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Boitor RA, Varma S, Sharma A, Odedra S, Elsheikh S, Eldib K, Patel A, Koloydenko A, Gran S, De Winne K, Koljenovic S, Williams HC, Notingher I. Diagnostic accuracy of autofluorescence-Raman spectroscopy for surgical margin assessment during Mohs micrographic surgery of basal cell carcinoma. Br J Dermatol 2024:ljae196. [PMID: 38736216 DOI: 10.1093/bjd/ljae196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/16/2024] [Accepted: 05/09/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Autofluorescence (AF) - Raman spectroscopy is a technology that can detect residual basal cell carcinoma (BCC) on the resection margin of fresh surgically excised tissue specimens. The technology does not require tissue fixation, staining, labelling, or sectioning, and provides quantitative diagnosis maps of the surgical margins in 30 minutes. OBJECTIVES To determine the accuracy of the AF-Raman instrument to detect incomplete excisions of BCC during Mohs micrographic surgery, using histology as reference standard. METHODS Skin layers from 130 patients undergoing Mohs surgery at the Nottingham University Hospitals NHS Trust (September 2022 to July 2023) were investigated with the AF-Raman instrument. The layers were measured fresh, immediately after excision. The AF-Raman results and the intra-operative assessment by Mohs surgeons were compared to a post-operative consensus-derived reference produced by three dermatopathologists. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS The AF-Raman analysis was successfully completed for 125 out of the 130 layers. The AF-Raman analysis covered 91% of the specimen surface area on average, with the lowest being 87% for eyelid and the highest being 94% for forehead specimens. The AF-Raman instrument identified positive margins in 24 out of 36 BCC-positive cases, resulting in a 67% sensitivity (95% confidence intervals (CI): 49%-82%) and negative margins in 65 out of 89 BCC-negative cases, resulting in a 73% specificity (95% CI 63%-82%). Only one out of the 12 false negative cases was caused by misclassification by the AF-Raman algorithm. The other 11 false negatives cases were produced because no valid Raman signal was recorded at the location of the residual BCC due to either occlusion by blood or poor contact between tissue and cassette window. The intra-operative diagnosis by Mohs surgeons identified positive margins in 31 out of 36 BCC-positive cases, 86% sensitivity (95% CI: 70%-95%), and negative margins in 79 out of 89 BCC-negative cases, 89% specificity (95% CI: 81%-95%). CONCLUSIONS This study shows that the AF-Raman instrument has potential for intra-operative microscopic assessment of surgical margins in surgery of BCC. Further improvements are required for tissue processing to ensure complete coverage of the surgical specimens. ClinicalTrials.gov ID NCT03482622.
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Affiliation(s)
- Radu A Boitor
- School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, UK
| | - Sandeep Varma
- Nottingham NHS Treatment Centre, Nottingham University Hospitals, Lister Rd, Nottingham, UK
| | - Ashish Sharma
- Nottingham NHS Treatment Centre, Nottingham University Hospitals, Lister Rd, Nottingham, UK
| | - Sunita Odedra
- Nottingham NHS Treatment Centre, Nottingham University Hospitals, Lister Rd, Nottingham, UK
| | - Somaia Elsheikh
- Department of Pathology, Nottingham University Hospitals NHS Trust, QMC Campus, Derby Road, Nottingham, UK
| | - Karim Eldib
- Department of Pathology, Nottingham University Hospitals NHS Trust, QMC Campus, Derby Road, Nottingham, UK
| | - Anand Patel
- Nottingham NHS Treatment Centre, Nottingham University Hospitals, Lister Rd, Nottingham, UK
| | - Alexey Koloydenko
- Mathematics Department, Royal Holloway, University of London, Egham, UK
| | - Sonia Gran
- Centre of Evidence-Based Dermatology, Nottingham University Hospital NHS Trust, QMC Campus, UK
| | - Koen De Winne
- Department of Pathology, University of Antwerp & Antwerp University Hospital, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Senada Koljenovic
- Department of Pathology, University of Antwerp & Antwerp University Hospital, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, Nottingham University Hospital NHS Trust, QMC Campus, UK
| | - Ioan Notingher
- School of Physics and Astronomy, University of Nottingham, University Park, Nottingham, UK
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Greenwell K, Becque T, Sivyer K, Steele M, Denison-Day J, Howells L, Ridd MJ, Roberts A, Lawton S, Langan SM, Hooper J, Wilczynska S, Griffiths G, Sach TH, Little P, Williams HC, Thomas KS, Yardley L, Muller I, Santer M, Stuart B. Online behavioural interventions for children and young people with eczema: a quantitative evaluation. Br J Gen Pract 2024:BJGP.2023.0411. [PMID: 38316467 PMCID: PMC11104514 DOI: 10.3399/bjgp.2023.0411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Two online behavioural interventions (one website for parents/carers of children with eczema; and one for young people with eczema) have been shown in randomised controlled trials to facilitate a sustained improvement in eczema severity. AIM To describe intervention use and examine potential mediators of intervention outcomes and contextual factors that may influence intervention delivery and outcomes. DESIGN AND SETTING Quantitative process evaluation in UK primary care. METHOD Parents/carers and young people were recruited through primary care. Intervention use was recorded and summarised descriptively. Logistic regression explored sociodemographic and other factors associated with intervention engagement. Mediation analysis investigated whether patient enablement (ability to understand and cope with health issues), treatment use, and barriers to adherence were mediators of intervention effect. Subgroup analysis compared intervention effects among pre-specified participant subsets. RESULTS A total of 340 parents/carers and 337 young people were recruited. Most parents/carers (87%, n = 148/171) and young people (91%, n = 153/168) in the intervention group viewed the core introduction by 24 weeks. At 24 weeks, users had spent approximately 20 minutes on average on the interventions. Among parents/carers, greater intervention engagement was associated with higher education levels, uncertainty about carrying out treatments, and doubts about treatment efficacy at baseline. Among young people, higher intervention use was associated with higher baseline eczema severity. Patient enablement (the ability to understand and cope with health issues) accounted for approximately 30% of the intervention effect among parents/carers and 50% among young people. CONCLUSION This study demonstrated that positive intervention outcomes depended on a modest time commitment from users. This provides further support that the wider implementation of Eczema Care Online is justified.
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Affiliation(s)
- Kate Greenwell
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine; Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton
| | - Taeko Becque
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton
| | - Mary Steele
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton
| | - James Denison-Day
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton
| | - Laura Howells
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham
| | - Sandra Lawton
- Queen's Nurse, Department of Dermatology, Rotherham NHS Foundation Trust, Rotherham
| | - Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Julie Hooper
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton
| | | | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton
| | - Tracey H Sach
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton
| | - Paul Little
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton; School of Psychological Science, University of Bristol, Bristol
| | - Ingrid Muller
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton
| | - Miriam Santer
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton
| | - Beth Stuart
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London
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Abhishek A, Stevenson MD, Nakafero G, Grainge MJ, Evans I, Alabas O, Card T, Taal MW, Aithal GP, Fox CP, Mallen CD, van der Windt DA, Riley RD, Warren RB, Williams HC. Discontinuation of anti-tumour necrosis factor alpha treatment owing to blood test abnormalities, and cost-effectiveness of alternate blood monitoring strategies. Br J Dermatol 2024; 190:559-564. [PMID: 37931161 DOI: 10.1093/bjd/ljad430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/23/2023] [Accepted: 10/29/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND There is no evidence base to support the use of 6-monthly monitoring blood tests for the early detection of liver, blood and renal toxicity during established anti-tumour necrosis factor alpha (TNFα) treatment. OBJECTIVES To evaluate the incidence and risk factors of anti-TNFα treatment cessation owing to liver, blood and renal side-effects, and to estimate the cost-effectiveness of alternate intervals between monitoring blood tests. METHODS A secondary care-based retrospective cohort study was performed. Data from the British Association of Dermatologists Biologic and Immunomodulators Register (BADBIR) were used. Patients with at least moderate psoriasis prescribed their first anti-TNFα treatment were included. Treatment discontinuation due to a monitoring blood test abnormality was the primary outcome. Patients were followed-up from start of treatment to the outcome of interest, drug discontinuation, death, 31 July 2021 or up to 5 years, whichever came first. The incidence rate (IR) and 95% confidence intervals (CIs) of anti-TNFα discontinuation with monitoring blood test abnormality was calculated. Multivariate Cox regression was used to examine the association between risk factors and outcome. A mathematical model evaluated costs and quality-adjusted life years (QALYs) associated with increasing the length of time between monitoring blood tests during anti-TNFα treatment. RESULTS The cohort included 8819 participants [3710 (42.1%) female, mean (SD) age 44.76 (13.20) years] that contributed 25 058 person-years (PY) of follow-up and experienced 125 treatment discontinuations owing to a monitoring blood test abnormality at an IR of 5.85 (95% CI 4.91-6.97)/1000 PY. Of these, 64 and 61 discontinuations occurred within the first year and after the first year of treatment start, at IRs of 8.62 (95% CI 6.74-11.01) and 3.44 (95% CI 2.67-4.42)/1000 PY, respectively. Increasing age (in years), diabetes and liver disease were associated with anti-TNFα discontinuation after a monitoring blood test abnormality [adjusted hazard ratios of 1.02 (95% CI 1.01-1.04), 1.68 (95% CI 1.00-2.81) and 2.27 (95% CI 1.26-4.07), respectively]. Assuming a threshold of £20 000 per QALY gained, no monitoring was most cost-effective, but all extended periods were cost-effective vs. 3- or 6-monthly monitoring. CONCLUSIONS Anti-TNFα drugs were uncommonly discontinued owing to abnormal monitoring blood tests after the first year of treatment. Extending the duration between monitoring blood tests was cost-effective. Our results produce evidence for specialist society guidance to reduce patient monitoring burden and healthcare costs.
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Affiliation(s)
| | - Matthew D Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | - Ian Evans
- BADBIR, University of Manchester, Manchester, UK
| | - Oras Alabas
- BADBIR, University of Manchester, Manchester, UK
| | | | - Maarten W Taal
- Centre for Kidney Research and Innovation, Translational Medical Sciences, University of Nottingham, Derby, UK
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, University of Nottingham, Nottingham, UK
| | - Christopher P Fox
- Centre for Cancer Studies, Translational Medical Sciences, School of Medicine, University of Nottingham, Derby, UK
| | | | | | - Richard D Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Richard B Warren
- Dermatology Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Thomas KS, Howells L, Leshem YA, Simpson EL, Apfelbacher C, Spuls PI, Gerbens LAA, Jacobson ME, Katoh N, Williams HC, Stuart BL. How to use the Harmonising Outcome Measures for Eczema Core Outcome Set for atopic dermatitis trials: a users' guide. Br J Dermatol 2024; 190:527-535. [PMID: 38123134 DOI: 10.1093/bjd/ljad497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/08/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The Harmonising Outcome Measures for Eczema (HOME) initiative has agreed upon the Core Outcome Set (COS) for use in atopic dermatitis (AD) clinical trials, but additional guidance is needed to maximize its uptake. OBJECTIVES To provide answers to some of the commonly asked questions about using the HOME COS; to provide data to help with the interpretation of trial results; and to support sample size calculations for future trials. METHODS AND RESULTS We provide practical guidance on the use of the HOME COS for investigators planning clinical trials in patients with AD. It answers some of the common questions about using the HOME COS, how to access the outcome measurement instruments, what training/resources are needed to use them appropriately and clarifies when the COS is applicable. We also provide exemplar data to inform sample size calculations for eczema trials and encourage standardized data collection and reporting of the COS. CONCLUSIONS By encouraging adoption of the COS and facilitating consistent reporting of outcome data, it is hoped that the results of eczema trials will be more comprehensive and readily combined in meta-analyses and that patient care will subsequently be improved.
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Affiliation(s)
- Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Laura Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Yael A Leshem
- Division of Dermatology, Rabin Medical Center, Petach-Tikva, Israel
- School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Christian Apfelbacher
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - Phyllis I Spuls
- Department of Dermatology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Michael E Jacobson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Norito Katoh
- Department of Dermatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Beth L Stuart
- Wolfston Institute of Population Health, Queen Mary University of London, London, UK
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Abhishek A, Grainge M, Card T, Williams HC, Taal MW, Aithal GP, Fox CP, Mallen CD, Stevenson MD, Nakafero G, Riley R. Risk-stratified monitoring for sulfasalazine toxicity: prognostic model development and validation. RMD Open 2024; 10:e003980. [PMID: 38453215 PMCID: PMC10921482 DOI: 10.1136/rmdopen-2023-003980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Sulfasalazine-induced cytopenia, nephrotoxicity and hepatotoxicity is uncommon during long-term treatment. Some guidelines recommend 3 monthly monitoring blood tests indefinitely during long-term treatment while others recommend stopping monitoring after 1 year. To rationalise monitoring, we developed and validated a prognostic model for clinically significant blood, liver or kidney toxicity during established sulfasalazine treatment. DESIGN Retrospective cohort study. SETTING UK primary care. Data from Clinical Practice Research Datalink Gold and Aurum formed independent development and validation cohorts. PARTICIPANTS Age ≥18 years, new diagnosis of an inflammatory condition and sulfasalazine prescription. STUDY PERIOD 1 January 2007 to 31 December 2019. OUTCOME Sulfasalazine discontinuation with abnormal monitoring blood-test result. ANALYSIS Patients were followed up from 6 months after first primary care prescription to the earliest of outcome, drug discontinuation, death, 5 years or 31 December 2019. Penalised Cox regression was performed to develop the risk equation. Multiple imputation handled missing predictor data. Model performance was assessed in terms of calibration and discrimination. RESULTS 8936 participants were included in the development cohort (473 events, 23 299 person-years) and 5203 participants were included in the validation cohort (280 events, 12 867 person-years). Nine candidate predictors were included. The optimism adjusted R2 D and Royston D statistic in the development data were 0.13 and 0.79, respectively. The calibration slope (95% CI) and Royston D statistic (95% CI) in validation cohort was 1.19 (0.96 to 1.43) and 0.87 (0.67 to 1.07), respectively. CONCLUSION This prognostic model for sulfasalazine toxicity uses readily available data and should be used to risk-stratify blood-test monitoring during established sulfasalazine treatment.
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Affiliation(s)
| | - Matthew Grainge
- Lifespan and Population Health, University of Nottingham, Nottingham, UK
| | - Tim Card
- Lifespan and Population Health, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Lifespan and Population Health, University of Nottingham, Nottingham, UK
- Centre for Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Maarten W Taal
- Translational Medical Sciences, University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- Translational Medical Sciences, University of Nottingham, Nottingham, UK
- Nottingham NIHR BRC, Nottingham, UK
| | - Christopher P Fox
- Translational Medical Sciences, University of Nottingham, Nottingham, UK
| | | | - Matthew D Stevenson
- School of Medicine and Population Health, University of Sheffield, Sheffield, UK
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Harvey J, Stuart B, Williams HC. Commentary: A comparative randomized clinical trial evaluating the efficacy and safety of tacrolimus versus hydrocortisone as a topical treatment of atopic dermatitis in children. Front Pharmacol 2024; 15:1372259. [PMID: 38487167 PMCID: PMC10937402 DOI: 10.3389/fphar.2024.1372259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/25/2024] [Indexed: 03/17/2024] Open
Affiliation(s)
- Jane Harvey
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Beth Stuart
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Abhishek A, Peckham N, Pade C, Gibbons JM, Cureton L, Francis A, Barber V, Williams JAE, Appelbe D, Eldridge L, Julier P, Altmann DM, Bluett J, Brooks T, Coates LC, Rombach I, Semper A, Otter A, Valdes AM, Nguyen-Van-Tam JS, Williams HC, Boyton RJ, McKnight Á, Cook JA. Effect of a 2-week interruption in methotrexate treatment on COVID-19 vaccine response in people with immune-mediated inflammatory diseases (VROOM study): a randomised, open label, superiority trial. Lancet Rheumatol 2024; 6:e92-e104. [PMID: 38267107 DOI: 10.1016/s2665-9913(23)00298-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Methotrexate is the first-line treatment for immune-mediated inflammatory diseases and reduces vaccine-induced immunity. We evaluated if a 2-week interruption of methotrexate treatment immediately after COVID-19 booster vaccination improved antibody response against the S1 receptor binding domain (S1-RBD) of the SARS-CoV-2 spike protein and live SARS-CoV-2 neutralisation compared with uninterrupted treatment in patients with immune-mediated inflammatory diseases. METHOD We did a multicentre, open-label, parallel-group, randomised, superiority trial in secondary-care rheumatology and dermatology clinics in 26 hospitals in the UK. Adults (aged ≥18 years) with immune-mediated inflammatory diseases taking methotrexate (≤25 mg per week) for at least 3 months, who had received two primary vaccine doses from the UK COVID-19 vaccination programme were eligible. Participants were randomly assigned (1:1) using a centralised validated computer program, to temporarily suspend methotrexate treatment for 2 weeks immediately after COVID-19 booster vaccination or continue treatment as usual. The primary outcome was S1-RBD antibody titres 4 weeks after COVID-19 booster vaccination and was assessed masked to group assignment. All randomly assigned patients were included in primary and safety analyses. This trial is registered with ISRCTN, ISRCTN11442263; following a pre-planned interim analysis, recruitment was stopped early. FINDING Between Sept 30, 2021, and March 7, 2022, we screened 685 individuals, of whom 383 were randomly assigned: to either suspend methotrexate (n=191; mean age 58·8 years [SD 12·5], 118 [62%] women and 73 [38%] men) or to continue methotrexate (n=192; mean age 59·3 years [11·9], 117 [61%] women and 75 [39%] men). At 4 weeks, the geometric mean S1-RBD antibody titre was 25 413 U/mL (95% CI 22 227-29 056) in the suspend methotrexate group and 12 326 U/mL (10 538-14 418) in the continue methotrexate group with a geometric mean ratio (GMR) of 2·08 (95% CI 1·59-2·70; p<0·0001). No intervention-related serious adverse events occurred. INTERPRETATION 2-week interruption of methotrexate treatment in people with immune-mediated inflammatory diseases enhanced antibody responses after COVID-19 booster vaccination that were sustained at 12 weeks and 26 weeks. There was a temporary increase in inflammatory disease flares, mostly self-managed. The choice to suspend methotrexate should be individualised based on disease status and vulnerability to severe outcomes from COVID-19. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
| | - Nicholas Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Corinna Pade
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joseph M Gibbons
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Vicki Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Jennifer A E Williams
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Patrick Julier
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Daniel M Altmann
- Department of Inflammation and Immunology, Imperial College London, London, UK
| | - James Bluett
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester UK; Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | | | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Biomedical Research Centre, Oxford, UK
| | - Ines Rombach
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, UK
| | | | | | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, London, UK; Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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Sach TH, Onoja M, Clarke H, Santer M, Muller I, Becque T, Stuart B, Hooper J, Steele M, Wilczynska S, Ridd MJ, Roberts A, Ahmed A, Yardley L, Little P, Greenwell K, Sivyer K, Nuttall J, Griffiths G, Lawton S, Langan SM, Howells L, Leighton P, Williams HC, Thomas KS. Cost-effectiveness of two online interventions supporting self-care for eczema for parents/carers and young people. Eur J Health Econ 2024:10.1007/s10198-023-01649-9. [PMID: 38194207 DOI: 10.1007/s10198-023-01649-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 11/14/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To estimate the cost-effectiveness of online behavioral interventions (EczemaCareOnline.org.uk) designed to support eczema self-care management for parents/carers and young people from an NHS perspective. METHODS Two within-trial economic evaluations, using regression-based approaches, adjusting for baseline and pre-specified confounder variables, were undertaken alongside two independent, pragmatic, parallel group, unmasked randomized controlled trials, recruiting through primary care. Trial 1 recruited 340 parents/carers of children aged 0-12 years and Trial 2 337 young people aged 13-25 years with eczema scored ≥ 5 on Patient-Oriented Eczema Measure (POEM). Participants were randomized (1:1) to online intervention plus usual care or usual care alone. Resource use, collected via medical notes review, was valued using published unit costs in UK £Sterling 2021. Quality-of-life was elicited using proxy CHU-9D in Trial 1 and self-report EQ-5D-5L in Trial 2. RESULTS The intervention was dominant (cost saving and more effective) with a high probability of cost-effectiveness (> 68%) in most analyses. The exception was the complete case cost-utility analysis for Trial 1 (omitting participants with children aged < 2), with adjusted incremental cost savings of -£34.15 (95% CI - 104.54 to 36.24) and incremental QALYs of - 0.003 (95% CI - 0.021 to 0.015) producing an incremental cost per QALY of £12,466. In the secondary combined (Trials 1 and 2) cost-effectiveness analysis, the adjusted incremental cost was -£20.35 (95% CI - 55.41 to 14.70) with incremental success (≥ 2-point change on POEM) of 10.3% (95% CI 2.3-18.1%). CONCLUSION The free at point of use online eczema self-management intervention was low cost to run and cost-effective. TRIAL REGISTRATION This trial was registered prospectively with the ISRCTN registry (ISRCTN79282252). URL www.EczemaCareOnline.org.uk .
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Affiliation(s)
- Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK.
| | - Mary Onoja
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Holly Clarke
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Miriam Santer
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Ingrid Muller
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Taeko Becque
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Beth Stuart
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
- Pragmatic Trials Unit, Wolfson Institute of Population Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK
| | - Julie Hooper
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Mary Steele
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Sylvia Wilczynska
- King's Clinical Trial Unit, King's College London, Institute of Psychiatry, Psychology and Neuroscience, 16 De Crespigny Park, London, SE5 8AB, UK
| | - Matthew J Ridd
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Amanda Roberts
- Patient and Public Contributor, Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Applied Health Services Research Building (Building Number 42), University Park, Nottingham, NG7 2RD, UK
| | - Amina Ahmed
- Patient and Public Contributor, Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Applied Health Services Research Building (Building Number 42), University Park, Nottingham, NG7 2RD, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Paul Little
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Kate Greenwell
- Primary Care Research Centre, Faculty of Medicine, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, 12A Priory Rd, Bristol, BS8 1TU, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, 12A Priory Rd, Bristol, BS8 1TU, UK
| | - Jacqui Nuttall
- Southampton Clinical Trial Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gareth Griffiths
- Southampton Clinical Trial Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sandra Lawton
- Dermatology, The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Sinéad M Langan
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Laura Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Applied Health Services Research Building (Building Number 42), University Park, Nottingham, NG7 2RD, UK
| | - Paul Leighton
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Applied Health Services Research Building (Building Number 42), University Park, Nottingham, NG7 2RD, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Applied Health Services Research Building (Building Number 42), University Park, Nottingham, NG7 2RD, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Applied Health Services Research Building (Building Number 42), University Park, Nottingham, NG7 2RD, UK
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9
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Leshem YA, Simpson EL, Apfelbacher C, Spuls PI, Thomas KS, Schmitt J, Howells L, Gerbens LAA, Jacobson ME, Katoh N, Williams HC. The Harmonising Outcome Measures for Eczema (HOME) implementation roadmap. Br J Dermatol 2023; 189:710-718. [PMID: 37548315 DOI: 10.1093/bjd/ljad278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/22/2023] [Accepted: 08/03/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Core outcome sets (COS) are consensus-driven sets of minimum outcomes that should be measured and reported in all clinical trials. COS aim to reduce heterogeneity in outcome measurement and reporting, and selective outcome reporting. Implementing COS into clinical trials is challenging. Guidance to improve COS uptake in dermatology is lacking. OBJECTIVES To develop a structured practical guide to COS implementation. METHODS Members of the Harmonising Outcome Measurement for Eczema (HOME) executive committee developed an expert opinion-based roadmap founded on a combination of a review of the COS implementation literature, the Core Outcome Measures in Effectiveness Trials (COMET) initiative resources, input from HOME members and experience in COS development and clinical trials. RESULTS The data review and input from HOME members was synthesized into themes, which guided roadmap development: (a) barriers and facilitators to COS uptake based on stakeholder awareness/engagement and COS features; and (b) key implementation science principles (assessment-driven, data-centred, priority-based and context-sensitive). The HOME implementation roadmap follows three stages. Firstly, the COS uptake scope and goals need to be defined. Secondly, during COS development, preparation for future implementation is supported by establishing the COS as a credible evidence-informed consensus by applying robust COS development methodology, engaging multiple stakeholders, fostering sustained and global engagement, emphasizing COS ease of use and universal applicability, and providing recommendations on COS use. Thirdly, incorporating completed COS into primary (trials) and secondary (reviews) research is an iterative process starting with mapping COS uptake and stakeholders' attitudes, followed by designing and carrying out targeted implementation projects. Main themes for implementation projects identified at HOME are stakeholder awareness/engagement; universal applicability for different populations; and improving ease-of-use by reducing administrative and study burden. Formal implementation frameworks can be used to identify implementation barriers/facilitators and to design implementation strategies. The effect of these strategies on uptake should be evaluated and implementation plans adjusted accordingly. CONCLUSIONS COS can improve the quality and applicability of research and, so, clinical practice but can only succeed if used and reported consistently. The HOME implementation roadmap is an extension of the original HOME roadmap for COS development and provides a pragmatic framework to develop COS implementation strategies.
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Affiliation(s)
- Yael A Leshem
- Division of Dermatology, Rabin Medical Center, Petach-Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Christian Apfelbacher
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - Phyllis I Spuls
- Department of Dermatology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Laura Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Michael E Jacobson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Norito Katoh
- Department of Dermatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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10
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Larson JH, Heinlein J, Morris C, Ramsey K, Michaels LC, Vu A, Williams HC, Simpson E. Frequency of newborn bathing in the first 9 weeks of life and related factors: An observational study in a community-based sample from Meta-LARC. Pediatr Dermatol 2023; 40:1042-1048. [PMID: 37800475 DOI: 10.1111/pde.15449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/09/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE Environmental factors such as bathing may play a role in atopic dermatitis (AD) development. This analysis utilized data from the Community Assessment of Skin Care, Allergies, and Eczema (CASCADE) Trial (NCT03409367), a randomized controlled trial of emollient therapy for AD prevention in the general population, to estimate bathing frequency and associated factors within the first 9 weeks of life. METHODS Data were collected from 909 parent/newborn dyads recruited from 25 pediatric and family medicine clinics from the Meta-network Learning and Research Center (Meta-LARC) practice-based research network (PBRN) consortium in Oregon, North Carolina, Colorado, and Wisconsin for the CASCADE trial. Ordinal logistic regression was used to conduct a cross-sectional analysis of the association between bathing frequency (measured in baths per week) and demographic, medical, and lifestyle information about the infant, their family, and their household. Variables were selected using a backwards-stepwise method and estimates from the reduced model are reported in the text. RESULTS Moisturizer use (OR = 2.03, 95% CI: 1.54-2.68), Hispanic or Latino ethnicity (OR = 1.97, 95% CI: 1.42-2.72), a parental education level lower than a 4-year college degree (OR = 2.48, 95% CI: 1.70-3.62), living in North Carolina or Wisconsin (compared to Oregon; OR = 2.12 and 1.47, 95% CI: 1.53-2.93 and 1.04-2.08, respectively), and increasing child age (in days; OR = 1.02, 95% CI: 1.01-1.02) were significantly associated with more frequent bathing, while pet ownership (OR = 0.67, 95% CI: 0.52-0.87) was significantly associated with less frequent bathing. CONCLUSIONS We found significant ethnic, geographic, and socioeconomic variation in bathing frequency before 9 weeks of age that may be of relevance to AD prevention studies.
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Affiliation(s)
- Jean Hiebert Larson
- Oregon Rural Practice Based Research Network, Oregon Health & Science University, Portland, Oregon, USA
| | - Julia Heinlein
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Cynthia Morris
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Katrina Ramsey
- Biostatistics and Design Program, Oregon Health & Science University, Portland, Oregon, USA
| | - LeAnn C Michaels
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Annette Vu
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Hywel C Williams
- Centre of Evidence-based Dermatology, University of Nottingham, Nottingham, England, UK
| | - Eric Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
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11
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Jacobson ME, Thomas KS, Apfelbacher CJ, Leshem YA, Williams HC, Gerbens LAA, Spuls PI, Schmitt J, Howells L, Katoh N, Simpson EL. Implementation of the HOME core outcome set for clinical trials of atopic eczema-barriers and opportunities: the HOME IX meeting report. Arch Dermatol Res 2023; 315:2617-2622. [PMID: 37432466 DOI: 10.1007/s00403-023-02647-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/06/2023] [Accepted: 05/17/2023] [Indexed: 07/12/2023]
Abstract
The Harmonising Outcome Measures for Eczema (HOME) initiative established a core outcome set (COS) for atopic eczema (AE) clinical trials in 2019. This set encompasses four core outcome domains and corresponding measurement instruments: clinical signs (EASI), patient-reported symptoms (POEM and NRS 11 point for worst itch over the last 24 h), quality of life (DLQI/CDLQI/IDQoLI), and long-term control (Recap or ADCT). Following its roadmap, the HOME initiative is now focused on supporting implementation of the COS. To identify barriers and facilitators to implementation of the COS, and to guide the effort to promote COS uptake, a virtual consensus meeting was held over 2 days (September 25-26, 2021) attended by 55 participants (26 healthcare professionals, 16 methodologists, 5 patients, 4 industry representatives, and 4 students). Implementation themes were identified by a pre-meeting survey distributed to HOME members, presentations, and whole-group discussion. Participants were divided into five multi-professional small groups which ranked their top 3 most important themes, followed by whole-group discussion and anonymous consensus voting (consensus criteria: < 30% disagreement). Three most important implementation themes were identified and agreed upon: (1) awareness and stakeholder engagement, (2) universal applicability of the COS, and (3) ensuring minimum administrative burden. Working groups to address these issues are now a priority for the HOME initiative. The results from this meeting will inform the development of a HOME Implementation Roadmap in an effort to support other COS groups planning for effective implementation of their core sets.
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Affiliation(s)
- M E Jacobson
- Department of Dermatology, Oregon Health and Science University, 3303 S. Bond Avenue, Portland, Oregon, 97239, USA
| | - K S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - C J Apfelbacher
- Institute of Social Medicine and Health Systems Research, Ottovon Guericke University Magdeburg, Magdeburg, Germany
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Y A Leshem
- Division of Dermatology, Rabin Medical Center, Petach-Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - H C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - L A A Gerbens
- Department of Dermatology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, The Netherlands
| | - P I Spuls
- Department of Dermatology, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, The Netherlands
| | - J Schmitt
- Center for Evidence-Based Healthcare, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - L Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - N Katoh
- Department of Dermatology, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - E L Simpson
- Department of Dermatology, Oregon Health and Science University, 3303 S. Bond Avenue, Portland, Oregon, 97239, USA.
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12
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Lax SJ, Roberts A, Cliffe E, Ramesh G, Ayodele D, Williams HC, Belmo S, Leighton P. Public views are needed for skin colour scales. Br J Dermatol 2023; 189:623-624. [PMID: 37287218 DOI: 10.1093/bjd/ljad189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/31/2023] [Accepted: 08/05/2023] [Indexed: 06/09/2023]
Abstract
Our public engagement exercise showed that the Fitzpatrick Scale does not adequately represent how members of the public consider their own skin. Descriptions offered by respondents regarding their skin tone were richly varied; some also indicated that structured and embedded inequalities affected the language they used. The patient voice is key to developing comprehensive, inclusive and widely understood tools.
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Affiliation(s)
- Stephanie J Lax
- Centre of Evidence Based Dermatology (CEBD), School of Medicine, University of Nottingham, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology (CEBD), School of Medicine, University of Nottingham, UK
- CEBD Patient Panel
- Nottingham Support Group for Carers of Children with Eczema, Nottingham, UK
| | - Eleanor Cliffe
- Centre of Evidence Based Dermatology (CEBD), School of Medicine, University of Nottingham, UK
| | - Grishma Ramesh
- Centre of Evidence Based Dermatology (CEBD), School of Medicine, University of Nottingham, UK
| | | | - Hywel C Williams
- Centre of Evidence Based Dermatology (CEBD), School of Medicine, University of Nottingham, UK
| | | | - Paul Leighton
- Centre of Evidence Based Dermatology (CEBD), School of Medicine, University of Nottingham, UK
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Ridd MJ, Wells S, MacNeill SJ, Sanderson E, Webb D, Banks J, Sutton E, Shaw AR, Wilkins Z, Clayton J, Roberts A, Garfield K, Liddiard L, Barrett TJ, Lane JA, Baxter H, Howells L, Taylor J, Hay AD, Williams HC, Thomas KS, Santer M. Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT. Health Technol Assess 2023; 27:1-120. [PMID: 37924282 PMCID: PMC10679965 DOI: 10.3310/gzqw6681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023] Open
Abstract
Background Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing. Objective To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema. Design Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks. Setting Primary care (78 general practitioner surgeries) in England. Participants Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents. Interventions Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked. Main outcome measures The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks. Results A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial. Limitations Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds. Conclusions The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them. Future work Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients. Trial registration This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew J Ridd
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Wells
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Douglas Webb
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jonathan Banks
- National Institute for Health and Care Research Collaborations for Leadership in Applied Health Research and Care West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Eileen Sutton
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alison Rg Shaw
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Zoe Wilkins
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Julie Clayton
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Roberts
- Nottingham Support Group for Carers of Children with Eczema, Nottingham, UK
| | | | - Lyn Liddiard
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tiffany J Barrett
- South West Medicines Information and Training, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - J Athene Lane
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Helen Baxter
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Laura Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Jodi Taylor
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton, UK
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14
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Sach TH, Lartey ST, Davies C, Chalmers JR, Haines RH, Bradshaw LE, Montgomery AA, Thomas KS, Brown SJ, Ridd MJ, Lawton S, Cork MJ, Flohr C, Mitchell E, Swinden R, Wyatt L, Tarr S, Davies-Jones S, Jay N, Kelleher MM, Perkin MR, Boyle RJ, Williams HC. Emollients for preventing atopic eczema: Cost-effectiveness analysis of the BEEP trial. Clin Exp Allergy 2023; 53:1011-1019. [PMID: 37574761 DOI: 10.1111/cea.14381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Recent discoveries have led to the suggestion that enhancing skin barrier from birth might prevent eczema and food allergy. OBJECTIVE To determine the cost-effectiveness of daily all-over-body application of emollient during the first year of life for preventing atopic eczema in high-risk children at 2 years from a health service perspective. We also considered a 5-year time horizon as a sensitivity analysis. METHODS A within-trial economic evaluation using data on health resource use and quality of life captured as part of the BEEP trial alongside the trial data. Parents/carers of 1394 infants born to families at high risk of atopic disease were randomised 1:1 to the emollient group, which were advised to apply emollient (Doublebase Gel or Diprobase Cream) to their child at least once daily to the whole body during the first year of life or usual care. Both groups received advice on general skin care. The main economic outcomes were incremental cost-effectiveness ratio (ICER), defined as incremental cost per percentage decrease in risk of eczema in the primary cost-effectiveness analysis. Secondary analysis, undertaken as a cost-utility analysis, reports incremental cost per Quality-Adjusted Life Year (QALY) where child utility was elicited using the proxy CHU-9D at 2 years. RESULTS At 2 years, the adjusted incremental cost was £87.45 (95% CI -54.31, 229.27) per participant, whilst the adjusted proportion without eczema was 0.0164 (95% CI -0.0329, 0.0656). The ICER was £5337 per percentage decrease in risk of eczema. Adjusted incremental QALYs were very slightly improved in the emollient group, 0.0010 (95% CI -0.0069, 0.0089). At 5 years, adjusted incremental costs were lower for the emollient group, -£106.89 (95% CI -354.66, 140.88) and the proportion without eczema was -0.0329 (95% CI -0.0659, 0.0002). The 5-year ICER was £3201 per percentage decrease in risk of eczema. However, when inpatient costs due to wheezing were excluded, incremental costs were lower and incremental effects greater in the usual care group. CONCLUSIONS In line with effectiveness endpoints, advice given in the BEEP trial to apply daily emollient during infancy for eczema prevention in high-risk children does not appear cost-effective.
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Affiliation(s)
- Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Stella T Lartey
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Charlotte Davies
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Mike J Cork
- Sheffield Dermatology Research, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Laura Wyatt
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stella Tarr
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Susan Davies-Jones
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital, Sheffield, UK
| | - Maeve M Kelleher
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael R Perkin
- Population Health Research Institute, St. George's University of London, London, UK
| | - Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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Nakafero G, Card T, Grainge MJ, Williams HC, Taal MW, Aithal GP, Fox CP, Mallen CD, van der Windt DA, Stevenson MD, Riley RD, Abhishek A. Risk-stratified monitoring for thiopurine toxicity in immune-mediated inflammatory diseases: prognostic model development, validation, and, health economic evaluation. EClinicalMedicine 2023; 64:102213. [PMID: 37745026 PMCID: PMC10514402 DOI: 10.1016/j.eclinm.2023.102213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/25/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
Background Patients established on thiopurines (e.g., azathioprine) are recommended to undergo three-monthly blood tests for the early detection of blood, liver, or kidney toxicity. These side-effects are uncommon during long-term treatment. We developed a prognostic model that could be used to inform risk-stratified decisions on frequency of monitoring blood-tests during long-term thiopurine treatment, and, performed health-economic evaluation of alternate monitoring intervals. Methods This was a retrospective cohort study set in the UK primary-care. Data from the Clinical Practice Research Datalink Aurum and Gold formed development and validation cohorts, respectively. People age ≥18 years, diagnosed with an immune mediated inflammatory disease, prescribed thiopurine by their general practitioner for at-least six-months between January 1, 2007 and December 31, 2019 were eligible. The outcome was thiopurine discontinuation with abnormal blood-test results. Patients were followed up from six-months after first primary-care thiopurine prescription to up to five-years. Penalised Cox regression developed the risk equation. Multiple imputation handled missing predictor data. Calibration and discrimination assessed model performance. A mathematical model evaluated costs and quality-adjusted life years associated with lengthening the interval between blood-tests. Findings Data from 5982 (405 events over 16,117 person-years) and 3573 (269 events over 9075 person-years) participants were included in the development and validation cohorts, respectively. Fourteen candidate predictors (21 parameters) were included. The optimism adjusted R2 and Royston D statistic in development data were 0.11 and 0.76, respectively. The calibration slope and Royston D statistic (95% Confidence Interval) in the validation data were 1.10 (0.84-1.36) and 0.72 (0.52-0.92), respectively. A 2-year period between monitoring blood-test was most cost-effective in all deciles of predicted risk but the gain between monitoring annually or biennially reduced in higher risk deciles. Interpretation This prognostic model requires information that is readily available during routine clinical care and may be used to risk-stratify blood-test monitoring for thiopurine toxicity. These findings should be considered by specialist societies when recommending blood monitoring during thiopurine prescription to bring about sustainable and equitable change in clinical practice. Funding National Institute for Health and Care Research.
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Affiliation(s)
- Georgina Nakafero
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Tim Card
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Matthew J. Grainge
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Hywel C. Williams
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
| | - Maarten W. Taal
- Centre for Kidney Research and Innovation, School of Medicine, Translational Medical Sciences, University of Nottingham, Derby DE22 3NE, UK
| | - Guruprasad P. Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
| | - Christopher P. Fox
- Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Christian D. Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele ST5 5BJ, UK
| | | | - Matthew D. Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Richard D. Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Abhishek Abhishek
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK
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Harvey J, Lax SJ, Lowe A, Santer M, Lawton S, Langan SM, Roberts A, Stuart B, Williams HC, Thomas KS. The long-term safety of topical corticosteroids in atopic dermatitis: A systematic review. Skin Health Dis 2023; 3:e268. [PMID: 37799373 PMCID: PMC10549798 DOI: 10.1002/ski2.268] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 10/07/2023]
Abstract
Background Topical corticosteroids (TCS) are a first-line treatment for eczema, but there are concerns about their safety when used long-term. Objectives To systematically review adverse effects associated with longer-term use of TCS for eczema. Methods Randomised controlled trials (RCTs), cohort and case-control studies reporting adverse effects of TCS (comparators: no TCS treatment, other topicals) in patients with eczema were identified. Included studies had greater than one year of follow-up, minimum cohort size of 50 participants, or minimum 50 per arm for RCTs. Evidence was GRADE-assessed. Prospero registration CRD42021286413. Results We found seven studies (two randomised, five observational); two RCTs (n = 2570, including 1288 receiving TCS), two cohort (all received TCS n = 148) and three case-control studies (cases n = 10 322, controls n = 12 201). Evidence from two RCTS (n = 2570, children, three and five years' duration) comparing TCS to topical calcineurin inhibitors found intermittent TCS use probably results in little to no difference in risk of growth abnormalities, non-skin infections, impaired vaccine response and lymphoma/non lymphoma malignancies. The five-year RCT reported only one episode of skin atrophy (n = 1213 TCS arm; mild/moderate potency), suggesting TCS use probably results in little to no difference in skin thinning when used intermittently to treat flares. No cases of clinical adrenal insufficiency were reported in 75 patients using mild/moderate TCS in the three-year RCT. Small associations between TCS and type-2 diabetes and lymphoma were identified in two case-control studies compared to no TCS, but the evidence is very uncertain. No long-term studies concerning topical steroid withdrawal or eye problems were identified. Conclusion This review provides some reassuring data on growth and skin thinning when TCS are used intermittently for up to 5 years, but many knowledge gaps remain.
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Affiliation(s)
- Jane Harvey
- Centre of Evidence Based DermatologySchool of MedicineUniversity of NottinghamNottinghamUK
| | - Stephanie J. Lax
- Centre of Evidence Based DermatologySchool of MedicineUniversity of NottinghamNottinghamUK
| | - Alison Lowe
- University Hospitals SussexNHS Foundation TrustWorthingUK
| | - Miriam Santer
- Primary Care Research CentreUniversity of SouthamptonSouthamptonUK
| | - Sandra Lawton
- Department of DermatologyRotherham NHS Foundation TrustRotherhamUK
| | | | - Amanda Roberts
- Nottingham Support Group for Carers of Children with EczemaNottinghamUK
| | - Beth Stuart
- Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
| | - Hywel C. Williams
- Centre of Evidence Based DermatologySchool of MedicineUniversity of NottinghamNottinghamUK
| | - Kim S. Thomas
- Centre of Evidence Based DermatologySchool of MedicineUniversity of NottinghamNottinghamUK
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17
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Attar R, Hurault G, Wang Z, Mokhtari R, Pan K, Olabi B, Earp E, Steele L, Williams HC, Tanaka RJ. Reliable Detection of Eczema Areas for Fully Automated Assessment of Eczema Severity from Digital Camera Images. JID Innov 2023; 3:100213. [PMID: 37719662 PMCID: PMC10504536 DOI: 10.1016/j.xjidi.2023.100213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 09/19/2023] Open
Abstract
Assessing the severity of eczema in clinical research requires face-to-face skin examination by trained staff. Such approaches are resource-intensive for participants and staff, challenging during pandemics, and prone to inter- and intra-observer variation. Computer vision algorithms have been proposed to automate the assessment of eczema severity using digital camera images. However, they often require human intervention to detect eczema lesions and cannot automatically assess eczema severity from real-world images in an end-to-end pipeline. We developed a model to detect eczema lesions from images using data augmentation and pixel-level segmentation of eczema lesions on 1,345 images provided by dermatologists. We evaluated the quality of the obtained segmentation compared with that of the clinicians, the robustness to varying imaging conditions encountered in real-life images, such as lighting, focus, and blur, and the performance of downstream severity prediction when using the detected eczema lesions. The quality and robustness of eczema lesion detection increased by approximately 25% and 40%, respectively, compared with that of our previous eczema detection model. The performance of the downstream severity prediction remained unchanged. Use of skin segmentation as an alternative to eczema segmentation that requires specialist labeling showed the performance on par with when eczema segmentation is used.
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Affiliation(s)
- Rahman Attar
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Guillem Hurault
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Zihao Wang
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Ricardo Mokhtari
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Kevin Pan
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Bayanne Olabi
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, United Kingdom
| | - Eleanor Earp
- Department of Dermatology, Lauriston Building, Edinburgh, United Kingdom
| | - Lloyd Steele
- Department of Dermatology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Reiko J. Tanaka
- Department of Bioengineering, Imperial College London, London, United Kingdom
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18
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Naldi L, Garcia-Doval I, Williams HC. Nutritional Supplements and Hair Loss-Limitations to the Interpretation of Clinical Studies Before Implementation in Clinical Practice. JAMA Dermatol 2023; 159:892-893. [PMID: 37379000 DOI: 10.1001/jamadermatol.2023.1779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Affiliation(s)
- Luigi Naldi
- Department of Dermatology, AULSS8 Berica, Ospedale San Bortolo, Vicenza, Italy
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, England
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19
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Card TR, Nakafero G, Grainge MJ, Mallen CD, Van-Tam JSN, Williams HC, Abhishek A. Is Vaccination Against COVID-19 Associated With Inflammatory Bowel Disease Flare? Self-Controlled Case Series Analysis Using the UK CPRD. Am J Gastroenterol 2023; 118:1388-1394. [PMID: 36826512 DOI: 10.14309/ajg.0000000000002205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 01/19/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION To investigate the association between vaccination against coronavirus disease 2019 (COVID-19) and inflammatory bowel disease (IBD) flare. METHODS Patients with IBD vaccinated against COVID-19 who consulted for disease flare between December 1, 2020, and December 31, 2021, were ascertained from the Clinical Practice Research Datalink. IBD flares were identified using consultation and corticosteroid prescription records. Vaccinations were identified using product codes and vaccination dates. The study period was partitioned into vaccine-exposed (vaccination date and 21 days immediately after), prevaccination (7 days immediately before vaccination), and the remaining vaccine-unexposed periods. Participants contributed data with multiple vaccinations and IBD flares. Season-adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) were calculated using self-controlled case series analysis. RESULTS Data for 1911 cases with IBD were included; 52% of them were female, and their mean age was 49 years. Approximately 63% of participants had ulcerative colitis (UC). COVID-19 vaccination was not associated with increased IBD flares in the vaccine-exposed period when all vaccinations were considered (aIRR [95% CI] 0.89 [0.77-1.02], 0.79 [0.66-0.95], and 1.00 [0.79-1.27] in IBD overall, UC, and Crohn's disease, respectively). Analyses stratified to include only first, second, or third COVID-19 vaccinations found no significant association between vaccination and IBD flares in the vaccine-exposed period (aIRR [95% CI] 0.87 [0.71-1.06], 0.93 [0.75-1.15], and 0.86 [0.63-1.17], respectively). Similarly, stratification by COVID-19 before vaccination and by vaccination with vectored DNA or messenger RNA vaccine did not reveal an increased risk of flare in any of these subgroups. DISCUSSION Vaccination against COVID-19 was not associated with IBD flares regardless of prior COVID-19 infection and whether messenger RNA or DNA vaccines were used.
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Affiliation(s)
- Timothy R Card
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Georgina Nakafero
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew J Grainge
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | | | - Hywel C Williams
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Abhishek Abhishek
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
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20
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Frewen J, de Brito M, Pathak A, Barlow R, Williams HC. How to critically appraise a systematic review: an aide for the reader and reviewer. Clin Exp Dermatol 2023; 48:854-859. [PMID: 37119274 DOI: 10.1093/ced/llad141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 05/01/2023]
Abstract
The number of published systematic reviews has soared rapidly in recent years. Sadly, the quality of most systematic reviews in dermatology is substandard. With the continued increase in exposure to systematic reviews, and their potential to influence clinical practice, we sought to describe a sequence of useful tips for the busy clinician reader to determine study quality and clinical utility. Important factors to consider when assessing systematic reviews include: determining the motivation to performing the study, establishing if the study protocol was prepublished, assessing quality of reporting using the PRISMA checklist, assessing study quality using the AMSTAR 2 critical appraisal checklist, assessing for evidence of spin, and summarizing the main strengths and limitations of the study to determine if it could change clinical practice. Having a set of heuristics to consider when reading systematic reviews serves to save time, enabling assessment of quality in a structured way, and come to a prompt conclusion of the merits of a review article in order to inform the care of dermatology patients.
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Affiliation(s)
- John Frewen
- Department of Dermatology, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | | | - Anjali Pathak
- Watford General Hospital, Watford, Hertfordshire, UK
| | - Richard Barlow
- Sandwell and West Birmingham Hospitals, Birmingham, UK
- Department of Dermatology, Birmingham City Hospital, Birmingham, UK
| | - Hywel C Williams
- Department of Dermatology, Queens Medical Centre, Nottingham, UK
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21
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Yamamoto-Hanada K, Kobayashi T, Mikami M, Williams HC, Saito H, Saito-Abe M, Sato M, Irahara M, Miyaji Y, Ishikawa F, Tsuchiya K, Tamagawa-Mineoka R, Takaoka Y, Takemura Y, Sato S, Wakiguchi H, Hoshi M, Natsume O, Yamaide F, Seike M, Ohya Y. Enhanced early skin treatment for atopic dermatitis in infants reduces food allergy. J Allergy Clin Immunol 2023; 152:126-135. [PMID: 36963619 DOI: 10.1016/j.jaci.2023.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/20/2023] [Accepted: 03/07/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Early-onset atopic dermatitis is a strong risk factor for food allergy, suggesting that early effective treatment may prevent transcutaneous sensitization. OBJECTIVES This study tested whether enhanced treatment of atopic dermatitis to clinically affected and unaffected skin is more effective in preventing hen's egg allergy than reactive treatment to clinically affected skin only. METHODS This was a multicenter, parallel-group, open-label, assessor-blind, randomized controlled trial (PACI [Prevention of Allergy via Cutaneous Intervention] study). This study enrolled infants 7-13 weeks old with atopic dermatitis and randomly assigned infants in a 1:1 ratio to enhanced early skin treatment or conventional reactive treatment using topical corticosteroids (TCSs). The primary outcome was the proportion of immediate hen's egg allergy confirmed by oral food challenge at 28 weeks of age. RESULTS This study enrolled 650 infants and analyzed 640 infants (enhanced [n = 318] or conventional [n = 322] treatment). Enhanced treatment significantly reduced hen's egg allergy compared with the conventional treatment (31.4% vs 41.9%, P = .0028; risk difference: -10.5%, upper bound of a 1-sided CI: -3.0%), while it lowered body weight (mean difference: -422 g, 95% CI: -553 to -292 g) and height (mean difference: -0.8 cm, 95% CI: -1.22 to -0.33 cm) at 28 weeks of age. CONCLUSIONS This study highlighted the potential of well-controlled atopic dermatitis management as a component of a hen's egg allergy prevention strategy. The enhanced treatment protocol of this trial should be modified before it can be considered as an approach to prevent hen's egg allergy in daily practice to avoid the adverse effects of TCSs. After remission induction by TCSs, maintenance therapy with lower potency TCSs or other topical therapies might be considered as alternative proactive treatments to overcome the safety concerns of TCSs.
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Affiliation(s)
| | - Tohru Kobayashi
- National Center for Child Health and Development, Tokyo, Japan
| | - Masashi Mikami
- National Center for Child Health and Development, Tokyo, Japan
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Hirohisa Saito
- National Center for Child Health and Development, Tokyo, Japan
| | | | - Miori Sato
- National Center for Child Health and Development, Tokyo, Japan
| | - Makoto Irahara
- National Center for Child Health and Development, Tokyo, Japan
| | - Yumiko Miyaji
- National Center for Child Health and Development, Tokyo, Japan
| | - Fumi Ishikawa
- National Center for Child Health and Development, Tokyo, Japan
| | | | | | | | | | - Sakura Sato
- National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | | | - Miyuki Hoshi
- National Hospital Organization Mie National Hospital, Mie, Japan
| | - Osamu Natsume
- Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Fumiya Yamaide
- Chiba University Graduate School of Medicine, Chiba, Japan
| | - Miwako Seike
- National Center for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- National Center for Child Health and Development, Tokyo, Japan.
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Nakafero G, Grainge MJ, Williams HC, Card T, Taal MW, Aithal GP, Fox CP, Mallen CD, van der Windt DA, Stevenson MD, Riley RD, Abhishek A. Risk stratified monitoring for methotrexate toxicity in immune mediated inflammatory diseases: prognostic model development and validation using primary care data from the UK. BMJ 2023; 381:e074678. [PMID: 37253479 DOI: 10.1136/bmj-2022-074678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To develop and validate a prognostic model to inform risk stratified decisions on frequency of monitoring blood tests during long term methotrexate treatment. DESIGN Retrospective cohort study. SETTING Electronic health records within the UK's Clinical Practice Research Datalink (CPRD) Gold and CPRD Aurum. PARTICIPANTS Adults (≥18 years) with a diagnosis of an immune mediated inflammatory disease who were prescribed methotrexate by their general practitioner for six months or more during 2007-19. MAIN OUTCOME MEASURE Discontinuation of methotrexate owing to abnormal monitoring blood test result. Patients were followed-up from six months after their first prescription for methotrexate in primary care to the earliest of outcome, drug discontinuation for any other reason, leaving the practice, last data collection from the practice, death, five years, or 31 December 2019. Cox regression was performed to develop the risk equation, with bootstrapping used to shrink predictor effects for optimism. Multiple imputation handled missing predictor data. Model performance was assessed in terms of calibration and discrimination. RESULTS Data from 13 110 (854 events) and 23 999 (1486 events) participants were included in the development and validation cohorts, respectively. 11 candidate predictors (17 parameters) were included. In the development dataset, the optimism adjusted R2 was 0.13 and the optimism adjusted Royston D statistic was 0.79. The calibration slope and Royston D statistic in the validation dataset for the entire follow-up period was 0.94 (95% confidence interval 0.85 to 1.02) and 0.75 (95% confidence interval 0.67 to 0.83), respectively. The prognostic model performed well in predicting outcomes in clinically relevant subgroups defined by age group, type of immune mediated inflammatory disease, and methotrexate dose. CONCLUSION A prognostic model was developed and validated that uses information collected during routine clinical care and may be used to risk stratify the frequency of monitoring blood test during long term methotrexate treatment.
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Affiliation(s)
- Georgina Nakafero
- Academic Rheumatology, University of Nottingham, Nottingham NG5 1PB, UK
| | - Matthew J Grainge
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Card
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, Translational Medical Sciences, University of Nottingham, Derby, UK
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, University of Nottingham, Nottingham, UK
| | - Christopher P Fox
- Department of Haematology, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | | | - Matthew D Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Richard D Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abhishek Abhishek
- Academic Rheumatology, University of Nottingham, Nottingham NG5 1PB, UK
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Charman C, Wainman H, Rabindranathnambi A, Whybrew C, Williams HC. How to do Advice and Guidance well. Clin Exp Dermatol 2023:7133812. [PMID: 37079879 DOI: 10.1093/ced/llad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
The COVID-19 pandemic has accelerated a rapid expansion of digital Advice and Guidance (A&G) across UK medical and surgical specialties. Dermatology A&G requests have increased by over 400% since the onset of the pandemic in 2020, with rapid expansion of teledermatology A&G services across England. Dermatology A&G is usually carried out asynchronously through dedicated digital platforms such as the NHS e-Referral service, with streamlined conversion to referral if clinically indicated. A&G with images is advocated as the main referral pathway to dermatology specialist services in England (excluding the two-week wait suspected skin cancer pathway). Providing dermatological care through A&G requires specific clinical skill sets to ensure rapid, safe and collaborative delivery, and optimisation of educational benefit. Little published guidance is available to signpost clinicians to what constitutes a high-quality A&G request and response. This educational article discusses good clinical practice based on extensive local and national experience from primary and secondary care doctors. We cover digital communication skills, shared decision making, clinical competency, and building collaborative links between patients, referrers and specialists. High quality A&G, with agreed turn-around times and optimisation of technology can significantly streamline patient care and strengthen links between clinicians, providing it is appropriately resourced within the wider planning of elective care and outpatient activity.
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Affiliation(s)
- Carolyn Charman
- Department of Dermatology, Royal Devon University Healthcare NHS Foundation Trust, UK
| | - Hannah Wainman
- Gloucestershire Hospitals NHS Foundation Trust and the University of Bristol, UK
| | | | - Chin Whybrew
- Stoke Road Surgery, Bishops Cleeve, Cheltenham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
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24
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Leducq S, Bonsu N, Clement K, Barlow R, Williams HC. Predator and Alien: the threat of predatory journals and conferences. Clin Exp Dermatol 2023:7107418. [PMID: 37017182 DOI: 10.1093/ced/llad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 04/06/2023]
Abstract
Predatory journals, first recognized in the early 2000s, are fraudulent journals characterized by aggressive marketing solicitations and deviation from best publishing practices. These journals claim to be legitimate scholarly journals, and accept articles for publication with no or poor peer review process or quality checks with a rapid publication process upon payment by the authors. They are a global threat as they are dishonest, lack transparency and seek only financial gain. More recently, predatory conferences have emerged and are expanding rapidly. Although they appear to be legitimate scientific conferences, they are also characterised by an over-riding profit motive, with no concern on academic values. Predatory journals and conferences are on the rise; dermatology trainees, readers and those new to publishing and conferences are vulnerable to predatory exploitation. The consequences of falling prey to such predation includes damage to the external reputation of the authors and their Institution and raises concerns about the legitimacy of the research. Several tools are available to help researchers recognise a predatory journal or conference. This educational review defines predatory journals and predatory conferences and summarises their distinguishing features such as no or poor peer review process, rapid acceptance, flattering language and lacking of meeting. We also highlight the consequences of publishing in a predatory journal or attending a predatory conference. The review finally outlines several tools available to use to reduce the likelihood of dermatologists falling into the hands of a predator.
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Affiliation(s)
- Sophie Leducq
- Centre of Evidence Based Dermatology, Faculty of Medicine & Health Sciences, Nottingham, UK
- Department of Dermatology, CHRU Tours, Tours, France
| | - Natalie Bonsu
- Centre of Evidence Based Dermatology, Faculty of Medicine & Health Sciences, Nottingham, UK
| | - Kate Clement
- Centre of Evidence Based Dermatology, Faculty of Medicine & Health Sciences, Nottingham, UK
| | | | - Hywel C Williams
- Centre of Evidence Based Dermatology, Faculty of Medicine & Health Sciences, Nottingham, UK
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25
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Steele L, Tan XL, Olabi B, Gao JM, Tanaka RJ, Williams HC. Determining the clinical applicability of machine learning models through assessment of reporting across skin phototypes and rarer skin cancer types: A systematic review. J Eur Acad Dermatol Venereol 2023; 37:657-665. [PMID: 36514990 DOI: 10.1111/jdv.18814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 11/09/2022] [Indexed: 12/15/2022]
Abstract
Machine learning (ML) models for skin cancer recognition may have variable performance across different skin phototypes and skin cancer types. Overall performance metrics alone are insufficient to detect poor subgroup performance. We aimed (1) to assess whether studies of ML models reported results separately for different skin phototypes and rarer skin cancers, and (2) to graphically represent the skin cancer training datasets used by current ML models. In this systematic review, we searched PubMed, Embase and CENTRAL. We included all studies in medical journals assessing an ML technique for skin cancer diagnosis that used clinical or dermoscopic images from 1 January 2012 to 22 September 2021. No language restrictions were applied. We considered rarer skin cancers to be skin cancers other than pigmented melanoma, basal cell carcinoma and squamous cell carcinoma. We identified 114 studies for inclusion. Rarer skin cancers were included by 8/114 studies (7.0%), and results for a rarer skin cancer were reported separately in 1/114 studies (0.9%). Performance was reported across all skin phototypes in 1/114 studies (0.9%), but performance was uncertain in skin phototypes I and VI from minimal representation of the skin phototypes in the test dataset (9/3756 and 1/3756, respectively). For training datasets, although public datasets were most frequently used, with the most widely used being the International Skin Imaging Collaboration (ISIC) archive (65/114 studies, 57.0%), the largest datasets were private. Our review identified that most ML models did not report performance separately for rarer skin cancers and different skin phototypes. A degree of variability in ML model performance across subgroups is expected, but the current lack of transparency is not justifiable and risks models being used inappropriately in populations in whom accuracy is low.
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Affiliation(s)
- Lloyd Steele
- Department of Dermatology, The Royal London Hospital, London, UK.,Centre for Cell Biology and Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| | - Xiang Li Tan
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Bayanne Olabi
- Biosciences Institute, Newcastle University, Newcastle, UK
| | - Jing Mia Gao
- Department of Dermatology, The Royal London Hospital, London, UK
| | - Reiko J Tanaka
- Department of Bioengineering, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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26
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Whalen-Browne A, Williams HC, Chu DK. Prise en charge de la dermatite atopique chez les nourrissons. CMAJ 2023; 195:E390-E391. [PMID: 36918176 PMCID: PMC10120418 DOI: 10.1503/cmaj.212094-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Affiliation(s)
- Anna Whalen-Browne
- Division d'immunologie clinique et d'allergologie, Département de médecine (Whalen-Browne, Chu), Université McMaster, Hamilton, Ont.; Centre of Evidence-Based Dermatology, École de médecine (Williams), Université de Nottingham, Centre médical Queen's, hôpitaux universitaires de Nottingham du NHS Trust, Nottingham, Royaume-Uni
| | - Hywel C Williams
- Division d'immunologie clinique et d'allergologie, Département de médecine (Whalen-Browne, Chu), Université McMaster, Hamilton, Ont.; Centre of Evidence-Based Dermatology, École de médecine (Williams), Université de Nottingham, Centre médical Queen's, hôpitaux universitaires de Nottingham du NHS Trust, Nottingham, Royaume-Uni
| | - Derek K Chu
- Division d'immunologie clinique et d'allergologie, Département de médecine (Whalen-Browne, Chu), Université McMaster, Hamilton, Ont.; Centre of Evidence-Based Dermatology, École de médecine (Williams), Université de Nottingham, Centre médical Queen's, hôpitaux universitaires de Nottingham du NHS Trust, Nottingham, Royaume-Uni.
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27
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Adams L, Nakafero G, Grainge MJ, Card T, Mallen CD, Van-Tam JSN, Williams HC, Abhishek A. Is vaccination against COVID-19 associated with psoriasis or eczema flare? Self-controlled case series analysis using data from the Clinical Practice Research Datalink (Aurum). Br J Dermatol 2023; 188:297-299. [PMID: 36763860 DOI: 10.1093/bjd/ljac061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/03/2022] [Accepted: 10/24/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Laura Adams
- University Hospitals of Derby and Burton, Derby, UK
| | | | | | - Tim Card
- Lifespan and Population Health and.,Nottingham Digestive Diseases Centre, Translational Medical Sciences; School of Medicine, University of Nottingham, Nottingham, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
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28
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Moledina Z, McPhee M, Ravenscroft JC, Healy E, Radley K, Thomas KS, Burden-Teh E, Healy E, Hepburn T, Layfield C, Layton A, Leighton P, Leng S, Mitchell ME, Northover G, Radley K, Ramesh MG, Ravenscroft JC, Sach T, Santer M, Thomas KS, Thompson A, Whitehouse H, Williams HC. How is oral isotretinoin prescribed for the treatment of acne vulgaris? Results from a UK Dermatology Clinical Trials Network (UKDCTN) and British Dermatological Nursing Group (BDNG) survey of health professionals. Clin Exp Dermatol 2023; 48:20-23. [PMID: 36669181 DOI: 10.1093/ced/llac015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/12/2022] [Accepted: 09/15/2022] [Indexed: 01/22/2023]
Abstract
We undertook a survey of UK healthcare professionals through the UK Dermatology Clinical Trials Network and British Dermatological Nursing Group to understand clinicians' routine practice of prescribing oral isotretinoin for treatment of acne vulgaris. We also wanted to understand clinicians' experiences and views on prescribing low daily dose regimens. Overall, the survey showed that clinicians adopted a patient-centred approach when deciding isotretinoin dosing. The rationale for using a low-dose regimen varied, but was focused on patient wellbeing during treatment. Some clinicians were concerned that use of a low-dose regimen could be less effective and lead to longer treatment durations. The survey results will be useful to inform a clinical trial investigating the effectiveness and safety of low daily dose isotretinoin for the treatment of acne.
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Affiliation(s)
- Zahra Moledina
- Department of Dermatology, Nottingham University Hospitals NHS Trust, UK
| | - Margaret McPhee
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, UK
| | - Jane C Ravenscroft
- Department of Paediatric Dermatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, UK
| | - Eugene Healy
- Department of Dermatopharmacology, Faculty of Medicine, University of Southampton, UK
| | - Kathy Radley
- Department of Clinical, Pharmaceutical and Biological Science, School of Life and Medical Sciences, University of Hertfordshire, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, UK
| | - Esther Burden-Teh
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, UK
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Santer M, Muller I, Becque T, Stuart B, Hooper J, Steele M, Wilczynska S, Sach TH, Ridd MJ, Roberts A, Ahmed A, Yardley L, Little P, Greenwell K, Sivyer K, Nuttall J, Griffiths G, Lawton S, Langan SM, Howells LM, Leighton P, Williams HC, Thomas KS. Eczema Care Online behavioural interventions to support self-care for children and young people: two independent, pragmatic, randomised controlled trials. BMJ 2022; 379:e072007. [PMID: 36740888 DOI: 10.1136/bmj-2022-072007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the effectiveness of two online behavioural interventions, one for parents and carers and one for young people, to support eczema self-management. DESIGN Two independent, pragmatic, parallel group, unmasked, randomised controlled trials. SETTING 98 general practices in England. PARTICIPANTS Parents and carers of children (0-12 years) with eczema (trial 1) and young people (13-25 years) with eczema (trial 2), excluding people with inactive or very mild eczema (≤5 on POEM, the Patient-Oriented Eczema Measure). INTERVENTIONS Participants were randomised (1:1) using online software to receive usual eczema care or an online (www.EczemaCareOnline.org.uk) behavioural intervention for eczema plus usual care. MAIN OUTCOME MEASURES Primary outcome was eczema symptoms rated using POEM (range 0-28, with 28 being very severe) every four weeks over 24 weeks. Outcomes were reported by parents or carers for children and by self-report for young people. Secondary outcomes included POEM score every four weeks over 52 weeks, quality of life, eczema control, itch intensity (young people only), patient enablement, treatment use, perceived barriers to treatment use, and intervention use. Analyses were carried out separately for the two trials and according to intention-to-treat principles. RESULTS 340 parents or carers of children (169 usual care; 171 intervention) and 337 young people (169 usual care; 168 intervention) were randomised. The mean baseline POEM score was 12.8 (standard deviation 5.3) for parents and carers and 15.2 (5.4) for young people. Three young people withdrew from follow-up but did not withdraw their data. All randomised participants were included in the analyses. At 24 weeks, follow-up rates were 91.5% (311/340) for parents or carers and 90.2% (304/337) for young people. After controlling for baseline eczema severity and confounders, compared with usual care groups over 24 weeks, eczema severity improved in the intervention groups: mean difference in POEM score -1.5 (95% confidence interval -2.5 to -0.6; P=0.002) for parents or carers and -1.9 (-3.0 to -0.8; P<0.001) for young people. The number needed to treat to achieve a 2.5 difference in POEM score at 24 weeks was 6 in both trials. Improvements were sustained to 52 weeks in both trials. Enablement showed a statistically significant difference favouring the intervention group in both trials: adjusted mean difference at 24 weeks -0.7 (95% confidence interval -1.0 to -0.4) for parents or carers and -0.9 (-1.3 to -0.6) for young people. No harms were identified in either group. CONCLUSIONS Two online interventions for self-management of eczema aimed at parents or carers of children with eczema and at young people with eczema provide a useful, sustained benefit in managing eczema severity in children and young people when offered in addition to usual eczema care. TRIAL REGISTRATION ISRCTN registry ISRCTN79282252.
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Affiliation(s)
- Miriam Santer
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Ingrid Muller
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Taeko Becque
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Beth Stuart
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Julie Hooper
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Mary Steele
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Sylvia Wilczynska
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Matthew J Ridd
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amina Ahmed
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lucy Yardley
- School of Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, UK
| | - Kate Greenwell
- School of Psychology, University of Southampton, Southampton, UK
| | - Katy Sivyer
- School of Psychology, University of Southampton, Southampton, UK
| | - Jacqui Nuttall
- Southampton Clinical Trial Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gareth Griffiths
- Southampton Clinical Trial Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Sinéad M Langan
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Laura M Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Paul Leighton
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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Greenwell K, Sivyer K, Howells L, Steele M, Ridd MJ, Roberts A, Ahmed A, Lawton S, Langan SM, Hooper J, Wilczynska S, Leighton P, Griffiths G, Sach T, Little P, Williams HC, Thomas KS, Yardley L, Santer M, Muller I. 'Eczema shouldn't control you; you should control eczema': qualitative process evaluation of online behavioural interventions to support young people and parents/carers of children with eczema. Br J Dermatol 2022; 188:506-513. [PMID: 36745562 DOI: 10.1093/bjd/ljac115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is a lack of well-conducted randomized controlled trials evaluating the effectiveness of theory-based online interventions for eczema. To address these deficiencies, we previously developed and demonstrated the effectiveness of two online behavioural interventions: Eczema Care Online for parents/carers of children with eczema, and Eczema Care Online for young people with eczema. OBJECTIVES To explore the views and experiences of people who have used the Eczema Care Online interventions to provide insights into how the interventions worked and identify contextual factors that may impede users' engagement with the interventions. METHODS Qualitative semistructured interviews were conducted with 17 parents/carers of children with eczema and 17 young people with eczema. Participants were purposively sampled from two randomized controlled trials of the interventions and recruited from GP surgeries in England. Transcripts were analysed using inductive thematic analysis, and intervention modifications were identified using the person-based approach table of changes method. RESULTS Both young people and parents/carers found the interventions easy to use, relatable and trustworthy, and perceived that they helped them to manage their eczema, thus suggesting that Eczema Care Online may be acceptable to its target groups. Our analysis suggested that the interventions may reduce eczema severity by facilitating empowerment among its users, specifically through improved understanding of, and confidence in, eczema management, reduced treatment concerns, and improved treatment adherence and management of irritants/triggers. Reading about the experiences of others with eczema helped people to feel 'normal' and less alone. Some (mainly young people) expressed firmly held negative beliefs about topical corticosteroids, views that were not influenced by the intervention. Minor improvements to the design and navigation of the Eczema Care Online interventions and content changes were identified and made, ready for wider implementation. CONCLUSIONS People with eczema and their families can benefit from reliable information, specifically information on the best and safest ways to use their eczema treatments early in their eczema journey. Together, our findings from this study and the corresponding trials suggest wider implementation of Eczema Care Online (EczemaCareOnline.org.uk) is justified.
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Affiliation(s)
- Kate Greenwell
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Laura Howells
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Mary Steele
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amina Ahmed
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sandra Lawton
- Department of Dermatology, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Julie Hooper
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sylvia Wilczynska
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Leighton
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Tracey Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Paul Little
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
| | - Miriam Santer
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ingrid Muller
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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31
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Affleck A, Jackson D, Williams HC, Chavez P, Albrecht J. Is routine laboratory testing in healthy young patients taking isotretinoin necessary: a critically appraised topic. Br J Dermatol 2022; 187:857-865. [PMID: 35986616 DOI: 10.1111/bjd.21840] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 12/24/2022]
Abstract
CLINICAL QUESTION Is monitoring of liver function, lipids and full blood count necessary in healthy people taking isotretinoin? BACKGROUND Routine blood testing was recommended in the original licence for Roaccutane™ (isotretinoin) in 1983. In recent years, less frequent monitoring has been suggested by various authors. DATA SOURCES We performed four individual systematic searches of the MEDLINE database, via PubMed, from origin to 2 May 2021, supplemented by a hand search of all references in the identified papers. STUDY SELECTION Inclusion criteria were any description of clinical symptoms, laboratory abnormalities and/or physical findings, and any paper that explicitly described the patients as asymptomatic, during treatment with oral isotretinoin. DATA EXTRACTION Two independent reviewers (J.A. and D.J.) assessed articles for eligibility of inclusion. Evaluation of the data was done also by two of the authors (A.A., D.J. and J.A.) for each section, with the aim to use the presented evidence including guidelines, databases, case series, case reports, cohort studies and randomized clinical trials to delineate the clinical presentation and frequency of adverse events that might be amenable to laboratory monitoring. RESULTS We identified 407 papers in our searches and reviewed 125 papers in four sections. Overall, reported adverse events were very rare (< 1 in 10 000) and were either idiosyncratic or not preventable by monitoring, accompanied by symptoms, or seen in identifiable predisposed individuals who might benefit from monitoring because of pre-existing conditions. RECOMMENDATION FOR CLINICAL CARE We could not find evidence to support the benefit of monitoring to detect adverse events. We suggest that in healthy young people laboratory monitoring for oral isotretinoin is unnecessary and risks detecting nonserious biochemical abnormalities. However, we recognize that new information about adverse events may change that recommendation.
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Affiliation(s)
| | - David Jackson
- Walsall Healthcare NHS Trust, Moat Rd, Walsall, West Midlands, WS2 9PS, UK
| | | | | | - Joerg Albrecht
- Division of Dermatology, Department of Medicine, J.H. Stroger Hospital of Cook County, Chicago, IL, USA.,Department of Otolaryngology, Division of Dermatology, Rush Medical College, Chicago, IL, USA
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32
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Leshem YA, Chalmers JR, Apfelbacher C, Katoh N, Gerbens LAA, Schmitt J, Spuls PI, Thomas KS, Howells L, Williams HC, Simpson EL. Measuring Atopic Eczema Control and Itch Intensity in Clinical Practice: A Consensus Statement From the Harmonising Outcome Measures for Eczema in Clinical Practice (HOME-CP) Initiative. JAMA Dermatol 2022; 158:1429-1435. [PMID: 36223090 DOI: 10.1001/jamadermatol.2022.4211] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Measuring outcomes in clinical practice can aid patient care, quality improvement, and real-world evidence generation. The Harmonising Outcome Measures for Eczema (HOME) Clinical Practice initiative is developing a list of validated, feasible instruments to measure atopic eczema in clinical care. Prior work identified symptoms and long-term control as the most important domains to measure in clinical practice. The Patient-Oriented Eczema Measure (POEM) and the Patient-Oriented Scoring Atopic Dermatitis Index (PO-SCORAD) were recommended by consensus to measure symptoms in clinical practice, but a need for instruments to measure itch intensity specifically was recognized. The HOME group also previously decided that long-term control should be captured by repeated measurements of eczema control. Recommended instruments to measure eczema control in clinical practice have not been defined. Objective To recommend instruments to measure eczema control and itch intensity in patients with atopic eczema in clinical practice. Evidence Review Available instruments to measure eczema control and itch intensity were identified through systematic reviews, informing a consensus process held at the HOME VIII virtual online meeting (October 6 and October 9, 2020). Feasibility aspects were highlighted to optimize instrument selection for the clinical practice. Consensus on an instrument was reached if fewer than 30% of the voters disagreed. Findings Of 7 identified instruments, the Recap of Atopic Eczema (RECAP) and Atopic Dermatitis Control Tool (ADCT) were the recommended instruments to measure eczema control (3 of 63 [5%] and 7 of 69 [10%] of voters disagreed, respectively). A single-question patient global assessment garnered support, but the current available instrument did not reach consensus. Six available itch-intensity instruments were identified. Of them, 3 instruments were recommended by consensus: a peak 24-hour numeric rating scale (NRS)-itch, and 1-week NRS-itch instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) Itch Questionnaire, measuring average and peak itch (11 of 63 [17%], 14 of 63 [22%], and 16 of 59 [27%] voters disagreed, respectively). Conclusions and Relevance Clinicians and patients are encouraged to incorporate these well-validated, quick-to-perform, and easy-to-use instruments into their clinic, selecting the instruments that best fit their need. These assessments are meant to enhance, not replace, the patient-clinician encounter, and to support real-world research and health care improvement.
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Affiliation(s)
- Yael A Leshem
- Division of Dermatology, Rabin Medical Center, Petach-Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Christian Apfelbacher
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany.,Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - Norito Katoh
- Department of Dermatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, Medical Faculty Carl Gustav Carus, TU Dresden, Germany
| | - Phyllis I Spuls
- Department of Dermatology, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Laura Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
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Kelleher MM, Phillips R, Brown SJ, Cro S, Cornelius V, Carlsen KCL, Skjerven HO, Rehbinder EM, Lowe AJ, Dissanayake E, Shimojo N, Yonezawa K, Ohya Y, Yamamoto-Hanada K, Morita K, Axon E, Cork M, Cooke A, Van Vogt E, Schmitt J, Weidinger S, McClanahan D, Simpson E, Duley L, Askie LM, Williams HC, Boyle RJ. Skin care interventions in infants for preventing eczema and food allergy. Cochrane Database Syst Rev 2022; 11:CD013534. [PMID: 36373988 PMCID: PMC9661877 DOI: 10.1002/14651858.cd013534.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Eczema and food allergy are common health conditions that usually begin in early childhood and often occur in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective for preventing eczema or food allergy. OBJECTIVES Primary objective To assess the effects of skin care interventions such as emollients for primary prevention of eczema and food allergy in infants. Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy. SEARCH METHODS We performed an updated search of the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase in September 2021. We searched two trials registers in July 2021. We checked the reference lists of included studies and relevant systematic reviews, and scanned conference proceedings to identify further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA: We included RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (≤ 12 months) without pre-existing eczema, food allergy, or other skin condition. Eligible comparisons were standard care in the locality or no treatment. Types of skin care interventions could include moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required. DATA COLLECTION AND ANALYSIS This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured at the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen. MAIN RESULTS We identified 33 RCTs comprising 25,827 participants. Of these, 17 studies randomising 5823 participants reported information on one or more outcomes specified in this review. We included 11 studies, randomising 5217 participants, in one or more meta-analyses (range 2 to 9 studies per individual meta-analysis), with 10 of these studies providing IPD; the remaining 6 studies were included in the narrative results only. Most studies were conducted at children's hospitals. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although the definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to three years. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported information on our prespecified outcomes, 13 assessed emollients. We assessed most of the evidence in the review as low certainty and had some concerns about risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. We assessed the evidence for the primary food allergy outcome as high risk of bias due to the inclusion of only one trial, where findings varied based on different assumptions about missing data. Skin care interventions during infancy probably do not change the risk of eczema by one to three years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; risk difference 5 more cases per 1000 infants, 95% CI 28 less to 47 more; moderate-certainty evidence; 3075 participants, 7 trials) or time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). Skin care interventions during infancy may increase the risk of IgE-mediated food allergy by one to three years of age (RR 2.53, 95% CI 0.99 to 6.49; low-certainty evidence; 976 participants, 1 trial) but may not change risk of allergic sensitisation to a food allergen by age one to three years (RR 1.05, 95% CI 0.64 to 1.71; low-certainty evidence; 1794 participants, 3 trials). Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial); however, this was only seen for cow's milk, and may be unreliable due to over-reporting of milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.33, 95% CI 1.01 to 1.75; risk difference 17 more cases per 1000 infants, 95% CI one more to 38 more; moderate-certainty evidence; 2728 participants, 6 trials) and may increase the risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) and stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although CIs for slippages and stinging/allergic reactions were wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses showed that the effects of interventions were not influenced by age, duration of intervention, hereditary risk, filaggrin (FLG) mutation, chromosome 11 intergenic variant rs2212434, or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and eczema or food allergy development. AUTHORS' CONCLUSIONS Based on low- to moderate-certainty evidence, skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema; may increase risk of food allergy; and probably increase risk of skin infection. Further study is needed to understand whether different approaches to infant skin care might prevent eczema or food allergy.
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Affiliation(s)
- Maeve M Kelleher
- National Heart & Lung Institute, Section of Inflammation and Repair, Imperial College London, London, UK
| | - Rachel Phillips
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Sara J Brown
- Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Karin C Lødrup Carlsen
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Håvard O Skjerven
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Eva M Rehbinder
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Dermatology, Oslo University Hospital, Oslo, Norway
| | - Adrian J Lowe
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Eishika Dissanayake
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Naoki Shimojo
- Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Kaori Yonezawa
- Department of Midwifery and Women's Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | | | - Kumiko Morita
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Emma Axon
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Michael Cork
- Sheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Alison Cooke
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Eleanor Van Vogt
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, Faculty of Medicine Carl Gustav Carus, Technischen Universität (TU) Dresden, Dresden, Germany
| | - Stephan Weidinger
- Department of Dermatology and Allergy, University Hospital Scheswig-Holstein, Kiel, Germany
| | - Danielle McClanahan
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Eric Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lisa M Askie
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Australia
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Robert J Boyle
- National Heart & Lung Institute, Section of Inflammation and Repair, Imperial College London, London, UK
- Cochrane Skin, Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Affiliation(s)
- Anna Whalen-Browne
- Division of Clinical Immunology and Allergy, Department of Medicine (Whalen-Browne, Chu), McMaster University, Hamilton, Ont.; Centre of Evidence-Based Dermatology, School of Medicine (Williams), University of Nottingham, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Hywel C Williams
- Division of Clinical Immunology and Allergy, Department of Medicine (Whalen-Browne, Chu), McMaster University, Hamilton, Ont.; Centre of Evidence-Based Dermatology, School of Medicine (Williams), University of Nottingham, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Derek K Chu
- Division of Clinical Immunology and Allergy, Department of Medicine (Whalen-Browne, Chu), McMaster University, Hamilton, Ont.; Centre of Evidence-Based Dermatology, School of Medicine (Williams), University of Nottingham, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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35
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Bradshaw LE, Wyatt LA, Brown SJ, Haines RH, Montgomery AA, Perkin MR, Lawton S, Sach TH, Chalmers JR, Ridd MJ, Flohr C, Brooks J, Swinden R, Mitchell EJ, Tarr S, Jay N, Thomas KS, Allen H, Cork MJ, Kelleher MM, Simpson EL, Lartey ST, Davies-Jones S, Boyle RJ, Williams HC. Emollients for prevention of atopic dermatitis; 5-year findings from the BEEP randomised trial. Allergy 2022; 78:995-1006. [PMID: 36263451 DOI: 10.1111/all.15555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/14/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effectiveness of emollients for preventing atopic dermatitis/eczema is controversial. The Barrier Enhancement for Eczema Prevention trial evaluated the effects of daily emollients during the first year of life on atopic dermatitis and atopic conditions to age 5 years. METHODS 1394 term infants with a family history of atopic disease were randomised (1:1) to daily emollient plus standard skin-care advice (693 emollient group) or standard skin-care advice alone (701 controls). Long-term follow-up at ages 3, 4 and 5 years was via parental questionnaires. Main outcomes were parental report of a clinical diagnosis of atopic dermatitis and food allergy. RESULTS Parents reported more frequent moisturiser application in the emollient group through to 5 years. A clinical diagnosis of atopic dermatitis between 12 and 60 months was reported for 188/608 (31%) in the emollient group and 178/631 (28%) in the control group (adjusted relative risk 1.10, 95% confidence interval 0.93 to 1.30). Although more parents in the emollient group reported food reactions in the previous year at 3 and 4 years, cumulative incidence of doctor diagnosed food allergy by 5 years was similar between groups (92/609 (15%) emollients and 87/632 (14%) controls, adjusted relative risk 1.11, 95% confidence interval 0.84 to 1.45). Findings were similar for cumulative incidence of asthma and hay fever. CONCLUSIONS Daily emollient application during the first year of life does not prevent atopic dermatitis, food allergy, asthma or hay fever.
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Affiliation(s)
- Lucy E Bradshaw
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Laura A Wyatt
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Skin Research Group, School of Medicine, University of Dundee, Dundee, UK.,Department of Dermatology, Ninewells Hospital and Medical School, Dundee.,Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, UK.,Department of Dermatology, NHS Lothian, Edinburgh, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael R Perkin
- Population Health Research Institute, St. George's, University of London, London, UK
| | | | - Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, UK
| | - Joanne Brooks
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Stella Tarr
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital, Sheffield, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hilary Allen
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael J Cork
- Sheffield Dermatology Research, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
| | - Maeve M Kelleher
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Eric L Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Stella T Lartey
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Susan Davies-Jones
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robert J Boyle
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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Abstract
Little attention is paid to disease definition in dermatology and how such definitions come about, yet defining a disease is a fundamental step upon which all subsequent clinical management and prognostic judgements depend. Developing diagnostic criteria is also a critically important step for research purposes so that studies referring to groups of people can be compared in a meaningful way. This short review introduces the concepts of regressive and progressive nosology, and how definitions of a dermatological disease can evolve in a useful way as knowledge about that disease increases. It also highlights the dangers of panchrestons - names that try to explain all yet end up explaining very little. It also considers approaches to disease definition, such as whether a binary yes/no or continuous approach is more appropriate. Conceptual frameworks including essentialistic vs. nominalistic approaches using the biomedical or biopsychosocial perspectives are articulated. The review then illustrates hazards of underdiagnosis and overdiagnosis, and introduces the notion of 'disease mongering' - the selling of disease in order to promote the use of medicines. The review concludes with a reaffirmation of the importance of defining dermatological disease, and why any new diagnostic criteria must be shown to increase predictive ability before they are assimilated into clinical practice and research.
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Affiliation(s)
- Hywel C. Williams
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of MedicineUniversity of NottinghamNottinghamUK
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Williams HC, Burden‐Teh E. On the definition of dermatological disease. Part 2: approaches for defining dermatological diseases. Clin Exp Dermatol 2022; 47:1812-1819. [PMID: 35635781 PMCID: PMC9795889 DOI: 10.1111/ced.15278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 12/30/2022]
Abstract
In Part 1 of this two-part review, conceptual frameworks for defining skin diseases were articulated. In this review, the main approaches that can be used to develop diagnostic criteria for skin disease are summarized, using atopic dermatitis (AD) as an example. Different frameworks for defining skin disease for research purposes are articulated, including statistical, prognostic, operational, clinical and epidemiological approaches. All share the common aim of attempting to develop criteria that enable meaningful comparisons between groups of people. The desirable attributes of a good definition are described: diagnostic criteria should measure what they are meant to measure; the results should be the same for different assessors; the criteria should be coherent with what is known about that disease; they should reflect some degree of morbidity and not pick up subclinical disease; they should be easy to administer; and they should be applicable to a range of people of different ages, sexes/genders and ethnicities. Consensus-based criteria are contrasted with epidemiological derivation methods that assess the performance of diagnostic criteria in relation to a reference standard. The sensitivity and specificity of a disease definition is explained, along with how the trade-off between these two properties can vary, depending on the purpose of the study and the study setting. The review closes with some reflections on when it is appropriate to consider splitting a disease into more than one category and how diagnostic criteria can be interpreted in the clinical setting.
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Affiliation(s)
- Hywel C. Williams
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of MedicineUniversity of NottinghamNottinghamUK
| | - Esther Burden‐Teh
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of MedicineUniversity of NottinghamNottinghamUK
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Nakafero G, Grainge MJ, Card T, Mallen CD, Nguyen Van-Tam JS, Williams HC, Abhishek A. Is vaccination against Covid-19 associated with autoimmune rheumatic disease flare? A self-controlled case series analysis. Rheumatology (Oxford) 2022; 62:1445-1450. [PMID: 36048896 PMCID: PMC10070057 DOI: 10.1093/rheumatology/keac484] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/28/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To investigate the association between vaccination against Covid-19 and autoimmune rheumatic disease (AIRD) flare. METHODS Patients with AIRDs vaccinated against Covid-19 who consulted for disease flare between 01/12/2020 and 31/12/2021 were ascertained in Clinical Practice Research Datalink (Aurum). AIRD flare was defined as consultation for AIRD with corticosteroid prescription on the same day or the next day. Vaccination was defined using date of vaccination and product code. The observation period was partitioned into vaccine-exposed (21-days after vaccination), pre-vaccination (7-days before vaccination), and remaining vaccine-unexposed periods. Participants contributed data with multiple vaccinations and outcomes. Season adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) were calculated using self-controlled case-series analysis. RESULTS Data for 3554 AIRD cases, 72% female, mean age 65 years, and 68.3% with rheumatoid arthritis were included. Covid-19 vaccination was associated with significantly fewer AIRD flares in the 21-day vaccine-exposed period when all vaccinations were considered (aIRR(95%CI) 0.89(0.80-0.98)). Using dose-stratified analyses there was a statistically significant negative association in 21-days after first Covid-19 vaccination but no association after the second or third Covid-19 vaccinations (aIRR(95%CI) 0.76(0.66-0.89), 0.94(0.79-1.11) and 1.01(0.85-1.20) respectively). On AIRD type stratified analyses, vaccination was not associated with disease flares. Vaccination without or after SARS-CoV-2 infection, and with vectored DNA or mRNA vaccines associated with comparable reduced risk of AIRD flares in the vaccine-exposed period after first Covid-19 vaccination. CONCLUSION Vaccination against Covid-19 was not associated with increased AIRD flares regardless of prior Covid-19, AIRD type, and whether mRNA or DNA vaccination technology were used.
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Affiliation(s)
- Georgina Nakafero
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham
| | - Matthew J Grainge
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham
| | - Tim Card
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham.,Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele
| | | | - Hywel C Williams
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham
| | - Abhishek Abhishek
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham
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Abhishek A, Boyton RJ, Peckham N, McKnight Á, Coates LC, Bluett J, Barber V, Cureton L, Francis A, Appelbe D, Eldridge L, Julier P, Valdes AM, Brooks T, Rombach I, Altmann DM, Nguyen-Van-Tam JS, Williams HC, Cook JA. Effect of a 2-week interruption in methotrexate treatment versus continued treatment on COVID-19 booster vaccine immunity in adults with inflammatory conditions (VROOM study): a randomised, open label, superiority trial. Lancet Respir Med 2022; 10:840-850. [PMID: 35772416 PMCID: PMC9236568 DOI: 10.1016/s2213-2600(22)00186-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Immunosuppressive treatments inhibit vaccine-induced immunity against SARS-CoV-2. We evaluated whether a 2-week interruption of methotrexate treatment immediately after the COVID-19 vaccine booster improved antibody responses against the S1 receptor-binding domain (S1-RBD) of the SARS-CoV-2 spike protein compared with uninterrupted treatment in patients with immune-mediated inflammatory diseases. METHODS We did an open-label, prospective, two-arm, parallel-group, multicentre, randomised, controlled, superiority trial in 26 hospitals in the UK. We recruited adults from rheumatology and dermatology clinics who had been diagnosed with an immune-mediated inflammatory disease (eg, rheumatoid arthritis, psoriasis with or without arthritis, axial spondyloarthritis, atopic dermatitis, polymyalgia rheumatica, and systemic lupus erythematosus) and who were taking low-dose weekly methotrexate (≤25 mg per week) for at least 3 months. Participants also had to have received two primary vaccine doses from the UK COVID-19 vaccination programme. We randomly assigned the participants (1:1), using a centralised validated computer randomisation program, to suspend methotrexate treatment for 2 weeks immediately after their COVID-19 booster (suspend methotrexate group) or to continue treatment as usual (continue methotrexate group). Participants, investigators, clinical research staff, and data analysts were unmasked, while researchers doing the laboratory analyses were masked to group assignment. The primary outcome was S1-RBD antibody titres 4 weeks after receiving the COVID-19 booster vaccine dose, assessed in the intention-to-treat population. This trial is registered with ISRCT, ISRCTN11442263; following the pre-planned interim analysis, recruitment was stopped early. FINDINGS Between Sept 30, 2021 and March 3, 2022, we recruited 340 participants, of whom 254 were included in the interim analysis and had been randomly assigned to one of the two groups: 127 in the continue methotrexate group and 127 in the suspend methotrexate group. Their mean age was 59·1 years, 155 (61%) were female, 130 (51%) had rheumatoid arthritis, and 86 (34%) had psoriasis with or without arthritis. After 4 weeks, the geometric mean S1-RBD antibody titre was 22 750 U/mL (95% CI 19 314-26 796) in the suspend methotrexate group and 10 798 U/mL (8970-12 997) in the continue methotrexate group, with a geometric mean ratio (GMR) of 2·19 (95% CI 1·57-3·04; p<0·0001; mixed-effects model). The increased antibody response in the suspend methotrexate group was consistent across methotrexate dose, administration route, type of immune-mediated inflammatory disease, age, primary vaccination platform, and history of SARS-CoV-2 infection. There were no intervention-related serious adverse events. INTERPRETATION A 2-week interruption of methotrexate treatment for people with immune-mediated inflammatory diseases resulted in enhanced boosting of antibody responses after COVID-19 vaccination. This intervention is simple, low-cost, and easy to implement, and could potentially translate to increased vaccine efficacy and duration of protection for susceptible groups. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, London, UK; Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, UK
| | - Nicholas Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Biomedical Research Centre, Oxford, UK
| | - James Bluett
- National Institute of Health and Care Research, Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Vicki Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Patrick Julier
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | | | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Daniel M Altmann
- Department of Inflammation and Immunology, Imperial College London, London, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK; Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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Hurault G, Pan K, Mokhtari R, Olabi B, Earp E, Steele L, Williams HC, Tanaka RJ. Detecting Eczema Areas in Digital Images: An Impossible Task? JID Innov 2022; 2:100133. [PMID: 36090300 PMCID: PMC9460154 DOI: 10.1016/j.xjidi.2022.100133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 12/02/2022] Open
Abstract
Assessing the severity of atopic dermatitis (AD, or eczema) traditionally relies on a face-to-face assessment by healthcare professionals and may suffer from inter- and intra-rater variability. With the expanding role of telemedicine, several machine learning algorithms have been proposed to automatically assess AD severity from digital images. Those algorithms usually detect and then delineate (segment) AD lesions before assessing lesional severity and are trained using the data of AD areas detected by healthcare professionals. To evaluate the reliability of such data, we estimated the inter-rater reliability of AD segmentation in digital images. Four dermatologists independently segmented AD lesions in 80 digital images collected in a published clinical trial. We estimated the inter-rater reliability of the AD segmentation using the intraclass correlation coefficient at the pixel and the area levels for different resolutions of the images. The average intraclass correlation coefficient was 0.45 ( standard error = 0.04 ) corresponding to a poor agreement between raters, whereas the degree of agreement for AD segmentation varied from image to image. The AD segmentation in digital images is highly rater dependent even among dermatologists. Such limitations need to be taken into consideration when AD segmentation data are used to train machine learning algorithms that assess eczema severity.
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Affiliation(s)
- Guillem Hurault
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Kevin Pan
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Ricardo Mokhtari
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Bayanne Olabi
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, United Kingdom
| | - Eleanor Earp
- Department of Dermatology, Lauriston Building, Edinburgh, United Kingdom
| | - Lloyd Steele
- Department of Dermatology, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Hywel C. Williams
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, United Kingdom
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Reiko J. Tanaka
- Department of Bioengineering, Imperial College London, London, United Kingdom
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Van Lee CB, Kan WC, Gran S, Mooyaart A, Mureau MAM, Williams HC, Matin R, Van den Bos R, Hollestein LM. Corrigendum: Dermatofibrosarcoma Protuberans Re-excision and Recurrence Rates in the Netherlands Between 1989 and 2016. Acta Derm Venereol 2022; 102:adv00772. [PMID: 36039505 PMCID: PMC9631245 DOI: 10.2340/actadv.v102.4518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Loes M Hollestein
- Department of Dermatology, Erasmus Medical Centre Cancer Institute, Box 2040, NL-3000 CA Rotterdam, The Netherlands.
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Ridd MJ, Santer M, MacNeill SJ, Sanderson E, Wells S, Webb D, Banks J, Sutton E, Roberts A, Liddiard L, Wilkins Z, Clayton J, Garfield K, Barrett TJ, Lane JA, Baxter H, Howells L, Taylor J, Hay AD, Williams HC, Thomas KS. Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial. Lancet Child Adolesc Health 2022; 6:522-532. [PMID: 35617974 DOI: 10.1016/s2352-4642(22)00146-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND To our knowledge, there are no trials comparing emollients commonly used for childhood eczema. We aimed to compare the clinical effectiveness and safety of the four main emollient types: lotions, creams, gels, and ointments. METHODS We did a pragmatic, individually randomised, parallel group, phase 4 superiority trial in 77 general practice surgeries in England. Children aged between 6 months and 12 years with eczema (Patient Orientated Eczema Measure [POEM] score >2) were randomly assigned (1:1:1:1; stratified by centre and minimised by baseline POEM score and age, using a web-based system) to lotions, creams, gels, or ointments. Clinicians and parents were unmasked. The initial emollient prescription was for 500 g or 500 mL, to be applied twice daily and as required. Subsequent prescriptions were determined by the family. The primary outcome was parent-reported eczema severity over 16 weeks (weekly POEM), with analysis as randomly assigned regardless of adherence, adjusting for baseline and stratification variables. Safety was assessed in all randomly assigned participants. This trial was registered with the ISRCTN registry, ISRCTN84540529. FINDINGS Between Jan 19, 2018, and Oct 31, 2019, 12 417 children were assessed for eligibility, 550 of whom were randomly assigned to a treatment group (137 to lotion, 140 to cream, 135 to gel, and 138 to ointment). The numbers of participants who contributed at least two POEM scores and were included in the primary analysis were 131 in the lotion group, 137 in the cream group, 130 in the gel group, and 126 in the ointment group. Baseline median age was 4 years (IQR 2-8); 255 (46%) participants were girls, 295 (54%) were boys; 473 (86%) participants were White; and the mean POEM score was 9·3 (SD 5·5). There was no difference in eczema severity between emollient types over 16 weeks (global p value=0·77), with adjusted POEM pairwise differences of: cream versus lotion 0·42 (95% CI -0·48 to 1·32), gel versus lotion 0·17 (-0·75 to 1·09), ointment versus lotion -0·01 (-0·93 to 0·91), gel versus cream -0·25 (-1·15 to 0·65), ointment versus cream -0·43 (-1·34 to 0·48), and ointment versus gel -0·18 (-1·11 to 0·75). This result remained unchanged following multiple imputation, sensitivity, and subgroup analyses. The total number of adverse events did not significantly differ between the treatment groups (lotions 49 [36%], creams 54 [39%], gels 54 [40%], and ointments 48 [35%]; p=0·79), although stinging was less common with ointments (12 [9%] of 138 participants) than lotions (28 [20%] of 137), creams (24 [17%] of 140), or gels (25 [19%] of 135). INTERPRETATION We found no difference in effectiveness between the four main types of emollients for childhood eczema. Users need to be able to choose from a range of emollients to find one that they are more likely to use effectively. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
- Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK.
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | | | | | - Sian Wells
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Douglas Webb
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan Banks
- National Institute for Health Research Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Eileen Sutton
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Amanda Roberts
- Nottingham Support Group for Carers of Children with Eczema, Nottingham, UK
| | - Lyn Liddiard
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Zoe Wilkins
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Julie Clayton
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Tiffany J Barrett
- South West Medicines Information and Training, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - J Athene Lane
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Helen Baxter
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Laura Howells
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Jodi Taylor
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
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Nakafero G, Grainge MJ, Card T, Mallen CD, Riley R, van der Windt D, Fox CP, Taal MW, Aithal GP, Williams HC, Abhishek A. Incidence and pattern of mycophenolate discontinuation associated with abnormal monitoring blood-test results: cohort study using data from the Clinical Practice Research Datalink Aurum. Rheumatol Adv Pract 2022; 6:rkac046. [PMID: 35702565 PMCID: PMC9187914 DOI: 10.1093/rap/rkac046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To examine the incidence and pattern of mycophenolate discontinuation associated with abnormal monitoring blood-tests.
Methods
Data from people prescribed mycophenolate for common inflammatory conditions in the Clinical Practice Research Datalink was used. Participants were followed from first mycophenolate prescription. Primary outcome was drug discontinuation with an associated abnormal blood-test result within 60 days. Secondary outcomes were drug discontinuation for any reason, and discontinuations associated with severely abnormal blood-test results within 60 days. Multivariable cox-regression was used to examine factors associated with primary outcome.
Results
The cohort included 992 participants (68.9% female, mean age 51.95 years, 47.1% with SLE) contributing 1,885 person-years of follow-up. The incidence of mycophenolate discontinuation associated with any (severely) abnormal blood-test results was 153.46 (21.07) per 1000 person-years in the first, and 32.39 (7.91) per 1000 person-years in later years of prescription, respectively. 11.5% (1.7%) patients prescribed mycophenolate discontinued treatment with any (severely) abnormal blood-test results in the first year of prescription. After this period mean 2.6% (0.7%) patients discontinued treatment with any (severely) abnormal blood-test results per year. Increased serum creatinine and cytopenia were more commonly associated with mycophenolate discontinuation than elevated liver enzymes. CKD-stage ≥3 was significantly associated with mycophenolate discontinuation with any blood-test abnormalities (aHR (95%CI) 2.22 (1.47–3.37)).
Conclusion
Mycophenolate is uncommonly discontinued for blood-test abnormalities, and, even less often discontinued for severe blood-test abnormalities after the first year of prescription. Consideration may be given for less frequent monitoring after one-year of treatment, especially in those without CKD-stage ≥3.
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Affiliation(s)
- Georgina Nakafero
- University of Nottingham Academic Rheumatology, School of Medicine, , Nottingham, UK
| | - Matthew J Grainge
- University of Nottingham Lifespan and Population Health, School of Medicine, , Nottingham, UK
| | - Tim Card
- University of Nottingham Lifespan and Population Health, School of Medicine, , Nottingham, UK
- University of Nottingham Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, , Nottingham, UK
| | - Christian D Mallen
- Keele University Primary Care Centre Versus Arthritis, School of Medicine, , Keele, UK
| | - Richard Riley
- Keele University Primary Care Centre Versus Arthritis, School of Medicine, , Keele, UK
| | | | - Christopher P Fox
- Nottingham University Hospitals NHS Trust Department of Haematology, , Nottingham, UK
| | - Maarten W Taal
- University on Nottingham Centre for Kidney Research and Innovation, Translational Medical Sciences, School of Medicine, , Nottingham, UK
| | - Guruprasad P Aithal
- University of Nottingham Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, , Nottingham, UK
- NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, and the University of Nottingham , Nottingham, UK
| | - Hywel C Williams
- University of Nottingham Centre of Evidence-Based Dermatology, School of Medicine, , Nottingham, UK
| | - Abhishek Abhishek
- University of Nottingham Academic Rheumatology, School of Medicine, , Nottingham, UK
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Sivyer K, Teasdale E, Greenwell K, Steele M, Ghio D, Ridd MJ, Roberts A, Chalmers JR, Lawton S, Langan SM, Cowdell F, Le Roux E, Wilczynska S, Williams HC, Thomas KS, Yardley L, Santer M, Muller I. Supporting families managing childhood eczema: developing and optimising eczema care online using qualitative research. Br J Gen Pract 2022; 72:e378-e389. [PMID: 35577586 PMCID: PMC9119812 DOI: 10.3399/bjgp.2021.0503] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/01/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Childhood eczema is often poorly controlled owing to underuse of emollients and topical corticosteroids (TCS). Parents/carers report practical and psychosocial barriers to managing their child's eczema, including child resistance. Online interventions could potentially support parents/carers; however, rigorous research developing such interventions has been limited. AIM To develop an online behavioural intervention to help parents/carers manage and co-manage their child's eczema. DESIGN AND SETTING Intervention development using a theory-, evidence-, and person-based approach (PBA) with qualitative research. METHOD A systematic review and qualitative synthesis of studies (n = 32) and interviews with parents/carers (n = 30) were used to identify barriers and facilitators to effective eczema management, and a prototype intervention was developed. Think-aloud interviews with parents/carers (n = 25) were then used to optimise the intervention to increase its acceptability and feasibility. RESULTS Qualitative research identified that parents/carers had concerns about using emollients and TCS, incomplete knowledge and skills around managing eczema, and reluctance to transitioning to co-managing eczema with their child. Think-aloud interviews highlighted that, while experienced parents/carers felt they knew how to manage eczema, some information about how to use treatments was still new. Techniques for addressing barriers included providing a rationale explaining how emollients and TCS work, demonstrating how to use treatments, and highlighting that the intervention provided new, up-to-date information. CONCLUSION Parents/carers need support in effectively managing and co-managing their child's eczema. The key output of this research is Eczema Care Online for Families, an online intervention for parents/carers of children with eczema, which is being evaluated in a randomised trial.
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Affiliation(s)
- Katy Sivyer
- Department of Psychology, University of Southampton, Southampton; lecturer, University of Portsmouth, Portsmouth
| | | | | | | | - Daniela Ghio
- University of Manchester, Manchester; research fellow, University of Southampton, Southampton
| | | | | | | | | | | | | | | | | | | | | | - Lucy Yardley
- University of Bristol, Bristol; professor of health psychology, University of Southampton, Southampton
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45
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Kelleher MM, Cro S, Phillips R, Williams HC, Lowe AJ, Boyle RJ. Correspondence to " Emollients in infancy to prevent atopic dermatitis: A systematic review and meta-analysis". Allergy 2022; 77:1931-1933. [PMID: 35643983 DOI: 10.1111/all.15238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/20/2022] [Accepted: 01/26/2022] [Indexed: 11/26/2022]
Affiliation(s)
| | - Suzie Cro
- Imperial Clinical Trials Unit Imperial College London London UK
| | - Rachel Phillips
- Imperial Clinical Trials Unit Imperial College London London UK
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology School of Medicine University of Nottingham Nottingham UK
| | - Adrian J. Lowe
- Allergy and Lung Health Unit Melbourne School of Population and Global Health Carlton Vic Australia
| | - Robert J. Boyle
- National Heart Lung Institute Imperial College London London UK
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46
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Jones OT, Matin RN, van der Schaar M, Prathivadi Bhayankaram K, Ranmuthu CKI, Islam MS, Behiyat D, Boscott R, Calanzani N, Emery J, Williams HC, Walter FM. Artificial intelligence and machine learning algorithms for early detection of skin cancer in community and primary care settings: a systematic review. The Lancet Digital Health 2022; 4:e466-e476. [DOI: 10.1016/s2589-7500(22)00023-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/29/2021] [Accepted: 01/28/2022] [Indexed: 12/17/2022]
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Sutton E, Shaw AR, Ridd MJ, Santer M, Roberts A, Baxter H, Williams HC, Banks J. How parents and children evaluate emollients for childhood eczema: a qualitative study. Br J Gen Pract 2022; 72:e390-e397. [PMID: 35606161 PMCID: PMC9172216 DOI: 10.3399/bjgp.2021.0630] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/06/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Eczema affects one in five children in the UK. Regular application of emollients is routinely recommended for children with eczema. There are four main emollient types, but no clear evidence of which is best. The current 'trial and error' approach to find suitable emollients can be frustrating for parents, children, and clinicians. AIM To identify how parents and children experience and evaluate emollients. DESIGN AND SETTING Qualitative interview study, nested within a primary care trial of emollients (Best Emollients for Eczema [BEE] trial). METHOD Semi-structured interviews with children with eczema and their parents were conducted. Participants were purposively sampled on emollient type (lotion, cream, gel, or ointment), age, and eczema severity. RESULTS Forty-four parents were interviewed, with children participating in 24 of those interviews. There was no clear preference for any one emollient type. The strongest theme was the variation of experience in each of the four types. Participants focused on thickness and absorbency, both positively and negatively, to frame their evaluations. Effectiveness and acceptability were both considered when evaluating an emollient but effectiveness was the primary driver for continued use. For some, participating in the trial had changed their knowledge and behaviour of emollients, resulting in use that was more regular and for a longer duration. CONCLUSION There is no one emollient that is suitable for everyone, and parents/children prioritise different aspects of emollients. Future research could evaluate decision aids and/or tester pots of different types, which could enable clinicians and parents/children to work collaboratively to identify the best emollient for them.
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Affiliation(s)
- Eileen Sutton
- Bristol Population Health Sciences Institute, University of Bristol, Bristol
| | - Alison Rg Shaw
- Bristol Population Health Sciences Institute, University of Bristol, Bristol
| | - Matthew J Ridd
- Bristol Population Health Sciences Institute, University of Bristol, Bristol
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton
| | - Amanda Roberts
- Nottingham Support Group for Parents of Children with Eczema, Nottingham
| | - Helen Baxter
- Bristol Population Health Sciences Institute, University of Bristol, Bristol
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham
| | - Jonathan Banks
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
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48
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Allen HI, Pendower U, Santer M, Groetch M, Cohen M, Murch SH, Williams HC, Munblit D, Katz Y, Gupta N, Adil S, Baines J, de Bont EGPM, Ridd M, Sibson VL, McFadden A, Koplin JJ, Munene J, Perkin MR, Sicherer SH, Boyle RJ. Detection and management of milk allergy: Delphi consensus study. Clin Exp Allergy 2022; 52:848-858. [PMID: 35615972 DOI: 10.1111/cea.14179] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is significant overdiagnosis of milk allergy in young children in some countries, leading to unnecessary use of specialized formula. This guidance, developed by experts without commercial ties to the formula industry, aims to reduce milk allergy overdiagnosis and support carers of children with suspected milk allergy. METHODS Delphi study involving two rounds of anonymous consensus building and an open meeting between January and July 2021. Seventeen experts in general practice, nutrition, midwifery, health visiting, lactation support and relevant areas of paediatrics participated, located in Europe, North America, Middle East, Africa, Australia and Asia. Five authors of previous milk allergy guidelines and seven parents provided feedback. FINDINGS Participants agreed on 38 essential recommendations through consensus. Recommendations highlighted the importance of reproducibility and specificity for diagnosing milk allergy in children with acute or delayed symptoms temporally related to milk protein ingestion; and distinguished between children directly consuming milk protein and exclusively breastfed infants. Consensus was reached that maternal dietary restriction is not usually necessary to manage milk allergy, and that for exclusively breastfed infants with chronic symptoms, milk allergy diagnosis should only be considered in specific, rare circumstances. Consensus was reached that milk allergy diagnosis does not need to be considered for stool changes, aversive feeding or occasional spots of blood in stool, if there is no temporal relationship with milk protein ingestion. When compared with previous guidelines, these consensus recommendations resulted in more restrictive criteria for detecting milk allergy and a more limited role for maternal dietary exclusions and specialized formula. INTERPRETATION These new milk allergy recommendations from non-conflicted, multidisciplinary experts advise narrower criteria, more prominent support for breastfeeding and less use of specialized formula, compared with current guidelines.
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Affiliation(s)
- Hilary I Allen
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ursula Pendower
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Marion Groetch
- Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mitchell Cohen
- Department of Paediatrics, University of Alabama at Birmingham & Children's of Alabama, Birmingham, Alabama, USA
| | | | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Yitzhak Katz
- Allergy and Immunology Institute, Assaf Harofeh Medical Center, Department of Paediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Neeraj Gupta
- Division of Paediatric Allergy, Department of Paediatrics, Institute of Child Health, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
| | - Sabeen Adil
- International Lactation Consultant Association, Raleigh, North Carolina, USA
| | | | - Eefje G P M de Bont
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Matthew Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Alison McFadden
- Mother and Infant Research Unit, University of Dundee, Dundee, UK
| | - Jennifer J Koplin
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Josephine Munene
- Certified Lactation Educator, Kenya Association for Breastfeeding and La Leche League South Africa, Nairobi, Kenya
| | - Michael R Perkin
- Population Health Research Institute, St George's University of London, London, UK
| | - Scott H Sicherer
- Department of Paediatrics, University of Alabama at Birmingham & Children's of Alabama, Birmingham, Alabama, USA
| | - Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, UK
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Abhishek A, Boyton RJ, McKnight Á, Coates L, Bluett J, Barber VS, Cureton L, Francis A, Appelbe D, Eldridge L, Julier P, Peckham N, Valdes AM, Rombach I, Altmann DM, Nguyen-Van-Tam J, Williams HC, Cook JA. Effects of temporarily suspending low-dose methotrexate treatment for 2 weeks after SARS-CoV-2 vaccine booster on vaccine response in immunosuppressed adults with inflammatory conditions: protocol for a multicentre randomised controlled trial and nested mechanistic substudy (Vaccine Response On/Off Methotrexate (VROOM) study). BMJ Open 2022; 12:e062599. [PMID: 35504634 PMCID: PMC9066090 DOI: 10.1136/bmjopen-2022-062599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION It is unknown if a temporary break in long-term immune-suppressive treatment after vaccination against COVID-19 improves vaccine response. The objective of this study was to evaluate if a 2-week interruption in low-dose weekly methotrexate treatment after SARS-CoV-2 vaccine boosters enhances the immune response compared with continuing treatment in adults with autoimmune inflammatory conditions. METHODS AND ANALYSIS An open-label, pragmatic, prospective, parallel group, randomised controlled superiority trial with internal feasibility assessment and nested mechanistic substudy will be conducted in rheumatology and dermatology clinics in approximately 25 UK hospitals. The sample size is 560, randomised 1:1 to intervention and usual care arms. The main outcome measure is anti-spike receptor-binding domain (RBD) antibody level, collected at prebooster (baseline), 4 weeks (primary outcome) and 12 weeks (secondary outcome) post booster vaccination. Other secondary outcome measures are patient global assessments of disease activity, disease flares and their treatment, EuroQol 5- dimention 5-level (EQ-5D-5L), self-reported adherence with advice to interrupt or continue methotrexate, neutralising antibody titre against SARS-CoV-2 (mechanistic substudy) and oral methotrexate biochemical adherence (mechanistic substudy). Analysis of B-cell memory and T-cell responses at baseline and weeks 4 and 12 will be investigated subject to obtaining additional funding. The principal analysis will be performed on the groups as randomised (ie, intention to treat). The difference between the study arms in anti-spike RBD antibody level will be estimated using mixed effects model, allowing for repeated measures clustered within participants. The models will be adjusted for randomisation factors and prior SARS-CoV-2 infection status. ETHICS AND DISSEMINATION This study was approved by the Leeds West Research Ethics Committee and Health Research Authority (REC reference: 21/HRA/3483, IRAS 303827). Participants will be required to give written informed consent before taking part in the trial. Dissemination will be via peer review publications, newsletters and conferences. Results will be communicated to policymakers. TRIAL REGISTRATION NUMBER ISRCTN11442263.
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Affiliation(s)
| | - R J Boyton
- Department of Infectious Diseases, Imperial College London, London, UK
- Lung Division, Royal Brompton and Harefield Hospitals, London, London
| | - Áine McKnight
- Blizard Institute, Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | | | - James Bluett
- Manchester Academic Health Science Centre, Manchester, UK
- The University of Manchester, Manchester, UK
| | - Vicki S Barber
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Lucy Cureton
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Anne Francis
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Duncan Appelbe
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Lucy Eldridge
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Patrick Julier
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Nicholas Peckham
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Nottingham, UK
| | - Ines Rombach
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
| | - Daniel M Altmann
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | | | - Hywel C Williams
- Population and Lifespan Health, University of Nottingham, Nottingham, UK
| | - Jonathan Alistair Cook
- NDORMS, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford Nuffield, Oxford, UK
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Affiliation(s)
- Saumya Panda
- Editor-in-Chief, Indian Journal of Dermatology, Venereology & Leprology
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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