Jaundice associated pruritis:A review of pathophysiology and treatment

To review the underlying pathophysiology and currently available treatments for pruritis associated with jaundice.English language literature was reviewed using MEDLINE,Pub Med,EMBASE and clinicaltrials.gov for papers and trails addressing the pathophysiology and potential treatments for pruritis associated with jaundice.Recent advances in the understanding of the peripheral anatomy of itch transmission have defined a histamine stimulated pathway and a cowhage stimulated pathway with sensation conveyed centrally via the contralateral spinothalamic tract.Centrally,cowhage andhistamine stimulated neurons terminate widely within the thalamus and sensorimotor cortex.The causative factors for itch in jaundice have not been clarified although endogenous opioids,serotonin,steroid and lysophosphatidic acid all play a role.Current guidelines for the treatment of itching in jaundice recommend initial management with biliary drainage where possible and medical management with ursodeoxycholic acid,followed by cholestyramine,rifampicin,naltrexone and sertraline.Other than biliary drainage no single treatment has proved universally effective.Pruritis associated with jaundice is a common but poorly understood condition for which biliary drainage is the most effective therapy.Pharmacological therapy has advanced but remains variably effective.     

Pharmacogenetic study of pruritus induced by epidural morphine for post cesarean section analgesia

Objective

The mechanism through which neuroaxial morphine causes pruritus has not been elucidated clearly and thoroughly.

皮肤瘙痒症血清P物质的检测及辣椒碱软膏的疗效观察

目的检测P物质在瘙痒症患者中的水平,观察辣椒碱软膏对皮肤瘙痒症的疗效及对P物质的影响。方法选取门诊确诊瘙痒症患者120例,随机分为两组,分别外用辣椒碱和丁酸氢化可的松治疗3周,观察瘙痒的缓解程度及不良反应。治疗前后ELISA法检测血清P物质浓度。结果瘙痒症患者血清P物质显著高于正常人(P<0.0001);治疗前后两组血清P物质差异均有统计学意义(P<0.0001);治疗后辣椒碱组血清P物质浓度显著低于丁酸氢化可的松组(P<0.05)。辣椒碱组和丁酸氢化可的松组的有效率分别为86.67%和70.00%,差异有统计学意义(P<0.05);丁酸氢化可的松组缓解瘙痒的平均起效时间(4.5±1.5)d较辣椒碱组(5.1±1.4)d明显缩短(P<0.05)。结论 P物质在瘙痒症的致痒中起重要作用,辣椒碱能有效降低血清中P物质,对治疗皮肤瘙痒症安全有效。     

PALLIATIVE CARE PHARMACOTHERAPY LITERATURE SUMMARIES AND ANALYSES

Timely and important studies are reviewed and commentaries provided by leading palliative care. Symptoms addressed in this issue are opioid resistant pain, itching, osteonecrosis, sever acute pain, insomnia, fatigue, and fever. Studies addressing the use of opioid rotation to manage opioid resistant pain, lidocaine for priritus due to cholestatic liver disease, osteonecrosis following use of bisphosphonates, morphine dosing for severe acute pain, sedative-hypnotics for older patients, central stimulants for chronic fatigue, and use of alternating ibuprofen and acetaminophen as an antipyretic regimen are presented.     

[Translated article] Patient-Reported Outcome Measures in Real-World Atopic Dermatitis Studies in Spain: A Systematic Review

Atopic dermatitis (AD) is a chronic inflammatory skin disease with symptoms such as pruritus that can be a major burden for patients. Patient-reported outcomes (PRO) complement clinician-reported outcomes in AD. This systematic review aims to identify and describe patient-reported outcome measures (PROM) used in observational studies of AD over the last decade in Spain. Eighteen PROM were identified to measure 13 different PRO that assess multiple aspects of the disease, including symptoms and disease severity, impact on daily activities and on work productivity/functioning, psychosocial impact, patient empowerment, and health-related quality of life (HRQoL). HRQoL, symptoms (particularly pruritus), and anxiety/depression were the most frequently assessed PRO, and the Dermatology Quality of Life Index, the Visual Analogue Pruritus Scale, and the Hospital Anxiety and Depression Scale were the most frequently used PROM, respectively. The growing number of observational studies on AD including PROM in Spain suggests that PRO are becoming increasingly important in the management of AD.     

Eosinophilic Rash Secondary to Temsirolimus

We present a case of a 73-year-old female with metastatic renal cell carcinoma, clear cell histologic subtype, who developed pruritic rash after 2 weeks of 25 mg weekly infusions of temsirolimus. Rash was located on bilateral antecubital areas and posterior knees. Skin biopsy showed spongiotic dermatitis with eosinophils. Based on history and clinical examination, a diagnosis of drug rash secondary to temsirolimus was made. Temsirolimus is a small-molecule inhibitor of the mammalian target of rapamycin (mTOR). Inhibition of mTOR kinase results in cell cycle arrest, antiangiogenesis, and apoptosis. The mechanism of skin toxicity is unknown; however, it can be hypothesized that there is a direct inhibitory effect on signaling pathways that regulate cell growth and tissue repair. The mTOR kinase inhibitor temsirolimus has shown great promise in increasing overall survival in patients with metastatic renal cell carcinoma. Dermatologic toxicities are among the most prevalent and necessitate early recognition and management, in order to maintain quality of life and consistent therapy. The patient presented was initiated on topical clobetasol resulting in rash resolution at a 2-week follow-up visit.     

A Randomized, Open-Label, Multicenter Trial of Topical Tacrolimus for the Treatment of Pruritis in Patients with Atopic Dermatitis

Background

Pruritis caused by atopic dermatitis (AD) is not always well controlled by topical corticosteroid therapy, but use of tacrolimus often helps to soothe such intractable pruritis in clinical settings.

Objective

To determine the anti-pruritic efficacy of topical tacrolimus in treating AD in induction and maintenance therapy.

Methods

Prior to the study, patients were randomly allocated into two groups, induction therapy followed by tacrolimus monotherapy maintenance, and induction therapy followed by emollient-only maintenance. In the induction therapy, the patients were allowed to use topical tacrolimus and emollients in addition to a low dose (<10 g/week) of topical steroids. Patients showing relief from pruritis were allowed to proceed to maintenance therapy. Recurrence of pruritis in maintenance therapy was examined as a major endpoint.

Results

Two-thirds of patients (44/68; 64.7%) showed relief from pruritis after induction therapy. Pruritis recurred in 23.8% (5/21) of the tacrolimus monotherapy group and in 100% (21/21) of the emollient group during maintenance period, a difference that was statistically significant.

Conclusion

Use of topical tacrolimus is effective in controlling pruritis of AD compared to emollient.     

Medidas de los resultados percibidos por el paciente en estudios de vida real en dermatitis atópica en España: revisión sistemática de la literatura

Atopic dermatitis (AD) is a chronic inflammatory skin disease with symptoms such as pruritus that can be a major burden for patients. Patient-reported outcomes (PRO) complement clinician-reported outcomes in AD. This systematic review aims to identify and describe patient-reported outcome measures (PROM) used in observational studies of AD over the last decade in Spain. Eighteen PROM were identified to measure 13 different PRO that assess multiple aspects of the disease, including symptoms and disease severity, impact on daily activities and on work productivity/functioning, psychosocial impact, patient empowerment, and health-related quality of life (HRQoL). HRQoL, symptoms (particularly pruritus), and anxiety/depression were the most frequently assessed PRO, and the Dermatology Quality of Life Index, the Visual Analogue Pruritus Scale, and the Hospital Anxiety and Depression Scale were the most frequently used PROM, respectively. The growing number of observational studies on AD including PROM in Spain suggests that PRO are becoming increasingly important in the management of AD.     

0.15%罗哌卡因与0.1%罗哌卡因复合舒芬太尼硬膜外分娩镇痛的比较

目的比较单用0.15%罗哌卡因与0.1%罗哌卡因复合舒芬太尼在硬膜外分娩镇痛的效果和不良反应。方法选择足月单胎初产妇257例,年龄18～40岁,BMI 18～35 kg/m~2,随机分为两组,分别采用0.1%罗哌卡因+舒芬太尼0.5μg/ml(A组,n=129)和0.15%罗哌卡因(B组,n=128)行硬膜外分娩镇痛。观察分娩镇痛前、硬膜外给药20 min后和产程中最大VAS疼痛评分,记录镇痛泵按压次数、补救镇痛次数、镇痛药物用量、改良Bromage评分、满意度、产程时间、分娩方式,新生儿出生后1 min和5 min的Apgar评分,记录镇痛期间皮肤瘙痒、恶心呕吐、尿潴留、产时发热等不良反应发生情况。结果两组在硬膜外给药20 min后和产程中最大VAS评分均明显低于分娩镇痛前(P0.05),但两组差异无统计学意义。两组镇痛泵按压次数、补救镇痛次数、麻醉药物用量、改良Bromage评分、满意度差异无统计学意义。两组产程时间、分娩方式、新生儿出生后1 min和5 min的Apgar评分差异无统计学意义。A组有10例(7.8%)皮肤瘙痒,而B组无一例皮肤瘙痒(P0.05)。两组恶心呕吐、尿潴留、产时发热发生率差异无统计学意义。结论单用0.15%罗哌卡因与0.1%罗哌卡因复合5μg/ml舒芬太尼对初产妇硬膜外分娩镇痛效果相当,但单用罗哌卡因时皮肤瘙痒发生率明显降低。     

Sensory symptoms in restless legs syndrome: the enigma of pain

Restless legs syndrome (RLS) is a common sensorimotor condition characterized by an urge to move the legs, worsening of symptoms at rest and during the evening/night, and improvement of symptoms with movement. Our review explores the role and impact of sensory symptoms in RLS. The phenomenology of RLS is discussed, highlighting the difficulty patients have in describing their sensations and in differentiating between sensory and motor symptoms. Sensory symptoms have a significant impact on quality of life but remain much less well understood than motor symptoms and sleep disturbances in RLS. Although RLS symptoms usually are not described as painful, sensory manifestations in RLS do share some similarities with chronic pain sensations, and RLS frequently occurs in chronic pain and neuropathic conditions. Peripheral neuropathies may account for some of the sensory disturbances in secondary RLS, while alterations in central somatosensory processing may be a more viable explanation for the sensory disturbances in primary RLS. The effectiveness of analgesics in treating RLS supports the concept of abnormal sensory modulation in RLS and suggests an overlap between pain modulatory pathways and sensory disturbances. Future studies are needed to better understand the experiential and biologic aspects of altered sensory experiences in RLS.