Virtual clinic for hearing loss and non-pulsatile tinnitus: initial experience of 210 cases

OBJECTIVE

Patients with hearing loss and tinnitus face lengthy waits to be seen in the ENT clinic. SHOEBOX Audiometry is an iPad-based, audiometric screening tool. A virtual hearing loss and non-pulsatile tinnitus clinic involving an ENT specialist virtually assessing cases based on the SHOEBOX audiogram, a patient symptom questionnaire and the primary care referral letter were implemented. This service evaluation explored the outcomes of the virtual clinic in reducing the need for a face-to-face ENT appointment.

METHOD

This was a retrospective service evaluation of the first six months of the virtual hearing loss and non-pulsatile tinnitus clinic.

RESULTS

A total of 210 patients were included: 34.8 per cent (73) were discharged without requiring audiologist assessment or an ENT appointment, 51.9 per cent (109) required formal audiological assessment, 36.7 per cent (77) required imaging and only 13.8 per cent (29) required a face-to-face ENT appointment.

CONCLUSION

A virtual hearing loss and non-pulsatile tinnitus clinic minimised the number of patients requiring a traditional face-to-face clinic appointment within ENT.

Clinical Utility of Deucravacitinib for the Management of Moderate to Severe Plaque Psoriasis

Introduction

Psoriasis is a chronic, immune-mediated skin condition with significant detriments to physical/mental health. While systemic therapies are available for the treatment of moderate-to-severe psoriasis, patients can experience therapeutic failure, loss of efficacy, or medical contraindications that require other therapeutic options.

Objective

With the recent approval of deucravacitinib, a first-in-class TYK2 small molecule inhibitor administered orally for psoriasis patients, we reviewed data from randomized controlled trials (RCTs) to synthesize its clinical utility. To our knowledge, this is the first systematic review and meta-analysis of deucravacitinib comparing its clinical efficacy to placebo in psoriasis.

Methods

A literature search was conducted in PubMed (MEDLINE), Embase, and the Cochrane Central Register of Controlled Trials to identify RCTs studying deucravacitinib in human patients with moderate-to-severe psoriasis.

Results

One placebo-controlled Phase II RCT and two placebo-controlled/active-comparator Phase III RCTs were included for review. Patients (N=1953) treated with deucravacitinib 6 mg daily showed marked improvement in disease severity (Psoriasis Area and Severity Index (PASI), static Physician Global Assessment (sPGA) and quality-of-life outcomes compared to patients administered comparator (apremilast) and placebo. Clinical improvement given deucravacitinib was noted for scalp psoriasis but not fingernail psoriasis. Meta-analysis (deucravacitinib, n=888; placebo, n=466) comparing rates of clearance (sPGA 0/1) demonstrated superior efficacy of deucravacitinib compared to placebo (odds ratio, 12.87; 95% confidence interval, 8.97-18.48; χ²=4.08, I²=51%). Deucravacitinib was well-tolerated, with similar rate of occurrence and type of adverse events reported among patients treated with placebo or apremilast at Week 12-16. No cardiovascular events, serious infections, or lab abnormalities were noted.

Conclusion

Deucravacitinib possesses good efficacy, with no report of safety concerns associated with prior JAK inhibitors used for psoriasis. Meta-analysis demonstrated deucravacitinib's superiority compared to placebo, indicating its promising clinical utility. Further studies are needed to observe long-term safety and efficacy, and to compare deucravacitinib to existing treatments.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Optimizing doxepin therapy in dermatology: introducing blood level monitoring and genotype testing

Doxepin, a tricyclic antidepressant, is the most efficacious antipruritic available to dermatologists; however its use is often suboptimal because of significant interindividual variability in doxepin plasma levels and clinical response between patients taking the same dose. As result, the Food and Drug Administration approves a maximum dose of 300 mg of doxepin per day and a 10 mg per cc liquid doxepin concentrate. These allow patients to significantly increase or decrease their dose, due to either a lack of clinical efficacy or side effects at typical dermatologic doses (often 10-25 mg per day). This review initially discusses the unique advantages of doxepin in dermatology. Then, it explores internal and external reasons why doxepin plasma levels and clinical response vary so significantly between patients, including genetic polymorphisms, drug interactions, comorbidities, sex, and ethnicity. Blood level monitoring is introduced, a tool dermatologists can use to optimize doxepin dosing in patients responding subtherapeutically to typical dermatologic doses. Without blood level monitoring, patients initially unresponsive to treatment could be labeled treatment failures when in fact they may be cases of inadequate dosing. Blood level monitoring allows for safe dose adjustments in these individuals to maximize patients' chances of achieving therapeutic success with this agent.

Dupilumab-Induced Facial Flushing After Alcohol Consumption

Dupilumab is a biologic agent approved by the US Food and Drug Administration for the treatment of atopic dermatitis (AD). Here, we report 2 patients with AD who were treated with dupilumab and subsequently developed facial flushing after consuming alcohol. A possible mechanism of action for this side effect is discussed along with a potential role of dupilumab.

Histopathologic spectrum of glomangioma: A clinico-pathologic review

Introduction/Objective

Glomus tumors are mesenchymal neoplasms with glomus body type modified smooth muscle cell differentiation. Most glomus tumors have a benign clinical course. However, rarely, they display malignant histologic features.

Methods/Case Report

We undertook a retrospective study using a natural language search in CoPath to find surgical pathology cases from 1993-2020 containing “glomus” in the pathology diagnosis. All relevant cases were included, and clinicopathologic data were reviewed in detail.

Results (if a Case Study enter NA)

A total of 66 tumors were identified, of which 42 were in female (63.6%) and 24 in male (36.4%) patients. The age at surgery ranged from 22 to 79 years with a median of 47.5. Females were significantly younger than males at presentation (p=0.025) by 8.8±3.8 years. Forty cases (60.6%) were located on the digits, 24 in nonvisceral soft tissue of extremities, trunk, and lip (36.4%), and one each in stomach and breast parenchyma. Sixty-three (95.5%) were benign (of which one recurred locally), 2 (3%) were malignant, and 1 (1.5%) was atypical. Four (6%) were multicentric. One case showed mixed histology (oncocytic and classic features) and one was classified as glomangiomatosis. The malignant cases each presented with a single tumor in lower extremity soft tissue in female patients (aged 33 and 49 years). The tumors measured 0.5 and 1.8 cm respectively and showed marked cytologic atypia in both and increased mitotic activity in the first. They were both completely excised.

Conclusion

The majority of glomus tumors are benign, however 3% are malignant. The most common location is the digits, followed by soft tissue. This tumor is more commonly seen in female patients. Unusual histologic variants such as glomangiomatosis and oncocytic component at times may create some difficulty to reach the diagnosis, especially on small biopsies. Unusual locations such as stomach can lead to a wrong diagnosis such as carcinoid, especially in a small biopsy material.

Acute safety and performance outcomes from the inspIRE trial using a novel pulsed field ablation system for the treatment of paroxysmal atrial fibrillation

Background/Introduction

The inspIRE clinical trial was designed to assess the safety and efficacy of a fully integrated biphasic pulsed field ablation (PFA) system comprised of a multi-channel generator, variable decapolar irrigated loop circular catheter, and mapping system (Figure A) for the treatment of paroxysmal atrial fibrillation (PAF).

Purpose

Using this novel PFA system in a multicentre clinical trial, we present the initial feasibility of electrical pulmonary vein isolation (PVI), procedural performance, and acute safety results.

Methods

inspIRE is a prospective, non-randomized, multi-centre study, planned to enrol up to 550 patients. PVI is performed with the novel, variable loop circular catheter, compatible mapping system and generator. Acute procedural effectiveness (entrance block in all clinically targeted PVs post adenosine/isoproterenol challenge) and the incidence of primary adverse events (PAEs) were assessed. PAEs are defined as the occurrence of cardiac tamponade/perforation, myocardial infarction, stroke/cerebrovascular accident, thromboembolism, transient ischemic attack, permanent phrenic nerve paralysis, pulmonary edema, pericarditis, and any major vascular access complications within 7 days of the ablation procedure. Additionally, any incidence of procedure or device related death, atrio-esophageal fistula, or PV stenosis (related to the ablation procedure or study catheter) within the 12M follow-up period is classified as a PAE.

Results

A total of 35 PAF subjects (age 59.7±10.7 years, 54.3% male) were treated across 5 European sites by 6 operators. Acute procedural success was achieved in 100% of study subjects (Figure B) with zero incidence of PAEs. Mean total procedure time was 82.9±19.9 minutes with 27.0±11.9 minutes of PFA from first to last application. Average fluoroscopy use was 10.6±6.8 minutes and LA dwell time was 45.6±15.3 minutes.

Conclusion

Initial results of the inspIRE trial demonstrate the acute safety and effectiveness of the new integrated IRE circular catheter, mapping system and generator for PVI in PAF patients.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): inspIRE is a company-sponsored study funded by Biosense Webster, Inc. Figure 1. (A) PFA System; (B) PVI Voltage Map

The use of Goeckerman therapy in managing erythrodermic psoriasis resistant to multiple medications

Erythrodermic psoriasis is a relatively rare, more dangerous inflammatory variant of psoriasis associated with high morbidity and mortality. It can be exceptionally challenging to manage, defeating even the most experienced dermatologist's arsenal of treatment strategies. Goeckerman therapy, a regimen of ultraviolet B phototherapy and crude coal tar, has demonstrable efficacy in severe and recalcitrant plaque-type psoriasis. However, its utility in erythrodermic psoriasis has not been explored within the dermatology literature. Herein, we present a patient with a long-standing history of erythrodermic psoriasis refractory to eleven treatment modalities including four biologic agents, who had his erythroderma 'turned around' following Goeckerman therapy. 'Turned around' is used to describe dramatically reducing a patient's cutaneous inflammation so that previously recalcitrant disease can now respond to maintenance therapy. The importance of a one to three week 'cool down' period of topical corticosteroid therapy prior to phototherapy or crude coal tar use is highlighted in this case as well. Although Goeckerman therapy is no longer regularly used, it remains one of the most efficacious treatments available for intractable psoriasis, attracting patients from all over the country desperate for symptom relief. This case suggests it may be useful in 'turning around' extremely difficult-to-treat erythrodermic psoriasis as well.

Prescribing Isotretinoin for Transgender Patients: A Call to Action and Recommendations

Case Scenerio: A 26-year-old patient presents to the dermatology clinic with severe nodulocystic scarring acne. The patient identifies as a transgender male and notes that he has been receiving hormone replacement therapy for the past 4 years with weekly intramuscular testosterone injections.

Biologic Treatment of 4 HIV-Positive Patients: A Case Series and Literature Review

The management of psoriatic disease in human immunodeficiency virus (HIV)-positive patients is challenging. Psoriasis in HIV-positive patients is often severe, progressive, and resistant to first- and second-line therapies, including topical treatments, phototherapy, highly active antiretroviral therapy (HAART), and oral retinoids. Other systemic agents used to treat psoriasis, such as methotrexate and cyclosporine, are immunosuppressants and thus many dermatologists may not feel comfortable prescribing them to HIV-positive patients who are already immunocompromised. Biologic agents, which target specific aspects of overactive immune pathways in psoriasis, have revolutionized the management of moderate-to-severe psoriasis. However, data is limited regarding their safety and efficacy in HIV-positive patients.

OBJECTIVE

Report four cases of HIV-positive patients managed on biologic therapy and summarize the cases of psoriasis in HIV-positive patients managed on biologic therapy that have been published in dermatologic literature to date.

METHODS

We searched PubMed and Embase databases using the terms HIV and psoriasis or HIV and psoriatic arthritis combined with one of the eleven biologics currently approved for treating psoriasis.

RESULTS

We identified 48 cases of anti-psoriasis biologic therapy (including adalimumab, infliximab, etanercept, ustekinumab, and guselkumab) in HIV-positive patients and added four. While data is limited, the evidence available suggests biologic agents are safe and efficacious in moderate-to-severe psoriasis and may even have a favorable effect on CD4 and HIV viral counts when used with concomitant HAART.

CONCLUSION

Further research would be helpful to establish practical guidelines for the use of anti-psoriasis biologic therapy in the HIV population, including that of newer agents.

B-Cell/Mixed Phenotype Acute Leukemia Following Lenalidomide Maintenance For Multiple Myeloma: A Study Of Two Cases

Introduction/Objective

The incidence of patients with multiple myeloma (MM) followed by hematologic malignancies as second primary malignancy is around 0.8 – 3.1%. The majority of cases are myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML), however, acute lymphoblastic or mixed phenotype leukemia can be rarely observed.

Methods

A retrospective chart review was performed for patients diagnosed with acute lymphoblastic or mixed phenotype leukemia from January 2009 through February 2020. Two patients were identified and the corresponding clinical data were reviewed.

Results

Case 1 was a 74-year old male diagnosed with pre-B ALL 5 years after an IgG Lambda MM. His MM therapy included Bortezomib-based chemotherapy followed by Lenalidomide maintenance. Pre-B diagnosis was confirmed on a pelvic lesion biopsy with sheets of intermediate sized cells (CD45+, PAX5+, CD34+, CD43+, CD10+, BCL6+ and BCL2+). The patient had 4 cycles of HyperCVAD chemotherapy, followed by Blinatumomab and Inotuzumab treatment. Unfortunately, the patient was referred to hospice 2 years after the diagnosis of ALL. Case 2 was a 69-year old male diagnosed with mixed phenotype acute leukemia 8 years after an lgA Lambda MM with del 13q and Trisomy 11. The patient was treated with Bortezomib-based chemotherapy followed by autologous hematopoietic stem cell transplantation (auto-HSCT) and Lenalidomide maintenance. Bone marrow biopsy showed around 79% blasts (CD34+, PAX-5+, CD79a+ and MPO+). Flow cytometry from bone marrow showed 90% precursor B cells, however MPO was negative. Furthermore, a DNTM3A p.T835M missense variant (25-30% fraction) was identified by next generation sequencing (NGS). The patient was scheduled for Hyper-CVAD chemotherapy.

Conclusion

Lenalidomide maintenance following auto-HSCT is considered a standard therapy for MM patients. Recent studies indicate that Lenalidomide maintenance is associated with an increased risk of second primary hematologic malignancies. Although AML and MDS are more commonly seen, ALL and rarely mixed phenotype leukemias can occur.

Management strategies for borderline and narcissistic personality disorders in dermatology practice: a review

Dermatologists are often ill-equipped to promptly identify and manage patients with personality disorders. Patients with borderline personality disorder (BPD) and narcissistic personality disorder (NPD) frequently present to dermatology clinics, particularly those that provide esthetic services. Although dermatologists should ideally utilize specific management strategies when working with these patients, there is a lack of awareness and availability of resources on how to do so. Here, we review the psychiatry, plastic and reconstructive surgery, and dermatology literature to provide recommendations on tangible management strategies for dermatologists to avoid common mistakes that are made while managing patients with BPD and NPD. Additionally, we also discuss common dermatologic manifestations of BPD and NPD to improve providers' ability to identify patients with these conditions in their practices.

Impact of Halobetasol Propionate and Tazarotene Lotion 0.01%/0.045% in the Management of Plaque Psoriasis in Adults

Halobetasol propionate and tazarotene lotion 0.01%/0.045% (HP/TAZ) is a topical medication approved for the treatment of plaque psoriasis in adults. As a treatment modality, HP/TAZ has a combinatory therapeutic effect because it contains both a corticosteroid (HP) and a retinoid (TAZ) component. Here, we review the important clinical efficacy and safety data derived from pivotal clinical trials for HP/TAZ in the treatment of plaque psoriasis. We also discuss the mechanism of action, dosage guidelines, pharmacokinetics/pharmacodynamics, and clinical considerations for HP/TAZ, including why HP/TAZ should be avoided in pregnant patients.

863Leadless endocardial pacing improves symptoms in patients with failed conventional CRT implant in long term follow up

Funding Acknowledgements

EBR Systems, Inc

OnBehalf

WiSE-CRT and LV-SELECT study and POST-M REGISTRY

Background

The WiSE-CRT (Wireless stimulation endocardial) system has advantages over conventional epicardial CRT. Whenever conventional CRT failed to implant or failed to echocardiographic response, the WiSE-CRT was implanted as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) over the last 8 years. All these studies have reported high rates of clinical and echocardiographic response compared to conventional CRT.

Objectives

The purpose of this analysis was to determine the safety and clinical response in the largest available number of implanted patients (pts) with long term follow up of 2 years and the first, second and third generation of WiSE-CRT devices.

Method

All pts undergoing a WiSE-CRT implantation as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) were analysed (N = 165). Pts were followed-up for 24 months and considered CRT responders if an improvement in NYHA ≥ 1 class from baseline (pre-implant) was achieved.

Results

In total, 165 pts were implanted, demographics include: 68.2 ± 9.6 year’s old, 81.8% male, 49.7% with history of AFib and 54.5% non-ischaemic aetiology. The mean intrinsic QRS duration was 165.0 ± 32.3 msec (28 pts pace-maker dependent). 161 pts had the system successfully implanted with no major complications, 3 (1.8%) pts developed a pericardial effusion and 1 (0.6%) electrode was lost during implantation and recovered surgically. During the 24-month follow-up period, 20 (12.1%) pts died from any cause, 4 (2.4%) pts developed TIA or Stroke and 15 (9.1%) pts had pocket or transmitter infection. There was a significant improvement in NYHA functional class in 63.6% pts and an average improvement of -26.1 (-45.1, -7.1) msec in QRS duration.

Conclusion

Despite a history of failed conventional CRT implantation, pts undergoing CRT upgrades with a WiSE-CRT have a high success rate and a complication rate similar to previously described. In addition endocardial LV pacing led to symptomatic improvements in 64% of patients reaching the 24 month of follow up.

Abstract Figure 1: Forest Plot NYHA Responder Rat

Machine Learning in Dermatology: Current Applications, Opportunities, and Limitations

Machine learning (ML) has the potential to improve the dermatologist's practice from diagnosis to personalized treatment. Recent advancements in access to large datasets (e.g., electronic medical records, image databases, omics), faster computing, and cheaper data storage have encouraged the development of ML algorithms with human-like intelligence in dermatology. This article is an overview of the basics of ML, current applications of ML, and potential limitations and considerations for further development of ML. We have identified five current areas of applications for ML in dermatology: (1) disease classification using clinical images; (2) disease classification using dermatopathology images; (3) assessment of skin diseases using mobile applications and personal monitoring devices; (4) facilitating large-scale epidemiology research; and (5) precision medicine. The purpose of this review is to provide a guide for dermatologists to help demystify the fundamentals of ML and its wide range of applications in order to better evaluate its potential opportunities and challenges.

Psoriasis Vulgaris Successfully Treated with Goeckerman Treatment at Home: A Patient and Physician's Experience

Goeckerman therapy is a highly effective treatment regimen for moderate-to-severe psoriasis. It involves regular exposure to ultraviolet B radiation and the application of crude coal tar. To our knowledge, only three centers in the USA currently offer a formal Goeckerman therapy treatment program; thus, access to this therapy is geographically limited. In this article, a motivated patient discusses his experience with generalized plaque psoriasis. This patient, while living in a Goeckerman-inaccessible area, deferred treatment with biologics and outpatient phototherapy to develop a modified Goeckerman regimen for at-home use. This home regimen, which did not involve the use of prescription-strength medications, resulted in full clearance of his psoriasis. We also discuss the patient’s case from the perspective of a dermatology treatment team that has reviewed his experience.

Clinical Evaluation of Risankizumab-rzaa in the Treatment of Plaque Psoriasis

Risankizumab-rzaa (Skyrizi^®; AbbVie) is a humanized IgG monoclonal antibody directed against interleukin-23p19 (IL-23p19) indicated for the treatment of moderate-to-severe psoriasis in adults who are candidates for systemic therapy or phototherapy. Four pivotal Phase III trials: UltIMMa-1, UltIMMa-2, IMMhance, and IMMvent have demonstrated efficacy and safety in patients with moderate-to-severe plaque psoriasis. This review highlights important findings from these and other clinical trials that have evaluated risankizumab. In addition, we discuss the mechanism of action, pharmacokinetics/pharmacodynamics, dosing recommendations, drug interactions, other potential indications, and ongoing clinical trials.

P1033Impact of workflow modifications in atrial fibrillation ablation for reducing the incidence of silent cerebral lesions with a new multi-electrode radiofrequency balloon catheter

Background

Silent cerebral lesions (SCL) often occur after invasive cardiac procedures. Reported SCL incidence with AF ablation varies (incidence, up to 50%), depending on technology used, procedural workflow, and detection method.

Objective

To evaluate the impact of ablation workflow modifications on SCL incidence following pulmonary vein isolation radiofrequency (RF) ablation with a novel multi-electrode RF balloon catheter in patients with symptomatic paroxysmal AF (PAF).

Methods

In the RADIANCE feasibility study of the balloon catheter, all enrolled patients who underwent ablation were screened for SCL using pre- and post-procedural diffusion-weighted MRI. Several modifications were made to the ablation workflow in a subsequent European registration study (SHINE) of the same catheter: eliminating dual transseptal access, using an over-the-wire mini lasso, continuously irrigating all side ports, bolus dosing with heparin before transseptal puncture, maintaining activated clotting time (ACT) at 350–400 sec, and setting a maximum temperature limit of 55°C (previously, 60–65°C). Interim data are presented for SHINE (data cutoff, 22 Oct 2018).

Results

In the neurological assessment evaluable (NAE) populations of RADIANCE (n=38) and SHINE (n=30), respectively, mean ages were 60.8±10.04 and 59.7±7.83 years, and 57.9% and 70.0% were male. One patient in each study had a history of TIAs. SCL incidences were 23.7% (10 lesions in 9 patients) in RADIANCE and 7.1% (2 lesions in 2 patients) in SHINE (excluding 1 SCL that occurred in a patient who failed to meet inclusion criteria [age>75] and 1 SCL that occurred after data cut-off). SHINE NAE enrollment has since completed with no further SCL occurrences. Overall, mean ACTs were 344.3±24.55 sec in RADIANCE and 381.6±73.31 sec in SHINE (p=0.01); in patients with SCL, mean ACTs were 349.3±25.65 and 417.8±87.33 sec, respectively.

Conclusion(s)

Modifications to the workflow led to a decrease in the SCL incidence for PAF ablation using the novel RF balloon catheter.

Acknowledgement/Funding

These studies were sponsored by Biosense Webster, Inc.

Anti IL-17 in psoriasis

Introduction: Psoriasis is a chronic, immune-mediated disease with significant associated comorbidities. Its pathogenesis is likely multifactorial, however, the interleukin-23/T helper 17 pathway has been identified as a critical axis in its pathogenesis. Interleukin-17A is the primary effector of this pathway and overexpression of IL-17A results in epidermal hyperplasia and an overly robust inflammatory response, resulting in the skin plaques and systemic inflammation seen in psoriasis. Targeted anti IL-17 therapies have demonstrated efficacy in the treatment of moderate-to-severe plaque psoriasis.Areas covered: A PubMed search was conducted for relevant literature. Secukinumab, ixekizumab, and brodalumab are anti IL-17 inhibitors currently approved for the treatment of moderate-to-severe plaque psoriasis. The efficacy and safety data from key phase III clinical trials are reviewed here.Expert opinion: By targeting a key mediator of the interleukin-23/T helper 17 pathway, IL-17 antagonists are an effective treatment for plaque psoriasis. It has demonstrated efficacy and a favorable safety profile in key phase III clinical trials. In addition to efficacy, IL-17 antagonists have also shown long-term maintenance of treatment response and a quick onset of action. The efficacy of IL-17 inhibitors in the treatment of moderate-to-severe psoriasis underscores the importance of the IL-23/Th17 pathway in the pathogenesis of psoriasis.

Ultrafiltration by Peritoneal Route in Refractory Chronic Congestive Cardiac Failure

Diuretics are the mainstay of treatment of refractory heart failure. There is a high incidence of dyselectrolytemia and suboptimal response due to diuretic resistance. Ultrafiltration by peritoneal route can be a safe and effective alternative. This study aims to study the ultrafiltration by peritoneal route in refractory heart failure patients with respect to change in functional status, renal parameters, left ventricular ejection fraction, number of days of hospitalization, and level of myocardial depressant factors. This was a prospective observational study conducted in Nephrology Department of tertiary care hospital. We studied patients with refractory heart failure who had persistent symptoms requiring frequent admissions despite optimal medical decongestion or had dyselectrolytemia with worsening renal parameters. The data were collected at baseline and then after 6 months of starting ultrafiltration. A total of 30 participants were studied. All the patients were in NYHA functional status Class IV before peritoneal ultrafiltration. There was a significant improvement in functional status and only 14 patients (46%) had Class III to Class IV status after application of ultrafiltration. (P < 0.001) There was a significant improvement in duration of hospital stay (75.8 ± 43.3 days to 7.8 ± 12.4, P > 0.001), serum creatinine (3.18 ± 0.98 to 2.16 ± 0.79 mg/dl, P < 0.001), and left ventricular ejection fraction [29.3 ± 7.4 (%) to 48.5 ± 11.8 (%), P < 0.0001] post ultrafiltration. There was also significant improvement in level of myocardial depressant factors (IL-1, IL-6, TNF alpha). Ultrafiltration by peritoneal route seems to be an effective alternative and should be offered to patients with chronic heart failure who are symptomatic despite maximal medical treatment.