Identifying Levels of Competency in Aesthetic Medicine: A Questionnaire-Based Study

BACKGROUND

In 2022, the US experienced a significant increase in demand for minimally invasive aesthetic procedures, underscoring its rising acceptance amidst an unregulated educational environment for practitioners. The absence of standardized educational pathways and quality control in aesthetic medicine, primarily provided by non-academic institutions, highlights a critical need for establishing educational standards to ensure practitioner competence and patient safety.

OBJECTIVES

To identify levels of competency for the aesthetic practitioner and for necessary achievement milestones during the educational path from novice to expert injector.

METHODS

A total of n = 386 international study participants responded to an online questionnaire regarding their experience in aesthetic medicine practice. The questionnaire comprised 58 questions focusing on professional data, the perceived difficulty of injection and risk for the occurrence of adverse events for specific facial regions in soft tissue filler and toxin injections.

RESULTS

Regardless of medical specialty and experience level, an average of 3.85 (1.8) years, 786.4 (2,628) filler injections, and 549.9 (1,543) toxin injections was estimated to progress from novice to advanced injector, while an average of 6.10 (3.7) years, 1,842.2 (4,793) filler injections, and 1,308.5 (3,363) injections was estimated to advance from advanced to expert injector. The nose and the perioral region have been ranked as the facial regions most difficult to achieve a perfect aesthetic outcome and with the greatest risk for the occurrence of adverse events for filler and toxin injections, respectively.

CONCLUSIONS

This study establishes an educational framework in aesthetic medicine by defining the progression from novice to competent and expert injector levels, suggesting 4 years of practice and over 790 filler and 550 neuromodulator injections for competence, and at least 6 years with 1,840 filler and 1,310 neuromodulator injections for expertise. It also identifies critical facial regions for targeted treatments by different expertise levels.

Interaction Between Baseline Participant Factors and Treatment Effects Following Peanut Oral Immunotherapy

BACKGROUND

The Probiotic Peanut Oral Immunotherapy-003 multicenter randomized trial found that both probiotic peanut oral immunotherapy (PPOIT) and peanut OIT alone (OIT) were effective compared with placebo in inducing clinical remission after 18 months of treatment, and improving health-related quality of life (HRQL) at 12 months after treatment. Understanding treatment effect modifiers can optimize outcomes through precision care.

OBJECTIVES

This post hoc study examined baseline clinical and demographic participant factors that modified treatment effects.

METHODS

The study sample included 201 children (aged 1-10 years) with challenge-confirmed peanut allergy. Exposure variables were baseline clinical and demographic factors. Outcomes were remission (double-blind, placebo-controlled food challenge, cumulative 4,950-mg peanut protein at 8 weeks after treatment) and HRQL (change in Food Allergy Quality of Life Questionnaire-Parent Form score). Interactions between baseline factors and treatment effects on remission and HRQL were explored with regression models.

RESULTS

A higher degree of peanut sensitivity (large peanut skin prick test, high peanut specific IgE, and low reaction-eliciting dose at study entry challenge) and other concurrent allergic conditions (multiple food allergies, asthma, or wheeze) were associated with the decreased likelihood of attaining remission after both PPOIT and OIT treatment. History of anaphylaxis was associated with the reduced likelihood of remission after PPOIT compared with OIT. For the HRQL outcome, there was evidence that sex, history of anaphylaxis, and age modified treatment effects.

CONCLUSIONS

Baseline participant factors modify PPOIT and OIT effects on remission and HRQL. Considering modifiers of treatment effect during participant selection may optimize treatment success and clinical trial design toward specific outcomes, such as the achievement of remission.

LetibotulinumtoxinA Attenuates the Psychological Burden of Glabellar Lines and Is Associated With High Subject Satisfaction in Phase 3 Clinical Trials

BACKGROUND

Hyperfunctional glabellar frown lines can transmit facial miscues that adversely affect emotional communication, increase perceptions of age, and diminish self-esteem.

OBJECTIVE

To evaluate the efficacy of letibotulinumtoxinA in mitigating the negative psychological impact associated with moderate to severe glabellar lines and to assess subject satisfaction with treatment outcome in the BLESS phase 3 clinical trials.

MATERIALS AND METHODS

Baseline and posttreatment assessments were made using validated subject-administered instruments: Modified Skindex-16 Glabellar Line Quality of Life (GL-QoL) Scale, Facial Assessment and Cosmetic Evaluation Questionnaire (FACE-Q) Appraisal of Lines Between Eyebrows Scale, FACE-Q Age Appraisal Visual Analog Scale, and FACE-Q Satisfaction with Outcome Scale. An integrated analysis using pooled BLESS data was conducted on these secondary end points.

RESULTS

Among enrolled and treated subjects (N = 1,272), 85.5% had moderate to severe psychological impact at baseline. LetibotulinumtoxinA subjects experienced significant improvements compared with placebo on all measures. Mean improvement to Week 4 for the Modified Skindex-16 GL-QoL Scale overall score was -33.84 for letibotulinumtoxinA subjects compared with -1.37 for placebo subjects (p < .001). Attenuation of psychological burden was highly correlated with improvement in glabellar line severity (p < .0001).

CONCLUSION

LetibotulinumtoxinA significantly improved the psychosocial burden associated with glabellar lines across all trials. Treated subjects experienced improved quality of life, younger perceived age, and satisfaction with treatment outcome.

A Novel Systems-Wide Approach in Addressing Acne with a Multi-Targeting Nutraceutical

Acne vulgaris (AV) is one of the top concerns dermatologists encounter from women. Until now, therapies addressing AV have largely centered around, and have been successful at, targeting the pathophysiological mechanisms that occur at the pilosebaceous unit: sebum hypersecretion, follicular keratinization, over-proliferation of Cutibacterium acnes, and a localized immune response. In addition to these, there is good evidence to suggest that other systemic drivers of a generalized inflammatory response may contribute to the development or exacerbation of acne and that addressing these underlying factors may open more opportunities for developing effective treatments. These include psycho-emotional stress, diet and metabolism, hormonal fluctuations, skin and gut microbiome, oxidative stress, and immune response. While there is accumulating evidence that vitamins, minerals, and botanicals may mitigate some of the pro-inflammatory effects from the activation of these underlying systems, their use and recommendations are limited by a lack of quality efficacy and safety evidence. Here, we present the current evidence for the use of individual supplements in addressing the 6 systemic underlying drivers of AV. We also present a clinical study on the safety and efficacy of a nutraceutical combining many of these ingredients in the management of AV in men and women.  J Drugs Dermatol. 2024;23(3):160-167     doi:10.36849/JDD.8138.

INDIVIDUAL ARTICLE: Real-World Patient Cases Using Botanical Serum-Containing Corrective Gel as an Adjunct to Aesthetic Facial Laser or Microneedling Radiofrequency (MRF) Treatment

Integrated skin care is defined as the complementary use of topical treatments to nonsurgical facial rejuvenation procedures, such as lasers and radiofrequency microneedling devices, to produce pleasing aesthetic results. Real-world experience from expert dermatologists is invaluable in guiding patient treatment plans, as there are limited clinical trials on the efficacy of integrated skincare regimens. The SkinCeuticals (New York, NY) Phyto Corrective gel (botanical serum-containing corrective gel) contains a lightweight botanical serum that hydrates, calms, and soothes skin. It contains antioxidant and anti-inflammatory ingredients derived from plant and fruit extracts, making it an appealing option for adjunctive treatment of post-procedure erythema and swelling.  J Drugs Dermatol. 2024;23:3(Suppl 2):s3-s14.

Actinin-4 controls survival signaling in B cells by limiting the lateral mobility of B-cell antigen receptors

The structure and dynamics of F-actin networks in the cortical area of B cells control the signal efficiency of B-cell antigen receptors (BCRs). Although antigen-induced signaling has been studied extensively, the role of cortical F-actin in antigen-independent tonic BCR signaling is less well understood. Because these signals are essential for the survival of B cells and are consequently exploited by several B-cell lymphomas, we assessed how the cortical F-actin structure influences tonic BCR signal transduction. We employed genetic variants of a primary cell-like B-cell line that can be rendered quiescent to show that cross-linking of actin filaments by α-actinin-4 (ACTN4), but not ACTN1, is required to preserve the dense architecture of F-actin in the cortical area of B cells. The reduced cortical F-actin density in the absence of ACTN4 resulted in increased lateral BCR diffusion. Surprisingly, this was associated with reduced tonic activation of BCR-proximal effector proteins, extracellular signal-regulated kinase, and pro-survival pathways. Accordingly, ACTN4-deficient B-cell lines and primary human B cells exhibit augmented apoptosis. Hence, our findings reveal that cortical F-actin architecture regulates antigen-independent tonic BCR survival signals in human B cells.

Early and Sustained Acne Lesion Reductions With Fixed-Dose Clindamycin Phosphate 1.2%/Adapalene 0.15%/Benzoyl Peroxide 3.1% Gel

BACKGROUND

A once-daily, three-pronged approach using an antibiotic, antibacterial, and retinoid may provide faster acne improvement versus monotherapy or dual-combination products. This post hoc analysis compared threshold acne lesion reductions with clindamycin phosphate 1.2%/adapalene 0.15%/benzoyl peroxide 3.1% (CAB) gel—the first FDA-approved triple-combination topical acne product—to its dyads and vehicle.

METHODS

Phase 2 (N=741; NCT03170388) and phase 3 (N=183; N=180; NCT04214639; NCT04214652), double-blind, 12-week studies randomized participants aged ≥9 years with moderate-to-severe acne to once-daily CAB or vehicle gel; the phase 2 study included three additional dyad gel arms. The pooled percentage of participants achieving ≥33%, ≥50%, and ≥75% reduction in inflammatory and noninflammatory acne lesions was evaluated.

RESULTS

As early as week 4 in the phase 2 study, ≥33% reduction in inflammatory lesions occurred in a significantly greater percentage of CAB gel-treated participants (82.7%) than with the 3 dyads and vehicle (61.1-69.8%; P<0.05, all). These early reductions were sustained throughout the study, with significantly (P<0.05) more CAB-treated participants achieving ≥50% reduction in inflammatory lesions versus dyads and vehicle from weeks 4-12. By week 12, CAB led to substantial reductions of ≥75% in significantly more participants than dyads and vehicle (65.8% vs 49.9-51.2% and 21.6%; P<0.05, all). Similar trends were observed for noninflammatory lesions in the phase 2 study and for inflammatory and noninflammatory lesions in the phase 3 studies.

CONCLUSIONS

Lesion count reductions were significantly greater with CAB versus its dyads and vehicle gel as early as week 4, with substantial reductions observed after 12 weeks of treatment. This faster-acting and sustained efficacy of CAB gel—coupled with its optimized formulation, once-daily dosing, and tolerability—may positively impact treatment adherence. J Drugs Dermatol. 2024;23(3):     doi:10.36849/JDD.7907.

Microplastics in dermatology: Potential effects on skin homeostasis

BACKGROUND

Microplastics (MPs) and nanoplastics (NPs) have become a growing concern in dermatology due to their widespread presence in cosmetic formulations and the environment. These minuscule synthetic polymer particles prompt an essential exploration of their potential impact on dermatological homeostasis.

AIMS

This study aims to investigate the effects of MPs and NPs on the integumentary system. Specifically, it seeks to understand the potential cutaneous alterations, inflammatory responses, and disruptions to the skin's physiological functions caused by these synthetic particles.

PATIENTS/METHODS

The investigation involves a comprehensive analysis of emerging research on MPs and NPs. This includes their presence in cosmetic formulations and environmental pervasiveness. The study delves into their capacity to breach the cutaneous barrier, raising concerns about the implications of prolonged exposure.

RESULTS

Evidence suggests that MPs and NPs may indeed incite cutaneous alterations, provoke inflammatory responses, and disturb the homeostasis of the skin's physiological functions. Their small dimensions enhance their capability to breach the cutaneous barrier, further emphasizing the apprehensions associated with prolonged exposure.

CONCLUSIONS

While a precise understanding of the implications of MPs and NPs on dermatological health remains an ongoing scientific endeavor, this study underscores the growing significance of these synthetic particles. The findings emphasize the need for proactive measures to safeguard both individual well-being and environmental preservation in the context of dermatological health.

Efficacy and Safety of LetibotulinumtoxinA in the Treatment of Moderate and Severe Glabellar Lines in Females 35 to 50 Years of Age: Post Hoc Analyses of the Phase 3 Clinical Study Data

Background

Botulinum toxin type A (BoNT-A) injections continue to be widely used as a common treatment for both males and females. According to a recent survey conducted by the International Society of Plastic Aesthetic Surgeons, the majority of patients receiving these injections are females between the ages 35 and 50.

Objectives

A post hoc analysis was conducted to examine whether there were variances in the effectiveness and safety of letibotulinumtoxinA for treating vertical glabellar lines between the broader female study population and a particularly defined group of female participants aged 35 to 50.

Methods

For this post hoc analysis, data from females aged 35 to 50 were extracted and analyzed from the BLESS III study. In this Phase 3 clinical trial, 355 participants with moderate-to-severe glabella frown lines received either 20 U of letibotulinumtoxinA or a placebo. The study evaluated Glabella Line Severity (GLS) score, treatment onset, duration of effects, time to retreatment, and adverse events. A positive response was determined by achieving a GLS score of 0 or 1, as assessed by both patients and investigators, along with at least a 2-point improvement in GLS score relative to baseline at Week 4 after the injections.

Results

Composite responder rates for patients aged 35 to 50 receiving active treatment were significantly higher than for the remaining female population receiving active treatment at Weeks 1, 2, and 4. Females aged 35 to 50 showed higher rates of GLS improvement of ≥1 at Weeks 1, 2, 4, 8, 12, 16, and 20 compared with the remaining female population receiving active treatment. At Week 4, a higher percentage of females aged 35 to 50 achieved a GLS score of 0 upon maximum frowning compared with the remaining females. Females aged 35 to 50 had a shorter median time to onset of GLS improvement compared with the remaining female population. Safety assessments showed a low incidence of treatment-related adverse events in females aged 35 to 50.

Conclusions

LetibotulinumtoxinA showed significantly higher response rates in females aged 35 to 50 compared with other female patients at Weeks 1, 2, and 4. Response rates remained higher up to Week 16. The treatment demonstrated efficacy and safety in treating vertical glabellar lines in this patient group.

Level of Evidence 2

A comprehensive review of the medical and cosmetic applications of exosomes in dermatology

BACKGROUND

Exosomes are a subset of extracellular vesicles that are released by all cell types and are theorized to play a crucial role in intercellular communication. Ranging from 40 to 160 nm in diameter, exosomes contain a variety of genetic materials including DNA, RNA, mRNA, metabolites, proteins, and lipids depending on their cellular origin.

AIM

Given that intercellular communication is abetted by the exchange of cellular components via exosomes, their applied use can have important implications for disease pathology and exosome-based therapeutics. We provide a comprehensive review of the current application of exosomes in medical (and skin) diseases and in cutaneous medical aesthetics.

METHODS

A literature search was conducted on PubMed reviewing exosomes and their application in medical and aesthetic fields.

RESULTS

While the therapeutic use of exosomes in the treatment of medical and cosmetic dermatological procedures is promising, it is also important to note that most studies implementing exosomes as therapeutic agents have been conducted in preclinical models, thus highlighting the need for additional studies and clinical trials. One more important note in the aesthetic world associated with exosomes is that in the United States, at the time of this writing, exosomes may only be topically applied and not injected into the skin, as is done in many countries worldwide.

CONCLUSION

There is a need for additional studies and clinical trials to evaluate the safety and therapeutic effect and safety of exosomes in medical and aesthetic fields.

Promoting a Healthy Skin Barrier Using Skin Care in People With Mature Skin Xerosis

INTRODUCTION

Most people are living into their sixties and beyond. Fundamental changes in chronologically aged skin have significant and widespread dermatological implications. This review discusses aging-associated alterations in epidermal function leading to xerosis and related pruritus and the benefits of maintaining or restoring a healthy skin barrier using skincare, specifically ceramide-containing skincare.   Methods: A panel of 7 dermatologists convened for a meeting to review aspects of xerosis in mature skin, skin barrier changes, and nuances in the treatment and maintenance of mature skin using gentle cleansers and moisturizers. From the selected literature, 13 statements were drafted. During the meeting, the draft statements underwent the panel's evaluation at a workshop, followed by a plenary discussion adopting 5 statements using evidence from the literature coupled with the panel's opinions and experiences.

RESULTS

The exact etiology of xerosis is not entirely understood and likely depends on several genetic and environmental mechanisms. Aging-associated changes in epidermal function include a marked reduction in total lipids in the stratum corneum relative to young skin due to reduced epidermal lipid synthesis. In aging skin, xerosis is significantly associated with pruritus. Studies have shown that lipid-containing skin care, such as a gentle ceramide-containing cleanser and moisturizer, promotes a healthy barrier reducing xerosis and pruritus in individuals with mature skin.  Conclusions: The development of xerosis in mature skin involves several genetic and environmental mechanisms. Skincare, including gentle cleansers and moisturizers, has reduced xerosis and pruritus in mature skin individuals.     J Drugs Dermatol. 2024;23(1):1253-1259.     doi:10.36849/JDD.7560.

Macrocystis pyrifera ferment-containing creams for optimizing facial skin rejuvenation

BACKGROUND

There is an increasing demand for facial skin rejuvenation. Specialized aesthetic skincare treatments may be one of the first steps to help prevent or treat facial signs of aging. This article discusses aesthetic skin care for facial skin rejuvenation, particularly data on two creams containing Macrocystis pyrifera ferment.

METHODS

The authors convened a dermatology advisory board to discuss challenges and practices in using skincare for facial rejuvenation, combining their expert opinion and experience on facial rejuvenation with preclinical and clinical data on two creams containing Macrocystis pyrifera ferment and a review of the literature.

RESULTS

Preclinical and clinical studies on Macrocystis pyrifera ferment and two creams containing the ferment exhibit anti-inflammatory, anti-aging, and healing properties. In preclinical studies, the ferment demonstrated collagen type I enhancing properties in ex vivo skin models, and skin cells treated with the ferment migrated faster than untreated cells in the in vitro study. In clinical studies measuring visible anti-inflammatory activity, the ferment alone and the ferment-containing products significantly decreased erythema, and in anti-aging studies, they improved visible skin aging parameters. Finally, in clinical studies on the stratum corneum, the two creams increased moisture levels and decreased transepidermal water loss (TEWL), reflecting healing by enhancing barrier strength and recovery.

CONCLUSIONS

The Macrocystis pyrifera ferment and creams containing the ferment are effective skin care treatment products to decrease the visible effects of inflammation and signs of aging while promoting healing by enhancing barrier resilience and recovery.

Improvements in acne and skin oiliness with tazarotene 0.045% lotion in patients with oily skin

BACKGROUND

Excessive sebum production is a factor in acne development. Tazarotene 0.045% lotion has demonstrated reductions in acne lesions and acne-induced sequelae.

OBJECTIVE

Evaluate efficacy, changes in skin oiliness, and safety with tazarotene 0.045% lotion in participants with moderate-to-severe acne and oily skin.

METHODS

In two phase 3, double-blind, 12-week studies (NCT03168321; NCT03168334), participants aged ≥ 9 years with moderate-to-severe acne were randomized 1:1 to once-daily tazarotene 0.045% lotion or vehicle lotion (N = 1614). This pooled, post hoc analysis included only participants self-categorized with oily skin at baseline on the Acne-Specific Quality of Life questionnaire item 19 (scores: 0 [extremely oily] to 6 [not at all oily]). Inflammatory/noninflammatory lesion counts, treatment success, skin oiliness, treatment-emergent adverse events (TEAEs), and cutaneous safety/tolerability were evaluated.

RESULTS

In all participants with oily skin (n = 793), tazarotene provided greater reductions in inflammatory/noninflammatory lesions (p < 0.001, both) and greater treatment success rates versus vehicle (p < 0.01) at week 12. Over two-thirds of polymeric lotion-treated participants had subjective skin oiliness reductions by week 12, with around a third reporting 'low/not' oily skin. Tazarotene TEAE rates were similar to the overall population.

CONCLUSIONS

Once-daily treatment with tazarotene 0.045% polymeric emulsion lotion may help improve patient-perceived skin oiliness in those with moderate-to-severe acne.

Clindamycin phosphate 1.2%/adapalene 0.15%/benzoyl peroxide 3.1% gel for moderate-to-severe acne: Efficacy and safety results from two randomized phase 3 trials

BACKGROUND

A three-pronged acne treatment approach-combining an antibiotic, antibacterial agent, and retinoid-may provide greater efficacy than single/double treatments. Topical clindamycin phosphate 1.2%/adapalene 0.15%/benzoyl peroxide (BPO) 3.1% gel (IDP-126) is the first fixed-dose triple-combination in development for acne.

OBJECTIVE

To confirm efficacy, safety, and tolerability of IDP-126 gel in acne treatment.

METHODS

Two phase 3, double-blind, 12-week studies randomized participants aged ≥9 years with moderate-to-severe acne (N = 183; N = 180) 2:1 to once-daily IDP-126 or vehicle gel. Co-primary endpoints comprised participants achieving ≥2-grade reduction from baseline in Evaluator's Global Severity Score (EGSS) and clear/almost clear skin (treatment success) and change from baseline in inflammatory/noninflammatory lesion counts. Treatment-emergent adverse events (TEAEs) were assessed.

RESULTS

At week 12, 49.6% and 50.5% of participants achieved treatment success with IDP-126 versus 24.9% and 20.5% with vehicle (P < .01, both). IDP-126 also provided significantly greater reductions in inflammatory/noninflammatory lesions versus vehicle (least-squares mean percent range: 72.7% to 80.1% vs 47.6% to 59.6%; P < .001, all). Most TEAEs were of mild-moderate severity.

LIMITATIONS

Inter-observer bias/variation in acne severity ratings, limited treatment duration, and population differences that may not generalize to real-world populations.

CONCLUSION

The innovative fixed-dose, triple-combination IDP-126 gel was efficacious and well tolerated in 2 clinical studies of participants with moderate-to-severe acne.

Insights into acne and the skin barrier: Optimizing treatment regimens with ceramide-containing skincare

INTRODUCTION

Acne is a common, complex, multifactorial inflammatory skin disease associated with epidermal barrier dysfunction. Beginning in childhood, acne affects many adolescents and adults. Acne is associated with lower self-esteem, anxiety, and depression and may cause scars and pigmentary sequelae. The review explores the relationships between acne and the skin barrier function and discusses nuances in the prevention, treatment, and maintenance of acne and its impact on the skin barrier.

METHODS

The advisors' previous publications addressed prescription and nonprescription pediatric acne treatment and skincare using cleansers, moisturizers, and a practical algorithm for treatment and maintenance, including skincare recommendations for pediatric acne patients and an algorithm for skin of color patients with acne. Before the meeting, literature was culled on the relationship between the skin barrier and acne and current best practices in acne, addressing prescription and nonprescription acne products and skincare as monotherapy, adjunctive, and maintenance treatment.

RESULTS

After discussing 13 draft statements, the advisors applied the selected literature and drew from their clinical knowledge and experience, and agreed on five statements. The follicular epithelial barrier is directly involved with changes that occur during both comedogenesis and in stages of inflammation, especially with follicular rupture compromising the barrier's integrity. In acne-affected skin, sebaceous glands are larger, sebum excretion and filaggrin expression higher, and stratum corneum lipids are reduced. Educating patients and clinicians about inflammation's central role in acne and measures to reduce inflammation is essential. Skin irritation and xerosis from acne and treatments lead to poor treatment adherence. A skincare regimen should be included in the acne prevention, treatment, and maintenance care regimen and should be ongoing. Maintenance treatment with topical agents and skincare using gentle ceramide-containing cleansers and moisturizers is a recommended strategy after successfully controlling the disease.

CONCLUSIONS

Epidermal barrier dysfunction contributes to acne exacerbation. Using the appropriate treatment and skincare helps to minimize irritation and inflammation, enhance treatment adherence, and improve patient outcomes.

The clinicopathological features of thrombosis with thrombocytopenia syndrome following ChAdOx1-S (AZD1222) vaccination and case outcomes in Australia: a population-based study

Background

Thrombosis with thrombocytopenia syndrome (TTS) associated with viral vector COVID-19 vaccines, including ChAdOx1-S (AstraZeneca AZD1222) vaccine, can result in significant morbidity and mortality. We report the clinicopathological features of TTS following ChAdOx1-S vaccination and summarise the case outcomes in Australia.

Methods

In this cohort study, patients diagnosed with TTS in Australia between 23 March and 31 December 2021 were identified according to predefined criteria. Cases were included if they met the Therapeutic Goods Administration (TGA) probable and confirmed case definitions and were reclassified using Centres for Disease Control and Prevention (CDC) definition for analysis. Data were collected on patient baseline characteristics, clinicopathological features, risk factors, treatment and outcomes.

Findings

A total of 170 TTS cases were identified, with most occurring after the first dose (87%) of ChAdOx1-S. The median time to symptom onset after vaccination and symptom onset to admission was 11 and 2 days respectively. The median age of cases was 66 years (interquartile range 55-74). All except two patients received therapeutic anticoagulation and 66% received intravenous immunoglobulin. Overall, 85.3% of cases were discharged home after a median hospitalisation of 6 days, 9.4% required ongoing rehabilitation and 5.3% died. Eight deaths were related to TTS, with another dying from an unrelated condition while receiving treatment for TTS. Deaths occurred more commonly in those classified as Tier 1 according to the CDC definition and were associated with more severe thrombocytopenia and disease-related haemorrhage.

Interpretation

TTS, while rare, can be severe and have catastrophic outcomes in some individuals. In Australia, the mortality rate was low compared to that reported in other high-income countries. Almost all received therapeutic anticoagulation with no bleeding complications and were successfully discharged. This emphasises the importance of community education and an established pathway for early recognition, diagnosis and treatment of TTS.

Funding

Australian Commonwealth Department of Health and Aged Care. H.A Tran, N. Wood, J. Buttery, N.W. Crawford, S.D. Chunilal, V.M. Chen are supported by Medical Research Future Funds (MRFF) grant ID 2015305.

Impact of Age on Subcutaneous Implantable Cardioverter-Defibrillator in a Large Patient Cohort: Mid-Term Follow-Up

BACKGROUND

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is an accepted alternative to transvenous (TV) ICD to provide defibrillation therapy to treat life-threatening ventricular tachyarrhythmias in high-risk patients. S-ICD outcomes by age group have not been reported.

OBJECTIVES

In this study, the authors sought to report S-ICD outcomes in different age groups in a multicenter S-ICD post-approval study (PAS) involving the largest cohort of patients ever reported.

METHODS

Patients were prospectively enrolled in the S-ICD PAS and stratified based on age: young, aged 15-34 years; adult, aged 35-69 years; and elderly, aged ≥70 years. Patient characteristics and clinical outcomes through 3 years of follow up after implantation were compared.

RESULTS

The S-ICD PAS enrolled 1,637 patients. Elderly patients were more likely to receive an S-ICD as a replacement of a TV-ICD (15.1% elderly vs 12.3% adult vs 7.4% young). Secondary prevention indication decreased with age (32.7% young vs 22.2% adult vs 20.5% elderly). Mortality rate was significantly higher in the elderly group (24.0% elderly vs 13.0% adult vs 7.4% young; P < 0.0001), whereas the complication rate did not differ significantly (12.3% young vs 11.3% adult vs 8.1% elderly). Rates of appropriate shock (12.7% young vs 13.0% adult vs 13.8% elderly) and inappropriate shock (7.8% young vs 9.1% adult vs 8.8% elderly) rates did not differ between groups (P = 0.96 and P = 0.98, respectively).

CONCLUSIONS

Implant complications and appropriate and inappropriate shock rates were similar among age groups. S-ICD for secondary prevention was more common in the young group. Replacing a TV-ICD for an S-ICD increases with age. (S-ICD System Post-Approval Study; NCT01736618).

Association of Reaction Symptoms and Eliciting Dose With Health-Related Quality of Life in Children With Peanut Allergy

BACKGROUND

Food allergy adversely affects the health-related quality of life (HRQoL) of patients. It is unclear whether factors such as the reaction eliciting dose (ED) and the nature of allergic reaction symptoms affect HRQoL.

OBJECTIVE

To explore associations between reaction ED or the nature of allergic symptoms and HRQoL among children with peanut allergy.

METHODS

This study was a secondary analysis of baseline data from the PPOIT-003 randomized trial in 212 children aged 1 to 10 years with challenge-confirmed peanut allergy. Children's past reaction symptoms were collected by clinicians during screening. Associations between variables of interest and parent-reported child-proxy HRQoL were examined by univariable and multivariable linear regression.

RESULTS

Mean age of study participants was 5.9 years; 63.2% were male. Children with a low reaction ED of 80 mg peanut protein had significantly poorer HRQoL (β = -0.81; 95% CI, -1.61 to -0.00; P = .049) compared with children with a high ED of 2,500 mg peanut protein. Gastrointestinal symptoms (β = 0.45; 95% CI, 0.03-0.87; P = .037), lower airway symptoms (β = 0.46; 95% CI, 0.05-0.87; P = .030), multisystem involvement (β = 0.71; 95% CI, 0.25-1.16; P = .003), or anaphylaxis (β = 0.46; 95% CI, 0.04-0.87; P = .031) during a previous reaction were associated with worse HRQoL.

CONCLUSIONS

Peanut-allergic children with a lower allergen reaction threshold experienced a greater negative HRQoL impact compared with children with higher reaction thresholds. In addition, specific past allergic reaction symptoms were associated with comparatively worse HRQoL. Children experiencing these symptoms and those with lower reaction ED require increased clinical support to manage the food allergy and are likely to benefit from interventions that can improve HRQoL.

Efficacy and Safety of Tapencarium (RZL-012) in Submental Fat Reduction

BACKGROUND

Tapencarium (RZL-012) (5-(3.6-dibromo-9H-carbazol-9-yl)-N, N, N-trimethylpentan-1-aminium chloride) is a novel injectable synthetic molecule with cytolytic properties, capable of reducing subcutaneous fat volume.

OBJECTIVES

The goal of this 3-armed, randomized, double-blind, placebo-controlled phase 2b study was to determine the safety and efficacy of low- and high-dose RZL-012 vs placebo on submental fat (SMF) reduction.

METHODS

Patients (n = 151, age 18-65 years) with excess SMF received a single treatment session of RZL-012 or placebo in the submental area, after which they were monitored for 84 days. SMF was assessed at baseline and after dosing with newly developed scales, namely the Clinician Chin Assessment Tool (C-CAT) and Subject Chin Assessment Tool (S-CAT). SMF was also assessed by magnetic resonance imaging (MRI) at screening and on Day 84 after treatment.

RESULTS

The proportion of patients who had a 1-grade or 2-grade improvement in C-CAT and/or S-CAT on Day 84 vs baseline was significantly higher in the high-dose RZL-012 group vs the placebo group (P < .002). The relative percentage reduction in MRI-measured SMF volume (Day 84 vs screening) was significantly greater in the high-dose RZL-012 group vs the low-dose RZL-012 or the placebo group (P < .0001). Local injection site reactions were the most common adverse events (AEs).

CONCLUSIONS

A single administration of RZL-012 into SMF resulted in significant improvement in submental appearance as assessed by clinicians, patients, and MRI. From a safety perspective, there were no serious AEs and no clinically significant changes in vital signs or laboratory tests over the course of the study.

LEVEL OF EVIDENCE: 1

An oligodendrocyte silencer element underlies the pathogenic impact of lamin B1 structural variants

The role of non-coding regulatory elements and how they might contribute to tissue type specificity of disease phenotypes is poorly understood. Autosomal Dominant Leukodystrophy (ADLD) is a fatal, adult-onset, neurological disorder that is characterized by extensive CNS demyelination. Most cases of ADLD are caused by tandem genomic duplications involving the lamin B1 gene ( LMNB1 ) while a small subset are caused by genomic deletions upstream of the gene. Utilizing data from recently identified families that carry LMNB1 gene duplications but do not exhibit demyelination, ADLD patient tissues, CRISPR modified cell lines and mouse models, we have identified a novel silencer element that is lost in ADLD patients and that specifically targets overexpression to oligodendrocytes. This element consists of CTCF binding sites that mediate three-dimensional chromatin looping involving the LMNB1 and the recruitment of the PRC2 repressor complex. Loss of the silencer element in ADLD identifies a previously unknown role for silencer elements in tissue specificity and disease causation.

Neutralizing RGMa with Elezanumab Promotes Cerebroprotection and Recovery in Rabbit Middle Cerebral Artery Occlusion

Repulsive guidance molecule A (RGMa) is an inhibitor of neuronal growth and survival which is upregulated in the damaged central nervous system following acute spinal cord injury (SCI), traumatic brain injury, acute ischemic stroke (AIS), and other neuropathological conditions. Neutralization of RGMa is neuroprotective and promotes neuroplasticity in several preclinical models of neurodegeneration and injury including multiple sclerosis, AIS, and SCI. Given the limitations of current treatments for AIS due to narrow time windows to intervention (TTI), and restrictive patient selection criteria, there is significant unmet need for therapeutic agents that enable tissue survival and repair following acute ischemic damage for a broader population of stroke patients. In this preclinical study, we evaluated whether elezanumab, a human anti-RGMa monoclonal antibody, could improve neuromotor function and modulate neuroinflammatory cell activation following AIS with delayed intervention times up to 24 h using a rabbit embolic permanent middle cerebral artery occlusion model (pMCAO). In two replicate 28-day pMCAO studies, weekly intravenous infusions of elezanumab, over a range of doses and TTIs of 6 and 24 h after stroke, significantly improved neuromotor function in both pMCAO studies when first administered 6 h after stroke. All elezanumab treatment groups, including the 24 h TTI group, had significantly less neuroinflammation as assessed by microglial and astrocyte activation. The novel mechanism of action and potential for expanding TTI in human AIS make elezanumab distinct from current acute reperfusion therapies, and support evaluation in clinical trials of acute CNS damage to determine optimal dose and TTI in humans. A: Ramified/resting astrocytes and microglia in a normal, uninjured rabbit brain. B: Rabbit pMCAO brain illustrating lesion on right side of brain (red), surrounded by penumbra (pink) during acute phase post stroke, with minimal injury to left brain hemisphere. Penumbra characterized by activated astrocytes and microglia (region in crosshair within circle), with upregulation of free and bound RGMa. C: Elezanumab binds to both free and bound RGMa, preventing full activation of astrocytes and microglia. D: Elezanumab is efficacious in rabbit pMCAO with a 4 × larger TTI window vs. tPA (6 vs. 1.5 h, respectively). In human AIS, tPA is approved for a TTI of 3-4.5 h. Elezanumab is currently being evaluated in a clinical Ph2 study of AIS to determine the optimal dose and TTI (NCT04309474).

Tilavonemab in early Alzheimer's disease: results from a phase 2, randomized, double-blind study

Tau accumulation in patients with Alzheimer's disease tracks closely with cognitive decline and plays a role in the later stages of disease progression. This phase 2 study evaluated the safety and efficacy of tilavonemab, an anti-tau monoclonal antibody, in patients with early Alzheimer's disease. In this 96-week, randomized, double-blind, placebo-controlled study (NCT02880956), patients aged 55-85 years meeting clinical criteria for early Alzheimer's disease with a Clinical Dementia Rating-Global Score of 0.5, a Mini Mental State Examination score of 22 to 30, a Repeatable Battery for the Assessment of Neuropsychological Status-Delayed Memory Index score of ≤85, and a positive amyloid PET scan were randomized 1:1:1:1 to receive one of three doses of tilavonemab (300 mg, 1000 mg, or 2000 mg) or placebo via intravenous infusion every four weeks. The primary endpoint was the change from baseline up to Week 96 in the Clinical Dementia Rating-Sum of Boxes score. Safety evaluations included adverse event monitoring and MRI assessments. A total of 453 patients were randomized, of whom 337 were treated with tilavonemab (300 mg, n = 108; 1000 mg, n = 116; 2000 mg, n = 113) and 116 received placebo. Baseline demographics and disease characteristics were comparable across groups. The mean age was 71.3 (standard deviation [SD] 7.0) years, 51.7% were female, and 96.5% were White. At baseline, the mean CDR-SB score was 3.0 (1.2), which worsened through Week 96 for all treatment groups. The least squares mean change from baseline at Week 96 in the CDR-SB score with tilavonemab was not significantly different compared with placebo (300 mg [n = 85]: -0.07 [95% confidence interval (CI): -0.83 to 0.69]; 1000 mg [n = 91]: -0.06 [95% CI: -0.81 to 0.68]; 2000 mg [n = 81]: 0.16 [95% CI: -0.60 to 0.93]; all P ≥ 0.05). The incidence of any adverse event and MRI findings were generally comparable across groups.Tilavonemab was generally well tolerated but did not demonstrate efficacy in treating patients with early Alzheimer's disease. Further investigations of tilavonemab in early Alzheimer's disease are not warranted.

Electrocardiogram Belt guidance for left ventricular lead placement and biventricular pacing optimization

BACKGROUND

Patients with ischemic cardiomyopathy, non-left bundle branch block, or QRS duration <150 ms have a lower response rate to cardiac resynchronization therapy (CRT) than did other indicated patients. The ECG Belt system (EBS) is a novel surface mapping system designed to measure electrical dyssynchrony via the standard deviation of the activation times of the left ventricle.

OBJECTIVES

The objectives of this study were to evaluate the efficacy of the EBS in patients less likely to respond to CRT and to determine whether EBS use in lead placement guidance and device programming was superior to standard CRT care.

METHODS

This was a prospective randomized trial of patients with heart failure and EBS-guided CRT implantation and programming vs standard CRT care. The primary end point was relative change in left ventricular end-systolic volume from baseline to 6 months postimplantation.

RESULTS

A total of 408 patients from centers in Europe and North America were randomized. Although both patients with EBS and control patients had a mean improvement in left ventricular end-systolic volume, there was no significant difference in relative change from baseline (P = .26). While patients with a higher baseline standard deviation of the activation times derived greater left ventricular reverse remodeling, improvement in electrical dyssynchrony did not correlate with the extent of reverse remodeling.

CONCLUSION

The findings of the present study do not support EBS-guided therapy for CRT management of heart failure with reduced ejection fraction.

Clinical research in dementia: A perspective on implementing innovation

The increasing global prevalence of dementia demands concrete actions that are aimed strategically at optimizing processes that drive clinical innovation. The first step in this direction requires outlining hurdles in the transition from research to practice. The different parties needed to support translational processes have communication mismatches; methodological gaps hamper evidence-based decision-making; and data are insufficient to provide reliable estimates of long-term health benefits and costs in decisional models. Pilot projects are tackling some of these gaps, but appropriate methods often still need to be devised or adapted to the dementia field. A consistent implementation perspective along the whole translational continuum, explicitly defined and shared among the relevant stakeholders, should overcome the "research-versus-adoption" dichotomy, and tackle the implementation cliff early on. Concrete next steps may consist of providing tools that support the effective participation of heterogeneous stakeholders and agreeing on a definition of clinical significance that facilitates the selection of proper outcome measures.

Physical characterization of frozen fruits from eight cultivars of the North American pawpaw (Asimina triloba)

Pawpaw (Asimina triloba [L.] Dunal) is an underutilized fruit native to North America. The fruit has a short shelf life, and browns and softens rapidly after harvesting. These characteristics present a challenge to the advancement of pawpaw as an economically viable specialty crop. This study evaluated the physical characteristics of frozen fruits from eight cultivars of the pawpaw fruit to establish the processing potential of pawpaw fruits. The results show that freeze-thaw cycle may have influenced the peel thickness, peel color, and pulp color of the fruits. Fruits of the Susquehanna cultivar had the highest fruit weight and pulp weight, making them potentially the most suitable for pulp processing. The pawpaw fruits had almost neutral pH ranging between 6.07 ± 0.21 and 6.47 ± 0.11, which could contribute to the rapid browning on exposure to air since an acidic pH is important for slowing enzymatic browning. To aid pawpaw juice extraction, enzymatic treatments may be necessary to increase the juice yield from the pulp. Overleese fruits may be the best for pawpaw juice production. These findings can aid in the selection of processing equipment and guide processors in their efforts to utilize pawpaw fruits to avoid postharvest and post-processing losses.

Black soldier fly larvae meal and fat as a replacement for soybeans in organic broiler diets: effects on performance, body N retention, carcase and meat quality

1. Due to the increasing global demand for more sustainably produced animal protein, there is an intensive search for feeds to replace soybeans. Black soldier fly larvae (BSFL) appear to have great potential for replacing soybeans in poultry diets. The main objective of this study was to determine if the nutritional value of BSFL is superior to soybeans when feeding organic broilers, since smaller amounts of BSFL could replace the soybean content in the feed, thus saving even more resources.2. Eighty Hubbard S757, a slow growing organic broiler type, were fattened for 63 d, spending the last 49 d on one of five diets. Two soybean cake- and soybean oil-based diets (SS, SS-) were compared with three diets based on partially defatted BSFL meal and BSFL fat from two origins (AA-, AB-, BB-). Different from diet SS, diets SS-, AA-, AB-and BB- were designed with approximately 20% less lysine and methionine. Growth (n = 16), metabolisability, body nitrogen retention, carcase and meat quality (n = 8) were evaluated.3. Broilers of the insect-based feeding groups, AA- and AB-, grew similarly well compared to those of group SS. They also retained more nitrogen in the body than those fed BB- and SS-. Breast meat yield was higher with AA- and AB- than with BB- and SS-, but still lower than with SS. Dietary variations in physicochemical meat quality were of low practical relevance. Diet BB- resulted in a more yellow skin and meat. The fatty acid profile of the breast meat lipids reflected the high lauric acid proportion of the BSFL lipids, resulting in up to 80 times higher proportions than when feeding the soybean-based diets.4. The results indicate that high-quality BSFL, depending on their origin, may indeed be superior to soybean protein, but that the meat lipids from BSFL-fed broilers can contain significant amounts of lauric acid, which, from a human nutrition perspective, could have a negative impact on meat quality.

Supplement Individual Article: Algorithm for Pre-/Post-Procedure Measures in Racial/Ethnic Populations Treated With Facial Lasers, Nonenergy Devices, or Injectables

BACKGROUND

Cosmetic procedures with lasers, nonenergy devices, and injectables are increasing in popularity among patients with skin of color. Published algorithms address measures to reduce side effects related to aesthetic procedures; however, none focus on reducing adverse events in skin of color.

METHODS

An expert panel of dermatologists and plastic surgeons conducted face-to-face and online meetings to develop an algorithm for measures before, during, and after using aesthetic devices (energy and nonenergy-based) and injectable treatments based on the best available evidence for skin of color. Published algorithms and literature searches for aesthetic procedures provided guidance for the current algorithm. A modified Delphi method was used to reach a consensus to apply outcomes of literature searches, along with expert opinion, resulting in the current algorithm.

RESULTS

The four sections of the algorithm outline an approach to optimize outcomes with specific before, during, and after procedure considerations. Pre-procedural consultation includes the development of a specific treatment plan based on individual patient goals and risk profile (including history and signs that may predict a higher risk for pigmentary or scarring complications). Before the procedure, sun avoidance and sunscreen use are emphasized; herpes simplex virus 1 prophylaxis and bleaching agents are administered if indicated. During the procedure, skin cleansing products are addressed, along with judicious techniques to minimize unintended cutaneous injury or inflammation. Post-procedural sunscreen and gentle skincare that may include skin-lightening agents or formulations designed to prevent infection and promote optimum healing are advised.

CONCLUSIONS

The algorithm strives to optimize treatment outcomes for patients with skin of color by providing their physicians with guidance on measures before, during, and after office-based medical aesthetic procedures. J Drugs Dermatol. 2022;21:9(Suppl 1):s3-10.

COVID vaccination can be completed in subjects with a history of allergic reactions to the vaccines or their components - experience from a specialist clinic in South Australia

The development of vaccines against SARS-CoV2 has been a key public health response to the COVID-19 pandemic. However, since their introduction there have been reports of anaphylactic reactions in vaccinees with history of allergy. We developed an allergy testing protocol allowing vaccination with available COVID-19 vaccines in Australia. Patients referred to a state-wide COVID-19 vaccine allergy clinic between March and August 2021 with a history of allergy underwent skin prick testing and intradermal testing to both available vaccine formulations (BNT162b2, ChAdOx1-S), excipients (polyethylene glycol, polysorbate 80), excipient-containing medications, and controls. Where available, basophil activation testing was conducted. 53 patients underwent testing for possible excipient allergy (n = 19), previous non-COVID vaccine reaction (n = 13), or previous reaction to dose 1 of COVID-19 vaccine (n = 21). Patients were predominantly female (n = 43, 81%), aged 18-83 (median 54) years. 44 patients tested negative and 42 of these received at least their first dose of a COVID-19 vaccine. 9 patients tested positive to excipients or excipient-containing medication only (n = 3), or vaccines (n = 6). 5 patients were positive to just BNT162b2, 3/5 have been vaccinated with ChAdOx1-S. 1 who was skin test positive to both vaccines, but negative BAT to ChAdOx1-S was successfully vaccinated with ChAdOx1-S. Even in a high-risk population, most patients can be vaccinated with available COVID-19 vaccines. This paper reports local experiences using a combined allergy testing protocol with skin testing and BAT during the pandemic. This article is protected by copyright. All rights reserved.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

First Leptophobic Dark Matter Search from the Coherent-CAPTAIN-Mills Liquid Argon Detector

We report the first results of a search for leptophobic dark matter (DM) from the Coherent-CAPTAIN-Mills (CCM) liquid argon (LAr) detector. An engineering run with 120 photomultiplier tubes (PMTs) and 17.9×10^{20} protons on target (POT) was performed in fall 2019 to study the characteristics of the CCM detector. The operation of this 10-ton detector was strictly light based with a threshold of 50 keV and used coherent elastic scattering off argon nuclei to detect DM. Despite only 1.5 months of accumulated luminosity, contaminated LAr, and nonoptimized shielding, CCM's first engineering run has already achieved sensitivity to previously unexplored parameter space of light dark matter models with a baryonic vector portal. With an expected background of 115 005 events, we observe 115 005+16.5 events which is compatible with background expectations. For a benchmark mediator-to-DM mass ratio of m_{V_{B}}/m_{χ}=2.1, DM masses within the range 9  MeV≲m_{χ}≲50  MeV are excluded at 90% C. L. in the leptophobic model after applying the Feldman-Cousins test statistic. CCM's upgraded run with 200 PMTs, filtered LAr, improved shielding, and 10 times more POT will be able to exclude the remaining thermal relic density parameter space of this model, as well as probe new parameter space of other leptophobic DM models.

FLORA-5/GOG3035: Frontline chemo-immunotherapy (paclitaxel-carboplatin-oregovomab [PCO] versus chemotherapy (paclitaxel-carboplatin-placebo [PCP]) in patients with advanced epithelial ovarian cancer (EOC)—Phase III, double-blind, placebo-controlled, global, multinational study

TPS5619

Background: Oregovomab, a murine IgGκ1 monoclonal antibody, has high affinity binding to tumor associated antigen CA125, thus, rendering the target antigen CA125 more immunogenic or “neoantigen-like” through altered and enhanced antigen processing and presentation to specific T cells. This phenomenon is hypothesized to bypass tumor-associated immune suppression when oregovomab is combined with chemotherapy. In a randomized phase II study, oregovomab in combination with paclitaxel and carboplatin (PC) induced tumor immunity and demonstrated significant improvement in median PFS (41.8 months(m) PCO vs 12.2 m PC, HR 0.46, p=0.0027) and median OS (N.E. PCO vs 43.2 m PC, HR O.35, p=0.043) in patients with previously untreated EOC. Oregovomab combined with PC had a favorable toxicity profile. FLORA-5/GOG3035, the definitive confirmatory global registration trial, is currently recruiting patients in the front-line setting. Methods: The study is a phase 3, multicenter, double-blind, placebo-controlled trial. Optimally debulked patients with FIGO III/IV EOC and serum CA125 ≥ 50 U/ml receiving adjuvant (Cohort 1) or patients receiving neoadjuvant chemotherapy post-interval cytoreductive surgery (Cohort 2) will be randomized to PC + oregovomab or placebo (PCO vs. PCP). Patients with germline BRCA1/2 mutations are excluded. Chemotherapy will be administered every 3 weeks in both cohorts. Oregovomab/placebo is administered simultaneously at cycles 1, 3, and 5 of chemotherapy with an additional dose at 12 weeks following cycle 5 in Cohort 1. Neoadjuvant patients will be administered oregovomab/placebo after debulking surgery at cycles 4 and 6 with two additional doses at 6- and 18-weeks following cycle 6 in Cohort 2. No other front-line maintenance therapy is permitted. The primary objective is PFS determined by RECIST 1.1. Cohort 1 will recruit 372 patients with a 90% power to detect a difference with an alpha of 0.025 and a hazard ratio of 0.65 when 252 PFS events have been observed. Cohort 2 will be analyzed separately recruiting 232 patients with a 90% power to detect a difference with an alpha of 0.025 and a hazard ratio of 0.60 when 165 PFS events have been observed. An interim futility analysis will be performed. Secondary objectives include OS, frequency and severity of AEs, and QoL. Exploratory objectives include iRECIST, TFST, TSST, PFS2, and evaluation of correlative biomarkers. The study is actively enrolling in the US, Canada, Belgium, Italy, Spain, Czech Republic, Hungary, Poland, Korea, Taiwan, Mexico, Argentina, and Chile. 179 patients were enrolled at time of submission. Clinical trial information: NCT04498117.

Allergic disease, sleep problems and psychological distress in children recruited from the general community

BACKGROUND

It is unclear which allergic disease is most strongly related to which sleep problem and whether sleep problems may mediate the association between allergic disease and psychological distress. There is also a need for more community-based studies using non-referred samples.

OBJECTIVE

To examine the association between individual allergic diseases and sleep problems and test whether the association between allergic disease and psychological distress is mediated through sleep problems.

METHODS

Parents of 1449 Australian children aged 6-10y recruited from the general community completed measures of sleep problems (Pediatric Sleep Survey Instrument), psychological distress (Strengths and Difficulties Questionnaire), and frequency of allergic disease.

RESULTS

Sleep and psychological distress scores were in the normal range. After controlling for co-existing allergic diseases: allergic rhinitis was associated with sleep routine problems, morning tiredness, night arousals, sleep disordered breathing and restless sleep; asthma with sleep routine problems, sleep disordered breathing and restless sleep; and eczema with restless sleep. Path analyses revealed that sleep problems mediated the association between asthma and allergic rhinitis but not eczema with psychological distress.

CONCLUSION

In this non-referred community sample, the frequency of sleep problems and psychological distress was lower than that typically reported in children referred to specialized centres. However, allergic rhinitis was associated with a broad range of sleep problems and to a lesser extent in children with asthma and least in children with eczema. Path analysis revealed that the association between allergic disease and psychological distress was mediated through sleep problems highlighting the importance of assessing sleep health in children with allergic disease.

High-precision measurement of the W boson mass with the CDF II detector

The mass of the W boson, a mediator of the weak force between elementary particles, is tightly constrained by the symmetries of the standard model of particle physics. The Higgs boson was the last missing component of the model. After observation of the Higgs boson, a measurement of the W boson mass provides a stringent test of the model. We measure the W boson mass, M_W, using data corresponding to 8.8 inverse femtobarns of integrated luminosity collected in proton-antiproton collisions at a 1.96 tera-electron volt center-of-mass energy with the CDF II detector at the Fermilab Tevatron collider. A sample of approximately 4 million W boson candidates is used to obtain [Formula: see text], the precision of which exceeds that of all previous measurements combined (stat, statistical uncertainty; syst, systematic uncertainty; MeV, mega-electron volts; c, speed of light in a vacuum). This measurement is in significant tension with the standard model expectation.

Alzheimer's Disease: Key Insights from Two Decades of Clinical Trial Failures

Given the acknowledged lack of success in Alzheimer’s disease (AD) drug development over the past two decades, the objective of this review was to derive key insights from the myriad failures to inform future drug development. A systematic and exhaustive review was performed on all failed AD compounds for dementia (interventional phase II and III clinical trials from ClinicalTrials.gov) from 2004 to the present. Starting with the initial ∼2,700 AD clinical trials, ∼550 trials met our initial criteria, from which 98 unique phase II and III compounds with various mechanisms of action met our criteria of a failed compound. The two recent reported phase III successes of aducanumab and oligomannate are very encouraging; however, we are awaiting real-world validation of their effectiveness. These two successes against the 98 failures gives a 2.0% phase II and III success rate since 2003, when the previous novel compound was approved. Potential contributing methodological factors for the clinical trial failures were categorized into 1) insufficient evidence to initiate the pivotal trials, and 2) pivotal trial design shortcomings. Our evaluation found that rational drug development principles were not always followed for AD therapeutics development, and the question remains whether some of the failed compounds may have shown efficacy if the principles were better adhered to. Several recommendations are made for future AD therapeutic development. The whole database of the 98 failed compounds is presented in the Supplementary Material.

Probiotic peanut oral immunotherapy versus oral immunotherapy and placebo in children with peanut allergy in Australia (PPOIT-003): a multicentre, randomised, phase 2b trial

BACKGROUND

Oral immunotherapy is effective at inducing desensitisation to allergens and induces sustained unresponsiveness (ie, clinical remission) in a subset of patients, but causes frequent reactions. We aimed to investigate whether addition of a probiotic adjuvant improved the efficacy or safety of peanut oral immunotherapy.

METHODS

PPOIT-003, a multicentre, randomised, phase 2b trial, was conducted in three tertiary hospitals in Australia (Adelaide [SA], Melbourne [VIC], and Perth [WA]) in children aged 1-10 years, weighing more than 7 kg, with peanut allergy confirmed by a double-blind placebo-controlled food challenge (cumulative 4950 mg dose of peanut protein) and positive peanut skin prick test (≥3 mm) or peanut-specific IgE (≥0·35 kU/L). Children were randomly assigned (2:2:1) to receive probiotic and peanut oral immunotherapy (PPOIT), placebo probiotic and peanut oral immunotherapy (OIT), or placebo probiotic and placebo OIT (placebo) for 18 months, and were followed up until 12 months after completion of treatment. Oral immunotherapy consisted of increasing doses of peanut protein (commercially available food-grade 12% defatted peanut flour [50% peanut protein]) until a 2000 mg daily maintenance dose was reached. The probiotic adjuvant was a daily dose of 2 × 10¹⁰ colony-forming units of the probiotic Lactobacillus rhamnosus ATCC 53103. Placebo immunotherapy comprised maltodextrin, brown food colouring, and peanut essence, and placebo probiotic was maltodextrin. Dual primary outcomes were 8-week sustained unresponsiveness, defined as no reaction to a cumulative dose of 4950 mg peanut protein at treatment completion and 8 weeks after treatment completion, in the PPOIT versus placebo groups and the PPOIT versus OIT groups, analysed by intention to treat. Safety endpoints were adverse events during the treatment phase, and peanut ingestion and reactions in the 12-month post-treatment period. This study is registered with the Australian New Zealand Clinical Trials Registry, 12616000322437.

FINDINGS

Between July 4, 2016, and Sept 21, 2020, 201 participants were enrolled and included in the intention-to-treat analysis. 36 (46%) of 79 children in the PPOIT group and 42 (51%) of 83 children in the OIT group achieved sustained unresponsiveness compared with two (5%) of 39 children in the placebo group (risk difference 40·44% [95% CI 27·46 to 53·42] for PPOIT vs placebo, p<0·0001), with no difference between PPOIT and OIT (-5·03% [-20·40 to 10·34], p=0·52). Treatment-related adverse events were reported in 72 (91%) of 79 children in the PPOIT group, 73 (88%) of 83 children in the OIT group, and 28 (72%) of 39 children in the placebo group. Exposure-adjusted incidence of adverse events was 10·58 in the PPOIT group, 11·36 in the OIT, and 2·09 in the placebo group (ratio 0·92 [95% CI 0·85 to 0·99] for PPOIT vs OIT, p=0·042; 4·98 [4·11-6·03] for PPOIT vs placebo, p<0·0001; 5·42 [4·48-6·56] for OIT vs placebo, p<0·0001), with differences seen primarily in gastrointestinal symptoms and in children aged 1-5 years. During the 12-month post-treatment period, 60 (85%) of 71 participants in the PPOIT group, 60 (86%) of 70 participants in the OIT group, and six (18%) of 34 participants in the placebo group were eating peanut; rescue epinephrine use was infrequent (two [3%] of 71 in the PPOIT group, four [6%] of 70 in the OIT group, and none in the placebo group).

INTERPRETATION

Both PPOIT and OIT were effective at inducing sustained unresponsiveness. Addition of a probiotic did not improve efficacy of OIT, but might offer a safety benefit compared with OIT alone, particularly in preschool children.

FUNDING

National Health and Medical Research Council Australia and Prota Therapeutics.

A Neuropsychological Perspective on Defining Cognitive Impairment in the Clinical Study of Alzheimer’s Disease: Towards a More Continuous Approach

The global fight against Alzheimer’s disease (AD) poses unique challenges for the field of neuropsychology. Along with the increased focus on early detection of AD pathophysiology, characterizing the earliest clinical stage of the disease has become a priority. We believe this is an important time for neuropsychology to consider how our approach to the characterization of cognitive impairment can be improved to detect subtle cognitive changes during early-stage AD. The present article aims to provide a critical examination of how we define and measure cognitive status in the context of aging and AD. First, we discuss pitfalls of current methods for defining cognitive impairment within the context of research shifting to earlier (pre)symptomatic disease stages. Next, we introduce a shift towards a more continuous approach for identifying early markers of cognitive decline and characterizing progression and discuss how this may be facilitated by novel assessment approaches. Finally, we summarize potential implications and challenges of characterizing cognitive status using a continuous approach.

Efficacy and Safety of a Fixed-Dose Clindamycin Phosphate 1.2%, Benzoyl Peroxide 3.1%, and Adapalene 0.15% Gel for Moderate-to-Severe Acne: A Randomized Phase II Study of the First Triple-Combination Drug

BACKGROUND

A three-pronged approach to acne treatment-combining an antibiotic, antibacterial, and retinoid-could provide greater efficacy and tolerability than single or dyad treatments, while potentially improving patient compliance and reducing antibiotic resistance.

OBJECTIVES

We aimed to evaluate the efficacy and safety of triple-combination, fixed-dose topical clindamycin phosphate 1.2%/benzoyl peroxide (BPO) 3.1%/adapalene 0.15% (IDP-126) gel for the treatment of acne.

METHODS

In a phase II, double-blind, multicenter, randomized, 12-week study, eligible participants aged ≥ 9 years with moderate-to-severe acne were equally randomized to once-daily IDP-126, vehicle, or one of three component dyad gels: BPO/adapalene; clindamycin phosphate/BPO; or clindamycin phosphate/adapalene. Coprimary endpoints were treatment success at week 12 (participants achieving a ≥ 2-grade reduction from baseline in Evaluator's Global Severity Score and clear/almost clear skin) and least-squares mean absolute changes from baseline in inflammatory and noninflammatory lesion counts to week 12. Treatment-emergent adverse events and cutaneous safety/tolerability were also assessed.

RESULTS

A total of 741 participants were enrolled. At week 12, 52.5% of participants achieved treatment success with IDP-126 vs vehicle (8.1%) and dyads (range 27.8-30.5%; P ≤ 0.001, all). IDP-126 also provided significantly greater absolute reductions in inflammatory (29.9) and noninflammatory (35.5) lesions compared with vehicle or dyads (range inflammatory, 19.6-26.8; noninflammatory, 21.8-30.0; P < 0.05, all), corresponding to > 70% reductions with IDP-126. IDP-126 was well tolerated, with most treatment-emergent adverse events of mild-to-moderate severity.

CONCLUSIONS

Once-daily treatment with the novel fixed-dose triple-combination clindamycin phosphate 1.2%/BPO 3.1%/adapalene 0.15% gel demonstrated superior efficacy to vehicle and all three dyad component gels, and was well tolerated over 12 weeks in pediatric, adolescent, and adult participants with moderate-to-severe acne.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03170388 (registered 31 May, 2017).

Safety and Effectiveness of a Novel Hyaluronic Acid Gel for Lip Augmentation

OBJECTIVE

To compare the safety and efficacy of a novel hyaluronic acid injectable gel with 0.3% lidocaine (test device) with that of a commercially available injectable hyaluronic acid gel with 0.3% lidocaine (comparator) for lip augmentation.

METHODS

Eligible patients (n = 158) with an overall score of very thin (n = 0) or thin (n = 1) on a 5-point Lip Fullness Grading Scale (LFGS) participated in the double-blind, randomized, multicenter study. Efficacy was assessed periodically over 6 months on a per protocol (PP) population (definitive) and a modified intent-to-treat (mITT) population (supportive).

RESULTS

In the PP population, the mean change from baseline (day 56) in LFGS score was 1.52 for the test device and 1.53 for the comparator. This 56-day change was the primary efficacy endpoint. The 95% confidence interval (CI) limits for the mean difference in scores (test device minus comparator) were -0.33 and 0.31. In the mITT population, the corresponding 95% CI limits were -0.26 and 0.31. In both populations, the lower limits, -0.33 and -0.26, were higher than the prespecified -0.50, indicating that the test device was non-inferior to comparator. The adverse event profile was similar between the treatment groups. Ninety-three percent of patients treated with test device considered themselves improved, much improved, or very much improved at day 168 compared to 82% of those treated with comparator. The corresponding investigator improvement ratings were 100% and 76%, respectively.

CONCLUSION

For lip augmentation, the efficacy and safety of the test device is non-inferior to comparator. J Drugs Dermatol. 2022;21(1):13-20 doi:10.36849/JDD.6548.

Safety and Effectiveness of a Novel Hyaluronic Acid Gel for Lip Augmentation

OBJECTIVE

To compare the safety and efficacy of a novel hyaluronic acid injectable gel with 0.3% lidocaine (test device) with that of a commercially available injectable hyaluronic acid gel with 0.3% lidocaine (comparator) for lip augmentation.

METHODS

Eligible patients (n = 158) with an overall score of very thin (n = 0) or thin (n = 1) on a 5-point Lip Fullness Grading Scale (LFGS) participated in the double-blind, randomized, multicenter study. Efficacy was assessed periodically over 6 months on a per protocol (PP) population (definitive) and a modified intent-to-treat (mITT) population (supportive).

RESULTS

In the PP population, the mean change from baseline (day 56) in LFGS score was 1.52 for the test device and 1.53 for the comparator. This 56-day change was the primary efficacy endpoint. The 95% confidence interval (CI) limits for the mean difference in scores (test device minus comparator) were -0.33 and 0.31. In the mITT population, the corresponding 95% CI limits were -0.26 and 0.31. In both populations, the lower limits, -0.33 and -0.26, were higher than the prespecified -0.50, indicating that the test device was non-inferior to comparator. The adverse event profile was similar between the treatment groups. Ninety-three percent of patients treated with test device considered themselves improved, much improved, or very much improved at day 168 compared to 82% of those treated with comparator. The corresponding investigator improvement ratings were 100% and 76%, respectively.

CONCLUSION

For lip augmentation, the efficacy and safety of the test device is non-inferior to comparator. J Drugs Dermatol. 2022;21(1):13-20 doi:10.36849/JDD.6548.

Treatment of Alopecia in Children

Alopecia or hair loss in children is an important and often challenging problem to diagnose and treat. Early diagnosis and treatment is the key because hair loss in children has a significant physical as well as psychological impact on their development. Alopecia in children are mainly non-scarring, but cicatricial alopecia can also be seen. The diagnosis can usually be made by direct examination of the scalp. Potassium hydroxide (KOH) examination of plucked hair and scalp scrapings, woods lamp examination and trichoscopy are useful diagnostic aids. When a cicatricial alopecia is suspected, scalp biopsy is recommended. Disease specific treatment should be initiated early and adequate counselling provided to both the patient and their parents. This review focuses on the treatment options available for various types of alopecia in children and their safety and efficacy data, analyzing the available literature evidences. J Drugs Dermatol. 2022;21(1):49-53. doi:10.36849/JDD.6096.

Treatment of Alopecia in Children

Alopecia or hair loss in children is an important and often challenging problem to diagnose and treat. Early diagnosis and treatment is the key because hair loss in children has a significant physical as well as psychological impact on their development. Alopecia in children are mainly non-scarring, but cicatricial alopecia can also be seen. The diagnosis can usually be made by direct examination of the scalp. Potassium hydroxide (KOH) examination of plucked hair and scalp scrapings, woods lamp examination and trichoscopy are useful diagnostic aids. When a cicatricial alopecia is suspected, scalp biopsy is recommended. Disease specific treatment should be initiated early and adequate counselling provided to both the patient and their parents. This review focuses on the treatment options available for various types of alopecia in children and their safety and efficacy data, analyzing the available literature evidences. J Drugs Dermatol. 2022;21(1):49-53. doi:10.36849/JDD.6096.