Narrowband UVB treatment is highly effective and causes a strong reduction in the use of steroid and other creams in psoriasis patients in clinical practice

Narrowband NB-UVB phototherapy (NB-UVB) is an effective treatment for psoriasis, as demonstrated by clinical trials. However, due to required infrastructure and need for treatment attendance opinions on the value of offering this treatment in routine practice vary. AIMS: To provide high quality large-scale and long-term data on the efficacy of NB-UVB for psoriasis under real-world conditions in order to assist in management decisions.The following resources were employed: (1) complete and prospectively recorded prescription drug records for a population of 420,000 marked by low demographic mobility, (2) prospectively recorded clinical treatment outcomes for all NB-UVB treatment episodes occurring in the local population; (3) complete dermatology electronic treatment records of all psoriasis patients, allowing cross-validation of diagnoses and treatment records. Using these data sets, we analysed all first-ever initial NB-UVB treatment episodes occurring over 79 months (n = 1749) for both clinical outcomes and the effect of NB-UVB on the use of topical treatments for psoriasis.Around 75% of patients both achieved a status of "clear/minimal disease" and used fewer topical treatments. NB-UVB treatment led to a strong reduction for both steroid creams (25%) and psoriasis-specific topicals, e.g. vitamin-D products (30%) during the 12-month period following NB-UVB treatment. The effects measured were specific as no effect of NB-UVB was noted on drug prescriptions unrelated to psoriasis. Results were independent of individuals administering and/or scoring treatment, as they were highly similar between four geographically separate locations.NB-UVB treatment is highly effective and leads to a remarkable reduction in the need for topical cream treatments for a period of at least 12 months

Parameters for the mathematical modelling of Clostridium difficile acquisition and transmission: a systematic review

INTRODUCTION: Mathematical modelling of Clostridium difficile infection dynamics could contribute to the optimisation of strategies for its prevention and control. The objective of this systematic review was to summarise the available literature specifically identifying the quantitative parameters required for a compartmental mathematical model of Clostridium difficile transmission. METHODS: Six electronic healthcare databases were searched and all screening, data extraction and study quality assessments were undertaken in duplicate. Results were synthesised using a narrative approach. RESULTS: Fifty-four studies met the inclusion criteria. Reproduction numbers for hospital based epidemics were described in two studies with a range from 0.55 to 7. Two studies provided consistent data on incubation periods. For 62% of cases, symptoms occurred in less than 4 weeks (3-28 days) after infection. Evidence on contact patterns was identified in four studies but with limited data reported for populating a mathematical model. Two studies, including one without clinically apparent donor-recipient pairs, provided information on serial intervals for household or ward contacts, showing transmission intervals of <1 week in ward based contacts compared to up to 2 months for household contacts. Eight studies reported recovery rates of between 75%-100% for patients who had been treated with either metronidazole or vancomycin. Forty-nine studies gave recurrence rates of between 3% and 49% but were limited by varying definitions of recurrence. No study was found which specifically reported force of infection or net reproduction numbers. CONCLUSIONS: There is currently scant literature overtly citing estimates of the parameters required to inform the quantitative modelling of Clostridium difficile transmission. Further high quality studies to investigate transmission parameters are required, including through review of published epidemiological studies where these quantitative estimates may not have been explicitly estimated, but that nonetheless contain the relevant data to allow their calculation

The change in the number of patients receiving topical psoriasis- treatments after one course of NB-UVB phototherapy¹.

<p>The change in the number of patients receiving topical psoriasis- treatments after one course of NB-UVB phototherapy<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0181813#t002fn001" target="_blank">¹</a>.</p

The clinical outcome of NB-UVB-phototherapy on psoriasis.

<p>A. Semi-quantitative outcome classes recorded for all phototherapy treatments (n = 1749), shown in number per patients (left y-axis), and as percentage of patients achieving either outcomes 0/1 or 2–5, respectively (right y-axis). B Outcomes achieved as a function of treatment duration, showing the percentage of patients in the lower 20^th percentile (“short” = less than 21 sessions), in the 21-80^th percentile (“normal’, 21–37 sessions), and above the 80^th percentile (“long”), respectively. P < 0.0001 for the difference across all three groups (chi-square).</p

The change in prescriptions per patient after NB-UVB phototherapy¹.

<p>The change in prescriptions per patient after NB-UVB phototherapy<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0181813#t003fn001" target="_blank">¹</a>.</p

Clinical outcomes of NB-UVB treatment for psoriasis, and change in topical prescriptions made out for psoriasis, at four independent treatment sites, as indicated (b).

<p>A, pie chart showing the percentage of the overall treatment cohort (n = 1749) receiving treatment at each individual site. B, The percentage of patients at each site exhibiting either a reduction, or increase in the number of topical prescriptions made out for psoriasis after compared to before NB-UVB treatment. C, The clinical outcome recorded at each site, shown as percent of patients assessed for each outcome. (Outcome classes are identical to those shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0181813#pone.0181813.g002" target="_blank">Fig 2</a>, above). D, The number of treatment session administered per NB-UVB course (average ± s.d.)</p

The effect of NB-UVB on drug prescribing.

<p>A. Top: Prescription of psoriasis-related (left) and–unrelated (right) drugs in psoriasis patients before (dark) and after (light shaded) NB-UVB phototherapy. H1 –antihistamine, Depr–anti-depressive drugs, HTN–antihypertensive drugs (for details see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0181813#sec006" target="_blank">Methods</a>). Shown is the percentage of patients on treatment. *** p <0.0001 (Qui-square); bottom: the number of scripts per patient in patients receiving treatment (data shown represent average ± s.e.m.). * p < 0.01 in a two-sided T-test. B. Histogram plots showing the overall distribution of prescriptions filled for the topical treatment classes psoriasis before (solid) and after NB-UVB (dashed), respectively.</p

Study design.

<p>A. Timeline illustrating the 12-month pre-treatment and post-treatment periods, respectively, as well as the 16-week treatment interval (for details, see text). B. The distribution of the duration of NB-UVB treatment episodes across all patients. Dashed line: median (9.3 weeks). Solid line indicates the 16-week cut-off selected for beginning of the “post-treatment” observational window with n = 74 (4.2% of all) treatments exceeding this cut-off.</p

The change in psoriasis-specific drug prescribing before vs. after NB-UVB phototherapy in patients achieving different clinical outcomes.

<p>A. The percentage of patients in each outcome class showing either a decrease, or an increase in the number of prescriptions for each drug class indicated. Black columns: outcomes 0/1 (“clear”, “minimal residual disease”), dark grey: outcome 2 (“moderate clearance”), light grey: outcomes 3/4/5 (“minimal change”, “no change”, “worsening”). B The change in prescriptions made per patient, compared between after vs. before NB-UVB treatment (detailed in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0181813#pone.0181813.t003" target="_blank">Table 3</a>), expressed as percentage reduction compared to baseline, for each of the outcome classes, as in A. *** p < 0.0001, ** p < 0.001, * p < 0.01 (chi-square for the difference between the three outcome classes).</p