Controversial cardiovascular and hematologic comorbidities in atopic dermatitis

Comprehensive management of challenging recurrent aortoiliac and lower extremity occlusive disease with simultaneous modified-covered endovascular reconstruction of the aortic bifurcation, inferior mesenteric artery snorkel, and lower extremity bypass

OBJECTIVES

Despite recent advancements in endovascular technology and proven durability of open surgeries, managing extensive aortoiliac occlusive disease (AIOD) with concurrent severe lower extremity (LE) arterial occlusion remains a formidable challenge. This paper introduces a comprehensive approach to addressing recurrent AIOD and LE occlusive diseases by employing modified-CERAB, inferior mesenteric artery (IMA) snorkel, and LE bypass in a challenging case.

METHODS

A 56-year-old male patient presented with subacute bilateral lower extremity rest pain with dry gangrene in the left great toe and a complex medical history. His history included a hostile abdomen stemming from past ischemic bowel episodes and multiple bowel resections through laparotomies. Furthermore, the patient had a persistent left ventricular thrombus (LVT), stage-2 chronic kidney disease (CKD), diabetes, and was currently experiencing bilateral LE rest pain and dry gangrene in the left great toe, accompanied by severe dermatitis in both LEs.

RESULTS

He successfully underwent modified-CERAB with a concurrent snorkel technique for IMA preservation, along with an LE bypass to resolve bilateral LE critical ischemia.

CONCLUSION

This comprehensive management approach, combining simultaneous modified-CERAB, IMA snorkel, and LE bypass, provides an effective alternative for addressing complex AIOD and LE occlusive disease patients with hostile abdomen.

Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations

BACKGROUND

Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology.

OBJECTIVE

To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of AD.

METHODS

A multidisciplinary guideline panel consisting of patients and caregivers, AD experts (dermatology and allergy/immunology), primary care practitioners (family medicine, pediatrics, internal medicine), and allied health professionals (psychology, pharmacy, nursing) convened, prioritized equity, diversity, and inclusiveness, and implemented management strategies to minimize influence of conflicts of interest. The Evidence in Allergy Group supported guideline development by performing systematic evidence reviews, facilitating guideline processes, and holding focus groups with patient and family partners. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed rating the certainty of evidence and strength of recommendations. Evidence-to-decision frameworks, subjected to public comment, translated evidence to recommendations using trustworthy guideline principles.

RESULTS

The panel agreed on 25 recommendations to gain and maintain control of AD for patients with mild, moderate, and severe AD. The eAppendix provides practical information and implementation considerations in 1-2 page patient-friendly handouts.

CONCLUSION

These evidence-based recommendations address optimal use of (1) topical treatments (barrier moisturization devices, corticosteroids, calcineurin inhibitors, PDE4 inhibitors [crisaborole], topical JAK inhibitors, occlusive [wet wrap] therapy, adjunctive antimicrobials, application frequency, maintenance therapy), (2) dilute bleach baths, (3) dietary avoidance/elimination, (4) allergen immunotherapy, and (5) systemic treatments (biologics/monoclonal antibodies, small molecule immunosuppressants [cyclosporine, methotrexate, azathioprine, mycophenolate, JAK inhibitors], and systemic corticosteroids) and UV phototherapy (light therapy).

Is Atopic Dermatitis Only a Skin Disease?

Atopic dermatitis (AD) is a chronic, pruritic, inflammatory dermatosis that imposes significant patient and population burdens. In addition to the cutaneous signs and symptoms, growing evidence suggests that AD is systemic in nature. Certain diseases can possibly co-occur with AD as a result of coincidental exposure to similar environmental factors. However, it is also suspected that they are linked to the pathogenesis of AD through more complex genetic and immunological mechanisms, but these correlations remain less understood. It is of great need to seek explanations for the higher frequency of the number of cardiovascular, autoimmune, neurological, psychiatric, and metabolic disorders that have been observed in epidemiologic investigations among AD patients. Moreover, analysing the immunology of chronic inflammation and its correction, activation, or suppression may prevent the development of a variety of comorbidities. As comorbid diseases in patients diagnosed with AD may potentially go undetected, physicians should be aware of them.

Association of Risk of Incident Venous Thromboembolism With Atopic Dermatitis and Treatment With Janus Kinase Inhibitors: A Systematic Review and Meta-analysis

Importance

The risk of venous thromboembolism (VTE) among patients with atopic dermatitis (AD), especially when receiving treatment with Janus kinase (JAK) inhibitors, is unclear.

Objective

To determine the association of AD with incident VTE and evaluate the risk of incident VTE among patients with AD who were receiving treatment with JAK inhibitors.

Data Sources

The MEDLINE, Embase, Cochrane Library, and Web of Science databases were searched with no restrictions on language nor geographic locations from their respective inception to February 5, 2022.

Study Selection

Cohort studies examining the association of AD with incident VTE and randomized clinical trials (RCTs) reporting VTE events in participants with AD receiving JAK inhibitors were included. Around 0.7% of initially identified articles met the selection criteria.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed. The risk of bias of included cohort studies and RCTs was assessed by the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool 2, respectively. A random-effects model meta-analysis was conducted to calculate the pooled hazard ratio (HR) and risk difference for incident VTE.

Main Outcomes and Measures

The HRs for incident VTE associated with AD and risk difference for incident VTE between participants with AD who were receiving treatment with JAK inhibitors and controls receiving placebo or dupilumab.

Results

Two cohort studies and 15 RCTs with a total of 466 993 participants were included. The meta-analysis found no significant association of AD with incident VTE (HR, 0.95; 95% CI 0.62-1.45; incidence rate of VTE, 0.23 events/100 patient-years). Overall, 3 of 5722 patients with AD (0.05%) who were receiving treatment with JAK inhibitors experienced VTE compared with 1 of 3065 patients with AD (0.03%) receiving placebo or dupilumab (Mantel-Haenszel risk difference, 0; 95% CI, 0-0). The incidence rate of VTE was 0.15 and 0.12 events per 100 patient-years in participants with AD receiving JAK inhibitors and placebo, respectively. The findings were similar in 4 unique JAK inhibitors (abrocitinib, baricitinib, upadacitinib, and SHR0302).

Conclusions and Relevance

The results of this systematic review and meta-analysis suggest that the currently available evidence does not detect an increased risk of VTE associated with AD or treatment with JAK inhibitors. These findings may provide a reference for clinicians in prescribing JAK inhibitors for patients with AD.

Investigating the association of atopic dermatitis with ischemic stroke and coronary heart disease: A mendelian randomization study

Background: Atopic dermatitis (AD) is the most common chronic skin inflammatory disease. Prior observational studies have reported inconsistent results on the association of AD with ischemic stroke and coronary heart disease. In this study, we applied two-sample Mendelian randomization (MR) to evaluate the causal effect of AD on ischemic stroke and coronary heart disease.

Methods: Twelve single-nucleotide polymorphisms robustly associated with AD (p < 5 × 10^–8) were obtained from a genome-wide association study that included 10,788 cases and 30,047 controls by the EArly Genetics and Life course Epidemiology (EAGLE) Consortium (excluding the 23andMe study). The corresponding data for ischemic stroke (34,217 cases and 406,111 controls), large artery stroke (4,373 cases and 406,111 controls), cardioembolic stroke (7,193 cases and 406,111 controls), small vessel stroke (5,386 cases and 192,662 controls), coronary heart disease (122,733 cases and 424,528 controls), and myocardial infarction (43,676 cases and 128,199 controls) were obtained from the MR-Base platform. In the primary MR analyses, we applied the inverse variance weighted method to evaluate the associations. We performed a sensitivity analysis using weighted median, MR-Egger, weighted mode, simple mode, Mendelian Pleiotropy RESidual Sum and Outlier (MR-PRESSO), and leave-one-out methods.

Results: In the primary MR analyses, we found no causal association of genetically predicted AD with ischemic stroke [odds ratio (OR) = 1.00, 95% confidence interval (CI): 0.95–1.06], large artery stroke (OR = 1.02, 95% CI: 0.88–1.17), cardioembolic stroke (OR = 1.06, 95% CI: 0.94–1.18), small vessel stroke (OR = 1.05, 95% CI: 0.94–1.17), coronary heart disease (OR = 1.00, 95% CI: 0.94–1.05), and myocardial infarction (OR = 1.03, 95% CI: 0.98–1.09). The results from the primary MR analyses were supported in sensitivity analyses using the weighted median, weighted mode, simple mode, and MR-Egger methods and multivariable MR analyses adjusting for asthma and several traditional risk factors for ischemic stroke and coronary heart disease. MR-Egger intercepts provided no evidence of directional pleiotropy. The MR-PRESSO and leave-one-out analyses did not indicate any outlier instruments.

Conclusion: Our MR study does not support a causal association of genetically predicted AD with ischemic stroke, large artery stroke, cardioembolic stroke, small vessel stroke, coronary heart disease, and myocardial infarction.

Association of atopic diseases with atrial fibrillation risk: A systematic review and meta-analysis

Background

Atopic diseases and atrial fibrillation (AF) seem to share an underlying inflammatory pathology. To date, some population-based studies have explored the relationship between the two. We aimed to conduct a meta-analysis to examine the role of atopic condition in AF risk.

Methods

All relevant observational studies in PubMed and EMBASE databases up to November 2021 were searched. In RevMan 5.3, we used random-effects or fixed-effects models to pool the effect sizes of hazard ratio (HR), odds ratio (OR) and their corresponding 95% confidence intervals (95% CI). In addition, I² and Cochran Q test were used to evaluate the heterogeneity.

Results

A total of 2488 records were retrieved. After screening according to the predetermined criteria, 6 cohort studies and 2 case-control studies were included in this meta-analysis. Herein, the meta-analysis of 6 cohort studies suggested that atopic diseases potentially increased the AF risk with the pooled HR of 1.26 (95%CI,1.14–1.39), while the pooled effect size (OR, 1.04; 95%CI,0.74–1.46) of 2 case-control studies was not statistically significant. Based on the types of atopic diseases, further subgroup analyses of 6 cohort studies revealed that asthma, allergic rhinitis, and atopic dermatitis all potentially increased the risk of subsequent AF with the pooled HR of 1.41 (n = 4; 95%CI, 1.25–1.58), 1.12 (n = 1; 95%CI,1.10–1.14) and 1.06 (n = 3; 95%CI, 1.01–1.12), respectively.

Conclusion

This meta-analysis demonstrated that patients with atopic diseases have a higher risk of developing AF, particularly those with asthma.

Iron-Deficiency in Atopic Diseases: Innate Immune Priming by Allergens and Siderophores

Although iron is one of the most abundant elements on earth, about a third of the world's population are affected by iron deficiency. Main drivers of iron deficiency are beside the chronic lack of dietary iron, a hampered uptake machinery as a result of immune activation. Macrophages are the principal cells distributing iron in the human body with their iron restriction skewing these cells to a more pro-inflammatory state. Consequently, iron deficiency has a pronounced impact on immune cells, favoring Th2-cell survival, immunoglobulin class switching and primes mast cells for degranulation. Iron deficiency during pregnancy increases the risk of atopic diseases in children, while both children and adults with allergy are more likely to have anemia. In contrast, an improved iron status seems to protect against allergy development. Here, the most important interconnections between iron metabolism and allergies, the effect of iron deprivation on distinct immune cell types, as well as the pathophysiology in atopic diseases are summarized. Although the main focus will be humans, we also compare them with innate defense and iron sequestration strategies of microbes, given, particularly, attention to catechol-siderophores. Similarly, the defense and nutritional strategies in plants with their inducible systemic acquired resistance by salicylic acid, which further leads to synthesis of flavonoids as well as pathogenesis-related proteins, will be elaborated as both are very important for understanding the etiology of allergic diseases. Many allergens, such as lipocalins and the pathogenesis-related proteins, are able to bind iron and either deprive or supply iron to immune cells. Thus, a locally induced iron deficiency will result in immune activation and allergic sensitization. However, the same proteins such as the whey protein beta-lactoglobulin can also transport this precious micronutrient to the host immune cells (holoBLG) and hinder their activation, promoting tolerance and protecting against allergy. Since 2019, several clinical trials have also been conducted in allergic subjects using holoBLG as a food for special medical purposes, leading to a reduction in the allergic symptom burden. Supplementation with nutrient-carrying lipocalin proteins can circumvent the mucosal block and nourish selectively immune cells, therefore representing a new dietary and causative approach to compensate for functional iron deficiency in allergy sufferers.