[Acute poisoning among patients attended to in an emergency department: From the pre-pandemic period to the new normality]. / Intoxicaciones agudas atendidas en un servicio de urgencias. De la prepandemia a la nueva normalidad.

Background: The COVID-19 pandemic has caused global changes that affect the daily life of the world's population, with a direct impact on individuals' physical and mental health as well as on their social and recreational habits. Methods: This study aimed to retrospectively analyze the demographic and clinical characteristics of patients attended to for acute poisoning in a hospital emergency department (ED) at three different periods of time: pre-pandemic (2019), after strict lockdown of the population in Spain (2020), and post-pandemic (2021). We analyzed 2 months (June and July) in each period. Results: A total of 1,182 cases of acute poisoning were included. Compared to the pre-pandemic period, during lockdown, the number of patients with acute poisoning decreased (2019: 1.9% vs. 2020: 1.5%; p<.01); the ratio of men to women increased (2.0 vs. 1.4; p=.02); and the mean age of patients increased (2019: 31.4 vs. 2020: 41.3; p<.001), a trend which continued in 2021 (38.3). Poisoning with suicidal intention also increased during the pandemic (2019: 8.71% vs. 2020: 21.0%; p<.01) whereas poisonings with a recreational intention declined (2019: 76.1% vs. 2020: 62.0%; p<.01) with a non-significant increase in 2021 (69.0%, p=.07). Conclusion: The COVID-19 pandemic generated clinical and epidemiological changes in the acute poisonings attended to in a hospital emergency department during the various phases of the pandemic.

Keys to the diagnosis of hair shaft disorders: Part I. / Claves diagnósticas en displasias pilosas I.

Hair shaft disorders, involving dysplastic abnormalities in the shaft, may be either congenital or acquired. Two large categories have been defined according to the presence or not of hair fragility. A diagnosis can usually be made after taking a thorough medical history and performing a physical examination. Trichoscopy has become a useful, cost-effective tool in recent years, particularly for examining the hair of children, because it facilitates inspection without removal of hairs. Structural abnormalities in the hair shaft are sometimes clues to the diagnosis of more complex diseases in which early treatment can improve prognosis. This review describes key features that enable the diagnosis of the most common hair shaft disorders and discusses the various treatments currently available.

Keys to the Diagnosis of Hair Shaft Disorders: Part II. / Claves diagnósticas en displasias pilosas II.

Hair shaft disorders, involving dysplastic abnormalities in the shaft, may be caused by genetic mutations or acquired through environmental exposures. The second part of this review presents these disorders classified according to the degree of hair fragility. It is important to take a thorough medical history and examine the hair to detect changes in texture, density, quality, and whether fragility is observed or not. Trichoscopy is a useful, noninvasive tool that can suggest a diagnosis in most cases. Specific treatments for hair shaft disorders are not available at present. We recommend general care practices to prevent hair damage; examples are avoiding excessive brushing, chemical products, hairstyles that introduce tension, and exposure to excessive heat. Some hair shaft disorders improve with puberty. Others may respond to treatments such as topical applications of minoxidil.

Skin manifestations of COVID-19 in children: Part 3.

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestations of COVID-19, chilblain-like lesions, and in Part 2 we expanded to other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome. In this part of the review, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children for both COVID-19 and any other pre-existing conditions.

Skin manifestations of COVID-19 in children: Part 2.

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults, as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discussed one of the first and most widespread cutaneous manifestations of COVID-19, chilblain-like lesions. In this part of the review, we describe other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome. In Part 3, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children for both COVID-19 and any other pre-existing conditions.

Skin manifestations of COVID-19 in children: Part 1.

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestation of COVID-19, chilblain-like lesions. In Part 2, we review other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome, while in Part 3, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children, for both COVID-19 and any other pre-existing conditions.

Primary immunodeficiency and chronic mucocutaneous candidiasis: pathophysiological, diagnostic, and therapeutic approaches.

Chronic mucocutaneous candidiasis (CMC) is characterized by a chronic or recurrent non-invasive infection, mainly due to Candida albicans, in skin, nails, and mucous membranes, associated in some cases with autoimmune manifestations. The key immune defect is a disruption of the action of cytokine IL-17, whose most common genetic etiology is STAT1 gene gain-of-function (GOF) mutations. The initial appropriate treatment for fungal infections is with azoles. However, the frequent occurrence of drug resistance is the main limitation. Therefore, identification of the underlying inborn error if immunity in CMC may allow to widen therapeutic options aimed at restoring immunological function. Type I and II Janus kinase-inhibitors have been shown to control CMC in cases associated with STAT1 GOF. In this review, we delve into the pathogenesis of CMC and the underlying immune mechanisms. We describe the reported genetic defects in which CMC is the main manifestation. Diagnostic and therapeutic approaches for these patients are also offered.

Poisoning among the elderly. / Intoxicaciones en la tercera edad.

OBJECTIVES: Poisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals. METHODS: Retrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital. RESULTS: A total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4). CONCLUSIONS: The prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

Alopecia areata totalis and universalis: a multicenter review of 132 patients in Spain.

BACKGROUND: Alopecia areata totalis (AAT) and universalis (AAU) pose a therapeutic challenge. OBJECTIVE: To describe the clinical and epidemiological features, therapeutic response and prognostic factors in a large series of patients diagnosed with AAT and AAU. METHODS: This retrospective multicenter study included patients diagnosed with AAT/AAU with a minimum follow-up of 12 months. Response was assessed based on the regrowth of scalp hair. RESULTS: In all, 132 patients (92 women and 40 men) - 80 (61%) diagnosed with AAU and 52 (39%) diagnosed with AAT - were included. The median time between the presentation of alopecia areata (AA) and the development of extensive AA was 1 year and it was less than 4 years in 121 patients (91%). There was an initial response to treatment in 64% of patients, although only 14% presented a persistent response. Adverse side effects from the medications used were detected in 33% of patients. The prognostic factors associated with poor response were the presence of AAU and a positive family history of AA. CONCLUSIONS: Treatment of AAT and AAU is challenging. Although an initial regrowth may be achieved, the duration of response is usually short. There were no significant differences on the effectiveness or duration of response between the various systemic therapies.

Left ventricular diastolic function and cardiometabolic factors in obese normotensive children.

BACKGROUND AND AIM: Left ventricular (LV) hypertrophy and diastolic function have been found to be associated with obesity and hypertension in adults. However, there are scarce data about the association of obesity itself to cardiac alteration in children. The aim of this study was to detect early changes in LV structure and function in obese children and whether they are associated with the biomarkers of metabolic risk and endothelial activation. METHODS AND RESULTS: A total of 130 children aged 7-16 years (88 obese and 42 normal-weight children) were studied. All children had normal resting blood pressure. Two-dimensional ultrasound with M-mode imaging was performed to assess the LV mass index (LVMi), calculated as LV mass/height(2.7), and the peak diastolic of pulmonary venous flow velocity (PVFD). Tissue Doppler imaging was used to analyze ventricular performance through the ratio of the transmitral peak early filling velocity to the early average diastolic peak myocardial velocity (E/E'). The indicators of metabolic control, inflammation, and endothelial cell activation were evaluated. Compared to the controls, the obese subjects had significantly higher LVMi and E/E' and lower PVFD values, the two latest being found especially in severely obese subjects. In the multivariate analysis, the parameters of diastolic function (E/E' and PVFD) were independently associated with obesity, apolipoprotein A1, soluble vascular cell endothelial molecule-1 (sVCAM-1), and retinol-binding protein 4 (RBP4). CONCLUSION: An echocardiographic evaluation of diastolic function is a useful tool to detect early cardiac changes in obese children. Emergent cardiovascular risk markers such as apolipoprotein A1, RBP4, and sVCAM-1 are associated with the parameters of diastolic function.

Anionic markers for the forensic identification of Chemical Ignition Molotov Cocktail composition.

An improved version of the famous Molotov cocktail is the Chemical Ignition Molotov Cocktail (CIMC). This incendiary device contains chemical reagents that enable its self-ignition. The analysis of anions from CIMC residues by capillary electrophoresis (CE) allows the identification of the reagents used to produce the device, and provides forensic analysts with valuable information. Although, sulfate, chlorate, chloride, and perchlorate anions have been recently proposed in the literature as target anions to determine the CIMC composition, the identification of some of them could be controversial due to their presence in the environment. Therefore, the purpose of this study was to identify highly reliable anions capable of indicating the components used to prepare these self-initiated devices. The relationship among the detected anions in CIMC residues and the reagents employed in their elaboration is discussed. Some anions have been proposed as anionic markers of CIMC as incendiary devices. Additionally, the viability of different CIMC compositions was studied.

Acute poisoning among patients attended to in an emergency department: from the pre-pandemic period to the new normality.

BACKGROUND: The COVID-19 pandemic has caused global changes that affect the daily life of the world's population, with a direct impact on individuals' physical and mental health as well as on their social and recreational habits. METHODS: This study aimed to retrospectively analyze the demographic and clinical characteristics of patients attended to for acute poisoning in a hospital emergency department (ED) at three different periods of time: pre-pandemic (2019), after strict lockdown of the population in Spain (2020), and post-pandemic (2021). We analyzed 2 months (June and July) in each period. RESULTS: A total of 1,182 cases of acute poisoning were included. Compared to the pre-pandemic period, during lockdown, the number of patients with acute poisoning decreased (2019: 1.9% vs. 2020: 1.5%; p < 0.01); the ratio of men to women increased (2.0 vs. 1.4; p = 0.02); and the mean age of patients increased (2019: 31.4 vs. 2020: 41.3; p < 0.001), a trend which continued in 2021 (38.3). Poisoning with suicidal intention also increased during the pandemic (2019: 8.71% vs. 2020: 21.0%; p < 0.01) whereas poisonings with a recreational intention declined (2019: 76.1% vs. 2020: 62.0%; p < 0.01) with a non-significant increase in 2021 (69.0%, p = 0.07). CONCLUSION: The COVID-19 pandemic generated clinical and epidemiological changes in the acute poisonings attended to in a hospital emergency department during the various phases of the pandemic.

[Opinion of Spanish dermatologists regarding the use of biologic therapy in patients with moderate to severe psoriasis]. / Encuesta a dermatólogos sobre terapia biológica en pacientes con psoriasis moderada-grave en España.

BACKGROUND AND OBJECTIVES: Biologic therapy has represented a major advance in the treatment of moderate to severe psoriasis but its use depends upon the characteristics of the patient and the criteria applied by the dermatologist. The aim of this survey was to determine the criteria employed by dermatologists in the decision to use these drugs. METHODS: A cross-sectional survey was undertaken among Spanish dermatologists with experience in the treatment of moderate to severe psoriasis. The survey comprised 31 items distributed in 5 sections: investigator profile, disease management, treatment of moderate to severe psoriasis, use of biologic drugs, and evaluation of the use of biologic drugs for the treatment of moderate to severe psoriasis. RESULTS: One hundred-ninety dermatologists were included in the study. The study participants reported that 31% of patients receiving treatment for moderate to severe psoriasis are treated with biologic drugs. Of those, 28% require a change in treatment at some point due either to lack of activity or the appearance of side effects. Biologic drugs would be administered as monotherapy in 73% of cases. In between 53% and 59% of cases, biologic drugs would be prescribed as continuous treatments. On a scale of 1 to 5, the most valued pharmacological properties by dermatologists were safety (4.8 points; 95% confidence interval [CI], 4.7-4.9), long-term efficacy (4.6 points [4.5-4.7]), and tolerance (4.5 [4.4-4.6]). CONCLUSIONS: Dermatologists with experience in the use of biologic drugs employ this treatment option in slightly more than a quarter of cases of moderate to severe psoriasis. In their opinion, the choice of biologic drug should be based on, in order of importance, safety, long-term efficacy, and tolerance.

Poisoning among the elderly.

OBJECTIVES: Poisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals. METHODS: Retrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital. RESULTS: A total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4). CONCLUSIONS: The prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

Pattern of care in radiotherapy at a University Hospital in Spain: the RENORT project.

PURPOSE: RENORT is a novel data mining application developed to extract relevant clinical data from oncology information systems (OIS; ARIA and Mosaiq) used in radiation oncology (RO). METHODS/PATIENTS: We used RENORT to extract demographic and clinical data from the OIS of all patients treated at the RO Department at the General Hospital of Valencia during the year 2019. RESULTS: A total of 1158 treatments were performed. The female/male ratio was 39.3%/60.7%, with a mean age of 66 years. The mean waiting time between the treatment decision/proposal to the first visit was 10.1 days. Mean duration of the treatment preparation process was 21 days. Most patients (90.4%) completed treatment within the prescribed time ± 7 days. The most common sites/treatment types were: metastatic/palliative treatments (n = 300; 25.9%), breast (209; 18.0%), genitourinary (195; 16.8%), digestive (116; 10.0%), thoracic (104; 9.0%), head and neck (62; 5.4%), and skin cancer (51; 4.4%). The distribution according to treatment intent was as follows: palliative (n = 266; 23.0%), adjuvant curative (335; 28.9%), radical without adjuvant treatment (229; 19.8%), radical with concomitant treatment (188; 16.2%), curative neoadjuvant (70; 6.0%), salvage radiotherapy (61; 5.3%); and reirradiation (9; 0.8%). The most common treatment techniques were IMRT/VMAT with IGRT (n = 468; 40.4%), 3D-CRT with IGRT (421; 36.4%), SBRT (127; 11.0%), 2DRT (57; 4.9%), and SFRT (56; 4.8%). A mean of 15.9 fractions were administered per treatment. Hypofractionated schemes were used in 100% of radical intent breast and prostate cancer treatments. CONCLUSIONS: The RENORT application facilitates data retrieval from oncology information systems to allow for a comprehensive determination of the real role of radiotherapy in the treatment of cancer patients. This application is valuable to identify patterns of care and to assess treatment efficacy.

Patterns of treatment failure in patients with prostate cancer treated with 76-80 Gy radiotherapy to the prostate and seminal vesicles ± hormonotherapy.

PURPOSE: To assess the pattern of treatment failure in patients with prostate cancer (PCa) treated with radiotherapy (76-80 Gy) ± hormone therapy (HT). We also evaluated the influence of treatment failure on survival outcomes. METHODS: Retrospective study of patients with PCa (n = 302) treated with radiotherapy (RT) ± HT at our centre between November 1999 and July 2007. The mean patient age was 70.2 years (range 51-87). Distribution by NCCN risk group was low (n = 80, 26.5%), intermediate (n = 86, 28.5%), high (n = 77, 25.5%), and very high (n = 49, 16.2%). Most patients (n = 273, 90.4%) received IMRT at a dose of 76-80 Gy. HT was administered in 237 patients (78.5%), in most cases (n = 167, 55.3%) for < 7 months RESULTS: Survival rates at 10 years were: overall survival (OS), 64.3%; biochemical disease-free survival, 83.9%; disease-free survival, 92.5%; and metastasis-free survival (MFS), 94.3%. Biochemical failure (BF) was observed in 55 cases (18.2%), 32 of whom subsequently developed clinical recurrence: metastasis (n = 17, 5.6%), local failure (n = 11, 3.6%), and regional failure (n = 4, 1.3%). The cause of death (n = 159) was intercurrent disease in 115 cases (72.3%), second cancer in 27 (17.0%), and PCa in 17 (10.7%). Biochemical failure-free survival ≤ 24 months was significantly associated with worse OS and MFS (p = 0.0001). Late genitourinary and gastrointestinal toxicity grade ≥ 3 (RTOG) was observed in 18 (6.0%) and 7 (2.3%) patients, respectively. CONCLUSIONS: The main type of treatment failure after 76-80 Gy of radiotherapy ± HT is local or metastatic. In all cases, biochemical failure occurred prior to treatment failure. BF within 24 months of treatment completion was significantly associated with worse OS and MFS.

[Attitude of the adult patient with atopic dermatitis to the disease and its treatment: the ACTIDA Study]. / Actitud del paciente adulto con dermatitis atópica frente a su patología y tratamiento. Estudio ACTIDA.

OBJECTIVE: To determine the attitude of adult patients with atopic dermatitis (AD) to their disease and its treatment. MATERIAL AND METHODS: A multicenter, cross-sectional study was performed in patients with at least 2 outbreaks of AD in the previous year. RESULTS: Two hundred twenty-seven dermatologists recruited 1441 analyzable patients, the majority women, with a mean of 3.6 outbreaks per year. Most of the patients (97.2%) indicated that they always or sometimes requested medical evaluation of a new outbreak. In the most recent outbreak, 72.2% had used combined therapy, regardless of the severity of the episode; 2-drug combinations were the most common. The majority of dermatologists prescribed combined therapy, most commonly a 2-drug combination for mild or minimal disease, and 3 or more drugs for moderate to very severe outbreaks. CONCLUSIONS: Treatments used by patients for an outbreak of AD are similar to those prescribed by dermatologists in recent outbreaks.