Pharmacological interventions for pruritus in adult palliative care patients.

BACKGROUND: This is the second update of the original Cochrane review published in 2013 (issue 6), which was updated in 2016 (issue 11). Pruritus occurs in patients with disparate underlying diseases and is caused by different pathologic mechanisms. In palliative care patients, pruritus is not the most prevalent but is a burdening symptom. It can cause considerable discomfort and negatively affect patients' quality of life. OBJECTIVES: To assess the effects of different pharmacological treatments compared with active control or placebo for preventing or treating pruritus in adult palliative care patients. SEARCH METHODS: For this update, we searched CENTRAL (the Cochrane Library), MEDLINE (OVID) and Embase (OVID) up to 6 July 2022. In addition, we searched trial registries and checked the reference lists of all relevant studies, key textbooks, reviews and websites, and we contacted investigators and specialists in pruritus and palliative care regarding unpublished data. SELECTION CRITERIA: We included randomised controlled trials (RCTs) assessing the effects of different pharmacological treatments, compared with a placebo, no treatment, or an alternative treatment, for preventing or treating pruritus in palliative care patients. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the identified titles and abstracts, performed data extraction and assessed the risk of bias and methodological quality. We summarised the results descriptively and quantitatively (meta-analyses) according to the different pharmacological interventions and the diseases associated with pruritus. We assessed the evidence using GRADE and created 13 summary of findings tables. MAIN RESULTS: In total, we included 91 studies and 4652 participants in the review. We added 42 studies with 2839 participants for this update. Altogether, we included 51 different treatments for pruritus in four different patient groups. The overall risk of bias profile was heterogeneous and ranged from high to low risk. The main reason for giving a high risk of bias rating was a small sample size (fewer than 50 participants per treatment arm). Seventy-nine of 91 studies (87%) had fewer than 50 participants per treatment arm. Eight (9%) studies had low risk of bias in the specified key domains; the remaining studies had an unclear risk of bias (70 studies, 77%) or a high risk of bias (13 studies, 14%). Using GRADE criteria, we judged that the certainty of evidence for the primary outcome (i.e. pruritus) was high for kappa-opioid agonists compared to placebo and moderate for GABA-analogues compared to placebo. Certainty of evidence was low for naltrexone, fish-oil/omega-3 fatty acids, topical capsaicin, ondansetron and zinc sulphate compared to placebo and gabapentin compared to pregabalin, and very low for cromolyn sodium, paroxetine, montelukast, flumecinol, and rifampicin compared to placebo. We downgraded the certainty of the evidence mainly due to serious study limitations regarding risk of bias, imprecision, and inconsistency. For participants suffering from uraemic pruritus (UP; also known as chronic kidney disease (CKD)-associated pruritus (CKD-aP)), treatment with GABA-analogues compared to placebo likely resulted in a large reduction of pruritus (visual analogue scale (VAS) 0 to 10 cm): mean difference (MD) -5.10, 95% confidence interval (CI) -5.56 to -4.55; five RCTs, N = 297, certainty of evidence: moderate. Treatment with kappa-opioid receptor agonists (difelikefalin, nalbuphine, nalfurafine) compared to placebo reduced pruritus slightly (VAS 0 to 10 cm, MD -0.96, 95% CI -1.22 to -0.71; six RCTs, N = 1292, certainty of evidence: high); thus, this treatment was less effective than GABA-analogues. Treatment with montelukast compared to placebo may result in a reduction of pruritus, but the evidence is very uncertain (two studies, 87 participants): SMD -1.40, 95% CI -1.87 to -0.92; certainty of evidence: very low. Treatment with fish-oil/omega-3 fatty acids compared to placebo may result in a large reduction of pruritus (four studies, 160 observations): SMD -1.60, 95% CI -1.97 to -1.22; certainty of evidence: low. Treatment with cromolyn sodium compared to placebo may result in a reduction of pruritus, but the evidence is very uncertain (VAS 0 to 10 cm, MD -3.27, 95% CI -5.91 to -0.63; two RCTs, N = 100, certainty of evidence: very low). Treatment with topical capsaicin compared with placebo may result in a large reduction of pruritus (two studies; 112 participants): SMD -1.06, 95% CI -1.55 to -0.57; certainty of evidence: low. Ondansetron, zinc sulphate and several other treatments may not reduce pruritus in participants suffering from UP. In participants with cholestatic pruritus (CP), treatment with rifampicin compared to placebo may reduce pruritus, but the evidence is very uncertain (VAS: 0 to 100, MD -42.00, 95% CI -87.31 to 3.31; two RCTs, N = 42, certainty of evidence: very low). Treatment with flumecinol compared to placebo may reduce pruritus, but the evidence is very uncertain (RR > 1 favours treatment group; RR 2.32, 95% CI 0.54 to 10.1; two RCTs, N = 69, certainty of evidence: very low). Treatment with the opioid antagonist naltrexone compared to placebo may reduce pruritus (VAS: 0 to 10 cm, MD -2.42, 95% CI -3.90 to -0.94; two RCTs, N = 52, certainty of evidence: low). However, effects in participants with UP were inconclusive (percentage of difference -12.30%, 95% CI -25.82% to 1.22%, one RCT, N = 32). In palliative care participants with pruritus of a different nature, the treatment with the drug paroxetine (one study), a selective serotonin reuptake inhibitor, compared to placebo may reduce pruritus slightly by 0.78 (numerical analogue scale from 0 to 10 points; 95% CI -1.19 to -0.37; one RCT, N = 48, certainty of evidence: low). Most adverse events were mild or moderate. Two interventions showed multiple major adverse events (naltrexone and nalfurafine). AUTHORS CONCLUSIONS: Different interventions (GABA-analogues, kappa-opioid receptor agonists, cromolyn sodium, montelukast, fish-oil/omega-3 fatty acids and topical capsaicin compared to placebo) were effective for uraemic pruritus. GABA-analogues had the largest effect on pruritus. Rifampin, naltrexone and flumecinol tended to be effective for cholestatic pruritus. However, therapies for patients with malignancies are still lacking. Due to the small sample sizes in most meta-analyses and the heterogeneous methodological quality of the included trials, the results should be interpreted cautiously in terms of generalisability.

The morphology of the reproductive system in the crab Percnon gibbesi (Decapoda: Brachyura: Grapsoidea) reveals a new combination of characters in Thoracotremata.

Recent studies revealed a high diversity of reproductive structures in heterotreme brachyurans, while those of Thoracotremata seem rather uniform. Yet, there still is a huge lack of data in this group as only few species have been studied with respect to their reproductive system. The phylogenetic position of Percnidae is ambiguous. Recent molecular studies place it within polyphyletic grapsoids. We herein study the reproductive morphology of Percnon gibbesi using histology, scanning electron microscopy, micro-computed tomography and 3D-reconstructions to test whether this species shows the characteristic thoracotreme pattern. Our results reveal that the male copulatory system conforms to other thoracotremes. It is composed of two pairs of pleopods (gonopods) and likewise paired penes. The first gonopod is relatively long. It possesses a bent terminal process with a distal opening of the ejaculatory canal, a character also present in other grapsoids. The second gonopod is short and terminates in an apical girdle. The female reproductive system reveals a combination of characters, so far unknown for thoracotremes. The paired oviducts do not lead into the seminal receptacles, but run into separate cuticular ducts joined with the vaginae. Accessory sperm storage organs, the bursae, are also connected to the vaginae. Bursae have previously only been described in heterotreme crabs. The data presented in this study reveals a higher diversity of thoracotreme reproductive systems than anticipated.

Paradorippe granulata - A crab with external fertilization and a novel type of sperm storage organ challenges prevalent ideas on the evolution of reproduction in Eubrachyura (Crustacea: Brachyura: Dorippidae).

Two fundamentally different sperm storage organs occur in Brachyura. The probably paraphyletic podotremes show intersegmental spermathecae, which are distant from oviducts and coxal gonopores. Hence, fertilization is external. In contrast to this, the seminal receptacles of Eubrachyura are directly connected with the ovaries. Thus, at least initial fertilization is internal. This pattern has been interpreted as an apomorphy of Eubrachyura. To test this hypothesis, we studied the morphology of the reproductive organs of Paradorippe granulata, a representative of the putatively early diverging eubrachyuran lineage Dorippoidea. Applying histology, 3D-reconstructions and micro-computed-tomography we revealed a novel type of sperm storage organ. Female P.granulata lack the characteristic eubrachyuran seminal receptacle. Instead sperm is stored in four cuticle-lined bursae, two on each side of the paired oviducts. The elaborate bulbous male gonopod with several terminal processes is adapted to transferring sperm into the female twin bursae. Since oviducts and twin bursae are not directly connected, spermatozoa and oocytes mix when gametes pass through the sternal vulva. Thus, fertilization in P.granulata is external. Our finding of a eubrachyuran crab that lacks seminal receptacles and exhibits external fertilization calls prevailing concepts on the evolution of sperm storage in Eubrachyura into question.

The reproductive system of Limnopilos naiyanetri indicates a thoracotreme affiliation of Hymenosomatidae (Decapoda, Eubrachyura).

The eubrachyuran Hymenosomatoidea is widely distributed in tropical and subtropical regions ranging from marine to freshwater habitats. Even though the biology of this taxon has been studied to some extent, its phylogenetic relationships are not resolved. Based on different morphological characters, some authors suggested a close affinity of hymenosomatid crabs to heterotremes. However, many of these characters are ambiguous, and the few molecular studies did not provide convincing solutions either. To address this issue, we studied the reproductive system of the hymenosomatid freshwater species Limnopilos naiyanetri Chuang and Ng, 1991 using histology and scanning electron microscopy. The females show the characteristic organization of the paired eubrachyuran reproductive system. Additionally, a bursa (an accessory sperm storing cuticle cavity) is present. The male copulatory system is characterized by paired long first and short second gonopods, and a pair of sternal gonopores equipped with a penis. Both, the female and male reproductive organs reveal a number of similarities to thoracotreme crabs. The seminal receptacle is lined by a very thin cuticle and by a mono-layered glandular epithelium. The male gonopods and the sternal genital opening also resemble the thoracotreme condition. Thus, our results indicate that Hymenosomatidae are most likely part of the Thoracotremata.

Adaptation Aftereffects in the Perception of Crabs and Lobsters as Examples of Complex Natural Objects.

To recognize a familiar object, incoming perceptual information is matched against object representations in memory. Mounting evidence suggests that these representations are not stable, but adapt flexibly to recently encountered perceptual information. This is evident in the form of aftereffects, where prolonged exposure to one object (adaptor) influences perception of the next (test stimulus). So far, adaptation aftereffects have been mainly shown for human faces and simple geometric shapes, and it has been concluded that face aftereffects partially derive from shape adaptation. However, it is largely unknown whether adaptation aftereffects generalize to other categories of complex, naturalistic biological objects, and if so, whether these effects can be explained by shape adaptation. To answer these questions, we conducted three experiments in which images of crabs and lobsters were presented in two versions: as complex, naturalistic images, or reduced to their simplified geometric shapes. In Experiment 1, we found robust adaptation aftereffects for the complex versions of the images, indicating that adaptation aftereffects generalize to animate objects other than faces. Experiment 2 showed adaptation aftereffects for the simplified stimuli, replicating previous findings on geometric shapes. Experiment 3 demonstrated that adaptation to the simplified animal shapes results in aftereffects on the complex naturalistic stimuli. Comparisons between experiments revealed that aftereffects were largest in the first experiment, in which complex stimuli served as adaptor and test stimuli. Together, these experiments show that the magnitude of adaptation aftereffects depends on the complexity of the adaptor, but not on that of the test stimuli, and that shape adaptation plays a role in - but cannot entirely account for - the object aftereffects.

A unified scale for female reproductive stages in the Norway lobster (Nephrops norvegicus): Evidence from macroscopic and microscopic characterization.

Knowledge of the reproductive cycle in exploited species is important for a sustainable management of fisheries. Standardized scales to assess maturity stages are a fundamental tool to understand the demographic composition of exploited populations. Staging scales for female Norway lobster, Nephrops norvegicus, have been subject to a series of changes, and multiple inconsistent scales are in use in different fisheries regions. A unified, evidence-based scale has not previously been established. We reviewed previous staging scales for the female ovary maturation and propose a revised scale based on the correlation between macroscopic and microscopic ovary characteristics. To provide better-informed tools for future stock assessment, female stages were characterized through external observation on ovary color and size, and the progress of vitellogenesis. This study clarifies several biological phases that were conflated in previous scales. First, we demonstrate how to distinguish between immature ovaries in juvenile females versus the earliest ovary maturation stage in adults. Second, the new scale differentiates between "mottled" ovaries seen in two separate biological stages: the spent ovaries that undergo partial resorption in berried females, versus ovaries of females which failed to spawn and undergo full resorption. To ensure consistent application, colors are assessed relative to international standards (RAL/Pantone). This new, practical staging scheme clarifies the correlation between microscopic characteristics and macroscopically observable details in ovary maturation. Adoption of this unified staging scale will improve maturity analyses, help to identify stocks with potentially reduced reproductive capacity, and facilitate broad-scale comparisons.

The crustacean cuticle does not record chronological age: New evidence from the gastric mill ossicles.

A proposed method to determine chronological age of crustaceans uses putative annual bands in the gastric mill ossicles of the foregut. The interpretation of cuticle bands as growth rings is based on the idea that ossicles are retained through the moult and could accumulate a continuous record of age. However, recent studies presented conflicting findings on the dynamics of gastric mill ossicles during ecdysis. We herein study cuticle bands in ossicles in four species of commercially important decapod crustaceans (Homarus gammarus, Nephrops norvegicus, Cancer pagurus and Necora puber) in different phases of the moult cycle using dissections, light microscopy, micro-computed tomography and cryo-scanning electron microscopy. Our results demonstrate that the gastric mill is moulted and ossicles are not retained but replaced during ecdysis. It is therefore not plausible to conclude that ossicles register a lifetime growth record as annual bands and thereby provide age information. Other mechanisms for the formation of cuticle bands and their correlation to size-based age estimates need to be considered and the effect of moulting on other cuticle structures where 'annual growth bands' have been reported should be investigated urgently. Based on our results, there is no evidence for a causative link between cuticle bands and chronological age, meaning it is unreliable for determining crustacean age.

Phylogenetic implications of sperm storage in Podotremata: Histology and 3D-reconstructions of spermathecae and gonopores in female carrier crabs (Decapoda: Brachyura: Homoloidea).

Female reproductive systems are important characters for understanding the evolution of Brachyura and resolving its phylogenetic relationships. We herein investigate a podotreme brachyuran reproductive system comprehensively for the first time studying spermathecae and gonopores of Homoloidea with histological methods, micro-computer tomography and scanning electron microscopy. Our results show that spermathecal apertures are species-specific and their shape corresponds closely to that of male copulatory organs. Apertures were either enclosed by membranous cuticle areas or otherwise occluded preventing direct access into spermathecae. 3D-reconstructions reveal that spermathecae differ between the species Paromola cuvieri and Homola barbata with regard to the involvement of sternite 7 and 8, respectively, in forming the sperm storage chamber. The cuticle epithelium that lines the spermathecal chamber is irregular and distinct from the remaining cylindrical cuticle epithelium. A first uniramous pleopod was present in all homoloids studied and always held in a position to cover spermathecal apertures. Specific pulvinated cuticle structures present on both sides of the first pleopod are herein interpreted as adhesive structures functioning in reproductive processes. The coxal gonopores were enclosed by a laterally arising muscular mobile operculum that resembles opercula described in eubrachyuran vaginae, which raises the question whether these two structures are homologous. Our results are compared with data available for other brachyuran groups and discussed in terms of phylogenetic relationships within the Brachyura and possible functions in insemination and fertilization in Podotremata. J. Morphol. 278:89-105, 2017. ©© 2016 Wiley Periodicals,Inc.

Male internal reproductive structures of European pea crabs (Crustacea, Decapoda, Brachyura, Pinnotheridae): vas deferens morphology and spermatozoal ultrastructure.

Pea crabs of the subfamily Pinnotherinae (Pinnotheridae) have a high investment in reproduction and an outstanding reproductive output, probably as an adaptation to the required increase in reproductive rate due to the pinnotherids small size and their parasitic, host-dependant way of life. In the present study, we investigate the male internal reproductive structures and the ultrastructure of spermatozoa of Pinnotheres pisum and Nepinnotheres pinnotheres by histological methods and both scanning- and transmission electron microscopy. In the Brachyura, the male internal reproductive systems generally consist of paired testes and corresponding vasa deferentia where spermatozoa develop and mature. Spermatozoal ultrastructure of the investigated pinnotherids conforms to the thoracotreme type, however, N. pinnotheres has an accessory opercular ring and a periopercular rim, neither of which are present in spermatozoa of P. pisum. Spermatozoa are enclosed within spermatophores in the secretory proximal vas deferens. Two types of secretions were observed in P. pisum and N. pinnotheres: an electron dense substance secreted in the proximal vas deferens involved in spermatophore formation, and large electron-luscent vesicles constituting the seminal plasma in the medial and distal vas deferens. The medial vas deferens is strongly widened compared to other brachyurans to purpose storing spermatophores embedded in seminal plasma. Tubular appendices, which produce and store large amounts of seminal plasma, arise from the distal region of the vas deferens. The appendices extend into the ventral cephalothorax and also in the first pleomere. The latter being an exceptional location for reproductive structures among male brachyurans.

The male copulatory system of European pea crabs (crustacea, brachyura, pinnotheridae).

The male copulatory system of the European pinnotherid species Pinnotheres pisum, Pinnotheres pectunculi, and Nepinnotheres pinnotheres was investigated by gross morphology, scanning electron microscopy, histological methods, and confocal laser scanning microscopy. The brachyuran copulatory system is consistently formed by paired penes and two pairs of abdominal appendages, the gonopods, functioning in sperm transfer. In pinnotherids, the long first gonopods transfer the sperm mass into the female ducts. The first gonopod has the ejaculatory canal inside that opens both basally and distally. The second gonopod is solid, short, and conical. During copulation, the penis and the second gonopod are inserted into the basal lumen of the first gonopod. While the penis injects the sperm mass, the second gonopod functions in the transport of spermatozoa inside the ejaculatory canal toward its distal opening. The second gonopod is adapted for the sealing of the tubular system in the first gonopod by its specific shape and the ability to swell. Longitudinal cuticle foldings of the second gonopod hook into structures inside the first gonopod. The second gonopod can interact with the penis during copulation by a flexible flap separating the lumina in which the second gonopod and the penis are inserted.

Morphology of the female reproductive system of European pea crabs (Crustacea, Decapoda, Brachyura, Pinnotheridae).

Commensal pea crabs inhabiting bivalves have a high reproductive output due to the extension andfecundity of the ovary. We studied the underlying morphology of the female reproductive system in the Pinnotheridae Pinnotheres pisum, Pinnotheres pectunculi and Nepinnotheres pinnotheres using light microscopy and transmission electron microscopy (TEM). Eubrachyura have internal fertilization: the paired vaginas enlarge into storage structures, the spermathecae, which are connected to the ovaries by oviducts. Sperm is stored inside the spermathecae until the oocytes are mature. The oocytes are transported by oviducts into the spermathecae where fertilization takes place. In the investigated pinnotherids, the vagina is of the "concave pattern" (sensu Hartnoll1968): musculature is attached alongside flexible parts of the vagina wall that controls the dimension of its lumen. The genital opening is closed by a muscular mobile operculum. The spermatheca can be divided into two distinct regions by function and morphology. The ventral part includes the connection with vagina and oviduct and is regarded as the zone where fertilization takes place. It is lined with cuticle except where the oviduct enters the spermatheca by the "holocrine transfer tissue." At ovulation, the oocytes have to pass through this multilayered glandular epithelium performing holocrine secretion. The dorsal part of the spermatheca is considered as the main sperm storage area. It is lined by a highly secretory apocrine glandular epithelium. Thus, two different forms of secretion occur in the spermathecae of pinnotherids. The definite role of secretion in sperm storage and fertilization is not yet resolved, but it is notable that structure and function of spermathecal secretion are more complex in pinnotherids, and probably more efficient, than in other brachyuran crabs.