A Belgian consensus on the definition of a treat-to-target outcome set in psoriasis management

OBJECTIVE

Treat-to-target (T2T) is an algorithm to reach a predefined outcome. Here, we define a T2T outcome for moderate-to-severe psoriasis vulgaris.

METHODS

Briefly, the study included a literature review, discussions with key opinion leaders, recruitment of additional dermatologists with experience in managing moderate-to-severe psoriasis, 3 eDelphi survey rounds and a patient focus group. Relevant topics were selected during discussions prior to the survey for the statements. Surveys were based on the eDelphi methodology for consensus-building using a series of statements. Consensus was defined as at least 80% of participants agreeing. A psoriasis patient focus group provided feedback on topic selection and outcome.

RESULTS

A total of 5 discussions were held, and 3 eDelphi rounds were conducted with an average of 19 participants per round. The T2T outcome was set assuming shared decision between patient and dermatologist, awareness and referral for comorbidities by the dermatologist and appropriate treatment adherence by the patient. We defined 'ideal' and 'acceptable' targets; the latter referring to conditions restricting certain drugs. The T2T outcome was multidimensional, including ≥ ΔPASI90/75 or PGA ≤ 1, itch VAS score ≤ 1, absence of disturbing lesions, DLQI ≤ 1/3, incapacity daily functioning VAS score ≤ 1, safety ≤ mild side-effects and full/mild tolerability of treatment for the ideal and acceptable target, respectively. Finally, time to achieve the T2T outcome was set at 12 weeks after initiation for all treatments. At all times, safety should not exceed the presence of mild side-effects.

CONCLUSION

With this novel T2T composite outcome for psoriasis, clinicians and patients can make shared decisions on the treatment goals they envisage, as a guidance for future treatment steps - leading to a tight control management of the disease.

Depression and social capital in people living with HIV

WHAT IS KNOWN ON THE SUBJECT?: Depression affects 1 in 20 Americans, and people living with HIV experience depression at 2-3 times the rate of the general population. Recent research has shown that a person's level of social connectedness (e.g., social networks) is important to understanding their health and ability to get help when they need it. The scientific rationale of this work is to determine whether there is a direct relationship between levels of depression and a measure of social connectedness in people with HIV who are at higher than normal risk of depression and depressive symptoms. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We examined the relationship between levels of depression and social capital in people living with HIV to determine whether depression may influence their beliefs about their social connectedness and available resources. We found that as depression increases, self-reported social capital decreases, suggesting that people living with HIV who are depressed may feel less socially connected and/or not be confident they can access resources when they need them. WHAT ARE THE IMPLICATIONS FOR PRACTICE: Mental health nurses are particularly well-positioned to help people living with HIV who are living with depression by helping them build skills for building and maintaining relationships, adhering to co-administered HIV and mental health medical treatments, and helping these individuals to identify and address barriers to social connectedness. Helping people living with HIV to address depression and promoting social connectedness can not only improve quality of life, but have major long-term health benefits. Abstract Introduction People living with HIV (PLWH) are disproportionately burdened by depression, with estimates as high as 80% of PLWH reporting depressive symptoms. Depression in PLWH is complex, and has been linked with biological and psychosocial causes, including low social capital. Few studies have examined the relationship between social capital and depression in PLWH. Aim/Question We conducted a secondary analysis of the relationship between social capital (Social Capital Scale score) and depression (Beck Depression Inventory-II scores) to determine whether depression predicted levels of social capital in a sample of 108 PLWH. Results Depression was significantly associated with lower social capital r(105) = -.465 p < .001. Depression remained a significant predictor of social capital in the linear regression model, F(5,101) = 8.508, p < .000, R²  = 0.296, when controlling for age and education level. Discussion Our results suggest that depression may be a significant predictor of low social capital, and these factors may have cyclical relationships that explain persistent depression in this population. Implications for practice Mental health nurses are particularly well-positioned to help PLWH who are living with depression by helping them build skills for building and maintaining relationships, adhering to co-administered HIV and mental health medical treatments, and helping these individuals to identify and address barriers to social connectedness.

Response to IL-17A inhibitors secukinumab and ixekizumab cannot be explained by genetic variation in the protein-coding and untranslated regions of the IL-17A gene: results from a multicentre study of four European psoriasis cohorts

BACKGROUND

Genetic predictors for treatment response could optimize allocation of biological treatment in patients with psoriasis. There is minimal knowledge about pharmacogenetics of anti-IL-17 agents.

OBJECTIVES

To assess whether genetic variants in the protein-coding region or untranslated regions of the IL-17A gene are associated with response to IL-17A inhibitors in patients with psoriasis.

METHODS

This was a multicenter European cohort study investigating pharmacogenetics of IL-17A inhibitors in patients with psoriasis. Patients with plaque psoriasis treated with secukinumab or ixekizumab in daily practice were included. For all participants, the protein-coding region and untranslated regions of the IL-17A gene were analysed using Sanger sequencing. Identified genetic variants were tested for association with response to secukinumab/ixekizumab, measured as ∆PASI, after 12 weeks (primary outcome) and after 24 weeks (secondary outcome). Association was tested using a linear regression model with correction for baseline PASI as a fixed covariate and for biological naivety and body mass index as additional covariates.

RESULTS

In total, 134 patients treated with secukinumab or ixekizumab were included. Genotyping of the cohort identified genetic variants present in untranslated regions and intronic DNA, but not in the protein-coding region of the IL-17A gene. Five genetic variants in non-coding DNA with a known or suspected functional effect on IL-17A expression were selected for association analyses: rs2275913, rs8193037, rs3819025, rs7747909 and rs3748067. After 12 weeks, 62% of patients achieved PASI75 and 39% achieved PASI90. At week 24, PASI75 and PASI90 response rates were 72% and 62%, respectively. No associations were found between the five genetic variants and ∆PASI, PASI75 or PASI90 after 12 and 24 weeks of anti-IL-17A treatment.

CONCLUSIONS

Response to IL-17A inhibitors secukinumab and ixekizumab cannot be explained by genetic variation in the protein-coding and untranslated regions of the IL-17A gene. Pharmacogenetics of IL-17A inhibitors in the treatment of psoriasis requires further exploration.

Stage IV cutaneous squamous cell carcinoma: treatment outcomes in a series of 42 patients

BACKGROUND

The prevalence and incidence of cutaneous squamous cell carcinoma (cSCC) are increasing due to the ageing of the population and sun exposure. Advanced cSCC forms (locally advanced and/or locoregional metastatic and/or distant metastatic) account for approximately 3% of cSCC and can result in death.

OBJECTIVE

Analysis of the clinical characteristics and treatment outcomes in stage IV cSCC with unresectable locoregional extension and/or the presence of metastases.

METHODS

A retrospective study was conducted at a single-centre university hospital for stage IV cSCC patients followed between 1 January 2008 and 31 December 2015. Descriptive analyses (demographic, anatomo-clinical characteristics, treatment sequences, response to treatment and survival analysis) were performed.

RESULTS

The study included 42 patients (median age = 75.5 years) with a diagnosis of stage IV cSCC who were treated with at least one line of chemotherapy and/or cetuximab. At the time of diagnosis, 85.7% of the patients had locoregional extension (19% of locally advanced and 67% of locoregional metastatic) and 14.3% had distant metastatic disease. Regarding treatment, 40% and 36% of patients received no more than 1 and 2 systemic treatment lines, respectively. The 4-year overall survival was 6%, and the median follow-up was 18.6 months. The objective response rate was 55% after the first line of treatment with a median progression-free survival (PFS) of 6.18 months and 12% after the second line with a median PFS of 6.51 months. Grade 3 and 4 adverse events were observed for 33% of patients.

CONCLUSION

Our study confirms a very poor prognosis of stage IV cSCC and a poor response to conventional therapies, indicating that the stage IV cSCC patient population remains with unmet medical needs.

A retrospective analysis omalizumab treatment patterns in patients with chronic spontaneous urticaria: a real-world study in Belgium

Background

Chronic spontaneous urticaria (CSU) is characterized by the repeated occurrence of persistent hives and/or angioedema for ≥6 weeks, without specific external stimuli. H₁‐antihistamines have long been the standard of care of CSU, but many patients remain uncontrolled even at 4× the approved dose. Add‐on therapy with omalizumab has proven effective in clinical trials, but little is known about omalizumab treatment in Belgium.

Objective

To collect real‐world clinical data on omalizumab treatment in adults with CSU in Belgium.

Methods

This was an observational, retrospective chart review of adults with CSU, who initiated omalizumab treatment between August 2014 and December 2016 (maximum 28 months follow‐up).

Results

In total, 235 patients were included (median time from symptom onset to diagnosis, 5.4 months; median time from diagnosis to commencing omalizumab, 6.7 months). Treatments used before/after commencing omalizumab did not always adhere to guidelines; many patients (26.4%/11.1%) received first‐generation H₁‐antihistamines, while 20.4% used omalizumab monotherapy after initiating treatment. The mean interval between omalizumab administrations was 4.8 (SD 1.7) weeks; 67.8% of patients had ≥1 interval prolongation and/or shortening. Mean baseline 7‐day Urticaria Activity Score (UAS7) was 32.0 (SD 6.05); this improved to 12.6 (SD 11.2) after 1 month of omalizumab. About 67.2% of patients reached UAS7 ≤ 6 (well controlled) during the study. A total of 87 patients stopped omalizumab and never restarted before the end of the observation period; the most prevalent reason was remission of symptoms (49.4% of patients), followed by lack of effect (12.6%), lost to follow‐up (6.9%) and adverse events (3.4%). Headache was the most common adverse event (n = 8/82). No anaphylaxis was reported.

Conclusions

This study revealed that patients initiated on omalizumab in Belgium had severe CSU at baseline, and showed substantial improvements after 1 month of treatment. Greater adherence to the prescription of guideline‐recommended medications is needed for the treatment of CSU.

Sex differences in kappa opioid receptor inhibition of latent postoperative pain sensitization in dorsal horn

Tissue injury produces a delicate balance between latent pain sensitization (LS) and compensatory endogenous opioid receptor analgesia that continues for months, even after re-establishment of normal pain thresholds. To evaluate the contribution of mu (MOR), delta (DOR), and/or kappa (KOR) opioid receptors to the silencing of chronic postoperative pain, we performed plantar incision at the hindpaw, waited 21 days for the resolution of hyperalgesia, and then intrathecally injected subtype-selective ligands. We found that the MOR-selective inhibitor CTOP (1-1000 ng) dose-dependently reinstated mechanical hyperalgesia. Two DOR-selective inhibitors naltrindole (1-10 μg) and TIPP[Ψ] (1-20 μg) reinstated mechanical hyperalgesia, but only at the highest dose that also produced itching, licking, and tail biting. Both the prototypical KOR-selective inhibitors nor-BNI (0.1-10 μg) and the newer KOR inhibitor with more canonical pharmocodynamic effects, LY2456302 (0.1-10 μg), reinstated mechanical hyperalgesia. Furthermore, LY2456302 (10 μg) increased the expression of phosphorylated signal-regulated kinase (pERK), a marker of central sensitization, in dorsal horn neurons but not glia. Sex studies revealed that LY2456302 (0.3 μg) reinstated hyperalgesia and pERK expression to a greater degree in female as compared to male mice. Our results suggest that spinal MOR and KOR, but not DOR, maintain LS within a state of remission to reduce the intensity and duration of postoperative pain, and that endogenous KOR but not MOR analgesia is greater in female mice.

Clinical response correlates with 4-week postinjection ustekinumab concentrations in patients with moderate-to-severe psoriasis

Background

Cost‐effective use of biologicals is important. As drug concentrations have been linked to clinical outcomes, monitoring drug concentrations is a valuable tool to guide clinical decision‐making. A concentration–response relationship for ustekinumab at trough is uncertain owing to the contradictory results reported.

Objectives

To investigate the relationship between 4‐week postinjection ustekinumab concentrations and clinical response in patients with psoriasis.

Methods

Forty‐nine patients with moderate‐to‐severe psoriasis treated with 45 mg or 90 mg ustekinumab every 12 weeks for ≥ 16 weeks were included. Ustekinumab serum concentrations and anti‐ustekinumab antibodies were measured at week 4 after injection and disease severity was assessed by Psoriasis Area and Severity Index (PASI).

Results

At week 4 after injection, a significantly negative correlation was observed between ustekinumab concentrations and absolute PASI score up to 5·9 μg mL⁻¹ (ρ = –0·357, P = 0·032). Ustekinumab concentrations were higher in optimal responders (PASI ≤ 2) than in suboptimal responders (PASI > 2) (4·0 vs 2·8 μg mL⁻¹, P = 0·036). The ustekinumab concentration threshold associated with optimal response was determined to be 3·6 μg mL⁻¹ (area under the curve 0·71, sensitivity 86%, specificity 63%). Only one patient (2%) had anti‐ustekinumab antibodies. Psoriatic arthritis was identified as an independent predictor of higher PASI scores and higher ustekinumab concentrations (P = 0·003 and P = 0·048, respectively).

Conclusions

A concentration–response relationship at week 4 after injection was observed for patients with psoriasis treated with ustekinumab. Monitoring 4‐week postinjection ustekinumab concentrations could timely identify underexposed patients who might benefit from treatment optimization.

What's already known about this topic?

Monitoring drug concentrations is a valuable tool that can guide clinical decision‐making when drug concentrations are linked to clinical outcomes.

The presence of a concentration–response relationship for ustekinumab at trough is still debated owing to the contradictory results reported.

What does this study add?

A concentration–response relationship at week 4 after injection for ustekinumab‐treated patients with psoriasis was demonstrated.

Monitoring 4‐week postinjection ustekinumab concentrations could timely identify underexposed patients who might benefit from treatment optimization.

Based on the findings of this study, a treatment algorithm for patients with a suboptimal response is proposed.

Linked Comment: https://doi.org/10.1111/bjd.18709.

https://doi.org/10.1111/bjd.18709 available online

Comparison of methods to estimate the affected body surface area and the dosage of topical treatments in psoriasis and atopic dermatitis: the advantage of a picture-based tool

BACKGROUND

The accurate determination of the dosage of topical treatments is important given its repercussions on patient adherence and therapeutic efficacy. Up till now, the fingertip unit calculated by the rule of hands is considered the gold standard, although its use is associated with several drawbacks.

OBJECTIVE

To compare different methods to estimate the affected body surface area (BSA) and dosage of topical treatments in atopic dermatitis and psoriasis and investigate its reliability, user-friendliness and timing.

METHODS

In this study, we compared the reliability of three different methods: (i) the fingertip unit calculated by the 1% hand rule; (ii) a picture-based tool [termed Cutaneous Inflammatory Disease Extent Score (CIDES)]; and (iii) a digital drawing tool. Eleven observers scored 40 patients with psoriasis and eczema to assess the inter-rater and intrarater reliability. Timing was automatically recorded, and user-friendliness was investigated by a questionnaire.

RESULTS

An excellent intraclass correlation (ICC) was found for both inter-rater agreement and intrarater agreement for the picture-based tool (ICC = 0.92 and ICC = 0.96, respectively). The ICCs for drawing the area of involvement on a silhouette were 0.89 and 0.93, respectively. Finally, the rule of hands was associated with an increased inter-rater variability although an excellent intrarater agreement was found (ICC = 0.79 and 0.95, respectively). Automated calculation of the amount of topical treatment improved reliability, and CIDES was associated with the least variation. CIDES was considered the preferred method by all observers and was fast to perform (median: 30 s).

CONCLUSION

A picture-based method offered the most advantages (in terms of reliability, speed and user-friendliness) to estimate the affected BSA and calculate the dosage of topical treatments.

Epidemiologic evaluation of Nhanes for environmental Factors and periodontal disease

Periodontitis is a chronic inflammation that destroys periodontal tissues caused by the accumulation of bacterial biofilms that can be affected by environmental factors. This report describes an association study to evaluate the relationship of environmental factors to the expression of periodontitis using the National Health and Nutrition Examination Study (NHANES) from 1999–2004. A wide range of environmental variables (156) were assessed in patients categorized for periodontitis (n = 8884). Multiple statistical approaches were used to explore this dataset and identify environmental variable patterns that enhanced or lowered the prevalence of periodontitis. Our findings indicate an array of environmental variables were different in periodontitis in smokers, former smokers, or non-smokers, with a subset of specific environmental variables identified in each population subset. Discriminating environmental factors included blood levels of lead, phthalates, selected nutrients, and PCBs. Importantly, these factors were found to be coupled with more classical risk factors (i.e. age, gender, race/ethnicity) to create a model that indicated an increased disease prevalence of 2–4 fold across the sample population. Targeted environmental factors are statistically associated with the prevalence of periodontitis. Existing evidence suggests that these may contribute to altered gene expression and biologic processes that enhance inflammatory tissue destruction.

Mitigation of Colonic Inflammation in Dextran Sulfate Sodium-treated Mice by Dietary Supplementation with Soybean Fiber (P06-079-19)

Objectives

Soybean fiber (SBF) is an insoluble, but highly fermentable dietary fiber. Previous in vitro fermentation studies with human feces have shown that SBF produces 1.5–8 times more acetate, propionate, and butyrate than oat bran, corn bran, or wheat bran fiber. Short chain fatty acids (SCFA) have been reported to play a key role in maintaining colon health and reducing inflammation. The impact of dietary SBF on colonic inflammation has not previously been examined. Our objective was to determine the anti-inflammatory efficacy of dietary supplementation with SBF in a mouse model of acute colonic inflammation.

Methods

Male C57BL/6 J mice (5 weeks old) were randomized to AIN93G diet (CTL) or diet where 40% of the fiber was replaced with SBF (SBF-Hi). After 2 weeks of pretreatment, mice were given 2% dextran sulfate sodium (DSS) as the sole source of drinking fluid for 1 week to induce colonic inflammation. During DSS treatment, mice were maintained on their diet treatments. After DSS treatment, mice were euthanized and colonic inflammation was assessed.

Results

DSS-treated mice had significantly larger spleens and shorter colons than mice treated with water. SBF-Hi mitigated DSS-induced increases in spleen weight (20% lower) and colon shortening (15% longer). Quantitative, reverse transcriptase PCR analysis showed that DSS-treatment increased colonic mRNA expression of interleukin-6 (Il6) and tumor necrosis factor-a (Tnfa) by 3-fold compared to water-treated mice. Dietary supplementation with SBF blunted these increases in Il6 and Tnfa by 87% and 71%, respectively.

Conclusions

Our results suggest that dietary supplementation with SBF may be a useful approach to mitigate colonic inflammation. On-going studies are focused on determining fecal levels of SCFA and measuring protein markers of inflammation and gut barrier function. Future studies are needed to evaluate whether the protective effects observed in this study are maintained in situations of more chronic colonic inflammation.

Funding Sources

This work was funded by a grant from the Pennsylvania Soybean Board and by USDA National Institute of Food and Agriculture Appropriations under Project PEN04565.

Utilization of a Model Cocoa Fermentation System and Roasting to Assess Differences Among Bioactive Compounds and Bioactivity of Cocoa Through Variable Processing Conditions (FS07-04-19)

Objectives

Cocoa beans (Theobroma cacao) are a highly concentrated source of dietary flavanols that undergo processing steps, to enhance sensory characteristics. Although it is widely accepted that preservation of native cocoa flavanols is critical for retaining bioactivity, it is possible that reactions occurring throughout cocoa processing may generate compounds with novel activities, potentially preserving or enhancing bioactivity. Our objective was to evaluate the impact of fermentation and roasting on levels of flavanols and bioactivity of cocoa.

Methods

Combinations of fermentation and roasting parameters were employed via a controlled laboratory fermentation model system and roasting operation. Cocoa powders were produced from unfermented cocoa beans using different treatments representing extremes of fermentation and roasting. Cocoa beans were fermented in a simulated pulp media for 168 h. Fermentation and roasting temperatures varied depending on treatment group. Further processing (winnowing, grinding, pressing) produced cocoa powders for each treatment. Extracts were made from the final beans and powders. Total polyphenols were quantified by the Folin-Ciocalteu assay. HILIC UPLC-MS/MS was employed to analyze flavanols based on their degree of polymerization (DP).

Results

Fermentation and roasting contributed to losses of native flavanols. Total polyphenol levels and individual flavanols (DP 1–10) were approximately 27–90% lower in hot fermented/hot roasted cocoa powder and approximately 11–54% lower in cool fermented/cool roasted cocoa powder when compared to the unfermented/unroasted (control) treatment. Hot roasting had the most significant impact on flavanol degradation. There was also a direct relationship between increasing flavanol concentration in cocoa powder and DP.

Conclusions

Compared to fermentation, roasting demonstrated a more significant impact on flavanol degradation and composition among cocoa bean treatments. Further research in vitro and in vivo is being performed currently to determine whether these process-induced flavanol losses correlate with reduced anti-obesity and anti-inflammatory activities.

Funding Sources

This work was supported by the Agriculture and Food Research Initiative (AFRI) of the US Department of Agriculture.

Deregulation of a Network of mRNA and miRNA Genes Reveals That CK2 and MEK Inhibitors May Synergize to Induce Apoptosis KRAS-Active NSCLC

KRAS-activation mutations occur in 25% to 40% of lung adenocarcinomas and are a known mechanism of epidermal growth factor receptor inhibitor (EGFRI) resistance. There are currently no targeted therapies approved specifically for the treatment of KRAS-active non–small cell lung cancers (NSCLC). Attempts to target mutant KRAS have failed in clinical studies leaving no targeted therapy option for these patients. To circumvent targeting KRAS directly, we hypothesized that targeting proteins connected to KRAS function rather than targeting KRAS directly could induce cell death in KRAS-active NSCLC cells. To identify potential targets, we leveraged 2 gene expression data sets derived from NSCLC cell lines either resistant and sensitive to EGFRI treatment. Using a Feasible Solutions Algorithm, we identified genes with deregulated expression in KRAS-active cell lines and used STRING as a source for known protein-protein interactions. This process generated a network of 385 deregulated proteins including KRAS and other known mechanisms of EGFRI resistance. To identify candidate drug targets from the network for further study, we selected proteins with the greatest number of connections within the network and possessed an enzymatic activity that could be inhibited with an existing pharmacological agent. Of the potential candidates, the pharmacological impact of targeting casein kinase 2 (CK2) as a single target was tested, and we found a modest reduction in viability in KRAS-active NSCLC cells. MEK was chosen as a second target from outside the network because it lies downstream of KRAS and MEK inhibition can overcome resistance to CK2 inhibitors. We found that CK2 and MEK inhibition demonstrates moderate synergy in inducing apoptosis in KRAS-active NSCLC cells. These results suggest promise for a combination inhibitor strategy for treating KRAS-active NSCLC.