Background:Patients undergoing hemodialysis or peritoneal dialysis often experience pruritus which is associated with morbidity and mortality. One proposed treatment approach is to target the opioid pathway using either µ-opioid antagonists or κ-opioid agonists.Objective:To review the efficacy of targeting the opioid pathway for pruritus among dialysis patients (uremic pruritus).Design:Systematic review and meta-analysis.Setting/Methods:The systematic review included randomized controlled and randomized crossover trials identified in the MEDLINE, EMBASE, and Cochrane databases (1990 to June 2014) evaluating the efficacy of µ-opioid antagonists or κ-opioid agonists in the treatment of uremic pruritus.Patients:Adult (≥18 years) chronic dialysis patients.Measurements:The primary outcome being evaluated was reduction in itch severity measured on a patient-reported visual analog scale (VAS).Results:Five studies out of 3587 screened articles met the inclusion criteria. Three studies evaluated the efficacy of naltrexone, a µ-opioid antagonist, and 2 studies evaluated the efficacy of nalfurafine, a κ-opioid agonist. Duration of included studies was short, ranging from 2 to 9 weeks.Limitations:Due to the heterogeneity in reporting of outcomes, data from the studies evaluating naltrexone could not be pooled. Pooled analysis, using a random effects model, found that use of nalfurafine resulted in a 9.50 mm (95% confidence interval [CI], 6.27-12.74, P < .001) greater reduction of itch severity (measured on a 100-mm VAS) than placebo in the treatment of uremic pruritus.Conclusions:Nalfurafine holds some promise with respect to the treatment of uremic pruritus among dialysis patients. However, more long-term randomized controlled trials evaluating the efficacy of therapies targeting the opioid pathway for uremic pruritus are required.
Objectives Pancreaticoduodenectomy specimens are complex, with varying gross examination techniques. In 2012, our institution began using axial sectioning. We sought to determine if this resulted in more complete pathology reporting. Methods Quality indicators were analyzed for pathology reports from 2 cohorts: 2001 to 2009 grossed traditionally and 2012 to 2017 using an axial technique (n = 81 and 51). Continuous and categorical data were compared using 2-tailed t test and Fisher exact test, respectively. Results The later cohort exhibited increased reporting of stage, lymphovascular invasion, margins/surfaces, mean number of lymph nodes, and mean number of slides (P < 0.01). No differences were seen in reporting of size, grade, or perineural invasion. In the later cohort, superior mesenteric vein/portal vein surface was positive in 17 cases (33%), showing strong correlation with superior mesenteric artery/uncinate margin involvement (13/17 cases; P = 0.0001). There was a higher rate of lymph node positivity (86% vs 65%, P < 0.01) in the later cohort. Conclusions There is a trend toward higher-quality pathology reports in 2012 to 2017. A possible drawback of the axial approach is increased histopathology slides. Potential additional contributors include College of American Pathologists protocols, increasing subspecialty practice, and updates to the American Joint Committee on Cancer staging criteria.
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