Children with psoriasis and COVID-19: factors associated with an unfavourable COVID-19 course, and the impact of infection on disease progression (Chi-PsoCov registry).

BACKGROUND: The COVID-19 pandemic has raised questions regarding the management of chronic skin diseases, especially in patients on systemic treatments. Data concerning the use of biologics in adults with psoriasis are reassuring, but data specific to children are missing. Moreover, COVID-19 could impact the course of psoriasis in children. OBJECTIVES: The aim of this study was therefore to assess the impact of COVID-19 on the psoriasis of children, and the severity of the infection in relation to systemic treatments. METHODS: We set up an international registry of paediatric psoriasis patients. Children were included if they were under 18 years of age, had a history of psoriasis, or developed it within 1 month of COVID-19 and had COVID-19 with or without symptoms. RESULTS: One hundred and twenty episodes of COVID-19 in 117 children (mean age: 12.4 years) were reported. The main clinical form of psoriasis was plaque type (69.4%). Most children were without systemic treatment (54.2%); 33 (28.3%) were on biologic therapies, and 24 (20%) on non-biologic systemic drugs. COVID-19 was confirmed in 106 children (88.3%) and 3 children had two COVID-19 infections each. COVID-19 was symptomatic for 75 children (62.5%) with a mean duration of 6.5 days, significantly longer for children on non-biologic systemic treatments (P = 0.02) and without systemic treatment (P = 0.006) when compared with children on biologics. The six children who required hospitalization were more frequently under non-biologic systemic treatment when compared with the other children (P = 0.01), and particularly under methotrexate (P = 0.03). After COVID-19, the psoriasis worsened in 17 cases (15.2%). Nine children (8%) developed a psoriasis in the month following COVID-19, mainly a guttate form (P = 0.01). DISCUSSION: Biologics appear to be safe with no increased risk of severe form of COVID-19 in children with psoriasis. COVID-19 was responsible for the development of psoriasis or the worsening of a known psoriasis for some children.

Monitoring of plasma concentrations of dabrafenib and trametinib in advanced BRAFV600mut melanoma patients.

BACKGROUND: Dabrafenib (D) and trametinib (T) improved survival in patients with BRAFV600mut melanoma. High plasma concentration of D (PCD) is weakly associated with adverse events (AE). We investigated the relationship between PCD/T and tumour control or AE. METHODS: We analysed PCD/T in patients treated with D+T for metastatic melanoma. We collected data of tumour response (RECIST 1.1) and AE (CTCAE 4.0) blinded to PCD/T results. RESULTS: We analysed 71 D and 58T assays from 34 patients. High inter-individual variability of PCD (median: 65.0ng/mL; interquartile range (IQR) [4-945]) and of PCT (median: 8.6ng/mL; IQR [5-39]) was observed. We found a weak relationship between PCD and progression-free survival, taking follow-up time into account (hazard ratio 0.991; 95%CI, 0.981 to 1.000; P=0.06). However, no difference was observed between mean PCD/T of progressing patients (n=21; 125±183ng/mL and 9.3±3.6ng/mL, respectively) and responders (complete, partial or stable response) (n=13; 159±225ng/mL, P=0.58 and 10.6±24.4ng/mL, P=0.29, respectively). No significant relationship was found between PCD/T and most common AEs (fever, lymphopenia, CPK increase, and hepatic cytolysis), body mass index, or age. Mean CPT (n=16) was significantly higher for female subjects (n=18; 11.5±4.8ng/mL) than for male subjects (8.8ng/mL±2.9, P=0.01), but no difference was observed between sex and CPD (P=0.32). CONCLUSION: Our study showed a weak relationship between PCD and progression-free survival, but no relationship between PCD/T and AE was found. Monitoring PCD and PCT alone is unlikely to be useful in assessing response to treatment.

[Reluctance determinants of dermatologists about tattooing in patients with psoriasis. An international study]. / Déterminants de la réticence des dermatologues vis-à-vis du tatouage chez les patients atteints de psoriasis. Une étude internationale.

BACKGROUND: Tattoos are an increasingly common phenomenon, with a prevalence of around 10-30 % of the population in Western countries. The "Tatou" project assessed the risks of tattooing for patients with psoriasis. The first part revealed strong opposition to tattoos in these patients on the part of dermatologists, despite fewer than a quarter of them having any personal experience of complications. The second part showed a very low rate (6.6 %) of local complications on tattoos in these patients as well as absence of severe complications. These observations led us to assess the reasons for reluctance about tattoos in the 468 dermatologists involved in the first part of the "Tatou" project. PATIENTS AND METHODS: We conducted a cross-sectional international study in France, Finland and Italy to evaluate the experience and opinions of dermatologists regarding tattoos in psoriasis patients via an anonymous questionnaire. We then examined the stated reasons for opposition to tattoos in order to establish the profiles of "tattoo-sceptical" dermatologists with regard to 4 different situations: active psoriasis, quiescent psoriasis, treatment with topical steroids and biotherapies. RESULTS: The opinion of dermatologists regarding tattoos was generally unfavourable (3.5±2.8/10), in particular, via multivariate analysis, among older dermatologists (P=0.01), dermatologists in private practice (P=0.04), and non-tattooed dermatologists (P<0.0001). In multivariate analysis, the main parameter affecting the position of practitioner with regard to tattoos was their personal opinion of tattoos (P<0.0001), regardless of disease activity or type of treatment. Italian, Finnish and female dermatologists exhibited greater reluctance but in a less consistent fashion. CONCLUSION: This analysis suggests a lack of objectivity among dermatologists opposed to tattoos probably stemming more from a poor opinion of this practice than from any fear of complications in their psoriatic patients.

[Off-label drugs in childhood psoriasis]. / Prescriptions hors AMM (autorisation de mise sur le marché) dans le psoriasis de l'enfant.

INTRODUCTION: Psoriasis affects 0.5% of children in Europe, with moderate to severe clinical forms in 15-35% of cases warranting the use of systemic treatments. Few treatments are licensed for childhood psoriasis. In this study, we analyzed the frequency of such prescriptions. MATERIALS AND METHODS: Our study was based on 3 retrospective cohort trials conducted in France between 2012 and 2018: χ-Psocar (313 children with psoriasis seen in hospitals), PsoLib (207 children seen in a private practice), and BiPe (134 children on biotherapies). Our evaluation was centered on off-label use. To avoid duplicates between cohorts, analysis focused on each cohort independently. RESULTS: In the χ-Psocar study, in 34.8% of cases, use of at least one off-label treatment, mainly topical vitamin D (36.0%), and systemic treatments (methotrexate and cyclosporine) was noted, on account of either the clinical type of psoriasis (13.7%) or patient age (24.6%). In the PsoLib study, in 41.5% of cases, at least one off-label treatment was noted, mainly combined calcipotriol-betamethasone (24.2%), ciclopirox shampoo (7.2%) and systemic treatments (n=20). The main reason was patient age (41.5%). In the BiPe study, in 97.0% of cases, at least one off-label treatment was noted. These prescriptions mainly concerned a combination of calcipotriol-betamethasone (68.7%) and tacrolimus (11.2%) along with systemic treatment comprising methotrexate, cyclosporin, methoxsalen or apremilast (n=125), but also biotherapies (n=85). The biotherapies were used off-label since at that time they had not yet been granted marketing authorisation. DISCUSSION: This study focused on 3 cohorts of children with psoriasis seen either in private practice or in a hospital setting, and it involved all types of treatment. Off-label prescriptions ranged from one-third to almost 100% of the children, depending on the individual cohorts. The prescribed drugs were topical treatments, conventional systemic drugs and biotherapies. Off-label prescription is not strictly prohibited in France provided it is within a well-defined regulatory framework. Where there is a rich bibliography, confident recommendations may be made. Unfortunately, in childhood psoriasis, the literature and recommendations are very limited, leaving prescribers with considerable individual responsibilities. Review of the license concerning children with psoriasis, a push to conduct therapeutic studies and the drafting of recommendations all appear necessary.

Tattoo complications in treated and non-treated psoriatic patients.

BACKGROUND: Tattooing is a widespread phenomenon, with an estimated prevalence of 10-30% in Western populations. For psoriasis patients, current recommendations are to avoid having a tattoo if the disease is active and they are receiving immunosuppressive treatments. Although scientific data supporting these recommendations are lacking, dermatologists are often reluctant to advocate tattooing in psoriasis patients. OBJECTIVE: We aimed to evaluate the frequency of tattoo complications in patients with psoriasis and determine whether the occurrence of complications was associated with psoriasis status and treatments received at the time of tattooing. METHODS: We performed a multicentre cross-sectional study. Adults with psoriasis were consecutively included and classified as tattooed or non-tattooed. Prevalence of complications associated with tattoos was then evaluated according to psoriasis onset and treatments. The study was divided into three parts, in which data were collected through a series of questionnaires filled in by the dermatologist. Complications included pruritus, oedema, allergic reaction/eczema, infection/superinfection, granuloma, lichenification, photosensitivity, Koebner phenomenon and psoriasis flare after tattooing. Diagnosis of complications was made retrospectively. RESULTS: We included 2053 psoriatic patients, 20.2% had 894 tattoos. Amongst non-tattooed patients, 15.4% had wished to be tattooed, with psoriasis being stated as a reason for not having a tattoo by 44.0% and 5.7% indicating that they planned to have a tattoo in the future. Local complications, such as oedema, pruritus, allergy and Koebner phenomenon, were reported in tattoos in 6.6%, most frequently in patients with psoriasis requiring treatment at the time of tattooing (P < 0.0001). No severe complications were reported. CONCLUSIONS: The rate of tattoo complications in psoriasis patients was low. Although the risk of complications was highest amongst patients with psoriasis requiring treatment at the time of tattooing, all the complications observed were benign. These results can be helpful for practitioners to give objective information to patients.

[Children with psoriasis in secondary care: Clinical aspects and comorbidities diverge from the generally published data]. / Psoriasis de l'enfant vu en milieu libéral : les aspects cliniques et épidémiologiques diffèrent des données habituellement publiées.

BACKGROUND: Psoriasis affects 0.2-0.7 % of children and is associated with obesity. Published studies have been conducted in hospital settings (tertiary care). The PsoLib study evaluated childhood psoriasis in private practice (secondary care) in terms of epidemiology, clinical aspects and comorbidities. PATIENTS AND METHODS: This was a non-interventional, cross-sectional, multicenter study of children with psoriasis performed by 41 dermatologists working in private practice. The clinical and therapeutic aspects and comorbidities were systemically evaluated. We compared data to the χ-Psocar study performed in hospitals using the same methodology. RESULTS: In all, 207 children (girls: 60.4 %; mean age: 10.5±4.2 years) were included. Scalp psoriasis (40.6 %) was the most frequent clinical type, while plaque psoriasis represented 26 % of cases. Nail, tongue, and arthritic involvement were rare. Less than 1 % of children suffered from hypertension, diabetes or dyslipidemia, but 16.4 % were overweight and 7.0 % were obese. Severity (PG≥4 at peak) was associated with excess weight (P=0.01). CONCLUSION: Scalp psoriasis is the most frequent clinical type of psoriasis in childhood. Comorbidities and extracutaneous localization are rare. Even in private practice, the severity of the disease is associated with excess weight.

Biological treatments for paediatric psoriasis : a retrospective observational study on biological drug survival in daily practice in childhood psoriasis.

BACKGROUND: Three biotherapies - etanercept, adalimumab and ustekinumab - are licensed in childhood psoriasis. The few data available on their efficacy and tolerance are mainly derived from industry trials. However, biological drug survival impacts long-term performance in real-life settings. OBJECTIVE: The objective of this study was to evaluate the survival rates of biological therapies in children with psoriasis in real-life conditions. Secondary objectives were to evaluate the factors associated with the choice of the biological therapy and to report severe adverse events. MATERIALS AND METHODS: This study was an observational retrospective study. Data were extracted from the clinical records of 134 children. Kaplan-Meier estimates were used to analyse drug survival overall and in subgroups of plaque psoriasis, bio-naïve and non-naïve patients. RESULTS: We analysed 184 treatment courses: 70 with etanercept, 68 with adalimumab and 46 with ustekinumab. Factors associated with the choice of first-line biological agent were age at initiation (younger for adalimumab, P < 0.0001), age at onset of psoriasis (younger for adalimumab and etanercept, P = 0.03) and baseline Psoriasis Assessment Severity Index and Physician global assessment (both higher for adalimumab, P < 0.001). Drug survival rates were higher for ustekinumab than for adalimumab and etanercept (P < 0.0001) for all treatment and all psoriasis types, plaque-type psoriasis (P = 0.0003), patients naïve for biological agents (P = 0.0007) and non-naïve patients (P = 0.007). We reported eight serious adverse events (SAEs): severe infections (n = 3), significant weight gain (n = 2), psoriasis flare (n = 1) and malaise (n = 1). Biological therapy was discontinued in three children (one with psoriasis flare and two with weight gain). Only the two cases of weight gain resulted in an unfavourable outcome. CONCLUSIONS: Our real-life comparative study found that ustekinumab had the best drug survival outcome. The profile of SAEs in children was comparable to that in adults. These results will assist dermatologists in the decision-making process when choosing treatment options for children with psoriasis in daily practice.

Methotrexate efficacy and tolerance in plaque psoriasis. A prospective real-life multicentre study in France.

BACKGROUND: Methotrexate (MTX) is a major systemic treatment for moderate to severe plaque psoriasis. A randomized trial has recently been published evaluating a single weekly dosage (17.5mg), but few prospective real-life data are available. The main objective of this study was to prospectively evaluate the efficacy of MTX in real-life. The secondary objectives were to evaluate predictive parameters for treatment efficacy and the frequency of adverse events. PATIENTS AND METHODS: A prospective cohort involving consecutive at in 25 centres belonging to GEM RESOPSO included all adults with plaque psoriasis in whom MTX treatment was initiated. The efficacy criterion was achievement of PASI 75 at week (W) 12/16. The impact of demographic data, psoriasis characteristics (duration, topography, rheumatism), dosage (W12/16 dosage, cumulative dose after 4 weeks), and mode of administration (subcutaneous vs. oral, concomitant use of folic acid) on efficacy was evaluated. Intention-to-treat (ITT),per protocol (PP), and multivariate analyses were performed. RESULTS: Two hundred and fifty-six patients (F/M: 105/151; mean age: 45.0 years; rheumatism: 12.6%) with plaque psoriasis were included. 99 patients were not analysed at W12/16 (16 because of inefficacy, 16 because of intolerance, 56 were lost to follow-up or had data missing). PASI 75 was achieved in 98 patients, with efficacy of 38.3% in the ITT analysis and 58.3% in the PP analysis. In the ITT analysis, absence of previous use of cyclosporine (P=0.01) and a cumulative dose of MTX>60mg after 4 weeks (P<0.0001) were associated with higher PASI 75 rates. In the PP analysis, only absence of previous use of cyclosporine (P=0.0009) was associated with a better PASI 75 results. There was no association between PASI 75 and patient characteristics (including body mass index), clinical aspects of psoriasis, route of administration, combination with folic acid, or W12/16 dose. Adverse events were reported by 34.8% of patients. These consisted mainly of digestive disorders (nausea, abdominal pain), asthenia and moderate hepatic cytolysis. The frequency of adverse events was correlated with methotrexate dosage. DISCUSSION: The efficacy of MTX in plaque psoriasis in this real-life study of 256 patients is consistent with the data in the literature, including the recently published randomized trial (41% PASI 75). This rate was unaffected by patient weight, route of administration and combined use of folic acid. Absence of previous use of cyclosporine appears to be associated with better efficacy although there is no clear explanation for this. The initial dosage (high dose in the first month) appears to be associated with superior efficacy for W12/W16.

Comparison of complete versus partial mesh removal for the treatment of chronic mesh infection after abdominal wall hernia repair.

PURPOSE: Treatment of chronic mesh infections (CMI) after parietal repair is difficult and not standardized. Our objective was to present the results of a standardized surgical treatment including maximal infected mesh removal. METHODS: Patients who were referred to our center for chronic mesh infection were analyzed according to CMI risk factors, initial hernia prosthetic cure, CMI characteristics and treatments they received to achieve a cure. RESULTS: Thirty-four patients (mean age 54 ± 13 years; range 23-72), were included. Initial prosthetic cure consisted of 26 incisional hernias and eight groin or umbilical hernias of which 21% were considered potentially contaminated because of three intestinal injuries, two stomas and two strangulated hernias. The mesh was synthetic in all cases. CMI appeared after a mean of 83 days (range 30-6740) and was characterized by chronic leaking in 52 cases (50%), an abscess in 22 cases (21%) and synchronous hernia recurrence in 17 cases (16.5%). Eighty-six reinterventions were necessary, including 36 mesh removals (42%), and 13 intestinal resections for entero-cutaneous fistula (15%). The CMI persistence rate was 81% (35 reinterventions out of 43) when mesh removal was voluntarily limited to infected and/or not incorporated material, but was 44% when mesh removal was voluntarily complete (19 reinterventions out of 43; p < 0.001). On average, 3.4 interventions (1-11) were necessary to achieve a cure, after 2.8 years (0-6). Fourteen incisional hernia recurrences occurred (41%). CONCLUSIONS: Treatment of chronic mesh infection is lengthy and resource-intensive, with a high risk of hernia recurrence. Maximal mesh removal is mandatory.

Tongue psoriasis: Clinical aspects and analysis of epidemiological associations in 313 children, with a systematic literature review.

BACKGROUND: Little information is available on the prevalence and clinical aspects of tongue involvement in children with psoriasis. The aim was to evaluate the prevalence, clinical aspects and risk factors concerning tongue involvement in children with psoriasis. PATIENTS AND METHODS: This study was carried out in two stages. We performed a multicentre, cross-sectional study in 23 French dermatology centers. All children seen for psoriasis during the one-year study were systematically included. The clinical features of the tongue and of psoriasis were recorded. Association with clinical aspects of psoriasis and comorbidities was evaluated. We then carried out a literature review to evaluate the prevalence of tongue involvement in children with psoriasis and its positive predictive value for psoriasis. A search was conducted in the PUBMED database using the following keywords: "child" and "psoriasis" and ("tongue" or "glossitis" or "migratory glossitis" or "benign migratory glossitis" or "geographic tongue" or "fissured tongue"). RESULTS: 7.7% of the 313 children with psoriasis had tongue involvement. The clinical aspects were geographic tongue (4.2%), fissured tongue (2.8%) and both (0.64%). There was no association between tongue involvement and the clinical characteristics of the children. Two hundred and ninety-five articles were referenced and 3 were analysed. Psoriasis is very rare in cases of tongue abnormalities. CONCLUSION: The prevalence of tongue involvement was 7.7% in children with psoriasis. No clinical or epidemiological association was shown. Tongue involvement does not modify the management of psoriasis. In the literature review it was not possible to evaluate either the prevalence of tongue involvement in psoriasis or the positive predictive value thereof.

Optimal oncologic treatment of rectal cancer in patients over 75 years old: Results of a strategy based on oncogeriatric evaluation.

BACKGROUND: Few data are available on the management of elderly rectal cancer patients, and especially on the ability to provide optimal oncological treatment. The aim of this study was to determine the feasibility and results of multimodality treatment for rectal cancer in patients 75years and older after simplified comprehensive geriatric assessment (CGA) according to Balducci score. METHODS: We reviewed the charts of elderly patients who underwent surgery for localized middle or low rectal cancer. Patients were classified into three CGA groups depending on their functional reserve, comorbidities, geriatric syndromes, and life expectancy. RESULTS: Neoadjuvant therapy was discussed for 27 patients (47%), but only 56% of them were treated, including 8, 7, and 1 patient from CGA groups 1, 2, and 3, respectively. Fifty-three patients (93%) underwent sphincter-preserving surgical resection and four patients underwent abdominoperineal resection (7%). Postoperative complications were observed in 21 patients (37%). The postoperative complication rate was correlated non-significantly with age (<85years: 40.6%; ≥85years: 57.1%; P=0.3), and with the CGA (P=0.64). In total, 10 patients (18%) had definitive colostomy, including five anastomotic leakages (9%), and one incontinence (2%). The total rate of sphincter preservation was 82% (n=47). The risk of secondary definitive colonic stoma formation was not correlated with CGA (group 1: 14%; group 2/3: 16%; P=0.8). Estimated OS at five years was 52%. CONCLUSIONS: After routine geriatric assessment, elderly rectal cancer patients have good rates of sphincter conservation and acceptable morbidity/mortality.

[Psoriatic arthritis in France, from infants to the elderly: Findings from two cross-sectional, multicenter studies]. / Rhumatisme psoriasique en France, du nourrisson à la personne âgée : données de deux études transversales multicentriques.

BACKGROUND: Psoriatic arthritis affects 20-30% of patients with psoriasis. Few epidemiological data are available in France about its prevalence and its association with skin lesions and comorbidities. OBJECTIVES: To assess the epidemiological aspects and the risk factors for psoriatic arthritis in children and adults in France. METHODS: Two cross-sectional studies were conducted in France in children (χ-Psocar, 23 pediatric dermatology centers belonging to the SFDP, 1 year) and adults (Resopsocar, 29 dermatology centers belonging to GEM RESOPSO, 4 months) to study the link between psoriasis and cardiovascular and metabolic comorbidities. RESULTS: Three hundred and thirteen children (males: 47.6%; mean age: 9.4 yrs) and 1,954 adults (males: 56.0%; mean age: 48.5 yrs) with psoriasis were included, with 4.2% of the children and 21.0% of the adults presenting psoriatic arthritis. Prevalence increased with age: 2.2% of children, 14.2% of adolescents, and over 20% after 40 years. It decreased after the age of 70 years (19.4%). Regardless of age, arthritis was not associated with gender. In the children's group, rheumatism was associated with nail involvement (P=0.04) and disease severity (P=0.0004). Adult rheumatism was associated with generalized plaque psoriasis (P=0.002), disease severity (P<0.0001), and obesity (P<0.0001). Localized plaque psoriasis was less often associated with arthritis (P<0.05). CONCLUSIONS: These two cross-sectional studies conducted in 2267 patients in France yielded information on the prevalence of joint involvement from infants to elderly subjects. It is the first study conducted in a single population to provide data for the whole population. Prevalence gradually increases with age, without gender difference, before decreasing in old age. We confirm the association of nail involvement in the first years of life, and of obesity in adults.

Impact of an antimicrobial stewardship programme to optimize antimicrobial use for outpatients at an emergency department.

BACKGROUND: Antimicrobial stewardship programmes (ASPs) have been effective in optimizing antibiotic use for inpatients. However, an emergency department's fast-paced clinical setting can be challenging for a successful ASP. AIM: In April 2015, an ASP was implemented in our emergency department and we aimed to determine its impact on antimicrobial use for outpatients. METHODS: This was a single-centre study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016). For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24h) were evaluated by an infectious disease specialist and an emergency department physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified. FINDINGS: Before and after ASP, 34,671 and 35,925 consultations were registered at our emergency department, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (P < 0.0001). There were 484 (62.9%) and 271 (46.7%) (P < 0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliance included unnecessary antimicrobial prescriptions, 197 (25.6%) vs 101 (17.4%) (P<0.0005); inappropriate spectrum, 108 (14.0%) vs 54 (9.3%) (P=0.008); excessive treatment duration, 87 (11.3%) vs 53 (9.1%) (P>0.05); and inappropriate choices, 11 (1.4%) vs 15 (2.6%) (P>0.05). CONCLUSION: The implementation of an ASP markedly decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

[Psoriatic patients: Analysis of patients dissatisfied with their management]. / Patients atteints de psoriasis : analyse de la population insatisfaite de sa prise en charge.

BACKGROUND: The French are frequently regarded as grouchy. In a recent study, we observed a high proportion of patients initially consulting for psoriasis because they were dissatisfied with their previous therapy. We analyzed the characteristics of these patients. PATIENTS AND METHODS: This was a cross-sectional multicenter study in 40 centers belonging to the ResoPso (psoriasis treatment network) multicenter study group, with consecutive inclusions over a period of 11months in 2014. All adults (age>18 years) consulting for the first time for psoriasis at a center were included in the study. RESULTS: Among patients, 1205 were included, of whom 249 (20.3%) were consulting because of their dissatisfaction with treatment. In the univariate analysis, these patients were younger (P=0.02) and presented psoriasis that had begun earlier in life (P<0.0001). It consisted mostly of generalized plaque psoriasis (P=0.047) and more severe forms of psoriasis (PASI and/or DLQI score>10, P<0.02). There were fewer cases of psoriatic arthritis (P=0.01). The "dissatisfied" patients reported significantly more frequent use of topical treatments (P<0.0001) and alternative medicines (P=0.02), and more infrequent use of biologics (P=0.006) as well as longer treatment periods (P=0.0005). They consulted at hospitals (P=0.01) and had previously seen more GPs and dermatologists (P≤0.0008). There was no impact of gender on the dissatisfaction profile by either comorbidities (metabolic, blood pressure, alcohol and tobacco consumption, and depression), or socio-economic data. In the multivariate analysis, DLQI>10 (P=0.01; 95% CI: 1.01-1.07) and longer duration of care (P=0.004; 95% CI: 1.23-2.99) were associated with dissatisfaction. CONCLUSION: Twenty percent of our psoriatic patients seem dissatisfied with their treatment. It is difficult to draw a specific demographic and socioeconomic profile of dissatisfied patients. Only disease severity and possibly inadequate treatment at the initial consultation are associated with patient dissatisfaction. Explanations related to the individual patients and doctors may be proposed. Finally, while the French may be considered grouchy, the frequency of patient dissatisfaction seen in our study does not appear to be any greater than that observed in other countries.

High intensity focused ultrasound as first line treatment in patients with chronic angle closure glaucoma at risk for malignant glaucoma.

PURPOSE: Evaluation of high intensity focused ultrasound (HIFU) transscleral cyclocoagulation as an alternative to trabeculectomy in the treatment of refractory chronic angle closure glaucoma (CACG). METHODS: This prospective one armed single center pilot study was conducted on patients with medically uncontrolled CACG who underwent high intensity focused ultrasound (HIFU) cyclocoagulation as first line surgical treatment, using the Eye-OP1 HIFU device (Eyetechcare-Rillieux-la-Pape, France) driven by ultrasound biomicroscopic (UBM) ciliary body localization. All patients had documented progression of their glaucoma despite conventional medical and laser therapy. The primary efficacy outcome was intraocular pressure (IOP) reduction; secondary outcomes included changes in number of glaucoma medications and complications after cyclocoagulation. RESULTS: The study involved 8 eyes of 7 patients between May 2013 and September 2014. The average follow-up was 5.6±2.1 months. The mean IOP was reduced from 18.4±3.5mmHg preoperatively to 14.8±4.1mmHg 6 months postoperatively. The average number of glaucoma medications decreased from 3.4±1.1 at baseline to 3.3±0.7 after 6 months. Visual acuity remained stable (median 0.17 log MAR preoperatively and 0.19 log MAR at last follow-up visit). No significant side effect occurred during the 6 months follow-up period. CONCLUSIONS: HIFU cyclocoagulation appears to be a safe and reliable alternative to filtering surgery in the management of chronic angle closure glaucoma among patients with a high risk of malignant glaucoma.

Total mesorectal excision for cancer: histological and immunohistochemical evidence of nerve removal and risk-factor analysis.

AIM: Whether or not nerve-sparing rectal-cancer surgery can effectively prevent removal of the pelvic autonomic nerves has not been substantiated microscopically. We aimed to analyse the quality of nerve preservation in female patients by quantifying residual nerve fibres in total mesorectal excision specimens, to analyse pro-erectile function of the nerve fibres removed and to determine risk factors for pelvic denervation. METHOD: Serial transverse sections from female patients, 64 ± 18 years of age, were studied after the mesorectal fascia was inked and studied histologically [using anti-S100 and anti-neuronal nitric oxide synthase (nNOS) antibodies]. Nerve fibres located within 1 mm of the inked surface were counted and analysed according to type of surgery, tumour location, pT stage, circumferential resection margin and the necessity for a posterior colpectomy. RESULTS: Twelve specimens were analysed. Per specimen, the mean number of nerve-fibre sections outside the mesorectum was 5.3 ± 3.6 (range: 1-12). The mean number of fibres per specimen was 6.4 ± 4.1 in patients having a low-rectal tumour and 4.4 ± 2.9 in those with mid or higher rectal tumours (P = 0.42). The mean number of fibres was higher (9.2) for T4 tumours than for T2/T3 tumours (5.0 ± 3.5), but this difference was not statistically sigmificant (P = 0.25). Patients having abdominoperineal excision, a posterior colpectomy or a circumferential resection margin of less than 1 mm had significantly more nerve fibres in the specimen (10.6 ± 1.9 vs 4.4 ± 2.8; P = .041). Fibres localized at the anterolateral rectum corresponded to branches of the neurovascular bundle, expressing rich pro-erectile activity (positive anti-nNOS immunostaining). CONCLUSION: The neurovascular bundle is a key risk zone for pelvic denervation during total mesorectal excision. Abdominoperineal excision, posterior colpectomy and an invaded circumferential resection margin are associated with perineal denervation.