Determining patient value profiles in psoriasis.

BACKGROUND: Healthcare professionals (HCPs) should strive to create the maximum value for their patients in which value is defined as the patient-relevant health outcomes achieved per costs made. However, currently it remains difficult to determine which outcomes matter to an individual psoriasis patient. OBJECTIVE: To define outcome profiles, or so called 'patient value profiles', within a cohort of psoriasis patients that can be translated to daily practice to increase value for the individual patient. METHODS: Hierarchical clustering on principal components (HCPC) was used to identify groups of patients sharing the same profile within an outcome ranking exercise. Once the clusters were defined, their characterization was provided based on a V-test. In a final step, a multi-class decision tree (MDT) based on relevant socio-demographic and clinical variables was built to allocate patients to a cluster. RESULTS: In the ranking exercise 120 patients participated. The median age was 50.0 (IQR 25.0) years and 36.7% were female. Median PASI score was 2.4 (IQR 5.2) and median duration of psoriasis was 17.0 (IQR 20.0) years. Primary treatment varied from topicals to biologicals. We found three distinct patient value profiles in this cohort (QoL, cost and treatment). A MDT was built which had an accuracy of 64%. CONCLUSION: We found three distinct patient value profiles in a cohort of psoriasis patients and patients can be easily assigned to one of these profiles based on a MDT. HCPs can use these profiles to steer psoriasis management accordingly allowing for a more goal-orientated approach.

Practical recommendations for systemic treatment in psoriasis according to age, pregnancy, metabolic syndrome, mental health, psoriasis subtype and treatment history (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis; part 1).

BACKGROUND: Impressive progress in new therapeutic options has been made for psoriasis. Treatments include topical steroids, phototherapy, conventional, synthetic disease-modifying drugs and an expanding list of biologics. OBJECTIVE: The primary objective of this work was to collect evidence for the creation of practice guidelines for systemic treatment of psoriasis (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis). METHODS: Evidence-based recommendations were formulated using a quasi-Delphi methodology after a systematic search of the literature and a consensus procedure involving 8 psoriasis experts. RESULTS: In this part, the use of systemic treatment in different age groups, during pregnancy, in metabolic syndrome, in patients with mental health problems, in different psoriasis subtypes and in previously systemically treated patients treatment is discussed. CONCLUSION: Guidance on therapeutic choice in specific clinical situations in psoriasis is provided in order to facilitate the decision-making in clinical practice.

Practical recommendations for systemic treatment in psoriasis in case of coexisting inflammatory, neurologic, infectious or malignant disorders (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis; part 2).

BACKGROUND: Psoriasis patients carry an increased risk for associated comorbidities. Dermatologists have to be aware of the effects of systemic treatments not only on psoriasis but also on co-occurring diseases. In case of other coexisting inflammatory diseases, the right psoriasis treatment may improve both disorders. For infectious and malignant disorders, some treatments have to be avoided as they may be harmful. OBJECTIVE: The primary objective of this project was to collect evidence for the creation of practice guidelines for systemic treatment of psoriasis (BETA-PSO: Belgian Evidence-based Treatment Advice in Psoriasis). METHODS: Evidence-based recommendations were formulated using a quasi-Delphi methodology after a systematic search of the literature and a consensus procedure involving eight psoriasis experts. RESULTS: Recommendations are given on the use of systemic treatment in psoriatic arthritis, inflammatory bowel disease, demyelinating disorders, hepatitis B and C, HIV and cancer. CONCLUSION: This expert opinion is a practical guide for dermatologists when handling psoriasis patients with these specific conditions.

Role of the HLA-C*06 allele in clinical response to ustekinumab: evidence from real life in a large cohort of European patients.

BACKGROUND: Little is known about the role of the HLA-C*06 allele in the response to psoriasis treatments. OBJECTIVES: To confirm the role of HLA-C*06 as a pharmacogenetic marker of response to ustekinumab in a new, large cohort of patients involving four European centres. METHODS: In this retrospective multicentre study we reviewed data of 255 patients with psoriasis genotyped for HLA-C*06 who started ustekinumab treatment between January 2014 and March 2015. The severity of psoriasis and response to treatment were evaluated using the Psoriasis Area and Severity Index (PASI) score at baseline and then at follow-up visits on weeks 4, 12, 28, 40 and 52. The primary end point was the proportion of patients achieving ≥ 50% reduction in PASI score (PASI 50) at week 4. A ≥ 75% reduction in PASI score (PASI 75) and a ≥ 90% reduction in the PASI score (PASI 90) after 12 weeks were secondary end points. RESULTS: At week 4, PASI 50 was seen in 71·7% of HLA-C*06-positive (C*06POS) and 35·2% of HLA-C*06-negative (C*06NEG) patients. At week 12, PASI 75 was reached by 69.1% of C*06POS patients and 40·5% of C*06NEG patients. After 52 weeks, PASI 75 was reached by 83.7% of C*06POS patients and 58.8% of C*06NEG patients. CONCLUSIONS: The results from our new, large cohort of European patients treated with ustekinumab in daily clinical practice confirm the role of HLA-C*06 as a potential predictor of response to ustekinumab.

Diagnostic yield of echocardiography in stroke: should we improve patient selection?

INTRODUCTION: Last year the European Society of Echocardiography published recommendations for the use of echocardiography in identifying potential sources of embolism as a cause of ischemic stroke in the absence of other cerebrovascular diseases. Both transthoracic echocardiography and transesophageal echocardiography play a fundamental role in the assessment, diagnosis and management of the embolic source. Due in part to the increased longevity of the population and improved survival of cardiac patients, we are now seeing a gradual increase in the application of echocardiographic studies as a diagnostic test. This has led us to critically analyse their performance in detecting various pathologies. OBJECTIVE: Our aim was to analyse the diagnostic yield of transthoracic echocardiography in patients with cerebrovascular accident in a tertiary hospital. MATERIAL AND METHODS: To this end, we retrospectively analysed all echocardiographic studies during 2010 requested from the Neurology Department with a diagnosis of stroke. We have studied the diagnostic yield of the test and its contribution to the etiological diagnosis based on major and minor echocardiographic criteria as recommended by the European Society of Echocardiography. RESULTS: We found major echocardiographic criteria in 6 patients (5%) with embolic stroke and in 2 (0.7%) non embolic, P=.005. In view of our results, the performance of transthoracic echocardiography in patients with embolic stroke has a low diagnostic yield, which leads us to question systematic use of this technique.

Risk factors associated with cytomegalovirus infection in heart transplant patients: a prospective, epidemiological study.

BACKGROUND: The objectives of this epidemiological, prospective study were to describe the characteristics of cytomegalovirus (CMV) infection in heart transplant (HT) recipients and to identify the variables that may influence the development of CMV viremia and CMV disease in these patients. METHODS: HT recipients ≥18 years of age (n=199) were included in the study. Variables studied included CMV serostatus, immunosuppressive treatment, and administration of anti-CMV prophylaxis. RESULTS: The mean age of the population was 52 years, and 84% were males. Immunosuppressive regimens were administered as induction therapy to 92.5% of patients; 88.5% of patients received calcineurin inhibitors as maintenance therapy. Anti-CMV treatment was given to 59% of 199 patients as prophylaxis (70%), preemptive therapy (10%), or to treat CMV infection (20%). Overall, 43% of patients had at least 1 positive viremia test. No patient with a high-risk serostatus (donor+/recipient-) receiving prophylaxis developed CMV syndrome, and only 2.5% of 199 patients developed CMV invasive disease. Multivariate analysis showed that having a positive donor CMV serostatus was associated with an increased risk of developing CMV viremia (P<0.012), while use of mammalian target of rapamycin (mTOR) inhibitors was associated with a decreased risk (P=0.005). CONCLUSIONS: In a population of HT recipients, the CMV infection rate was similar to that seen in previous studies, but the progression to overt CMV disease was very low. Having a CMV-positive donor was identified as an independent risk factor for developing CMV viremia, while the use of mTOR inhibitors was protective against viremia.

Fever, Malaise, and Dyspnea in a Diabetic Heart Transplant Patient: A Case Report.

Patients with solid-organ transplants usually present at the emergency department with nonspecific symptoms. The physician should consider a great variety of syndromes and diseases, given the greater risk that solid-organ transplant patients carry because of immunosuppression and transplant-related conditions. Myocardial infarction caused by cardiac allograft vasculopathy must be always suspected and ruled out, even when initial symptoms do not orientate in that direction. We present a case that conjugates signs that can be present in different pathologies. It shows that fever is not always related to infection or rejection but could also appear in acute cardiac allograft vasculopathy. It emphasizes the need of a multi-disciplinary team led by a heart transplant specialist when dealing with this sort of clinical case.

A protocol of trauma care in the emergency service including MDCT imaging.

Trauma is the principal cause of young peo ple's death. Care should be appropriate to the severity of the injuries and involves a multidisciplinary team around the clock. In this article, we examine a protocol of care based on ATLS (Advanced Trauma Life Support) recom mendations, including advances in imaging technology, which have greatly increased quality care in our institu tion. The protocol is based on patient stability and on injury mechanisms. The challenge is to avoid wasting time in the definitive treatment of lesions. Multi-detector computed tomogra phy (MDCT) has brought complete and rapid imaging in stable traumas but it shouldn't delay immediate surgical operations. When patients are unstable despite reanima tion, three important x-rays are taken right on the stretch er (pelvis, neck, and chest) before going into surgery. The head of the trauma team makes a decision on the pertinence of such procedure.

Association of Presence of Band Cells and Toxic Neutrophils with Systemic Inflammatory Response Syndrome and Outcome in Horses with Acute Disease.

BACKGROUND: Band cells and toxic neutrophils are thought to indicate acute and severe systemic illness but no studies have investigated their importance in adult equine emergency admissions. OBJECTIVES: The objective of this study was to evaluate the association of band cells and toxic neutrophils with systemic inflammatory response syndrome (SIRS) and outcome in horses. ANIMALS: One hundred and five adult horses admitted on emergency basis to a private primary referral practice. METHODS: Prospective observational study with sample collection. All horses admitted on emergency basis over the study period were included in the study if they had a CBC and a blood smear collected on admission. RESULTS: The detection of band neutrophils on admission was associated with the SIRS status of the horse (RR = 2.80; 95% CI = 1.57-4.99; P < .001) and with poor outcome (RR = 1.88; 95% CI: 1.05-3.37; P = .038). Similarly, the presence of a neutrophil toxic grade higher than 3 was associated with SIRS (RR = 1.71; 95% CI: 1.03-2.82; P = .034) and death (RR = 2.34; 95% CI: 1.22-4.50, P = .007). The information gained from the blood smear review could not be captured by looking at only the WBC or neutrophil count. CONCLUSIONS AND CLINICAL IMPORTANCE: The microscopic review of blood smears from critically ill horses to detect band cells or neutrophil toxic change is valuable and could help in assessing disease severity and prognosis in adult equine emergency admissions.

Quality of Life According to Urgency Status in De Novo Heart Transplant Recipients.

INTRODUCTION: Elective heart transplantation (HTX) aims to improve physical ability, increase survival, and improve health-related quality of life (HRQoL) in patients with chronic heart failure. Nevertheless, most patients who undergo urgent HTX are previously healthy, and a transplant could be perceived as a limitation. The aim of this study is to compare HRQoL between elective and urgent heart transplant recipients. METHODS: Cohort study including patients undergoing heart transplantation between January 1998 and March 2012 in a single center. Patients with retransplantation or multiorgan transplantation were excluded. Clinical variables including comorbidities were collected. For assessment of HRQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ) was completed by the survivors on March 2013. Univariate analysis (Mann-Whitney U test) was performed. RESULTS: Questionnaires were collected from 95 of 106 elective recipients and 28 of 33 urgent recipients. Urgent heart recipients were younger, with more cardiovascular risk factors, and ischemic etiology was the leading cause of transplant. All domain results were higher in elective heart transplant recipients, but after univariate analysis only the punctuation of the self-efficacy domain remained superior in the elective HTX group (87.5 vs 79.7, P = .034). CONCLUSION: Both urgent and elective heart transplant patients reported a good HRQoL, and there were no significant differences between their scores.

Didanosine (ddI) and zidovudine (ZDV) susceptibilities of human immunodeficiency virus (HIV) isolates from long-term recipients of ddI.

Thirty HIV isolates, obtained from 15 patients before and after receiving single drug therapy with didanosine (ddI), were examined for sensitivity to ddI and zidovudine (ZDV) using a peripheral blood mononuclear leukocyte (PBML)-based assay. Fourteen of the patients had ARC, one had AIDS and 12 had received previous therapy with ZDV. After a median of 1 year of ddI therapy, isolates were significantly less sensitive to ddI than were isolates obtained prior to therapy (P = 0.03). A decrease in ddI sensitivity was observed in ten of the 15 isolate pairs. In contrast to ddI susceptibilities, sensitivity to ZDV increased over the same period of time (P = 0.03). Additional isolates were obtained from four patients who received ddI monotherapy for 2 years. Three of these isolates demonstrated no change in ddI sensitivity compared to baseline. No correlation could be made in this study between development of decreased ddI sensitivity and serum p24 levels, CD4 counts, or clinical outcome. Decreased ddI sensitivity occurs frequently among HIV isolates obtained from long-term recipients of ddI. This decreased sensitivity is modest in degree and is of unknown clinical significance.

A noninvasive glucose monitor: preliminary results in rabbits.

BACKGROUND: Glucose in the aqueous humor appears to correlate with plasma glucose in humans. It is therefore a potential substrate for noninvasive optical glucose monitoring techniques. We wished to determine the potential for using rabbit aqueous humor as a model to develop a noninvasive method of measuring glucose with Raman spectroscopy. METHODS: Aqueous humor from 32 rabbit eyes was removed immediately after sacrifice by rapid exsanguination under anesthesia. Raman spectroscopy was performed on the aqueous humor using near infrared (NIR) excitation wavelengths. The Raman spectra from 785 nm and 787.2 nm were subtracted one from the other to eliminate broadband fluorescence. The spectra were then analyzed with linear and nonlinear multivariate analysis and assessed for ability to predict actual aqueous humor glucose concentration. Nine other rabbits were anesthetized with xylazine in order to cause elevation of blood glucose by blocking release of insulin. Blood and aqueous humor glucose were measured at various times after injection of xylazine. Correlation of aqueous humor glucose with simultaneous plasma glucose was assessed. RESULTS: Partial least squares analysis of raw Raman spectra of aqueous humor showed fair correlation with actual glucose concentration (r2 = 0.76). When the fluorescence spectrum was subtracted prior to linear multivariate analysis correlation was good (r2 = 0.90). When back-propagation with an artificial neural network was added to the analysis, correlation was further improved (r2 = 0.98). Aqueous humor glucose concentration exceeded blood glucose concentration at normoglycemic levels. When blood glucose rose above 200 mg/dL, aqueous humor glucose correlated linearly with plasma glucose. CONCLUSIONS: Raman spectroscopy can accurately predict glucose concentration in rabbit aqueous humor in vitro. Although rabbit aqueous humor is probably not a good model of human aqueous humor glucose physiology, its reliable correlation with plasma glucose makes it a good model on which to test noninvasive optical sensing techniques.

The protonated 4,4'-diaminotriphenylmethyl cation as a reagent and cyclohexanone as an absorbant for sulphur dioxide determination.

Protonated 4,4'-diaminotriphenylmethyl cation, DATM, has been investigated as a colorimetric reagent for the determination of sulphur dioxide. The bisulphite addition compound with formaldehyde alkylates a primary arylamine group in the protonated reagent to re-establish resonance, and hence produces a colour that is proportional in intensity to the concentration of either bisulphite or formaldehyde (the other being in excess). The large bathochromic spectral shift results in a negligible blank correction. Cyclohexanone in aqueous solution has been found to stabilize bisulphite solutions for up to 6 hr. The stabilization by cyclohexanone has been compared with stabilization by tetrachloromercurate(II). The Beer-Lambert law is obeyed with good precision for both sulphite and formaldehyde determination.

Sequential contrast effects with retarded subjects after discrimination learning with and without errors.

Four retarded adults were exposed to a multiple variable interval-extinction schedule of reinforcement. The 2 min components were presented in a random order. Two subjects acquired the discrimination with an errorless procedure. The two other subjects learned the discrimination with errors. The schedule generated sequential contrast effects under both training procedures: response rates during periods of reinforcement were higher when a reinforcement period followed an extinction period than when it followed another reinforcement period. These results were confirmed in a second observation where eight retarded children were exposed to a multiple fixed ratio-extinction schedule of reinforcement. This study is the first demonstration of sequential contrast effects with human subjects during the acquisition of a discrimination without errors. The results are discussed in terms of Terrace's theory of errorless learning.

A new method for recovering latent fingerprints from skin.

The developed method for detecting fingerprints on live human skin involves first fuming the suspected area with iodine, and then placing a 35-mm clear plastic strip with a leuco crystal violet coating and a trace of water over the fumed area. A few seconds later a dark purple reproduction of the ridge pattern develops. It is a stable direct positive and can be mounted in a 35-mm slide mount for direct viewing. Readable prints may be obtained up to 1 h after impression on live human skin and two or three lifts may be obtained from the same print.

[Spontaneous calcific embolization in calcified aortic valve stenosis. A case report]. / Embolia cálcica espontánea en la estenosis valvular aórtica calcificada. Presentación de un caso.

Calcific embolism from an aortic stenosis is an uncommon event that can be seen after cardiac surgery or left heart catheterization but extremely rare in a spontaneous way. We report a case of a patient with calcified aortic stenosis presenting a spontaneous calcareous embolism in the retinal artery. We review the literature about this problem as well.

[Coronary angioplasty through 6 French guiding catheters]. / Angioplastia coronaria a través de catéteres guía 6 French.

BACKGROUND: The development of new small guiding catheters with large internal lumen has allowed their use in routine coronary angioplasty. OBJECTIVES: The aim of this study is to present the technical characteristics, results and complication rates obtained with the use of 6 French guiding catheters compared with those obtained with the use of 8 French. METHODS: During a 23 month period, a total of 355 consecutive patients was enrolled in this study. Coronary angioplasty was performed in 177 of them using a 6F guiding catheter and 178 using an 8F. RESULTS: We found no differences in technical characteristics between both groups: Radiation time (15.7 +/- 14 min vs 16.2 +/- 14 min), guiding catheter to patient ratio (1.1 +/- 0.3 vs 1.06 +/- 0.2), number of balloon catheters per patient (1.2 +/- 0.7 vs 1.36 +/- 0.7). There were no differences in the results obtained (Success 93% in 6F group vs 91% in 8F), major complication rates (Death 0.5% vs 1.6%, CABG 1.1% vs 2.2% or AMI 0% vs 2.2%), or peripheral complications. CONCLUSIONS: In coronary angioplasty, with the use of 6F guiding catheters the same results can be achieved as with the use of larger catheters without an increase in technical difficulties or in complication rates.

[Left coronary artery with anomalous origin and course]. / Arteria coronaria izquierda con origen y trayecto anómalos.

We report a 45 year-old patient with angina and positive exercise test. In the coronary arteriography that left coronary artery rose from a vascular structure that connected the aorta to the middle of the left anterior descending coronary artery. In the right coronary artery there was a 90% stenosis. An ACTP was made in this stenosis. The patient displayed no symptoms eight months after the procedure. We have not found in the literature and anomaly of the left coronary artery similar to what was found in this patient.