Pain mediators and wound healing--establishing the connection

Slaughter of cattle without stunning: Questions related to pain, stress and endorphins

EEG studies have suggested that cattle perceive pain when bled without stunning. The present study on bleeding without stunning, compared cows that had received a local anaesthetic on the site of the bleeding cut (Lurocaine; Luro cows) one hour before bleeding with a 35 cm knife, with cows that had not (saline: Placebo cows). Various physiological indicators potentially related to pain or stress were evaluated. Increases in heart rate (P < 0.02) and cortisol levels (P < 0.001) during slaughter, compared to control levels are indicative of slaughter stress in both groups. GSH/GSSG ratio, plasma PGE2, TNFα, and NO levels and blood haematocrit levels at slaughter were not influenced by slaughter or treatment. At bleeding, excluding two out of the 15 cows with non-missing data, Placebo cows presented a longer delay between the loss of the corneal reflex and respiratory arrest. Post-mortem, Longissimus muscle of Placebo cows had a faster pH decline and remained warmer. Overall, results suggest greater stress levels in this group, probably due to pain. Plasma or brain β-endorphin contents in relevant brain structures did not increase following bleeding in either group, thus not supporting the hypothesis that stress or pain-induced release of endorphins reduces pain perceived following the cut. Furthermore, according to existing knowledge, plasma β-endorphins do not reduce pain perceived. Thus, both our study and previous research do not provide evidence that slaughter without stunning does not cause pain or other forms of stress in at least part of the animals.

Technology and Children's health: Effect of virtual reality on pain and clinical outcomes during hydrotherapy for children with burns

BACKGROUND

Virtual Reality (VR) has been frequently used as an engaging, interactive, and effective non-pharmacological distraction technique for children during painful procedures, including burnt wound care.

AIM

This study aimed to evaluate the effect of virtual reality on pain and clinical outcomes during hydrotherapy for children with burns.

DESIGN

A randomized controlled pretest, during, and post-test research design was utilized.

METHODS

Sixty children with burns underwent hydrotherapy, divided randomly and assigned equally into two groups. Children of the control group received the standard pharmacological treatment of the unit to manage pain and stabilize their physiological parameters throughout the three days of study. Children of the virtual reality intervention group received all basic standard care as the control group plus VR intervention across different software content, and interaction immersion designs which took place using a cell phone coupled with the three-dimensional (3D) image glasses. Outcome measures were physiological parameters, wound healing, and Face, Leg, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale.

SETTING

This study was carried out in the burns unit at the Plastic, Reconstructive, and Burns Surgery Center affiliated to Mansoura University, from September to November 2023.

RESULTS

Children in the study group had lower pain scores, more stable physiological parameters, and higher rates of wound healing compared to the control group with a statistically significant difference between both groups.

CONCLUSION

Using VR intervention significantly reduced pain intensity, enhanced physiological parameters and promoted the rate of wound healing in children with burns during hydrotherapy.

Person-Centred Pain Measurement in the ICU: A Multicentre Clinimetric Comparison Study of Pain Behaviour Observation Scales in Critically Ill Adult Patients with Burns

Pain in critically ill adults with burns should be assessed using structured pain behavioural observation measures. This study tested the clinimetric qualities and usability of the behaviour pain scale (BPS) and the critical-care pain observation tool (CPOT) in this population. This prospective observational cohort study included 132 nurses who rated pain behaviour in 75 patients. The majority of nurses indicated that BPS and CPOT reflect background and procedural pain-specific features (63-72 and 87-80%, respectively). All BPS and CPOT items loaded on one latent variable (≥0.70), except for compliance ventilator and vocalisation for CPOT (0.69 and 0.64, respectively). Internal consistency also met the criterion of ≥0.70 in ventilated and non-ventilated patients for both scales, except for non-ventilated patients observed by BPS (0.67). Intraclass correlation coefficients (ICCs) of total scores were sufficient (≥0.70), but decreased when patients had facial burns. In general, the scales were fast to administer and easy to understand. Cut-off scores for BPS and CPOT were 4 and 1, respectively. In conclusion, both scales seem valid, reliable, and useful for the measurement of acute pain in ICU patients with burns, including patients with facial burns. Cut-off scores associated with BPS and CPOT for the burn population allow professionals to connect total scores to person-centred treatment protocols.

Changes in serum levels of pain mediators in hemiplegic shoulder pain

OBJECTIVE

To provide a new insight into the diagnosis and treatment of hemiplegic shoulder pain (HSP) by investigating changes in serum pain mediators.

DESIGN

Cross-sectional study.

SUBJECTS/PATIENTS

Shoulder pain group (n = 34) and control group (n = 21).

METHODS

Pain-free shoulder mobility, anxiety status, depression status, and shoulder pain were measured by passive range of motion (PROM), self-rating anxiety scale, self-rating depression scale (SDS), and visual analog scale, respectively. The enzyme-linked immunosorbent assay was used to test the serum pain mediators, including interleukin (IL)-1β, IL-2, IL-6, IL-10, nerve growth factor (NGF), tumor necrosis factor-α (TNF-α), substance P (SP), calcitonin gene-related peptide (CGRP), bradykinin (BK), 5-hydroxytryptamine (5-HT), prostaglandin E2 (PGE2), and lysophosphatidic acid (LPA).

RESULTS

Shoulder pain group pain-free PROM significantly lower than control (p < .01), and SDS index score of shoulder pain group was significantly higher than control (p < .05). The rate of spasticity in the flexor elbow muscles is higher in shoulder pain group (p < .01). CGRP, IL-10, and IL-2 were significantly upregulated in shoulder pain group compared with control (p < .01), whereas NGF, TNF-α, IL-6, 5-HT, PGE2, SP, LPA, BK, and IL-1β were significantly decreased (p < .01).

CONCLUSION

Patients with HSP have a higher risk of joint mobility disorders and depression; spasticity may be an important factor in the development of shoulder pain; CGRP is thought to be the major pain mediator in HSP, and HSP may not be inflammatory.

Clinical Hypnosis for Procedural Pain and Distress in Children: A Scoping Review

OBJECTIVE

Pain and distress are common in children undergoing medical procedures, exposing them to acute and chronic biopsychosocial impairments if inadequately treated. Clinical hypnosis has emerged as a potentially beneficial treatment for children's procedural pain and distress due to evidence of effectiveness and potential superiority to other psychological interventions. However, systematic reviews of clinical hypnosis for children's procedural pain and distress have been predominantly conducted in children undergoing oncology and needle procedures and are lacking in broader pediatric contexts. This scoping review maps the evidence of clinical hypnosis for children's procedural pain and distress across broad pediatric contexts while highlighting knowledge gaps and areas requiring further investigation.

METHODS

Published databases (PubMed, Cochrane Library, PsycINFO, Embase, CINAHL, Scopus, and Web of Science) and grey literature were searched in addition to hand-searching reference lists and key journals (up to May 2022). Two independent reviewers screened the titles and abstracts of search results followed by a full-text review against eligibility criteria. Articles were included if they involved a clinical hypnosis intervention comprising an induction followed by therapeutic suggestions for pain and distress in children undergoing medical procedures. This review followed the Arksey and O'Malley (2005) methodology and incorporated additional scoping review recommendations by the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 38 eligible studies involving 2,205 children were included after 4,775 articles were screened. Research on clinical hypnosis for children's procedural pain and distress was marked by a lack of fidelity measures and qualitative data as well as by inadequate intervention reporting and high attrition rates. Evidence regarding the safety of clinical hypnosis, pain unpleasantness outcomes, factors influencing outcomes, as well as barriers and facilitators to implementing hypnosis and study procedures was also lacking. Clinical hypnosis has potential benefits for children's procedural pain and distress based on evidence of superiority to control conditions and nonpharmacological interventions (e.g., distraction, acupressure) with moderate to large effect sizes as reported in 76% of studies. However, heterogeneous interventions, contexts, study designs, and populations were identified, and the certainty of the evidence was not evaluated.

CONCLUSIONS

The review suggests potential benefits of clinical hypnosis for children's procedural pain and distress and thus provides a precursor for further systematic reviews and trials investigating the effectiveness of clinical hypnosis. The review also indicates the need to further explore the feasibility, acceptability, implementation, and safety of clinical hypnosis in children undergoing painful procedures. Based on the review, researchers implementing clinical hypnosis should adequately report interventions or use treatment manuals, follow recommended research guidelines, and assess the fidelity of intervention delivery to promote replicating and comparing interventions. The review also highlights common methodological shortcomings of published trials to avoid, such as the lack of implementation frameworks, small sample sizes, inadequate reporting of standard care or control conditions, and limited evidence on pain unpleasantness outcomes.

Effectiveness of virtual reality intervention on reducing the pain, anxiety and fear of needle-related procedures in paediatric patients: A systematic review and meta-analysis

AIMS

To evaluate the effectiveness of virtual reality (VR) intervention in the management of pain, anxiety and fear in paediatric patients undergoing needle-related procedures.

DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

DATA SOURCES

A librarian-designed search of the Cochrane Library, PubMed, Web of Science, EMBASE, CINAHL, CBM, CNKI, and Wanfang databases was conducted to identify research articles in English or Chinese on RCTs up to February 28, 2022.

REVIEW METHODS

Two researchers independently screened eligible articles. The Cochrane Handbook for Systematic Reviews was used to assess the risk of bias in the included studies. A fixed- or random-effects meta-analysis model was used to determine the pooled mean difference based on the results of the heterogeneity test.

RESULTS

A total of 2269 articles were initially screened. The meta-analysis included data from 27 studies representing 2224 participants. Compared with the non-VR group, the VR intervention group significantly reduced pain, anxiety, and fear in paediatric patients who underwent puncture-related procedures. Subgroup analysis showed that VR has advantages over conventional and other distraction methods.

CONCLUSION

Paediatric patients undergoing needle-related procedures would benefit from VR interventions for pain, anxiety and fear management.

IMPACT

VR intervention has the potential to reduce pain, anxiety and fear in paediatric patients undergoing puncture-related procedures. Future clinical interventions could incorporate VR into puncture procedures as an effective method to reduce negative emotions in children eligible for VR distractions.

PATIENT OR PUBLIC CONTRIBUTION

Our paper is a systematic review and meta-analysis and such details don't apply to our work.

The importance of periwound skin in wound healing: an overview of the evidence

DECLARATION OF INTEREST

The authors have no conflicts of interest.

The effect of self-management online modules plus nurse-led support on pain and quality of life among young adults with irritable bowel syndrome: A randomized controlled trial

BACKGROUND

Irritable bowel syndrome is a chronic pain condition that needs life-long self-management. However, the effect of self-management among young adults with irritable bowel syndrome is limited.

OBJECTIVES

This study aimed to examine the effect of a nurse-led self-management program on pain, symptoms, and quality of life among young adults with irritable bowel syndrome.

DESIGN

A randomized controlled trial.

SETTINGS AND PARTICIPANTS

Eighty young adults with irritable bowel syndrome recruited from two campuses of a public university and two gastrointestinal clinics were randomly assigned into a self-management online education and learning modules alone group (Online Modules, n = 41) or a nurse-led one-to-one consultation plus self-management online education and learning modules group (Nurse-Led Online Modules, n = 39). Twenty-one healthy controls were also recruited from these two campuses.

METHODS

Both the intervention groups received ten online modules after baseline data collection. Participants in the Nurse-Led Online Modules group received additional three nurse-led one-to-one consultations at baseline, 6- and 12-week follow-ups. Self-reported pain, symptoms, quality of life, self-efficacy for managing chronic disease, and coping were measured at baseline, and 6- and 12-week follow-ups among the participants with irritable bowel syndrome. The healthy controls completed data collection of pain and symptoms at baseline and the 12-week follow-up. The intervention effects across study time points and the comparisons between the two interventional groups were analyzed using linear mixed models. A longitudinal mediation analysis was also conducted to explore the mediation effects of self-management mechanisms of the interventions.

RESULTS

Both the intervention groups showed significant interventional effects on decreasing pain intensity and pain interference and increasing quality of life at the 12-week follow-up (all p < 0.05). At the 12-week follow-up, the Nurse-Led Online Modules significantly reduced anxiety (p = 0.016) and had a significant greater improvement in quality of life than the Online Modules (p = 0.040). Increased self-efficacy mediated the intervention effect of the Nurse-Led Online Modules group on reducing pain interference and improving quality of life, while the effect of the Online Modules was mediated through decreasing inefficient coping strategy-catastrophizing.

CONCLUSIONS

This study showed that both the pain self-management online education and nurse-led intervention were effective for alleviating pain and improving quality of life among young adults with irritable bowel syndrome by targeting the self-management process. The nurse-led intervention had a better outcome than the online education alone in improving quality of life.

REGISTRATION NUMBER

NCT03332537.

Management of non-severe burn wounds in children and adolescents: optimising outcomes through all stages of the patient journey

Paediatric burn injuries are common, especially in children younger than 5 years, and can lead to poor physical and psychosocial outcomes in the long term. In this Review, we aim to summarise the key factors and interventions before hospital admission and following discharge that can improve the long-term outcomes of paediatric burns. Care can be optimised through first aid treatment, correct initial assessment of burn severity, and appropriate patient referral to a burns centre. Scar prevention or treatment and patient follow-up after discharge are also essential. As most burn injuries in children are comparatively small and readily survivable, this Review does not cover the perioperative management associated with severe burns that require fluid resuscitation, or inhalational injury. Burns disproportionately affect children from low socioeconomic backgrounds and those living in low-income and middle-income countries, with ample evidence to suggest that there remains scope for low-cost interventions to improve care for those patients with the greatest burden of burn injury. Current knowledge gaps and future research directions are discussed.

Analgesic and Anti-Arthritic Activities of Polysaccharides in Chaenomeles speciosa

Chaenomeles speciosa (Sweet) Nakai has been long used as a folk medicine for rheumatic diseases treatment. This study aimed to investigate the effects and underlying mechanism of polysaccharides in Chaenomeles speciosa (CSP) on the pro-inflammatory cytokines and MAPK pathway in complete Freund’s adjuvant (CFA)-induced arthritis and LPS-induced NR8383 cells. We used acetic acid (HAc)-induced writhing and CFA induced paw edema to determine the analgesic activity and anti-inflammatory activity, respectively. CFA rats were administered CSP (12.5, 25.0, and 50.0 mg/kg) daily for 3 weeks via oral gavage. The analgesic test was done using three different doses of the extract (50, 100, and 200 mg/kg). The anti-arthritic evaluation involved testing for paw swelling, swelling inhibition, and histological analysis in CFA rats. Finally, ELISA, western blot, qRT-PCR were done to determine the effect of CSP on the activation of MAPK pathway, production of pro-inflammatory cytokines in lipopolysaccharide (LPS)-stimulated NR838 macrophage cells. In pain models, oral uptake of CSP greatly reduced pain perception. Furthermore, in CFA rats, CSP substantially decreased paw swelling as well as synovial tissue proliferation and inflammatory cell infiltration. In addition, CSP was shown to inhibit pro-inflammatory cytokines (TNF-α, IL-1β, and COX-2) as well as JNK and ERK1/2 phosphorylation in LPS-stimulated NR8383 cells. Thus, pro-inflammatory cytokine secretion and MAPK signaling downregulation promoted the analgesic and anti-arthritic effects of CSP.

Hypnotherapy for Procedural Pain and Distress in Children: A Scoping Review Protocol

OBJECTIVE

Inadequately treated pain and distress elicited by medical procedures can put children at higher risk of acute and chronic biopsychosocial sequelae. Children can benefit from hypnotherapy, a psychologically tailored intervention, as an adjunct to pharmacological agents to address the multiple components of pain and distress. Despite providing evidence on the effectiveness and potential superiority of hypnotherapy to other psychological interventions, research on hypnotherapy for pediatric procedural pain and distress has been predominantly limited to oncology and needle procedures. Plus, there is a lack of reporting of intervention manuals, factors influencing hypnotic responding, pain unpleasantness outcomes, theoretical frameworks, adverse events, as well as barriers and facilitators to the feasibility of delivering the intervention and study procedures. The proposed review aims to map the range and nature of the evidence on hypnotherapy for procedural pain and distress in children to identify gaps in literature and areas requiring further investigation.

METHODS

This review will follow the Arksey and O'Malley (2005) methodology and incorporate additional scoping review recommendations by the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses. Relevant studies will be identified through searching published literature databases (PubMed, Cochrane Library, PsycINFO, Embase, CINAHL, Scopus and Web of Science) and grey literature in addition to hand-searching of reference lists and key journals. Two authors will independently screen titles and abstracts of search results followed by full-texts review against eligibility criteria.

CONCLUSION

Findings are anticipated to guide future research and inform the development of tailored hypnotic interventions in children.

Evaluation of acute and chronic nociception in subchronically administered MK-801-induced rat model of schizophrenia

Patients diagnosed with schizophrenia have been reported to exhibit atypically low pain sensitivity and to vary in their experience of chronic pain. To the best of our knowledge, there has yet to be an animal study that provides information concerning the relationship between models of schizophrenia and pain. In the present study, we investigated several distinct nociceptive behaviors in a translational rat model of schizophrenia (0. 5 mg/kg MK-801, twice a day for 7 days followed by a 7-day washout period). The presence of the expected cognitive deficit was confirmed with novel object recognition (NOR) paradigm prior to nociception testing. MK-801-treated rats with lack of novelty interest in NOR testing showed: hyposensitivity to thermal and mechanical stimuli; short-term hypoalgesia followed by augmented hyperalgesia in response to formalin-induced spontaneous nociception and increased thermal and mechanical hyperalgesia in the complete Freund's adjuvant (CFA) induced chronic pain model. In conclusion, MK-801 induced antinociception effects for thermal stimuli in rats that were consistent with the decreased pain sensitivity observed in schizophrenia patients. Additionally, the amplified biphasic response exhibited by the MK-801 group in the formalin-induced spontaneous nociception test affirms the suitability of the test as a model of acute to delayed pain transition.

Pain Management in Patients with Severe Pemphigus Vulgaris

To describe the pain management and clinical course of patients with severe Pemphigus Vulgaris (PV) admitted to a third-level Intensive Care Unit (ICU). This was a retrospective cohort study conducted in the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán over the period 2013-2020. Study population comprised patients with severe PV admitted to the ICU. Eleven patients with severe PV were included. Mean age of presentation was 43.6 years. Percentage of the total body surface area affected ranged from 70 to 85% (mean: 80%). Visual Analogue Scale was used for pain assessment upon admission. Nine patients (72%) reported a 10/10 pain. The median Morphine Equivalent Daily Dose was 200 mg (range: 90-518 mg). Mortality was 27% during the ICU stay. One patient (9%) continued to experience severe pain and consume opioids after discharge. PV is a life-threatening disease characterized by painful, persistent erosions and ulcers. Integrated and multidisciplinary approach is often required. Opioids remain the mainstay for acute pain control in patients with severe PV. Biological, psychological, and social factors influence patients' daily opioid requirements and dose escalation. Successful pain management contributes to improving the quality of life, and the suppression and remission of PV.

'This won't hurt a bit!' - A descriptive review of health care professionals' pharmacological management of pain in minor trauma

BACKGROUND

Emergency Centres (ECs) have a prominent trauma burden requiring effective pain management. This study aimed to review analgesia-prescribing habits in minor trauma, reviewing the patient demographics and diagnoses, analgesia-prescribing habits of health care professionals (HCPs) managing these cases, and differences in prescribing noted by patients' age group, gender and triage code.

METHODS

A prospective, cross-sectional, descriptive study was conducted in a regional EC in KwaZulu-Natal. HCPs managing minor trauma patients completed a closed-ended questionnaire which indicated the patients' demographics, diagnosis and analgesia prescribed.

RESULTS

The study comprised of 314 cases of which the demographic most represented were male patients aged between 20-30 years with soft tissue injuries. Simple analgesics and weak opioids (paracetamol, ibuprofen and tramadol) accounted for 87.9% of prescriptions. Referral clinics prescribed less analgesics than that provided in the EC. There were mostly no significant differences in prescription habits by patients' age group, gender and triage code.

CONCLUSION

Presenting complaints in our study were varied and likely to result in mild to moderate pain. Only a minority of patients received analgesics at initial contact. Standardised protocols providing treatment guidance for nurse-initiated pain management at initial contact is thus important. There were no significant differences in analgesics prescribed for adults and the elderly, which is worrisome given the potential negative side effects of analgesics in the elderly. Similar concerns in our paediatric population were not noted. Ensuring adequate analgesia with cognisance for safety at the extremes of age is of paramount importance.

The Management of Burn Pain in a Pediatric Burns-Specialist Hospital

Appropriate pain management for children who have experienced an acute burn injury is critical to improve patient outcomes and reduce potential morbidities. With 60% of our patients being under the age of 4 years, pain management is crucial in reducing pain and anxiety in both patients and parents. It is imperative that appropriate pain relief is commenced from initial contact with healthcare workers as this will affect the success or failure of future wound procedures. Uncontrolled pain can negatively affect a patient, both short and long term. It may cause anticipatory anxiety for future medical procedures, increased pain and anxiety can decrease wound re-epithelialization which can lead to long-term consequences for growth and mobility, and increased pain can also influence the possibility of patients and families displaying signs of post-traumatic stress disorder. Pain management in the form of pharmaceuticals is imperative during burn wound treatment and should incorporate pain relief targeted at both background and procedural pain. It also requires a multimodal, individualized, and targeted approach combining both pharmaceutical and nonpharmaceutical techniques, including cold running water, multimodal distraction devices, hypnotherapy, and bubbles. We discuss the research and knowledge that our center has gained through treating pediatric patients with burns over the last 20 years.

Modular design of a hybrid hydrogel for protease-triggered enhancement of drug delivery to regulate TNF-α production by pro-inflammatory macrophages

Systemic drug administration has conventionally been prescribed to alleviate persistent local inflammation which is prevalent in chronic diseases. However, this approach is associated with drug-induced toxicity, particularly when the dosage exceeds that necessitated by pathological conditions of diseased tissues. Herein, we developed a modular hybrid hydrogel which could be triggered to release an anti-inflammatory drug upon exposure to elevated protease activity associated with inflammatory diseases. Modular design of the hybrid hydrogel enabled independent optimization of its protease-cleavable and drug-loaded subdomains to facilitate hydrogel formation, cleavability by matrix-metalloprotease-9 (MMP-9), and tuning drug release rate. In vitro study demonstrated the protease-triggered enhancement of drug release from the hybrid hydrogel system for effective inhibition of TNF-α production by pro-inflammatory macrophages and suggested its potential to mitigate drug-induced cytotoxicity. Using non-invasive imaging to monitor the activity of reactive oxygen species in biomaterial-induced host response, we confirmed that the hybrid hydrogel and its constituent materials did not induce adverse immune response after 5 days following their subcutaneous injection in immuno-competent mice. We subsequently incorporated this hybrid hydrogel onto a commercial wound dressing which could release the drug upon exposure to MMP-9. Together, our findings suggested that this hybrid hydrogel might be a versatile platform for on-demand drug delivery via either injectable or topical application to modulate inflammation in chronic diseases.

Immersive Virtual Reality as Analgesia during Dressing Changes of Hospitalized Children and Adolescents with Burns: A Systematic Review with Meta-Analysis

Children and adolescents with severe burns require medical and nursing interventions, associated with pain. As immersive virtual reality (VR) gained prominence as non-pharmacological adjuvant analgesia, we conducted a systematic review and meta-analysis on the efficacy of full immersive VR on pain experienced during dressing changes in hospitalized children and adolescents with severe burns. This exercise included quality and risk of bias assessment. The systematic review resulted in eight studies and 142 patients. Due to missing data, four studies were excluded from the meta-analysis. Fixed effects meta-analysis of the four included studies (n = 104) revealed a large effect size (ES) (Standardized Mean Difference = 0.94; 95% Confidence Interval = 0.62, 1.27; Z = 5.70; p < 0.00001) for adjuvant full immersive VR compared to standard care (SC). In conclusion, adjuvant full immersive VR significantly reduces pain experienced during dressing changes in children and adolescents with burns. We therefore recommend implementing full immersive VR as an adjuvant in this specific setting and population. However, this requires further research into the hygienic use of VR appliances in health institutions. Furthermore, due to the high cost of the hardware, a cost-benefit analysis is required. Finally, research should also verify the long term physical and psychological benefits of VR.

Pain reduction by dehydrated human amnion/chorion membrane allograft in nondiabetic leg ulcers might be an early indicator of good response: A case series

Dehydrated human amnion/chorion membrane allograft (dHACM) derived from placenta is increasingly used for skin and soft tissue repair in several medical specialties. Promising effects of dHACM were also reported in chronic venous and diabetic leg ulcers. However, dHACM is cost-intensive and its effect on chronic leg ulcers of other etiologies and pain reduction is unknown. Clinical predictors of a favorable response to dHACM during the early treatment period could help to limit unnecessary costs. In our case series with six patients suffering from chronic lower leg ulcers of various etiology, the effect of dHACM once per week on reduction of pain and wound size during a 5-week period was examined. dHACM resulted in effective pain reduction and improved wound healing in three patients with chronic leg ulcers due to calciphylaxis, chronic venous disease and reactive angioendotheliomatosis. Pain reduction after 1 to 2 applications of dHACM predicted a favorable healing response. Hence, our observation indicates that assessment of pain 3 weeks after initiation of dHACM may be a clinical predictor to justify dis-/continuation of dHACM and thereby may help to limit costs.

Successful treatment of painful chronic wounds with amniotic and umbilical cord tissue: A case series

Patients with chronic wounds may experience persistent, debilitating pain that cannot be adequately managed with analgesics and that negatively impacts their quality of life. In this case series, three painful chronic and ischemic wounds that were caused by polyarteritis nodosa vasculitis (n = 1) and peripheral arterial disease (PAD) (n = 2) were successfully treated with cryopreserved umbilical cord tissue and/or amniotic membrane and umbilical cord particulate, resulting in notable reduction in pain within 7 days followed by expedited wound closure. No adverse events related to these tissue products were observed. These preliminary data demonstrate its safety and efficacy in reducing pain and promoting wound healing in painful chronic and ischemic wounds.

The analgesic potential of glycosides derived from medicinal plants

Pain represents an unpleasant sensation linked to actual or potential tissue damage. In the early phase, the sensation of pain is caused due to direct stimulation of the sensory nerve fibers. On the other hand, the pain in the late phase is attributed to inflammatory mediators. Current medicines used to treat inflammation and pain are effective; however, they cause severe side effects, such as ulcer, anemia, osteoporosis, and endocrine disruption. Increased attention is recently being focused on the examination of the analgesic potential of phytoconstituents, such as glycosides of traditional medicinal plants, because they often have suitable biological activities with fewer side effects as compared to synthetic drugs. The purpose of this article is to review for the first time the current state of knowledge on the use of glycosides from medicinal plants to induce analgesia and anti-inflammatory effect. Various databases and search engines, including PubMed, ScienceDirect, Scopus, Web of Science and Google Scholar, were used to search and collect relevant studies on glycosides with antinociceptive activities. The results led to the identification of several glycosides that exhibited marked inhibition of various pain mediators based on different well-established assays. Additionally, these glycosides were found to induce most of the analgesic effects through cyclooxygenase and lipoxygenase pathways. These findings can be useful to identify new candidates which can be clinically developed as analgesics with better bioavailability and reduced side effects. Graphical abstract Analgesic mechanisms of plant glycosides.

The role of parental acute psychological distress in paediatric burn re-epithelialization

OBJECTIVES

Following a paediatric burn, parents commonly experience high levels of acute psychological distress, which has been shown to increase child psychological distress as well as child procedural distress. The influence of psychological stress and perceived pain on wound healing has been demonstrated in several laboratory and medical populations. This paper investigates the influence of parental acute psychological distress and procedural behaviour on the child's rate of re-epithelialization, after controlling for child procedural distress.

DESIGN

A prospective observational study with longitudinal outcome.

METHODS

Eighty-three parents of children 1-6 years old reported acute psychological distress (post-traumatic stress symptoms [PTSS], guilt, pre-procedural fear, general anxiety/depression symptoms) in relation to their child's burn. A researcher observed parent-child behaviour at the first dressing change, and parents and nurses reported child procedural distress (pre-, peak-, and post-procedural pain and fear). These variables, along with demographic and injury information, were tested for predicting time to re-epithelialization. Date of re-epithelialization was determined by the treating consultant.

RESULTS

Days to re-epithelialization ranged from 3 to 35 days post-injury. A hierarchical multiple regression analysis found wound depth and size significantly accounted for 28% of the variance in time to re-epithelialization. In Block 2, child peak-procedural pain significantly accounted for 6% additional variance. In Block 3, parental PTSS significantly accounted for 5% additional variance.

CONCLUSIONS

Parental PTSS appears to be an important but under-recognized factor that may influence their child's burn re-epithelialization. Further investigation is required to understand the mechanisms contributing to this association. Statement of contribution What is already known on this subject? Psychological stress delays wound healing, and this relationship has been found in paediatric burn populations with procedural pain. Parental psychological stress is often present after a child's burn and is related to the child's procedural coping and distress. What does this study add? Parental post-traumatic stress is related to delayed child burn re-epithelialization. This association is in addition to procedural pain delaying re-epithelialization.

Targeting epigenetic mechanisms for chronic visceral pain: A valid approach for the development of novel therapeutics

BACKGROUND

Chronic visceral pain is persistent pain emanating from thoracic, pelvic, or abdominal origin that is poorly localized with regard to the specific organ affected. The prevalence can range up to 25% in the adult population as chronic visceral pain is a common feature of many visceral disorders, which may or may not be accompanied by distinct structural or histological abnormalities within the visceral organs. Mounting evidence suggests that changes in epigenetic mechanisms are involved in the top-down or bottom-up sensitization of pain pathways and the development of chronic pain. Epigenetic changes can lead to long-term alterations in gene expression profiles of neurons and consequently alter functionality of peripheral neurons, dorsal root ganglia, spinal cord, and brain neurons. However, epigenetic modifications are dynamic, and thus, detrimental changes may be reversible. Hence, external factors/therapeutic interventions may be capable of modulating the epigenome and restore normal gene expression for extended periods of time.

PURPOSE

The goal of this review is to highlight the latest discoveries made toward understanding the epigenetic mechanisms that are involved in the development or maintenance of chronic visceral pain. Furthermore, this review will provide evidence supporting that targeting these epigenetic mechanisms may represent a novel approach to treat chronic visceral pain.

Tachykinins modulate nociceptive responsiveness and sensitization: In vivo electrical characterization of primary sensory neurons in tachykinin knockout (Tac1 KO) mice

Since the failure of specific substance P antagonists to induce analgesia, the role of tachykinins in the development of neuropathic pain states has been discounted. This conclusion was reached without studies on the role of tachykinins in normal patterns of primary afferents response and sensitization or the consequences of their absence on the modulation of primary mechanonociceptive afferents after injury. Nociceptive afferents from animals lacking tachykinins (Tac1 knockout) showed a disrupted pattern of activation to tonic suprathreshold mechanical stimulation. These nociceptors failed to encode the duration and magnitude of natural pronociceptive stimuli or to develop mechanical sensitization as consequence of this stimulation. Moreover, paw edema, hypersensitivity, and weight bearing were also reduced in Tac1 knockout mice 24 h after paw incision surgery. At this time, nociceptive afferents from these animals did not show the normal sensitization to mechanical stimulation or altered membrane electrical hyperexcitability as observed in wild-type animals. These changes occurred despite a similar increase in calcitonin gene-related peptide immunoreactivity in sensory neurons in Tac1 knockout and normal mice. Based on these observations, we conclude that tachykinins are critical modulators of primary nociceptive afferents, with a preeminent role in the electrical control of their excitability with sustained activation or injury.

Visceral pain: gut microbiota, a new hope?

BACKGROUND

Visceral pain is a complex and heterogeneous disorder, which can range from the mild discomfort of indigestion to the agonizing pain of renal colic. Regulation of visceral pain involves the spinal cord as well as higher order brain structures. Recent findings have linked the microbiota to gastrointestinal disorders characterized by abdominal pain suggesting the ability of microbes to modulate visceral hypersensitivity and nociception to pain.

MAIN BODY

In this review we describe the neuroanatomical basis of visceral pain signaling and the existing evidence of its manipulation exerted by the gut microbiota. We included an updated overview of the potential therapeutic effects of dietary intervention, specifically probiotics and prebiotics, in alleviating hypersensitivity to visceral pain stimuli.

CONCLUSIONS

The gut microbiota dramatically impacts normal visceral pain sensation and affects the mechanisms mediating visceral nociception. Furthermore, manipulation of the gut microbiota using prebiotics and probiotics plays a potential role in the regulation of visceral pain disorders.

Stress-Induced Chronic Visceral Pain of Gastrointestinal Origin

Visceral pain is generally poorly localized and characterized by hypersensitivity to a stimulus such as organ distension. In concert with chronic visceral pain, there is a high comorbidity with stress-related psychiatric disorders including anxiety and depression. The mechanisms linking visceral pain with these overlapping comorbidities remain to be elucidated. Evidence suggests that long term stress facilitates pain perception and sensitizes pain pathways, leading to a feed-forward cycle promoting chronic visceral pain disorders such as irritable bowel syndrome (IBS). Early life stress (ELS) is a risk-factor for the development of IBS, however the mechanisms responsible for the persistent effects of ELS on visceral perception in adulthood remain incompletely understood. In rodent models, stress in adult animals induced by restraint and water avoidance has been employed to investigate the mechanisms of stress-induce pain. ELS models such as maternal separation, limited nesting, or odor-shock conditioning, which attempt to model early childhood experiences such as neglect, poverty, or an abusive caregiver, can produce chronic, sexually dimorphic increases in visceral sensitivity in adulthood. Chronic visceral pain is a classic example of gene × environment interaction which results from maladaptive changes in neuronal circuitry leading to neuroplasticity and aberrant neuronal activity-induced signaling. One potential mechanism underlying the persistent effects of stress on visceral sensitivity could be epigenetic modulation of gene expression. While there are relatively few studies examining epigenetically mediated mechanisms involved in visceral nociception, stress-induced visceral pain has been linked to alterations in DNA methylation and histone acetylation patterns within the brain, leading to increased expression of pro-nociceptive neurotransmitters. This review will discuss the potential neuronal pathways and mechanisms responsible for stress-induced exacerbation of chronic visceral pain. Additionally, we will review the importance of specific experimental models of adult stress and ELS in enhancing our understanding of the basic molecular mechanisms of pain processing.

Development, Optimization and In Vitro/In Vivo Characterization of Collagen-Dextran Spongious Wound Dressings Loaded with Flufenamic Acid

The aim of this study was the development and optimization of some topical collagen-dextran sponges with flufenamic acid, designed to be potential dressings for burn wounds healing. The sponges were obtained by lyophilization of hydrogels based on type I fibrillar collagen gel extracted from calf hide, dextran and flufenamic acid, crosslinked and un-crosslinked, and designed according to a 3-factor, 3-level Box-Behnken experimental design. The sponges showed good fluid uptake ability quantified by a high swelling ratio. The flufenamic acid release profiles from sponges presented two stages—burst effect resulting in a rapid inflammation reduction, and gradual delivery ensuring the anti-inflammatory effect over a longer burn healing period. The resistance to enzymatic degradation was monitored through a weight loss parameter. The optimization of the sponge formulations was performed based on an experimental design technique combined with response surface methodology, followed by the Taguchi approach to select those formulations that are the least affected by the noise factors. The treatment of experimentally induced burns on animals with selected sponges accelerated the wound healing process and promoted a faster regeneration of the affected epithelial tissues compared to the control group. The results generated by the complex sponge characterization indicate that these formulations could be successfully used for burn dressing applications.

Intrathecal Morphine Versus Extended-Release Epidural Morphine for Postoperative Pain Control in Pediatric Patients Undergoing Posterior Spinal Fusion

BACKGROUND

Posterior spinal fusion for scoliosis is one of the most painful elective pediatric surgeries. Good postoperative pain control allows early ambulation and return of ability to tolerate oral intake. Options for analgesia in this patient population are suboptimal. We hypothesized that extended-release epidural morphine (EREM) would provide better pain control and less adverse effects compared to intrathecal (IT) morphine.

METHODS

The primary outcome was total IV morphine consumption during 0-48 hours postoperatively. Secondary outcomes included time until first patient-controlled analgesia (PCA) demand, pain scores, and adverse opioid effects. After institutional review board approval, 71 subjects undergoing posterior spinal fusion for idiopathic scoliosis completed the study. The subjects were randomly allocated to 7.5 μg/kg IT morphine or 150 μg/kg EREM. The final IT morphine and EREM groups contained 37 and 34 subjects, respectively. Postoperative pain was treated with morphine PCA, ketorolac, oral oxycodone, and acetaminophen. Morphine consumption, pain scores, nausea and vomiting, pruritus, and respiratory depression were measured every 4 hours. Parents completed a caregiver questionnaire about their child's pain control regimen after the first postoperative day.

RESULTS

There was no difference in total morphine consumption over the first 48 hours between subjects in the EREM and IT morphine groups: median (range) 42.2 (5.5-123.0) and 34.0 (4.5-128.8) mg, respectively (P = .27). EREM and IT morphine groups had no difference in time until first PCA demand. Pain scores were no different between the groups from 8 to 24 hours after surgery. Compared to IT morphine, EREM subjects had lower pain scores from 28 to 36 hours after surgery. The reported incidence of pruritus was lower in the EREM subjects.

CONCLUSIONS

There was no difference in total morphine consumption or time until first PCA demand between the EREM and IT morphine groups. EREM provides a longer duration of analgesia after posterior spinal fusion for scoliosis and may be associated with less opioid-induced pruritus.

The effects of psychological interventions on wound healing: A systematic review of randomized trials

PURPOSE

Psychological stress has been shown to delay wound healing. Several trials have investigated whether psychological interventions can improve wound healing, but to date, this evidence base has not been systematically synthesized. The objective was to conduct a systematic review of randomized controlled trials in humans investigating whether psychological interventions can enhance wound healing.

METHODS

A systematic review was performed using PsychINFO, CINAHL, Web of Science, and MEDLINE. The searches included all papers published in English up until September 2016. The reference lists of relevant papers were screened manually to identify further review articles or relevant studies. Nineteen studies met inclusion criteria and were included in the review.

RESULTS

Fifteen of nineteen studies were of high methodological quality. Six studies were conducted with acute experimentally created wounds, five studies with surgical patients, two studies with burn wounds, two studies with fracture wounds, and four studies were conducted with ulcer wounds. Post-intervention standardized mean differences (SMD) between groups across all intervention types ranged from 0.13 to 3.21, favouring improved healing, particularly for surgical patients and for relaxation interventions. However, there was some evidence for publication bias suggesting negative studies may not have been reported. Due to the heterogeneity of wound types, population types, and intervention types, it is difficult to pool effect sizes across studies.

CONCLUSIONS

Current evidence suggests that psychological interventions may aid wound healing. Although promising, more research is needed to assess the efficacy of each intervention on different wound types. Statement of contribution What is already known on this subject? Psychological stress negatively affects wound healing. A number of studies have investigated whether psychological interventions can improve healing. However, no systematic reviews have been conducted. What does this study add? Synthesis and review of 19 trials conducted on psychological interventions and wound healing. Most evidence supports improved healing, particularly for surgical wounds and relaxation interventions. More research is needed on different intervention types with clinical wounds and into mechanisms of action.

Acmella oleracea and Achyrocline satureioides as Sources of Natural Products in Topical Wound Care

The Brazilian forests have one of the world's biggest biodiversities. Achyrocline satureioides (macela) and Acmella oleracea (jambu) are native species from Brazil with a huge therapeutic potential, with proved anti-inflammatory and anesthetic action, respectively. The jambu's crude extract after depigmentation with activated charcoal and macela's essential oil were incorporated in a film made with hydroxyethyl cellulose. Those films were evaluated by mechanical test using a texturometer and anti-inflammatory and anesthetic activities by in vivo tests: wound healing and antinociceptive. The film containing the highest concentration of depigmented jambu's extract and macela's essential oil obtained an anesthesia time of 83.6 (±28.5) min longer when compared with the positive control EMLA®; the same occurred with the wound healing test; the film containing the highest concentration had a higher wound contraction (62.0% ± 12.1) compared to the positive control allantoin and the histopathological analysis demonstrated that it increases collagen synthesis and epidermal thickening. The results demonstrate that the films have a potential use in skin wounds, pressure sore, and infected surgical wounds treatment.

Chronic wounds should be one of Australia's National Health Priority Areas

Chronic wounds are a poorly recognised chronic disease that cause pain and suffering and cost the Australian healthcare system A $2.85 billion dollars per annum. Unlike the highly profiled and relatively well-funded chronic diseases that comprise the Australian National Health Priority Areas, chronic wounds remain a largely hidden and poorly supported problem in the Australian community. This perspective article proposes that one approach to generate action to reduce the burden of chronic wounds is to better articulate the relationship between chronic wounds and the Australian National Health Priority Areas, and to establish a profile of chronic wounds as a chronic disease of national significance in its own right. This approach has the potential to raise awareness of the significance of chronic wounds and garner support from the public, healthcare sector, research funders and policy makers to improve the outcomes for people who are living with or at risk of developing this condition and to potentially reduce expenditure in this area.

Effectiveness of medical hypnosis for pain reduction and faster wound healing in pediatric acute burn injury: study protocol for a randomized controlled trial

BACKGROUND

Burns and the associated wound care procedures can be extremely painful and anxiety-provoking for children. Burn injured children and adolescents are therefore at greater risk of experiencing a range of psychological reactions, in particular posttraumatic stress disorder, which can persist for months to years after the injury. Non-pharmacological intervention is critical for comprehensive pain and anxiety management and is used alongside pharmacological analgesia and anxiolysis. However, effective non-pharmacological pain and anxiety management during pediatric burn procedures is an area still needing improvement. Medical hypnosis has received support as a technique for effectively decreasing pain and anxiety levels in adults undergoing burn wound care and in children during a variety of painful medical procedures (e.g., bone marrow aspirations, lumbar punctures, voiding cystourethrograms, and post-surgical pain). Pain reduction during burn wound care procedures is linked with improved wound healing rates. To date, no randomized controlled trials have investigated the use of medical hypnosis in pediatric burn populations. Therefore this study aims to determine if medical hypnosis decreases pain, anxiety, and biological stress markers during wound care procedures; improves wound healing times; and decreases rates of traumatic stress reactions in pediatric burn patients.

METHODS/DESIGN

This is a single-center, superiority, parallel-group, prospective randomized controlled trial. Children (4 to 16 years, inclusive) with acute burn injuries presenting for their first dressing application or change are randomly assigned to either the (1) intervention group (medical hypnosis) or (2) control group (standard care). A minimum of 33 participants are recruited for each treatment group. Repeated measures of pain, anxiety, stress, and wound healing are taken at every dressing change until ≥95 % wound re-epithelialization. Further data collection assesses impact on posttraumatic stress symptomatology, speed of wound healing, and parent perception of how easy the dressing change is for their child.

DISCUSSION

Study results will elucidate whether the disease process can be changed by using medical hypnosis with children to decrease pain, anxiety, and stress in the context of acute burn wounds.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000419561.

The Pharmacology of Visceral Pain

Visceral pain describes pain emanating from the internal thoracic, pelvic, or abdominal organs. Unlike somatic pain, visceral pain is generally vague, poorly localized, and characterized by hypersensitivity to a stimulus such as organ distension. While current therapeutics provides some relief from somatic pain, drugs used for treatment of chronic visceral pain are typically less efficacious and limited by multiple adverse side effects. Thus, the treatment of visceral pain represents a major unmet medical need. Further, more basic research into the physiology and pathophysiology of visceral pain is needed to provide novel targets for future drug development. In concert with chronic visceral pain, there is a high comorbidity with stress-related psychiatric disorders including anxiety and depression. The mechanisms linking visceral pain with these overlapping comorbidities remain to be elucidated. However, persistent stress facilitates pain perception and sensitizes pain pathways, leading to a feed-forward cycle promoting chronic visceral pain disorders. We will focus on stress-induced exacerbation of chronic visceral pain and provide supporting evidence that centrally acting drugs targeting the pain and stress-responsive brain regions may represent a valid target for the development of novel and effective therapeutics.

Behavioral signs of pain and functional impairment in a mouse model of osteogenesis imperfecta

Osteogenesis imperfecta (OI) is a congenital disorder caused most often by dominant mutations in the COL1A1 or COL1A2 genes that encode the alpha chains of type I collagen. Severe forms of OI are associated with skeletal deformities and frequent fractures. Skeletal pain can occur acutely after fracture, but also arises chronically without preceding fractures. In this study we assessed OI-associated pain in the Col1a1Jrt/+ mouse, a recently developed model of severe dominant OI. Similar to severe OI in humans, this mouse has significant skeletal abnormalities and develops spontaneous fractures, joint dislocations and vertebral deformities. In this model, we investigated behavioral measures of pain and functional impairment. Significant hypersensitivity to mechanical, heat and cold stimuli, assessed by von Frey filaments, radiant heat paw withdrawal and the acetone tests, respectively, were observed in OI compared to control wildtype littermates. OI mice also displayed reduced motor activity in the running wheel and open field assays. Immunocytochemical analysis revealed no changes between OI and WT mice in innervation of the glabrous skin of the hindpaw or in expression of the pain-related neuropeptide calcitonin gene-related protein in sensory neurons. In contrast, increased sensitivity to mechanical and cold stimulation strongly correlated with the extent of skeletal deformities in OI mice. Thus, we demonstrated that the Col1a1Jrt/+ mouse model of severe OI has hypersensitivity to mechanical and thermal stimuli, consistent with a state of chronic pain.

Cost-Effectiveness of a Nonpharmacological Intervention in Pediatric Burn Care

OBJECTIVE

To report the cost-effectiveness of a tailored handheld computerized procedural preparation and distraction intervention (Ditto) used during pediatric burn wound care in comparison to standard practice.

METHODS

An economic evaluation was performed alongside a randomized controlled trial of 75 children aged 4 to 13 years who presented with a burn to the Royal Children's Hospital, Brisbane, Australia. Participants were randomized to either the Ditto intervention (n = 35) or standard practice (n = 40) to measure the effect of the intervention on days taken for burns to re-epithelialize. Direct medical, direct nonmedical, and indirect cost data during burn re-epithelialization were extracted from the randomized controlled trial data and combined with scar management cost data obtained retrospectively from medical charts. Nonparametric bootstrapping was used to estimate statistical uncertainty in cost and effect differences and cost-effectiveness ratios.

RESULTS

On average, the Ditto intervention reduced the time to re-epithelialize by 3 days at AU$194 less cost for each patient compared with standard practice. The incremental cost-effectiveness plane showed that 78% of the simulated results were within the more effective and less costly quadrant and 22% were in the more effective and more costly quadrant, suggesting a 78% probability that the Ditto intervention dominates standard practice (i.e., cost-saving). At a willingness-to-pay threshold of AU$120, there is a 95% probability that the Ditto intervention is cost-effective (or cost-saving) against standard care.

CONCLUSIONS

This economic evaluation showed the Ditto intervention to be highly cost-effective against standard practice at a minimal cost for the significant benefits gained, supporting the implementation of the Ditto intervention during burn wound care.

Stress-induced pain: a target for the development of novel therapeutics

Although current therapeutics provide relief from acute pain, drugs used for treatment of chronic pain are typically less efficacious and limited by adverse side effects, including tolerance, addiction, and gastrointestinal upset. Thus, there is a significant need for novel therapies for the treatment of chronic pain. In concert with chronic pain, persistent stress facilitates pain perception and sensitizes pain pathways, leading to a feed-forward cycle promoting chronic pain disorders. Stress exacerbation of chronic pain suggests that centrally acting drugs targeting the pain- and stress-responsive brain regions represent a valid target for the development of novel therapeutics. This review provides an overview of how stress modulates spinal and central pain pathways, identifies key neurotransmitters and receptors within these pathways, and highlights their potential as novel targets for therapeutics to treat chronic pain.

Vitamin D deficiency leads to sensory and sympathetic denervation of the rat synovium

Vitamin D deficiency is associated with increased susceptibility to inflammatory arthritis. Sensory and sympathetic synovial nerves are critical to the development of inflammatory arthritis and spontaneously degenerate in the early phases of disease. These nerves contain vitamin D receptors and vitamin D influences nerve growth and neurotrophin expression. We therefore examined the density of synovial nerves and neurotrophin-containing cells in vitamin D-deficient rats. Seven-week-old Sprague-Dawley rats were fed either control or vitamin D-deficient diets for 4weeks. Knee synovium sections extending from the patella to the meniscus were immunostained for total nerves, myelinated and unmyelinated nerves, sympathetic nerves, peptidergic and non-peptidergic sensory nerves, and neurotrophins and immune cell markers. In control rats, intimal innervation by unmyelinated sensory fibers was denser than subintimal innervation. In contrast, sympathetic innervation was confined to the subintima. Many sensory axons contained markers for both peptidergic and non-peptidergic nerves. Nerve growth factor (NGF) was primarily expressed by intimal CD163-negative type B synoviocytes, while neurturin, a ligand selective for non-peptidergic sensory neurons, was expressed by synovial mast cells. In vitamin D-deficient rats, there were significant reductions in sensory nerves in the intima and sympathetic nerves in the subintima. While there was no significant change in NGF-immunoreactivity, the number of neurturin-expressing mast cells was significantly reduced in the intima, suggesting that intimal reductions in sensory nerves may be related to reductions in neurturin. Vitamin D deficiency therefore may increase susceptibility to inflammatory arthritis by depleting sensory and sympathetic synovial nerves as a result of reduced synovial neurotrophin content.

Predictors of re-epithelialization in pediatric burn

INTRODUCTION

An important treatment goal for burn wounds is to promote early wound closure. This study identifies factors associated with delayed re-epithelialization following pediatric burn.

METHODS

Data were collected from August 2011 to August 2012, at a pediatric tertiary burn center. A total of 106 burn wounds were analyzed from 77 participants aged 4-12 years. Percentage of wound re-epithelialization at each dressing change was calculated using Visitrak™. Mixed effect regression analysis was performed to identify the demographic factors, wound and clinical characteristics associated with delayed re-epithelialization.

RESULTS

Burn depth determined by laser Doppler imaging, ethnicity, pain scores, total body surface area (TBSA), mechanism of injury and days taken to present to the burn center were significant predictors of delayed re-epithelialization, accounting for 69% of variance. Flame burns delayed re-epithelialization by 39% compared to all other mechanisms (p = 0.003). When initial presentation to the burn center was on day 5, burns took an average of 42% longer to re-epithelialize, compared to those who presented on day 2 post burn (p < 0.000). Re-epithelialization was delayed by 14% when pain scores were reported as 10 (on the FPS-R), compared to 4 on the first dressing change (p = 0.015) for children who did not receive specialized preparation/distraction intervention. A larger TBSA was also a predictor of delayed re-epithelialization (p = 0.030). Darker skin complexion re-epithelialized 25% faster than lighter skin complexion (p = 0.001).

CONCLUSIONS

Burn depth, mechanism of injury and TBSA are always considered when developing the treatment and surgical management plan for patients with burns. This study identifies other factors influencing re-epithelialization, which can be controlled by the treating team, such as effective pain management and rapid referral to a specialized burn center, to achieve optimal outcomes.