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Ku YC, Akhavan AA, Hultman CS. Surgical Management of Chronic Neuropathic Burn Pain. Clin Plast Surg 2024; 51:419-434. [PMID: 38789151 DOI: 10.1016/j.cps.2024.02.009] [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: 05/26/2024]
Abstract
Burn-related chronic neuropathic pain can contribute to a decreased quality of life. When medical and pharmacologic therapies prove ineffective, patients should undergo evaluation for surgical intervention, consisting of a detailed physical examination and elective diagnostic nerve block, to identify an anatomic cause of pain. Based on symptoms and physical examination findings, particularly Tinel's sign, treatments can vary, including a trial of laser therapies, fat grafting, or nerve surgeries (nerve decompression, neuroma excision, targeted muscle reinnervation, regenerative peripheral nerve interfaces, and vascularized denervated muscle targets). It is essential to counsel patients to establish appropriate expectations prior to treatment with a multidisciplinary team.
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Affiliation(s)
- Ying C Ku
- Department of Surgery, Campbell University School of Osteopathic Medicine, 4350 US Highway 421 South, Lillington, NC 27546, USA
| | - Arya Andre Akhavan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 90 Bergen St., Newark, NJ 07103
| | - Charles Scott Hultman
- Department of Plastic and Reconstructive Surgery, WPP Plastic and Reconstructive Surgery, WakeMed Health and Hospitals, 3000 New Bern Avenue, Raleigh, NC 27610, USA.
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2
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Klifto KM, Hultman CS. Pain Management in Burn Patients: Pharmacologic Management of Acute and Chronic Pain. Clin Plast Surg 2024; 51:267-301. [PMID: 38429049 DOI: 10.1016/j.cps.2023.11.004] [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: 03/03/2024]
Abstract
Burn-related pain can contribute to decreased quality of life and long-term morbidity, limiting functional recovery. Burn-related pain should be assessed first by chronicity (acute or chronic), followed by type (nociceptive, neuropathic, nociplastic), to guide multimodal pharmacologic management in a stepwise algorithm approach. Combination therapies increase the efficacy and reduce toxicity by offering a multimodal approach that targets different receptors in the peripheral nervous system and central nervous system. When multimodal pharmacologic management is ineffective, etiologies of burn-related pain amenable to surgical interventions must be considered. It is important to know when to refer a patient to pain management.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri Health Care, 1 Hospital Drive, Columbia, MO 65212, USA.
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, WPP Plastic and Reconstructive Surgery, WakeMed Health and Hospitals, 3000 New Bern Avenue, Raleigh, NC 27610, USA
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3
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Radzikowska-Büchner E, Łopuszyńska I, Flieger W, Tobiasz M, Maciejewski R, Flieger J. An Overview of Recent Developments in the Management of Burn Injuries. Int J Mol Sci 2023; 24:16357. [PMID: 38003548 PMCID: PMC10671630 DOI: 10.3390/ijms242216357] [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: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.
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Affiliation(s)
- Elżbieta Radzikowska-Büchner
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Inga Łopuszyńska
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Wojciech Flieger
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4 Street, 20-090 Lublin, Poland;
| | - Michał Tobiasz
- Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Krasnystawska 52 Street, 21-010 Łęczna, Poland;
| | - Ryszard Maciejewski
- Faculty of Medicine, University of Warsaw, Żwirki i Wigury 101 Street, 02-089 Warszawa, Poland;
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A Street, 20-093 Lublin, Poland
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Bhalla A, Bamer AM, Temes C, Roaten K, Carrougher GJ, Schneider JC, Stoddard FJ, Stewart B, Gibran NS, Wiechman SA. Posttraumatic Stress Disorder Symptom Clusters as Predictors of Pain Interference in Burn Survivors: A Burn Model System National Database Study. J Burn Care Res 2023; 44:27-34. [PMID: 35866527 PMCID: PMC9990905 DOI: 10.1093/jbcr/irac088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Individuals who experience burns are at higher risk of developing posttraumatic stress disorder and chronic pain. A synergistic relationship exists between posttraumatic stress disorder and chronic pain. We sought to evaluate the role of individual posttraumatic stress disorder symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two posttraumatic stress disorder symptom clusters, pain intensity, and other covariates. Multivariate linear regression analyses were completed using data from the Burn Model System National Database. A total of 439 adult participants had complete responses on self-report measures assessing posttraumatic stress disorder symptoms, pain intensity, and pain interference at 6-month after discharge and were included in analyses. Results indicate hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) posttraumatic stress disorder symptom clusters were each significantly associated with pain interference, even when accounting for pain intensity (B = .64, p < .001). Results highlight the importance of the emotional numbing and hyperarousal posttraumatic stress disorder symptom clusters in explaining pain interference. Findings suggest that when posttraumatic stress disorder symptoms or chronic pain are present, screening for and treating either condition may be warranted to reduce pain interference. Further, psychological interventions that target emotional numbing and hyperarousal posttraumatic stress disorder symptoms may be fruitful for promoting better coping with chronic pain and reducing pain interference.
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Affiliation(s)
- Arjun Bhalla
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Alyssa M. Bamer
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Christina Temes
- Department of Psychiatry, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly Roaten
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jeffrey C. Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Frederick J. Stoddard
- Department of Psychiatry, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Barclay Stewart
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Nicole S. Gibran
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Shelley A. Wiechman
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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5
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Van Loey NEE, de Jong AEE, Hofland HWC, van Laarhoven AIM. Role of burn severity and posttraumatic stress symptoms in the co-occurrence of itch and neuropathic pain after burns: A longitudinal study. Front Med (Lausanne) 2022; 9:997183. [PMID: 36314001 PMCID: PMC9596796 DOI: 10.3389/fmed.2022.997183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Itch and pain are common after burns. Neuropathic mechanisms may underlie both modalities but remain not well-understood. This study aims to prospectively document neuropathic pain symptoms and to identify potential itch symptom profiles that differ regarding duration and co-occurrence with neuropathic pain which may inform underlying pathophysiological mechanisms and respond to different treatments. Adult burn survivors (n = 192) self-reported itch and neuropathic pain at 2 weeks post-discharge, 3, 6, 12, and 18 months post-burn. Based on the presence of itch and pain symptoms over time, participants were allocated to one itch profile: transient itch/pain, chronic itch, or chronic itch & pain. Profiles were compared on itch intensity over time using General Linear Modeling. Age, gender, burn severity, posttraumatic stress (PTS) symptoms and baseline itch intensity were examined as potential predictors of the profiles in a Multi-nominal regression analysis. Neuropathic pain occurred in 54% after discharge which decreased to 24% 18 months later. Itch intensity was highest in the chronic itch & pain profile. Compared to the transient itch profile, the chronic itch & pain profile was associated with higher burn severity and more PTS symptoms. Compared to the chronic itch profile, the chronic itch & pain profile was associated with more PTS symptoms. Findings suggest that biological and psycho-dermatological processes underlie both chronic neuropathic pain and itch processes in burn scars. Further research should elucidate the mechanisms underlying the different itch profiles, with specific focus on skin innervation and psychological factors.
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Affiliation(s)
- N. E. E. Van Loey
- Association of Dutch Burn Centres, Maasstad Hospital, Department of Burn Center, Rotterdam, Netherlands,Department of Clinical Psychology, Utrecht University, Utrecht, Netherlands,*Correspondence: N. E. E. Van Loey
| | | | - H. W. C. Hofland
- Association of Dutch Burn Centres, Maasstad Hospital, Department of Burn Center, Rotterdam, Netherlands
| | - A. I. M. van Laarhoven
- Health, Medical and Neuropsychology Unit, Faculty of Social and Behavioural Sciences, Leiden University, Leiden, Netherlands,Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, Netherlands
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The nonopioid cholinergic agonist GTS-21 mitigates morphine-induced aggravation of burn injury pain together with inhibition of spinal microglia activation in young rats. Br J Anaesth 2022; 129:959-969. [DOI: 10.1016/j.bja.2022.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 11/20/2022] Open
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Scrambler Therapy for Chronic Pain after Burns and Its Effect on the Cerebral Pain Network: A Prospective, Double-Blinded, Randomized Controlled Trial. J Clin Med 2022; 11:jcm11154255. [PMID: 35893347 PMCID: PMC9332864 DOI: 10.3390/jcm11154255] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/16/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023] Open
Abstract
Chronic pain is common after burn injuries, and post-burn neuropathic pain is the most important complication that is difficult to treat. Scrambler therapy (ST) is a non-invasive modality that uses patient-specific electrocutaneous nerve stimulation and is an effective treatment for many chronic pain disorders. This study used magnetic resonance imaging (MRI) to evaluate the pain network-related mechanisms that underlie the clinical effect of ST in patients with chronic burn-related pain. This prospective, double-blinded, randomized controlled trial (ClinicalTrials.gov: NCT03865693) enrolled 43 patients who were experiencing chronic neuropathic pain after unilateral burn injuries. The patients had moderate or greater chronic pain (a visual analogue scale (VAS) score of ≥5), despite treatment using gabapentin and other physical modalities, and were randomized 1:1 to receive real or sham ST sessions. The ST was performed using the MC5-A Calmare device for ten 45 min sessions (Monday to Friday for 2 weeks). Baseline and post-treatment parameters were evaluated subjectively using the VAS score for pain and the Hamilton Depression Rating Scale; MRI was performed to identify objective central nervous system changes by measuring the cerebral blood volume (CBV). After 10 ST sessions (two weeks), the treatment group exhibited a significant reduction in pain relative to the sham group. Furthermore, relative to the pre-ST findings, the post-ST MRI evaluations revealed significantly decreased CBV in the orbito-frontal gyrus, middle frontal gyrus, superior frontal gyrus, and gyrus rectus. In addition, the CBV was increased in the precentral gyrus and postcentral gyrus of the hemisphere associated with the burned limb in the ST group, as compared with the CBV of the sham group. Thus, a clinical effect from ST on burn pain was observed after 2 weeks, and a potential mechanism for the treatment effect was identified. These findings suggest that ST may be an alternative strategy for managing chronic pain in burn patients.
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Roy TK, Uniyal A, Tiwari V. Multifactorial pathways in burn injury-induced chronic pain: novel targets and their pharmacological modulation. Mol Biol Rep 2022; 49:12121-12132. [PMID: 35842856 DOI: 10.1007/s11033-022-07748-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
Burn injuries are among the highly prevalent medical conditions worldwide that occur mainly in children, military veterans and victims of fire accidents. It is one of the leading causes of temporary as well as permanent disabilities in patients. Burn injuries are accompanied by pain that persists even after recovery from tissue damage which puts immense pressure on the healthcare system. The pathophysiology of burn pain is poorly understood due to its complex nature and lack of considerable preclinical and clinical shreds of evidence, that creates a substantial barrier to the development of new analgesics. Burns damage the skin layers supplied with nociceptors such as NAV1.7, TRPV1, and TRPA1. Burn injury-mediated co-localization and simultaneous activation of TRPA1 and TRPV1 in nociceptive primary afferent C-fibers which contributes to the development and maintenance of chronic pain. Burn injuries are accompanied by central sensitization, a key feature of pain pathophysiology mainly driven by a series of cascades involving aberrations in the glutamatergic system, microglial activation, release of neuropeptides, cytokines, and chemokines. Activation of p38 mitogen-activated protein kinase, altered endogenous opioid signaling, and distorted genomic expression are other pathophysiological factors responsible for the development and maintenance of burn pain. Here we discuss comprehensive literature on molecular mechanisms of burn pain and potential targets that could be translated into near future therapeutics.
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Affiliation(s)
- Tapas Kumar Roy
- Neuroscience & Pain Research Laboratory, Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology, Banaras Hindu University, 221005, Varanasi, U.P, India
| | - Ankit Uniyal
- Neuroscience & Pain Research Laboratory, Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology, Banaras Hindu University, 221005, Varanasi, U.P, India
| | - Vinod Tiwari
- Neuroscience & Pain Research Laboratory, Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology, Banaras Hindu University, 221005, Varanasi, U.P, India.
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9
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Werthman EH, Colloca L, Oswald LM. Adverse childhood experiences and burn pain: a review of biopsychosocial mechanisms that may influence healing. Pain Rep 2022; 7:e1013. [PMID: 38304399 PMCID: PMC10833651 DOI: 10.1097/pr9.0000000000001013] [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: 12/19/2021] [Revised: 04/09/2022] [Accepted: 04/20/2022] [Indexed: 11/26/2022] Open
Abstract
Adverse childhood experiences (ACEs) affect over half of the adults in the United States and are known to contribute to the development of a wide variety of negative health and behavioral outcomes. The consequences of ACE exposure have been studied in patient populations that include individuals with gynecologic, orthopedic, metabolic, autoimmune, cardiovascular, and gastrointestinal conditions among others. Findings indicate that ACEs not only increase risks for chronic pain but also influence emotional responses to pain in many of these individuals. A growing body of research suggests that these effects may be the result of long-lasting changes induced by ACEs in neurobiological systems during early development. However, one area that is still largely unexplored concerns the effects of ACEs on burn patients, who account for almost 450,000 hospitalizations in the United States annually. Patients with severe burns frequently suffer from persistent pain that affects their well-being long after the acute injury, but considerable variability has been observed in the experience of pain across individuals. A literature search was conducted in CINAHL and PubMed to evaluate the possibility that previously documented ACE-induced changes in biological, psychological, and social processes might contribute to these differences. Findings suggest that better understanding of the role that ACEs play in burn outcomes could lead to improved treatment strategies, but further empirical research is needed to identify the predictors and mechanisms that dictate individual differences in pain outcomes in patients with ACE exposure and to clarify the role that ACE-related alterations play in early healing and recovery from burn injuries.
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Affiliation(s)
- Emily H. Werthman
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, USA
- The Johns Hopkins Bayview Medical Center, The Johns Hopkins Burn Center, Baltimore, MD, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, USA
- Departments of Anesthesiology and Psychiatry, School of Medicine, University of Maryland, Baltimore, MD, USA
- Center to Advance Chronic Pain Research (CACPR), University of Maryland, Baltimore, MD, USA
| | - Lynn M. Oswald
- Department of Family and Community Health, School of Nursing, University of Maryland, Baltimore, MD, USA
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Karina K, Ekaputri K, Biben JA, Hadi P, Andrew H, Sadikin PM. Therapeutic Effect of Autologous Activated Platelet-rich Plasma Therapy on Mid-dermal to Full-thickness Burns: A Case Series. Arch Plast Surg 2022; 49:405-412. [PMID: 35832167 PMCID: PMC9142229 DOI: 10.1055/s-0042-1744423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Although modern medicine has made great strides in the management of burn injuries, associated complications such as pain, infection, dyspigmentation, and scarring have yet to be fully dealt with. Although skin grafting and meshing are routinely performed on burn patients, this method poses a risk for adverse effects. Activated autologous platelet-rich plasma (aaPRP), which is increasingly used in the field of plastic surgery, contains growth factors beneficial for wound regeneration. Seven cases of burns with varying severity and conditions that were treated with intralesional subcutaneous injection and intravenous aaPRP are presented and discussed herein. This case series indicates that subcutaneous and intravenous aaPRP is a safe procedure with the potential to be an alternative when skin grafting cannot be done or as an adjunct treatment to skin grafting.
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Affiliation(s)
- Karina Karina
- Klinik Hayandra, Yayasan Hayandra Peduli, Jakarta Pusat, Indonesia
- HayandraLab, Yayasan Hayandra Peduli, Jakarta Pusat, Indonesia
- Faculty of Medicine, Universitas Pembangunan Nasional Veteran Jakarta, Indonesia
- Pusat Kajian Stem Cell, Universitas Pembangunan Nasional Veteran Jakarta, Indonesia
| | - Krista Ekaputri
- Klinik Hayandra, Yayasan Hayandra Peduli, Jakarta Pusat, Indonesia
| | | | - Pritha Hadi
- Faculty of Medicine and Health Sciences, Universitas Jambi, Jambi, Indonesia
- Raden Mattaher Regional Hospital, Jambi, Indonesia
| | - Hubert Andrew
- HayandraLab, Yayasan Hayandra Peduli, Jakarta Pusat, Indonesia
- Faculty of Medicine, Universitas Indonesia, Jakarta Pusat, Indonesia
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Kim J, Kim HC, Kowsari K, Yoon K, Yoo SS. Transcutaneous application of ultrasound enhances the effects of finasteride in a murine model of androgenic alopecia. Ultrasonography 2021; 41:382-393. [PMID: 34963257 PMCID: PMC8942741 DOI: 10.14366/usg.21186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose The purpose of this study was to evaluate if transcutaneous application of low-intensity ultrasound can locally enhance the effects of finasteride on hair growth in a murine model of androgenic alopecia (AA). Methods AA mice (injected twice per week with testosterone enanthate, n=11), under daily oral administration of finasteride, received 1-MHz ultrasound for 1 hour at the unilateral thigh area five times per week for 5 weeks. Non-thermal and non-cavitational ultrasound was delivered in a pulsed manner (55-ms pulse duration with a repetition frequency of 4 Hz). Skin temperature was measured during sonication, and the measurements were validated with numerical simulations of sonication-induced tissue temperature changes. Hair growth was assessed both photographically and histologically. Results We found more hair growth on the sonicated thigh area than on the unsonicated thigh, beginning from week 3 through the end of the experiment. Histological analyses showed that the number of hair follicles doubled in the skin sections that received sonication compared to the unsonicated zone, with thicker follicular diameter and skin. An over five-fold increase was also observed in the anagen/telogen ratio in the sonicated area, suggesting an enhanced anagen phase. Skin temperature was unaltered by the administered sonication. Conclusion The findings of the present study suggest that pulsed application of ultrasound promotes hair growth, potentially by disrupting the binding of albumin to finasteride. This may suggest further applications to enhance the pharmacological effects of other relevant drugs exhibiting high plasma protein binding.
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Affiliation(s)
- Jaeho Kim
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Hyun-Chul Kim
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kavin Kowsari
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyungho Yoon
- Center for Healthcare Robotics, Korea Institute of Science and Technology, Seoul, Korea
| | - Seung-Schik Yoo
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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12
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Chronic Nerve Pain after Burn Injury: An Anatomical Approach and the Development and Validation of a Model to Predict a Patient's Risk. Plast Reconstr Surg 2021; 148:548e-557e. [PMID: 34550938 DOI: 10.1097/prs.0000000000008315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A model that predicts a patient's risk of developing chronic, burn-related nerve pain may guide medical and/or surgical management. This study determined anatomy-specific variables and constructed a mathematical model to predict a patient's risk of developing burn-related nerve pain. METHODS A retrospective analysis was conducted from 1862 adults admitted to a burn center from 2014 to 2019. One hundred thirteen patients developed burn-related nerve pain. Comparisons were made using 11 anatomy-specific locations between patients with and without burn-related nerve pain. The modified Delphi technique was used to select 14 potential risk variables. Multivariate regression techniques, Brier scores, area under the curve, Hosmer-Lemeshow goodness-of-fit, and stratified K-fold cross-validation was used for model development. Chronic pain was defined as pain lasting 6 or more months after release from the Burn Center. RESULTS Prevalence rates of burn-related nerve pain were similar in the development (6.1 percent) and validation (5.4 percent) cohorts [Brier score = 0.15; stratified K-fold cross-validation (K = 10): area under the curve, 0.75; 95 percent CI, 0.68 to 0.81; Hosmer-Lemeshow goodness-of-fit, p = 0.73; n = 10 groups]. Eight variables were included in the final equation. Burn-related nerve pain risk score = -6.3 + 0.02 (age) + 1.77 (tobacco use) + 1.04 (substance abuse) + 0.67 (alcohol abuse) + 0.84 (upper arm burn) + 1.28 (thigh burn) + 0.21 (number of burn operations) + 0.01 (hospital length-of-stay). Burn-related nerve pain predicted probability = 1 - 1/[1 + exp(burn-related nerve pain risk score)] for 6-month burn-related nerve pain risk score. As the number of risk factors increased, the probability of pain increased. CONCLUSIONS Risk factors were identified for developing burn-related nerve pain at 11 anatomical locations. This model accurately predicts a patient's risk of developing burn-related nerve pain at 6 months. Age, tobacco use, substance abuse, alcohol abuse, upper arm burns, thigh burns, the number of burn operations, and hospital length of stay represented the strongest predictors. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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13
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Abdullahzadeh M, Shafiee S. To compare the effect of sea buckthorn and silver sulfadiazine dressing on period of wound healing in patients with second-degree burns: A randomized triple-blind clinical trial. Wound Repair Regen 2021; 29:732-740. [PMID: 33792111 DOI: 10.1111/wrr.12916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/15/2021] [Accepted: 03/19/2021] [Indexed: 01/29/2023]
Abstract
Burn injuries can be associated with the incidence of disability and death, yet their management remains a costly difficult problem. We conducted this clinical trial to evaluate the period of wound healing with sea buckthorn dressings for the second-degree burns and compare the results with 1% silver sulfadiazine (SSD) dressings. This randomized triple-blind clinical trial was conducted in a hospital in Isfahan, Iran. Fifty-five patients suffering second-degree burns were recruited through convenient sampling and randomly divided into two groups and treated with either sea buckthorn cream or 1% SSD. Wound dressings were done until complete wound healing was attained. The process of healing burns was monitored using the Bates-Jensen Wound Assessment Tool; complete healing was determined by using the standard burn healing checklist. It was deduced that the period of healing second-degree burns in the group treated with sea buckthorn cream was shorter than the group treated with 1% SSD (p < 0.001). The results demonstrated the greater clinical efficacy of sea buckthorn cream over 1% SSD for healing second-degree burns. It was concluded that using sea buckthorn dressing by reducing the period of wound healing can shorten the course of treatment of second-degree burns as well as reduce the burden of care in health care services.
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Affiliation(s)
- Mehrdad Abdullahzadeh
- Department of Nursing and Midwifery, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran
| | - Saeed Shafiee
- Department of Medical-Surgical Nursing, Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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14
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Klifto KM, Yesantharao PS, Dellon AL, Hultman CS, Lifchez SD. Chronic Neuropathic Pain Following Hand Burns: Etiology, Treatment, and Long-Term Outcomes. J Hand Surg Am 2021; 46:67.e1-67.e9. [PMID: 32855013 DOI: 10.1016/j.jhsa.2020.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 05/16/2020] [Accepted: 07/13/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment. METHODS Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP. RESULTS Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up. CONCLUSIONS Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Kevin M Klifto
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pooja S Yesantharao
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott D Lifchez
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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