[Translated article] Approach to the Epidemiology, Disease Management, and Current Challenges in the Management of Generalized Pustular Psoriasis Through a Survey Conducted Among Spanish Dermatologists.

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.

[Translated article] Requirements for Accessing New Dermatology Drugs in Spain: Results of the EQUIDAD Study.

BACKGROUND: Although the Spanish Ministry of Health prepares national therapeutic positioning reports (TPRs) and drug reimbursement policies, each of the country's 17 autonomous communities (ACs) is responsible for health care services and prescription requirements in its territory. The aim of the EQUIDAD study was to describe and explore potential differences in prescription requirements for new dermatology drugs across the autonomous communities. MATERIAL AND METHODS: Cross-sectional study conducted in April and May, 2023. Two dermatologists with management responsibilities from each autonomous community reported on territorial and more local prescription requirements for drugs covered by national TPRs issued between 2016 and 2022. RESULTS: Thirty-three researchers from 17 autonomous communities participated. The data submitted revealed between-community inequities in access to new drugs. Overall, 64.7% of the regions imposed additional prescription requirements to those mentioned in the TPRs for psoriasis. This percentage was lower for atopic dermatitis (35.3%) and melanoma (11.8%). The most common requirement for accessing a new drug was a previous prescription for another drug. Differences and additional requirements were also detected at the local level (i.e., differences between hospitals within the same autonomous community). CONCLUSIONS: Spain's autonomous communities have multiple regional and local prescription requirements that are not aligned with national TPR recommendations. These differences result in inequitable access to new drugs for both patients and practitioners across Spain.

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.

Requirements for Accessing New Dermatology Drugs in Spain: Results of the EQUIDAD Study. / Condicionantes de acceso a nuevos medicamentos dermatológicos en España: resultados del proyecto EQUIDAD.

BACKGROUND: Although the Spanish Ministry of Health prepares national therapeutic positioning reports (TPRs) and drug reimbursement policies, each of the country's 17 autonomous communities (ACs) is responsible for health care services and prescription requirements in its territory. The aim of the EQUIDAD study was to describe and explore potential differences in prescription requirements for new dermatology drugs across the autonomous communities. MATERIAL AND METHODS: Cross-sectional study conducted in April and May, 2023. Two dermatologists with management responsibilities from each autonomous community reported on territorial and more local prescription requirements for drugs covered by national TPRs issued between 2016 and 2022. RESULTS: Thirty-three researchers from 17 autonomous communities participated. The data submitted revealed between-community inequities in access to new drugs. Overall, 64.7% of the regions imposed additional prescription requirements to those mentioned in the TPRs for psoriasis. This percentage was lower for atopic dermatitis (35.3%) and melanoma (11.8%). The most common requirement for accessing a new drug was a previous prescription for another drug. Differences and additional requirements were also detected at the local level (i.e., differences between hospitals within the same autonomous community). CONCLUSIONS: Spain's autonomous communities have multiple regional and local prescription requirements that are not aligned with national TPR recommendations. These differences result in inequitable access to new drugs for both patients and practitioners across Spain.

Evolving etiologies, comorbidities, survival, and costs of care in adult encephalitis.

Encephalitis is a central nervous system disorder, often caused by infectious agents or aberrant immune responses. We investigated causes, comorbidities, costs, and outcomes of encephalitis in a population-based cohort. ICD-10 codes corresponding to encephalitis were used to identify health services records for all adults from 2004 to 2019. Data were cross-validated for identified diagnoses based on laboratory confirmation using univariate and multivariate statistical analyses. We identified persons with a diagnosis of encephalitis and abnormal cerebrospinal fluid (CSF) results (n = 581) in whom viral genome was detected (n = 315) in a population of 3.2 million adults from 2004 to 2019. Viral genome-positive CSF samples included HSV-1 (n = 133), VZV (n = 116), HSV-2 (n = 34), enterovirus (n = 4), EBV (n = 5), and CMV (n = 3) with the remaining viruses included JCV (n = 12) and HHV-6 (n = 1). The mean Charlson Comorbidity Index (2.0) and mortality rate (37.6%) were significantly higher in the CSF viral genome-negative encephalitis group although the mean costs of care were significantly higher for the CSF viral genome-positive group. Cumulative incidence rates showed increased CSF VZV detection in persons with encephalitis, which predominated in persons over 65 years with a higher mean Charlson index. We detected HSV-2 and VZV more frequently in CSF from encephalitis cases with greater material-social deprivation. The mean costs of care were significantly greater for HSV-1 encephalitis group. Encephalitis remains an important cause of neurological disability and death with a viral etiology in 54.2% of affected adults accompanied by substantial costs of care and mortality. Virus-associated encephalitis is evolving with increased VZV detection, especially in older persons.

Prueba de patrones de frecuencia y patrones de duración: evaluación del ordenamiento auditivo temporal / Frequency pattern and duration pattern test: assessment of auditory temporal ordering

Los aspectos temporales de la audición se consideran unos de los mecanismos claves del procesamiento auditivo, ya que resultarían críticos para el adecuado funcionamiento del resto de los procesos auditivos centrales. El ordenamiento auditivo temporal es una de las cuatro habilidades de los aspectos temporales de la audición y se refiere al procesamiento de dos o más estímulos auditivos según su orden de aparición u ocurrencia en el dominio temporal. Ha sido uno de los procesos más ampliamente estudiados debido a sus implicancias en el resto de las habilidades auditivas, así como también en numerosas actividades de la vida diaria, incluyendo la percepción y la discriminación de los sonidos del habla. Históricamente se han utilizado dos pruebas para evaluarlo: la prueba de patrones de frecuencia y la prueba de patrones de duración. Ambas pruebas cuentan con buena sensibilidad y especificidad para detectar lesiones del sistema nervioso auditivo central, incluyendo el hemisferio derecho, izquierdo y cuerpo calloso. En la actualidad, ambas pruebas son utilizadas con frecuencia debido a su eficiencia, su facilidad para ser administrada y la disponibilidad de valores normativos para un amplio rango de población. Se recomienda ampliamente su utilización en la práctica clínica considerando la obtención de valores normativos locales.

The temporal aspects of audition are considered one of the key mechanisms of auditory processing, as they would be critical for the proper functioning of the rest of the central auditory processes. The auditory temporal ordering is referred to one of the four skills of the temporal aspects of audition and refers to the processing of two or more auditory stimuli in their order of appearance or occurrence in the time domain. It has been one of the most widely studied processes due to its implications for the rest of listening skills, as well as in numerous activities of daily life, including perception and discrimination of speech sounds. Historically, two test has been used to evaluate: the frequency pattern and duration pattern tests. Both tests have good sensitivity and specificity to detect lesions at the central auditory nervous system, such as right and left hemisphere and corpus callosum dysfunctions. Currently, both tests are commonly used clinically due to its efficiency, ease of administration and the availability of normative data in wide range of population. Their use is strongly recommended in clinical practice considering obtaining local normative values.

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.

Acute respiratory distress syndrome among trauma patients: trends in ICU mortality, risk factors, complications and resource utilization.

OBJECTIVE: To evaluate trends in mortality and related factors among trauma patients who developed acute respiratory distress syndrome (ARDS). STUDY: Observational study based on data prospectively gathered in computerized trauma registry. SETTING: Trauma intensive care unit (ICU) of 48 beds in level I trauma center. PATIENTS: All trauma patients with ARDS admitted during 1985-87 (486, group 1 [G1]) and 1993-95 (552, group 2[G2]). METHODS: ARDS was defined by American-European Consensus Conference criteria and the need for 48 h or more on mechanical ventilation with FIO2 greater than 0.50 and PEEP of more than 5 cmH2O. Demographics, severity score, injury-admission delay time, first 24-h transfusion and septic and organ system failure complications were independent variables. ICU mortality was the dependent variable. ICU length of stay (LOS) and life support techniques were considered. Respiratory and renal support strategies were different in the two time periods. RESULTS: Mortality decreased over the period (G1: 29.2% vs G2: 21.4%, p < 0.04), in patients aged both over and under 65 years. Multivariate analysis showed mortality was related to age, severity and time period (G1 1.68-fold that in G2) and that the greater G1 mortality was related to more renal failure and hematologic failure/dysfunction. ICU LOS decreased from 31.7+/-26.7 days (G1) to 27.3+/-22 days (G2) (p < 0.003). CONCLUSIONS: Mortality among trauma patients with ARDS declined over the 8 years studied and was associated with less organ failure. This reduction was probably the result of new approaches to mechanical ventilation, renal failure replacement and vasoactive drug therapy.

Acute respiratory distress syndrome: resource use and outcomes in 1985 and 1995, trends in mortality and comorbidities.

PURPOSE: The purpose of this study was to compare resource consumption and mortality between (ARDS) patients with adult respiratory distress syndrome treated at our center in 1985 (45 patients) and those treated in 1995. MATERIALS AND METHODS: This was a retrospective observational study, considering trauma and nontrauma ARDS separately. We recorded severity index scores (APACHE III), infectious complications and multiorgan failure, intensive care unit (ICU) resource consumption (TISS 28), length of stay, time on mechanical ventilation, and ICU mortality. RESULTS: We found no variation in overall ARDS mortality and no reduction in mortality in the ARDS trauma group (43.5% in 1985 vs. 38.5% in 1995, not significant) but a significant increase in mortality among nontrauma septic ARDS patients (68.2% vs. 82.9%, P < .001), largely attributable to the new comorbidities of human immunodeficiency virus (HIV) infection and hematologic malignancy. TISS-28 showed an overall reduction over this time period (49.7 +/- 6.6 vs. 38.3 +/- 9.7, P < .001), due to fewer monitoring measures, particularly a lower use of pulmonary artery catheter. There were no overall changes in length of stay or days on mechanical ventilation between 1985 and 1995, but these variables did increase among the trauma subgroup. CONCLUSION: In our setting, mortality remained constant from 1985 to 1995 among ARDS trauma patients but not among nontrauma ARDS patients because of the new case-mix of the latter population, which now includes HIV and other immunodepressed patients.

Role burdens: the impact of employment and family responsibilities on the health status of Latino women.

This paper explores the relative effects of employment and family responsibility on the perceived health status of Latino women. The data source analyzed for this study was the 1990 Panel Study of Income Dynamics/Latino National Political Survey (PSID/LNPS) Early-Release File (n = 1,502). Regression analyses were used to investigate the contributions of variables associated with perceived health status, including sociodemographics, Latino ethnicity, language, employment, and family responsibility. The results suggest that annual employment hours, occupation, and family responsibilities, such as child care and weekly housework, significantly affect self-reported health status of employed Latinas. Both social causation and social selection may be underlying the associations found. The results suggest that there is need for the development of public policies that seek to increase Latinas' labor force participation rate since any expansion has the potential to have a positive impact on their health status.

Computed tomography vs clinical and multidisciplinary procedures for early evaluation of severe abdomen and chest trauma--a cost analysis approach.

OBJECTIVE: To compare contrast computed tomography (CT) for evaluating abdominal and vascular chest injuries after emergency room resuscitation with multidisciplinary management based on bedside procedure (BP), e.g., peritoneal lavage, abdomen ultrasonography urography and, if indicated, CT and/or aortography or transesophageal echocardiography. DESIGN: Randomized study. SETTING: Emergency, critical care and radiology departments in a trauma center. PATIENTS: The study was performed in 103 severe blunt trauma patients with a revised trauma index < 8, admitted over a 16 month period and divided into group (G1, n = 52, CT management) and group 2 (G2, n = 51, BP management). INTERVENTIONS: A relative direct cost scale used in our trauma center was applied, and cost units (U) were assigned to each diagnostic test for cost-minimization analysis (abdomen ultrasonograph = 7.5 U, peritoneal lavage = 8 U, urography = 9 U, computed tomography = 9 U, transesophageal echocardiography = 13.5 U, and aortography = 15 U). One unit is approximately equivalent to $43.7. RESULTS: Injury severity score (ISS) was 31.7 +/- 15.4 in G1 and 33.8 +/- 18.3 in G2. Sensitivity for CT was 90.4% (G1) vs 72.5% for BP (G2) in abdomen (P < 0.01) and 60% in chest for evaluating mediastinal hematoma etiology (G1). As Table 2 shows, G1 needed 59 tests for evaluating injuries (1.1 +/- 0.3 tests patient) while G2 required 81 tests (1.68 +/- 0.8 tests/patient) (P < 0.01). The total relative cost was 538 U for G1, 7.04 +/- 2.2 U cost/injury and 10.3 +/- 3.3 U/evaluation of trauma vs 698 U for G2, 9.84 +/- 5.03 U cost/injury and 13.68 +/- 8.5 U/evaluation (P < 0.05). CONCLUSIONS: This cost-minimization study suggests that CT is a more cost-effective method for the post-emergency room resuscitation evaluation of severe abdominal blunt trauma than the multidisciplinary BP. Chest CT is a screening method for mediastinal hematoma but not for etiology.

The intrauterine device in the present and future.

Good counseling and better selection of candidates would result in the intrauterine device's (IUD) safer use. Age and parity of the IUD acceptor do not seem to be associated with an increased risk of pelvic inflammatory disease (PID). The newer generation of copper- and hormone-releasing IUDs are associated with improved safety and efficacy.

PIP: The IUD is a very safe and effective contraceptive method for women in a mutually monogamous relationship. The 8-year pregnancy rates for the Copper T 380A IUD is 2.3%. Studies in the late 1960s and early 1970s suggested that IUDs caused pelvic inflammatory disease (PID). These studies may have been subject to methodological flaws (e.g., use of inadequate controls, such as users of methods protecting against PID [e.g. barrier methods] and failure to control for likely confounding variables [e.g., sexual behavior]). Recent large scale prospective studies tend to report low PID rates in IUD users (e.g., 7-year rate, 2.6% for the levonorgestrel releasing and a copper releasing IUDs). The risk of PID is highest within the first 20 days postinsertion, especially in women using a unmedicated IUD. The copper IUD has been modified to better conform to the uterine cavity throughout the menstrual cycle, thus, reducing the likelihood of bleeding and pain. Another new copper IUD likely to reduce bleeding and pain has 6 copper sleeves on 1 filament polypropylene thread. The knot at the thread's end is implanted into the myometrium at the fundus. The LNG-IUD releases a daily dose of 20 mcg levonorgestrel. It can be used effectively for 5 years. Amenorrhea and/or hormonal side effects contribute to its lower continuation rate than copper releasing IUDs. Providers must assess the risk of sexually transmitted diseases, conduct a pelvic exam, and counsel clients before IUD insertion. Only when IUD users experience symptoms do follow-up visits result in a significant cost saving. In the best interest of the client and to reduce discontinuation, counseling should address life style, user perspective, culture, possible increased risk of genital infection associated with nonmonogamous sexual behavior, and side effects.

Breast-feeding and the return to ovulation in Durango, Mexico.

Twenty-nine breast-feeding mothers and 10 non-breast-feeding postpartum comparison mothers from a rural area of Mexico were followed longitudinally until ovulation resumed. A simple set of guidelines is described involving three obvious milestones for the breast-feeding mother to safely use the natural contraceptive benefit of breast-feeding. Those milestones are: the first vaginal bleeding episode, the initiation of supplementation, and the child's monthly birthday. In the absence of bleeding and supplementation, 100% of breast-feeding mothers remained anovular for 3 months postpartum, 96% for 4 months, 96% for 5 months, and 96% for 6 months. This suggests that, if a mother understands these three conditions, she can use breast-feeding alone as effectively as modern family planning methods for the prevention of pregnancy.

Clinical and hemodynamic assessment of the Angell-Shiley porcine xenograft.

Valve replacement with an Angell-Shiley bioprosthesis was accomplished in 449 patients. To evaluate the bioprostheses from this total series, 344 patients who did not undergo associated operation, had no previous operations, or had no other valve substitutes were selected. Hospital mortality was 2.6% for aortic (4 out of 156), 7.2% for mitral (9 out of 125), and 12.7% for multiple-valve replacements (8 out of 63). The 323 patients discharged from the hospital were followed for 6 to 36 months. There were 15 late deaths. Hepatitis, bleeding, thromboembolism, endocarditis, and residual valvular incompetence, always periprosthetic, were the major complications. Forty-five patients with single-valve replacement (16 mitral and 29 aortic) without clinical valve dysfunction were electively recatheterized to assess hemodynamic performance. Measurements were recorded at rest and during exercise on a bicycle ergometer. Functional aortic valve orifice averaged 1.23 +/- 0.33 cm2 and the mean systolic gradient was 21.51 +/- 6.68 mm Hg at rest. During exercise, aortic gradient increased to 26.60 +/- 7.54 mm Hg and mean functional area to 1.51 +/- 0.34 cm2. In the mitral position, the mean diastolic gradient at rest was 8.44 +/- 3.17 mm Hg and the functional orifice area averaged 1.67 +/- 0.51 cm2. Exercise increased the mean gradient to 11.92 +/- 3.8 mm Hg and the mean orifice area to 2.05 +/- 0.57 cm2.

The occupational hazards of formulating oral contraceptives--a survey of plant employees.

In May 1976 an investigation of a factory in Puerto Rico which formulates oral contraceptives revealed that during the previous 12 months five of the company's twenty-five employees (20%), and twelve of the company's thirty female employees (40%) had experienced symptoms associated with hyperestrogenism. The affected males had gynecomastia and three of them also reported a history of decreased libido or impotence. The affected females each had had at least one episode of intermenstrual bleeding during the preceding 12 months. There was an estimated relative risk of 4.3 for intermenstrual bleeding in nonclerical female employees compared with matched controls who did not work at the plant. Elevated levels of plasma ethinyl estradiol were twice as frequent in the two highest-risk job categories compared with the rest of the factory population, but the difference in prevalence of elevated levels was not statistically significant (P = 0.08). Wide variations in mestranol concentration were noted in the environmental dust samples. Prompt consideration should be given to establishing health standards for persons occupationally exposed to estrogens in view of the possible long-term sequelae of such exposure.