Pimecrolimus in atopic dermatitis: Consensus on safety and the need to allow use in infants
Identifieur interne : 000D88 ( Main/Exploration ); précédent : 000D87; suivant : 000D89Pimecrolimus in atopic dermatitis: Consensus on safety and the need to allow use in infants
Auteurs : Thomas Luger [Allemagne] ; Mark Boguniewicz [États-Unis] ; Warner Carr [États-Unis] ; Michael Cork [Royaume-Uni] ; Mette Deleuran [Danemark] ; Lawrence Eichenfield [États-Unis] ; Philippe Eigenmann [Suisse] ; Regina Fölster-Holst [Allemagne] ; Carlo Gelmetti [Italie] ; Harald Gollnick [Allemagne] ; Eckard Hamelmann [Allemagne] ; Adelaide A. Hebert [États-Unis] ; Antonella Muraro [Italie] ; Arnold P. Oranje [Pays-Bas] ; Amy S. Paller [États-Unis] ; Carle Paul [France] ; Luis Puig [Espagne] ; Johannes Ring [Allemagne] ; Elaine Siegfried [États-Unis] ; Jonathan M. Spergel [États-Unis] ; Georg Stingl [Autriche] ; Alain Taieb [France] ; Antonio Torrelo [Espagne] ; Thomas Werfel [Allemagne] ; Ulrich Wahn [Allemagne]Source :
- Pediatric Allergy and Immunology [ 0905-6157 ] ; 2015-06.
Abstract
Atopic dermatitis (AD) is a distressing dermatological disease, which is highly prevalent during infancy, can persist into later life and requires long‐term management with anti‐inflammatory compounds. The introduction of the topical calcineurin inhibitors (TCIs), tacrolimus and pimecrolimus, more than 10 yr ago was a major breakthrough for the topical anti‐inflammatory treatment of AD. Pimecrolimus 1% is approved for second‐line use in children (≥2 yr old) and adults with mild‐to‐moderate AD. The age restriction was emphasized in a boxed warning added by the FDA in January 2006, which also highlights the lack of long‐term safety data and the theoretical risk of skin malignancy and lymphoma. Since then, pimecrolimus has been extensively investigated in short‐ and long‐term studies including over 4000 infants (<2 yr old). These studies showed that pimecrolimus effectively treats AD in infants, with sustained improvement with long‐term intermittent use. Unlike topical corticosteroids, long‐term TCI use does not carry the risks of skin atrophy, impaired epidermal barrier function or enhanced percutaneous absorption, and so is suitable for AD treatment especially in sensitive skin areas. Most importantly, the studies of pimecrolimus in infants provided no evidence for systemic immunosuppression, and a comprehensive body of evidence from clinical studies, post‐marketing surveillance and epidemiological investigations does not support potential safety concerns. In conclusion, the authors consider that the labelling restrictions regarding the use of pimecrolimus in infants are no longer justified and recommend that the validity of the boxed warning for TCIs should be reconsidered.
Url:
DOI: 10.1111/pai.12331
Affiliations:
- Allemagne, Autriche, Danemark, Espagne, France, Italie, Pays-Bas, Royaume-Uni, Suisse, États-Unis
- Aquitaine, Basse-Saxe, Bavière, Berlin, Californie, Catalogne, Communauté de Madrid, District de Haute-Bavière, District de Münster, Hollande-Méridionale, Illinois, Lombardie, Midi-Pyrénées, Nouvelle-Aquitaine, Occitanie (région administrative), Rhénanie-du-Nord-Westphalie, Saxe-Anhalt, Schleswig-Holstein, Texas, Vienne (Autriche)
- Barcelone, Berlin, Bordeaux, Chicago, Hanovre, Houston, Kiel, Madrid, Magdebourg, Milan, Munich, Münster, Rotterdam, San Diego, Toulouse, Vienne (Autriche)
- Université autonome de Barcelone, Université de Bordeaux, Université technique de Munich
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xml:lang="fr">Allemagne</country><wicri:regionArea>Department of Dermatology, University of Münster, Münster</wicri:regionArea><placeName><region type="land" nuts="1">Rhénanie-du-Nord-Westphalie</region><region type="district" nuts="2">District de Münster</region><settlement type="city">Münster</settlement></placeName></affiliation><affiliation></affiliation><affiliation wicri:level="1"><country wicri:rule="url">Allemagne</country></affiliation></author><author><name sortKey="Boguniewicz, Mark" sort="Boguniewicz, Mark" uniqKey="Boguniewicz M" first="Mark" last="Boguniewicz">Mark Boguniewicz</name><affiliation wicri:level="1"><country xml:lang="fr">États-Unis</country><wicri:regionArea>Division of Pediatric Allergy‐Immunology, Department of Pediatrics, National Jewish Health and University of Colorado School of Medicine, CO, Denver</wicri:regionArea><wicri:noRegion>Denver</wicri:noRegion></affiliation></author><author><name sortKey="Carr, Warner" sort="Carr, Warner" uniqKey="Carr W" 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Hospital, Aarhus C</wicri:regionArea><wicri:noRegion>Aarhus C</wicri:noRegion></affiliation></author><author><name sortKey="Eichenfield, Lawrence" sort="Eichenfield, Lawrence" uniqKey="Eichenfield L" first="Lawrence" last="Eichenfield">Lawrence Eichenfield</name><affiliation wicri:level="3"><country xml:lang="fr">États-Unis</country><wicri:regionArea>Departments of Pediatrics and Medicine, University of California, San Diego School of Medicine, Rady Children's Hospital, CA, San Diego</wicri:regionArea><placeName><settlement type="city">San Diego</settlement><region type="state">Californie</region></placeName></affiliation></author><author><name sortKey="Eigenmann, Philippe" sort="Eigenmann, Philippe" uniqKey="Eigenmann P" first="Philippe" last="Eigenmann">Philippe Eigenmann</name><affiliation wicri:level="1"><country xml:lang="fr">Suisse</country><wicri:regionArea>Pediatric Allergy Unit, Children's University Hospital, Geneva</wicri:regionArea><wicri:noRegion>Geneva</wicri:noRegion></affiliation></author><author><name sortKey="Folster Olst, Regina" sort="Folster Olst, Regina" uniqKey="Folster Olst R" first="Regina" last="Fölster-Holst">Regina Fölster-Holst</name><affiliation wicri:level="3"><country xml:lang="fr">Allemagne</country><wicri:regionArea>Department of Dermatology, University Clinics of Schleswig‐Holstein, Kiel</wicri:regionArea><placeName><region type="land" nuts="2">Schleswig-Holstein</region><settlement type="city">Kiel</settlement></placeName></affiliation></author><author><name sortKey="Gelmetti, Carlo" sort="Gelmetti, Carlo" uniqKey="Gelmetti C" first="Carlo" last="Gelmetti">Carlo Gelmetti</name><affiliation wicri:level="3"><country xml:lang="fr">Italie</country><wicri:regionArea>Department of Pathophysiology and Transplantation, University of Milan, Clinica Dermatologica, Fondazione I.R.C.C.S. Ca’ Granda “Ospedale Maggiore Policlinico”, Milan</wicri:regionArea><placeName><settlement type="city">Milan</settlement><region nuts="2">Lombardie</region></placeName></affiliation></author><author><name sortKey="Gollnick, Harald" sort="Gollnick, Harald" uniqKey="Gollnick H" first="Harald" last="Gollnick">Harald Gollnick</name><affiliation wicri:level="3"><country xml:lang="fr">Allemagne</country><wicri:regionArea>Department of Dermatology & Venereology, Otto‐von‐Guericke University of Magdeburg, Magdeburg</wicri:regionArea><placeName><region type="land" nuts="2">Saxe-Anhalt</region><settlement type="city">Magdebourg</settlement></placeName></affiliation></author><author><name sortKey="Hamelmann, Eckard" sort="Hamelmann, Eckard" uniqKey="Hamelmann E" first="Eckard" last="Hamelmann">Eckard Hamelmann</name><affiliation wicri:level="1"><country xml:lang="fr">Allemagne</country><wicri:regionArea>Allergy Center Ruhr, Ruhr‐University Bochum, & Evangelisches Krankenhaus Bielefeld, Klinik für Kinder und Jugendmedizin, Bielefeld</wicri:regionArea><wicri:noRegion>Bielefeld</wicri:noRegion><wicri:noRegion>Bielefeld</wicri:noRegion></affiliation></author><author><name sortKey="Hebert, Adelaide A" sort="Hebert, Adelaide A" uniqKey="Hebert A" first="Adelaide A." last="Hebert">Adelaide A. Hebert</name><affiliation wicri:level="3"><country xml:lang="fr">États-Unis</country><wicri:regionArea>Departments of Dermatology and Pediatrics, The University of Texas Medical School‐Houston, TX, Houston</wicri:regionArea><placeName><settlement type="city">Houston</settlement><region type="state">Texas</region></placeName></affiliation></author><author><name sortKey="Muraro, Antonella" sort="Muraro, Antonella" uniqKey="Muraro A" first="Antonella" last="Muraro">Antonella Muraro</name><affiliation wicri:level="1"><country xml:lang="fr">Italie</country><wicri:regionArea>Food Allergy Referral Centre, Department of Woman and Child Health, University Hospital of Padua, Padua</wicri:regionArea><wicri:noRegion>Padua</wicri:noRegion></affiliation></author><author><name sortKey="Oranje, Arnold P" sort="Oranje, Arnold P" uniqKey="Oranje A" first="Arnold P." last="Oranje">Arnold P. Oranje</name><affiliation wicri:level="3"><country xml:lang="fr" wicri:curation="lc">Pays-Bas</country><wicri:regionArea>Department of Dermatology, Maasstad Hospital, Rotterdam</wicri:regionArea><placeName><settlement type="city">Rotterdam</settlement><region nuts="2" type="province">Hollande-Méridionale</region></placeName></affiliation><affiliation wicri:level="1"><country xml:lang="fr" wicri:curation="lc">Pays-Bas</country><wicri:regionArea>Dermicis Skin Hospital, Alkmaar</wicri:regionArea><wicri:noRegion>Alkmaar</wicri:noRegion></affiliation><affiliation wicri:level="1"><country xml:lang="fr" wicri:curation="lc">Pays-Bas</country><wicri:regionArea>Intermedica Dermatology and Hair Clinic, Boxmeer</wicri:regionArea><wicri:noRegion>Boxmeer</wicri:noRegion></affiliation></author><author><name sortKey="Paller, Amy S" sort="Paller, Amy S" uniqKey="Paller A" first="Amy S." last="Paller">Amy S. Paller</name><affiliation wicri:level="3"><country xml:lang="fr">États-Unis</country><wicri:regionArea>Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, IL, Chicago</wicri:regionArea><placeName><settlement type="city">Chicago</settlement><region type="state">Illinois</region></placeName></affiliation></author><author><name sortKey="Paul, Carle" sort="Paul, Carle" uniqKey="Paul C" first="Carle" last="Paul">Carle Paul</name><affiliation wicri:level="3"><country xml:lang="fr">France</country><wicri:regionArea>Dermatology Department, INSERM 1056, Paul Sabatier University, Larrey Hospital, Toulouse</wicri:regionArea><placeName><region type="region">Occitanie (région administrative)</region><region type="old region">Midi-Pyrénées</region><settlement type="city">Toulouse</settlement></placeName></affiliation></author><author><name sortKey="Puig, Luis" sort="Puig, Luis" uniqKey="Puig L" first="Luis" last="Puig">Luis Puig</name><affiliation wicri:level="4"><country xml:lang="fr">Espagne</country><wicri:regionArea>Department of Dermatology, Hospital de la Santa Creu i Sant Pau & Universitat Autònoma de Barcelona, BarcelonaCatalonia</wicri:regionArea><orgName type="university">Université autonome de Barcelone</orgName><placeName><settlement type="city">Barcelone</settlement><region nuts="2" type="region">Catalogne</region></placeName></affiliation></author><author><name sortKey="Ring, Johannes" sort="Ring, Johannes" uniqKey="Ring J" first="Johannes" last="Ring">Johannes Ring</name><affiliation wicri:level="4"><country xml:lang="fr">Allemagne</country><wicri:regionArea>Department of Dermatology and Allergology Biederstein, Christine Kühne‐Center for Allergy Research and Education, Technische Universität München, Munich</wicri:regionArea><placeName><region type="land" nuts="1">Bavière</region><region type="district" nuts="2">District de Haute-Bavière</region><settlement type="city">Munich</settlement></placeName><orgName type="university">Université technique de Munich</orgName></affiliation></author><author><name sortKey="Siegfried, Elaine" sort="Siegfried, Elaine" uniqKey="Siegfried E" first="Elaine" last="Siegfried">Elaine Siegfried</name><affiliation wicri:level="1"><country xml:lang="fr">États-Unis</country><wicri:regionArea>Departments of Pediatrics and Dermatology, Saint Louis University School of Medicine, MO, St. Louis</wicri:regionArea><wicri:noRegion>St. Louis</wicri:noRegion></affiliation></author><author><name sortKey="Spergel, Jonathan M" sort="Spergel, Jonathan M" uniqKey="Spergel J" first="Jonathan M." last="Spergel">Jonathan M. Spergel</name><affiliation wicri:level="1"><country xml:lang="fr">États-Unis</country><wicri:regionArea>Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, PennsylvaniaPA</wicri:regionArea><wicri:noRegion>PennsylvaniaPA</wicri:noRegion></affiliation></author><author><name sortKey="Stingl, Georg" sort="Stingl, Georg" uniqKey="Stingl G" first="Georg" last="Stingl">Georg Stingl</name><affiliation wicri:level="3"><country xml:lang="fr">Autriche</country><wicri:regionArea>Department of Dermatology, Medical University of Vienna, Vienna</wicri:regionArea><placeName><settlement type="city">Vienne (Autriche)</settlement><region nuts="2" type="province">Vienne (Autriche)</region></placeName></affiliation></author><author><name sortKey="Taieb, Alain" sort="Taieb, Alain" uniqKey="Taieb A" first="Alain" last="Taieb">Alain Taieb</name><affiliation wicri:level="4"><country xml:lang="fr">France</country><wicri:regionArea>Service de Dermatologie et Dermatologie Pédiatrique Centre de référence pour les maladies rares de la peau, INSERM 1035, Université de Bordeaux, Bordeaux</wicri:regionArea><placeName><region type="region">Nouvelle-Aquitaine</region><region type="old region">Aquitaine</region><settlement type="city">Bordeaux</settlement></placeName><orgName type="university">Université de Bordeaux</orgName></affiliation></author><author><name sortKey="Torrelo, Antonio" sort="Torrelo, Antonio" uniqKey="Torrelo A" first="Antonio" last="Torrelo">Antonio Torrelo</name><affiliation wicri:level="3"><country xml:lang="fr">Espagne</country><wicri:regionArea>Department of Dermatology, Hospital Niño Jesus, Madrid</wicri:regionArea><placeName><settlement type="city">Madrid</settlement><region nuts="2" type="region">Communauté de Madrid</region></placeName></affiliation></author><author><name sortKey="Werfel, Thomas" sort="Werfel, Thomas" uniqKey="Werfel T" first="Thomas" last="Werfel">Thomas Werfel</name><affiliation wicri:level="3"><country xml:lang="fr">Allemagne</country><wicri:regionArea>Department of Dermatology and Allergy, Hannover Medical School, Hannover</wicri:regionArea><placeName><region type="land" nuts="2">Basse-Saxe</region><settlement type="city">Hanovre</settlement></placeName></affiliation></author><author><name sortKey="Wahn, Ulrich" sort="Wahn, Ulrich" uniqKey="Wahn U" first="Ulrich" last="Wahn">Ulrich Wahn</name><affiliation wicri:level="3"><country xml:lang="fr">Allemagne</country><wicri:regionArea>Department of Pediatric Pneumology and Immunology, Charite, Berlin</wicri:regionArea><placeName><region type="land" nuts="3">Berlin</region><settlement type="city">Berlin</settlement></placeName></affiliation></author></analytic><monogr></monogr><series><title level="j" type="main">Pediatric Allergy and Immunology</title><title level="j" type="alt">PEDIATRIC ALLERGY AND IMMUNOLOGY</title><idno type="ISSN">0905-6157</idno><idno type="eISSN">1399-3038</idno><imprint><biblScope unit="vol">26</biblScope><biblScope unit="issue">4</biblScope><biblScope unit="page" from="306">306</biblScope><biblScope unit="page" to="315">315</biblScope><biblScope unit="page-count">10</biblScope><date type="published" when="2015-06">2015-06</date></imprint><idno type="ISSN">0905-6157</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0905-6157</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract">Atopic dermatitis (AD) is a distressing dermatological disease, which is highly prevalent during infancy, can persist into later life and requires long‐term management with anti‐inflammatory compounds. The introduction of the topical calcineurin inhibitors (TCIs), tacrolimus and pimecrolimus, more than 10 yr ago was a major breakthrough for the topical anti‐inflammatory treatment of AD. Pimecrolimus 1% is approved for second‐line use in children (≥2 yr old) and adults with mild‐to‐moderate AD. The age restriction was emphasized in a boxed warning added by the FDA in January 2006, which also highlights the lack of long‐term safety data and the theoretical risk of skin malignancy and lymphoma. Since then, pimecrolimus has been extensively investigated in short‐ and long‐term studies including over 4000 infants (<2 yr old). These studies showed that pimecrolimus effectively treats AD in infants, with sustained improvement with long‐term intermittent use. Unlike topical corticosteroids, long‐term TCI use does not carry the risks of skin atrophy, impaired epidermal barrier function or enhanced percutaneous absorption, and so is suitable for AD treatment especially in sensitive skin areas. Most importantly, the studies of pimecrolimus in infants provided no evidence for systemic immunosuppression, and a comprehensive body of evidence from clinical studies, post‐marketing surveillance and epidemiological investigations does not support potential safety concerns. In conclusion, the authors consider that the labelling restrictions regarding the use of pimecrolimus in infants are no longer justified and recommend that the validity of the boxed warning for TCIs should be reconsidered.</div></front></TEI><affiliations><list><country><li>Allemagne</li><li>Autriche</li><li>Danemark</li><li>Espagne</li><li>France</li><li>Italie</li><li>Pays-Bas</li><li>Royaume-Uni</li><li>Suisse</li><li>États-Unis</li></country><region><li>Aquitaine</li><li>Basse-Saxe</li><li>Bavière</li><li>Berlin</li><li>Californie</li><li>Catalogne</li><li>Communauté de Madrid</li><li>District de Haute-Bavière</li><li>District de Münster</li><li>Hollande-Méridionale</li><li>Illinois</li><li>Lombardie</li><li>Midi-Pyrénées</li><li>Nouvelle-Aquitaine</li><li>Occitanie (région administrative)</li><li>Rhénanie-du-Nord-Westphalie</li><li>Saxe-Anhalt</li><li>Schleswig-Holstein</li><li>Texas</li><li>Vienne (Autriche)</li></region><settlement><li>Barcelone</li><li>Berlin</li><li>Bordeaux</li><li>Chicago</li><li>Hanovre</li><li>Houston</li><li>Kiel</li><li>Madrid</li><li>Magdebourg</li><li>Milan</li><li>Munich</li><li>Münster</li><li>Rotterdam</li><li>San Diego</li><li>Toulouse</li><li>Vienne (Autriche)</li></settlement><orgName><li>Université autonome de Barcelone</li><li>Université de Bordeaux</li><li>Université technique de Munich</li></orgName></list><tree><country name="Allemagne"><region name="Rhénanie-du-Nord-Westphalie"><name sortKey="Luger, Thomas" sort="Luger, Thomas" uniqKey="Luger T" first="Thomas" last="Luger">Thomas Luger</name></region><name sortKey="Folster Olst, Regina" sort="Folster Olst, Regina" uniqKey="Folster Olst R" first="Regina" last="Fölster-Holst">Regina Fölster-Holst</name><name sortKey="Gollnick, Harald" sort="Gollnick, Harald" uniqKey="Gollnick H" first="Harald" last="Gollnick">Harald Gollnick</name><name sortKey="Hamelmann, Eckard" sort="Hamelmann, Eckard" uniqKey="Hamelmann E" first="Eckard" last="Hamelmann">Eckard Hamelmann</name><name sortKey="Luger, Thomas" sort="Luger, Thomas" uniqKey="Luger T" first="Thomas" last="Luger">Thomas Luger</name><name sortKey="Ring, Johannes" sort="Ring, Johannes" uniqKey="Ring J" first="Johannes" last="Ring">Johannes Ring</name><name sortKey="Wahn, Ulrich" sort="Wahn, Ulrich" uniqKey="Wahn U" first="Ulrich" last="Wahn">Ulrich Wahn</name><name sortKey="Werfel, Thomas" sort="Werfel, Thomas" uniqKey="Werfel T" first="Thomas" last="Werfel">Thomas Werfel</name></country><country name="États-Unis"><noRegion><name sortKey="Boguniewicz, Mark" sort="Boguniewicz, Mark" uniqKey="Boguniewicz M" first="Mark" last="Boguniewicz">Mark Boguniewicz</name></noRegion><name sortKey="Carr, Warner" sort="Carr, Warner" uniqKey="Carr W" first="Warner" last="Carr">Warner Carr</name><name sortKey="Eichenfield, Lawrence" sort="Eichenfield, Lawrence" uniqKey="Eichenfield L" first="Lawrence" last="Eichenfield">Lawrence Eichenfield</name><name sortKey="Hebert, Adelaide A" sort="Hebert, Adelaide A" uniqKey="Hebert A" first="Adelaide A." last="Hebert">Adelaide A. Hebert</name><name sortKey="Paller, Amy S" sort="Paller, Amy S" uniqKey="Paller A" first="Amy S." last="Paller">Amy S. Paller</name><name sortKey="Siegfried, Elaine" sort="Siegfried, Elaine" uniqKey="Siegfried E" first="Elaine" last="Siegfried">Elaine Siegfried</name><name sortKey="Spergel, Jonathan M" sort="Spergel, Jonathan M" uniqKey="Spergel J" first="Jonathan M." last="Spergel">Jonathan M. Spergel</name></country><country name="Royaume-Uni"><noRegion><name sortKey="Cork, Michael" sort="Cork, Michael" uniqKey="Cork M" first="Michael" last="Cork">Michael Cork</name></noRegion></country><country name="Danemark"><noRegion><name sortKey="Deleuran, Mette" sort="Deleuran, Mette" uniqKey="Deleuran M" first="Mette" last="Deleuran">Mette Deleuran</name></noRegion></country><country name="Suisse"><noRegion><name sortKey="Eigenmann, Philippe" sort="Eigenmann, Philippe" uniqKey="Eigenmann P" first="Philippe" last="Eigenmann">Philippe Eigenmann</name></noRegion></country><country name="Italie"><region name="Lombardie"><name sortKey="Gelmetti, Carlo" sort="Gelmetti, Carlo" uniqKey="Gelmetti C" first="Carlo" last="Gelmetti">Carlo Gelmetti</name></region><name sortKey="Muraro, Antonella" sort="Muraro, Antonella" uniqKey="Muraro A" first="Antonella" last="Muraro">Antonella Muraro</name></country><country name="Pays-Bas"><region name="Hollande-Méridionale"><name sortKey="Oranje, Arnold P" sort="Oranje, Arnold P" uniqKey="Oranje A" first="Arnold P." last="Oranje">Arnold P. Oranje</name></region><name sortKey="Oranje, Arnold P" sort="Oranje, Arnold P" uniqKey="Oranje A" first="Arnold P." last="Oranje">Arnold P. Oranje</name><name sortKey="Oranje, Arnold P" sort="Oranje, Arnold P" uniqKey="Oranje A" first="Arnold P." last="Oranje">Arnold P. Oranje</name></country><country name="France"><region name="Occitanie (région administrative)"><name sortKey="Paul, Carle" sort="Paul, Carle" uniqKey="Paul C" first="Carle" last="Paul">Carle Paul</name></region><name sortKey="Taieb, Alain" sort="Taieb, Alain" uniqKey="Taieb A" first="Alain" last="Taieb">Alain Taieb</name></country><country name="Espagne"><region name="Catalogne"><name sortKey="Puig, Luis" sort="Puig, Luis" uniqKey="Puig L" first="Luis" last="Puig">Luis Puig</name></region><name sortKey="Torrelo, Antonio" sort="Torrelo, Antonio" uniqKey="Torrelo A" first="Antonio" last="Torrelo">Antonio Torrelo</name></country><country name="Autriche"><region name="Vienne (Autriche)"><name sortKey="Stingl, Georg" sort="Stingl, Georg" uniqKey="Stingl G" first="Georg" last="Stingl">Georg Stingl</name></region></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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