[Clinical application of extracorporeal membrane oxygenation in the treatment of burn patients with acute respiratory distress syndrome: a retrospective analysis and systematic review]

Objective: To analyze the clinical effect of extracorporeal membrane oxygenation (ECMO) in the treatment of burn patients with acute respiratory distress syndrome (ARDS). Methods: The retrospective observational study and the systematic review were applied. From March 2014 to July 2020, five burn patients with ARDS received ECMO treatment in the First Affiliated Hospital of Army Medical University (the Third Military Medical University). All the five patients were male, aged from 40 to 62 years. The average total burn surface area was 58.8% total body surface area (TBSA) and four cases had severe inhalation injury. Patient's ECMO starting time, duration and mode, and whether successfully weaned or the cause of death, and others. were recorded. Furthermore, the changes of oxygenation and infection before, during, and after utilizing ECMO were analyzed. PubMed and Web of Science from the establishment of each database to August 2021 were searched using "Extracorporeal Membrane Oxygenation", "ECMO", "burn", "inhalation" as the search terms and "Title/Abstract" as the field to retrieve the clinical articles that meet the selection criteria . Basic information were extracted from the articles, including sample size, gender, age, total burn area, inhalation injury, the indication of ECMO, the start and lasting time of ECMO, ECMO mode, rate of successful weaning, complications of ECMO, mortality, the combined application of continuous renal replacement therapy (CRRT). Results: Five patients started venovenous ECMO on an average of 10.2 days after injury and lasted an average of 180.4 hours. Three out of 5 patients were weaned successfully with one patient survived. Four patients died of multiple organ dysfunction syndrome (MODS) and septic shock. Compared with those before ECMO treatment, the arterial oxygen partial pressure (PaO2) and oxygen saturation in arterial blood (SaO2) of three successfully weaned patients obviously increased during and after ECMO treatment. The fraction of inspired oxygen (FiO2) decreased below 50% and PaO2/FiO2 ratio increased above 200 mmHg (1 mmHg=0.133 kPa) during and after ECMO. Furthermore, lactic acid and respiratory rate decreased, basically. Compared with those before ECMO, PaO2 and SaO2 in the other two patients during ECMO, who failed to be weaned, continuously decreased while lactic acid increased. Before and during ECMO, the PaO2/FiO2 ratios of unsuccessfullg weaned cases were less than 200 mmHg, and partial pressure of carbon dioxide in arterial blood (PaCO2) were more than 40 mmHg. Compared with those before ECMO, there were no significant changes in body temperature during and after ECMO, which were less than 38 ℃. Compared with those before ECMO, the leucocyte number (the index without this in unsuccessfully weaned cases was omitted, the same as below) in four patients showed a significant decrease during ECMO, but rose after removal of ECMO. The proportion of neutrophils in three patients were slightly higher during ECMO than before ECMO, and did not change significantly after removal of ECMO. Compared with those before ECMO, platelet counts in three patients were significantly reduced during ECMO, and all five patients during ECMO were below normal levels. Compared with those before ECMO, the procalcitonin levels in four deaths were significantly increased during ECMO. Catheter culture of microorganism was performed in three successfully weaned patients, all of which were negative. A total of 13 literature were included, ranging from 1990 to 2019. The sample size in 6 studies was less than 10, and the sample size in 4 studies was between 10 and 20, and only 2 literatures had a sample size larger than 50. ECMO was applied in 295 burn patients with overall mortality of 48.8% (144/295), including 157 adults and 138 children. The most common indication of ECMO was severe ARDS. Among 157 adult burn patients (95 males and 65 females), 36 cases had inhalation injury. The average burn area was 27%-37%TBSA in 5 reported studies and was more than 50%TBSA in 2 reported studies. The most common mode was venovenous ECMO. ECMO treatment began 26.5 hours to 7.4 days after injury and lasted from 90 hours to 18 days, and the rate of successful weaning ranged from 50% to 100%. The most common complications were bleeding and infection. The mortality was 52.9% (83/157). MODS and sepsis were the leading causes of death. Among 138 pediatric burn patients (77 boys and 61 girls), 29 patients had inhalation injury. The average burn area was 17%-50.2%TBSA in 3 studies. ECMO treatment lasted from 165.2 hours to 324.4 hours. Bleeding was the most common complication. The mortality was 44.2% (61/138). Conclusions: ECMO is an effective strategy for the salvage treatment of burns complicated with ARDS. Furthermore, the prevention and treatment of bleeding, infection and organ dysfunction should be emphasized during the use of ECMO. More importantly, evidence-based guidelines for burns are urgently needed to further improve the clinical effect of ECMO.

[Recommendations for normalizing the medical practices of burn treatment during the outbreak of coronavirus disease 2019]

2019 novel coronavirus (2019-nCoV) is one of the beta coronaviruses and is identified as the pathogen of the severe " coronavirus disease 2019 (COVID-19)" in 2019. China manages COVID-19 according to the reguirement of the highest level infectious diseases in China. Currently, the prevention and control of COVID-19 in China is at a critical period. Burn Department as an emergency discipline is confronted with risk of 2019-nCoV infection. Based on the guidelines for the diagnosis and treatment of COVID-19 (6th trial edition), in combination with the latest literature at home and abroad, the features of the COVID-19, the recommendations for the COVID-19 prevention and control issued by the National Health Commission of China, and the management experience of COVID-19 diagnosis and treatment of other related disciplines, we put forward some recommendations for the medical practices of burn treatment during the outbreak of the COVID-19 in outpatient and emergency, inpatient treatment, and the management of operation theatres and wards, etc. We hope these recommendations could benefit the medical professionals in the field of burn treatment and relevant hospital management during the outbreak of COVID-19, improve burn treatment, and avoid or reduce the risk of infection of medical staff.

[Retrospective study on the characteristics of early organ injury in elderly patients with severe burns]

Objective: To analyze the clinical characteristics of early organ injury in elderly patients with severe burns and the effects on the prognosis of patients. Methods: From January 2010 to August 2018, 62 patients with severe burns (43 men and 19 women, aged from 60 to 89 years at the time of admission) who were hospitalized in the Institute of Burn Research of the First Affiliated Hospital of Army Medical University (the Third Military Medical University, hereinafter referred to as the author's affiliation), meeting the inclusion criteria, were included in elderly (E) group, and 124 patients with severe burns (86 men and 38 women, aged from 18 to 59 years at the time of admission) at the same term were included in young and middle-aged (YM) group. Treatment of patients in the 2 groups followed the conventional procedures of the author's affiliation. The following data of patients in the 2 groups were retrospectively analyzed. (1) Fluid replacement volume and urine volume within the first and second post injury hour (PIH) 24 were recorded. The levels of hemoglobin, haematocrit, and blood lactic acid at admission, PIH 24 and 48 were recorded. (2) The creatine kinase isozyme-MB (CK-MB), total bilirubin, blood creatinine, oxygenation index, and blood platelet count at admission, at shock stage, and on post injury day (PID) 3 to 7 were collected. (3) The days of seriously or critically ill and deaths were recorded. Data were processed with chi-square test, group t test, Mann-Whitney U test, analysis of variance for repeated measurement, and Bonferroni correction. Results: (1) There were no statistically significant differences in fluid replacement volume within the first and second PIH 24, and urine volume within the second PIH 24 between patients in the 2 groups (t=0.351, 1.307, 1.110, P>0.05). The urine volume of patients in group E within the first PIH 24 was significantly less than that in group YM (t=5.628, P<0.05). There were no statistically significant differences in levels of hemoglobin (t=0.011, 1.075, 0.239), haematocrit (t=0, 0.033, 0.199), and blood lactic acid (t=0.017, 1.002, 0.739) at admission, PIH 24 and 48 between patients in the 2 groups (P>0.05). (2) There were no statistically significant differences in levels of CK-MB at admission and on PID 3 to 7 between patients in the 2 groups (t=0.069, 0.001, P>0.05). The level of CK-MB of patients in group E at shock stage was significantly higher than that in group YM (t=4.017, P<0.05). There were no statistically significant differences in levels of total bilirubin at admission and on PID 3 to 7 between patients in the 2 groups (t=0.227, 0.002, P>0.05). However, the level of total bilirubin of patients in group E at shock stage was significantly higher than that in group YM (t=6.485, P<0.05). The levels of blood creatinine of patients in group E at admission and shock stage were significantly higher than those in group YM (t=4.226, 12.299, P<0.05 or P<0.01), while there was no statistically significant difference between them on PID 3 to 7 (t=0.693, P>0.05). The oxygenation indexes of patients in group E at admission and shock stage and on PID 3 to 7 [(371±16), (263±16), and (228±18) mmHg (1 mmHg=0.133 kPa)] were lower than (420±13), (327±13), and (281±17) mmHg of patients in group YM, respectively (t=5.650, 9.782, 4.856, P<0.05 or P<0.01). There were no statistically significant differences in levels of blood platelet count at admission and shock stage between patients in the 2 groups (t=0.038, 0.588, P>0.05), while the level of blood platelet count of patients in group E on PID 3 to 7 was significantly lower than that in group YM (t=6.636, P<0.05). (3) The days of seriously or critically ill and death rate of patients in group E were respectively longer or higher than those in group YM (Z=-2.303, χ(2)=13.676, P<0.05 or P<0.01). Conclusions: In the case of the same tissue perfusion at shock stage, injuries in heart, liver, kidney, lung, and coagulation system in elderly patients with severe burns are more obvious than those in young and middle-aged patients, with more severe illness and higher mortality.

[Effects of RGD peptides-grafted porous tantalum on morphological change of MG63 osteoblasts-tantalum conjunctive interface and expression of osteogenesis factors]

OBJECTIVE

To investigate the effects of the Arg-Gly-Asp polypeptedes (RGD) peptides-modified porous tantalum surface on osteoblasts morphology and expressions of osteogenesis factors, and to evaluate RGD peptides promotes junctura ossium of tantalum-bone interface in vivo.

METHODS

RGD peptides of different concentrations (1 g/L, 5 g/L, and 10 g/L) were loaded to porous tantalum slices with a diameter of 10 mm and a thickness of 3 mm by physical absorption. The 3rd generation of MG63 cells were co-cultured with tantalum and divided into 4 groups: Ta-cells (control) group, 1 g/L cells/Ta/RGD group, 5 g/L cells/Ta/RGD group, and 10 g/L cells/Ta/RGD group. Porous tantalum compo-sites and osteoblasts-tantalum interface were observed by scanning electron microscopy. The adhesion rate of osteoblasts was detected and immunocytochemistry was used to detect the expressions of filamentous actin (F-actin), osteocalcin (OC) and fibronectin (FN).

RESULTS

The scanning electron microscope (SEM) revealed that osteoblasts distributed on the surface of porous tantalum and secreted extracellular matrix on outside and inner of micro-pores. The osteoblasts adhesion rate on porous tantalum modified with RGD was higher than that in the unmodified porous tantalum at the end of 24, 48, and 72 hours. The best adhesion effect was got in 5 g/L cells/Ta/RGD group at hour 48 [(68.07±3.80) vs. (23.40±4.39), P<0.05]. The results of immunocytochemistry showed that the expressions intensity of F-actin, OC and FN in osteoblasts on porous tantalum modified groups with RGD were stronger than that in the unmodified groups, and the expressions of 5 g/L cells/Ta/RGD group were significantly higher than those in the 10 g/L group and 1 g/L group [OC: (18.08±0.08) vs. (15.14±0.19), P<0.05; (18.08±0.08) vs. (14.04±0.61), P<0.05. FN: (24.60±0.98) vs. (15.90±0.53), P<0.05; (24.60±0.98) vs. (15.30±0.42), P<0.05. F-actin: (29.20±1.31) vs. (24.50±1.51), P<0.05; (29.20±1.31) vs. (16.92±0.40), P<0.05]. Correspondingly F-actin in osteoblasts was showed in longitudinal arrangement, and the expressions intensity was stronger than those OC and FN.

CONCLUSION

The RGD peptides is beneficial to enhance adhesion of osteoblast, spreading and reorganization of cytoskeleton on porous tantalum surface and improve the interface morphology, further promoting osteoblasts-tantalum conjunctive interface osseointegration.

Parathyroid hormone (1-34) promotes fracture healing in ovariectomized rats with type 2 diabetes mellitus

Ovariectomized (OVX) rats with type 2 diabetes mellitus (T2DM) with femur fracture received vehicle, insulin, or insulin plus parathyroid hormone (PTH) treatment for 2 and 3 weeks. Radiography, histomorphometry, histology, and immunohistochemistry in callus were evaluated.

INTRODUCTION

Reports about effects of PTH plus insulin on callus formation of osteoporotic fracture with T2DM were limited. This study was designed to investigate the effects of the combination of PTH and insulin on fracture healing in OVX rats with T2DM.

METHODS

Two-month-old female rats were randomly divided into five groups: normal fracture (F), OVX fracture (OF), T2DM + OVX fracture (DOF), insulin-treated (2-4 u/daylight, 4-6 u/night, DOFI), and treated with insulin and PTH (50 μg/kg/day, 5 days/week, DOFIP). A closed mid-shaft fracture was established in the right femurs of all rats after 6 weeks of OVX. Rats were euthanized at 2 and 3 weeks post-fracture according to the time schedule, respectively.

RESULTS

The administration of insulin alone or insulin combined with PTH significantly increased mineralized bone volume fraction (BV/TV) and connectivity density (Conn.D) compared with those of the DOF group at 3 weeks post-fracture and also increased cartilaginous callus area ratio in the DOFI and DOFIP groups at 2 weeks and bony callus area ratio in the DOFIP groups at both the 2 and 3 weeks post-fracture.

CONCLUSIONS

OVX rats with T2DM exhibited a marked delay in the fracture healing process; insulin treatment ameliorated these effects, and the healing process was enhanced following treatment with a combination of insulin and PTH.

Determination of InN/Diamond Heterojunction Band Offset by X-ray Photoelectron Spectroscopy

Diamond is not only a free standing highly transparent window but also a promising carrier confinement layer for InN based devices, yet little is known of the band offsets in InN/diamond system. X-ray photoelectron spectroscopy was used to measure the energy discontinuity in the valence band offset (VBO) of InN/diamond heterostructure. The value of VBO was determined to be 0.39 ± 0.08 eV and a type-I heterojunction with a conduction band offset (CBO) of 4.42 ± 0.08 eV was obtained. The accurate determination of VBO and CBO is important for the application of III-N alloys based electronic devices.

Effect of gamma irradiation on the survival of pathogens in kwamegi, a traditional Korean semidried seafood

Kwamegi (semidried raw Pacific saury) is traditional seafood available in Korea. It has water activity in the range of 0.90 to 0.95. Spoilage and the growth of most pathogenic bacteria is retarded because of low water activity, low temperature, and packaging. However, it is contaminated with bacteria of public health significance and poses a hazard to the consumer because it is consumed raw without any cooking. The effectiveness of these hurdles in preventing the growth of Staphylococcus aureus, Bacillus cereus, Salmonella Typhimurium, and Escherichia coli and the efficacy of irradiation treatment in eliminating these bacteria from kwamegi using inoculated pack studies was examined. Radiation sensitivity of S. aureus, B. cereus, Salmonella Typhimurium, and E. coli in kwamegi was investigated. D10-values of these organisms in kwamegi were 590 +/- 13.6, 640 +/- 14.9, 560 +/- 45.4, and 550 +/- 8.6 Gy, respectively. The growth of all four test organisms inoculated into these foods during 4 weeks of storage at an ambient winter temperature (ranging from -5 degrees C to +5 degrees C) was recorded. All four pathogens (inoculated at 10(6) CFU/g) were eliminated by irradiation at 4 kGy. These studies unequivocally demonstrate that irradiation, with a combination of low water activity and low temperature, results in microbiologically safe kwamegi.

Irradiation effects on embryotoxicity and oxidative properties of gossypol dissolved in methanol

Gossypol dissolved in methanol (0.25 and 0.5 mg/ml) was gamma-irradiated at 0, 5, 10, and 20 kGy. The gossypol content was significantly reduced by irradiation in a dose-dependent manner. Ames test performed with nonirradiated and irradiated gossypol solutions was negative at the level of 0.1, 0.5, 1, 10, 50, and 100 microg gossypol/plate. At the gossypol concentration of 2.5 microg/ml, the blastocysts formation rate of mice embryo were decreased by a factor of two as compared with the control, but irradiation at 20 kGy increased the blastocysts formation, resulting in no difference from the control. Addition of gossypol to oil emulsion system or oil showed a prooxidative effect of lipids at the beginning stage by increasing 2-thiobarbituric acid reactive substances (TBARS) and peroxide value but irradiation of the gossypol solution decreased the oxidative changes significantly as compared with the nonirradiated one. Results indicated that irradiation decreased the gossypol concentration dissolved in methanol, resulting in a reduction of embryotoxicity in mice.

[Study on base insertion/deletion of CAG-rich region in insulin receptor substrate-1 5'-regulatory sequence]

To study the relationship of the polymorphism of the insulin receptor substrate-1 (IRS-1) gene 5'-flanking regulatory sequence and Type 2 diabetes, the IRS-1 gene 5'-flanking regulatory sequence was scanned by PCR-SSCP in 78 healthy control subjects and 76 Type 2 diabetic subjects. Applying PCR-denatured polyacrylamide gel electrophoresis and silver staining, the insertion/deletion polymorphism of the CAG-rich region was analyzed. The genome DNA of the normal and variant subjects was amplified with high-fidelity pfu DNA polymerase. The purified and digested target fragments were then subcloned into the pCAT Basic vector. Each allele was identified according to the mobility by the restrictive endonuclease digestion of the recombinant combined with denatured polyacrylamide gel electrophoresis and silver staining, and finally the constructive plasmids containing different alleles were analyzed by DNA sequencing. Firstly, we found several insertion/deletion variations in the CAG-rich region of IRS-1 gene. Secondly, 7 genotypes and 6 alleles(T1-T6) in this site were detected. Moreover, T5 and T6 were only observed in Type 2 diabetic group.

[Screening of all types of alleles of (A-C)n dinucleotide tandem repeat sequence of aldose reductase gene]

The screening method of seven alleles (Z-6, Z-4, Z-2, Z, Z + 2, Z + 4 and Z + 6) in the (A-C)n dinucleotide tandem repeat sequence was studied. These alleles constitute a microsatellite DNA marker upstream of the transcription initiation site on the aldose reductase gene. At first, genoimic DNAs were isolated from leucocyte pellets, and the region containing the dinucleotide repeats was amplified by PCR with a pair of amplification primers that flanked 132-144 bp region. Then, the PCR products of the DNA samples whose alleles belonged to homozygotes were selected, purified, and sequenced directly in order to find out the types of alleles. Finally, using Z-2 allele as a marker, the samples containing Z-2 allele were detected by 12% fromamide-urea gel electrophoresis together with silver-staining. This method is simple, quick and accurate. It facilitates the screening of a large number of samples and is also suitable for identification of other dinucleotide tandem repeat sequences.

Activities of aldose reductase, ATPases, and nucleotide concentrations of erythrocytes in patients with type 2 (non-insulin-dependent) diabetes mellitus

Aldose reductase (EC 1.1.1.21) is implicated in the pathophysiology of diabetic complications. In this paper we determined the activities of aldose reductase and ATPases of the erythrocytes in 17 patients with Type 2 (non-insulin-dependent) diabetes mellitus (NIDDM). In the aldose reductase assay we used fluorometric method to avoid the disturbance of hemoglobin. With dihydronicotinamide adenine dinucleotide (NADH), we verified it was aldose reductase but not aldehyde reductase II that was activated in the erythrocytes of the patients with NIDDM. The aldose reductase activity of the erythrocytes in the patients was significantly higher (P less than 0.01) than that in the controls. The activity of Na+/K(+)-ATPase of the patients was significantly lower (P less than 0.01) than that of the controls. The activities of Ca(2+)-ATPase and Mg(2+)-ATPase on the erythrocyte membranes of the patients were similar to those of the controls. At the same time we measured the seven nucleotide concentrations in the erythrocytes of the patients. In this experiment we used ultrafiltration method, instead of acid precipitation to make it possible to determine dihydronicotinamide adenine dinucleotide phosphate (NADPH) and NADH. The concentrations of ATP, ADP and AMP were similar to those of the controls. The concentrations of NADPH, NAD+ and NADH in the erythrocytes of the patients were significantly lower (P less than 0.01, 0.05 and 0.05 respectively) than those of controls. The concentration of nicotinamide adenine dinucleotide phosphate (NADP+) in the patients was significantly higher (P less than 0.01) than that of controls.

Microdetermination of aldose and aldehyde reductases from human tissues

Microfluorometric method has been described for the determination of aldose reductase and aldehyde reductase II activities in human erythrocyte, brain, and lens. The enzyme activity determined by the microfluorometric method was compared with the activity determined spectrophotometrically by following the oxidation of NADPH and fluorometrically by the formation of sorbitol. The activity of aldose reductase in homogenous preparations from human lens, brain, and erythrocyte was identical when determined by NADPH oxidation, NADP formation, and sorbitol formation using glucose as substrate and NADPH as co-factor. This indicated that NADPH oxidation by aldose reductase is not due to a non-specific oxidation by oxidants generated as a result of interaction of aldose reductase and glucose. Similarly, the activity of aldehyde reductase II obtained by NADPH oxidation and that by NADP formation were in good agreement. The microfluorescent method is convenient and accurate and can be used for the determination of aldose reductase in human tissues using glucose as substrate even when the sample size is small.