The effects of systemic immunomodulatory treatments on COVID-19 outcomes in patients with atopic dermatitis: Results from the global SECURE-AD registry

BACKGROUND

Limited data are available on the effects of systemic immunomodulatory treatments on COVID-19 outcomes in patients with atopic dermatitis (AD).

OBJECTIVE

To investigate COVID-19 outcomes in patients with AD treated with or without systemic immunomodulatory treatments, using a global registry platform.

METHODS

Clinicians were encouraged to report cases of COVID-19 in their patients with AD in the Surveillance Epidemiology of Coronavirus Under Research Exclusion for Atopic Dermatitis (SECURE-AD) registry. Data entered from 1 April 2020 to 31 October 2021 were analysed using multivariable logistic regression. The primary outcome was hospitalization from COVID-19, according to AD treatment groups.

RESULTS

442 AD patients (mean age 35.9 years, 51.8% male) from 27 countries with strongly suspected or confirmed COVID-19 were included in analyses. 428 (96.8%) patients were treated with a single systemic therapy (n = 297 [67.2%]) or topical therapy only (n = 131 [29.6%]). Most patients treated with systemic therapies received dupilumab (n = 216). Fourteen patients (3.2%) received a combination of systemic therapies. Twenty-six patients (5.9%) were hospitalized. No deaths were reported. Patients treated with topical treatments had significantly higher odds of hospitalization, compared with those treated with dupilumab monotherapy (odds ratio (OR) 4.65 [95%CI 1.71-14.78]), including after adjustment for confounding variables (adjusted OR (aOR) 4.99 [95%CI 1.4-20.84]). Combination systemic therapy which did not include systemic corticosteroids was associated with increased odds of hospitalization, compared with single agent non-steroidal immunosuppressive systemic treatment (OR 8.09 [95%CI 0.4-59.96], aOR 37.57 [95%CI 1.05-871.11]). Hospitalization was most likely in patients treated with combination systemic therapy which included systemic corticosteroids (OR 40.43 [95%CI 8.16-207.49], aOR 45.75 [95%CI 4.54-616.22]).

CONCLUSIONS

Overall, the risk of COVID-19 complications appears low in patients with AD, even when treated with systemic immunomodulatory agents. Dupilumab monotherapy was associated with lower hospitalization than other therapies. Combination systemic treatment, particularly combinations including systemic corticosteroids, was associated with the highest risk of severe COVID-19.

Feasibility of a school-based exercise intervention for children with intellectual disability to reduce cardio-metabolic risk

BACKGROUND

People with intellectual disabilities (ID) are at increased risk of secondary health conditions, reduced quality of life and life expectancy. Children with ID demonstrate low levels of physical activity in association with a higher prevalence of obesity, a modifiable risk factor associated with secondary health conditions including type 2 diabetes and cardiovascular disease. Despite this, physical activity interventions addressing weight and weight-related complications in this population are limited. This study aimed to establish the feasibility of a school-based group exercise intervention for children with moderate to severe ID.

METHODS

A single-arm intervention study was used to establish the feasibility of a 16-week exercise intervention. Children attending a School for Specific Purposes in Sydney, Australia, participated in two 30-min exercise sessions per week across the intervention period in addition to their regular physical education class. Each exercise session was 60% aerobically based, 20% strength based and 20% targeted towards fundamental movement skill development. We used two facilitation strategies to assist the delivery of the intervention, including the implementation of a variety of communication resources and promotion of social interaction. Feasibility was assessed through recruitment rates, program retention, adverse effects, attendance, group size feasibility and non-compliance. Anthropometric measures included height (m), weight (kg) and waist circumference (cm; umbilicus), with body mass index (BMI) and waist-to-height ratios (WtHR) used to determine cardio-metabolic risk. Aerobic capacity was assessed using the submaximal 6-min walk test (6-MWT). Intensity of physical activity sessions was measured through the use of tri-axial accelerometers and compared to physical activity recommendations.

RESULTS

Ten children aged between 9 and 13 years completed the 16-week intervention, with a 55% recruitment rate, 91% program retention, 86% attendance and with no adverse effects reported. Sessions commenced as 1:1 supervisor to child ratios before progressing to established small groups of 2:7 (supervisor : child). Children spent 38.4% (11.5 min) of each session in moderate to vigorous physical activity (MVPA), equating to 20% of their MVPA recommended daily physical activity levels (twice per week). There was a significant change in weight across the intervention period, with a trend towards increased weight between mid-intervention and 3-month follow-up time points. There were no significant changes in child BMI, WtHR or aerobic capacity.

CONCLUSIONS

A school-based group exercise intervention for children with moderate to severe ID is feasible and safe, with high retention rates and physical activity participation. No significant improvements in body composition or aerobic capacity were determined. The present study demonstrates that engaging children with moderate-severe ID in school-based group exercise is feasible to assist in physical activity participation.

Delays in the diagnosis and treatment of bone and joint tuberculosis in the United Kingdom

Aims

Tuberculosis (TB) infection of bones and joints accounts for 6.7% of TB cases in England, and is associated with significant morbidity and disability. Public Health England reports that patients with TB experience delays in diagnosis and treatment. Our aims were to determine the demographics, presentation and investigation of patients with a TB infection of bones and joints, to help doctors assessing potential cases and to identify avoidable delays.

Patients and Methods

This was a retrospective observational study of all adults with positive TB cultures on specimens taken at a tertiary orthopaedic centre between June 2012 and May 2014. A laboratory information system search identified the patients. The demographics, clinical presentation, radiology, histopathology and key clinical dates were obtained from medical records.

Results

A total of 31 adult patients were identified. Their median age was 37 years (interquartile range (IQR): 29 to 53); 21 (68%) were male; 89% were migrants. The main sites affected were joints (10, 32%), the spine (8, 26%) and long bones (6, 19%); 8 (26%) had multifocal disease. The most common presenting symptoms were pain (29/31, 94%) and swelling (26/28, 93%). ‘Typical’ symptoms of TB, such as fever, sweats and weight loss, were uncommon. Patients waited a median of seven months (IQR 3 to 13.5) between the onset of symptoms and referral to the tertiary centre and 2.3 months (IQR 1.6 to 3.4.)) between referral and starting treatment. Radiology suggested TB in 26 (84%), but in seven patients (23%) the initial biopsy specimens were not sent for mycobacterial culture, necessitating a second biopsy. Rapid Polymerase Chain Reaction-based testing for TB using Xpert MTB/RIF was performed in five patients; 4 (80%) tested positive for TB. These patients had a reduced time between the diagnostic biopsy and starting treatment than those whose samples were not tested (median eight days versus 36 days, p = 0.016).

Conclusion

Patients with bone and joint TB experience delays in diagnosis and treatment, some of which are avoidable. Maintaining a high index of clinical suspicion and sending specimens for mycobacterial culture are crucial to avoid missing cases. Rapid diagnostic tests reduce delays and should be performed on patients with radiological features of TB. Cite this article: Bone Joint J 2018;100-B:119–24.

Prophylaxis in real life scenarios

Prophylaxis has become the standard mantra of care for those individuals with severe haemophilia A and B. Primary prophylaxis is advocated to prevent the occurrence of symptomatic acute spontaneous haemarthroses and to preserve joint structure and function. Typically, twice or thrice weekly infusions of factor VIII or IX concentrates are integral to this treatment approach. Secondary prophylaxis is initiated after the relentless cycle of progressive joint damage has been triggered by prior haemarthroses and is intended to preserve existing joint health by preventing additional spontaneous bleeding events. Event-driven prophylaxis involves the administration of clotting factor concentrates to prevent acute traumatic bleeds, which are anticipated to occur in association with surgical or physical trauma. This regimen enhances the effectiveness of primary or secondary prophylaxis protocols or on-demand approaches to replacement therapy. Besides the marked reduction in the so-called annual bleed rate, prophylaxis regimens frequently increase personal self-confidence to embark on a more active and physical lifestyle; however, in reality, prophylaxis must be individualized in accordance with bleeding phenotypes, with the unique pharmacokinetic profile of administered replacement clotting factor concentrates, with the specific clinical scenario, and with the degree of intensity anticipated for any physical activity. The introduction of extended half-life replacement products will also influence how these prophylaxis regimens will be accomplished. The following scenarios will discuss how prophylaxis regimens can be implemented to protect the individual from developing spontaneous and activity-induced acute bleeding complications and to maintain an improved quality of life.

Stable rAAV-mediated transduction of rod and cone photoreceptors in the canine retina

Recombinant adeno-associated virus (rAAV) vectors are attractive candidates for the treatment of inherited and acquired retinal disease. Although rAAV vectors are well characterized in rodent models, a prerequisite to their clinical application in human patients is the thorough evaluation of their efficacy and safety in intermediate animal models. In this study, we describe rAAV-2-mediated expression of GFP reporter gene in retinal cells following local vector delivery in dogs. Subretinal delivery of rAAV.CMV.GFP was performed unilaterally in eight normal dogs from 6 weeks of age. The area of retinal transduction was maximized by the optimization of surgical techniques for subretinal vector delivery by pars-plana vitrectomy and the use of fine-gauge subretinal cannulae to create multiple retinotomies. rAAV-2 vectors mediated efficient stable reporter gene expression in photoreceptors and retinal pigment epithelial cells. We found efficient transduction of cone photoreceptors in addition to rods in both the canine retina and after subretinal vector delivery in another intermediate animal model, the feline retina. GFP expression in dogs was confined to the area of the retinal bleb and was sustained in cells at this site for at least 18 months. Electroretinography demonstrated a modest reduction in global rod-mediated retinal function following subretinal delivery of rAAV.CMV.GFP. Three of the eight animals developed delayed-onset intraocular inflammation, in two cases associated with a serum antibody response to GFP protein. We conclude that rAAV-2 vectors mediate efficient sustained transgene expression in rod and cone photoreceptors following subretinal delivery in this intermediate animal model. The possibility of adverse effects including intraocular immune responses and reduced retinal function requires further investigation prior to clinical applications in patients.

Distribution of OX2 antigen and OX2 receptor within retina

PURPOSE

OX2 is a member of the immunoglobulin superfamily expressed on a broad range of tissues including neurons of the central and peripheral nervous systems, thymocytes, and endothelium. The recently identified OX2 receptor (OX2R) is restricted to the surfaces of myeloid lineage cells, including microglia. Functional data have implicated the OX2-OX2R interaction as a myeloid downregulatory signal. The purpose of this study was to determine the distribution and extent of expression of OX2 and its receptor within the retina, a tissue developed to restrain immune-mediated inflammatory damage.

METHODS

OX2 and OX2R monoclonal antibodies (mAbs) were used to determine OX2 and OX2R protein expression, respectively, by flow cytometry of isolated myeloid-derived cells from normal and inflamed rat retina and by immunohistochemistry of serial sections of rat retina. For comparison, distribution of OX2 was documented using species-specific monoclonal antibodies in mouse and human retina. No OX2R mAbs are available for mouse or human detection.

RESULTS

OX2 was expressed on retinal vascular endothelium and glial fibrillary acidic protein (GFAP)-negative neurons in retina and optic nerve and on a subpopulation of CD45(+) perivascular and juxtavascular cells. Within normal retina, OX2R was not detected on myeloid-derived cells. During experimental autoimmune uveoretinitis (EAU), expression of both OX2 and OX2R was noted on infiltrating leukocytes.

CONCLUSIONS

Taking these results of the distribution of OX2 in normal and OX2R in inflamed retina with other functional data of OX2-OX2R interaction, it is suggested that the OX2-OX2R interaction has the potential to contribute to a novel pathway that suppresses and limits immunologic inflammatory damage within the retina.

IFN-gamma and LPS-mediated IL-10-dependent suppression of retinal microglial activation

PURPOSE

Human retinal microglia (MG) express constitutively major histocompatability complex (MHC) class II molecules and have thus been highlighted as potential immunocompetent antigen-presenting cells (APCs). This study was undertaken to characterize microglial expression of coaccessory molecules and the functional changes in antigen expression, cytokine production, migration, and phagocytosis after proinflammatory stimulation.

METHODS

Fresh donor retinal MG were obtained and isolated using a percoll density gradient technique. Phenotypic characteristics used for isolating rodent microglia were applied and modified. Coaccessory molecule expression and intracellular cytokine production were assessed using three-color flow cytometric analysis in both freshly isolated and interferon (IFN)gamma-lipopolysaccharide (LPS)-stimulated MG. Using five-millimeter retinal explants in culture, microglial migratory behavior, changes in cell surface antigen expression and phagocytic activity were documented.

RESULTS

MG could be clearly defined by the flow cytometric phenotype CD45low CD11b+ MHC class II+ CD86low CD40low. Freshly isolated MG showed mannose receptor-mediated uptake of dextran-FITC. MG migrated from explants, were adherent, and upregulated MHC class II expression. After IFNgamma-LPS stimulation of single-cell suspension of MG isolates, MHC class II expression was reduced, with an increase occurring in MG intracellular interleukin (IL)-10 and IL-10 production. Microglial migration from explants was reduced after IFNgamma-LPS stimulation.

CONCLUSIONS

These results highlight both phenotypic and behavioral characteristics that support an antigen-processing and -presenting capability of freshly isolated MG. However, proinflammatory stimulation with IFNgamma-LPS induces an IL-10-mediated downregulation of cell surface antigen expression and loss of migratory and phagocytic activity. Therefore, although equipped to act as APCs, MG are able to rapidly modulate their own function and behavior and as a result may have the potential to limit inflammation.

Fas-Fas ligand-mediated apoptosis within aqueous during idiopathic acute anterior uveitis

PURPOSE

Despite ocular immune privilege, (auto)immune-mediated acute anterior uveitis (AAU) is relatively common. However, although relapses of AAU are usually self-limiting, possible regulatory mechanisms remain undefined in humans. Experimentally, Fas-Ligand (FasL)-mediated apoptosis of Fas+ inflammatory cells contributes to the immune privilege within the anterior chamber and provides an explanation for the success of corneal allograft transplantation. Therefore, whether such mechanisms regulate the immune response in AAU was investigated.

METHODS

Aqueous and peripheral blood samples from consecutive patients presenting with idiopathic AAU were obtained with consent. Leukocytic phenotype was analyzed by flow cytometry, and apoptosis was determined by both flow cytometry and TdT-dUTP terminal nick-end labeling analysis. Presence of soluble Fas and FasL was determined by western blot analysis and enzyme-linked immunosorbent assay and compared with control aqueous from patients undergoing cataract surgery. The ability of the aqueous to induce apoptosis in a Fas+ Jurkat cell line was also determined.

RESULTS

During AAU aqueous-infiltrating Fas+ cells included CD3+ T cells and granulocytes, whereas FasL+ cells comprised predominantly of non-CD3+ T cells. Higher levels of functional soluble FasL were found in aqueous of AAU patients than in normal aqueous, capable of inducing apoptosis in 68.9% +/- 7.6% of Fas+ lymphoid cells. Compared with peripheral blood, the CD4+ T cells infiltrate within aqueous showed significantly increased CD69 and CD25(IL-2r) expression. Flow cytometric analysis of aqueous showed that 9.32% +/- 1.2% of infiltrating non-granulocyte CD45+ cells were apoptotic, confirmed as T cells on subsequent three-color flow cytometric analysis.

CONCLUSIONS

Taken together with published experimental data, the present study provides evidence for FasL-mediated apoptotic cell death contributing to the local immune regulation of ocular inflammatory disease and provides a mechanism to account for the self-limiting clinical course of AAU.

Instrument performance in bone density testing at five Australian centres

AIMS

To assess the in vitro precision and accuracy of bone mineral densitometry (BMD) within and between locations at five Australian centres.

METHODS

Using a multicentre reliability study the accuracy and short- and long-term precision of dual-energy X-ray absorptiometry (DXA) in vitro was compared on five instruments. Measures were performed using pencil beam mode on four Hologic QDR-2000 densitometers and one Hologic QDR-1000/W (Hologic Inc, Waltham, MA).

RESULTS

Short-term precision of bone mineral density measurement was less than 0.5% for spine phantoms (n = 10 for each centre, mean intrasite coefficient of variation [CV] 0.39 +/- 0.09% [SD]) and for hip phantoms (n = 10 for each centre, mean intrasite coefficient of variation [CV] 0.34 +/- 0.10% [SD]). Between-centre measurement (n = 10 for each phantom) of a single spine phantom and a single hip phantom (specified mineral contents-58.5 g and 38.6 g, respectively) revealed ranges of bone mineral content of 57.7-58.1 g (all-point CV = 0.52%) and 37.1-37.8 g (all-point CV = 0.70%), respectively. When results from pairs of machines were compared there were statistically different mean BMD results for the majority of the ten possible pairings for both spine and hip measurements. Each study centre measured in vitro stability of phantom BMD measurements over a one year period (n = 45-283, median 157 for spine; and n = 0-262, median 38, for hip); CVs ranged from 0.38 to 0.53% for the spine measurements and from 0.38 to 0.54% for the hip measurements. The mean all-point accuracy of the spine phantom measurements was 99.1% and the hip phantom measurements was 96.7%.

CONCLUSIONS

Across a number of instruments DXA demonstrates in vitro all-point precision of 0.5% for the spine phantom and 0.7% for the hip phantom. The instrument demonstrates accuracy of greater than 99% at the spine and 96% at the hip. This finding has clinical, research and quality control implications.

Effect of colony-stimulating factors on number and function of circulating monocytes in normal dogs

Recombinant human granulocyte-macrophage colony-stimulating factor (rhuGM-CSF) and recombinant canine granulocyte colony-stimulating factor (rcG-CSF) were administered to normal dogs, and effect on monocyte number and function was evaluated. rhuGM-CSF, administered for 14 days, induced a 2.5-fold increase in monocyte counts on day 3. Leukocytes increased two-fold after 1 day. Counts peaked on day 11, then declined, approaching pretreatment counts by day 15. On day 7, in vivo monocyte cytostasis activity was significantly enhanced, and declined on day 14. rcG-CSF induced a 4.5-fold increase in monocyte counts on day 3. Leukocyte counts increased three-fold after 1 day. Increased counts were maintained for 69 days, at which time treatment was discontinued. There was no effect of rcG-CSF on in vivo monocyte cytostasis activity on days 7 and 14.