Efficacy of systemic therapies for moderate-to-severe psoriasis: a systematic review and meta-analysis of long-term treatment.

BACKGROUND: Despite the chronicity of psoriasis, most systematic reviews focus on short-term treatment. METHODS: The systematic search strategy and results from the German Psoriasis Guidelines were adapted. To update the data a literature search in Medline, Embase and the Cochrane Library was conducted. The proportion of participants achieving ≥75% decrease in Psoriasis Area and Severity Index (PASI) as well as Dermatology Life Quality Index (DLQI) reduction at different time points were assessed. Trials were summarized with respect to time periods and study designs. Suitable trials were included in a meta-analysis. Particular attention was paid to statistical approaches of handling dropouts. RESULTS: A total of 33 articles including 27 trials totaling 6575 patients with active treatment were included in the systematic review. Seven randomized controlled trials were eligible for the meta-analysis. Over a 24 week treatment period infliximab [risk difference (RD) 78%, 95% confidence interval (CI) 72-83%] and ustekinumab 90 mg every 12 weeks (RD 77%, 95% CI 71-83%) were the most efficacious treatments. Adalimumab (RD: 60%, 95% CI 45-74%) showed results within the range of different etanercept dosages (etanercept 50 mg once weekly: RD 62%, 95% CI, 52-72%), (etanercept 25 mg twice weekly: RD 45%, 95% CI 34-56%), (etanercept 50 mg twice weekly: RD 56%, 95% CI 49-62%) and (etanercept 50 mg twice weekly until week 12, then 25 mg twice weekly: RD 50%, 95% CI 42-57%). After 24 weeks a decrease in efficacy for inflximab, adalimumab and etanercept was observed. CONCLUSIONS: More sufficient data is required to draw reliable conclusions in extended long-term treatment and head-to-head comparisons are necessary.

On the development of the European S3 guidelines on the systemic treatment of psoriasis vulgaris: structure and challenges.

BACKGROUND: The development of evidence based guidelines is a demanding and time consuming process. Therefore it is important to share the knowledge and discuss the structure of these guidelines in detail. OBJECTIVES: To present a method report on the development process of the European evidence based guidelines on the systemic treatment of psoriasis vulgaris with the aim to offer guidance to other guidelines groups with lesser experience and to critically appraise the methodology of the guidelines development process. METHODS: The guidelines are based on the previously evaluated literature from three European national evidence based guidelines and an additional systematic search and evaluation of new literature. Further steps included a structured consensus conference and a DELPHI procedure to develop the recommendations, as well as several internal and external reviews. All steps were coordinated by the Division of evidence based medicine in cooperation with a group of methodologists. RESULTS: A total of 114 studies were included, serving as base for the efficacy chapters of the intervention. The recommendations, based on the efficacy and the level of evidence of the included studies were discussed and finally consented by the guidelines group. After subsequent reviews the guidelines were presented to the European Dermatology Forum, European Academy of Dermatology and Venereology and Union Européenne des Médicins Spécialistes for approval and published in October 2009. CONCLUSION: The development of European evidence based guidelines requires a coordinated structure which can be achieved by the integration of an experienced group of methodologists. Nevertheless further improvements are imaginable and might be considered for an update or other European evidence based guidelines.

European S3-guidelines on the systemic treatment of psoriasis vulgaris.

Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

Short version of the German evidence-based Guidelines for prophylactic vaccination against HPV-associated neoplasia.

Persistent infection with HPV 16 and 18 has been causally associated with the development of cervical cancer and its precursor lesions as well as with other carcinomas and their precursors, e.g. some vulvar and vaginal cancers. Furthermore HPV 6 and 11 are responsible for anogenital condylomata acuminata in more than 90% of cases. With the recently developed prophylactic bivalent (HPV 16 and 18) and quadrivalent (HPV 6, 11, 16 and 18) vaccines, it is possible to prevent infection of the cervical epithelium and other squamous epithelia, the development of premalignant lesions and, in the case of the quadrivalent vaccine, the development of condylomata acuminata. The following paper represents a summary of the full-text version of the German evidence-based Guidelines, including all evidence-based recommendations regarding the safety as well as the efficacy of the vaccines in preventing CIN, VIN/VaIN, genital warts and other HPV-associated lesions.

A preliminary study on neonatal septicaemia in a tertiary referral hospital paediatric unit.

OBJECTIVE: To estimate the incidence of neonatal septicaemia, and to identify risk factors, clinical presentations and causal organisms. DESIGN: A cross-sectional study. SETTING: Neonatal Care Unit, University Paediatric Unit, Colombo North Teaching Hospital. SUBJECTS: Neonates admitted from January to December 1996 with clinical evidence of septicaemia. METHOD: Gestational age, birth weight and mode of delivery were evaluated as risk factors for septicaemia. Although diagnosis of septicaemia was made on clinical grounds, blood cultures were performed in all babies. Data was analysed by using Epi Info version 6. RESULTS: 98 babies had septicaemia. Incidence of septicaemia was 24.4 per 1000 live births and case fatality rate was 11.2%. Incidence was significantly higher in preterm babies, babies with low birth weight (LBW) and those born following instrumental delivery. 21.4% developed septicaemia on the first day of life, 74.5% between 2 and 7 days and 4.1% after the first week. Common presenting features were fever 61.2%, jaundice 52%, lethargy 37.8% refusal of feeds 25.5%, coffee grounds vomiting 22.4%, and fits 12.2%. Common bacteria identified were Klebsiella 26.5%, Staphylococcus aureus 15.3%, coliform bacilli 9.2% and spore forming bacilli 9.2%. Common sensitive antibiotics were amikacin 88.9%, amoxycillin + clavulanic acid 83%, ceftriaxone 78.1% and netilmicin 63.9%. CONCLUSIONS: Septicaemia is an important cause of morbidity, particularly in preterm babies, in babies with LBW and those with instrumentation at birth. The high incidence of late onset septicaemia together with the findings of Klebsiella and Staphylococcus aureus as common and resistant pathogens for septicaemia indicate that the majority were nosocomial infections.

A case of progressive hemifacial atrophy with uveitis and retinal vasculitis.

Parry Romberg syndrome is a rare disorder characterised by progressive hemifacial atrophy that is usually unilateral, involving the skin, subcutaneous tissue, and subsequently the muscle, cartilage and bone. Previous cases with various ocular manifestations have been reported. A case of Parry Romberg syndrome with retinal vasculitis is reported.