[Effects of a smoke-free policy on healthcare staff attitudes and aggression in psychiatry]. / Effecten van een rookvrijbeleid op attitudes zorgpersoneel en agressie in de psychiatrie.

Background The prevalence of smoking among patients with psychiatric disorders is 3-4 times higher than the general population. However, smoking is still permitted in many psychiatric clinics. The National Prevention Agreement (2018) mandates that all psychiatric wards be smoke-free by 2025. The UMC Utrecht clinics have been smoke-free since November 2020. Aim To examine healthcare workers’ attitudes before and after implementing the smoke-free policy. Method In an observational study with quantitative data analysis, data were collected in one center from healthcare workers in psychiatry departments with surveys. We collected demographic information, smoking status, attitudes towards the smoke-free policy, and its impact on patients and care. Incidents of aggression were prospectively recorded and reported in the MAP (aggression incidents in patient care). Results Out of 172 healthcare workers invited to participate, 30% (n = 52) completed the pre-implementation survey, and 20% (n = 34) completed the post-implementation survey. Prior to implementation, 62% (n = 32/52) of healthcare workers had a positive attitude towards the smoke-free policy, which increased to 77% (n = 26/34) post-implementation. Expectations of increased aggression incidents were reported by 62% (n = 32/52) during the pre-implementation phase. The number of aggression incidents was 46 in the one-year period before implementation (November 2019 – February 2020) and 45 incidents after implementation (November 2020 – February 2021). Conclusion This study supports the implementation of a smoke-free policy in psychiatric clinics due to the lack of a significant increase in aggression incidents. Healthcare workers perceived this outcome and observed quicker granting of ‘green’ freedoms.

Drug Survival in Cyclosporine Treatment for Moderate to Severe Atopic Dermatitis: Analysis of the Spanish Atopic Dermatitis Registry (BIOBADATOP). / Supervivencia de la ciclosporina en el tratamiento de la dermatitis atópica moderada-grave: Registro Español de Dermatitis Atópica (BIOBADATOP).

BACKGROUND: The past 5 years have seen a proliferation of new treatments for atopic dermatitis (AD). We analyzed recent drug survival data for cyclosporine in this setting. Because the Spanish National Healthcare system requires patients with AD to be treated with cyclosporine before they can be prescribed other systemic treatments, drug survival for cyclosporine may be shorter than in other diseases. MATERIAL AND METHOD: Multicenter, observational, prospective cohort study using data from the Spanish Atopic Dermatitis Registry (BIOBADATOP). Data from the Spanish Registry of Systemic Treatments in Psoriasis (BIOBADADERM) were used to create a comparison cohort. RESULTS: We analyzed data for 130 patients with AD treated with cyclosporine (median drug survival, 1 year). Median cyclosporine survival in the psoriasis comparison group (150 patients) was 0.37 years. Drug survival was significantly longer in AD than in psoriasis (P<.001). CONCLUSION: Drug survival of cyclosporine in the BIOBADATOP registry is similar to that described in other series of patients with AD and longer than that observed in the BIOBADADERM psoriasis registry.

Longitudinal associations between alcohol use, smoking, genetic risk scoring and symptoms of depression in the general population: a prospective 6-year cohort study.

BACKGROUND: Alcohol consumption, smoking and mood disorders are leading contributors to the global burden of disease and are highly comorbid. Yet, their interrelationships have remained elusive. The aim of this study was to examine the multi-cross-sectional and longitudinal associations between (change in) smoking and alcohol use and (change in) number of depressive symptoms. METHODS: In this prospective, longitudinal study, 6646 adults from the general population were included with follow-up measurements after 3 and 6 years. Linear mixed-effects models were used to test multi-cross-sectional and longitudinal associations, with smoking behaviour, alcohol use and genetic risk scores for smoking and alcohol use as independent variables and depressive symptoms as dependent variables. RESULTS: In the multi-cross-sectional analysis, smoking status and number of cigarettes per day were positively associated with depressive symptoms (p < 0.001). Moderate drinking was associated with less symptoms of depression compared to non-use (p = 0.011). Longitudinally, decreases in the numbers of cigarettes per day and alcoholic drinks per week as well as alcohol cessation were associated with a reduction of depressive symptoms (p = 0.001-0.028). Results of genetic risk score analyses aligned with these findings. CONCLUSIONS: While cross-sectionally smoking and moderate alcohol use show opposing associations with depressive symptoms, decreases in smoking behaviour as well as alcohol consumption are associated with improvements in depressive symptoms over time. Although we cannot infer causality, these results open avenues to further investigate interventions targeting smoking and alcohol behaviours in people suffering from depressive symptoms.

[Translated article] Acne Fulminans: A Narrative Review.

Acne fulminans is a severe and rare form of inflammatory acne. Lesion severity and subsequent scarring has a negative impact on the patient's quality of life. We conducted a narrative review of the literature on acne fulminans based on a search for relevant English- and Spanish-language articles published in Medline. We included case reports and case series. The main aim was to describe the clinical and demographic characteristics of patients with acne fulminans. A secondary aim was to determine whether quality of life was affected by the site or extent of lesions. We reviewed 91 articles describing 212 cases of acne fulminans. The mean age of the patients (91.94% male) was 16.6 years. A personal and family history of acne vulgaris was reported for 97.63% and 54.90% of patients, respectively. A trigger was identified in 44.79% of cases. The main cause was pharmacologic (96.63%) and the main drug isotretinoin (65.28%). The sites most often affected were the face (89.31%), the posterior trunk (77.86%), and the anterior trunk (74.81%). The predominant disease subtype was acne fulminans with systemic symptoms (59.12%), which were mostly general (97.06%). Systemic corticosteroids were the most widely used treatment (81.03%). The impact of the disease on quality of life was reported for two patients. In conclusion, acne fulminans mainly affects the face and trunk of male adolescents with a history of acne vulgaris. The main subtype was acne fulminans with systemic symptoms, and most patients were treated with systemic corticosteroids. The effect of acne fulminans on quality of life is under-reported.

Acne Fulminans: A Narrative Review. / Acné fulminans: revisión narrativa de la literatura.

Acne fulminans is a severe and rare form of inflammatory acne. Lesion severity and subsequent scarring has a negative impact on the patient's quality of life. We conducted a narrative review of the literature on acne fulminans based on a search for relevant English- and Spanish-language articles published in Medline. We included case reports and case series. The main aim was to describe the clinical and demographic characteristics of patients with acne fulminans. A secondary aim was to determine whether quality of life was affected by the site or extent of lesions. We reviewed 91 articles describing 212 cases of acne fulminans. The mean age of the patients (91.94% male) was 16.6 years. A personal and family history of acne vulgaris was reported for 97.63% and 54.90% of patients, respectively. A trigger was identified in 44.79% of cases. The main cause was pharmacologic (96.63%) and the main drug isotretinoin (65.28%). The sites most often affected were the face (89.31%), the posterior trunk (77.86%), and the anterior trunk (74.81%). The predominant disease subtype was acne fulminans with systemic symptoms (59.12%), which were mostly general (97.06%). Systemic corticosteroids were the most widely used treatment (81.03%). The impact of the disease on quality of life was reported for 2 patients. In conclusion, acne fulminans mainly affects the face and trunk of male adolescents with a history of acne vulgaris. The main subtype was acne fulminans with systemic symptoms, and most patients were treated with systemic corticosteroids. The effect of acne fulminans on quality of life is underreported.

BIOBADATOP Spanish Atopic Dermatitis Registry: Description and Early Findings. / BIOBADATOP: Registro Español de Dermatitis Atópica. Descripción y primeros resultados.

BACKGROUND: In recent years, remarkable improvements in our understanding of atopic dermatitis (AD) have revolutionized treatment perspectives, but access to reliable data from clinical practice is essential. MATERIALS AND METHOD: The Spanish Atopic Dermatitis Registry, BIOBADATOP, is a prospective, multicenter database that collects information on patients of all ages with AD requiring systemic therapy with conventional or novel drugs. We analyzed the registry to describe patient characteristics, diagnoses, treatments, and adverse events (AEs). RESULTS: We studied data entries for 258 patients who had received 347 systemic treatments for AD. Treatment was discontinued in 29.4% of cases, mostly due to a lack of effectiveness (in 10.7% of cases). A total of 132 AEs were described during follow-up. Eighty-six AEs (65%) were linked to a systemic treatment, most commonly dupilumab (39AEs) and cyclosporine (38AEs). The most common AEs were conjunctivitis (11patients), headache (6), hypertrichosis (5), and nausea (4). There was 1severe AE (acute mastoiditis) associated with cyclosporine. CONCLUSIONS: Initial findings on AEs from the Spanish BIOBADATOP registry are limited by short follow-up times precluding comparisons or calculation of crude and adjusted incidence rates. At the time of our analysis, no severe AEs had been reported for novel systemic therapies. BIOBADATOP will help answer questions on the effectiveness and safety of conventional and novel systemic therapies in AD.

Effect of Drug Compounding on Quality of Life in Patients With Genodermatoses: A Cross-Sectional Study. / Formulación magistral en pacientes con genodermatosis. Impacto en la calidad de vida: un estudio transversal.

BACKGROUND: Cutaneous manifestations are complicated to treat in rare diseases. The main aim of this study was to analyze the impact of compounded drugs prepared by hospital pharmacists on the quality of life of patients with genodermatoses. MATERIAL AND METHODS: We undertook a cross-sectional study of patients with genodermatoses treated with topical medications compounded and dispensed by the pharmacy at Complejo Hospitalario Universitario in Pontevedra, Spain. We collected demographic data and answers to questionnaires examining generic and disease-specific quality of life, treatment satisfaction, and treatment adherence. RESULTS: Nine patients were included. We observed a significant improvement in health-related quality of life following treatment with compounded drugs. Satisfaction with the topical medications was 2.8 on a scale of 0 (greatest satisfaction) to 25. Treatment adherence was 59%. CONCLUSIONS: Drug compounding facilitates access to orphan drugs that are not available for many rare diseases. Few studies, however, have analyzed impact on quality of life in this setting. In this series of patients with genodermatoses, topical medications compounded and dispensed by a hospital pharmacy improved health-related quality of life. This preliminary study has given rise to a multicenter study of compounding for ichthyosis. We expect that analysis of a larger sample will confirm our findings.

0.5% 5-Fluorouracil/10% Salicylic Acid for the Treatment of Distal Actinic Keratoses Under Daily Practice Conditions

Background: Actinic keratosis (AKs) are sun-induced skin lesions that are at risk to progress to invasive squamous cell carcinoma (SCC). Treatments have shown to be effective on face or balding scalp area but limited data support their efficacy on distal extremities. Objective: To describe the efficacy of 0.5% 5-fluorouracil/10% salicylic acid (5FU/AS) in the treatment of distally-located AKs in daily clinical practice. Additional objectives were to review tolerance and adherence to this treatment. Methods: Retrospective review of 23 patients with distal grade II to III AKs who were treated with 5FU/AS under daily practice conditions. Primary endpoint included local skin response according to percentage on AKs reduction at week 20 (8 weeks after ending the treatment). Results: 75% (30/40) treatment areas showed a percentage reduction in AKs from to 75% to 100% at week 20. Complete response (100% clearance) was recorded in more than half of the cases (53%, 21/40). Good, partial, and low responses were respectively observed in 22% (9/40), 20% (8/40), and 5% (2/40) of patients. Most adverse events were graded as low, and adherence to treatment was considered correct in 25 patients (63%). In addition, a correct adherence to treatment was significantly related to a better response (P=0.001). Conclusion: Findings indicate that topical 5FU/AS is an effective treatment for multiple distal AKs, with a proper safety profile. J Drugs Dermatol. 2019;18(3):285-288.

IL17RA gene variants and anti-TNF response among psoriasis patients.

Polymorphisms at genes encoding proteins involved in the pathogenesis of psoriasis (Psor) or in the mechanism of action of biological drugs could influence the treatment response. Because the interleukin (IL)-17 family has a central role in the pathogenesis of Psor, we hypothesized that IL17RA variants could influence the response to anti-TNF drugs among Psor patients. To address this issue we performed a cross-sectional study of Psor patients who received the biological treatments for the first time, with a follow-up of at least 6 months. All of the patients were Caucasian, older than 18 years old, with chronic plaque Psor, and had completed at least 24 weeks of anti-TNF therapy (adalimumab, etanercept or infliximab). The treatment response to anti-TNF agents was evaluated according to the achievement of PASI50 and PASI75 at weeks 12 and 24. Those who achieved PASI75 at week 24 were considered good responders. All patients were genotyped for the selected single-nucleotide polymorphisms (SNPs) at IL17RA gene. A total of 238 patients were included (57% male, mean age 46 years). One hundred and five patients received adalimumab, 91 patients etanercept and 42 infliximab. The rs4819554 promoter SNP allele A was significantly more common among responders at weeks 12 (P=0.01) and 24 (P=0.04). We found a higher frequency of AA versus AG+GG among responders, but the difference was only significant at week 12 (P=0.03, odd ratio=1.86, 95% confidence of interval=1.05-3.27). Thus, in the study population, the SNP rs4819554 in the promoter region of IL17RA significantly influences the response to anti-TNF drugs at week 12.

Cardiomyopathy in Patients With Hereditary Bullous Epidermolysis. / Miocardiopatía en pacientes con epidermólisis ampollosa hereditaria.

INTRODUCTION AND OBJECTIVE: In recent decades, an association has been reported between epidermolysis bullosa (EB) and dilated cardiomyopathy (DC). DC is typically in an advanced phase when detected, leading to a poorer prognosis. Our objective was to determine the prevalence of DC in patients with EB seen in Hospital San Joan de Déu in Barcelona, Spain, between May 1986 and April 2015. METHODS: This was a descriptive, cross-sectional chart-review study in which we recorded the type and main subtypes of EB and the presence or absence of DC. RESULTS: Fifty-seven patients with EB were found, 19 with EB simplex, 10 with junctional EB, 27 with dystrophic EB (14 dominant dystrophic and 13 recessive dystrophic), and just 1 with Kindler syndrome. DC was detected in only 2 patients with recessive dystrophic EB. Twenty-three patients had presented factors that could have had a causal relationship with the potential onset of DC. CONCLUSION: DC is a possible complication of EB, particularly in recessive dystrophic EB. Periodic follow-up should be performed to make an early diagnosis and start treatment.

Common and rare CARD14 gene variants affect the antitumour necrosis factor response among patients with psoriasis.

BACKGROUND: The CARD14 gene encodes a protein that enhances nuclear factor (NF)-κB activation and the upregulation of proinflammatory pathway genes. CARD14 is upregulated in psoriatic vs. normal skin, and rare and common CARD14 variants have been associated with the risk of developing psoriasis. Our hypothesis was that CARD14 variants could also influence the response to antitumour necrosis factor (anti-TNF) therapies among patients with psoriasis. OBJECTIVES: To determine whether CARD14 gene variants were linked to a significant positive anti-TNF response in patients with psoriasis. METHODS: DNA from 116 patients with psoriasis was subjected to next-generation sequencing of the CARD14 gene. All of the patients were nonresponders or had contraindications to conventional systemic treatments. RESULTS: A reduction of at least 75% in Psoriasis Area and Severity Index (PASI 75) at week 24 was considered a positive response to treatment. In total 116 patients (79 responders and 37 nonresponders) were next-generation sequenced, and we identified five nucleotide variants that would result in missense amino acid changes. These variants were determined in all of the patients, and allele and genotype frequencies were compared between the two groups. We found a significantly higher frequency of rs11652075 CC (p.Arg820Trp) among the group with a positive response (P = 0.01, odds ratio 3.71, 95% confidence interval 1.30-10.51). Furthermore, among responders, six patients were heterozygous carriers of the rare p.Glu422Lys variant, and two patients were heterozygous for p.Arg682Trp (P = 0.04). CONCLUSIONS: The common CARD14 p.Arg820Trp variant might have a significant effect on the response to anti-TNF therapies among patients with psoriasis. In addition, rare CARD14 missense variants could also predispose to a better response.

Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments.

BACKGROUND: Cannabis use and misuse have become a public health problem. There is a need for reliable screening and assessment tools to identify harmful cannabis use at an early stage. We conducted a systematic review of published instruments used to screen and assess cannabis use disorders. METHOD: We included papers published until January 2013 from seven different databases, following the PRISMA guidelines and a predetermined set of criteria for article selection. Only tools including a quantification of cannabis use and/or a measurement of the severity of dependence were considered. RESULTS: We identified 34 studies, of which 25 included instruments that met our inclusion criteria: 10 scales to assess cannabis use disorders, seven structured interviews, and eight tools to quantify cannabis use. Both cannabis and substance use scales showed good reliability and were validated in specific populations. Structured interviews were also reliable and showed good validity parameters. Common limitations were inadequate time-frames for screening, lack of brevity, undemonstrated validity for some populations (e.g., psychiatric patients, female gender, adolescents), and lack of relevant information that would enable routine use (e.g., risky use, regular users). Instruments to quantify consumption did not measure grams of the psychoactive compounds, which hampered comparability among different countries or regions where tetrahydrocannabinol concentrations may differ. CONCLUSIONS: Current instruments available for assessing cannabis use disorders need to be further improved. A standard cannabis unit should be studied and existing instruments should be adapted to this standard unit in order to improve cannabis use assessment.

Clinical Response to Ingenol Mebutate in Patients With Actinic Keratoses.

Cryotherapy is the most common treatment for actinic keratosis, but its effect is limited to individual lesions. Several topical drugs, however, are available that, in addition to treating individual actinic keratoses, target field cancerization and thereby act on subclinical lesions. Examples are 5-fluorouracil, imiquimod, diclofenac, and ingenol mebutate. We report on 17 patients with actinic keratoses treated with ingenol mebutate and describe our findings on treatment effectiveness, adherence, and tolerance. Complete and partial response rates were 35% and 53%, respectively. Ninety-four percent of patients fully adhered to treatment and 18% developed severe local reactions. Ingenol mebutate is an effective treatment for actinic keratosis. Although it has a similar rate of local reactions to other treatments available for actinic keratosis, its short treatment regimen favors better adherence.

Multiple lentigines in areas of resolving psoriatic plaques after ustekinumab therapy.

The development of lentigines in areas previously involved by psoriasis has been reported in the literature, classically related to phototherapy but also to topical products. More recently, some authors have described several cases of lentigines appearing in resolving psoriatic plaques during or after treatment with anti-tumour necrosis factor (TNF) drugs used to treat severe plaque psoriasis, including adalimumab, etanercept, and infliximab. We report the case of a patient that developed multiple lentigines after clearance of the plaques of psoriasis receiving treatment with ustekinumab for his psoriasis.

Nevus oligemicus: a case series.

BACKGROUND: Nevus oligemicus is a functional nevus caused by vasoconstriction of the cutaneous deep vascular plexus, and vasodilatation of vessels of the superficial dermis due to abnormal responses of adrenergic receptors. To the best of our knowledge, only 14 cases in 8 articles were reported in the revised indexed literature. Case report We present five cases of nevus oligemicus in two males and in three female patients. Common characteristics in all patients were overweight and sedentary habits. DISCUSSION: Nevus oligemicus is an uncommon condition characterized by livid and cyanotic patches with localized hypothermia as the key-diagnostic sign. It has been suggested that this entity is probably underdiagnosed, as it is asymptomatic and remains stable in its evolution.

Usefulness of Cochrane Skin Group reviews for clinical practice.

BACKGROUND AND OBJECTIVE: Systematic reviews are one of the most important sources of information for evidence-based medicine. However, there is a general impression that these reviews rarely report results that provide sufficient evidence to change clinical practice. The aim of this study was to determine the percentage of Cochrane Skin Group reviews reporting results with the potential to guide clinical decision-making. MATERIAL AND METHODS: We performed a bibliometric analysis of all the systematic reviews published by the Cochrane Skin Group up to 16 August, 2012. We retrieved 55 reviews, which were analyzed and graded independently by 2 investigators into 3 categories: 0 (insufficient evidence to support or reject the use of an intervention), 1 (insufficient evidence to support or reject the use of an intervention but sufficient evidence to support recommendations or suggestions), and 2 (sufficient evidence to support or reject the use of an intervention). RESULTS: Our analysis showed that 25.5% (14/55) of the studies did not provide sufficient evidence to support or reject the use of the interventions studied, 45.5% (25/25) provided sufficient but not strong evidence to support recommendations or suggestions, and 29.1% (16/55) provided strong evidence to support or reject the use of 1 or more of the interventions studied. CONCLUSIONS: Most of the systematic reviews published by the Cochrane Skin Group provide useful information to improve clinical practice. Clinicians should read these reviews and reconsider their current practice.

A quality-of-life study of cutaneous lupus erythematosus.

BACKGROUND AND OBJECTIVES: The study of quality of life in patients with skin disorders has become more important in recent decades. In the case of lupus erythematosus, most quality-of-life studies have focused on the systemic form of the disease, with less attention being paid to the cutaneous form. The main objective of this study was to evaluate quality of life in patients with cutaneous lupus erythematosus (CLE) using a dermatology-specific questionnaire: the Dermatology Life Quality Index (DLQI). Our secondary objective was to investigate associations between DLQI scores and other aspects of the disease. MATERIAL AND METHODS: Thirty-six patients with CLE completed the DLQI questionnaire. Other factors assessed were disease severity (measured using the Cutaneous Lupus Erythematosus Disease Area and Severity Index), time since diagnosis, body surface area affected, previous and current treatments, and the presence of criteria for systemic lupus erythematosus (SLE). RESULTS: According to the DLQI, CLE had a moderate, very large, or extremely large effect on quality of life in 50% of the patients analyzed (18/36). No significant associations were found between DLQI scores and disease severity, time since diagnosis, body surface area affected, number, type, or duration of pharmacologic treatments, or the presence or absence of SLE criteria. CONCLUSION: CLE has a significant and lasting effect on patient quality of life. This effect is probably primarily due to multiple factors, including the chronic nature of the disease, the visibility of the lesions, and the fact that they can cause disfigurement.

[Products for hand hygiene and antisepsis: use by health professionals and relationship with hand eczema]. / Productos de higiene y antisepsia de manos: su empleo y relación con el eccema de manos en los profesionales sanitarios.

Hand hygiene is the most important measure for the prevention of nosocomial infection. We describe the different products available for hygiene and antisepsis of the hands and the use of these products in daily practice. Hand hygiene products such as soaps and detergents are a cause of irritant dermatitis in health professionals. This irritation is one of the principal factors affecting their use in clinical practice. Alcohol-based products are better tolerated and less irritant than soap and water; irritation should not therefore be a limiting factor in the use of these products and they are to be recommended in place of soap and water. Informative and continued education programs could increase their use.

[Who funds research by Spanish dermatologists? Comparative analysis of articles published in 2008]. / ¿Quién financia la investigación de los dermatólogos españoles? Análisis del año 2008 y comparación con otros grupos.

BACKGROUND: References have been made in the literature to the funding of clinical trials by the pharmaceutical industry. Other types of funding, however, have been less well studied. OBJECTIVE: To describe the sources of funding for research by Spanish dermatology departments published in 2008. MATERIAL AND METHODS: A bibliometric study was performed of the research articles published by Spanish, French, and British dermatology departments and by Spanish rheumatology departments in 2008 according to MEDLINE records. RESULTS: Articles published by Spanish dermatology departments received funding in 36.4% of cases. This percentage is lower than that found for the other groups studied and remained low for all different types of funding. Statistically significant relationships were found between a higher percentage of funding and a higher level of evidence, as well as between a higher level of funding by the pharmaceutical industry and the publication of research into quality of life and pharmacological treatment. Inadequate declaration of funding was observed in 57.1% of articles from Spanish dermatology departments and the role of the sponsor was not declared in any article. Similar findings were obtained for the other groups studied. CONCLUSIONS: The proportion of research articles published by Spanish dermatology departments that receive external funding is low, and this is associated with a lower level of scientific evidence. In order to obtain more external funding, we must improve our competitiveness.