Ioannis Goutos

Pruritus in burns: review article.

Pruritus represents a common and distressing feature of burn wounds. Over the last decades, significant advances in neuroanatomical and neurophysiological knowledge have resulted in the elucidation of the mediators and pathways involved in the transmission of pruritic impulses. A plethora of therapeutic approaches have been evaluated mostly in small-scale studies involving burns patients targeting both the peripheral and the central components of the neurologic pathway. Antihistamines, doxepin, massage therapy, and transcutaneous electrical nerve stimulation are effective strategies to combat pruritus in burns patients. Recent studies have provided preliminary evidence regarding the effectiveness of gabapentin and ondansetron. The area of burns pruritus is under-researched and large-scale studies are required to reinforce the armamentarium of specialists with evidence-based regimens for the treatment of this highly distressing symptom.

Comparative evaluation of antipruritic protocols in acute burns. The emerging value of gabapentin in the treatment of burns pruritus.

Pruritus is a distressing symptom in burns rehabilitation and its treatment represents a challenge for the multidisciplinary burns team. We conducted a comparative study of two different therapeutic approaches in hospitalized burns patients using a combination of pharmacological agents. The observed symptomatic response to gabapentin as monotherapy as well as in combination therapy with two antihistamines was higher than chlorpheniramine alone and in combination with another two antihistamines (t = 3.70, df = 89, P < .001 for monotherapy and &khgr;2 = 12.2, df = 1, P = .001 for polytherapy). Patients with higher initial itch scores needed a combination of pharmacologic agents for effective symptomatic relief. A linear regression model showed that the likelihood of failure of monotherapy was marginally associated with decreasing patient age (P = .013) and increasing TBSA (P = .021, sum of square = 1.986, df = 2, P = .04). A combined approach using centrally and peripherally acting agents is most effective in the treatment of acute burns pruritus.

Neuropathic mechanisms in the pathophysiology of burns pruritus: redefining directions for therapy and research.

Pruritus in burn wounds is a common symptom affecting patient rehabilitation. Over the last decades, there has been a resurgence of interest into more effective strategies to combat this distressing problem; nevertheless, no reports exist in the literature to propose pathophysiological mechanisms responsible for the generation and persistence of pruritic symptoms in the late phases of burns rehabilitation. Neuronal pathways mediating pruritic and painful stimuli share striking similarities, which allows the comparative exploration of the less extensively studied pruritic mechanisms using pain models. Furthermore, emerging anatomical, neurophysiological, and pharmacological evidence supports the involvement of neuropathic mechanisms in chronic burns pruritus. This work updates the conceptual framework for the pathophysiology of burns itch by embracing the contribution of the central nervous system in the maintenance of symptoms into a chronic state. The proposed pathophysiological model paves new avenues in burns pruritus research and is likely to have implications in the quest for more effective therapeutic regimens in clinical practice.

Extravasation injuries: A review

Extravasation injuries are common emergencies in clinical practice. If they are not recognized and treated promptly, they can lead to deleterious functional and cosmetic outcomes. There is a vast range of agents involved in these injuries and marked paucity of evidence to support their specific management. Following an extensive literature review, we outline management principles for clinicians involved in the care of patients with extravasation injuries. Key parameters in deciding appropriate management plans include the volume/toxicity of the agent, the necrosis interval of the injury, patient-related factors, as well as the facilities and expertise available in the setting of individual cases of extravasation.

Obesity and Burns

The population of overweight patients presenting to burn facilities is expected to increase significantly over the next decades due to the global epidemic of obesity. Excess adiposity mediates alterations to key physiological responses and poses challenges to the optimal management of burns. The purpose of this study is to document the general epidemiological aspects of thermal injuries in the obese population, outline relevant physiological aspects associated with obesity, and draw attention to topics relating to the management, rehabilitation, and prognosis of burns in this emerging subpopulation of patients.

Review of therapeutic agents for burns pruritus and protocols for management in adult and paediatric patients using the GRADE classification.

To review the current evidence on therapeutic agents for burns pruritus and use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) classification to propose therapeutic protocols for adult and paediatric patients. All published interventions for burns pruritus were analysed by a multidisciplinary panel of burns specialists following the GRADE classification to rate individual agents. Following the collation of results and panel discussion, consensus protocols are presented. Twenty-three studies appraising therapeutic agents in the burns literature were identified. The majority of these studies (16 out of 23) are of an observational nature, making an evidence-based approach to defining optimal therapy not feasible. Our multidisciplinary approach employing the GRADE classification recommends the use of antihistamines (cetirizine and cimetidine) and gabapentin as the first-line pharmacological agents for both adult and paediatric patients. Ondansetron and loratadine are the second-line medications in our protocols. We additionally recommend a variety of non-pharmacological adjuncts for the perusal of clinicians in order to maximise symptomatic relief in patients troubled with postburn itch. Most studies in the subject area lack sufficient statistical power to dictate a ‘gold standard’ treatment agent for burns itch. We encourage clinicians to employ the GRADE system in order to delineate the most appropriate therapeutic approach for burns pruritus until further research elucidates the most efficacious interventions. This widely adopted classification empowers burns clinicians to tailor therapeutic regimens according to current evidence, patient values, risks and resource considerations in different medical environments.

Onychomatricoma: an unusual case of ungual pathology. Case report and review of the literature

Onychomatricoma represents a rare fibro-epithelial nail bed tumour. Numerous clinical variants of the condition have been described, and explicit diagnostic criteria have been recently developed. In this article, we outline the clinical and histopathological features of a case of onychomatricoma and review the literature with regards to the clinical presentation, differential diagnosis and management.

The value of MRI undertaken immediately after reduction of the hip as a predictor of long-term acetabular dysplasia

Our aim was to determine whether abnormalities noted on MRI immediately after reduction for developmental dysplasia of the hip could predict the persistance of dysplasia and aid surgical planning. Scans of 13 hips in which acetabular dysplasia had resolved by the age of four years were compared with those of five which had required pelvic osteotomy for persisting dysplasia. The scans were analysed by two consultant musculoskeletal radiologists who were blinded to the outcome in each child. The postreduction scans highlighted a number of anatomical abnormalities secondary to developmental dysplasia of the hip, but statistical analysis showed that none were predictive of persisting acetabular dysplasia in the older child, suggesting that the factors which determine the long-term outcome were not visible on these images.

Reconstruction of the burnt perionychium: literature review and treatment algorithm.

Nail apparatus deformities associated with burn injuries can cause significant functional and aesthetic concerns. The majority of perionychial deformities result from eponychial retraction and scarring, whereas a minority are due to direct damage to the regenerative part of the nail complex. A variety of different techniques have been described for reconstruction including the use of local flaps, skin/composite grafts, and microvascular transfer. The authors review the different strategies available in the current burns literature and present an algorithm for the management of perionychial burn deformities.

Sexual function following burn injuries: literature review

Sexual function is a profound facet of the human personality. Burns due their sudden and devastating nature can have longstanding effects on intimate function by virtue of physical sequelae as well as alterations in body image and perceived desirability. A considerable number of patients encounter problems with intimate function in burns rehabilitation; nevertheless, the topic appears to be poorly addressed in specialist centers worldwide. Review of the literature suggests that a number of parameters can affect the quality of sexual life following burn injuries including age at the time of injury, location, and severity of the burn as well as coping mechanisms employed by the individual survivor. Addressing issues of intimacy relies on awareness, education, and a holistic approach on behalf of the multidisciplinary team members and, to this effect, recommendations are made on managing sexual function concerns in burns rehabilitation.