Prostate Tumor Regression during Radiation Therapy in Relation to Image Derived Estimates of Fibrosis Using Ultrashort Echo Time MRI

PURPOSE/OBJECTIVE(S)

An inflammatory response due to radiation injury can lead to the activation of fibroblasts and their transformation into myofibroblasts that produce organized collagen layers. We term these organized collagen layers "acute fibrosis" (FA). Small animal imaging has shown that accumulation of fibrosis is accelerated at a higher radiation dose with later remodeling of type III collagen into densely packed type I collagen structures, which later transform into what we term "chronic fibrosis" (FC). In prostate cancer (PCa) patients treated with EBRT, we evaluated image derived FA (IDFA) and FC (IDFC) estimates using non-contrast and late gadolinium contrast enhanced (LGE) IR UTE, respectively. We hypothesized that fibrosis changes during RT are associated to tumor regression.

MATERIALS/METHODS

Four PCa patients undergoing radiation and hormone suppression were included. 1.5T MR imaging was acquired at three time-points (TPs); pre-RT, on-RT (30-40 Gy), and post-RT (60-78 Gy). IDFA imaging: Stack of spirals dual echo (TE = 50, 2690µs, TI = 60ms) IR UTE research application. Subtracting the two echoes yielded short TE signal intensity (SI). IDFC imaging: stack of spirals dual echo IR UTE research application, TE = 50µs, TI = 200ms, acquired 15 minutes following Gadovist administration. Remnant tumor was contoured at each TP with T2, ADC, and DCE. Relative quantification; IDFA = IR UTE SI/Gluteal Muscle SI and IDFC = LGE IR UTE SI/Gluteal Muscle SI. The sum of normalized IDFA and IDFC SI within the remnant tumor at each TP was divided by the corresponding tumor volume yielding tumor intensity (TI) FA and FC accumulation estimates: TIFA and TIFC. Mean delivered dose within the treated volume to regions where post-RT IDFA and IDFC > 100% gluteal muscle SI was determined. Univariate relationships were evaluated using correlation coefficients (r).

RESULTS

The coefficients of variation for TIFA = 10% and TIFC = 11%. IDFA and IDFC were observed pre-RT on the prostate gland periphery, and on RT and post RT within the prostate gland. IDFA and IDFC mean doses were 74% and 85% of prescription, respectively. Tumor regression was incomplete by post-RT. Initial tumor burden was inversely correlated with pre-RT TIFC (r = -0.98, p = .01). Tumor volume change post RT was inversely correlated with larger on-RT TIFA (r = -0.76) and post-RT TIFC (r = -0.78).

CONCLUSION

In this small pilot study, results suggest that IDFA and IDFC may be associated with improved tumor regression. They also suggest higher delivered dose is related to regions of greater IDFC. Quantitative fibrosis may be an early marker of RT response. Caution must be taken when interpreting these results given the small sample size. Future work will include a larger cohort of patients and include post-RT imaging.

Image Derived Estimates of Fibrosis Using Ultrashort Echo Time MRI in Gynecologic Cancer

PURPOSE/OBJECTIVE(S)

Fibrosis forms during and after radiation therapy (RT) due to wound-healing and cell death. In gynecologic cancer patients treated with EBRT and HDR, we evaluated image derived (ID) acute fibrosis (IDFA) and chronic fibrosis (IDFC) estimates using non-contrast and late gadolinium contrast enhanced (LGE) inversion recovery ultrashort echo time (IR UTE) MRI, respectively. We hypothesized that that ID markers can quantify FA and FC within tumor as a result of response to RT and that fibrosis changes over the course of RT are associated with tumor regression.

MATERIALS/METHODS

Subjects: Three subjects with cervical squamous cell carcinoma (SCC), 1 subject with cervical adenocarcinoma, and 2 subjects with vaginal SCC undergoing RT were included. Image Acquisition & Analysis: 1.5T MR imaging at four time-points (TPs): pre-RT, on-RT, post-RT, and post 3mo RT. IDFA imaging: Stack of spirals dual echo (TE = 50, 2690µs), TI = 60ms IR UTE research application. Subtracting the two echoes yielded short TE signal intensity (SI). IDFC imaging: stack of spirals dual echo IR UTE research application, TE = 50µs, TI = 200ms, acquired 15 minutes following contrast. Remnant tumor was contoured at each TP with T2, ADC, and DCE. Relative IDFA, IDFC quantification: voxel-wise IR UTE and LGE IR UTE signal intensity (SI) normalized to gluteal muscle SI. The sum of normalized IDFA and IDFC SI within the remnant tumor at each TP was divided by the corresponding tumor volume yielding tumor intensity (TI) TIFA and TIFC fibrosis accumulation estimates.

STATISTICS

The coefficients of variation (COV) for TIFA and TIFC were calculated by varying tumor margins and re-computing TIFA and TIFC. Univariate relationships were evaluated using linear regression.

RESULTS

The COVs for TIFA = 13% and TIFC = 7%. IDFA and IDFC were observed pre-RT on the tumor periphery, on-RT and post-RT within the tumor, with IDFA potentially transforming into IDFC. Table 1 shows that a greater decrease in tumor volume post RT was correlated with a larger pre-RT TIFA (r = -0.85, p = .03). Decrease in tumor volume was correlated with a larger TIFC post-RT (r = -0.79, p = .05). Post 3 month TIFC was associated with tumor reduction (r = 0.82, n = 4).

CONCLUSION

In this pilot study, we developed reproducible methods to quantify IDFA and IDFC within remnant tumor. Our results suggest that IDFA and IDFC may be associated with tumor response based on tumor volume.

Injurious pecking in organic turkey fattening-effects of husbandry and feeding on injuries and plumage damage of a slow- (Auburn) and a fast-growing (B.U.T.6) genotype

Injuries and plumage damage (PD) are important indicators of welfare. First priority in turkey fattening is to reduce injurious pecking, which includes aggressive pecking (agonistic behavior) and additionally severe feather pecking (SFP) and cannibalism with their multifactorial reasons. Still, there are few studies available evaluating different genotypes for their welfare status under organic conditions. The aim of this study was to investigate the effects of genotype and husbandry with 100% organic feeding (2 variants with different riboflavin content: V1 and V2) on injuries and PD. During rearing nonbeaktrimmed male turkeys of a slow- (Auburn, n = 256) and fast-growing (B.U.T.6, n = 128) genotype were kept in 2 indoor housing systems (without environmental enrichment (EE) = H1-, n = 144 and with EE = H2+, n = 240). During fattening 13 animals per pen of H2+ were relocated to a free-range system (H3 MS, n = 104). EE included pecking stones, elevated seating platforms and silage feeding. The study included five 4-wk feeding phases. At the end of each phase, injuries and PD were scored to assess animal welfare. Injury scores ranged from 0 (=no damage) to 3 (=severe damage) and PD from 0 to 4. Injurious pecking was observed from the 8th week onward (injuries: 16.5% and PD: 31.4%). Binary logistic regression models showed that both indicators were affected by genotype (each P < 0.001), husbandry (each P < 0.001), feeding (injuries P = 0.004; PD P = 0.003), and age (each P < 0.001). Auburn showed less injuries and PD than B.U.T.6. H1- had the fewest injuries and PD for Auburn animals compared to H2+ or H3 MS. In summary, the use of alternative genotypes (Auburn) in organic fattening improved welfare, but keeping them in free-range systems or in husbandry with EE, does not lead to a reduction of injurious pecking. Therefore, further studies are needed with more and changing enrichment materials, further management measures, changes in housing structure, and even more intensive animal care.

A systematic literature review of the economic and healthcare resource burden of cytomegalovirus

OBJECTIVE

Cytomegalovirus (CMV) can infect individuals at any age, including infants, who may contract it from infected mothers (congenital CMV [cCMV]). Whereas CMV infection is typically asymptomatic or causes mild illness in healthy individuals, infection can result in severe outcomes in immunocompromised individuals and in infants with cCMV. This systematic review aims to characterize the economic impact of CMV and cCMV infections.

METHODS

Medline, Embase, and LILACS databases were searched for publications reporting the economic impact of cCMV and CMV infections across all age groups. Manuscripts published between 2010 and 2020 from Australia, Latin America, Canada, Europe, Israel, Japan, the United States, and global (international, worldwide) studies were included; congress materials were excluded. Outcomes of interest included cCMV- and CMV-attributable direct costs/charges, resource utilization, and indirect/societal costs.

RESULTS

Of 751 records identified, 518 were excluded based on duplication, population, outcome, study design, or country. Overall, 55 articles were eligible for full-text review; 25 were further excluded due to population, outcome, study design, or congress abstract. Two publications were additionally identified, resulting in economic impact data compiled from 32 publications. Of these, 24 publications reported cost studies of cCMV or CMV, including evaluation of direct costs/charges, healthcare resource utilization, and indirect/societal costs, and 7 publications reported economic evaluations of interventions. The populations, methods and outcomes used across these studies varied widely.

CONCLUSIONS

CMV and cCMV infections impose a considerable economic impact on different countries, populations, and outcomes. There are substantial evidence gaps where further research is warranted.

[Current dermatology guidelines in Germany-selected recommendations from 2021 and 2022]

Guidelines are systematically developed decision-making aids to ensure appropriate clinical care for specific medical conditions. In Germany, dermatological guidelines are developed under the aegis of the German Dermatological Society (DDG) and the Professional Association of German Dermatologists (BVDD), while European and international guidelines are published by organisations such as the European Centre for Guidelines Development (EuroGuiDerm), founded by the European Dermatology Forum (EDF) in cooperation with the Division of Evidence-Based Medicine at Charité-Universitätsmedizin Berlin. In 2021 and 2022, the German guidelines were revised or developed on topics such as the management of anticoagulation during dermatological procedures, chronic pruritus, contact dermatitis, laser therapy of the skin, psoriasis vulgaris, rosacea, extracorporeal photopheresis, onychomycosis, mucous membrane pemphigoid and prevention of skin cancer. A selection of the most important recommendations and innovations in the guidelines is summarized here.

Photosensitisation and green egg yolks in laying hens caused by the feeding of ensiled alfalfa leaves

1. The present study was carried out to determine the effects of feeding ensiled alfalfa leaves (ALS) as an alternative protein source to laying hens under the terms of an organic diet. Due to the occurrence of unexpected negative health effects and undesirable egg yolk pigmentation in the test groups the trial was prematurely stopped and further analysis was conducted to evaluate the responsible substances.2. Body weights of the test groups decreased significantly already in week 2 of the trial. Performance variables dropped. Olive green pigmented egg yolks were found in groups fed diets containing ALS. Severe comb necrosis occurred in the experimental group receiving the highest level of ALS (20%) combined with the option of free-range access and therefore natural light exposure.3. The noxious agent found in ALS, blood serum and egg yolk was the photosensitising chlorophyll derivate pheophorbid a (PPBa), deriving from a strong depletion of chlorophyll contained in the alfalfa leaves. PPBa caused the olive-green pigmentation found in yolks and led to photosensitivity in groups with the highest level of ALS in the diet in combination with light exposure.4. By aiming for high protein and amino acid levels, harvesting and processing have, unintentionally and initially unnoticed, led to a strong accumulation of phototoxic PPBa. From these results it is strongly advised not to include ensiled alfalfa leaves as a protein source in organic laying hen diets.

A systematic literature review on the humanistic burden of cytomegalovirus

OBJECTIVE

Cytomegalovirus (CMV) infection is typically asymptomatic in healthy individuals; however, certain populations are vulnerable to infection and may develop serious sequelae. CMV infection may also have a broad impact on humanistic outcomes, including patient health status and quality of life (QoL). We conducted a systematic literature review (SLR) to describe the global humanistic burden of CMV and congenital CMV (cCMV) infections across all age groups.

METHODS

Medline, Embase, and LILACS were searched to identify studies on humanistic outcomes following CMV infection, including health status/QoL and any outcomes in domains such as auditory, cognitive ability, developmental status, intelligence, language, memory, mental health, motor performance, social communication, speech, and vocabulary. The SLR included articles published from 2000-2020 and focused geographically on Australia, Europe, Israel, Japan, Latin America, and North America.

RESULTS

Sixty-three studies met the inclusion criteria. In general, individuals with symptomatic cCMV infection experience a greater burden of disease and more substantial impact on QoL versus those with asymptomatic cCMV infection. Children with hearing loss due to cCMV infection, both symptomatic and asymptomatic, showed improved auditory outcomes following cochlear implantation. Newborns, infants, and children with cCMV infections had worse cognitive outcomes in psychological development, sequential and simultaneous processing, phonological working memory, and attention control versus age-matched controls without cCMV infection. CMV infection was also associated with cognitive decline in elderly populations.

CONCLUSIONS

CMV infection can have substantial, lifelong, heterogenous impacts on humanistic outcomes, including health status and QoL, which should be considered when developing and implementing treatment and prevention strategies.

Onset of epidermolysis bullosa acquisita under therapy with ustekinumab for the treatment of Crohn disease

A 32-year-old man with a long history of Crohn disease was put on ustekinumab, and after about 1 year of treatment, developed blisters and inflammatory lesions. He was diagnosed with epidermolysis bullosa acquisita and treated with dapsone.

[Fracture sequelae type 2 of the proximal humerus-clinical results after arthroplasty]

Locked dislocations of the glenohumeral joint are rare but often painful and are associated with limited range of motion in the shoulder. In patients of advanced age, arthroplasty is increasingly indicated as a surgical treatment option. Preoperatively, the direction of dislocation, the presence and extent of a glenoid defect, and the soft tissue situation (rotator cuff status, joint capsule) should be analyzed in a differentiated manner. Based on the above factors, we recommend the subclassification of type 2 according to Boileau: posterior locked dislocation (2a), anterior locked dislocation without glenoid defect (2b), and anterior locked dislocation with glenoid defect (2c). In the case of dorsally locked dislocation, a good clinical result can be achieved by using an anatomical endoprosthesis. For ventrally locked dislocations, we recommend using an inverse total endoprosthesis with, if necessary, bony glenoid reconstruction and transfer of the pectoralis major muscle.Level of evidence: IV.

A systematic literature review of the global seroprevalence of cytomegalovirus: possible implications for treatment, screening, and vaccine development

Background

Cytomegalovirus (CMV) is a common pathogen that affects individuals of all ages and establishes lifelong latency. Although CMV is typically asymptomatic in healthy individuals, infection during pregnancy or in immunocompromised individuals can cause severe disease. Currently, treatments are limited, with no prophylactic vaccine available. Knowledge of the current epidemiologic burden of CMV is necessary to understand the need for treatment and prevention. A systematic literature review (SLR) was conducted to describe the most recent epidemiologic burden of CMV globally.

Methods

Medline, Embase, and LILACS were searched to identify data on CMV prevalence, seroprevalence, shedding, and transmission rates. The SLR covered the time period of 2010–2020 and focused geographically on Australia, Europe, Israel, Japan, Latin America (LATAM), and North America. Studies were excluded if they were systematic or narrative reviews, abstracts, case series, letters, or correspondence. Studies with sample sizes < 100 were excluded to focus on studies with higher quality of data.

Results

Twenty-nine studies were included. Among adult men, CMV immunoglobulin G (IgG) seroprevalence ranged from 39.3% (France) to 48.0% (United States). Among women of reproductive age in Europe, Japan, LATAM, and North America, CMV IgG seroprevalence was 45.6-95.7%, 60.2%, 58.3-94.5%, and 24.6-81.0%, respectively. Seroprevalence increased with age and was lower in developed than developing countries, but data were limited. No studies of CMV immunoglobulin M (IgM) seroprevalence among men were identified. Among women of reproductive age, CMV IgM seroprevalence was heterogenous across Europe (1.0-4.6%), North America (2.3-4.5%), Japan (0.8%), and LATAM (0-0.7%). CMV seroprevalence correlated with race, ethnicity, socioeconomic status, and education level. CMV shedding ranged between 0% and 70.2% depending on age group. No findings on CMV transmission rates were identified.

Conclusions

Certain populations and regions are at a substantially higher risk of CMV infection. The extensive epidemiologic burden of CMV calls for increased efforts in the research and development of vaccines and treatments.

Trial registration

N/A.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13971-7.

Updated S2 K guidelines for the management of bullous pemphigoid initiated by the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or, most frequently, generalized bullous lesions. A subset of patients only develops excoriations, prurigo-like lesions, and eczematous and/or urticarial erythematous lesions. The disease, which is significantly associated with neurological disorders, has high morbidity and severely impacts the quality of life.

OBJECTIVES AND METHODOLOGY

The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology sought to update the guidelines for the management of BP based on new clinical information, and new evidence on diagnostic tools and interventions. The recommendations are either evidence-based or rely on expert opinion. The degree of consent among all task force members was included.

RESULTS

Treatment depends on the severity of BP and patients' comorbidities. High-potency topical corticosteroids are recommended as the mainstay of treatment whenever possible. Oral prednisone at a dose of 0.5 mg/kg/day is a recommended alternative. In case of contraindications or resistance to corticosteroids, immunosuppressive therapies, such as methotrexate, azathioprine, mycophenolate mofetil or mycophenolate acid, may be recommended. The use of doxycycline and dapsone is controversial. They may be recommended, in particular, in patients with contraindications to oral corticosteroids. B-cell-depleting therapy and intravenous immunoglobulins may be considered in treatment-resistant cases. Omalizumab and dupilumab have recently shown promising results. The final version of the guideline was consented to by several patient organizations.

CONCLUSIONS

The guidelines for the management of BP were updated. They summarize evidence- and expert-based recommendations useful in clinical practice.

Cichlids and stingrays can add and subtract 'one' in the number space from one to five

The numerical understanding of cichlids and stingrays was examined regarding addition and subtraction abilities within the number space of one to five. Experiments were conducted as two-alternative forced-choice experiments, using a delayed matching to sample technique. On each trial, fish had to perform either an addition or subtraction, based on the presentation of two-dimensional objects in two distinct colors, with the color signaling a particular arithmetic process. Six cichlids and four stingrays successfully completed training and recognized specific colors as symbols for addition and subtraction. Cichlids needed more sessions than stingrays to reach the learning criterion. Transfer tests showed that learning was independent of straightforward symbol memorization. Individuals did not just learn to pick the highest or lowest number presented based on the respective color; instead, learning was specific to adding or subtracting ‘one’. Although group results were significant for both species in all tests, individual results varied. Addition was learned more easily than subtraction by both species. While cichlids learned faster than stingrays, and more cichlids than stingrays learned the task, individual performance of stingrays exceeded that of cichlids. Previous studies have provided ample evidence that fish have numerical abilities on par with those of other vertebrate and invertebrate species tested, a result that is further supported by the findings of the current study.

Mast cell‐deficient mice Mcpt5Cre/Dicer fl/fl redefine the role of mast cells in experimental bullous pemphigoid

Background

Bullous pemphigoid (BP) is the most frequent autoimmune blistering disease of the skin affecting the elderly. BP is immunopathologically characterized by autoantibodies against BP180 and BP230. With the growing evidence of cell‐mediated autoimmunity in the pathogenesis of BP, it still remains unclear whether mast cells (MCs) are involved, due to conflicting data obtained from Kit‐dependent MC‐deficient mouse models.

Objectives

To clarify the role of MCs in experimental BP; the dynamics in cutaneous MC numbers, associated immune cells and the development of disease in Kit‐independent MC‐deficient mouse model.

Methods

Employing a recently established murine adult passive transfer model of BP induced by the transfer of pathogenic immunoglobulin G (IgG), lesional skin biopsies were investigated histologically and immunohistochemically for the time‐dependent MC accumulation and dermal infiltration.

Results

The numbers of cutaneous MCs increased following the induction of BP, in part, maintained by MC proliferation. Numbers of T cells, neutrophils and eosinophils in the skin also increased after BP induction, with eosinophils showing a preferential co‐localization with MCs. Furthermore, clinical disease manifestation in MC‐deficient Mcpt5Cre/Dicer^fl/fl mice remained unchanged compared to MC‐sufficient Dicer^fl/fl mice. The composition of the immune cell infiltration including as T cells, neutrophils and eosinophils was largely unaffected by the absence of MCs.

Conclusion

MCs do not play a pivotal role in the pathogenesis of passive IgG‐transfer mediated BP model. Their increase in number may be a bystander effect following tissue injury. We therefore suggest caution regarding the selection of MCs as sole targets for the development of novel drugs for BP.

1190. Burden of Congenital Cytomegalovirus Among Newborns/Infants &lt; 2 Years of Age From 2010 to 2020

Background

Congenital cytomegalovirus (cCMV) is a leading cause of preventable congenital birth defects worldwide. In the United States, approximately 1 in 200 infants are born with cCMV and about 10% exhibit symptoms at birth; of those, 40-60% experience long-term sequelae including sensorineural hearing loss and developmental delays. As routine newborn surveillance is universally absent, it is difficult to assess the absolute burden of cCMV and demonstrate the need for CMV treatment and prevention. Here we describe the global epidemiologic burden of cCMV from 2010-2020 by performing a systematic review of the literature.

Methods

Publications from 2000-2020 on CMV-related epidemiologic, economic, and humanistic burden across all ages were identified using Medline, Embase, and LILACS. Epidemiologic burden estimates of cCMV in at-risk age groups (newborns [≤ 1 month] and infants [2 months to 2 years]) were extracted from recent studies published from 2010-2020, excluding previous systematic literature reviews, chart reviews, case series, gray literature, and studies in immunosuppressed populations. The primary outcome measure was seroprevalence, defined by CMV-specific immunoglobulin G titer or confirmed by CMV polymerase chain reaction in saliva or urinary samples.

Results

Of 8970 records on CMV epidemiologic burden across all ages, 3600 were screened (Fig. 1). Records were excluded based on study population, outcome, design, or other reason, yielding 157 articles; 24 reported cCMV infection in newborns/infants in 13 countries (Fig. 2). cCMV seroprevalence estimates differed based on type of screening (Fig. 3). cCMV seroprevalence ranged from 0.28-67.2% among publications reporting on universal screening (n=6), 0.6-29.2% among publications reporting on targeted screening (n=17) based on hearing loss, low birth weight, or small for gestational age, and 36.0% in one publication reporting on prenatal screening.

Figure 1. Study selection for epidemiological burden

Conclusion

There is a worldwide lack of cCMV epidemiologic data with heterogeneity in seroprevalence, influenced by inconsistent and varied screening efforts. Implementation of consistent screening methods is essential to accurately describe the burden of cCMV, justify future vaccine (or other prevention or treatment) introduction, and measure impact.

Disclosures

Jacek Mucha, MS, Certara (Employee) Neumann Monika, Information Specialist, Certara (Employee) Witold Lewandowski, MD, BA, Certara (Other Financial or Material Support, Former employee during abstract development)Tata Consultancy Services (Employee) Magdalena Kaczanowska, MPH, Certara (Employee) Elvira Schmidt, MSc, Certara (Employee) Andrew Natenshon, MA, Moderna, Inc. (Employee) Carla Talarico, MPH, PhD, Moderna, Inc. (Employee) Philip Buck, MPH, PhD, Moderna, Inc. (Employee) John D. Diaz-Decaro, MS, PhD, Moderna, Inc. (Employee)

Prevention of measles, mumps and rubella: 40 years of global experience with M-M-RII

Measles, mumps, and rubella are highly contagious diseases that caused significant global mortality and morbidity in the pre-vaccine era. Since its first approval in the United States over 40 years ago, M-M-R_II has been used in >75 countries for prevention of these diseases. The vaccine has been part of immunization programs that have achieved dramatic global reductions in case numbers and mortality rates, as well as the elimination of measles and rubella in several countries and regions. This report summarizes over four decades of global safety, immunogenicity, efficacy, and effectiveness data for the vaccine. We include studies on the use of M-M-R_II in different age groups, concomitant use with other routine childhood vaccines, administration via different routes, persistence of immunity, and vaccine effectiveness during outbreaks of measles and mumps. We conclude that M-M-R_II is well tolerated and has shown consistently high performance during routine use in multiple countries, in randomized controlled trials with diverse designs, and in outbreak settings, including use as measles postexposure prophylaxis. Physicians, parents, and the public can continue to have a high degree of confidence in the use of M-M-R_II as a vital part of global public health programs.

Treatment of pemphigus vulgaris and foliaceus with efgartigimod, a neonatal Fc receptor inhibitor: a phase II multicentre, open-label feasibility trial

BACKGROUND

Pemphigus vulgaris and pemphigus foliaceus are potentially life-threatening autoimmune disorders triggered by IgG autoantibodies against mucosal and epidermal desmogleins. There is an unmet need for fast-acting drugs that enable patients to achieve early sustained remission with reduced corticosteroid reliance.

OBJECTIVES

To investigate efgartigimod, an engineered Fc fragment that inhibits the activity of the neonatal Fc receptor, thereby reducing serum IgG levels, for treating pemphigus.

METHODS

Thirty-four patients with mild-to-moderate pemphigus vulgaris or foliaceus were enrolled in an open-label phase II adaptive trial. In sequential cohorts, efgartigimod was dosed at 10 or 25 mg kg^-1 intravenously with various dosing frequencies, as monotherapy or as add-on therapy to low-dose oral prednisone. Safety endpoints comprised the primary outcome. The study is registered at ClinicalTrials.gov (identifier NCT03334058).

RESULTS

Adverse events were mostly mild and were reported by 16 of 19 (84%) patients receiving efgartigimod 10 mg kg^-1 and 13 of 15 (87%) patients receiving 25 mg kg^-1 , with similar adverse event profiles between dose groups. A major decrease in serum total IgG and anti-desmoglein autoantibodies was observed and correlated with improved Pemphigus Disease Area Index scores. Efgartigimod, as monotherapy or combined with prednisone, demonstrated early disease control in 28 of 31 (90%) patients after a median of 17 days. Optimized, prolonged treatment with efgartigimod in combination with a median dose of prednisone 0·26 mg kg^-1 per day (range 0·06-0·48) led to complete clinical remission in 14 of 22 (64%) patients within 2-41 weeks.

CONCLUSIONS

Efgartigimod was well tolerated and exhibited an early effect on disease activity and outcome parameters, providing support for further evaluation as a therapy for pemphigus.

European Guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part II

This guideline has been initiated by the task force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology, including physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline that systematically reviewed the literature on mucous membrane pemphigoid (MMP) in the MEDLINE and EMBASE databases until June 2019, with no limitations on language. While the first part of this guideline addressed methodology, as well as epidemiology, terminology, aetiology, clinical presentation and outcome measures in MMP, the second part presents the diagnostics and management of MMP. MMP should be suspected in cases with predominant mucosal lesions. Direct immunofluorescence microscopy to detect tissue-bound IgG, IgA and/or complement C3, combined with serological testing for circulating autoantibodies are recommended. In most patients, serum autoantibodies are present only in low levels and in variable proportions, depending on the clinical sites involved. Circulating autoantibodies are determined by indirect IF assays using tissue substrates, or ELISA using different recombinant forms of the target antigens or immunoblotting using different substrates. The major target antigen in MMP is type XVII collagen (BP180), although in 10-25% of patients laminin 332 is recognized. In 25-30% of MMP patients with anti-laminin 332 reactivity, malignancies have been associated. As first-line treatment of mild/moderate MMP, dapsone, methotrexate or tetracyclines and/or topical corticosteroids are recommended. For severe MMP, dapsone and oral or intravenous cyclophosphamide and/or oral corticosteroids are recommended as first-line regimens. Additional recommendations are given, tailored to treatment of single-site MMP such as oral, ocular, laryngeal, oesophageal and genital MMP, as well as the diagnosis of ocular MMP. Treatment recommendations are limited by the complete lack of high-quality randomized controlled trials.

European guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part I

This guideline on mucous membrane pemphigoid (MMP) has been elaborated by the Task Force for Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology (EADV) with a contribution of physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline encompassing a systematic review of the literature until June 2019 in the MEDLINE and EMBASE databases. This first part covers methodology, the clinical definition of MMP, epidemiology, MMP subtypes, immunopathological characteristics, disease assessment and outcome scores. MMP describes a group of autoimmune skin and mucous membrane blistering diseases, characterized by a chronic course and by predominant involvement of the mucous membranes, such as the oral, ocular, nasal, nasopharyngeal, anogenital, laryngeal and oesophageal mucosa. MMP patients may present with mono- or multisite involvement. Patients' autoantibodies have been shown to be predominantly directed against BP180 (also called BPAG2, type XVII collagen), BP230, laminin 332 and type VII collagen, components of junctional adhesion complexes promoting epithelial stromal attachment in stratified epithelia. Various disease assessment scores are available, including the Mucous Membrane Pemphigoid Disease Area Index (MMPDAI), the Autoimmune Bullous Skin disorder Intensity Score (ABSIS), the 'Cicatrising Conjunctivitis Assessment Tool' and the Oral Disease Severity Score (ODSS). Patient-reported outcome measurements (PROMs), including DLQI, ABQOL and TABQOL, can be used for assessment of quality of life to evaluate the effectiveness of therapeutic interventions and monitor disease course.

International multicentre observational study to assess the efficacy and safety of a 0·5 mg kg-1 per day starting dose of oral corticosteroids to treat bullous pemphigoid

BACKGROUND

European guidelines propose a 0·5 mg kg^-1 per day dose of oral prednisone as initial treatment for bullous pemphigoid (BP). We assessed the safety and efficacy of this regimen depending on BP extent and general condition of the patients.

METHODS

In a prospective international study, we consecutively included all patients diagnosed with BP. Patients received a 0·5 mg kg^-1 per day dose of prednisone, which was then gradually tapered 15 days after disease control, with the aim of stopping prednisone or maintaining minimal treatment (0·1 mg kg^-1 per day) within 6 months after the start of treatment. The two coprimary endpoints were control of disease activity at day 21 and 1-year overall survival. Disease severity was assessed according to the Bullous Pemphigoid Disease Area Index (BPDAI) score.

RESULTS

In total, 198 patients were included between 2015 and 2017. The final analysis comprised 190 patients with a mean age of 80·9 (SD 9·1) years. Control of disease activity was achieved at day 21 in 119 patients [62·6%, 95% confidence interval (CI) 55·3-69.5]; 18 of 24 patients (75%, 95% CI 53·3-90·2), 75 of 110 patients (68·8%, 95% CI 59·2-77·3) and 26 of 56 patients (46.4%, 95% CI 33·0-60·3) had mild, moderate and severe BP, respectively (P = 0·0218). A total of 30 patients died during the study. The overall Kaplan-Meier 1-year survival was 82·6% (95% CI 76·3-87·4) corresponding to 90·9%, 83·0% and 80·0% rates in patients with mild, moderate and severe BP, respectively (P = 0·5). Thresholds of 49 points for BPDAI score and 70 points for Karnofsky score yielded maximal Youden index values with respect to disease control at day 21 and 1-year survival, respectively.

CONCLUSIONS

A 0·5 mg kg^-1 per day dose of prednisone is a valuable therapeutic option in patients with mild or moderate BP whose general condition allows them to be autonomous.

The burden of neurological comorbidities in six autoimmune bullous diseases: a population-based study

BACKGROUND

Apart from bullous pemphigoid (BP), the association of other autoimmune bullous diseases (AIBDs) with neurological conditions is poorly understood.

OBJECTIVE

To estimate the association between a wide array of AIBDs and neurological conditions.

METHODS

A retrospective cross-sectional study recruited patients with BP, mucous membrane pemphigoid (MMP), epidermolysis bullosa acquisita (EBA), pemphigoid gestationis (PG), pemphigus vulgaris (PV) and pemphigus foliaceus (PF). These patients were compared with their age- and sex-matched control subjects with regard to the lifetime prevalence of Parkinson's disease (PD), Alzheimer's disease (AD), stroke, epilepsy and multiple sclerosis (MS). Logistic regression was used to calculate OR for specified neurological disorders.

RESULTS

The current study included 1743, 251, 106, 126, 860 and 103 patients diagnosed with BP, MMP, EBA, PG, PV and PF, respectively. These patients were compared with 10 141, 1386, 606, 933, 5142 and 588 matched controls, respectively. Out of the investigated neurological conditions, PD associated with BP (OR, 2.71; 95% CI, 2.19-3.35); AD with BP (OR, 2.11; 95% CI, 1.73-2.57), MMP (OR, 2.37; 95% CI, 1.03-5.47), EBA (OR, 6.00; 95% CI, 1.90-18.97) and PV (OR, 2.24; 95% CI, 1.40-3.60); stroke with BP (OR, 1.84; 95% CI, 1.55-2.19) and EBA (OR, 2.79; 95% CI, 1.11-7.01); and epilepsy with BP (OR, 2.18; 95% CI, 1.72-2.77) and PV (OR, 1.80; 95% CI, 1.19-2.73). MS did not significantly cluster with any of the six AIBDs.

CONCLUSION

In addition to BP, EBA and PV were found to cluster with neurological comorbidities. Patients with these AIBDs with compatible symptoms may be carefully assessed for comorbid neurological disorders.

The impact of lesional inflammatory cellular infiltrate on the phenotype of bullous pemphigoid

BACKGROUND

The influence of cutaneous cellular infiltration on the phenotype of bullous pemphigoid (BP) remains to be established.

OBJECTIVES

To evaluate the main histopathological characteristics of patients with BP and to assess the association between the composition of lesional inflammatory infiltrate and the various clinical, immunological and immunopathological aspects of the disease.

METHODS

Retrospective study encompassing patients diagnosed with BP throughout the years 2009-2020 in a specialized tertiary referral centre.

RESULTS

The study encompassed 136 patients with BP, of whom 27 (19.9%) demonstrated a cell-poor inflammatory infiltrate in lesional skin specimens. Overall, 78 (57.4%), 71 (52.2%) and 5 (3.7%) specimens were found to include eosinophil-predominant, lymphocyte-predominant and neutrophil-predominant inflammatory infiltrates, respectively. Relative to the remaining patients with BP, those with an eosinophil-predominant inflammatory infiltrate had higher (90.8% vs. 77.2%; P = 0.030) whilst those with a cell-poor inflammatory infiltrate lower (70.3% vs. 88.7%; P = 0.017) seropositivity of anti-BP180 NC16A IgG. The latter subgroup presented with higher prevalence of mucosal involvement (25.9% vs. 8.3%; P = 0.011) and a non-inflammatory clinical phenotype (50.0% vs. 17.1%; P = 0.041). Patients with lymphocyte-predominant inflammatory infiltrate manifested with higher severity BPDAI scores and a lower frequency of the non-inflammatory subtype (11.1% vs. 36.4%; P = 0.035), whilst those with a neutrophilic infiltrate presented with lower mean (SD) levels of anti-BP180 NC16A IgG [269.3 (227.6) vs. 722.7 (1499.6) U/mL; P = 0.003].

CONCLUSIONS

Eosinophil-predominance and high cellularity in the lesional inflammatory infiltrate of BP skin are associated with increased seropositivity of anti-BP180 NC16A IgG. Lymphocyte-predominant infiltrates predict a more severe phenotype, pointing towards a pathogenic role of autoreactive lymphocytes.

Use of M-M-R II outside of the routinely recommended age range - a systematic literature review

M-M-R®_II (M-M-R II) is routinely used in many countries at 12–15 months with a second dose at 4 to 6 years of age. However, the vaccine may need to be administered at other ages due to delays in the immunization schedule or in certain situations such as outbreaks or international travel. A systematic literature review was conducted to evaluate efficacy, immunogenicity and safety of M-M-R II among 6- to 11-month-olds and persons ≥7 years of age. A search for randomized controlled trials (RCTs) was conducted in 2019 including Medline, Embase and Cochrane CENTRAL. Only one study reported seroconversion rates after one dose in infants at 9 months of age: 87.4% (measles), 92.3% (mumps), and 91.2% (rubella); no safety data were reported. Seven studies reported immunogenicity and safety data for M-M-R II at ≥7 years of age. Seroconversion rates ranged from 96%-100% (measles), 65%-100% (mumps), and 91%-100% (rubella). Rates of selected adverse events ranged from 5.2%-8.7% for fever (≥38°C or ≥38.1°C), 2%-33.3% for injection site reactions, and 0.4% for measles/rubella-like rash (one study). No efficacy studies were found. This literature review identified RCTs with evidence to support that M-M-R II is immunogenic and well tolerated in individuals ≥7 years of age.

Ca2+ signalling is critical for autoantibody-induced blistering of human epidermis in pemphigus

BACKGROUND

Pemphigus is a severe bullous autoimmune skin disease. Pemphigus foliaceus (PF) is characterized by antidesmoglein (Dsg) 1 IgG causing epidermal blistering; mucosal pemphigus vulgaris (mPV) by anti-Dsg3 IgG inducing erosions in the mucosa; and mucocutaneous pemphigus vulgaris (PV) by affecting both, with autoantibodies targeting Dsg1 and Dsg3.

OBJECTIVES

To characterize the Ca²⁺ flux pathway and delineate its importance in pemphigus pathogenesis and clinical phenotypes caused by different antibody profiles.

METHODS

Immunoprecipitation, Ca²⁺ flux analysis, Western blotting, immunofluorescence staining, dissociation assays and a human skin ex vivo model were used.

RESULTS

PV IgG and PF IgG, but neither Dsg3-specific monoclonal antibody (AK23) nor mPV IgG, caused Ca²⁺ influx in primary human keratinocytes. Phosphatidylinositol 4-kinase α interacts with Dsg1 but not with Dsg3. Its downstream target - phospholipase-C-γ1 (PLC) - was activated by PV IgG and PF IgG but not AK23 or mPV IgG. PLC releases inositol 1,4,5-trisphosphate (IP3) causing IP3 receptor (IP3R) activation and Ca²⁺ flux from the endoplasmic reticulum into the cytosol, which stimulates Ca²⁺ release-activated channels (CRAC)-mediated Ca²⁺ influx. Inhibitors against PLC, IP3R and CRAC effectively blocked PV IgG and PF IgG-induced Ca²⁺ influx; ameliorated alterations of Dsg1 and Dsg3 localization, and reorganization of keratin and actin filaments; and inhibited loss of cell adhesion in vitro. Finally, inhibiting PLC or IP3R was protective against PV IgG-induced blister formation and redistribution of Dsg1 and Dsg3 in human skin ex vivo.

CONCLUSIONS

Ca²⁺ -mediated signalling is important for epidermal blistering and dependent on the autoantibody profile, which indicates different roles for signalling complexes organized by Dsg1 and Dsg3. Interfering with PLC and Ca²⁺ signalling may be a promising approach to treat epidermal manifestations of pemphigus.

S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV)

INTRODUCTION

Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH.

METHODS

The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF).

RESULTS

The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix).

CONCLUSION

These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.

Patterns of integrating palliative care into standard oncology in an early ESMO designated center: a 10-year experience

BACKGROUND

Integration of specialist palliative care (PC) into standard oncology care is recommended. This study investigated how integration at the Cantonal Hospital St. Gallen (KSSG) was manifested 10 years after initial accreditation as a European Society for Medical Oncology (ESMO) Designated Center (ESMO-DC) of Integrated Oncology and Palliative Care.

METHODS

A chart review covering the years 2006-2009 and 2016 was carried out in patients with an incurable malignancy receiving PC. Visual graphic analysis was utilized to identify patterns of integration of PC into oncology based on the number and nature of medical consultations recorded for both specialties. A follow-up cohort collected 10 years later was analyzed and changes in patterns of integrating specialist PC into oncology were compared.

RESULTS

Three hundred and forty-five patients from 2006 to 2009 and 64 patients from 2016 were included into analyses. Four distinct patterns were identified using visual graphic analysis. The 'specialist PC-led pattern' (44.9%) and the 'oncology-led pattern' (20.3%) represent disciplines that took primary responsibility for managing patients, with occasional and limited involvement from other disciplines. Patients in the 'concurrent integrated care pattern' (18.3%) had medical consultations that frequently bounced between specialist PC and oncology. In the 'segmented integrated care pattern' (16.5%), patients had sequences of continuous consultations provided by one discipline before alternating to a stretch of consultations provided by the other specialty. In the 2016 follow-up, while the 'oncology-led pattern' occurred significantly less frequently relative to the 'specialist PC-led pattern' and the 'segmented integrated care pattern', the 'concurrent integrated care pattern' emerged more frequently when compared with the 2006-2009 follow-up.

CONCLUSION

The 'specialist PC-led pattern' was the most prominent pattern in this data. The 2016 follow-up showed that a growing number of patients received a collaborative pattern of care, indicating that integration of specialist PC into standard oncology can manifest as either segmented or concurrent care pathways. Our data suggest a closer, more dynamic and flexible collaboration between oncology and specialist PC early in the disease course of patients with advanced cancer and concurrent with active treatment.

Coexistence of bullous pemphigoid with neuropsychiatric comorbidities is associated with anti-BP230 seropositivity

BACKGROUND

While clustering of bullous pemphigoid (BP) with neuropsychiatric diseases is well-established, the clinical and immunological profile of BP patients with this comorbidity remains to be decisively determined.

OBJECTIVES

To evaluate the burden of neurological and psychiatric comorbidities among patients with BP and to elucidate the clinical, immunological and immunopathological features of patients with BP and comorbid neuropsychiatric conditions.

METHODS

We performed a retrospective study encompassing patients diagnosed with BP throughout the years 2009-2020 in a specialized tertiary referral centre. Multivariate logistic regression model was used to identify predictors of neuropsychiatric conditions among patients with BP.

RESULTS

The study included 273 patients with BP, of whom 123 (45.1%) presented with comorbid neuropsychiatric disease. Compared to the remaining patients with BP (n = 150), those with pre-existing neuropsychiatric diseases demonstrated older mean [standard deviation (SD)] age [81.7 (9.1) vs. 76.9 (10.1); P < 0.001], female preponderance (65.0% vs. 49.3%; P = 0.009), higher seropositivity rate of anti-BP230 (67.7% vs. 36.5%; P = 0.006) and higher levels of anti-BP180 NC16A IgG [651.3 (1279.6) vs. 370.4 (818.6) U/mL; P = 0.039]. In multivariate analysis, anti-BP230 seropositivity was independently associated with coexistence of BP with neuropsychiatric conditions [adjusted odds ratio (OR), 3.43; 95% CI, 1.24-9.52; P = 0.018]. In a sensitivity analysis confined to patients with neurological diseases (n = 103), older age [82.1 (8.4) vs. 77.2 (10.3); P < 0.001] and increased anti-BP230 seropositivity (68.0% vs. 39.7%; P = 0.018) were identified.

CONCLUSIONS

The coexistence of BP with neuropsychiatric diseases is independently associated with the generation of anti-BP230 antibodies.

Incidence of pemphigoid diseases in Northern Germany in 2016 - first data from the Schleswig-Holstein Registry of Autoimmune Bullous Diseases

BACKGROUND

Autoimmune bullous diseases (AIBD) are rare disorders characterized by autoantibody formation against components of adhesion molecules; in pemphigoid diseases (PD), these are proteins of hemidesmosomes and basement membrane, important for cell-matrix adhesion in skin and/or mucous membranes. Incidences of these diseases vary considerably between different populations.

OBJECTIVES

To establish a registry prospectively recruiting all AIBD patients in a geographically well-defined region in Northern Germany (Schleswig-Holstein).

METHODS

Only patients with verified disease (by clinical presentation, histology, direct and/or indirect immunofluorescence and /or ELISA) living in Schleswig-Holstein were included. Incidences of PD were estimated based on the total number of inhabitants in Schleswig-Holstein, stratified by birth year and sex.

RESULTS

Of 67 patients with PD [35 male, 32 female, mean age 75 (standard deviation 14.3 years)], 83% were patients with bullous pemphigoid [n = 56, 28 male, 28 female, mean age 78 (SD 9.9)]. The resulting crude incidences were 23.4 patients/million/year for all pemphigoid patients, 19.6 patients/million/year for bullous pemphigoid (age-standardized 16.9 patients/million/year) with a strong increase in bullous pemphigoid patients in the age group of 85-90 years with 262 patients/million/year. Incidences for bullous pemphigoid were higher in urban compared to rural areas. Other PD (mucous membrane pemphigoid, linear IgA disease, anti-p200 pemphigoid) were less frequent with crude incidences of 2.1, 1.0 and 0.7 patients/million/year, respectively.

CONCLUSIONS

This study prospectively analyses the incidence of PD in a carefully defined geographical area. The highest incidence among PD patients was found for bullous pemphigoid. The incidence of bullous pemphigoid is considerably increased compared to previous reports and reveals regional differences. Further studies are needed in order to clarify these findings.

Single-photon detection in the mid-infrared up to 10 μm wavelength using tungsten silicide superconducting nanowire detectors

We developed superconducting nanowire single-photon detectors based on tungsten silicide, which show saturated internal detection efficiency up to a wavelength of 10 μm. These detectors are promising for applications in the mid-infrared requiring sub-nanosecond timing, ultra-high gain stability, low dark counts, and high efficiency, such as chemical sensing, LIDAR, dark matter searches, and exoplanet spectroscopy.

1390. Effectiveness of M-M-R® II in outbreaks - a systematic literature review of real-world observational studies

Background

M-M-R^® II was approved in the US in 1978 and has been used globally for over 40 years. Widespread use of M-M-R^® II has resulted in important declines in incidence, morbidity, and mortality of measles, mumps, and rubella in the US and other countries. While vaccine immunogenicity and efficacy were established in multiple placebo-controlled trials of each vaccine component, there are limited studies on vaccine effectiveness (VE) of M-M-R^® II. This systematic literature review was conducted to summarize the VE of M-M-R^® II from real-world observational studies.

Methods

The literature search was conducted in Medline and Embase (through May 2019), and grey literature sources (through July 2019). All publications and findings in English language were screened by two independent reviewers. The study characteristics and VE results were extracted for each study.

Results

Ten full-text publications related to VE of M-M-R^® II were all identified from outbreak investigations and mainly in the US (n=8, sample size=318 - 20,496).

For measles outbreaks (n=4), VE ranged from 71% to 96% in different age groups. Among high school students, VE of ≥1-dose of M-M-R^® II was 94-96%. Among young adolescents, the incremental VE of ≥2-dose vs. 1-dose was 94.1%. When M-M-R^® II was used as post-exposure prophylaxis within 72 hours of exposure during an outbreak, the VE was 83.4% among children 6 months to 19 years old. In another study among infants 6-14 months old, VE was 71% against laboratory-confirmed measles.

Among mumps outbreaks, the VE of 1-dose, 2-dose, and ≥1-dose M-M-R^® II compared to unvaccinated was 83-84%, 80-89%, 83-86% respectively. Three studies evaluating the effectiveness of a third dose of M-M-R^® II showed an incremental mumps VE of 60-88% for 3-dose vs. ≤ 2-dose. One study found that individuals who had received a 2^nd dose of M-M-R^® II ≥13 years (vs. < 13 years) before the outbreak had higher risk for contracting mumps.

No study reported VE of M-M-R^® II in a rubella outbreak.

Conclusion

M-M-R^® II was found to be effective against measles and mumps during outbreaks. More effectiveness studies are warranted to further address questions on the relationship of VE and time since vaccination as well as the effectiveness of a third dose of M-M-R^® II for measles or mumps outbreak control.

Disclosures

Se Li, PhD, Merck & Co., Inc. (Employee, Shareholder) Barbara J. Kuter, PhD, MPH, Merck (Other Financial or Material Support, Former employee) Elvira Schmidt, MSc, Certara (Employee of Certara, paid contractor to Merck) (Employee, Other Financial or Material Support) Elizabeth Richardson, BS, Merck Sharp & Dohme Corp. (Employee) Louise P. Saldutti, PhD, Mercfk & Co., Inc (Employee) Neumann Monika, Information Specialist, Certara (Employee, Employee of Certara, who was paid contractor to Merck.) Linnea Koller, n/a, Merck (Employee, Other Financial or Material Support, Employee of Certara who was paid contractor to Merck) Manica Agrawal, n/a, Certara (Employee)Merck (Grant/Research Support) Manjiri D. Pawaskar, PhD, Merck & Co., Inc (Employee, Shareholder)

Patients with bullous pemphigoid and comorbid psoriasis present with less blisters and lower serum levels of anti-BP180 autoantibodies

BACKGROUND

Although the association of bullous pemphigoid (BP) and psoriasis is well-established, the clinical and immunological features of patients with coexisting BP and psoriasis are yet to be investigated.

OBJECTIVE

We aimed to estimate the prevalence of psoriasis amongst patients with BP and to elucidate the clinical and immunological characteristics of BP patients with comorbid psoriasis.

METHODS

A retrospective cohort study including all consecutive patients diagnosed with BP throughout the years 2009-2019 in a tertiary referral centre.

RESULTS

The study encompassed 273 patients with BP, of whom 11 (4.0%; 95% CI, 2.3-7.1%) had comorbid psoriasis. The onset of psoriasis preceded that of BP in 81.8% of patients by a median (range) latency of 26.5 (5.0-34.0) years. Compared to BP patients without psoriasis, those with BP and comorbid psoriasis were significantly younger at the onset of BP [71.8 (9.3) vs. 79.4 (9.8) years; P = 0.023], had a milder erosive phenotype [erosion/blister BPDAI mean (SD)score; 5 (4.1) vs. 22.3 (15.2); P = 0.025], lower levels of anti-BP180 NC16A serum autoantibodies [236.6 (266.3) vs. 556.2 (1323.6) U/mL; P = 0.008] and a higher prevalence of isolated linear C3 deposits (36.4% vs. 14.1%; P = 0.043) and a lower prevalence of linear immunoglobulin G deposits (36.4% vs. 68.7%; P = 0.025) along the dermal-epidermal junction by direct immunofluorescence microscopy.

CONCLUSIONS

Patients with BP and comorbid psoriasis present at a younger age with milder erosive phenotype and lower levels of pathogenic autoantibodies.

Long-term outcomes of rituximab therapy in pemphigus

BACKGROUND

Rituximab induces a rapid remission in most patients with pemphigus.

OBJECTIVE

Our aim was to assess the long-term efficacy of rituximab in this disease.

METHOD

We conducted a retrospective study of 59 patients with pemphigus treated with rituximab and observed over a median period of 104 months.

RESULTS

The rate of complete remission off therapy (CRoff) after the first rituximab cycle was 39%, increasing to 61% with additional rituximab courses. Long-term CRoff was achieved in 27% of patients. The recurrence rate after the first rituximab cycle was 63%, decreasing to approximately 40% with subsequent rituximab cycles. Median time to relapse after the first and subsequent rituximab cycles was 25 months. Renewed rituximab therapy reinduced complete remission in 94% of cases. Baseline anti-desmoglein antibody levels of ≤250 U/mL were significantly associated with the outcome of CRoff. In paired serum samples obtained before the first and six months after the last rituximab therapy, significant reductions of desmoglein-specific autoantibodies were observed. Patients relapsing after a complete remission induced by the first rituximab cycle were more likely to achieve CRoff than patients relapsing after a less favourable outcome and non-responders. There was no significant difference in age, sex, pemphigus subtype, rituximab dosing and disease duration between patients achieving CRoff and those not meeting this end point.

CONCLUSIONS

Lower desmoglein-specific antibody levels at baseline were predictive of CRoff. In patients receiving multiple rituximab cycles, complete remission after the first cycle was associated with a favourable long-term outcome. Repeated rituximab courses were highly effective for relapsed disease and improved the overall outcome.

Prevalence and age distribution of pemphigus and pemphigoid diseases among paediatric patients in Germany

BACKGROUND

Autoimmune bullous diseases are rare and mostly occur in adults. Several cases and small case series have been described in children, but no systematic study about the prevalence of autoimmune bullous diseases (AIBD) in children is available.

PATIENTS AND METHODS

We analysed data of 1.7 million children insured in the largest German health insurance company based on the ICD-10-GM classification for the year 2015. Data were adjusted to the general German population based on the data of the Federal Statistical Office for the year 2015.

RESULTS

The prevalence of AIBD was calculated to 101.1/million children in 2015, resulting in about 1351 patients below the age of 18 years in Germany. The highest prevalence of all AIBD was seen for pemphigus vulgaris (30.5/million children) followed by linear IgA disease (24.5/million children) and bullous pemphigoid (4.9/million children).

CONCLUSION

Autoimmune bullous diseases in minors are scarce but should be taken into consideration in patients with pruritus and/or blisters and erosions on the skin and/or mucous membranes. Treatment is challenging, and due to the rarity of AIBD in minors, the management of these disorders in this patient population is best performed in specialized centres in a multidisciplinary approach, including paediatric dermatologists or dermatologists and paediatricians.