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Critical Care Medicine May 2021Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review...
OBJECTIVES
Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications.
DATA SOURCES
A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane).
STUDY SELECTION
Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications.
DATA EXTRACTION
Data from the relevant publications were reviewed, summarized and the information synthesized.
DATA SYNTHESIS
This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions.
CONCLUSION
Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.
Topics: Anaphylaxis; Anti-Inflammatory Agents; Bronchodilator Agents; Critical Care; Glucocorticoids; Humans; Intensive Care Units; Life Support Care
PubMed: 33653974
DOI: 10.1097/CCM.0000000000004893 -
Journal of the European Academy of... Jul 2023Pruritus is a common symptom of cutaneous graft-versus-host disease (GVHD) following haematopoietic stem cell transplantation (HSCT). However, little is known about its... (Review)
Review
Pruritus is a common symptom of cutaneous graft-versus-host disease (GVHD) following haematopoietic stem cell transplantation (HSCT). However, little is known about its prevalence, pathophysiology, perceptual characteristics, impact on quality of life and response to antipruritic therapies. The aim of this review was to determine the current knowledge on pruritus in cutaneous GVHD. The review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement. Of the 338 studies screened, 13 were included. The prevalence of pruritus in cutaneous GVHD was reported in three studies, ranging from 37.0% to 63.8%. Only four trials used pruritus assessment tools. There was little or no information on the intensity of pruritus, its qualitative perception, the location of pruritus and the impact of pruritus on quality of life. Antipruritic treatments for GVHD-associated pruritus were mentioned in five studies (38.5%), including topical ointments (steroids, tacrolimus and calcipotriene), broadband UVB, systemic antihistamines and oral ursodeoxycholic acid. In conclusion, pruritus in cutaneous GVHD appears to be common, but very little is known about the pathophysiology, impact on quality of life and effective treatment options. Basic research and controlled clinical trials are warranted to improve knowledge and management of this important issue.
Topics: Humans; Antipruritics; Quality of Life; Skin Diseases; Pruritus; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation
PubMed: 36950958
DOI: 10.1111/jdv.19057 -
Frontiers in Medicine 2022Pruritus is a major and burdensome symptom in atopic dermatitis (AD). The number of systemic treatments available for AD has increased recently, enabling improved...
INTRODUCTION
Pruritus is a major and burdensome symptom in atopic dermatitis (AD). The number of systemic treatments available for AD has increased recently, enabling improved patient relief.
OBJECTIVE
To evaluate the effect of AD treatments on pruritus.
METHODS
A systematic literature review and a meta-analysis were conducted to evaluate and compare the effects of treatment used in AD on pruritus. PubMed and Embase databases were searched to find articles published between January 1990 and December 2021. Topical and systemic treatments were studied in patients aged ≥10 years.
RESULTS
Among the 448 articles identified, 56 studies were retained in the systematic review. A total of 15 studies evaluated topical treatments: topical corticosteroids (TCS; 2), calcineurin inhibitors (6), PDE4 inhibitors (3), and Jak inhibitors (4). A total of five studies were included in the meta- analysis. All treatments had a positive effect on pruritus, with a mean overall reduction of 3.32/10, 95% IC [2.32-4.33]. The greatest reduction was observed with halometasone (mean: 4.75), followed by tofacitinib 2% (mean: 4.38). A total of 41 studies evaluated systemic therapies: cyclosporine (6), phototherapy (5), azathioprine (2), dupilumab (9), anti-IL 13 (5), nemolizumab (3), Jak inhibitors (9), mepolizumab (1), and apremilast (1). A total of 17 studies were included in 2 meta-analyses according to the concomitant use or not of TCS. In the meta-analysis without TCS, the overall decrease was 3.07/10, 95% IC [2.58-3.56]. The molecules with the highest efficacy on pruritus were upadacitinib 30 mg (mean: 4.90) and nemolizumab (mean: 4.81).
DISCUSSION
The therapeutic arsenal for AD has increased rapidly, and many molecules are under development. The primary endpoint of clinical trials is most often a score that assesses the severity of AD; however, the assessment of pruritus is also essential. The majority of molecules have a positive effect on pruritus, but the improvement varies between them. Efficacy on pruritus is not always correlated with efficacy on AD lesions; therefore, these two criteria are crucial to evaluate. The limitations of this study were the heterogeneity in the assessment of pruritus, the moment of the assessment, and the concomitant application of TCS or not for studies evaluating systemics. In the future, it would be useful to use standardized criteria for assessing pruritus.
PubMed: 36619624
DOI: 10.3389/fmed.2022.1079323 -
British Journal of Anaesthesia Sep 2023Neuraxial opioids provide effective analgesia for Caesarean delivery, however, pruritus can be a troubling side-effect. Effective agents to prevent pruritus are needed.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Neuraxial opioids provide effective analgesia for Caesarean delivery, however, pruritus can be a troubling side-effect. Effective agents to prevent pruritus are needed. Our objective was to perform an updated systematic review and network meta-analysis to provide clinicians with a comparison of relative efficacy of available interventions to reduce the incidence of pruritus, induced by either intrathecal or epidural single-shot morphine, in women undergoing Caesarean delivery.
METHODS
Databases systematically searched (up to January 2022) included PubMed MEDLINE, Web of Science, EBSCO CINAHL, Embase, LILACS, and two Cochrane databases. We included randomised, controlled trials involving adult female patients undergoing Caesarean delivery. We pooled trials comparing interventions used for preventing pruritus after Caesarean delivery and performed a Bayesian model network meta-analysis.
RESULTS
The final primary network included data from comparisons of 14 distinct interventions (including placebo) used to reduce the incidence of pruritus in 6185 participants. We judged five interventions to be 'definitely superior' to placebo: propofol, opioid agonist-antagonists (neuraxial), opioid antagonists, opioid agonist-antagonists (systemic), and serotonin antagonists. For the network evaluating the incidence of severe pruritus (warranting additional therapeutic treatment of pruritus), data were available for 14 interventions (including placebo) in 4489 patients. For this outcome, we judged three interventions to be 'definitely superior' to placebo: dopamine antagonists (neuraxial) and systemic and neuraxial opioid agonist-antagonists.
CONCLUSION
Our analysis found several interventions to be effective in reducing the incidence of pruritus. Although sub-hypnotic doses of propofol appear to have an antipruritic effect, replication of this finding and further investigation of optimal dosing are warranted.
SYSTEMATIC REVIEW PROTOCOL
PROSPERO (CRD42022367058).
Topics: Pregnancy; Adult; Humans; Female; Morphine; Analgesics, Opioid; Propofol; Network Meta-Analysis; Bayes Theorem; Cesarean Section; Pruritus
PubMed: 37455197
DOI: 10.1016/j.bja.2023.05.028 -
Journal of Clinical Medicine Feb 2022Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are two types of chronic cholestatic liver disease (CCLD). Little is known regarding the... (Review)
Review
Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are two types of chronic cholestatic liver disease (CCLD). Little is known regarding the relationship between these conditions and pregnancy. We performed a systematic review and meta-analysis regarding the maternal and fetal outcomes amongst patients with a known diagnosis of PBC and PSC undergoing pregnancy. Our analysis shows that patients with PBC and PSC who undergo pregnancy are at an increased risk of pre-term delivery, as well as the development of new or worsening pruritus during pregnancy. Additionally, patients with PBC are at higher risk of undergoing a biochemical disease flare during the postpartum period compared to during pregnancy. However, there were no documented cases of maternal mortality or development of decompensated cirrhosis during pregnancy or the postpartum period.
PubMed: 35207342
DOI: 10.3390/jcm11041068 -
The Australasian Journal of Dermatology May 2022Hypertrophic scars (HTS) are elevated scars which occur due to abnormalities in wound healing after injury and may be associated with pain, pruritus and functional... (Meta-Analysis)
Meta-Analysis Review
Hypertrophic scars (HTS) are elevated scars which occur due to abnormalities in wound healing after injury and may be associated with pain, pruritus and functional impairment. Despite multiple available treatment options, there is no universal approach to treating HTS. We searched the Web of Science (Core Collection), MEDLINE and EMBASE databases. Title, abstract and full-text screening, along with data extraction, were performed in duplicate. Risk of bias was assessed using the Cochrane risk-of-bias tool. The Vancouver Scar Scale (VSS) scores and mean differences were used for meta-analysis. We screened 3800 abstracts and included 34 randomised controlled trials evaluating treatments for HTS in adults. Silicone and laser modalities improved VSS scores by 5.06 (95% CI: 6.78, 3.34) and 3.56 (95% CI: 5.58, 1.54), respectively. Intralesional triamcinolone combined with silicone or 5-fluorouracil was superior to intralesional triamcinolone monotherapy. Limitations of this study include exclusion of studies which did not utilise VSS, and pooling of studies based on common modalities. Further studies are needed to examine the efficacy of existing and emerging treatment modalities for HTS. Our study supports the treatment of HTS in adults with silicone gel or sheets, injected triamcinolone (preferably combined with 5-fluorouracil or silicone products), pulsed dye laser and fractionated CO laser.
Topics: Adult; Cicatrix, Hypertrophic; Fluorouracil; Humans; Keloid; Silicones; Treatment Outcome; Triamcinolone
PubMed: 35099068
DOI: 10.1111/ajd.13790 -
Sleep Medicine Reviews Oct 2016Psoriasis is an immune-mediated chronic inflammatory disorder which manifests as dermatologic lesions, and psoriatic arthritis (PsA) in about 30% of cases. Psoriasis is... (Review)
Review
Psoriasis is an immune-mediated chronic inflammatory disorder which manifests as dermatologic lesions, and psoriatic arthritis (PsA) in about 30% of cases. Psoriasis is associated with multiple comorbidities including metabolic syndrome, hypertension, diabetes, cardiovascular events, obesity and psychiatric disorders, which can all affect the course of sleep disorders. A systematic review of the literature on the relationship between psoriasis, PsA, and formal sleep disorders identified 33 studies. There is an increased prevalence of obstructive sleep apnea (OSA) with 36%-81.8% prevalence in psoriasis versus 2%-4% in the general population. There was also an increase in the prevalence of restless legs syndrome of 15.1%-18% in psoriasis versus 5%-10% in European and North American samples. The wide variety of insomnia criteria used in studies resulted in an insomnia prevalence of 5.9%-44.8% in psoriasis, which is insufficient to show an elevated prevalence when the general population has a 10% prevalence of chronic insomnia and 30-35% prevalence of transient insomnia. There is evidence that symptoms of insomnia in psoriasis are directly mediated by pruritus and pain. Treatments that decrease the cutaneous symptoms in psoriasis were successful in mitigating insomnia, but did not show improvements in OSA where the relationship with psoriasis is multifactorial.
Topics: Comorbidity; Humans; Psoriasis; Restless Legs Syndrome; Sleep Apnea, Obstructive; Sleep Initiation and Maintenance Disorders; Sleep Wake Disorders
PubMed: 26624228
DOI: 10.1016/j.smrv.2015.09.003 -
Journal of Clinical Gastroenterology Feb 2023We aim to summarize the current management of pruritus in primary biliary cholangitis (PBC) by evaluating the efficacy and safety of pharmacological therapies. (Meta-Analysis)
Meta-Analysis
GOALS
We aim to summarize the current management of pruritus in primary biliary cholangitis (PBC) by evaluating the efficacy and safety of pharmacological therapies.
BACKGROUND
Pruritus is a common symptom of PBC, and evidence regarding the most effective antipruritic agents available is lacking. New pharmacotherapy for PBC has shown promising antipruritic effects.
STUDY
We performed a systematic literature review and meta-analysis including all available double-blind, randomized, placebo-controlled clinical trials that evaluated the efficacy of pharmacotherapy for the symptomatic management of pruritus in PBC. Pruritus was assessed as either a change from baseline or a postintervention score.
RESULTS
We included 33 studies and 20 medications. Using the visual analog scale, cholestyramine did not significantly improve pruritus compared with placebo [standardized mean differences (SMD): -0.94, 95% CI: -2.05 to 0.17], whereas rifampin and nalfurafine hydrochloride both significantly improved pruritus (SMD: -3.29, 95% CI: -5.78 to -0.80; n=23 and SMD: -0.58, 95% CI: -1.04 to -0.12). In addition, Bezafibrate and linerixibat significantly improved pruritus (SMD: -1.05, 95% CI: -1.41 to -0.68; n=110 and SMD: -0.31, 95% CI: -0.62 to -0.04, respectively). This effect was also present within the subgroup analysis by pruritus scale, where both bezafibrate and linerixibat significantly improved pruritus compared with placebo (SMD: -1.09, 95% CI: -1.54 to -0.65; P <0.001; visual analog scale; as postintervention score and SMD: -0.31, 95% CI: -0.62 to -0.01; P =0.04; numeric rating scale; as a change from baseline score, respectively).
CONCLUSIONS
Bezafibrate and Linerixibat are potential second-line antipruritic medications for PBC, particularly those with moderate to severe pruritus.
Topics: Humans; Liver Cirrhosis, Biliary; Antipruritics; Treatment Outcome; Bezafibrate; Randomized Controlled Trials as Topic; Pruritus
PubMed: 36598806
DOI: 10.1097/MCG.0000000000001797 -
Archives of Dermatological Research Jul 2023Chronic inflammatory skin disorders are known to affect sleep quality; however, the relationship between hidradenitis suppurativa (HS) and sleep is not well understood....
Chronic inflammatory skin disorders are known to affect sleep quality; however, the relationship between hidradenitis suppurativa (HS) and sleep is not well understood. We performed a systematic review of HS and sleep disorders and sleep quality in HS patients. We identified seven studies comprising 343,870 subjects. We found that HS patients have a higher likelihood of having a sleep disorder such as obstructive sleep apnea, as well as other non-sleep apnea. Several studies showed that patients reported worse sleep quality due to symptoms of HS such as pruritus and pain. HS patients may be at risk for additional cardiovascular comorbidities and poorer quality of life secondary to these sleep disorders and poor sleep quality. Further high-quality research evaluating these associations is warranted.
Topics: Humans; Hidradenitis Suppurativa; Quality of Life; Skin; Comorbidity; Sleep Wake Disorders
PubMed: 36396891
DOI: 10.1007/s00403-022-02460-x -
BMJ Open Feb 2022To systematically assess the prevalence and risk factors for senile pruritus (SP) in the elderly (≥60 years of age). (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To systematically assess the prevalence and risk factors for senile pruritus (SP) in the elderly (≥60 years of age).
DESIGN
A meta-analysis was used to pool the prevalence and risk factors for SP estimated from individual studies. Four subgroup analyses were conducted to explore the prevalence for SP in different age, sex, research sites and region.
SETTING, PARTICIPANTS AND MEASURES
SP reduces quality of life in the elderly, yet the worldwide prevalence is unclear. Moreover, the risk factors for SP are controversial. Data from cross-sectional studies, case-control studies, longitudinal studies and cohort studies that reported the prevalence or the risk factors for SP were collected by searching nine electronic databases up to October 2020, including Web of Science, PubMed, Embase, Cochrane Library, CINAHL, CBM, CNKI, Wanfang and VIP. Two reviewers independently screened studies according to the inclusion and exclusion criteria, extracted data and assessed methodological quality. Data analysis was performed using Stata V.15.1 software.
RESULTS
Seventeen studies involving 28 666 participants were included. The overall pooled prevalence of SP was 21.04% (95% CI 11.37% to 32.72%). In addition, the results showed that smoking, excessive drinking and monophagism were possible risk factors for SP, with pooled ORs of 1.26 (95% CI 1.14 to 1.40), 25.03 (95% CI 18.28 to 34.25) and 1.22 (95% CI 1.12 to 1.33), respectively.
CONCLUSIONS
The overall prevalence of SP was high. Smoking, excessive drinking and monophagism were possible risk factors for SP.
PROSPERO REGISTRATION NUMBER
CRD42019143295.
Topics: Aged; Cross-Sectional Studies; Humans; Prevalence; Pruritus; Quality of Life; Risk Factors
PubMed: 35210338
DOI: 10.1136/bmjopen-2021-051694