Immune checkpoint blockers in solid organ transplant recipients and cancer: the INNOVATED cohort

BACKGROUND

Patients with solid organ transplant (SOT) and solid tumors are usually excluded from clinical trials testing immune checkpoint blockers (ICB). As transplant rates are increasing, we aimed to evaluate ICB outcomes in this population, with a special focus on lung cancer.

METHODS

We conducted a multicenter retrospective cohort study collecting real data of ICB use in patients with SOT and solid tumors. Clinical data and treatment outcomes were assessed by using retrospective medical chart reviews in every participating center. Study endpoints were: overall response rate (ORR), 6-month progression-free survival (PFS), and grade ≥3 immune-related adverse events.

RESULTS

From August 2016 to October 2022, 31 patients with SOT (98% kidney) and solid tumors were identified (36.0% lung cancer, 19.4% melanoma, 13.0% genitourinary cancer, 6.5% gastrointestinal cancer). Programmed death-ligand 1 expression was positive in 29% of tumors. Median age was 61 years, 69% were males, and 71% received ICB as first-line treatment. In the whole cohort the ORR was 45.2%, with a 6-month PFS of 56.8%. In the lung cancer cohort, the ORR was 45.5%, with a 6-month PFS of 32.7%, and median overall survival of 4.6 months. The grade 3 immune-related adverse events rate leading to ICB discontinuation was 12.9%. Allograft rejection rate was 25.8%, and risk of rejection was similar regardless of the type of ICB strategy (monotherapy or combination, 28% versus 33%, P = 1.0) or response to ICB treatment.

CONCLUSIONS

ICB could be considered a feasible option for SOT recipients with some advanced solid malignancies and no alternative therapeutic options. Due to the risk of allograft rejection, multidisciplinary teams should be involved before ICB therapy.

Tralokinumab therapy for moderate-to-severe atopic dermatitis: Clinical outcomes with targeted IL-13 inhibition

Atopic dermatitis (AD) is a chronic, inflammatory, intensely pruritic skin disorder associated with significant patient burden. Interleukin (IL)-13 is a cytokine that acts as a driver of immune dysregulation, skin-barrier dysfunction, and microbiome dysbiosis that characterizes AD, and is consistently overexpressed in AD skin. Tralokinumab is a fully human immunoglobulin (Ig) G4 monoclonal antibody that binds specifically to IL-13 with high affinity, thereby inhibiting subsequent downstream IL-13 signaling. Three pivotal phase 3 clinical trials demonstrated that tralokinumab 300 mg every other week, as monotherapy or in combination with topical corticosteroids as needed, provides significant improvements in signs and symptoms of moderate-to-severe AD, as measured by Investigator's Global Assessment 0/1 (clear/almost clear) and Eczema Area and Severity Index-75 at Week 16. Improvements were observed soon after tralokinumab initiation and were maintained over 52 weeks of therapy. Tralokinumab significantly improved patient-reported outcomes such as itch and sleep, and demonstrated a safety profile comparable with placebo; conjunctivitis during tralokinumab therapy was generally mild. Similar results were observed in a phase 3 adolescent trial. The role of IL-13 in the pathophysiology of AD justifies a targeted approach and a wealth of clinical data supports tralokinumab as a new therapeutic option for people with moderate-to-severe AD.

Safety and Efficacy of Tralokinumab in Older Adults With Moderate-to-Severe Atopic Dermatitis: A Secondary Analysis

Importance

Older adults with atopic dermatitis (AD) face unique treatment challenges, including comorbidities, polypharmacy, and a higher risk for infections (eg, herpes zoster). Furthermore, limited data are available from clinical trials for treatments in this population. In phase 3 studies, tralokinumab showed superior efficacy in moderate-to-severe AD vs placebo, but results were not stratified by age group.

Objective

To evaluate the safety and efficacy of tralokinumab in older (≥65 years) patients with moderate-to-severe AD.

Design, Setting, and Participants

A post hoc analysis for adults 65 years or older was conducted from a subset of patients in the US, Canada, Europe, and Asia in 3 randomized, placebo-controlled, phase 3 trials (ECZTRA 1 and 2 [monotherapy] and ECZTRA 3 [tralokinumab + topical corticosteroids as needed]). The post hoc data were analyzed in 2022.

Main Outcomes and Measures

Pooled data from up to 16 weeks of treatment from ECZTRA 1, 2, and 3 were used to assess safety. Statistical analyses followed prespecifications of primary end points. Separate efficacy analyses were conducted in these trials respectively at 16 weeks.

Results

A total of 75 older adults (42 women [56%]) treated with tralokinumab from the ECZTRA 1, 2, and 3 trials were included in this post hoc analysis. Similar proportions of patients reported adverse events (AEs) with tralokinumab and placebo (44 [58%]). Three patients (4%) in the tralokinumab arm and 3 (10.3%) in the placebo arm experienced severe AEs, and 4 (5.3%) and 2 (6.9%), respectively, had AEs leading to discontinuation. More patients achieved 75% or greater improvement in Eczema Area and Severity Index scores with tralokinumab than placebo (33.9% vs 4.8%; P < .001) in ECZTRA 1 and 2. Similar trends, although not statistically significant, were seen in ECZTRA 3. Safety and efficacy outcomes in this population were similar compared with the younger patient cohorts. The small sample size limited generalizations from this analysis.

Conclusion and Relevance

The results of this post hoc analysis suggest that tralokinumab is well tolerated and efficacious in patients 65 years or older with moderate-to-severe AD.

The JAK1/2 inhibitor ruxolitinib in patients with COVID-19 triggered hyperinflammation: the RuxCoFlam trial

Dysregulated hyperinflammatory response is key in the pathogenesis in patients with severe COVID-19 leading to acute respiratory distress syndrome and multiorgan failure. Whilst immunosuppression has been proven to be effective, potential biological targets and optimal timing of treatment are still conflicting. We sought to evaluate efficacy and safety of the Janus Kinase 1/2 inhibitor ruxolitinib, employing the previously developed COVID-19 Inflammation Score (CIS) in a prospective multicenter open label phase II trial (NCT04338958). Primary objective was reversal of hyperinflammation (CIS reduction of ≥25% at day 7 in ≥20% of patients). In 184 patients with a CIS of ≥10 (median 12) ruxolitinib was commenced at an initial dose of 10 mg twice daily and applied over a median of 14 days (range, 2-31). On day 7, median CIS declined to 6 (range, 1-13); 71% of patients (CI 64-77%) achieved a ≥25% CIS reduction accompanied by a reduction of markers of inflammation. Median cumulative dose was 272.5 mg/d. Treatment was well tolerated without any grade 3-5 adverse events related to ruxolitinib. Forty-four patients (23.9%) died, all without reported association to study drug. In conclusion, ruxolitinib proved to be safe and effective in a cohort of COVID-19 patients with defined hyperinflammation.

Prevalence of scabies worldwide-An updated systematic literature review in 2022

Scabies is a World Health Organization-defined neglected tropical disease, with continuously rising incidence worldwide in recent years. The aim of this study was to provide an update of the worldwide prevalence and new treatment approaches of scabies in population-based settings. MEDLINE (PubMed), Embase and LILACS databases were reviewed for English and German language population-based studies from October 2014 to March 2022. Two authors independently screened the records for eligibility, extracted all data and one critically appraised the quality of the studies and risk of bias. Systematic review registration: PROSPERO CRD42021247140. Overall, 1273 records were identified through database searching, of which 43 studies were included for the systematic review. Most of the studies (n = 31) examined the scabies prevalence in medium or low human development index countries. The highest prevalence of scabies reported in the general population (children and adults) was recorded in five randomly selected communities in Ghana (71.0%), whereas the highest scabies prevalence in studies, which only examined children (76.9%), was recorded in an Indonesian boarding school. The lowest prevalence was recorded in Uganda (0.18%). The systematic review highlights the prevalence of scabies worldwide, showing that scabies is still a serious, increasing disease that occurs globally and is clustered in developing countries. More transparent data on scabies prevalence are needed to identify risk factors to find new prevention measures.

Efficacy and safety of switching between biologics in chronic rhinosinusitis with nasal polyps or N-ERD

BACKGROUND AND OBJECTIVE

The effectiveness of biologics in chronic rhinosinusitis with nasal polyps (CRSwNP) is well-established. However, real-world experience on the effectiveness of transitioning between two monoclonal antibodies is scarce. Therefore, we aimed to analyze the safety and efficacy of antibody switching in treatment of chronic rhinosinusitis.

METHODS

All patients with CRSwNP or nonsteroidal anti-inflammatory drugs-exacerbated respiratory disease (N-ERD) requiring a switch between biologics were retrospectively studied. Analysis included changes in polyp size, quality of life parameters, asthma control, and side effects.

RESULTS

Out of 195 patients treated with biologics for CRSwNP or N-ERD in our center, 23 (11.8%) required transition to a different monoclonal antibody. The majority switched from omalizumab to dupilumab (17/23, 73.9%), mostly due to inadequate symptom control. Nine out of these 17 patients (52.9%) were switched without a washout period. All patients showed significant improvement in nasal polyp score, asthma control test and sino-nasal outcome test-22 after changing to dupilumab. Keratoconjunctivitis sicca was the side-effect (4.3%) reported after the switch from omalizumab to dupilumab, which lead to termination of therapy in one patient. Due to limited sample size, other antibody transitions were reported in a descriptive manner.

CONCLUSION

The transition to dupilumab is an effective option in patients with inadequate treatment response or side-effects of omalizumab in nasal polyposis. Our preliminary results indicate that a wash-out period may not be necessary when switching between biologics, however, these findings require further investigations. Other monoclonal antibody transitions also show promising results, but warrant validations in larger cohorts due to small patient samples in our study.

Raster-scanning optoacoustic mesoscopy biomarkers for atopic dermatitis skin lesions

Atopic dermatitis (AD) is the most common chronic inflammatory skin disease worldwide. Its severity is assessed using scores that rely on visual observation of the affected body surface area, the morphology of the lesions and subjective symptoms, like pruritus or insomnia. Ideally, such scores should be complemented by objective and accurate measurements of disease severity to standardize disease scoring in routine care and clinical trials. Recently, it was shown that raster-scanning optoacoustic mesoscopy (RSOM) can provide detailed three-dimensional images of skin inflammation processes that capture the most relevant features of their pathology. Moreover, precise RSOM biomarkers of inflammation have been identified for psoriasis. However, the objectivity and validity of such biomarkers in repeated measurements have not yet been assessed for AD. Here, we report the results of a study on the repeatability of RSOM inflammation biomarkers in AD to estimate their precision. Optoacoustic imaging analysis revealed morphological inflammation biomarkers with precision well beyond standard clinical severity metrics. Our findings suggest that optoacoustic mesoscopy may be a good choice for quantitative evaluations of AD that are inaccessible by other methods. This could potentially enable the optimization of disease scoring and drug development.

Generation of three CRISPR/Cas9 edited human induced pluripotent stem cell lines (DHMi005-A-5, DHMi005-A-6 and DHMi005-A-7) carrying a Holt-Oram Syndrome patient-specific TBX5 mutation with known cardiac phenotype and a FLAG-tag after exon 9 of the TBX5 gene

TBX5 is a transcription factor (TF) playing essential role during cardiogenesis. It is well known that TF mutations possibly result in non- or additional binding of the DNA due to conformational changes of the protein. We introduced a Holt-Oram Syndrome (HOS) patient-specific TBX5 mutation c.920_C > A heterozygously in a healthy induced pluripotent stell cell (iPSC) line. This TBX5 mutation results in conformational changes of the protein and displayed ventricular septal defects in the patient itself. Additionally we introduced a FLAG-tag on the TBX5 mutation-carrying allele. The resulting heterozygous TBX5-FLAG iPSC lines are a powerful tool to investigate altered TF activity bonding.

Generation of two CRISPR/Cas edited human induced pluripotent stem cell lines (DHMi005-A-3 and DHMi005-A-4) carrying a FLAG-tag after exon 9 of the TBX5 gene

Although TBX5 plays a major role during human cardiogenesis and initiates and controls limb development, many of its interactions with genomic DNA and the resulting biological consequences are not well known. Existing anti-TBX5-antibodies work very inefficiently in certain applications such as ChIP-Seq analysis. To circumvent this drawback, we introduced a FLAG-tag sequence into the TBX5 locus at the end of exon 9 prior to the stop codon by CRISPR/Cas9. The expressed TBX5-FLAG fusion protein can effectively be precipitated by anti-FLAG antibodies. Therefore, these gene-edited iPSC lines represent powerful cellular in vitro tools to unravel TBX5:DNA interactions in detail.

Postoperative instructions after endoscopic sinus surgery: is there a consensus?

BACKGROUND: Most endoscopic sinus surgeons instruct their patients to avoid certain activities during the postoperative period. Due to the scarcity of empirical data on this issue, most instructions are based on surgeons’ personal insights. In this study we evaluated if restrictions for performing specific activities have a consensus among endoscopic sinus surgeons. METHODOLOGY: A nationwide survey was conducted among experienced Israeli endoscopic sinus surgeons. Participants were asked to note the optimal postoperative time restrictions of 25 different activities. RESULTS: The response rate was 30/36 (83%). Surgeons’ responses regarding time restrictions of specific activities postoperatively showed high variance. The greatest variance was noted for using a hair dryer, light physical activities, nose blowing, driving a car, having sexual intercourse, eating/drinking hot food or beverages, taking hot showers and drinking alcohol. CONCLUSIONS: The time restrictions given by endoscopic sinus surgeons for specific activities postoperatively vary greatly among them. The study findings call upon rhinology boards to establish consensus-based guidelines for postoperative management after endoscopic sinus surgery.

Nutrition education in medical schools (NEMS) project: Promoting clinical nutrition in medical schools - Perspectives from different actors

BACKGROUND & AIMS

Nutrition education is not adequately represented in the medical curriculum, and this prompted the European Society for Clinical Nutrition and Metabolism (ESPEN) to launch the Nutrition Education in Medical Schools (NEMS) Project in 2017. The aim of this original paper was to describe the perspectives of different actors in the promotion of nutrition education in medical schools.

METHODS

On 11 November 2021, an online meeting was held on this topic, where nine representatives from different backgrounds participated in the scientific programme. More than 640 participants registered to this webinar.

RESULTS

The different models of Nutrition Education in Medical Schools were introduced by Prof. Cristina Cuerda (Spain) and Prof. Maurizio Muscaritoli (Italy). The students' perspective was given by Ms. Alexandra Archodoulakis (Germany) and Ms. Sila Gürbüz (Turkey), representing the European Medical Students' Association. The dietitian's perspective was given by Dr. Kirsten Berk (The Netherlands), whereas Dr. Matti Aapro (Switzerland) gave the medical doctor (oncology)'s perspective. Ms. Clare Farrand (Australia) gave the WHO perspective and Dr. Kristiina Patja (Finland) explained the healthy lifestyle teaching to medical students. Lastly, Prof. Michael Chourdakis (Greece) and Prof. Zeljko Krznaric (Croatia) hosted the round-table discussion.

CONCLUSIONS

There was strong agreement among the representatives from different settings joining this ESPEN initiative that increasing nutritional knowledge and skills of young doctors is now possible and will launch a virtuous cycle that will proactively involve all the other healthcare professionals working in the nutritional field.

Understanding addiction in e-cigarette users – the EVAPE project

Background

Electronic cigarettes (e-cigarettes) are often advertised as a healthier option to combustible cigarettes and as smoking cessation aid. However, e-cigarettes are a growing health concern and their addictive potential remains to be fully understood. Within the EValuation of the Addictive Potential of E-cigarettes (EVAPE) project, we studied subjective and objective measures of addiction in relation to e-cigarette use.

Methods

This cross-sectional analysis was based on 832 participants of the first wave (2016) of England from the ITC Four Country Smoking and Vaping (4CV) Survey, who were using e-cigarettes daily or weekly for at least four months. Perceived addiction to e-cigarettes was categorised as very vs. not/somewhat addicted, and perceived addictiveness of e-cigarettes relative to combustible cigarettes as equally/more addictive vs. less addictive. Objective measures of addiction included urge to vape, time to first vape after waking, frequency of use, and used nicotine strength. We examined associations between these objective and subjective measures of addiction using multivariate logistic regression, adjusted for age, gender, education, and cigarette smoking.

Results

17.8% of participants reported feeling very addicted to e-cigarettes and 42.3% considered e-cigarettes equally/more addictive than combustible cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive (OR 3.43 (95%-CI 2.29-5.19)). All objective measures of addiction were associated with higher perceived addiction, whereas only a shorter time to first vape was associated with perceived product addictiveness.

Conclusions

Subjective measures of addiction to e-cigarettes, in particular perceived addiction, correspond with objective measures. Understanding the addictive potential of e-cigarettes is the cornerstone for developing new strategies for prevention and treatment, and ultimately understanding their role from a public health perspective.

Key messages

Do family characteristics explain a social gradient in overweight in early childhood?

Background

Children's overweight is associated with many factors, including their living situation, in particular their family's socioeconomic position (SEP) and family characteristics. Research on the extent to which family characteristics account for a social gradient in overweight in early life is scarce. This study evaluated whether family characteristics explain SEP differences in the risk of overweight in early childhood.

Methods

The study used baseline data of 3-6 year-old children (n = 1,116) from the intervention ‘Ene mene fit’ conducted at kindergartens in Baden-Württemberg, Germany. Data included overweight (body mass index &gt; 90 percentile) and parents’ reports on their education and family characteristics associated with overweight (child consumes: sweets in front of TV, soft drinks; family joined time: outdoor, breakfast, sports; cooking; child sets table; role model). Model-based single mediation analyses decomposed the total effect of highest parental education on overweight into direct (unmediated) and indirect (mediated) effects (OR, 95% CI).

Results

Girls and boys with low parental education had higher odds for overweight than children with high/medium education. Among boys, low education influenced the risk of overweight via indirect effects of i. ‘sweets consumption in front of TV’ (OR = 1.31, 1.05-1.59) and ii. ‘no joined sports’ (OR = 1.14, 1.00-1.44). The direct effect of low education only remained significant when ‘no joined sports’ was considered (OR = 2.19, 1.11-5.19). Among girls, family characteristics measured here did not explain SEP differences in overweight.

Conclusions

The family characteristics ‘sweets consumption in front of TV’ and ‘no joined sports’ contribute to inequalities in overweight among boys, but not among girls. Therefore, more gender-sensitive research is needed to identify family risk and protective characteristics that explain health inequalities among both boys and girls.

A sport focus of ECEC centres appears especially health-promoting for boys from lower socio-economic background

Background

Pediatric overweight is considered one of the 21st century's most serious public health challenges. Many studies investigated individual level determinants of children's body mass index (BMI), yet studies measuring determinants at the meso- level are sparse. As there is a lack of theoretical and empirical knowledge about the role of child care facilities, the aim was to examine the combined effects of family socio-economic position (SEP) and the meso-level variable early childhood education and care (ECEC) centre with sport focus on the BMI of pre-schoolers.

Methods

We used data from the German National Educational Panel Study (NEPS) and included 1,891 children from 224 ECEC centre groups. Multilevel mixed-effects linear regressions were applied to calculate the main association of ECEC centre focus and family SEP, as well as their interaction on children's BMI. All analyses were adjusted for age, migration background, number of siblings, and employment status of parents and were stratified by gender.

Results

Boys attending an ECEC centre with a sport focus have on average a lower BMI than boys from ECEC centres not having this focus. Interactive effects between family SEP and ECEC centre focus were found. Considering predictive margins, boys with low family SEP not attending a sport focused ECEC centre had the highest BMI while boys with low family SEP attending a sport focused ECEC centre had the lowest BMI. For girls, no association regarding ECEC centre focus or interactive effects emerged. Girls in the high family SEP tertile had the lowest BMI in both ECEC centre types.

Conclusions

Our analysis shows the social gradient towards a higher BMI for children from lower SEP families. Considering meso-level factors, we provide evidence for the relevance of ECEC centre characteristics for BMI in boys, whereas for girls the association of family SEP with BMI remains. The ECEC centre focus appears to lower the association of family SEP with BMI for boys.

The role of regional health policy for socioeconomic inequality in health services utilization

Background

“J1” is a preventative routine examination in Germany recommended for adolescents at the age of 12-14 years. In contrast to the well-established U1-U9 examinations for younger children, with participation rates above 90%, the attendance of the J1 examination is approximately only 40%. The most frequent reason for not attending J1 is the unawareness of this examination. “Ticket to J1” is an intervention including an information leaflet introduced in Bavaria in 2017 to inform adolescents about J1. The aims of the present analysis are to investigate (1) if the regional policy was effective in increasing the attendance in J1, (2) if the effects vary by family socioeconomic status (SES), and (3) which meso-level characteristics of the healthcare system correlate with attendance rates in J1.

Methods

We used anonymised data of a large statutory health insurance in Germany for the timeframe of 2016-2018. To investigate the effect of the policy, a difference-in-differences design at the individual level was used. Assuming a parallel trend at the level of federal states, the likelihood of attendance in J1 of 13- and 14-year-olds was compared between Bavaria and other federal German states before and after policy introduction. All analyses were additionally stratified by SES.

Results

The introduction of “Ticket to J1” increased participation in J1 by 1% after controlling for all confounders. Furthermore, the effect was stronger for children from families with lower SES (an increase of 5%). Density of pediatricians was positively significantly correlated with participation in J1.

Discussion

Regional health policy intervention had a significant positive impact on attendance of J1 and appears to have the potential to reduce socioeconomic inequalities in healthcare utilization. Informing adolescents about J1 seems to increase the attendance, in particular for children from families with lower SES.

Influence of radiotherapy on cardiac implantable device lead parameters

Purpose

Incidences of both cardiac implantable electronic devices (CIED) and malignant tumors are rising, likewise the number of patients undergoing radiotherapy (RT) while having CIED increases. There is evidence that there is a higher failure rate with increasing cumulative dose at device and higher – neutron-inducing – photon beam energy above 10 MV. There is a paucity of data regarding lead function, lead insertion site dose and analysis of change of lead parameter during RT treatment. Aim of this work is a detailed analysis of CIED malfunctions and technical alterations in patients treated at our clinic with a special focus on device lead parameters.

Methods

In a total of 54 patients treated at our department, we evaluated the dose statistics for the leads and devices as well as lead parameters aggregated through telemetric device interrogations. Irradiation mostly took place in the thoracic (32%), pelvic (24%) and the head region (22%). A total of 80% of all patients had implanted a pacemaker and 17% an implantable cardioverter defibrillator. Two Patients (4%) were under cardiac resynchronization therapy. Overall 33% of patients were device-dependent.

Dose statistics for myocardial lead insertion sites and CIED were calculated. We collected interrogation data (intrinsic pacing impedance, pacing threshold, signal amplitude) before and after RT treatment (median number of interrogations was 3, range 1–22) and information about any CIED malfunction.

We assessed whether lead parameters changes exceeded predefined thresholds of 30% in pacing impedance, 50% in pacing threshold, or 50% in signal amplitude.

Results

24 of the 54 patients received a measurable dose at the device (median dose of patients with thoracic RT: 1.82 Gy, range 0.18–14.88 Gy). Dose data was available for atrial leads of 12 patients (median dose 7.27 Gy, ranging from barely measurable to 46.02 Gy) and right-ventricular leads of 13 patients (median dose 0.83 Gy, range 0.004–42.66 Gy).

There was no lead parameter threshold violation for pacing impedance detected, however predefined thresholds of signal amplitude and pacing threshold were exceeded in 14% and 15% of cases, respectively. These threshold violations did not compromise device function. There was no significant difference of lead parameter changes when patient groups receiving more and less than 10 Gy at lead insertion site were compared.

Two CIEDs (4%) showed a malfunction (electric restart of device) during RT, however no clinically relevant complication was reported. Both patients underwent thoracic RT (esophageal cancer) with a beam energy of 10 and 15 MV.

Conclusion

In the observed patient group, lead parameter threshold violation was neither able to predict a device malfunction nor dependent of cumulative dose at myocardial insertion side. Device malfunction occurred rarely and only at higher beam energies, however with no life-threatening outcome.

Funding Acknowledgement

Type of funding sources: None.

Tralokinumab Efficacy and Safety, with or without Topical Corticosteroids, in North American Adults with Moderate-to-Severe Atopic Dermatitis: A Subanalysis of Phase 3 Trials ECZTRA 1, 2, and 3

Introduction

In pivotal phase 3 tralokinumab monotherapy (ECZTRA 1/2) and topical corticosteroid (TCS) combination (ECZTRA 3) trials in adults with moderate-to-severe atopic dermatitis (AD), tralokinumab significantly improved signs and symptoms of AD. Geographic region may impact treatment response due to potential differences in race and ethnicity, and based on findings in other therapy areas. Here, we evaluated the efficacy and safety of tralokinumab in the ECZTRA 1/2/3 North American population at week 16, as well as maintenance of responses over time, and compared these data side-by-side with those of the ECZTRA 1/2/3 non-North American population.

Methods

Primary endpoints were Investigator’s Global Assessment score of 0 or 1 (IGA 0/1; clear or almost clear) or at least 75% improvement in Eczema Area and Severity Index (EASI-75) at week 16. At week 16, tralokinumab-treated IGA 0/1 or EASI-75 responders were re-randomized 2:2:1 to tralokinumab 300 mg q2w, or q4w, or placebo (ECZTRA 1/2) and 1:1 to tralokinumab 300 mg q2w or q4w (ECZTRA 3).

Results

Overall, 559/1596 (35%) and 160/380 (42.1%) patients randomized in ECZTRA 1/2 and ECZTRA 3 were from North America, respectively. At week 16, IGA 0/1 and EASI-75 response rates were greater with tralokinumab versus placebo in ECZTRA 1/2 (IGA 0/1: 25.3% vs 15.1%; 95% confidence interval [CI] 3.0, 17.3; p = 0.012; EASI-75, 40.1% vs 19.4%; 95% CI 12.6, 28.7; p < 0.001) and ECZTRA 3 (IGA 0/1, 40.0% vs 25.9%; 95% CI − 0.5, 28.3; p = 0.074; EASI-75: 58.1% vs 37.0%; 95% CI 4.9, 37.0; p = 0.012) and tralokinumab was well tolerated in the North American population. Patients with IGA 0/1 or EASI-75 response at week 16 demonstrated sustained responses at week 52 and week 32 in ECZTRA 1/2 and ECZTRA 3, respectively. Similar findings were observed in the non-North American trial populations.

Conclusions

Tralokinumab, with or without TCS, displayed similar efficacy and safety in patients with moderate-to-severe AD across the North American population, and was comparable to the non-North American population.

Clinical Trial Registration

NCT03131648 (registered 27-Apr-2017); NCT03160885 (registered 19-May-2017); NCT03363854 (registered 6-Dec-2017).

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00805-y.

Patient-oriented measures for phase 3 studies of tralokinumab for treatment of atopic dermatitis (ECZTRA 1, 2 and 3)

BACKGROUND

Tralokinumab, as monotherapy or in combination with topical corticosteroids (TCS), has demonstrated significant efficacy through 52 weeks in phase 3 trials of adults with moderate-to-severe atopic dermatitis (AD) and additional efficacy in a long-term extension trial. Early changes in patient-reported symptoms have not been communicated.

OBJECTIVE

To examine early changes in patient-reported outcomes (PROs) across the ECZTRA 1, 2, and 3 tralokinumab trials.

METHODS

Monotherapy data (ECZTRA 1+2) was pooled; ECZTRA 3 examined tralokinumab + optional TCS. PROs were assessed through the trials.

RESULTS

1596 and 380 patients were randomized in ECZTRA 1+2 and ECZTRA 3, respectively. Baseline demographics and clinical characteristics were similar between groups. Early separation from placebo was observed in percentage improvement in worst average daily pruritus numerical rating score (NRS) [week 1, ECZTRA 1+2; week 2, ECZTRA 3] and from day 2 in ECZTRA 1+2 daily data. More tralokinumab-treated patients achieved clinically meaningful improvements (≥4 points) in NRS by week 2 (ECZTRA 1+2) or week 3 (ECZTRA 3) versus placebo. Improvements in eczema-related sleep NRS were seen within 2 weeks (week 1, ECZTRA 1+2; week 2, ECZTRA 3), supported by similar improvements in other sleep measures. Meaningful changes in Dermatology Life Quality Index were observed from week 2 (ECZTRA 1+2). Results were supported by numerical differences from placebo in Patient-Orientated Eczema Measure total score (week 2, both datasets).

CONCLUSION

Tralokinumab +/- TCS demonstrated early and clinically meaningful improvements versus placebo in several PROs, which may be beneficial to patients because AD symptom relief is a key treatment concern for patients.

Investigating the feasibility and effectiveness of a modular treatment program for children and adolescents with depression and interpersonal problems: study protocol of a quasi-experimental pilot feasibility trial (CBASP@YoungAge)

Background

Depression is a serious disorder in childhood and adolescence. Affected children and adolescents show significant impairments in various aspects of life. Studies on the effectiveness or efficacy of psychotherapy in depressed children and adolescents are qualitatively very heterogeneous and reveal small effect sizes. There is thus a need to better tailor psychotherapy approaches to these age groups to improve outcomes like parent-child relationship, symptomatology, or quality of life.

To address this gap, we designed a modular, individualized treatment program for children and adolescents based on the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) including caregiver involvement.

Method

This quasi-experimental pilot feasibility trial is a phase 1 to phase 2 study investigating the feasibility and effectiveness of CBASP@YoungAge by including an intervention group (CBASP@YoungAge) and a treatment-as-usual control group. The treatment of depressive symptoms as well as interpersonal problems with primary caregivers are the main targets of CBASP@YoungAge. Personalization is ensured concerning the treatment course, caregivers’ involvement, and the patient’s age. The primary outcome relates to two areas: the feasibility of the CBASP@YoungAge treatment program in an outpatient context and a change in patients' depressive symptomatology from before to after treatment. We conduct a brief process evaluation after each session in the intervention group to closely monitor the treatment process and examine feasibility from the therapists' and patients' perspectives and mechanisms of symptom change. In addition, we consider interpersonal behavior between children and caregivers, parenting behavior, and monitor the global-health-index in children and parents as secondary outcomes. Pre-, post-, and follow-up data are evaluated.

Discussion

This is the first study of a modular-based intervention program for children and adolescents with depression and a clear focus on the interpersonal problems between the depressed young patient and her/his caregiver. It will provide important knowledge on the feasibility and effectiveness of the program and potential benefits of including caregivers in psychotherapy. Based on this study’s results, we plan a multicenter, randomized, controlled trial whose long-term aim is to improve the psychotherapeutic care of young patients with depression while preventing persistent courses of depressive disorders.

Trial registration

German Clinical Trials Register, DRKS (identifier DRKS00023281). Registered 17 November 2020–Retrospectively registered 

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01091-3.

Chronic, acute and protocol-dependent effects of exercise on psycho-physiological health during long-term isolation and confinement

Exercise could prevent physical and psychological deteriorations, especially during pandemic times of lock-down scenarios and social isolation. But to meet both, the common exercise protocols require optimization based on holistic investigations and with respect to underlying processes. This study aimed to explore individual chronic and acute effects of continuous and interval running exercise on physical and cognitive performance, mood, and affect and underlying neurophysiological factors during a terrestrial simulated space mission. Six volunteers (three females) were isolated for 120 days. Accompanying exercise training consisted of a continuous and interval running protocol in a cross-over design. Incremental stage tests on a treadmill were done frequently to test physical performance. Actigraphy was used to monitor physical activity level. Cognitive performance, mood (MoodMeter^®), affect (PANAS), brain-derived neurotrophic factor (BDNF), insulin-like growth factor 1 (IGF-1), vascular-endothelial growth factor (VEGF), and saliva cortisol were investigated prior to, four times during, and after isolation, pre- and post-exercise on two separate days, respectively. As a chronic effect, physical performance increased (and IGF-1 tended) in the course of isolation and training until the end of isolation. Subjective mood and affect state, as well as cognitive performance, basal BDNF and VEGF levels, were well-preserved across the intervention. No acute effects of exercise were detected, besides slower reaction time after exercise in two out of nine cognitive tests, testing sensorimotor speed and memory of complex figures. Consistently higher basal IGF-1 concentrations and faster reaction time in the psychomotor vigilance test were found for the continuous compared to the interval running protocol. The results suggest that 120 days of isolation and confinement can be undergone without cognitive and mental deteriorations. Regular, individual aerobic running training supporting physical fitness is hypothesized to play an important role in this regard. Continuous running exercise seems to trigger higher IGF-1 levels and vigilance compared to interval running. Systematic and prolonged investigations and larger sample size are required to follow up on exercise-protocol specific differences in order to optimize the exercise intervention for long-term psycho-physiological health and well-being.

Comparison of CT and adjusted MRI for evaluating paranasal sinuses surgical key landmarks

Background: Sinus CT is the imaging technique of choice for planning endoscopic sinus surgery (ESS). Although MRI has a better soft tissue demonstration, it is not commonly used for ESS due to suboptimal bone demonstration. We hypothesised that adjustment of certain MRI parameters, would allow better demonstration of bones and enable the surgeon to adequately identify surgical landmarks. Methodology: Twenty patients identified as candidates for ESS underwent CT and adjusted MRI exams of the paranasal sinuses (40 in total). rhinologist and a neuroradiologist independently compared and graded 46 bony structures (23 on each side) in each patient's CT and MRI. Overall, 920 anatomical structures were graded by each observer (1840 structures in total). Statistical analysis included overall and per variable grading distribution for each observer, and overall agreement. Results: MRI images were equal, or superior to CT for assessing paranasal anatomy in 66.8% and 86.4% of structures evaluated by the rhinologist and neuroradiologist, respectively. Overall agreement between observers (77%) was moderate. Conclusion: The rhinologist prefers CT demonstration of bony structures, while the neuroradiologist prefers MRI. Still, with the MRI protocol used in this study, according to both, most bony structures are well demonstrated by MRI.

Establishment of an induced pluripotent stem cell line DHMi005-A from a healthy male proband

We generated an induced pluripotent stem cell (iPSC) line from a healthy male 29-year-old proband. Adipose fibroblasts (AFs) were reprogrammed using Sendai virus. Generated iPSCs showed typical stem cell morphology. From passage 9 on, iPSCs were free of virus. Pluripotency in the iPSCs was verified and spontaneous differentiation showed expression of all three germ layers. Karyotyping indicated no anomalies for the generated iPSCs. Many patient-specific iPSCs are generated from subcutaneous fat fibroblasts obtained during surgical procedure. The described control iPSC line was generated equally and therefore serves as an ideal control for adipose-fibroblast-based patient-specific iPSC lines in disease modeling.

[Inappropriate systemic therapy in severe atopic dermatitis-severe long-term damage]

Die Therapiemöglichkeiten der schweren atopischen Dermatitis waren bis vor Kurzem sehr begrenzt und haben sich mit der Zulassung des ersten Biologikums Dupilumab Ende 2017 bis heute deutlich verbessert. Aktuell wurden mit dem Biologikum Tralokinumab sowie den Januskinase-Inhibitoren Baricitinib und Upadacitinib weitere neue Systemtherapeutika zugelassen. Dennoch gibt es Fälle, in denen es zur Nichtberücksichtigung moderner Behandlungsmöglichkeiten kommt, wie die Falldarstellung eines 28-jährigen Patienten mit schwerwiegenden Nebenwirkungen einer Langzeitbehandlung mit systemischen Glukokortikosteroiden zeigt. Neben der umfangreichen Abklärung der Folgeschäden, erfolgten die Einleitung einer leitliniengerechten Therapie mit Dupilumab sowie eine interdisziplinäre Zusammenarbeit mit Endokrinologen, Ophthalmologen, Osteologen und Ernährungsmedizinern.

Establishment of a patient-specific induced pluripotent stem cell line DHMi004-A from a male Holt-Oram syndrome patient with verified TBX5 mutation

The Holt-Oram syndrome (HOS) is a rare autosomal dominant disorder, mostly based on mutations in the TBX5 gene. Patients show malformation of at least one upper limb along with congenital heart defects. The established induced pluripotent stem cell (iPSC) line was generated from a patient displaying pronounced and typical features of HOS and carrying a single-nucleotide change c.920_C>A leading to an amino acid change from proline to threonine at amino acid position 85, which appeared de novo. Adipose fibroblasts from the patient were reprogrammed using Sendai virus. Pluripotency of the iPSCs was fully demonstrated.

Online computer or therapist-guided cognitive behavioral therapy in university students with anxiety and/or depression: study protocol of a randomised controlled trial

INTRODUCTION

Emerging adulthood is a phase in life that is associated with an increased risk to develop a variety of mental health disorders including anxiety and depression. However, less than 25% of university students receive professional help for their mental health reports. Internet-based cognitive behavioural therapy (iCBT) may entail useful interventions in a format that is attractive for university students. The aim of this study protocol is to test the effectiveness of a therapist-guided versus a computer-guided transdiagnostic iCBT programme with a main focus on anxiety and depression.

METHODS AND ANALYSIS

University students with anxiety and/or depressive symptoms will be randomised to a (1) 7-week iCBT programme (excluding booster session) with therapist feedback, (2) the identical iCBT programme with computer feedback only or (3) care as usual. Participants in the care as usual condition are informed and referred to conventional care services and encouraged to seek the help they need. Primary outcome variables are self-reported levels of anxiety as measured with the General Anxiety Disorder-7 and self-reported levels of depression as measured with the Patient Health Questionnaire-9. Secondary outcomes include treatment adherence, client satisfaction, medical service use, substance use, quality of life and academic achievement. Assessments will take place at baseline (t1), midtreatment (t2), post-treatment (t3), at 6 months (t4) and 12 months (t5) postbaseline. Social anxiety and perfectionism are included as potentially important predictors of treatment outcome. Power calculations are based on a 3 (group) × 3 (measurement: pretreatment, midtreatment and post-treatment) interaction, resulting in an aimed sample of 276 participants. Data will be analysed based on intention-to-treat and per protocol samples using mixed linear models.

ETHICS AND DISSEMINATION

The current study was approved by the Medical Ethics Review Committee (METC) of the Academic Medical Centre, Amsterdam, The Netherlands (number: NL64929.018.18). Results of this trial will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NL7328.

Do families have moderating or mediating effects on early health inequalities? A scoping review

Background

During early childhood, families have a crucial impact on children's health behaviour, health, and development (bhd). However, a family's socioeconomic position (SEP) determines both the parental behaviour, living conditions, and child health. To understand how family characteristics may influence the development of health inequalities, this scoping review synthesised research on their mediating and moderating effects.

Methods

The review followed the guidelines of the PRISMA Extension for Scoping Reviews. The search included German and English peer-reviewed articles published between January 1st, 2000 and December 19th, 2019. The search in PubMed, PsycINFO, and Scopus used both free text terms in the title/abstract and index terms within linked keyword blocks: (1) family characteristics, (2) inequalities, (3) income, education, occupation, (4) bhd, (5) newborn, infant, toddler, preschooler. Two researchers independently examined eligibility for inclusion in two rounds (title/abstract; full-text).

Results

Of 7,089 articles identified, ten sources were included that studied family characteristics and health inequalities among 0-6 years olds. Parental rules, stress, and screentime, and TV in bedroom showed mediating effects on inequalities in behaviour problems or children's screentime. Families' negativity, single parenthood, and the number of children in the household moderated differences in impairment, health, behaviour problems, development or breastfeeding initiation.

Conclusions

The effect of family characteristics on early health inequalities has been sparsely investigated. The evidence supported models of family stress and investment. Further research is needed to comprehensively understand this association.

Key messages

Family characteristics contribute to health inequalities. Taking families’ stress and investment into account could improve targeted prevention efforts aimed at reducing health inequalities.

ADP-receptor antagonists in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis

Purpose

The purpose of this pooled analysis is to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated with either clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor. Patients from the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial were included.

Methods and results

For the current analysis, the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. Eight hundred fifty-six patients were eligible for analysis. Of these, five hundred seven patients (59.2%) received clopidogrel, one hundred seventy-eight patients (20.8%) prasugrel and one hundred seventy-one patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60–1.09, padj=0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65–1.15, padj=0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20–0.69, padj=0.002) and not different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43–1.24, padj=0.24), see Table 1.

Conclusion

This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that an acute therapy with either clopidogrel, prasugrel or ticagrelor is no predictor of 1-year mortality. Treatment with ticagrelor seems to be associated with less in-hospital moderate and severe bleeding events in comparison to clopidogrel.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): German Heart FoundationEuropean Union 7th Framework Program

Interventional treatment of para-valvular leaks after prosthetic valve replacement with plug devices -first results from a prospective registry

Background

Interventional closure of symptomatic paravalvular leaks (PVL) after surgical or interventional valve replacement by plug implantation has emerged as an alternative to surgical correction, which is associated with high morbitity and mortality rates. To date, data on procedural efficacy and clinical outcome after transcatheter closure with plugs is sparse, especially prospective data are missing.

Methods

We analysed data from a multi-center prospective registry on interventional PVL closure with plug devices.

Results

Between 06/2012 and 04/2020 55 interventions were performed with different numbers of plugs (maximal 4) in 51 patients at 9 hospitals. Interventions were performed in 15 women and 36 men at high surgical risk for repeat surgery. 48% of procedures were performed for mitral PVLs and 52% procedures were performed for aortic PVLs. Mean age of the population treated was 69±13 years and mean log. Euro-Score I was 22.5±14.2%. Patients were treated by implantation of Amplatzer Vascular Plug III (80%) and Occlutec occluders (9%). Aortic PVLs were treated using a retrograde transfemoral access, mitral PVLs were treated using either a transseptal (25/26) or transapical access (1/26) with 3-dimensional transesophageal echocardiographic and fluoroscopic guidance. Indication for PVL closure was previous surgery (n=39), high-risk patients (n=24), heart failure (n=22), age (n=20) and hemolysis (n=12). 40 patients had NYHA class III/IV at admission. Interventional closure of PVL was completely successful in 40 procedures (73%), partially successful in 7 procedures (13%) and failed in 7 procedures (13%). NYHA class I/II after PVL closure was achieved in 75% patients. However, 8 out of 12 patients with hemolysis as indication still hemolyzed at discharge. Complications occurred in 16% of patients. In-hospital mortality rate was 4% of procedures (2/51). After hospital discharge no death occurred during 30-day follow-up.

Conclusions

In this prospective interventional PVL registry inclusion rate was lower than expected. There was an equal distribution of aortal and mitral PVLs. At least partial success could be achieved in 86% of patients, with significant functional improvement in most patients. In this high risk population hospital mortaliy was low (4%), indicating that interventional PVL treatment should be the treatment of choice, when discussed by a heart team.

Funding Acknowledgement

Type of funding sources: None.