Actigraphy-measured nocturnal wrist movements and assessment of sleep quality in patients with bullous pemphigoid: a pilot case-control study

Burden of Disease of Bullous Pemphigoid: A Targeted Literature Review

BACKGROUND

Bullous pemphigoid (BP) is a rare, chronic, autoimmune, blistering disease characterized by heterogenous lesions including the formation of fluid-filled blisters on frequently flexed areas of the skin and involvement of the mucosa in 10-25% of patients. BP mainly affects older patients and is associated with increased morbidity and mortality. The aim of the targeted literature review was to assess the clinical, humanistic, and economic burden associated with BP.

SUMMARY

Targeted searches were conducted in Embase and MEDLINE for studies published in English up to November 2022 that reported burden of illness of BP. A total of 42 publications on the clinical (n = 37), humanistic (n = 6), and economic (n = 8) burden of BP were identified. BP was associated with a high mortality rate (27-72%) and an increased risk of death compared to matched controls. The majority of patients had at least one comorbidity, including hypertension, diabetes mellitus, stroke, and neurological disorders, and showed severe symptoms such as itching and pain. BP was associated with a negative impact on BP- and pruritus-related quality of life and mental health, with 31% and 38% of patients with BP experiencing depression and anxiety in the "borderline/abnormal" range, respectively. BP was further associated with high economic burden, reflected by increased healthcare resource utilization, such as longer hospital stays (7.3 days in patients with BP vs. 4.7 days in those without BP), and direct disease-related costs.

KEY MESSAGES

This review provides a detailed assessment of the evidence base for BP, characterizing key aspects of the disease burden including clinical, humanistic, and economic burden. The results emphasize that this rare disease is associated with a substantial burden to patients and have implications for clinical practice in the management of BP.

Psychopathology Associated with Chronic Pruritus: A Systematic Review

There are no previous studies of the psychopathology associated with different aetiologies of chronic pruritus. A systematic review was performed of cohort and case-control studies comparing healthy controls with patients with chronic pruritus related to primary dermatoses, systemic diseases, psychogenic pruritus, idiopathic pruritus, prurigo nodularis and/or lichen simplex chronicus. The review was registered in PROSPERO and performed according to the PRISMA statement, which allowed the inclusion of 26 studies. The quality of eligible studies was assessed using the modified Newcastle-Ottawa Scale. Most of the studies concern primary dermatoses and systemic diseases. Sleep disorders are a common comorbidity interrelated with pruritus, anxiety and depressive symptoms, in primary dermatoses. Sleep disorders are linked with pruritus and depressive symptoms in end-stage renal disease and hepatobiliary disease. Depressive and anxiety symptoms are associated with psychogenic pruritus. Psychogenic pruritus, lichen simplex chronicus and some primary dermatoses are linked with personality characteristics. Further studies are required to explore in depth the psychopathology linked with psychogenic pruritus and prurigo nodularis, as well as psychopathology linked with other primary dermatoses and systemic disorders associated with chronic pruritus, and to better differentiate psychogenic pruritus from psychopathological characteristics linked with other aetiologies of chronic pruritus, in order to improve the management of patients with chronic pruritus.

Association of autoimmune blistering disease, and specifically, pemphigus vulgaris, with cardiovascular disease and its risk factors: a systematic review and meta-analysis

Previous studies have found conflicting results about the association of autoimmune blistering disease (AIBD) with cardiovascular disease (CVD) risk. The objective of the study was to systematically review the relationship of AIBD, including pemphigus vulgaris (PV), and its treatment with CVD and CVD risk factors. MEDLINE, EMBASE, Cochrane, LILACS, SCOPUS, and Web of Science were searched. We included all studies of CVD and CVD risk factors in AIBD patients. Two reviewers performed title and/or abstract review and data extraction. Pooled random-effects meta-analysis was performed. Forty papers met inclusion criteria. AIBD was associated with higher odds of diabetes (DM) (odds ratio [95% confidence interval]: 1.809 [1.258-2.601]), hypertension (HTN) (1.393 [1.088-1.784]), dyslipidemia (2.177 [1.163-4.073]) and heart failure (1.919 [1.603-2.298]), but was not associated with obesity, stroke, angina, heart attack, or arrhythmia. The pooled random-effects prevalence for treatment-related adverse events (AEs) in AIBD was 13.7% for DM, 10.7% for HTN, and 17.1% for CVD. Sensitivity analysis of high-quality studies revealed similar results. AIBD patients have increased CVD risk factors and heart failure. Systemic corticosteroid treatment results in CVD-related AEs in AIBD. Increased CVD screening and prevention strategies are warranted in AIBD.

Potential effects of shift work on skin autoimmune diseases

Shift work is associated with systemic chronic inflammation, impaired host and tumor defense and dysregulated immune responses to harmless antigens such as allergens or auto-antigens. Thus, shift workers are at higher risk to develop a systemic autoimmune disease and circadian disruption with sleep impairment seem to be the key underlying mechanisms. Presumably, disturbances of the sleep-wake cycle also drive skin-specific autoimmune diseases, but epidemiological and experimental evidence so far is scarce. This review summarizes the effects of shift work, circadian misalignment, poor sleep, and the effect of potential hormonal mediators such as stress mediators or melatonin on skin barrier functions and on innate and adaptive skin immunity. Human studies as well as animal models were considered. We will also address advantages and potential pitfalls in animal models of shift work, and possible confounders that could drive skin autoimmune diseases in shift workers such as adverse lifestyle habits and psychosocial influences. Finally, we will outline feasible countermeasures that may reduce the risk of systemic and skin autoimmunity in shift workers, as well as treatment options and highlight outstanding questions that should be addressed in future studies.

Which objective itch-assessment tools are applicable to patients with advanced cognitive impairments? A scoping review

BACKGROUND

Itching is an irritating and uncomfortable sensation that has a profound effect on patients' physical and mental health. It is a major under-recognised problem in older patients who cannot express their pain due to advanced cognitive impairment. Therefore, objective itch-assessment tools that do not rely on patients' reports of itching may be of value for this patient group.

OBJECTIVE

To summarise the characteristics of validated objective itch-assessment tools for patients with advanced cognitive impairment.

METHODS

This scoping review was conducted according to the PRISMA extension for scoping reviews checklist. The PubMed, CINAHL and Cochrane Library databases were searched, via database-specific search strategies, for articles published in English between January 1, 1990 and March 11, 2020. Based on the eligibility criteria, two authors independently screened the articles for inclusion. Thereafter, the lead author performed data extraction and analysis.

RESULTS

Three validated scratch-monitoring using accelerometers and a sound sensor and one validated scratch-mark assessment have been reported. The Actiwatch Plus, ActiTrac^® , body-conducted sound sensor and Scoring Atopic Dermatitis index for scratching (SCORAD-scratch) had positive criterion validity outcomes. The Actiwatch Plus, ActiTrac^® and body-conducted sound sensor were significantly correlated with scratch behaviour (r = 0.91, p < 0.001; r = 0.71, p = 0.042; r = 0.99, and p-value not shown, respectively). The SCORAD-scratch was significantly correlated with subjective itch-assessment scores (r = 0.78-0.80, p = <0.0001-0.010).

CONCLUSIONS

This scoping review summarises the characteristics of validated objective itch-assessment tools to investigate which of these are applicable to older patients with advanced cognitive impairments. Although there are limitations and further verification is required, the ActiTrac^® , Actiwatch Plus and body-conducted sound sensor may be useful for measuring scratch movements and itching.

IMPLICATIONS FOR PRACTICE

Nurses and patients' families may better understand the characteristics and validity of each objective itch-assessment tool and select the optimal tool for patients with advanced cognitive impairment who cannot express their discomfort caused due to itching.

Prevalence and Persistence of Uremic Symptoms in Incident Dialysis Patients

Background

Uremic symptoms are major contributors to the poor quality of life among patients on dialysis, but whether their prevalence or intensity has changed over time is unknown.

Methods

We examined responses to validated questionnaires in two incident dialysis cohort studies, the Choices for Health Outcomes in Caring for ESRD (CHOICE) study (N=926, 1995-1998) and the Longitudinal United States/Canada Incident Dialysis (LUCID) study (N=428, 2011-2017). We determined the prevalence and severity of uremic symptoms-anorexia, nausea/vomiting, pruritus, sleepiness, difficulty concentrating, fatigue, and pain-in both cohorts.

Results

In CHOICE and LUCID, respectively, mean age of the participants was 58 and 60 years, 53% and 60% were male, and 28% and 32% were black. In both cohorts, 54% of the participants had diabetes. Median time from dialysis initiation to the symptoms questionnaires was 45 days for CHOICE and 77 days for LUCID. Uremic symptom prevalence in CHOICE did not change from baseline to 1-year follow-up and was similar across CHOICE and LUCID. Baseline symptom prevalence in CHOICE and LUCID was as follows: anorexia (44%, 44%, respectively), nausea/vomiting (36%, 43%), pruritus (72%, 63%), sleepiness (86%, 68%), difficulty concentrating (55%, 57%), fatigue (89%, 77%), and pain (82%, 79%). In both cohorts, >80% of patients had three or more symptoms and >50% had five or more symptoms. The correlation between individual symptoms was low (ρ<0.5 for all comparisons). In CHOICE, no clinical or laboratory parameter was strongly associated with multiple symptoms.

Conclusions

The burden of uremic symptoms among patients on dialysis is substantial and has not changed in the past 15 years. Improving quality of life will require identification of the factors that underlie the pathogenesis of uremic symptoms and better ways of removing the toxins that are responsible.