What can Europe learn from HCP knowledge and attitudes towards hepatitis A vaccination in the US?

Background

An estimated >100 million new hepatitis A (hepA) infections occur annually worldwide. Centres for disease control and prevention reported 38795 hepA cases in the US since 2016, and 4475 outbreak-confirmed cases in Europe between 2016-2018. HepA outbreaks resulted mainly from person-to-person contact, especially among homeless, illegal drug users (IDU) and men who have sex with men (MSM). In 2020, we surveyed US health care providers (HCPs) to understand their knowledge and attitudes towards hepA vaccination in these populations at higher risk of infection and complications.

Methods

This was a cross-sectional, web-based survey of 400 HCPs (primary care providers, nurse practitioners, gastroenterologists, internal medicine and infectious disease specialists [IDs], emergency room physicians [ERs]) who had recommended and/or administered hepA vaccines to ≥ 19-year-olds.

Results

85% of 371 HCPs reported recommending hepA vaccine to homeless, 87% of 393 to IDU and 83% of 397 to MSM, although vaccination may not actually occur after recommendation. Results varied by specialty, 16% fewer ERs than IDs reported recommending the vaccine in these at-risk populations. Moreover, 64%, 75% and 71% of all (400) HCPs reported extremely important that homeless, IDU and MSM, respectively, get vaccinated for hepA, while 6%, 7% and 8% of all HCPs reported this as slightly, or not important. Reasons for not recommending hepA vaccine to homeless, IDU and MSM included uncertainty on guidelines (reported by 22/56, 24/50 and 29/66 HCPs, respectively) and low risk of infection (reported by 20/56, 30/50 and 27/66 HCPs, respectively).

Conclusions

Despite recent hepA outbreaks and strengthened recommendations for vaccination in at-risk populations, knowledge gaps persist among US HCPs. This survey may motivate European countries to reinforce national hepA vaccination recommendations and, in parallel, consider efforts to raise vaccination awareness.

Funding

GlaxoSmithKline Biologicals SA

Key messages

Education on hepatitis A vaccination recommendations in at-risk populations is needed. Health care providers’ vaccination knowledge plays a critical role to control the hepatitis A outbreak in the US and preventing hepatitis A in Europe.

POS1060 A PROSPECTIVE, LONGITUDINAL STUDY TO EVALUATE REAL-WORLD PATIENT EXPERIENCES AND TREATMENT SATISFACTION WITH SECUKINUMAB FOR PSORIATIC ARTHRITIS

Background:

Psoriatic arthritis (PsA) is an inflammatory disease that impairs quality of life. Despite therapeutic advances, up to a third of patients do not respond or are unable to sustain a treatment response. Thus, data on patient treatment experience in PsA is critical.

Objectives:

To assess real-world experiences of patients with PsA treated with secukinumab.

Methods:

This is an ongoing 12-month, prospective, longitudinal, web-based survey study of patients with PsA initiating secukinumab. Patient demographics and medical history are collected at baseline using a rheumatologist case report form. Patient experience data are collected at baseline, 3, 6, 9, and 12 months by patient surveys. The primary endpoint is change in the Psoriatic Arthritis Impact of Disease 12-item questionnaire (PsAID12) from baseline to 3 months. In addition, this study will explore other changes at 3 months, including PsA symptoms, treatment satisfaction with secukinumab, and other patient-reported outcome measures. Baseline and available month 3 data from patients enrolled to date were analyzed descriptively.

Results:

Baseline demographic and medical history data were available for 72 patients; 32 (44.4%) were male, 59 (81.9%) were White, and 15 (20.8%) reported modifying their diet because of PsA. The mean (SD) time since symptom onset (n = 29) and since PsA diagnosis (n = 53) was 56.3 (45.6) and 34.4 (44.7) months, respectively. More than half of the patients who started treatment with secukinumab were biologic experienced (38/62; 61.3%). Primary and secondary loss of effectiveness were the main reasons for previous biologic discontinuation (Table 1). At 3 months (n = 49), the mean (SD) PsAID12 change from baseline was –1.8 (1.8) points. Additionally, 24.5% of patients reported their PsA symptoms to be “much better,” 40.8% reported “moderately better,” and 32.7% “a little better” compared with baseline; none reported “no change” or worsened symptoms. On a scale of 1-10, patients rated their overall satisfaction with secukinumab treatment at month 3 with a mean (SD) score of 6.8 (2.1). Patients were also highly satisfied with their symptom improvement, speed to symptom improvement, and the mode and frequency of secukinumab administration (Table 1).

Table 1.

Summary of Prior PsA Treatment and Treatment Satisfaction with Secukinumab at Month 3

Physician-reported treatment characteristicsBaseline measure(N = 62)Most recent PsA biologic prior to secukinumab, n (%)n = 31Adalimumab12 (38.7)Certolizumab pegol8 (25.8)Etanercept6 (19.4)Infliximab, including -dyyb3 (9.7)Golimumab1 (3.2)Unknown/not sure1 (3.2)Primary reasons for discontinuing previous PsA biologic treatment, n (%)an = 30Primary and secondary loss of effectiveness25 (83.3)Disease progression6 (20.0)Worsening of or new comorbidities1 (3.3)How the medication was taken2 (6.7)Adverse effects/intolerance4 (13.3)Otherb1 (3.3)Patient-reported treatment satisfaction with secukinumab, mean (SD)cMonth 3 (N = 49)Symptom improvement6.7 (2.3)Speed of symptom improvement6.9 (2.0)Dose frequency7.4 (1.9)cMethod of administration7.2 (1.5)Ease of use8.2 (1.5)Side effects, if any7.9 (1.9)Patient support services by manufacturer8.3 (1.7)

PsA, psoriatic arthritis.

a Rheumatologists may list > 1 reason. Data tabulated based on the number of case report forms received from rheumatologists at analysis cutoff (n = 30).

b Other reasons included availability of new treatment, patient request, or family history of disease.

c n = 48.

Conclusion:

Most patients were biologic experienced and reported primary or secondary loss of effectiveness as the main reason for discontinuation of their previous biologic. Patients reported overall symptom improvement and satisfaction with secukinumab treatment at 3 months after initiation.

Disclosure of Interests:

M Elaine Husni Consultant of: AbbVie, Amgen, Janssen, Novartis, Eli Lilly, UCB, and Regeneron, Michael Bozyczko Employee of: National Psoriasis Foundation, Daniel Wolin Employee of: RTI Health Solutions, Carolyn Sweeney Employee of: RTI Health Solutions, Eric Davenport Employee of: RTI Health Solutions, Steven Hass Employee of: Novartis, Esther Yi Employee of: Novartis, Peter Hur Employee of: Novartis, Linda Grinnell-Merrick Consultant of: AbbVie, Amgen (previously Celgene), Novartis, Pfizer, and Regeneron.

The Overseas Registration Examination of the General Dental Council

The Overseas Registration Examination is a route to entry to the UK Dentists Register for dentists who have qualified outside the European Economic Area. The role of the examination is to protect the public by ensuring that such dentists meet minimum standards of competence. Candidates invest considerable time and resource in attempting the examination. For these reasons it is essential that the examination is both robust and fair. This paper describes the fundamental principles of assessment underpinning the design of the examination and the steps taken by the General Dental Council's ORE Advisory Group to assure its ongoing quality.

Secukinumab demonstrates greater sustained improvements in daily activities and personal relationships than ustekinumab in patients with moderate-to-severe plaque psoriasis: 52-week results from the CLEAR study

Background

Psoriasis can greatly impact patients’ lives by influencing clothing worn as well as by impairing sexual functioning. Secukinumab, a human monoclonal antibody selectively neutralizing interleukin‐17A, has demonstrated good efficacy and safety in the treatment of moderate‐to‐severe psoriasis and psoriatic arthritis with a rapid onset of action and sustained response.

Objective

This analysis using the CLEAR study, a phase 3b double‐blind study comparing the efficacy and safety of secukinumab vs. ustekinumab in adults with moderate‐to‐severe plaque psoriasis, evaluated the treatment effects on patient's daily activities and personal relationships.

Methods

Impact on daily activities (interference with home/shopping/garden, and influence on clothes worn) and impact on personal relationships (problems with partner/others, and sexual difficulties) as well as their corresponding subscales were selected from the Dermatology Life Quality Index scale and evaluated for patients treated with secukinumab vs. ustekinumab from the CLEAR study. Treatment differences in mean scores and proportions of responders (score = 0, indicating no impact) were evaluated through 52 weeks. Time to response was evaluated through Week 16.

Results

Significant differences between secukinumab and ustekinumab were observed for daily activities and personal relationships at Week 16 and sustained through Week 52 (Week 52 response rates for daily activities: 82.9% vs. 73.5%, including interference with home/shopping/garden: 88.5% vs. 78.2%, and influence on clothes worn: 85.6% vs. 74.4%; personal relationships: 86.1% vs. 73.7%, including problems with partner/others: 86.6% vs. 74.8%, and sexual difficulties: 88.5% vs. 74.3%; all P < 0.01). The median time to response was 4 weeks for secukinumab vs. 8 weeks for ustekinumab for daily activities and personal relationships (both P < 0.05).

Conclusion

Secukinumab treatment helps patients with moderate‐to‐severe plaque psoriasis have a more normal life faster when compared to ustekinumab, by providing greater and sustained improvement in clothing choice and sexual functioning.

Assessment of trace elements and legacy contaminant concentrations in California mussels (Mytilus spp.): relationship to land use and outfalls

NOAA's Mussel Watch Program funded a regional pilot project in California that characterized contaminants associated with various land uses in conjunction with state, federal and private partners. Herein we assess the magnitude and distribution of trace elements and persistent organic contaminants in indigenous mussels with respect to land use, presence of outfalls and a subset of California Areas of Special Biological Significance (ASBS). We detected significant differences among the land use categories for the majority of trace elements and legacy contaminants measured. There was no significant difference between sites with and without outfalls. PCBs and PAHs were significantly lower in sites within ASBS boundary compared to other sites. The findings of this study will help fine tune future regional and national assessments as well as guide development of resource management and remediation activities and programs.

Cholecystectomy deferral in patients with endoscopic sphincterotomy

BACKGROUND

Cholecystectomy is not required in up to 64% of patients who adopt a wait-and-see policy after endoscopic clearance of common bile duct stones. Although reports of retrospective cohort series have shown a higher mortality among patients who defer cholecystectomy, it is not known if this is due to the patients' premorbid health status or due to the deferral of cholecystectomy. Randomised clinical trials of prophylactic cholecystectomy versus wait-and-see have not had sufficient power to demonstrate differences in survival.

OBJECTIVES

To evaluate the beneficial and harmful effects of cholecystectomy deferral (wait-and-see) versus elective (prophylactic) cholecystectomy in patients who have had an endoscopic biliary sphincterotomy.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Controlled Trials Register (CENTRAL) in The Cochrane Library, MEDLINE (1966 to 2007), EMBASE (1980 to 2007), and Science Citation Index Expanded without language restrictions until April 2007.

SELECTION CRITERIA

Randomised clinical trials comparing patients whose gallbladder was left in-situ after endoscopic sphincterotomy (wait-and-see group) versus patients who had cholecystectomy with either endoscopic sphincterotomy or common bile duct exploration (prophylactic cholecystectomy group), irrespective of blinding, language, or publication status.

DATA COLLECTION AND ANALYSIS

We assessed the impact of a wait-and-see policy on mortality. Secondary outcomes assessed were the incidence of biliary pain, cholangitis, pancreatitis, need for cholangiography, need for cholecystectomy, and the rate of difficult cholecystectomy. We pooled data using relative risk with fixed-effect and random-effects models.

MAIN RESULTS

We included 5 randomised trials with 662 participants out of 93 publications identified through the literature searches. The number of deaths was 47 in the wait-and-see group (334 patients) compared to 26 in the prophylactic cholecystectomy group (328 patients) for a 78% increased risk of mortality (RR 1.78, 95% CI 1.15 to 2.75, P = 0.010). The survival benefit of prophylactic cholecystectomy was independent of trial design, inclusion of high risk patients or inclusion of any one of the five trials. Patients in the wait-and-see group had higher rates of recurrent biliary pain (RR 14.56, 95% CI 4.95 to 42.78, P < 00001), jaundice or cholangitis (RR 2.53, 95% CI 1.09 to 5.87, P = 0.03), and of repeat ERCP or other forms of cholangiography (RR 2.36, 95% CI 1.29 to 4.32, P = 0.005). Cholecystectomy was eventually performed in 35% (115 patients) of the wait-and-see group.

AUTHORS' CONCLUSIONS

Prophylactic cholecystectomy should be offered to patients whose gallbladders remain in-situ after endoscopic sphincterotomy and common bile duct clearance.

Proteinase-activated receptor-2-mediated activation of stress-activated protein kinases and inhibitory kappa B kinases in NCTC 2544 keratinocytes

In this study we examined the regulation of the stress-activated protein (SAP) kinases and inhibitory kappa B kinases (IKKs) through stimulation of the novel G-protein-coupled receptor proteinase-activated receptor-2 in the human keratinocyte cell line NCTC2544. Trypsin and the peptide SLIGKV stimulated a time-dependent increase in both c-Jun N-terminal kinase and p38 mitogen-activated protein kinase activity. Trypsin also stimulated NF kappa B-DNA binding and the activation of the upstream kinases IKK alpha and -beta. Phorbol 12-myristate 13-acetate also strongly activated both SAP kinases and IKK isoforms, suggesting the potential for a protein kinase C-mediated regulatory mechanism underlying the effects of trypsin. Pre-incubation with selective protein kinase C (PKC) inhibitors GF109203X and Gö6983, or transfection of dominant negative (DN)-PKC alpha, abolished phorbol 12-myristate 13-acetate-mediated c-Jun N-terminal kinase activity, although it only partially inhibited the response to trypsin. In contrast, Gö6983 reduced trypsin-stimulated p38 mitogen-activated protein kinase activity to a greater extent than GF109203X, although DN-PKC alpha or PKC zeta had no substantial effect. Additionally, inhibitors of PKC partially reduced trypsin-stimulated IKK alpha activity but abolished that of IKK beta, whereas DN-PKC alpha but not DN-PKC zeta substantially reduced trypsin-stimulated Flag-IKK beta activity. This study shows for the first time proteinase-activated receptor-2-mediated stimulation of both SAP kinase and IKK signaling and differing roles for PKC isoforms in the regulation of each pathway.

The relationships between premilitary school record data and risk for posttraumatic stress disorder among Vietnam war veterans

The purpose of this study was to determine whether Vietnam veterans' risk for posttraumatic stress disorder (PTSD) was correlated with their premilitary school performance. The authors compared both primary and secondary school record data on hospitalized chemically dependent PTSD patients with those of both non-PTSD, chemically dependent and community controls. All participants were male Vietnam war combat veterans. The comparisons were made with MANCOVA analyses with the effects of combat and age differences between groups controlled. For the most part, primary-school grade point average, absenteeism, and tardiness data on three groups did not differ significantly. However, the mean secondary school grade points of the future PTSD patients were generally substantially lower than those of controls. Additionally, more secondary school absenteeism and tardiness were reported among future PTSD patients than in the controls. The groups did not differ significantly on number of extracurricular activities. Academic weakness, absenteeism, and tardiness in secondary school appear to be moderately strong predictors of vulnerability to PTSD after traumatization. It also supports the claim that chronic PTSD is, in part, the result of weaknesses present before exposure to trauma.

Measurement of moral development in medicine

The past two decades have been a time of heightened interest in the moral aspects of the practice of medicine. This interest has been reflected in medical education by the establishment of medical humanities programs in both preclinical and clinical education in many medical schools. It has also been reflected in the literature with a dramatic increase in journal articles on medical ethics as well as the development of medical ethics in textbooks. A number of journals have developed that are specifically devoted to medical ethics, including The Journal of Medical Ethics, The Journal of Medicine and Philosophy, The Journal of Medical Humanities, Theoretical Medicine, Cambridge Quarterly of Healthcare Ethics, just to name a few. The literature includes both theoretical foundations and conceptual analyses of particular issues as well as practical advice and general suggestions for how to implement programs in medical humanities.