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By Z. Murak. Kansas Wesleyan University.

This finding is consistent with many earlier studies in young adult chronic pain patients (see Jensen viagra soft 50 mg amex, Turner discount viagra soft 50 mg without a prescription, Romano viagra soft 50 mg on-line, & Karoly, 1991, for review) and has since been confirmed in older popula- tions as well (Bishop, Ferraro, & Borowiak, 2001). It is in the use of other coping strategies, however, that age differences start to emerge. In the elderly cohort, self-coping statements and diverting attention were shown to be significant predictors of clinical outcome measures, whereas ignoring pain and reinterpretation of pain sensations were of more importance in young chronic pain patients. As these coping strategies were secondary to catastrophizing and only account for between 5 and 10% of the variation in reports of pain, mood disturbance, and disability, the observed age differ- ence probably represents a subtle shift in the interaction between coping and clinical presentation rather than some major change. In summary, these findings document some clear age-related differ- ences in many types of pain beliefs, coping mechanisms, attribution of pain symptoms, and attitudes towards pain. These psychological influ- ences are likely to shape the overall pain experience, but observed age differences may be very dependent on the intensity of painful symptoms. If a pain symptom is mild or transient in older adults, it is likely to be at- tributed to the normal aging process, be more readily accepted, and be ac- companied by a different choice of strategy to cope with pain. These fac- tors are likely to diminish the importance of mild aches and pains, and actually alter the fundamental meaning of pain symptoms. More stoic atti- tudes to mild pain and a stronger belief in chance factors as the major de- terminant of pain onset and severity are likely to lead to the under- reporting of pain symptoms by older segments of the adult population. However, many of the age differences in coping, misattribution, and be- liefs disappear if pain is persistent or severe. There is some limited evidence of an age-related decline in the physiologic function of peripheral, spinal, and central nervous system nociceptive mechanisms. For instance, a marked decrease in the density of myelinated and unmyelinated nerve fibers has been found in older adults (Ochoa & Mair, 1969). Moreover, the neuronal content of the pain-related neuropep- tides substance P and calcitonin gene-related peptide (CGRP) are known to fall with advancing age (Helme & McKernan, 1984; Li & Duckles, 1993). Nerve conduction studies indicate a prolonged latency and decreased amplitude of sensory nerve action potentials in apparently healthy older adults (Adler & Nacimiento, 1988; Buchthal & Rosenfalck, 1966). Studies of the perceptual experience associated with activation of nociceptive fibers indicate a selec- tive age-related impairment in A fiber function and a greater reliance on C- fiber information for the report of pain in older adults (Chakour, Gibson, Bradbeer, & Helme, 1996). Given that A fibers subserve the epicritic, first warning aspects of pain, while C-fiber sensation is more prolonged, dull, and diffuse, one might reasonably expect some changes in pain quality and intensity in older adults. Three recent studies have shown that the temporal sum- mation of noxious input may be altered in older persons (Edwards & Fil- lingim, 2001; Gibson, Chang, & Farrell, 2002; Harkins, Davis, Bush, & Price, 1996). Temporal summation refers to the enhancement of pain sensation as- sociated with repeated stimulation. It results from a transient sensitization of dorsal horn neurons in the spinal cord and is thought to play an impor- tant role in the development and expression of postinjury tenderness and hyperalgesia. Zheng, Gibson, Khalil, McMeeken, and Helme (2000) extended these observations by comparing the intensity and time course of post- injury hyperalgesia in young (20–40) and older (73–88) adults. Although the intensity and area of hyperalgesia were similar in both groups, the state of mechanical tenderness persisted for a much longer duration in the older group. As mechanical tenderness is known to be mediated by sensitized spinal neurons, these findings may indicate a reduced capacity of the aged CNS to reverse the sensitization process once it has been initiated. The clin- ical implication is that postinjury pain and tenderness will resolve more slowly in older persons. However, in combination with the studies of tem- poral summation, these findings provide strong evidence for an age-related reduction in the functional plasticity of spinal nociceptive neurons follow- ing an acute noxious event. PAIN OVER THE LIFE SPAN 135 Variations in pain sensitivity depend not only on activity in the afferent nociceptive pathways but also endogenous pain inhibitory control mecha- nisms that descend from the cortex and midbrain onto spinal cord neu- rons. A recent study has shown that the analgesic efficacy of this endoge- nous inhibitory system may decline with advancing age (Washington, Gibson, & Helme, 2000). Following activation of the endogenous analgesic system, young adults showed an increase in pain threshold of up to 150% whereas the apparently healthy older adult group increased pain thresh- old by approximately 40%. Such age differences in the efficiency of endog- enous analgesic modulation are consistent with many earlier animal stud- ies (see Bodnar, Romero, & Kramer, 1988, for review) and would be expected to reduce the ability of older adults to cope with severe or per- sistent pain states. There are widespread morphological and neurochemical changes to the central nervous system with advancing age, although few studies have ex- amined those areas specifically related to the processing of nociceptive in- formation (see Gibson & Helme, 1995, for review). An investigation of the cortical response to painful stimulation has documented some changes in adults over 60 years. Using the pain-related encephalographic response in order to index the central nervous system processing of noxious input, older adults were found to display a significant reduction in peak amplitude and an increased latency of response (Gibson, Gorman, & Helme, 1990). These findings might suggest an age-related slowing in the cognitive proc- essing of noxious information and a reduced cortical activation.

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The anesthesia team and nursing team also play key roles in the actual performance of the operation buy viagra soft 100mg low price. At our institution purchase viagra soft 50mg, the anesthesia team not only administers anesthesia 100mg viagra soft visa, but also participates by holding the airway during position changes, turning on the air pressure for the Pitkin’s device, and irrigating the wounds with dilute epinephrine solution. The nursing staff has the responsibility not only for providing instruments and other equipment required to do the opera- tion but also for meshing the grafts. For excision of large burns ( 40% TBSA), we have found that two of the nursing staff should be scrubbed, with one providing instruments and another meshing the skin. TREATMENTS SPECIFIC TO ANATOMICAL LOCATION Particular anatomical regions require specific treatments. These issues should be considered and incorporated into the operative plan. Head and Neck The head and neck have an ample blood supply that enable it to resist invasive infection better than other parts of the body. It is also probably the most important area in terms of cosmesis and function (eyes, mouth). Since the face is so important cosmetically, sharp excision of eschar is not recommended in order to preserve any dermal and epidermal structures The Major Burn 243 FIGURE 3 Cosmetic units of the face. Application of sheet grafts should be in this distribution, if possible. This practice is tolerated because of the excellent blood supply to the area that resists infection. Once the eschar separates in 10–14 days, the underlying wound can be grafted. Because of the unique skin coloration in this area, autograft skin should be obtained from donor sites above the clavicles. Since it is almost always neces- sary to have seams in the grafts, the autograft skin pieces should be applied in cosmetic units, which are designed to hide the seams in natural lines on the face (Fig. Nipple/areolar Complex Because of the nature of the mammary ducts, keratinocytes are often found deep beneath the skin. These will proliferate and affect wound closure in this area if left in place. The coloration of the areola is also very specific, and not easily reconstructed outside of color tattooing. For these reasons, the nipple/areolar complex should not be excised even if it appears to have eschar and all the surrounding skin is lost. For this reason, I always try to graft this region first, before loose stools occur. If this is unsuccessful, it may be necessary to leave the patient in the prone position at later operations after application of grafts to this area while they adhere. The penis and scrotum have an excellent blood supply, so they will usually heal in a timely fashion. The skin in this region occupies a highly important function, so, in general, excision is avoided. In the case of a small burn to the shaft of the penis, excision and primary closure akin to a circumcision can suffice. The scrotum is also a very good donor site because it heals well, is relatively hidden, and can be vastly expanded to provide a surprising amount of donor skin. Most burns of the hand are limited to the dorsal surface as the hand is clenched during injury. Unfortunately, sometimes the digits sustain a second injury associated with diminished perfusion during resuscitation. I usually allow the necrotic part to demarcate clearly prior to amputation in an attempt to preserve as much length as possible; even a few millimeters will contribute greatly to function. Once a viable wound bed is achieved on the hand, grafts should be placed that are either not meshed or meshed tightly at a 1:1 ratio to improve cosmesis. Because of the anatomical structure on the dorsum of the digits, burns through to the extensor tendons can result in boutonniere deformities even with complete wound closure due to sliding of tendons medial and lateral around the proximal interphalangeal joint. Extension contractures at the metacarpophalangeal joint are also common because the burn and subsequent scarring are limited to the dorsal surface. For these two reasons, consideration should be given to fixing the digits in extension at the proximal interphalangeal joint and flexion at the metacarpophalangeal joint by insertion of threaded Kirschner wires which are removed after complete wound healing, and position can be maintained easily with splints. The skin on the palm of the hand is specialized in that it is very thick and highly keratinized to withstand the significant shearing forces. Burns to the palm of the hand are uncommon, but when they occur, should be treated with debride- ment and spontaneous separation, as they will often heal spontaneously because of the depth of the skin.

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