Effect of upadacitinib on atopic hand eczema in patients with moderate-to-severe atopic dermatitis: Results from two randomized phase 3 trials

BACKGROUND

Approximately 60% of patients with atopic dermatitis have involvement of the hands adding to the burden of disease.

OBJECTIVE

This analysis aims to evaluate the effect of upadacitinib monotherapy on atopic hand eczema in patients with moderate-to-severe AD over 16 weeks in the Measure Up 1 and 2 studies.

METHODS

Data from patients (ages 12-75) randomized 1:1:1 to receive upadacitinib 15 mg, 30 mg, or placebo once daily in the Measure Up 1 and 2 studies were analysed for impact on atopic hand eczema assessed using the Hand Eczema Severity Index (HECSI). The percent change from baseline in HECSI score was a prespecified additional endpoint at all visits. The proportion of patients with at least a 75% improvement in HECSI score (HECSI 75) was evaluated post hoc.

RESULTS

Patients treated with upadacitinib 15 mg or 30 mg experienced greater improvement in HECSI score compared with placebo as early as Week 1, which was maintained through Week 16. At Week 16, the mean change from baseline in HECSI score for patients receiving upadacitinib 15 mg, 30 mg, and placebo was -68%, -74%, and -15% in Measure Up 1 and -68%, -74% and +21% (positive change indicates worsening for placebo) in Measure Up 2, respectively. A greater proportion of upadacitinib-treated patients achieved HECSI 75 compared with placebo at all timepoints beginning at Week 1 through Week 16.

CONCLUSIONS

Upadacitinib 15 mg and 30 mg monotherapy provided rapid and sustained improvement in atopic hand eczema compared with placebo through Week 16 in patients with moderate-to-severe AD. At Week 16, the observed mean improvements in HECSI score in upadacitinib-treated patients were clinically meaningful based on previous interpretability studies. These results suggest that upadacitinib may be an effective treatment option for atopic hand eczema in patients with moderate-to-severe AD.

Cardiovascular disease in women: A review of spontaneous coronary artery dissection

Research has demonstrated the disproportionate quality of care for women with cardiovascular disease. These findings have prompted a renewed focus on cardiovascular disease awareness and disease prevention in women. Spontaneous coronary artery dissection (SCAD) is a significant cause of myocardial infarction (MI) and sudden death that primarily affects women. ongoing research has led to improved diagnostic capabilities and changes in approaches to initial and long-term management most importantly this research has provided evidence that SCAD is more common than previously thought and must be evaluated and treated differently from atherosclerotic MI. The difference between SCAD and atherosclerotic MI is highlighted in high rates of recurrent disease, gender distribution, association with exogenous hormones, pregnancy, migraine, physical and emotional stress triggers, concurrent systemic arteriopathies, and connective tissue disease. In this review, we provide updated insights and a summary of the epidemiology, risk factors, clinical presentation, diagnosis, treatment options, prognosis, and recurrence prevention of SCAD. We aim to provide a review of SCAD as a focus on cardiovascular disease awareness and disease prevention in women.

Clinical presentation and management of myocardial infarction with nonobstructive coronary arteries (MINOCA): A literature review

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA), as the name implies, is an acute myocardial infarction (MI) in the absence of significant coronary artery obstruction. Diagnosis and management of such cases have been challenging. There are many etiologies of MINOCA including coronary artery spasm, coronary microvascular dysfunction, plaque disruption, spontaneous coronary thrombosis or emboli, spontaneous coronary artery dissection, or cardiomyopathies. In this paper, the pathophysiology, diagnostic work-up, and clinical management for each subtype are described, and an overarching approach on how to evaluate and manage a patient presenting with MINOCA.

Secukinumab shows high and sustained efficacy in nail psoriasis: 2.5-year results from the randomized placebo-controlled TRANSFIGURE study

BACKGROUND

Secukinumab, a fully human monoclonal antibody that selectively neutralizes interleukin-17A, a cornerstone cytokine in psoriasis, has shown long-lasting efficacy and safety in the complete spectrum of psoriasis manifestations.

OBJECTIVES

To report the long-term (2·5-year) efficacy and safety of secukinumab in nail psoriasis.

METHODS

TRANSFIGURE, a double-blind, randomized, placebo-controlled, parallel-group, multicentre phase IIIb study in 198 patients, investigated secukinumab 150 mg and 300 mg in patients with moderate-to-severe nail psoriasis.

RESULTS

At week 16, the primary endpoint Nail Psoriasis Severity Index (NAPSI) was met, demonstrating superiority of secukinumab to placebo. The effect was sustained over 2·5 years with a large benefit for nail clearance, with mean NAPSI improvement of -73·3% and -63·6% with secukinumab 300 mg and 150 mg, respectively. At 2·5 years, secukinumab demonstrated sustained clinically significant reductions in total mean Nail Assessment in Psoriasis and Psoriatic Arthritis (NAPPA) quality-of-life (QoL) scores of -52·4% and -18·1%, and 70% and 71% of patients achieved a weighted NAPPA Patient Benefit Index global score of ≥ 2 with secukinumab 300 mg and 150 mg, respectively. Patients showed considerable improvements in the EuroQol 5-Dimension health status questionnaire at 2·5 years, reporting a decrease in pain and discomfort. No new safety findings were observed.

CONCLUSIONS

Secukinumab demonstrated strong and clinically meaningful efficacy for up to 2·5 years in nail psoriasis, with significant sustained QoL improvements and a favourable safety profile.

Secukinumab administration by autoinjector maintains reduction of plaque psoriasis severity over 52 weeks: results of the randomized controlled JUNCTURE trial

BACKGROUND

User satisfaction is an important factor associated with treatment adherence in chronic diseases including moderate-to-severe psoriasis.

OBJECTIVE

To evaluate the efficacy, safety and patient acceptability of 300 and 150 mg secukinumab - a fully human anti-interleukin-17A monoclonal antibody that has demonstrated efficacy in the treatment of patients with moderate-to-severe plaque psoriasis - self-administered by autoinjection.

METHODS

Patients with moderate-to-severe plaque psoriasis were randomized to secukinumab 300 mg, secukinumab 150 mg or placebo self-administered by autoinjection at baseline, Weeks 1, 2 and 3 and then every 4 weeks from Week 4 to Week 48. Efficacy responses [≥75/90/100% improvement in Psoriasis Area and Severity Index (PASI 75/90/100) and clear/almost clear skin by Investigator's Global Assessment 2011 modified version (IGA mod 2011 0/1)] were measured at Week 52. Patient-reported usability of the autoinjector was evaluated by the self-injection assessment questionnaire to Week 48.

RESULTS

At Week 52 with secukinumab 300 mg, PASI 75/90/100 and IGA mod 2011 0/1 responses were achieved by 81.4/64.1/38.8% and 69.6% of patients, respectively, by multiple imputation. At Week 52 with secukinumab 150 mg, PASI 75/90/100 and IGA mod 2011 0/1 responses were achieved by 75.2/57.4/33.1% and 60.2% of patients, respectively, by multiple imputation. Patient-assessed acceptability of the autoinjector remained high to Week 48. The proportion of patients experiencing adverse events was greater with secukinumab 300 mg (88.6%) than with secukinumab 150 mg (78.7%).

CONCLUSION

Self-administration of secukinumab using an autoinjector was associated with robust and sustained efficacy, a good safety profile and high acceptability.

The effect of alpha-lipoic acid (ALA) supplementation on cardiovascular risk factors in men with chronic spinal cord injury: a clinical trial

STUDY DESIGN

A randomized, double-blind, placebo-controlled clinical trial.

OBJECTIVE

To assess the effect of alpha-lipoic acid (ALA) supplementation on IL-6, hs-CRP, FBS, anthropometric indices, food intake and blood pressure in male patients with chronic spinal cord injury (SCI).

SETTING

Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.

METHODS

Fifty-eight men with chronic SCI participated in the study. Participants were divided in two groups: one group received 600 mg of supplemental ALA (n=28) and the other group received placebo (n=30) for 12 weeks. At the beginning and end of the study, biochemical parameters, anthropometric indices, blood pressure and dietary intakes were measured. Dietary intake was measured using N4 software, and statistical analyses were carried out using SPSS16.

RESULTS

No significant reduction was found in IL-6 (P=0.97) and hs-CRP levels (P=0.23). There was significant reduction in fasting blood sugar (P=0.001), body weight (P=0.001), BMI (P=0.001), waist circumference (P=0.001) and blood pressure (P=0.001). Dietary intake was significantly reduced, including fat (P=0.001), carbohydrate (P=0.001), protein (P=0.002) and energy intakes (P=0.001).

CONCLUSION

Lipoic acid supplementation had no significant effect on the measured inflammatory markers but it reduces fasting blood sugar, anthropometric parameters, food intake and blood pressure in men with chronic SCI.

Efficacy, safety and usability of secukinumab administration by autoinjector/pen in psoriasis: a randomized, controlled trial (JUNCTURE)

BACKGROUND

Secukinumab is a fully human anti-interleukin-17A monoclonal antibody.

OBJECTIVE

Determine the efficacy, safety and usability of secukinumab administered via autoinjector/pen.

METHODS

This phase III trial randomized subjects with moderate to severe plaque psoriasis to secukinumab 300 mg, 150 mg or placebo self-injection once weekly to Week 4, then every 4 weeks. Co-primary end points at Week 12 were ≥75% improvement in Psoriasis Area and Severity Index (PASI 75) and clear/almost clear skin by investigator's global assessment 2011 modified version (IGA mod 2011 0/1). Secondary end points included autoinjector usability, assessed by successful, hazard-free self-injection and subject-reported acceptability on Self-Injection Assessment Questionnaire.

RESULTS

Week 12 PASI 75 and IGA mod 2011 0/1 responses were superior with secukinumab 300 mg (86.7% and 73.3%, respectively) and 150 mg (71.7% and 53.3%, respectively) vs. placebo (3.3% and 0%, respectively) (P < 0.0001 for all). All subjects successfully self-administered treatment at Week 1, without critical use-related hazards. Subject acceptability of autoinjector was high throughout 12 weeks. Adverse events were higher with secukinumab (300 mg, 70.0%; 150 mg, 63.9%) vs. placebo (54.1%), with differences largely driven by mild/moderate nasopharyngitis.

CONCLUSION

Secukinumab delivered by autoinjector/pen is efficacious, well-tolerated and associated with high usability in moderate to severe plaque psoriasis.

[Cardiac papillary fibroelastoma, a rare valvular source of cerebral embolism: report of two cases]

Cardiac papillary fibroelastomas are very rare and benign tumors, usually involving heart valves. They are sometimes asymptomatic. However, they become serious illnesses when associated with clinical events, as systemic embolism. Diagnosis is evoked by echocardiography and confirmed by histopathological examination. The only curative treatment consists of the excision of the tumor under cardiopulmonary bypass. This approach is safe and prevents the risk of embolism recurrence. We report the cases of two patients suffering from acute cerebral embolism. Transthoracic and transoesophageal echocardiography detected tumors of the mitral and aortic valve in the first and second patients, respectively. Preserving the valve integrity, both masses were surgically excised and pathological findings confirmed the diagnosis. As surgical management is curative, we believe that these lesions should be always removed.

["Spontaneous" rupture of the left iliac vein complicating Cockett's syndrome]

The case history reported concerns a female patient aged 42 years for whom the clinical picture was that of a blue phlebitis (phlegmatia caerulea dolens), associated with a state of shock evoking a severe pulmonary embolus. The absence of echocardiographic dilatation of the right cavities, and the appearance of a left iliac fossa mass, steered the diagnosis towards internal haemorrhage. Emergency laparotomy allowed diagnosis and treatment of a so-called spontaneous rupture of the left iliac vein, a rare condition for which 20 cases have been reported in the literature. Re-operation performed 24 hours afterwards for the absence of venous return allowed the discovery of Cockett's syndrome with ascending thrombosis, requiring cross-venous bypass associated with the creation of an arterio-venous fistula in order to maintain permeability. One year afterwards the appearance of signs of cardiac insufficiency led to the closure of this fistula.

Fatal cardiovascular complications in a patient with Ehlers-Danlos syndrome type IV and dextrocardia

A report is presented of a 31 year female patient with Ehlers-Danlos syndrome type IV who presented a bilateral renal artery dissection and a hematoma of the ascending aorta simultaneously. She had had an uneventful delivery six months before. We also discovered a situs solitus with dextrocardia in this patient. These complications were managed conservatively. Unfortunately the patient died of a pulmonary infection and a multi-organ failure syndrome several days after her admission.

[Cardiogenic shock complicating extensive infarction with ventricular septal defect. Circulatory assistance and heart transplantation]

A 47 year old man had a massive anterior myocardial infarction with cardiogenic shock with a left parasternal murmur. Coronary angiography showed occlusion of the left anterior descending artery for which angioplasty resulted in failure. There was antero-lateral-apical akinesia and a ventricular septal defect (VSD) with a left-right shunt (Qp/Qs = 1.54). Persistence and aggravation of haemodynamic instability led to intra-aortic balloon pumping with inotropic pharmacological support followed by biventricular assistance with a MEDOS device. Under transoesophageal echocardiographic monitoring, the outcome was marked over 7 days by the progressive increase in the shunt volume of the VSD, a decrease of drainage and injection flow, progressive increase in spontaneous contrast echos followed by the presence of fibrin in the cardiac chambers and canulae, the presence of thrombus in the external ventricles, blockage of the right external valve which only opened after increasing the degree of anticoagulation, and, finally, cardiac tamponade which required drainage before the patient's state improved. On the 8th day, the patient being stable with a normal neurological status, the availability of a donor heart led to the decision to transplant, which was carried out without complications. This case poses the problem of cardiac assist devices and their daily monitoring, and then that of cardiac transplantation in this indication.

Fracture embolization of a Tekna mitral prosthesis: case report

The modified Duromedics-Tekna bileaflet pyrolitic carbon mechanical prosthesis was reintroduced by Baxter in 1990. This report details the first case of sudden leaflet fracture of a Tekna mitral valve five years after implantation, which was managed successfully by replacement with a St. Jude Medical mechanical prosthesis. The fracture had occurred transversely, with the fragments embolizing to the terminal aortic bifurcation and the left common femoral artery. These were localized by computed tomography and removed two days after valve replacement.

[Long-term hemodynamic function of the transplanted heart]

The aim of this study was to identify the long-term haemodynamic changes of the transplanted heart. Between 1987 and 1997, 136 patients required cardiac transplantation at Dijon hospital. During follow-up, 76 patients aged 51.2 +/- 9.46 years underwent catheter studies (12 women, 15.8%; and 64 men, 84.2%). Right and left heart catheterisation was performed at 3 months, 1, 2, 3 and 5 years after transplantation. Right heart catheterisation included measurement of mean pulmonary artery and pulmonary capillary pressures and pulmonary arteriolar resistances. During left heart catheterisation, cardiac output, mean aortic pressure, the ejection fraction, the dp/dt max of the left ventricular wall, systemic arterial resistances and left ventricular end diastolic pressures were measured. At each catheter study, the indexed myocardial mass, indexed end systolic and end diastolic left ventricular volumes, the mass/volume ratio, the residual serum cyclosporine concentrations and the serum creatinine were analysed. In addition, an endomyocardial biopsy was also performed. Initially raised, the mean pulmonary artery and pulmonary capillary pressures decrease from the 3rd month to the 2nd year. From the 3rd year onwards, they readjust to the upper limits of normal. The pulmonary artery resistances underwent the same changes. The left heart parameters remained constant over the period of follow-up but with a heart rate, mean aortic pressure and left ventricular end diastolic pressure higher than normal. The indexed myocardial mass was increased at all periods. The indexed left ventricular end systolic and diastolic volumes decreased with a M/V ratio which increased. Cyclosporine concentrations decreased whereas serum creatinine increased. The frequency of severe rejection and of coronary atherosclerosis was low. Significant correlations were observed between different parameters at different periods. In the long-term, the function of the transplanted heart is not normal in the strict sense of the term. The apparent normality is obtained by anti-hypertensive treatment. The transplanted heart adapts to the increase in cyclosporine-induced afterload by permanent myocardial hypertrophy, and increased diastolic pressure probably relates to diastolic dysfunction without noticeable intracardiac fibrosis.

Surgical outcome of traumatic rupture of the thoracic aorta

BACKGROUND

The aim of this study was to point out the results of different techniques of spinal cord protection in surgically-treated patients with traumatic thoracic aorta (TTA).

METHODS

A multicentric study was carried out involving 182 patients with TTA. Four patients died before surgery. Two patients were operated on without any investigation and 2 had no aortic tear at thoracotomy. The remaining 174 patients had aortic isthmus disruption and were included in the study. The mean age was 32.3+/-14.29 years with 126 men (72.4%) and 48 women (27.6%). Road accidents were causal in 163 patients (93.66%); polytraumatism was frequent. A standard chest roentgenogram led to a diagnosis which was confirmed with aortography in 94.8% of cases. Surgical repair of visceral lesions was performed in 52 patients (29.9%) for traumatic spleen, liver, diaphragm, mesentery, and gut. These operations were done before or after aortic operation in 21.3% and 8.6% of cases, respectively. Thirty-three patients (19%) died and 9 (5.2%) had paraplegia. Sixty-nine patients had clamp and sew technique (group 1). Ninety-three patients had different types of extracorporeal circulation (group 2), and 12 patients had Gott shunt (group 3). No difference appeared between the 3 groups according to mortality and paraplegia. But the sex ratio, age, visceral lesions, craniocerebral lesions, the type of aortic repair, and cross-clamp time were discriminative.

RESULTS

The univariate analysis point out age, cross-clamp time, hemothorax, and anatomical type of aortic injury as the risk factors of death. This was confirmed by a multivariable test which retained age, cross-clamp time, and hemothorax as risk factors. When not diagnosed in time, TTA is serious and has a bad prognosis. In spite of a high mortality and morbidity, the surgical management has improved. Immediate operation and medullar protection are the stumbling block in this operation.

CONCLUSIONS

Operation can be delayed in some cases, but one must take care of hemodynamic instability. This calls for a repair of the serious associated lesions first, or of a quick performing of a thoracotomy for ruptured aorta. The question remains, is it better to protect the spinal cord with the lower aortic perfusion and avoid the simple cross-clamp? Clinical studies give few answers to this question, and the best answer has not yet been given, as we lack prospective studies in this field.

[Ten-year experience with heart transplantation (1987-1997)]

OBJECTIVES

Analyze ten years experience with heart transplantation at the Dijon University Hospital and determine which parameters control mid and long term outcome.

PATIENTS AND METHODS

One hundred thirty six heart transplantations were performed over a 10 year period (1987-1997) in 118 men and 18 women aged 51-87 years. Heart transplantation was indicated on the basis of the following criteria: ejection fraction *20%, pulmonary arteriole resistance < 6 Wood units, peak oxygen uptake < 14 l/kg/min. The Shumway or anatomic technique was used. The triple immunosuppressive protocol combined corticosteroids, azathioprine and cyclosporin. The same team conducted the post-transplantation follow-up with regular programmed consultations in addition to those requested by the general practitioner, the cardiologist or the patient. Follow-up was oriented according to the clinical situation (blood chemistry, cell counts, cyclosporinemia, search for infection, echocardiography, endomyocardial biopsy, coronarography).

RESULTS

Five patients (3.6%) died when still on the waiting list. Absolute emergency transplantation was performed for patients (28.1%) including 8 (5.9%) after circulatory assist. Hospital mortality was 11.7% and late mortality was 16.1%. Actuarial survival was 78% at 1 year, 71% at 5 years and 69% at 10 years. Among the survivors, 94% were taking two, three or even four drugs for hypertension. Cyclosporin levels decreased and creatinine levels increased. Episodes of rejection were minimal: 86.57% of the biopsies were * grade 1 and 4.45% * grade 2. Cytomegalovirus infection was documented and treated in 7.55% of the cases. Incidence of graft coronary artery disease was 3.4% at 1 year, 6.5% at 2 years and 7.9% at 3 years.

CONCLUSION

Our follow-up structure where the same small team conducts regular examinations together with our approach to heart transplantation appears to be the main factor leading to the quality results obtained in this series.