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Introducción: la radiodermitis es uno de los efectos secundarios más frecuentes de la radioterapia y afecta aproximadamente al 95% de los pacientes que la reciben. La radiodermitis aguda se presenta dentro de los 90 días posteriores al inicio del tratamiento, tiene un profundo impacto en la calidad de vida de los pacientes y puede ser la causa de la interrupción prematura de la radioterapia. Su tratamiento es complejo y el papel de los corticoides sistémicos en él aún no ha sido evaluado. Materiales y métodos: estudio descriptivo de 6 pacientes mayores de 18 años con radiodermitis grave, tratados con corticoides sistémicos al no responder a la terapia tópica inicial. Hubo un seguimiento de 6 meses, entre el 1 de junio de 2019 y el 30 de mayo de 2020, en el Servicio de Dermatología del Hospital Italiano de Buenos Aires. Resultados: se indicó tratamiento con corticoides sistémicos en dosis de meprednisona 40 mg/día o equivalentes, durante 5 días, con resolución completa del cuadro en un período máximo de 15 días. Discusión: en la bibliografía no hemos encontrado trabajos científicos que comuniquen o evalúen la utilidad de los corticoides sistémicos en la radiodermitis grave. Proponemos, entonces, demostrar su utilidad en esta patología. Conclusión: el objetivo de este trabajo es comunicar nuestra experiencia en pacientes con radiodermitis aguda grave, con gran repercusión en el estado general, que evolucionaron con una rápida resolución del cuadro y un adecuado manejo sintomático, mediante el uso de corticoides sistémicos.

Summary Background Cutaneous immune-related adverse events (irAEs) represent the most frequent toxicities induced by immune checkpoint inhibitors (ICIs). Objectives To investigate clinical associations of cutaneous toxicities induced by different ICI therapies. Methods This was a multicentre retrospective international cohort study of patients with cancer who developed cutaneous irAEs under ICI therapy. Analysis was performed of the rates and basic characteristics of all cutaneous toxicities, and identification of any associations was performed using univariate and multivariate models. Results In total, 762 patients were included, who developed 993 cutaneous toxicities. Forty different types of skin toxicities were identified. Psoriasis (175 patients, 23·0%) and pruritus (171 patients, 22·4%) were the most common toxicities, followed by macular rash (161 patients, 21·1%) and eczematous-type reactions (150 patients, 19·7%). Multivariate analysis showed that among patients with macular rash, vitiligo or multiple toxicities, patients received ICIs more frequently for melanoma than for NSCLC. Moreover, anti-CTLA4 was less frequent than anti-programmed death 1 treatment in patients with macular rash [odds ratio (OR) 0·11, 95% confidence interval (CI) 0·01–0·76] and vitiligo (OR 0·07, 95% CI 0·006–0·78). A significant association was also seen in patients treated with a combination of ICI and chemotherapy vs. ICI monotherapy. They less frequently developed psoriasis (OR 0·08, 95% CI 0·02–0·31), lichenoid reactions (OR 0·15, 95% CI 0·03–0·77) and eczematous reactions (OR 0·24, 95% CI 0·07–0·78), all compared with pruritic rash. Conclusions Our study showed that skin-oriented toxicities do not share a single pattern and are related to several factors, including the specific agent administered and the underlying malignancy treated. Follow-up plans should be individualized in order to minimize the risk for severe reactions that could compromise optimum therapeutic outcome. What is already known about this topic? Patients with cancer treated with different immune checkpoint inhibitors (ICIs) carry an increased risk of developing various types of skin toxicities. What are the clinical implications of this work? In this multicentre cohort study we showed that ICI-related skin toxicities do not share a single pattern and may depend on several factors, including the specific agent administered and the underlying malignancy.Among patients with macular rash, vitiligo or multiple skin toxicities, patients received ICIs more frequently for melanoma than for non-small cell lung cancer.The combination of ICI and chemotherapy compared with ICI monotherapy occurred to a lesser extent in patients with psoriatic rash lichenoid and eczematous reactions, compared with patients with pruritus.Clinical awareness and specialized dermatological consultation should be advocated.

Durante la pandemia por COVID-19 se observaron diversas reacciones adversas a fármacos. Esto pudo haber estado relacionado con una mayor susceptibilidad inmunológica de los pacientes con SARS-CoV-2 a presentar este tipo de cuadros, así como también con la exposición a múltiples medicamentos utilizados en su tratamiento. Comunicamos el caso de un paciente con una infección respiratoria grave por COVID-19, que presentó 2 reacciones adversas graves a fármacos en un período corto de tiempo.

Telemedicine is the provision of services by health professionals through the use of information and communication technologies. Its implementation is usually carried out through systems of va riable usability. In 2016, Parmanto et al, developed and validated a questionnaire in English that measures its usability and allows to evaluate all factors that influence it. In 2019, we translated, adapted cross-culturally, and published this questionnaire in Spanish. With the aim of transforming it into a reliable and accessible tool, the utility of which is indisputable in the current context, we carried out a research work that allowed its validation and simplification.

Telemedicine is the provision of services by health professionals, through the use of information and communication technologies. Its implementation helps to shorten distances, facilitate access to the health system, improve the effectiveness of care and reduce costs. In 2016, Bambang Parmanto et al, developed and validated a questionnaire in English that measures its usability and allows to evaluate all the factors that influence it. Since similar tools do not exist in the Spanish language to date, a research work was carried out for transcultural translation and adaptation that included seven steps. The questionnaire obtained after this process provides a valuable tool to objectify information that is vital to contribute to the cycle of continuous improvement of the care process of these characteristics, in which patients, health professionals and funders are involved.

Allergy to natural rubber latex emerged as one of the main allergies at the beginning among some professional groups and the general population. Sensitization and development of latex allergy have been attributed to exposure to products containing residual latex proteins. The prevailing cross-reactivity of latex proteins with other food allergens is of great concern. Numerous purified allergens are currently available, which greatly help in patient management, thus determining their specific profile. We conducted a multicenter study to investigate changes, from the ROC analysis, in the characteristics of patients with latex allergy by measuring its major protein components. Sensitization to latex proteins is crucial because it highlights the cross reactivity to inhalants (pollen) and food (fruit). It is very essential in an accurate and specific clinical setting.

FundingE.C.T. has been supported by the Erasmus+ mobility programme of the European Union. MB was supported by a grant of the Ministry of National Education of the Republic of Turkey, grant number MEB1416. Adipose-derived mesenchymal stromal cells (ASCs) are multipotent stem cells which can differentiate into various cell types, including osteocytes and adipocytes. Due to their ease of harvesting, multipotency, and low tumorigenicity, they are a prime candidate for the development of novel interventional approaches in regenerative medicine. ASCs exhibit slow, spontaneous Ca2+ oscillations and the manipulation of Ca2+ signalling via electrical stimulation was proposed as a potential route for promoting their differentiation in vivo. However, the effects of differentiation-inducing treatments on spontaneous Ca2+ oscillations in ASCs are not yet fully characterised. In this study, we used 2-photon live Ca2+ imaging to assess the fraction of cells showing spontaneous oscillations and the frequency of the oscillation (measured as interpeak interval-IPI) in ASCs undergoing osteogenic or adipogenic differentiation, using undifferentiated ASCs as controls. The measurements were carried out at 7, 14, and 21 days in vitro (DIV) to assess the effect of time in culture on Ca2+ dynamics. We observed that both time and differentiation treatment are important factors associated with a reduced fraction of cells showing Ca2+ oscillations, paralleled by increased IPI times, in comparison with untreated ASCs. Both adipogenic and osteogenic differentiation resulted in a reduction in Ca2+ dynamics, such as the fraction of cells showing intracellular Ca2+ oscillations and their frequency. Adipogenic differentiation was associated with a more pronounced reduction of Ca2+ dynamics compared to cells differentiating towards the osteogenic fate. Changes in Ca2+ associated oscillations with a specific treatment had already occurred at 7 DIV. Finally, we observed a reduction in Ca2+ dynamics over time in untreated ASCs. These data suggest that adipogenic and osteogenic differentiation cell fates are associated with specific changes in spontaneous Ca2+ dynamics over time. While this observation is interesting and provides useful information to understand the functional correlates of stem cell differentiation, further studies are required to clarify the molecular and mechanistic correlates of these changes. This will allow us to better understand the causal relationship between Ca2+ dynamics and differentiation, potentially leading to the development of novel, more effective interventions for both bone regeneration and control of adipose growth. Erasmus+ mobility programme of the European Union Ministry of National Education - Turkey MEB1416

Dermatological emergencies are a frequent reason for emergency departments consultation. In order to determine the prevalence of dermatological emergencies, to describe the kind of dermatological diseases that present as emergencies, to analyze the coincidence between the diagnoses received by the patients in those cases with a previous consultations for the same cutaneous manifestation, and to analyze the behavior according to the health system segment in which they were attended: public segment and private segment; a prospective, observational, analytical, cross-sectional and multi-center study was carried out. Two thousand eight hundred one patients were included. The prevalence of consultations for dermatological emergencies in adults was 15% in the same time period (public segment: 10.6 and private segment: 22.5%, p0.05). The consultation was due to an infectious disease in 35.5%, allergic in 29.6% and neoplastic in 8.6%; 0.7% of patients were hospitalized. In 31.7% of patients who had a previous consultation, a coincidence was found between the diagnoses made in 80.7% of those attended by a dermatologist, and 52.6% evaluated by non-dermatologist physician. The high prevalence of dermatological consultations and the existing differences in the probability of receiving an appropriate diagnosis according to the specialization of the intervening professional, show the importance of the presence of dermatology-trained physicians in the emergency area.Las urgencias dermatológicas constituyen un motivo de consulta frecuente en los departamentos de urgencias. Con el objetivo de determinar la prevalencia de las consultas por urgencias dermatológicas, describir las mismas, analizar la coincidencia entre los diagnósticos recibidos por los pacientes, en los casos que realizaron dos consultas por el mismo cuadro, y analizar el comportamiento de las variables de acuerdo al subsector del sistema de salud en el cual fueron atendidos: subsector público, y subsector privado, se realizó un estudio prospectivo, observacional, analítico, de corte transversal y multicéntrico. Se incluyeron 2801 pacientes. La prevalencia de las consultas por urgencias dermatológicas en adultos fue de 15% en el mismo período horario (subsector público: 10.6% y subsector privado: 22.5%, p0.05). Motivó la consulta una enfermedad infecciosa en el 35.5%, alérgica en el 29.6% y neoplásica en el 8.6%. Se hospitalizó el 0.7% de los pacientes. El 31.7% de los pacientes había realizado consultas previas. En estos casos se encontró coincidencia entre los diagnósticos realizados en el 80.7% de los atendidos de forma precedente por un médico dermatólogo, y el 52.6% de los evaluados por médicos no dermatólogos. La alta prevalencia de las consultas por urgencias dermatológicas y las diferencias existentes en la probabilidad de recibir un diagnóstico apropiado de acuerdo con la especialización del profesional interviniente, muestran la importancia de la presencia de un médico con formación en dermatología en el área de urgencias.

BACKGROUND A clinically meaningful impairment of bone mass secondary to malabsorption is frequent in untreated celiac disease. In adult patients, a rigorous gluten-free diet (GFD) significantly improves, but does not always normalize, bone mineral density (BMD). The reason for this marginal response is unclear. Accordingly, we evaluated the role of both local and systemic factors for bone loss in celiac patients on long-term GFD. STUDY In a prospective cohort, 22 patients with low lumbar and/or femoral BMD and 22 with normal BMD underwent bone and mineral metabolism evaluation: we tested calcium, phosphate, parathyroid hormone, and vitamin D; telopeptide of type I collagen, a bone resorption index; propeptide of type I procollagen, a bone neoformation index; receptor antagonist of NF-kB ligand, an osteoclast-stimulating factor; osteoprotegerin (OPG), a decoy receptor for RANKL. Sunlight exposure and physical exercise were measured. RESULTS Patients with bone loss showed prevalently osteopenia, severe osteoporosis was rare. In comparison with normal BMD patients, they showed higher serum OPG, telopeptide, and lower serum propeptide, suggesting an increased bone turnover. Lumbar T-score was negatively correlated with OPG, telopeptide and RANKL and positively with propeptide. Propeptide was negatively correlated with OPG and telopeptide. OPG was positively correlated with telopeptide. CONCLUSIONS The persistent activation of inflammation should be considered the main pathophysiological mechanism for bone defect in celiac disease patients with bone loss on long-term GFD. High levels of OPG, an attempt at protective mechanism, and low levels of propeptide of type I procollagen, reflecting an insufficient matrix production, characterize this subgroup of patients.

El pioderma gangrenoso ampollar es una variedad infrecuente de pioderma gangrenoso, que se asocia en el 50-70% de los casos con trastornos oncohematológicos. Se comunica el caso de una paciente de 59 años, que consultó por fiebre y ampollas purpúricas de rápida progresión, con compromiso cutáneo mucoso. Con sospecha de una enfermedad neutrofílica, ampollar, o infección por gérmenes oportunistas, se realizó biopsia de piel para estudio histopatológico, inmunofluorescencia directa y cultivo. Los cultivos y la inmunofluorescencia directa fueron negativos, y la anatomía patológica reveló un denso infiltrado inflamatorio con predominio neutrofílico en dermis. Ante el diagnóstico de pioderma gangrenoso ampollar, se realizó una punción-aspiración de médula ósea cuyo resultado fue compatible con leucemia mieloide aguda. Se instauró tratamiento con corticosteroides sistémicos, a pesar de lo cual la paciente evolucionó desfavorablemente y falleció a los 15 días de su ingreso hospitalario. Este caso ilustra la asociación de esta enfermedad cutánea con trastornos oncohematológicos y el mal pronóstico que esto implica a corto plazo.

[EN] Benzene is a highly toxic aromatic hydrocarbon. Inhaling benzene can cause dizziness, vertigo, headaches, aplasia, mutations and, in the most extreme cases, cancer. Trans,trans-muconic acid (t,t-MA) is one of the metabolization products of benzene. Although different analytical methods have been reported for the determination of t,t-MA, these are often expensive, require trained personnel, are not suitable for on-site measurements, and use hazardous organic solvents. For these reasons, the development of reliable, selective and sensitive methods for rapid and in situ detection of t,t-MA are of importance. Addressing this challenge, a nanodevice for the selective and sensitive quantification of t,t-MA in urine is reported. The nanodevice used is achieved using mesoporous silica nanoparticles loaded with a dye reporter and capped with a dicopper(II) azacryptand. Pore opening and payload release is induced rapidly (10 min) and selectively with t,t-MA in urine, using a simple fluorimeter without sample pretreatment., The authors thank the Spanish Government (RTI2018-100910-B-C41) and the Generalitat Valenciana (PROMETEO 2018/024) for support.

Research Question Infections and/or inflammation processes of male genital tract are highly prevalent and often associated with risk of infertility. These conditions represent a possible cause of leukocytospermia, which is still under debate. Leukocytes are key-factors to reactive oxygen species (ROS) production and the increase of ROS in semen fluid is associated with the worsening of semen parameters. At present, there are not appropriate andrological tests to identify asymptomatic inflammatory conditions when the amount of leukocytes is in the normal range. Design We studied the innate immunity profile of myeloperoxidase and lactoferrin (MPO/LAC) proteins expressed in the semen fluid of 39 men evaluated for couple infertility, in the absence of leukocytospermia. Results The presence of both MPO and LAC proteins was associated with a decrease of sperm concentration and of progressive/total motility, whereas the increase of MPO-/LAC + indicated a worse sperm morphology. It is worth to report the predictive potential of MPO+/LAC + pattern (above 4.36 %) as a biological marker to distinguish normozoospermic from pathological patients. Conclusion Our findings indicate MPO/LAC analysis as a potential diagnostic tool to identify asymptomatic conditions eventually related to male infertility, even when the number of leukocytes in semen fluid is below 1 million/mL.

Background Due to the difficulties in acquiring large numbers of megakaryocytes, the impact of inflammatory responses on these cells and their ability to produce fully functional platelets under various pathological conditions has not been investigated in detail. Objectives The primary objective of this study is to develop and functionally characterise a novel megakaryocyte NF-κB reporter cell line in order to determine the effects of various inflammatory molecules on megakaryocytes and their signalling pathways. Methods A Meg-01-NF-κB-GFP-Luc (Meg-01R) cell line was developed by inserting a reporter NF-κB-GFP-Luc cassette into normal Meg-01 cells to produce luciferase following activation of NF-κB to enable easy detection of pro-inflammatory and reparative signalling. Results and conclusions Meg-01 and Meg-01R cells have comparable characteristics including the expression of both GPIb and integrin β3. Meg-01R cells responded to various inflammatory molecules as measured by NF-κB-dependent bioluminescence. For example, inflammatory molecules such as TNFα and Pam3CSK4 increased NF-κB activity, whereas an antimicrobial peptide, LL37, reduced its activity. Meg-01R cells were also found to be sensitive to inhibitors (IMD0354 and C87) of inflammatory pathways. Notably, Meg-01R cells were able to respond to LPS (non-ultrapure) although it was not able to react to ultrapure LPS due to the lack of sufficient TLR4 molecules on their surface. For the first time, we report the development and characterisation of a novel megakaryocyte NF-κB reporter cell line (Meg-01R) as a robust tool to study the inflammatory responses/signalling of megakaryocytes upon stimulation with a broad range of inflammatory molecules that can affect NF-κB activity.

BackgroundHydroxychloroquine has recently received Emergency Use Authorization by the FDA and is currently prescribed in combination with azithromycin for COVID-19 pneumonia. We studied the safety of hydroxychloroquine, alone and in combination with azithromycin.MethodsNew user cohort studies were conducted including 16 severe adverse events (SAEs). Rheumatoid arthritis patients aged 18+ and initiating hydroxychloroquine were compared to those initiating sulfasalazine and followed up over 30 days. Self-controlled case series (SCCS) were conducted to further establish safety in wider populations. Separately, SAEs associated with hydroxychloroquine- azithromycin (compared to hydroxychloroquine-amoxicillin) were studied. Data comprised 14 sources of claims data or electronic medical records from Germany, Japan, Netherlands, Spain, UK, and USA. Propensity score stratification and calibration using negative control outcomes were used to address confounding. Cox models were fitted to estimate calibrated hazard ratios (CalHRs) according to drug use. Estimates were pooled where I2ResultsOverall, 956,374 and 310,350 users of hydroxychloroquine and sulfasalazine, and 323,122 and 351,956 users of hydroxychloroquine-azithromycin and hydroxychloroquine-amoxicillin were included. No excess risk of SAEs was identified when 30-day hydroxychloroquine and sulfasalazine use were compared. SCCS confirmed these findings. However, when azithromycin was added to hydroxychloroquine, we observed an increased risk of 30-day cardiovascular mortality (CalHR2.19 [1.22- 3.94]), chest pain/angina (CalHR 1.15 [95% CI 1.05-1.26]), and heart failure (CalHR 1.22 [95% CI 1.02- 1.45])ConclusionsShort-term hydroxychloroquine treatment is safe, but addition of azithromycin may induce heart failure and cardiovascular mortality, potentially due to synergistic effects on QT length. We call for caution if such combination is to be used in the management of Covid-19.Trial registration numberRegistered with EU PAS; Reference number EUPAS34497 (http://www.encepp.eu/encepp/viewResource.htm?id=34498). The full study protocol and analysis source code can be found at https://github.com/ohdsi-studies/Covid19EstimationHydroxychloroquine.Funding sourcesThis research received partial support from the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC) and Senior Research Fellowship (DPA), US National Institutes of Health, Janssen Research & Development, IQVIA, and by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea [grant number: HI16C0992]. Personal funding included Versus Arthritis [21605] (JL), MRC-DTP [MR/K501256/1] (JL), MRC and FAME (APU). The European Health Data & Evidence Network has received funding from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 806968. The JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA. No funders had a direct role in this study. The views and opinions expressed are those of the authors and do not necessarily reflect those of the Clinician Scientist Award programme, NIHR, NHS or the Department of Health, England.

EnglishIn the Ancient Age, the very rare appearance of the phoenix in the world became proverbial and was exploited in constructing similes, aiming to praise exceptional individuals or stress the uniqueness of an event. This paper focuses on Seneca’s comparison between the rarity of both the true sapiens and the mythical phoenix. This is found in Letter 42 and also alluded to in De constantia sapientis (ch. 7), where the role of the sapiens-phoenix is played by Cato the Younger. Nonetheless, the proverbial feature which those Senecan passages also exhibit should not obscure a deeper meaning embodied here. What we attempt to argue is precisely that not only the device of Stoic paradox in itself is involved here, but also the main, philosophical question of how to define a truly good man is posed. Accordingly, the phoenix simile is not simply one of the manifestations of the Stoic sapiens, but rather the expression of this paradox in itself; or, better still, permeated as it is with ambiguity and hyperbole, the phoenix may constitute the portrayal of the essence and conceptual possibility of the Stoic paradox and Senecan utopia as such. italianoNel mondo antico la proverbiale rarita dell’apparizione della fenice era usata come metafora per lodare individui eccezionali o rimarcare l’unicita di un certo evento. Al topico paragone ricorre anche Seneca nella Lettera 42 per sottolineare la rarita del sapiens. In via allusiva, la stessa immagine compare nel capitolo settimo del De constantia sapientis, in riferimento a Catone Uticense, rarissima incarnazione del saggio stoico. Tuttavia il carattere indubbiamente stereotipo del paragone non deve obliterarne un piu profondo significato: esso merita infatti di essere valorizzato in rapporto alla costruzione dell’utopia senecana del sapiens sullo sfondo di una ricca e non univoca tradizione filosofica intorno al problema della definizione dell’uomo virtuoso. In conclusione, l’immagine della fenice non e in Seneca ≪una≫ delle manifestazioni del sapiens stoico, ma la forma stessa della sua paradossalita, quindi della sua essenza e della sua possibilita concettuale, fondata sull’ambiguita e sull’iperbole.

Introduction Obstructive sleep apnea (OSA) is a recognized risk factor for ischemic stroke; however, there is a paucity of studies devoted to modifying stroke risk factors in patients with OSA. We aimed to evaluate the prevalence and treatment of stroke risk factors in newly diagnosed OSA patients. Methods We evaluated consecutive patients with an OSA diagnosis made within 12 months and CHADS2 score of >2, consistent with high risk for atrial fibrillation. The patients completed polysomnography, sleep questionnaires, and systematic assessments for demographic variables, vascular risk factors, and medication use. Participants also completed up to four weeks of ambulatory cardiac monitoring. A six-month follow-up visit screened for new hospitalizations associated to vascular events and use of new anticoagulants or antiplatelet therapy. Results The sample consisted of 87 patients, mean age 59±8 years, 53% women, and 69% of Hispanic/Latino background. The mean BMI was 35±9. Hypertension was seen in 57% and diabetes mellitus in 33% of the sample. The mean apnea-hypopnea index was 41±27 events/hour. Atrial fibrillation was detected in 3% of the sample through prolonged monitoring. At six-month follow-up, 9% of the sample was hospitalized due to stroke, transient ischemic attack, or coronary artery disease, while 13% reported use of anticoagulants and 38% antiplatelet therapy. Conclusion In this high risk sample of OSA patients, there was a high prevalence of cerebrovascular events and use of medical treatment for secondary stroke prevention. Future studies evaluating the treatment of vascular risk factors in OSA can provide strategies to minimize stroke occurrence. Support Boehringer Ingelheim

Pemphigus vulgaris (PV) is an uncommon, serious disease that is treated with systemic corticosteroids and corticosteroid-sparing agents.To describe and analyze the demographic and clinical characteristics of patients with PV.Retrospective cohort study of adults diagnosed with PV over a period of 12years.PV presented with mucosal lesions in 20 of the 32 patients studied (63%); the most common site was the oral mucosa followed by the vulva. Mucosal involvement was more common in women (P=.03). Lesions were found at more than 1 mucosal site in patients whose disease began in the mucosa, independently of age or sex (P=.003). Disease onset before the age of 40years was associated with generalized skin lesions (P=.003), a need for corticosteroid-sparing therapy (P=.05), and refractory PV (P=.02). Azathioprine was the most widely prescribed corticosteroid-sparing agent (in 22 patients). Eight patients (25%) were dependent on corticosteroids and disease recurred in 26 (81%). Complete remission, with or without treatment, was achieved in 15 patients (47%). Patients remained disease-free for a median of 14months, and 2 patients died (6%).Onset before the age of 40 years could be a sign of poor prognosis in patients with PV, as it was significantly associated with a higher risk of generalized skin involvement, a need for corticosteroid-sparing therapy, and refractory disease.

Background:Apremilast is a non-biologic systemic agent approved for the treatment of plaque psoriasis, oral ulcers of Behcet’s disease and PsA with proven efficacy in clinical trials [1,2]. However, more real-world evidence of apremilast use and effectiveness is needed to identify the patient profile most likely to benefit from this treatment [3].Objectives:To evaluate the persistence of apremilast treatment in patients with PsA naïve to biological treatments in routine clinical practice and assess its effectiveness. Baseline clinical characteristics on patients who started apremilast were also evaluated.Methods:Observational, prospective, multicenter (20 centers) study including consecutive adult patients with PsA naïve to biological therapies who had started treatment with apremilast during the previous 5 to 7 months and were followed-up during 12 months. Variables recorded were persistence of treatment with apremilast at 6 months (6mo) and number of swelling joints, presence of enthesitis and dactylitis, and disease activity, measured by the Disease Activity in Psoriatic Arthritis (DAPSA) score and Physician Global Assessment (PGA) of psoriasis, collected at baseline (BL) (i.e., apremilast treatment start) and 6mo; comorbidities were retrospectively collected at BL. Categorical and quantitative variables were compared using McNemar’s and Wilcoxon test, respectively. Data sets analyzed included all assessable patients.Results:Of the 60 patients recruited at the time of this interim analysis, 54 (90.0%) [mean (SD) age 53.4 (13.9) years] were assessable; 41 (75.9%) of these continued treatment with apremilast at 6mo. At BL, 34 (63.0%) patients had at least one comorbidity, the most frequent being cardiovascular disease (n=15, 27.8%), including hypertension (n=8, 14.8%), metabolic/endocrine disease (n=18, 33.3%), including obesity (n=8, 14.8%) and dyslipidemia (n=10, 18.5%). Psychiatric disease (i.e., depression) (n=5, 9.3%) and neoplasia (n=8, 14.8%) were also observed. The number of swelling joints decreased from median (Q1, Q3) 4.0 (2.0, 7.0) at BL to 1.5 (0.0, 4.0) at 6mo (p=0.0012). Patients with dactylitis and enthesitis decreased from 19 (35.2%) and 16 (29.6%) at BL to 10 (18.5%) and 9 (16.7%) at 6mo (p=0.0225 and p=0.0391), respectively. The distribution of patients in the different disease activity categories according to DAPSA scale changed between BL and 6mo, indicating a favorable disease evolution (Figure 1 next page). According to PGA, at BL (n=53), disease activity was categorized as mild in 18.0%, as moderate in 72.0%, and as severe in 10% of patients and, at 6mo (n=54), as mild in 70.6%, as moderate in 25.5%, and as severe in 3.9% of patients. Fifteen (27.8%) patients interrupted treatment permanently (n=13, 24.1%) or temporarily (n=2, 3.7%), due to no/partial response (n=8, 14.8%), tolerability issues leading to adverse events (n=3, 5.6%), patient decision (n=2, 3.7%), and other reasons (n=2, 3.7%) after a mean (SD) treatment of 3.05 (2.20) months.Conclusion:Forty-one (75.9%) patients with PsA naïve to biological therapies were treated with apremilast during ≥6 months. After treatment, the number of swelling joints, and dactylitis and enthesitis decreased and changes in disease activity according to DAPSA and PGA pointed to a favorable disease evolution. Apremilast treatment provides a clinical benefit to patients with PsA treated in clinical practice.References:[1]Gossec L, Smolen JS, Ramiro S, et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. 2016 Feb 10;75(3):499 LP-510[2]Torres T and Puig L. Apremilast: A novel oral treatment for psoriasis and psoriatic arthritis. Am J clin Dermatol. 2018 Feb;19(1):23-32[3]Coates LC, Kavanaugh A, Mease PJ et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015. Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68(5):1060– 71.Disclosure of Interests:Jordi Gratacos-Masmitja Speakers bureau: MSD, Pfizer, AbbVie, Janssen Cilag, Novartis, Celgene y Lilly., Consultant of: MSD, Pfizer, AbbVie, Janssen Cilag, Novartis, Celgene y Lilly., José Luis Álvarez Vega Speakers bureau: Abbvie, Amgen, MSD, Lilly, Roche, Esteve, UCB, Menarini, Pfizer, GSK, BMS, Janssen, Novartis, Gebro., Consultant of: Abbvie, Amgen, MSD, Lilly, Roche, Esteve, UCB, Menarini, Pfizer, GSK, BMS, Janssen, Novartis, Gebro., Grant/research support from: Abbvie, Amgen, MSD, Lilly, Roche, Esteve, UCB, Menarini, Pfizer, GSK, BMS, Janssen, Novartis, Gebro., Emma Beltrán Speakers bureau: Abbvie, Bristol, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: Abbvie, Bristol, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, ANA URRUTICOECHEA-ARANA: None declared., C. Fito-Manteca: None declared., Francisco Maceiras: None declared., Joaquin Maria Belzunegui Otano Speakers bureau: Lilly, Amgen, Novartis, Abbvie, Janssen., J. Fernández-Melón Speakers bureau: Amgen SL, Eugenio Chamizo Carmona: None declared., Abad Hernández Speakers bureau: MSD, Abbvie, Pfizer, Kern, Novartis, Biogen, Sandoz, Amgen, Sanofi, Lilly, Roche and Janssen-Cilag, Consultant of: MSD, Abbvie, Pfizer, Kern, Novartis, Biogen, Sandoz, Amgen, Sanofi, Lilly, Roche and Janssen-Cilag, Grant/research support from: MSD, Abbvie, Pfizer, Kern, Novartis, Biogen, Sandoz, Amgen, Sanofi, Lilly, Roche and Janssen-Cilag, Inmaculada Ros Consultant of: Amgen, Grant/research support from: MSD, Roche, Novartis, lilly, Pfizer, Amgen, Eva Pascual Shareholder of: Amgen, Employee of: Amgen, Juan Carlos Torre Speakers bureau: Amgen, Lilly, Novartis, Janssen, Pfizer, Consultant of: Amgen, Lilly, Novartis, Janssen, Pfizer, Grant/research support from: Amgen, Lilly, Novartis, Janssen, Pfizer.

Animal sterilization is suggested to promote food overconsumption, although it is unknown whether this effect is mediated by variations in satiety-related hormones, which are released in response to food intake. The aim of this study was to evaluate the effect of sterilization and of the main energy-delivery nutrients, fat and nonstructural carbohydrates, on food intake, blood concentration of satiety-related hormones, and activity level in dogs. In a 2-phase experiment (phase I [Ph.I], 74 d, and Ph.II, 84 d), 12 female Beagle dogs were assigned to a control group (intact in both phases) and a sterilization group (spayed 20 d before Ph.II). In each phase, dogs received a high-carbohydrate (HC) diet (313 and 105 g/kg DM starch and fat, respectively) and a high-fat (HF) diet (191 and 213 g/kg DM starch and fat, respectively), both high in total dietary fiber (>200 g/kg DM) and providing 27% ME as protein, in 2 consecutive periods following a crossover arrangement. During each period, dogs’ voluntary DMI and activity level were recorded during 5 d. Then, energy allowance was restricted to 0.7 maintenance and the level of intake of a common challenge food offered 4 h after feeding the experimental diets (challenge food intake [ChFI]) was used as an index of the satiety state of dogs. Blood concentration of active ghrelin, cholecystokinin (CCK), total peptide YY (PYY), and insulin were determined before and 15, 60, 120, 240, and 360 min after feeding. Voluntary DMI was greater (P 0.10). Dogs fed the HF diet showed a lower increase of CCK at 120 (P 0–240 ). A lower PYY elevation (P 0–240 correlated (P 0.10) but led to a reduced activity level compared with control dogs (P

Objectives The purpose of the study was to evaluate the mucosal immune response in women affected by primary human papillomavirus (HPV) infection, in comparison with HPV-negative women with no previous history of HPV. Methods A case-control study comparing the activity of myeloperoxidase (MPO) and lactoferrin (LF) between 19 HPV-positive and 19 HPV-negative women matched for age. Plasmatic and cervicovaginal levels of polymorphonuclear neutrophils (PMN) exhibiting MPO and LF receptors were measured using cytofluorimetric analysis and expressed as mean of percentages. Results Cervicovaginal levels of MPO-/LF- PMN were lower among HPV-negative women, with a mean rate of 18.81% (SD, 21.38), as opposed to a mean rate of 35.56% (SD, 21.02) (P = 0.020) in HPV-positive women. A similar significant difference was not proven in plasma. The mean rates of plasmatic levels of MPO-/LF- PMN were 36.21% (SD, 16.87) and 36.93% (SD, 10.54) (P = 0.875) in cases and controls, respectively. All patients were evaluated 1 year later, and only 6 cases became negative. Conclusions The presence of MPO-/LF- PMN has been considered as a marker of lower rate of apoptosis of HPV-infected cells. This could explain why HPV-positive women are less capable to deal with a primary infection.

Background/Aims: Patients with type 1 diabetes mellitus (T1DM), autoimmune thyroiditis (ATD), and celiac disease (CD) are at increased risk for developing other autoimmune diseases. We evaluated zinc transporter 8 (ZnT8) prevalence in patients with ATD and/or CD in order to define the usefulness of ZnT8 autoantibodies for prediabetes screening. Methods: Eighty-one young patients with ATD and/or CD were included in the study; 32 subjects with clinical onset of T1DM were enrolled as a control group. GAD65, IA-2, and ZnT8 antibodies were measured. An intravenous glucose tolerance test, C-peptide, glycosylated hemoglobin levels, and genomic analysis of HLA-DQA1* and -DQB1* were also considered in patients positive for autoantibodies. Results: The ZnT8 prevalence was higher in T1DM patients than in patients with other autoimmune diseases (p < 0.001); positive ZnT8 detection was found in 2 ATD (p = 0.004) and 3 ATD + CD (p = 0.04) patients. Positive ZnT8 was associated with GAD65 (p = 0.01) but not with IA-2 positivity. No correlation between ZnT8 detection and the number of T1DM-susceptible HLA-DQ heterodimers was found. Pathological C-peptide levels and insulin response were found in subjects with islet autoimmunity and genetic susceptibility. Conclusion: ZnT8 autoantibodies detection in ATD and/or CD patients is low, and routine ZnT8 screening is not justified. ZnT8 evaluation may be recommended in subjects with autoimmune diseases as a marker for predicting compromised insulin secretion.

Background Some cardiovascular risk factors (CVRF) have been related to poorer responses to biological therapy 1 . We aimed to evaluate the potential link between the MDA response and the presence of CVRF in patients treated with traditional and/or biological DMARDs. Objectives The objective has been to evaluate the potential association beetween classic CVRF and the probability of reaching an MDA response in PsA patients. Methods Cross-sectional study carried out at 25 rheumatology outpatient clinics in patients who fulfilled the Classification for Psoriatic Arthritis (CASPAR) criteria with at least one year disease duration, and treated with biological or conventional synthetic (cs) DMARDs according to routine clinical practice in Spain. Patients were considered in MDA if they met at least 5/7 of the MDA criteria 2 . The relationship between MDA and CVRF was evaluated by uni and multivariate analyses. Results 227 patients were included, 133 (58.6%) were in MDA state (52% on anti-TNFα monotherapy, 24% on csDMARD monotherapy, 24% on anti-TNFα in combination with csDMARD). Among the classic CVRF, tobacco (crude OR: 0.54), sedentary lifestyle (crude OR: 1.95), hyperuricemia (crude OR: 2.01) and obesity (crude OR: 1.54) were related to the likelihood of MDA in the univariate model (p Conclusions Contrary to what has been found in other studies, in this cross-sectional multicenter study we could not find any relationship between traditional CVRF (except for sedentary lifestyle) and MDA. In any case, patients with psoriatic disease should be encouraged to maintain healthy lifestyle habits. References Ogdie A, Eder L. Improving cardiovascular health and metabolic comorbidities in patients with psoriatic arthritis. Int J Clin Rheumatol 2015; 10(6):451–459. Coates LC, Fransen J, Helliwell PS. Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann Rheum Dis 2010; 69(1):48–53. Acknowledgements This study was funded by Pfizer. Disclosure of Interest None declared

Phaeohyphomycosis is an infrequent infection in human beings. However, in recent years, its prevalence has augmented in immunosuppressed patients (mostly in solid organ transplanted patients). Infection can be mucocutaneous or disseminated. In the former, the fungus inoculation occurs mainly through traumatism. Lesions may be polymorphic and asymptomatic, isolated or multiple, and are usually localized in exposed areas of the limbs and head. Treatment is not standardized. When possible, surgical resection of the lesion is combined with systemic antifungals.We communicate three phaeohyphomycosis cases with cutaneous compromise.The cases we present show diverse clinical characteristics and varied severity and evolution.It is important for dermatologists to recognize this cutaneous fungus infection because the diagnosis using microscopic examination and mycological culture depends on the clinical suspicion.

Animal sterilization is suggested to promote food overconsumption, although it is unknown whether this effect is mediated by variations in satiety-related hormones, which are released in response to food intake. The aim of this study was to evaluate the effect of sterilization and of the main energy-delivery nutrients, fat and nonstructural carbohydrates, on food intake, blood concentration of satiety-related hormones, and activity level in dogs. In a 2-phase experiment (phase I [Ph.I], 74 d, and Ph.II, 84 d), 12 female Beagle dogs were assigned to a control group (intact in both phases) and a sterilization group (spayed 20 d before Ph.II). In each phase, dogs received a high-carbohydrate (HC) diet (313 and 105 g/kg DM starch and fat, respectively) and a high-fat (HF) diet (191 and 213 g/kg DM starch and fat, respectively), both high in total dietary fiber (200 g/kg DM) and providing 27% ME as protein, in 2 consecutive periods following a crossover arrangement. During each period, dogs' voluntary DMI and activity level were recorded during 5 d. Then, energy allowance was restricted to 0.7 maintenance and the level of intake of a common challenge food offered 4 h after feeding the experimental diets (challenge food intake [ChFI]) was used as an index of the satiety state of dogs. Blood concentration of active ghrelin, cholecystokinin (CCK), total peptide YY (PYY), and insulin were determined before and 15, 60, 120, 240, and 360 min after feeding. Voluntary DMI was greater (0.05) in HF-fed dogs, but ChFI did not differ between diets (0.10). Dogs fed the HF diet showed a lower increase of CCK at 120 (0.01) and 240 min (0.05), resulting in a lower (0.001) total area under the curve from 0 to 240 min (tAUC). A lower PYY elevation (0.05) was also found in HF-fed dogs at 120 min. Only active ghrelin concentration at 240 min and insulin tAUC correlated (0.05) with ChFI (r = 0.357 and r = -0.364, respectively), suggesting a role of these hormones in appetite. Dog sterilization did not affect voluntary DMI, ChFI, or blood hormones (0.10) but led to a reduced activity level compared with control dogs (0.05). In summary, dog sterilization was not associated with an impaired appetite control. Feeding dogs the HF diet led to energy overconsumption and to a lower blood elevation of CCK and PYY but was not associated with a weaker satiating effect 4 h later compared with the HC diet.

Histoplasmosis is a systemic mycosis caused by the dimorphous fungus Histoplasma capsulatum (H. capsulatum). The fungus enters the body through the respiratory tract in the form of microconidia, which are transformed into intracellular yeast-like structures in the lungs before disseminating hematogenously. Primary infection is usually asymptomatic and self-resolving. Some patients develop severe disease with acute or chronic respiratory involvement. Immunosuppressed patients, mainly those with altered cellular immunity, may have disseminated disease with variable mucocutaneous involvement characterized by papules, nodules, gummas, or ulcers with a granulomatous base. We report the case of 3 HIV-negative patients infected by H capsulatum in whom diagnosis based on the skin lesions proved essential for early initiation of treatment.

Shingles is the cutaneous expression of the reactivation of latent varicella zoster virus infection in sensory ganglia. It presents as vesicles in the corresponding dermatome. The condition is called disseminated herpes zoster (DHZ) when more than 2 contiguous dermatomes are affected, more than 20 vesicles are observed outside the initial dermatome, or involvement is systemic. DHZ is rare and most frequently occurs in immunocompromised patients.To describe the epidemiology, predisposing factors, clinical presentation, laboratory findings, and clinical course of patients with DHZ, and to compare the findings in immunocompromised and immunocompetent patients.We analyzed a retrospective case series of adults hospitalized between February 2010 and October 2015.Forty-one patients with virologically confirmed manifestations of DHZ were included. Stress as a trigger factor was detected in 39% and immunodepression in 58.5%. Immunocompromised patients were younger than the immunocompetent patients (mean ages, 60.5 vs 82 years, P.01). The 8 immunocompetent patients with no detectable trigger factors were older (mean age, 85 years). In 95% of cases, DHZ was initially limited to a single dermatome and then spread to other dermatomes or became disseminated. Thrombocytopenia was detected in 56% of cases. Complication rates were similar in immunocompromised and immunocompetent patients (54% vs 59%, P.01). Six patients died; there was no difference in mortality between the 2 groups.This study provides evidence on the relationship between DHZ, the presence of underlying immunodepression, and complications. Immunosenescence may play an important role in the onset of this disease in older immunocompetent patients.

Although studies in rodents and humans have evidenced a weaker effect of fat in comparison to carbohydrates on the suppression of food intake, very few studies have been carried out in this field in dogs. This study investigates the effects of a high-carbohydrate (HC) and a high-fat (HF) diets on subsequent food intake and blood satiety-related hormones in dogs. Diets differed mainly in their starch (442 vs. 271 g/kg dry matter) and fat (99.3 vs. 214 g/kg dry matter) contents. Twelve Beagle dogs received the experimental diets at maintenance energy requirements in two experimental periods, following a cross-over arrangement. In week 7 of each period, blood concentrations of active ghrelin, glucagon-like peptide (GLP-1), peptide YY, insulin, and glucose were determined before and at 30, 60, 120, 180, and 360 min post-feeding. The following week, intake of a challenge food offered 180 min after the HC and HF diets was recorded over two days. In comparison to the dogs on the HC diet, those on the HF diet had a higher basal concentration of GLP-1 (p =.010) and a higher total area under the curve over 180 min post-prandial (tAUC) (p =.031). Dogs on the HC diet showed a higher elevation of ghrelin at 180 min (p =.033) and of insulin at 360 min (p =.041), although ghrelin and insulin tAUC did not differ between the two diets (p ˃.10). Diet had no effect on challenge food intake (p ˃.10), which correlated with the tAUC of ghrelin (r =.514, p =.010), insulin (r = −.595, p =.002), and glucose (r = −.516, p =.010). Feeding a diet high in carbohydrate or fat at these inclusion levels does not affect the feeding response at 180 min post-prandial, suggesting a similar short-term satiating capacity., This work was funded by Affini Petcare, with the participation of the Department of Industry and Innovation of the Government of Aragón and the European Social Fund. The authors wish to thank the Servicio de Apoyo a la Investigación (SAI) team for their dedicated dog care and for their invaluable assistance with sampling. We also thank the laboratory technicians of the Animal Nutrition Unit of the Faculty of Veterinary Sciences of Zaragoza for carrying out the analysis of food and faeces.

INTRODUCTION Completion thyroidectomy plays an important role in the management of patients with thyroid cancer. The aim of this study is to determine the indications for and timing of a second surgery, as well as surgical complications. MATERIAL AND METHODS Operative reports, as well as the hospital and outpatient records of 686 consecutive patients, who had undergone surgery for differentiated thyroid cancer, were reviewed. Among these, 68 (9,9%) patient records of a completion thyroidectomy for cancer were analyzed. RESULTS The mean time interval between the first and second operation was 3.6 months (range: 1-9). Post-operative complications occurred in 9 patients (12,9%). Among three patients with inferior laryngeal nerve palsy (4,4%) one had definitive palsy (1.4%). Hypoparathyroidism occurred in 6 patients (8,8%) being permanent in one of them (1.4%). No significant difference either for definitive inferior laryngeal nerve lesions (p = 0.9) or for definitive hypocalcemia (p = 1) was found between the groups of patients who had a completion thyroidectomy and those who had a one-step total thyroidectomy for cancer. CONCLUSIONS Correct indications for re-operation, total lobectomy as a primary surgical procedure as well as lateral access to the residual thyroid gland could all reduce the high risks of complications related to this kind of surgery.

The objectives of this clinical study were firstly, to assess the effects of breed/genetic group on body composition in dogs using Dual-X-ray absorptiometry (DEXA) as the reference method and secondly, to check, in clinical field conditions, if methods easy to apply in veterinary practice [bioelectrical impedance (BIA), morphometric equations, body condition score and body mass index] can give similar body composition results to DEXA results, using canine breeds with very different genetic and morphologic backgrounds. 19 dogs from 6 breeds with different genetic origin were used. Results showed that breed differences exist regarding body composition in dogs. Body condition score and morphometric equation should be developed by breed or by groups of breeds for an accurate estimation of body composition of the various breeds of dogs with a different genetic background or morphology. Any of the other tested methodologies (BIA or morphometric equations) gave results in agreement with DEXA value, when dogs with different genetic background and morphologic characteristics are used, but BIA, eventually in combination with morphometric measurements, could be a method to develop to estimate fat-free mass in dogs of different breeds.

Background An IgG response to allergens has been well characterized, however few studies have investigated IgG and IgG4 production in normal subjects. Objective The aim of this study was to find reference values for six common inhalant allergens in a population of healthy children. Methods One hundred and six females and 107 males, from one to 12 years old, were studied assessing the serum levels of specific total IgG and IgG4 for six allergens. Results A homogeneous behaviour was not observed, among allergens or among patient subgroups. Some allergens increased, while others decreased from pre-school to elementary school age. In females, this decrease was less evident, while increases were more evident. Differences were found between seasonal and perennial allergens, the latter showing higher values. We also observed differences between temporal trends of IgG and IgG 4 in some patient groups. Percentiles of distributions have been provided as reference values, for all subgroups that were significantly different. Conclusion Defining an individual profile would be useful for characterising the specific humoral response.