Incapacitating lower limb pain syndrome in cord blood stem cell transplant recipients with calcineurin inhibitor

Calcineurin-inhibitor induced pain syndrome (CIPS) is a newly described entity with a characteristic feature of sudden onset of severe lower limb pain, and high levels of cyclosporine or tacrolimus may be involved in the pathogenesis. This syndrome is rarely seen in recipients of hematopoietic stem cell transplantation (HSCT) compared with other organ transplant recipients, however, heightened awareness of this complication after HSCT may be needed for hematologists, as misdiagnosis can result in catastrophic consequences. We report herein two cases of lower limb pain syndrome, with some clinical features resembling CIPS, occurring during the early phase of cord blood stem cell transplantation for hematological malignancy.     

The minimally effective concentration of adrenaline in a low-concentration thoracic epidural analgesic infusion of bupivacaine,fentanyl and adrenaline after major surgery. A randomized,double-blind,dose-finding study

BACKGROUND: We have documented that adrenaline 2.0 micro g.ml- 1 markedly improves relief of dynamic pain when added to a thoracic epidural analgesic infusion of bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1. Concern about possible adverse effects on spinal cord blood flow, expressed by others, prompted us to find the lowest concentration of adrenaline needed to produce effective and reliable pain relief after major surgery. METHODS: A prospective, randomized, double-blind, parallel group study was carried out in 36 patients after major thoracic or upper abdominal surgery. Patients with only mild pain when coughing during titrated thoracic epidural infusion of approximately 9 ml per hour of bupivacaine 1 mg.ml- 1, fentanyl 2 micro g.ml- 1, and adrenaline 2.0 micro g.ml- 1 were included. The study was conducted as a dose-finding study comparing three different adrenaline concentrations in the epidural mixture (0.5, 1.0, and 1.5 micro g.ml- 1) with each other and with adrenaline 2.0 micro g.ml- 1 in our standard epidural mixture. On the 1st postoperative day, the patients were randomly allocated into three equal groups of 12 patients each, and given a double-blind epidural infusion at the same rate, but with different adrenaline concentrations (0.5, 1.0, or 1.5 micro g.ml- 1). The effects were observed for 4 h or until pain when coughing became unacceptable in spite of rescue analgesia. Rescue analgesia consisted of up to two patient-controlled epidural bolus injections per hour (4 ml) and subsequent i.v. morphine, if necessary. All patients received rectal paracetamol 1 g, every 6th hour. Main outcome measures were pain intensity at rest and when coughing, evaluated by a visual analogue scale and an overall quality of pain relief score. The extent of sensory blockade was evaluated by determining dermatomal hypaesthesia to cold. RESULTS: Pain intensity when coughing increased (P < 0.001) and the number of hypaesthetic dermatomal segments decreased (P < 0.002) when the concentration of adrenaline was reduced below 1.5 micro g.ml- 1 in the triple epidural mixture. This change started within two hours after reducing the concentration of adrenaline below 1.5 micro g.ml- 1. The differences in pain intensities at rest were less pronounced. After 4 h with adrenaline 0.5 or 1.0 micro g.ml- 1 pain intensity when coughing was unacceptable in spite of rescue analgesia. After restarting the standard epidural mixture with adrenaline 2.0 micro g.ml- 1, pain intensity was again reduced to mild pain when coughing and the sensory blockade was restored. Occurrence of pruritus increased with a decreasing adrenaline concentration. CONCLUSIONS: Adrenaline in a dose-related manner improves the pain-relieving effect and sensory blockade and decreases the occurrence of pruritus of a low-concentration thoracic epidural analgesic infusion of bupivacaine 1 mg. ml- 1 and fentanyl 2 micro g.ml- 1 after major thoracic or upper abdominal surgery. The minimally effective concentration of adrenaline, when added to bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1, to maintain relief of dynamic pain is approximately 1.5 micro g.ml- 1. The data clearly document that dynamic, cough-provoked pain is a more sensitive outcome measure for postoperative pain relief than pain at rest.     

Management of sulfur mustard-induced chronic pruritus: a review of clinical trials

Skin is among the most heavily damaged organs upon sulfur mustard (SM) exposure. Chronic complications due to SM-induced dermatotoxicity are quite frequent among intoxicated patients. Nevertheless, the exact pathophysiology of SM-induced chronic cutaneous complications has not been well clarified yet. The present review highlights clinically important findings on the management of SM-induced chronic skin complications with a particular focus on pruritus as the most prevalent symptom that has a significant impact on patients’ quality of life. Some methodological pitfalls that implicate the validity of the trials have also been identified.     

Effects of thermal therapy on uremic pruritus and biochemical parameters in patients having haemodialysis

Title.  Effects of thermal therapy on uremic pruritus and biochemical parameters in patients having haemodialysis.
Aim.  This paper is a report of a trial to identify the effect of thermal therapy with far-infrared rays in comparison with non-thermal therapy on uremic pruritus and biochemical parameters.
Background.  Uremic pruritus remains one of the most frustrating, common, and potentially disabling symptoms in patients undergoing haemodialysis. The mechanism underlying uremic pruritus is poorly understood. Although enough is known to determine a reasonable treatment approach, more research is needed to evaluate more reliable treatments.
Methods.  A randomized, double-blind, controlled trial was conducted in 2005 using questionnaires and measurement of blood biochemical parameters. A total of 41 uremic patients on maintenance haemodialysis were randomly assigned either to the thermal therapy group or the control group. The thermal therapy group was treated with 40°C thermal therapy with far-infrared rays at the Sanyinjiao acupoint for 15 minutes once a day on two days a week for a total of 18 sessions. The control group received a plain adhesive patch placed on the same acupoint.
Findings.  Both groups showed statistically significant improvements but there were no differences between groups, while a relatively large decrease in pruritus scores was found in the thermal therapy group ( P  < 0·001) as compared with the non-thermal therapy group. Serum calcium level decreased statistically significantly in the thermal therapy group and was statistically significantly different from that of the control group.
Conclusion.  The lack of effect does not necessarily demonstrate that thermal therapy is not effective or has no therapeutic benefits for uremic pruritus in patients having haemodialysis. Further investigation is warranted, with larger samples and longer intervention.     

Lichen planus and other cutaneous manifestations in chronic hepatitis C: pre- and post-interferon-based treatment prevalence vary in a cohort of patients from low hepatitis C virus endemic area

Background Several controversies exist regarding the relationship between hepatitis C virus (HCV) infection and some cutaneous manifestations, lichen planus (LP) in particular. Objectives To determine the prevalence of LP and other cutaneous manifestations in a cohort of patients infected with HCV from low HCV endemic area of Slovenia, to correlate findings with chosen biological variables and to assess the role of interferon (IFN)‐based treatment of HCV infection in cutaneous manifestations. Methods A total of 171 consecutive HCV‐seropositive patients and 171 HCV‐seronegative age‐ and gender‐matched controls were studied prospectively. Prevalence of cutaneous manifestations, comparison between study patients and controls and correlation of skin findings with demographic, biochemical, virological and liver histologic findings as well as IFN‐based therapy were assessed. Results Overall presence of LP in HCV‐seropositives was 2.3%; although LP was not found in controls, the difference was not statistically significant (P = 0.123). Significantly higher than in controls was the prevalence of pruritus (31.0%, P < 0.001), dry skin (16.4%, P < 0.001) and hair loss (9.9%, P < 0.001). In IFN‐based treatment naïves, skin findings were more frequent compared with controls, but not significantly, with no correlation to chosen biological variables. Current IFN‐based treatment was significantly connected to pruritus (P < 0.001) and dry skin (P < 0.001). Compared with treatment naïves, in post‐treated patients pruritus (odds ratio, 19.13; 95% confidence interval, 6.85–53.42; P < 0.001), dry skin (odds ratio, 4.21; 95% confidence interval, 1.44–12.31; P < 0.001) and hair loss (P < 0.001) were significantly more common. Conclusions LP was not significantly related to HCV infection. Prevalence of pruritus, dry skin and hair loss was significantly higher in post‐compared with pre‐treated patients. The role of IFN in post‐treatment persistence of skin manifestations needs to be assessed.     

C ASE R EPORT: Oral antioxidant therapy for the treatment of primary biliary cirrhosis: A pilot study

BACKGROUND: The symptoms of the chronic cholestatic liver disease primary biliary cirrhosis (PBC), in particular fatigue and chronic pruritus, adversely affect quality of life and respond only poorly to treatment. Recent studies have suggested that oxidative stress may play a role in tissue damage in cholestatic liver disease and may contribute to symptoms, such as fatigue. We have, therefore, examined, in an open-label pilot study, the therapeutic effects of antioxidant medication on the biochemistry and symptomatology of PBC. METHODS: Patients were randomized to 3 months treatment with a compound antioxidant vitamin preparation (Bio-Antox), four tablets daily (n = 11, group 1), or the combination of Bio-Quinone Q10 (100 mg) with Bio-Antox (n = 13, group 2). Biochemical and symptomatic responses were assessed at 3 months. RESULTS: Significant improvement in both pruritus and fatigue was seen in the patients in group 2. Mean itch visual analogue score improved from 2.4 +/- 3.0 to 0.4 +/- 0.7 post therapy (P < 0.05) while mean night itch severity score improved from 2.6 +/- 1.9 to 1.3 +/- 0.7 (P < 0.05). Nine of 13 of these patients reported less fatigue, while 10/13 showed an improvement in at least one domain of their Fisk Fatigue Severity Score. No significant improvement in itch and only limited improvement in fatigue were seen in the patients in group 1. No change in biochemical parameters was seen in either group. CONCLUSIONS: Antioxidant therapy, as a combination of Bio-Antox and Bio-Quinone Q10, may improve the pruritus and fatigue of PBC. This combination of therapy should be investigated further in a double-blind, placebo-controlled trial.     

The specific dermatoses of pregnancy: a re-appraisal.

Pregnancy is associated with immunological, endocrine, metabolic and vascular changes that may adversely affect the skin. The specific dermatoses of pregnancy are disease entities almost exclusively related to the pregnancy or the puerperium. Learning objective: At the conclusion of this learning activity, participants should be aware of the main entities of the specific pregnancy dermatoses, their clinical presentations, the main diagnostic criteria and therapeutic options.     

祛风排毒止痒汤药浴联合氯雷他定片口服治疗慢性肾衰竭尿毒症透析皮肤瘙痒的效果

分析对尿毒症皮肤瘙痒患者应用祛风排毒止痒汤药浴治疗的效果。方法 选取2022年10月- 2023年10月于镇江市中医院接受透析治疗的80例尿毒症患者为研究对象，患者均于透析期间出现皮肤 瘙痒合并症，按入院时间先后将其分为对照组和观察组，每组40例。对照组予以氯雷他定片口服治 疗，观察组予以祛风排毒止痒汤药浴联合氯雷他定片口服治疗，比较两组症状评分、血清学指标及临 床疗效。结果 观察组治疗后瘙痒症状评分、继发皮损症状评分均低于对照组（P ＜0.05）；观察组治疗 后血清IL-2、TNF-α、IgE、P、Ca水平均低于对照组（P ＜0.05）；观察组治疗总有效率为90.00%，高 于对照组的70.00%（P ＜0.05）。结论 祛风排毒止痒汤药浴联合氯雷他定片口服治疗尿毒症皮肤瘙痒的 效果良好，能够有效改善患者的机体钙磷代谢，修复炎症反应，减轻透析相关皮肤瘙痒症状。