Regulatory T cells (Treg cells) are important for preventing autoimmunity and maintaining tissue homeostasis, but whether Treg cells can adopt tissue-or immune-context-specific suppressive mechanisms is unclear. Here, we found that the enzyme hydroxyprostaglandin dehydrogenase (HPGD), which catabolizes prostaglandin E 2 (PGE 2 ) into the metabolite 15-keto PGE 2 , was highly expressed in Treg cells, particularly those in visceral adipose tissue (VAT). Nuclear receptor peroxisome proliferator-activated receptor-g (PPARg)-induced HPGD expression in VAT Treg cells, and consequential Treg-cell-mediated generation of 15-keto PGE 2 suppressed conventional T cell activation and proliferation. Conditional deletion of Hpgd in mouse Treg cells resulted in the accumulation of functionally impaired Treg cells specifically in VAT, causing local inflammation and systemic insulin resistance. Consistent with this mechanism, humans with type 2 diabetes showed decreased HPGD expression in Treg cells. These data indicate that HPGD-mediated suppression is a tissue-and context-dependent suppressive mechanism used by Treg cells to maintain adipose tissue homeostasis. (C) Time course of relative HPGD mRNA expression in human Treg and Tconv cells in the presence of IL-2. (D) Immunoblotting for HPGD (top) and b-actin (bottom) in human Treg and Tconv cells after isolation (0 h) or cultivated for 48 or 72 h without stimulation (unstim) or stimulated with IL-2 (left) and densitometric analysis (right). (E and F) Relative HPGD mRNA expression in unstimulated or IL-2-stimulated human Treg cells cultured for 24 h in the presence of DMSO (control) or increasing doses of a STAT5 inhibitor (E) or JAK3 inhibitor (F). (G) ChIP qPCR analysis of human IL-2-stimulated Treg and Tconv cells with a STAT5-specific antibody. Relative enrichment of STAT5 ChIP over input normalized to immunoglobulin G (IgG) is shown. (H and I) IL-2-and STAT5-dependent activation of luciferase reporter constructs. (H) IL-2-induced HPGD promoter activity. (I) STAT5-dependent HPGD induction. (J) ChIP qPCR analysis of human expanded cord blood Treg cells with a FOXP3-specific antibody. Relative enrichment of FOXP3 ChIP over input normalized to IgG was calculated. A region within intron 4 was used as a negative control. (K) Luciferase assay of FOXP3 binding to the respective BRs at the HPGD locus. Numbers indicate Foxp3-binding motifs within each region. (L) Relative HPGD mRNA expression in human Treg cells after silencing of FOXP3. Treg cells were transfected and cultivated for 48 h without stimulation. (A, B, G, J, and L) *p < 0.05 (paired Student's t test); (C) *p < 0.05 (two-way ANOVA with false-discovery rate [FDR]); (D-F) *p < 0.05 (one-way ANOVA with FDR); (H) *p < 0.05 (Mann-Whitney U test); (I and K) *p < 0.05 (unpaired Student's t test). Data are representative of fourteen experiments (A; mean and SEM), six experiments (B; mean and SEM), two to five experiments (L; mean and SEM), four experiments (C-F; mean and SEM), three experiments (G and J; mean and SEM), each with ...

IMPORTANCE Several studies have linked chronic inflammatory skin diseases (CISDs) with venous thromboembolism (VTE) in a range of data sources with mixed conclusions. OBJECTIVE To examine the incidence of VTE in patients with vs without CISD. DESIGN, SETTING, AND PARTICIPANTSA cohort study using commercial insurance claims data from a nationwide US health care database from January 1, 2004, through 2019 was conducted. A total of 158 123 patients with dermatologist-recorded psoriasis, atopic dermatitis, alopecia areata, vitiligo, or hidradenitis suppurativa were included. Risk-set sampling identified patients without a CISD. Patient follow-up lasted until the first of the following occurred: VTE, death, disenrollment, or end of data stream. EXPOSURES Patients with vs without CISD.MAIN OUTCOMES AND MEASURES Venous thromboembolism events were identified with validated algorithms. Incidence rates were computed before and after 1:1 propensity-score matching to account for VTE risk factors. Hazard ratios were estimated to compare the incidence of VTE in the CISD vs non-CISD cohorts.RESULTS A total of 158 123 patients were identified with CISD: with psoriasis (n = 96 138), atopic dermatitis (n = 30 418), alopecia areata (n = 17 889), vitiligo (n = 7735), or HS (n = 5934); 9 patients had 2 of these conditions. A total of 1 570 387 patients were without a CISD. The median follow-up time was 1.9 years (interquartile range, 0.8-4.0 years) in patients with CISD. The incidence rate (per 1000 person-years) of outpatient or inpatient VTE was 1.57 in psoriasis, 1.83 in atopic dermatitis, 0.94 in alopecia areata, 0.93 in vitiligo, 1.65 in HS and 1.53 in CISD overall, compared with 1.76 in patients without a CISD. Incidence rates increased in patients aged 50 years or older (2.3 per 1000 person-years) and decreased in those aged 18 to 49 years (0.8 per 1000 person-years). After propensity-score matching to patients without a CISD, the hazard ratio (HR) of VTE was 0.86 (95% CI, 0.75-0.99) in psoriasis, 1.19 (95% CI, 0.95-1.48) in atopic dermatitis, 0.97 (95% CI, 0.65-1.46) in alopecia areata, 0.90 (95% CI, 0.49-1.65) in vitiligo, 1.64 (95% CI, 0.82-3.27) in hidradenitis suppurativa, and 0.94 (95% CI, 0.84-1.05) in CISD overall. CONCLUSIONS AND RELEVANCEIn this large-scale cohort study, CISDs were not associated with an increased incidence of VTE after controlling for relevant VTE risk factors in a representative dermatology patient population.

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The small improvement in metabolic screening immediately after the 2004 ADA guidelines were issued was not sustained. Overall, metabolic screening rates remained suboptimal throughout the study period.

Purpose: To understand the validity of real-world evidence (RWE) studies in ulcerative colitis (UC), we emulated the SUCCESS randomized controlled trial (RCT) on the effectiveness of infliximab plus thiopurines, using US and French healthcare insurance claims data.Methods: The SUCCESS trial showed improved remission with infliximab plus thiopurines combined compared to infliximab monotherapy in patients with UC. Based on two US commercial claims databases (IBM MarketScan and Optum) and the French nationwide health insurance database (SNDS) from 2004 through 2019, all patients with UC who initiated combination therapy or infliximab alone were identified. The primary outcome of treatment failure was emulated by: Hospitalization related to UC or colectomy, treatment switch to another biologic or immunosuppressant, or use of corticosteroids 16 weeks after infliximab initiation. We estimated risk ratios with 95% confidence intervals after 1:1 propensity score (PS) matching.Results: Among 620 PS-matched pairs of combination therapy and infliximab monotherapy users, treatment failure occurred in 124 (20%) of patients initiating combination therapy and 170 (27%) during monotherapy. Like in SUCCESS, the risk of treatment failure was decreased with combination therapy in the overall cohort

2.Fossa AJ, Bell SK, DesRoches C. OpenNotes and shared decision making: a growing practice in clinical transparency and how it can support patient-centered care.

Background Several studies have linked various chronic inflammatory skin diseases (CISDs) with inflammatory bowel disease (IBD) in a range of data sources with mixed conclusions. Objectives We compared the incidence of IBDulcerative colitis (UC) and Crohn disease (CD)in patients with a CISD vs. similar persons without a CISD. Methods In this cohort study using nationwide, longitudinal, commercial insurance claims data from the USA, we identified adults and children who were seen by a dermatologist between 2004 and 2020, and diagnosed with either psoriasis, atopic dermatitis, alopecia areata, vitiligo or hidradenitis suppurativa. Comparator patients were identified through risk-set sampling; they were eligible if they were seen by a dermatologist at least twice and not diagnosed with a CISD. Patient follow-up lasted until either IBD diagnosis, death, disenrolment or end of data stream, whichever came first. IBD events, UC or CD, were identified via validated algorithms: hospitalization or diagnosis with endoscopic confirmation. Incidence rates were computed before and after adjustment via propensity-score decile stratification to account for IBD risk factors. Hazard ratios (HR) and 95% confidence intervals (CIs) were estimated to compare the incidence of IBD in CISD vs. non-CISD. Results We identified patients with atopic dermatitis (n = 123 614), psoriasis (n = 83 049), alopecia areata (n = 18 135), vitiligo (n = 9003) or hidradenitis suppurativa (n = 6806), and comparator patients without a CISD (n = 2 376 120). During a median follow-up time of 718 days, and after applying propensity-score adjustment for IBD risk factors, we observed increased risk of both UC (HR UC 2Á30, 95% CI 1Á61-3Á28) and CD (HR CD 2Á70, 1Á69-4Á32) in patients with hidradenitis suppurativa, an increased risk of CD (HR CD 1Á23, 1Á03-1Á46) but not UC (HR UC 1Á01, 0Á89-1Á14) in psoriasis, and no increased risk of IBD in atopic dermatitis (HR UC 1Á02, 0Á92-1Á12; HR CD 1Á08, 0Á94-1Á23), alopecia areata (HR UC 1Á18, 0Á89-1Á56; HR CD 1Á26, 0Á86-1Á86) or vitiligo (HR UC 1Á14, 0Á77-1Á68; HR CD 1Á45, 0Á87-2Á41).Conclusions IBD was increased in patients with hidradenitis suppurativa. CD alone was increased in patients with psoriasis. Neither UC nor CD was increased in patients with atopic dermatitis, alopecia areata or vitiligo.