Clinical Briefs
Markers of Hidradenitis Suppurativa
SOURCE: Hessam S, et al. Correlation of inflammatory serum markers with disease severity in patients with hidradenitis suppurativa (HS). J Am Acad Dermatol 2015;73:998-1005.
Hidradenitis suppurativa sometimes has been called a “heart sink” diagnosis. Patients often suffer chronic bacterial infections in multiple body sites (axillae, chest wall, perineum, glutei) that are unsightly, often painful, and require multiple, often not fully satisfactory treatments. Recently, insights into some of the underlying immunologic pathologies in hidradenitis have prompted utilization of systemic pharmacotherapies usually reserved for patients with rheumatoid arthritis or advanced psoriasis. Though such rheumatologic immunomodulatory agents are expensive, and not without risk, the serious disease burden of hidradenitis, coupled with the generally poor results seen with “traditional” therapies, justifies their consideration.
Probably the two most commonly used scales in the dermatological literature to stratify disease severity in hidradenitis are the Hurley stage scale (stages I, II, and III, with III being most severe) and the modified Hidradenitis Suppurativa Score. Both scores use characteristics noted on physical exam, such as number of lesions, presence of fistulas, presence of sinus tracts, etc. to assess severity.
Hessam et al studied whether systemic markers of inflammation, such as C-reactive protein (CRP) and white blood cell (WBC) count, might correlate with disease severity as assessed through the two severity scales. By evaluating 275 cases of hidradenitis in which CRP and/or WBC had been reported, the investigators determined that there was significant correlation between CRP levels and both clinical scoring systems; WBC correlated only with Hurley stage scores. The authors suggested that measurement of CRP, an inexpensive and readily available test, in hidradenitis patients may enhance assessment of disease severity.
Antibiotic Exposure and Mood Disorders
SOURCE: Lurie I, et al. Antibiotic exposure and the risk for depression, anxiety, or psychosis: A nested case-control study. J Clin Psychiatry 2015;7:1522-1528.
There might be a more important gut-brain connection than we have previously recognized. Animal data indicate that germ-free mice, whose intestinal tract is absent bacteriae, have magnified hypothalamic-pituitary-adrenal responses to stress, which may be normalized by restoration of the intestinal microbiome with probiotics (Bifidobacterium infantis). Similarly, germ-free mice differ in turnover of neurotransmitters associated with mood disorders (e.g., norepinephrine, dopamine, serotonin) from mice with established intestinal bacterial flora. Since gut flora alteration through antibiotic administration is a commonplace experience for most adults, might such exposures, by altering the intestinal microbiome, also be associated with mood disorders in humans?
Lurie et al performed a case-control study using medical records from a very large database in the United Kingdom inclusive of the interval from 1995-2013. Patients with depression (n = 202,974 with 803,961 age- and sex-matched controls), anxiety (n = 14,570 with 57,862 matched controls), and psychosis (n = 2690 with 10,644 matched controls) were compared for likelihood of having received an antibiotic prescription at least 1 year prior to the recorded mental health diagnosis.
Patients who had received a prescription for penicillin, cephalosporin, or quinolone were more than 20% more likely to incur depression, which increased to 40% more likely if multiple penicillin prescriptions had been issued. Similar odds ratios for anxiety occurred in relation to penicillin and sulfa drugs. Psychosis was not associated with antibiotic administration. Indeed, all antibiotic classes studied demonstrated increased risk for subsequent incident depression. Of course, it could be that persons with anxiety and depression, even in the pre-morbid state, might be more likely to become ill and receive an antibiotic prescription, nullifying a cause-and-effect relationship. Until the causal relationship between antibiotic administration and mental health is better understood, clinicians could consider adding still another rationale for why we might need to be ever more judicious about the appropriate use of antibiotics.
On-demand Pre-exposure HIV Prophylaxis
SOURCE: Molina JM, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med 2015;373:2237-2246.
There is no doubt that continuous pre-exposure prophylaxis (PrEP) with antiretroviral therapy in HIV-discordant men who have sex with men (MSM) substantially reduces the risk of seroconversion (> 40%). Curiously, similar trials among heterosexual women have not demonstrated the same risk reduction. Experts opine that failed efficacy in this population might be attributed to poor compliance. Might PrEP administration timed immediately before and after sexual activity, rather than daily, be effective?
Molina et al randomized MSM (n = 400) to antiretroviral treatment (tenofovir + emtricitabine) or placebo administered before and after sexual activity. The method of administration was two pills 2-24 hours before sex, a third pill 24 hours after the first dose, and a fourth pill 24 hours later. At a median of 9.3 months follow-up, there was a relative risk reduction in incident HIV infection of 86% (two cases in the antiretroviral group vs 16 in the placebo group).
These results stack up very favorably with continuous prophylaxis trials, and may be less cumbersome for some patients to administer. The authors cautioned that early enthusiasm for treatment might support better adherence, which could wane over time and potentially reduce efficacy.
In this section: The measurement of C-reactive protein in hidradenitis patients may enhance assessment of disease severity; studying the relationship between gut flora and mood disorders; and weighing the benefits of administration of pre-exposure prophylaxis immediately before and after sexual activity.
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