Approach to the Epidemiology, Disease Management, and Current Challenges in the Management of Generalized Pustular Psoriasis Through a Survey Conducted Among Spanish Dermatologists. / Aproximación a la epidemiología, manejo de la enfermedad y retos actuales en la gestión de la psoriasis pustulosa generalizada en España a través de un cuestionario dirigido a dermatólogos.

BACKGROUND: Generalized pustular psoriasis (GPP) is a rare and severe inflammatory skin disease characterised by recurrent or intermittent flares. Epidemiological and disease management data in Spain are limited. Our goal was to estimate the epidemiology of GPP, explore its management, and reach consensus on the current challenges faced in Spain. METHODS: An electronic survey was submitted to dermatologists from the Spanish Academy of Dermatology and Venereology Psoriasis Working Group. This group is experienced in the management of GPP. It included a Delphi consensus to establish the current challenges. RESULTS: A total of 33 dermatologists responded to the survey. A 5-year prevalence and incidence of 13.05 and 7.01 cases per million inhabitants, respectively, were estimated. According to respondents, the most common GPP symptoms are pustules, erythema, and desquamation, while 45% of patients present > 1 annual flares. A total of 45% of respondents indicated that flares often require a length of stay between 1 and 2 weeks. In the presence of a flare, 67% of respondents often or always prescribe a non-biological systemic treatment as the first-line therapy [cyclosporine (55%); oral retinoid (30%)], and 45% a biological treatment [anti-TNFα (52%); anti-IL-17 (39%)]. The dermatologists agreed that the main challenges are to define and establish specific therapeutic goals to treat the disease including the patients' perspective on the management of the disease. CONCLUSION: Our study describes the current situation on the management of GPP in Spain, increasing the present knowledge on the disease, and highlighting the current challenges faced at the moment.

Patch Testing During the COVID-19 Pandemic: Recommendations of the AEDV's Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC). / Recomendaciones del Grupo Español de Investigación en Dermatitis de Contacto y Alergia Cutánea (GEIDAC) de la AEDV en relación con la realización de pruebas epicutáneas durante la pandemia por SARS-CoV-2 (COVID-19).

As the COVID-19 pandemic gradually comes under control, the members of the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) have drawn up a proposed list of the requirements, limitations, and conditioning factors affecting the resumption of work in contact dermatitis units. The assumption is that the severe acute respiratory syndrome coronavirus2 is still circulating and that occasional or seasonal outbreaks will occur. They recommend that the first step should be to assess how many patch tests each clinic can handle and review the waiting list to prioritize cases according to disease severity and urgency. Digital technologies can, where possible, be used to send and receive the documentation necessary for the patch test (information, instructions, informed consent, etc.). If the necessary infrastructure is available, patients can be offered the option of a remote initial consultation. Likewise, in selected cases, the patch test results can be read in a virtual visit using photographs taken by the patient or a video visit can be scheduled to allow the physician to evaluate the site of application remotely. These measures will reduce the number of face-to-face visits required, but will not affect the time spent on each case, which must be scheduled in the normal manner. All of these recommendations are suggestions and should be adapted to the needs and possibilities of each health centre.

Expert consensus on the persistence of biological treatments in moderate-to-severe psoriasis.

BACKGROUND: Treatment persistence is becoming a useful measure to evaluate long-term effectiveness and safety of biological therapies in real-world settings. OBJECTIVE: The main objective of this study was to explore the scientific opinion of a panel of dermatologists and hospital pharmacists to reach a consensus about the impact, causes, and best strategies and interventions that might be associated with improved drug persistence in patients with psoriasis in Spain. METHODS: This research was conducted using a modified Delphi method organized in two rounds and involving a panel of 90 dermatologists and 34 hospital pharmacists. A questionnaire of 70 items was developed. The items proposed to reach a consensus included topics such as definitions and measures in the treatment of psoriasis, analysis of treatment persistence, factors that may influence treatment persistence, impact of treatment persistence and economic cost of treatment. RESULTS: Dermatologists reached a consensus on 77.1% of the items proposed, and hospital pharmacists reached a consensus on 71.4%. Both groups agreed that it is important to use standardized measures in the evaluation of treatment maintenance over time. Dermatologists agreed that treatment survival, persistence and retention are synonymous, but hospital pharmacists considered only treatment persistence as a valid term. In addition, panelists agreed that drug persistence is an indicator of success in the treatment of psoriasis that may be influenced by a drug's effectiveness and safety profile, as well as by patient satisfaction. They agreed that the different causes of treatment discontinuation should be considered in Kaplan-Meier analysis of treatment persistence. Moreover, treatment persistence was agreed to decrease the cost of therapy. CONCLUSION: This Delphi consensus highlights the different perspectives of dermatologists and hospital pharmacists regarding the interpretation of treatment persistence, and the challenge of harmonizing the results obtained.

Obesity and psoriasis: inflammatory nature of obesity, relationship between psoriasis and obesity, and therapeutic implications.

Obesity, particularly abdominal obesity, is currently considered a chronic low-grade inflammatory condition that plays an active role in the development of the pathophysiologic phenomena responsible for metabolic syndrome and cardiovascular disease through the secretion of proinflammatory adipokines and cytokines. In recent years clear genetic, pathogenic, and epidemiologic links have been established between psoriasis and obesity, with important implications for health. The relationship between the 2 conditions is probably bidirectional, with obesity predisposing to psoriasis and psoriasis favoring obesity. Obesity also has important implications in the treatment of psoriasis, such as a greater risk of adverse effects with conventional systemic drugs and reduced efficacy and/or increased cost with biologic agents, for which dosage should be adjusted to the patient's weight.

Spanish evidence-based guidelines on the treatment of psoriasis with biologic agents, 2013. Part 1: on efficacy and choice of treatment. Spanish Psoriasis Group of the Spanish Academy of Dermatology and Venereology.

Biologic therapy is a well-established strategy for managing moderate and severe psoriasis. Nevertheless, the high cost of such therapy, the relatively short span of clinical experience with biologics, and the abundance of literature now available on these agents have made evidence-based and consensus-based clinical guidelines necessary. The ideal goal of psoriasis treatment is to achieve complete or nearly complete clearing of lesions and to maintain it over time. Failing that ideal, the goal would be to reduce involvement to localized lesions that can be controlled with topical therapy. Although current evidence allows us to directly or indirectly compare the efficacy or risk of primary or secondary failure of available biologics based on objective outcomes, clinical trial findings cannot be directly translated to routine practice. As a result, the prescribing physician must tailor the treatment regimen to the individual patient. This update of the clinical practice guidelines issued by the Spanish Academy of Dermatology and Venereology (AEDV) on biologic therapy for psoriasis incorporates information from the most recent publications on this topic.

A prospective evaluation of the cost of psoriasis in Spain (EPIDERMA project: phase II).

OBJECTIVE: To estimate the direct and indirect costs related to psoriasis in Spain. METHODS: We performed a 12-month, multicentre, prospective longitudinal and observational study. Overall expense of care was assessed as the sum of direct and indirect costs. RESULTS: A total of 797 patients with varying demographics and different degrees of severity of psoriasis were included in the study. The mean total cost of psoriasis, including direct and indirect items, was 1,079 euro per patient and year. The major sources of expenditure were prescription drugs (46.6%), followed by medical activities (34.5%). Mean costs in patients with moderate and severe psoriasis were approximately 1.5 and 2.5 times higher than in those with mild psoriasis, respectively. CONCLUSIONS: In Spain, psoriasis is associated with substantial costs both to the National Health System and to the patients.

The molecular chaperone TF55. Assessment of symmetry.

TF55-like factor from Sulfolobus solfataricus was purified to homogeneity and analyzed by electron microscopy and image analysis to determine the symmetries of these particles. Three different procedures were used to analyze the electron micrographs: (1) fuzzy-set based classification of the particles according to their rotational power spectra; (2) multivariate statistical analysis based on singular value decomposition; (3) circular harmonic analysis. Averages obtained from the three methods show unequivocally that the TF55-like complex presents a 9-fold symmetry.

[Critical evaluation of echography in the diagnosis of cholestatic jaundice]. / Valoración crítica de la ecografía en el diagnóstico de la ictericia colestática.

Seventy one patients affected by cholestasis and jaundice were studied by means of ultrasound between september 1980 and february 1983 in order to evaluate the accuracy of this procedure in the investigation of the site of obstruction and its ethiology. The ultrasound findings were correlated with those obtained by opacification of the bile ducts, either endoscopic or percutaneous, and by surgery. The sonographic diagnosis of cholestatic jaundice was based on the size of the biliary tract taking in account that the intrahepatic branches are not evident in normal conditions and considering 4-5 mm and 7-8 mm as the upper limits for the proximal and distal segments of the common bile duct respectively. The accuracy of ultrasound in establishing the common bile duct size was 98%. Forty eight patients had extrahepatic obstruction, 45 of whom had a dilated common bile duct (94%), while 3 were normal (6%). Twenty two patients had an intrahepatic cholestasis, 20 of whom had a normal size of the common bile duct (91%) while 2 showed a dilatation (9%). Thus, the sensitivity was 95.7% and the specificity 86.9%. The ethiologic diagnosis was available in 31 patients with extrahepatic obstruction (65%) and in 7 with intrahepatic cholestasis (32%). Dilated common bile duct with stones and pancreas and gallbladder carcinoma were the most common causes of obstructions we have found in this group of patients. In patients with cholestasis and jaundice the ultrasonic diagnosis should establish the site of obstruction and, if it is possible, the ethiology.