Burn Pain: A Systematic and Critical Review of Epidemiology, Pathophysiology, and Treatment

Translation, adaptation, and psychometric evaluation of the Burn-Specific Pain Anxiety Scale (BSPAS) for Czech patients with burn injuries

This study aimed to adapt the Burn-Specific Pain Anxiety Scale (BSPAS) for use in the Czech language and evaluate its validity and reliability. Conducted across three university hospitals in the Czech Republic-Prague, Brno, and Ostrava-from September 2022 to February 2024, the study involved 203 inpatients and outpatients from burn units who met inclusion criteria and consented to participate. The adaptation process included rigorous analysis of validity and reliability, employing language, content, and construct validity assessments. Language validity was ensured through back translation, whereas content validity was confirmed through expert evaluations. Exploratory factor analysis revealed at least a two-factor structure with satisfactory factor loading. Loading of factors to questions was consistent between BSPAS-9 and BSPAS-5. Confirmatory factor analysis further substantiated the model fit for both five- and nine-item versions (RMSEA 0.06 and 0.1 respectively). Internal consistency was assessed using item-total correlation, yielding acceptable results (range 0.63-0.82 for nine items and 0.71-0.82 for five items). Cronbach's alpha coefficients were 0.94 for the nine-item version and 0.91 for the five-item version. These findings indicate that the Czech version of the BSPAS is a valid and reliable tool for assessing pain-related anxiety in patients with burns. Additionally, we show that in our population, the information from the nine-item version is well captured by the five-item version and pain alone explains most of the variance in BSPAS scores.

Neurone-satellite glial cell interactions in dorsal root ganglia drive peripheral sensitisation in a mouse burn pain model

BACKGROUND

Accumulating evidence suggests that glial mechanisms are pivotal in regulating chronic pain. Our previous findings revealed that the interactions between spinal microglia and astrocytes are crucial for burn-induced pain hypersensitivity. However, the mechanisms underlying burn-induced peripheral sensitisation remain incompletely understood.

METHODS

Sensory neurone-satellite glial cell (SGC) interactions within peripheral dorsal root ganglia were investigated using in vitro and in vivo experiments. Behavioural tests were conducted to evaluate the therapeutic potential of targeting peripheral sensitisation mechanisms for burn pain management.

RESULTS

Burn injury upregulated calcitonin gene-related peptide (CGRP) expression in sensory neurones (1.5-fold; P=0.013) through transient receptor potential vanilloid 1 (TRPV1) channels. Pharmacological blockade of the TRPV1/CGRP signalling pathway effectively attenuated burn-induced mechanical allodynia and thermal hyperalgesia. Additionally, neurone-derived CGRP triggered SGC activation (from 6.8% pre-injury to 41.6% at day 5 post-injury), concomitant with enhanced gap junction-mediated SGC coupling (from 16.7% pre-injury to 40.5% at day 5 post-injury). Furthermore, chemokine expression (particularly CXCL1) in SGCs was elevated after burn injury, which potentiated sensory neurone excitability and exacerbated pain hypersensitivity. Blocking SGC coupling exerted potent analgesic effects in this burn pain model.

CONCLUSIONS

A novel neurone-SGC interaction mechanism drives burn-induced peripheral sensitisation, providing translational implications for burn pain therapeutics.

BSP promotes skin wound healing by regulating the expression level of SCEL

Burn injuries are complex, life-threatening events involving intricate cellular and molecular processes, including angiogenesis, which is vital for effective wound healing. Bletilla striata polysaccharide (BSP), a bioactive compound from Bletilla striata, exhibits anti-inflammatory and wound-healing properties. However, its impact on angiogenesis modulation, particularly through the synaptopodin-2-like (SCEL) gene, remains poorly understood. The effects of BSP on HMEC-1 cells exposed to lipopolysaccharide (LPS) were assessed using cell viability, migration, apoptosis, and angiogenesis assays. SCEL's role was explored through lentiviral transfection to manipulate SCEL expression. Animal models were employed to evaluate BSP's therapeutic potential in burn wound healing, with histological analysis, immunohistochemistry (IHC), and molecular assays to assess tissue repair and angiogenesis. BSP significantly alleviated LPS-induced damage in HMEC-1 cells by promoting cell survival, reducing apoptosis, and enhancing migration and angiogenesis. BSP treatment downregulated SCEL expression, reversing LPS-induced cellular damage. In SCEL-overexpressing cells and mice, BSP's beneficial effects on wound healing were attenuated, indicating SCEL's regulatory role in angiogenesis. In vivo, BSP accelerated burn wound closure, improved tissue organization, and enhanced angiogenesis, as evidenced by increased CD31 expression. SCEL overexpression impaired these effects, highlighting the essential role of SCEL downregulation in BSP-mediated healing. BSP promotes burn wound healing by modulating angiogenesis via SCEL downregulation, facilitating cell survival, migration, and vascularization. These findings position BSP as a promising therapeutic agent for burn wound treatment, with further investigation into SCEL's molecular mechanisms offering potential for novel wound care strategies.

Virtual reality as an intervention for adult burn patients: an integrative review

Background

Virtual reality (VR) allows burn patients to engage in a virtual world and can provide patients with a distraction from pain.

Aims

To assess the types of VR models available for use in the adult burn population and determine their efficacy regarding pain management and other health outcomes.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines guided this review. We searched the databases of CINAHL and PubMed to identify the peer-reviewed journals that matched the inclusion criteria. We utilised the Joanna Briggs Institute (JBI) quality appraisal tools to evaluate the selected studies.

Results

The search results ended in nine studies. The types of VR identified included passive and active scenarios with a focus on natural environments. The findings of the quantitative studies indicated that VR decreased patients' pain during therapeutic interventions. In contrast, the findings of most qualitative studies revealed that VR provided distraction for patients during wound care. Regarding secondary outcomes, VR was shown to improve hand rehabilitation, anxiety and pulmonary functions.

Conclusion

This integrative review contributes to nursing by synthesising the evidence on VR as a non-pharmacological and complementary intervention to manage pain among adult burn patients. The implications of this review in nursing practice include consideration of staff training and technical support for practising nurses to successfully and safely implement the VR experience into their practice. Healthcare policies should delineate the best practices for VR use among burn patients to guide its implementation, funds to cover the costs of VR equipment, and equitable access to VR experience for all adult burn patients.

Burn Injury Severity in Adults: Proposed Definitions Based on the National Burn Research Dataset

Previous iterations of burn severity (mild, moderate, and severe) were not data-driven and were outdated. Clustering analyses have gained popularity for identifying homogenous subgroups from heterogeneous medical conditions, such as asthma, sepsis, and lung disease. There is no consensus in burn literature regarding what constitutes massive burns. The current classification includes a 20% total body surface area (TBSA) burn and a 95% TBSA burn as severe. Latent class and hierarchical clustering analyses were applied to the American Burn Association National Burn Research Dataset. Cluster variables included length of stay, length of stay, intensive care unit length of, number and type of procedures, and number and type of complications. Nonclustering variables were evaluated after clustering, including burned TBSA, inhalation injury, mortality, discharge disposition, age, sex, and race. Latent class analysis suggested 3 clusters. Hierarchical clustering analysis was applied to the most severe latent class, creating 4 total burn severity groups. In total, 112 297 patients were included in the final analysis. The mean TBSA burned for each class is 4.26 ± 4.91 for minor, 8.07 ± 8.39 for moderate, 22.76 ± 17.31 for severe and 36.72 ± 21.61 for massive. The age and sex proportions were similar among all clusters. The clustering variables steadily increased for each severity cluster. Mortality was the highest in the massive cluster (18.2%). Data-informed categories of burn severity were formed using clustering analyses, which will be helpful for triage, data benchmarking, and class-specific research.

Trends and hotspots in burns-related pain research: A bibliometric analysis

OBJECTIVE

The aim of this investigation was to conduct a thorough synthesis of the extant scholarly discourse and to delineate the prevailing global trends in the domain of burn pain, employing a bibliometric analysis.

METHODS

A bibliometric analysis was performed utilizing the Web of Science Core Collection database. Articles were selected based on titles or abstracts containing keywords associated with burns and pain. Both quantitative and qualitative methodologies were applied to examine the retrieved data, encompassing an analysis of publication trends, research themes, and collaboration networks.

RESULTS

The number of articles on this topic has been increasing, averaging an annual growth rate of 6.9 % from 1997 to 2023. Contributions have come from 645 institutions across 53 countries, resulting in 446 papers that span areas such as nursing, anesthesia, and immunology. Key journals include Burns, Journal of Burn Care & Research, and Pain. The United States has demonstrated a significant research output in this field, with active international collaboration, notably with Washington University leading in contributions. Patterson DR was the most prolific author in terms of published papers, while Choiniere M was the most frequently co-cited author. The focus of research has shifted from symptom management to exploring pain mechanisms. Current research priorities in burn pain include "quality of life," "music therapy," and "psychological state." Recent analysis has highlighted key areas in neuropathic pain mechanisms, novel analgesic therapies, and specific groups such as pediatric burn patients. Influential studies have advanced our understanding of pathophysiology, while psychological interventions and inflammation are increasingly receiving attention. Emerging topics include non-pharmacological interventions, psychological support, technology in pain assessment and management, quality of life, and personalized pain management.

CONCLUSION

Research on burn pain is advancing rapidly; however, collaboration among countries and institutions remains limited. Increased cooperation and communication across these entities could significantly advance the field in the future. Future research should prioritize placebo-controlled trials of targeted therapeutic drugs and innovative pain management approaches, with a strong emphasis on patient outcomes and quality of life.

Investigation into nurses' emotion regulation while causing pain to adult patients during burns dressing changes: a qualitative study

BACKGROUND

Burns can cause patients significant pain at the time of injury and during subsequent treatment. Other people's pain often elicits empathic responses in observers. However, effective emotion regulation strategies are needed to manage personal distress, which may otherwise inhibit helping behaviour.

METHODS

This study used an interpretative qualitative approach to conduct semi-structured interviews with burns nurses. Interviews explored emotion regulation strategies used by nurses whilst causing pain to adult patients during burns dressing changes. Transcripts were analysed using Braun and Clarke's six stages of thematic analysis.

RESULTS

Eight burns nurses participated in the interviews. Thematic analysis developed five themes: Emotions get in the way of being a good nurse; Pain's an inevitable and justifiable part of treatment and healing; If I'm not made aware of the pain, maybe there is no pain; The pain's due to other factors, not my actions; and Sometimes it's too much.

CONCLUSION

Burns nurses' attempts at regulating their emotions were influenced by their beliefs about what makes a 'good' nurse. Gross's model of emotion regulation provides a useful framework for understanding these strategies, but further research is needed into the helpfulness thereof for nurses and patients.

Effects of Parecoxib Sodium on Early Cognitive Impairment and Inflammation Levels in Burned Rats

To study the effect of parecoxib sodium in alleviating inflammation in burned rats and restoring cognitive function in burned rats. A total of 30 specific pathogen free grade Sprague-Dawley rats were randomly divided into 6 groups: (1) blank control group (group C), (2) Sham surgery group (group Sham), (3) second-degree burn model (group B), (4) low-dose (1 mg/kg/d) parecoxib sodium (group L + B), (5) medium-dose (10 mg/kg/d) parecoxib sodium (group M + B), and (6) high-dose (20 mg/kg/d) parecoxib sodium (group H + B). ELISA measures inflammatory factors interleukin (IL)-2, IL-6, tumor necrosis factor-alpha (TNF-α), and interferon-gamma (IFN-γ), and cognitive function factors neuron-specific enolase (NSE), cortisol, and S-100β. Combined with water maze and dark-avoidance experiments to further verify the recovery of cognitive function in rats. The contents of IL-2, TNF-α, and IL-6 in group M + B were significantly lower than those in group Sham (P < .05), and the content of IFN-γ was significantly lower than that in group Sham (P < .05). The cognitive markers NSE, S-100β, and cortisol levels in group M + B were significantly higher than those in group Sham at 2 h, 1 d, 5 d, and 10 d after operation (P < .05). In the group M + B dark-avoidance experiment, the number of probes and errors was not significantly different than those in group Sham and group C (P > .05), and the number of times group M + B found a platform in the water maze experiment and crossed the platform was second only to group B and group C. Parecoxib sodium can effectively reduce inflammation in burn rats and promote cognitive recovery in burn rats, and the optimal dose of parecoxib sodium for burn rats is 10 mg/kg.

The effects of inhalation aromatherapy on pain, anxiety, and sleep quality in burn patients: A randomized controlled study

BACKGROUND AND PURPOSE

Patients suffering from burn injuries experience high levels of pain, anxiety, and sleep problems. These symptoms negatively affect the healing process of patients. In this study, it was aimed to determine the effect of inhalation aromatherapy applied with lavender essential oil on pain, anxiety, and sleep quality in burn patients.

METHODS

The randomized, placebo-controlled study was conducted with a total of 60 patients, 30 of whom were treated with aromatherapy (lavender) and 30 with placebo (sterile/ saline water), who were hospitalized in the burn treatment center of the hospital between October 2021 and April 2022. Interventions were applied for 20 min in the morning and evening for five days. "State-Trait Anxiety Inventory", "Visual Analog Scale" and "Richards-Campbell Sleep Questionnaire" were used for data collection.

RESULTS

It was determined that the pain levels of the patients in the aromatherapy group decreased significantly compared to the patients in the placebo group (p < 0.05), but the anxiety levels did not differ significantly between the groups (p > 0.05). It was determined that the sleep quality of the patients in the aromatherapy group was higher from the 3rd day than the patients in the placebo group (p < 0.05).

CONCLUSIONS

It was determined that inhalation aromatherapy applied to burn patients reduced the level of pain and increased sleep quality. Aromatherapy is recommended for healthcare professionals to reduce pain and improve sleep quality in burn patients.

The impact of an open-label design on human amniotic membranes vs. silver sulfadiazine dressings for second-degree burns: a randomized controlled clinical trial

BACKGROUND

Burn wounds require optimal medical management due to associated psycho-emotional and socioeconomic impacts and severe pain. The use of synthetic and biological dressings improves healing and reduces burn wound complications. The present study aimed to compare the outcomes of using human amniotic membrane (hAM) dressings and conventional silver sulfadiazine (SSDZ) ointment dressings in the management of second-degree burn wounds.

METHODS

Fifty patients who participated in this clinical trial were divided into two groups via simple randomization. All the enrolled patients, who had burnt in the last 24 h, had thermal damage mechanisms and were suffering from less than 20% second-degree heat-burn wounds on the skin surface. The target group (n = 25) was treated with hAM, and the control group (n = 25) was treated with SSDZ ointment. The researcher-designed checklist was used to determine the clinical performance in the follow-up assessments on days 7, 14, and 30.

RESULTS

No significant differences were detected in terms of sex, age, or percentage of burn wounds (p > 0.05). Wound epithelialization at days 7, 14, and 30, scar formation, wound pigmentation, pain severity, analgesia requirements, and hospital stay length (on day 30) were significantly lower in the target group (treated with hAM) than in the control group (treated with SSDZ ointment) (p < 0.05). However, treatment costs in the target group ($170) were significantly higher than those in the control group ($71) (p < 0.001).

CONCLUSION

Despite its higher cost, hAM, as a technology-based therapy dressing, demonstrates superiority over SSDZ ointment in terms of wound healing and pain management.

EMLA cream in burns: A systematic review of safety, analgesic efficacy, and effects on burn pathophysiology

AIM

Management of procedural pain in burn care is challenging. Lidocaine-prilocaine cream 5%, eutectic mixture of local anesthetics (EMLA®), is a widely used, effective local anesthetic cream approved for normal intact skin, genital mucosa for superficial surgical procedures, and debridement of chronic leg ulcers. This comprehensive review aimed to determine the safety, analgesic efficacy, and effects of EMLA on burn pathophysiology to provide evidence-based clinical recommendations for introducing the topical anesthetic into burn care.

METHODS

The PRISMA guidelines were followed for conducting a systematic PubMed search to include all relevant preclinical and clinical studies, according to pre-specified eligibility criteria.

RESULTS

Fifteen studies were included in a qualitative synthesis, among which nine were human and six were animal studies. To date, safety and pharmacokinetic data on EMLA application in burns have been limited. Nevertheless, human studies indicated that EMLA is safe and provides adequate procedural-pain relief in adults when applied to smaller burns. Caution should be exercised when using EMLA in younger children, as systemic toxicity, pertaining to prilocaine-induced methemoglobinemia, has been reported owing to overdosing (high doses applied over large burn areas). Furthermore, animal studies demonstrate the potential beneficial effects of EMLA on burn pathophysiology such as anti-inflammatory, decreased capillary permeability to plasma proteins and edema formation, and improved tissue perfusion, which are factors that may impact burn wound progression.

CONCLUSION

Current data on EMLA use in the management of procedural pain in small burns are sparse but suggest that EMLA is safe and effective in adults. Further clinical pharmacokinetic studies are warranted, especially for application on larger burn areas.

Effect of quality nursing care on wound pain and anxiety in burn patients: A meta-analysis

To systematically evaluate the effects of quality nursing care on wound pain and anxiety in burn patients. Computerised searches of PubMed, Google Scholar, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database and China National Knowledge Infrastructure databases randomised controlled trials (RCTs) on the application of quality nursing care to burn patients were carried out from database inception to October 2023. Literature was screened and evaluated by two researchers based on inclusion and exclusion criteria, and data were extracted from the final included literature. Stata 17.0 software was employed for data analysis. Overall, 15 RCTs and 1115 burn patients were included, including 563 and 552 in the quality care and routine care groups. It was found that, compared with routine care, burn patients who implemented quality care had significantly less wound pain (SMD: -1.79, 95% CI: -2.22 to -1.36, p < 0.001), anxiety (SMD: -2.71. 95% CI: -3.49 to -1.92, p < 0.001) and depression (SMD: -1.74, 95% CI: -2.35 to -1.14, p < 0.001) levels were significantly reduced post-trauma.

Pain Management in Burn Patients: Pharmacologic Management of Acute and Chronic Pain

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.

Hydrogel burn dressing effectiveness in burn pain

Severe burns are painful and dramatic injuries. Studies show that pain is underestimated and often not adequately treated. This study aims to evaluate the analgesic efficacy of hydrogel burn dressing and silver sulfadiazine, which are two agents commonly used in first-aid dressings for burn patients. This study, designed as a prospective, observational, and cross-sectional study. Study included 64 pediatric patients admitted to our burn center between 01.03.2020 and 01.09.2020 who were examined by our burn service after their first treatment in the emergency dressing room. Two groups of patients were included in the study. Pain level was assessed in the dressing room before and 10 min after the procedure using the Visual Analog Scale and FLACC (Face, Legs, Activity, Cry, Consolability) pain assessment scales.During the study period, Burnaid® was applied to 62.5% of patients (40 patients) and silver sulfadiazine to 37.5% (24 patients). In terms of pain scores, pre-dressing FLACC values were higher in Group B (p = 0.039); post-dressing VAS and FLACC values were significantly lower in group B (p 0.001; p 0.001). In terms of additional analgesia, we found more patients in Group S received analgesics (p 0.001).We believe that its effect on burn wound pain is superior to that of silver sulfadiazine.

Predictors at 6 and 12 Months for Social Participation Outcome at 24 Months in the Adult Burn Injury Population: A Burn Model System National Database Study

OBJECTIVE

To identify clinical factors (physical and psychological symptoms and post-traumatic growth) that predict social participation outcome at 24-month after burn injury.

DESIGN

A prospective cohort study based on Burn Model System National Database.

SETTING

Burn Model System centers.

PARTICIPANTS

181 adult participants less than 2 years after burn injury (N=181).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographic and injury variables were collected at discharge. Predictor variables were assessed at 6 and 12 months: Post-Traumatic Growth Inventory Short Form (PTGI-SF), Post-Traumatic Stress Disorder Checklist Civilian Version (PCL-C), Patient-Reported Outcomes Measurement Information System (PROMIS-29) Depression, Anxiety, Sleep Disturbance, Fatigue, and Pain Interference short forms, and self-reported Heat Intolerance. Social participation was measured at 24 months using the Life Impact Burn Recovery Evaluation (LIBRE) Social Interactions and Social Activities short forms.

RESULTS

Linear and multivariable regression models were used to examine predictor variables for social participation outcomes, controlling for demographic and injury variables. For LIBRE Social Interactions, significant predictors included the PCL-C total score at 6 months (β=-0.27, P<.001) and 12 months (β=-0.39, P<.001), and PROMIS-29 Pain Interference at 6 months (β=-0.20, P<.01). For LIBRE Social Activities, significant predictors consisted of the PROMIS-29 Depression at 6 months (β=-0.37, P<.001) and 12 months (β=-0.37, P<.001), PROMIS-29 Pain Interference at 6 months (β=-0.40, P<.001) and 12 months (β=-0.37, P<.001), and Heat Intolerance at 12 months (β=-4.55, P<.01).

CONCLUSIONS

Post-traumatic stress and pain predicted social interactions outcomes, while depression, pain and heat intolerance predicted social activities outcomes in people with burn injury.

Cassia Angustifolia Primed ASCs Accelerate Burn Wound Healing by Modulation of Inflammatory Response

BACKGROUND

Thermal traumas impose a huge burden on healthcare systems. This merits the need for advanced but cost-effective remedies with clinical prospects. In this context, we prepared a regenerative 3D-construct comprising of Cassia angustifolia extract (SM) primed adipose-derived stem cells (ASCs) laden amniotic membrane for faster burn wound repair.

METHODS

ASCs were preconditioned with SM (30 µg/ml for 24 h), and subsequently exposed to in-vitro thermal injury (51 °C,10 min). In-vivo thermal injury was induced by placing pre-heated copper-disc (2 cm diameter) on dorsum of the Wistar rats. ASCs (2.0 × 105) pre-treated with SM (SM-ASCs), cultured on stromal side of amniotic membrane (AM) were transplanted in rat heat-injury model. Non-transplanted heat-injured rats and non-heat-injured rats were kept as controls.

RESULTS

The significantly upregulated expression of IGF1, SDF1A, TGFβ1, VEGF, GSS, GSR, IL4, BCL2 genes and downregulation of BAX, IL6, TNFα, and NFkB1 in SM-ASCs in in-vitro and in-vivo settings confirmed its potential in promoting cell-proliferation, migration, angiogenesis, antioxidant, cell-survival, anti-inflammatory, and wound healing activity. Moreover, SM-ASCs induced early wound closure, better architecture, normal epidermal thickness, orderly-arranged collagen fibers, and well-developed skin appendages in healed rat-skin transplanted with AM+SM-ASCs, additionally confirmed by increased expression of structural genes (Krt1, Krt8, Krt19, Desmin, Vimentin, α-Sma) in comparison to untreated-ASCs laden-AM transplanted in heat injured rats.

CONCLUSION

SM priming effectively enabled ASCs to counter thermal injury by significantly enhancing cell survival and reducing inflammation upon transplantation. This study provides bases for development of effective combinational therapies (natural scaffold, medicine, and stem cells) with clinical prospects for treating burn wounds.

Functional Brain Changes Following Burn Injury: A Narrative Review

BACKGROUND

Burn injuries cause significant motor and sensory dysfunctions that can negatively impact burn survivors' quality of life. The underlying mechanisms of these burn-induced dysfunctions have primarily been associated with damage to the peripheral neural architecture, however, evidence points to a systemic influence of burn injury. Central nervous system (CNS) reorganizations due to inflammation, afferent dysfunction, and pain could contribute to persistent motor and sensory dysfunction in burn survivors. Recent evidence shows that the capacity for neuroplasticity is associated with self-reported functional recovery in burn survivors.

OBJECTIVE

This review first outlines motor and sensory dysfunctions following burn injury and critically examines recent literature investigating the mechanisms mediating CNS reorganization following burn injury. The review then provides recommendations for future research and interventions targeting the CNS such as non-invasive brain stimulation to improve functional recovery.

CONCLUSIONS

Directing focus to the CNS following burn injury, alongside the development of non-invasive methods to induce functionally beneficial neuroplasticity in the CNS, could advance treatments and transform clinical practice to improve quality of life in burn survivors.

Toward a Platform for the Treatment of Burns: An Assessment of Nanoemulsions vs. Nanostructured Lipid Carriers Loaded with Curcumin

Curcumin is a highly promising substance for treating burns, owing to its anti-inflammatory, antioxidant, antimicrobial, and wound-healing properties. However, its therapeutic use is restricted due to its hydrophobic nature and low bioavailability. This study was conducted to address these limitations; it developed and tested two types of lipid nanocarriers, namely nanoemulsions (NE-CUR) and nanostructured lipid carriers (NLC-CUR) loaded with curcumin, and aimed to identify the most suitable nanocarrier for skin burn treatment. The study evaluated various parameters, including physicochemical characteristics, stability, encapsulation efficiency, release, skin permeation, retention, cell viability, and antimicrobial activity. The results showed that both nanocarriers showed adequate size (~200 nm), polydispersity index (~0.25), and zeta potential (~>-20 mV). They also showed good encapsulation efficiency (>90%) and remained stable for 120 days at different temperatures. In the release test, NE-CUR and NCL-CUR released 57.14% and 51.64% of curcumin, respectively, in 72 h. NE-CUR demonstrated better cutaneous permeation/retention in intact or scalded skin epidermis and dermis than NLC-CUR. The cell viability test showed no toxicity after treatment with NE-CUR and NLC-CUR up to 125 μg/mL. Regarding microbial activity assays, free curcumin has activity against P. aeruginosa, reducing bacterial growth by 75% in 3 h. NE-CUR inhibited bacterial growth by 65% after 24 h, and the association with gentamicin had favorable results, while NLC-CUR showed a lower inhibition. The results demonstrated that NE-CUR is probably the most promising nanocarrier for treating burns.

A Narrative Review of Outcomes in Burn Rehabilitation Based on the International Classification of Functioning, Disability, and Health

Burn injury commonly causes long-term physical impairments and psychosocial limitations that impact survivorship. This article uses the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) framework to summarize burn rehabilitation outcomes related to body functions and structures and how they relate to activities and participation within the social context. This article will contribute to a better understanding of burn recovery, facilitate the identification of specific and meaningful issues common to burn survivorship that may be under-reported in prior investigations and guide future rehabilitation to advance long-term burn outcomes.

Effectiveness and Adverse Events of Gabapentinoids as Analgesics for Patients with Burn Injuries: A Systematic Review with Meta-Analysis and Trial Sequential Analysis

(1) Background: Pain after a burn injury is difficult to endure, and emerging studies aim to ascertain the effects of gabapentin and pregabalin as non-opioid treatment options. (2) Methods: We searched for randomised controlled trials (RCTs) in six databases. The risk of bias was assessed using the RoB 2.0 tool. We performed meta-analysis and trial sequential analysis and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology for judging the certainty of evidence (CoE). (3) Results: Five RCTs were included. Compared with placebo, gabapentinoids significantly decreased the pain intensity within 24 h (mean difference (MD) = -1.06, 95% confidence interval (CI): -1.47--0.65) and from 72 h to 9 days (MD = -0.82, 95% CI: -1.16--0.48), but not after 3 weeks (MD = -0.44, 95% CI: -1.31-0.42). Opioid consumption (mg/day) was reduced within 24 h (MD = -13.34, 95% CI: -22.16--4.52) and from 72 h to 9 days (MD = -7.87, 95% CI: -14.82--0.91). Increased risks of drowsiness (risk ratio (RR) = 3.255, 95% CI: 1.135-9.335) and dizziness (RR = 3.034, 95% CI: 1.006-9.147) were observed, but sensitivity analysis using the Bayesian method showed no increased risk. All endpoints were judged as low to very low CoE. (4) Conclusions: Gabapentinoids offer modest analgesic benefits as a component of multimodal pain management for burn injuries of less than 3 weeks. The adverse effects should be carefully monitored. Large-scale RCTs are warranted for the reinforcement of CoE in clinical use.

ATP-induced hypothermia improves burn injury and relieves burn pain in mice

Thermal burn injury is a severe and life-threatening form of trauma that presents a significant challenge to clinical therapy. Therapeutic hypothermia has been shown to be beneficial in various human pathologies. Adenosine triphosphate (ATP) induces a hypothermic state that resembles hibernation-like suspended animation in mammals. This study investigates the potential protective role of ATP-induced hypothermia in thermal burn injury. Male C57BL/6 mice underwent a sham procedure or third-degree burn, and ATP-induced hypothermia was applied immediately or 1 h after burn injury. Our results show that ATP-induced hypothermia significantly improved burn depth progression and reduced collagen degradation. Moreover, hypothermia induced by ATP alleviated burn-induced hyperinflammatory responses and oxidative stress. Metabolomic profiling revealed that ATP-induced hypothermia reversed the shifts of metabolic profiles of the skin in burn mice. In addition, ATP-induced hypothermia relieved nociceptive and inflammatory pain, as observed in the antinociceptive test. Our findings suggest that ATP-induced hypothermia attenuates burn injury and provides new insights into first-aid therapy after thermal burn injury.

Use of Virtual Reality in Burn Rehabilitation: A Systematic Review and Meta-analysis

OBJECTIVES

We systematically reviewed published clinical trials to evaluate the effectiveness of virtual reality (VR) technology on functional improvement, pain relief, and reduction of mental distress among burn patients undergoing rehabilitation.

DATA SOURCES

Systematic searches were conducted in 4 databases, including PubMed, the Cochrane Library, Embase, and Web of Science, from inception to August 2021.

STUDY SELECTION

Randomized controlled trials (RCTs) evaluating any type of VR for the rehabilitation in burn patients with dysfunction were included.

DATA EXTRACTION

Two reviewers evaluated the eligibility, and another 2 reviewers used the Cochrane risk of bias assessment tool to assess the risk of bias. The extracted data included the main results of rehabilitation evaluation (quality of life [QOL], work performance, range of motion [ROM] of joints, hand grip and pinch strength, pain, fun, anxiety), the application performance of VR (realness and presence), adverse effects (fatigue and nausea), and characteristics of the included studies. Heterogeneity was evaluated using the chi-square tests and I² statistics. Random- or fixed-effects models were conducted to pool the effect sizes expressed as standardized mean differences (SMDs).

DATA SYNTHESIS

Sixteen RCTs with 535 burn patients were included. VR-based interventions were superior to usual rehabilitation in QOL and work performance of burn patients and produced positive effect on the average gain of ROM (SMD=0.72) as well. VR was not associated with improved hand grip and pinch strength (SMD=0.50, 1.22, respectively) but was associated with reduced intensity, affective, and cognitive components of pain (SMD=-1.26, -0.71, -1.01, respectively) compared with control conditions. Ratings of fun in rehabilitation therapy were higher (SMD=2.38), and anxiety scores were lower (SMD=-0.73) than in control conditions.

CONCLUSIONS

VR-based burn rehabilitation significantly improves the QOL and work performance of burn patients, increases the ROM gain in the joints, reduces the intensity and unpleasantness of pain and the time spent thinking about pain, increases the fun in the rehabilitation therapy, reduces the anxiety caused by the treatment, and has no obvious adverse effects. However, it did not significantly improve hand grip or pinch strength.

Use of sensory modulation approaches to improve compression garment adherence in adults after burn: An e-Delphi study

BACKGROUND

Sensory over-responsiveness, identified through self-report and quantitative sensory testing, has been associated with compression garment non-adherence in a burn-injured cohort. This study sought expert consensus on the usefulness of, and recommendations for, sensory modulation strategies to improve compression garment adherence in sensory over-responsive adults after burn.

METHOD

Experts in the field of sensory modulation were invited to participate in a mixed-methods, three-round electronic Delphi study.

RESULTS

Experts (N = 18) agreed that sensory modulation therapy may be a useful clinical tool to improve compression garment adherence. Twenty-two items reached consensus as essential to assessment, treatment, or therapist training.

CONCLUSION

With adequate therapist training and individualized assessment and treatment, sensory modulation strategies may be a useful clinical approach to improving compression garment adherence in those who are sensory over-responsive after burn. Further research is needed to gather perceptions from burns therapists, and to implement and evaluate the effectiveness in clinical practice.

Defining numerical cut points for mild, moderate, and severe pain in adult burn survivors: A northwest regional burn model system investigation

INTRODUCTION

Pain is a common and often debilitating sequela of burn injury. Burn pain develops following damage to peripheral sensory nerves and the release of inflammatory mediators from injury. Burn pain is complex and can include background and procedural pain that result from the injury itself, wound care, stretching, and surgery. Clinicians and researchers need valid and reliable pain measures to guide screening, treatment, and research protocols. Unlike other conditions, visual analog, or numeric pain rating scale (VAS/NRS) scores that represent mild, moderate, and severe pain among people with burn injury have not been established. The aim of this study was to identify the most suitable average pain intensity rating scores for mild, moderate, and severe pain in adult burn survivors using a PROMIS Pain Interference (PROMIS-PI) short form.

METHODS

An average pain intensity VAS/NRS score (0-10) and customized PROMIS-PI short form were administered to adults with burn injury treated at a regional burn center at hospital discharge (baseline) and at 6, 12, and 24-months after injury. To identify pain intensity scores that represent mild, moderate, and severe pain, we computed F values and Bayesian Information Criterion (BIC) statistics associated with multiple ANOVA comparisons for mean pain interference scores by various pain intensity cut points. Six possible cut points (CP) were compared: CP 3,6; 3,7; 4,6; 4,7; 2,5; and 3,5. Optimal cut points were considered those with the highest ANOVA F statistics. Models with similar F statistics were also compared with BIC.

RESULTS

Data from a sample of 253 participants (83% white, 66% male, mean age 47 years) with VAS/NRS pain intensity and PROMIS-PI scores at one or more timepoints were analyzed. The optimal classification for mild, moderate, and severe pain was CP 2,5 at baseline and 12-months. Although CP 3,6 had the highest F value at 6-months, there was not strong evidence to support CP 3,6 over CP 2,5 (BIC difference: 2.9); similarly, CP 3,7 had the highest value at 24-months, but the BIC difference over CP 2,5 was only 2.2.

CONCLUSIONS

VAS/NRS scores for pain among adults with burn injury can be categorized as mild (0-2), moderate (3-5), and severe (6-10). These findings advance our understanding regarding the meaning of pain intensity ratings after burn injury, and provide an objective definition for clinical management, quality improvement, and pain research.

A Multimodal Pain Management Strategy for Burn Patients

BACKGROUND

Acute burn pain is difficult to manage, and poorly managed pain can lead to deleterious consequences such as post-traumatic stress disorder, prolonged recovery, chronic pain and long-term dependence on opioids. Understanding the role of nursing in promoting self-efficacy and minimizing opioid use is valuable. It is unknown whether strategic efforts aimed at enhancing patient self-efficacy will improve pain managment and lessen opioid requirements in the adult burn population.

AIM

The aim of this study was to examine the effect of a multi-modal, interdisciplinary pain management strategy on coping self-efficacy, pain scores, and opioid use in adult burn patients in the acute care setting.

METHOD

A quasi-experimental pre-test/post-test design was employed in an American Burn Association (ABA) verified burn center in the Pacific Northwestern United States. Data were collected prospectively for a 6-month period on 44 burn patients. The comparison group received usual care (n = 28), and the intervention received a pain management protocol (n = 16). Coping self-efficacy was measured on admission and at discharge in both groups using the Coping Self-Efficacy Scale. Numeric pain scores and opioid use in morphine milligram equivalents were averaged for each participant. Burn nurse perceptions were gathered via an anonymous electronic survey post data collection in February 2021.

RESULTS

There were no significant differences in measured coping self-efficacy, pain scores, or opioid use between the intervention and comparison groups. A significant positive correlation was found between length of stay, size of burn, and coping self-efficacy and problem focused self-efficacy. Burn nurses reported increased use of nonpharmacologic adjuncts since protocol implementation.

CONCLUSION

Nonpharmacologic adjuncts are more likely to be used consistently when protocolized. There is also evidence to support that certain aspects of self-efficacy may be enhanced during acute phase of burn care.

The Social Legitimacy of Pain: Protocol for a Systematic Literature Review

Introduction: Pain is a perception conditioned both by the subjective experience of the sufferer and their social context. A preliminary literature search suggests that, today, information about the social legitimacy of pain is scarce, although it is known that this phenomenon is an element that is closely linked to the type of pain and contributes to the sufferer's experience. Thus, our objective is to explore how the social legitimacy of pain is tackled in the scientific literature. Methods: This study is a protocol for a systematic literature review where six databases were reviewed: Pubmed, Web of Science, Scielo, Scopus, PsycInfo, and CINAHL, were searched for papers dealing with the social legitimacy of pain from any discipline/study design. The obtained papers will be exported to Zotero, where the duplicates will be deleted. Later, the studies of interest will be selected, first on the basis of their titles/abstracts, and, later, on the complete text. This process will be carried out in pairs. Finally, the data of interest will be extracted, analyzing their quality, to finally make a qualitative analysis of the results. Discussion: This will be the first review to systematically explore the available evidence on the social legitimacy of pain. Therefore, it will be able, not only to extend the theoretical knowledge on this phenomenon, but also to extend its visibility, which will make it possible for the social legitimacy of pain to be studied from different disciplines and fields, thus improving the way it is approached.

Efficacy of dexmedetomidine versus midazolam when combined with butorphanol for sedation and analgesia during burn dressing changes: A randomized clinical trial

Objective: The aim of this study was to compare dexmedetomidine-butorphanol (DB) and midazolam-butorphanol (MB) combinations for sedation, and analgesia in burn patients undergoing dressing changes.

Methods: A total of 56 ASA I–II burn patients were included in this single-center randomized clinical trial. The ages of these patients were between 20 and 60 years. TBSA ranged from 10% to 50%. They were randomized to group DB and group MB during dressing change. In the DB group, each patient received a bolus dose of dexmedetomidine (0.5 μg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). In the MB group, each patient received a bolus dose of midazolam (0.05 mg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). The primary outcomes were sedation scores and pain scores. The second outcomes were vital signs, side effects, and butorphanol consumption.

Results: The sedation scores of these two groups did not differ significantly (p &gt; 0.05), and the pain scores of these groups were not significantly different (p &gt; 0.05). More patients had hypotension in the DB group than in the MB group (6 versus 0, p = 0.01), but the number of patients who had respiratory depression was higher in the MB group compared with the DB group (4 versus 0, p = 0.038). Butorphanol consumption in the MB group was higher than in the DB group (p = 0.025).

Conclusion: Dexmedetomidine is comparable to midazolam when combined with butorphanol in burn patients during dressing change. Compared with midazolam, it has the advantage of opioid-sparing effect.

Clinical Trial Registration: [http://www.chictr.org.cn/showproj.aspx&amp;proj=130622], identifier [ChiCTR2100049325].

The Trend of Burn Injury Patients in Ningbo between 2012 and 2021: A Clinical Study

Objective

This study was designed to understand the local changes of burn injuries in recent 10 years, so as to provide reliable reference data and viewpoints for prevention and vigilance of local burn injuries.

Methods

In this study, 184 patients with a burn injury admitted to our hospital from 2012 to 2021 were enrolled and analyzed retrospectively. According to their information in the electronic database, the number of patients with burn injuries and the location of each disaster each year were analyzed, and the age, sex, hospital stay and hospitalization expense of each patient were collected. With 5 years as the boundary, the patients were divided into a 2012-2016 group and a 2017-2021 group and the differences of the two groups in the abovementioned aspects were compared.

Results

During 2012-2021, the incidence rate of burn injuries in men was higher than that in women and workplaces had a higher burn injury rate than residents' homes. Compared with the period of 2012-2016, the number of fires or explosions and the number of patients with a burn injury during 2017-2028 both increased, but there was no significant change in disaster location, male-female ratio, age, average hospital stay, and average hospitalization expense.

Conclusion

In the face of the increasing prevalence of burn injuries, we should strengthen fire-fighting knowledge-related education and fire prevention management and actively explore post-burn injury treatment strategies and potential treatment targets to promote the development of burn injury management and treatment strategies.

Choosing wisely in burn care

BACKGROUND

The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices.

METHODS

The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™.

RESULTS

Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations.

CONCLUSIONS

The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

Multifactorial pathways in burn injury-induced chronic pain: novel targets and their pharmacological modulation

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.

Adverse childhood experiences and burn pain: a review of biopsychosocial mechanisms that may influence healing

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.

Preparation, Characterization of Pregabalin and Withania coagulans Extract-Loaded Topical Gel and Their Comparative Effect on Burn Injury

The current study depicts the comparative effects of nanogel using Withania coagulans extract, pregabalin alone, and a co-combination gel. The gels prepared were then analyzed for conductivity, viscosity, spread ability, globule size, zeta potential, polydispersity index, and TEM. The globule size of the co-combination gel, determined by zeta sizer, was found to be (329 ± 0.573 nm). FTIR analysis confirms the successful development of gel, without any interaction. Drug distribution at the molecular level was confirmed by XRD. DSC revealed no bigger thermal changes. TEM images revealed spherical molecules with sizes of 200 nm for the co-combination gel. In vivo studies were carried out by infliction of third degree burn wounds on rat skin, and they confirmed that pregabalin and Withania coagulans heals the wound more effectively, with a wound contraction rate of 89.95%, compared to remaining groups. Anti-inflammatory activity (IL-6 and TNF-α), determined by the ELISA technique, shows that the co-combination gel group reduces the maximum inflammation with TNF-α value (132.2 pg/mL), compared to the control (140.22 pg/mL). Similarly, the IL-6 value was found to be (78 pg/mL) for the co-combination gel and (81 pg/mL) in the case of the control. Histopathologically, the co-combination gel heals wounds more quickly, compared to individual gel. These outcomes depict that a co-combination gel using plant extracts and drugs can be successfully used to treat burn injury.

"A Wanderer's Tale": The development of a virtual reality application for pain and quality of life in Australian burns and oncology patients

OBJECTIVES

The primary objective of this study was to co-design and conduct a pilot evaluation of a novel, immersive virtual reality (VR) experience for procedural pain and anxiety in an Australian healthcare setting. The secondary objective was to identify key parameters that can facilitate the development and implementation of VR experiences in clinical practice.

METHOD

A qualitative, Design Box method was selected for co-design. It was used with adult burns survivors and adolescents and young adults (AYAs) with cancer, and healthcare professionals from these fields to identify the practical and design parameters required for the application of VR technology within the clinical setting. Results informed the development of the VR experience that was evaluated by consumers and healthcare professionals, who completed qualitative surveys. Thematic analysis was conducted on co-design notes and survey data.

RESULTS

Procedural pain and management was a challenge for both cohorts, but particularly the burns cohort. Anxiety was significant challenge for both cohorts. Boredom and quality of life was a significant challenge, particularly for the AYA oncology cohort. These results informed the development of "A Wanderers Tale," an Australiana-themed, gaze-controlled VR application for Oculus Quest platforms. Thematic analysis results suggest that cultural preferences, procedural contexts of use, and agency through customization and interaction are three parameters to consider when creating or selecting VR experiences for application in health.

SIGNIFICANCE OF RESULTS

This work describes a novel method for the use VR as an adjuvant pain management tool in patients with burns and cancer. The VR experience may provide a culturally, practice and procedure-appropriate tool in comparable settings of care. The study also describes interdisciplinary co-design and evaluation approaches that can help maximize the use of VR to improve healthcare approaches that address clinical challenges in pain, anxiety, and quality of life for patients while in hospital.

Therapeutic Effect of Autologous Activated Platelet-rich Plasma Therapy on Mid-dermal to Full-thickness Burns: A Case Series

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.

Spinal microglia-derived TNF promotes the astrocytic JNK/CXCL1 pathway activation in a mouse model of burn pain

Burn injury-induced pain (BIP) is an extremely complicated condition usually resistant to analgesic drugs, while its pathogenesis remains unknown. Considerable attention has been attracted to elucidate the glial mechanisms in chronic pain. In this study, we initiatively used a mouse model of second-degree BIP to investigate the underlying non-neuronal mechanisms at the spinal cord level. Our behavioral results showed that hind-paw burn injury caused persistent allodynia and hyperalgesia for 2 weeks in mice. Further studies revealed that both microglia and astrocytes activated in a spatially- and temporally-dependent manner in spinal cord after burn injury. In addition, the phosphorylated p38 mitogen-activated protein kinase (MAPK)-mediated tumor necrosis factor (TNF) release in spinal microglia is essentially attributed to the early stage of BIP, while the c-Jun N-terminal kinase (JNK) MAPK-dependent chemokine CXCL1 expression is mainly involved in the maintenance of pain hypersensitivity. Most strikingly, burn injury-induced pain symptoms and the activation of astrocytes were significantly suppressed by TNF inhibitor Thalidomide. On the contrary, intrathecal injection of TNF caused apparent pain hypersensitivity, accompanied by the activation of astrocytes and the upregulation of CXCL1 via the JNK MAPK signaling pathway, indicating that TNF is the key cytokine in the interaction between microglia and astrocytes at the spinal level. Moreover, treatment with the CXCR2 receptor antagonist SB225002 to block the biological activities of CXCL1 significantly attenuated the mechanical allodynia and thermal hyperalgesia in this BIP model. Taken together, this study indicates that intervention of glial pathways provides a new perspective in the management of BIP.

Music therapy and music medicine interventions with adult burn patients: A systematic review and meta-analysis

BACKGROUND

Pain is one of the most common and most difficult symptoms to manage in adult burn patients in the Intensive Care Unit (ICU). Insufficient or unsuccessful pain management can negatively affect physiological, psychological, and social health in burn patients, both during and after hospitalization. Music therapy and music medicine interventions have been shown to positively affect pain and mental health in this population. This systematic review and meta-analysis provide an update of Randomized Controlled Trials (RCTs) using music therapy or music medicine interventions in adult burn patients.

METHODS

A variety of databases were searched from their beginning to June 2020, including PsycINFO and PsycArticles (via APAsycNET), PubMed and MEDLINE (via OvidSP), Scopus, Web of Science, and the Cochrane Library. Data of all articles meeting the inclusion criteria were extracted, organized, and processed according to the PRISMA guidelines. Statistical analysis was performed using Q-test and I2 statistics.

RESULTS

10 RCTs with a total of 1061 participants were included. The results of the meta-analysis showed a statistically significant reduction of pain (I² = 96.03%, P < 0.001), anxiety (I² = 98.85%, P < 0.002), and improved relaxation (I² = 87.19%, P < 0.001) favoring music interventions compared to control groups.

CONCLUSIONS

This review provides preliminary evidence for the effectiveness of music interventions for adult burn patients. However, more high-quality RCTs are needed to safely establish guidelines for music therapists and other health care professionals in using music for health purposes with this population.

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.

Prescribing of Gabapentinoids with or without opioids after burn injury in the US, 2012-2018

Burn injury pain manifests as a combination of inflammatory, nociceptive, and neuropathic features. While opioids are the mainstay of burn pain management, non-opioid medications, such as gabapentinoids, have also been considered as they target the central nervous system. Increased opioid adverse events and overdose deaths in the United States led to the 2014 and 2016 guidelines to reduce opioid prescribing and consider alternatives, such as gabapentinoids. In the context of burn, the rate of gabapentinoid prescribing at the national level is unknown and it is unclear whether any shift has occurred in prescribing practices over time. We conducted a population level cohort study of adult burn patients from 2012 to 2018 to evaluate the rates and determinants of gabapentinoid prescribing, with and without opioids. Of 98,001 patients with burn, 22,521 (22.98%) received opioids and/or gabapentinoids (GABA). GABA represented 2.4% of prescriptions in 2012, but increased to 7.2% by 2018, while GABA-opioid co-prescriptions increased from 2.3% to 5.1%. The rate of increase in GABA prescriptions was higher for those aged 50-65 years or residing in the South. After adjustment, GABA was 44% more likely to be prescribed in 2017 and 2018 compared to 2012 and 2013, opioids were 38% less likely, while co-prescribing did not show a statistically significant change. Our study showed a modest increase in gabapentinoids' outpatient prescribing for burn patients after the 2014 and 2016 guidelines, indicating more opportunities for prescribers to expand non-opioid pain management in this population.

Acute Burn Treatment and History of Drug and Alcohol Addiction: Treatment Outcomes and Opioid Use

Treating pain in burn patients with a history of opioid or drug abuse is challenging. There is no consensus on pain management for burn patients with a history of drug usage. Our aim was to study the association of previous drug addiction and the treatment of acute burn patients, focusing on daily morphine milligram equivalent (MME) requirements and outcomes. We compared patients with (group 1) and without (group 2) a drug addiction history who were admitted to an American Burn Association verified burn center using the Premier database from 2013 to 2018 (n = 3046). Primary outcome was daily MME usage. Secondary outcomes included mortality, expected mortality rate, length of stay (LOS), and number of surgeries. Linear regression was performed to predict MME usage. In total, 16.6% of patients had history of drug abuse. In unadjusted analysis, group 1 had more males (68.1% vs. 57.3%, p < 0.001) and was younger (median 47 vs. median 53, p < 0.001) compared to group 2. In the adjusted analysis, group 1 required 84.1 additional daily MME usage than group 2 (p < 0.01). Drug addiction was associated with an increased number of surgeries, LOS, and higher daily MME usage. Patients with a history of drug usage required almost 60 mg of additional oxycodone per day.

Neuropathic agents in the management of pruritus in burn injuries: a systematic review and meta-analysis

Objectives

Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury.

Methods

A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included.

Results

Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83).

Conclusion

This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce.

Level of evidence

Systematic review, level II.

Sensory processing and detection thresholds of burn-injured patients: A comparison to normative data

OBJECTIVE

Emerging evidence suggests that individual levels of sensory sensitivity may impact treatment outcomes for people recovering from burn injuries. For example, individuals with higher levels of sensory sensitivity were less adherent with compression garment wear, often used for scar management. The purpose of this study was to characterise sensory patterns for a sample of burn-injured patients as a cohort, using normative data as the reference. As different patterns of sensory processing can have implications clinically, understanding this at the cohort level may provide valuable insight for therapy.

METHOD

This was a secondary analysis of data collected during a cross-sectional study. Adults (N = 117) attending the Professor Stuart Pegg Adult Burns Unit outpatient clinic completed the Adolescent/Adult Sensory Profile and the following quantitative sensory tests: two-point discrimination; mechanical detection threshold; and pressure pain threshold.

RESULTS

Compared to matched normative data, burn-injured patients reported higher levels of sensory sensitive and avoiding patterns, and experienced lower detection thresholds for touch and pain.

CONCLUSIONS

Higher reports of sensory sensitivity and sensory avoiding, and lower thresholds for touch and pain, have been correlated with tactile defensiveness. Tactile defensiveness has been associated with social withdrawal and isolation, all of which could contribute to decreased engagement in therapy. The ways in which these sensory characteristics impact on burn-related treatments, such as compression garment adherence, warrant further investigation.

The Effect of Music Therapy on Perceived Pain, Mental Health, Vital Signs, and Medication Usage of Burn Patients Hospitalized in the Intensive Care Unit: A Randomized Controlled Feasibility Study Protocol

Background: Burn patients experience major physiological and psychological stressors during treatment and rehabilitation, including elevated levels of pain, anxiety, stress, or depression. Music interventions inclusive of music therapy (MT) have been shown to improve such symptoms, but rigorous clinical trials investigating specific music therapy methods in adult burn patients are scarce. Methods: This is a single center Randomized Controlled Trial (RCT) protocol with two parallel arms. Participants are 81 adult burn patients admitted to the Intensive Care Unit (ICU) of the University Hospital Fundación Santa Fe de Bogotá in Colombia. The intervention consists of a Music Assisted Relaxation (MAR) protocol, a music therapy technique composed of entrained live music combined with a guided relaxation and/or the use of imagery. The effects of the MAR will be compared to a control group (treatment as usual) over a period of maximum 2 weeks or six interventions. The primary outcome measure is perceived background pain, as measured with a Visual Analog Scale (VAS) before and after each intervention. Secondary outcomes are anxiety and depression levels; vital signs; and the use of pain medication. Additionally, some patients in the intervention group will be invited to participate in electroencephalography, electromyography, and electrocardiography recordings during the MAR. Discussion: This study protocol follows the SPIRIT guidelines for defining items of clinical trials and is the first study in Colombia to evaluate the effects of music therapy for adult burn patients. With this RCT it is hoped to gather new knowledge about the potential of music therapy to help critical care patients cope and recover from their injuries during the hospitalization in the ICU. Trial registration: www.clinicaltrials.gov, Identifier: NCT04571255. Protocol version: V1.0, May 24th 2021.

Autologous platelet-rich plasma repairs burn wound and reduces burn pain in rats

OBJECTIVE

To investigate the effects of autologous platelet-rich plasma (PRP) on burn wound and burn pain in rats.

METHODS

Rats were treated with high-temperature copper rod to induce skin burn. During treatment, the wound area of rats was recorded on days 0, 3, 7, 10, 14 and healing rates were calculated. After 14-day treatment, the paw withdrawal mechanical threshold (PWMT) as well as paw withdrawal thermal latency (PWTL) were measured. In addition, CD31 expression in burn wound was detected by Immunohistochemistry. The contents of TNF-α and IL-1β in wound tissues were detected by ELISA. Moreover, the mRNA and protein expression levels of VEGF, MMP-9 and TGF-β1 in wound tissues were detected by RT-qPCR together with Western blot.

RESULTS

Burn wound of rats in the PRP group gradually got better with a decreased wound area. Compared with the NS group, the wound area of the PRP group was significantly reduced and the healing rate was significantly increased. Meanwhile, PWMT of the rats in the PRP group was obviously increased compared with the NS group. Compared with the NS group, the rate of CD31-positive cells in the wound tissue of burned rats was increased; while the contents of TNF-α and IL-1β were significantly decreased after a subcutaneous injection of PRP. In addition, the mRNA and protein expression levels of VEGF, MMP-9 and TGF-β1 in the wound tissue of rats from PRP group were evidently increased.

CONCLUSION

Autologous platelet-rich plasma not only shortened the healing time, but also relieved the burn pain.

Burn Survivors' Experiences of the Ongoing Challenges after Discharge in South Korea: A Qualitative Study

OBJECTIVE

To help burn survivors during the recovery time after discharge, healthcare professionals need to understand their experiences and care requirements. However, little is known about the experience of burn survivors after discharge in South Korea. This study aims to explore their experiences in a community setting.

METHODS

Using a qualitative descriptive format, data were collected by semistructured interview from 10 patients who had sustained major burns. Each interview was based on a protocol of 60 to 90 minutes' duration and used a qualitative content analysis.

RESULTS

Three themes were identified in the analysis: (1) ongoing distressing symptoms and the unpredictability of hypertrophic scars, (2) difficulties in reintegration into society, and (3) burden of health expenditure.

CONCLUSIONS

Several participants expressed consistent difficulties with distressing symptoms such as wound pain, pruritus, sleep disturbances, and unpredictable scar and symptom changes. Survivors further described the financial burden associated with high expenditures from nonreimbursable rehabilitation expenses, and the high cost incurred with consistent skin care. By providing support based on their needs, appropriate interventions would be more readily available for burn survivors.

A narrative review of changes in microvascular permeability after burn

OBJECTIVE

We aimed to review and discuss some of the latest research results related to post-burn pathophysiological changes and provide some clues for future study.

BACKGROUND

Burns are one of the most common and serious traumas and consist of a series of pathophysiological changes of thermal injury. Accompanied by thermal damage to skin and soft tissues, inflammatory mediators are released in large quantities. Changes in histamine, bradykinin, and cytokines such as vascular endothelial growth factor (VEGF), metabolic factors such as adenosine triphosphate (ATP), and activated neutrophils all affect the body's vascular permeability.

METHODS

We searched articles with subject words "microvascular permeability", "burn" "endothelium", and "endothelial barrier" in PubMed in English published from the beginning of database to Dec, 2020.

CONCLUSIONS

The essence of burn shock is the rapid and extensive fluid transfer in burn and non-burn tissue. After severe burns, the local and systemic vascular permeability increase, causing intravascular fluid extravasation, leading to a progressive decrease in effective circulation volume, an increase in systemic vascular resistance, a decrease in cardiac output, peripheral tissue edema, multiple organ failure, and even death. There are many cells, tissues, mediators and structures involved in the pathophysiological process of the damage to vascular permeability. Ulinastatin is a promising agent for this problem.

Burn patients' pain experiences and perceptions

INTRODUCTION

Burns are painful injuries associated with a long recovery. Patients may not be receiving sufficient pain management education to optimize their experience and recovery after burn injury. Therefore, we aimed to obtain patients' perspectives about the effectiveness of current burn pain education to inform future efforts.

METHODS

We used a mixed-methods research design that included both inpatients and outpatients cared for at a single, American Burn Association-verified burn center. Participants were at least 14 years of age with an acute burn who received a minimum of two wound interventions. The interview was designed by clinician stakeholders using a modified Delphi technique and focused on patient respondent's pain experience, understanding and desire to gain knowledge concerning burn pain and its management. Descriptive quantitative analysis was performed on categorical data. Recorded interview segments were transcribed for content analysis.

RESULTS

Twenty-one adult burn patients were interviewed. Participants reported experiencing variable levels of pain and pain management effectiveness. Inpatients reported more severe pain than outpatients. Only 11% of inpatients reported having received enough pain information, compared to 50% of outpatients. Content analysis yielded 3 themes: patient's pain experience, range of expectations, and clinical information/services desired. Mental and physical effects were key factors in respondents' pain experiences, with many participants reporting mental anguish in addition to pain. Of participants who had pain expectations, most were matched by their experience (56%), although many individuals (44%) described higher pain levels than they anticipated. Positive experiences with the burn care team primarily revolved around receiving pain education from a provider, whereas negative experiences focused on wound care events. Participants desired more information on sleep and pain medications, alternative treatments, weaning and addiction risk, realistic expectations of recovery timelines, and available mental health services. Written (pamphlet) education ranked as the most desirable delivery method, followed by in-person and video education.

CONCLUSIONS

Burn patients reported variable pain experiences and a strong desire to receive additional pain education. This project informs key strategies to educate burn patients on pain: leverage the high-level of interest in pain to foster education, describe pharmacologic and alternative therapies, offer weaning plans and explanation of addiction risks.

APPLICABILITY TO PRACTICE

Burn patients' perspectives help inform strategies and content creation for pain-related education materials that burn centers can provide to improve patients' experiences.

EXTERNAL FUNDING

Project was supported in part by the NIH grant for Insight Student Research Program at the Harborview Injury Prevention and Research Center (R25 HD094336).

Ultrasound-guided Fascia Iliaca Plane Block for the treatment of donor site pain in the burn injured patient: a randomized control trial

Burn injuries requiring surgical intervention often result in split- thickness skin grafting procedures, with donor skin frequently harvested from the patient's anterolateral thigh. The donor site is often reported as the primary site of post-operative pain due to the damage sustained to localised nociceptors.A randomised control trial was undertaken to evaluate the impact an ultrasound-guided regional nerve block would have on patient reported pain scores in donor site wounds, and associated rescue analgesia consumption. Twenty participants requiring split-skin grafting for burn injuries of <15% total body surface area were enrolled from a tertiary burns unit and randomised to control (10 participants) or intervention group (10 participants). The intervention group received the addition of an ultrasound-guided facia iliaca plane block prior to their surgery. Primary outcome was pain score in the donor site during the postoperative phase; while secondary outcome was pain on day 1 post-surgery as measured by the numeric pain score (0-10). During the post-operative phase, the intervention group had a significantly lower median donor site pain score of 0 (interquartile range (IQR) 0 - 0), compared to the control group median 6 (IQR 4 - 7) (p < 0.001). Day 1 post-surgery the intervention group had a median pain score of 0 (IQR 0 - 4) compared to control group median 4.5 (IQR 2 - 6) (p= 0.043).The study findings demonstrated that regional anaesthesia was an effective way to reduce pain scores and requirement for additional analgesics during the postoperative phase.

Impact of Multimodal Analgesia in Critically Ill Burn Patients

Opioids are the mainstay of treatment for burn pain. However, these medications may be associated with, respiratory depression, and dependence. Multimodal analgesia is an alternative method that utilizes both opioid and non-opioid medications with different mechanisms. This study examines the impact of multimodal therapy for post-operative pain control in a burn intensive care unit.This was a retrospective cohort study of patients admitted to the burn unit at a tertiary medical center. Consecutively admitted patients with burns greater than or equal to 10% total body surface area and intensive care unit length of stay greater than seven days were eligible for inclusion (2012 - 2018). Patients were excluded if they received an opioid infusion greater than 48 hours.  Patients treated with multimodal analgesia were compared to those treated with opioids alone. Data was calculated for 5 days after surgery. There were 98 patients in the non-multimodal group and 97 in the multimodal group. . Mean cumulative opioid dose was lower in the multimodal group (1,028.7 mg vs. 1,423.2 mg, P = 0.0031). Patients with greater than 20% burns had a larger reduction in mean opioid equivalents in the multimodal group (1,106 vs 1,594 mg, P=0.009) compared to patients with burns less than 20% (940 vs. 1,282 mg, P=0.058). There was no difference in mean pain scores on post-operative day 5 (6.2 + 2.2 vs. 5.5 + 2.3 P=0.07) or at intensive care unit discharge (4.7 + 2.4 vs 4.7 + 2.8, P=0.99). The use of multimodal analgesia significantly reduced cumulative opioid equivalent dose without compromising pain control.    .

Effectiveness of a hydrogel dressing as an analgesic adjunct to first aid for the treatment of acute paediatric burn injuries: a prospective randomised controlled trial

OBJECTIVE

To compare the effectiveness of two acute burn dressings, Burnaid hydrogel dressing and plasticised polyvinylchloride film, on reducing acute pain scores in paediatric burn patients following appropriate first aid.

DESIGN

Single-centre, superiority, two-arm, parallel-group, prospective randomised controlled trial.

PARTICIPANTS AND SETTING

Paediatric patients (aged ≤16) presenting to the Emergency Department at the Queensland Children's Hospital, Brisbane, Australia, with an acute thermal burn were approached for participation in the trial from September 2017-September 2018.

INTERVENTIONS

Patients were randomised to receive either (1) Burnaid hydrogel dressing (intervention) or (2) plasticised polyvinylchloride film (Control) as an acute burn dressing.

PRIMARY AND SECONDARY OUTCOMES

Observational pain scores from nursing staff assessed 5 min post application of the randomised dressing, measured using the Face Legs Activity Cry and Consolability Scale was the primary outcome. Repeated measures of pain, stress and re-epithelialisation were also collected at follow-up dressing changes until 95% wound re-epithelialisation occurred.

RESULTS

Seventy-two children were recruited and randomised (n=37 intervention; n=35 control). No significant between-group differences in nursing (mean difference: -0.1, 95% CI -0.7 to 0.5, p=0.72) or caregiver (MD: 1, 95% CI -8 to 11, p=0.78) observational pain scores were identified. Moreover, no significant differences in child self-report pain (MD: 0.3, 95% CI -1.7 to 2.2, p=0.78), heart rate (MD: -3, 95% CI -11 to 5, p=0.41), temperature (MD: 0.6, 95% CI -0.13 to 0.24, p=0.53), stress (geometric mean ratio: 1.53, 95% CI 0.93 to 2.53, p=0.10), or re-epithelialisation rates (MD: -1, 95% CI -3 to 1, p=0.26) were identified between the two groups.

CONCLUSIONS

A clear benefit of Burnaid hydrogel dressing as an analgesic adjunct to first aid for the treatment of acute paediatric burns was not identified in this investigation.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12617001274369).