Physician perspectives in the management of psoriasis and psoriatic arthritis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis survey

Background

Available literature on psoriasis and psoriatic arthritis (PsA) demonstrates a tremendous burden of disease and suggests underdiagnosis and undertreatment.

Objective

To obtain real‐world physician perspectives on the impact of psoriasis and PsA and its treatment on patients' daily lives, including perceptions of, and satisfaction with, current therapies.

Methods

The Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) surveyed dermatologists (n = 391) and rheumatologists (n = 390) in North America (Canada and the United States) and Europe (France, Germany, Italy, Spain and United Kingdom).

Results

Dermatologists classified 20.3% and 25.7% of their patients as having severe psoriasis and severe PsA respectively; rheumatologists indicated that 48.4% of their PsA patients had active disease. Of the psoriasis patients complaining of joint pain, only 33.0% had a diagnosis of PsA. An impact on daily activities or social/emotional well‐being was recognized by 57.2% to 79.3% of physicians. In patients with moderate‐to‐severe psoriasis, dermatologists reported 74.9% were receiving topical therapy, 19.5% conventional oral therapy and 19.6% biologics. Dermatologists and rheumatologists reported similar rates of topical (≈45%) and biologic (≈30%) therapy utilization for their PsA patients; conventional oral therapy was more often prescribed by rheumatologists (63.4%) vs. dermatologists (35.2%). Reasons for not initiating or maintaining systemic therapies were related to concerns about long‐term safety, tolerability, efficacy and costs (biologics).

Conclusion

Physicians in North America and Europe caring for patients with psoriasis and PsA acknowledge unmet treatment needs, largely concerning long‐term safety/tolerability and efficacy of currently available therapies; evidence suggests underdiagnosis of PsA and undertreatment of psoriasis among dermatologists.

One-year safety and efficacy of ustekinumab and results of dose adjustment after switching from inadequate methotrexate treatment: the TRANSIT randomized trial in moderate-to-severe plaque psoriasis

BACKGROUND

There are limited long-term, 'real-world' data on ustekinumab, or the effect of dose adjustment in suboptimal responders.

OBJECTIVES

We describe 52-week data from TRANSIT, which initiated ustekinumab by licensed regimen and investigated exploratory dose adjustment.

METHODS

Patients with moderate-to-severe psoriasis and inadequate methotrexate response received ustekinumab, with immediate or gradual methotrexate withdrawal. Outcomes were similar between treatment arms at week 12 (primary endpoint), so week 52 data were pooled. Patients weighing ≤ 100 kg or > 100 kg were administered ustekinumab 45 or 90 mg, respectively. Patients weighing ≤ 100 kg without 75% improvement in Psoriasis Area and Severity Index (PASI 75) response at weeks 28 or 40 received a dose adjustment to 90 mg. The primary analysis used observed data.

RESULTS

Overall, 391 and 98 patients received ustekinumab 45 and 90 mg, respectively. Forty-four patients (9%) discontinued before week 52 (0·4% due to adverse events). At week 52 (in the overall population), 369 patients (83%) achieved a PASI score ≤ 5, and 341 patients (77%) achieved PASI 75; the median PASI score decreased from 15 at baseline to 1·8. At weeks 28 and 40, 84 and 31 patients, respectively, did not achieve PASI 75 and received a dose adjustment; by week 52, 35/82 (43%) and 15/31 (48%) of these patients, respectively, achieved PASI 75 (two discontinued between weeks 28 and 40).

CONCLUSIONS

Ustekinumab showed sustained 1-year efficacy and was well tolerated when initially administered according to label. Adjusting the ustekinumab dose to 90 mg may result in clinically meaningful improvement in response in patients weighing ≤ 100 kg with suboptimal initial response.

Establishment and characterization of the Masquelet induced membrane technique in a rat femur critical-sized defect model

The Masquelet induced membrane technique for reconstructing large diaphyseal defects has been shown to be a promising clinical treatment, yet relatively little is known about the cellular, histological and biochemical make-up of these membranes and how they produce this positive clinical outcome. We compared cellular make-up, histological changes and growth factor expression in membranes induced around femur bone defects and in subcutaneous pockets at 2, 4 and 6 weeks after induction, and to the periosteum. We found that membranes formed around bone defects were similar to those formed in subcutaneous pockets; however, both were significantly different from periosteum with regard to structural characteristics, location of blood vessels and overall thickness. Membranes induced at the femur defect (at 2 weeks) and in periosteum contain mesenchymal stem cells (MSCs; STRO-1⁺ ) which were not found in membranes induced subcutaneously. BMP-2, TGFβ and VEGF were significantly elevated in membranes induced around femur defects in comparison to subcutaneously induced membranes, whereas SDF-1 was not detectable in membranes induced at either site. We found that osteogenic and neovascular activity had mostly subsided by 6 weeks in membranes formed at both sites. It was conclude that cellular composition and growth factor content in induced membranes depends on the location where the membrane is induced and differs from periosteum. Osteogenic and neovascular activity in the membranes is maximal between 2 and 4 weeks and subsides after 6. Based on this, better and quicker bone healing might be achieved if the PMMA cement were replaced with a bone graft earlier in the Masquelet technique. Copyright © 2013 John Wiley & Sons, Ltd.

Determination of stanozolol and 3'-hydroxystanozolol in rat hair, urine and serum using liquid chromatography tandem mass spectrometry

Background

Anabolic androgenic steroids, such as stanozolol, are typically misused by athletes during preparation for competition. Out-of-competition testing presents a unique challenge in the current anti-doping detection system owing to logistic reasons. Analysing hair for the presence of a prohibited drug offers a feasible solution for covering the wider window in out-of-competition testing. To assist in vivo studies aiming to establish a relationship between drug levels detected in hair, urine and blood, sensitive methods for the determination of stanozolol and its major metabolite 3^′-hydroxystanozolol were developed in pigmented hair, urine and serum, using brown Norway rats as a model system and liquid chromatography tandem mass spectrometry (LC-MS/MS).

Results

For method development, spiked drug free rat hair, blood and urine samples were used. The newly developed method was then applied to hair, urine and serum samples from five brown Norway rats after treatment (intraperitoneal) with stanozolol for six consecutive days at 5.0 mg/kg/day. The assay for each matrix was linear within the quantification range with determination coefficient (r²) values above 0.995. The respective assay was capable of detecting 0.125 pg/mg stanozolol and 0.25 pg/mg 3^′-hydroxystanozolol with 50 mg hair; 0.063 ng/mL stanozolol and 0.125 ng/mL 3^′-hydroxystanozolol with 100 μL of urine or serum. The accuracy, precision and extraction recoveries of the assays were satisfactory for the detection of both compounds in all three matrices. The average concentrations of stanozolol and 3^′-hydroxystanozolol, were as follows: hair = 70.18 ± 22.32 pg/mg and 13.01 ± 3.43 pg/mg; urine = 4.34 ± 6.54 ng/mL and 9.39 ± 7.42 ng/mL; serum = 7.75 ± 3.58 ng/mL and 7.16 ± 1.97 ng/mL, respectively.

Conclusions

The developed methods are sensitive, specific and reproducible for the determination of stanozolol and 3^′-hydroxystanozolol in rat hair, urine and serum. These methods can be used for in vivo studies further investigating stanozolol metabolism, but also could be extended for doping testing. Owing to the complementary nature of these tests, with urine and serum giving information on recent drug use and hair providing retrospective information on habitual use, it is suggested that blood or urine tests could accompany hair analysis and thus avoid false doping results.

Abstract P4-17-03: Towards the standardisation of outcome reporting in reconstructive breast surgery: Initial results of the BRAVO (Breast Reconstruction and Valid Outcome) Study–A multicentre consensus process to develop a core outcome set for reconstructive breast surgery

Introduction: Appropriate outcome selection is essential if research is to guide decision-making for patients, professionals and policy makers. Systematic reviews evaluating the clinical, cosmetic and patient-reported outcomes of breast reconstruction, however, have demonstrated marked heterogeneity of outcome reporting such that results from individual studies cannot be compared or combined. Standardising end-points by developing and using core outcome sets - an agreed minimum set of outcomes that should be measured and reported in all research and audit studies – is one way by which outcome reporting may be improved. We therefore report the initial results of the BRAVO (Breast Reconstruction and Valid Outcomes) Study which aims to use a scientifically rigorous Delphi consensus process to develop a core outcome set for reconstructive breast surgery.

Methods: The Delphi process involves the sequential completion of questionnaires to allow stakeholder opinions to be synthesised using item responses to prioritise outcome domains.

The questionnaire was developed from a long list of 148 outcomes generated from literature reviews and qualitative work with stakeholders. The outcomes were categorised into 34 domains in six categories (short-term complications; late complications; symptoms; psychosocial issues; practical issues and cosmesis) and each domain operationalised.

Key stakeholders were identified as patients, surgeons, specialist nurses and psychologists and participants were sampled purposively to ensure a breadth of perspectives. Each participant was sent a questionnaire and asked to prioritise the outcomes on a nine-point likert scale from 1(not important) to 9(extremely important).

The number of respondents in each group rating each outcome as not important(scores 1–3); equivocal(scores 4–6) or very important(score 7–9) were calculated for each item and compared between groups. The proportions of respondents rating each item as very important(score 7–9) was used to rank the items.

Results: 213 of the 430 questionnaires were returned(126/274 patients and 87/156 professionals) giving a response rate of 49.5%.

Patient participants had a median age of 53.4 years(range 34–76) and had undergone a full range of reconstructive procedures. The professional group included 39 breast surgeons, 20 plastic surgeons and 18 clinical nurse specialists.

There was agreement between 7 of the 10 outcomes that each group rated most highly. Items with consensus included patient-reported cosmesis, cosmetic satisfaction and early complications. Patients, but not professionals, considered generic complications such as bleeding to be important while professionals valued psychosocial issues such as self-esteem more highly than patients.

Conclusions: Patients and professionals prioritise similar outcomes, but areas of discrepancy with regard to complications and psychosocial outcomes remain. A further Delphi round asking participants to re-prioritise outcomes and a consensus meeting to ratify the final decisions will be necessary to determine a final core outcome set for reconstructive breast surgery.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-17-03.

Simultaneous analysis of antiretroviral drugs abacavir and tenofovir in human hair by liquid chromatography-tandem mass spectrometry

A sensitive and reproducible method has been developed and validated for the simultaneous quantification of the key antiretroviral drugs abacavir and tenofovir in hair using LC-MS/MS. The method was validated according to the US Food and Drug Administration (FDA) guidelines for the parameters: specificity, stability, limits of detection (LOD), limits of quantification (LOQ), linearity, accuracy, precision and recovery. Hair samples (50mg) were decontaminated and subjected to methanolic extraction, where 1 ml methanol was added along with the internal standard abacavir-d4 at a final concentration of 0.15 ng/mg hair. After 16 h, the drugs were recovered by liquid-liquid extraction using ammonium acetate buffer and a mixture of methyl tert-butyl ether:ethyl acetate (1:1). The samples were reconstituted with 200 μl acetonitrile:water (1:1) prior to injection for LC-MS/MS. The LOD and LOQ values were 0.06 and 0.12 ng/mg (drug/hair) for both drugs. Calibration curves were linear in the concentration range of 0.12-4.0 ng/mg of drug/hair with regression coefficient (r(2)) value of 0.999 for both drugs. The data for accuracy, precision and recovery were within the FDA limits. The concentrations of the drugs in the hair samples ranged from 0.12 ng/mg to 4.48 ng/mg and 0.32 ng/mg to 1.67 ng/mg for tenofovir and abacavir, respectively. This is the first full report of a method for the simultaneous determination of these two key antiretroviral drugs in hair. The newly developed method is useful for future routine analysis of tenofovir and abacavir in human hair and could be used in therapeutic drug monitoring and adherence to medicines studies, which would be helpful in decision making regarding treatment change in combination anti-retroviral therapies.

Acute lung injury induced by Staphylococcal enterotoxin B: disruption of terminal vessels as a mechanism of induction of vascular leak

The current hypothesis of alveolar capillary membrane dysfunction fails to completely explain the severe and persistent leak of protein-rich fluid into the pulmonary interstitium, seen in the exudative phase of acute lung injury (ALI). The presence of intact red blood cells in the pulmonary interstitium may suggest mechanical failure of pulmonary arterioles and venules. These studies involved the pathological and ultrastructural evaluation of the pulmonary vasculature in Staphylococcal enterotoxin B (SEB)-induced ALI. Administration of SEB resulted in a significant increase in the protein concentration of bronchoalveolar lavage fluid and vascular leak in SEB-exposed mice compared to vehicle-treated mice. In vivo imaging of mice demonstrated the pulmonary edema and leakage in the lungs of SEB-administered mice. The histopathological studies showed intense clustering of inflammatory cells around the alveolar capillaries with subtle changes in architecture. Electron microscopy studies further confirmed the diffuse damage and disruption in the muscularis layer of the terminal vessels. Cell death in the endothelial cells of the terminal vessels was confirmed with TUNEL staining. In this study, we demonstrated that in addition to failure of the alveolar capillary membrane, disruption of the pulmonary arterioles and venules may explain the persistent and severe interstitial and alveolar edema.