Imatinib mesylate in scleroderma-associated diffuse skin fibrosis: a phase II multicentre randomized double-blinded controlled trial

BACKGROUND

Imatinib mesylate is a potent inhibitor of platelet-derived growth factor and transforming growth factor-β signalling pathways which may play a role in systemic sclerosis (SSc)-associated skin changes.

OBJECTIVES

We aimed primarily at assessing the efficacy of imatinib mesylate in scleroderma skin fibrosis.

METHODS

We performed a phase II double-blinded trial on patients with scleroderma with either morphoea involving > 20% of body surface area or SSc with extensive skin involvement: modified Rodnan Skin Score (mRSS) ≥ 20/51. Each patient was randomized to receive either imatinib mesylate 400 mg or placebo daily for a total of 6 months, and then was followed up 6 months after therapy discontinuation. Skin fibrosis was assessed by mRSS and measurement of the dermal thickness using skin biopsies performed at inclusion and at 6 months of treatment. In addition, quality of life (Dermatology Life Quality Index and modified Health Assessment Questionnaire for Scleroderma) was recorded at each visit, and pulmonary function before and after intervention.

RESULTS

Twenty-eight patients were included in the study with a mean age of 48·9 years (range 30-71): 25 had a diagnosis of a SSc and three of diffuse cutaneous scleroderma. Demographic data, frequency of organ involvement of SSc and mRSS were comparable between groups. At 6 months, the proportion of variation of mRSS from inclusion was not statistically significantly different between the two groups (median +0·10 in imatinib group vs. -0·16 in placebo group, P = 0·098). Similarly, changes in dermal thickness, quality of life and diffusion capacity for carbon monoxide were not significantly different between groups.

CONCLUSIONS

This study failed to demonstrate the efficacy of imatinib 400 mg daily to improve skin fibrosis of diffuse scleroderma after 6 months of treatment based on validated outcome measurements.

Topical corticosteroids in plaque psoriasis: a systematic review of efficacy and treatment modalities

INTRODUCTION

Topical steroids are used for more than 50 years to treat mild-to-moderate plaque psoriasis. The purpose of this systematic review was to evaluate the efficacy but also the optimal modalities of administration of topical corticosteroids in psoriasis i.e. influence of steroid potency on clinical response, putative impact of topical formulation, occlusion procedure, rate of application to control the initial response and the potential interest of a maintenance treatment to prolong psoriasis clearance.

MATERIAL AND METHODS

A systematic search was performed between 1980 and January 2011 in Medline, Embase and Cochrane databases (English and French language, adults), using the keywords 'psoriasis'/exp/mj AND 'corticosteroid'/exp/mj. To analyse response across studies, three levels of response were categorized depending on the data available in studies: percentage of patients who achieved more than 50%, 75% or 90% improvement of initial psoriasis severity.

RESULTS

From an initial selection of 1269 references, 1166 references were excluded on reading the title or the abstract and 32 on reading the article and 71 were finally retained and analysed. Fifty randomized controlled trials (RCT) assessing topical steroids in the initial treatment of mild-to-severe psoriasis body plaque psoriasis were retained: 40 were parallel-group studies and 10 were within-patient studies. Treatment duration was mostly 4 weeks. Sample size varied from 30 to 1 603 patients. Outcome measures to assess efficacy were highly variable. A total of 30-90% patients across parallel group studies experienced more than 50% of initial mild-to-severe psoriasis improvement while from 7% to 85% experienced more than 75% improvement and from 5% to 85% experienced at least 90% of improvement. The success rate in the within-patient studies varied from 10% to 70%. Eighteen RCT were performed in scalp psoriasis: 16 were parallel-group and two were within-patient studies, with a treatment follow-up time from 2 weeks to 6 months, enrolling 42-1417 patients. A total from 40% to 75% patients across studies experienced more than 75% of initial scalp psoriasis improvement and from 43% to 90% experienced more than 90% initial psoriasis improvement. Only three RCT studies evaluated topical steroids as a maintenance treatment for body psoriasis and one for scalp lesions. Despite heterogeneity in treatment schedule, topical steroid intermittent maintenance treatment was shown to prolong remission. The literature analysis did not provide with high evidence-based quality data on the role of formulation, topical steroid potency, number of applications per day to obtain the highest rate of success excepting occlusion dressing which provided with additional benefit.

CONCLUSION

The clinical development of topical steroids in psoriasis did not follow state of the art modern methodology. Treatment success appears to be highly variable across studies. Maintenance intermittent treatment appears to be useful to prolong remission. Recommendations concerning topical steroids treatment modalities in plaque psoriasis should be mostly based on expert opinion.

Adherence to topical treatment in psoriasis: a systematic literature review

BACKGROUND

Treatment adherence has been recognized as an important issue in the management of chronic diseases such as psoriasis.

OBJECTIVE

The aim of this work was to analyse data about topical treatment adherence in psoriasis.

METHODS

Systematic literature review (62 references) between 1980 and 2011 (database: PubMed, Embase and Cochrane; Mesh keywords: Patient Compliance [Mesh] OR Medication Adherence [Mesh] AND Psoriasis [Mesh]; limits: date of publication >1980, humans subjects, written in French or English, aged ≥ 19 years). Two parameters were evaluated: (i) the ratio of number of product applications performed vs. number of applications expected according to physician recommendations, (ii) the ratio of amount of product used vs. amount of product prescribed.

RESULTS

A total of 22 studies were selected. Nine studies reported on the frequency of topical treatment application in a real world setting. Five studies showed a frequency of applications varying between 50% and 60% of those expected. Because of the high variability in medication adherence assessment methods, the data could not be combined. Twelve articles reported on the frequency of topical treatment application in randomized controlled trials with adherence varying between 55% and 100%. Concerning the amount of product use, four studies showed patients applied between 35% and 72% of the recommended dose during a treatment period of 14 days to 8 weeks. The most frequently mentioned reasons for non-adherence to topical treatment were low efficacy, time consumption and poor cosmetic characteristics of topical agents. Patients experiencing adherence issues were significant younger, were men, had younger age at onset of psoriasis and had a higher self-assessed severity. To improve adherence, the following strategies were suggested: to give patients information about psoriasis, to recognize social impact, to give written instructions for use such as a care plan, to explain side effects of topical therapies, to choose treatment and its cosmetic properties in agreement with the patient.

CONCLUSIONS

Literature data about topical treatment adherence are heterogeneous and scarce. They confirm the limited topical treatment adherence in psoriasis in real life, much lower than what is reported in randomized controlled trials. Therapeutic education and clear instructions on the use of topical agents are necessary to improve adherence. Studies are needed to identify predictors of limited adherence and to identify interventions improving adherence to topical medications in psoriasis.

Topical corticosteroids in plaque psoriasis: a systematic review of risk of adrenal axis suppression and skin atrophy

BACKGROUND

Topical steroids have been used for more than 50 years in mild-to-moderate plaque psoriasis and carry a theoretical risk of adverse events.

OBJECTIVES

The aim of this systematic literature review was to evaluate the risk of hypothalamo-pituitary-adrenal (HPA) axis suppression and the risk of skin atrophy with topical steroids in the treatment of plaque psoriasis.

METHODS

A systematic search between 1980 and January 2011 in Medline, Embase and Cochrane databases (English, French language, adults), using the keywords 'psoriasis'/exp/mj AND 'corticosteroid'/exp/mj,

RESULTS

Altogether 1269 references were found. Of these 1124 articles were excluded by reading the abstract and 123 by reading the article. A total of 22 randomized trials were selected. Effects on HPA axis: Thirteen studies, with a sample size varying from 7 to 341 patients, were selected. The effect on HPA axis was evaluated by the morning cortisol level (11 studies), the 24 h urine steroid levels (five studies) and/or by the Synacthen test (three studies). Reduction of morning cortisol was observed in 0-25% of patients in 10 short-term studies (two in scalp psoriasis, eight in body psoriasis) and in 48% of patients in the remaining short-term study (body psoriasis). Only four of these studies with three on body psoriasis evaluated the effect of long-term treatment defined as 6-month treatment duration or longer and did not identify HPA axis suppression by cortisol level measurement. The Synacthen test, considered as the gold standard to assess HPA axis, was always normal. There was no evidence of clinically significant HPA axis suppression due to absorption of topical steroids even when treating the scalp or in patients with extensive disease. Risk of skin atrophy: Thirteen studies with topical steroid evaluating treatment durations from 4 weeks to 1 year were analysed. The frequency of skin atrophy assessed clinically, varied from 0% to 5% of patients.

CONCLUSIONS

The literature analysis on topical steroids in psoriasis is reassuring although the quality of safety studies is limited with a majority of short-term studies. Although short-term biological effects of topical steroids on the HPA axis were observed in several clinical studies, they were not associated with clinical signs. Adequately designed long-term studies would be necessary to better determine the risk of skin atrophy using modern methods of evaluation such as dermoscopy and echography.

A Cut-Stem Inoculation Technique to Evaluate Soybean for Resistance to Macrophomina phaseolina

Charcoal rot of soybean is caused by the fungal pathogen Macrophomina phaseolina. Effective and reliable techniques to evaluate soybean for resistance to this fungus are needed to work toward a management scheme that would utilize host resistance. Three experiments were conducted to investigate the use of a cut-stem inoculation technique to evaluate soybean genotypes for resistance to M. phaseolina. The first experiment compared aggressiveness of M. phaseolina isolates collected from soybean on different soybean genotypes. Significant (P < 0.05) differences among the isolates and genotypes for relative area under disease progress curve (RAUDPC) were found without a significant isolate-genotype interaction. The second experiment compared 14 soybean genotypes inoculated with M. phaseolina in multiple trials conducted in two environments, the greenhouse and growth chamber. Significant (P < 0.05) differences among environments and highly significant (P < 0.001) differences among soybean genotypes for RAUDPC were found. The environment-genotype interaction was nonsignificant (P > 0.05). Soybean genotypes DT97-4290, DT98-7553, DT98-17554, and DT99-16864 had significantly (P < 0.05) lower RAUDPC than 7 of the 14 genotypes. The third experiment evaluated resistance in selected Phaseolus spp. and soybean genotypes. The range of RAUDPC for Phaseolus spp. was similar to that of soybean. The Phaseolus lunatus 'Bush Baby Lima' had significantly (P < 0.05) lower RAUDPC than P. vulgaris genotypes evaluated. The cut-stem inoculation technique, which has several advantages over field tests, successfully distinguished differences in aggressiveness among M. phaseolina isolates and relative differences among soybean genotypes for resistance to M. phaseolina comparable with results of field tests.

Money as motivation to quit: a survey of a non-random Australian sample of socially disadvantaged smokers' views of the acceptability of cash incentives

OBJECTIVE

This study aimed to a) assess acceptability of personal financial incentives to socially disadvantaged smokers and non-smokers; b) examine factors associated with acceptability; and c) examine preferred levels of incentive amounts.

METHODS

A cross-sectional touch screen computer survey was conducted between February and October 2010 in New South Wales, Australia. Participants were clients experiencing financial or social hardship and receiving emergency welfare aid from a non-government social and community service organisation.

RESULTS

Of 383 participants (69% response rate), 46% believed personal financial incentives were an excellent/good idea, 47% believed personal financial incentives did more good than harm and 61% agreed they would motivate smokers to quit. High acceptability ratings were associated with participants being female, current smokers, living in low socioeconomic areas, experiencing smoking-induced deprivation, making a previous quit attempt and intending to quit in the next 6 months. When asked what amount of incentive they felt would be acceptable, 23% selected amounts between $50 and $500 AUD and 37% selected amounts over $500 AUD.

CONCLUSIONS

Given high smoking prevalence among socially disadvantaged groups and consequent health disparities, it is imperative novel methods of encouraging smoking cessation are explored and tested. This survey found financial incentives may be an acceptable method. Further research to understand all possible positive and negative effects is warranted.

Cancer patients' concerns regarding access to cancer care: perceived impact of waiting times along the diagnosis and treatment journey

Waiting times can raise significant concern for cancer patients. This study examined cancer patients' concern levels at each phase of waiting. Demographic, disease and psychosocial characteristics associated with concern at each phase were also assessed. 146 consenting outpatients (n= 146) were recruited from two hospitals in Sydney, Australia. Each completed a touch-screen computer survey, asking them to recall concern experienced regarding waiting times at each treatment phase. Approximately half (52%) reported experiencing concern during at least one treatment phase, while 8.9% reported experiencing concern at every phase. Higher proportions of patients reported concern about waiting times from: deciding to have radiotherapy to commencement of radiotherapy (31%); the first specialist appointment to receiving a cancer diagnosis (28%); and deciding to have chemotherapy to commencement of chemotherapy (28%). Patient groups more likely to report concern were those of lower socio-economic status, born outside Australia, or of younger age. Although a small proportion of patients reported very high levels of concern regarding waiting times, the experience of some concern was prevalent. Opportunities for reducing this concern are discussed. Vulnerable groups, such as younger and socio-economically disadvantaged patients, should be the focus of efforts to reduce waiting times and patient concern levels.

Do cancer patients' psychosocial outcomes and perceptions of quality of care vary across radiation oncology treatment centres?

This study aimed to explore whether rates of depression, and anxiety and patient views about quality of patient-centred care varied across four metropolitan radiation therapy treatment centres in Sydney, Australia. Participants were radiation therapy outpatients, aged 18 or older and English-speaking. Participants completed a brief survey by touch screen computer while waiting for their radiation therapy treatment appointment. For eight indicators of patient-centred care, participants were asked to indicate whether their well-being would have been improved by better care related to the indicator. Participants also completed the Hospital Anxiety and Depression Scale. No differences between treatment centres were found for rates of anxiety and depression, or for the mean number of domains of care endorsed as needing improvement (indicated by agreeing or strongly agreeing that their well-being would have been improved by better care). The lack of variance in these outcomes may reflect that variation in treatment centre characteristics does not influence psychosocial outcomes and patient views of their care. Alternatively, it may suggest that the characteristics of the four treatment centres which participated in the present study were too similar for differences in patient outcomes to be observed.

The small heat shock proteins family: the long forgotten chaperones

Small heat shock proteins are a rather heterogeneous family of ATP-independent chaperones, some of which have been proven to block protein aggregation and help the cells to survive stressful conditions. Although much less studied than high molecular weight HSPs like HSP70/HSPA or HSP90/HSPC, their implication in physio-pathological processes and human diseases is now well evidenced, as it will be discussed in the different reviews of this special issue. In this mini-review we will just present a general introduction about the small heat shock proteins family. This article is part of a Directed Issue entitled: Small HSPs in physiology and pathology.

The histone- and PRMT5-associated protein COPR5 is required for myogenic differentiation

Myogenic differentiation requires the coordination between permanent cell cycle withdrawal, mediated by members of the cyclin-dependent kinase inhibitor (CKI) family, and activation of a cascade of myogenic transcription factors, particularly MYOGENIN (MYOG). Recently, it has been reported that the Protein aRginine Methyl Transferase PRMT5 modulates the early phase of induction of MYOG expression. Here, we show that the histone- and PRMT5-associated protein COPR5 (cooperator of PRMT5) is required for myogenic differentiation. C2C12 cells, in which COPR5 had been silenced, could not irreversibly exit the cell cycle and differentiate into muscle cells. This phenotype might be explained by the finding that, in cells in which COPR5 was downregulated, p21 and MYOG induction was strongly reduced and PRMT5 recruitment to the promoters of these genes was also altered. Moreover, we suggest that COPR5 interaction with the Runt-related transcription factor 1 (RUNX1)-core binding factor-β (CBFβ) complex contributes to targeting the COPR5-PRMT5 complex to these promoters. Finally, we present evidence that COPR5 depletion delayed the in vivo regeneration of cardiotoxin-injured mouse skeletal muscles. Altogether, these data extend the role of COPR5 from an adaptor protein required for nuclear functions of PRMT5 to an essential coordinator of myogenic differentiation.

[Choice of therapy based on clinical setting]

The choice of therapy in psoriasis is a complex multidimensional process based on both patient-related and disease-related factors. Standardisation of inclusion criteria for clinical trials leads to the exclusion of large numbers of patients with special forms of psoriasis or presenting comorbidities that must nevertheless be dealt with in real-life situations. The main patient-related factors affecting choice of therapy are age, pregnancy for women and the desire to father children for men, renal and hepatic failure, the risk of infection and neoplasia, metabolic and both cardiovascular and psychiatric comorbidities, as well as compliance and lifestyle. Disease-related factors affecting choice of therapy include unstable lesions, acral sites (palms, soles, nails, face and scalp), erythrodermic psoriasis, pustular psoriasis, guttate psoriasis and associated psoriatic rheumatism. The therapeutic recommendations set out in this study are based upon a critical analysis of the literature and upon the actual therapeutic practice of the experts.