Effects of Topical Sesame Oil Extracted from Tahini (Ardeh) on Pain Severity in Trauma Patients: A Randomized Double-Blinded Placebo-Controlled Clinical Trial

Objective

To investigate the effects of sesame oil extracted from tahini (Ardeh) on pain severity in patients with upper or lower limbs trauma.

Methods

This double-blinded randomized clinical trial study was conducted on 120 patients with upper or lower trauma in Shahid Rajaee Hospital, Shiraz, Iran, from May the 1^st through November 30^th, 2016. The patients were randomly assigned to two groups using block randomization. The intervention group received topical sesame oil extracted from tahini (Ardeh) and the placebo group received cooking oil. Pain severity, pain sensitivity and heaviness of painful site were assessed.

Results

Overall, we included 90 patients with traumatic limb injuries in this study who were randomized to two study groups. The mean age of the patients was 28.3 ± 6.8 (ranging from 25 to 35) years and there were 63 (70%) men and 27 (30%) women among the patients. In the sesame oil group, the mean changes in the pain severity (-1.53 ± 0.57, P<0.001), pain sensitivity (-1.45 ± 0.64, P<0.001) and heaviness of painful site (-1.56 ± 0.68, P<0.001) were significantly lower when compared to the placebo group in the second day of the intervention. None of the patients experience adverse drug effects.

Conclusion

Our findings suggest that the topical use of sesame oil extracted from Tahini has a pain reliever effect on the skin after bruising and it helps prevent skin discoloration in patients with traumatic injuries of limbs.

Evaluation of a model of bruising in pigmented skin for investigating the potential for alternate light source illumination to enhance the appearance of bruises by photography of visible and infrared light

The purpose of this study was to evaluate the ability of alternate light source illumination to enhance bruises in pigmented skin. Previous work was limited to simulating bruises in non-pigmented (Caucasoid type) skin by injecting blood into pigskin. In this study, it was investigated if adding a layer of melanin to the surface of the skin would simulate pigmented skin. The study included evaluating the use of a filter that transmitted infrared light (wavelength greater than 720 nm) in place of the recommended visible light filters for the alternate light sources. The results obtained using pigskin with a layer of melanin were almost the same as results using the naturally pigmented goat ear. This indicated adding a layer of melanin could be used as a model for pigmented skin in this simulation of fresh bruising. Comparing the pigskin without melanin with pigskin with melanin revealed that the optimal light source to enhance the appearance of bruising, simulated by injection of blood, changed from violet to blue-green. Using the infrared transmitting filter resulted in greater enhancement than using the alternate light sources with their recommended visible light filter. The advantage of using the infrared transmitting filter was greater with the pigskin coated with melanin and the naturally pigmented goat ears than in the non-pigmented pigskin, however, the results remain to be validated using real bruises in naturally pigmented human skin.

Determination of the age of bruises using a bilirubinometer

The dating of bruises can be of crucial interest in clinical forensic medicine, but the macroscopic or photographic evaluation of a bruise has not been regarded as reliable. Several methods have thus been regularly evaluated for this purpose, with reflectance spectrometry yielding promising results. The objective of this study is to evaluate the value of a bilirubinometer as a tool for dating bruises on living victims. A clinical follow-up was carried out on patients presenting a bruise with a known onset. Using a bilirubinometer, we obtained daily measurements of the bruise (bili-bruise) and of healthy skin (bili-skin). Potential confounding factors were collected: age, sex, body mass index, trauma mechanism and Fitzpatrick skin phototype. We followed 20 patients for a total of 88 measurements of bruises. Bili-skin values showed significant differences according to skin phototype. Differences between the bili-bruise and bili-skin values (Δ-bili) followed an increase phase, peaking between 3 and 5 days, and then there was a decrease phase. No significant Δ-bili value differences were observed based on the suspected confounding factors. Our results are in favour of a peak Δ-bili value generally at day 4 or 5 post-trauma. Notably, decreasing values were not observed before day 3. Decreasing Δ-bili values would then indicate a bruise resulting from an injury formed at least 3 days before the first measurement. Complementary work confirming such data would enable improvement of the performance of bruise dating in forensic medicine.

The intensity of the inflammatory response in experimental porcine bruises depends on time, anatomical location and sampling site

The assessment of the age of bruises inflicted on livestock is an important component of veterinary forensic pathology investigations. However, the sampling site within a bruise, the anatomical location and the mass and speed of the object inflicting the blunt trauma might influence the intensity of the inflammatory reaction. In the present study, the variation of the inflammatory reaction within and along experimental porcine bruises was evaluated in order to determine the optimal sampling site. Moreover, we evaluated if a combination of histological characteristics and gene expression signatures was able to differentiate bruises according to anatomical location, age of bruises and the speed and mass of the object used to cause the impact. Twelve experimental slaughter pigs were anesthetized, and on each animal four blunt traumas were inflicted on the back using either a plastic tube or an iron bar, respectively. The pigs were euthanized at 2, 5 or 8 h after infliction. Following gross examination, skin and underlying muscle tissue were sampled from the center and both ends of bruises and evaluated histologically. Subcutaneous fat tissue from the center of the bruises was sampled for quantitative real-time polymerase chain reaction to evaluate mRNA expression of 13 selected genes. Uninjured tissue was sampled from the right thigh of all pigs and served as control tissue. The amount of tissue damage and the intensity of the inflammatory reaction in bruises depended on the sampling site within and along a bruise, the anatomical location and the age of the bruise. The optimal site for sampling, i.e. the most pronounced inflammatory reaction, was at the center of the bruises where the plastic tube or iron bar first struck the skin. Moreover, bruises inflicted in areas with a thin layer of subcutaneous fat tissue showed more damage and inflammation in the underlying muscle tissue compared to bruises inflicted in areas with a thicker layer of subcutaneous fat tissue. In addition, hemorrhage in the muscle tissue was more likely present when bruises were inflicted with an iron bar compared to a plastic tube. Combining histology and mRNA expression of the 13 genes showed that the age of bruises could be determined with a precision of ±2.04 h. Moreover, the age of bruises could be determined with a precision of ±1.84 h based solely on mRNA expression of a selection of four genes.

A pilot study demonstrating the efficacy of transcutaneous bilirubin meters to quantitatively differentiate contusions from Congenital Dermal Melanocytosis

OBJECTIVE

Congenital Dermal Melanocytosis (CDM) can be difficult to differentiate from contusions. The need for a prompt and accurate diagnosis is best illustrated in cases where child abuse and maltreatment is of concern. Transcutaneous bilirubin (TCB) spectrophotometry has been well established to measure bilirubin under the skin for jaundice in infants. The use of TCB spectrometry has not been used to identify or differentiate contusions from CDM. We hypothesized that bilirubin, a degradation product of hemoglobin, would be elevated in contusions but not in CDM thus demonstrating the efficacy of a novel diagnostic technique to compliment or improve on physical assessment alone.

METHODS

Pilot study with thirty-seven infants and children noted to have CDM and fifty-six infants, children and adults with contusions underwent measurement of their lesion with TCB spectrometry. In each patient, the affected skin was scanned along with the adjacent unaffected native skin allowing an internal control for individual pigment variation.

RESULTS

TCB measurements of CDM resulted in lower transcutaneous bilirubin values that were not significantly different from adjacent native skin pigmentation. This was in contrast to cutaneous contusions, which resulted in a higher measured value (mean 5.01 mg/dL) compared to adjacent native tissue (1.24 mg/dL) demonstrating a four-fold increase in measurement at the lesion site (P < 0.001). Direct comparison of a ΔTCB value (lesion measurement minus the adjacent tissue) demonstrated a significantly higher value in contusions compared to CDM with a mean value of 3.77 and 0.12 mg/dL, respectively (P < 0.001).

CONCLUSIONS

TCB Spectrometry as a novel diagnostic technique has the potential to discern contusions from CDM and may therefore have the ability to compliment the use of physical assessment alone.

Visualization of old bruises in children: Use of violet light to record long-term bruises

When a child consultation center evaluates abused children, evidence of the abuse must be documented. Children who have suffered physical abuse often have bruises, which cannot be confirmed by visualization when the bruise has healed. In forensics, a method to confirm an old bruise by ultraviolet radiation is possible. However, long-term ultraviolet exposure can be harmful. In this study, we observed 15 bruises on healthy volunteer children using four kinds of light sources, including ultraviolet radiation, over time. The violet light source enabled observation of a bruise for a longer time than ultraviolet radiation. Although other studies have shown that violet light is superior for enhancing bruises, this is the first report to evaluate data concerning the ability to identify bruises over time in living children. These results might help to identify evidence of past violence suffered by children.

Forensic aspects of gene expression signatures for age determination in bruises as evaluated in an experimental porcine model

Determining the age of bruises and the force used to inflict the trauma is of crucial importance in both human and veterinary forensic pathology. In the present study, the expression of more than 50 different genes in subcutaneous fat and muscle tissue from experimental bruises in pigs was investigated. The aim was to evaluate if expression signatures of selected genes were capable of determining bruises according to age and the force of impact. Eighteen experimental pigs were anesthetized, and on each animal four blunt traumas were inflicted on the back with a low, moderate or high force. The pigs were euthanized from 1 to 10 h after infliction of the trauma and subcutaneous fat and muscle tissues were sampled. As control, subcutaneous fat and muscle tissues were sampled from two un-injured pigs. Quantitative real-time polymerase chain reaction was performed to evaluate mRNA expression of genes involved in inflammation, tissue damage and repair. Expression signatures of thirteen selected genes in subcutaneous fat but not in muscle tissue reflected the age of bruises with a precision of approximately ±2 h. Moreover, the gene expression signature in the subcutaneous fat was to some extend able to separate bruises inflicted with different forces. Expression signatures of selected genes in the subcutaneous fat will increase the precision of the age determination of bruises in pigs. Further, due to the similarity of porcine and human skin physiology and immunity, these results might also provide valuable information in human forensic science.

A mimic of sexually-motivated homicide: insect stings and heat exhaustion in a forest

We report the case a woman who was found dead in a forest. The body was nude and the position of the body suggested a sexually motivated homicide. We concluded that death was not related to homicide, but was related to the conjunction of environmental factors, including insect stings, and acute psychosis. A medicolegal death investigation with postmortem examination was undertaken to determine cause of death. At the scene, the body was supine with legs spread apart and the knees flexed, exposing the external genitalia. There were multiple apparent bruises on the body and neck. At autopsy, based on macroscopic and microscopic examination, the apparent bruises were found to be hemorrhagic insect bites. No significant injuries were present and no semen was found. Death appeared to be related to heat exhaustion and innumerable insect stings. Investigation of the medical history revealed longstanding schizoaffective disorder with episodic psychotic decompensations. In the past, during an acute psychotic episode the decedent removed her clothing and ran wildly in a forest, until she was rescued in a state of exhaustion and marked agitation, and taken to hospital for treatment. We concluded that the same circumstances had been repeated but with a fatal outcome. This case is an example of a mimic of sexually-motivated homicide and is a reminder to forensic pathologists to avoid tunnel vision. We need to be skeptical of the allure of common sense based on first impressions of the scene and the body. Forensic pathologists must be unafraid to scientifically explore improbable, but true, alternate explanations.

Gross and histopathological evaluation of human inflicted bruises in Danish slaughter pigs

Background

Human inflicted bruises in slaughter pigs are hampering animal welfare, are an infringement of the animal protection act, and are a focus of public attention. The aim of the present study was to evaluate the gross appearance of human inflicted bruises in slaughter pigs and to compare the inflammatory changes in two lesions as a basis for estimating the age of lesions in the same pig.

Pigs with human inflicted bruises slaughtered at two major slaughterhouses in Denmark from November 2013 to May 2014 were evaluated. After slaughter, the bruises were examined grossly and skin and underlying muscle tissue from two similar but separate bruises (a and b) on each pig were sampled for histology.

Results

Skin and muscle tissue from 101 slaughter pigs were subjected to gross evaluation. Eighty-one of these were also subjected to histological evaluation. Most frequently (51 out of 101 pigs, 50 %), bruises had a tram-line pattern due to blunt trauma inflicted with long objects such as sticks. Other bruises reflected the use of tattoo-hammers, plastic paddles, double U profiles and chains. Histological evaluation of two bruises from a pig with multiple lesions was found insufficient to assess the overall age of the lesions as substantial variation in the inflammatory response between bruises was present.

Conclusions

Grossly, the pattern of bruises often reflected the shape of the object used for inflicting the lesions. When determining the age of multiple bruises on a pig more than two lesions should be evaluated histologically.

Electronic supplementary material

The online version of this article (doi:10.1186/s12917-016-0869-3) contains supplementary material, which is available to authorized users.

Vascular lesions simulating bruising

Careful examination of the skin and soft tissues is a routine part of the forensic autopsy to identify and characterise traumatic lesions. Three cases are reported where benign vascular lesions presented as bruises. In case 1, a 44-year-old man with a history of epilepsy was found dead on the floor. Dissection of the neck revealed a haemorrhagic area 15 mm × 1.5 mm, deep to the left thyrohyoid muscle. In case 2, an 87-year-old man was found dead with a plastic bag over his head attached to an opened cylinder of nitrogen gas. On the mucosal surface of his upper lip, there was an apparent 5 mm blue/purple bruise. In case 3, examination of the back of a 16-month-old girl revealed an apparent 15 mm bruise. Histological examination of all three lesions revealed benign vascular lesions. In the absence of microscopy, these lesions would have been considered traumatic in origin, raising the possibility of inflicted trauma.

Skin manifestations of Cushing's syndrome

Among the most common diagnostic manifestations of Cushing's syndrome (CS) are those involving the skin; they include violaceous striae, facial acne, hirsutism, acanthosis nigricans (AN), fungal infections, hyperpigmentation (Hp) and easy bruisability. Fortunately, most resolve within a year or two after cure of CS, although light-colored striae can persist for years depending on the age of the patients. AN, Hp, and bruisability usually resolve within months after cure in almost all ages. Facial plethora (along with acne and other facial skin changes) is a typical sign of CS that is due to increased perfusion. It resolves immediately after curative therapy of CS. Typically, the severity of the manifestations does not correlate with the biochemical indices of the disease, pointing to age, gender, genetic and skin-type differences that determine the cutaneous manifestations of CS.

The effects of kinesio taping on the color intensity of superficial skin hematomas: A pilot study

OBJECTIVES

To analyze the effects of kinesio taping (KT) -applied with three different strains that induced or not the formation of skin creases (called convolutions)- on color intensity of post-surgical superficial hematomas.

DESIGN

Single-blind paired study.

SETTING

Rehabilitation clinic.

PARTICIPANTS

A convenience sample of 13 inpatients with post-surgical superficial hematomas.

INTERVENTIONS

The tape was applied for 24 consecutive hours. Three tails of KT were randomly applied with different degrees of strain: none (SN); light (SL); and full longitudinal stretch (SF). We expected to obtain correct formation of convolutions with SL, some convolutions with SN, and no convolutions with SF.

MAIN OUTCOME MEASURES

The change in color intensity of hematomas, measured by means of polar coordinates CIE L*a*b* using a validated and standardized digital images system.

RESULTS

Applying KT to hematomas did not significantly change the color intensity in the central area under the tape (p > 0.05). There was a significant treatment effect (p < 0.05) under the edges of the tape, independently of the formation of convolutions (p > 0.05).

CONCLUSIONS

The changes observed along the edges of the tape could be related to the formation of a pressure gradient between the KT and the adjacent area, but were not dependent on the formation of skin convolutions.

Reliability of tristimulus colourimetry in the assessment of cutaneous bruise colour

BACKGROUND

Bruising is one of the most common types of injury clinicians observe among victims of violence and other trauma patients. However, research has shown commonly used qualitative description of cutaneous bruise colour via the naked eye is subjective and unreliable. No published work has formally evaluated the reliability of tristimulus colourimetry as an alternative for assessing bruise colour, despite its clinical and research applications in accurately assessing skin colour. The purpose of this study was to systematically evaluate the test-retest and inter-observer reliability of tristimulus colourimetry in the assessment of cutaneous bruise colour.

METHODS

Two researchers obtained repeated tristimulus colourimetry measures of cutaneous bruises with participants of diverse skin colour. Measures were obtained using the Minolta CR-400 Chomameter. Commission Internationale d'Eclairage (CIE) L*a*b* colour space was used. Data was analysed using intraclass correlation coefficients (ICC), Cronbach's alpha, and minimal detectable change (MDC) on all three L*a*b* values.

RESULTS

The colorimeter demonstrated excellent test-retest or intra-rater reliability (L* ICC=0.999; a* ICC=0.973; b* ICC=0.892) and inter-rater reliability (L* ICC=0.997; a* ICC=0.976; b* ICC=0.982).

CONCLUSIONS

With consistent placement, the tristimulus colourimetry is reliable for the objective assessment and documentation of cutaneous bruise colour for purposes of clinical practice and research. Recommendations for use in practice/research are provided.

The impact of force on the timing of bruises evaluated in a porcine model

In animal models developed in order to estimate the age of bruises, focus has been on the changes over time and not considering the force used to inflict the trauma. In the present study, gross and histological changes in 2, 4, 6 and 8 h old bruises which were inflicted with a low, moderate and high force were compared. Twelve experimental pigs were randomly assigned to three groups of force (low, moderate and high force). All pigs were anesthetized, and on each animal four blunt traumas were inflicted on the back with the low, moderate or high force according to the groups. The pigs were kept in anesthesia for 2, 4, 6 or 8 h, after which they were euthanized, and skin and muscle tissues were sampled for histology. As control, two pigs were included. The gross appearance of bruises developed similarly until 0.5 h after infliction at which time the visibility of the bruises depended on the force. The infiltration of subcutaneous neutrophils depended on the time and force used which was confirmed by both manual evaluation and image analysis of immunostained skin sections. In the muscle tissue, the number of macrophages was found useful for age determination in bruises inflicted with the highest force. Therefore, when evaluating forensic cases of bruises in both human and veterinary pathology the impact of force and not only the timing should be taken into consideration.

Heme oxygenase-1 and heme oxygenase-2 expression in bruises

The first step in catabolism of hemoglobin in a bruise is performed by the enzyme heme oxygenase, which produces biliverdin that is then reduced to bilirubin. The development of yellow coloration in bruises can be attributed to local accumulation of degradation products of hemoglobin, including bilirubin, but it is not clear why there is a delay before this color change is apparent. One explanation may be that time is required for the establishment of heme oxygenase activity at the bruise site. This study used immunohistochemistry to examine the time course of expression of heme oxygenase-1 and heme oxygenase-2 in a rat bruise model. Heme oxygenase-1 levels rose above background from 6 h to peak from days 1 to 3. There was strong expression by macrophages, but only occasional neutrophils expression of heme oxygenase-1. Heme oxygenase-2 did not change significantly from background levels. The results suggest that the delay in the development of yellow coloration of bruises may in part be attributed to the requirement for macrophages to be recruited to the site of injury.

Bruising in children who are assessed for suspected physical abuse

OBJECTIVE

To describe the characteristics of bruising and mode of presentation of children referred to the paediatric child protection team with suspected physical abuse (PA), and the extent to which these differ between the children where abuse was confirmed and those where it was excluded.

DESIGN

Cross-sectional study.

SETTING AND PATIENTS

519 children, <6 years, referred to two paediatric child protection teams.

MAIN OUTCOME MEASURES

The mode of presentation, number, anatomical distribution, size and appearance of bruises according to whether PA was confirmed or excluded. ORs with 95% CI were calculated where relevant.

RESULTS

PA was confirmed in 69% of children; the rate varied from 84% when abuse was witnessed, admitted, alleged or where explanation for injury was absent or implausible, to 50% where there was a concerning history. Significantly more children with PA had bruises (89.4%) than PA-excluded (69.9%) and had significantly more sites affected (p<0.001). The odds of a PA child having bruising to: buttocks/genitalia (OR 10.9 (CI 2.6 to 46), left ear (OR 7.10 (CI 2.2 to 23.4), cheeks (Left (OR 5.20 (CI 2.5 to 10.7), Right OR 2.83 (CI 1.5 to 5.4)), neck (OR 3.77 (CI 1.3 to 10.9), trunk (back (OR 2.85 (CI 1.6 to 5.0) front (OR 4.74 (CI 2.2 to 10.2), front of thighs (OR2.48 (CI 1.4 to 4.5) or upper arms (OR 1.90 (CI 1.1 to 3.2) were significantly greater than in children with PA-excluded. Petechiae, linear or bruises with distinct pattern, bruises in clusters, additional injuries or a child known to social services for previous child abuse concerns were significantly more likely in PA.

CONCLUSIONS

Features in the presenting history, the extent and pattern of bruising differed between children with confirmed PA and those where abuse was excluded. These findings can provide a deeper understanding of bruising sustained from PA.

The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective

Bruises commonly occur in children and are most often the result of a minor accidental injury. However, bruises can also signal an underlying medical illness or an inflicted injury (maltreatment). Although bruising is the most common manifestation of child physical maltreatment, knowing when to be concerned about maltreatment and how to assess bruises in this context can be challenging for clinicians. Based on current literature and published recommendations, this practice point will help clinicians to distinguish between accidental and inflicted bruises, to evaluate and manage bruising in the context of suspected child maltreatment, and to evaluate for an underlying medical predisposition to bruising.