Current treatment of psoriasis with biologics

Psoriasis is a chronic inflammatory skin disease with a significant number of patients suffering from additional joint involvement and other co-morbidities. The precise pathomechanisms of this disease are still unknown. But based on recent findings a picture emerges putting a new subset of inflammatory T cells, so-called Th17 T cells, into the centre of psoriasis pathogenesis. These cells secrete interleukin (IL)-17 and a further set of so-called Th17 cytokines such as IL-21 and IL-22, the latter of which appears to significantly contribute to the epidermal changes observed in this disease. Differentiation and maintenance of Th17 cells depends on IL-23 and transforming growth factor (TGF)-beta, secreted by activated monocytes or macrophages within the dermal compartment. In recent years, a plethora of new treatment approaches was introduced using antibodies or small molecule inhibitors specifically targeting inflammatory cytokines, cellular receptors or signalling mechanisms. Based on current results from large clinical trials, a more individualized treatment for affected patients may be achieved in the near future. In this review, we summarize the current knowledge about treatment of psoriasis with biological agents targeting inflammatory mechanisms.

Birth-cohort and dual diagnosis effects on age-at-onset in Brazilian patients with bipolar I disorder

OBJECTIVE

Substance use disorders and birth-cohort have been associated with an earlier onset in bipolar disorder (BD). This study aimed at evaluating the inter-relations of these factors in age-at-onset in bipolar illness.

METHOD

Two-hundred and thirty patients with bipolar I disorder were cross-sectionally evaluated. Patients were categorized into four age groups for analysis. Lifetime comorbidity and age-at-onset were derived from the Structured Clinical Interview for DSM-IV.

RESULTS

There was a strong linear association between age group and age-at-onset. Lifetime alcohol and drug use disorders were also associated with age-at-onset. Illicit drug and alcohol use disorders and age group remained significant in the multivariate model. No interactions appeared.

CONCLUSION

Both age group and dual diagnoses had strong and independent impacts on age-at-onset in out-patients with BD. Substance abuse may be partly accountable for earlier symptom onset, but other features of BD in younger generations are still in need to be accounted for.

Bleeding pattern and safety of consecutive use of the levonorgestrel-releasing intrauterine system (LNG-IUS)--a multicentre prospective study

BACKGROUND

The LNG-IUS has increasingly been used for contraception, treatment of menorrhagia and endometrial protection during hormone replacement therapy since mid-1990s. Thus, many women use the LNG-IUS consecutively. However, published data on the bleeding pattern regarding consecutive use of the LNG-IUS is scarce.

METHODS

We performed a prospective 15-month multicentre study on the bleeding profile, removal and insertion procedures and safety of the second LNG-IUS in fertile-aged women who had used their first LNG-IUS between 4 years 3 months and 4 years 9 months and who opted for the insertion of a second IUS immediately after removal of the first IUS. Bleeding data were reported descriptively starting from the last 90 days of the first IUS use and continuing for up to 1 year.

RESULTS

Of the 234 subjects screened, 204 (87%) entered the trial. The median number of bleeding/spotting days during the last 90 days of the first LNG-IUS was 7 (25 and 75% percentiles 0 and 15). Due to bleeding associated with the insertion procedure, this increased to 8 days (4 and 18) during the first 90-day reference period, thereafter decreasing to 4 (0 and 10) days during the second to fourth reference periods. Only one expulsion and no pregnancies, pelvic inflammatory diseases or perforations occurred. A total of 12 subjects (5.9%) prematurely discontinued the study: five due to an adverse event and seven due to other reasons (inclusive of loss to follow-up).

CONCLUSIONS

This study confirms the favourable bleeding profile and safety of consecutive use of the LNG-IUS.

The mtDNA nt7778 G/T polymorphism affects autoimmune diseases and reproductive performance in the mouse

Mitochondria are organelles of all nucleated cells, and variations in mtDNA sequence affect a wide spectrum of human diseases. However, animal models for mtDNA-associated diseases are rare, making it challenging to explore mechanisms underlying the contribution of mitochondria. Here, we identify a polymorphism in the mitochondrial genome, G-to-T at position 7778, which results in an aspartic acid-to-tyrosine (D-Y) substitution in the fifth amino acid of the highly conserved N-terminus of ATP synthase 8 (ATP8). Using a series of conplastic strains we show that this polymorphism increases susceptibility to multiple autoimmune diseases, including collagen-induced arthritis, autoimmune diabetes, nephritis and autoimmune pancreatitis. In addition, it impairs reproductive performance in females, but only in the MRL/MpJ strain. We also demonstrate that the mtAtp8 polymorphism alters mitochondrial performance, increasing H(2)O(2) production and affecting mitochondrial structure. Functional analysis reveals that the polymorphism increase the CD4 T cell adaptive potential to an oxidative phosphorylation impaired condition. Our findings provide direct experimental evidence for the role of mitochondria in autoimmunity and reproduction.

14-3-3sigma gene silencing during melanoma progression and its role in cell cycle control and cellular senescence

Background

The family of 14-3-3 proteins plays an important role in cancer biology by interfering with intracellular signalling pathways and cell cycle checkpoints. The 14-3-3σ isoform acts as a tumor suppressor and is often inactivated during tumor development.

Results

Here, we demonstrate enhanced CpG methylation of the 14-3-3σ gene in lymph node and cutaneous melanoma metastases compared with primary tumors, associated with dramatically reduced mRNA expression. In line with this, treatment of different metastatic melanoma cell lines with 5-aza-2'-deoxycytidine (5-Aza-CdR), a potent inhibitor of cytosine methylation, significantly induces 14-3-3σ protein expression. Additional treatment with histone deacetylase inhibitor 4-phenylbutyric acid (Pba) further enhances 14-3-3σ expression. Induction of 14-3-3σ expression by 5-Aza-CdR/Pba treatment leads to almost complete inhibition of cell proliferation, with cells predominantly arrested in G2-M. The antiproliferative effect of 5-Aza-CdR/Pba was reversed in 14-3-3σ knockdown cells. Similarly, melanoma cell lines stably overexpressing 14-3-3σ show dramatically reduced cell proliferation rates. Moreover, synchronous 14-3-3σ stably overexpressing cells do not progress through cell cycle, but display a permanent increase in the population of 4n DNA containing cells. Interestingly, overexpression of 14-3-3σ induces senescence of melanoma cells and is involved in melanoma cell senescence under genotoxic stress. Finally, 14-3-3σ knockdown supports migratory capacity of melanoma cells in vitro, while 14-3-3σ overexpression has opposing effects.

Conclusion

Taken together, the present report indicates that epigenetic silencing of 14-3-3σ might contribute to tumor progression in malignant melanoma via loss of cell cycle control, impaired cellular senescence program and support of migratory capacity.

Quantitative MR imaging evaluation of the cartilage thickness and subchondral bone area in patients with ACL-reconstructions 7 years after surgery

OBJECTIVE

To evaluate the cartilage thickness (ThC) and subchondral bone area (tAB) of the operated and contra-lateral non-operated (healthy) knees in patients with anterior cruciate ligament (ACL)-reconstruction 7 years after surgery using a quantitative and regional cartilage MR imaging (qMRI) technique.

METHODS

Charts of 410 patients with ACL-reconstructions were retrospectively reviewed. Fifty-two patients (male/female, 28/24; mean age, 33.3 years) were included. Patients underwent KT-1000 testing and qMRI of both knees using coronal fat-saturated 3D spoiled gradient-recalled echo (SPGR) sequences (TR/TE, 44/4 ms) at 1.5 T. Quantitative analyses of ThC and tAB in the femoro-tibial cartilage plates were performed using a subregional approach. In addition, qualitative and quantitative assessment of femoral condyle shapes was performed. t tests with Bonferroni corrections were used for statistical analysis of side-to-side differences between the operated and non-operated knees.

RESULTS

KT-1000 testing was abnormal in 3/52 patients (6%). Lateral femoral tAB was significantly lower (-9.2%), and medial tibial tAB was significantly larger (+2%) in the operated vs non-operated knee (P<0.001). Regional and subregional ThC side-to-side differences were less than 0.1mm and, except for the external lateral femoral subregion, they were not statistically significant. Flattened and broader shapes of medial femoral condyles (P<0.001) were found in operated knees. No significant association of presence of cartilage or meniscus lesions at surgery with ThC 7 years post-operatively was found (P=0.06-0.98).

CONCLUSION

There is evidence for changes in the tAB and femoral shape 7 years post-ACL-reconstruction, but no side-to-side differences in subregional ThC were found between the operated and contra-lateral non-operated knees.

Association of UCP2 -866 G/A polymorphism with chronic inflammatory diseases

We reported earlier that two mitochondrial gene polymorphisms, UCP2 -866 G/A (rs659366) and mtDNA nt13708 G/A (rs28359178), are associated with multiple sclerosis (MS). Here we aim to investigate whether these functional polymorphisms contribute to other eight chronic inflammatory diseases, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Wegener' granulomatosis (WG), Churg-Strauss syndrome (CSS), Crohn's disease (CD), ulcerative colitis (UC), primary sclerosing cholangitis (PSC) and psoriasis. Compared with individual control panels, the UCP2 -866 G/A polymorphism was associated with RA and SLE, and the mtDNA nt13708 G/A polymorphism with RA. Compared with combined controls, the UCP2 -866 G/A polymorphism was associated with SLE, WG, CD and UC. When all eight disease panels and the original MS panel were combined in a meta-analysis, the UCP2 was associated with chronic inflammatory diseases in terms of either alleles (odds ratio (OR)=0.91, 95% confidence interval (95% CI): 0.86-0.96), P=0.0003) or genotypes (OR=0.88, (95% CI: 0.82-0.95), P=0.0008), with the -866A allele associated with a decreased risk to diseases. As the -866A allele increases gene expression, our findings suggest a protective role of the UCP2 protein in chronic inflammatory diseases.

Predominant polarity in bipolar disorder: diagnostic implications

BACKGROUND

It has been reported that patients with bipolar disorder (BD) remain about 10 years symptomatic before the correct diagnosis is made. This fact is particularly important for patients with predominantly depressed polarity who tend to be diagnosed as suffering from unipolar major depressive disorder and treated with antidepressants. The present study was carried out to assess clinical differences between predominantly manic and depressed BD patients with a special focus on the time that patients remained undiagnosed.

METHODS

Clinical and socio-demographic characteristics were obtained from a sample of 149 euthymic bipolar outpatients. Patients were divided into depressive or manic predominance of polarity. Clinical features, number of years undiagnosed (NYU) and occupational functioning were assessed in the two groups.

RESULTS

Forty-five patients were classified as a "Depressive Polarity" whilst forty-seven were considered as "Manic Polarity". Depressive Polarity was associated with a longer delay to be diagnosed (F=14.43, df=89, p=0.001). The predominantly depressive patients tended to present a depressive onset of illness, earlier age of onset, longer duration of illness and higher number of suicide attempts than manic polarity patients.

CONCLUSION

There was a marked clinical difference between predominantly manic and depressive bipolar patients. Predominantly depressive polarity is associated with a longer delay in receiving a correct diagnosis and effective treatment which has an important impact on the management of the illness.

Genomic signatures for individualized treatment of malignant tumors

In recent years, significant progresses have been achieved in clinical oncology due to a plethora of new chemotherapeutic drugs and agents for targeted therapy. However, clinical response and overall survival rates have not improved significantly for a large number of different tumors. This may at least in part be due to the enormous genetic heterogeneity among tumors, even within a tumor entity. Moreover, besides individual somatic mutations or combinations of these in malignant tumors, the genetic background of each individual cancer patient appears to have a major impact on treatment response and overall survival. Current DNA microarray technology allows the simultaneous gene expression analysis of all known genes, and large-scale gene expression studies have provided new molecular classifications for a series of different tumors. Evidence has also been provided that gene expression signatures of malignant tumors may predict treatment response to classical chemotherapeutic or targeted anticancer drugs. The presented report summarizes the current knowledge about the role of gene expression signatures as putative guides for treatment decisions, with the future prospect of individualized treatment approaches for cancer patients.

Long-term results after fluoroscopy-guided closure of patent foramen ovale for secondary prevention of paradoxical embolism

OBJECTIVES

To carry out long-term follow-up after percutaneous closure of patent foramen ovale (PFO) in patients with cryptogenic stroke.

DESIGN

Prospective cohort study.

SETTING

Single tertiary care centre.

PARTICIPANTS

525 consecutive patients (mean (SD) age 51 (12) years; 56% male).

INTERVENTIONS

Percutaneous PFO closure without intraprocedural echocardiography.

MAIN OUTCOME MEASURES

Freedom from recurrent embolic events.

RESULTS

A mean (SD) of 1.7 (1.0) clinically apparent embolic events occurred for each patient, and 186 patients (35%) had >1 event. An atrial septal aneurysm was associated with the PFO in 161 patients (31%). All patients were followed up prospectively for up to 11 years. The implantation procedure failed in two patients (0.4%). There were 13 procedural complications (2.5%) without any long-term sequelae. Contrast transoesophageal echocardiography at 6 months showed complete closure in 86% of patients, and a minimal, moderate or large residual shunt in 9%, 3% and 2%, respectively. Patients with small occluders (<30 mm; n = 429) had fewer residual shunts (small 11% vs large 27%; p<0.001). During a mean (SD) follow-up of 2.9 (2.2) years (median 2.3 years; total 1534 patient-years), six ischaemic strokes, nine transient ischaemic attacks (TIAs) and two peripheral emboli occurred. Freedom from recurrent stroke, TIA, or peripheral embolism was 98% at 1 year, 97% at 2 years and 96% at 5 and 10 years, respectively. A residual shunt (hazard ratio = 3.4; 95% CI 1.3 to 9.2) was a risk factor for recurrence.

CONCLUSIONS

This study attests to the long-term safety and efficacy of percutaneous PFO closure guided by fluoroscopy only for secondary prevention of paradoxical embolism in a large cohort of consecutive patients.

Two year longitudinal change and test-retest-precision of knee cartilage morphology in a pilot study for the osteoarthritis initiative

OBJECTIVE

Fast low angle shot (FLASH) and double echo steady state (DESS) magnetic resonance imaging (MRI) acquisitions were recently cross-calibrated for quantification of cartilage morphology at 3T. In this pilot study for the osteoarthritis (OA) initiative we compare their test-retest-precision and sensitivity to longitudinal change.

METHOD

Nine participants with mild to moderate clinical OA were imaged twice each at baseline, year 1 (Y1) and year 2 (Y2). Coronal 1.5mm FLASH and sagittal 0.7mm DESS sequences were acquired; 1.5mm coronal multiplanar reformats (MPR) were obtained from the DESS. Patellar, femoral and tibial cartilage plates were quantified in a paired fashion, with blinding to time point.

RESULTS

In the weight-bearing femorotibial joint, average precision errors across plates were 1.8% for FLASH, 2.6% for DESS, and 3.0% for MPR-DESS. Volume loss at Y1 was not significant; at Y2 the average change across the femorotibial cartilage plates was -1.7% for FLASH, -2.8% for DESS, and -0.3% for MPR-DESS. Volume change in the lateral tibia (-5.5%; P<0.03), and in the medial (-2.9%; P<0.04) and lateral femorotibial compartments (-3.8%; P<0.03) were significant for DESS.

CONCLUSIONS

FLASH, DESS and MPR-DESS all displayed adequate test-retest precision. Although the comparison between protocols is limited by the small number of participants and by the relatively small longitudinal change in cartilage morphology in this pilot study, the data suggest that significant change can be detected with MRI in a small sample of OA subjects over 2 years.

Mehrdimensionale Schmerzmessung bei Demenzpatienten

BACKGROUND

It is well known that patients with dementia complain less about pain and receive fewer analgesics than other patients. The question arises of whether disorders associated with dementia change the processing of pain.

METHODS

A total of 20 patients with dementia and 40 patients with mild cognitive impairment (MCI) as well as 40 healthy control subjects were investigated for their subjective (category scale), facial (FACS) and motor (R-III reflex) pain responses to mechanical and electrical stimuli.

RESULTS

Patients with dementia did not rate the intensity of the stimuli differently; however, they were less frequently capable of providing ratings. At equal levels of stimulus intensity, demented patients showed stronger facial responses. The R-III reflex thresholds were lowered in demented patients. MCI patients appeared only slightly changed.

CONCLUSIONS

Our findings suggest that the processing of acute noxious stimuli is intensified in patients with dementia. Against the background of a reduced prescription of analgesics, an under-treatment of pain in patients with dementia might be the consequence.