Search

Background Pain is a significant factor associated with wounds. Its presence can impact on every aspect of an individual, affecting their overall quality of life (QoL) including ability to function, as well as their social and psychological well-being. Holistic approaches that can help to address wound-related pain are vital to improve patient outcomes. Aim We aimed to review the evidence for the holistic management of wound-related pain in individuals with chronic wounds in order to provide recommendations for healthcare professionals in clinical practice. Method The L OVE platform was used for the search as wound and burn are in the same search category. L OVE collects systematic reviews retrieved from the systematic reviews database Epistemonikos and allocates them to specific L OVEs and questions. We conducted our search for reviews related to wounds and burns in November 2022. Retrieved titles and abstracts were exported into Rayyan. The search was organised within Rayyan according to the focus for each chapter to retrieve evidence on pain assessment, physical therapies, patient education, psychological approaches, and complementary and alternative approaches. A systematic approach was used by senior experts in wound and pain management for double-blind screening and application of inclusion criteria (chronic wounds and pain) to agree on articles for review. Sources related to acute wounds (including burn injuries) were excluded. The L OVE search was supplemented by narrative reviews of literature identified from the individual systematic reviews and handsearching of relevant sources. Results Thirty-eight systematic reviews and 27 additional articles were identified providing a total of 65 individual pieces of evidence. The number of reviews and articles included: pain assessment (n=25); physical therapies (n=8); patient education (n=12); psychological approaches (n=2); complementary and alternative approaches (n=18). The literature related to pain assessment highlighted that assessment of wound-related pain is complex and multidimensional. Healthcare providers must determine the most suitable assessment tool for their patients and in doing so consider an individual's ability to respond to the assessment, as there is no one assessment tool to measure pain, as 'one size does not fit all'. In terms of physical therapies, physical exercise is important, although the majority of evidence relates to individuals with venous leg ulcers (VLUs). In relation to management, clinicians need to recognize procedural-related pain, particularly in relation to debridement procedures. There may be a role for topical impregnated dressings and topical anaesthetics in this case. Equally it is important to manage moisture to prevent maceration and reduce the risk of pain from periwound skin irritation (dermatitis). For individuals with malignant fungating wounds (MFW) a combination of therapies to manage symptoms is recommended. Specific research related to patient education and woundrelated pain is lacking, however areas that should be considered include aetiology of the wound and causes of pain, non-pharmacological and pharmacological methods for pain relief, methods for assessing pain relief, as well as impact of pain on QoL. Psychological approaches need to consider the factors associated with pain (attention, cognitions, emotions and emotion regulation and overt behaviour) in order to determine the most appropriate treatment strategy. Evidence to make recommendations for wound-related pain is sparse; however, there may be a role for social models of care and motivation enhancement programmes for individuals with leg ulcers. Additionally, aromatherapy and music therapy may also be helpful. Evidence for other chronic wounds is lacking. There is some evidence to support the role of honey for the management of wound-related pain, specifically the research indicates that the analgesic action may be related to its anti-inflammatory properties. Evidence for traditional Chinese medicine (TCM), plants, low-dose topical steroids and low level-laser therapy was very weak. Conclusion The experience of wound-related pain is complex and needs to take into consideration the psychological and social factors that can impact on an individual's QoL to ensure a holistic approach. Equally the assessment of wound-related pain is complex and multidimensional. Healthcare providers must determine the most suitable assessment tool for their patients and in doing so consider an individual's ability to respond to the assessment. Management of wound-related pain may require both non-pharmacological and pharmacological approaches and can include dressings and devices. A holistic strategy should also incorporate both education (patient and healthcare professional) and psychological approaches to improve patient outcomes. Our review has identified a lack of scientific resources on wound-related pain management to make clear recommendations for effective strategies. What is needed are further prospective studies of patients with woundrelated pain and different types of non-healing wounds. Such research should be cognisant that a phenomenon as complex as pain must also be examined comprehensively. The phenomenon of pain has a high degree of subjective perception and individuals have different coping strategies, and healthcare professionals need to be mindful of this. The main determinants of wound-related pain management cannot solely be based on the wound symptomatology and the process of care (healing), but also need to consider the individuality of the patient and their current needs. [ABSTRACT FROM AUTHOR]

Background and purpose: Primary Sjögren syndrome (pSS) is a chronic, systemic, autoimmune disorder characterized by lymphocytic infiltrates of the exocrine organs, leading to sicca symptoms and parotid enlargement. pSS has been linked to various neurological manifestations, including peripheral neuropathy (PN). We aimed to provide a comprehensive analysis of the currently available evidence regarding pSS‐related PN. Methods: A literature search in the PubMed database was performed, and 49 papers were eligible to be included in this systematic review and meta‐analysis. Results: The pooled prevalence of PN in pSS is estimated to be 15.0% (95% confidence interval = 10.7%–20.7%). The mean age of pSS patients at PN diagnosis is 59 years. Among the patients with pSS and PN, 83% are females. Neuropathic symptoms usually precede or lead to the pSS diagnosis at a 2:1 ratio in patients with pSS‐related PN. The commonest type of pSS‐related PN is distal axonal polyneuropathy (80% of patients with pSS‐related PN), followed by sensory ganglionopathy. Peripheral and cranial mononeuropathies—particularly trigeminal—are also frequent. Risk factors for developing PN include increasing age and presence of vasculitis. Immune‐mediated pathogenetic mechanisms are discussed. Glucocorticoids are the most commonly used treatment option for managing pSS‐related PN, when associated with vasculitis, followed by the use of intravenous immunoglobulin. Conclusions: PN is very common in pSS patients. Evidence on long‐term prognosis of PN in pSS is limited, and further research is needed. Research into the use of immunosuppressive medication in nonvasculitic neuropathies in the context of pSS merits further consideration. [ABSTRACT FROM AUTHOR]

Understanding of the basis of osteoarthritis (OA) has seen some interesting advancements in recent years. It has been observed that cartilage degeneration is preceded by subchondral bone lesions, suggesting a key role of this mechanism within the pathogenesis and progression of OA, as well as the formation of ectopic bone and osteophytes. Moreover, low-grade, chronic inflammation of the synovial lining has gained a central role in the definition of OA physiopathology, and central immunological mechanisms, innate but also adaptive, are now considered crucial in driving inflammation and tissue destruction. In addition, the role of neuroinflammation and central sensitization mechanisms as underlying causes of pain chronicity has been characterized. This has led to a renewed definition of OA, which is now intended as a complex multifactorial joint pathology caused by inflammatory and metabolic factors underlying joint damage. Since this evidence can directly affect the definition of the correct therapeutic approach to OA, an improved understanding of these pathophysiological mechanisms is fundamental. To this aim, this review provides an overview of the most updated evidence on OA pathogenesis; it presents the most recent insights on the pathophysiology of OA, describing the interplay between immunological and biochemical mechanisms proposed to drive inflammation and tissue destruction, as well as central sensitization mechanisms. Moreover, although the therapeutic implications consequent to the renewed definition of OA are beyond this review scope, some suggestions for intervention have been addressed. [ABSTRACT FROM AUTHOR]

Acute lung injury (ALI) is a common and devastating clinical disorder with a high mortality rate and no specific therapy. The pathophysiology of ALI is characterized by increased alveolar/capillary permeability, lung inflammation, oxidative stress and structural damage to lung tissues, which can progress to acute respiratory distress syndrome (ARDS). Adelmidrol (ADM), an analogue of palmitoylethanolamide (PEA), is known for its anti-inflammatory and antioxidant functions, which are mainly due to down-modulating mast cells (MCs) and promoting endogenous antioxidant defense. The aim of this study is to evaluate the protective effects of ADM in a mice model of ALI, induced by intratracheal administration of lipopolysaccharide (LPS) at the dose of 5 mg/kg. ADM 2% was administered by aerosol 1 and 6 h after LPS instillation. In this study, we clearly demonstrated that ADM reduced lung damage and airway infiltration induced by LPS instillation. At the same time, ADM counteracted the increase in MC number and the expression of specific markers of MC activation, i.e., chymase and tryptase. Moreover, ADM reduced oxidative stress by upregulating antioxidant enzymes as well as modulating the Nf-kB pathway and the resulting pro-inflammatory cytokine release. These results suggest that ADM could be a potential candidate in the management of ALI. [ABSTRACT FROM AUTHOR]

Type 1 and Type 2 diabetes mellitus patients experience periprandial, interprandial and nocturnal peaks in their hunger sensation. (HS). An amplification of the three peaks corresponding to meal times in compensated type 1 DM patients increases HS. In uncompensated type 1 DM patients, HS increases due to additional orectic peaks in the nocturnal and diurnal parts of the day. Interposed diurnal peaks and an increase in periprandial peaks cause elevated levels of HS in type 2 DM patients.

Chronic pain is a major health-care problem worldwide, affecting more than one out of five adults in Europe. Although multiple analgesic agents have been extensively investigated in terms of clinical response and tolerability profile, few studies have focused on the impact of these therapies on patients' quality of life (QoL). Of note, improvement in QoL, together with functional recovery, has been recognized since the late 1990s as two main goals of analgesic therapy. Tapentadol is a novel analgesic molecule that synergistically combines two mechanisms of action, μ-opioid receptor agonism and norepinephrine reuptake inhibition, and for which multiple literature data are available that confirm its efficacy and safety in controlling pain. This narrative review summarizes the information available on the impact of tapentadol on QoL, with the aim to provide clinicians with a comprehensive overview of the analgesic effects of tapentadol prolonged release beyond the reduction of pain. [ABSTRACT FROM AUTHOR]

Osteoarthritis (OA) is the most prevalent joint disease in older people worldwide. Pain owing to OA is considered one of the most frequent causes of chronic pain; however, current pharmacological approaches have some limitations in terms of efficacy and safety. Of note, descending inhibitory pain pathways are often disrupted in chronic OA pain, and pharmacotherapies targeting those pathways – eg, those that block norepinephrine reuptake may be more appropriate for managing chronic pain than pure μ-opioid receptor (MOR) agonists. Tapentadol is an analgesic molecule, which combines two synergistic mechanisms of action, MOR, and norepinephrine reuptake inhibition. This narrative review will briefly discuss the mechanisms contributing to the onset and maintenance of pain in OA patients; clinical data on the use of tapentadol in this setting will then be presented and commented. [ABSTRACT FROM AUTHOR]

Background: Chronic pain (CP) has been shown as an important public health problem and several studies emphasize the need to strengthen the health care and social systems to reduce its marginalization. This study aimed to: evaluate the epidemiology of CP in the general population in an Italian area and assess the awareness of a specific law, unanimously approved in Parliament, which provides citizens the right to access pain management ( Italian Law 38/2010). Methods: A cross-sectional population-based study carried out during the spring of 2014 at Narni, Umbria, Italy. All the citizens residing in that area, aged >18, were enrolled in the study. Outcome measures were: prevalence of CP and therapies. The awareness of the Italian Law 38/2010 was also recorded. Results: Data of 1293 questionnaires were analyzed. The prevalence of CP was 28.4%. In 51.5% of cases, pain was severe, with higher prevalence in females (p<0.001). Moreover, pain was generally increasing with age (p<0.001). The risk of suffering from severe pain was modeled using logistic regression. Significant predictors were female gender (OR 2.59; 95% CI: 1.77-3.79), living in an urban area (OR 0.63; 95% CI 0.45-0.88) and age (OR 1.06; 95% CI: 1.04-1.08). Among people with CP, 77.9% were receiving therapy; the proportion of individuals in therapy for severe pain significantly increased with age (OR 1.03; 95% CI: 1.02-1.05) and was smaller in individuals with light pain (OR 0.21; 95% CI: 0.07-0.66). The majority of subjects (61.9%) are not aware of the existence of a specific law stating their rights to receive pain management. Conclusion: CP, at least in the rural part of the community investigated in Italy, is not perceived as a chronic disease in its own right. A socio-cultural transformation in patients and in the health care system seems necessary. [ABSTRACT FROM AUTHOR]

Introduction. This observational study was designed to evaluate the efficacy of ultramicronized palmitoylethanolamide (um-PEA) (Normast®) administration, as add-on therapy for chronic pain, in the management of pain-resistant patients affected by failed back surgery syndrome. Methods. A total of 35 patients were treated with tapentadol (TPD) and pregabalin (PGB). One month after the start of standard treatment, um-PEA was added for the next two months. Pain was evaluated by the Visual Analogue Scale (VAS) at the time of enrollment (T0) and after one (T1), two (T2), and three (T3) months. Results. After the first month with TDP + PGB treatment only, VAS score decreased significantly from 5.7±0.12 at the time of enrollment (T0) to 4.3 ± 0.11 (T1) (p<0.0001); however, it failed to provide significant subjective improvement in pain symptoms. Addition of um-PEA led to a further and significant decrease in pain intensity, reaching VAS scores of 2.7 ± 0.09 (T2) and 1.7 ± 0.11 (T3, end of treatment) (p<0.0001) without showing any side effects. Conclusions. This observational study provides evidence, albeit preliminary, for the efficacy and safety of um-PEA (Normast) as part of a multimodal therapeutic regimen in the treatment of pain-resistant patients suffering from failed back surgery syndrome. [ABSTRACT FROM AUTHOR]

Chronic low back pain: Chronic pain is the most common cause for people to utilize healthcare resources and has a considerable impact upon patients' lives. The most prevalent chronic pain condition is chronic low back pain (CLBP). CLBP may be nociceptive or neuropathic, or may incorporate both components. The presence of a neuropathic component is associated with more intense pain of longer duration, and a higher prevalence of co-morbidities. However, many physicians' knowledge of chronic pain mechanisms is currently limited and there are no universally accepted treatment guidelines, so the condition is not particularly well managed.Diagnosis: Diagnosis should begin with a focused medical history and physical examination, to exclude serious spinal pathology that may require evaluation by an appropriate specialist. Most patients have non-specific CLBP, which cannot be attributed to a particular cause. It is important to try and establish whether a neuropathic component is present, by combining the findings of physical and neurological examinations with the patient's history. This may prove difficult, however, even when using screening instruments. Multimodal management: The multifactorial nature of CLBP indicates that the most logical treatment approach is multimodal: i.e. integrated multidisciplinary therapy with co-ordinated somatic and psychotherapeutic elements. As both nociceptive and neuropathic components may be present, combining analgesic agents with different mechanisms of action is a rational treatment modality. Individually tailored combination therapy can improve analgesia whilst reducing the doses of constituent agents, thereby lessening the incidence of side effects.Conclusions: This paper outlines the development of CLBP and the underlying mechanisms involved, as well as providing information on diagnosis and the use of a wide range of pharmaceutical agents in managing the condition (including NSAIDs, COX-2 inhibitors, tricyclic antidepressants, opioids and anticonvulsants), supplemented by appropriate non-pharmacological measures such as exercise programs, manual therapies, behavioral therapies, interventional pain management and traction. Surgery may be appropriate in carefully selected patients. [ABSTRACT FROM AUTHOR]

Rheumatic and joint diseases, as exemplified by osteoarthritis and rheumatoid arthritis, are among the most widespread painful and disabling pathologies across the globe. Given the continuing rise in life expectancy, their prevalence is destined to grow. Osteoarthritis, a degenerative joint disease, is, in particular, on its way to becoming the fourth leading cause of disability worldwide by 2020, with the rising incidence of obesity in addition to age being important factors. It is estimated that 25% of osteoarthritic individuals are unable to perform daily activities. Accompanying osteoarthritis is rheumatoid arthritis, which is a chronic systemic disease that often causes pain and deformity. At least 50% of those affected are unable to remain gainfully employed within 10 years of disease onset. A growing body of evidence now points to inflammation, locally and more systemically, as a promoter of damage to joints and bones, as well as joint-related functional deficits. The pathogenesis underlying joint diseases remains unclear; however, it is currently believed that cross-talk between cartilage and subchondral bone-and loss of balance between these two structures in joint diseases-is a critical element. This view is amplified by the presence of mast cells, whose dysregulation is associated with alterations of junction structures (cartilage, bone, synovia, matrix, nerve endings, and blood vessels). In addition, persistent activation of mast cells facilitates the development of spinal neuroinflammation mediated through their interaction with microglia. Unfortunately, current treatment strategies for rheumatic and articular disease are symptomatic and do little to limit disease progression. Research now should be directed at therapeutic modalities that target osteoarticular structural elements and thereby delaying disease progression and joint replacement. [ABSTRACT FROM AUTHOR]

Chronic pain affects a large proportion of the population, imposing significant individual distress and a considerable burden on society, yet treatment is not always instituted and/or adequate. Comprehensive multidisciplinary management based on the biopsychosocial model of pain has been shown to be clinically effective and cost-efficient, but is not widely available. A literature review of stakeholder groups revealed many reasons for this, including: i) many patients believe healthcare professionals lack relevant knowledge, and consultations are rushed, ii) general practitioners consider that pain management has a low priority and is under-resourced, iii) pain specialists cite non-adherence to evidence-based treatment, sub-optimal prescribing, and chronic pain not being regarded as a disease in its own right, iv) nurses’, pharmacists’ and physiotherapists’ skills are not fully utilized, and v) psychological therapy is employed infrequently and often too late. Many of the issues relating to physicians could be addressed by improving medical training, both at undergraduate and postgraduate levels – for example, by making pain medicine a compulsory core subject of the undergraduate medical curriculum. This would improve physician/patient communication, increase the use of standardized pain assessment tools, and allow more patients to participate in treatment decisions. Patient care would also benefit from improved training for other multidisciplinary team members; for example, nurses could provide counseling and follow-up support, psychologists offer coping skills training, and physiotherapists have a greater role in rehabilitation. Equally important measures include the widespread adoption of a patient-centered approach, chronic pain being recognized as a disease in its own right, and the development of universal guidelines for managing chronic non-cancer pain. Perhaps the greatest barrier to improvement is lack of political will at both national and international level. Some powerful initiatives and collaborations are currently lobbying policy-making bodies to raise standards and reduce unnecessary pain – it is vital they continue. [ABSTRACT FROM PUBLISHER]

Twenty years ago, the main barriers to successful cancer pain management were poor assessment by physicians, and patients' reluctance to report pain and take opioids. Those barriers are almost exactly the same today. Cancer pain remains under-treated; in Europe, almost three-quarters of cancer patients experience pain, and almost a quarter of those with moderate to severe pain do not receive any analgesic medication. Yet it has been suggested that pain management could be improved simply by ensuring that every consultation includes the patient's rating of pain, that the physician pays attention to this rating, and a plan is agreed to increase analgesia when it is inadequate. After outlining current concepts of carcinogenesis in some detail, this paper describes different methods of classifying and diagnosing cancer pain and the extent of current under-treatment. Key points are made regarding cancer pain management. Firstly, the pain may be caused by multiple different mechanisms and therapy should reflect those underlying mechanisms - rather than being simply based on pain intensity as recommended by the WHO three-step ladder. Secondly, a multidisciplinary approach is required which combines both pharmacological and non-pharmacological treatment, such as psychotherapy, exercise therapy and electrostimulation. The choice of analgesic agent and its route of administration are considered, along with various interventional procedures and the requirements of palliative care. Special attention is paid to the treatment of breakthrough pain (particularly with fast-acting fentanyl formulations, which have pharmacokinetic profiles that closely match those of breakthrough pain episodes) and chemotherapy-induced neuropathic pain, which affects around one third of patients who receive chemotherapy. Finally, the point is made that medical education should place a greater emphasis on pain therapy, both at undergraduate and postgraduate level. [ABSTRACT FROM AUTHOR]

In many countries, the number of elderly people has increased rapidly in recent years and this is expected to continue; it has been predicted that almost a quarter of the population in the European Union will be over 65 years of age in 2035. Many elderly people suffer from chronic pain but it is regularly under-treated, partly because managing these patients is often complex. This paper outlines the extent of untreated pain in this population and the consequent reduction in quality of life, before articulating the reasons why it is poorly or inaccurately diagnosed. These include the patient's unwillingness to complain, atypical pain presentations, multiple morbidities and cognitive decline. Successful pain management depends upon accurate diagnosis, which is based upon a complete history and thorough physical examination, as well as an assessment of psychosocial functioning. Poor physician/patient communication can be improved by using standardized instruments to establish individual treatment targets and measure progress towards them. User-friendly observational instruments may be valuable for patients with dementia. In line with the widely accepted biopsychosocial model of pain, a multidisciplinary approach to pain management is recommended, with pharmacotherapy, psychological support, physical rehabilitation and interventional procedures available if required. Declining organ function and other physiological changes require lower initial doses of analgesics and less frequent dosing intervals, and the physician must be aware of all medications that the patient is taking, in order to avoid drug/drug interactions. Non-adherence to treatment is common, and various strategies can be employed to improve it; involving the elderly patient's caregivers and family, using medication systems such as pill-boxes, or even sending text messages. In the long term, the teaching of pain medicine needs to be improved - particularly in the use of opioids - both at undergraduate level and after qualification. [ABSTRACT FROM AUTHOR]

Diffuse large B-cell non-Hodgkin's lymphoma (DLBCL) accounting for approximately 30% of new lymphoma diagnoses in adult patients. Complete remissions (CRs) can be achieved in 45% to 55% of patients and cure in approximately 30-35% with anthracycline-containing combination chemotherapy. The ageadjusted IPI (aaIPI) has been widely employed, particularly to "tailor" more intensive therapy such as high-dose therapy (HDT) with autologous hemopoietic stem cell rescue (ASCT). IPI, however, has failed to reliably predict response to specific therapies. A subgroup of young patients with poor prognosis exists. To clarify the role of HDT/ASCT combined with rituximab in the front line therapy a longer follow-up and randomized studies are needed. The benefit of HDT/ASCT for refractory or relapsed DLBCL is restricted to patients with immunochemosensitive disease. Currently, clinical and biological research is focused to improve the curability of this setting of patients, mainly young. [ABSTRACT FROM AUTHOR]

Sjogren's Syndrome (SS) is a chronic autoimmune disease characterized by the presence of xerostomia and xerophthalmia and by the dysfunction of salivary and lacrimal glands. The disease is frequently associated with other systemic manifestations, including vasculitis, pulmonary interstitial disorders and lymphoma. SS constitutes the primary cause of disability and xerostomia can represent an obstacle to deglutition and to oral hygiene, making it diffi cult for these patients to talk, eat, and swallow. In addition, it can cause tooth decay and recurring candidosis of the oral cavity, as well as premature teeth loss. The treatment of SS is based on the use of artifi cial tears, saliva substitutes, and lubricants to control the symptoms, and is usually associated with muscarinic agonist drugs such as pilocarpine, especially in cases of severe dryness. Pilocarpine has been proven to increase the secretion of saliva, but its use in clinical practices is highly limited to the short duration of its action, less than 3 hours, which considerably reduces its compliance. There have recently been studies of a new muscarinic receptor agonist, Cevimeline, which has a longer half-life than Pilocarpine (about 5 hours), and has already been commercialised in some countries. The purpose of this article is to review the published literature regarding the pharmacological and clinical properties of this drug, as well as its effi cacy, tolerability, and safety in the treatment of xerostomia in patients suffering from primary and secondary SS. [ABSTRACT FROM AUTHOR]

Introduction. Since low adherence to a long-term therapy results in a poor clinical outcome and significantly increases healthcare costs, adherence to the treatment of chronic disorders is an issue of great interest. This is particularly true of the treatment of osteoporosis (OP). Purpose of study. Adherence to the osteoporosis therapy in patients treated with bisphosphonates in tablet form has been evaluated in comparison with the adherence of those taking alendronate in soluble solution. Methods and materials. Here we present a retrospective study of 245 patients treated with alendronate, risedronate and ibandronate tablets and a prospective study of 118 patients treated with soluble alendronate. In both studies, patients have been observed for a period of 12 months. Results. The analysis of patients' persistence with the treatment plan, assessed at three, six and 12 months, revealed a significantly higher adherence (p < 0.005) in the cohort of patients treated with soluble alendronate (92.37% at 12 months) compared with those who followed the course of treatment with tablets (65.4 %, 12 months). Conclusions. The investigation showed higher adherence to the oral therapy with soluble alendronate, demonstrating that a formulation obtained by this method can contribute to a higher level of persistence with the treatment of a disease such as osteoporosis, which requires a long-term therapeutic plan. [ABSTRACT FROM AUTHOR]