Dallas Nephrology Associates

Background Cutaneous squamous cell carcinoma (cSCC) causes more annual mortality than metastatic melanoma. However, risk stratification protocols remain based solely on clinicopathologic features, excluding tumor biology. (Table 1) Objective To illustrate how integration of 40-gene expression profile (GEP) testing influences prognostic assessment and post-treatment management in high-risk cSCC. Methods We present a case report of a 70-year-old male whose incidental cSCC was reclassified as high-risk following 40-GEP testing despite histologic clearance, resulting in enhanced surveillance. Results Tumor profiling yielded a Class 2A (higher risk) result, which altered post-operative follow-up strategies beyond conventional staging. Conclusion Gene expression profiling provides valuable, individualized prognostic data, which may improve management of high-risk cSCC patients and should be considered for broader integration into clinical guidelines.

Erythrokeratodermia cardiomyopathy (EKC) syndrome is a rare autosomal dominant disorder characterized by generalized erythrokeratoderma and progressive dilated cardiomyopathy, caused by pathogenic variants in the SR6 domain of desmoplakin (DSP). We report two cases of EKC with novel de novo missense DSP variants at phenylalanine position 590 (F590S and F590V), expanding the mutational spectrum beyond proline substitutions. Immunostaining demonstrated disrupted desmosomal protein localization. One patient showed significant clinical improvement with ustekinumab therapy. These findings underscore the need for early cardiac monitoring and support IL-12/23p40 inhibition as a potential therapeutic strategy in EKC.

In 2016, Dallas Nephrology Associates recognized that the economic, humanistic, and societal burden of end-stage kidney disease was unsustainable and the fee-for-service model of reimbursement did not support a value-based care approach. We decided to be proactive by creating new workflows, education, and disease management so that patients could make well-informed choices, ultimately resulting in better outcomes. Our shift toward value-based care focused on patient engagement, education, integrated infrastructure, collaboration, and monitoring of metrics associated with improved outcomes. Our practice invested millions of dollars in a population health division, which includes nurse navigators and data analysts focused on managing chronic kidney disease (CKD), delaying progression, and promoting transplantation and home-based dialysis. This retrospective review demonstrates improved outcomes, lower costs, and increased quality of care. Performance metrics have consistently met or exceeded targets. Seventy-three percent of patients now experience an optimal planned start to dialysis. Preemptive transplantation referrals have increased from 7% in 2017 to 61% through June 2023. Referral of patients with stage 4 CKD to educational workshops increased from 38% to 68%, and medical nutrition therapy referrals increased from 23% to 67%. Although reimbursement challenges persist, our commitment to improving care and slowing CKD progression remains steadfast. We emphasize teamwork, robust analytics, and continuous improvement. Future initiatives include encouraging patients receiving in-center hemodialysis to convert to home-based dialysis, addressing behavioral health, and focusing on preventable complications in high-risk patients. By embracing value-based models, we have demonstrated that a patient-centered approach can lead to improved outcomes and value for payers.

Abstract BackgroundPeople with genital psoriasis may avoid close social interactions (hugs, handshakes, kisses, touching others, or being touched), which can have a significant impact on quality of life. Ixekizumab, an interleukin 17A antagonist, demonstrated rapid and persistent improvement in moderate‐to‐severe genital psoriasis through 52 weeks in a phase 3 trial (IXORA‐Q).ObjectivesTo evaluate general touch avoidance (TA) in patients with moderate‐to‐severe genital psoriasis treated with ixekizumab through 52 weeks in the IXORA‐Q trial.MethodsIn IXORA‐Q (NCT02718898), adult patients received 80 mg ixekizumab every 2 weeks (IXE Q2W, N = 75) or placebo (PBO, N = 74) for 12 weeks. At Week 12, all patients received open‐label 80 mg ixekizumab every 4 weeks (IXE Q4W) through Week 52, with an opportunity to escalate dosing to Q2W at Weeks 24, 28, or 40. Patients used a numeric rating scale (NRS) to self‐report the degree of TA experienced over the past 2 weeks (score of 0 [not at all] to 10 [very much]). Outcomes included TA NRS score change from baseline and the proportion of patients achieving a TA NRS score of 0 through Week 52. Correlations between TA NRS scores and psoriasis outcomes were also examined.ResultsMean (standard deviation) baseline TA NRS score was 2.7 (3.3) for IXE Q2W and 3.0 (3.5) for PBO. Among patients with a baseline TA NRS score >0, mean (standard deviation) change from baseline at Week 52 (where a lower score indicates greater improvement) and the proportion of patients who achieved a TA NRS score of 0 at Week 52 were −4.4 (3.2) [78.0%] for patients treated continuously with ixekizumab (Q2W then Q4W, N = 41) and −4.1 (3.6) [62.5%] for PBO/IXE Q4W (N = 40). TA NRS score improved in parallel with the majority of psoriasis outcomes examined, with the strongest positive association between the TA NRS score and Dermatology Life Quality Index total score.ConclusionsAmong patients with moderate‐to‐severe genital psoriasis, ixekizumab treatment achieves continued sustained improvement in general TA to 52 weeks.