Health-related quality of life in patients with generalized pustular psoriasis: A systematic literature review.

Generalized pustular psoriasis (GPP) is a rare, chronic, neutrophilic inflammatory skin disease characterized by episodes of widespread eruption of sterile, macroscopic pustules that can be accompanied by systemic inflammation and symptoms. A systematic literature review and narrative synthesis were conducted to determine the impact of GPP on patients' health-related quality of life (HRQoL) and patient-reported severity of symptoms and to compare its impact to patients with plaque psoriasis (plaque PsO). Searches were undertaken in Embase, MEDLINE and the Cochrane Library from 1 January 2002 to 15 September 2022. Screening was carried out by two reviewers independently. Outcome measures included generic (e.g. EQ-5D, SF-36) and dermatology-specific (e.g. DLQI) clinical outcome assessments, and other relevant patient-reported outcome measures (PROMs) (e.g. severity of pain measured by a numerical rating scale). Overall, 20 studies were found to be eligible for inclusion, of which seven also had data for plaque PsO. The DLQI was the most frequently reported outcome measure (16 out of 20 studies). When reported, mean DLQI (SD) scores varied from 5.7 (1.2) to 15.8 (9.6) across the studies, indicating a moderate to very large effect on HRQoL; the wide range of scores and large SDs were explained by the small population sizes (n ≤ 12 for all studies except two). Similar ranges and large SDs were also observed for other measures within individual studies. However, in general, people with GPP reported a greater impact of their skin condition on HRQoL, when compared to people with plaque PsO (i.e. higher DLQI scores) and higher severity for itch, pain and fatigue. This systematic review highlighted the need for studies with a larger population size, a better understanding of the impact of cutaneous and extracutaneous symptoms and comorbidities on HRQoL during and between GPP flares, and outcome measures specifically tailored to the unique symptoms and the natural course/history of GPP.

Risk Factors in Severe Anaphylaxis: Which Matters the Most, Food or Cofactors?

BACKGROUND AND OBJECTIVE: The prevalence of anaphylactic shock, the most severe manifestation of anaphylaxis, remains unknown. Risk factors and biomarkers have not been fully identified. Objective: To identify risk factors in patients who experience anaphylactic shock. METHODS: Using lipid transfer protein (LTP) allergy as a model, we compared the characteristics of patients who developed anaphylaxis and anaphylactic shock. We recorded demographics, pollen sensitization, foods ingested up to 2 hours before onset of the reaction, and the presence of cofactors. Culprit foods were identified through a compatible clinical history and positive allergology work-up (skin prick test and/or sIgE). RESULTS: We evaluated 150 reactions in 55 patients with anaphylaxis (134 reactions) and 12 with anaphylactic shock (16 reactions). Patients in the anaphylaxis group experienced twice as many reactions (mean [SD], 2.4 [2.5] for anaphylaxis vs 1.3 [1.5] for anaphylactic shock; P<.02). No relationship was found between any food group and severity of the reaction. The most frequent food involved in both groups of patients was the combination of several plant-derived foods (plant food mix), followed by peach and nuts. Indeed, in the reactions caused by plant food mix, the presence of a cofactor was observed more often than in other food groups. On the other hand, cofactors were not present in peach- and nut-related reactions. Exercise was the most frequent cofactor in all groups. CONCLUSION: In our series, the severity of the reactions was not determined by the kind of food or presence of a cofactor. Anaphylactic shock seems to be an infrequent presentation that may be associated with other individual-related factors requiring further evaluation.

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey.

BACKGROUND: Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments. OBJECTIVES: We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation. METHODS: Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model. RESULTS: Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations. CONCLUSIONS: Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.

The incidence of psoriasis in Chile: an analysis of the National Waiting List Repository.

BACKGROUND: Psoriasis is a serious and chronic noncommunicable disease. However, the fundamental measure of disease occurrence, the incidence, has been scarcely reported globally. There are no previous studies of psoriasis incidence in Latin America. AIM: To estimate the incidence rates of psoriasis in Chile during 2016 and 2017 using an administrative database, the Waiting List Repository. METHODS: We examined referrals of psoriasis at onset, made by physicians to dermatologists, evaluated the agreement of diagnosis, and estimated the incidence of the disease considering the eligible population at risk. RESULTS: In most cases, the referrals corresponded to incident cases of psoriasis (73.3%; 95% CI: 66.6-79.2). The national incidence rates of psoriasis were 22.1 (95% CI: 21.1-23.1) and 22.7 (95% CI: 21.8-23.6) per 100 000 person-years in 2016 and 2017, respectively. The most common type of psoriasis was the late-onset type. We observed a high variation in the figures throughout the country, with a range from 0.75 (95% CI: 0.3-1.5) per 100 000 person-years in the Metropolitan region to 164.9 (95% CI: 138.6-195.1) per 100 000 person-years in the Aysen region. CONCLUSION: We describe for the first time the incidence of psoriasis in a Latin American country. Our findings could potentially guide collaborations to improve our global understanding of psoriasis in Latin America.

Biosimilars for psoriasis: worldwide overview of regulatory guidelines, uptake and implications for dermatology clinical practice.

The introduction of biological drugs for the treatment of patients with psoriasis has revolutionized treatment paradigms and enabled numerous patients to achieve disease control with an acceptable safety profile. However, the high cost of biologics limits access to these medications for the majority of patients worldwide. In recent years, the introduction of biosimilars for inflammatory diseases has become a fast evolving field. The future use of biosimilars offers the potential for decreased cost and increased access to biologics for patients with psoriasis. For approval of biosimilars, different regulatory agencies use highly variable methods for definition, production, approval, marketing and postmarketing surveillance. Due to potential interchangeability between biologics and biosimilars, traceability and pharmacovigilance are required to collect accurate data about adverse events in patients with psoriasis; spontaneous reporting, registries and use of 'big data' should facilitate this process on a global basis. The current article describes biosimilar regulatory guidelines and examples of biosimilar uptake in clinical practice in several countries around the world. As it is apparent that biological therapy treatment decisions may become more physician independent, the International Psoriasis Council recommends that dermatologists should take an active role in the development of biosimilar prescribing policies with their respective healthcare settings and government agencies.

Candidate Elastic Quantum Critical Point in LaCu_{6-x}Au_{x}.

The structural properties of LaCu_{6-x}Au_{x} are studied using neutron diffraction, x-ray diffraction, and heat capacity measurements. The continuous orthorhombic-monoclinic structural phase transition in LaCu_{6} is suppressed linearly with Au substitution until a complete suppression of the structural phase transition occurs at the critical composition x_{c}=0.3. Heat capacity measurements at low temperatures indicate residual structural instability at x_{c}. The instability is ferroelastic in nature, with density functional theory calculations showing negligible coupling to electronic states near the Fermi level. The data and calculations presented here are consistent with the zero temperature termination of a continuous structural phase transition suggesting that the LaCu_{6-x}Au_{x} series hosts an elastic quantum critical point.

Auriculotemporal Neuralgia: Eight New Cases Report.

BACKGROUND: Auriculotemporal neuralgia (ATN) is an infrequent syndrome consisting in strictly unilateral pain in the temporal region associated with nerve tenderness, which can be successfully treated with anesthetic blockade. We analysed clinical characteristics and treatment response in a series of eight patients. METHODS: Series of consecutive patients diagnosed with ATN at Headache Clinics of two university hospitals in Spain. Data on demographic and pain characteristics, as well as response to treatment are presented. RESULTS: Eight patients (seven women). Mean age at onset was 52.8 ± 14.3 years. Pain was strictly unilateral (left-sided in five cases, right-sided in three), and triggered by pressing the preauricular area. Four patients presented background pain, mostly dull in quality, with an intensity of 5.75 ± 1.2 on the verbal analogical scale (VAS). In six, burning exacerbations occurred, ranging from 2 seconds to 30 minutes, with intensity 7.3 ± 1.5 on VAS. Complete relief was achieved with gabapentin in three cases, anaesthetic blockade in three and spontaneously in two. CONCLUSION: ATN is uncommon in headache units. Gabapentin is a good alternative therapeutic option to anesthetic blockade.

Morphological, molecular and phylogenetic analyses of the spirurid nematode Stegophorus macronectes (Johnston & Mawson, 1942).

Stegophorus macronectes (Johnston & Mawson, 1942) is a gastrointestinal parasite found in Antarctic seabirds. The original description of the species, which was based only on females, is poor and fragmented with some unclear diagnostic characters. This study provides new morphometric and molecular data on this previously poorly described parasite. Nuclear rDNA sequences (18S, 5.8S, 28S and internal transcribed spacer (ITS) regions) were isolated from S. macronectes specimens collected from the chinstrap penguin Pygoscelis antarctica Forster on Deception Island, Antarctica. Using 18S rDNA sequences, phylogenetic analyses (maximum likelihood, maximum parsimony and Bayesian inference) of the order Spirurida were performed to determine the phylogenetic location of this species. Primer pairs of the ITS regions were designed for genus-level identification of specimens, regardless of their cycle, as an alternative to coprological methods. The utility of this molecular method for identification of morphologically altered specimens is also discussed.

HaNDL syndrome: Correlation between focal deficits topography and EEG or SPECT abnormalities in a series of 5 new cases. / Síndrome HaNDL: correlación entre la topografía del déficit neurológico y las alteraciones en electroencefalograma y SPECT en una serie de 5 nuevos casos.

INTRODUCTION: Transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) is characterised by migraine-like headache episodes accompanied by neurological deficits consisting of motor, sensory, or aphasic symptoms. Electroencephalogram (EEG) and single photon emission computed tomography (SPECT) may show focal abnormalities that correspond to the neurological deficits. We aim to evaluate the correlation between focal deficit topography and EEG or SPECT abnormalities in 5 new cases. PATIENTS: We retrospectively reviewed patients attended in a tertiary hospital (January 2010-May 2014) and identified 5 patients (3 men, 2 women) with a mean age of 30.6 ± 7.7 (21-39) years. They presented 3.4 ± 2.6 episodes of headache (range, 2-8) of moderate to severe intensity and transient neurological deficits over a maximum of 5 weeks. Pleocytosis was detected in CSF in all cases (70 to 312 cells/mm3, 96.5-100% lymphocytes) with negative results from aetiological studies. RESULTS: At least one EEG was performed in 4 patients and SPECT in 3 patients. Patient 1: 8 episodes; 4 left hemisphere, 3 right hemisphere, and 1 brainstem; 2 EEGs showing left temporal and bilateral temporal slowing; normal SPECT. Patient 2: 2 episodes, left hemisphere and right hemisphere; SPECT showed decreased left temporal blood flow. Patient 3: 3 left hemisphere deficits; EEG with bilateral frontal and temporal slowing. Patient 4: 2 episodes with right parieto-occipital topography and right frontal slowing in EEG. Patient 5: 2 episodes, right hemisphere and left hemisphere, EEG with right temporal slowing; normal SPECT. CONCLUSION: The neurological deficits accompanying headache in HaNDL demonstrate marked clinical heterogeneity. SPECT abnormalities and most of all EEG abnormalities were not uncommon in our series and they did not always correlate to the topography of focal déficits.

Characteristics of the first 2,000 patients registered in a specialist headache clinic.

OBJECTIVES: Headache is a common cause of medical consultations. We aim to analyze demographic characteristics of first two thousand patients in our register, and the incidence of their different headaches coded according to the International Classification of Headache Disorders, ii edition (ICHD-II). PATIENTS AND METHODS: On January 2008 a headache outpatient clinic was established in a tertiary hospital. Patients could be referred by general practitioners according to previously consensused criteria, as well as by general neurology or other specialities clinics. The following variables were prospectively collected on all patients; age, sex, referral source, complementary tests required, and the previously prescribed symptomatic or prophylactic therapies. All headaches were classified accordingly to ICHD-II. When a patient fulfilled criteria for more than one type of headache, all of them were diagnosed and classified. RESULTS: In October 2012, 2000 patients (ratio women/men 2.59/1) had been seen in our headache clinic. The median age was 42 years (range: 11-94), 55.3% were referred from primary care, and 68.1% did not require complementary tests. A total of 3095 headaches were recorded in these 2000 patients, of which 2222 (71.8%) were considered primary headaches, 382 (12.3%) secondary headaches, with 117 (3.8%) corresponding to cranial neuralgias, 136 (4.3%) were unclassified headaches, and 238 (7.7%) were included in the research Appendix of the ICHD-II. The most represented group was 1 (migraine) with 53% of all headaches. CONCLUSIONS: The characteristics of first 2000 patients in our register were comparable to those previously described in other types of headache outpatient clinics. Migraine was the most frequent diagnosis, and secondary headaches were not as frequent in our series. Most headaches could be coded according to ICHD-II criteria.

Chronic migraine with and without medication overuse: experience in a hospital series of 434 patients.

INTRODUCTION: Chronic migraine (CM) is a complication of episodic migraine, favored by risk factors as medication overuse (MO). We intend to compare demographic and clinic characteristics of a series of CM patients, with and without MO. METHODS: The study included patients with CM (2006 revised criteria) attended in a headache outpatient office located in a tertiary hospital between January 2008 and May 2012. We recorded demographic characteristics, age at migraine onset, time from onset, previous use of symptomatic or preventive therapy, and headache impact measured with six-item headache impact test (HIT-6). RESULTS: A total of 434 patients (357 women, 77 men) were diagnosed with CM out of the 1868 (23.2%) that attended our clinic. Of these, 258 (72.2%) fulfilled criteria of MO, and 59.8% of those with MO, and 41.1% of cases without MO had previously received preventative treatment (P<.001). Age at onset of migraine was lower in MO patients (21.2±10.1 vs 23.8±12.5 years, P=.02) and time from onset to headache clinic consultation was higher in MO cases (23.8±14.1 vs 18.3±14.8 years, P<.001). We found no difference between both groups in average HIT-6 score and the percentage of patients with a HIT-6 score over 55. CONCLUSIONS: CM, with or without MO, is a burdensome group of patients in our headache clinic. Patients with MO are referred later and have more frequently received preventive treatments.

Headache in the elderly: characteristics in a series of 262 patients.

INTRODUCTION: Although headache prevalence decreases in patients older than 65, headaches are a common complaint and their different clinical and therapeutic features must be understood. This article analyses the clinical characteristics of elderly patients treated in an outpatient headache unit. METHODS: We collected demographic and clinical data from patients treated in a tertiary hospital headache unit between January 2008 and May 2013. Headaches were codified according to the International Classification of Headache Disorders, 2nd edition (ICHD-2). RESULTS: Of a total of 1868 patients treated, 262 patients (14%, 189 women and 73 men) were older than 65 years. Ninety-nine (68 women, 31 men, 5.3% of the total) were over 75. Headaches began after the age of 65 in only 136 patients (51.9%). The 362 headaches were codified as follows: 23.8% as Group 1 (Migraine) and 28.7% as Group 2 (Tension-type headache). We diagnosed 58 (16%) secondary headaches; 26 (7.2%) were classified as Group 13 (Cranial neuralgias) and 23 (6.4%) in Group 14 (Other headaches). Symptomatic medication overuse was detected in 38 patients (14.5%). We also identified headaches considered typical in the elderly, including chronic migraine (41 cases), hypnic headache (6), occipital neuralgia (4), SUNCT (2), cervicogenic headache (1), primary cough headache (1), and giant cell arteritis (2). CONCLUSIONS: Elderly patients were frequently treated in our outpatient headache unit. Tension-type headache was the most common diagnosis in this population. Geriatric headache syndromes such as hypnic headache or occipital neuralgia were also represented in our series.

Gastrointestinal parasites in Chinstrap Penguins from Deception Island, South Shetlands, Antarctica.

Knowledge about parasites of Antarctic birds is fragmented and scarce. The aim of this work is to contribute to the knowledge of gastrointestinal parasites of the Chinstrap Penguin (Pygoscelis antarctica) from Deception Island (South Shetlands, Antarctica). Gastrointestinal tracts of 64 fresh dead individuals (61 chicks and three adults) were collected from December 2006 to February 2009 and examined for macroparasites. Three adult parasite species were found: two Cestoda species (Parorchites zederi and Tetrabothrius pauliani) and one Nematoda species (Stegophorus macronectes). Also, immature acanthocephalans (Corynosoma sp.) were found in one penguin. The low parasite richness observed could be related to the stenophagic and pelagic diet of the host species. False negatives were found in coprological studies.

Does maternal obesity cause preeclampsia? A systematic review of the evidence.

AIM: The aim of this paper was to assess whether maternal obesity causes preeclampsia. METHODS: A systematic literature review of the previous two decades (1992-2011) was conducted. The exposure was maternal obesity while the outcome of interest was preeclampsia. RESULTS: Our review revealed consistent findings showing strong association between obesity and preeclampsia. Multiple biomarkers that potentially explain the mechanistic pathway in this relationship were identified, including leptin and adiponectin, matrix metalloproteinase (MMP), C-reactive protein (CRP), and sex hormone-binding globulin (SHBG). A causative biologic linkage remains, however, elusive. CONCLUSION: Epidemiologic evidence exists linking maternal obesity and preeclampsia. However, the exact causal pathway remains poorly defined. Given the minimal understanding of the nature of this relationship, research studies that utilize prospective designs and expand on the previous examination of biomarkers are recommended to determine potential causative pathways.

Development and integration of photonic Doppler velocimetry as a diagnostic for radiation driven experiments on the Z-machine.

Plasma density measurements are key to a wide variety of high-energy-density (HED) and laboratory astrophysics experiments. We present a creative application of photonic Doppler velocimetry (PDV) from which time- and spatially resolved electron density measurements can be made. PDV has been implemented for the first time in close proximity, ∼6 cm, to the high-intensity radiation flux produced by a z-pinch dynamic hohlraum on the Z-machine. Multiple PDV probes were incorporated into the photoionized gas cell platform. Two probes, spaced 4 mm apart, were used to assess plasma density and uniformity in the central region of the gas cell during the formation of the plasma. Electron density time histories with subnanosecond resolution were extracted from PDV measurements taken from the gas cells fielded with neon at 15 Torr. As well, a null shot with no gas fill in the cell was fielded. A major achievement was the low noise high-quality measurements made in the harsh environment produced by the mega-joules of x-ray energy emitted at the collapse of the z-pinch implosion. To evaluate time dependent radiation induced effects in the fiber optic system, two PDV noise probes were included on either side of the gas cell. The success of this alternative use of PDV demonstrates that it is a reliable, precise, and affordable new electron density diagnostic for radiation driven experiments and more generally HED experiments.

[Psoriasis and obesity: a review and practical recommendations]. / Psoriasis y obesidad: revisión y recomendaciones prácticas.

Epidemiological studies have shown that patients with psoriasis have a higher risk of developing certain metabolic disorders, particularly obesity. Psoriasis and obesity are linked through a common pathophysiological mechanism of chronic low-grade inflammation. Not only is obesity associated with a higher incidence of psoriasis and greater severity, but it also affects response to treatment. The dermatologic management of these patients must therefore take their overall metabolic situation into consideration. We present a review of the recent literature on this subject and practical recommendations on the management of this group of patients, including relevant additional tests and advice on diet and a healthy lifestyle.

Oral bioavailability, tissue distribution and depletion of flumequine in the food producing animal, chicken for fattening.

Chickens were used to investigate kinetic properties including metabolism of flumequine after single IV and oral dose, and to study tissue depletion of flumequine after multiple oral doses. Plasma and tissue (muscle, kidney, liver and skin plus fat) concentrations of flumequine and its metabolite 7-hydroxyflumequine were determined using a HPLC method. After IV and oral administration (single-dose of 12 mg flumequine/kg bw), plasma concentration-time curves were best described by a two-compartment open model. Elimination half-life and mean residence time of flumequine in plasma were 6.91 and 5.90 h, respectively, after IV administration and 10.32 and 8.95 h after oral administration. Maximum plasma concentration was 3.62 microg/ml and interval from oral administration until maximum concentration was 1.43 h. Oral bioavailability was found to be 57%. Flumequine was converted to 7-hydroxyflumequine. After oral administration (24 mg/kg bw every 24 h for 5 days), renal and hepatic concentrations of flumequine (18-25 microg/kg) persisted for 4 days; however, at that time, flumequine residues were not detected in skin plus fat and muscle tissues. Flumequine administered at a dosage of 24 mg/kg bw every 24h for 5 days, with a withdrawal time of 2d ays, resulted in flumequine concentrations in target tissues that were less than the European Union maximal residue limits.

[Cardiac perforation as a late complication in a man with an implantable cardioverter-defibrillator]. / Perforación cardiaca como complicación tardía en paciente portador de un Desfibrilador Automático Implantable.

A 55-year-old man with an implantable cardioverter-defibrillator (ICD) placed after diagnosis of Brugada syndrome 4 years earlier was admitted to hospital with dyspnea and a large left pleural effusion. After several episodes of cardiorespiratory arrest and application of advanced cardiac life support measures, an emergency sternotomy was performed. Cardiac and pleural perforation by the ICD lead was observed and the device was removed. Since the ICD was introduced in 1980, it has been effective in the treatment of malignant ventricular arrhythmias and in reducing the incidence of sudden death. Increased use, however, has meant a rise in the number of complications, some of which are potentially fatal. The rare complication we describe should therefore be considered whenever a patient with an ICD develops sudden respiratory failure or massive hemoptysis that cannot be explained by other causes.

Effects of dietary protein level and age at photo stimulation on reproduction traits of broiler breeders and progeny performance.

A study with a 2 × 2 factorial arrangement was conducted to determine the effects of 2 dietary crude protein levels, high (CPh) or low (CPl), supplemented with free amino acids (AA), and 2 ages at photo stimulation (PS)-early (21 wk; PSe) or late (23 wk; PSl)-on reproduction traits of broiler breeders and progeny performance. Diets were isocaloric, and calculated CP content of the CPl diets was 15 g/kg lower than the CPh diets during all phases. A total of 480 female and 64 male Ross 308 breeders of 20 wk of age were used. Total egg production was similar between CPl and CPh birds during phase 1 and 2 but was reduced by 2.8 eggs for CPl birds during phase 3. For the overall laying period, CPl birds tended (P = 0.075) to produce 4.7 fewer total eggs. Hatchability of set eggs was similar between CPl and CPh birds during phases 1 and 2 but tended (P = 0.064) to be lower for CPl birds in phase 3. PSe birds showed an advanced age at sexual maturity and age at peak production of 4.6 and 5.3 d, respectively, resulting in 2.5 more total eggs during phase 1. During phase 1, PSe birds showed an almost 5% increased fertility. Chick production in phase 1 was higher for PSe birds resulting in a tendency (P = 0.071) to higher overall chick production of almost 8 chicks. Progeny from early PS breeders showed an overall significant lower feed conversion ratio (FCR). It was concluded that egg and chick production during phases 1 and 2 were not affected by dietary CP level, but egg and chick production was reduced for CPl birds during phase 3. On the other hand, PSe birds showed an increased number of chicks. It is possible to decrease CP level of breeder diets with comparable reproduction from 22 to 46 wk; however, this is questionable for phase 3. For maximal chick production, early PS is recommended.