Management of moderate to severe psoriasis with brodalumab-Real-world evidence from the LIBERO study

BACKGROUND

Brodalumab, a fully human monoclonal immunoglobulin IgG2 antibody that binds the human interleukin 17 receptor subunit A, is available for the treatment of moderate-to-severe plaque psoriasis in Europe since September 2017, but so far there are only a few studies on its use in real-world conditions.

OBJECTIVES

To assess the management of moderate-to-severe psoriasis with brodalumab 210 mg in daily practice after 12 and 52 weeks (W). In addition, patient profiles and treatment pathways are described.

METHODS

LIBERO is a prospective, multicenter, non-interventional study including adult patients with plaque psoriasis treated with brodalumab 210 mg.

RESULTS

In total, 638 patients (65% male, mean age: 49.3 ± 14.4 years) from 148 sites in Germany were enrolled. The majority suffered from severe (51.1%) or very severe (13.1%) psoriasis according to physician global assessment (PGA0-5). When starting with brodalumab, 58.5% were biologic naïve and 41.5% were previously treated with another biologic, mainly adalimumab (18.5%) and secukinumab (17.9%). About 74.0% of patients met the primary endpoint of an absolute PASI ≤3 at ~W12 (n = 618, LOCF). The mean PASI was reduced significantly as of ~W2 from 17.2 (±11.7) to 9.7 (±8.8) and improved further to 3.3 (±6.3) at ~W12 (p < 0.001). At ~W52 85.5% of patients reached a PGA0/1-response (primary endpoint) and 54.1% patients were assessed as completely clear (PGA0) (both n = 399, as observed). Effectiveness of brodalumab was confirmed in relevant subgroup analysis by previous treatment regimen. Most frequently reported adverse events were nasopharyngitis (4.6%), psoriasis (4.6%) and arthralgia (4.1%), new safety signals were not detected.

CONCLUSION

This representative, non-interventional study confirms the short- and long-term effectiveness and safety profile of brodalumab in the management of psoriasis in daily practice as well as in relevant treatment pathways.

H1-antihistamine-refractory chronic spontaneous urticaria: it's worse than we thought - first results of the multicenter real-life AWARE study

BACKGROUND

Most data on chronic spontaneous urticaria (CSU) originate from highly selected patient populations treated at specialized centres. Little is known about CSU patient characteristics and the burden of CSU in routine clinical practice. AWARE (A World-wide Antihistamine-Refractory chronic urticaria patient Evaluation) is an ongoing global study designed to assess chronic urticaria in the real-life setting.

OBJECTIVE

To describe the baseline characteristics of the first 1539 German AWARE patients with H1-antihistamine-refractory CSU.

METHODS

This prospective non-interventional study included patients (18-75 years) with a diagnosis of H1-antihistamine-refractory CSU for > 2 months. Baseline demographic and disease characteristics, comorbidities, and pharmacological treatments were recorded. Quality of life (QoL) was assessed using the dermatology life quality index (DLQI), chronic urticaria QoL questionnaire (CU-Q₂ oL), and angioedema QoL questionnaire (AE-QoL, in cases of angioedema). Previous healthcare resource utilization and sick leave data were collected retrospectively.

RESULTS

Between March and December 2014, 1539 patients were assessed in 256 sites across Germany. The percentage of females, mean age, and mean body mass index were 70%, 46.3 years, and 27 kg/m² , respectively. The mean urticaria control test score was 7.9, one in two patients had angioedema, and the most frequent comorbidities were chronic inducible urticaria (CIndU; 24%), allergic rhinitis (18.2%), hypertension (18.1%), asthma (12%), and depression (9.5%). Overall, 57.6% of patients were receiving at least one pharmacological treatment including second-generation H1-antihistamines (46.3%), first-generation H1-antihistamines (9.1%), and corticosteroids (15.8%). The mean DLQI, total CU-Q₂ oL, and total AE-QoL scores were 8.3, 36.2, and 46.8, respectively. CSU patients reported frequent use of healthcare resources, including emergency services (29.7%), general practitioners (71.9%), and additional allergists or dermatologists (50.7%).

CONCLUSIONS AND CLINICAL RELEVANCE

This study reveals that German H1-antihistamine-refractory CSU patients have high rates of uncontrolled disease, angioedema, and comorbid CIndU, are undertreated, have impaired QoL, and rely heavily on healthcare resources.

[Families with Migrant Backgrounds as Target Group of Early Interventions: Results of a Social Early Warning System in a Metropolitan Region]

OBJECTIVES

Families with migrant backgrounds (MB) are exposed to several psychosocial risk factors that increase the likelihood of impaired child development, in particular.

QUESTIONS

We investigated whether families with MB differ from families without MB regarding their psychosocial stressors in the period of pregnancy and birth.

METHOD

As part of a social early warning system in an obstetrics clinic in Germany n=502 families with MB were compared with n=349 families without MB with respect to the degree of stress and stress factors on the basis of an initial screening of risk factors for child maltreatment by a midwife or physician and a subsequent structured clearing interview by social education workers during the mothers' inpatient hospitalisation.

RESULTS

For families without MB, a significantly higher total score was found in the risk screening (M=3,9 points vs. M=2,9 points) in comparison to families with MB. While families with MB compared to families without MB were faced more frequently by social stressors, e. g., financial problems or a difficult housing situation (81 vs. 37%), they were less frequently impacted by mental strain (27 vs. 48%), young fathers (2 vs. 10%) and maternal psychiatric diseases (3 vs. 17%), according to the risk screening. Socio-economic determinants such as social inclusion and living environment were found to be important factors influencing the psychosocial stress level of families.

CONCLUSION

Explanations and implications for research and practice are discussed.

[Health Promotion and Child Protection in the Paediatric Practice - Paediatricians as Protagonists in an Invitation and Reporting System for Child Health Check-ups]

INTRODUCTION

Since 1971 routine child health check-ups allow the routine identification of dis-eases in children and adolescents. Paediatricians play a central role in health prevention in childhood and adolescence and are - on account of their acceptance and admission requirements - important actors in child protection. Thus, paediatric practitioners were actively involved in the invitation and reporting system for the routine child health check-ups (U6 and U7), which was introduced to increase participation rates and improve child protection in Hamburg.

METHOD

By means of a questionnaire survey, all paediatric practitioners practicing in Hamburg were asked a year after introduction of the invitation and reporting system to report on their practical experience, and to share their assessment and criticism of the system (response rate 73%).

RESULTS

Out of 110 participating pediatricians (M=19.5 years practical experience), 81% evaluated the invitation and reporting system as very useful, useful or rather useful; 83% supported an expansion of the system for routine child health check-ups, and about 18% observed an increased utilisation of routine child health check-ups especially from families with a migrant background and by socially-disadvantaged families. Criticism was made concerning ineffective procedures.

CONCLUSION

The invitation and reporting system for routine child health check-ups in Hamburg shows how pediatricians can be integrated into the network of prevention and child welfare. It also shows their support of this system. Paying more systematic attention and an interdisciplinary network connecting paediatricians may contribute to a more comprehensive prevention and child protection.

[Nationwide Evaluation of the "Parental Folder" and its Utility Value--Insights into the Health and Information Behaviour of Parents]

The "parental folder" is meant as a primary prevention programme for children starting at birth with the aim to give access to relevant health knowledge to all parents and to strengthen the parental competence in doctor-parent communication. In a sample of N=1,634 families the effects of the folder were examined in a randomized controlled study in the federal states Rhineland-Palatinate and Saxony. In addition N=103 experts were asked for their valuation of the folder.

Molecular epidemiology of Candida albicans isolates from AIDS and cancer patients using a novel standardized CARE-2 DNA fingerprinting technique

A total of 277 Candida isolates from various body sites of 149 AIDS and cancer patients treated in four different university clinics in Würzburg, Germany were collected over a period of 27 months and phenotypically and genotypically characterized. The fingerprinting patterns of 194 Candida albicans isolates obtained with the moderately repetitive, C. albicans-specific DNA fragment CARE-2 were digitized and retrospectively compared with a highly accurate computer-assisted standardization method. A total of 168 different genotypic patterns (< 100% identity) could be differentiated using this technique. Although comparative analysis of C. albicans subsets revealed a pronounced tendency of C. albicans isolates from HIV patients to form clusters, the mean genetic variability in HIV and cancer patient isolates was virtually identical. Patients with a specific disease condition or in a certain age group were not found to harbour C. albicans isolates displaying a characteristic "signature genotype". Micro-evolutionary changes were detected by CARE-2 fingerprinting in temporal successive isolates of one patient, but nosocomial transmission of identical isolates between unrelated patients was never seen. Genotyping showed that patient isolates can replace one another; occasionally also species switches were observed. Secreted aspartic protease (SAP) production was not correlated with a specific C. albicans banding pattern; isolates obtained from HIV patients and from an internal control group secreted comparable amounts of SAP. Candida dubliniensis isolates in this study showed an elevated level of SAP production. When used under standardized conditions, CARE-2 fingerprinting is an efficient, reproducible and sensitive technique to characterize C. albicans isolates.

Molecular differentiation of dermatophyte fungi

Our previous studies of the ribosomal DNA variation in dermatophytes have shown that these fungi are monophyletic in origin. However, this approach did not allow us to differentiate all the species defined by classical means. Therefore, we studied the internal transcribed spacer 1 (ITS 1) region of 17 species of the fungal order Onygenales, comprising the pathogenic keratinophilic fungi. Interspecific nucleotide composition and sequence length variation of the ITS 1 region was high, mean identities were as low as 40% and sequence lengths varied from 169 to 293 basepairs. Each established dermatophyte species could be identified. In contrast, the flanking sequences at the 3' end of 18S and the 5.8S rDNA were conserved. Although the value of the ITS 1 region as a phylogenetic tool may be limited because of its high variability, it provides the information necessary to design species-specific probes, or polymerase chain reaction restriction fragment polymorphism systems useful for taxonomic or rapid diagnostic tests.

Short duration treatment with terbinafine for tinea capitis caused by Trichophyton or Microsporum species. The Study Group

Thirty-five patients with mycologically proven scalp infections were enrolled in a randomized, double-blind clinical trial with oral terbinafine (dose adjusted according to patient weight) for either 1 or 2 weeks. Patients were observed for 12 weeks; after 4 weeks, non-responders were offered an additional 4 weeks of treatment followed by a second observation period. The causative organisms were Microsporum canis (n = 12), Trichophyton tonsurans (n = 12) and other Trichophyton spp. (n = 11). The Trichophyton infections were treated effectively in five of nine (56%) patients treated for 1 week and 12 of 14 (86%) patients treated for 2 weeks. Three of the non-responders were treated for an additional 4 weeks, and one responded. In the Microsporum group only one of seven patients treated for 1 week and none of five treated for 2 weeks responded. However, treatment was effective in four of six (66%) patients treated for an additional 4 weeks. Mild to moderate adverse events believed to be drug related occurred in four patients in each of the two groups. Terbinafine is well tolerated, and requires 2 weeks of treatment in most patients with Trichophyton scalp infections and 4 weeks or more in Microsporum scalp infections, to achieve a successful clinical and mycological response.

[White genital piedra]

White piedra is a rare hair infection of man and certain animals, caused by the widespread Trichosporon fungi. The infection is characterized clinically by whitish, soft and easily removable coating of the hair shafts; however, the shafts may be destroyed by the pathogens invading at localized points. While all body hair may be affected, the pubic hair is most frequently affected. This paper is the first report genital white piedra in a 34-year-old Central European man. In all, 22 cases have been described world-wide in young men ranging in age from 20 to 40 years. Only 2 men, aged 42 and 53 years, do not fall in this range. Recently, a major African study disclosed this disease in women for the first time. In moderate latitudes, however, this infection appears to occur almost exclusively in young men.

[Trichophyton soudanense as the pathogen of tinea corporis et capitis]

Tinea capitis and corporis caused by Trichophyton soudanense were identified in a 6-year-old coloured boy who was born in Zaire and had been living for 3 years in Germany. This dermatophyte is very rarely seen outside the region in Africa where it is endemic. The disease is frequently overlooked at diagnosis because of the pathogen's capacity for causing chronic and oligosymptomatic infections. In our case the tinea did not a become apparent until the patient had been in Germany for 3 years. No-one else in his family had any comparable scalp or skin lesions. Consistent therapy with itraconazole (Sempera) dosed at 3 mg/kg body weight per day over a period of 4 weeks led to a permanent cure.

Phylogeny and dating of some pathogenic keratinophilic fungi using small subunit ribosomal RNA

The phylogenetic relationship of representative members of the genera Trichophyton, Microsporum and Epidermophyton was studied. 844 base pairs were compared after sequencing the nuclear 18S ribosomal RNA gene spanning the most variable area within the central 600 bases of this gene. The dermatophytes, which are monophyletic in origin, could be classified most effectively when placed as a subgroup in the Onygenales, Ascomycotina. The calculated radiation time was about 50 million years ago. The early cenozoic adaptive explosion of mammals, which can serve as a host for the keratinophilic fungi, provides corroboration for proximate co-evolution.

Trichophyton rubrum as the causative agent of tinea capitis in three children

Tinea capitis, which is caused by Trichophyton rubrum, is only rarely described in medical literature. Incidence of this disease appears to lie well below 1% in Europe. Microsporum canis, Trichophyton mentagrophytes and Trichophyton tonsurans are the predominant causative agents discussed here. In April 1993 T. rubrum was isolated from typical pathological changes to the capillitium area in three children from a Nigerian family, who had been living in Germany for 3 years. All three children revealed multiple, round or irregularly formed, partially infiltrated, partially pustular, hairless areas measuring up to 2 cm in diameter and covered with tightly clinging scales. The children's parents did not suffer from any dermatological complaints. The oldest child had had these pathological changes for about 5 months, the other two for a shorter length of time. Therapy with 10 mg kg(-1) body weight of griseofulvin led to rapid recovery over a period of 4 weeks.

Frequency of Trichophyton rubrum in tinea capitis

Trichophyton rubrum has led to unprecedented worldwide suppression of other dermatophytes which had been predominant earlier as a causative agent of superficial dermatomycoses. In tinea capitis on the other hand, several other species of Trichophyton or Microsporum are dominant depending on the region or continent. Tinea capitis caused by T. rubrum is a rare event worldwide. Occasional concentrations may be explained by several cases occurring by chance in one family or community. The relative frequency of this causative agent in tinea capitis in children is under 1%. In adults, however, where tinea capitis occurs very infrequently indeed, the incidence of T. rubrum appears to exceed 10%. Apart from two studies from India, one from Iran, two from Portugal and observations from Germany, which in the first country report of around 30% of all cases published, while the others document some 10% each, there are not only any conspicuous, unequivocal concentrations at all. Increased frequency of T. rubrum in this clinical picture has not been easily recognizable over the last decades due to low absolute case numbers.

Phaeohyphomycosis caused by Exophiala jeanselmei treated with itraconazole

Phaeohyphomycotic cysts developed on the right knee of a 72-year-old woman undergoing immunosuppressive treatment for ulcerative colitis 6 years after accidental inoculation of soil in a bicycle accident. The lesions were red, firm, slightly raised, 0.5-1 cm in size and completely asymptomatic. The diagnosis was made by histopathological examination of three excised cysts and by repeated isolation of Exophiala jeanselmei in pure culture. The excised cyst walls contained large numbers of dematiaceous fungal elements in the form of hyphae, yeast-like cells and some cells dividing internally by a transverse septum. The patient was treated with 200 mg of itraconazole daily, but the treatment had to be stopped because of severe side-effects after 6 weeks. Histologically the cysts were cleared of dematiaceous elements, but E. jeanselmei could still be isolated from one of two skin biopsies 1 month after the end of therapy.

In vitro and in vivo infection of rhesus monkey microglial cells by simian immunodeficiency virus

The observation that microglial cells in brain tissue are probably a major target for human immunodeficiency virus (HIV) infection has raised interest in the pathogenic role of this cell population for the development of neuro-AIDS. Since it is very difficult to obtain microglia from normal or diseased human brain we studied microglial cells isolated from fresh brain tissue of uninfected and simian immunodeficiency virus (SIV) infected rhesus monkeys (Macacca mulatta) in comparison to peripheral blood macrophages. Besides the characterization of the phenotypes of these two cell populations, we examined the replication of SIV in the cells in addition to the effect of viral infection on the expression of cell surface molecules. We found that microglia and macrophages support replication of the wild-type SIVmac251 strain as well as the infectious clone (SIV239). Infectious virus was produced and a CPE developed. Isolated microglial cells from SIV-infected monkeys were latently infected independent of the presence of neuropathological lesions and produced infectious virus after 20-25 days in culture. In situ hybridization revealed that only a small percentage of isolated microglial cells are productively infected in vivo, yet the majority of these expressed MHC class II molecules. This indicated a state of activation that is acquired in vivo. These findings indicate that microglia are a prime target cell for SIV infection in CNS tissue.

Lesion-specific activation of cloned human tumor-infiltrating lymphocytes by autologous tumor cells: induction of proliferation and cytokine production

To investigate the mechanisms by which tumor-infiltrating lymphocytes exert their antitumor effects, tumor-specific tumor-infiltrating lymphocyte clones, as well as autologous tumor cell lines from primary and secondary tumors of two patients during the course of melanoma progression were established. Enrichment for tumor-infiltrating lymphocytes expressing CD25, as well as low concentrations of interleukin-2 (30 IU/ml) in the culture medium, led to a preferential outgrowth of cells that express the high-affinity interleukin-2 receptor. All of these expressed CD2, CD3, CD11, and CD25. Coculture of tumor-infiltrating lymphocyte clones with irradiated, autologous tumor cells induced an up to 480% greater proliferative responses than recombinant interleukin-2 alone. Approximately 60% of the tumor-infiltrating lymphocyte clones showed cytotoxicity against the relevant tumor in a 4-h 51Cr-release assay. When tested in an 18-h 51Cr-release assay, the number of tumor-infiltrating lymphocyte clones exhibiting cytotoxicity against the relevant tumor increased to over 85%. In response to autologous tumor cells, nine of 15 clones secreted interferon-gamma, tumor necrosis factor-alpha, or both. Cytokine production was not restricted to either CD4+ or CD8+ T cells because both CD4+ and CD8+ tumor-infiltrating lymphocyte clones secreted cytokines. Tumor-infiltrating lymphocyte tumor interaction appears to be lesion specific because induction of proliferation and cytokine production, as well as susceptibility to cytolysis, was found not only restricted to the autologous system, but also to the specific lesion. The pattern of tumor-infiltrating lymphocyte tumor interaction specificity indicates a possible loss of antigens expressed on the tumor during disease progression.

Tumour-infiltrating lymphocytes in primary melanoma: functional consequences of differential IL-2 receptor expression

Tumour-infiltrating lymphocytes (TIL) have been isolated from early primary melanoma (Clark level III) and expanded in vitro using culture conditions with low concentrations of IL-2 (50 U/ml). Immediately after isolation TIL consisted of mainly CD3+ T cells, and the portion of CD56+ natural killer (NK) cells was below 20%. Fresh TIL cultures could be distinguished by CD25 expression since some contained up to 33%, others less than 5% CD25+ cells. These showed differences in subsequent development during in vitro expansion. CD25-expressing cultures remained stable in their phenotype, whereas the second TIL type showed major changes: CD3 (ca 70-30%) expression decrease, CD25 (ca 5-35%) and CD56 (ca 15-55%) expression increase. The TIL type, which remained dominated by CD3+ T cells, killed autologous tumour cells efficiently (51Cr-release greater than 30% at a E/T ratio of 20:1), which could be blocked by MoAbs against MHC class I molecules. In contrast, the other TIL type exhibited weak cytotoxicity (less than 17% 51Cr-release at an E/T ratio of 20:1) against the autologous tumour. Therefore, the expression of CD25 on freshly isolated TIL is a good marker for tumour specificity of in vitro expanded TIL.

Circulating Intercellular Adhesion Molecule-1 in Melanoma Patients: Induction by Interleukin-2 Therapy

Intercellular adhesion molecule-1 (ICAM-1, CD54), a molecule bound to the cell surface membrane, mediates various cell-cell interactions in inflammation and immunosurveillance. By means of a new specific enzyme-linked immunosorbent assay (ELISA) for soluble ICAM-1, free circulating ICAM-1 was measured in serum from five healthy volunteers, 10 melanoma patients at different stages of their disease, and eight patients receiving high-dose interleukin-2 (IL-2) for metastatic melanoma. No correlation between the concentration of circulating ICAM-1 and the tumor burden could be detected. In melanoma patients receiving high-dose IL-2, we observed an increase of circulating ICAM-1 of up to 200%, compared to the concentration prior to therapy, ranging between 4 and 13 ng/ml. The increase in circulating ICAM-1 was associated with the induction of tumor necrosis factor-alpha and interferon-gamma.

Human immunodeficiency virus infection in microglia: correlation between cells infected in the brain and cells cultured from infectious brain tissue

In acquired immunodeficiency syndrome, the lesions of the central nervous system in association with the human immunodeficiency virus are thought to be related to an infection of microglia, although no studies are available in which cultured and physiological characteristics of microglia cells infected in vivo have been examined. In this report, we used brain tissue from a child dying of human immunodeficiency virus infection and show that microglia cells were the main cell population being infected. Moreover, isolated macrophage-like cells from fresh brain material revealed a close resemblance to peripheral blood macrophages in their content of surface and intracellular antigens. No virus particles or viral antigens were produced by these cells during the first week of cultivation. Productive infection was readily apparent, however, by day 30. This finding illustrates the slow nature of the virus life cycle in these cells and the minimal cytopathology that accompanied the infection.

Annexins I to VI: quantitative determination in different human cell types and in plasma after myocardial infarction

Concentrations of annexins I to VI were quantitatively determined in extracts of placenta and different human cell types. They were detectable in all extracts studied, but lymphocytes/monocytes, endothelial cells and fibroblasts had very high annexin contents. The results indicate cell type specific annexin-repertoires. Annexins are intracellular proteins lacking signal sequences but which are detectable in trace amounts in plasma of healthy humans. The majority of plasma samples drawn from 14 patients suffering from myocardial infarction had elevated annexin III, IV and V concentrations. Shortly after infarction increased annexin levels were detected, reaching maximal values 24 to 48 h later. In the course of the following days annexin concentrations returned towards normal plasma levels.

Seroepidemiological correlations of antibodies to human herpesviruses and human immunodeficiency virus type 1 in African patients

A seroepidemiological evaluation of the humoral immune response against human herpes viruses was carried out in patients with and without HIV infection in Tanzania to study the role of these viruses as a cofactor in AIDS. Serum specimens were obtained from 321 outpatients and 100 healthy schoolchildren of a rural population in the Kagera Region, Tanzania, and from 149 inpatients of an urban population in Dar-es-Salaam, Tanzania. The data were analysed by logistic models taking into account demographic variables. The data obtained revealed no differences in the prevalence of antibodies to human herpes viruses between the different groups. Therefore, our study under the present conditions and the observed stages of AIDS does not suggest an influence of HIV infection on human herpesvirus infection or serologic response.