Obesity and psoriasis: inflammatory nature of obesity, relationship between psoriasis and obesity, and therapeutic implications

Obesity, particularly abdominal obesity, is currently considered a chronic low-grade inflammatory condition that plays an active role in the development of the pathophysiologic phenomena responsible for metabolic syndrome and cardiovascular disease through the secretion of proinflammatory adipokines and cytokines. In recent years clear genetic, pathogenic, and epidemiologic links have been established between psoriasis and obesity, with important implications for health. The relationship between the 2 conditions is probably bidirectional, with obesity predisposing to psoriasis and psoriasis favoring obesity. Obesity also has important implications in the treatment of psoriasis, such as a greater risk of adverse effects with conventional systemic drugs and reduced efficacy and/or increased cost with biologic agents, for which dosage should be adjusted to the patient's weight.

Psoriasis in patients older than 65 years. A comparative study with younger adult psoriatic patients

OBJECTIVES

To examine the clinical characteristics of psoriasis, prevalence of comorbidities and quality of life in psoriasis patients older than 65 years and to compare them with younger adult psoriatic patients.

DESIGN

Prospective observational study of prevalence.

SETTING AND PARTICIPANTS

Patients older than 18 years with diagnosis of psoriasis attended at the Dermatology Department of the University Hospital of A Coruña (Galicia, Spain). A total of 371 patients were included (218 males and 153 females) with ages ranging from 18 to 85 years, of whom 70 were older than 65 years.

MEASUREMENTS

Demographic data, clinical characteristics and psoriasis treatment, history of hypertension, diabetes mellitus, smoking and alcohol consumption and quality of life impairment were registered. Body mass index, waist-hip ratio, left ventricular hypertrophy, average value of systolic and diastolic blood pressure, cholesterol, triglycerides and glucose blood levels were also measured.

RESULTS

Patients older than 65 years have statistically significant higher prevalence of hypertension, left ventricular hypertrophy, waist-hip ratio, diabetes mellitus and raised blood glucose levels. There was also association between clinical severity of psoriasis and smoking and alcohol intake as well as between quality of life and type of psoriasis treatment.

CONCLUSIONS

Psoriasis in patients older than 65 years represents a significant proportion of cases and its prevalence is expected to increase. Because these patients are more prone to suffer comorbidities and to develop adverse effects due to psoriasis treatment, attention to pharmacologic interactions and correction of cardiovascular risk factors and toxic habits should be especially taken in mind in this age group.

[BRAF gene mutation in the natural history of papillary thyroid carcinoma: diagnostic and prognostic implications]

The papillary carcinoma is the most prevalent malignant neoplasm of the thyroid gland, representing 85-90% of all cases, and its incidence has been increasing in recent years. It is relatively indolent, however other types poorly differentiated or anaplastic, are more aggressive and usually associated with poor prognosis. Approximately half of these papillary carcinomas harbor a thymine-to-adenine transversion (T1799A) point mutation, in the gene encoding the serine/threonine-kinase B-type Raf kinase (BRAF), with substitution of valine by glutamate (V600E). Mutated BRAF, generates a constitutive activation of the mitogen-activated protein kinases (MAPK) signaling pathway, which plays a critical role in transmitting proliferative signals generated by cell surface receptors and cytoplasmic signaling elements, to the nucleus. BRAF mutation is mutually exclusive with other common genetic alterations, supporting its independent oncogenic role in cell proliferation, survival and tumor de-differentiation. The BRAFV600E occurs exclusively in papillary thyroid carcinoma and papillary carcinoma-derived anaplastic cancer, rising as a specific diagnostic marker for this tumor when identified in cytological / histological exams. This mutation has recently emerged, as a potential prognostic marker for papillary thyroid carcinoma, after several studies have found this mutation to be associated with some clinicopathological characteristics, known to predict tumor recurrence and progression, including, for instance, old patient age, extrathyroidal invasion and lymph node metastasis. It is therefore considered a marker of aggressive disease in these tumors, associated with increased cancer recurrence and even loss of radioiodine avidity. Several studies were not able to confirm these associations. It has become clearer that BRAF mutation will likely have significant impact on the clinical management of papillary thyroid carcinoma.

[Clinical characteristics and disease course in patients treated with efalizumab following suspension of marketing authorization by the European medicines agency: a multicenter observational study]

BACKGROUND AND OBJECTIVES

The withdrawal of marketing authorization for efalizumab by the European Medicines Agency in February, 2009 provided a unique opportunity to assess the course of disease in patients who were not subject to the selection criteria and biases that were common in the pivotal trials. The aim of this study was to evaluate the course of psoriasis following forced suspension of efalizumab in a group of patients treated in normal clinical practice. As secondary objectives, we sought to assess the relationships between clinical characteristics, treatment response, and disease course during efalizumab treatment and 12 and 24 weeks after suspension.

PATIENTS AND METHODS

Information on the epidemiological profile and disease course during treatment and following suspension of the drug was collected from a group of patients treated with efalizumab. Statistical analyses were performed to identify predictive factors.

RESULTS

One hundred forty-seven patients from 12 Spanish hospitals were included in the study. During treatment, 4% of patients were diagnosed with generalized inflammatory flares. Most patients could be classified as having a good (55%) or moderate (18%) response to treatment. Rebound following withdrawal of efalizumab was observed in 30% of patients. The likelihood of rebound was independent of clinical characteristics, treatment response, or therapeutic approach used by the dermatologist following suspension.

CONCLUSIONS

There was a high frequency of rebound following suspension of efalizumab, exceeding the rate reported in pivotal trials. This is particularly noteworthy given the large proportion of patients with a good response to treatment and therefore believed to have a better prognosis. Other significant findings were the higher frequency of positive treatment response than observed in previous studies (possibly influenced by the mean treatment duration) and the high frequency of generalized inflammatory flares.

Complications of ambulatory major dermatological surgery in patients older than 85 years

BACKGROUND

During the last decades, the progressive ageing of the population has resulted in a rising skin cancer incidence. Although previous studies detected no higher morbidity for dermatological surgery in senior patients, their exclusion from optimal surgical treatment remains as a common clinical practice.

OBJECTIVE

The aim of this study was to determine the diseases treated with ambulatory major dermatological surgery, the surgical morbidity and the associated variables in ≥ 85 year-old patients.

PATIENTS/METHODS

This is an observational study on 247 successive patients older than 85 years of age who underwent dermatological surgery in a single Ambulatory Mayor Surgery unit. Studied variables were age, gender, tobacco-alcohol exposure, co-morbid medical conditions, blood-thinning medication, antibiotic prophylaxis, number of lesions, location, histopathological diagnosis, area of skin removed, surgical technique, type of flap, length of surgery, entrance order, suture thread, surgical complications and need of post-operative admission.

RESULTS

The most common site was head and neck (82.7%). The most frequent tumour was basal cell carcinoma (45.1%), followed by squamous cell carcinoma (38.7%) and melanoma (8.3%). Direct closure was the most frequent procedure (55.6%). Of the total number of patients, 7.9% of patients suffered complications; necrosis followed by cellulitis were the most frequent. Length of surgical procedure, area of skin removed and reconstruction with skin-graft were significantly related to higher risk of post-operative complications.

CONCLUSIONS

No intra or post-surgical mortality or life-threatening local complications were detected. Most post-surgical local complications appeared after wide excisions and complex reconstruction techniques that prolonged the length of the surgery.

Second-line chemotherapy with capecitabine (CAP) and oxaliplatin (OX) in patients with pancreatic or biliary tree adenocarcinoma (ADC)

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Background: Pancreatic and biliary tree ADC represent poor prognostic tumors. Gemcitabine is usually considered the first- line chemotherapy and after that no standard treatment has been established. CAP and OX have demonstrated some activity in metastatic (M1) and locally advanced (LA) pancreatic cancer, and the combination of these drugs confers additional benefit as well. We conducted this study in order to establish the efficacy of this schedule on pancreatic and biliary tree ADC.

Methods: Pts with M1 or LA pancreatic or biliary tree ADC with progression to one previous chemotherapy treatment were included. Performance status≤2, age≥18 years and adequate renal and hepatic function were selected. Schedule of chemotherapy: CAP 1000 mg/m2 bid on days 2 to 15 and OX 130 mg/m2 on day 1 of a 3-week cycle. RECIST criteria were used for assessment of response and NCI-CTCAE v 3.0 for toxicity.

Results: Between April 2006 and March 2010, 40 pt were included. Male/female: 29/11. Mean age: 60.7 years (37-74). Pancreatic/biliary: 23/17. PS 0/1/2: 3/27/10. LA/ M1: 1/39. Mean number of cycles: 2.50 (1-10). Disease response per pt, partial/ stable disease/progression/not evaluated: 1/9/21/9. Tumor control (partial/stable disease): 10 pt (22%). Hematologic toxicity (grade1/2/3/4) (%) per pt: neutropenia 5/2.5/7.5/0; thrombocytopenia 15/5/2.5/5; anemia 42.5/10/52.5/0. Nonhematologic toxicity (grade 1/2/3) (%) per pt: asthenia 10/45/17.5; emesis 22.5/15/2.5.; anorexia 12.5/35/7.5; diarrhea 7.5/12.5/5; neurotoxicity 42.5/17.5/2.5; hand-foot syndrome 5/2.5/2.5. One toxic death was reported. Median time to progression: 15 weeks (95% CI 6.6-23.3). Median survival time: 19 weeks (95% CI 10.4-27.5). For pts with PS0 or 1 median overall survival was 23 weeks (95% CI 6.3-39.6) and for pts with PS2 was 8 weeks (95% CI 5.3-1.6) (p 0.004).

Conclusions: Advanced pancreatic and biliar ADC have unfavorable prognosis. After first-line treatment, CAPOX shows a tolerable toxicity and some activity and it can represent an alternative on selected pretreated pts.

No significant financial relationships to disclose.

104 COMPARATIVE ANALYSIS OF THE YOLK SAC OF BOVINE EMBRYOS AT 30 DAYS OF PREGNANCY DERIVED FROM ARTIFICIAL INSEMINATION OR IN VITRO FERTILIZATION

The yolk sac has importance related to hematopoiesis, because it carries blood cells, and is part of the circulatory system in early embryos. The yolk sac is related to proper embryonic development because the organ is responsible for transmitting metabolic, nutrition, protection, and training of key organs, such as the intestine, in early embryos before formation of the placenta. This study attempted to compare the yolk sac of bovine embryos derived from fixed-time artificial insemination (TAI) and in vitro fertilization (IVF), relating them to their stage of development and growth at 30 days of gestation. Morphological, histological and immunological diseases were also compared. Yolk sacs from TAI or IVF bovine embryos at 30 days of gestation were collected (n = 2/group). The yolk sacs were immersed in fixative solution of 10% formaldehyde and embedded in Paraplast for light microscopy and immunohistochemical techniques. Sample cuts of 5 μm thickness were stained with hematoxylin and eosin (HE) and exposed to primary (anti-Ki-67; 1:100; Santa Cruz Biotechnology, Santa Cruz, CA, USA) and secondary (LSAB + Peroxidase Kit – K0690, DakoCytomation, Glostrup, Denmark) antibodies. To reveal immunoreactivity, diaminobenzidine (DAB, Dako) was used and the background was counter-stained with Harris hematoxylin. On Day 30 of gestation, the yolk sac of embryos from either TAI or IVF were quite developed, yellowish coloured, and presented signs of early regression. Moreover, they showed a central compact area that was clearly visible next to the embryo. The free ends were elongated and accompanied by umbilical vessels towards the ends of the gestational sac. There were no signs of fusion between the chorion and allantois, but the juxtaposition was evident with the allantois. The yolk sac is composed of three layers: the endoderm, mesothelium (simple mesothelial), and an intermediate layer (vascular mesenchymal). The layer corresponding to the mesenchyme presented thin and elongated cells with characteristics of synthesising cells. The KI-67 is a marker of cell proliferation, present in all active forms of the cell cycle and absent during quiescence. This expression reflects proliferative activity; however, in all samples subjected to immunohistochemical reaction, there was no nuclear staining of the antibody. We conclude that on Day 30 of gestation, the yolk sac shows no differences in morphological and microscopic characteristics between TAI and IVF groups. It also appears that the process of regression had not occurred as indicated by staining patterns of the Ki-67 antibody. Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Sociedade Agropecuária Imaculada Conceição Ltda. (SAIC).

[Treatment of moderate-to-severe psoriasis in clinical practice: a survey of Spanish dermatologists]

BACKGROUND AND OBJECTIVES

Various treatment options are available for use in moderate-to-severe psoriasis and election is dependent upon the clinical criteria applied by the attending physician. We undertook a survey among dermatologists to assess the treatment of moderate-to-severe psoriasis currently used in clinical practice in Spain.

METHODS

A cross-sectional study was performed by sending a questionnaire to dermatologists in Spain who treat patients with moderate-to-severe psoriasis. The questionnaire comprised 33 items distributed in 6 sections: profile of the dermatologist, case load, patient profile, follow-up and management of the disease, treatment regimens, and assessment of pharmacological treatments.

RESULTS

According to the responses of the 164 dermatologists surveyed, 6.8% of patients seen in their clinics have moderate-to-severe psoriasis; of those, 45.8% receive systemic treatment and 22.9% are treated with biologic drugs. In many of those patients (50.2%), the dermatologist felt that a change in treatment was necessary; in 51.1% of cases, this change would be from systemic therapy to a biologic drug. The principal reason for the change (50.8%) would be lack of efficacy or the appearance of adverse effects. Efficacy and safety were considered essential criteria in the choice of an appropriate treatment (82.9% and 28.0% of dermatologists, respectively). Patient quality of life was also considered an essential consideration in choice of treatment by 28.0% of dermatologists.

CONCLUSIONS

Optimal treatment for moderate-to-severe psoriasis should be effective and safe, and improve patient quality of life. This makes it essential to use drugs with an excellent efficacy and safety profile.

[Skin manifestations of toxic syndrome due to denatured rapeseed oil]

This article offered an extensive description of the clinical and pathological features and time-course of the skin manifestations of toxic syndrome caused by denatured rapeseed oil, also known as toxic oil syndrome. This new condition occurred in Spain in 1981 and was due to the ingestion of rapeseed oil intended for industrial use that had been denatured with anilines and subsequently refined and sold fraudulently as olive oil. In total, 20,000 cases and 400 deaths were reported. The disease affected mainly women, particularly in the late stages. In the acute phase, the predominant skin manifestations were toxic-allergic rashes reminiscent of allergic urticaria in the dermatopathologic study. In approximately 25% of cases, the patients' skin subsequently took on an edematous appearance, with pigmentary abnormalities shown to be related to cutaneous mucinosis. Finally, a characteristic sclerodermatous condition would develop that tended to improve spontaneously. The constant presence of mast cells in all biopsies and the development of mastocytosis in several patients pointed to an important role for these cells in the pathogenesis of the condition. This was subsequently confirmed in other sclerodermatous processes. In 1989, eosinophilia-myalgia syndrome caused by toxins present in tryptophan food supplements was reported in the United States. This syndrome resembled toxic oil syndrome in many ways and demonstrated that mucinosis and toxic sclerodermatous processes do exist.