Quadruplet pregnancy outcome with and without fetal reduction: Danish national cohort study (2008-2018) and comparison with dichorionic twins

OBJECTIVES

To perform a nationwide study of quadrichorionic quadriamniotic (QCQA) quadruplet pregnancies and to compare the pregnancy outcome in those undergoing fetal reduction with non-reduced quadruplets and dichorionic diamniotic (DCDA) twin pregnancies from the same time period.

METHODS

This was a retrospective Danish national register-based study performed using data from the national Danish Fetal Medicine Database, which included all QCQA quadruplets and all non-reduced DCDA twin pregnancies with an estimated due date between 2008 and 2018. The primary outcome measure was a composite of adverse pregnancy outcomes, including pregnancy loss or intrauterine death of one or more fetuses. Secondary outcomes included gestational age at delivery, the number of liveborn children, preterm delivery before 28, 32 and 37 gestational weeks and birth weight. Data on pregnancy complications and baseline characteristics were also recorded. Outcomes were compared between reduced and non-reduced quadruplet pregnancies, and between DCDA pregnancies and quadruplet pregnancies reduced to twins. A systematic literature search was performed to describe and compare previous results with our findings.

RESULTS

Included in the study were 33 QCQA quadruplet pregnancies, including three (9.1%) non-reduced pregnancies, 28 (84.8%) that were reduced to twin pregnancy and fewer than three (6.1%) that were reduced to singleton pregnancy, as well as 9563 DCDA twin pregnancies. Overall, the rate of adverse pregnancy outcome was highest in non-reduced quadruplets (66.7%); it was 50% in quadruplets reduced to singletons and 10.7% in quadruplets reduced to twins. The proportion of liveborn infants overall was 91.1% of the total number expected to be liveborn in quadruplet pregnancies reduced to twins. This was statistically significantly different from 97.6% in non-reduced dichorionic twins (P = 0.004), and considerably higher than 58.3% in non-reduced quadruplets. The rates of preterm delivery < 28, < 32 and < 37 weeks were decreased in quadruplets reduced to twins compared with those in non-reduced quadruplet pregnancies. Quadruplets reduced to twins did not achieve equivalent pregnancy outcomes to those of DCDA twins.

CONCLUSION

This national study of QCQA quadruplets has shown that multifetal pregnancy reduction improves pregnancy outcome, including a decreased rate of preterm delivery and higher proportion of liveborn children. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Response to Interleukin-17A Inhibitors According to Prior Biologic Exposures: A Danish Nationwide Study

Whether response to an interleukin (IL-17) inhibitor is different in patients with previous exposure to an IL-17 inhibitor compared with patients with exposure to biologics with other cytokine targets remains to be elucidated. Therefore, the aim of this study was to  assess whether previous exposure to an IL-17A inhibitor was associated with worse response than exposure to (an)other biologic(s). All patients in the DERMBIO register treated with an IL-17A inhibitor (secukinumab or ixekizumab) were included. With an absolute Psoriasis Area and Severity Index (PASI) ≤ 2 as response, the proportion of responders treated with IL-17A inhibitors was assessed in patients previously treated with another IL-17A inhibitor and compared with patients with previous exposure to (an)other biologic(s), using a χ2 test. In total, 100, 93 and 83 patients with  previous exposure to an IL-17A inhibitor and 414, 372 and 314 patients with previous exposure to (an) other biologic(s) were assessed after 3, 6 and 12 months, respectively. No differences in the proportion of  patients achieving PASI ≤ 2 were observed between the 2 groups after 3 months (54% vs 57%, p = 0.59), 6months (70% vs 66%, p = 0.42) and 12 months (69% vs 60%, p = 0.14). In conclusion, when treating patients with IL-17A inhibitors the cytokine target of the previous biologic does not appear to affect the  response.

Drug Survival of Adalimumab, Secukinumab, and Ustekinumab in Psoriasis as Determined by Either Dose Escalation or Drug Discontinuation during the First 3 Years of Treatment - a Nationwide Cohort Study

The real-world efficacy of biologics may be insufficiently assessed through common drug survival studies. The objective was thus to examine the real-world performance of biologics in the treatment of psoriasis using the composite endpoint of either discontinuation or off-label dose escalation. Using a prospective nationwide registry (DERMBIO, 2007-2019), we included patients with psoriasis treated with adalimumab, secukinumab, and/or ustekinumab, which have all been used as first-line therapy during the inclusion period. The primary endpoint was a composite of either off-label dose escalation or discontinuation of treatment, whereas the secondary outcomes were dose escalation and discontinuation, respectively. Kaplan-Meier curves were used for the presentation of unadjusted drug survival curves. Cox-regression models were used for risk assessment. In 4,313 treatment series (38.8% women, mean age 46.0 years, and 58.3% bio-naivety), we found that the risk of the composite endpoint was lower for secukinumab when compared with ustekinumab (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.59-0.76), but higher for adalimumab (HR 1.15, 95% CI 1.05-1.26). However, the risk of discontinuation was higher for secukinumab (HR 1.24, 95% CI 1.08-1.42) and adalimumab (HR 2.01, 95% CI 1.82-2.22). For bio-naive patients treated with secukinumab, the risk of discontinuation was comparable to that of ustekinumab (HR 0.95, 95% CI 0.61-1.49).

Prevalence and characterization of treatment-refractory psoriasis and super-responders to biologic treatment: a nationwide study

INTRODUCTION

Treatment with biologics often leads to clearance of psoriasis. However, some patients do repeatedly fail to respond and/or lose an achieved response (treatment refractory) to the biologic, whereas other patients achieve excellent response to one biologic and remain clear of psoriasis for several years (super-responders).

OBJECTIVE

To identify and characterize patients with treatment refractory psoriasis and patients who are super-responders to biologic treatment.

MATERIAL AND METHODS

Patients registered in DERMBIO between January 2007 and November 2019 were included. Patients were categorized as being treatment refractory if they had had treatment failure to ≥3 biologics targeting ≥2 different pathways. Super-responders were patients treated with their first biologic for minimum 5 years without an absolute psoriasis area and severity index (PASI) > 3 between 6 months and 5 years of treatment. All remaining patients from DERMBIO served as comparators.

RESULTS

In total, 3280 patients were included with a mean age of 45.0 years. 1221 (37%) of the patients were females. Of the included patients, 214 (6.5%) were categorized as treatment refractory and 207 (6.3%) were categorized as super-responders. Treatment refractory patients had higher mean body weight (100.6 kg vs. 90.6 kg, P < 0.0001) and higher mean BMI (32.2 vs. 29.4, P < 0.0001) compared with the rest of patients in DERMBIO. Super-responders had higher socioeconomic status and fewer comorbidities compared with the comparator group (P < 0.0001).

CONCLUSION

A small proportion of patients with psoriasis treated with biologics are either super-responders or treatment refractory. Treatment refractory patients have higher body weight, whereas super-responders have fewer comorbidities and higher socioeconomic status.

Economic evaluations of interventions against viral pandemics: a scoping review

Objectives

The COVID-19 pandemic has led to suggestions that cost-effectiveness analyses should adopt a broader perspective when estimating costs. This review aims to provide an overview of economic evaluations of interventions against viral pandemics in terms of the perspective taken, types of costs included, comparators, type of economic model, data sources and methods for estimating productivity costs.

Study design

Scoping literature review.

Methods

Publications were eligible if they conducted a cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis or cost-minimisation analysis and evaluated interventions aimed at viral pandemics or for patients infected with viral pandemic disease. We searched PubMed, Embase and Scopus for relevant references and charted data from the selected full-text publications into a predefined spreadsheet based on research sub-questions, summary tables and figures.

Results

From 5410 references, 36 full-text publications fulfilled the inclusion criteria. The economic evaluations were mainly model based and included direct medical costs of hospital treatment. Around half of the studies included productivity costs and the proportion of total costs attributed to productivity costs ranged from 10% to 90%, depending on estimation methods, assumptions about valuation of time, type of intervention, severity of illness and degree of transmission.

Conclusions

Economic evaluations of interventions against viral pandemics differed in terms of estimation methods and reporting of productivity costs, even for similar interventions. Hence, the literature on economic evaluations for pandemic response would benefit from having standards for conducting and reporting economic evaluations, especially for productivity costs.

Dimethyl Fumarate Targets MSK1, RSK1, 2 and IKKα/β Kinases and Regulates NF-κB /p65 Activation in Psoriasis: A Demonstration of the Effect on Peripheral Blood Mononuclear Cells, Drawn from Two Patients with Severe Psoriasis Before and After Treatment with Dimethyl Fumarate

Background

Dimethyl fumarate (DMF) has an inhibitory effect on the production of pro-inflammatory proteins from different cells which participate in the immune reaction in psoriatic skin. Most recently it was shown that DMF is an allosteric covalent inhibitor of the p90 ribosomal S6 kinases (RSK1, 2), determined by X-ray crystallography. DMF binds to a specific cysteine residue in RSK2 and in the closely related mitogen and stress-activated kinases 1 (MSK1) which inhibits further downstream activation.

Objectives

The aim of this study was to review the literature on the effects of DMF on activation of MSK1, RSK1, 2 kinases, and downstream transcription factors NF-κB/p65 and IκBα in cells contributing to the pathogenesis of psoriasis. We also hypothesized and studied if treatment with DMF would inhibit the activation of MSK1, RSK1, 2 kinases in peripheral blood mononuclear cells (PBMCs) in psoriatic patients.

Methods

PBMCs were purified from patients with severe psoriasis before and after 90 days of treatment with DMF. Cells were stimulated with anisomycin, IL-1β or EGF for 10 and 20 minutes. The levels of phosphorylation of MSK1, RSK1, 2 or NF-κB/p65, IκBα were analyzed by Western blotting.

Results

Our case study showed that treatment with DMF inhibited the activation of MSK1 and RSK1, 2 kinases in PBMCs in patients. This supports that DMF is the active metabolite in vivo in psoriatic patients during DMF treatment.

Conclusion

Pro-inflammatory proteins are induced through activation of MSK1 and NF-κB/p65 at (S276). The extracellular signal-regulated kinases (ERK1/2) control cell survival by activating both MSK1 and RSK1, 2 kinases. P-RSK1, 2 activates P-κBα and NF-κB/p65 at (S536). The phosphorylation of NF-κB/p65 at (S276) and (S536) controls different T cell and dendritic cell functions. DMF´s inhibitory effect on MSK1 and RSK1, 2 kinase activations reduces multiple immune reactions in psoriatic patients.

Protein phosphatase 2Cδ/Wip1 regulates phospho-p90RSK2 activity in lesional psoriatic skin

Objectives

P90 ribosomal S6 kinase (RSK) 1 and 2 are serine/threonine protein kinases believed to mediate proliferation and apoptosis via the extracellular signal-regulated kinases (ERK1/2) signaling pathway. Macrophage migration inhibitory factor (MIF) and epidermal growth factor (EGF) are activators of this pathway and are elevated in the serum of patients with psoriasis compared with healthy controls. Studies on COS-7 cell cultures have shown that protein phosphatase 2Cδ (PP2Cδ) decreases the activity of RSK2 following EGF stimulation. We therefore hypothesize that PP2Cδ regulates RSK2 activity in psoriasis.

Methods

In paired biopsies from nonlesional (NL) and lesional (L) skins, we analyzed the level of RSK1, 2 phosphorylation and the expression of PP2Cδ isoforms, integrin-linked kinase-associated serine/threonine phosphatase (ILKAP) and wild-type p53-induced phosphatase 1 (Wip1) by Western blotting, immunofluorescence and coimmunoprecipitation with monoclonal antibody for RSK2. The induction of Wip1 by MIF or EGF was studied in cultured normal human keratinocytes.

Results

The protein level of RSK1, 2 phosphorylated at T573/T577 was significantly increased in L compared with NL psoriatic skin, while phosphorylation at S380/S386 was reduced in L compared with NL psoriatic skin when assayed by Western blotting and immunofluorescence microscopy. ILKAP expression was significantly higher in L than in NL skin, whereas Wip1 was expressed in similar amounts but showed increased coimmunoprecipitation with RSK2 in L compared with NL psoriatic skin. In cultured normal human keratinocytes stimulated with MIF, Wip1 phosphorylation and Wip1 expression were increased after 24 hours, but not when costimulated with dimethyl fumarate (DMF). The increased coimmunoprecipitation of Wip1 with RSK2 was significantly induced by EGF or MIF activation at 24 hours and could be significantly inhibited by DMF or the ERK1/2 inhibitor PD98059.

Conclusion

The complex formation of Wip1 with RSK2 indicates a direct interaction reducing P-RSK2 (S386) activation in L skin and indicates that Wip1 has a role in the pathogenesis of psoriasis.

Non-contact atomic force microscopy study of hydroxyl groups on the spinel MgAl2O4(100) surface

Atom-resolved non-contact atomic force microscopy (NC-AFM) studies of the magnesium aluminate (MgAl(2)O(4)) surface have revealed that, contrary to expectations, the (100) surface is terminated by an aluminum and oxygen layer. Theoretical studies have suggested that hydrogen plays a strong role in stabilizing this surface through the formation of surface hydroxyl groups, but the previous studies did not discuss in depth the possible H configurations, the diffusion behaviour of hydrogen atoms and how the signature of adsorbed H is reflected in atom-resolved NC-AFM images. In this work, we combine first principles calculations with simulated and experimental NC-AFM images to investigate the role of hydrogen on the MgAl(2)O(4)(100) surface. By means of surface energy calculations based on density functional theory, we show that the presence of hydrogen adsorbed on the surface as hydroxyl groups is strongly predicted by surface stability considerations at all relevant partial pressures of H(2) and O(2). We then address the question of how such adsorbed hydrogen atoms are reflected in simulated NC-AFM images for the most stable surface hydroxyl groups, and compare with experimental atom-resolved NC-AFM data. In the appendices we provide details of the methods used to simulate NC-AFM using first principles methods and a virtual AFM.

Gender-related differences in cytochrome P450 in porcine liver--implication for activity, expression and inhibition by testicular steroids

In pigs, the hepatic cytochrome P450 (CYP) 1A2, 2A and 2E1 activity is important in the regulation of skatole accumulation in adipose tissue. This study investigated gender-related differences in CYP1A2, 2A and 2E1 dependent activity, protein and mRNA expression. This study also investigated the gonadal steroid dependent inhibition of CYP activity in relation to gender and dietary composition. Microsomes were prepared from the liver of female and entire male pigs (Landrace × Yorkshire sire and Duroc boars) reared under similar conditions and slaughtered at an age of 164 days. A group of entire male pigs fed dried chicory root for 16 days prior to slaughter were included in the study. CYP activities were assessed by the use of probe substrates, whilst mRNA and protein expression were analysed by RT-PCR and Western blotting. Furthermore inhibition of CYP dependent activity by gonadal steroids was assessed in vitro. Microsomes from female pigs had greater CYP1A2 and 2A activity, as well as mRNA expression compared to entire male pigs. The antibodies used did not detected differences in protein expression. In vitro inhibition by 17β-oestradiol, oestrone, androstenone and 3β-OH androstenol of CYP2E1 activity in microsomes from entire male pigs as well as inhibition of CYP1A activity in chicory fed entire male pigs was observed. Apart from that no effect of steroids was shown. In conclusion, female pigs show greater CYP activity and mRNA expression. Including chicory in the diet for 16 days changed the gonadal steroid dependent inhibition of CYP activity in entire male pigs.

Exercise-induced regulation of phospholemman (FXYD1) in rat skeletal muscle: implications for Na+/K+-ATPase activity

BACKGROUND

Na(+)/K(+)-ATPase activity is upregulated during muscle exercise to maintain ionic homeostasis. One mechanism may involve movement of alpha-subunits to the outer membrane (translocation).

AIM

We investigated the existence of exercise-induced translocation and phosphorylation of phospholemman (PLM, FXYD1) protein in rat skeletal muscle and exercise-induced changes in V(max) and K(m) for Na(+) of the Na(+)/K(+)-ATPase.

METHODS

Two membrane fractionation methods and immunoprecipitation were used.

RESULTS

Both fractionation methods revealed a 200-350% increase in PLM in the sarcolemma after 30 min of treadmill running, while the phosphorylation of Ser-68 of PLM appeared to be unchanged. Exercise did not change V(max) or K(m) for Na(+) of the Na(+)/K(+)-ATPase in muscle homogenate, but induced a 67% increase in V(max) in the sarcolemmal giant vesicle preparation; K(m) for Na(+) remained constant. The main part of the increase in V(max) is related to a 36-53% increase in the level of alpha-subunits; the remainder may be related to increased PLM content. Similar results were obtained with another membrane purification method. In resting muscle, 29% and 32% of alpha(1)- and alpha(2)-subunits, respectively, were co-immunoprecipitated by PLM antibodies. In muscle homogenate prepared after exercise, immunoprecipitation of alpha(1)-subunits was increased to 227%, whereas the fraction of precipitated alpha(2) remained constant.

CONCLUSION

Exercise translocates PLM to the muscle outer membrane and increases its association with mainly the alpha(1)-subunit, which may contribute to the increased V(max) of the Na(+)/K(+)-ATPase.

Dimethylfumarate specifically inhibits the mitogen and stress-activated kinases 1 and 2 (MSK1/2): possible role for its anti-psoriatic effect

The p38 mitogen-activated protein kinase (MAPK) signaling pathway, which regulates the activity of different transcriptions factors including NF-kappaB, is activated in lesional psoriatic skin. The purpose of this study was to investigate the effect of fumaric acid esters (FAEs) on the p38 MAPK and the downstream kinases mitogen- and stress-activated protein kinase (MSK)1 and 2 in cultured human keratinocytes. Cell cultures were incubated with dimethylfumarate (DMF), methylhydrogenfumarate (MHF), or fumaric acid (FA) and then stimulated with IL-1beta before kinase activation was determined by Western blotting. A significant inhibition of both MSK1 and 2 activations was seen after preincubation with DMF and stimulation with IL-1beta, whereas MHF and FA had no effect. In addition, DMF decreased phosphorylation of NF-kappaB/p65 (Ser276), which is known to be transactivated by MSK1. Furthermore, incubation with DMF before stimulation with IL-1beta resulted in a significant decrease in NF-kappaB binding to the IL-8 kappaB and the IL-20 kappaB-binding sites as well as a subsequent decrease in IL-8 and IL-20 mRNA expression. Our results suggest that DMF specifically inhibits MSK1 and 2 activations and subsequently inhibits NF-kappaB-induced gene-transcriptions, which are believed to be important in the pathogenesis of psoriasis. These effects of DMF explain the anti-psoriatic effect of FAEs.

Non-steroidal anti-inflammatory drugs in the treatment of migraine

NSAIDs can be used in both the acute and prophylactic treatment of migraine with and without aura. It is a safe therapeutic alternative fore young healthy patients, but should be used with caution in the elderly. NSAIDs do not influence blood pressure and can be used in combination with most other migraine agents. The selective COX-2 inhibitors are an interesting therapeutic possbility for the future.

Impact of blood sampling in very preterm infants

In a prospective investigation, 99 very preterm infants (gestational age (GA) 24 32 weeks, birthweight 560-2,255 g) were studied during the first 4 weeks of life. The infants were divided into two groups: infants born extremely early (GA <28 weeks, n = 20) and infants of GA 28 - 32 weeks; the groups were then subdivided into critically ill or not. Diagnostic blood sampling and blood transfusion events were recorded. In total, 1905 blood samples (5,253 analysis) were performed, corresponding to 0.7 samples (1.9 analysis) per day per infant. The highest frequencies were found during the first week, in infants with extremely low GA and in critically ill infants. The mean blood loss and transfusion volume values were 13.6 ml/kg and 6.3 ml/kg, respectively. In total, 19 infants (19%) received 34 transfusions corresponding to 0.3 transfusions per infant. Thirteen out of 20 infants of extremely low GA received 28 blood transfusions, corresponding to 27.0 ml/kg of blood on average during the study period. Four developed late anaemia; thus, in total, 14 (70%) of the infants born extremely early received 35 transfusions during the first 3 months of life, corresponding to a total mean of 34.8 ml/kg. For the extremely preterm infants a significant correlation between sampled and transfused blood volume was found (mean 37.1 and 33.3 ml/kg, respectively, r = + 0.71, p = 0.0003). The most frequently requested analyses were glucose, sodium and potassium. Few blood gas analyses were requested (1.9/ infant). No blood losses attributable to excessive generous sampling were detected. The results show an acceptable low frequency of sampling and transfusion events for infants of GA 28-32 weeks. The study emphasizes the necessity of thorough reflection and monitoring of blood losses when ordering blood sampling in extremely preterm, critically ill infants.

Ethical aspects of clinical decision-making

The aim of the present investigation was to describe and to classify significant ethical problems encountered by the members of the staff during the daily clinical work at a hospital medical department. A set of definitions was prepared for the purpose, including the definition of a 'significant ethical problem'. During a three month period 426 inpatients and 173 outpatients were admitted. Significant ethical problems were encountered during the management of 106 in-patients (25 per cent) and 9 out-patients (5 per cent). No significant difference was found between the frequency of ethical problems in female and male patients, but a positive correlation was noted between the number of problems and the patients' age. The problem types were classified according to a problem list. The results of this investigation suggest that greater attention must be paid to discussions about ethical problems among doctors and other categories of health personnel and that, among others, medical students ought to be taught the analysis of ethical problems.