Applications of Laser Speckle Contrast Imaging Technology in Dermatology.

Laser speckle contrast imaging or laser speckle imaging (LSI) is a noninvasive imaging technology that can detect areas of dynamic perfusion or vascular flow. Thus, LSI has shown increasing diagnostic utility in various pathologies and has been employed for intraoperative, postoperative, and long-term monitoring in many medical specialties. Recently, LSI has gained traction in clinical dermatology because it can be effective in the assessment of pathologies that are associated with increased perfusion and hypervascularity compared with that of normal tissue. To date, LSI has been found to be highly accurate in monitoring skin graft reperfusion, determining the severity of burns, evaluating neurosurgical revascularization, assessing persistent perfusion in capillary malformations after laser therapy, and differentiating malignant and benign skin lesions. LSI affords the advantage of noninvasively assessing lesions before more invasive methods of diagnosis, such as tissue biopsy, while remaining inexpensive and exhibiting no adverse events to date. However, potential obstacles to its clinical use include tissue movement artifact, primarily qualitative data, and unclear impact on clinical practice given the lack of superiority data compared with the current standard-of-care diagnostic methods. In this review, we discuss the clinical applications of LSI in dermatology for use in the diagnosis and monitoring of vascular, neoplastic, and inflammatory skin conditions.

Identifying risk factors for cutaneous disease among solid organ transplant recipients: A retrospective review.

Background: As solid organ transplant recipient (SOTR) life expectancy lengthens, the risk of developing other chronic diseases also increases. Objective: To determine the cutaneous pathologies for which SOTRs are at an increased risk. Methods: We performed a retrospective review of SOTRs seen by dermatology from January 1, 2012 and June 1, 2022. Data were analyzed using multivariate logistic regression. Benjamini Hochberg-adjusted P values were examined for multiplicity. Results: Five hundred and thirty SOTRs were identified. Patients had cutaneous malignancy (38.3%), precancerous lesions (32.5%), inflammatory (35.5%), and infectious diseases (33.1%). Odds of precancerous lesions were higher with increased age at transplant (odds ratio [OR], 1.04; adjusted P =.006), and lower with female sex (OR, 0.505; adjusted P =.006) and African American race (OR, 0.027; adjusted P =.006). Odds of inflammatory lesions were lower with increased age at transplant (OR, 0.979; adjusted P =.023). Odds of infectious diseases were higher with prednisone use (OR, 2.615; adjusted P value =.023). Limitations: This study is retrospective and was not able to capture patients seen by dermatology outside of our institution. Conclusions: SOTRs at risk of cutaneous lesions should be referred to dermatology because these conditions may place a significant burden on the quality of life.

Comparison of Patient and Provider Practices between Bone Marrow and Solid Organ Transplantation Programs for Patient Education on Increased Risk of Skin Cancer.

Patients receiving immunosuppressive therapy following transplantation are at risk for skin cancer owing to dampened tumor surveillance. As long-term immunotherapy is necessary to prevent graft rejection, transplantation providers and recipients are expected to perform regular surveillance for the development of suspicious lesions, and recipients are encouraged to practice preventative sun safe behaviors. No consensus exists regarding the timing of full body skin exams, and despite the well-established risk, patient education is not always prioritized. We investigated whether differences exist between bone marrow transplant (BMT) and organ transplant (OT) recipients and their providers regarding prevention and screening. We distributed surveys to adult and pediatric BMT and OT recipients, as well as their providers, at a single academic institution. Results were evaluated using the chi-square test. The survey results show that most BMT recipients (69%) and OT recipients (77%) were aware of their increased risk for skin cancer, but despite this knowledge, only 13% of patients overall reported using sunscreen, 29% reported reapplying sunscreen, and 48% reported wearing sun protective clothing. Most OT recipients (63%) reported never having a total body skin exam, whereas only 34% BMT recipients reported having a total body skin exam every 6 months (P = .006). BMT providers recommended a total body skin exam every 6 or 12 months (44.4% each), and OT providers recommended a total body skin exam every 12 months (58.3%). Only 11.1% of BMT providers and 8.3% of OT providers reported performing a total body skin exam at each visit. Despite results indicating widespread patient knowledge of skin cancer risk, most patients do not practice adequate prevention. Inclusion of a transplantation dermatologist in the care team or use of risk stratification tools by providers may help streamline timely referrals to Dermatology.

Characterizing Skin Cancer in Transplant Recipients by Fitzpatrick Skin Phototype.

INTRODUCTION: Nearly half of organ transplants occur annually in patients with Fitzpatrick skin phototypes (Fitz type) III-VI. Organ transplant recipients (OTRs) are at risk for sequelae of chronic immunosuppression, of which skin cancer is common. As literature regarding skin cancer risk is largely conducted in OTRs with Fitz types I and II, we aimed to further characterize the incidence and risk factors for skin cancer in OTRs with higher Fitz types. METHODS: We conducted a retrospective review of OTRs with Fitz types III-VI evaluated by dermatology between 1 January 2012 and 1 June 2022. The primary outcome of this study was development of skin cancer post-transplant. Secondary outcomes included risk factors for skin cancer development. Data were analyzed using two-sample t-tests and Pearson's chi-squared. RESULTS: Of 530 OTRs, 193 had Fitz type III or higher. Ten patients (5.18%) developed 87 skin cancers and one recurrence at a mean of 5.17 years posttransplant. Patients with skin cancer self-identified as Black (70%, p-value ≤ 0.001), male (70%, p-value ≤ 0.001), and kidney transplant recipients (70%, p-value ≤ 0.001), with a mean age of 58.20 years at transplant (p-value ≤ 0.001). Subjects with skin cancer were more likely to be former smokers (60%) and prescribed tacrolimus (p-value ≤ 0.001 each). Development of cutaneous squamous cell carcinoma (66, 75.86%) was most common, followed by basal cell carcinoma (17, 19.54%), and malignant melanoma (3, 3.45%). Skin cancer most often occurred on the face or scalp (60%, p-value = 0.027), though also developed in sun-protected sites (30%, p-value = 0.002). Verruca vulgaris was present in 10% of patients (p-value = 0.028). CONCLUSIONS: Risk factors for skin cancer post-transplant differ in OTRs with higher Fitz types. Our results suggest that among OTRs who self-identified as Black, kidney recipients are at increased risk for skin cancer in non-sun-exposed regions. These cancers may be associated with human papillomavirus (HPV). Education is key for preventing morbidity and mortality secondary to skin cancer.

Vascular Anomalies: Nomenclature and Diagnosis.

Before the development of the International Society for the Study of Vascular Anomalies (ISSVA) classification system in 1996, nomenclature used to describe vascular lesions was inconsistent and imprecise. This since widely adopted system stratifies vascular anomalies into vascular malformations and tumors. Vascular tumors involve abnormal proliferation of vascular cells and are further classified as benign, locally aggressive/borderline, or malignant. Vascular malformations are lesions of defective vascular morphogenesis with quiescent endothelium and are named according to their vessel composition, and subdivided into simple; combined, of major named vessels; and syndrome-associated malformations. The updated 2018 ISSVA criteria are referenced in this review.

Industry experiences with immune-mediated findings in biotherapeutic nonclinical toxicology studies.

With the growth of monoclonal antibodies and other proteins as major modalities in the pharmaceutical industry, there has been an increase in pharmacology and toxicity testing of biotherapeutics in animals. Animals frequently mount an immune response to human therapeutic proteins. This can result in asymptomatic anti-drug antibody formation, immune complexes that affect drug disposition and/or organ function such as kidney, cytokine release responses, fatal hypersensitivity, or a range of reactions in between. In addition, an increasing number of oncology therapeutics are being developed that enhance or directly stimulate immune responses by a variety of mechanisms, which could increase the risk of autoreactivity and an autoimmune-like syndrome in animals and humans. When evaluating the risk of biotherapeutics prior to entering the clinic, the nonclinical safety data may include any of these responses and it is critical to understand whether they represent a safety liability for humans. The DruSafe Leadership group of the IQ Consortium conducted a survey of industry to understand sponsors' experiences with these immune reactions in nonclinical studies related to both immunogenicity and pharmacologically-mediated immune perturbations. The survey covered what pathways were affected, how the immune responses were presented, how the company and health authorities interpreted the data and whether the immune responses were observed in the clinic. Additionally, the survey gathered information on association of these findings with anti-drug antibodies as well as sponsor's use of immunogenicity predictive tools. The data suggests that the ability of a biotherapeutic to activate the immune system, intended or not, plays a significant role on characteristics of the response and whether theys are translatable.

Nano-lipospheres as acoustically active ultrasound contrast agents: evolving tumor imaging and therapy technique.

Applying nanobubbles (NBs) for contrast-enhanced ultrasound imaging has received increased attention. NBs are biocompatible, multifunctional, theranostic agents. Their properties of high echogenicity and stability create an agent suitable for ultrasonography diagnosis. Their favorable properties of size, in vivo stability, and ease of modification are being exploited to implement a theranostic platform for cancer treatment. The considerable development offers the potential to overcome drug resistance and adverse side effects that are associated with traditional chemotherapy. This review outlines the principles of ultrasonography and angiogenesis. Microbubbles and micelles are also discussed to underline the superior capabilities of NBs for the application. NBs could passively accumulate to tumor tissue by enhanced permeability and retention effect. In addition, it can also achieve the active transportation by surface modification. Active targeting modalities and stimuli-responsive drug delivery modifications generate a therapeutic vehicle. The cytotoxicity of NBs formulations, multimodal imaging capability, active targeting mechanisms, and drug delivery methods are highlighted to confirm the NB as a vehicle for targeted treatment and enhanced ultrasound imaging.

Current strategies in the non-clinical safety assessment of biologics: New targets, new molecules, new challenges.

Nonclinical safety testing of biopharmaceuticals can present significant challenges to human risk assessment with these innovative and often complex drugs. Emerging topics in this field were discussed recently at the 2016 Annual US BioSafe General Membership meeting. The presentations and subsequent discussions from the main sessions are summarized. The topics covered included: (i) specialty biologics (oncolytic virus, gene therapy, and gene editing-based technologies), (ii) the value of non-human primates (NHPs) for safety assessment, (iii) challenges in the safety assessment of immuno-oncology drugs (T cell-dependent bispecifics, checkpoint inhibitors, and costimulatory agonists), (iv) emerging therapeutic approaches and modalities focused on microbiome, oligonucleotide, messenger ribonucleic acid (mRNA) therapeutics, (v) first in human (FIH) dose selection and the minimum anticipated biological effect level (MABEL), (vi) an update on current regulatory guidelines, International Council for Harmonization (ICH) S1, S3a, S5, S9 and S11 and (vii) breakout sessions that focused on bioanalytical and PK/PD challenges with bispecific antibodies, cytokine release in nonclinical studies, determining adversity and NOAEL for biologics, the value of second species for toxicology assessment and what to do if there is no relevant toxicology species.

Bilateral cystoid macular edema with giant retinal achromic patch in a patient with tuberous sclerosis.

Retinal astrocytic hamartoma is the most common retinal finding in tuberous sclerosis and has been reported in association with cystoid macular edema. A retinal achromic patch is the second most common retinal finding in tuberous sclerosis. The authors report the first case of bilateral cystoid macular edema in which one the eyes does not have an identifiable retinal astrocytic hamartoma. They also describe a new retinal finding in tuberous sclerosis termed giant retinal achromic patch.

Idiopathic intracranial hypertension and obesity.

Idiopathic intracranial hypertension (IIH), also known as primary pseudotumor cerebri syndrome (PTCS), is a condition of unknown etiology which affects primarily overweight, reproductive-aged women and causes increased intracranial pressure (ICP). This review discusses the recently revised diagnostic criteria for PTCS for adults and children. Additionally, the role of obesity in the epidemiology, etiology, and management of IIH as well as the current knowledge of obesity profiles and markers in IIH are reviewed. We also highlight the emerging, unifying theory of the neuroendocrine effects on the mineralocorticoid receptor to explain a possible mechanism for the increased cerebrospinal fluid production and ICP in secondary PTCS.

Shared decision making in prostate-specific antigen testing: the effect of a mailed patient flyer prior to an annual exam.

INTRODUCTION AND AIMS: Professional societies recommend that the decision to screen for prostate cancer involves a shared discussion between patient and provider. Many men are tested without this discussion. Prostate cancer screening decision aids increase patient knowledge and participation in prostate-specific antigen (PSA) testing decisions under ideal circumstances but are often resource intensive and elaborate. There is a need for evaluation of interventions that are low cost, low literacy, and practical for widespread distribution. The authors evaluated the effect of a mailed low-literacy informational patient flyer about the PSA test on measures of shared decision making. METHODS: A pragmatic randomized controlled trial comparing the mailed flyer versus usual care was conducted among 303 men aged 50 to 74 years who were scheduled for annual health maintenance exams in 2 general internal medicine clinics (University of Colorado and University of Colorado Hospital). Charts were reviewed after the visits for documentation of PSA screening discussions and PSA testing rates. Follow-up patient surveys assessed include perceived participation in PSA screening decisions, knowledge of the PSA test, and flyer acceptability. RESULTS: Rates of chart-documented PSA discussions were low with no difference between the flyer and control groups (17.7% and 13.6%, respectively; P = .28). Rates of PSA testing were also similar in both groups (62.5% vs 58.5%; P = .48). Rates of patient-reported PSA discussions were higher than the documented rates but also without differences between the groups (71.8% vs 62.3%; P = .22). The intervention had no effect in the PSA knowledge scores (3.5/5 vs 3.3/5, P = .60). Patients found the flyer to be highly acceptable. CONCLUSIONS: A mailed low-literacy informational flyer was well received by patients but had no effect on rates of PSA discussions, PSA testing, or patient knowledge of prostate cancer screening.

Histone deacetylase inhibition reduces cardiac connexin43 expression and gap junction communication.

Histone deacetylase inhibitors (HDACIs) are being investigated as novel therapies for cancer, inflammation, neurodegeneration, and heart failure. The effects of HDACIs on the functional expression of cardiac gap junctions (GJs) are essentially unknown. The purpose of this study was to determine the effects of trichostatin A (TSA) and vorinostat (VOR) on functional GJ expression in ventricular cardiomyocytes. The effects of HDAC inhibition on connexin43 (Cx43) expression and functional GJ assembly were examined in primary cultured neonatal mouse ventricular myocytes. TSA and VOR reduced Cx43 mRNA, protein expression, and immunolocalized Cx43 GJ plaque area within ventricular myocyte monolayer cultures in a dose-dependent manner. Chromatin immunoprecipitation experiments revealed altered protein interactions with the Cx43 promoter. VOR also altered the phosphorylation state of several key regulatory Cx43 phospho-serine sites. Patch clamp analysis revealed reduced electrical coupling between isolated ventricular myocyte pairs, altered transjunctional voltage-dependent inactivation kinetics, and steady state junctional conductance inactivation and recovery relationships. Single GJ channel conductance was reduced to 54 pS only by maximum inhibitory doses of TSA (≥ 100 nM). These two hydroxamate pan-HDACIs exert multiple levels of regulation on ventricular GJ communication by altering Cx43 expression, GJ area, post-translational modifications (e.g., phosphorylation, acetylation), gating, and channel conductance. Although a 50% downregulation of Cx43 GJ communication alone may not be sufficient to slow ventricular conduction or induce arrhythmias, the development of class-selective HDACIs may help avoid the potential negative cardiovascular effects of pan-HDACI.

NADH distribution in live progenitor stem cells by phasor-fluorescence lifetime image microscopy.

NADH is a naturally fluorescent metabolite associated with cellular respiration. Exploiting the different fluorescence lifetime of free and bound NADH has the potential to quantify the relative amount of bound and free NADH, enhancing understanding of cellular processes including apoptosis, cancer pathology, and enzyme kinetics. We use the phasor-fluorescence lifetime image microscopy approach to spatially map NADH in both the free and bound forms of live undifferentiated and differentiated myoblast cells. The phasor approach graphically depicts the change in lifetime at a pixel level without the requirement for fitting the decay. Comparison of the spatial distribution of NADH in the nucleus of cells induced to differentiate through serum starvation and undifferentiated cells show differing distributions of bound and free NADH. Undifferentiated cells displayed a short lifetime indicative of free NADH in the nucleus and a longer lifetime attributed to the presence of bound NADH outside of the nucleus. Differentiating cells displayed redistribution of free NADH with decreased relative concentration of free NADH within the nucleus whereas the majority of NADH was found in the cytoplasm.

Clinical assessment of a recombinant simian adenovirus ChAd63: a potent new vaccine vector.

BACKGROUND: Vaccine development in human Plasmodium falciparum malaria has been hampered by the exceptionally high levels of CD8(+) T cells required for efficacy. Use of potently immunogenic human adenoviruses as vaccine vectors could overcome this problem, but these are limited by preexisting immunity to human adenoviruses. METHODS: From 2007 to 2010, we undertook a phase I dose and route finding study of a new malaria vaccine, a replication-incompetent chimpanzee adenovirus 63 (ChAd63) encoding the preerythrocytic insert multiple epitope thrombospondin-related adhesion protein (ME-TRAP; n = 54 vaccinees) administered alone (n = 28) or with a modified vaccinia virus Ankara (MVA) ME-TRAP booster immunization 8 weeks later (n = 26). We observed an excellent safety profile. High levels of TRAP antigen-specific CD8(+) and CD4(+) T cells, as detected by interferon γ enzyme-linked immunospot assay and flow cytometry, were induced by intramuscular ChAd63 ME-TRAP immunization at doses of 5 × 10(10) viral particles and above. Subsequent administration of MVA ME-TRAP boosted responses to exceptionally high levels, and responses were maintained for up to 30 months postvaccination. CONCLUSIONS: The ChAd63 chimpanzee adenovirus vector appears safe and highly immunogenic, providing a viable alternative to human adenoviruses as vaccine vectors for human use. CLINICAL TRIALS REGISTRATION: NCT00890019.

A human Phase I/IIa malaria challenge trial of a polyprotein malaria vaccine.

We examined the safety, immunogenicity and efficacy of a prime-boost vaccination regime involving two poxvirus malaria subunit vaccines, FP9-PP and MVA-PP, expressing the same polyprotein consisting of six pre-erythrocytic antigens from Plasmodium falciparum. Following safety assessment of single doses, 15 volunteers received a heterologous prime-boost vaccination regime and underwent malaria sporozoite challenge. The vaccines were safe but interferon-γ ELISPOT responses were low compared to other poxvirus vectors, despite targeting multiple antigens. There was no vaccine efficacy as measured by delay in time to parasitaemia. A number of possible explanations are discussed, including the very large insert size of the polyprotein transgene.

Preclinical safety evaluation of AAV2-sFLT01- a gene therapy for age-related macular degeneration.

AAV2-sFLT01 is a vector that expresses a modified soluble Flt1 receptor designed to neutralize the proangiogenic activities of vascular endothelial growth factor (VEGF) for treatment of age-related macular degeneration (AMD) via an intravitreal injection. Owing to minimal data available for the intravitreal route of administration for adeno-associated virus (AAV), we initiated a 12-month safety study of AAV2-sFLT01 administered intravitreally at doses of 2.4 × 10(9) vector genomes (vg) and 2.4 × 10(10) vg to cynomolgus monkeys. Expression of sFlt01 protein peaked at ~1-month postadministration and remained relatively constant for the remainder of the study. Electroretinograms, fluorescein angiograms, and tonometry were assessed every 3 months, with no test article-related findings observed in any group. Indirect ophthalmoscopy and slit lamp exams performed monthly revealed a mild to moderate but self-resolving vitreal inflammation in the high-dose group only, which follow-up studies suggest was directed against the AAV2 capsid. Histological evaluation revealed no structural changes in any part of the eye and occasional inflammatory cells in the trabecular meshwork, vitreous and retina in the high-dose group. Biodistribution analysis in rats and monkeys found only trace amounts of vector outside the injected eye. In summary, these studies found AAV2-sFLT01 to be well-tolerated, localized, and capable of long-term expression.