Comparative analysis of scoring systems for predicting mortality in Fournier gangrene: single center, 15 years experience.

To compare 5 published scoring systems (Fournier gangrene severity index [FGSI], Uludag FGSI [UFGSI], age-adjusted Charlson Comorbidity Index [ACCI] and the Quick Sequential Organ Failure Assessment (qSOFA) and the Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) scores and to evaluate risk factors for outcome prediction in patients with Fournier gangrene (FG). Between 2010 and 2024, 311 patients were included in the study. The data of 276 survivors and 55 non-survivors were compared. Univariate and multivariate analyses were performed to determine which of the 5 scoring systems calculated according to demographic, laboratory and clinical data predicted mortality better. In addition, a cut-off value for these scoring systems was determined by ROC analysis. The mortality rate was 17.6% in FG patients. In all 5 scoring systems, univariate analyses showed higher values in non-survivor patients, while UFGSI and FGSI scoring systems were superior to other scoring systems in multivariate analyses (p < 0.001). ROC analysis using mortality-based sensitivity and specificity revealed that the optimal cut-off values for FGSI, UFGSI, ACCI, SOFA and LRINEC should be equal to or higher than 10, 12, 4, 2 and 8, respectively. UFGSI and FGSI scores had the highest AUC values among all scores. This was followed by ACCI, qSOFAand LRINEC. For a UFGSI score ≥ 12, the sensitivity was 84%, specificity 97%, PPV 85% and NPV 97%. Among the scoring systems used to predict mortality, UFGSI was the most accurate, while LRINEC was the least accurate.

Psoriasis localization patterns in the Swiss Psoriasis Registry (SDNTT) over 11 years: an analysis by sex and age.

Real-world data on anatomically localized psoriasis and its response to systemic therapy across different age-groups and sexes is limited. This study aimed to evaluate the severity and distribution of psoriasis over time in female and male patients receiving systemic therapies, categorized by age within the Swiss psoriasis registry (SDNTT). Patient-data was obtained over 11 years through the SDNTT. The localized Psoriasis Area and Severity Index (locPASI) of the head, trunk, upper and lower extremities was analyzed over two years following the start of systemic non-/biologic treatment. A total of 316 female and 517 male patients were analyzed. Male patients had a higher baseline locPASI for legs, trunk and arms (p < 0.001), but not for the head (p = 0.961). The locPASI for the head in younger female patients (18-40 years) had a higher score than those aged 55 + (p = 0.022) and after two years, middle aged (41-54) showed a lower score compared to younger patients (p = 0.045). Younger male patients revealed a lower score after two years of therapy in the leg- and arm-area compared to older (p = 0.018 and p = 0.048, respectively). Female patients on non-biologics had a fast initial response, converging with male patients' scores over 24 months. Over 75% locPASI reduction was observed for female head-area (81.4%), male trunk (82.7%) and legs (76.1%). Absolute locPASI ≤ 2 was achieved 3-6 months for all locations with interleukin (IL)-17, IL-12/23 and IL-23-inhibitors, except for the legs of male patients on anti-IL-17 and female patients on anti-IL-12/23 and -IL-23. After two years, male patients did not achieve a locPASI ≤ 2 for any biologic-treatment in the legs, nor for the arms on anti-TNF-α. Significant disparities in localized PASI were observed between female and male patients. The age, sex and severity of distinct localizations should be considered to optimize treatment goals.

Assessing systemic inflammatory markers in psoriasis: A retrospective study.

BACKGROUND: Psoriasis is a chronic inflammatory disease often associated with serious cardiovascular comorbidities. The aim of this study was to investigate the systemic inflammatory burden in psoriasis by examining various inflammatory markers and to assess the relationship between these markers and the severity of the disease. METHODS: This retrospective study was conducted on medical records of patients who visited the dermatology outpatient clinic between 1 January 2016 and 31 December 2022. The study included patients with psoriasis vulgaris and healthy volunteers. Demographic data, Psoriasis Area and Severity Index score, C-reactive protein, monocyte-high-density lipoprotein cholesterol ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, systemic immune-inflammation index, and Systemic Inflammation Response Index were analysed and compared. RESULTS: A total of 278 psoriasis patients and 90 healthy volunteers were analysed. Compared to the control group, psoriasis patients showed significantly higher systemic immune-inflammation index, Systemic Inflammation Response Index, neutrophil-to-lymphocyte ratio, monocyte-high-density lipoprotein cholesterol ratio, serum C-reactive protein levels, neutrophil count, monocyte count, body mass index, and waist circumference (p < 0.001, p = 0.001, p < 0.001, p = 0.014, p < 0.001, p < 0.001, p = 0.046, p < 0.001, and p = 0.011, respectively). Among patients with severe psoriasis (Psoriasis Area and Severity Index >10), systemic immune-inflammation index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and serum C-reactive protein levels were significantly higher compared to patients with mild/moderate psoriasis (Psoriasis Area and Severity Index ≤10). In the ROC curve analysis, the optimal cut-off (AUC, sensitivity, specificity) values for neutrophil-to-lymphocyte ratio, systemic immune-inflammation index, and platelet-to-lymphocyte ratio were found to be 2.11 (0.592, 62%, 57%), 552.9 (0.579, 61%, 58%), and 111.9 (0.578, 64%, 46%), respectively. The inflammatory parameters that showed correlation with Psoriasis Area and Severity Index were systemic immune-inflammation index, Systemic Inflammation Response Index, neutrophil-to-lymphocyte ratio, monocyte-high-density lipoprotein cholesterol ratio, monocyte-to-lymphocyte ratio, and C-reactive protein. CONCLUSION: The findings of this study suggest that systemic immune-inflammation index, Systemic Inflammation Response Index, neutrophil-to-lymphocyte ratio, monocyte-high-density lipoprotein cholesterol ratio, and C-reactive protein values have the potential to serve as simple and cost-effective markers for assessing the inflammatory burden in individuals with psoriasis.

Long-Term High-Flow Nasal Therapy in Patients with Bronchiectasis of Different Severity: A Retrospective Cohort Study.

Background/Objectives: High-flow nasal therapy (HFNT) has been shown to reduce exacerbations of COPD and some evidence displays benefits in non-cystic fibrosis bronchiectasis (NCFB) patients. The present study aimed to compare the effectiveness of 12 months of home HFNT on the annual exacerbation rate between mild/moderate and severe NCFB patients, classified by the bronchiectasis severity index (BSI). Secondary outcomes were the evaluation of the dyspnea, pulmonary function, and sputum cultures in both groups. Methods: The study population included NCFB adult patients, with at least one severe exacerbation in the previous year on optimized therapy. NCFB exacerbations, dyspnea (mMRC score), pulmonary function test, and sputum cultures were assessed at baseline and after 12 months of HFNT. Results: A total of 86 NCFB patients were enrolled: 36 in the mild/moderate (BSI < 9) and 50 in the severe (BSI ≥ 9) group. A significant improvement in the annual exacerbation rate was found in both BSI ≥ 9 (p < 0.0001) and BSI < 9 cohorts (p < 0.0001), with a between-group difference of -1 (95% CI: -2 to 0) exacerbations per year (p = 0.0209). The change in the annual exacerbation rate was significantly correlated with BSI (ρ = -0.26, p = 0.0151) and with HFNT daily use (ρ = -0.22, p = 0.0460). The mMRC score significantly improved by -2 points (95% CI: -2 to -1) after treatment in both groups (p < 0.0001). The percentage of patients with P. aeruginosa colonization decreased from 34.9% to 27.9%. Conclusions: Long-term HFNT reduces the annual exacerbation rate in NCFB patients and its effectiveness increases alongside disease severity and daily use of HFNT.

Real-world Safety and Efficacy of Risankizumab in Psoriatic Patients: A Multicenter, Retrospective, and Not-interventional Study. / [[Artículo traducido]]Eficacia y seguridad del risankizumab en pacientes con psoriasis en el mundo real: un estudio retrospectivo, multicéntrico y no intervencionista.

BACKGROUND AND OBJECTIVE: risankizumab-a humanized monoclonal antibody that targets the p19 subunit of IL-23-has been recently approved to treat moderate-to-severe plaque psoriasis. Real-world data based on a representative pool of patients are currently lacking. Objective To assess the mid- and long-term safety and efficacy profile of risankizumab in patients with moderate-to-severe psoriasis in the routine clinical practice. METHODS: This was a retrospective and multicenter study of consecutive psoriatic patients on risankizumab from April 2020 through November 2022. The primary endpoint was the number of patients who achieved a 100% improvement in their Psoriasis Area and Severity Index (PASI) (PASI100) on week 52. RESULTS: A total of 510 patients, 198 (38.8%) women and 312 (61.2%) men were included in the study. The mean age was 51.7 ± 14.4 years. A total of 227 (44.5%) study participants were obese (body mass index [BMI] > 30kg/m2). The mean baseline PASI score was 11.4 ± 7.2, and the rate of patients who achieved PASI100 on week 52, 67.0%. Throughout the study follow-up, 21%, 50.0%, 59.0%, and 66% of the patients achieved PASI100 on weeks 4, 16, 24, and 40, respectively. The number of patients who achieved a PASI ≤ 2 was greater in the group with a BMI ≤ 30 kg/m2 on weeks 4 (P = .04), 16 (P = .001), and 52 (P = .002). A statistically significantly greater number of patients achieved PASI100 in the treatment-naïve group on weeks 16 and 52 (P = .001 each, respectively). On week 16 a significantly lower number of participants achieved PASI100 in the group with psoriatic arthropathy (P = .04). Among the overall study sample, 22 (4.3%) patients reported some type of adverse event and 20 (3.9%) discontinued treatment. CONCLUSIONS: Risankizumab proved to be a safe and effective therapy for patients with moderate-to-severe psoriasis in the routine clinical practice.

Effect of iberdomide on cutaneous manifestations in systemic lupus erythematosus: a randomized phase 2 clinical trial.

BACKGROUND: Iberdomide, a cereblon modulator, promotes degradation of transcription factors Ikaros and Aiolos. OBJECTIVE: Evaluate iberdomide efficacy and safety in cutaneous lupus erythematosus (CLE) in a phase 2 study. METHODS: Patients were randomized (2:2:1:2) to iberdomide 0.45 (n=81), 0.30 (n=82), or 0.15 mg (n=42) or placebo (n=83) daily while continuing background lupus medications. RESULTS: The mean (SD) baseline Cutaneous Lupus Area and Severity Index Activity (CLASI-A) score was 6.9 (7.0); 28% of patients had a score ≥8; 56% had acute CLE, 29% chronic CLE, and 16% subacute CLE. Mean CLASI-A improvement in patients with baseline score ≥8 was 39.7% for iberdomide 0.45 mg versus 20.1% for placebo at week 4 (P=0.032), with continued improvement through week 24 (66.7% vs 54.2%; P=0.295). Proportions of patients achieving ≥50% CLASI-A reduction from baseline at week 24 were significantly greater for iberdomide 0.45 mg versus placebo for patients with subacute (91.7% vs 52.9%, P=0.035) and chronic (62.1% vs 27.8%; P=0.029) CLE but not for the overall population (55.6% vs 44.6%) or patients with baseline CLASI-A ≥8 (66.7% vs 50.0%). LIMITATIONS: Small patient subgroups of CLE subtypes. CONCLUSIONS: Iberdomide showed beneficial effects when added to background lupus medications in patients with subacute and chronic CLE.

Association between insomnia and four domains of health based on an Indigenous Medicine Wheel: Findings from two Saskatchewan First Nation communities.

OBJECTIVES: Research has shown that insomnia and chronic diseases can simultaneously impact overall health, including physical, mental, emotional, and spiritual health. This study aims to find the association between insomnia and the four domains of health based on an Indigenous Medicine Wheel and to find the role of multimorbidity as a mediator between this relation among First Nations people. METHODS: We used data (n = 588) from the First Nations Sleep Health Project, a collaboration between two Cree First Nations communities in Saskatchewan and a research team at the University of Saskatchewan. Insomnia was measured by the Insomnia Severity Index (ISI). A multivariable logistic regression model was fitted, and the strength of significant predictors was presented as odds ratio (OR) and 95% confidence interval (CI). Using generalized structural equation modelling, we assessed the mediating effect of multimorbidity after adjusting confounders. RESULTS: Most participants (~ 70%) reported good or better health in the four domains. After adjusting for potential risk factors, we found that the probability of having poor or fair health in all four domains (physical, mental, emotional, and spiritual) was higher among people with severe to moderate insomnia (OR = 3.06 (1.76-5.30), 2.77 (1.54-4.99), 3.19 (1.85-5.52), and 1.57 (0.88-2.80), respectively). Additionally, the total effect of ISI on physical, mental, emotional, and spiritual health was 51.34%, 61.72%, 44.81%, and 57.27%, respectively, mediated by multimorbidity. CONCLUSION: The impact of insomnia on four domains of health and the mediation effect of multimorbidity on this path are unique findings. Early diagnosis and treatment of these conditions might improve overall health.

RéSUMé: OBJECTIFS: Des études ont montré que l'insomnie et les maladies chroniques peuvent avoir des effets simultanés sur la santé globale, c'est-à-dire la santé physique, mentale, émotionnelle et spirituelle. Nous avons donc cherché à découvrir : l'association entre l'insomnie et les quatre domaines de santé figurant sur une roue médicinale autochtone; et l'effet médiateur de la multimorbidité sur cette relation chez les personnes des Premières Nations. MéTHODE: Nous avons utilisé les données (n = 588) du First Nations Sleep Health Project, un projet mené en collaboration par deux communautés cries des Premières nations de la Saskatchewan et par une équipe de recherche de l'Université de la Saskatchewan. Nous avons mesuré l'insomnie à l'aide de l'Index de sévérité de l'insomnie (ISI). Nous avons ajusté un modèle de régression logistique multivariée et présenté la force des variables prédictives significatives sous la forme de rapports de cotes (RC) et d'intervalles de confiance (IC) de 95%. En utilisant la modélisation par équation structurelle généralisée, nous avons évalué l'effet médiateur de la multimorbidité après ajustement des facteurs confusionnels. RéSULTATS: La plupart des participants (~ 70 %) ont déclaré une santé bonne ou mieux que bonne dans les quatre domaines. Après ajustement en fonction des facteurs de risque potentiels, nous avons constaté que la probabilité d'avoir une santé mauvaise ou passable dans les quatre domaines (physique, mental, émotionnel et spirituel) était plus élevée chez les personnes souffrant d'insomnie sévère à modérée (RC = 3,06 [1,76­5,30], 2,77 [1,54­4,99], 3,19 [1,85­5,52] et 1,57 [0,88­2,80], respectivement). Par ailleurs, l'effet total de l'ISI sur la santé physique, mentale, émotionnelle et spirituelle était de 51,34 %, 61,72 %, 44,81 % et 57,27 %, respectivement, avec l'effet médiateur de la multimorbidité. CONCLUSION: L'effet de l'insomnie sur quatre domaines de santé et l'effet médiateur de la multimorbidité à cet égard représentent des constats singuliers. Le diagnostic précoce et le traitement de ces affections pourraient améliorer la santé globale.

Relationship of Modified Sleep Apnea Severity Index and HGNS Efficacy and Adherence in OSA Patients.

OBJECTIVES: Hypoglossal nerve stimulation (HGNS) is a treatment option for patients with CPAP-intolerant (CPAPi) obstructive sleep apnea (OSA). The modified sleep apnea severity index (mSASI) combines patient anatomy, weight, sleep study metrics, and symptoms into a composite index ranging from 1 (least severe) to 3 (most severe). Prior studies have associated mSASI with quality of life, CPAP adherence, and hypertension, but its utility in CPAPi patients is unknown. We evaluate the relationship between mSASI, HGNS efficacy, and adherence. METHODS: Retrospective cohort study of consecutive CPAPi OSA patients who underwent HGNS from 2014 to 2023. Patients were included if data were available to calculate preoperative mSASI and postoperative HGNS adherence/efficacy. Kruskal-Wallis rank-sum, Fisher's exact, and Chi-squared tests were performed. RESULTS: 264 patients were included (mean age = 61.3 years, 95% White, 66% Male). Preoperatively, 168 (64%) patients had mSASI of 1, 81 (31%) mSASI = 2, and 15 (5.7%) mSASI = 3. At 3 months post-op, patients with baseline mSASI of 1, 2, and 3 showed 6.72, 6.39, and 5.88 hours/night of device usage (p = 0.4). This pattern persisted, although showing no significance, at 6 months, 12 months, and most recent follow-up. There were similar reductions in Epworth Sleepiness Scale (ESS) across cohorts, with the mSASI3 group having the highest ESS postoperatively (p < 0.01). Sher15 response was similar between cohorts (mSASI1 = 52%, mSASI2 = 40%, mSASI3 = 25%, p = 0.2). CONCLUSION: Preoperative mSASI was not significantly correlated with HGNS adherence. Higher baseline mSASI was associated with greater postoperative daytime sleepiness. Further study is needed to evaluate mSASI as a tool within this population. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Association between initial diquat plasma concentration, severity index and in-hospital mortality in patients with acute diquat poisoning: a retrospective cohort study.

BACKGROUND: Since 2016, diquat has replaced paraquat in China, resulting in increased diquat poisoning cases. However, understanding of diquat poisoning is still limited. This study aimed to investigate the relationship between initial diquat plasma concentration, severity index, and in-hospital mortality in acute diquat poisoning cases. METHODS: This retrospective cohort study, conducted from January 2016 to July 2023 in a tertiary care hospital, used univariate logistic regression to examine the link between the initial diquat plasma concentration, severity index, and in-hospital mortality in acute diquat poisoned patients. A receiver operating characteristic curve assessed the predictive value of these parameters for prognosis. RESULTS: Among the 87 participants, the median age was 32 years, 35 (40.2%) were female. The overall mortality rate was 37.9%. Logistic regression analysis revealed that the initial diquat plasma concentration and severity index were associated with increased in-hospital mortality. These factors also effectively predicted the prognosis of acute diquat poisoning, with an area under the receiver operating characteristic curve of 0.851 and an optimal diquat concentration threshold of 2.25 mg/L (sensitivity 90.9%, specificity 74.1%, P < 0.05) and an area under the receiver operating characteristic curve of 0.845 with an optimal cut-off value for the sevity index of 9.1 mg/L*min (sensitivity 97%, specificity 74.1%, P < 0.05). DISCUSSION: Our results are limited by the retrospective design of this study. However, if validated, these results could impact management strategies, especially in East Asia. Further research is needed due to potential confounding factors. CONCLUSIONS: The findings suggest that a higher initial plasma concentration and severity index in patients with acute diquat poisoning were correlated with higher in-hospital mortality. Prospective validation will confirm the predicative value of these findings.

Correlation and Clinical Significance of HBD-2 and CXCL-1/2 Levels at Skin Lesions with Psoriasis Vulgaris Severity.

OBJECTIVE: This study was performed to explore the clinical significance of the expression of human beta-defensin 2 (HBD-2) and chemokine ligand 1/2 (CXCL-1/2) in psoriasis vulgaris. METHODS: This study retrospectively included the study group (n = 160) and control group (n = 100) for analysis. The levels of inflammatory indicators, blood biochemical indicators, and immune indicators using ELISA. The psoriasis area and severity index (PASI) was used to evaluate disease severity. Levels of HBD-2, CXCL-1, CXCL-2 and CCL20 were determined by RT-PCR. The correlations of HBD-2, CXCL-1 and CXCL-2 levels with CCL20 and PASI scores were analyzed. The diagnostic value of HBD-2, CXCL-1 and CXCL-2 in psoriasis vulgaris was analyzed by ROC curve. RESULTS: HBD-2, CXCL-1 and CXCL-2 were highly expressed in the lesions of psoriasis vulgaris patients, and were positively correlated with CCL20 and PASI score. HBD-2, CXCL-1 and CXCL-2 alone or in combination had high diagnostic value for psoriasis vulgaris and severe psoriasis, and the combined diagnostic value of the three was higher than that of a single indicator. CONCLUSION: HBD-2, CXCL-1, and CXCL-2 levels are closely related to the severity of psoriasis vulgaris and can effectively diagnose the occurrence and progression of psoriasis vulgaris.

Does Practice Match Protocol? A Comparison of Triage-to-Provider Time Among More vs. Less Acute Emergency Department Patients.

Introduction The Emergency Severity Index (ESI) stratifies emergency department (ED) patients for triage, from "most acute" (level 1) to "least acute" (level 5). Many EDs have a split flow model where less acute (ESI 4 and 5) are seen in a fast track, while more acute (ESI 1, 2, and 3) are seen in the acute care area. A core principle of emergency medicine (EM) is to attend to more acute patients first. Deliberately designating an area for less acute patients to be initially assessed quickly by a first provider might result in them being seen before more acute patients. This study aims to determine the percentage of less acute patients seen by a provider sooner after triage than more acute patients who arrived within 10 minutes of one another. Additionally, this study compares the fast track and acute care areas to see if location affects triage-to-provider time. Methods A random convenience sample of 252 ED patients aged ≥18 was taken. Patients were included if their ESI was available for the provider during sign-up. Patients were excluded if they were directly sent to the ED psychiatric area or attended to by the author. We collected data on the ESI level, time stamps for triage and first provider sign-up, and the location to which the patient was triaged (fast track vs. acute care). Paired patients' ESI levels, locations, and triage and first provider sign-up times were compared. Results  The study included 126 pairs of patients. There was a statistically significant difference in triage-to-provider times for paired ESI 2 vs. 3 patients (60.5 vs. 35.5 minutes, p = 0.0007) and overall paired high- vs. low-acuity patients (55 vs. 39.5 minutes, p = 0.004). However, in 34.8% of paired ESI 2 vs. 3 patients, the ESI 3 patient was seen prior to the paired ESI 2 patient, and in 39.4% of overall paired high vs. low acuity patients, the less acute patient was seen before the more acute patient. Additionally, patients in the acute care area had significantly shorter median triage-to-provider times (~40 minutes) compared to those in the fast track area for ESI 2 (acute care) vs. ESI 3 (fast track) and overall high acuity (acute care) vs. low acuity (fast track). Nonetheless, approximately one-third of ESI 3 patients triaged to fast track were seen before ESI 2 patients triaged to the acute care area. Conclusion The split flow model reduces overall ED length of stay, improving flow volume, revenue, and patient satisfaction. However, it comes at the expense of the fundamental ethos of EM and potentially subverts the intended triage process. Although most more acute patients are seen by a provider sooner after triage than less acute patients, a substantial number are seen later, which could delay urgent medical needs and negatively impact patients' outcomes. Furthermore, patients triaged to acute care are, in general, seen sooner post-triage than identical-ESI-level fast track patients, suggesting fast track might not function as intended (for low-acuity patients to be quickly assessed and initiate diagnostic and treatment plans). We intend to follow this exploratory study with a more comprehensive, multivariate analysis that will consider confounding variables such as initial vital signs, how busy a provider was that day, etc. The future study will also examine patient outcomes to determine the impact on more acute patients of the split flow model and, in particular, on less acute patients being seen sooner by a first provider.

Biomarkers and patient-related factors associated with clinical outcomes in dupilumab-treated atopic dermatitis.

Background: Atopic dermatitis (AD) is a common chronic eczematous skin disease with severe pruritus. Several new therapeutic agents for AD such as dupilumab, an anti-IL-4Rα antibody, have been developed in recent years. We need to predict which agent is the best choice for each patient, but this remains difficult. Objective: Our aim was to examine clinical background factors and baseline biomarkers that could predict the achievement of improved clinical outcomes in patients with AD treated with dupilumab. Methods: A multicenter, prospective observational study was conducted on 110 patients with AD. The Eczema Area and Severity Index was used as an objective assessment, and the Patient-Oriented Eczema Measure and Numerical Rating Scale for Pruritus were used as patient-reported outcomes. In addition, some clinical background factors were evaluated. Results: The achievement of an absolute Eczema Area and Severity Index of 7 or less was negatively associated with current comorbidity of food allergy and baseline serum lactate dehydrogenase (LDH) levels. There were negative associations between achievement of a Patient-Oriented Eczema Measure score of 7 or less and duration of severe AD and between achievement of an itching Numerical Rating Scale for Pruritus score of 1 or less and current comorbidity of allergic conjunctivitis or baseline serum periostin level. Furthermore, signal detection analysis showed that a baseline serum LDH level less than 328 U/L could potentially be used as a cutoff value for predicting the efficacy of dupilumab. Conclusion: Baseline biomarkers such as LDH and periostin and clinical background factors such as current comorbidity of food allergy and a long period of severe disease may be useful indicators when choosing dupilumab for systemic treatment for AD, as they can predict the efficacy of dupilumab.

Emergency department triaging using ChatGPT based on emergency severity index principles: a cross-sectional study.

Erroneous and delayed triage in an increasingly crowded emergency department (ED). ChatGPT is an artificial intelligence model developed by OpenAI® and is being trained for use in natural language processing tasks. Our study aims to determine the accuracy of patient triage using ChatGPT according to the emergency severity index (ESI) for triage in EDs. In our cross-sectional study, 18 years and over patients who consecutively presented to our ED within 24 h were included. Age, gender, admission method, chief complaint, state of consciousness, and comorbidities were recorded on the case form, and the vital signs were detected at the triage desk. A five-member expert committee (EC) was formed from the fourth-year resident physicians. The investigators converted real-time patient information into a standardized case format. The urgency status of the patients was evaluated simultaneously by EC and ChatGPT according to ESI criteria. The median value of the EC decision was accepted as the gold standard. There was a statistically significant moderate agreement between EC and ChatGPT assessments regarding urgency status (Cohen's Kappa = 0.659; P < 0.001). The accuracy between these two assessments was calculated as 76.6%. There was a high degree of agreement between EC and ChatGPT for the prediction of ESI-1 and 2, indicating high acuity (Cohen's Kappa = 0.828). The diagnostic specificity, NPV, and accuracy of ChatGPT were determined as 95.63, 98.17 and 94.90%, respectively, for ESI high acuity categories. Our study shows that ChatGPT can successfully differentiate patients with high urgency. The findings are promising for integrating artificial intelligence-based applications such as ChatGPT into triage processes in EDs.

Are long-term alcohol health harms overlooked in individuals with illicit drug problems? Alcohol-related morbidity and mortality in a Danish cohort of clients in residential rehabilitation for drug use disorders.

AIMS: This study described the burden of alcohol-related morbidity and mortality among those who had been enrolled in residential treatment for drug use disorders in Denmark and investigated whether self-reported information on alcohol use provided at treatment admission can be used to assess risk for future serious alcohol-related harms. METHODS: At baseline (entry in drug use disorder treatment during 2000-10), clients completed a European adaptation of the Addiction Severity Index-5. We tracked 4981 clients through 2018 using multiple national registers to identify fully (100%) alcohol-attributable hospital contacts and deaths. RESULTS: The death rate due to fully alcohol-attributable causes was 411 per 100 000 person-years, with an average of 0.18 fully alcohol-attributable hospital contacts per person-year. Using the Addiction Severity Index-5 alcohol composite score as a predictor in an adjusted competing risks regression model, a higher score was associated with a higher risk of alcohol-related death. The alcohol composite score was a significant predictor of alcohol-related hospital contacts in an adjusted recurrent events model. CONCLUSIONS: A substantial proportion of people originally identified as experiencing drug use disorders have alcohol problems that need to be monitored and managed to prevent serious complications. By demonstrating the predictive power of self-reported data, our study concludes that the Addiction Severity Index-5 can be used to identify individuals with drug use disorders at risk for severe long-term alcohol-related health outcomes.

Severity Scores for Cutaneous Lupus Erythematosus.

Despite the significant disease burden of cutaneous lupus erythematosus (CLE), there have been no United States Food and Drug Administration-approved therapies for 65 years. To facilitate advancement of therapies, severity scores are needed to evaluate QOL, how patients feel, activity of disease, and organ-specific damage to assess response to therapies and disease progression. In this paper, we delineate the development process of provider- and patient-reported severity scores for CLE. Cutaneous Lupus Disease Area and Severity Index (CLASI), a provider-reported measure that distinguishes between activity and damage, has undergone rigorous validation and reliability testing for over 20 years. Its performance has been tested in clinical trials as a primary or secondary endpoint and tool to stratify patients. As an objective disease measure that captures a provider's perspective of disease activity and damage, the CLASI inherently does not assess disease impact on patients' QOL. Cutaneous Lupus Erythematosus Quality of Life (CLEQoL), a patient-reported measure, captures features elucidated through focus groups, including symptoms, emotions, functioning, body image, and photosensitivity. It has undergone psychometric property testing to ensure reliability and validity. Together, CLASI and CLEQoL are simple and reliable CLE-specific severity scores capturing disease activity, damage, and QOL from provider and patient perspectives.

Efficacy and safety of vunakizumab in moderate-to-severe chronic plaque psoriasis: A randomized, double-blind, placebo-controlled phase 3 trial.

BACKGROUND: Vunakizumab, a novel anti-interleukin-17A antibody, has shown promising efficacy for moderate-to-severe plaque psoriasis in a phase 2 trial. OBJECTIVE: We conducted a double-blind, randomized phase 3 trial (NCT04839016) to further evaluate vunakizumab in this population. METHODS: Six hundred ninety subjects were randomized (2:1) to receive vunakizumab 240 mg or placebo at weeks 0, 2, 4, and 8. At week 12, subjects on placebo were switched to vunakizumab 240 mg (weeks 12, 14, 16, and every 4 weeks thereafter). The co-primary endpoints were ≥90% improvement from baseline in the Psoriasis Area and Severity Index score (PASI 90) and a static Physicians Global Assessment score of 0/1 (sPGA 0/1) at week 12. RESULTS: At week 12, the vunakizumab group showed higher PASI 90 (76.8% vs 0.9%) and sPGA 0/1 (71.8% vs 0.4%) response rates, as well as higher PASI 75 (93.6% vs 4.0%), PASI 100 (36.6% vs 0.0%), and sPGA 0 (38.2% vs 0.0%) response rates (all two-sided P < .0001 vs placebo). Efficacy was maintained through week 52 with continuous vunakizumab. Possible treatment-related serious adverse events occurred in 0.9% of vunakizumab-treated subjects. LIMITATIONS: Chinese subjects only; no active comparator. CONCLUSION: Vunakizumab demonstrated robust clinical response at week 12 and through week 52, with good tolerability in moderate-to-severe plaque psoriasis.

Real-World Data on Brodalumab Treatment in Patients with Moderate-to-Severe Plaque Psoriasis: An Observational Study from the Czech Republic BIOREP Registry.

INTRODUCTION: The aim of this observational, multicenter study was to assess the real-world use of brodalumab for the treatment of moderate-to-severe plaque psoriasis in patients in the Czech Republic, using data from the BIOREP registry. METHODS: The study included 273 patients aged ≥ 18 years with moderate-to-severe psoriasis who received brodalumab. Endpoints were drug survival (time from treatment initiation to discontinuation), effectiveness [Psoriasis Area and Severity Index (PASI)], and health-related quality-of-life [Dermatology Life Quality Index (DLQI)]. RESULTS: Predicted drug survival probability was 92.4% [95% confidence interval (CI): 89.1, 95.7%] at 6 months and 84.2% (95% CI 79.5, 89.1%) at 12 months; this was maintained at 24 months [80.4% (95% CI 74.5, 86.8%)]. Younger age, higher body mass index, and no previous biologic treatment were significantly associated with longer drug survival. Absolute PASI ≤ 3 after 3 months was achieved by 89.8% of patients; 92.4%, 77.8%, and 59.1% reached PASI 75, PASI 90, and PASI 100, respectively. After 12 months, 96.5% of 141 patients had an absolute PASI ≤ 3. The proportion of patients achieving DLQI 0/1 was 87.3% at 12 months. CONCLUSION: This study demonstrated high and sustained drug survival with high rates of skin clearance and improved quality of life in patients with relatively severe disease treated with brodalumab. Improvements were observed as early as 3 months post-treatment initiation and were sustained for up to 24 months in a real-life setting.

Anifrolumab for systemic lupus erythematosus with multi-refractory skin disease: A case series of 18 patients.

OBJECTIVE: Skin involvement is common in systemic lupus erythematosus (SLE), but may be resistant to conventional treatment. We sought to evaluate the efficacy of anifrolumab (ANI) in refractory cutaneous manifestations of SLE. METHODS: Case series of patients with refractory cutaneous SLE from three Rheumatology Departments in Greece. Outcome measures were improvement in Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), physician global assessment (PGA) and Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI). Clinically relevant improvement in skin was defined as decrease ≥50% (CLASI50) from baseline values. RESULTS: Eighteen patients received ANI; all had active skin involvement at baseline. Mean (SD) SLEDAI and PGA at ANI initiation were 7.4 (2.7) and 1.4 (0.5), respectively, with a mean prednisone dose 4.9 (4.5) mg/day. Mean CLASI (Activity/Damage) at baseline was 13.9 (9.7)/2.9 (4.6). Patients were refractory to a mean 6.3 (1.5) immunomodulatory agents (including hydroxychloroquine and glucocorticoids) before the initiation of ANI. After a mean 8.5 (4.6) months, 89% (n = 16/18) of patients demonstrated significant improvement in general lupus and cutaneous disease activity, and glucocorticoid tapering. Mean SLEDAI and mean CLASI at last visit were 3.4 (1.9) and 2.1 (2.4)/1.4 (2.2), respectively, and mean daily prednisone dose decreased to 2.4 (2.2). Of note, in this group of highly refractory patients CLASI50 was achieved in 16/18 (89%) patients. One patient discontinued ANI after 4 infusions due to a varicella-zoster virus infection and one patient, who initially responded to treatment with ANI, experienced a skin flare due to temporary discontinuation due to Covid 19 infection. DORIS remission and LLDAS were attained in two (11.1%) and eleven (61.1%) patients, respectively. CONCLUSION: Anifrolumab is highly effective in various skin manifestations of SLE, even after prior failure to multiple treatments.

Using joint probability density to create most informative unidimensional indices: a new method using pain and psychiatric severity as examples.

BACKGROUND: Dimension reduction methods do not always reduce their underlying indicators to a single composite score. Furthermore, such methods are usually based on optimality criteria that require discarding some information. We suggest, under some conditions, to use the joint probability density function (joint pdf or JPD) of p-dimensional random variable (the p indicators), as an index or a composite score. It is proved that this index is more informative than any alternative composite score. In two examples, we compare the JPD index with some alternatives constructed from traditional methods. METHODS: We develop a probabilistic unsupervised dimension reduction method based on the probability density of multivariate data. We show that the conditional distribution of the variables given JPD is uniform, implying that the JPD is the most informative scalar summary under the most common notions of information. B. We show under some widely plausible conditions, JPD can be used as an index. To use JPD as an index, in addition to having a plausible interpretation, all the random variables should have approximately the same direction(unidirectionality) as the density values (codirectionality). We applied these ideas to two data sets: first, on the 7 Brief Pain Inventory Interference scale (BPI-I) items obtained from 8,889 US Veterans with chronic pain and, second, on a novel measure based on administrative data for 912 US Veterans. To estimate the JPD in both examples, among the available JPD estimation methods, we used its conditional specifications, identified a well-fitted parametric model for each factored conditional (regression) specification, and, by maximizing the corresponding likelihoods, estimated their parameters. Due to the non-uniqueness of conditional specification, the average of all estimated conditional specifications was used as the final estimate. Since a prevalent common use of indices is ranking, we used measures of monotone dependence [e.g., Spearman's rank correlation (rho)] to assess the strength of unidirectionality and co-directionality. Finally, we cross-validate the JPD score against variance-covariance-based scores (factor scores in unidimensional models), and the "person's parameter" estimates of (Generalized) Partial Credit and Graded Response IRT models. We used Pearson Divergence as a measure of information and Shannon's entropy to compare uncertainties (informativeness) in these alternative scores. RESULTS: An unsupervised dimension reduction was developed based on the joint probability density (JPD) of the multi-dimensional data. The JPD, under regularity conditions, may be used as an index. For the well-established Brief Pain Interference Inventory (BPI-I (the short form with 7 Items) and for a new mental health severity index (MoPSI) with 6 indicators, we estimated the JPD scoring. We compared, assuming unidimensionality, factor scores, Person's scores of the Partial Credit model, the Generalized Partial Credit model, and the Graded Response model with JPD scoring. As expected, all scores' rankings in both examples were monotonically dependent with various strengths. Shannon entropy was the smallest for JPD scores. Pearson Divergence of the estimated densities of different indices against uniform distribution was maximum for JPD scoring. CONCLUSIONS: An unsupervised probabilistic dimension reduction is possible. When appropriate, the joint probability density function can be used as the most informative index. Model specification and estimation and steps to implement the scoring were demonstrated. As expected, when the required assumption in factor analysis and IRT models are satisfied, JPD scoring agrees with these established scores. However, when these assumptions are violated, JPD scores preserve all the information in the indicators with minimal assumption.

Does initiating care in alternate care sites decrease time to disposition in the emergency department?

Objectives: During the coronavirus disease 2019 (COVID-19) pandemic surge, alternate care sites (ACS) such as the waiting room or hospital lobby were created amongst hospitals nationwide to help alleviate emergency department (ED) overflow. Despite the end of the pandemic surge, many of these ACS remain functional given the burden of prolonged ED wait times, with providers now utilizing the waiting room or ACS to initiate care. Therefore, the objective of this study is to evaluate if initiating patient care in ACS helps to decrease time to disposition. Methods: Retrospective data were collected on 61,869 patient encounters presenting to an academic medical center ED. Patients with an emergency severity index (ESI) of 1 were excluded. The "pre-ACS" or control data consisted of 38,625 patient encounters from September 30, 2018 to October 1, 2019, prior to the development of ACS, in which the patient was seen by a physician after they were brought to an assigned ED room. The "post-ACS" study cohort consisted of 23,244 patient encounters from September 30, 2022 to October 1, 2023, after the initiation of ACS, during which patients were initially seen by a provider in an ACS. ACS at this institution included the three following areas: waiting room, ambulance waiting area, and a newly constructed ACS that was built next to the ED entrance on the first floor of the hospital. The newly constructed ACS consisted of 16 care spaces each containing an upright exam chair with dividers between each care space. Door-to-disposition time (DTD) was calculated by identifying the time when the patient entered the ED and the time when disposition was decided (admission requested or patient discharged). Using regression analysis, we compared the two data sets to determine significant differences among DTD time. Results: The largest proportion of encounters were among ESI 3 patients, that is, 56.1%. There was a significant increase in median DTD for ESI 2 and 3 patients who were seen initially in an ACS compared to those who were not seen until they were in an assigned ER room. Specifically, there was a median increase of 40.9 min for ESI 2 patients and 18.8 min for ESI 3 patients who were seen initially in an ACS (p < 0.001). There was a 29-min decrease in median DTD for ESI 5 patients who were seen in ACS (p = 0.09). Conclusions: Initiating patient care earlier in ACS did not appear to decrease DTD time for patients in the ED. Overall, the benefits of early initiation of care likely lie elsewhere within patient care and the ED throughput process.