Anakinra for palmoplantar pustulosis: results from a randomized, double-blind, multicentre, two-staged, adaptive placebo-controlled trial (APRICOT)

BACKGROUND

Palmoplantar pustulosis (PPP) is a rare, debilitating, chronic inflammatory skin disease that affects the hands and feet. Clinical, immunological and genetic findings suggest a pathogenic role for interleukin (IL)-1.

OBJECTIVES

To determine whether anakinra (an IL-1 receptor antagonist) delivers therapeutic benefit in PPP.

METHODS

This was a randomized (1 : 1), double-blind, two-staged, adaptive, UK multicentre, placebo-controlled trial [ISCRTN13127147 (registered 1 August 2016); EudraCT number: 2015-003600-23 (registered 1 April 2016)]. Participants had a diagnosis of PPP (> 6 months) requiring systemic therapy. Treatment was 8 weeks of anakinra or placebo via daily, self-administered subcutaneous injections. Primary outcome was the Palmoplantar Pustulosis Psoriasis Area and Severity Index (PPPASI) at 8 weeks.

RESULTS

A total of 374 patients were screened; 64 were enrolled (31 in the anakinra arm and 33 in the placebo arm) with a mean (SD) baseline PPPASI of 17·8 (10·5) and a PPP investigator's global assessment of severe (50%) or moderate (50%). The baseline adjusted mean difference in PPPASI favoured anakinra but did not demonstrate superiority in the intention-to-treat analysis [-1·65, 95% confidence interval (CI) -4·77 to 1·47; P = 0·30]. Similarly, secondary objective measures, including fresh pustule count (2·94, 95% CI -26·44 to 32·33; favouring anakinra), total pustule count (-30·08, 95% CI -83·20 to 23·05; favouring placebo) and patient-reported outcomes, did not show superiority of anakinra. When modelling the impact of adherence, the PPPASI complier average causal effect for an individual who received ≥ 90% of the total treatment (48% in the anakinra group) was -3·80 (95% CI -10·76 to 3·16; P = 0·285). No serious adverse events occurred.

CONCLUSIONS

No evidence for the superiority of anakinra was found. IL-1 blockade is not a useful intervention for the treatment of PPP.

Malakoplakia of the parotid gland: a case report and review of localised malakoplakia of the head and neck

INTRODUCTION

Malakoplakia is a rare chronic inflammatory disorder, predominantly affecting the urinary tract. In the head and neck region, it is very rare and may confuse the clinicians during investigations, as features may mimic malignancy.

MATERIALS AND METHODS

We report a case of malakoplakia involving the parotid gland and review of the reported cases of malakoplakia in head and neck region.

RESULTS

Histologically, this is the first classic case report of malakoplakia involving the parotid gland in the world literature. A total of 49 cases have been reported in the head and neck region; 38.7% of these are cutaneous. In soft tissue, the tongue is the most common site. Salivary gland involvement is very rare. Previously, submandibular salivary gland involvement has been reported.

CONCLUSION

A possibility of malakoplakia should be considered as a differential diagnosis in patients with enlarged head and neck masses. Histology is essential to diagnose this benign inflammatory disorder and to differentiate from a malignant process.

Recommendation to test limonene hydroperoxides 0·3% and linalool hydroperoxides 1·0% in the British baseline patch test series

BACKGROUND

There is a significant rate of sensitization worldwide to the oxidized fragrance terpenes limonene and linalool. Patch testing to oxidized terpenes is not routinely carried out; the ideal patch test concentration is unknown.

OBJECTIVES

To determine the best test concentrations for limonene and linalool hydroperoxides, added to the British baseline patch test series, to optimize detection of true allergy and to minimize irritant reactions.

METHODS

During 2013-2014, 4563 consecutive patients in 12 U.K. centres were tested to hydroperoxides of limonene in petrolatum (pet.) 0·3%, 0·2% and 0·1%, and hydroperoxides of linalool 1·0%, 0·5% and 0·25% pet. Irritant reactions were recorded separately from doubtful reactions. Concomitant reactions to other fragrance markers and clinical relevance were documented.

RESULTS

Limonene hydroperoxide 0·3% gave positive reactions in 241 (5·3%) patients, irritant reactions in 93 (2·0%) and doubtful reactions in 110 (2·4%). Linalool hydroperoxide 1·0% gave positive reactions in 352 (7·7%), irritant reactions in 178 (3·9%) and doubtful reactions in 132 (2·9%). A total of 119 patients with crescendo reactions to 0·3% limonene would have been missed if only tested with 0·1% and 131 patients with crescendo reactions to 1·0% linalool would have been missed if only tested with 0·25%. In almost two-thirds of patients with positive patch tests to limonene and linalool the reaction was clinically relevant. The majority of patients did not react to any fragrance marker in the baseline series.

CONCLUSIONS

We recommend that limonene hydroperoxides be tested at 0·3% and linalool hydroperoxides at 1·0% in the British baseline patch test series.

Orofacial granulomatosis related to amalgam fillings

This paper reports on a case of Orofacial Granulomatosis (OFG) in which the presence of amalgam fillings appears to have played a part in the aetiology. Once these restorations were removed and replaced with an alternative composite restorative material, all symptoms and signs of OFG resolved completely. This case highlights the necessity to include dental metals in the patch test battery when performing delayed patch testing on patients with OFG.

Abstract P5-10-18: Echocardiography on Neonates Exposed to Anthracycline Therapy In Utero for Maternal Breast Cancer

Background: Anthracycline therapy carries a risk for cardiac toxicity in pediatric and adult populations. It is unknown if this risk also applies to fetuses exposed in utero. The objective of this study is to evaluate the cardiac function of neonates exposed to anthracyclines in utero. Materials and Methods: This was an observational study. Pregnant women diagnosed with breast cancer who underwent anthracycline based chemotherapy and delivered a liveborn infant after 24 weeks, were offered enrollment. Patients provided written consent to obtain doses and dates of chemotherapy treatment. Echocardiograms were offered to all newborns exposed as fetuses to anthracyclines. Women chose to perform this echocardiogram locally or at the institution of the primary investigator. Baseline fetal cardiac evaluation was reportedly normal on ultrasound prior to starting chemotherapy.

Chemotherapy Regimens:

Adriamycin/Cytoxan (n=20).

5-Fluorouracil/Adriamycin/Cytoxan (n=3)

There were no cases of exposure to epirubicin or idarubicin.

Mean dosage of Adriamycin was 57/m2 +/−8.0.

Results: Twenty three neonates participated.

Neonatal echocardiograms done at a mean age of 15 +/−26 months, (range 3 days of life to 9.75 years). RV wall, IVS and LV posterior wall diastolic and systolic thickness measurements were within normal limits for age and BSA. Mean shortening fraction was 41+/−10%. (normal 33 +/− 3%). In all 23, AV and semilunar valves were normal. Great arteries were normal in 22/23, with one case of a small pulmonary artery fistula. At 2 years of age, this was not hemodynamically significant. Patent foramen ovale was noted in 4 cases, all in children less than 2.0 months of age. Two children ages 3 days to 1.4 months had a PDA. One child at 1 year of age had an ASD. No structural or functional heart defects were diagnosed in any of these children.

Discussion:

Cardiac function appears to be preserved in neonates exposed to adriamycin chemotherapy in utero.

Any toxic effects on fetal myocytes was not evident in postnatal echocardiograms.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-10-18.

Diaphragmatic hernia

We describe a case of acute dyspnea in a patient with Marfan syndrome secondary to bowel herniation into the thoracic cavity.

Levels of dioxins and dibenzofurans in breast milk of women residing in two cities in the Irkutsk Region of Russian Siberia compared with American levels

The presence of dioxins, dibenzofurans, and polychlorinated biphenyls (PCBs) in human tissue, food, and environmental samples from Russia has been monitored since 1988 as part of a research collaboration between a number of countries including Finland, the United States, Germany, the former Soviet Union, and Canada. Although elevated TCDD and PnCDD levels have previously been found in blood of male and female Russian chemical manufacturing workers and in their children, dioxin levels in the general population have usually been found to be lower than in Americans and Europeans. This study continues earlier work in the Irkutsk region of Russian Siberia, where we report levels of dioxin, dibenzofurans, and PCBs in human milk samples taken from general population women living in the industrialized cities of Angarsk and Usolye-Sibirskoye, near Lake Baikal. Total polychlorinated dibenzo-p-dioxin (PCDD) toxic equivalents (TEQs) compared in this paper for the industrialized regions of Siberia, Ukraine, and the US are similar, ranging from 6.1 to 7 parts per trillion (ppt). Recent 1998 milk samples from Angarsk and Usolye-Sibirskoye have total mean polychlorinated dibenzofuran (PCDF) TEQs of 10 and 21.7 ppt, respectively, with the other industrialized countries ranging from 2.3 to 6.7 ppt. Although dioxin-like PCBs were not measured for the city of Usolye-Sibirskoye (1998), total mean PCDD/F TEQ from Angarsk and Usolye-Sibirskoye (1998) were the two highest levels in this study, with 26.9 and 28.5 ppt, respectively, followed by 1993-1994 Ukraine samples with 24 ppt, 1989 Siberian samples with 13.6 ppt, and 1996 USA with 11.4 ppt total TEQ. In this study, higher levels of dioxins are noted in milk from Angarsk and Usolye-Sibirskoye than found in earlier Russian studies, with mean levels also exceeding 1996 and 1999 US breast milk dioxin levels.

Transient first-degree atrioventricular block following intercostal nerve block for vascular ring repair

Transient first-degree heart block developed following surgery to divide a vascular ring. This unusual complication was related to autonomic impairment secondary to a local nerve block. The role of the autonomic innervation of the atrioventricular node and the potential role of the local anesthetic are reviewed.

Placenta percreta with bladder invasion as a cause of life threatening hemorrhage

PURPOSE

Abnormal placental penetration through the myometrium with bladder invasion is a rare obstetric complication with potential for massive blood loss. Urologists are usually consulted after a life threatening emergency has already arisen. Their familiarity with this condition is crucial for effective management. We describe 2 cases of placenta percreta with bladder invasion to highlight the catastrophic nature of this clinical entity, and review the literature on current diagnostic and management strategies.

MATERIALS AND METHODS

Between 1986 and 1998, 250 cases of adherent placenta (0.9%) were identified in 25,254 births at our institution, including 2 (0.008%) of placenta percreta with bladder invasion. We treated these 2 multiparous women who were 33 and 30 years old, respectively. Each had undergone 2 previous cesarean sections.

RESULTS

Presenting symptoms were severe hematuria in 1 patient and prepartum hemorrhage with shock in the other. Ultrasound showed complete placenta previa in each with evidence of bladder invasion in 1 patient. Hysterectomy, bladder wall resection and repair, and bilateral internal iliac artery ligation were required to control massive intraoperative hemorrhage. The patients received 22 and 15 units of packed red blood cells, respectively. Fetal death occurred in each case. Convalescence was complicated by disseminated intravascular coagulation in patient 1 but subsequent recovery was uneventful.

CONCLUSIONS

A high index of suspicion for placenta percreta with bladder invasion is required when evaluating pregnant women with a history of cesarean delivery and placenta previa who present with hematuria and lower urinary tract symptoms. Ultrasonography and magnetic resonance imaging may assist in establishing the diagnosis preoperatively. With proper planning and a multidisciplinary approach fetal and maternal morbidity and mortality may be decreased.