Laboratory Safety of Dupilumab in Patients Aged 6-11 Years with Severe Atopic Dermatitis: Results from a Phase III Clinical Trial

BACKGROUND

Previous studies of dupilumab in adolescents and adults with moderate-to-severe atopic dermatitis (AD) showed no clinically meaningful adverse changes in laboratory parameters.

OBJECTIVE

The aim of this study was to assess laboratory outcomes in children aged 6-11 years with severe AD in a randomized, placebo-controlled, phase III trial of dupilumab.

METHODS

Children aged 6-11 years with severe AD were randomized 1:1:1 to 16 weeks of dupilumab 300 mg every 4 weeks, 100 or 200 mg every 2 weeks, or matching placebo, all with concomitant topical corticosteroids (TCS). Blood samples were collected at baseline and Weeks 4, 8, and 16; urine samples were collected at baseline and Weeks 4 and 16.

RESULTS

Of 367 patients enrolled in the study, 362 were included in the safety analysis, 351 completed study treatment, and 4 withdrew due to treatment-emergent adverse events not related to laboratory abnormalities. Both dupilumab + TCS groups showed overall trends toward increases in mean blood levels of eosinophils and alkaline phosphatase, and decreases in mean blood levels of platelets, neutrophils, and lactate dehydrogenase levels, without corresponding mean changes in the placebo + TCS group. None of these changes were associated with symptoms or clinically meaningful adverse outcomes, and none led to treatment modification. No clinically significant changes or trends were observed for other measured laboratory parameters.

CONCLUSION

There were no clinically meaningful adverse changes in routine laboratory parameters attributable to treatment with dupilumab + TCS. Changes in platelet counts and lactate dehydrogenase levels likely reflect reduced inflammation. These results confirm similar findings in adults and adolescents, and suggest that there is no need for routine laboratory monitoring of children aged 6-11 years treated with dupilumab + TCS for severe AD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03345914. Does treatment with dupilumab require routine laboratory monitoring in 6- to 11-year-old children with severe atopic dermatitis? (MP4 180482 kb).

Rad6 is a Potential Early Marker of Melanoma Development

Melanoma is the leading cause of death from skin cancer in industrialized countries. Several melanoma-related biomarkers and signaling pathways have been identified; however, their relevance to melanoma development/progression or to clinical outcome remains to be established. Aberrant activation of Wnt/β-catenin pathway is implicated in various cancers including melanoma. We have previously demonstrated Rad6, an ubiquitin-conjugating enzyme, as an important mediator of β-catenin stability in breast cancer cells. Similar to breast cancer, β-catenin-activating mutations are rare in melanomas, and since β-catenin signaling is implicated in melanoma, we examined the relationship between β-catenin levels/activity and expression of β-catenin transcriptional targets Rad6 and microphthalmia-associated transcription factor-M (Mitf-M) in melanoma cell models, and expression of Rad6, β-catenin, and Melan-A in nevi and cutaneous melanoma tissue specimens. Our data show that Rad6 is only weakly expressed in normal human melanocytes but is overexpressed in melanoma lines. Unlike Mitf-M, Rad6 overexpression in melanoma lines is positively associated with high molecular weight β-catenin protein levels and β-catenin transcriptional activity. Double-immunofluorescence staining of Rad6 and Melan-A in melanoma tissue microarray showed that histological diagnosis of melanoma is significantly associated with Rad6/Melan-A dual positivity in the melanoma group compared to the nevi group (P=.0029). In contrast to strong β-catenin expression in normal and tumor areas of superficial spreading malignant melanoma (SSMM), Rad6 expression is undetectable in normal areas and Rad6 expression increases coincide with increased Melan-A in the transformed regions of SSMM. These data suggest a role for Rad6 in melanoma pathogenesis and that Rad6 expression status may serve as an early marker for melanoma development.

Engineering a waste management enzyme to overcome cancer resistance to apoptosis: adding DNase1 to the anti-cancer toolbox

Cancer treatment is often complicated by resistance to conventional anti-cancer treatment and to more recently developed immunotherapy and gene therapy. These therapeutic modalities aim at activating death pathways within cancer cells. Attempts to activate the apoptotic death pathway, by overexpressing proapoptotic signals, are compromised by cancer defense mechanisms, which disrupt the apoptotic-signaling cascade downstream of the overexpressed component. Here, we describe a therapeutic option of triggering apoptosis without activating the apoptotic-signaling cascade or using the native apoptosis executioner nuclease. We have engineered Deoxyribonuclease-1 (DNase1), a waste-management enzyme, by deleting its signal peptide, adding a nuclear localization signal, and mutating its actin-binding site. Apoptosis studies and colony-forming assay for assessing cell viability were conducted in apoptosis-resistant Mel-Juso human melanoma cells. The modified DNase1 reduced cell viability by 77% relative to controls. It also induced typical microscopic features of cellular apoptosis, such as Terminal Transferase dUTP Nick-End Labeling-positive cells and DNA fragmentation. Quantification of apoptosis by Laser scanning cytometry demonstrated high-killing efficiency of 70-100%. The results suggest that this modified DNase1 can efficiently eliminate apoptosis-resistant cancer cells through apoptosis. Coupled to different tissue-specific gene expression elements, this recombinant DNase1 may serve as a platform for eliminating a variety of cancer types.

Subtypes of immunoglobulin (Ig)-G antibodies against donor class II HLA and cross-match results in three kidney transplant candidates

Preexisting donor-specific antibodies (DSA) play a critical role in the success of solid-organ transplantation. Cross-match (CM) between donor lymphocytes and recipient serum is a pivotal methodology for detecting these antibodies. Luminex platform based solid-phase methodology for anti-human leukocyte antigen (HLA) antibody analysis has revolutionized the approach to antibody detection and HLA specificity identification. In this study, we have reported three cases of successful living donor kidney transplantations performed against strongly positive B lymphocyte flow cytometry (FC) CM owing to highly reactive DSA directed to HLA class II. IgG solid-phase subtype analysis showed that more than 50% of these antibodies were represented by non-complement binding IgG2/IgG4 subtypes. These findings account for antibody mediated rejection (AMR) free long-term post-transplant course in these patients despite, the high level of DSA. Thus, we conclude that routine application of single HLA-coated beads (SAB) IgG subtype assay may provide new insights regarding transplantation or desensitization of patients presenting with negative B-cell complement dependent cytotoxic (CDC) and positive FC CM.

WT1 marker is not sufficient for distinguishing between melanoma and melanocytic nevi

BACKGROUND

The heterogeneous histological features of melanoma may often overlap with melanocytic nevi. For this reason, pathologists have sought after immunohistochemistry to assist with difficult cases. Recently, Wilms' tumor 1 protein (WT1) has been suggested to differentiate between melanoma and melanocytic nevi.

OBJECTIVE

Our objective was to determine whether immunohistochemistry analysis of WT1 expression is a reliable tool in differentiating cutaneous melanoma from melanocytic nevi.

METHODS

Forty-five melanoma and 43 melanocytic nevi were immunostained with anti-WT1 monoclonal antibody (clone 6F-H2).

RESULTS

Forty of the 45 cutaneous melanoma (89%) and 22 of the 43 melanocytic nevi (51%) stained (> 10% cells) for WT1. The highest sensitivity for WT1 was expressed by nodular melanoma (19/20), superficial spreading melanoma (8/10) and Spitz nevi (9/11). At the threshold of above 75% WT1-stained cells, the specificity for melanoma was 95% but the sensitivity was only 31%. At the threshold of 10%, the sensitivity increased to 89% but the specificity decreased to only 49%. Finally, at the threshold of 25% and 50%, the sensitivity and specificity were 71%, 61% and 64%, 77%, respectively.

CONCLUSIONS

Our data suggest that melanoma is associated with increased WT1 expression. However, as a single immunostaining marker, WT1 is not sufficient for distinguishing melanoma from melanocytic nevi.

Late type apoptosis and apoptosis free lethal effect of quercetin in human melanoma

No satisfactory treatment is currently available for metastatic malignant melanoma. Recently, the flavonoid quercetin was suggested as a potential treatment due to its anti-tumorogenic properties. Some of these properties appeared to correspond to those published for UVB irradiation. To determine quercetin's long-term effects, type of apoptosis, and shared properties with UVB, we exposed Mel-Juso, M14, and G361 human melanoma cell-lines to a large range of quercetin or UVB doses, 20-400 microm and 25-1000 mJ/cm2 respectively. Apoptosis was measured for 4 consecutive d by flow cytometry and cell viability was studied by colony-forming assay. Quercetin decreased cell viability level in a dose-dependent manner to almost zero at 100 microm. Up to this concentration, it did not induce significant apoptosis nor did it decrease the survival-fractions below 90% during a 4 d follow-up. The data suggest that Quercetin is lethal to melanoma cells at concentrations that do not activate apoptosis during the first 4 d post-exposure and that quercetin's effects extend beyond the period of direct contact. Both quercetin and UVB induced late-type apoptosis at the upper range of the tested doses, but they do not appear to share all the pathways that they activate. Finally, this paper provides novel data showing that quercetin causes two different lethal effects on human melanoma cells, suggesting the activation of at least two different dose-depended mechanisms.

Role of LFA-1/ICAM-1, CLA/E-selectin and VLA-4/VCAM-1 pathways in recruiting leukocytes to the various regions of the chronic leg ulcer

The center, edge and distant regions of the venous leg ulcer differ in inflammatory cell composition, suggesting that these represent different developmental stages. Our goal was to determine which recruitment pathways contribute to the differences in leukocyte composition between the various ulcer regions. The multiple region biopsy approach, which enables to study the different development phases of the ulcer at one time-point, was employed to immunohistochemically identify the vascular adhesion molecules E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1), and their counter-ligands on extravasated leukocyte cutaneous lymphocyte-associated antigen (CLA), lymphocyte function-associated antigen (LFA-1) and very late activation antigen-4 (VLA-4), respectively. E-selectin expression was highest at the ulcer edge, while ICAM-1 was highest at the ulcer center. VCAM-1 expression was minor at all ulcer regions. CLA stained up to 80% of the epidermal Langerhans' cells, 62% of the T cells, and only 9% of the macrophages. LFA-1 did not stain Langerhans' cells, stained up to 89% of the T cells and up to 11% of the macrophages. VLA-4 stained up to 30% of the T cells and 71% of the macrophages. In conclusion, the results indicate that Langerhans' cells, T cells and macrophage are each recruited by more than one adhesion-molecule pathway to any of the chronic venous leg ulcer regions.

Analysis of microsatellite instability and hypermutation of immunoglobulin variable genes in Werner syndrome

Werner syndrome (WS) is a human premature aging syndrome, which is associated with high frequencies of neoplasia and genetic instability. We have examined the occurrence of microsatellite instability, which may result from defective mismatch repair, in lymphoblastoid cell lines derived from nine WS patients. Instability was measured at the D2S123 locus by gel analysis of PCR products. Three WS cell lines had 4-13% altered alleles, compared with 0% in the other six lines. The increased frequency of microsatellite instability could not readily be associated with overt cancer or any other known clinical condition in the three patients. To examine whether the WS defect affected the humoral immune system, we measured the hypermutation of immunoglobulin variable genes in peripheral blood cells from the WS patient who donated the cell line with the highest frequency of microsatellite instability. The frequency and pattern of mutation was similar to that from normal individuals, suggesting that the Werner protein is not involved in generating hypermutation.

Third complementarity-determining region of mutated VH immunoglobulin genes contains shorter V, D, J, P, and N components than non-mutated genes

The third complementarity-determining region (CDR3) of immunoglobulin variable genes for the heavy chain (VH) has been shown to be shorter in length in hypermutated antibodies than in non-hypermutated antibodies. To determine which components of CDR3 contribute to the shorter length, and if there is an effect of age on the length, we analysed 235 cDNA clones from human peripheral blood of VH6 genes rearranged to immunoglobulin M (IgM) constant genes. There was similar use of diversity (D) and joining (JH) gene segments between clones from young and old donors, and there was similar use of D segments among the mutated and non-mutated heavy chains. However, in the mutated heavy chains, there was increased use of shorter JH4 segments and decreased use of longer JH6 segments compared to the non-mutated proteins. The overall length of CDR3 did not change with age within the mutated and non-mutated categories, but was significantly shorter by three amino acids in the mutated clones compared to the non-mutated clones. Analyses of the individual components that comprise CDR3 indicated that they were all shorter in the mutated clones. Thus, there were more nucleotides deleted from the ends of VH, D, and JH gene segments, and fewer P and N nucleotides added. The results suggest that B cells bearing immunoglobulin receptors with shorter CDR3s have been selected for binding to antigen. A smaller CDR3 may allow room in the antibody binding pocket for antigen to interact with CDRs 1 and 2 as well, so that as the VDJ gene undergoes hypermutation, substitutions in all three CDRs can further contribute to the binding energy.

Impact of age on hypermutation of immunoglobulin variable genes in humans

Chronological aging is associated with an accumulation of DNA mutations that results in cancer formation. The effect of aging on spontaneous mutations in humans is difficult to study because mutations are infrequent in the overall genome and tumors are relatively rare. In contrast, somatic mutations in immunoglobulin variable genes are abundant and can be studied in peripheral blood lymphocytes. To determine if aging alters the frequency and pattern of hypermutation, we sequenced 331 cDNA clones with rearranged V(H)6 genes and compared 452 mutations from young humans to 570 mutations from old humans. There were more mutated clones in the young population compared to the old population. Among the mutated clones, the frequency, location, and types of substitutions were similar between the young and the old groups. However, the ratio of replacement-to-silent mutations was much higher in the complementarity-determining regions of heavy chains from old people, which indicates that their B cells had been selected by antigen. Among individuals, there was variability in the frequency of tandem mutations, which we have observed in mice defective for the PMS2 mismatch repair protein. Microsatellite variability in DNA, which is caused by impaired mismatch repair, was then measured, and there was a strong correlation between the frequency of tandem mutations and microsatellite alterations. The data suggest that individuals vary in their mismatch repair capacity, which can affect the mutational spectra in their antibodies.

A case for cellulosic membrane hemodialyzers

Regenerated cellulose membranes have been held responsible for a variety of ill effects in dialysis patients. Many of these effects (hypotension, changes in well-being) have not been supported by studies, while other effects were more likely due to ethylene oxide. The lower cost of dialyzers composed of these membranes may allow implementation of otherwise cost-prohibitive lifesaving therapy in some countries.

Immunohistochemical characterization of the cutaneous cellular infiltrate in different areas of chronic leg ulcers

Current understanding of the immunological mechanisms involved in the pathogenesis of venous leg ulcers is insufficient. In this study the cellular composition of skin biopsies taken from the center, the edge, and 2 cm distant from the edge of venous leg ulcers was characterized quantitatively by immunohistochemical staining. In the epidermis the mean numbers of Langerhans cells (CD1a+) were four times lower at the edge of the ulcer compared to clinically intact epidermis 2 cm distant from the edge. In the dermis a statistically significant increase in the mean numbers of macrophages (CD68+) and neutrophils (NP57+) from the distant area towards the center of the ulcer was observed. No significant differences were observed in the distribution of T cells nor in the ratio of CD4+/CD8+ T-cell subsets between the different regions of the ulcer. About 30% of T lymphocytes were CD8+ in all microenvironments. The center and the edge of the ulcer were dominated by macrophages comprising 63% and 53% of the cells respectively, while T lymphocytes dominated the distant area. The area 2 cm distant from the edge was also heavily infiltrated by macrophages and neutrophils. B cells (CD22+) and NK cells (CD56+) were relatively rare in all areas, comprising less than 3% of the dermal infiltrate. In conclusion, local microenvironments each with a different cellular composition can be defined within venous leg ulcers.

Effect of Moloney murine leukemia virus on the carcinogenicity of 3-methylcholanthrene in normal rat kidney cells

Normal rat kidney (NRK) cell were found to be resistant to neoplastic transformation by diverse carcinogenic chemicals. To study chemical-retroviral co-carcinogenesis in this cells they were infected with a low multiplicity of Moloney murine leukemia virus (M-MLV). Using a single cell cloning procedure, a virus-producing clone was isolated from the infected cells, which was shown to carry only one integrated M-MLV provirus per cell. It was found that this single provirus was sufficient to render the clone susceptible to transformation by 3-methylcholanthrene (3-MC). However this clone responded differently to the carcinogen at different passages after infection. When exposed to 3-MC at a low passage postinfection (passage 5), cell transformation was evident only after 11 subsequent subcultures. On the other hand when it was chemically treated at a high passage postinfection (passage 29), cell transformation could clearly be detected already at the next subculture after the chemical treatment. It is suggested that an M-MLV-mediated cumulative effect is necessary to complement the action of the carcinogen in order to complete the carcinogenic process in these cells. This cumulative viral effect appeared to be associated with a change in the control of the virus expression, since 3-MC was found to stimulate virus replication in this clone also only at the high passage postinfection. Indeed virus release by cells of isolated transformed foci, produced by the chemical-M-MLV co-carcinogenesis, was extremely higher than by untransformed cells.

Characteristics of women forensic patients in a federal hospital

Increased criminal activity among women has prompted greater interest in the mentally ill female offender. An analysis of 72 women forensic inpatients at St. Elizabeths Hospital in Washington, D.C., indicated the typical patient was black, unmarried, in her mid-30s, poorly educated, and diagnosed as schizophrenic. The authors examine some relationships between race, type of crime, drug use, institutional history, and age and the utility of such variables as predictors of adjustment. A comparison of the primary sample with a cohort of 72 patients admitted ten years earlier showed that admissions related to public-order and technical offenses such as prostitution, parole violations, and drug violations decreased from 50 to 12 per cent, while admissions related to crimes of violence rose by 17 per cent.