SF3B1 mutations provide genetic vulnerability to copper ionophores in human acute myeloid leukemia

In a phenotypical screen of 56 acute myeloid leukemia (AML) patient samples and using a library of 10,000 compounds, we identified a hit with increased sensitivity toward SF3B1-mutated and adverse risk AMLs. Through structure-activity relationship studies, this hit was optimized into a potent, specific, and nongenotoxic molecule called UM4118. We demonstrated that UM4118 acts as a copper ionophore that initiates a mitochondrial-based noncanonical form of cell death known as cuproptosis. CRISPR-Cas9 loss-of-function screen further revealed that iron-sulfur cluster (ISC) deficiency enhances copper-mediated cell death. Specifically, we found that loss of the mitochondrial ISC transporter ABCB7 is synthetic lethal to UM4118. ABCB7 is misspliced and down-regulated in SF3B1-mutated leukemia, creating a vulnerability to copper ionophores. Accordingly, ABCB7 overexpression partially rescued SF3B1-mutated cells to copper overload. Together, our work provides mechanistic insights that link ISC deficiency to cuproptosis, as exemplified by the high sensitivity of SF3B1-mutated AMLs. We thus propose SF3B1 mutations as a biomarker for future copper ionophore-based therapies.

Implementation of the HOME core outcome set for clinical trials of atopic eczema-barriers and opportunities: the HOME IX meeting report

The Harmonising Outcome Measures for Eczema (HOME) initiative established a core outcome set (COS) for atopic eczema (AE) clinical trials in 2019. This set encompasses four core outcome domains and corresponding measurement instruments: clinical signs (EASI), patient-reported symptoms (POEM and NRS 11 point for worst itch over the last 24 h), quality of life (DLQI/CDLQI/IDQoLI), and long-term control (Recap or ADCT). Following its roadmap, the HOME initiative is now focused on supporting implementation of the COS. To identify barriers and facilitators to implementation of the COS, and to guide the effort to promote COS uptake, a virtual consensus meeting was held over 2 days (September 25-26, 2021) attended by 55 participants (26 healthcare professionals, 16 methodologists, 5 patients, 4 industry representatives, and 4 students). Implementation themes were identified by a pre-meeting survey distributed to HOME members, presentations, and whole-group discussion. Participants were divided into five multi-professional small groups which ranked their top 3 most important themes, followed by whole-group discussion and anonymous consensus voting (consensus criteria: < 30% disagreement). Three most important implementation themes were identified and agreed upon: (1) awareness and stakeholder engagement, (2) universal applicability of the COS, and (3) ensuring minimum administrative burden. Working groups to address these issues are now a priority for the HOME initiative. The results from this meeting will inform the development of a HOME Implementation Roadmap in an effort to support other COS groups planning for effective implementation of their core sets.

β^{+} Gamow-Teller Strengths from Unstable ^{14}O via the (d,^{2}He) Reaction in Inverse Kinematics

For the first time, the (d,^{2}He) reaction was successfully used in inverse kinematics to extract the Gamow-Teller transition strength in the β^{+} direction from an unstable nucleus. The new technique was made possible by the use of an active-target time-projection chamber and a magnetic spectrometer, and opens a path to addressing a range of scientific challenges, including in astrophysics and neutrino physics. In this Letter, the nucleus studied was ^{14}O, and the Gamow-Teller transition strength to ^{14}N was extracted up to an excitation energy of 22 MeV. The data were compared to shell-model and state-of-the-art coupled-cluster calculations. Shell-model calculations reproduce the measured Gamow-Teller strength distribution up to about 15 MeV reasonably well, after the application of a phenomenological quenching factor. In a significant step forward to better understand this quenching, the coupled-cluster calculation reproduces the full strength distribution well without such quenching, owing to the large model space, the inclusion of strong correlations, and the coupling of the weak interaction to two nucleons through two-body currents.

Molecular Analysis of the Superior Efficacy of a Dual Epidermal Growth Factor Receptor (EGFR)-DNA-Targeting Combi-Molecule in Comparison with Its Putative Prodrugs 6-Mono-Alkylamino- and 6,6-Dialkylaminoquinazoline in a Human Osteosarcoma Xenograft Model

Background: ZR2002 is a dual EGFR-DNA-targeting combi-molecule that carries a chloroethyl group at the six-position of the quinazoline ring designed to alkylate DNA. Despite its good pharmacokinetics, ZR2002 is metabolized in vivo into dechlorinated metabolites, losing the DNA-alkylating function required to damage DNA. To increase the DNA damage activity in tumor cells in vivo, we compared ZR2002 with two of its 6-N,N-disubstituted analogs: "JS61", with a nitrogen mustard function at the six-position of the quinazoline ring, and "JS84", with an N-methyl group. Methods: Tumor xenografts were performed with the human Saos-2 osteosarcoma cell line expressing EGFR. Mice were treated with ZR2002, JS84 or JS61, and the tumor burden was measured with a caliper and CT/PET imaging. Drug metabolism was analyzed with LC-MS. EGFR and ɣ-H2AX phosphorylation were quantified via Western blot analysis and immunohistochemistry. Results: In vivo analysis showed that significant tumor growth inhibition was only achieved when ZR2002 was administered in its naked form. The metabolic dealkylation of JS61 and JS84 did not release sufficient concentrations of ZR2002 for the intratumoral inhibition of P-EGFR or enhanced levels of P-H2AX. Conclusions: The results in toto suggest that intratumoral concentrations of intact ZR2002 are correlated with the highest inhibition of P-EGFR and induction of DNA damage in vivo. ZR2002 may well represent a good drug candidate for the treatment of EGFR-expressing osteosarcoma.

Exploring the overlap between alopecia areata and major depressive disorder: Epidemiological and genetic perspectives

BACKGROUND

Research suggests that Alopecia areata (AA) and Major Depressive Disorder (MDD) show substantial comorbidity. To date, no study has investigated the hypothesis that this is attributable to shared genetic aetiology.

OBJECTIVES

To investigate AA-MDD comorbidity on the epidemiological and molecular genetic levels.

METHODS

First, epidemiological analyses were performed using data from a cohort of adult German health insurance beneficiaries (n = 1.855 million) to determine the population-based prevalence of AA-MDD comorbidity. Second, analyses were performed to determine the prevalence of MDD in a clinical AA case-control sample with data on psychiatric phenotypes, stratifying for demographic factors to identify possible contributing factors to AA-MDD comorbidity. Third, the genetic overlap between AA and MDD was investigated using a polygenic risk score (PRS) approach and linkage disequilibrium score (LDSC) regression. For PRS, summary statistics from a large MDD GWAS meta-analysis (PGC-MD2) were used as the training sample, while a Central European AA cohort, including the above-mentioned AA patients, and an independent replication US-AA cohort were used as target samples. LDSC was performed using summary statistics of PGC-MD2 and the largest AA meta-analysis to date.

RESULTS

High levels of AA-MDD comorbidity were reported in the population-based (MDD in 24% of AA patients), and clinical samples (MDD in 44% of AA patients). MDD-PRS explained a modest proportion of variance in AA case-control status (R²  = 1%). This signal was limited to the major histocompatibility complex (MHC) region on chromosome 6. LDSC regression (excluding MHC) revealed no significant genetic correlation between AA and MDD.

CONCLUSIONS

As in previous research, AA patients showed an increased prevalence of MDD. The present analyses suggest that genetic overlap may be confined to the MHC region, which is implicated in immune function. More detailed investigation is required to refine understanding of how the MHC is involved in the development of AA and MDD comorbidity.

[Evolution of histocompatibility methods in organ transplantation: an update in 2022]

The evaluation of anti-HLA immunization in organ transplantation has evolved dramatically since the first lymphocytotoxic crossmatch between donor and recipient was described. The same is true for HLA typing, which can now be performed by high-resolution sequencing. Nevertheless, the transplantation of a totally compatible organ remains an exception and the appearance of anti-HLA antibodies during the transplantation is inevitable, which conditions the long-term survival of the graft. New computer tools are currently being developed to evaluate and quantify the degree of incompatibility between donor and recipient, with a view to predicting the risk of rejection and adapting immunosuppressive therapy in a targeted manner for each patient.

How to: Basics der Schrittmacherprogrammierung

Die Programmierung von Schrittmachersystemen, insbesondere von Zweikammerschrittmachersystemen kann die untersuchenden Ärzte vor große Herausforderungen stellen. Eine genaue Kenntnis der zu programmierenden Parameter sowie der herstellerspezifischen Algorithmen ist essentiell. Bei der Programmierung sollte darauf geachtet werden, die Programmierung den individuellen Bedürfnissen der Patient:innen anzupassen und „Out-of-the-box“-Programmierungen zu vermeiden. Ein weiteres wichtiges Ziel der Programmierung ist es, unnötige Stimulation im rechten Ventrikel zu vermeiden und dem Patienten eine gute Belastbarkeit zu ermöglichen sowie zu vermeiden, dass er eine Stimulation wahrnimmt. Algorithmen der Hersteller können hierbei helfen, müssen jedoch verstanden und bei inadäquatem Verhalten ggf. deaktiviert werden.

Electroanatomic visualization of coronary arteries: a case series to elicit safety, feasibility and diagnostic value in complex ablation procedures

Funding Acknowledgements

Type of funding sources: None.

Background

Although three dimensional (3D) electroanatomic mapping systems allow detailed assessment of anatomy and substrates, ablation still carries substantial risk when close proximity to coronary arteries is suspected. 3D integration of coronary anatomy in mapping systems is still cumbersome, highlighting the need for an option of ad hoc acquirement of coronary artery anatomy. The goal of this case series was to evaluate the feasibility of a wire-based approach to the live visualization of coronary arteries and to assess its diagnostic information regarding procedure guiding.

Methods

For this single center case series, we included procedures in which close proximity of an ablation site to an epicardial vessel had to be suspected. An uninsulated-tip wire was then introduced into the relevant coronaries via diagnostic catheters after exclusion of critical stenosis by coronary angiography. The wire was connected to an impedance based 3D mapping system using a clamp and standard pin connection. Integrating this setup in the mapping system allows for live visualization of the wire tip, as well as the assessment of local electrograms within the respective vessel.

Results

We included a total of 9 procedures (4 ventricular tachycardia (VT) ablation procedures and 5 procedures for the ablation of premature ventricular contractions (PVCs)). The left coronary arteries were mapped in 8 cases, the right coronary artery was mapped in one case. In the majority of cases, the arrhythmogenic substrate was found in the left ventricle (5/9) or left ventricular summit area and the distal coronary sinus respectively (3/9). In two cases, epicardial mapping was performed combined with visualization of the right or left coronary arteries, respectively. There were no complications attributed to coronary wiring and mapping in this case series.

In two cases, the diagnostic information from mapping of the coronary arteries could be used to rule out an epicardial origin of arrhythmia. In the majority of cases, coronary visualization was used to ascertain a proper distance between the ablation site and the vessel.

Discussion

In this case series, we could demonstrate the feasibility and safety of coronary artery visualization and its integration in a 3D mapping system. The data obtained was used for diagnostic, as well as safety aspects. The electrograms from the wire were used to quickly assess relative timing of arrhythmias, thus allowing for an estimation of possible epicardial origin.

Conclusion

Applying the same caveats as for any other wiring of coronary arteries, their electroanatomic visualization is achieved in a safe and straightforward manner, with minimal technical requirements. Mapping of the coronary arteries adds critical diagnostic information and their real-time visualization is feasible without exceeding costs or risks

Incidence of premature battery depletion in subcutaneous cardioverter-defibrillator patients. Insights from a multicenter registry

Funding Acknowledgements

Type of funding sources: None.

Introduction

A subset of more than 35,000 S-ICD is under FDA advisory, warning of the potential of premature battery depletion (PBD), caused by a faulty low-voltage capacitor. Based on internal data, the manufacturer projects the incidence at 3.7% after 5 years. Data independent from the manufacturer is sparse.

Methods

This study was a multicenter effort of 14 centers in Europe, the US, and Canada. Consecutive patients who received a S-ICD at the participating centers were included in this retrospective analysis. Patients with the 1010 S-ICD generator model, and those without available follow-up information were excluded. Data was collected and managed using REDCap electronic data capture tools hosted at the University Hospital Cologne.

The primary endpoint in this registry was device explantation, generator replacement, or generator failure. Reasons for explantation, replacement, or failure were collected. Device longevity was defined in months. It was calculated as the time from device insertion to the time of replacement, or explantation, or failure, where applicable. Premature battery depletion was defined as the occurrence of battery depletion requiring generator replacement after 60 months or less.

The study complies with the Declaration of Helsinki. Ethics committee approval was obtained. This study is registered with Clinicaltrials.gov.

Results

Data of n=1,102 S-ICD devices was analyzed. The registry comprised of S-ICD generators implanted between 03/2015 and 09/2021 (43.4% A209 model and 56.6% A219 model). Of these, 611 devices (55.4%) were identified by the Boston Scientific serial number lookup tool as affected by the advisory. The mean and median follow-up duration was 2.43±1.66 and 2.29 years, respectively.

During follow-up, 110 devices (10%) were explanted after 2.9±1.7 years. Battery depletion was the indication in 52. The endpoint of PBD (battery depletion after less than 5 years) was met in 37 devices (6% of the devices under advisory), after 4.1±0.6 years.

In 58 cases, the S-ICD was explanted for reasons other than battery depletion.

Infection (16), system upgrade (20), heart transplant or LVAD therapy (7), and inappropriate shocks or inappropriate sensing (7) were the most common indications.

Discussion

This registry provides a systematic and manufacturer independent analysis of premature battery depletion in S-ICD patients. In the affected devices, the incidence of premature battery occurred in 6%. This is higher than what is projected by the manufacturer. The rate of PBD increases notably around the 4-year mark.

Conclusion

S-ICD generators under advisory suffer from PBD at a higher incidence than previously reported. Patients equipped with these devices should be closely monitored.

Are patients benefiting from participation in the German skin cancer screening programme? A large cohort study based on administrative data

BACKGROUND

The German programme for skin cancer screening was established in 2008 with the aim of reducing skin cancer mortality. However, the effectiveness and risk-benefit ratio of the programme remain unclear.

OBJECTIVES

To compare the mortality rates of patients with melanoma who participate in a screening programme to those who do not.

METHODS

A retrospective cohort study, based on pseudonymized health insurance data of 1 431 327 individuals from Saxony, Germany, was conducted for the period 2010-2016. Patients with prevalent and incident melanoma were defined based on diagnosis, medical procedures and prescriptions. Patients who underwent screening and had a first diagnosis of melanoma within 2 years of screening were assigned to the intervention group. Relative survival and Cox regression were used to assess potential differences in mortality.

RESULTS

We identified 4552 individuals with prevalent and 2475 individuals with incident melanoma. The percentage of screening participants (n = 1801) who had locoregional (4·2% vs. 13·5%) and/or distant metastases (4·3% vs. 8·0%), or who were treated with systemic anticancer therapies (11·6% vs. 21·8%) was lower vs. nonparticipants (n = 674). Screening participants had significantly better survival rates. The unadjusted Cox model gave a hazard ratio (HR) of 0·37 [95% confidence interval (CI) 0·30-0·46]. After adjusting for named confounders, the effect remained (HR 0·62, 95% CI 0·48-0·80).

CONCLUSIONS

Patients who participated in the screening programme had lower mortality than those who had not undergone screening. However, these findings may result from a healthy screen bias and/or overdiagnosis associated with screening, and not from the screening itself.

Potentials and current shortcomings in the cooperation between German centers for rare diseases and primary care physicians: results from the project TRANSLATE-NAMSE

Background

The TRANSLATE-NAMSE project with the strengthening of the centers for rare diseases with their affiliation to the European Reference Networks was a major step towards the implementation of the German National Plan of Action for People with Rare Diseases establishing better care structures. As primary care physicians, general practitioners and pediatricians play a central role in the diagnosis of patients with rare disease, as it is usually them referring to specialists and rare disease centers. Therefore, the interface management between primary care physicians and the centers for rare diseases is of particular importance.

Methods

In a mixed-method-approach an anonymous postal survey of 1,500 randomly selected primary care physicians in Germany was conducted with focus on (1) knowledge about a center for rare diseases and how it works, (2) in case of cooperation, satisfaction with the services provided by centers, and (3) expectations and needs they have with regard to the centers. In addition, in-depth telephone interviews were conducted with physicians who had already referred patients to a center.

Results

In total, 248 physicians responded to the survey, and 15 primary care physicians were interviewed. We observed a wide lack of knowledge about the existence of (45.6% confirmed to know at least one center) about how to access rare disease centers (50.4% of those who know a center confirmed knowledge) and what the center specializes in. In case of cooperation the evaluation was mostly positive.

Conclusion

To improve medical care, the interplay between primary care physicians and rare disease centers needs to be strengthened. (1) To improve the communication, the objectives and functioning of the rare disease centers should become more visible. (2) Other projects dealing with the analysis and improvement of interface management between centers and primary care physicians, as described in the National Plan of Action for People with Rare Diseases, need to be implemented immediately. (3) If the project is evaluated positively, the structures of TRANSLATE-NAMSE should be introduced nationwide into the German health care system to ensure comprehensive, quality-assured care for people with rare diseases with special consideration of the key role of primary care physicians—also taking into account the financial expenditures of this new care model.

Lifetime prevalence and determinants of hand eczema in an adolescent population in Germany: 15-year follow-up of the LISA cohort study

BACKGROUND

Hand eczema is a common inflammatory skin disorder in both adolescence and adulthood.

OBJECTIVES

We sought to assess the lifetime prevalence of hand eczema and associated exogenous and endogenous risk factors among adolescents in Germany.

METHODS

This was a cross-sectional study embedded into a prospective population-based birth cohort in four regions of Germany, which recruited healthy neonates born between November 1997 and January 1999. We included 1736 participants who had completed the 15-year follow-up from birth cohort and 84.6% (1468/1736) had clearly reported whether they have ever had hand eczema. All the data were based on questionnaires and blood tests (immunoglobulin E). Multivariable logistic regression analysis was used to examine endogenous and exogenous factors in relation to the lifetime prevalence of hand eczema among adolescents.

RESULTS

One thousand four hundred and sixty-eight adolescents (715 girls, 48.7%) were included in the final analysis. The lifetime prevalence of hand eczema among adolescents at the age of 15 was 10.4% (95% confidence interval [CI]: 8.9%-12.1%), with a significantly higher lifetime prevalence among girls than boys (12.7% vs. 8.2%, P = 0.005). Multivariable logistic regression analysis indicated statistically significant associations between the lifetime prevalence of hand eczema and having ever been diagnosed with atopic dermatitis (aOR = 1.8, 95% CI: 1.1-2.8) or having ever had dry skin (aOR = 1.9, 95% CI: 1.1-3.1), respectively. No statistically significant independent associations were found between asthma, hay fever, allergy-related clinical symptoms, immunoglobulin E positivity and other exogenous factors in relation to hand eczema.

CONCLUSION

Our study fills a research gap on the epidemiological burden of hand eczema among adolescents. One out of ten ever suffered from hand eczema until age 15 years indicating that hand eczema constitutes a significant burden in paediatric populations. The role of atopic dermatitis in hand eczema reinforces previous findings. Exogenous risk factors warrant further investigation.

Atopic Dermatitis: Disease Characteristics and Comorbidities in Smoking and Nonsmoking Patients from the TREATgermany Registry

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a multifactorial genesis including genetic predispositions and environmental risk and trigger factors. One of the latter possibly is smoking, indicated by an increased prevalence of AD in adults and children that are actively or passively exposed to cigarette smoke.

OBJECTIVES

In this study AD characteristics and its atopic comorbidities are compared in smoking and nonsmoking AD patients.

METHODS

TREATgermany is a non-interventional clinical registry which includes patients with moderate to severe AD in Germany. Baseline data of patients included into TREATgermany from inception in June 2016 to April 2020 in 39 sites across Germany was analyzed comparing AD disease characteristics and comorbidities in smokers versus non-smokers.

RESULTS

Of 921 patients, 908 (male: 58.7%) with a mean age of 41.9 ± 14.4 reported their smoking status. The objective Scoring of Atopic Dermatitis (oSCORAD) did not differ between smokers (n=352; 38.8%) and nonsmokers, however lesions' intensity of oozing/crusts and excoriations as well as patient global assessment scores (PGA) of AD severity were higher in smoking as opposed to nonsmoking patients. Smokers reported a lower number of weeks with well-controlled AD and more severe pruritus than nonsmokers. Total IgE levels were more elevated in smokers and they displayed a younger age at initial diagnosis of bronchial asthma. After adjustment for potential confounders, the increased intensity of oozing/crusts, the reduced number of weeks with well-controlled AD and the greater pruritus remained different in smokers compared to nonsmokers. In addition, smoking patients with adult-onset AD showed a 2.5 times higher chance of involvement of the feet.

CONCLUSIONS

German registry data indicate that AD patients who smoke have a higher disease burden with a different distribution pattern of lesions in adult-onset AD.

Investigations regarding the role of NOS1AP in the heart using a conditional overexpression mouse model

Background

35.3% of deaths in 2019 in Germany are caused by cardiovascular diseases (Destatis). 95% of these people were 60 years and older. To increase survival rate in elderly patients we investigate the relevance of altered expression of neuronal nitric oxide synthase 1 (NOS1) adaptor protein (NOS1AP) acting as an L-type calcium channel (CaV1.2) modulator via directing NOS1 to CaV1.2 on cardiac electrophysiology. Genome-wide association studies have linked genetic polymorphisms in NOS1AP to variations in QT interval duration (QTc). The QT interval reflects ventricular de- and repolarization. It may predispose individuals to ventricular tachycardia and sudden cardiac death (SCD) if prolonged, shortened or otherwise unregularly. In addition, about 20% of families with a clinically proven diagnosis of long QT syndrome (LQTS) host no mutation in any of the 16 associated genes.

Methods and results

Transgenic mice with conditional overexpression of NOS1AP in cardiac myocytes were used as model organism. We confirmed the interaction of NOS1AP with NOS1 and CaV1.2. Electrocardiography in NOS1AP overexpressing mice showed atrial and ventricular tachycardia both spontaneously and upon programmed stimulation associated with a significant decrease in QTc. Heart rates in NOS1AP overexpressing mice were similar to non-induced animals. Survival was significantly reduced (only 60% after 12 weeks vs. 100% in non-induced mice). Induced QTc alterations and accompanied deaths subsided upon re-administration of doxycycline.

Whole-cell patch-clamp measurements in isolated adult ventricular myocytes were performed and action potential duration at 90% of repolarization (APD90) was significantly reduced in induced transgenic NOS1AP overexpressing mice compared to control littermates.

In addition, we investigated the functional effect of the human SNP rs16847548 (T/C) located within the NOS1AP promoter. The SNP was found to decrease the transcriptional activity of NOS1AP in vitro and therefore, potentially leading to a decrease in NOS1AP expression in humans.

Conclusion

Myocardial overexpression of NOS1AP leads to short QT syndrome with increased susceptibility to atrial and ventricular arrhythmias and cardiac death. In accordance, APD90 is significantly shortened in overexpressing animals. The human SNP rs16847548, which is located in the promoter region of NOS1AP, results in a reduced NOS1AP promoter activity in vitro, hereby providing an explanation for the frequently published elongation of QT intervals. In summary, not only mutations in ion channels themselves but also genetic alterations in the expression of ion channel modulators such as NOS1AP, have an impact on QTc and arrhythmogenesis and represent a promising therapeutic target for LQTS patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Gesundheitscampus Brandenburg (MWFK)

eCross-cultural adaptation of the spine oncology-specific SOSGOQ2.0 questionnaire to German language and the assessment of its validity and reliability in the clinical setting

Background

The recently developed Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) was proven a valid and reliable instrument measuring health-related quality of life (HRQOL) for patients with spinal malignancies. A German version was not available.

Objective

A cross-cultural adaptation of the SOSGOQ2.0 to the German language and its multicenter evaluation.

Methods

In a multistep process, a cross-cultural adaptation of the SOSGOQ2.0 was conducted. Subsequently, a multicenter, prospective observational cohort study was initiated to assess the reliability and validity of the German adaptation. To assess external construct validity of the cross-cultural adapted questionnaire, a comparison to the established questionnaire QLQ-C30 from the European Organisation for Research and Treatment of Cancer was conducted. Mean-difference plots were used to measure the agreement between the questionnaires in total score and by domain (deviation from mean up to 10% allowed). Further reliability and validity tests were carried out. Change to baseline was analysed 3–16 weeks later after different interventions occurred. Clinically relevant thresholds in comparison to the EORTC QLQ-C30 questionnaire were evaluated by ROC curve analysis.

Results

We could enroll 113 patients from four different university hospitals (58 females, 55 males). Mean age was 64.11 years (sd 11.9). 80 patients had an ECOG performance status of 2 or higher at baseline. External construct validity in comparison to the EORTC QLQ-C30 questionnaire in total score and by domain was confirmed (range of deviation 4.4 to 9.0%). Good responsiveness for the domains Physical Functioning (P < .001) and Pain (P < .001) could be shown. The group mean values also displayed a difference in the domains of Social Functioning (P = .331) and Mental Health (P = .130), but not significant. The minimum clinically relevant threshold values for the questionnaire ranged from 4.0 to 7.5 points.

Conclusions

According to our results, the cross-cultural adapted questionnaire is a reliable and valid tool to measure HRQOL in German speaking patients with spinal malignancies. Especially the domains Physical Functioning and Pain showed overall good psychometric characteristics. In this way, a generic questionnaire, such as the EORTC QLQ-C30, can be usefully supplemented by spine-specific questions to increase the overall accuracy measuring HRQOL in patients with spinal malignancies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08578-x.

[Telemedicine in stroke-pertinent to stroke care in Germany]

BACKGROUND AND OBJECTIVE

Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution.

METHODS

The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks.

RESULTS

Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states.

CONCLUSION

Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

Impact of the Covid-19 related lockdown on physical activity, heart rate and arrhythmia burden in a large prospective cohort of CHF patients

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): BIOTRONIK SE & Co. KG

OnBehalf

BIO|STREAM.HF

Background

At the beginning of the Covid-19 pandemic in spring 2020, governments around the world issued curfews and other stay at home orders (‘lockdown’) to limit the spread of the SARS-CoV19 virus. This may have forced people to decrease their physical activity. Physical inactivity as well as social stress is known to be especially deleterious for heart failure (HF) patients. The BIO|STREAM.HF study enrolled such HF patients into a prospective registry with Home Monitoring.

Purpose

We aimed to evaluate the impact of the lockdown during the first Covid-19 pandemic wave on physical activity and arrhythmia burden of heart failure patients.

Methods

We analysed daily transmitted data of patients enrolled into a large international registry (BIO|STREAM.HF) being implanted with a cardiac resynchronization therapy (CRT) devices. Patients with NYHA ≥ II and LVEF ≤ 40% before CRT implantation were selected.

Intra-individual weekly mean and median values were calculated for the following daily transmitted parameters: physical activity (measured as % of the day during which the patient moves), atrial arrhythmia burden, mean heart rate (at rest), PP variability, PVC burden, and rate of biventricular pacing. Values were calculated for 12 weeks before and 12 weeks after the country-specific effective date of most rigorous restrictions in spring 2020 to visualize the general trend of parameter changes. Moreover, values for intra-individual changes between three 28-days periods (before, during, and after the lockdown) were calculated.

Results

Of 444 patients, 76% were male. They had a mean age of 69 ± 10 years and LVEF of 28.2 ± 6.7%. HF was of ischemic etiology in 42% of cases and they were in NYHA class II (47.5%), III (50.0%) or IV (2.5%).

On average, patients were active for 9% of the day (2 h 10 min). The physical activity decreased by approx. 10% with the onset of the lockdown (figure 1) and recovered within the following eight weeks.

Comparison of the 28-days periods before, during and after the lockdown showed a statistically significant intra-individual decrease in physical activity (mean decrease 9 min per day) during the lockdown compared to pre- and post-lockdown values and a trend toward reduced mean heart rates. In parallel, a significant increase in device detected atrial arrhythmia burden (mean increase 17 min per day) was observed. All other parameters did not change significantly.

Conclusion 

Our results show that patients reduced their physical activity during the Covid-19 related lockdown in spring 2020. This was associated with an increase in atrial arrhythmia burden and a reduction of the mean heart rate. Prognostic implications of these results will further be analysed.

New ^{59}Fe Stellar Decay Rate with Implications for the ^{60}Fe Radioactivity in Massive Stars

The discrepancy between observations from γ-ray astronomy of the ^{60}Fe/^{26}Al γ-ray flux ratio and recent calculations is an unresolved puzzle in nuclear astrophysics. The stellar β-decay rate of ^{59}Fe is one of the major nuclear uncertainties impeding us from a precise prediction. The important Gamow-Teller strengths from the low-lying states in ^{59}Fe to the ^{59}Co ground state are measured for the first time using the exclusive measurement of the ^{59}Co(t,^{3}He+γ)^{59}Fe charge-exchange reaction. The new stellar decay rate of ^{59}Fe is a factor of 3.5±1.1 larger than the currently adopted rate at T=1.2  GK. Stellar evolution calculations show that the ^{60}Fe production yield of an 18 solar mass star is decreased significantly by 40% when using the new rate. Our result eliminates one of the major nuclear uncertainties in the predicted yield of ^{60}Fe and alleviates the existing discrepancy of the ^{60}Fe/^{26}Al ratio.

Recommended core outcome instruments for health-related quality of life, long-term control and itch intensity in atopic eczema trials: results of the HOME VII consensus meeting

Background

The Harmonising Outcome Measures for Eczema (HOME) initiative has established a core outcome set of domains for atopic eczema (AE) clinical trials. Previous consensus meetings have agreed on preferred instruments for clinician‐reported signs (Eczema Area and Severity Index, EASI) and patient‐reported symptoms (Patient‐Oriented Eczema Measure, POEM). This paper reports consensus decisions from the HOME VII meeting.

Objectives

To complete the core outcome set for AE by agreeing on core outcome instruments for the domains of quality of life (QoL), long‐term control and itch intensity.

Methods

A face‐to‐face consensus meeting was held in Tokyo, Japan (8–10 April 2019) including 75 participants (49 healthcare professionals/methodologists, 14 patients, 12 industry representatives) from 16 countries. Consensus decisions were made by presentations of evidence, followed by whole and small group discussions and anonymous voting using predefined consensus rules.

Results

It was agreed by consensus that QoL should be measured using the Dermatology Life Quality Index (DLQI) for adults, the Children’s Dermatology Life Quality Index (CDLQI) for children and the Infant’s Dermatology Quality of Life Index (IDQoL) for infants. For long‐term control, the Recap of Atopic Eczema (RECAP) instrument or the Atopic Dermatitis Control Test (ADCT) should be used. Consensus was not reached over the frequency of data collection for long‐term control. The peak itch numerical rating scale (NRS)‐11 past 24 h was recommended as an additional instrument for the symptom domain in trials of older children and adults. Agreement was reached that all core outcome instruments should be captured at baseline and at the time of primary outcome assessment as a minimum.

Conclusions

For now, the core outcome set for clinical trials in AE is complete. The specified domains and instruments should be used in all new clinical trials and systematic reviews of eczema treatments.

What is already known about this topic?

Core outcomes sets improve the design and reporting of clinical trials, reduce selective outcome reporting bias and facilitate meta‐analysis of results in systematic reviews.

The HOME core outcome set for eczema recommends the inclusion of four core domains in all atopic eczema trials: clinician‐reported signs, patient‐reported symptoms, health‐related quality of life (HrQoL) and long‐term control.

Clinician‐reported signs should be captured using the Eczema Area and Severity Index (EASI) and patient‐reported symptoms using the Patient‐Oriented Eczema Measure (POEM).

What does this study add?

The HOME core outcome set is now complete and recommended core outcome instruments have been agreed on for all four domains.

Core outcome instruments for HrQoL: Dermatology Life Quality Index (DLQI) for adults, Children’s Dermatology Life Quality Index (CDLQI) for children and Infant’s Dermatology Quality of Life Index (IDQoL) for infants.

Core outcome instruments for long‐term control: either the Recap of Atopic Eczema (RECAP) or the Atopic Dermatitis Control Test (ADCT).

In addition, itch intensity should be measured using the peak NRS‐11 past 24 h for trials including older children and adults.

What are the clinical implications of this work?

If all future trials of eczema treatments include the HOME core outcome instruments, then trial results will be more readily incorporated into meta‐analyses in systematic reviews and clinical care will be informed by the best available evidence.

Linked Comment: D.F. Murrell and C.F. Paul. Br J Dermatol 2021; 185:13–14.

Development of a core outcome set for cutaneous squamous cell carcinoma trials: identification of core domains and outcomes

BACKGROUND

The lack of uniformity in the outcomes reported in clinical studies of the treatment of cutaneous squamous cell carcinoma (cSCC) complicates efforts to compare treatment effectiveness across trials.

OBJECTIVES

To develop a core outcome set (COS), a minimum set of agreed-upon outcomes to be measured in all clinical trials of a given disease or outcome, for the treatment of cSCC.

METHODS

One hundred and nine outcomes were identified via a systematic literature review and interviews with 28 stakeholders. After consolidation of this long list, 55 candidate outcomes were rated by 19 physician and 10 patient stakeholders, in two rounds of Delphi exercises. Outcomes scored 'critically important' (score of 7, 8 or 9) by ≥ 70% of patients and ≥ 70% of physicians were provisionally included. At the consensus meeting, after discussion and voting of 44 international experts and patients, the provisional list was reduced to a final core set, for which consensus was achieved among all meeting participants.

RESULTS

A core set of seven outcomes was finalized at the consensus meeting: (i) serious or persistent adverse events, (ii) patient-reported quality of life, (iii) complete response, (iv) partial response, (v) recurrence-free survival, (vi) progression-free survival and (vii) disease-specific survival.

CONCLUSIONS

In order to increase the comparability of results across trials and to reduce selective reporting bias, cSCC researchers should consider reporting these core outcomes. Further work needs to be performed to identify the measures that should be reported for each of these outcomes.

Recommended core outcome instruments for health-related quality of life, long-term control and itch intensity in atopic eczema trials: results of the HOME VII consensus meeting

BACKGROUND

The Harmonising Outcome Measures for Eczema (HOME) initiative has established a core outcome set of domains for atopic eczema clinical trials. Previous consensus meetings have agreed upon preferred instruments for clinician-reported signs (Eczema Area and Severity Index - EASI) and patient-reported symptoms (Patient-Oriented Eczema Measure - POEM). This paper reports consensus decisions from the HOME VII meeting.

OBJECTIVE

To complete the core outcome set for atopic eczema by agreeing upon core outcome instruments for the domains of quality of life, long-term control and itch intensity.

METHODS

Face-to-face consensus meeting held in Tokyo, Japan (8th to 10th April, 2019) including 74 participants (47 healthcare professionals/methodologists, 14 patients, 13 industry representatives), from 16 countries. Consensus decisions were made by presentations of evidence, followed by whole and small group discussions and anonymous voting using pre-defined consensus rules.

RESULTS

It was agreed by consensus that quality of life should be measured using the Dermatology Life Quality Index (DLQI) for adults, the Children's Dermatology Life Quality Index (CDLQI) for children, and the Infant's Dermatology Quality of Life Index (IDQoL) for infants. For long-term control, the Recap of Atopic Eczema (RECAP) instrument or the Atopic Dermatitis Control Test (ADCT) should be used. Consensus was not reached over the frequency of data collection for long-term control. The peak itch numerical rating scale(NRS)-11 past 24 hours was recommended as an additional instrument for the symptom domain in trials of older children and adults. Agreement was reached that all core outcome instruments should be captured at baseline and at the time of primary outcome assessment as a minimum.

CONCLUSIONS

For now, the core outcome set for clinical trials in atopic eczema is complete. The specified domains and instruments should be used in all new clinical trials and systematic reviews of eczema treatments.

Outcome assessment in dermatology clinical trials and cochrane reviews: call for a dermatology-specific outcome taxonomy

BACKGROUND

Standardized outcome reporting is crucial for trial evidence synthesis and translation of findings into clinical decision-making. The OMERACT 2.0 Filter and COMET outcome domain taxonomy propose frameworks for consistent reporting of outcomes. There is an absence of a uniform dermatology-specific reporting strategy that uses precise and consistent outcome definitions.

OBJECTIVES

Our aim was to map efficacy/effectiveness outcomes assessed in dermatological trials to the OMERACT 2.0 Filter as a starting point for developing an outcome taxonomy in dermatology.

METHODS

We critically appraised 10 Cochrane Skin Reviews randomly selected from all 69 Cochrane Skin Reviews published until 01/2015 and the 220 trials included covering a broad spectrum of dermatological conditions and interventions. Efficacy/effectiveness outcomes were mapped to core areas and domains according to the OMERACT 2.0 Filter. The extracted trial outcomes were used for critical appraisal of outcome reporting in dermatology trials and for the preliminary development of a dermatology-specific outcome taxonomy.

RESULTS

The allocation of 1086 extracted efficacy/effectiveness outcomes to the OMERACT 2.0 Filter resulted in a hierarchically structured dermatology-specific outcome classification. In 506 outcomes (47%), the outcome concept to be measured was insufficiently described, hindering meaningful evidence synthesis. Although the core areas assessed in different dermatology trials of the same condition overlap considerably, quantitative evidence synthesis usually failed due to imprecise outcome definitions, non-comparable outcome measurement instruments, metrics and reporting.

CONCLUSIONS

We present an efficacy/effectiveness outcome classification as a starting point for a dermatology-specific taxonomy to provide trialists and reviewers with the opportunity to better synthesize and compare evidence.

Basal cell carcinoma risk and solar UV exposure in occupationally relevant anatomic sites: do histological subtype, tumor localization and Fitzpatrick phototype play a role? A population-based case-control study

Background

A two-fold risk increase to develop basal cell carcinoma was seen in outdoor workers exposed to high solar UV radiation compared to controls. However, there is an ongoing discussion whether histopathological subtype, tumor localization and Fitzpatrick phototype may influence the risk estimates.

Objectives

To evaluate the influence of histological subtype, tumor localization and Fitzpatrick phototype on the risk to develop basal cell carcinoma in highly UV-exposed cases and controls compared to those with moderate or low solar UV exposure.

Methods

Six hundred forty-three participants suffering from incident basal cell carcinoma in commonly sun-exposed anatomic sites (capillitium, face, lip, neck, dorsum of the hands, forearms outside, décolleté) of a population-based, case-control, multicenter study performed from 2013 to 2015 in Germany were matched to controls without skin cancer. Multivariate logistic regression analysis was conducted stratified for histological subtype, phototype 1/2 and 3/4. Dose-response curves adjusted for age, age², sex, phototype and non-occupational UV exposure were calculated.

Results

Participants with high versus no (OR 2.08; 95% CI 1.24–3.50; p = 0.006) or versus moderate (OR 2.05; 95% CI 1.15–3.65; p = 0.015) occupational UV exposure showed a more than two-fold significantly increased risk to develop BCC in commonly UV-exposed body sites. Multivariate regression analysis did not show an influence of phototype or histological subtype on risk estimates. The restriction of the analysis to BCC cases in commonly sun-exposed body sites did not influence the risk estimates. The occupational UV dosage leading to a 2-fold increased basal cell carcinoma risk was 6126 standard erythema doses.

Conclusion

The risk to develop basal cell carcinoma in highly occupationally UV-exposed skin was doubled consistently, independent of histological subtype, tumor localization and Fitzpatrick phototype.

Abrupt CO2 release to the atmosphere under glacial and early interglacial climate conditions

Pulse-like carbon dioxide release to the atmosphere on centennial time scales has only been identified for the most recent glacial and deglacial periods and is thought to be absent during warmer climate conditions. Here, we present a high-resolution carbon dioxide record from 330,000 to 450,000 years before present, revealing pronounced carbon dioxide jumps (CDJ) under cold and warm climate conditions. CDJ come in two varieties that we attribute to invigoration or weakening of the Atlantic meridional overturning circulation (AMOC) and associated northward and southward shifts of the intertropical convergence zone, respectively. We find that CDJ are pervasive features of the carbon cycle that can occur during interglacial climate conditions if land ice masses are sufficiently extended to be able to disturb the AMOC by freshwater input.

Design and Synthesis of a Trifunctional Molecular System "Programmed" to Block Epidermal Growth Factor Receptor Tyrosine Kinase, Induce High Levels of DNA Damage, and Inhibit the DNA Repair Enzyme (Poly(ADP-ribose) Polymerase) in Prostate Cancer Cells

Resistance to chemotherapy in advanced cancers can be mediated by different factors such as epidermal growth factor receptor (EGFR) overexpression and DNA repair enzymes. Therefore, current standards of care usually involve combinations of multiple treatments. Here, to reduce the adverse effects of multiple drug combinations and improve outcome, we proposed a single drug approach to block multiple overlapping effects that characterize chemoresistance. Thus, we designed a new linker that allows assembly of multiple functions (e.g., inhibition of EGFR phosphorylation, induction of DNA lesions, and blockade of their repair) into a single molecule. This led to the successful synthesis of a novel and potent combi-molecule JS230. Here, we demonstrated that in resistant prostate cancer cells overexpressing EGFR, it was capable of (a) inhibiting EGFR in a dose-dependent manner, (b) damaging DNA, and (c) sustaining the damage by inhibiting the DNA repair protein poly(ADP-ribose) polymerase (PARP). The triple mechanism of action of JS230 cumulated into growth inhibitory potency superior to that of classical two- or three-drug combinations.

P1061Incidence and location of PVI gaps identified post-cryoballoon ablation for atrial fibrillation

Background

 Successful delivery of continuous and durable pulmonary vein isolation (PVI) lesion sets is recognized as being critical to long-term clinical outcomes following ablation for atrial fibrillation (AF). Confirmation of PVI following cryoballoon ablation is commonly achieved using a 3.3F circular mapping catheter (CMC) which can be delivered through the central lumen of the cryoballoon, but other diagnostic tools may be used alone or in conjunction with the 3.3F CMC. A high-density, grid-style mapping catheter is now available in multiple geographies; use in cryoballoon ablation procedures and associated outcomes has not been previously reported.

Purpose

 To evaluate diagnostic catheter usage patterns in cryoablation procedures and identify associated trends in procedural characteristics and acute outcomes.

Methods

 Self-reported procedural data was prospectively collected in AF cryoablation cases utilizing various diagnostic catheter tools, including the 3.3F CMC and high-density, grid-style mapping catheter (HD Grid). Procedural characteristics and acute outcomes, including the incidence and location of gaps post-ablation, were recorded and analyzed.

Results

 Data was collected in 23 cryoablation procedures performed in 7 centers across the United States and Europe. De novo and repeat ablations represented 65.2% and 21.7% of cases, respectively (13.0% not reported). 3D mapping was employed in 95.7% of cases. A left common pulmonary vein was present and ablated in 8.7% (2/23). The 28mm cryoballoon was utilized in all cases, with a single case using both a 23mm and 28mm cryoballoon. The 3.3F CMC was used to confirm isolation in all cases using a variety of techniques: voltage mapping (60.9%), exit block (56.5%), entrance block (30.4%), propagation mapping (4.3%), and activation mapping (4.3%); note: total exceeds 100% as more than one technique may be employed in a single case. In 18 cases, PVI was confirmed using a 3.3F CMC followed by secondary confirmation with HD Grid, enabling a direct comparison of the two technologies. The HD Grid identified a total of 12 gaps in 4 (22.2%) patients, which were missed by the 3.3F CMC (Figure 1). No adenosine or isoproterenol use was documented in any case.

Conclusion(s): The 3.3F CMC is routinely used to confirm PVI following cryoballoon ablation for atrial fibrillation, but it may fail to identify gaps in some patients. Subsequent assessment of PVI using the HD Grid identified residual gaps in nearly a quarter of patients, suggesting that sensitivity for gap detection may be improved with this tool. Limitations of this analysis include the small sample size and workflows which consistently assessed PVI with the high-density mapping catheter after confirming isolation with the 3.3F CMC. Despite these limitations, the incidence of residual gaps observed is noteworthy and may warrant additional study.

Abstract Figure.

Baseline characteristics, disease severity and treatment history of patients with atopic dermatitis included in the German AD Registry TREATgermany

BACKGROUND

The Atopic Dermatitis (AD) TREATgermany registry was initiated by the German Society for Dermatology (DDG) in 2011 to evaluate the 'real-life' situation of health care for patients with AD.

OBJECTIVES

Interim data analysis on baseline characteristics as well as current and prescribed systemic treatments of the TREATgermany registry patients.

METHODS

Patients (≥18 years) with moderate-to-severe AD [objective (o)SCORAD > 20], or with current or previous anti-inflammatory systemic treatment for AD within 24 months, were included and are followed up over at least 24 months. To assess clinical signs, the eczema area severity index (EASI, 0-72), the oSCORAD (0-83) and the Investigator Global Assessment (IGA; 6-point scale) were used. The disease severity was globally scored by the patients [Patient Global Assessment (PGA); six-step Likert scale]. Disease symptoms were assessed by the patient-oriented eczema measure (POEM, 0-28) and numeric rating scales (NRS, 0-10). Health-related quality of life was measured using the dermatological life quality index (DLQI, 0-30).

RESULTS

A total of 612 patients were recruited across 32 sites between 06/2016 and 01/2019 (mean age: 42.6 ± 14.2 years; mean oSCORAD: 40.8 ± 16.3). The mean POEM score was 16.3 ± 7.5. Pruritus was rated highest among subjective symptoms (NRS: 5.4 ± 2.7). The mean DLQI value was 11.3 ± 7.5. The frequency of arterial hypertension was lower (20.8%) compared with the general population, whilst this was higher for depression (10%). More than 60% of the patients had received systemic glucocorticosteroids, and 36.8% had received cyclosporine A prior to inclusion. Dupilumab was the leading substance documented as either 'current' (12.1%) or 'prescribed' (31.4%) at baseline.

CONCLUSIONS

These 'real-life' data clearly demonstrate the substantial disease burden. Most of TREATgermany patients were already treated with or prescribed dupilumab at baseline. Moreover, current findings indicate the urgent need for further alternative agents in order to achieve a perceptible improvement of quality of life of patients with moderate-to-severe AD.

Old carbon reservoirs were not important in the deglacial methane budget

Permafrost and methane hydrates are large, climate-sensitive old carbon reservoirs that have the potential to emit large quantities of methane, a potent greenhouse gas, as the Earth continues to warm. We present ice core isotopic measurements of methane (Δ¹⁴C, δ¹³C, and δD) from the last deglaciation, which is a partial analog for modern warming. Our results show that methane emissions from old carbon reservoirs in response to deglacial warming were small (<19 teragrams of methane per year, 95% confidence interval) and argue against similar methane emissions in response to future warming. Our results also indicate that methane emissions from biomass burning in the pre-Industrial Holocene were 22 to 56 teragrams of methane per year (95% confidence interval), which is comparable to today.

The European TREatment of ATopic eczema (TREAT) Registry Taskforce survey: prescribing practices in Europe for phototherapy and systemic therapy in adult patients with moderate-to-severe atopic eczema

Background

For many years dermatologists have had access to few therapies for patients with moderate‐to‐severe atopic eczema (AE). New promising therapies are entering the market but conventional phototherapies and systemic therapies have more well‐known safety profiles, lower costs and wider availability.

Objectives

To provide insight into current prescribing practices of conventional phototherapy and systemic immunomodulatory therapies for adults with chronic AE, and the factors influencing these prescribing practices, before biologics and other novel therapeutics become routine clinical practice.

Methods

In this exploratory study dermatologists were invited to participate in an online survey via a mailing list of the European Academy of Dermatology and Venereology and national societies. Data were collected on participant characteristics (including clinical practice data), the use of phototherapies and systemic therapies, and factors influencing their use.

Results

From 30 European countries, 238 out of 361 dermatologists willing to participate (65·9%) completed the survey, with 229 meeting the inclusion criteria. For phototherapy (prescribed by 84·7%), most preferred narrowband ultraviolet B as first line (80·9%) and psoralen plus ultraviolet A as second (21·6%). For systemic therapy (prescribed by 95·2%) ciclosporin (54·1%), oral corticosteroids (32·6%) and methotrexate (30·7%) were used first line. Dermatologists relied mostly on personal experience for prescribing phototherapy and systemic therapy. Azathioprine and mycophenolic acid were prescribed by only 135 (59·0%) and 85 (37·1%) participants in total, mostly due to a lack of personal experience.

Conclusions

This study provides insight into prescribing practices for conventional phototherapy and systemic therapy in Europe and shows that off‐label therapies are also preferred as first‐line choice of systemic therapy.

What is already known about this topic?

Varying prescribing practices were found for adult (in the UK) and paediatric (in Northern America and Europe) patients with moderate‐to-severe atopic eczema (AE).

Not much is known about the prescription of phototherapy and (off‐label) systemic therapy for adult patients in Europe.

Although therapies like dupilumab are promising new treatment modalities, better‐known safety profiles, lower costs and better availability are reasons to improve the evidence profile of conventional systemic therapies like ciclosporin.

What does this study add?

Prescribing practices of European dermatologists treating adult patients with moderate‐to-severe AE show diversity.

Most dermatologists prefer narrowband ultraviolet B as first‐line phototherapy, followed by psoralen plus ultraviolet A as second line.

Next to ciclosporin, which is most commonly prescribed, (off‐label) methotrexate and oral corticosteroids are also frequently used as first‐line systemic agents in chronic AE.

Lack of personal experience with azathioprine and mycophenolic acid was the most important reason against their prescription.

What are the clinical implications of the work?

The results from this study might help to improve the experience with, and prescribing of, all available conventional phototherapies and (off‐label) systemic therapies.

Guidelines developers might use these results to develop and implement treatment algorithms.

Linked Comment:Bruin‐Weller. Br J Dermatol 2020; 183:987–988.

Plain language summary available online

[Tachycardia and pulmonary arterial hypertension]

Pulmonary hypertension is newly defined as an elevation of the mean pulmonary arterial pressure >20 mmHg and a pulmonary vascular resistance ≥3 Wood units. Arrhythmias are an increasing problem in patients with pulmonary hypertension. Pathophysiological aspects leading to supraventricular arrhythmias are atrial fibrosis caused by increased right atrial pressure and dilation. An increased sympathetic tone leads to prolongation of action potential and delayed polarisations causing arrhythmias. Therapy of arrhythmias includes drugs (preferred amiodarone) and electrophysiological therapy like electric cardioversion and ablation, which is safe in patients with pulmonary hypertension.

Healthcare costs associated with allergic rhinitis, asthma allergy immunotherapy

Summary

Allergic rhinitis (AR) and asthma are chronic diseases in which the airways become inflamed in response to allergens. Allergy immunotherapy (AIT) is recommended for those unable to manage symptoms using pharmacotherapy. This study estimated healthcare costs and utilisation for patients with AR and asthma. Mean annual outpatient visits, pharmaceutical costs and inpatient hospitalisations were calculated for 2010 and 2014, with pharmaceutical and inpatient costs stratified by AIT use. AR and asthma patients had a 35% higher mean number of physician visits and up to 90% higher mean pharmaceutical costs compared to controls. The cost of pharmaceuticals and inpatient hospitalisations were 54% lower in those prescribed AIT. Further research is recommended to understand the reasons for these cost differences.