iloprost initiation was reduced from 32.9 hours in 2015 to 3.0 hours in 2020. Sports (10 cases [45%]) and alcohol use (6 [27%]) were the most common precipitating events, with alcohol use tending to result in more severe injury (grade 4 in 5 of 6 cases). Adverse reactions with iloprost (e.g., headache) were common but mild. Adverse reactions with alteplase (e.g., bleeding) were less common but of greater clinical significance. INTERPRETATION Over the study period, our protocol contributed to improvement in frostbite care at our institution, resulting in a digit salvage rate comparable to other published results. Our 5-year experience shows that advanced medical care of frostbite can be achieved, even at a rural centre.
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Affiliation(s)
- Alexander Poole
- Whitehorse General Hospital (Poole), Whitehorse, Yukon; Department of Surgery (Poole), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Whitehorse General Hospital (Gauthier), Yukon Hospital Corporation, Whitehorse, Yukon; University of Saskatchewan (Gauthier), Saskatoon, Sask.; Department of Surgery (MacLennan), McMaster University, Hamilton, Ont.; Harvard T.H. Chan School of Public Health (MacLennan), Boston, Mass.
| | - Josianne Gauthier
- Whitehorse General Hospital (Poole), Whitehorse, Yukon; Department of Surgery (Poole), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Whitehorse General Hospital (Gauthier), Yukon Hospital Corporation, Whitehorse, Yukon; University of Saskatchewan (Gauthier), Saskatoon, Sask.; Department of Surgery (MacLennan), McMaster University, Hamilton, Ont.; Harvard T.H. Chan School of Public Health (MacLennan), Boston, Mass
| | - Mira MacLennan
- Whitehorse General Hospital (Poole), Whitehorse, Yukon; Department of Surgery (Poole), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Whitehorse General Hospital (Gauthier), Yukon Hospital Corporation, Whitehorse, Yukon; University of Saskatchewan (Gauthier), Saskatoon, Sask.; Department of Surgery (MacLennan), McMaster University, Hamilton, Ont.; Harvard T.H. Chan School of Public Health (MacLennan), Boston, Mass
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20
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Gao Y, Wang F, Zhou W, Pan S. Research progress in the pathogenic mechanisms and imaging of severe frostbite. Eur J Radiol 2021; 137:109605. [PMID: 33621855 DOI: 10.1016/j.ejrad.2021.109605] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/02/2021] [Accepted: 02/14/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE This article reviews the pathological mechanisms and progress of imaging of severe frostbite to assist in the search for targets for clinical diagnosis and treatment of severe frostbite. This review also aims to provide strong evidence for clinical diagnosis and treatment of deep frostbite. METHODS The review was based on the summary and analysis of the existing literature, and explored the pathological mechanism of deep frostbite and the advantages and disadvantages of imaging diagnostic methods. RESULTS According to the depth of tissue involvement, frostbite is divided into 4 levels. Severe frostbite includes Grade 3 and Grade 4 frostbite. Clinical performance evaluation and imaging diagnostic research have always been the mainstream of severe frostbite diagnosis. Imaging methods focus on vascular patency and tissue vitality. This article introduces angiography, SETCT/CT and MRA, and we summarize the advantages and disadvantages of these imaging methods. We recommend corresponding imaging modalities according to the state of frostbite patients. CONCLUSIONS Imaging examination, especially angiography and bone scans, provide useful information for determining the diagnosis and prognosis of severe frostbite. In order to obtain a good clinical prognosis, clinicians should first perform SPECT/CT. MRA does not burden the patient's body, but the balance between cost and benefit must be considered. Angiography provides a good feedback on the changes in blood vessel status before and after treatment, which is helpful for discovering the response of limbs to treatment.
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Affiliation(s)
- Yue Gao
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Fengzhe Wang
- Department of Radiology, the Fourth People's Hospital of Shenyang: Shenyang Medical College, Shenyang, China
| | - Wei Zhou
- Department of Radiology, General Hospital of Northern Military Area: General Hospital of Northern Theatre Command, Shenyang, China
| | - Shinong Pan
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China.
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Joshi K, Goyary D, Mazumder B, Chattopadhyay P, Chakraborty R, Bhutia YD, Karmakar S, Dwivedi SK. Frostbite: Current status and advancements in therapeutics. J Therm Biol 2020; 93:102716. [PMID: 33077129 DOI: 10.1016/j.jtherbio.2020.102716] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 01/02/2023]
Abstract
Frostbite is a severe ischemic injury which occurs due to the tissue vascular damage after sub-zero temperature tissue exposure. Deep frostbite can result in necrosis and may need amputation of affected tissue. Though a serious injury, it is not very well understood, and further scientific exploration is needed. This work explores the current understanding of the pathophysiology of frostbite. We reviewed the current status of the diagnostics, the drugs, the therapies and the surgical practices for prevention and management of frostbite. Advances in nanotechnology and drug delivery had improved the therapeutic outcomes significantly. This review also explored the latest advancements and researches done for development of newer therapeutics and diagnostics for frostbite care.
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Affiliation(s)
- Kumud Joshi
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India; Department of Pharmaceutical Sciences, Dibrugarh University, Assam, India
| | - Danswrang Goyary
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India.
| | - Bhaskar Mazumder
- Department of Pharmaceutical Sciences, Dibrugarh University, Assam, India
| | | | - Reshmi Chakraborty
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Y D Bhutia
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Sanjeev Karmakar
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Sanjai Kumar Dwivedi
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
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22
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Deep frostbite: Clinical characteristics and outcomes in northeastern China. J Tissue Viability 2020; 29:110-115. [DOI: 10.1016/j.jtv.2020.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/08/2019] [Accepted: 01/27/2020] [Indexed: 11/18/2022]
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Paine RE, Turner EN, Kloda D, Falank C, Chung B, Carter DW. Protocoled thrombolytic therapy for frostbite improves phalangeal salvage rates. BURNS & TRAUMA 2020; 8:tkaa008. [PMID: 32341921 PMCID: PMC7175769 DOI: 10.1093/burnst/tkaa008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 12/27/2019] [Accepted: 01/21/2020] [Indexed: 01/12/2023]
Abstract
Background Frostbite is a cold injury that has the potential to cause considerable morbidity and long-term disability. Despite the complexity of these patients, diagnostic and treatment practices lack standardization. Thrombolytic therapy has emerged as a promising treatment modality, demonstrating impressive digit salvage rates. We review our experience with thrombolytic therapy for severe upper extremity frostbite. Methods Retrospective data on all frostbite patients evaluated at our institution from December 2017 to March 2018 was collected. A subgroup of patients with severe frostbite treated with intra-arterial thrombolytic therapy (IATT) were analysed. Results Of the 17 frostbite patients treated at our institution, 14 (82%) were male and the median age was 31 (range: 19–73). Substance misuse was involved in a majority of the cases (58.8%). Five (29.4%) patients with severe frostbite met inclusion criteria for IATT and the remaining patients were treated conservatively. Angiography demonstrated a 74.5% improvement in perfusion after tissue plasminogen activator thrombolysis. When comparing phalanges at risk on initial angiography to phalanges undergoing amputation, the phalangeal salvage rate was 83.3% and the digit salvage rate was 80%. Complications associated with IATT included groin hematoma, pseudoaneurysm and retroperitoneal hematoma. Conclusions Thrombolytic therapy has the potential to greatly improve limb salvage and functional recovery after severe frostbite when treated at an institution that can offer comprehensive, protocoled thrombolytic therapy. A multi-center prospective study is warranted to elucidate the optimal treatment strategy in severe frostbite.
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Affiliation(s)
| | - Elizabeth Noel Turner
- Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
| | - Daniel Kloda
- Department of Radiology, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
| | - Bruce Chung
- Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
| | - Damien Wilson Carter
- Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
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What Interventional Radiologists Need to Know About Managing Severe Frostbite: A Meta-Analysis of Thrombolytic Therapy. AJR Am J Roentgenol 2020; 214:930-937. [DOI: 10.2214/ajr.19.21592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Bender D, Tweer S, Werdin F, Rothenberger J, Daigeler A, Held M. The acute impact of local cooling versus local heating on human skin microcirculation using laser Doppler flowmetry and tissue spectrophotometry. Burns 2020; 46:104-109. [DOI: 10.1016/j.burns.2019.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 12/09/2018] [Accepted: 03/03/2019] [Indexed: 02/02/2023]
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Hickey S, Whitson A, Jones L, Wibbenmeyer L, Ryan C, Fey R, Litt J, Fabia R, Cancio L, Mohr W, Twomey J, Wagner A, Cochran A, Bailey JK. Guidelines for Thrombolytic Therapy for Frostbite. J Burn Care Res 2020; 41:176-183. [DOI: 10.1093/jbcr/irz148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
The data are insufficient to support standardized treatment of all patients with frostbite with thrombolytic therapy. The following guidelines, however, should be applied to all patients with cyanosis persisting proximal to the distal phalanx (Grade 3 or 4 frostbite injury) and demonstrated loss of perfusion at or proximal to the middle phalanx immediately after rewarming.
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Affiliation(s)
- Sean Hickey
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy Whitson
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Larry Jones
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Lucy Wibbenmeyer
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - Colleen Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School Shriners Hospitals for Children-Boston
| | - Ryan Fey
- Department of Surgery, Hennepin County Medical Center, Minneapolis Minnesota
| | - Jeffrey Litt
- Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Renata Fabia
- Department of Pediatric Surgery, Nationwide Childrens Hospital, Columbus, Ohio
| | - Lee Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - William Mohr
- Burn Center and Department of Trauma and General Surgery, Regions Hospital, St. Paul, Minnesota
- Department of Surgery, University of Minnesota, Minneapolis
| | - John Twomey
- Department of Surgey, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Anne Wagner
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Amalia Cochran
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - J Kevin Bailey
- Department of Surgery, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina
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McIntosh SE, Freer L, Grissom CK, Auerbach PS, Rodway GW, Cochran A, Giesbrecht GG, McDevitt M, Imray CH, Johnson EL, Pandey P, Dow J, Hackett PH. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update. Wilderness Environ Med 2019; 30:S19-S32. [PMID: 31326282 DOI: 10.1016/j.wem.2019.05.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/14/2019] [Accepted: 05/17/2019] [Indexed: 12/13/2022]
Abstract
The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2014.
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Affiliation(s)
- Scott E McIntosh
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT.
| | - Luanne Freer
- Everest Base Camp Medical Clinic, Nepal; Yellowstone National Park, WY
| | - Colin K Grissom
- Division of Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT
| | - Paul S Auerbach
- Department of Emergency Medicine, Stanford University, School of Medicine, Palo Alto, CA
| | - George W Rodway
- College of Nursing and School of Medicine, UC Davis, Davis, CA
| | - Amalia Cochran
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Gordon G Giesbrecht
- Faculty of Kinesiology and Recreation Management, Departments of Anesthesia and Emergency Medicine, University of Manitoba, Winnipeg, Canada
| | - Marion McDevitt
- Emergency Medicine, Peace Health Ketchikan Medical Center, Ketchikan, AK
| | - Christopher H Imray
- Warwick Medical School, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Eric L Johnson
- Wound & Hyperbaric Medicine, Bozeman Health, Bozeman, MT
| | | | | | - Peter H Hackett
- Division of Emergency Medicine, Altitude Research Center, University of Colorado Denver School of Medicine, Denver, CO; Institute for Altitude Medicine, Telluride, CO
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Drinane J, Kotamarti VS, O’Connor C, Nair L, Divanyan A, Roth MZ, Patel A, Ricci JA. Thrombolytic Salvage of Threatened Frostbitten Extremities and Digits: A Systematic Review. J Burn Care Res 2019; 40:541-549. [DOI: 10.1093/jbcr/irz097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Abstract
Frostbite is a cold injury that results in soft tissue loss and can lead to amputation. Vascular thrombosis following injury causes ischemic tissue damage. Despite understanding the pathology, its treatment has remained largely unchanged for over 30 years. Threatened extremities may be salvaged with thrombolytics to restore perfusion. The authors performed a systematic review to determine whether thrombolytic therapy is effective and to identify patients who may benefit from this treatment. The Pubmed, EBSCO, and Google Scholar databases were queried using the key words “thrombolytics,” “frostbite,” “fibrinolytics,” and “tPA.” Studies written after 1990 in English met inclusion criteria. Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as administration of tPA, alteplase, urokinase, or streptokinase. Forty-two studies were identified and 17 included. Included were 1 randomized trial, 10 retrospective studies, 2 case series, and 4 case reports. One thousand eight hundred and forty-four limbs and digits in 325 patients were studied and 216 patients treated with thrombolytics and 346 amputations performed. The most common means of thrombolysis was intra-arterial tPA. The most common duration of therapy was 48 hours. Limb salvage rates ranged from 0% to 100% with a weighted average of 78.7%. Thrombolytics are a safe and effective treatment of severe frostbite. They represent the first significant advancement in frostbite treatment by preventing otherwise inevitable amputations warranting both greater utilization and further research to clarify the ideal thrombolytic protocol.
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Affiliation(s)
- James Drinane
- Division of Plastic Surgery, Albany Medical Center, New York
| | | | - Casey O’Connor
- Division of Orthopedic Surgery, Albany Medical Center, New York
| | | | | | - Malcolm Z Roth
- Division of Plastic Surgery, Albany Medical Center, New York
| | - Ashit Patel
- Division of Plastic Surgery, Albany Medical Center, New York
| | - Joseph A Ricci
- Division of Plastic Surgery, Albany Medical Center, New York
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Khan SL, Parikh R, Mooncai T, Sandhu S, Jawa R, Farber HW. Barriers to frostbite treatment at an academic medical center. Am J Emerg Med 2019; 37:1601.e3-1601.e5. [PMID: 31088748 DOI: 10.1016/j.ajem.2019.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 05/05/2019] [Indexed: 02/08/2023] Open
Abstract
The treatment of frostbite injuries has undergone a radical change over the past decade with a shift from supportive therapy and observation towards early and aggressive medical intervention with thrombolytics and vasodilators. Institutions that have implemented evidence-based protocols have significantly decreased their amputation rates (Bruen et al., 2007; Lindford et al., 2017a; Twomey et al., 2005). We present the case of a middle-aged male treated for frostbite of multiple fingers on both hands. Because there was no treatment protocol at our institution, there were multiple delays in the patient's care including imaging and initiation of intravenous (IV) prostanoids. This case illustrates the deleterious effects of delays in treatment and strongly suggests that all facilities located in areas of cold exposure should have protocols in place for such an occurrence.
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Affiliation(s)
- Sarah L Khan
- Boston Medical Center, Department of Internal Medicine, United States of America.
| | - Raj Parikh
- Boston Medical Center, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, United States of America
| | - Theodore Mooncai
- Boston Medical Center, Department of Emergency Medicine, United States of America
| | - Sukhmeet Sandhu
- Boston Medical Center, Department of Internal Medicine, United States of America
| | - Raagini Jawa
- Boston Medical Center, Department of Internal Medicine, United States of America
| | - Harrison W Farber
- Tufts Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, United States of America
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Carceller A, Javierre C, Ríos M, Viscor G. Amputation Risk Factors in Severely Frostbitten Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16081351. [PMID: 30991721 PMCID: PMC6517929 DOI: 10.3390/ijerph16081351] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 01/20/2023]
Abstract
In recent years, the incidence of frostbite has increased among healthy young adults who practice winter sports (skiing, mountaineering, ice climbing and technical climbing/alpinism) at both the professional and amateur levels. Moreover, given that the population most frequently affected is healthy and active, frostbite supposes a substantial interruption of their normal activity and in most cases is associated with long-term sequelae. It particularly has a higher impact when the affected person’s daily activities require exposure to cold environments, as either sports practices or work activities in which low temperatures are a constant (ski patrols, mountain guides, avalanche forecasters, workers in the cold chain, etc.). Clinical experience with humans shows a limited reversibility of injuries via potential tissue regeneration, which can be fostered with optimal medical management. Data were collected from 92 frostbitten patients in order to evaluate factors that represent a risk of amputation after severe frostbite. Mountain range, years of expertise in winter mountaineering, time elapsed before rewarming and especially altitude were the most important factors for a poor prognosis.
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Affiliation(s)
- Anna Carceller
- Secció de Fisiologia, Departament de Biologia Cel·lular, Fisiologia i Immunologia, Facultat de Biologia, Universitat de Barcelona, 08028 Barcelona, Spain.
- Medical Commission of the International Federation for Climbing and Mountaineering (UIAA MedCom), CH 3000 Bern, Switzerland.
| | - Casimiro Javierre
- Departament de Ciències Fisiològiques, Facultat de Medicina, Universitat de Barcelona, 08907 Barcelona, Spain.
| | - Martín Ríos
- Secció d'Estadística, Departament de Genètica, Estadística i Microbiologia, Facultat de Biologia, Universitat de Barcelona, 08028 Barcelona, Spain.
| | - Ginés Viscor
- Secció de Fisiologia, Departament de Biologia Cel·lular, Fisiologia i Immunologia, Facultat de Biologia, Universitat de Barcelona, 08028 Barcelona, Spain.
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Abstract
BACKGROUND The use of tissue plasminogen activator (tPA) for the treatment of frostbite has been reported and advocated, but its efficacy has not been well established. We conducted a systematic review to guide physicians on the role of tPA in the treatment of frostbite. Our hypothesis was that the use of tPA improves clinical outcomes, as measured by amputation rate. METHODS We searched MEDLINE (PubMed) and EMBASE for primary research articles on the use of tPA for the treatment of extremity frostbite. Information related to study design, outcomes, and complications was extracted. A total of 204 citations were screened, and then 35 abstracts and 24 reports were reviewed. Fifteen studies met the standard for final review. RESULTS One randomized, prospective study; 3 cohort studies; 8 case series; and 3 case reports were found. A total of 208 patients were treated. Differences in protocols, inclusion criteria, and outcomes measures prevented combining the study results. In all the studies, the authors reported that the use of tPA was or may have been useful in reducing amputation rates or increasing tissue salvage. Complication rates ranged from 0% to 100%, with a combined rate of 13%. The quality of the evidence was low. CONCLUSIONS Due to the low scientific quality of the studies, the efficacy of tPA in reducing amputation rates cannot currently be established. Randomized, prospective trials or well-controlled cohort studies are needed to better assess the role of tPA. Consideration should be given to limiting its use to research protocols.
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Affiliation(s)
- Richard L. Hutchison
- The University of Mississippi Medical
Center, Jackson, USA,Richard L. Hutchison, Division of Plastic
Surgery, The University of Mississippi Medical Center, 2500 North State Street,
Jackson, MS 39216, USA.
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Fisher OL, Benson RA, Venus MR, Imray CHE. Pedicled Abdominal Flaps for Enhanced Digital Salvage After Severe Frostbite Injury. Wilderness Environ Med 2018; 30:59-62. [PMID: 30591302 DOI: 10.1016/j.wem.2018.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/28/2018] [Accepted: 09/10/2018] [Indexed: 12/19/2022]
Abstract
Extremities are the area of the body most commonly affected by frostbite, which can also affect the face, ears, perineum, or genitals. Optimum management has moved away from early amputation and debridement toward maximizing tissue preservation and delaying surgical intervention. Increasing length of digit amputation increases morbidity, in terms of loss of hand function, experienced by patients. Reconstruction of affected digits is limited by bone necrosis, which often leads to shortened residual stumps and limited functional outcomes. This case describes the management of a severe frostbite injury affecting both hands and feet in a 39-y-old man, sustained during descent of Mount Everest. The use of a pedicled abdominal flap to provide soft-tissue cover permitted optimized digit length and function and sensate digits. The case highlights the benefits of early multidisciplinary team involvement in the management of severe frostbite to optimize functional outcome.
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Affiliation(s)
- Owain L Fisher
- Department of Vascular Surgery, University Hospital Coventry and Warwickshire, Coventry, UK.
| | - Ruth A Benson
- Department of Vascular Surgery, University Hospital Coventry and Warwickshire, Coventry, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, UK
| | - Matthew R Venus
- Department of Plastic Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Christopher H E Imray
- Department of Vascular Surgery, University Hospital Coventry and Warwickshire, Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK
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Kaller M. BET 2: Treatment of frostbite with iloprost. Emerg Med J 2017; 34:689-690. [DOI: 10.1136/emermed-2017-207129.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 08/15/2017] [Indexed: 01/28/2023]
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