Therapeutic Protein Drug Interaction Potential in Subjects With Psoriasis: An Assessment Based on Population Pharmacokinetic Analyses of Sensitive Cytochrome P450 Probe Substrates.

Elevated cytokine levels in inflammatory diseases are associated with downregulation of certain cytochrome P450 (CYP) enzymes. Upon treatment with some cytokine-targeting therapeutic proteins, the CYP enzymes levels may be restored resulting in therapeutic protein-mediated drug interactions (TP-DI). These analyses characterized the worst-case scenario for CYP1A2, 2C9, and 3A-based TP-DI potential in patients with psoriasis by comparing the pharmacokinetics of probe substrates between healthy volunteers and subjects with moderate to severe psoriasis. Data for the CYP probe substrates midazolam (CYP3A), caffeine (CYP1A2), and S-warfarin (CYP2C9) from 7 drug interaction studies (1 in patients with psoriasis and 6 in healthy subjects) were pooled to develop a population pharmacokinetics model for each substrate. A 2-compartment model with absorption lag time for midazolam, a 1-compartment model with 5 transit absorption compartments for caffeine, and a 3-compartment model with absorption lag time for S-warfarin best described the observed data. Apparent oral clearance and relative bioavailability for caffeine and S-warfarin were not significantly different between the subject populations. Psoriasis patients were estimated to have 17% lower midazolam oral bioavailability than healthy volunteers. Compounded with other covariate effects, the ratio of median post hoc area under the plasma concentration-time estimates in subjects with psoriasis relative to healthy subjects was 0.96, 1.13, and 0.65 for midazolam, caffeine, and S-warfarin, respectively. Therefore, inflammation in psoriasis had no relevant effect on reducing CYP1A2, 2C9, and 3A activities in vivo and no significant TP-DIs mediated through these enzymes are expected in patients with psoriasis. This approach can potentially be used in lieu of dedicated TP-DI studies to identify TP-DI risks within a disease area.

Applying precision medicine to unmet clinical needs in psoriatic disease.

Psoriatic disease (PsD) is a heterogeneous condition that can affect peripheral and axial joints (arthritis), entheses, skin (psoriasis) and other structures. Over the past decade, considerable advances have been made both in our understanding of the pathogenesis of PsD and in the treatment of its diverse manifestations. However, several major areas of continued unmet need in the care of patients with PsD have been identified. One of these areas is the prediction of poor outcome, notably radiographic outcome in patients with psoriatic arthritis, so that stratified medicine approaches can be taken; another is predicting response to the numerous current and emerging therapies for PsD, so that precision medicine can be applied to rapidly improve clinical outcome and reduce the risk of toxicity. In order to address these needs, novel approaches, including imaging, tissue analysis and the application of proteogenomic technologies, are proposed as methodological solutions that will assist the dissection of the critical immune-metabolic pathways in this complex disease. Learning from advances made in other inflammatory diseases, it is time to address these unmet needs in a multi-centre partnership aimed at improving short-term and long-term outcomes for patients with PsD.

The landscape of psoriasis provision in the UK.

Psoriasis remains one of the commonest conditions seen in dermatological practice, and its treatment is one of the greatest cost burdens for the UK National Health Service. Treatment of psoriasis is complex, with numerous overlapping lines and therapies used in combination. This complexity reflects the underlying pathophysiology of the disease as well as the heterogeneous population that it affects. National Institute for Health and Care Excellence (NICE) guidance for the treatment of psoriasis has been available since 2013, and has been the subject of three national audits conducted by the British Association of Dermatologists. This report synthesizes the results of the most recent of those exercises and places it in the context of the NICE guidance and previous audits. It clearly shows the significant burden of disease, issues with provision of services and long waiting times and the marked shift in therapies towards targeted biologic therapies.

The clinical, humanistic, and economic burden of palmoplantar pustulosis: a structured review.

Introduction: Palmoplantar pustulosis (PPP) is a chronic, relapsing and refractory disease characterized by sterile pustules appearing on the palms and/or soles, accompanied by erythema, blistering, scales and/or keratinization. The overall burden of PPP in terms of its clinical impact, effect on patients and families, and economic consequences has not previously been investigated in a structured manner.Areas covered: A structured search focused on identification of studies in PPP using specific search terms in PubMed and EMBASE® from 2005 onwards, with additional back-referencing and pragmatic searches. Outcomes of interest included clinical burden, humanistic burden, and economic burden.Expert opinion: In cross-sectional studies, approximately 75% of all PPP patients suffer from active disease, with risk of relapse remaining constant over time. Patients' health-related quality of life is significantly impaired, as expected for a disease affecting hands and feet. Tools have been described that assess the clinical as well as patient-reported burden of PPP; their performance in larger cohorts and/or clinical trials remains to be investigated. The key data limitations identified include inconsistent definitions for characterizing remission/relapse, and limited humanistic and economic burden data; future studies are required to address these evidence gaps.

The clinical, humanistic, and economic burden of generalized pustular psoriasis: a structured review.

Introduction: Generalized pustular psoriasis (GPP) is characterized by widespread erythema and edema, superficial sterile coalescing pustules, and lakes of pus. Although the impact of GPP is thought to be substantial, emerging literature on its clinical, humanistic, and economic burden has not previously been described in a structured way.Areas covered: A structured search focused on the identification of studies in GPP using specific search terms in PubMed and EMBASE® from 2005 onwards, with additional back-referencing and pragmatic searches. Outcomes of interest included clinical, humanistic, and economic burden.Expert opinion: Despite its significant clinical, humanistic, and economic burden, GPP is poorly classified and inadequately studied. A recent European (ERASPEN) consensus classifies GPP into relapsing and persistent disease and classifies patients on the presence or absence of psoriasis vulgaris. Classification of GPP lesions involving >30% body surface area or use of hospitalization as a surrogate may be a way to identify significant flares. Given the frequency of flares, the impaired quality of life during the post-flare period, and safety/tolerability issues, it is clear that current treatment options are not sufficient. Long-term studies utilizing the European consensus statement with subclassifiers are required to supplement our current understanding of the burden of GPP.

Automatic Scale Severity Assessment Method in Psoriasis Skin Images Using Local Descriptors.

Psoriasis is a chronic skin condition. Its clinical assessment involves four measures: erythema, scales, induration, and area. In this paper, we introduce a scale severity scoring framework for two-dimensional psoriasis skin images. Specifically, we leverage the bag-of-visual words (BoVWs) model for lesion feature extraction using superpixels as key points. BoVWs model is based on building a vocabulary with specific number of words (i.e., codebook size) by using a clustering algorithm with some local features extracted from a constructed set of key points. This is followed by three-class machine learning classifiers for scale scoring using support vector machine (SVM) and random forest. Besides, we examine eight different local color and texture descriptors, namely color histogram, local binary patterns, edge histogram descriptor, color layout descriptor, scalable color descriptor, color and edge directivity descriptor (CEDD), fuzzy color and texture histogram, and brightness and texture directionality histogram. Further, the selection of codebook and superpixel sizes are studied intensively. A psoriasis image set, consisting of 96 images, is used in this study. The conducted experiments show that color descriptors have the highest performance measures for scale severity scoring. This is followed by the combined color and texture descriptors, whereas texture-based descriptors come last. Moreover, K-means algorithm shows better results in vocabulary building than Gaussian mixed model, in terms of accuracy and computations time. Finally, the proposed method yields a scale severity scoring accuracy of 80.81% using the following setup: a superpixel of size [Formula: see text], a combined color and texture descriptor (i.e., CEDD), a constructed codebook of size 128 using K-means, and SVM for scale scoring.

Improvement of Disease Management and Cost Effectiveness in Chinese Patients with Ankylosing Spondylitis Using a Smart-Phone Management System: A Prospective Cohort Study.

OBJECTIVES: Ankylosing spondylitis (AS) is a chronic disease that decreases mobility, function, and quality of life. This study introduced the "Smart-phone SpondyloArthritis Management System" (SpAMS), an interactive mobile health (mHealth) tool designed for AS/spondyloarthritis (SpA) disease management and used SpAMS data to evaluate clinical characteristics of Chinese patients with AS. METHODS: SpAMS integrates patient's and physician's portals in a smart phone application. The Chinese Ankylosing Spondylitis Prospective Imaging Cohort was launched using SpAMS in April 2016. Patient self-assessments were completed online at baseline and at every subsequent clinic visit. Physician-reported assessments and treatments were recorded by rheumatologists during each visit. RESULTS: In total, 1201 patients with AS [mean (SD) age, 30.6 (8.7) years; male, 82.6%] were recruited. Mean (SD) disease duration was 8.4 (6.1) years. Past or current symptoms of acute anterior uveitis (AAU), psoriasis, and inflammatory bowel disease (IBD) were observed in 21.0%, 3.7%, and 9.4% of patients, respectively. AAU and IBD occurred significantly more in patients with symptom duration > 10 years. The most commonly used medications at baseline were nonsteroidal anti-inflammatory drugs (98.2%). Patients using tumour necrosis factor inhibitors accounted for 20.8%, and 66.4% of patients used conventional synthetic disease-modifying antirheumatic drugs. At baseline, 57.2% of patients had inactive disease (ID)/low disease activity (LDA); this rate significantly improved to 79.2% after a mean follow-up of 13.3 (5.9) months. Compared with relapsed patients, new achievers of ID/LDA underwent more online patient assessments (P < .001). Problems solved in SpAMS caused 29.1% of clinic visits to a tertiary hospital unnecessary. SpAMS saved an average of 5.3 hours and 327.4 RMB per person on traffic expenses; these expenses equalled 16% of the Chinese monthly disposable personal income. CONCLUSIONS: SpAMS is a time- and cost-saving disease management tool that can help patients with AS perform self-management and provide valuable data to clinicians.

Assessment of cardiac and vessel functions in childhood psoriasis

Background/aim: Psoriasis is a chronic inflammatory disease. The effect of psoriasis on the cardiovascular system has not been studied in children before. We studied ventricular strain and vascular functions to assess early cardiovascular effects of psoriasis during childhood. Materials and methods: The study population consisted of 20 psoriatic and 20 age- and sex-matched control subjects. Two-dimensional echocardiography images, longitudinal and global strain, and carotid and brachial ultrasound studies were performed. Results: The mean age of psoriatic children was 14 ± 0.89 years and that of the controls was 14.05 ± 0.88. There were significant increases in terms of interventricular septum diastolic and left ventricular posterior wall diastolic diameter and decreases in mitral E, mitral A, and E/A values between groups. Tissue Doppler imaging revealed significant differences between groups in terms of lateral annulus E', A', E'/A, isovolumetric contraction time, and ejection time. Aortic stiffness was significantly higher and global circumferential strain and longitudinal strain were significantly lower in the psoriasis group. Carotid intima media thickness and flow-mediated dilatation did not differ significantly between the groups. Conclusion: Cardiac left ventricular and arterial functions are affected in psoriatic children and may be an alarming sign of atherosclerotic heart disease in the long term. Early detection of these changes may be helpful for eliminating other risk factors.

Impact of chronic urticaria on quality of life and work in Japan: Results of a real-world study.

Little attention has been given to the burden of chronic urticaria (CU) in Japan compared with other skin diseases, such as atopic dermatitis (AD) and psoriasis. The primary objective of the RELEASE study was to evaluate the real-life quality-of-life impairment in CU patients in Japan. Data were collected from 1443 urticaria, 1668 AD and 435 psoriatic patients; 552 urticaria patients who presented urticaria symptoms for over 6 weeks were defined as CU. The mean Dermatology Life Quality Index (DLQI) total score was 4.8, 6.1 and 4.8 in CU, AD and psoriatic patients, respectively. Disease control of urticaria evaluated by the Urticaria Control Test (UCT) and DLQI exhibited a strong correlation with a Spearman's rank correlation coefficient of -0.7158. CU and AD patients had relatively higher scores in all Work Productivity and Activity Impairment - General Health subscales except for absenteeism. At the time of the survey, approximately 64% of CU patients reported UCT scores of <12 and demonstrated higher work productivity loss and activity impairment versus patients with UCT scores of ≥12. Patients with lower UCT scores also displayed a higher percentage of dissatisfaction with their health state and the treatment they received. Approximately 85% of patients with CU had visited dermatology clinics, and less than 20% had visited hospital, indicating existence of a highly burdened population outside specialized centers. These results highlight the unmet medical needs of CU patients, suggesting the need to increase awareness of CU burden among both physicians and patients and to pursue improved real-life patient care.

The association between psoriasis and health-related quality of life, work productivity, and healthcare resource use in Brazil.

BACKGROUND: Psoriasis is a chronic, immune mediated inflammatory condition that affects a significant amount of the global population. Yet geographic variability in the consequences of psoriasis warrants region-level analyses. OBJECTIVE: The current study contributes to the psoriasis outcomes literature by offering a comprehensive assessment of the humanistic and economic burden in Brazil. METHODS: The 2012 Brazil National Health and Wellness Survey (N=12,000) was used to assess health-related quality of life (Short Form-12, version 2), work productivity, and healthcare resource use associated with experiencing psoriasis vs. no psoriasis, along with varying levels of psoriasis severity. RESULTS: A total of 210 respondents reported diagnosis of psoriasis (N=157, 42, and 11 reporting mild, moderate, and severe psoriasis, respectively). Compared with controls, respondents with psoriasis reported diminished mental component summary scores and health utilities, as well as increased presenteeism, activity impairment, and physician visits over the past six months, adjusting for covariates. Among those with psoriasis, physical health decreased as psoriasis severity increased. Although work productivity and healthcare resource utilization did not differ with psoriasis severity, the high rates of productivity loss (e.g. 45.5% presenteeism in the severe psoriasis group) suggest an economic burden. STUDY LIMITATIONS: Cost analyses were not performed, and cross-sectional patient-reported data limit causal conclusions and may reflect reporting biases. CONCLUSIONS: Nevertheless, these results suggest a significant burden to patients with psoriasis across both humanistic and economic outcomes. The association between psoriasis and mental health aspects and health utilities were particularly strong and exceeded what would be considered clinically meaningful.

The association between psoriasis and health-related quality of life, work productivity, and healthcare resource use in Brazil

Abstract: Background: Psoriasis is a chronic, immune mediated inflammatory condition that affects a significant amount of the global population. Yet geographic variability in the consequences of psoriasis warrants region-level analyses. Objective: The current study contributes to the psoriasis outcomes literature by offering a comprehensive assessment of the humanistic and economic burden in Brazil. Methods: The 2012 Brazil National Health and Wellness Survey (N=12,000) was used to assess health-related quality of life (Short Form-12, version 2), work productivity, and healthcare resource use associated with experiencing psoriasis vs. no psoriasis, along with varying levels of psoriasis severity. Results: A total of 210 respondents reported diagnosis of psoriasis (N=157, 42, and 11 reporting mild, moderate, and severe psoriasis, respectively). Compared with controls, respondents with psoriasis reported diminished mental component summary scores and health utilities, as well as increased presenteeism, activity impairment, and physician visits over the past six months, adjusting for covariates. Among those with psoriasis, physical health decreased as psoriasis severity increased. Although work productivity and healthcare resource utilization did not differ with psoriasis severity, the high rates of productivity loss (e.g. 45.5% presenteeism in the severe psoriasis group) suggest an economic burden. Study limitations: Cost analyses were not performed, and cross-sectional patient-reported data limit causal conclusions and may reflect reporting biases. Conclusions: Nevertheless, these results suggest a significant burden to patients with psoriasis across both humanistic and economic outcomes. The association between psoriasis and mental health aspects and health utilities were particularly strong and exceeded what would be considered clinically meaningful.

Routine Assessment of Patient Index Data 3 Score and Psoriasis Quality of Life Assess Complementary Yet Different Aspects of Patient-Reported Outcomes in Psoriasis and Psoriatic Arthritis.

BACKGROUND: Psoriasis Quality of Life (PQoL-12) is a validated composite tool assessing patients' quality of life (QoL) with psoriasis (PsO) and psoriatic arthritis (PsA). Routine Assessment of Patient Index Data 3 (RAPID3), measuring physical function, pain, and patient global assessment, is used for rheumatoid arthritis. Routine Assessment of Patient Index Data 3 has not been used to assess PsO/PsA patients' QoL. OBJECTIVE: The aim of this study was to investigate the correlation between PQoL-12 and RAPID3 in PsO and PsA patients in a cross-sectional and longitudinal analyses. METHODS: Data came from PsO and PsA patients seen from 2008 to 2015 at Oregon Health & Science University (n = 558: 393 with PsO and 165 with PsA). Nonlinear least squares regressions modeled PQoL-12 with functions of RAPID3, controlling for time since first visit. Nonparametric ROC determined RAPID3 scores best correlating with PQoL-12 cutoffs. RESULTS: Among the PsO cohort, PQoL-12 was explained by RAPID3, the square of RAPID3, time since first visit, and the square of time since first visit; adjusted R = 0.414. For the PsA cohort, PQoL-12 was explained by RAPID3, change in slope of RAPID3 at 2.28, time since first visit, the square of time since first visit; adjusted R = 0.340. Routine Assessment of Patient Index Data 3 cutoffs for PQoL-12 scores of 48 and 96 (mild and moderate QoL impairment) in PsO were 1.55 and 5.72 and in PsA were 1.89 and 6.34. CONCLUSIONS: Routine Assessment of Patient Index Data 3 weakly correlated with PQoL-12, indicating these indices assess different aspects of PsO and PsA. Routine Assessment of Patient Index Data 3 fails to capture mental health information that greatly impacts patients' QoL, whereas PQoL-12 fails to capture the physical and functional aspects of the disease. Results indicate the importance of capturing mental health assessment in order to create a comprehensive tool to measure how psoriatic disease affects patients' QoL.

Tear film and ocular surface assessment in psoriasis.

BACKGROUND: Psoriasis is a skin disease with also systemic involvement: its impact on the eye is not well established and often clinically underestimated. Aim of this study was to investigate the presence of ocular discomfort symptoms and of ocular surface changes in a population of patients with psoriasis. METHODS: For this cross-sectional, comparative study, 66 patients with psoriasis were subdivided according to the presence of arthritis and to the use of biological therapy. All patients underwent clinical evaluation with the following tests: Ocular Surface Disease Index Questionnaire, Tearscope examination, meibometry, tear film breakup time, corneal and conjunctival fluorescein staining, Schirmer I test, corneal aesthesiometry, meibomian gland dysfunction (MGD) assessment and conjunctival impression cytology. 28 healthy subjects were also enrolled and treated with the same clinical tests. A statistical analysis of the results was performed. RESULTS: Patients with psoriasis showed a significant deterioration of the ocular surface tests, if compared with healthy subjects, demonstrated by tear film lipid layer alteration, tear film instability, corneal and conjunctival epithelial suffering and mild squamous metaplasia at impression cytology. No differences were found in ocular surface test results of the psoriatic group when patients were divided according to the presence of arthritis, whereas the anti-inflammatory treatment with biological drugs demonstrated a significant improvement of corneal stain and MGD. CONCLUSIONS: Our findings suggest that the ocular surface involvement in patients with psoriasis indicates the need of periodic ophthalmological examinations to diagnose the condition and allow a proper treatment, so contributing to the amelioration of patients' quality of life.

Tailored Therapist-guided Internet-based Cognitive-behavioural Treatment for Psoriasis and Rheumatoid Arthritis: Two Case Reports.

Chronic somatic conditions, such as psoriasis, arthritis psoriatica and rheumatoid arthritis, have a large impact on patients' lives. Tailored therapist-guided internet-based cognitive-behavioural therapy (ICBT) has been shown to be effective in improving physical and psychological well-being in these patients. Two cases are presented here, in order to provide an in-depth illustration of the course and content of this novel treatment and to investigate the therapeutic alliance in an online treatment. After face-to-face intakes, both patients received therapist-guided ICBT tailored to their specific problems and treatment goals. The treatment resulted in improved physical and psychological well-being and these clinically significant improvements were maintained at 6-month follow-up. In addition, the therapeutic relationship was evaluated positively by both patients and increased further during treatment, indicating an adequate therapeutic working alliance in this online treatment. These case reports show that tailored ICBT may contribute to improved care for patients with chronic somatic conditions.

A European subset analysis from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis shows country-specific features: results from psoriasis patients in Spain.

BACKGROUND: The Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey data were not analysed to account for cultural and healthcare system differences across European countries (EC). OBJECTIVE: To utilize MAPP data to characterize psoriasis in Spanish patients, including severity assessment and Dermatology Life Quality Index (DLQI). METHODS: The MAPP survey was conducted between June and August 2012. This analysis included 1700 patients with self-reported psoriasis (without psoriatic arthritis) from France (n = 349), Germany (n = 311), Italy (n = 359), Spain (n = 354) and the United Kingdom (n = 327). RESULTS: Patients from Spain vs. other EC self-reported higher mean body mass index (26.9 vs. 25.6, P ≤ 0.001), lower prevalence of depression (6% vs. 12%, P = 0.002) and higher mean self-perceived psoriasis severity at its worst (5.92 vs. 5.33, P < 0.001) despite lower estimated body-surface-area involvement. Overall, patients from Spain vs. other EC had lower mean global DLQI scores (4.70 vs. 6.06, P = 0.001) and lower mean scores for each DLQI dimension [all P < 0.001, except leisure (P = 0.002), treatment (P = 0.002), and work and school (P = 0.005)]. Higher DLQI values were inversely associated with age and directly correlated with perceived severity. Palmoplantar, nail and scalp psoriasis were reported less frequently in Spanish patients (P = 0.026) and were associated with higher DLQI values (P < 0.01). Spanish patients were more likely to have seen multiple healthcare providers (HCPs; P < 0.001) and achieve therapeutic goals (P < 0.001), but current treatments were similar to patients in other EC. CONCLUSIONS: In the MAPP survey, Spanish patients differed from other EC in several characteristics, including comorbidities, extent and distribution of psoriasis lesions, perception of severity and impact on quality of life. Their perception of psoriasis severity was higher despite a lower estimated extent, and DLQI scores were significantly lower. Spanish patients had more HCP visits and a higher rate of therapeutic goal achievement. These differences might be attributed to cultural factors, phenotypical variation and differences in HCP access.

Advances in psoriasis physiopathology and treatments: Up to date of mechanistic insights and perspectives of novel therapies based on innovative skin drug delivery systems (ISDDS).

Psoriasis is a chronic inflammatory disease affecting mainly the skin but which can be complicated by psoriatic arthritis (PsA).This autoimmune skin disorder concerns 2-5% of the world population. To date, the physiopathology of psoriasis is not still completely elucidated but many researches are ongoing which have led for example to the discovery of the Th17/Th22 pathway. The conventional therapeutic approaches (local or systemic route) appeal to various classes of drugs with complex mechanisms of action and non-negligible side effects. Although there is no therapy capable to cure psoriasis, the current goal is to relieve symptoms as longer as possible with a good benefit/risk ratio. That is one of the principal limits of conventional antipsoriatic drugs. New formulations based on nanoencapsulation are a promising opportunity to answer to this limit by offering an optimization of the conventional antipsoriatic drug use (higher activity, lower side effects and frequency of application, etc.). Herein, we tried to put in perspective the mechanistic insights (histological and immunological views) proposed into scientific literature these last years in order to have a better comprehension of psoriasis physiopathology resulting in skin lesions and PsA. The therapeutic armamentarium and the different strategies in the management of psoriasis are discussed in greater details. To finish, the field of encapsulation in nanoparticles is broached in order to put forward recent advances in innovative skin drug delivery systems (ISDDSs) of antipsoriatic active agents for a better efficacy, safety and compliance.

Comprehensive Assessment of the Psoriasis Patient (CAPP): A Report from the GRAPPA 2015 Annual Meeting.

Outcome measures for psoriasis severity are complex because of the heterogeneous presentation of the disease. At the 2015 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members introduced the Comprehensive Assessment of the Psoriasis Patient (CAPP), a novel disease severity measure to more accurately assess the full burden of plaque psoriasis and subtypes, including inverse, scalp, nail, palmoplantar, and genital psoriasis. The CAPP is based on a 5-point physician's global assessment for 7 psoriasis phenotypes and incorporates visual analog scale-based, patient-derived, patient-reported outcomes. By quantifying disease effects of plaque psoriasis, 6 other psoriasis subtypes, as well as quality of life and daily function, the CAPP survey identifies a subset of psoriasis patients with moderate to severe psoriasis that would not be considered moderate to severe when assessed by the Psoriasis Area and Severity Index. The current version of CAPP is focused entirely on psoriasis. Feedback from our industry colleagues and collaborators has suggested that a psoriatic arthritis (PsA) measure may be important to include in the CAPP. At the 2015 GRAPPA meeting, we administered a survey to 106 GRAPPA members to determine whether a PsA measure should be included. A majority (74%) of respondents across all professions agreed that the CAPP should include a measure of PsA. Although responses varied widely on how PsA should be measured, a majority of the respondents reported that presence of PsA in both peripheral and axial joint assessment was important.

COMPETENCE IN TOPIC OF PSORIASIS AMONG NURSES IN HEALTHCARE INSTITUTIONS.

UNLABELLED: Nurses in their everyday work meet patients with various diseases (including chronic skin diseases), and play an important role in improving patients' quality of life. Nurses working in dermatology clinics frequently play leading roles in the care of patients with skin disorders. The aim of the study was to investigate the knowledge about the psoriasis among nurses working in non-dermatological healthcare institutions. A cross-sectional study in randomly selected 16 healthcare institutions of Kaunas city was conducted. The study included 505 nurses. A questionnaire to assess the knowledge was developed, containing 15 questions about signs of psoriasis. Based on the responses, the nurses' level of knowledge was evaluated in points. The respondents' age was 45.34±10.52 years, and the mean duration of their work experience was 23.2±11.42 years. CONCLUSION: the nurses' level of knowledge depended on their education level and the frequency of contacts with psoriasis patients. Nurses working in non-dermatological healthcare institutions had insufficient knowledge about psoriasis, and expressed willingness to learn more.

Patterns of medication utilization and costs associated with the use of etanercept, adalimumab, and ustekinumab in the management of moderate-to-severe psoriasis.

BACKGROUND: Dose escalations of biologic agents may be attempted in the management of moderate-to-severe psoriasis. This has implications for the real-world cost of treatment. OBJECTIVE: To examine the utilization patterns and costs associated with the use of etanercept, adalimumab, and ustekinumab among patients with moderate-to-severe psoriasis. METHODS: This was a retrospective cross-sectional study. Patients with 2 or more medical claims with a diagnosis of psoriasis (excluding psoriatic arthritis) who were enrolled in large employer-sponsored health plans (including a pharmacy benefit) in the United States from January 2007 to March 2012 were identified and extracted from the MarketScan Commercial Encounters Database. Patients aged at least 18 years were required to have 2 or more pharmacy claims for etanercept, adalimumab, or ustekinumab; the index date was the first biologic fill date. Demographics and comorbidities were identified during the 1-year pre-index period, and medication utilization and costs were evaluated in the 1-year post-index period after a titration period according to the product prescribing information (2 weeks to 12 weeks). Medication utilization parameters such as dose escalation, dose reduction, persistence, switching, discontinuation, and restarts were assessed at 6, 9, and 12 months from the end of the dose titration window. RESULTS: A total of 4,309 patients were included with a mean average age of 46 years, and 55% were male. Fifty-seven percent of the patients were started on etanercept, 39% on adalimumab, and 5% on ustekinumab. Patients had substantial dose escalation rates (etanercept: 41%; adalim-umab: 37%; ustekinumab: 36%, P less than 0.05) and discontinuation rates (etanercept: 35%; adalimumab: 27%; ustekinumab: 16%, P less than 0.05) over the 12-month post-titration period. Many patients also restarted the same biologic (etanercept: 37%; adalimumab: 10%; ustekinumab: 6%, P less than 0.05) or switched to another biologic (etanercept: 15%; adalimumab: 10%; ustekinumab: 5%, P less than 0.05) over the 12-month post-titration period. The persistence rates over 12 months were 19%, 53%, and 71% for etanercept, adalimumab, and ustekinumab, respectively (P less than 0.05). Close to one-third of the patients at 6 months and 39% at 12 months postdose titration experienced a dose escalation. Approximately half of the patients who experienced a dose escalation also had a discontinuation or a dose reduction over the 12-month post-titration period. CONCLUSIONS: Over one-third of psoriasis patients experienced a dose escalation of their biologic agents, and most of the dose escalation occurred during the first 6 months. Restarting, switching, and discontinuing index biologics were also common.

Assessment of atrial electromechanical delay and left atrial mechanical functions in patients with psoriasis vulgaris.

OBJECTIVES: Increased frequency of atrial fibrillation (AF) has been demonstrated in psoriasis cases. Prolongation of the duration of atrial electromechanical delay (AEMD) is a well-known characteristic of the atrium, which is vulnerable to AF. In the current study, our aims are to investigate AEMD durations and mechanical functions of the left atrium (LA) in patients with psoriasis. METHODS: A total of 90 patients, 45 with psoriasis vulgaris and 45 as the control group, were included in the study. Atrial electromechanical coupling (PA) and intra- and inter-atrial electromechanical delay (IA-AEMD) were measured with tissue Doppler echocardiography. P-wave dispersion (PWD) was calculated from the 12-lead electrocardiogram. The severity of the disease was evaluated by the Psoriasis Area and Severity Index. RESULTS: The durations of PA lateral and PA septal were significantly high in the psoriasis group when compared with the control group (47.7 ± 9.8 vs. 57.1 ± 8.4 msec, P < 0.001 and 38.6 ± 9.9 vs. 43.6 ± 8 msec, P = 0.016, respectively). The durations of IA-AEMD, intra-right electromechanical delay, and intra-left electromechanical delay in the psoriasis group were significantly prolonged compared with the control group (15.2 ± 4.1 vs. 21.7 ± 5.6 msec, P < 0.001; 6 ± 2.5 vs. 8.7 ± 2.7 msec, P < 0.001; and 9.1 ± 3.9 vs. 13.5 ± 5.2 msec, P < 0.001; respectively). PWD was significantly higher in patients with psoriasis vulgaris compared with controls (36.1 ± 7.9 vs. 40.2 ± 9.1 msec, P = 0.043). CONCLUSION: In the present study, we found prolongation in the durations of AEMD and PWD in the psoriasis group compared with the control group. These results might be an early predictor of AF and other arrhythmias.