Health-related quality of life and economic burden of prurigo nodularis.

BACKGROUND: Prurigo nodularis (PN) is an understudied, pruritic inflammatory skin disease. Little is known about the effect of PN on quality of life and its associated economic burden. OBJECTIVE: To quantify the impact of PN on quality of life and its economic implications. METHODS: A cohort study of PN patients (n = 36) was conducted using the Health Utilities Index Mark 3 questionnaire. Control data from US adults (n = 4187) were obtained from the 2002-2003 Joint Canada/United States Survey of Health. Quality-adjusted life year loss and economic costs were estimated by comparing the Health Utilities Index Mark 3 scores of the PN patients with those of the controls. RESULTS: The PN patients had lower overall health performance compared to the controls, (mean ± SE, 0.52 ± 0.06 vs 0.86 ± 0.003, respectively, P < .001). In multivariable regression, PN was found to be associated with worse health performance (coefficient -0.34, 95% CI [-0.46 to -0.23]), most prominent in the pain subdomain (coefficient -0.24, 95% CI [-0.35 to -0.13]). This correlated to an average of 6.5 lifetime quality-adjusted life years lost per patient, translating to an individual lifetime economic burden of $323,292 and a societal burden of $38.8 billion. CONCLUSION: These results demonstrate that PN is associated with significant quality-of-life impairment, similar to the level of other chronic systemic conditions. PN is also associated with a substantial individual economic burden, emphasizing the necessity of research on effective treatment options.

Student curriculum review team, 8 years later: Where we stand and opportunities for growth.

BACKGROUND: The Student Curriculum Review Team (SCRT) was founded at the Johns Hopkins University School of Medicine (JHUSOM) in 2012 to refine pre-clinical courses. Since then, SCRT has provided a voice for student feedback - offering forums for discussion through 'Town Hall meetings' and confidential avenues for peer-to-peer comments. Here, we assess the perceived efficacy and utility of SCRT among the student body and faculty course directors. METHODS: A cross-sectional analysis was conducted in 2019 using an anonymous survey distributed to second- (MS2) and third-year (MS3) medical students as well as faculty course directors at JHUSOM. RESULTS: A total of 113 student surveys and 13 faculty surveys were returned. The majority of students (97%) endorsed SCRT as effective in enabling them to express their concerns. Most faculty (69%) reported SCRT's impact on their respective course as positive and found SCRT suggestions to be 'realistic and actionable.' Students (84%) and faculty (62%) alike considered SCRT to meet needs not met by other curricular organizations at JHUSOM. CONCLUSION: Students and faculty find that SCRT satisfies an unfilled position in the landscape of curricular feedback at JHUSOM. This study may be beneficial for other academic institutions considering ways to better engage students in curricular reform.

Health-Related QOL and Economic Burden of Chronic Pruritus.

Chronic pruritus (CP) has considerable implications for QOL. However, its impact on health-related QOL and economic burden is not fully characterized. We administered a cross-sectional survey on 132 patients with CP using the Health Utilities Index Mark 3 instrument. Normative data from healthy adults (n = 4,187) were obtained from the Joint Canada/US Survey of Health. Quality-adjusted life-year loss and economic costs were estimated on the basis of Health Utilities Index Mark 3 scores of patients with CP versus controls. Patients with CP had lower overall health performance than the control (0.56 ± 0.03 vs. 0.86 ± 0.003, P < 0.001). In multivariable regression, CP was associated with worse overall health performance (coefficient = -0.30, 95% confidence interval = -0.33 to -0.27), most accentuated in the domains of pain (coefficient = -0.24, confidence interval = -0.28 to -0.21) and emotion (coefficient = -0.11, confidence interval = -0.13 to -0.10). The reduced Health Utilities Index Mark 3 score correlated with 5.5 average lifetime quality-adjusted life-years lost per patient. Using conservative estimates for willingness to pay, the quality-adjusted life-year loss translated to an individual lifetime economic burden of $274,921 and a societal burden of $88.8 billion. CP is associated with significant QOL impairment. The economic burden of CP highlights the necessity for further research into management options.

Racial and Ethnic Disparities in Access to Emerging and Frontline Therapies in Common Dermatological Conditions: A Cross-Sectional Study.

OBJECTIVE: This study investigates possible race- and ethnicity-related disparities in the treatment of acne, atopic dermatitis, and psoriasis of newly approved treatments as well as existing therapies. METHODS: Aggregate level data was collected from patient medical records between 2013 and 2018. The odds ratio of patients who had been prescribed treatments for acne, atopic dermatitis, and psoriasis per racial and ethnic group were calculated using a 95% confidence interval after applying Bonferroni correction to account for multiple comparisons. RESULTS: Black patients with acne had statistically significant (p < 0.001) lower odds of receiving isotretinoin 0.26 [0.22-0.30], adapalene 0.72 [0.67-0.78], tazarotene 0.74 [0.64-0.86], and dapsone 0.39 [0.34-0.45] than white patients. The exceptions were tretinoin 1.28 [1.23-1.34] and benzoyl peroxide 3.00 [2.79-3.23] (p < 0.001). Hispanic patients with acne had statistically lower odds of receiving tretinoin 0.86 [0.79-0.95] (p < 0.001) compared to non-Hispanics. Black patients with atopic dermatitis were less likely to receive desonide 0.90 [0.78-0.93], tacrolimus 0.75 [0.68-0.83], pimecrolimus 0.71 [0.60-0.84], crisaborole 0.39 [0.26-0.57], dupilumab 0.42 [0.27-0.65]. The exception was hydrocortisone 2.50 [2.34-2.65] (p < 0.001). There was no statistically significant difference for Hispanics compared to non-Hispanics. Black patients with psoriasis had a lower likelihood of receiving cyclosporine 0.54 [0.35-0.83] and etanercept 0.65 [0.49-0.87]. CONCLUSIONS: This study demonstrates a racial and ethnic disparity in accessing newly approved and standard of care medical therapies for acne, atopic dermatitis, and psoriasis within the past three years.

Racial and Gender Differences in the Presentation of Pruritus.

Background: Pruritus is a common disease symptom with a variety of etiologies known to reduce patient quality of life. We aimed to characterize the racial and gender differences in the presentation of pruritus for itch-related patient visits both within a single institution and nationally. Methods: Cross sectional study of patients ≥ 18 years old seen at Johns Hopkins Health System between 1/1/12 and 1/1/18. Results were compared to data from 2005-2011 from the National Ambulatory Medical Care Survey (NAMCS) and the National Health Ambulatory Medical Care Survey (NHAMCS). Results: Our findings indicate that itch patients at JHHS (n = 18,753) were more likely to be black compared to white patients (37% vs. 19%, p < 0.01) when compared to patients without itch-a trend also noted nationally based on data from NAMCS/NHAMCS (26% vs. 21%, p = 0.05). Black itch patients are also more likely to be diagnosed with prurigo nodularis (OR 2.37, p < 0.0001), lichen planus (OR 1.22, p < 0.0001), and atopic dermatitis OR 1.51, p < 0.0001). Female itch patients are more likely to be diagnosed with autoimmune (OR 1.66, p < 0.0001) and psychiatric comorbidities (OR 1.2-1.8, p < 0.0001) than male itch patients. When compared to black itch patients nationally, white itch patients were more likely to visit a dermatologist (29% vs. 18%, p = 0.028). Our data can identify associated conditions and demographic differences but are unable to support a causal relationship. Conclusions: Black and female patients are more likely to present with pruritus, a symptom associated with comorbidities such as prurigo nodularis, lichen planus, atopic dermatitis, and psychiatric conditions.

Inpatient Burden of Prurigo Nodularis in the United States.

Background: Although prurigo nodularis (PN) has a significant burden of disease, little is known about its epidemiology and disease burden within the United States. We describe the characteristics of hospitalized patients diagnosed with PN and assess the factors associated with hospitalization. Methods: We performed a cross-sectional study of the 2016 National Inpatient Sample, a representative sample of 20% of hospital discharges nationally. Results: Patients diagnosed with PN accounted for 3.7 inpatient visits per 100,000 discharges nationally in 2016. Patients with PN were more likely to be black (odds ratio (OR) 4.43, 95% CI (3.33-6.08), p < 0.001) or Asian (OR 3.44, 95% CI (1.39-5.08), p = 0.003) compared with white patients. Patients diagnosed with PN had both a longer length of hospital stay (mean ± SD, 6.51 ± 0.37 days vs. 4.62 ± 0.02 days, p < 0.001) and higher cost of care ($14,772 ± $964 vs. $11,728 ± $106, p < 0.001) compared with patients without PN. Patients with PN were significantly more likely to be admitted for HIV complications (OR 78.2, 95% CI (46.4-131.8), p < 0.001). PN contributes to increased inpatient cost of care and length of hospitalization. Conclusions: There are racial disparities associated with hospital admission of patients diagnosed with PN.

Predicting the response to CTLA-4 blockade by longitudinal noninvasive monitoring of CD8 T cells.

Immunotherapy using checkpoint-blocking antibodies against targets such as CTLA-4 and PD-1 can cure melanoma and non-small cell lung cancer in a subset of patients. The presence of CD8 T cells in the tumor correlates with improved survival. We show that immuno-positron emission tomography (immuno-PET) can visualize tumors by detecting infiltrating lymphocytes and, through longitudinal observation of individual animals, distinguish responding tumors from those that do not respond to therapy. We used 89Zr-labeled PEGylated single-domain antibody fragments (VHHs) specific for CD8 to track the presence of intratumoral CD8+ T cells in the immunotherapy-susceptible B16 melanoma model in response to checkpoint blockade. A 89Zr-labeled PEGylated anti-CD8 VHH detected thymus and secondary lymphoid structures as well as intratumoral CD8 T cells. Animals that responded to CTLA-4 therapy showed a homogeneous distribution of the anti-CD8 PET signal throughout the tumor, whereas more heterogeneous infiltration of CD8 T cells correlated with faster tumor growth and worse responses. To support the validity of these observations, we used two different transplantable breast cancer models, yielding results that conformed with predictions based on the antimelanoma response. It may thus be possible to use immuno-PET and monitor antitumor immune responses as a prognostic tool to predict patient responses to checkpoint therapies.