Topical resiquimod dosing regimens in patients with multiple actinic keratoses: a multicentre, partly placebo-controlled, double-blind clinical trial.

BACKGROUND: Topical immune response modifiers are established for actinic keratosis (AK) treatment and efforts are underway to make further improvements to their efficacy and safety. OBJECTIVES: To investigate the optimal dosing regimens of the Toll-like receptor 7/8 agonist resiquimod in terms of efficacy, safety and tolerability. METHODS: In a multicentre, partly placebo-controlled, double-blind clinical trial, we randomized 217 patients with AK lesions to 0·03% resiquimod gel once-daily application three times per week for 4 weeks or seven times within 2 weeks or five times for 1 week (arms 1/2/3) followed by a treatment-free interval of 8 weeks and one repetition of the cycle. In two additional arms (arms 4/5), patients applied either resiquimod gel 0·01% or 0·03% three times per week up to a biological end point defined by skin erosion or for a maximum duration of 8 weeks. Clearance was assessed clinically and histologically. RESULTS: Complete clinical clearance ranged from 56% to 85% with the highest rate observed in arm 2. Resiquimod 0·03% gel was more effective than 0·01% gel. Clearance rates in arms 1/2/3 were comparable and higher than with placebo and were reached with 24, 14 and 10 gel applications, respectively. Overall, 128 patients (59%) experienced treatment-related adverse reactions. CONCLUSIONS: Resiquimod 0·03% gel is more effective than 0·01% gel. From the perspectives of safety and tolerability, the lower concentration and shorter duration are preferable. The clinical response in arms 2/3 was reached with fewer gel applications. The dosing regimens that used the biological end point (arms 4/5) proved equally efficacious as predefined treatment durations and may therefore be suitable for personalized AK treatment.

Randomized, double-blind, placebo-controlled study of safety and efficacy of miltefosine in antihistamine-resistant chronic spontaneous urticaria.

BACKGROUND: Chronic spontaneous urticaria (CSU), a mast cell-driven condition, is debilitating, common, and hard to treat. Miltefosine, a lipid raft modulator, can inhibit mast cell responses in vivo. OBJECTIVE: To study the safety and efficacy of systemic miltefosine treatment in CSU patients resistant to standard-dosed antihistamines. METHODS: In this investigator-initiated multicentre, randomized, double-blind, placebo-controlled study, CSU patients were treated for 4 weeks with daily doses of up to 150-mg miltefosine (n = 47) or placebo (n = 26). Disease activity was assessed using the urticaria activity score. Safety and tolerability of miltefosine were also assessed. RESULTS: After 4 weeks of treatment, Urticaria Activity Score (UAS7) levels were substantially more reduced in miltefosine-treated patients (-6.3 vs. -3.5 in placebo-treated patients; P = 0.05). Also, the number of weals, but not the intensity of pruritus, was significantly reduced in miltefosine-treated patients vs. placebo-treated patients (P = 0.02). In general, adverse events were frequent in both groups (miltefosine: 88%, placebo: 65% of patients) but mostly mild to moderate in severity. We did not observe any serious adverse events. CONCLUSIONS: The results of this study indicate that miltefosine is an effective and safe treatment option for CSU patients who do not respond to standard-dosed antihistamines.

Long-term follow-up of photodynamic therapy with a self-adhesive 5-aminolaevulinic acid patch: 12 months data.

BACKGROUND: Photodynamic therapy with a self-adhesive 5-aminolaevulinic acid (5-ALA) patch shows high efficacy rates in the treatment of mild to moderate actinic keratosis (AK) in short term trials. OBJECTIVES: The purpose of the trial was to follow up patients after successful 5-ALA patch-PDT at 3 month intervals over a total period of 12 months. Patients who had received placebo-PDT or cryosurgery served for comparison. PATIENTS/METHODS: Three months after therapy, 360 patients from two separate randomized parallel group phase III studies (one superiority trial vs. placebo-PDT, one noninferiority trial vs. cryosurgery) were suitable for the follow-up study. Patients had to show at least one successfully treated AK lesion after initial therapy. A total of 316 patients completed the follow-up. RESULTS: Twelve months after a single treatment, 5-ALA patch-PDT still proved superior to placebo-PDT and cryosurgery (P < 0.001 for all tests). On a lesion basis, efficacy rates were 63% and 79% for PDT, 63% for cryosurgery and 9% and 25% for placebo-PDT. Recurrence rates of patch-PDT proved superior to those of cryosurgery (per protocol set: P = 0.011, full analysis set: P = 0.049). While 31% of cryosurgery lesions were still hypopigmented after 1 year, the 5-ALA patch-PDT groups showed hypopigmentation in 0% (superiority trial) and 3% (noninferiority trial) of the treated lesions. CONCLUSION: Twelve months after a single 5-ALA patch-PDT the majority of lesions were still cleared with an excellent cosmetic outcome. 5-ALA patch-PDT proved to be superior to cryosurgery in the noninferiority study setting.

Optimization of photodynamic therapy with a novel self-adhesive 5-aminolaevulinic acid patch: results of two randomized controlled phase III studies.

BACKGROUND: Photodynamic therapy (PDT) is increasingly used for treatment of actinic keratoses (AKs) but is a cumbersome procedure. A thin self-adhesive patch (PD P 506 A) containing 5-aminolaevulinic acid (5-ALA) was developed to facilitate PDT. OBJECTIVES: To investigate efficacy and safety of the patch in comparison with placebo-PDT (superiority design, observer-blinded; study AK 03) and standard therapy, cryosurgery (noninferiority design, open; study AK 04). METHODS: Two separate confirmatory randomized parallel-group phase III studies were set up. In total, 449 patients with up to eight mild to moderate AK study lesions located on the head were treated in 29 German study centres (study AK 03: 103 patients; study AK 04: 346 patients). RESULTS: Twelve weeks after treatment, 5-ALA patch-PDT proved to be superior to placebo-PDT (P < 0.001) and cryosurgery (P = 0.007). Efficacy rates on a lesion basis were 82% (AK 03) and 89% (AK 04) for PDT, 77% for cryosurgery and 19% (AK 03) and 29% (AK 04) for placebo-PDT. Local reactions at the treatment site occurred in almost all patients treated with 5-ALA patch-PDT or cryosurgery. Headache was the only side-effect not related to the treatment site which occurred in more than one patient. CONCLUSIONS: PD P 506 A is an innovative, easy-to-handle 5-ALA patch for PDT of mild to moderate AK lesions. Compared with current PDT procedures, pretreatment (e.g. curettage) is not needed and handling is considerably facilitated. A single PDT treatment results in efficacy rates being statistically significantly superior to placebo and cryosurgery.

Primary nociceptive afferents mediate the blood flow dysfunction in non-glabrous (hairy) skin of type 2 diabetes: a new model for the pathogenesis of microvascular dysfunction.

OBJECTIVE: To test the independent contributions of vascular endothelium, sympathetic activation and inhibition, vessel distensibility, and nociceptor-mediated vasodilation in both glabrous and hairy skin circulations. RESEARCH DESIGN AND METHODS: We measured blood flow using laser Doppler techniques in 10 people with type 2 diabetes and 10 age- and BMI-matched healthy control subjects at the pulp of the index finger (glabrous skin) and the dorsum of the hand (hairy skin). A 5-min ischemic block of the arm was used to test vascular endothelium. Warming of the probe site to 45 degrees C tested neurogenic vasodilation in hairy skin only. Vessel distensibility was tested by gravitational pressure. RESULTS: Basal blood flow and reactive hyperemia did not differ between groups at either skin site. The vasodilative response to local warming (P < 0.01) and limb lowering (P < 0.05) were significantly different between groups in hairy skin but not in glabrous skin in the absence of objective measured neuropathy. Nociceptor-mediated flow correlated significantly with the warm thermal threshold (r = -0.50, P < 0.05). Endothelial-mediated blood flow correlated with systolic blood pressure (r = -0.76, P < 0.01), LDL cholesterol (r = -0.62, P < 0.001), C-peptide (r = 0.65, P < 0.05), and triglycerides (r = 0.47, P < 0.05). CONCLUSIONS: These data suggest that neurogenic nociceptor-mediated vasodilation is impaired in subjects with type 2 diabetes when endothelial and sympathetic function are relatively intact. Heat-induced vasodilation may be a specific test of small heat-sensitive C-fiber peripheral neurons and may be an integral part of the metabolic syndrome.

Regulated O-glycosylation of the Alzheimer beta-A4 amyloid precursor protein in thyrocytes.

In thyrocytes, the beta-amyloid precursor protein (beta-APP) is expressed, proteolytically cleaved and released into the extracellular space in a TSH-dependent fashion. Immunocytochemically, beta-APP was detectable mainly in the stacked Golgi cisternae indicating the accumulation in this organelle. Because this unusual immunoreactivity might be related to the Golgi-specific posttranslational processing we studied the glycosylation of beta-APP and the possible regulation of this process. For this purpose we used FRTL-5 cells which showed that the degree of glycosylation was also TSH dependent. Glycosidase digestion experiments revealed that only the O-glycans, not the N-glycans, of beta-APP were regulated by TSH. Using enzyme digestion and lectin precipitation analyses we showed that O-glycosylation involved mainly alpha 2,6-sialylated Gal 1-3 GalNAc-alpha-core glycans (approximately 85%) whereas the 2,3 linked sialic acids amounted to only approximately 15% of total sialic acid residues. Upon stimulation with TSH, O-glycosylation as measured by the degree of sialylation increased by a factor of approximately 1.7 thereby raising the molecular mass of mature beta-APP by 4 to 5 kDa above that from control cells. This process coincided with the accumulation of a proteolytically derived 8.5 kDa C-terminal beta-APP fragment indicating that the proteolytic processing of mature beta-APP was not inhibited by its O-glycosylation. When cells were stimulated with TSH in the presence of cycloheximide, the Golgi cisternae lost their predominant immunoreactivity for beta-APP and were rapidly emptied (within 30 min). Hence, under the conditions of normal protein synthesis, the Golgi cisternae may operate as a storage compartment for beta-APP.

Identification of iodinated proteins in cultured thyrocytes and their possible significance for thyroid hormone formation.

The thyroid gland is known to generate the iodinated hormones T3 and T4 from the prohormone thyroglobulin. In this report we examined whether polypeptides other than thyroglobulin are iodinated and hormonogenic in thyrocytes and the prerequisites for their iodination. In primary cultures of porcine thyrocytes, a substantial portion of organified radioiodine was incorporated into cellular proteins other than thyroglobulin. Some of these were identified by immunoprecipitation. They included proteins of the extracellular matrix, plasma membrane proteins, and lysosomal enzymes, which follow in part a secretion and recapture pathway. All of these proteins come into contact with the iodinating system of thyrocytes located on the apical plasma membrane and possess iodination consensus sequences. Immunoprecipitation with T3- or T4-specific antibodies showed that thyroid hormones were detectable only within thyroglobulin. This was confirmed by an analysis of the iodoamino acids of thyroglobulin, cathepsin-D (representing a secretory protein), and aminopeptidase-N (a membrane-integrated protein) by two-dimensional TLC, which revealed the presence of T3 and T4 only within the polypeptide chain of thyroglobulin. These results indicate that iodoproteins other than thyroglobulin do not participate in the generation of thyroid hormones in situ.

Growth regulation of rat thyrocytes (FRTL-5 cells) by the secreted ectodomain of beta-amyloid precursor-like proteins.

The TSH-dependent expression of amyloid precursor-like proteins and the secretion of their ectodomain (sAPP) in rat thyroids coincide with increased rates of thyrocyte proliferation. To analyze whether the secretion of sAPP and the proliferation of thyrocytes are regulatorily linked, we employed [3H]thymidine or 5-bromo-2'-deoxyuridine assays and found that conditioned culture medium stimulated the proliferation of FRTL-5 cells depending on the content of sAPP. These observations prompted experiments with sAPP-derived peptides known to stimulate the growth of APP-deficient fibroblasts. Using autoradiography and radiochemical assays, we observed that an iodinated 19-mer sAPP peptide was bound specifically to the surface of FRTL-5 cells. Binding of this peptide was followed by a 2- to 8-fold increase in cell proliferation, which reached a plateau at 1 nM. This effect was significant only when cells were cultured in nonconfluent monolayers, and contact inhibition did not interfere. Our observations indicate that sAPP and sAPP-derived peptides increased the proportion of proliferation-competent FRTL-5 cells and suggest that sAPP may be a new member in the family of peptides involved in the growth regulation of thyrocytes.

Platypnea-orthodeoxia related to aortic elongation.

An 80-year-old woman presented with progressive shortness of breath. There was no history of pulmonary or cardiac disease. Results of a physical examination were normal. She had significant oxygen desaturation while she was in an upright position. Admission to the hospital for workup followed, and evaluation included tilt-table transesophageal echocardiogram and cardiac catheterization. A massive right-to-left shunt through a patent foramen ovale was detected, and surgical intervention resulted in dramatic improvement of symptoms. In this patient, it seems that the syndrome of platypnea-orthodeoxia was related to aortic elongation, allowing significant right-to-left shunt.

Studies on the influence of selective adenomectomy on hormone secretion from normal anterior pituitary gland.

In 70 patients with pituitary adenomas combined stimulation tests using releasing factors were performed before and 10 to 20 days after pituitary surgery. Qualitatively, the dynamics of hormone secretion were mostly unaltered after surgery. Quantitatively, the mean amounts of secreted hormones were found lowered after surgery. In some individual patients, however, a postoperative improvement was also observed. Pituitary testing early after surgery proved to be helpful for assessing the definite need for a hormonal replacement therapy.