Proteomic, miRNA and bacterial biomarker patterns in atopic dermatitis patients and their course upon anti-IL-4Rα therapy

BACKGROUND

Identification of biomarkers is required for a systems medicine approach and personalized treatment in atopic dermatitis (AD). These biomarkers may not only aid in diagnosing but also might be suitable to predict the effectiveness of targeted treatment.

OBJECTIVE

We aimed to identify proteomic, microbial and miRNA biomarkers in AD patients and investigated their course in relation to the clinical response upon anti-IL-4Rα therapy.

METHODS

Proteomic and miRNA screening was performed in AD patients in comparison to healthy controls. Differentially regulated serum proteins, miRNA and selected skin microbiota were measured consecutively in 50 AD patients before and upon systemic dupilumab treatment. A random forest classifier was used to predict the outcome of dupilumab therapy based on the initial biomarker patterns.

RESULTS

We identified 27 proteomic candidates, miRNA and three microbial strains to be dysregulated in AD. CCL17, CCL13, CCL22, E-selectin and BDNF were differently regulated and significantly associated with treatment response. In contrast, neither the microbial composition nor the miRNA pattern was associated with treatment response upon dupilumab treatment.

CONCLUSION

AD patients display defined dysregulations regarding their systemic proteomic serum profile, miRNA patterns and their skin microbiome. The proteomic profile and selected skin bacteria changed profoundly upon anti-IL-4Rα therapy which was associated with an overall clinical response. This was not seen in miRNA-related biomarkers. Our findings support the hypothesis that biomarker profiles reflect treatment responses and may in the future be used to develop a personalized medicine approach for the treatment of AD patients.

Fatal and Near-Fatal Anaphylaxis: Data From the European Anaphylaxis Registry and National Health Statistics

BACKGROUND

Anaphylaxis is a serious systemic reaction-data on fatal and near-fatal reactions are limited.

OBJECTIVE

To better understand clinical patterns and risks factors of severe anaphylaxis by a deep analysis of data from fatal and near-fatal anaphylaxis.

METHODS

Data from the European Anaphylaxis Registry on fatal/near-fatal anaphylactic reactions and national data on anaphylaxis fatalities were investigated.

RESULTS

A total of 305 fatal/near-fatal reactions among children and adults including 35 fatalities from the European Anaphylaxis Registry were identified. The most frequent elicitors were drugs, insects, and food. Male patients (66%/60%) were more frequently affected. Male sex, higher age, concomitant mastocytosis, and cardiovascular disease were associated with a more severe outcome. With increasing reaction severity, skin symptoms were less frequently observed (45% of fatal reactions). In parallel, anaphylaxis mortality rates were studied. The data show that anaphylaxis mortality rates increased in Germany from 0.48 (2009) to 0.59 per 1,000,000 population per year (2020). This increase was apparent only in the female population. In this data set, drugs were the most frequent elicitor of anaphylaxis fatalities, and the rate for this increased over time.

CONCLUSIONS

We identified not only elicitors but also individual factors to be associated with an increased risk of fatal anaphylaxis. Such patients should be recognized and managed with great caution. The increase in drug-induced fatalities points to the need for a better allergological care of patients suffering from drug hypersensitivity.

A concept for integrated care pathways for atopic dermatitis-A GA2 LEN ADCARE initiative

INTRODUCTION

The integrated care pathways for atopic dermatitis (AD-ICPs) aim to bridge the gap between existing AD treatment evidence-based guidelines and expert opinion based on daily practice by offering a structured multidisciplinary plan for patient management of AD. ICPs have the potential to enhance guideline recommendations by combining interventions and aspects from different guidelines, integrating quality assurance, and describing co-ordination of care. Most importantly, patients can enter the ICPs at any level depending on AD severity, resources available in their country, and economic factors such as differences in insurance reimbursement systems.

METHODS

The GA2 LEN ADCARE network and partners as well as all stakeholders, abbreviated as the AD-ICPs working group, were involved in the discussion and preparation of the AD ICPs during a series of subgroup workshops and meetings in years 2020 and 2021, after which the document was circulated within all GAL2 EN ADCARE centres.

RESULTS

The AD-ICPs outline the diagnostic procedures, possible co-morbidities, different available treatment options including differential approaches for the pediatric population, and the role of the pharmacists and other stakeholders, as well as remaining unmet needs in the management of AD.

CONCLUSION

The AD-ICPs provide a multidisciplinary plan for improved diagnosis, treatment, and patient feedback in AD management, as well as addressing critical unmet needs, including improved access to care, training specialists, implementation of educational programs, assessment on the impact of climate change, and fostering a personalised treatment approach. By focusing on these key areas, the initiative aims to pave the way for a brighter future in the management of AD.

Food-Induced Anaphylaxis: Data From the European Anaphylaxis Registry

BACKGROUND

Food is one of the most common elicitors of anaphylaxis, with an increasing incidence over recent years.

OBJECTIVES

To characterize elicitor-specific phenotypes and identify factors enhancing the risk or severity of food-induced anaphylaxis (FIA).

METHODS

We analyzed data from the European Anaphylaxis Registry applying an age- and sex-matched analysis of associations (Cramer's V) for single food triggers and calculated odds ratios (ORs) for severe FIA.

RESULTS

We identified 3,427 cases of confirmed FIA showing an age-dependent elicitor ranking (for children: peanut, cow's milk, cashew, and hen's egg; and for adults: wheat flour, shellfish, hazelnut, and soy). The age- and sex-matched analysis revealed defined symptom patterns for wheat and cashew. Wheat-induced anaphylaxis was more frequently associated with cardiovascular symptoms (75.7%; Cramer's V = 0.28) and cashew-induced anaphylaxis with gastrointestinal symptoms (73.9%; Cramer's V = 0.20). Furthermore, concomitant atopic dermatitis was slightly associated with anaphylaxis to hen's egg (Cramer's V = 0.19) and exercise was strongly associated with anaphylaxis to wheat (Cramer's V = 0.56). Additional factors influencing the severity were alcohol intake in wheat anaphylaxis (OR = 3.23; CI, 1.31-8.83) and exercise in peanut anaphylaxis (OR = 1.78; CI, 1.09-2.95).

CONCLUSIONS

Our data show that FIA is age-dependent. In adults, the range of elicitors inducing FIA is broader. For some elicitors, the severity of FIA seems to be related to the elicitor. These data require confirmation in future studies considering a clear differentiation between augmentation and risk factors in FIA.

An interdisciplinary approach to characterize peanut-allergic patients-First data from the FOOD@ consortium

Background

Peanut allergy is a frequent cause of food allergy and potentially life‐threatening. Within this interdisciplinary research approach, we aim to unravel the complex mechanisms of peanut allergy. As a first step were applied in an exploratory manner the analysis of peanut allergic versus non‐allergic controls.

Methods

Biosamples were studied regarding DNA methylation signatures, gut microbiome, adaptive and innate immune cell populations, soluble signaling molecules and allergen‐reactive antibody specificities. We applied a scalable systems medicine computational workflow to the assembled data.

Results

We identified combined cellular and soluble biomarker signatures that stratify donors into peanut‐allergic and non‐allergic with high specificity. DNA methylation profiling revealed various genes of interest and stool microbiota differences in bacteria abundances.

Conclusion

By extending our findings to a larger set of patients (e.g., children vs. adults), we will establish predictors for food allergy and tolerance and translate these as for example, indicators for interventional studies.

Serological profiling reveals hsa-miR-451a as a possible biomarker of anaphylaxis

Background

There is a need to support the diagnosis of anaphylaxis by objective markers. miRNAs are promising noncoding RNA species that may serve as serological biomarkers, but their use in diagnosing anaphylaxis has not been systematically studied to our knowledge. We aimed to comprehensively investigate serum biomarker profiles (proteins, lipids, and miRNAs) to support the diagnosis of anaphylaxis.

Methods

Adult patients admitted to the emergency room with a diagnosis of anaphylaxis (<3 hours) were included. Blood samples were taken upon emergency room arrival and 1 month later.

Results

Next-generation sequencing of 18 samples (6 patients with anaphylaxis in both acute and nonacute condition, for 12 total samples, and 6 healthy controls) identified hsa-miR-451a to be elevated during anaphylaxis, which was verified by quantitative real-time PCR in the remaining cohort. The random forest classifier enabled us to classify anaphylaxis with high accuracy using a composite model. We identified tryptase, 9α,11β-PGF2, apolipoprotein A1, and hsa-miR-451a as serological biomarkers of anaphylaxis. These predictors qualified as serological biomarkers individually but performed better in combination.

Conclusion

Unexpectedly, hsa-miR-451a was identified as the most relevant biomarker in our data set. We were also able to distinguish between patients with a history of anaphylaxis and healthy individuals with higher accuracy than any other available model. Future studies will need to verify miRNA biomarker utility in real-life clinical settings.

Funding

This work is funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) as part of the clinical research unit (CRU339): Food Allergy and Tolerance (FOOD@) (project number 409525714) and a grant to MW (Wo541-16-2, project number 264921598), as well as by FOOD@ project numbers 428094283 and 428447634.

Safety of dupilumab in patients with atopic dermatitis: expert opinion

Introduction: Dupilumab, the first biologic drug to be approved for the treatment of moderate to severe atopic dermatitis in adolescents and adults, has shown efficacy and safety in clinical trials. Data on long-term safety is limited but crucial for pharmacovigilance. Therefore, we performed this review to evaluate available real-world data on the long-term safety of dupilumab in atopic dermatitis.Areas covered: PubMed and Google Scholar databases were searched for randomized controlled clinical trials (RCTs), observational studies, case series, and case reports regarding the use of dupilumab for the treatment of atopic dermatitis. Adverse events were summarized and critically evaluated.Expert opinion: Atopic dermatitis patients receiving dupilumab reported ocular surface disease more often than patients receiving placebo. Real-world data show previously unreported adverse events (blood eosinophilia, rosacea-like skin lesions, weight gain), but their mechanistic association to dupilumab treatment still requires clarification. Cutaneous T-cell lymphomas occurring under the therapy with dupilumab might be unrelated to the drug use itself but long-term follow-up data of large patient cohorts is necessary to rule out such possibility. Real-world data show that dupilumab is well tolerated in atopic dermatitis; however, ocular adverse events are not rare. Registries are needed to monitor future adverse events.

Therapy Changes During Pemphigus Management: A Retrospective Analysis

Pemphigus diseases are rare, and the treatment response differs between patients. Several therapy changes are often required to achieve disease control and avoid unwanted side effects. We aimed to analyze the treatment courses of pemphigus patients and the clinical responses regarding therapy changes. Pemphigus patients in our center were retrospectively examined according to the medication and dosage, disease activity, reason for treatment changes, and autoantibody concentrations. Therapy changes due to insufficient therapeutic effects or side effects were analyzed. Seventy-seven pemphigus patients with repeated consultations were identified (81% pemphigus vulgaris, 19% pemphigus foliaceus). Disease control was achieved in 66 patients (86%; score “almost clear” or “clear”), with an average of 4 different therapy regimens (range 1–18 changes), after an average of 2 years of treatment (range 0–11 years). Twenty-two patients (29%) with refractory disease received rituximab, of which 19 (86%) subsequently achieved remission. Anti-desmoglein-1 and−3 concentrations correlated with disease severity, but not with the number of treatment changes. The identification of an effective and safe therapy for the individual pemphigus patient is a challenge and often requires time, which is reflected by a high number of therapy changes. Predictive parameters are warranted to directly identify the safest and most efficient treatment regimen for an individual patient.

Modern therapies in atopic dermatitis: biologics and small molecule drugs

Atopic dermatitis (AD) is a frequent, chronic remittent skin disease. The pathophysiology of AD has been increasingly understood within the last years, which may help to identify different endotypes suitable for defined therapies in the future. A patient-oriented therapy considers phenotypical features in addition to genetic and biological markers. The most recent developments in biologics and small-molecule drugs for AD treatment are presented in this article. These molecules, if approved, could change the perspectives for future therapies. Dupilumab is the first approved biologic for the treatment of moderate to severe atopic dermatitis in adolescence and adulthood and has led to a significant improvement in the treatment of this chronic disease. In the present article we present real-life data on the efficacy of dupilumab in adult dermatitis patients. We also discuss other data relevant to the use of dupilumab, and address open questions important for the standard care of atopic dermatitis patients.

Prevention and therapy of acute and chronic wounds using NPWT devices during the COVID-19 pandemic, recommendation from The NPWT Working Group

Recent SARS-CoV-2 pandemic leading to a rapidly increasing number of hospitalizations enforced reevaluation of wound management strategies. The optimal treatment strategy for patients with chronic wounds and those recovering from emergency and urgent oncological surgery should aim to minimize the number of hospital admissions, as well as the number of surgical procedures and decrease the length of stay to disburden the hospital staff and to minimize viral infection risk. One of the potential solutions that could help to achieve these goals may be the extensive and early use of NPWT devices in the prevention of wound healing complications. Single-use NPWT devices are helpful in outpatient wound treatment and SSI prevention (ciNPWT) allowing to minimize in-person visits to the health care center while still providing the best possible wound-care. Stationary NPWT should be used in deep SSI and perioperative wound healing disorders as soon as possible. Patient’s education and telemedical support with visual wound healing monitoring and video conversations have the potential to minimize the number of unnecessary in-person visits in patients with wounds and therefore substantially increase the level of care.

Refractory Anaphylaxis: Data From the European Anaphylaxis Registry

Refractory anaphylaxis (unresponsive to treatment with at least two doses of minimum 300 μg adrenaline) is a rare and often fatal hypersensitivity reaction. Comprehensive data on its definition, prevalence, and risk factors are missing. Using the data from the European Anaphylaxis Registry (11,596 cases in total) we identified refractory anaphylaxis cases (n = 42) and analyzed these in comparison to a control group of severe anaphylaxis cases (n = 4,820). The data show that drugs more frequently elicited refractory anaphylaxis (50% of cases, p < 0.0001) compared to other severe anaphylaxis cases (19.7%). Cases elicited by insects (n = 8) were more often due to bees than wasps in refractory cases (62.5 vs. 19.4%, p = 0.009). The refractory cases occurred mostly in a perioperative setting (45.2 vs. 9.05, p < 0.0001). Intramuscular adrenaline (as a first line therapy) was administered in 16.7% of refractory cases, whereas in 83.3% of cases it was applied intravenously (significantly more often than in severe anaphylaxis cases: 12.3%, p < 0.0001). Second line treatment options (e.g., vasopression with dopamine, methylene blue, glucagon) were not used at all for the treatment of refractory cases. The mortality rate in refractory anaphylaxis was significantly higher (26.2%) than in severe cases (0.353%, p < 0.0001). Refractory anaphylaxis is associated with drug-induced anaphylaxis in particular if allergens are given intravenously. Although physicians frequently use adrenaline in cases of perioperative anaphylaxis, not all patients are responding to treatment. Whether a delay in recognition of anaphylaxis is responsible for the refractory case or whether these cases are due to an overflow with mast cell activating substances—requires further studies. Reasons for the low use of second-line medication (i.e., methylene blue or dopamine) in refractory cases are unknown, but their use might improve the outcome of severe refractory anaphylaxis cases.

A case-control analysis of skin contact allergy in children and adolescents

BACKGROUND

Contact sensitization in children is increasing. The offending allergens differ depending on patient age and sex. We aimed to determine the sensitization profiles in children (aged 6-12) and adolescents (aged 13-18), to compare these to a control group of adults (aged 60-66), and to evaluate differences in sensitization patterns between working and non-working adolescents.

PATIENTS/MATERIALS/METHODS

We analyzed Information Network of Departments of Dermatology (IVDK) data from 2009 to 2016 using multiple logistic regression analysis. Of the 99 082 patients documented in the IVDK database, 591 children, 2451 adolescents and 12 122 adults were included in further analysis.

RESULTS

Nickel was the most frequent contact allergen among all age-groups. Children and adolescents showed significantly lower reaction rates to fragrance mix, methyldibromo-glutaronitrile, methylisothiazolinone, and propolis than adults. Positive reactions to sorbitan sesquioleate and mercapto mix among children and to cobalt among adolescents were significantly more frequent than in adults. Working adolescents had more often positive reactions to methyl(chloro)isothiazolinone (skin lesions predominantly on hands) and paraben mix (skin lesions predominantly on feet) when compared to non-working peers. Patch-tested children were more often diagnosed with atopic dermatitis than adults (P < 0.0001).

CONCLUSIONS

Contact allergens display age-specific patterns, which should be considered in a standardized series targeting different patient populations (children and adolescents). Employed adolescents should preferably be tested with the baseline series to optimize allergen identification.

Thymic stromal lymphopoietin production induced by skin irritation results from concomitant activation of protease-activated receptor 2 and interleukin 1 pathways

BACKGROUND

Thymic stromal lymphopoietin (TSLP) mediates proallergic T helper 2-type responses by acting on leucocytes. Endogenous pathways regulating TSLP production are poorly defined.

OBJECTIVES

To uncover the mechanisms by which skin barrier disruption elicits TSLP production and to delineate the level at which individual mechanistic components may converge.

METHODS

A combination of primary keratinocytes, skin explants and in vivo strategies was employed. Murine skin was tape stripped in the presence of neutralizing antibodies or antagonists. Cells and explants were stimulated with interleukin (IL)-1 and protease-activated receptor 2 agonist (PAR-2-Ag). TSLP levels were quantified by enzyme-linked immunosorbent assay and real-time quantitative polymerase chain reaction. Chromatin immunoprecipitation and promoter reporter assays were used to examine recruitment and functional activity of nuclear factor kappa B (NF-κB) at the TSLP promoter.

RESULTS

TSLP induction in mouse skin occurred in a PAR-2- and IL-1-dependent manner. This scenario was duplicated by exogenous IL-1 plus PAR-2-Ag vs. each stimulus alone. Joint activity of PAR-2 and IL-1 was also observed in human keratinocytes. The TSLP promoter was identified as the target of PAR-2/IL-1, whereby PAR-2 activation augmented the recruitment of NF-κB and transcriptional activation over IL-1 alone. Combined treatment showed activity at concentrations of IL-1 unable to elicit NF-κB activity on their own.

CONCLUSIONS

Skin barrier disruption activates the IL-1 and the PAR-2 pathways, which act in concert to activate the TSLP promoter and possibly other inflammatory genes. Awareness of this combined activity may permit a more flexible clinical management by selective targeting of either pathway individually or collectively. What's already known about this topic? Thymic stromal lymphopoietin (TSLP) is rapidly induced upon skin perturbation and mediates proallergic T helper 2-type responses by acting on leucocytes. Endogenous control of TSLP expression is poorly understood, but interleukin (IL)-1 is one regulator in the cutaneous environment In addition to IL-1, protease-activated receptor 2 (PAR-2) organizes central inflammatory pathways in the skin. What does this study add? IL-1 and PAR-2 pathways cooperate in driving TSLP production in mice and humans. Pathway integration occurs at the level of the TSLP promoter through enhanced recruitment and transcriptional activation of nuclear factor kappa B. When PAR-2 is co-stimulated, very low IL-1 levels (inactive by themselves) can induce biologically meaningful responses in the skin environment. What is the translational message? Physical skin irritation results in robust TSLP production by simultaneous activation of PAR-2 and IL-1 pathways.

Anaphylaxis in Elderly Patients-Data From the European Anaphylaxis Registry

Background: Elicitors and symptoms of anaphylaxis are age dependent. However, little is known about typical features of anaphylaxis in patients aged 65 years or more.

Methods: The data from the Network for Online Registration of Anaphylaxis (NORA) considering patients aged ≥65 (elderly) in comparison to data from adults (18–64 years) regarding elicitors, symptoms, comorbidities, and treatment measures were analyzed.

Results: We identified 1,123 elderly anaphylactic patients. Insect venoms were the most frequent elicitor in this group (p < 0.001), followed by drugs like analgesics and antibiotics. Food allergens elicited less frequently anaphylaxis (p < 0.001). Skin symptoms occurred less frequently in elderly patients (77%, p < 0.001). The clinical symptoms were more severe in the elderly (51% experiencing grade III/IV reactions), in particular when skin symptoms (p < 0.001) were absent. Most strikingly, a loss of consciousness (33%, p < 0.001) and preexisting cardiovascular comorbidity (59%, p < 0.001) were more prevalent in the elderly. Finally, adrenaline was used in 30% of the elderly (vs. 26% in the comparator group, p < 0.001) and hospitalization was more often required (60 vs. 50%, p < 0.001).

Discussion and Conclusion: Anaphylaxis in the elderly is often caused by insect venoms and drugs. These patients suffer more often from cardiovascular symptoms, receive more frequently adrenaline and require more often hospitalization. The data indicate that anaphylaxis in the elderly tends to be more frequently life threatening and patients require intensified medical intervention. The data support the need to recognize anaphylaxis in this patient group, which is prone to be at a higher risk for a fatal outcome.

Factors increasing the risk for a severe reaction in anaphylaxis: An analysis of data from The European Anaphylaxis Registry

BACKGROUND

Preventive measures to decrease the frequency and intensity of anaphylactic events are essential to provide optimal care for allergic patients. Aggravating factors may trigger or increase the severity of anaphylaxis and therefore need to be recognized and avoided.

OBJECTIVE

To identify and prioritize factors associated with an increased risk of developing severe anaphylaxis.

METHODS

Data from the Anaphylaxis Registry (122 centers in 11 European countries) were used in logistic regression models considering existing severity grading systems, elicitors, and symptoms to identify the relative risk of factors on the severity of anaphylaxis.

RESULTS

We identified higher age and concomitant mastocytosis (OR: 3.1, CI: 2.6-3.7) as the most important predictors for an increased risk of severe anaphylaxis. Vigorous physical exercise (OR: 1.5, CI: 1.3-1.7), male sex (OR: 1.2, CI: 1.1-1.3), and psychological burden (OR: 1.4, CI: 1.2-1.6) were more often associated with severe reactions. Additionally, intake of beta-blockers (OR: 1.9, CI: 1.5-2.2) and ACE-I (OR: 1.28, CI: 1.05, 1.51) in temporal proximity to allergen exposition was identified as an important factor in logistic regression analysis.

CONCLUSION

Our data suggest it may be possible to identify patients who require intensified preventive measures due to their relatively higher risk for severe anaphylaxis by considering endogenous and exogenous factors.

Propionibacterium acnes Abundance Correlates Inversely with Staphylococcus aureus: Data from Atopic Dermatitis Skin Microbiome

The microbiome may influence disease severity in atopic dermatitis. The skin of atopic dermatitis patients and healthy individuals was sampled in a standardized manner and the microbial composition analysed using next-generation sequencing. Optical density measurements were used to investigate bacterial growth under defined conditions in vitro. Lesional skin from patients with atopic dermatitis had a higher abundance of Staphylococcus aureus and reduced quantities of Propionibacterium acnes and Lawsonella clevelandensis compared with non-lesional skin. The abundance of P. acnes correlated negatively with that of S. aureus (ρ= -0.6501, p < 0.0001). Fermentation products of P. acnes inhibited the growth of S. aureus and S. epidermidis. Serum from patients with atopic dermatitis inhibited the growth of S. aureus to a greater extent than did serum from healthy individuals. These results suggest that selective modification of the skin microbiome could potentially be used as a therapeutic strategy in atopic dermatitis.

Negative pressure wound therapy in a chronic radiation dermatitis of the scalp

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Risk factors and treatment of refractory anaphylaxis - a review of case reports

INTRODUCTION

Patients experiencing anaphylaxis who do not recover after treatment with intramuscular adrenaline are regarded as suffering from refractory anaphylaxis. The incidence of refractory anaphylaxis is estimated to range between 3-5% of anaphylaxis cases. The risk factors for refractory anaphylaxis are unknown. Areas covered: In the present analysis, we aimed to evaluate the management and risk factors of refractory anaphylaxis to highlight possible clinical implications for updating current management algorithms. Expert commentary: According to international guidelines, adrenaline given through the intramuscular (i.m.) route is a rapid and safe treatment but may be insufficient. Therefore, defined standardized treatment protocols for such cases of refractory anaphylaxis are needed to optimize the treatment. Point-of-care diagnostics may enable doctors to identify patients experiencing severe, refractory anaphylaxis early in order to initiate intensified critical care treatment.

Serum levels of 9α,11β-PGF2 and apolipoprotein A1 achieve high predictive power as biomarkers of anaphylaxis

Anaphylaxis is a life-threatening hypersensitivity reaction. To identify biomarkers for the condition, we assessed serum levels of apolipoprotein (Apo)A and ApoE. We found a reduction of both lipoproteins in anaphylactic mice as well as in orally challenged food allergic patients. We then compared patients after acute anaphylaxis with several control groups (nonallergic, history of allergen-triggered anaphylaxis, acute cardiovascular/febrile reactions). In this unpaired setting, ApoE levels were unaltered, while ApoA1 was reduced in the anaphylactic group. Although unable to discriminate between anaphylaxis and cardiovascular/febrile reactions, ROC curve analysis revealed a reasonably high area under the curve (AUC) of 0.91 for ApoA1. Serum 9α,11ß-PGF₂ , recently identified as a suitable biomarker for anaphylaxis, outperformed ApoA1 with AUC=0.95. Intriguingly however its power further increased upon combination of both mediators reaching AUC=1_. Our data suggest that ApoA1 combined with 9α,11ß-PGF₂ represents a useful composite biomarker of anaphylaxis, achieving superior diagnostic power over either factor alone.

The influence of rifaximin on diverticulitis rate and quality of life in patients with diverticulosis

Diverticulosis, its associated symptoms and complications are one of the most common pathologies of the gastrointestinal tract in more economically developed countries. Presence of diverticuli and their clinical consequences can be divided into four categories: 1) diverticulosis, i.e. an asymptomatic presence of diverticuli that are usually found by accident 2) symptomatic uncomplicated diverticulosis 3) diverticulitis (acute uncomplicated diverticulitis) 4) complications of diverticulitis (conditions requiring hospital stay). The aim of this study was to retrospectively analyze the efficacy of rifaximin in preventing diverticulitis in patients visiting proctology clinics. The diagnostic criterium for diverticulosis was confirmation by colonoscopy, barium enema or CT colography (virtual colonoscopy) as well as history of at least one documented episode of diverticulosis. History of diverticulosis was evaluated based on medical records, clinical symptoms, elevated level of CRP (&gt;5.0) and/or diagnostic imaging (ultrasound, CT). After setting strict exclusion criteria, 248 patients were qualified for the study out of 686, and they were later divided into two groups: control group (group I - 145 patients) and studied group (group II - 103 patients receiving rifaximin prophylaxis). Diverticulitis rate was comparable in both groups over a period of 6 months before study (p = 0.1306) and 6 months of treatment (p=0.3044). Between the 6th and 12th month of treatment, a significantly lower rate of diverticulitis was noted in the group receiving rifaximin compared to control group (p&lt;0.0001). Patients receiving rifaximin reported higher quality of life (which was assessed using the VAS scale) compared to control group after 12 months. The results confirmed the efficacy of riaximin in prevention of diverticulitis, even in the scheme of repeated courses every 3 months. Not only did application of rifaximin lower the rate of diverticulitis and its complications in patients after an episode of diverticulitis, but also it improved the patients' quality of life. It seems that diverticulitis prophylaxis based on rifaximin can be economically efficient, however, it requires further research.

Botulinum Toxin Injection for Treatment of Chronic Anal Fissure: Is There Any Dose-Dependent Efficiency? A Meta-Analysis

BACKGROUND

Chronic anal fissure (CAF) is a linear split of the anoderm. The minimally invasive management of CAF such as botulinum toxin (BT) injection is recommended. However, the exact efficient dose of BT, number of injections per session and the injection sites are still debatable. The aim of this analysis was to assess the dose-dependent efficiency of botulinum toxin injection for CAF.

METHODS

PubMed and Web of Science databases were searched for terms: "anal fissure" AND "botulinum toxin." Studies published between October 1993 and May 2015 were included and had to meet the following criteria: (1) chronic anal fissure, (2) prospective character of the study, (3) used simple BT injection without any other interventions and (4) no previous treatment with BT.

RESULTS

A total of 1577 patients from 34 prospective studies used either Botox or Dysport formulations were qualified for this meta-analysis. A total number of BT units per session ranged from 5 to 150 IU, whereas the efficiency across analyzed studies ranged from 33 to 96 %. Surprisingly, we did not observe a dose-dependent efficiency (Spearman's rank correlation coefficient, ρ = 0.060; p = 0.0708). Moreover, there were no BT dose-dependent postoperative complications or fecal incontinence and significant difference in healing rates compared BT injection into the anal sphincter muscles.

CONCLUSIONS

BT injection has been an accepted method for the management of CAF. Surprisingly, there is no dose-dependent efficiency, and the postoperative incontinence rate is not related to the BT dosage regardless the type of formulation of botulinum neurotoxin used. Moreover, no difference in healing rate has been observed in regard to the site and number of injections per session.

Knowledge about Ultraviolet Radiation Hazards and Tanning Behavior of Cosmetology and Medical Students

Dear Editor, Ultraviolet (UV) radiation is a well-known physical hazard responsible for photoaging, photoallergic, and phototoxic reactions as well as carcinogenesis, including life-threatening melanomas (1,2). Overexposure to both natural and artificial UV radiation is a public health concern. 30% of cancers diagnosed worldwide are skin cancers. Approximately three million non-melanoma skin cancers and 132 000 new cases of melanomas are diagnosed globally each year (3). Sunburns, especially in childhood, are a very important risk factor for melanomas. Several studies demonstrated a positive association between sunbed use and an increased incidence of malignant melanoma (4). Current medical and cosmetology students will soon be knowledge providers about the risks of excessive exposure to UV radiation and prophylaxis of its consequences. Our aim was to evaluate their knowledge about the side effects of ultraviolet radiation and tanning behaviors. Details on the knowledge and habits of students were obtained during classes at the Poznan University of Medical Sciences. With approval from the Institutional Bioethical Committee, a 41-question anonymous survey was conducted in the spring of 2012 among 190 medical (1-6 year) and cosmetology students (1-5 year). The mean age of the study group was 22.3 years (standard deviation (SD) = 2.4 years), range 19-28 years. The survey was composed of closed and open-ended questions prepared by the authors. The first part of the form included demographic data: gender, age, degree course, and school year. The students were also asked about their reaction to sunlight, sunburns in childhood, and personal and family history of skin cancers or dysplastic nevus syndrome. The factual section of the survey contained questions evaluating responder knowledge about sunbeds and risk of UV radiation as well as their personal tanning habits. The open-ended questions asked responders to provide definitions of: skin phototype, sun protection factor (SPF), and tanorexia. The students were additionally asked to mention possible side effects of solar radiation and contraindications to sunbeds and drugs, which may induce photosensitivity. Statistical analysis was performed using The R Project for Statistical Computing. Chi-squared test was used to compare both sun-risk knowledge and tanning behaviors between medical and cosmetology students. P<0.05 was considered statistically significant. We distributed 220 questionnaires and received 190 (86%) eligible for evaluation. Table 1 shows the study population. Gender distribution among groups was uneven, with significantly more male subjects in the medicine program group. We decided to include their answers in this study to provide an unbiased view of both of those programs. Where appropriate, we additionally provided comparisons between female subjects in both groups to prove that differences were not solely due to uneven gender distribution. When we asked students to define skin phototype, cosmetology students more frequently gave a correct definition. In the group of students who stated they knew the definition of skin phototype, medical students were significantly more frequently wrong when we asked them to explain the term in their own words. Cosmetology students correctly answered significantly more knowledge checking questions (Table 2). When we asked students to list photosensitizing agents, students of the cosmetology program gave twice as many correct answers per respondent as students of the medicine program (see Table 3). Cosmetology students more frequently listed retinoids, while medical students listed tetracyclines as the main photosensitizing drug. The most common answer in the cosmetology group was the herb of Hypericum perforatum, although it is not considered a drug. Psoralens were identified by only 4 medical students as a possible cause of phototoxicity. When students were asked to list adverse effects of sunbathing, we specifically looked for three responses (see Table 4). Cosmetology students listed those answers significantly more often than medical students. Students of the cosmetology program gave significantly more correct answers when asked to list contraindications for sunbathing. While medical students reported mainly pregnancy (as a contraindication for most medical procedures), cosmetology students reported history of skin cancer as the most frequent answer (Table 5). Cosmetology students (89.04%) stated they visited a tanning salon more often than medical students (46.55%) (P<0.0001). When we restricted this analysis to only female subjects there still was a significant difference (P=0.0002) between cosmetology and medical female students. Cosmetology students reported lower incidence of sunscreen use (83.78% vs. 97.39%; P=0.0019). The age of the first tanning studio visit was also lower for cosmetology students (mean = 16.5 years) than medical students (mean = 17.2 years), (P=0.0290). Figure 1 illustrates the frequency of student tanning studio visits; the difference between groups was significant (P=0.0308). Skin cancers, dysplastic nevi syndrome, and precancerous lesions were reported in the family history by 19 students (10.00%). 12 of those students (63.16%) were also tanning salons users. 85 students (44.74%) reported a history of a sunburn in their childhood and over half of them continue visiting tanning salons. Some American (5) and French (6) studies assessed medical student knowledge and behaviors concerning sun risk and its prevention. The results of these studies indicated that medical school students did not have a satisfactory awareness about sun risk hazards. The French evaluation showed medical student knowledge was comparable to that of the French general population. Studies evaluating Polish student knowledge (7-9) showed ignorance of the term Fitzpatrick's skin phototype. We emphasize this because patients with phototype 1 and 2 are more susceptible to the development of skin cancers (10) and ignorance in this matter may be dangerous. UV rays may promote drug-induced photosensitivity reactions such as phototoxicity and photoallergy (1), with the most common causes being: non-steroidal anti-inflammatory agents (ketoprofen, ibuprofen, piroxicam, diclofenac), cardiovascular drugs (furosemid, amiodarone, thiazides), antibiotics (tetracyclines, ciprofloxacine, sulfonamides), psoralens, and oral contraceptives (11). Our study found deficient knowledge about drugs which may trigger photosensitivity reactions. Cosmetology students reported significantly more risky tanning behavior but did better in knowledge checking questions, which may be explained by their personal interest in this subject or by educational focus due to their major. We suggest that better knowledge about sunbathing in general is due to increased interest in this matter (not solely due to formal education) and this interest derives from a positive attitude towards a tanned appearance. It has been proven that sunbathing shows signs of addictive behavior (12). Tanorexia as a term was more widely known among cosmetology students, which may illustrate that although students knew about the addictive properties of tanning, they were sure that this did not apply to them. Many studies showed that increased knowledge did not translate into safer tanning habits (13,14). Our study agrees with those findings. Our study demonstrated that medical and cosmetology student knowledge about sunbeds and risk of UV radiation is deficient. However, cosmetology students demonstrated better knowledge than medical students. Future cosmetologists may be better information providers about sun risk and its prevention. On the other hand, students of the cosmetology faculty tended to tan more often and longer and engage in more risky behavior despite being aware of the hazards of tanning. They may be more likely to develop skin cancers in the future.

Improvement of Therapy Outcomes after Negative Pressure Wound Therapy in a Patient with Acne inversa

Treatment of acne inversa (also known as hidradenitis suppurativa) is complicated and chronic. This debilitating, inflammatory disease of the follicular sacks affects mostly young adults and has a strong negative impact on their quality of life. We present a case of a 28 year old woman with a history of acneinversa of Hurley grade 2 for 6 years. Patient underwent surgical excision of the skin of the left inguinum followed by negative pressure therapy dressings for 2 and a half weeks (5 dressing changes). This allowed a full closure of the wound after 12 weeks and formation of a well accepted scar. Patient’s paindecreased from 4.5 to 1.5 according to visual assessment scale. We also noted a 28 point decrease in disease severity score according to Sartorius scale and a 19 point decrease in Dermatology Life Quality Index. Two years prior admission patient had undergone surgical treatment of her right inguinum with split thickness skin grafting, which healed for 26 weeks and yielded less satisfactory results. Comparison photographs of both treatment results are presented.