Effectiveness and safety of dupilumab in the treatment of atopic dermatitis in children (6-11 years): data from a French multicentre retrospective cohort in daily practice.

BACKGROUND: Dupilumab is the first biotherapy available for the treatment of moderate-to-severe childhood atopic dermatitis (AD). OBJECTIVE: The aim of this study was to evaluate the effectiveness and safety of dupilumab in daily practice. METHODS: Patients aged 6-11, who had received a first dose of dupilumab, were included in this multicentre retrospective cohort study. The primary endpoint was change in SCORAD after 3 months of treatment. Secondary endpoints were change in IGA score at 3 months, proportion of patients with SCORAD50 and SCORAD75, description of adverse events and proportion of children in our cohort who would be excluded from pivotal phase 3 clinical trial. RESULTS: Eighty patients were included. After 3 months of treatment, there was a significant decrease in SCORAD (mean: 21.8 ± 13.8 vs 53.9 ± 18.5; P < 0.0001) and IGA (1.3 ± 0.8 vs 3.5 ± 0.7; P < 0.0001). Conjunctivitis was observed in 11.3% (n = 9/80); three patients experienced dupilumab facial redness (DFR); 17.5% (n = 14/80) reported injection site reactions; 6.3% (n = 5/80) discontinued treatment. 61.2% (n = 49/80) children were ineligible in the phase 3 trial. LIMITATIONS: There is no control group. Because it was a real life study based on information from patient medical records in a French multicentre cohort, we cannot rule out the presence of reporting bias generated by the use of patient reported characteristics and missing information. CONCLUSION: These real-life data confirm the efficacy and safety of dupilumab in children with moderate to severe AD extended to dyshidrosis and atopic prurigo, but it also revealed a lower frequency of DFR and conjunctivitis. However, administration in injectable form may be a barrier in this age group.

[Early-onset melanoma (congenital, neonatal, infantile): A systematic review of literature cases]. / Les mélanomes d'apparition précoce (congénitaux, néonataux, du nourrisson) : revue systématique des cas de la littérature.

INTRODUCTION: Neonatal and infantile malignant melanoma is rare. It may be difficult to diagnose and often carries a poor prognosis. MATERIAL AND METHODS: We decided to review the data on congenital, neonatal and infantile malignant melanomas in order to understand their presentation (clinical, histological, molecular), diagnosis, management and outcomes. We performed a literature search of all cases of early-onset melanoma published in PubMed from its inception to March 2019 using the following keywords: "malignant melanoma" OR "melanoma" OR "pigmented nevus" OR "malignant pigmented" AND "infantile" OR "congenital" OR "children" OR "childhood" OR "infancy" OR "neonatal". Congenital melanoma associated with maternal-foetal transmission was not included in the study. RESULTS: Sixty-five articles were selected and 85 cases were included in the study. Most patients were male (sex ratio: 1.6). The average age at diagnosis was 5.5 months (minimum-maximum: 0-24 months). The main site reported for congenital melanoma was the head-and-neck area and for neonatal and infantile melanoma the trunk. Half of all patients had a metastatic disease at the time of diagnosis. In metastatic cases, the prognosis was poor with the exception of patients undergoing complete excision of the tumour and metastases. The main treatment for cutaneous melanomas and operable metastasis was surgery, and secondarily, chemotherapy/immunotherapy. CONCLUSION: Neonatal and infantile malignant melanoma are rarely reported and not well-documented. It is necessary to collect additional cases to improve our knowledge of this rare disease.

[The role of new molecular tests in the diagnosis of melanoma in a setting of congenital nævus in an infant]. / Apport des nouveaux tests moléculaires dans le diagnostic d'un mélanome sur nævus congénital chez un nourrisson.

INTRODUCTION: Congenital and infantile melanomas are extremely rare. We report a case of a child presenting at birth with a giant congenital nevus complicated by melanoma and on long-term follow-up with exploration using new immunohistochemistry and molecular biology tools. OBSERVATION: A new-born girl presented at birth with a large congenital cervico-mandibular tumour with para-pharyngeal extension and underlying osteolysis. At 7 months, histology and immunohistochemistry of the operative specimen revealed nodules with atypical features (mitotic figures, necrosis and positive expression of KI67 and P53 in approximatively 50 % of the melanocytic nuclei). A diagnosis was made of infantile melanoma associated with congenital nevi. Repeated surgery and monitoring (clinical and imaging) were performed. At the age of 7 years, as there was no evidence of metastatic lesions, further analyses were performed on the initial operative specimen. Investigation of transcription factor expression using immunohistochemistry, comparative genomic hybridization and histology-guided mass spectrometry, although suspect, did not in itself support a diagnosis of melanoma. Finally, at the age of 7 years, hepatic and pulmonary metastases were reported. Despite combined immunotherapy with ipilimumab and nivolumab, the child died 5 months later. CONCLUSION: This case illustrates the complexity of diagnosis of infantile melanoma and the risk of metastatic involvement long after the initial diagnosis. Diagnosis may be difficult and necessitates expert advice and the application of several recent methods to reach a conclusion and initiate appropriate treatment.

Users of biologics in clinical practice: would they be eligible for phase III clinical studies? Cohort Study in the French Psoriasis Registry PSOBIOTEQ.

BACKGROUND: Numerous inclusion and exclusion criteria are involved in phase III moderate to severe psoriasis trials investigating the safety and efficacy of biologics. This questions the generalization of results. METHODS: In this cohort study, we applied inclusion/exclusion criteria for phase III trials from original protocols (adalimumab - REVEAL, ustekinumab - PHOENIX, brodalumab - AMAGINE, secukinumab FIXTURE) to all patients enrolled in the PsoBioTeq prospective registry who received a biological agent for the first time between July 2012 and November 2017. We then compared the efficacy, drug survival and occurrence of adverse events between patients who satisfied/did not satisfy the eligibility criteria for these phase III trials. RESULTS: A total of 1267 patients were enrolled, of whom 993 (78.4%) were not eligible for at least one RCT (randomized controlled trial) and 251 (19.1%) did not meet the PASI/PGA severity requirements. Apart from disease severity, the most frequent criteria resulting in exclusion were as follows: non-plaque psoriasis (12.6%), significant cardiac disease (8.4%), significant liver disease (7.3%), elevated liver enzymes (4.9-9.6%) and personal history of diabetes (9.2%). There was no difference in drug survival between the two groups. The incidence ratio of adverse events was significantly lower in eligible versus non-eligible patients [0.78 (95% CI 0.62-0.97) (P = 0.03)]. CONCLUSION: The majority of patients treated with biologics in the PsoBioTeq real-life registry would not have been eligible for phase III moderate to severe psoriasis trials. Patients not eligible for psoriasis phase III clinical trials have a higher incidence of adverse events.

Early relapse of psoriasis after stopping brodalumab: a retrospective cohort study in 77 patients.

BACKGROUND: Biological agents targeting IL-17 are very effective for clearing moderate to severe psoriasis. There is limited information regarding the frequency and pattern of psoriasis relapse upon treatment cessation. OBJECTIVE: To investigate the pattern of psoriasis recurrence in patients who were treated with brodalumab following Amgen's decision to stop the clinical programme in June 2015. MATERIALS AND METHODS: Between June 2015 and March 2016, we constructed a retrospective multicenter cohort study including patients who were treated with brodalumab in Amgen's protocols after the abrupt interruption of the drug development programme. The relapse was defined as the request of patient to initiate a new treatment after brodalumab withdrawal. RESULTS: Seventy-seven patients were followed up. At the time brodalumab treatment was stopped, 67 (87%) patients had reached PASI 90. After brodalumab discontinuation, all 77 patients relapsed after a follow-up of 9 months. The median time to relapse was 46 days (range 7-224 days). Concerning the type of relapse, 73 patients presented with plaque psoriasis, one patient presented with erythrodermic psoriasis, and three patients experienced pustular psoriasis. In seven patients who had no previous history of psoriatic arthritis (PsA), the relapse of psoriasis was associated with inflammatory joint pain suggestive of PsA. At week 36, eight patients who had a limited relapse were controlled with topical treatment, 43 patients received a biological agent, two patients were included in a clinical trial with an investigational drug and 15 patients were treated with conventional systemic agents. CONCLUSION: Abrupt cessation of brodalumab is associated with a rapid relapse of psoriasis with some patients experiencing a rebound. It seems not advisable to stop treatment with IL-17 receptor antagonists abruptly even in patients who experience complete clearance of psoriasis.

[Irritant contact dermatitis caused by direct contact with oleander (Nerium oleander)]. / Dermatite irritative par contact direct avec du laurier rose (Nerium oleander).

BACKGROUND: Although the oleander plant is practically ubiquitous throughout the Mediterranean area, very few publications refer to its cutaneous toxicity. PATIENTS AND METHODS: Herein, we report two cases of irritant contact dermatitis caused by oleander. The patients in question were twins who had oleander leaves applied directly to their face for 20minutes. The initial lesions consisted of periorbital erythema, followed by the emergence of papules and macules. Vesicles and crusts appeared over the ensuing 24hours. Treatment included withdrawal of the toxic agent, prescription of oral antihistamines, and the topical application of dermocorticoids to the lesions for two weeks. The outcome on the 9th day was slightly hypochromic and atrophic. Complete restitutio ad integrum of the skin was observed after 30 days. DISCUSSION: In our patients, a joint effect of ultraviolet radiation (phytophotodermatitis) and chlorine from the swimming pool cannot be ruled out. Although the substances present in oleanders (irritant saponins and glycosides) can cause chemical irritant dermatitis, immunological reactions cannot be excluded. The lack of signs of systemic toxicity observed is the result of the factors governing transdermal diffusion of the toxic glycosides found in oleander. CONCLUSION: These two cases provide a timely reminder, both for the general public and for healthcare professionals, of the potential biohazards of oleander, not only because of its systemic toxicity but also because of the risks associated with cutaneous exposure.

Nitrogen excretion and changes in blood components during emersion of the subtidal spider crab Maia squinado (L.).

Survival ability of Maia squinado to emersion and subsequent reimmersion was determined in winter and summer conditions. Male spider crabs were less tolerant of emersion than females. Emersion (up to 24 h in summer and to 48 h in winter) induced a marked reduction of nitrogen excretion, especially ammonia excretion. Increase in blood ammonia content was rapid and very high in summer (1750 micromol l(-1)), but non-lethal levels. Estimation of the body ammonia overload showed that only 30% of unexcreted ammonia accumulated in blood. The ammonia release at reimmersion indicated that ammonia also accumulated in other body compartments. Increase in blood urate content, which indirectly reduces ammonia production, was similar at both seasons. Emersed M. squinado was rapidly resorting to anaerobic metabolism, especially in summer when its blood haemocyanin content is low. A strong hyperglycemia was developed in the first 12 h of emersion at both seasons. Mortality occurring beyond 24 h of reimmersion, when the body ammonia overload is cancelled and the recovery of most of blood components is achieved, remains unexplained.

Nitrogen metabolites and related enzymatic activities in the body fluids and tissues of the hydrothermal vent tubeworm Riftia pachyptila.

The distribution of nitrogen metabolism end-products and the associated enzyme activities, free amino acids and purine base catabolites were investigated in all the body compartments (circulating fluids and tissues) of the hydrothermal vent tubeworm Riftia pachyptila to acquire a general overview of nitrogen metabolism in this symbiotic organism. There were striking differences between the symbiont-containing trophosome tissue and other host tissues. High concentrations of ammonia, creatinine and, in particular, urate were found in all tissues, but they were present at consistently higher concentrations in the trophosome, which also contained large amounts of urea. Uric acid crystals were present at the periphery of trophosome lobules. The urea cycle appears to be fully functional in this tissue, which also uses creatine phosphate for phosphagen storage, while arginine phosphate or a combination of both phosphagens occurs in other tissues. The amino acid patterns are dominated by sulphated compounds in all tissues except the trophosome, which has high levels of aspartate and glutamate. Although no definitive conclusions could be drawn regarding the nitrogen regime of Riftia pachyptila, this in vitro study gives several indications for future research in this area.

Increases in tissue free amino acid levels in response to prolonged emersion in marine crabs: an ammonia-detoxifying process efficient in the intertidal Carcinus maenas but not in the subtidal Necora puber.

Carcinus maenas and Necora puber were exposed to air for 72 h and 18 h, respectively, at 18 °C. Changes in the free amino acid (FAA) content of their muscle, hepatopancreas and haemolymph were recorded during air-exposure and subsequent reimmersion. Muscle and hepatopancreas urate contents and haemolymph serum protein levels were also measured during emersion. In air-exposed C. maenas, the muscle FAA pool increased significantly within the first 24 h of emersion. This increase was due to an increase in the non-essential amino acid (NEAA) pool only; the essential amino acid (EAA) pool did not change. In haemolymph, the EAA pool decreased during the first 24 h of emersion, whereas the FAA and NEAA pools did not change. However, in this compartment, glutamine levels increased throughout the air-exposure period. No significant changes in FAA, NEAA and EAA contents of the hepatopancreas were observed during the 72 h emersion. In air-exposed N. puber, the FAA pools of muscle and hepatopancreas did not change, although changes in the levels of some amino acids were observed during the 18 h emersion period. In this species, large increases in both the NEAA and EAA pools in the haemolymph were recorded. High levels of urate were observed in the muscle and hepatopancreas of immersed N. puber, but no significant changes occurred during emersion. In contrast, immersed C. maenas exhibited low levels of urate in both compartments, and hepatopancreas urate levels increased slightly during emersion. Haemolymph protein content did not change in air-exposed N. puber, whereas it increased in the haemolymph of 72 h emersed C. maenas. The origin of newly formed NEAAs and their role in ammonia detoxification, particularly in C. maenas, which is able to regulate its internal ammonia levels during such a prolonged emersion, are discussed.

Nitrogen metabolism of two portunid crabs, carcinus maenas and necora puber, during prolonged air exposure and subsequent recovery: a comparative study

Carcinus maenas and Necora puber were exposed to air for 72 h and 18 h, respectively, at 18 degreesC. Nitrogen excretion, blood and muscle ammonia content and blood urate and lactate content were recorded throughout the experimental emersion and following reimmersion (recovery period). During emersion, the rate of ammonia excretion was strongly reduced in both species, while urea and amine excretion were not enhanced. Blood and muscle ammonia content increased steadily, reaching 1.3 and 10.4 mmol l-1, respectively, after an 18 h emersion in N. puber. In contrast, in C. maenas, blood ammonia levels increased slightly during the first 12 h and then remained at this level (approximately 0.12 mmol l-1) until the end of emersion. Muscle ammonia content showed a non-significant increase at 12 h, after which values returned to control values (3.3 mmol l-1) for the next 60 h. Blood urate and lactate content increased in emersed N. puber, indicating strong internal hypoxia, but urate content did not increase in C. maenas until the third day of emersion. Upon reimmersion, both species released large amounts of ammonia within a few minutes. Two different patterns of ammonia release then were observed: ammonia excretion was enhanced for a further 3 h in N. puber, whereas raised ammonia excretion rates were observed for a further 24 h in C. maenas. These patterns, the recovery of blood and muscle ammonia levels and the calculated nitrogen balance between emersed and control crabs indicated that specific processes were used to manage the nitrogen overload induced by air exposure. Whereas N. puber shows little or no ability to limit ammonia accumulation in its body, C. maenas exhibits strong regulation of its nitrogen metabolism. The probability that amino acid synthesis is involved in this regulation and whether these species use metabolic depression as a survival strategy are discussed.

Effect of air exposure on nitrogen metabolism in the crab Cancer pagurus.

In C. pagurus exposed to air for 18 h, blood ammonia content decreased within the 2 first hours, then increased at a relatively constant rate (25 microM/h); blood urate content increased at a lower rate (10 microM/h) and a classical blood acidosis was observed. In the cheliped muscle, a transient 22% decrease in GDH activity for ammonia formation and a 48% increase in GDH activity in the reverse reaction (glutamate synthesis) occurred following 6 and 12 h of emersion, respectively. Changes in LDH activity, used as an indicator of anaerobic potential of muscle, were not observed, except for an 18% increase in crabs exposed to air for 24 h. The increase in blood urate content, not known as a response to emersion in decapods, appeared to be different from that observed in response to hypoxia. The relatively low blood ammonia overload and the GDH increased activity for glutamate synthesis suggested that part of the produced ammonia was stored under a bound form in some tissues. The response of C. pagurus to air exposure is discussed on account of the Storey and Storey ('90) theory.