Effects of online care on functional and psychological outcomes in patients with psoriasis: A randomized controlled trial

BACKGROUND

The impact of online care on patients' functional and psychological outcomes is critical to determine yet still unknown.

OBJECTIVE

To evaluate how a novel online health model that facilitates physician-patient collaboration compares with in-person care for improving functional status and mental health of patients with psoriasis.

METHODS

This 12-month randomized controlled equivalency trial randomly assigned patients with psoriasis 1:1 to receive online or in-person care. Functional impairment and depression were assessed at baseline and at 3-month intervals using the 5-level EuroQol-5 Dimensions index and Patient Health Questionnare-9.

RESULTS

Overall, 296 patients were randomly assigned to the online or in-person groups. The between-group difference in overall improvement in the EuroQol Visual Analogue Scale was -0.002 (95% confidence interval, -2.749 to 2.745), falling within an equivalence margin of ±8. The between-group difference in overall improvement in the 5-level EuroQol-5 Dimensions index was 0 (95% confidence interval, -0.003 to 0.003), falling within an equivalence margin of ±0.1. The between-group difference in overall improvement in Patient Health Questionnare-9 score was -0.33 (95% CI, -1.20 to 0.55), falling within an equivalence margin of ±3.

LIMITATIONS

Slightly different attrition rates between online and in-person arms (11% vs 9%), but no impact on outcomes.

CONCLUSION

The online health model was equivalent to in-person care for reducing functional impairment and depressive symptoms in patients with psoriasis.

Dietary Recommendations for Adults With Psoriasis or Psoriatic Arthritis From the Medical Board of the National Psoriasis Foundation: A Systematic Review

Importance

Psoriasis is a chronic, inflammatory skin disease and has significant associated morbidity and effect on quality of life. It is important to determine whether dietary interventions help reduce disease severity in patients with psoriatic diseases.

Objective

To make evidence-based dietary recommendations for adults with psoriasis and/or psoriatic arthritis from the Medical Board of the National Psoriasis Foundation.

Evidence Review

We used literature from prior systematic reviews as well as additional primary literature from the MEDLINE database from January 1, 2014, to August 31, 2017, that evaluated the impact of diet on psoriasis. We included observational and interventional studies of patients with psoriasis or psoriatic arthritis. The quality of included studies was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Risk of Bias Tool for interventional studies. We made evidence-based dietary recommendations, which were voted on by the National Psoriasis Foundation Medical Board.

Findings

We identified 55 studies meeting the inclusion criteria for this review. These studies represent 77 557 unique participants of which 4534 have psoriasis. Based on the literature, we strongly recommend dietary weight reduction with a hypocaloric diet in overweight and obese patients with psoriasis. We weakly recommend a gluten-free diet only in patients who test positive for serologic markers of gluten sensitivity. Based on low-quality data, select foods, nutrients, and dietary patterns may affect psoriasis. For patients with psoriatic arthritis, we weakly recommend vitamin D supplementation and dietary weight reduction with a hypocaloric diet in overweight and obese patients. Dietary interventions should always be used in conjunction with standard medical therapies for psoriasis and psoriatic arthritis.

Conclusions and Relevance

Adults with psoriasis and/or psoriatic arthritis can supplement their standard medical therapies with dietary interventions to reduce disease severity. These dietary recommendations from the National Psoriasis Foundation Medical Board will help guide clinicians regarding the utility of dietary interventions in adults with psoriatic diseases.

Access to Dermatological Care with an Innovative Online Model for Psoriasis Management: Results from a Randomized Controlled Trial

Background:Many patients with chronic skin diseases lack regular access to dermatologists in the United States and suffer poor clinical outcomes.Introduction:We performed a 12-month randomized controlled trial to evaluate the impact of an online, collaborative connected health (CCH) model for psoriasis management on access to specialty care.Materials and Methods:The 300 enrolled patients were randomized to online or in-person care. We compared distance traveled as well as transportation and in-office waiting time between the two groups and obtained patient and provider perspectives on CCH.Results:At baseline, no differences existed between the groups in difficulties obtaining specialty care. Over 12 months, the mean (standard deviation [SD]) distance traveled to and from appointments was 174.8 (±577.4) km/person for the in-person group and 2.2 (±14.2) km/person for the online group (p = 0.0003). The mean (SD) time spent on transportation and in-office waiting for in-person appointments was 4.0 (±4.5) h/person for the in-person group and 0.1 (±0.4) h/person for the online group (p = 0.0001). Patients found CCH to be safe, accessible, equitable, efficient, effective, and patient-centered. Providers found CCH to be useful for providing psoriasis care.Discussion:The CCH model resulted in significantly less distance traveled as well as transportation and in-office waiting time compared to in-person care. Both patients and providers were highly satisfied with CCH.Conclusions:The CCH model resulted in increased access to specialty care and enabled patient-centered, safe, and effective management of psoriasis patients.

GRAPPA Trainees Symposium 2018: A Report from the GRAPPA 2018 Annual Meeting

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) held a trainee symposium at its 2018 annual meeting in Toronto, Ontario, Canada. Rheumatology and dermatology trainees engaged in psoriasis or psoriatic arthritis research presented their work. This report briefly reviews 5 oral presentations and 21 posters presented at the meeting.

Socially Assistive Robots for Helping Pediatric Distress and Pain: A Review of Current Evidence and Recommendations for Future Research and Practice

OBJECTIVES

Interacting with socially assistive robots (SAR) has been shown to influence human behaviors and emotions. This study sought to review the literature on SAR intervention for reducing pediatric distress and pain in medical settings.

METHODS

Databases (PubMed, Cochrane Library, CINAHL, PsycINFO, ERIC, Web of Science, Engineering Village, Scopus, Google Scholar, IEEE Xplore) were searched from database inception to January 2018 with the aid of a medical librarian. Included studies examined any SAR intervention for reducing pain or improving emotional well-being in children related to physical or psychiatric care, with outcomes assessed by some quantitative measure. Study quality was assessed using the modified Downs and Black checklist (max. score, 28). The review is registered in PROSPERO (CRD42016043018).

RESULTS

Eight studies met the eligibility criteria and represented 206 children. Of the 2 studies using Wong-Baker's FACES scale, 1 study claimed to be effective at reducing pain (Cohen d=0.49 to 0.62), while the other appeared effective only when parents and child interacted with SAR together. Distress was evaluated using validated measures in 4 studies, 3 of which showed reduction in distress while one showed no difference. Satisfaction surveys from 4 studies showed that children were interested in using SAR again. Quality scores ranged from 8 to 26.

CONCLUSIONS

There is limited evidence suggesting that SAR interventions may reduce distress and no clear evidence showing reduction in pain for children in medical settings. Engineers are conducting interventions using SAR in pediatric populations. Health care providers should be engaged in technology research related to children to facilitate testing and improve the effectiveness of these systems.

Effectiveness of Online vs In-Person Care for Adults With Psoriasis: A Randomized Clinical Trial

IMPORTANCE

Innovative, online models of specialty-care delivery are critical to improving patient access and outcomes.

OBJECTIVE

To determine whether an online, collaborative connected-health model results in equivalent clinical improvements in psoriasis compared with in-person care.

DESIGN, SETTING, AND PARTICIPANTS

The Patient-Centered Outcomes Research Institute Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to evaluate the effect of an online model for psoriasis compared with in-person care. Participant recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California, and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a primary care physician. Analyses were on an intention-to-treat basis.

INTERVENTIONS

Participants were randomized 1:1 to receive online or in-person care (148 randomized to online care and 148 randomized to in-person care). The online model enabled patients and primary care physicians to access dermatologists online asynchronously. The dermatologists provided assessments, recommendations, education, and prescriptions online. The in-person group sought care in person. The frequency of online or in-person visits was determined by medical necessity. All participants were exposed to their respective interventions for 12 months.

MAIN OUTCOMES AND MEASURES

The prespecified primary outcome was the difference in improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the online and in-person groups. Prespecified secondary outcomes included body surface area (BSA) affected by psoriasis and the patient global assessment score.

RESULTS

Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person groups in the mean change in the self-administered PASI score during the 12-month study period was -0.27 (95% CI, -0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis between the 2 groups was -0.05% (95% CI, -1.58% to 1.48%). Between-group differences in the PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence between the 2 interventions. The difference in the mean change in the patient global assessment score between the 2 groups was -0.11 (95% CI, -0.32 to 0.10), which exceeded the equivalence margin, with the online group displaying greater improvement.

CONCLUSIONS AND RELEVANCE

The online, collaborative connected-health model was as effective as in-person management in improving clinical outcomes among patients with psoriasis. Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be transformative to improving patient-centered outcomes in chronic diseases.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02358135.

Techniques for studying the pharmacodynamic effects of cardiac glycosides on patients' own erythrocytes during glycoside therapy

We have measured the effects of digoxin on the cation transport mechanisms of patients' erythrocytes during treatment with digoxin for atrial fibrillation and cardiac failure in sinus rhythm. The results show that during short-term treatment with digoxin there is occupation of erythrocytic cardiac glycoside receptors by digoxin with resultant inhibition of active cation transport. These effects correlate well with the patients' clinical responses to treatment. During long-term treatment, however, these effects are not seen, suggesting that there is pharmacological tolerance to the effects of digoxin. The clinical implications of these results are discussed.

The acute changes seen in cardiac glycoside receptor sites, 86rubidium uptake and intracellular sodium concentrations in the erythrocytes of patients during the early phases of digoxin therapy are not found during chronic therapy: pharmacological and therapeutic implications for chronic digoxin therapy

1 Measurements of the binding of 12-alpha-[3H]-digoxin to the membranes of intact erythrocytes, erythrocyte 86rubidium uptake and intraerythrocytic sodium concentrations have been made in the red cells of various groups of patients--those who have not received digoxin, those during the early phases of treatment, those during chronic (greater than 2 months) treatment, and those toxic. 2 The values of those measurements in the patients in the early phases of therapy and in the toxic patients differed significantly from those of the untreated patients. 3 However, the values in the chronically treated patients were not different from those of the untreated patients. 4 The results suggest that the biochemical pharmacological effects of digoxin which occur during the early phases of therapy do not persist in the long-term. 5 The possible clinical significance of these observations is discussed.

The characteristics of the binding of 12-alpha-[3H]-digoxin to the membranes of intact human erythrocytes: relevance to digoxin therapy

1 The characteristics of the binding of 12-alpha-[3H]-digoxin to the membranes of intact human erythrocytes are described. 2 Only one class of binding site can be demonstrated. Binding is time- and temperature-dependent, saturable and slowly reversible; it is inhibited by other cardiac glycosides and by potassium. 3 Pre-incubation with unlabelled digoxin reduces the subsequent binding of 12-alpha-[3H]-digoxin in stoichiometric fashion. 4 The possible application of the measurement of the binding of 12-alpha-[3H]-digoxin to the study of biochemical pharmacological events occurring during digoxin therapy is discussed.

Changes in cardiac glycoside receptor sites, 86rubidium uptake and intracellular sodium concentrations in the erythrocytes of patients receiving digoxin during the early phases of treatment of cardiac failure in regular rhythm and of atrial fibrillation

1 Measurements of the binding of 12-alpha-[3H]-digoxin to the membranes of intact erythrocytes, erythrocytic 86rubidium uptake and intraerythrocytic sodium concentrations have been made in the red cells of patients receiving digoxin in the short-term for atrial fibrillation or cardiac failure in regular rhythm. 2 During the first few days of treatment [3H]-digoxin binding and 86rubidium uptake fall and intraerythrocytic sodium concentrations rise. 3 Subsequently parallel fluctuations occur in [3H]-digoxin binding and 86rubidium uptake but not in intraerythrocytic sodium concentrations and the significance of the fluctuations is discussed. 4 The values of all three measurements correlate significantly with the response of the heart in sinus rhythm as measured by QS2I. 5 Plasma digoxin concentrations do not correlate with QS2I.

Improvement of renal failure due to membranous glomerulonephritis after unsuccessful renal transplantation

Membranous glomerulonephritis is not usually considered to be responsive to steroid or cytotoxic therapy. This report describes a patient with advanced renal failure who responded to treatment with prednisolone and azathioprine, initially given as immunosuppression for a renal graft which did not function.