Anakinra for palmoplantar pustulosis: results from a randomized, double-blind, multicentre, two-staged, adaptive placebo-controlled trial (APRICOT)

BACKGROUND

Palmoplantar pustulosis (PPP) is a rare, debilitating, chronic inflammatory skin disease that affects the hands and feet. Clinical, immunological and genetic findings suggest a pathogenic role for interleukin (IL)-1.

OBJECTIVES

To determine whether anakinra (an IL-1 receptor antagonist) delivers therapeutic benefit in PPP.

METHODS

This was a randomized (1 : 1), double-blind, two-staged, adaptive, UK multicentre, placebo-controlled trial [ISCRTN13127147 (registered 1 August 2016); EudraCT number: 2015-003600-23 (registered 1 April 2016)]. Participants had a diagnosis of PPP (> 6 months) requiring systemic therapy. Treatment was 8 weeks of anakinra or placebo via daily, self-administered subcutaneous injections. Primary outcome was the Palmoplantar Pustulosis Psoriasis Area and Severity Index (PPPASI) at 8 weeks.

RESULTS

A total of 374 patients were screened; 64 were enrolled (31 in the anakinra arm and 33 in the placebo arm) with a mean (SD) baseline PPPASI of 17·8 (10·5) and a PPP investigator's global assessment of severe (50%) or moderate (50%). The baseline adjusted mean difference in PPPASI favoured anakinra but did not demonstrate superiority in the intention-to-treat analysis [-1·65, 95% confidence interval (CI) -4·77 to 1·47; P = 0·30]. Similarly, secondary objective measures, including fresh pustule count (2·94, 95% CI -26·44 to 32·33; favouring anakinra), total pustule count (-30·08, 95% CI -83·20 to 23·05; favouring placebo) and patient-reported outcomes, did not show superiority of anakinra. When modelling the impact of adherence, the PPPASI complier average causal effect for an individual who received ≥ 90% of the total treatment (48% in the anakinra group) was -3·80 (95% CI -10·76 to 3·16; P = 0·285). No serious adverse events occurred.

CONCLUSIONS

No evidence for the superiority of anakinra was found. IL-1 blockade is not a useful intervention for the treatment of PPP.

The PROCLIPI international registry of early-stage mycosis fungoides identifies substantial diagnostic delay in most patients

BACKGROUND

Survival in mycosis fungoides (MF) is varied and may be poor. The PROCLIPI (PROspective Cutaneous Lymphoma International Prognostic Index) study is a web-based data collection system for early-stage MF with legal data-sharing agreements permitting international collaboration in a rare cancer with complex pathology. Clinicopathological data must be 100% complete and in-built intelligence in the database system ensures accurate staging.

OBJECTIVES

To develop a prognostic index for MF.

METHODS

Predefined datasets for clinical, haematological, radiological, immunohistochemical, genotypic, treatment and quality of life are collected at first diagnosis of MF and annually to test against survival. Biobanked tissue samples are recorded within a Federated Biobank for translational studies.

RESULTS

In total, 430 patients were enrolled from 29 centres in 15 countries spanning five continents. Altogether, 348 were confirmed as having early-stage MF at central review. The majority had classical MF (81·6%) with a CD4 phenotype (88·2%). Folliculotropic MF was diagnosed in 17·8%. Most presented with stage I (IA: 49·4%; IB: 42·8%), but 7·8% presented with enlarged lymph nodes (stage IIA). A diagnostic delay between first symptom development and initial diagnosis was frequent [85·6%; median delay 36 months (interquartile range 12-90)]. This highlights the difficulties in accurate diagnosis, which includes lack of a singular diagnostic test for MF.

CONCLUSIONS

This confirmed early-stage MF cohort is being followed-up to identify prognostic factors, which may allow better management and improve survival by identifying patients at risk of disease progression. This study design is a useful model for collaboration in other rare diseases, especially where pathological diagnosis can be complex.

U.K. consensus statement on safe clinical prescribing of bexarotene for patients with cutaneous T-cell lymphoma

BACKGROUND

Bexarotene is a synthetic retinoid from the subclass of retinoids called rexinoids which selectively activate retinoid X receptors. It has activity in cutaneous T-cell lymphoma (CTCL) and has been approved by the European Medicines Agency since 1999 for treatment of the skin manifestations of advanced-stage (IIB-IVB) CTCL in adult patients refractory to at least one systemic treatment. In vivo bexarotene produces primary hypothyroidism which may be managed with thyroxine replacement. It also affects lipid metabolism, typically resulting in raised triglycerides, which requires prophylactic lipid-modification therapy. Effects on neutrophils, glucose and liver function may also occur. These side-effects are dose dependent and may be controlled with corrective therapy or dose adjustments.

OBJECTIVES

  To produce a U.K. statement outlining a bexarotene dosing schedule and monitoring protocol to enable bexarotene prescribers to deliver bexarotene safely for optimal effect.

METHODS

 Leaders from U.K. supraregional centres produced this consensus statement after a series of meetings and a review of the literature.

RESULTS

 The statement outlines a bexarotene dosing schedule and monitoring protocol. This gives instructions on monitoring and treating thyroid, lipid, liver, blood count, creatine kinase, glucose and amylase abnormalities. The statement also includes algorithms for a bexarotene protocol and lipid management, which may be used in the clinical setting.

CONCLUSION

 Clinical prescribing of bexarotene for patients with CTCL requires careful monitoring to allow safe administration of bexarotene at the optimal dose.

Linkage and association analysis of nevus density and the region containing the melanoma gene CDKN2A in UK twins

Rare mutations in the CDKN2A gene are highly penetrant for melanoma. Density of nevi is under strong genetic control and high density is a potent risk factor for melanoma. We used linkage and association analysis in adolescent twins from the UK to examine the hypothesis that the region containing the CDKN2A gene also contains a quantitative trait locus influencing normal nevus development. Five markers in the CDKN2A region were genotyped in 115 dizygotic twin pairs, and one marker (D9S942) was genotyped in 103 monozygotic twin pairs, all of whom had been phenotyped for nevus density. Linkage analysis showed no evidence of a quantitative trait locus influencing nevus density in this chromosomal region. A model partitioning the variation in phenotype into within- and between-twin pair components showed weak evidence of association between higher nevus density and longer mean length of the two D9S942 alleles (P=0.01). This relation, which was also observed in an earlier Australian twin study, could be because of the linkage disequilibrium between D9S942 and a neighbouring functional locus. Further investigation of this region is warranted in large-scale linkage or association studies.

Assessment of brain function in adolescent anorexia nervosa before and after weight gain

This study assessed brain function in 20 adolescent females with anorexia nervosa (AN) and 20 controls using event-related potentials (ERPs) and a battery of neuropsychological tests. In the AN group, N4 latencies for a nonverbal memory task were significantly longer than for a verbal task, and P3 latencies for the verbal task were significantly longer among anorexics as compared to controls. On the nonverbal task, the AN group failed to show a right > left hemispheric asymmetry for P3 amplitudes which was observed for controls. These group differences for P3 latency and amplitude were particularly pronounced in the central-parietal region of the head. Body Mass Index (BMI) in the anorexic group significantly predicted N4 amplitudes for the verbal task in the left hemisphere and P3 amplitudes for the nonverbal task in the right hemisphere. The two groups did not differ on any of the tests used to assess neuropsychological functioning. Eight nutritionally recovered patients and their matched controls were retested using the same procedures. Anorexics showed larger P3 amplitudes for the verbal as compared to the nonverbal task at follow-up. These findings provide evidence for localized brain dysfunction in anorexia nervosa that only partially normalizes with weight gain.

Oppositional disorder in children: a validation study comparing conduct disorder, oppositional disorder and normal control children

Subjects with oppositional disorder (OD, N = 21) and conduct disorder (CD, N = 22) were compared with normal controls (NC, N = 20) to determine whether OD is a distinct disorder. OD subjects exhibited high rates of associated attention deficit, emotional and learning disorders. Compared with NC, OD subjects had high rates of problems in social relationships and came from families characterized by marital fights, dysfunction, and paternal psychopathology. Compared with CD, OD was less often characterized by undersocialization and separations from fathers and more often characterized by dissatisfaction in the marital relationship. These results suggest that OD is a variant of CD rather than of normality.

A pilot study of panic attacks in a child and adolescent psychiatric population

This preliminary study examines the prevalence of panic attacks in a child and adolescent psychiatric population through a questionnaire survey of child psychiatrists. Panic attacks were reported in 26% of the sample. The rates varied with patient diagnosis, age, and sex.

Hyperactivity and parental psychopathology

The association of child hyperactivity and parental psychopathology was explored by establishing lifetime DSM-III diagnoses and histories of childhood hyperactivity among the parents of boys, aged 7-11 yrs, in five diagnostic groups: attention deficit disorder with hyperactivity (ADDH), conduct disorder (CD), ADDH + CD, emotional disorder (ED) and no disorder (NC). These groups were differentiated by a family history of parental psychopathology or childhood hyperactivity. ADDH + CD, CD and ED groups all had significantly higher rates of parental psychopathology than the ADDH and NC groups, for which rates were similar. Significantly more boys in the ADDH, CD and ADDH + CD groups had family histories of parental childhood hyperactivity than did boys in the ED and NC groups.

Effects of event rate and display time on sustained attention in hyperactive, normal, and control children

Two experiments were conducted to determine whether hyperactive boys have a unique deficit in sustained attention. Groups with DSM-III diagnoses of attention deficit disorder (ADDH), conduct disorder (CD), ADDH + CD, and learning disorder were compared with normal controls on the Continuous Performance Task. In Experiment 1, stimulus presentation rate (stimulus onset asynchrony, SOA) and display time were varied to manipulate attentional demand, and speed and accuracy of performance were measured. The ADDH group was uniquely affected, with less accurate performance at the fastest and slowest SOA. To distinguish the effects of time on task and SOA, the duration of each SOA condition was held constant in Experiment 2. The poorer performance of the ADDH group at the fastest SOA was no longer evident. This finding indicates that the deficit of sustained attention in boys who have ADDH is associated with a greater susceptibility to refractory effects, which is influenced by practice.

Attaining and maintaining preparation: a comparison of attention in hyperactive, normal, and disturbed control children

The hypothesis that hyperactive children have a deficit in sustained attention was investigated. Eighteen children who had attention deficit disorder with hyperactivity (ADDH), aged 7 to 11 years, were compared with children who had conduct disorder (n = 15), mixed conduct disorder and ADDH (n = 26), emotional disorder (n = 18), or learning disability (n = 22), and with normal controls (n = 15). The subjects were tested on three versions of the Continuous Performance Task. Sustained attention was assessed from performance with increasing time on task and from ability to prepare attention in response to a warning. Performance of all subjects deteriorated with increasing time and improved with the opportunity to prepare attention. Hyperactive subjects were not more adversely affected by increasing time, nor did they benefit less than controls from the opportunity to prepare attention. Data reanalysis after rediagnosis according to ICD-9 criteria did not change the results. This study did not confirm the hypothesis that hyperactive children have a unique sustained attention deficit.

Maprotiline and seizures

Maprotiline has been reported to be less likely to cause epileptic seizures than the tricyclic antidepressants. The authors describe two cases in which patients suffered their first epileptic attacks while on therapeutic doses of maprotiline. They recommend that the newer antidepressants, as well as the tricyclics, should not be used with the aliphatic neuroleptics because of a possible additive or synergistic epileptic effect. If patients are to be withdrawn from C.N.S. depressants, then this should be accomplished prior to initiation of antidepressant therapy. Patients who are predisposed to seizures should have lower initial doses of antidepressants.