Dose escalation and associated economic outcomes in patients with psoriasis treated with biologics: A retrospective analysis of German health claims data.

BACKGROUND: In Germany, several biologic therapies are available for the treatment of moderate-to-severe plaque psoriasis, with the option of exceeding recommended dosages if standard dosing does not achieve a satisfactory treatment response. OBJECTIVES: To examine dose escalation in patients with biologic-treated psoriasis and associated cost development for German statutory health insurance (SHI). METHODS: We conducted a retrospective, non-interventional cohort study using German SHI health claims data from 2016 to 2021. Adult patients initiating biologic treatment were included in drug-specific cohorts. The odds for dose escalation, defined as the exceedance of the individually received daily dose over the maintenance dose recommended by the European product information, was compared between cohorts using multivariate logistic regression. The impact of dose escalation on SHI expenditures was analyzed with a generalized linear model. RESULTS: The relative frequency of dose escalation varied between cohorts (range 1.1% [risankizumab] to 42.9% [infliximab]). Compared to risankizumab-treated patients, the odds for dose escalation were statistically significantly (p < 0.05) higher in patients treated with all other biologic drugs except tildrakizumab. Patients with dose escalation during the maintenance phase accrued on average €6,473 more in direct healthcare costs to the SHI over a one-year period compared to those without dose escalation, with statistical significance (p < 0.05) after controlling for differences in covariates. CONCLUSIONS: Compared to patients treated with other biologics, dose escalation during the maintenance phase was lowest among risankizumab-treated patients. Dose escalation was associated with higher costs and thus a higher economic burden for the German SHI.

Comparison of risankizumab and apremilast for the treatment of adults with moderate plaque psoriasis eligible for systemic therapy: results from a randomized, open-label, assessor-blinded phase IV study (IMMpulse).

BACKGROUND: Treatment of psoriasis with risankizumab has demonstrated superior efficacy to other treatments, such as adalimumab, ustekinumab and secukinumab. OBJECTIVES: This study compared the efficacy and safety of risankizumab and apremilast in adults with moderate plaque psoriasis eligible for systemic therapy. It also evaluated the efficacy and safety of switching to risankizumab vs. continuing apremilast in patients who did not achieve ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75 nonresponders) after 16 weeks of treatment with apremilast. METHODS: This 52-week, phase IV, multicentre, randomized, open-label, efficacy assessor-blinded study (NCT04908475) enrolled patients (aged ≥ 18 years) with a diagnosis of moderate chronic plaque psoriasis (≥ 6 months) and who were candidates for systemic therapy. The enrolled patients (randomized 1 : 2) received subcutaneous risankizumab (150 mg at weeks 0 and 4) or oral apremilast (30 mg twice daily). At week 16, all patients treated with apremilast were re-randomized (1 : 1) to risankizumab or apremilast, stratified by week-16 PASI 75 response. The co-primary outcomes in period A at week 16 were the achievement of ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) and static Physician's Global Assessment (sPGA) 0/1 with a two-grade or better improvement from baseline. At week 52, the primary endpoint in period B was the achievement of PASI 90 in PASI 75 nonresponders with apremilast at week 16. Safety was monitored throughout the study. All patients who received one dose of treatment were included in the efficacy and safety analysis. RESULTS: At baseline, 118 and 234 patients were assigned to receive risankizumab and apremilast, respectively. At week 16, PASI 90 was achieved by 55.9% [95% confidence interval (CI) 47.0-64.9] and 5.1% (95% CI 2.3-8.0), and sPGA 0/1 by 75.4% (95% CI 67.7-83.2) and 18.4% (95% CI 13.4-23.3), respectively. In period B, among PASI 75 nonresponders with apremilast at week 16, 83 switched to risankizumab and 78 continued apremilast. At week 52, 72.3% (95% CI 62.7-81.9) who switched to risankizumab achieved PASI 90 vs. 2.6% (95% CI 0.0-6.1) who continued apremilast. The most frequent adverse events (reported in ≥ 5%) in risankizumab-treated patients were COVID-19 infection and nasopharyngitis. Diarrhoea, nausea and headache were most frequent among apremilast-treated patients. CONCLUSIONS: For patients with moderate psoriasis, treatment with risankizumab demonstrated superior efficacy to those treated with apremilast, including those who did not benefit from prior treatment with apremilast. The safety profile of risankizumab was similar to prior studies, and no new safety signals were identified. These results show that, compared with apremilast, risankizumab treatment can significantly improve clinical outcomes in systemic-eligible patients with moderate psoriasis.

Semantic Evidential Grid Mapping Using Monocular and Stereo Cameras.

Accurately estimating the current state of local traffic scenes is one of the key problems in the development of software components for automated vehicles. In addition to details on free space and drivability, static and dynamic traffic participants and information on the semantics may also be included in the desired representation. Multi-layer grid maps allow the inclusion of all of this information in a common representation. However, most existing grid mapping approaches only process range sensor measurements such as Lidar and Radar and solely model occupancy without semantic states. In order to add sensor redundancy and diversity, it is desired to add vision-based sensor setups in a common grid map representation. In this work, we present a semantic evidential grid mapping pipeline, including estimates for eight semantic classes, that is designed for straightforward fusion with range sensor data. Unlike other publications, our representation explicitly models uncertainties in the evidential model. We present results of our grid mapping pipeline based on a monocular vision setup and a stereo vision setup. Our mapping results are accurate and dense mapping due to the incorporation of a disparity- or depth-based ground surface estimation in the inverse perspective mapping. We conclude this paper by providing a detailed quantitative evaluation based on real traffic scenarios in the KITTI odometry benchmark dataset and demonstrating the advantages compared to other semantic grid mapping approaches.

Unraveling the Self-Assembly of Heterocluster Janus Dumbbells into Hybrid Cubosomes with Internal Double-Diamond Structure.

Cubosomes are bicontinuous cubic-phase particles generated by amphiphile self-assembly with bicontinuous cubic phases, which creates an intricate network of interconnected nanochannels that endow these materials with special functions for advanced applications. On the other hand, clusters are an attractive class of molecules that exhibit intriguing functions and properties that differ from those of atoms and nanoparticles. Inspired by lipid self-assembly and attracted to the new functionalities of clusters, we prepared special heterocluster Janus dumbbells (HCJDs) composed of dissimilar nanoclusters: namely, a polyoxometalate and a polyhedral oligomeric silsesquioxane. HCJDs resemble conventional amphiphiles and, as such, they self-assemble in solution into faceted hybrid cubosomes via the transformation of vesicles into spongelike aggregates. Multiple mechanisms that lead to equilibrium, including molecular self-assembly, vesicle accumulation, membrane fusion, inner-structure reorganization, and cubic crystal growth, contributed to the overall process. On the basis of these results, we proposed a strategy for self-assembly-from basic molecular design that goes beyond traditional amphiphiles to the construction of micro- or nanomaterials with hierarchical structures and advanced functions.

Bioinspired Metal-Free Formal Decarbonylation of α-Branched Aliphatic Aldehydes at Ambient Temperature.

A sequence of a Baeyer-Villiger oxidation and a Lewis acid-promoted reduction of the resulting formate with Et3 SiH enabled the metal-free formal decarbonylation of tertiary and secondary aliphatic aldehydes. The new methodology mimics the biosynthetic decarbonylation pathway through oxidative C-C bond cleavage rather than the C(O)-H bond activation known from conventional Tsuji-Wilkinson-type reactions. The substrate scope is complementary to existing transition-metal-catalyzed protocols.

Cultivation and purification of two stereoselective imine reductases from Streptosporangium roseum and Paenibacillus elgii.

The reductive amination is one of the most important reactions in the synthesis of chiral amines. Imine reductases (IREDs) are novel enzymes that catalyze the asymmetric reduction of imines and reductive aminations using NADPH as hydride donor. In this study, we have developed a simple method to produce two enantiocomplementary IREDs from Streptosporangium roseum DSM 43021 (R-IRED-Sr) and Paenibacillus elgii (S-IRED-Pe). The proteins were expressed efficiently in Escherichia coli (E. coli) JW5510 at the 4-L-cultivation scale and were purified to 95% homogeneity in two steps by immobilized metal ion affinity and anion-exchange chromatography. The total protein yield was about 9 g per liter of E. coli culture and resulted in 150-220 mg purified IRED per liter of E. coli culture. The bioactivity of both IREDs was measured by the depletion of the NADPH cofactor in the reduction of model substrates 2-methylpyrroline (R-IRED-Sr) and 3,4-dihydroisoquinoline (S-IRED-Pe). High level reducing activity was found demonstrating the production of correctly folded and active IRED proteins. Specific activities of about 2.58 U/mg and 0.24 U/mg for the R- and S-selective IREDs were obtained, being in agreement with activities reported in the literature.

Synergistic Heterobimetallic Manifold for Expedient Manganese(I)-Catalyzed C-H Cyanation.

The manganese-catalyzed cyanation of inert C-H bonds was achieved within a heterobimetallic catalysis regime. The manganese(I) catalysis proved widely applicable and enabled C-H cyanations on indoles, pyrroles and thiophenes by facile C-H manganesation. The robustness of the manganese catalyst set the stage for the racemization-free C-H cyanation of amino acids with excellent levels of positional and chemo selectivity by the new cyanating agent NCFS. Experimental and computational mechanistic studies provided strong support for a synergistic heterobimetallic activation mode, facilitating the key C-C formation.

Manganese(I)-Catalyzed Substitutive C-H Allylation.

The first manganese(I)-catalyzed C-H allylations with ample scope were achieved by carboxylate assistance. The highly selective C-H/C-O functionalizations proved viable with densely substituted allyl carbonates, and the organometallic C-H allylation strategy set the stage for expedient late-stage diversification with excellent levels of positional selectivity.

C-H alkenylations with alkenyl acetates, phosphates, carbonates, and carbamates by cobalt catalysis at 23 °C.

Inexpensive cobalt catalysts with N-heterocyclic carbene ligands enable direct arene alkenylations with easily accessible alkenyl acetates through regioselective C-H/C-O functionalizations in a stereoconvergent fashion. The versatile cobalt catalyst was broadly applicable and thus also allowed for the efficient conversion of alkenyl phosphates, carbonates, and carbamates at ambient temperature.

Synthesis of cyclopropyl-substituted furans by brønsted Acid promoted cascade reactions.

Chloroacetic acid promotes an efficient and diastereoselective intramolecular cascade reaction of electron-deficient ynenones to deliver products featuring a 2,3,5-trisubstituted furan bearing a fused cyclopropyl substituent at the 5-position. Synthetically relevant polycyclic building blocks featuring rings of various sizes and heteroatoms have been synthesized in high yield using this mild acid-catalyzed reaction.

The role of cryosurgery in the treatment of colorectal liver metastases: a matched-pair analysis of cryotherapy vs. liver resection.

BACKGROUND/AIMS: Although liver resection is the gold standard for patients with colorectal liver metastases (CRLM), only 15-20% of the patients are candidates for surgery. As ablative therapies may extend this low rate of curative option, the aim of the present study was to analyze the impact of cryosurgery (cryo) on survival of patients with CRLM compared to liver resection (Phx). METHODOLOGY: In a matched-pair analysis, patients undergoing Phx or cryo were compared (n = 39 each). Analysis included pre-, peri-and postoperative data and follow-up for tumor-free and overall survival. Survival was estimated by Kaplan-Meier method. RESULTS: Out of 124 patients undergoing 143 cryosurgical procedures, 39 patients could be identified undergoing single liver cryo procedure for CRLM with a curative approach. Matching of these patients with a Phx cohort, patients undergoing Phx revealed better overall (20 vs. 46 months) and tumor-free survival (7.8 vs. 33.6 months) than patients with cryo. CONCLUSIONS: Liver resection is strongly recommended for patients with CRLM compared to cryosurgery.

Resolution-enhanced multi-core fiber imaging learned on a digital twin for cancer diagnosis.

Significance: Deep learning enables label-free all-optical biopsies and automated tissue classification. Endoscopic systems provide intraoperative diagnostics to deep tissue and speed up treatment without harmful tissue removal. However, conventional multi-core fiber (MCF) endoscopes suffer from low resolution and artifacts, which hinder tumor diagnostics. Aim: We introduce a method to enable unpixelated, high-resolution tumor imaging through a given MCF with a diameter of around 0.65 mm and arbitrary core arrangement and inhomogeneous transmissivity. Approach: Image reconstruction is based on deep learning and the digital twin concept of the single-reference-based simulation with inhomogeneous optical properties of MCF and transfer learning on a small experimental dataset of biological tissue. The reference provided physical information about the MCF during the training processes. Results: For the simulated data, hallucination caused by the MCF inhomogeneity was eliminated, and the averaged peak signal-to-noise ratio and structural similarity were increased from 11.2 dB and 0.20 to 23.4 dB and 0.74, respectively. By transfer learning, the metrics of independent test images experimentally acquired on glioblastoma tissue ex vivo can reach up to 31.6 dB and 0.97 with 14 fps computing speed. Conclusions: With the proposed approach, a single reference image was required in the pre-training stage and laborious acquisition of training data was bypassed. Validation on glioblastoma cryosections with transfer learning on only 50 image pairs showed the capability for high-resolution deep tissue retrieval and high clinical feasibility.

Prediction of WHO grade and methylation class of aggressive meningiomas: Extraction of diagnostic information from infrared spectroscopic data.

Background: Infrared (IR) spectroscopy allows intraoperative, optical brain tumor diagnosis. Here, we explored it as a translational technology for the identification of aggressive meningioma types according to both, the WHO CNS grading system and the methylation classes (MC). Methods: Frozen sections of 47 meningioma were examined by IR spectroscopic imaging and different classification approaches were compared to discern samples according to WHO grade or MC. Results: IR spectroscopic differences were more pronounced between WHO grade 2 and 3 than between MC intermediate and MC malignant, although similar spectral ranges were affected. Aggressive types of meningioma exhibited reduced bands of carbohydrates (at 1024 cm-1) and nucleic acids (at 1080 cm-1), along with increased bands of phospholipids (at 1240 and 1450 cm-1). While linear discriminant analysis was able to discern spectra of WHO grade 2 and 3 meningiomas (AUC 0.89), it failed for MC (AUC 0.66). However, neural network classifiers were effective for classification according to both WHO grade (AUC 0.91) and MC (AUC 0.83), resulting in the correct classification of 20/23 meningiomas of the test set. Conclusions: IR spectroscopy proved capable of extracting information about the malignancy of meningiomas, not only according to the WHO grade, but also for a diagnostic system based on molecular tumor characteristics. In future clinical use, physicians could assess the goodness of the classification by considering classification probabilities and cross-measurement validation. This might enhance the overall accuracy and clinical utility, reinforcing the potential of IR spectroscopy in advancing precision medicine for meningioma characterization.

Optimized expression of the dirigent protein AtDIR6 in Pichia pastoris and impact of glycosylation on protein structure and function.

Phenoxy radical coupling reactions are involved in the biosynthesis of lignans in planta. Interestingly, the reaction can be guided by dirigent proteins, which mediate the stereoselective formation of either (+) or (-)-pinoresinol from coniferyl alcohol. So far, the mechanism is poorly understood, and for detailed mechanistic studies, a heterologous expression platform which allows the cost-effective, fast, and robust expression in high yields is needed. We established a reliable, high-yield fed-batch fermentation process with Pichia pastoris resulting in 47 mg L⁻¹ of the dirigent protein AtDIR6, which represents a more than 250-fold increase compared to previous studies. Biochemical characterization of AtDIR6 produced with P. pastoris showed an overall agreement in protein structure, N-glycosylation sites, and dirigent activity compared to AtDIR6 produced by plant cell cultures of Solanum peruvianum. CD spectroscopy verified the ß-barrel structure proposed by earlier studies and bioconversion experiments revealed similar activities to plant-derived protein, validating P. pastoris as a suitable expression system for dirigent proteins. Compared to the complex glycan structures of most plant cells, proteins produced with P. pastoris have the advantage that they can be enzymatically deglycosylated under non-denaturating conditions. With this study, we demonstrate that the glycan structures of AtDIR6 are essential for structure, solubility, and function of the protein as deglycosylation induced conformational changes leading to the complete loss in dirigent activity and subsequent protein aggregation.

Evidence for tumor cell spread during local hepatic ablation of colorectal liver metastases.

INTRODUCTION: The aim of the present study was to analyze the impact of cryosurgery (CRYO) on liver metastases compared to other thermoablative techniques. In a rat liver metastases model, evidence for tumor cell spread was analyzed comparing CRYO, radiofrequency ablation (RFA), and laser-induced thermotherapy (LITT). METHODS: In an experimental study, we compared cell spillage in the washout of isolated perfused rat livers undergoing thermal ablation. Within the same model, CC531-GFP rat liver tumors were treated with CRYO, RFA, or LITT and the number of vital tumor cells within the perfusate was measured. Matrix metalloproteinases (MMP-2, MMP-9) were analyzed after in vivo ablation of rat colorectal liver metastases in the third experimental model. RESULTS: Our data showed pronounced washout of cells after CRYO with a higher amount of intravascular cells and cell detritus compared to RFA and LITT. Only the effluent fluid of cryosurgery-treated livers revealed GFP-stained tumor cells. MMP-2 and MMP-9 expression was significantly higher after cryosurgery than after RFA and LITT. CONCLUSION: When using thermoablative techniques, intravascular metastatic cell spillage is highest in CRYO, and increased expression of matrix metalloproteinases may further facilitate tumor cell spread. Therefore, RFA and LITT may be preferable whenever surgical resection of liver tumors is impossible.

Normative values in anorectal manometry using microtip technology: a cohort study in 172 subjects.

PURPOSE: The aims of this study were to obtain normative values in resting/squeeze pressure and surface electromyography (s-EMG) in anorectal manometry using microtip technology and to determine the relationship between objective measurable values, gender and age in a cohort with no anorectal disorders. METHODS: One hundred seventy-two white central European subjects (106 males/66 females) were recruited prior to left colonic or upper rectal surgery and studied by anorectal rapid pull-through manometry with a microtip transducer system and endoanal s-EMG using a bipolar plug electrode. s-EMG patterns were determined as plateau, peak and decrease by a blinded co-investigator. Objective measurable sphincter pressures and s-EMG values were correlated with gender, age and s-EMG patterns. RESULTS: Squeeze pressure, voluntary pressure as well as s-EMG amplitude and its area under the curve were significantly lower in women compared to men (p < 0.001 each), whereas resting pressure showed no gender differences. s-EMG patterns were strongly influenced by gender. Male patients showed significantly more plateau pattern whereas peak pattern was significantly more often in women. In both genders, the peak pattern was associated with significant higher squeeze pressures. In all measurements, we found considerable inter-individual variations being higher in elder patients. There was no manometric parameter correlating with age. CONCLUSIONS: Gender is the strongest factor influencing objective measurable manometric data for healthy men and women. There are significant gender differences concerning squeeze patterns. All manometric values should be interpreted in the context of gender and of methodology used. Large prospective cohort studies matched for gender are necessary to clarify the effect of ageing on anal sphincter strength.

Estimate or calculate? How surgeons rate volumes and surfaces.

PURPOSE: Surgeons frequently describe the shape of intraoperative findings using visual judgement and their own sense of proportion or describing these findings in comparison to commonly used or metaphoric subjects. The aim of the study was to analyse the reliability of surgeon's estimations of dimensions. METHODS: The study was performed in two phases. First, physicians had to estimate the metric proportions of four well-known objects. Second, surgeons were asked intraoperatively to estimate the liver resection surface after partial hepatectomy. The exact surface of the resection plane was measured using computed tomography-guided planimetry of the resection specimen. Physician's estimations and the exact measurements of the well-known objects and the liver resection surface were compared. Systematic error was defined by the natural logarithm of estimated/real size. RESULTS: We found a large individual discrepancy in estimating the metric proportions of commonly used objects and a tendency to underestimate both commonly used objects and liver resection surface. Experienced liver surgeons were more accurate in estimating liver resection surface compared with younger staff members. CONCLUSIONS: We found a large bias in estimating the dimension of both commonly used objects and the surface area of liver parenchyma transection. Obviously, estimating errors are more influenced by the individual subject who estimates than by the object itself. In clinical routine, surgeons should rely more on simple measuring devices than on their own sense of proportion. Education in how to estimate more correctly human liver resection surfaces can be achieved by ex vivo studies using porcine livers.

Parenchyma-preserving hepatic resection for colorectal liver metastases.

BACKGROUND: Hepatic resection of colorectal liver metastases is the only curative treatment option. As clinical and experimental data indicate that the extent of liver resection correlates with growth of residual metastases, the present study analyzes the potential benefit of a parenchyma-preserving liver surgery approach. METHODS: Data from a prospectively maintained database of patients undergoing liver resection for colorectal metastases were reviewed. Evaluation of outcome was performed using the Kaplan-Meier method. Correlations were calculated between clinical-pathological variables. RESULTS: One hundred sixty-three patients underwent 198 liver resections for colorectal metastases: 26 major hepatectomies, 65 minor anatomical resections, 78 non-anatomical resections, as well as 29 combinations of minor anatomical and non-anatomical procedures. Overall 1-, 3-, and 5-year survival was 93%, 62%, and 40%, respectively. Patients with repeated liver resections had a 5-year survival of 27%. Interestingly, large dissection areas were associated with a significant reduction of the 5-year survival rate (33%). Five-year survival after major hepatectomy was not significantly reduced. CONCLUSION: For colorectal liver metastases, minor resections offer a prolonged survival compared to major hepatectomies. As patients with stage IV colorectal disease are candidates for repeat resections, preservation of hepatic parenchyma is of increasing importance in the setting of multi-modal and repeated therapy approaches.

Biologic initiation rates in systemic-naive psoriasis patients after first-line apremilast versus methotrexate use.

Aim: To compare rates of biologic initiation after commencing treatment with apremilast (APR) versus methotrexate (MTX) in systemic-naive patients with psoriasis (PsO). Methods: This was a retrospective cohort study of systemic-naive patients with PsO who initiated treatment with APR or MTX between 1 January 2015 and 31 March 2018. Outcomes: Adjusted rates of biologic initiation during follow-up were compared by logistic and Cox regressions. Results: APR initiators had 58% lower likelihood of biologic initiation (odds ratio: 0.42; 95% CI: 0.37-0.48; p < 0.001), lower adjusted biologic initiation rate (14.4% [95% CI: 13.2-15.7%] vs 28.6% [95% CI: 26.8-30.5%]), lower risk of biologic initiation (hazard ratio: 0.45; 95% CI: 0.40-0.51; p < 0.001) compared with MTX initiators. Conclusion: Systemic-naive patients with PsO have a lower rate of biologic initiation over 1 year following APR initiation.

Baseline Disease Activity Predicts Achievement of cDAPSA Treatment Targets With Apremilast: Phase III Results in DMARD-naïve Patients With Psoriatic Arthritis.

OBJECTIVE: The probability of achieving Clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA) treatment targets (remission [REM], low disease activity [LDA]) was evaluated following apremilast monotherapy in disease-modifying antirheumatic drug (DMARD)-naïve patients with psoriatic arthritis (PsA) based on baseline disease activity. METHODS: This post hoc probability analysis of PALACE 4, a phase III, multicenter, randomized, placebo-controlled study, evaluated shifting across cDAPSA categories from baseline to week 52 and included DMARD-naïve patients receiving apremilast 30 mg BID with available baseline cDAPSA data. Changes in articular/extraarticular manifestations were evaluated in patients with week 52 cDAPSA components. cDAPSA treatment target achievement was assessed in a subgroup with baseline extraarticular PsA manifestations (skin involvement, enthesitis, dactylitis). RESULTS: Of 175 apremilast-treated patients in the probability analysis, 66.3% were in high disease activity (HDA) and 31.4% in moderate disease activity (ModDA) at baseline. Approximately twice as many patients in ModDA at baseline reached REM/LDA at week 52 vs those in HDA (61.7% vs 28.2%). Achieving cDAPSA treatment targets was associated with reductions in articular (swollen/tender joints) and extraarticular (skin involvement, enthesitis, dactylitis, functional disability) disease activity. Similar treatment target achievement rates were observed in the subgroup with ≥ 1 extraarticular PsA manifestation (n = 126; ModDA: 66.7%, HDA: 32.2%). CONCLUSION: Apremilast-treated patients with baseline ModDA had higher probability of achieving cDAPSA treatment targets than patients with HDA. Resolution and/or near resolution of articular and/or extraarticular PsA manifestations was achieved by patients in REM/LDA at week 52. Consistent treatment target achievement was observed in patients with 1 or multiple extraarticular manifestations of active PsA.