Impact of Crisaborole in Treatment-Experienced Patients With Mild-to-Moderate Atopic Dermatitis

Background: Crisaborole ointment, 2%, is a nonsteroidal phosphodiesterase 4 inhibitor for the treatment of patients with mild-to-moderate atopic dermatitis (AD). Objective: To assess the efficacy and safety of crisaborole in patients with AD who had received prior treatment with (a) corticosteroids (systemic or topical) or topical calcineurin inhibitors (TCIs) or (b) topical corticosteroids (TCSs) or TCIs or (c) who were treatment-naive (TN). Methods: This post hoc analysis comprised patients aged ≥2 years with mild-to-moderate AD. Patients were assigned (2:1) to receive crisaborole or vehicle twice daily for 28 days. Patient response was assessed with the Investigator's Static Global Assessment (ISGA), Dermatology Life Quality Index (DLQI), Children's Dermatology Life Quality Index (CDLQI), and Dermatitis Family Impact (DFI) tools. Safety was also assessed. Results: A significantly higher percentage of patients treated with crisaborole versus vehicle achieved ISGA success regardless of treatment history. Patients treated with crisaborole had significant reductions in DLQI, CDLQI, and DFI scores versus those who received vehicle regardless of treatment history, with the exception of DLQI and DFI scores in the TN group. Crisaborole was well tolerated in all subgroups. Conclusion: Crisaborole demonstrated a favorable efficacy and safety profile in both treatment-experienced and TN patients. ClinicalTrials.gov, NCT02118766 and NCT02118792.

Aging and injury affect nuclear shape heterogeneity in tendon

Tissue level properties are commonly studied using histological stains assessed with qualitative scoring methods. As qualitative evaluation is typically insensitive, quantitative analysis provides additional information about pathological mechanisms, but cannot capture structural heterogeneity across cell subpopulations. However, molecular analyses of cell and nuclear behavior have identified that cell and more recently also nuclear shape are highly associated with cell function and malfunction. This study combined a Visually Aided Morpho-Phenotyping Image Recognition analysis that automatically segments cells based on their shape with an added capacity to further discriminate between cells in certain protein-rich extracellular matrix regions. We used tendon as a model system given the enormous changes in organization and cell and nuclear shape they undergo during aging and injury. Our results uncover that multiple shape modes of nuclei exist during maturity and aging in rat tendon and that distinct subgroups of cell nuclei shapes exist in proteoglycan-rich regions during aging. With injury, several immunomarkers (αSMA, CD31, CD146) were associated with more rounded shape modes. In human tendons, the cell nuclei at sites of injury were found to be more rounded relative to uninjured tissues. To conclude, the tendon tissue changes occurring during aging and injury could be associated with a variation in cell nuclear morphology and the appearance of various region-specific subpopulations. Thus, the methodologies developed allow for a deeper understanding of cell heterogeneity during tendon aging and injury and may be extended to study further clinical applications.

The Skin Barrier and Moisturization: Function, Disruption, and Mechanisms of Repair

BACKGROUND

The anatomic layers of the skin are well-defined, and a functional model of the skin barrier has recently been described. Barrier disruption plays a key role in several skin conditions, and moisturization is recommended as an initial treatment in conditions such as atopic dermatitis. This review aimed to analyze the skin barrier in the context of the function model, with a focus on the mechanisms by which moisturizers support each of the functional layers of the skin barrier to promote homeostasis and repair.

SUMMARY

The skin barrier is comprised of four interdependent layers - physical, chemical, microbiologic, and immunologic - which maintain barrier structure and function. Moisturizers target disruption affecting each of these four layers through several mechanisms and were shown to improve transepidermal water loss in several studies. Occlusives, humectants, and emollients occlude the surface of the stratum corneum (SC), draw water from the dermis into the epidermis, and assimilate into the SC, respectively, in order to strengthen the physical skin barrier. Acidic moisturizers bolster the chemical skin barrier by supporting optimal enzymatic function, increasing ceramide production, and facilitating ideal conditions for commensal microorganisms. Regular moisturization may strengthen the immunologic skin barrier by reducing permeability and subsequent allergen penetration and sensitization.

KEY MESSAGES

The physical, chemical, microbiologic, and immunologic layers of the skin barrier are each uniquely impacted in states of skin barrier disruption. Moisturizers target each of the layers of the skin barrier to maintain homeostasis and facilitate repair.

Isolated benign persistent proteinuria with novel association of CUBN (cubilin) variants

We present two siblings with persistent proteinuria and normal kidney function, each carrying the same compound heterozygous variants in the CUBN gene. The CUBN-related phenotype appears to be dependent upon both variant type and the domain site within the gene. Knowledge of CUBN status may allow for avoidance of invasive testing.

Burden, Control, and Treatment of Moderate to Severe Atopic Dermatitis in 2021: A United States Patient Survey Study

BACKGROUND

Recent data on unmet needs in the treatment of moderate to severe atopic dermatitis (AD) in the US are not available.

OBJECTIVE

To describe disease control, quality of life (QoL), and treatment satisfaction in a United States population with moderate-to-severe AD.

METHODS

Cross-sectional 2021 survey conducted among US patients recruited to an online survey from Kantar e-profiles, their panel partners, and Global Perspectives. Adults with self-reported, physician-diagnosed AD completed the primary survey. Of those reporting moderate to severe AD, a subset, including patients who “strongly disagreed,” “somewhat disagreed,” or were “neutral” on the statement “my eczema is adequately controlled” (“inadequately controlled”) with varying experience with approved biologic treatment (dupilumab), completed a second, enriched survey. Outcome measures evaluated included self-reported disease control and severity and validated measures including Patient-Oriented Scoring Atopic Dermatitis (PO-SCORAD), Dermatology Life Quality Index (DLQI), Recap of Atopic Eczema (RECAP), and Treatment Satisfaction Questionnaire for Medication (TSQM-9).

RESULTS

Of 3,285 patients who participated in the primary survey, 1,935 self-reported moderate-to-severe AD, 979 (51%) of whom reported inadequate control. A total of 371 completed the enriched survey, leading to an analytic sample with 87 controlled patients and 284 inadequately controlled patients (178/284 inadequately controlled patients never received dupilumab, 23 previously received it, and 83 were currently receiving it). Mean RECAP, PO-SCORAD, and DLQI scores were significantly worse (P<0.01) for inadequately controlled vs controlled patients: 7.26 vs 13.9; 38.3 vs 26.9; and 9.9 vs 7.0, respectively. Mean TSQM-9 scores for inadequately controlled vs controlled patients were significantly worse across all domains—effectiveness, convenience, and global satisfaction (P<0.01): 45.5 vs 69.5, 62.3 vs 72.5, 48.3 vs 69.3, respectively.

CONCLUSIONS AND RELEVANCE

This study found about half of the patients had inadequate control of their disease. This may partially be due to underuse of systemic biologics in eligible patients. There remains an unmet need for additional education on current and new systemic biologics that could allow patients to achieve better AD control, improved QoL, and greater overall treatment satisfaction. J Drugs Dermatol. 2023;22(2):119-131. doi:10.36849/JDD.7071.

Prognostic implications of NYHA class and NT-proBNP levels in mild heart failure: a PARADIGM-HF analysis

Background

Treatment recommendations for heart failure (HF) with reduced ejection fraction are primarily centered on New York Heart Association (NYHA) classification, such that apparently asymptomatic patients might not be eligible for disease-modifying therapies. NYHA classification, however, may be particularly limited to discriminate mild forms of HF.

Purpose

The present study aimed to determine the relationship between NYHA classification and an objective measure of HF severity (N-terminal pro–B-type natriuretic peptide [NT pro-BNP]), and their association with long-term prognosis in the PARADIGM-HF trial.

Methods

We compared PARADIGM-HF patients classified as NYHA class I, II, and III at randomization (NYHA class IV patients or with unavailable NYHA class were excluded [n=73]). We present kernel density estimation (KDE) plots–a non-parametric way to describe the underlying distribution of a variable–to compare NT-proBNP levels across NYHA classes. Logistic regression and the area under the receiver operating characteristic curve (AUC) were used to assess the ability to predict a patient's NYHA class using NT-proBNP levels. Time-to-event data were calculated with Kaplan–Meier estimates and NYHA class were further stratified by median baseline NT-proBNP (< or ≥1600 pg/ml). The primary outcome was cardiovascular death or first HF hospitalization.

Results

8326 patients were included in this analysis (median age, 64 years; women, 22%; and median left ventricular ejection fraction, 30%). Of 389 patients classified as NYHA class I at randomization, 228 (59%) changed functional class during the first year after randomization. For log-transformed NT-proBNP, KDE overlapped substantially across NYHA classes (Figure 1A). NT-proBNP levels were a poor predictor of NYHA classification: for NYHA class I vs. II, AUC (95% confidence interval [CI]) was 0.51 (0.48–0.54); for NHYA I vs. III, 0.57 (0.54–0.60); and for NYHA II vs. III, 0.56 (0.54–0.57). NYHA class III patients displayed a distinctively higher rate of cardiovascular deaths or first HF hospitalizations (Figure 1B). NYHA class I and II patients revealed lower event rates that were not significantly different (NYHA II vs. I, HR 1.24 [0.97–1.58]). Stratification by NT-proBNP levels identified subgroups with distinctive risk, such that NYHA I patients with high NT-proBNP levels (n=175) had a higher event rate than patients with low NT-proBNP with any NYHA class (Figure 1C).

Conclusion

NYHA class I and II patients overlapped substantially in objective HF measures and long-term prognosis. NYHA classification remains a powerful predictor of cardiovascular events but might be limited to differentiate mild forms of HF, as apparently asymptomatic patients based on physician-defined functional class might become symptomatic within a year and conceal subjects at substantial risk for adverse outcomes.

Funding Acknowledgement

Type of funding sources: None.

Point-of-care diagnostics: recent developments in a pandemic age

In this review, we provide an overview of developments in point-of-care (POC) diagnostics during the COVID-19 pandemic. We review these advances within the framework of a holistic POC ecosystem, focusing on points of interest - both technological and non-technological - to POC researchers and test developers. Technologically, we review design choices in assay chemistry, microfluidics, and instrumentation towards nucleic acid and protein detection for severe acute respiratory coronavirus 2 (SARS-CoV-2), and away from the lab bench, developments that supported the unprecedented rapid development, scale up, and deployment of POC devices. We describe common features in the POC technologies that obtained Emergency Use Authorization (EUA) for nucleic acid, antigen, and antibody tests, and how these tests fit into four distinct POC use cases. We conclude with implications for future pandemics, infectious disease monitoring, and digital health.

Proceeding report of the Fourth Symposium on Hidradenitis Suppurativa Advances 2019

The Fourth Annual Symposium on Hidradenitis Suppurativa (SHSA) took place on November 1-3, 2019, at the Westin Book Cadillac Hotel in Detroit, Michigan. This symposium was a joint meeting of the US Hidradenitis Suppurativa Foundation and the Canadian Hidradenitis Suppurativa Foundation. This cross-disciplinary meeting with experts from around the world was an opportunity to discuss the most recent advances in the study of hidradenitis suppurativa (HS) pathogenesis, clinical trials, classification, scoring systems, complementary/alternative medical treatments, diet, pain management, surgical and laser treatment, and ultrasonographic assessment. A special preconference workshop was held on the use of neodymium-doped yttrium-aluminum-garnet laser hair reduction, sinus tract deroofing, and carbon dioxide laser excision with ultrasonographic mapping and tumescent anesthesia for the treatment of HS. The focused workshops on establishing an HS clinic, setting up an HS support group, the Hidradenitis Suppurativa Prospective Observational Registry and Biospecimen Repository, and wound care were held during the meeting. A special program called HS Ambassadors was established for patients who may have questions about the conference presentations, and in addition, a meet and greet for patients and HS Ambassadors was arranged. To facilitate networking between those early in their careers and clinical and research experts, a mentoring reception was held.

Point-of-care, multispectral, smartphone-based dermascopes for dermal lesion screening and erythema monitoring

SIGNIFICANCE

The rates of melanoma and nonmelanoma skin cancer are rising across the globe. Due to a shortage of board-certified dermatologists, the burden of dermal lesion screening and erythema monitoring has fallen to primary care physicians (PCPs). An adjunctive device for lesion screening and erythema monitoring would be beneficial because PCPs are not typically extensively trained in dermatological care.

AIM

We aim to examine the feasibility of using a smartphone-camera-based dermascope and a USB-camera-based dermascope utilizing polarized white-light imaging (PWLI) and polarized multispectral imaging (PMSI) to map dermal chromophores and erythema.

APPROACH

Two dermascopes integrating LED-based PWLI and PMSI with both a smartphone-based camera and a USB-connected camera were developed to capture images of dermal lesions and erythema. Image processing algorithms were implemented to provide chromophore concentrations and redness measures.

RESULTS

PWLI images were successfully converted to an alternate colorspace for erythema measures, and the spectral bandwidth of the PMSI LED illumination was sufficient for mapping of deoxyhemoglobin, oxyhemoglobin, and melanin chromophores. Both types of dermascopes were able to achieve similar relative concentration results.

CONCLUSION

Chromophore mapping and erythema monitoring are feasible with PWLI and PMSI using LED illumination and smartphone-based cameras. These systems can provide a simpler, more portable geometry and reduce device costs compared with interference-filter-based or spectrometer-based clinical-grade systems. Future research should include a rigorous clinical trial to collect longitudinal data and a large enough dataset to train and implement a machine learning-based image classifier.

Navigating Targeted Therapeutics in Dermatology: Biologics and Small Molecules

Dermatology is entering an exciting era with new, targeted immune-modulating medications for treating a variety of dermatologic conditions including psoriasis, atopic dermatitis (AD), and hidradenitis suppurativa. Previously, mainstay treatments consisted of topical corticosteroids or broad systemic immunosuppressants. Recently, our understanding of cytokine signaling cascades has grown, presenting new opportunities to target skewed immune responses. Two major classes are biologics and small molecules. Herein, we highlight the similarities and differences between these two categories of targeted medications. J Drugs Dermatol. 2018;17(12):1330-1332.

Phase II study of single-agent copanlisib in patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL)

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Background: Relapsed/refractory (r/r) DLBCL patients (pts) are characterized by poor prognosis. Copanlisib is a pan-Class I phosphatidylinositol 3-kinase (PI3K) inhibitor, with modest single-agent activity in unselected DLBCL pts. Here we report the treatment effect of copanlisib in r/r DLBCL pts with regards to cell of origin (COO) and molecular biomarker profiles (NCT02391116). Methods: Patients with r/r DLBCL and ≥1 prior lines of therapy were eligible. Copanlisib (60 mg IV infusion) was administered on days 1, 8 and 15 of a 28-day cycle. Tumor samples were evaluated for COO, CD79B mutations and > 400 genes by next generation sequencing (NGS). The primary endpoint was objective tumor response rate (ORR; per Lugano Classification, 2014) by COO and CD79B status. Results: The full-analysis (FAS) and per-protocol sets (PPS; ≥3 doses, post-baseline scans and NGS/COO data) included 67 and 40 pts, respectively. Pts were 58% male, median age 69 (range 25-93), ECOG status 0/1/2 22%/57%/21%, and heavily pretreated (median prior lines = 3, range 1-13). In the PPS, COO (and mutant CD79B status) analysis identified 22 GCB DLBCL (2 mutant), 16 ABC DLBCL (6 mutant), and 2 unclassifiable. The ORR in the PPS was 25% (10 of 40), with 5 complete responses (CR) and 5 partial responses (PR); stable disease in 12 pts. The ORR was 13.6% with 1 CR in GCB pts and 37.5% with 4 CRs (25%) in ABC pts. Response to copanlisib was 25% in pts with (2/8) and without (8/32) CD79B mutations. Five of 10 ABC DLBCL-wtCD79B pts and one GCB DLBCL-mCD79B responded (ongoing > 17 cycles). NGS analysis in 54 pts detected 348 mutations; BCL2 (54% of pts), TP53 (41%), BCL6 (30%), MYC (22%), CD79B (19%)/A (6%), MYD88 (19%), TNFAIP3 (17%), CARD11 (13%), and NFKBIA (9%). Response to copanlisib was not significantly different based on BCL2, BCL6, MYC, and MYD88 mutations. With a median of 6 cycles (range 1-29), the most common AEs (% all grade/gr3+4) were diarrhea (36/2), nausea (31/2), fatigue (31/3), fever (21/2) and transient hypertension (40/33) and hyperglycemia (34/31). There were 14 gr5 AEs (none drug-related). Conclusions: Copanlisib treatment of r/r DLBCL pts resulted in encouraging responses, especially in the ABC subtype, with a manageable toxicity. Clinical trial information: NCT02391116.

Down-modulation of cancer targets using locked nucleic acid (LNA)-based antisense oligonucleotides without transfection

Usually, small interfering RNAs and most antisense molecules need mechanical or chemical delivery methods to down-modulate the targeted mRNA. However, these delivery approaches complicate the interpretations of biological consequences. We show that locked nucleic acid (LNA)-based antisense oligonucleotides (LNA-ONs) readily down-modulate genes of interest in multiple cell lines without any delivery means. The down-modulation of genes was quick, robust, long-lasting and specific followed by potent down-modulation of protein. The efficiency of the effect varied among the 30 tumor cell lines investigated. The most robust effects were found in those cells where nuclear localization of the LNA-ON was clearly observed. Importantly, without using any delivery agent, we demonstrated that HER3 mRNA and protein could be efficiently down-modulated in cells and a tumor xenograft model. These data provide a simple and efficient approach to identify potential drug targets and animal models. Further elucidation of the mechanism of cellular uptake and trafficking of LNA-ONs may enhance not only the therapeutic values of this platform but also antisense molecules in general.

Somatostatin receptors and the potential use of Sandostatin to interfere with vascular remodelling

Graft vessel disease (GVD) is a major cause of graft loss after the first year following transplantation. GVD is a complex, multifunctional process that involves immunological as well as non-immunological events such as ischaemia/reperfusion injury. An important target cell to interfere with the development of GVD is the smooth muscle cell (SMC). Somatostatin (SRIF) analogues have been shown previously to inhibit the proliferation of SMC in vitro and in vivo. We provide evidence that Sandostatin, an octapeptide SRIF analogue that is known to have anti-proliferative properties on SMC proliferation, inhibits vascular remodelling in a rat angioplasty model. Furthermore, in two allotransplantation models, Sandostatin effectively interferes with the development of signs of chronic rejection/GVD. The role of the different SRIF receptor subtypes in chronic graft rejection is currently under investigation.