Relief Of Pruritus Research Articles

A retrospective, non-interventional, electronic medical record based real world data analysis in patients suffering from pruritus in type 2 diabetes mellitus

<p class="abstract"><strong>Background: </strong>There is limited data highlighting the association of pruritus with Type 2 Diabetes Mellitus (T2DM). This was the first Electronic Medical Record (EMR) based real-world observational study on the demographics, clinical characteristics, associated risk factors and treatment(s) of pruritus in T2DM in India.</p><p class="abstract"><strong>Methods:</strong> EMR data of patients was retrospectively analysed with a baseline (V1) visit and two or more follow-up visits between June 2014-December 2019.</p><p class="abstract"><strong>Results: </strong>Majority of patients were 40-64 years old and mainly females (57%). Body mass index and co-morbidity data indicated a trend of obesity and hypertension. Observed HbA1c values were high (mean value of 9%). Majority of the patients were on hydroxyzine. Miconazole, fluconazole and corticosteroids were prescribed in 40% patients. Correlation between HbA1c levels with clinical pruritus was noted.</p><p class="abstract"><strong>Conclusions: </strong>Management of glycaemia along with timely dermatological intervention is needed for pruritus relief in T2DM, the use of antihistamines; in particular, hydroxyzine, should be further evaluated.</p>

Therapeutic potential of biologics in prurigo nodularis

ABSTRACT Introduction Prurigo nodularis (PN) or chronic prurigo of nodular type (CNPG) is a subtype of chronic prurigo with severe pruritus and neuroimmune underlying pathophysiology occurring in a plethora of dermatological, systemic, neurologic, and psychiatric conditions. Areas covered We review the increasing repertoire of biologics in the treatment of CNPG focusing on those targeting interleukins 4, 13, 31, oncostatin M and IgE. Presented information is based on a database research on current clinical trials (clinicaltrials.gov, European Clinical Trials Database (EudraCT), US clinical trial registry ICH-GCP) and a PubMed search for latest publications conducted with the combinations of the terms ‘chronic prurigo,’ ‘prurigo nodularis,’ ‘pathophysiology,’ ‘treatment,’ ‘therapy’, and ‘biologics.’ Expert opinion CNPG gets more and more attention as new therapeutic targets have been revealed in recent years, thus allowing the use of targeted approaches. The off-label advent of dupilumab offered advanced insight into the pathogenesis of CNPG and showed an impressive relief of pruritus in the vast majority of patients. New therapies including biologics (e.g. nemolizumab, tralokinumab, lebrikizumab), small molecules (e.g. neurokinin-1 receptor antagonists, janus kinase inhibitors) as well as mu-opioid receptor antagonists and nalbuphine, a μ-antagonist/κ-agonist, are in the pipeline and offer new hope for an improved future patient care.

Outcome of loop cholecystojejunostomy as a palliative procedure in unresectable distal malignant biliary obstruction

Background: Up to 70-80% of patients with malignant biliary obstruction seek medical attention only at unresectable stage. Though R0 resection is the therapeutic modality, surgical palliation has a definite role for securing biliary bypass. Hepatico (choledocho) jejunostomy and cholecystojejunostomy are the procedures of choice. As loop CCJ is technically simple to perform as well as having less operating time and blood loss;anappealing choice. Aim of the current study was to assess the outcome of loop CCJ as a palliative procedure in unresectable distal malignant biliary obstruction.Methods: 25 patients who underwent loop CCJ for radiologically and histopathologically proven unresectable distal malignant biliary obstruction in GMC, Thiruvananthapuram, were studied for a period from 1st January 2015 to 31st December 2016. Each patient was followed up for 6 months post operatively for the occurrence of cholangitis, relief from pruritus, number of hospitalization, duration of hospital stay, postoperative 30 day mortality and life span. Pre and postoperative serum bilirubin were studied using paired t test. Palliative surgery outcome score was calculated to assess the outcome.Results: Serum bilirubin levels were significantly reduced postoperatively. Mean pre and post-operative total bilirubin values were 15.10±1.65 (mg/dl) and 4.30±3.04 (mg/dl) respectively with p<0.001. 80% had relief of pruritus and 96% were free of cholangitis 76% had a PSOS more than 0.7.Conclusions: Loop CCJ has acceptable outcome as a palliative option for surgical bypass to relieve jaundice, pruritus in patients with unresectable distal malignant biliary obstruction with a good PSOS. This procedure is technically simpler and having fewer incidences of post-operative cholangitis, pruritus, post-operative hospital stays as well as 30 day mortality.

Pruritus in psoriasis and atopic dermatitis: current treatments and new perspectives

Psoriasis and atopic dermatitis (AD) are two common chronic inflammatory skin diseases. Although showing different etiology and clinical manifestations, patients with either disease suffer from low health-related quality of life due to pruritus (dermal itch). Recent studies have revealed that more than 85% of psoriasis patients suffer from pruritus, and it is also the dominating symptom of AD. However, as this is a non-life treating symptom, it was partly neglected for years. In this review, we focus on current findings as well as the impact and potential treatments of pruritus in these two skin diseases. We first distinguish the type of itch based on involved mediators and modulators. This clear delineation between the types of pruritus based on involved receptors and pathways allows for precise treatment. In addition, insights into recent clinical trials aimed to alleviate pruritus by targeting these receptors are presented. We also report about novel advances in combinatorial treatments, dedicated to the type of pruritus linked to a causal disease. Altogether, we suggest that only a focused treatment tailored to the primary disease and the underlying molecular signals will provide fast and sustained relief of pruritus associated with psoriasis or AD.

US Prescription trends of antihistamines for atopic dermatitis, 2011-2016.

Antihistamine use for primary treatment of atopic dermatitis (AD) is not recommended, but current guidelines state that sedating antihistamines are favored over non-sedating antihistamines for relief of burdensome pruritus. We analyzed the National Ambulatory Medical Care Survey data to compare use of antihistamines between dermatologists and non-dermatologists. Overall, dermatologists are more likely to prescribe sedating than non-sedating antihistamines when compared to non-dermatologists (P<.001, δabs =0.45). Patients under 21years old (P=.03, δabs =0.10) and Black patients (P<.001, δabs =0.19) were also more likely to receive sedating antihistamines than non-sedating antihistamines. These findings highlight the differential prescribing practices for atopic dermatitis among physicians.

Partial Biliary Diversion May Promote Long-Term Relief of Pruritus and Native Liver Survival in Children with Cholestatic Liver Diseases

Rare cholestatic liver diseases may cause debilitating pruritus in children. Partial biliary diversion (PBD) may relieve pruritus and postpone liver transplantation which is the only other alternative when conservative treatment fails. The aim was to report long-term outcome after PBD in a population of 26 million people during a 25-year period. This is an international, multicenter retrospective study reviewing medical journals. Complications were graded according to the Clavien-Dindo classification system. Thirty-three patients, 14 males, underwent PBD at a median of 1.5 (0.3-13) years at four Nordic pediatric surgical centers. Progressive familial intrahepatic cholestasis was the most common underlying condition. Initially, all patients got external diversion, either cholecystojejunostomy (25 patients) or button placed in the gallbladder or a jejunal conduit. Early complications occurred in 14 (42%) patients, of which 3 were Clavien-Dindo grade 3. Long-term stoma-related complications were common (55%). Twenty secondary surgeries were performed due to stoma problems such as prolapse, stricture, and bleeding, or conversion to another form of PBD. Thirteen children have undergone liver transplantation, and two are listed for transplantation due to inefficient effect of PBD on pruritus. Serum levels of bile acids in the first week after PBD construction were significantly lower in patients with good relief of pruritus than in those with poor effect (13 [2-192] vs. 148 [5-383] μmol/L; p = 0.02). PBD may ensure long-term satisfactory effect on intolerable pruritus and native liver survival in children with cholestatic liver disease. However, stoma-related problems and reoperations are common.

Correction

[This corrects the article DOI: 10.7759/cureus.7419.].

Mutations in Myosin 5B in Children With Early-onset Cholestasis.

Mutations in Myosin 5B (MYO5B) are known to be associated with microvillous inclusion disease (MVID) a genetic cause of neonatal intractable diarrhoea. More recently, they have been reported in children with cholestasis but without typical gastrointestinal symptoms of MVID. We describe our series of children with cholestasis and mutations in MYO5B. Clinical, laboratory, and histological data were collected from patients with cholestasis and pathogenic mutations in MYO5B, found by next generation sequencing (NGS) but with minimal gastrointestinal disease. Six patients (3 boys) were identified. Median age at presentation was 19 months (range, 3-92). Presenting features were jaundice, pale stools, pruritus, and failure to thrive. Patients 5 and 6 had intractable diarrhoea until the age of 3 and 7 years, respectively, but currently are on full enteral diet with no intestinal symptoms. Median values for serum total bilirubin were 55 μmol/L (2-500), alanine aminotransferase 73I IU/L (32-114), γ-glutamyltransferase 7 IU/L (7-10), and serum bile acids 134 μmol/L (18-274). Three patients underwent 1 or more types of biliary diversion for symptom control. Median follow-up was 5 years (2-22). At most recent follow-up, they all reported pruritus while on antipruritics. Patient 1 had a liver transplant. We identified 6 patients, with mutations in MYO5B, early-onset cholestasis and pruritus, with variable response to biliary diversion without typical MVID.

Obstetric Cholestasis: Comparison of Maternal and Perinatal Outcome of Ursodeoxycholic Acid versus Placebo

Objectives: Objective: To compare the maternal and perinatal outcomes of ursodeoxycholic acid with placebo in obstetric cholestasis. Method: It was an open randomized parallel-group study with convenient sampling, conducted at Pakistan ordinance factories hospital (POF Hospital) Wah Cantt, from 1st June 2016-30th May 2019. Patients with obstetric cholestasis of pregnancy, diagnosed between 24-34 weeks of gestation, were randomized to receive either ursodeoxycholic acid 500mg twice daily or placebo one capsule twice daily for 4 weeks. The data was collected on a pre-designed proforma. The data of 84 patients, who full fill the inclusion criteria were analyzed using SPSS vs 19. Maternal outcomes measured were a relief in pruritus and a decrease in hepatic alanine aminotransferase levels (ALT) at the end of 2 weeks and 4 weeks of treatment. The mode of delivery was noted. Fetal outcomes measured were meconium staining of amniotic fluid and the need for neonatal intensive care unit (NICU) admission. Results: The results showed significant improvement in maternal itch score (P=0.001) and serum transaminases level (p=0.001) in patients using UDCA as compared to placebo. Although there were less number of caesarean sections (p=0.36), meconium-stained liquor (p=0.29) and NICU admissions (P=0.33) in the UDCA group the differences were not statistically significant. Conclusion: Treatment with UDCA in obstetric cholestasis improved maternal complaint of itching and decreased raised transaminases levels but did not affect significantly the mode of delivery, incidence of meconium-stained liquor and NICU admissions. Keywords: Obstetric cholestasis, Ursodeoxycholic acid, perinatal outcome, Pruritus.

Evaluation of newer imidazoles in dermatophytosis

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Eberconazole, a newer Imidazole derivative, antimycotic drug. Similarly, sertaconazole and luliconazole are also newer antifungal which all exhibit fungicidal, fungistatic and anti-inflammatory actions. But, sertaconazole in addition have antipruritic effect also.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Randomized, open-labelled, prospective study comprising of 75 patients divided into three equal groups A, B, C of 25 patients each. Group A received eberconazole 1%, Group B received sertaconazole 2% and Group C received luliconazole 1% for twice daily topical application for 4 weeks. Patients were asked to review at 2&lt;sup&gt;nd&lt;/sup&gt; and 4&lt;sup&gt;th&lt;/sup&gt; week to record clinical and mycological cure.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In this study out of 75, seventy patients completed the complete course of treatment whereas, five patients were not reported for review citing personal reasons. Parameters included are pruritus, erythema, scaling and vesicles in all three groups. In this study, marked relief of pruritus was achieved clinically with eberconazole (72.7%) followed by luliconazole and sertaconazole with 50.0% and 33.3% respectively at 4&lt;sup&gt;th&lt;/sup&gt; week of treatment phase and reduction of scaling was achieved more with eberconazole (90.9%), sertaconazole (87.5%) and luliconazole (83.3%). All three groups of patients showed successful mycological cure by confirming with negative 10% potassium hydroxide examination at the end of treatment course.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Eberconazole 1% cream was better than sertaconazole 2% cream and luliconazole 1% cream in relieving symptoms like pruritus and scaling at the end of treatment phase and follow up.&lt;/p&gt;

Case series of reports of pruritus and sipuleucel-T submitted to the Food and Drug Administration Adverse Event Reporting System

Sipuleucel-T, an autologous active cellular immunotherapy, is indicated for the treatment of asymptomatic or minimally symptomatic castration-resistant prostate cancer. The U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) received a report of pruritus without rash following the second dose of sipuleucel-T in a patient who had otherwise not started any new medications concurrent with the first and second doses of sipuleucel-T. No further sipuleucel-T was administered, but symptoms persisted for at least 6 weeks despite treatment with several medications aimed at symptomatic relief of pruritus. Rash is the only dermatologic adverse event included in the sipuleucel-T U.S. package insert. A search of the FAERS database yielded seven additional U.S. reports of pruritus and sipuleucel-T identified as the primary suspect medication; two of these occurred prior to the administration of sipuleucel-T (following leukapheresis). In data mining analyses, pruritus following sipuleucel-T was not reported more frequently than expected when compared to all other adverse event-drug/biologic combinations in FAERS. Thus, pruritus following sipuleucel-T administration was rarely, but not disproportionately, reported to FAERS. Although we cannot exclude the possibility that diabetes, malignancy, or other conditions may have contributed to pruritus in our index patient, in view of the timing of sipuleucel-T therapy and onset of symptoms, a drug/biologic-related reaction is plausible. In the appropriate clinical scenario, sipuleucel-T (or its components) should not be overlooked as a potential etiological agent in pruritus.

Ileal exclusion for pruritus treatment in children with progressive familial intrahepatic cholestasis and other cholestatic diseases

BackgroundPruritus is a major health-related quality-of-life burden in progressive familial intrahepatic cholestasis (PFIC) and other childhood cholestatic liver diseases. Several nontransplant surgical techniques were developed in an attempt to ameliorate symptoms and slow disease progression. Very few case-series have been published on a particular intervention, ileal exclusion (IE), which has been considered to be inferior to the other approaches. MethodsWe conducted a single-center retrospective chart-review case-series of patients submitted to IE as the first-line surgical treatment at our institution from 1995 to 2018. The primary goal was pruritus relief, followed by survival with the native liver and improvement in biochemical parameters. ResultsEleven patients were submitted to IE, with a mean follow-up of 60 months. Complete resolution or significant reduction of pruritus was obtained in 72.7% (n = 8) of patients. One patient (9.1%) had a major postoperative complication that required surgery. No other morbidities were reported. Two cases progressed to end-stage liver disease (ESLD) within the short-term and one year after surgery. ConclusionsThis case series study shows that IE provided excellent results in pruritus control and permitted survival with the native liver. We believe IE is a safe procedure, with few associated morbidities, and should be considered more often as primary surgical treatment for PFIC and other cholestasis. Level of evidenceIV.

2481 Severe Transaminitis in Intrahepatic Cholestasis of Pregnancy: An Atypical Presentation

INTRODUCTION: Intrahepatic cholestasis of pregnancy (ICP) is a self-resolving hepatic condition noted during the second and third trimesters of pregnancy. ICP is a relatively benign condition. However in severe cases ICP can influence fetal outcomes resulting in prematurity and rarely intrauterine fetal demise. Diagnosis of ICP is clinical and suspected when pregnant patients present with moderate to severe pruritus and concomitant elevation in serum aminotransferases and/or bile acids. Total bile acid levels can rise by 10- to 25-fold, however aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels do not characteristically increase more than two times the upper limit of normal. The mainstay of treatment, ursodeoxycholic acid (UDCA) offers symptomatic relief of pruritus and may benefit fetal outcomes. Delivery of the fetus is followed by resolution of pruritus and normalization of transaminases and bile acids. Our case describes a rare presentation of ICP with marked 10-fold increase in AST and nearly 30-fold increase in ALT. CASE DESCRIPTION/METHODS: A 31-year-old female at 28 weeks gestation was admitted for two-day history of generalized pruritus and abnormal transaminases on surveillance testing. Past histories remarkable cholecystectomy following gallstone pancreatitis. Physical examination was benign and was without scleral icterus or jaundice. Investigations were remarkable for: alkaline phosphatase (ALK) 172, gamma glutamyl transferase (GGT) 20, AST 465, ALT 1023, and total bile acids 48.7. Further evaluations revealed negative hepatitis serologies and chronic liver disease work-up, liver doppler ultrasound without occlusion, MRCP without choledocholithiasis or other features of pancreaticobiliary pathology. The patient was started on UDCA and continued follow-up with Gastroenterology and Obstetric Clinics. Shortly after initiation of UDCA, transaminases began a steady down trend. After delivery of a healthy fetus, the patient's transaminases returned to baseline levels. DISCUSSION: Classically ICP presents with mild AST and ALT elevations no more than two times the upper limit of normal. In cases of ICP presenting with marked transaminitis it is important to exclude other causes of cholestasis and hepatic disease including viral hepatitis, gallstones, preeclampsia, and HELLP syndrome. With close multi-disciplinary monitoring, even severe cases of ICP can lead to favorable fetal and maternal outcomes including complete resolution of transaminitis and uncomplicated fetal delivery.

Real-World, Non-Interventional, Observational Study of Hydroxyzine Hydrochloride in Chronic Pruritus: a Prospective, Non-Comparative Study.

IntroductionAlthough hydroxyzine is widely used for symptom relief in pruritus, its clinical safety and efficacy data in the Indian setting are scarce. We conducted a study to assess the effectiveness and tolerability of hydroxyzine in the management of Indian patients with chronic pruritus in a real-world setting.MethodsThis was a prospective, observational, patient-reported outcomes (PRO) study in patients with chronic pruritus due to dermatological causes treated with hydroxyzine as per the clinician’s discretion for a period of up to 12 weeks. The primary outcome was improvement in quality of life from baseline, assessed using the 10-point Dermatology Quality of Life Index (DLQI) at week 12 of the study period. Secondary outcomes were improvement in the pruritus scores (5-D itch scale) at 12 weeks, improvements in the DLQI and 5-D itch scores at 2, 4 and 8 weeks and safety.ResultsThe study included 400 patients (179 males, 221 females) from 7 dermatology centres across India. Of the 400 patients recruited, 391 patients completed at least 2 weeks of treatment. There was significant (p < 0.0001) improvement from baseline in the DLQI scores and 5-D itch scores at 2, 4, 8 and 12 weeks; 189/391 (48.34%) patients had symptom relief leading to early termination. Overall, the treatment was well tolerated with a total of 11 mild-to-moderate adverse events reported during the study, which included dizziness, constipation, drowsiness, dry mouth and sedation. All events resolved without any intervention. There were no serious adverse events.ConclusionThis real-world, observational, PRO study demonstrates that hydroxyzine significantly improves symptoms of pruritus and quality of life in patients with chronic pruritus due to dermatological causes over 12 weeks. Despite the sedating potential of the drug, hydroxyzine is well tolerated in real-world settings.Trial RegistrationCTRI/2017/06/008847.FundingDr. Reddy’s Laboratories.Electronic supplementary materialThe online version of this article (10.1007/s13555-019-0293-2) contains supplementary material, which is available to authorized users.

Efficacy and safety of bilastine in reducing pruritus in patients with chronic spontaneous urticaria and other skin diseases: an exploratory study

Purpose: To evaluate the efficacy/safety of bilastine in pruritus relief in patients with chronic spontaneous urticaria (CSU) or other pruritic skin diseases.Methods: In this multicenter, open-label, exploratory study (EudraCT No.: 2016-001505-17), 115 adults with CSU (n = 34), eczema/dermatitis (n = 30), prurigo (n = 25) or cutaneous pruritus (n = 26), received bilastine 20 mg once daily for 8 weeks, or in non-responder patients (<30% improvement in pruritus score at week 2), 40 mg/day from week 2.Results: The mean change in weekly pruritus severity score from baseline to week 8 (primary endpoint) was reduced with bilastine (overall and by disease group); overall, percentage and absolute reductions were 71.16% and 1.63 points, respectively (p < .001). Updosed non-responders (n = 31) had improved weekly pruritus severity scores from baseline to week 8; percentage and absolute reductions were 49.08% and 1.13 points, respectively (p < .001). Bilastine improved the Dermatology Life Quality Index at weeks 4 and 8 (p < .001) in all disease groups, and the 7-day Urticaria Activity Score in CSU patients (p < .001). Bilastine was well tolerated.Conclusions: Bilastine relieved pruritus associated with urticaria and other skin diseases, with a very good safety profile.

Relief of intractable pruritus with romidepsin in patients with cutaneous T ‐ cell lymphoma: A series of four cases

Cutaneous T‐cell lymphomas (CTCL) are a relatively rare and heterogeneous group of non‐Hodgkin lymphomas that typically present in the skin. The majority of patients with CTCL experience pruritus, which can interfere with daily activities, significantly impact quality of life, and is typically uncontrolled by standard anti‐itch therapies. Several lymphoma treatments have reported anti‐pruritic effects including romidepsin, a potent class 1 selective histone deacetylase inhibitor approved for the treatment of patients with CTCL who have had at least one prior systemic therapy. Here, we describe the cases of four patients with debilitating and refractory pruritus that were resolved with romidepsin. Resolution of pruritus was observed in both clinical responders and nonresponders, and dose modification was used successfully to manage adverse events and for maintenance treatment. The potential for pruritus relief with romidepsin should be considered when treating patients with CTCL.

Development of a Postburn Pruritus Relief Protocol

Postburn pruritus is a syndrome of stressful symptoms that is pervasive and occurs in over 90% of burn patients and continues for years after the burn has healed. Postburn pruritus is experienced by burn survivors that may require medical management and effective interventions. This article shows how to effectively relieve postburn pruritus by developing a postburn pruritus relief protocol. A descriptive literature review was conducted, and relevant empirical articles written during the years 2000-2014 were appraised to create a postburn pruritus relief protocol. Twenty-six of 79 articles were selected using preestablished inclusion criteria: any age group experiencing burn-related pruritus after second- or third-degree burns. Databases were Cochrane Central Register of Controlled Trials, CINAHL, EBSCO, PubMed, the National Guideline Clearinghouse, Google Scholar, and the American Burn Association website. This protocol included both nonpharmacological and pharmacological interventions that have been delineated for use and was developed to apply based on the healing stage: prehealing, healing, and posthealing.

Treatment Outcomes for Unresectable Intrahepatic Cholangiocarcinoma

No prospective randomized trial has evaluated the efficacy of no treatment with palliation of pain or jaundice, definitive concurrent chemoradiotherapy (CCRT), sequential chemotherapy (CT) and radiotherapy (RT), or CT alone for unresectable intrahepatic cholangiocarcinoma (ICC). Using propensity score (PS) matching with the Mahalanobis metric (PSM-MM), we designed a nationwide, population-based, cohort study to determine the effects of different treatments on patients with unresectable ICC. We minimized confounding of different treatment outcomes among the following unresectable ICC groups of patients from the Taiwan Cancer Registry database: group 1, definitive CCRT; group 2, sequential CT and RT; group 3, no treatment (palliative therapy; relief of pain, pruritus, or jaundice); and group 4, CT alone. The matching process yielded a final cohort of 936 patients (234, 234, 234, and 234 patients in groups 1, 2, 3, and 4, respectively). In both univariate and multivariate Cox regression analyses, adjusted hazard ratios (aHRs; 95% confidence interval [CI]) derived for the definitive CCRT and sequential CT and RT cohorts compared with the CT alone cohort were 0.54 (0.46-0.64) and 0.73 (0.62-0.87), respectively. An aHR (95% CI) of 1.95 (1.51-2.51) was derived for significant independent prognostic risk factors for poor overall survival for the no treatment cohort compared with the CT alone cohort. Adding RT to CT for unresectable ICC is more beneficial instead of CT alone. Definitive CCRT is the optimal therapy for patients with unresectable ICC without distant metastasis.

Treatment outcomes for unresectable intrahepatic cholangiocarcinoma: Nationwide, population-based, cohort study based on propensity score matching with the Mahalanobis metric

PurposeNo prospective randomized trials have been conducted to date to evaluate the efficacy of palliation of pain or jaundice without treatment, definitive concurrent chemoradiotherapy (CCRT), sequential chemotherapy and radiotherapy (CTRT), or chemotherapy (CT) alone for treating unresectable intrahepatic cholangiocarcinoma (ICC). We designed a nationwide, population-based, cohort study to determine the effects of different treatments on patients with unresectable ICC using propensity score matching (PSM) with the Mahalanobis metric. Patients and methodsWe classified patients with unresectable ICC from the Taiwan Cancer Registry database into the following 4 treatment groups: group 1, definitive CCRT; group 2, sequential CTRT; group 3, no treatment (palliative therapy for relief of pain, pruritus, or jaundice); and group 4, CT alone. Confounding factors among the 4 treatment groups were minimized through propensity score matching (PSM). ResultsAfter PSM, the final cohort consisted of 844 patients (211 patients in each of the 4 groups). In both univariable and multivariable Cox regression analyses, adjusted hazard ratios (aHRs; 95% confidence interval [CI]) derived for groups 1 and 2 compared with group 4 were 0.65 (0.59–0.71) and 0.95 (0.83–1.48), respectively. Furthermore, an aHR (95% CI) of 2.25 (1.89–2.67) was derived for significant independent prognostic risk factors for poor overall survival for group 3 compared with group 4. ConclusionsDefinitive CCRT is the optimal therapy for patients with unresectable ICC without distant metastasis.

Segment III bypass: An Option to Palliate Proximal Biliary Obstruction

Introduction: In the era of minimally invasive therapy, endoscopic or interventional radiological techniques have become preferred technique for palliating advanced malignant hilar obstruction due to carcinoma gallbladder or cholangiocarcionmas. However, in selected group of these locally advanced unresectable disease and fit patients, surgical segment III bypass could still be a viable option for palliation.&#x0D; Methods: I retrospectively reviewed the medical records of all the patients of segment III bypass performed over last six years (Oct 2012- May 2018) and analyzed the indication, perioperative morbidity, symptom relief and survival.&#x0D; Results: Total 17 patients underwent palliative biliary bypass over the specified period. Among them 8 patients underwent segment three III biliary bypass for proximal biliary obstruction. Except 1 patient, all segment three bypass were offered to malignant proximal biliary obstruction. One patient developed postoperative sepsis and had mortality on day 7. Symptom relief in the form of relief of pruritus, improved sleep pattern and improved appetite was seen in 5 patients. In remaining 2 patients, the bilirubin didn’t drop to normal level and the symptom reliefs were partial. However, the patient had good satisfaction over not having an external tube attached to their body. Despite the patent anastomosis, failure in dropping bilirubin level significantly was considered due to segmental obstructions. One patient survived for 18months, 1 had follow up to 13 months. Three patients were lost to follow up after 3 months. Two patients had six weeks follow up and were symptomatically doing better.&#x0D; Conclusion: Surgical segment III bypass is still a good option for palliating malignant hilar obstruction in selected group of patients.