Psoriatic Arthritis: A comprehensive review for the dermatologist Part I: Epidemiology, Comorbidities, Pathogenesis, and Diagnosis.

Psoriatic arthritis (PsA) is an inflammatory seronegative arthritis strongly associated with psoriasis. Recognition of the clinical features of PsA is critical, as delayed detection and untreated disease may result in irreparable joint damage, impaired physical function, and a significantly reduced quality of life. Dermatologists are poised for the early detection of PsA, as psoriasis predates its development in as many as 80% of patients. In an effort to further acquaint dermatologists with PsA, this review provides a detailed overview, emphasizing its epidemiology, comorbidities, etiopathogenesis, and diagnostic features.

A systematic review of the incidence and outcomes of ICD-11 defined stroke.

BACKGROUND: The World Health Organisation has expanded the definition of stroke to include people with symptoms less than 24 h if they have evidence of stroke on neuroimaging. The impact is that people previously diagnosed as having a transient ischaemic attack (TIA) would now be considered to have had a stroke. This change will impact incidence and outcomes of stroke and increase eligibility for secondary prevention. We aimed to evaluate the new ICD-11 criteria retrospectively to previous TIA studies to understand the change in incidence and outcomes of this type of stroke. METHODS: We conducted a systematic review of observational studies of the incidence and outcomes of clinically defined TIA. We searched PubMed, EMBASE, and Google Scholar from inception to 23rd May 2023. Study quality was assessed using a risk of bias tool for prevalence studies. FINDINGS: Our review included 25 studies. The rate of scan positivity for stroke among those with clinically defined TIA was 24 %, (95 % CI, 16-33 %) but with high heterogeneity (I2 = 100 %, p <0.001). Sensitivity analyses provided evidence that heterogeneity could be explained by methodology and recruitment method. The scan positive rate when examining only studies at low risk of bias was substantially lower, at 13 % (95 % CI, 11-15 %, I2 = 0, p = 0.77). We estimate from population-based incidence studies that ICD-11 would result in an increase stroke incidence between 4.8 and 10.5 per 100,000 persons/year. Of those with DWI-MRI evidence of stroke, 6 % (95 % CI, 3-11 %) developed a recurrent stroke in the subsequent 90 days, but with substantial heterogeneity (I2 = 67 %, p = 0.02). CONCLUSION: The impact of the ICD-11 change in stroke definition on incidence and outcomes may have been overestimated by individual studies. Community-based stroke services with access to DWI MRI are likely to accurately diagnose greater numbers of people with mild ICD-11 stroke, increasing access to effective prevention.

Risk Factors, Presentation, and Outcome in Acute Stroke according to Social Position Indicators in Patients Hospitalised in a Referral Centre in Bogotá 2011-2019.

INTRODUCTION: Treatment of stroke is time-dependent and it challenges patients' social and demographic context for timely consultation and effective access to reperfusion therapies. OBJECTIVE: The objective of this study was to relate indicators of social position to cardiovascular risk factors, time of arrival, access to reperfusion therapy, and mortality in the setting of acute stroke. METHODS: A retrospective analysis of patients with a diagnosis of ischaemic stroke in a referral hospital in Bogotá was performed. A simple random sample with a 5% margin of error and 95% confidence interval was selected. Patients were characterised according to educational level, place of origin, marital status, occupation, duration of symptoms before consultation, cardiovascular risk factors, access to reperfusion therapy, and mortality during hospitalisation. RESULTS: 558 patients were included with a slight predominance of women. Diagnosis of diabetes was more common in women and smoking in men (n = 68, 28.4% vs. n = 51, 15.9%; p = 0.0004). Rural origin was associated with higher prevalence of hypertension, diabetes, and dyslipidaemia (hypertension n = 45, 73.8% vs. n = 282, 57.4%; p = 0.007; diabetes n = 20, 33.3% vs. 109, 19.5%; p = 0.02; dyslipidaemia n = 19, 32.7% vs. n = 93, 18.9%; p = 0.02). Mortality was higher in rural patients (n = 8, 14.2% vs. n = 30, 6.1%; p = 0.03). Lower schooling was associated with higher frequency of hypertension and dyslipidaemia (hypertension n = 152, 76.0% vs. n = 94, 46.3%; p ≤ 0.0001; dyslipidaemia n = 56, 28% vs. n = 35, 17.0%; p = 0.009) as well as with late consultation (n = 30, 15% vs. n = 59, 28.7%; p = 0.0011) and lower probability of accessing reperfusion therapy (n = 12, 6% vs. n = 45, 22%; p ≤ 0.0001). Formal employment was associated with a visit to the emergency department in less than 3 h (n = 50, 25.2% vs. n = 58, 18%, p = 0.04 and a higher probability of accessing reperfusion therapy (n = 35, 17.6% vs. n = 33, 10.2%; p = 0.01). Finally, living in a household with a stratum higher than 3 was associated with a consultation before 3 h (n = 77, 25.5% vs. n = 39, 15.6%; p = 0.004) and a higher probability of reperfusion therapy (n = 57, 18.9% vs. n = 13, 5.2%; p ≤ 0.0001). CONCLUSION: Indicators of socio-economic status are related to mortality, consultation time, and access to reperfusion therapy. Mortality and reperfusion therapy are inequitably distributed and, therefore, more attention needs to be directed to the cause of these disparities in order to reduce the access gap in the context of acute stroke in Bogotá.

Corruption and its relation to prevalence and death due to noncommunicable diseases and risk factors: a global perspective.

Objective: To describe the relation between corruption indicators and statistics on noncommunicable diseases and their risk factors by continent. Methods: An ecological study was conducted to examine the relation of the GINI coefficient, the Country Policy and Institutional Assessment (CPIA), and the Corruption Perception Index (CPI) with noncommunicable diseases, using the Spearman's rank correlation test. Results: There is a moderate and positive correlation between Corruption Perception Index and cause of death due to noncommunicable diseases and risk factors for these diseases (r = 0.532), prevalence of schizophrenia (r = 0.526), bipolar disorder (r = 0.520), and eating disorders (r = 0.677). There is a moderate negative association between the GINI index and cause of death due to noncommunicable diseases (r = -0.571) and smoking prevalence (r = -0.502), and between the Corruption Perception Index and mortality caused by cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases between the exact ages of 30 and 70 years (r = -0.577) and malnutrition prevalence (r = -0.602). Conclusions: This study indicates a correlation between corruption and noncommunicable diseases and their risk factors. This suggests that the high prevalence of noncommunicable diseases and risk factors could be related with political practices that negatively impact the population. Further research should study the weight of these associations, to take action on the way corruption is impacting on the health of societies.

Loxin Reduced the Inflammatory Response in the Liver and the Aortic Fatty Streak Formation in Mice Fed with a High-Fat Diet.

Oxidized low-density lipoprotein (ox-LDL) is the most harmful form of cholesterol associated with vascular atherosclerosis and hepatic injury, mainly due to inflammatory cell infiltration and subsequent severe tissue injury. Lox-1 is the central ox-LDL receptor expressed in endothelial and immune cells, its activation regulating inflammatory cytokines and chemotactic factor secretion. Recently, a Lox-1 truncated protein isoform lacking the ox-LDL binding domain named LOXIN has been described. We have previously shown that LOXIN overexpression blocked Lox-1-mediated ox-LDL internalization in human endothelial progenitor cells in vitro. However, the functional role of LOXIN in targeting inflammation or tissue injury in vivo remains unknown. In this study, we investigate whether LOXIN modulated the expression of Lox-1 and reduced the inflammatory response in a high-fat-diet mice model. Results indicate that human LOXIN blocks Lox-1 mediated uptake of ox-LDL in H4-II-E-C3 cells. Furthermore, in vivo experiments showed that overexpression of LOXIN reduced both fatty streak lesions in the aorta and inflammation and fibrosis in the liver. These findings were associated with the down-regulation of Lox-1 in endothelial cells. Then, LOXIN prevents hepatic and aortic tissue damage in vivo associated with reduced Lox-1 expression in endothelial cells. We encourage future research to understand better the underlying molecular mechanisms and potential therapeutic use of LOXIN.

OnabotulinumtoxinA for Systemic Sclerosis-associated Raynaud's Phenomenon: A Multi-Institutional Study on Accessibility and Effectiveness.

Raynaud’s phenomenon (RP), a common presenting symptom of systemic sclerosis (SSc), is a painful and debilitating condition of the digits caused by increased vascular reactivity.1,2.

Reversible Cerebral Vasoconstriction Syndrome Associated with a Suprarenal Mass.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterised by severe thunderclap headaches (with or without the presence of acute neurological symptoms) and segmental vasoconstriction of cerebral arteries that resolves spontaneously in a period of three months. Cases have been described in the literature with producing and non-producing masses of metanephrines. Within these reports, associations with cavernous haemangioma, medulloblastoma, colon cancer, paraganglioma, pheochromocytoma, uterine fibroids, among others were found. However, no association with adrenal masses which do not produce metanephrines was found. In this context, we reported the case of a woman with this type of tumour associated with RCVS which provided a treatment challenge, as well as we reviewed the literature on cases of RCVS associated with masses.

Epidermolytic hyperkeratosis of the vulva: Case report and review of the literature.

Epidermolytic hyperkeratosis is a rare histopathological phenomenon which has been reported in a number of dermatological conditions. It is rare but can cause chronic and intractable symptoms which can impede the quality of life of those affected. Treatment options are variable and not enough data exists to provide a definitive protocol for management. We present this case to highlight a simple, efficacious way for dermatologists to treat the condition and provide a literature review.

Obesity as a Risk Factor for Severe COVID-19 in Hospitalized Patients: Epidemiology and Potential Mechanisms.

SARS-CoV-2 infection is a global public health problem, causing significant morbidity and mortality. Evidence shows that obesity is a recognized risk factor for hospitalization, admission to critical care units, and the development of serious complications from COVID-19. This review analyzes the available epidemiological evidence that relates obesity to a higher risk of severity and mortality from COVID-19, examining the possible pathophysiological mechanisms that explain this phenomenon on a cellular and molecular level.

Challenges of securing insurance approval for oral tofacitinib for the treatment of alopecia areata: a multi-institution retrospective review.

Alopecia areata (AA) is a psychologically distressing disorder for which few reliable treatments exist. Although oral tofacitinib has demonstrated efficacy in treating AA, it is not approved by the Food and Drug Administration (FDA) for this indication. To investigate and identify the challenges associated with securing insurance approval for oral tofacitinib for AA. We conducted a retrospective review of patient records from two academic medical centers to identify patients with AA in whom insurance approval was sought for oral tofacitinib from 2015-2019. We recorded information on prior authorization (PA) submissions, appeals, and peer-to-peer reviews. We noted whether patients were documented to experience negative impact on mood/QOL or suicidal ideation (SI) due to their disease. We identified 37 patients in whom insurance approval was sought for oral tofacitinib for the treatment of AA. PAs were initially denied for 36/37 (97%) patients. The most commonly cited reason for denial was "tofacitinib not covered for AA/off-label medication use" (n = 26/36; 72%). 26/37 (70%) patients ultimately failed to obtain coverage. Of the 11 (30%) patients who obtained coverage, 10 (91%) were privately insured, 0 (0%) had Medicare and 1 (9%) had Medicaid. 13 patients (34%) experienced documented diminished QOL/mood (including SI) due to their disease burden; 6/13 (46%) of these patients eventually secured insurance approval. Lack of FDA approval of oral tofacitinib for the treatment of AA creates challenges in caring for patients with this disease. Policymakers should consider the negative implications lack of FDA approval may have for patients with recalcitrant dermatologic conditions.

Cannabis and pain: a scoping review.

For centuries, cannabis has been used with many different purposes, including medicinal use, usually bypassing any formal approval process. However, during the last decade, interest in cannabis in medicine has been increasing, and several countries, including the United States and Canada, have produced their own legislation about marihuana and cannabis-based medicines. Because of this, interest in research has been increasing and evidence about its medical effects is becoming necessary. We conducted a review examining the evidence of cannabis in pain. Cannabis had been shown to be useful in acute and chronic pain, however recently, these results have been controverted. Within the different types of chronic pain, it has a weak evidence for neuropathic, rheumatic pain, and headache, modest evidence for multiple sclerosis related pain, and as adjuvant therapy in cancer pain. There is no strong evidence to recommend cannabis in order to decrease opioids in patients with chronic use. Even though cannabis-based medications appear to be mostly safe, mild adverse effects are common; somnolence, sedation, amnesia, euphoric mood, hyperhidrosis, paranoia, and confusion may limit the use of cannabis in clinical practice. Risks have not been systematically analyzed. Special concern arises on how adverse effect might affect vulnerable population such as elderly patients. More research is needed in order to evaluate benefits and risks, as well as the ideal administration route and dosages. As cannabis use increases in several countries, answers to these questions might be coming soon.

Prevalence of Misrepresentation of Nonphysician Clinicians at Dermatology Clinics.

INTRODUCTION: To evaluate the use of inaccurate terminology used by dermatology practices to describe the training and qualifications of their nonphysician clinicians (NPCs) when new patients are booking appointments. METHODS: Clinics were randomly selected and called to determine the first available appointment for a new patient with a new and changing mole. If the receptionist confirmed the first-offered appointment was with an NPC, the encounter was included in this study. If receptionists used inaccurate terminology to describe the NPCs and their qualifications, this instance was recorded along with the specific language that they used. RESULTS: A total of 344 unique dermatology clinics were contacted on February 27, 2020, in 25 states. Phone calls at 128 clinics (37.2%) met our inclusion criterion. Inaccurate language was used to describe NPCs at 23 (18%) unique clinic locations across 12 states, with "dermatologist," "doctor," "physician," and "board-certified" being used to describe NPCs as the most common inaccurate terms. CONCLUSION: These findings demonstrate that front office staff at dermatology clinics use inaccurate and potentially misleading terminology to refer to NPCs working in their clinics. While we cannot establish whether this is intentional or due to a lack of training, additional focus should be placed on accurately representing provider qualifications to patients.

Insurance Acceptance, Appointment Wait Time, and Dermatologist Access Across Practice Types in the US.

Importance: In the 15 years since dermatology access was last investigated on a national scale, the practice landscape has changed with the rise of private equity (PE) investment and increased use of nonphysician clinicians (NPCs). Objective: To determine appointment success and wait times for patients with various insurance types at clinics with and without PE ownership. Design, Setting, and Participants: In this study, PE-owned US clinics were randomly selected and matched with 2 geographically proximate clinics without PE ownership. Researchers called each clinic 3 times over a 5-day period to assess appointment/clinician availability for a fictitious patient with a new and changing mole. The 3 calls differed by insurance type specified, which were Blue Cross Blue Shield (BCBS) preferred provider organization, Medicare, or Medicaid. Main Outcomes and Measures: Appointment success and wait times among insurance types and between PE-owned clinics and control clinics. Secondary outcomes were the provision of accurate referrals to other clinics when appointments were denied and clinician and next-day appointment availability. Results: A total of 1833 calls were made to 204 PE-owned and 407 control clinics without PE ownership across 28 states. Overall appointment success rates for BCBS, Medicare, and Medicaid were 96%, 94%, and 17%, respectively. Acceptance of BCBS (98.5%; 95% CI, 96%-99%; P = .03) and Medicare (97.5%; 95% CI, 94%-99%; P = .02) were slightly higher at PE-owned clinics (compared with 94.6% [95% CI, 92%-96%] and 92.8% [95% CI, 90%-95%], respectively, at control clinics). Wait times (median days, interquartile range [IQR]) were similar for patients with BCBS (7 days; IQR, 2-22 days) and Medicare (7 days; IQR, 2-25 days; P > .99), whereas Medicaid patients waited significantly longer (13 days; IQR, 4-33 days; P = .002). Clinic ownership did not significantly affect wait times. Private equity-owned clinics were more likely than controls to offer a new patient appointment with an NPC (80% vs 63%; P = .001) and to not have an opening with a dermatologist (16% vs 6%; P < .001). Next-day appointment availability was greater at PE-owned clinics than controls (30% vs 21%; P = .001). Conclusions and Relevance: Patients with Medicaid had significantly lower success in obtaining appointments and significantly longer wait times regardless of clinic ownership. Although the use of dermatologists and NPCs was similar regardless of clinic ownership, PE-owned clinics were more likely than controls to offer new patient appointments with NPCs.

Daily genital cares of female gynecologists: a descriptive study.

INTRODUCTION: Genital hygiene can play an essential role in avoiding vulvovaginal discomfort and preventing infections. The scientific evidence on best practices on genital hygiene is scarce, and without doubt, gynecologists should be the best person to discuss and guide the subject. OBJECTIVE: Evaluate the general genital female gynecologist hygiene. METHODS: This descriptive analytic study identified genital hygiene and sexual practices of 220 female gynecologists, through a questionnaire with 60 self-answered questions. The data were analyzed and presented using frequency, percentage, mean and standard deviation. RESULTS: The studied population was constituted by middle age (37.3 years) and white (71.3%) female gynecologists. More than a half (53.6%) declared spending over 10 hours a day away from home and complained of vaginal discharge in 48.1% of the cases. Regular vulvovaginal hygiene: 17.8% reported washing genitals once a day and 52% twice a day. The use of dry paper alone was reported in 66.4% post urination and 78.5% post-evacuation. Using running water and soap was practiced by 25.9% and 21.5% respectively. Vulvovaginal hygiene related to sex: More than half of them had intercourse 1-3 times a week, and 37.4% and 24.1% had frequent oral sex and eventually anal sexof the participants, respectively. Genital hygiene before sex was positive in 52.7% of the subjects and, post-sex hygiene in 78.5% of them. CONCLUSION: Genital hygiene habits of female gynecologists can be improved, despite the high grade of scientific knowledge they hold.

The L-shaped mastopexy / A mastopexia de aumento em L

Introduction: The mastopexy with implants and L-shaped scarring aims to correct grades I to II breast ptosis using implants in retroglandular space and retromuscular dual plane space, at the same surgical time. The objective is to describe the experience with the L-augmentation mastopexy technique, analyzing complications and reoperations. Methods: Retrospective study of 123 patients with mild to moderate breast ptosis, operated using the L-augmentation mastopexy technique from January 2011 to November 2021. Results: The mean age of patients was 35.6 years. The average volume of implants used was 315ml (range 175 to 600ml). The placement of the prosthesis was in retroglandular (46.5%) and dual plane retromuscular space (53.5%). The average operative time was two hours and fifty-four minutes. The main complications presented were superficial dehiscence (7.3%), recurrence of ptosis (7.3%) and unsightly scars (5.7%). Surgical reviews took place in 13 patients (10.5%). Conclusion: Safe and effective mastopexy technique with implant in the treatment of mild to moderate breast ptosis, providing well designed breasts with reduced L-shaped scars.

Introdução: A mastopexia com implantes e cicatriz em L visa corrigir ptoses mamárias graus I a II com utilização de implantes em espaço retroglandular e retromuscular dual plane, no mesmo tempo cirúrgico. O objetivo é descrever a experiência com a técnica de mastopexia de aumento em L, analisando complicações e reoperações. Método: Estudo retrospectivo de 123 pacientes com ptose mamária leve a moderada, operadas pela técnica de mastopexia de aumento em L no período de janeiro de 2011 a novembro de 2021. Resultados: A média de idade das pacientes foi de 35,6 anos. O volume médio de implantes utilizado foi de 315ml (variação de 175 a 600ml). O posicionamento da prótese foi em espaço retroglandular (46,5%) e retromuscular dual plane (53,5%). O tempo médio operatório foi de duas horas e cinquenta e quatro minutos. As principais complicações apresentadas foram deiscências superficiais (7,3%), recorrência da ptose (7,3%) e cicatrizes inestéticas (5,7%). Revisões cirúrgicas aconteceram em 13 pacientes (10,5%). Conclusão: Técnica de mastopexia com implante segura e eficaz no tratamento da ptose mamária leve a moderada, proporcionando mamas bem projetadas com cicatrizes reduzidas em L.

SISPRO: La base de datos administrativa del sistema de salud colombiano / SISPRO: The administrative database of the Colombian healthcare system

RESUMEN Colombia es reconocida en la región por la universalidad tanto de su sistema de salud como de sus sistemas de información. Si bien el Sistema de Información Integral para la Protección Social (SISPRO) tiene como finalidad cumplir una función administrativa dentro del sistema de salud, se están reconociendo sus usos en investigación. SISPRO está compuesto por varias bases de datos diferentes: las estadísticas vitales, el registro individual de prestaciones en salud (RIPS) y la clasificación única de trámites en salud (CUPS), entre otras. Las estadísticas vitales registran los nacimientos y las defunciones, junto con la ubicación geográfica, la edad de la madre o la causa de la muerte, entre otra información. Los RIPS son la base de datos más utilizada en investigación en salud, ya que permiten establecer el número de contactos que las personas tienen con el sistema de salud (más de 2 mil millones en el último quinquenio) y conocer los principales diagnósticos registrados en cada uno de estos contactos. Con RIPS, ha sido posible establecer la prevalencia de esclerosis múltiple o estimar la carga de enfermedad de la epilepsia en Colombia. RIPS también tiene información útil sobre el costo de la atención médica. Finalmente, los CUPS permiten cuantificar los procedimientos de salud, por ejemplo, podemos estimar en 1879 el número de procedimientos de trombólisis de vasos intracraneales en Colombia entre 2017 y 2021. La calidad de la información es una gran limitación en toda base de datos administrativa, sin embargo, SISPRO representa una gran oportunidad para utilizar los registros oficiales para generar conocimiento, comprender la distribución geográfica de las enfermedades y contribuir al diseño de políticas públicas en nuestra población.