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Resumen: Antecedentes y objetivos: El Wound-QoL es un cuestionario validado para medir la calidad de vida en pacientes con heridas crónicas, que fue desarrollado originalmente para su uso en alemán.El objetivo de este estudio fue traducir el cuestionario Wound-QoL para su uso en la práctica clínica y estudios de investigación en España, así como validar esta versión. Materiales y métodos: Se realizaron dos traducciones independientes del Wound-QoL, directa e inversa, a partir de la versión original en alemán, seguidas de un consenso de expertos sobre las versiones resultantes. Después de su perfeccionamiento se realizó un estudio piloto y posteriormente el estudio de validación. Resultados: Se incluyó un total de 115 pacientes. La edad media fue de 69,5 (DE 14,5) años, y el 60,0% eran mujeres. La versión española del Wound-QoL mostró una excelente consistencia interna (índice alfa de Cronbach > 0,8 en todas las escalas). El análisis factorial dio como resultado las mismas escalas que la versión original. Se objetivaron características satisfactorias de la distribución de la puntuación global y de las subescalas. La validez de constructo y la validez convergente con otros resultados (calidad de vida genérica, tasa de curación) fueron satisfactorias. La gran mayoría de los pacientes consideraron que el cuestionario era una herramienta sencilla y factible. El tiempo medio necesario para completar el cuestionario fue de 5 minutos. El 99,1% de los participantes consideraron que las preguntas eran fáciles de entender y el 94,7% declaró que personal. Conclusiones: La versión española del Wound-QoL muestra una excelente validez en la práctica clínica. Por lo tanto, puede ser recomendada para su uso tanto en la rutina clínica como en los ensayos. Abstract: Background and aims: The Wound-QoL is a validated and feasible questionnaire for measuring disease-specific health-related quality of life in chronic wounds, originally developed for use in German.The objective of this study was to translate the Wound-QoL for use in clinical care and in clinical trials in Spain and to validate this version. Materials and methods: Two independent fourth- and back translations of the Wound-QoL from the original German version were conducted, followed by an expert consensus of the resulting versions. After refinement, the final tool was piloted in N = 10 patients and then used in the validation study. Results: A total of 115 patients were recruited. Mean age was 69.5 (SD 14.5) years, 60.0% were female. The Spanish version of Wound-QoL showed high internal consistency (Cronbach's alpha > 0.8 in all scales). Factor analysis resulted in the same scales as the original version. There were satisfactory distribution characteristics of the global score and the subscales. Construct validity and convergent validity with other outcomes (generic QoL, healing rate) were satisfactory. The vast majority of patients considered the Wound-QoL a simple and feasible tool. Mean time needed for completing the questionnaire was 5 minutes. Overall, 99.1% of the participants found it easy to understand the questions and 94.7% stated that the questionnaire suits the personal situation. Conclusions: The Spanish version of the Wound-QoL shows good validity in clinical practice. It can be recommended for use in clinical routine and trials.

Malignant syphilis is an uncommon form of secondary syphilis associated with HIV infection. Clinically, it is characterized by necrotic nodules and generalized ulcerated lesions. We present 4 cases of malignant syphilis diagnosed after evaluating syphilis cases diagnosed at our hospital between 2012 and 2016. We describe the epidemiologic, clinical, histiopathologic, and serologic characteristics of malignant syphilis and explore its response to treatment and association with HIV infection. Although malignant syphilis is uncommon, there has been an increase in the number of cases published in recent years, particularly in young HIV-positive patients. Malignant syphilis must be contemplated in the differential diagnosis of HIV patients with ulcerated, necrotic lesions.

Resumen La sifilis maligna es una forma infrecuente de sifilis secundaria asociada a la infeccion por el VIH, caracterizada clinicamente por nodulos necroticos y lesiones ulceradas generalizadas. Presentamos 4 pacientes diagnosticados de sifilis maligna tras revisar los casos de sifilis diagnosticados en nuestro centro entre 2012 y 2016. Describimos los aspectos epidemiologicos, clinicos, histopatologicos y serologicos, asi como su relacion con el VIH y la respuesta al tratamiento. Aunque se trate de una forma de sifilis poco frecuente, en los ultimos anos ha aumentado el numero de casos publicados, principalmente pacientes jovenes infectados por el VIH. Es necesario incluir la sifilis maligna en el diagnostico diferencial de pacientes infectados por el VIH con lesiones ulceradas y necroticas.

Resumen Introduccion y objetivos La utilizacion clinica habitual de los farmacos biologicos en el tratamiento de la psoriasis es en segunda linea, es decir, tras el uso previo de un farmaco clasico. Sin embargo, en casos particulares –particularidades del paciente o criterio medico– se realiza la indicacion en primera linea. No existen estudios sobre las caracteristicas demograficas, clinicas y de seguridad de los pacientes que reciben farmaco biologico en primera linea. Como objetivo primario se pretende determinar dichas caracteristicas de acuerdo con la iniciacion de la terapia biologica en primera o segunda linea. Material y metodo Se realizo un estudio descriptivo, multicentrico, de 181 pacientes que iniciaron tratamiento biologico como primer farmaco sistemico para control de su psoriasis moderada-grave, y que forman parte del Registro Espanol de Acontecimientos Adversos Asociados con Medicamentos Biologicos en Dermatologia, entre enero de 2008 y noviembre de 2016. Resultados Los pacientes de ambos grupos son muy similares, si bien se evidencia que el grupo que recibe el biologico en primera linea presenta una edad mas avanzada, sin que se justifique por gravedad de la enfermedad (PASI) ni por el tiempo de evolucion de esta desde el diagnostico. En este grupo de pacientes es mas frecuente la presencia de hipertension, diabetes y hepatopatia. No hemos encontrado diferencias en motivos de suspension ni seguridad entre ambos grupos. Conclusiones No se han encontrado diferencias relevantes entre los 2 grupos, lo cual refuerza la seguridad de los farmacos biologicos en este contexto.

Introduction and objectives Biologic drugs are usually prescribed as second-line treatment for psoriasis, that is, after the patient has first been treated with a conventional psoriasis drug. There are, however, cases where, depending on the characteristics of the patient or the judgement of the physician, biologics may be chosen as first-line therapy. No studies to date have analyzed the demographics or clinical characteristics of patients in this setting or the safety profile of the agents used. The main aim of this study was to characterize these aspects of first-line biologic therapy and compare them to those observed for patients receiving biologics as second-line therapy. Material and method We conducted an observational study of 181 patients treated in various centers with a systemic biologic drug as first-line treatment for moderate to severe psoriasis between January 2008 and November 2016. All the patients were registered in the Spanish Registry of Adverse Events Associated with Biologic Drugs in Dermatology. Results The characteristics of the first- and second-line groups were very similar, although the patients receiving a biologic as first-line treatment for their psoriasis were older. No differences were observed for disease severity (assessed using the PASI) or time to diagnosis. Hypertension, diabetes, and liver disease were all more common in the first-line group. There were no differences between the groups in terms of reasons for drug withdrawal or occurrence of adverse effects. Conclusions No major differences were found between patients with psoriasis receiving biologic drugs as first- or second-line therapy, a finding that provides further evidence of the safety of biologic therapy in patients with psoriasis.

Background The number of consultations for sexually transmitted infections (STIs) is increasing in Spain. The aim of this study was to describe and analyze the epidemiological, behavioral, clinical, and microbiological characteristics of patients registered at the STI unit of a tertiary hospital. Methods This was a retrospective, single-center descriptive study carried out between 2010 and 2013 in a multidisciplinary unit specialized in STIs, situated in a tertiary hospital. Epidemiological, clinical, and behavioral data were gathered using a face-to-face interview and a standardized questionnaire. Samples were collected for microbiology analysis. Results The study included 546 patients: 96% were men, 41% had human immunodeficiency virus (HIV) infection, and 56% were men who have sex with men. The reasons for consultation were the following: urethritis; genital, anal, or perianal ulcers; proctitis; oral ulcers; sexual contact with a person with a known STI; and high-risk sexual contact. The most common microbiological diagnoses were Neisseria gonorrhoeae in urethritis, Treponema pallidum in genital and anal or perianal ulcers, and Chlamydia trachomatis lymphogranuloma venereum serovars in proctitis. The highest prevalences of the main STIs studied occurred in homosexual men with HIV infection. Conclusion This study confirms the increase in the incidence of STIs in recent years and the epidemiological characteristics of the HIV/STI epidemic in Spain.

Resumen Introduccion Las infecciones de transmision sexual son un motivo de consulta creciente en nuestro medio. El objetivo de este trabajo es describir y analizar las caracteristicas epidemiologicas, conductuales, clinicas y microbiologicas de los pacientes registrados en una unidad de infecciones de transmision sexual de un hospital terciario. Metodos Estudio descriptivo, retrospectivo y unicentrico realizado en una unidad multidisciplinar especializada en infecciones de transmision sexual de un hospital terciario entre 2010 y 2013. Se recogieron datos epidemiologicos, clinicos y conductuales mediante entrevista oral abierta y cuestionario estandarizado, y se llevo a cabo la obtencion de muestras para estudio microbiologico. Resultados Se estudiaron 546 pacientes, de los cuales fueron 96% varones, 41% infectados por el VIH, 56% hombres que tienen sexo con hombres. Los motivos de consulta mas prevalentes fueron: uretritis, ulceras genitales y/o anales/perianales, proctitis, ulceras orales, contacto sexual de persona con ITS conocida y contacto sexual de riesgo. Los diagnosticos microbiologicos mas frecuentes fueron: Neisseria gonorrhoeae en uretritis, Treponema pallidum en ulceras genitales y/o anales/perianales y Chlamydia trachomatis serovares de linfogranuloma venereo en proctitis. Las principales ITS estudiadas fueron mas prevalentes en varones homosexuales e infectados por el VIH. Conclusion Se confirma el incremento en la incidencia de las infecciones de transmision sexual en los ultimos anos y las caracteristicas epidemiologicas de la epidemia VIH/ITS de nuestro entorno.

Background and objectives Cutaneous leishmaniasis is the most common form of leishmaniasis, which is endemic in Spain. The aim of this study was to evaluate the epidemiological and clinical characteristics of cutaneous leishmaniasis seen in our hospital over a period of 20 years, with a particular focus on clinical differences according to immune status and origin of infection Materials and methods We performed a chart review of 67 cases of cutaneous leishmaniasis diagnosed between 1992 and 2012. Follow-up data were available for 54 patients. Results Fifty-four patients with cutaneous leishmaniasis were included in the study. Of these, 26 had been diagnosed between 1992 and 2002 and 28 between 2003 and 2012. The mean age at diagnosis was 49 years, there was a predominance of male patients, and the mean time from onset of symptoms to consultation was 3 months. The most common clinical manifestations were plaques and ulcers. Most of the immunodepressed patients and patients with imported leishmaniasis had skin ulcers and/or multiple lesions. During the first decade of the study, diagnosis was based on clinical and histologic findings. These were supported by molecular techniques in the second decade. Pentavalent antimonials were the treatment of choice, producing good results and very few adverse effects Conclusion The number of patients with cutaneous leishmaniasis and with compromised immune status was similar in the periods 1992-2002 and 2003-2013, but more cases of imported leishmaniasis were diagnosed in the second period. Patients with ulcers and/or multiple lesions should be evaluated to rule out immunosuppression or infection by Leishmania species from other parts of the world. Both systemic and intralesional meglumine antimonate was effective and safe

Resumen Introduccion y objetivos La leishmaniasis es endemica en Espana, siendo la leishmaniasis cutanea la forma mas habitual de presentacion. El objetivo del estudio fue valorar las caracteristicas epidemiologicas y clinicas de la leishmaniasis cutanea en las ultimas 2 decadas, haciendo hincapie en las diferencias clinicas segun el estado inmunitario del paciente y el origen de la infeccion. Materiales y metodos Se revisaron retrospectivamente 67 historias clinicas de pacientes diagnosticados de leishmaniasis entre 1992 y 2012, de ellas 54 eran cutaneas, y con datos de seguimiento. Resultados Se incluyeron 54 pacientes: 26 diagnosticados entre 1992-2002 y 28 entre 2003-2012. La edad media fue de 49 anos, con un predominio en varones y un tiempo medio de evolucion previo a la consulta de 3 meses. Las manifestaciones clinicas mas frecuentes fueron placas y ulceras. La mayoria de pacientes inmunodeprimidos y con leishmaniasis importada presentaron lesiones ulceradas y/o multiples. El diagnostico se baso en los hallazgos clinico-patologicos en la primera decada, asociandose el diagnostico por metodos moleculares en la segunda. El tratamiento de eleccion fue los antimoniales pentavalentes, con buenos resultados y escasos efectos adversos. Conclusion El numero de casos y de pacientes inmunodeprimidos fueron similares en ambas decadas, diagnosticandose un mayor numero de leishmaniasis importada en la segunda. En los pacientes con lesiones multiples y/o ulceradas deberian descartarse la inmunosupresion del huesped y la infeccion por cepas importadas. El tratamiento con antimoniato de meglumina fue eficaz y seguro, tanto por via sistemica como intralesional.

Psoriatic lesions affecting the scalp, nails, palms, and the soles of the feet are described as difficult-to-treat psoriasis and require specific management. Involvement of these sites often has a significant physical and emotional impact on the patient and the lesions are difficult to control with topical treatments owing to inadequate penetration of active ingredients and the poor cosmetic characteristics of the vehicles used. Consequently, when difficult-to-treat sites are involved, psoriasis can be considered severe even though the lesions are not extensive. Scant information is available about the use of biologic therapy in this setting, and published data generally comes from clinical trials of patients who also had moderate to severe extensive lesions or from small case series and isolated case reports. In this article we review the quality of the scientific evidence for the 4 biologic agents currently available in Spain (infliximab, etanercept, adalimumab, and ustekinumab) and report level i evidence for the use of biologics to treat nail psoriasis (level of recommendation A) and a somewhat lower level of evidence in the case of scalp involvement and palmoplantar psoriasis.

Resumen El termino de psoriasis en localizaciones de dificil tratamiento se emplea para hacer referencia a la psoriasis localizada en el cuero cabelludo, las unas, las palmas y las plantas y que requiere un manejo diferenciado. A menudo los pacientes presentan un importante impacto fisico y emocional, unido a la dificultad para controlar adecuadamente sus lesiones con tratamientos topicos, debido a una insuficiente penetracion de los principios activos y la escasa cosmeticidad de los vehiculos empleados. Esta circunstancia justifica que la psoriasis en estas localizaciones pueda ser considerada grave, a pesar de su extension limitada. La experiencia con terapias biologicas en estas localizaciones es escasa, en general en el contexto de ensayos clinicos de formas extensas de psoriasis moderada y grave, junto con series limitadas o casos aislados. En el presente articulo se presenta la calidad de la evidencia cientifica para los 4 agentes biologicos disponibles en Espana (infliximab, etanercept, adalimumab y ustekinumab) siendo de nivel i en el caso de la psoriasis ungueal (nivel de recomendacion A) y algo inferior en la psoriasis del cuero cabelludo y palmoplantar.

Biologic drugs are usually prescribed as second-line treatment for psoriasis, that is, after the patient has first been treated with a conventional psoriasis drug. There are, however, cases where, depending on the characteristics of the patient or the judgement of the physician, biologics may be chosen as first-line therapy. No studies to date have analyzed the demographics or clinical characteristics of patients in this setting or the safety profile of the agents used. The main aim of this study was to characterize these aspects of first-line biologic therapy and compare them to those observed for patients receiving biologics as second-line therapy.We conducted an observational study of 181 patients treated in various centers with a systemic biologic drug as first-line treatment for moderate to severe psoriasis between January 2008 and November 2016. All the patients were registered in the Spanish Registry of Adverse Events Associated with Biologic Drugs in Dermatology.The characteristics of the first- and second-line groups were very similar, although the patients receiving a biologic as first-line treatment for their psoriasis were older. No differences were observed for disease severity (assessed using the PASI) or time to diagnosis. Hypertension, diabetes, and liver disease were all more common in the first-line group. There were no differences between the groups in terms of reasons for drug withdrawal or occurrence of adverse effects.No major differences were found between patients with psoriasis receiving biologic drugs as first- or second-line therapy, a finding that provides further evidence of the safety of biologic therapy in patients with psoriasis.

Malignant syphilis is an uncommon form of secondary syphilis associated with HIV infection. Clinically, it is characterized by necrotic nodules and generalized ulcerated lesions. We present 4 cases of malignant syphilis diagnosed after evaluating syphilis cases diagnosed at our hospital between 2012 and 2016. We describe the epidemiologic, clinical, histiopathologic, and serologic characteristics of malignant syphilis and explore its response to treatment and association with HIV infection. Although malignant syphilis is uncommon, there has been an increase in the number of cases published in recent years, particularly in young HIV-positive patients. Malignant syphilis must be contemplated in the differential diagnosis of HIV patients with ulcerated, necrotic lesions.

Background Biobadaderm is the Spanish registry of psoriasis patients receiving systemic treatment in clinical practice. Objective To compare the safety of biologics and classic systemic treatment. Methods Prospective cohort of patients receiving biologics and classic systemic therapies between 2008 and 2013 in 12 hospitals are included. We registered demographic data, diagnoses, comorbidities, treatments and adverse events (AE). We obtained raw relative risks (RR) for specific AE. Multivariate analysis consisted of Cox models adjusting for age, gender, chronic hepatic disease and previous cancer. Results A total of 1030 patients received biologics (2061 AE in 3681 person-years), 926 patients classic systemic drugs (1015 AE in 1517 person-years). Ninety-three per cent of AE in both groups were non-serious, 6% serious and 0.003% fatal. The age- and gender-adjusted hazard ratio of AE was lower in the biologics group [hazard ratio 0.6 (95% CI: 0.5–0.7)].We found no differences in rates of serious and mortal AE. Some system organ class AE rates differed between both groups. As limitations: Prescription bias might affect the incidence of AE in both groups. Association of drug and AE was based on timing: associations might not be causal. Conclusion Patients receiving biologics had lower risk of AE. We did not find differences in the risk of serious or fatal AE.

SummaryBackground An algorithm based on measurement of a serum tumour necrosis factor antagonists (anti-TNF) and antidrug antibodies (ADA) has been proposed previously to guide dose escalation or therapy switching in the early (i.e. the first months of) treatment of psoriasis by anti-TNF. In long-term treatment of responding patients with psoriasis, it is usual to empirically reduce standard doses of anti-TNF to reduce exposure while maintaining clinical response. The relationship between serum anti-TNF, ADA levels and clinical efficacy in long-term treated patients with psoriasis has not yet been determined, so the potential role of these parameters in guiding dose escalation in this scenario is unknown. Aims To evaluate the relationship between drug/ADA levels and clinical efficacy in a group of patients with psoriasis undergoing long-term treatment with adalimumab or etanercept. Methods This was a single-centre, prospective, cohort study of patients with psoriasis receiving adalimumab or etanercept for a minimum of 48 weeks. All patients were started on the standard dose, but some adalimumab users had a reduced frequency of administration. Clinical efficacy was measured using the Psoriasis Area and Severity Index. Serum concentrations were measured by ELISA. Clinical assessment and blood sample collection were carried out simultaneously within 24 h before the next drug administration. Results In total, 21 patients were enrolled (67 simultaneous clinical and serum determinations: 38 receiving adalimumab, 29 receiving etanercept). We did not find any association between serum anti-TNF levels and clinical response. None of the patients developed ADA. Conclusions ADA and anti-TNF levels are not related to clinical effectiveness in patients with psoriasis undergoing long-term treatment with adalimumab or etanercept.

Resumen Introduccion Las ulceras vasculares (venosas y arteriales) de las extremidades inferiores afectan aproximadamente al 1% de la poblacion. Para su tratamiento pueden utilizarse equivalentes cutaneos vivos procedentes de donantes cadavericos o desarrollados mediante bioingenieria tisular. Un 25% de las ulceras no se resuelven, lo que conlleva dolor y perdida de autonomia para los pacientes, ademas de un aumento de la morbilidad y de los costes sanitarios. La membrana amniotica aplicada en ulceras corneales ha demostrado poseer propiedades antimicrobianas y bacteriostaticas, y ser capaz de proteger la herida sin inducir respuesta inmunologica. En ulceras postromboticas y quemaduras tambien se han descrito estas mismas cualidades. Objetivos Valorar la eficacia de la aplicacion del injerto de membrana amniotica en las ulceras vasculares cronicas refractarias de extremidades inferiores. Pacientes y metodos Se aplico el injerto de membrana amniotica en cuatro ulceras refractarias de tres pacientes. Se calculo el tiempo medio de epitelizacion total o parcial de la lesion mediante el registro del area y se valoro el dolor mediante escala visual analogica, en las semanas 0, 4, 8, 12 y 16. Resultados En la semana 8 se observo la epitelizacion completa de una ulcera y la reduccion del 50% de las otras tres. En la semana 16 la reduccion del area fue de media un 81,93% en los cuatro casos. La intensidad del dolor percibido se redujo un 86,6%. No se detectaron efectos adversos. Conclusiones La membrana amniotica puede ser una alternativa eficaz en el tratamiento de las ulceras vasculares cronicas refractarias de extremidades inferiores.

Introduction Approximately 1% of the general population have venous or arterial lower limb ulcers. These lesions can be treated with biological skin substitutes such as cadaver skin or tissue-engineered skin equivalents, but treatment fails in 25% of cases, resulting in pain and loss of patient autonomy, as well as increased morbidity and health care costs. In the treatment of corneal ulcers, amniotic membrane has been shown to have antimicrobial and bacteriostatic properties, and to protect the wound without eliciting an immune response. The same properties have been reported in the treatment of burns and postthrombotic ulcers. Objectives To assess the effectiveness of amniotic membrane transplantation in the treatment of refractory chronic leg ulcers. Patients and methods Amniotic membrane was grafted onto 4 refractory ulcers in 3 patients. The mean time required for partial and complete reepithelialization was calculated by measuring the wound area at weeks 0, 4, 8, 12, and 16. Pain intensity was assessed at the same intervals using a visual analog scale. Results Complete wound reepithelialization was achieved for 1 ulcer by week 8; in the other 3 cases, there was a 50% reduction in size compared to baseline. At week 16, the mean reduction in wound size for the 4 ulcers was 81.93%. The corresponding reduction in pain intensity was 86.6%. No adverse effects were observed. Conclusions Amniotic membrane transplantation might be an effective alternative for the treatment of refractory chronic vascular ulcers on the lower limbs.

Resumen Introduccion El tratamiento estandar compresivo de las ulceras venosas de extremidades inferiores no promueve la cicatrizacion. El autoinjerto es uno de los tratamientos que acelera la reparacion tisular, sin embargo, su aplicacion es dificil en pacientes pluripatologicos o cuando se requieren aplicaciones multiples. La membrana amniotica se ha empleado como material de cobertura y como epitelizante, por lo que podria ser una buena opcion terapeutica para cuando el autoinjerto no este indicado. Objetivos Analizar el estado de conocimiento cientifico sobre la seguridad y la eficacia de la membrana amniotica y comparar los costes de los injertos disponibles actualmente (autoinjertos, membrana amniotica y sustitutos cutaneos biocompatibles) para promover la reparacion tisular de las ulceras venosas. Material y metodos Se realizo una busqueda y revision sistematica de la literatura cientifica hasta marzo del 2010 sobre el uso de la membrana amniotica como tratamiento de las ulceras venosas. Asimismo, se realizo un analisis coste-minimizacion (horizonte temporal 3 y 6 meses). Se consideraron los costes directos sanitarios. Para comprobar la estabilidad de los resultados se llevo a cabo un analisis de sensibilidad. Resultados Se identifico un unico estudio sobre seguridad y eficacia. El analisis de costes mostro que el autoinjerto es siempre la opcion mas barata (1.053 € versus 1.825 € membrana amniotica, 5.767 € sustitutos cutaneos biocompatibles). A los 6 meses la membrana amniotica costaria 6.765 € menos que el uso de los sustitutos cutaneos biocompatibles. Conclusiones El transplante de membrana amniotica para la reepitelizacion de ulceras venosas refractarias al tratamiento convencional es una opcion terapeutica de gran potencial, pero aun en estado experimental. El autoinjerto es el tratamiento mas eficiente; pero la membrana amniotica es mas economica que los sustitutos cutaneos biocompatibles.

Background Standard compression therapy for venous ulcers of the legs does not promote healing. Although autografting accelerates tissue repair, it is difficult to use in patients with concomitant diseases or when multiple grafts are required. The amniotic membrane has been used as a covering material and promotes epithelialization, making it a good potential treatment option when autografts are not indicated. Objectives To analyze the literature on the safety and efficacy of amniotic membrane grafting and compare the cost of currently available grafts (autografts, amniotic membrane grafts, and biocompatible skin substitutes) to promote tissue repair in venous ulcers. Material and methods A systematic review of the literature on the use of amniotic membrane grafts for the treatment of venous ulcers was performed up to 2010. A cost-minimization analysis of direct healthcare costs was then performed (at 3 and 6 months). A sensitivity analysis was performed to confirm the stability of the results. Results Only 1 study addressing safety and efficacy was identified. The cost-minimization analysis showed that autografts are always the least-expensive option (€ 1053 compared with € 1825 for amniotic membrane grafts and € 5767 for biocompatible skin grafts). At 6 months, however, amniotic membrane grafts would have cost € 6765 less than the use of biocompatible skin substitutes. Conclusions Despite having excellent therapeutic potential for the re-epithelialization of venous ulcers that do not respond to conventional treatment, amniotic membrane transplant remains an experimental therapy. Autograft is the most efficient treatment but amniotic membrane graft is less expensive than the use of biocompatible skin substitutes.

The number of consultations for sexually transmitted infections (STIs) is increasing in Spain. The aim of this study was to describe and analyze the epidemiological, behavioral, clinical, and microbiological characteristics of patients registered at the STI unit of a tertiary hospital.This was a retrospective, single-center descriptive study carried out between 2010 and 2013 in a multidisciplinary unit specialized in STIs, situated in a tertiary hospital. Epidemiological, clinical, and behavioral data were gathered using a face-to-face interview and a standardized questionnaire. Samples were collected for microbiology analysis.The study included 546 patients: 96% were men, 41% had human immunodeficiency virus (HIV) infection, and 56% were men who have sex with men. The reasons for consultation were the following: urethritis; genital, anal, or perianal ulcers; proctitis; oral ulcers; sexual contact with a person with a known STI; and high-risk sexual contact. The most common microbiological diagnoses were Neisseria gonorrhoeae in urethritis, Treponema pallidum in genital and anal or perianal ulcers, and Chlamydia trachomatis lymphogranuloma venereum serovars in proctitis. The highest prevalences of the main STIs studied occurred in homosexual men with HIV infection.This study confirms the increase in the incidence of STIs in recent years and the epidemiological characteristics of the HIV/STI epidemic in Spain.

A 5% risk of reactivation of hepatitis B virus (HBV) infection has been reported in patients with diseases other than psoriasis treated with tumor necrosis factor inhibitors. The aim of this study was to investigate the risk of HBV reactivation in patients with a past history of HBV infection who were receiving biologic therapy for psoriasis.This was a multicenter study of 20 patients with psoriasis who were treated with at least 1 biologic agent. All the patients had serologic evidence of past HBV infection (positive total hepatitis B core antibody and negative hepatitis B surface antibody). We analyzed the clinical, serological, and liver function variables recorded before, during, and at the end of follow-up. The viral load at the end of follow-up was also analyzed for all patients.None of the patients fulfilled the criteria for HBV reactivation at the end of a median follow-up period of 40 months. Combining our data with data from other studies of psoriasis patients with a past history of HBV infection who were treated with a biologic, we calculated a maximum estimated risk of HBV reactivation for a mean follow-up period of 30 months of 2.7 reactivations per 100 patients.Biologic therapy did not cause HBV reactivation in our series of patients. Nonetheless, because of the potentially serious complications associated with HBV reactivation, it is important to measure viral load in patients with a history of HBV infection prior to initiation of biologic therapy to rule out occult carriage. These patients should also be monitored regularly in conjunction with a hepatologist.

Psoriatic lesions affecting the scalp, nails, palms, and the soles of the feet are described as difficult-to-treat psoriasis and require specific management. Involvement of these sites often has a significant physical and emotional impact on the patient and the lesions are difficult to control with topical treatments owing to inadequate penetration of active ingredients and the poor cosmetic characteristics of the vehicles used. Consequently, when difficult-to-treat sites are involved, psoriasis can be considered severe even though the lesions are not extensive. Scant information is available about the use of biologic therapy in this setting, and published data generally comes from clinical trials of patients who also had moderate to severe extensive lesions or from small case series and isolated case reports. In this article we review the quality of the scientific evidence for the 4 biologic agents currently available in Spain (infliximab, etanercept, adalimumab, and ustekinumab) and report level i evidence for the use of biologics to treat nail psoriasis (level of recommendation A) and a somewhat lower level of evidence in the case of scalp involvement and palmoplantar psoriasis.

Approximately 1% of the general population have venous or arterial lower limb ulcers. These lesions can be treated with biological skin substitutes such as cadaver skin or tissue-engineered skin equivalents, but treatment fails in 25% of cases, resulting in pain and loss of patient autonomy, as well as increased morbidity and health care costs. In the treatment of corneal ulcers, amniotic membrane has been shown to have antimicrobial and bacteriostatic properties, and to protect the wound without eliciting an immune response. The same properties have been reported in the treatment of burns and postthrombotic ulcers.To assess the effectiveness of amniotic membrane transplantation in the treatment of refractory chronic leg ulcers.Amniotic membrane was grafted onto 4 refractory ulcers in 3 patients. The mean time required for partial and complete re-epithelialization was calculated by measuring the wound area at weeks 0, 4, 8, 12, and 16. Pain intensity was assessed at the same intervals using a visual analog scale.Complete wound re-epithelialization was achieved for 1 ulcer by week 8; in the other 3 cases, there was a 50% reduction in size compared to baseline. At week 16, the mean reduction in wound size for the 4 ulcers was 81.93%. The corresponding reduction in pain intensity was 86.6%. No adverse effects were observed.Amniotic membrane transplantation might be an effective alternative for the treatment of refractory chronic vascular ulcers on the lower limbs.

Nail psoriasis represents a challenge for specialists. There is no comparative study of systemic treatment's effectiveness at this site.Evaluate the response of nail psoriasis to classical and biological therapy and to compare the effectiveness and safety of the different treatments.We performed a retrospective study of 84 patients with moderate-severe psoriasis seen at our Department between January 2006 and January 2009.Psoriasis was severe in 53.4%. In 75% of cases, the fingernails were affected, and the mixed form was the most frequently subtype. The mean baseline scores on the PASI and the NAPSI were 23.12 and 14.7 respectively; the correlation between the two scores fell at weeks 12 and 24 but had risen again at week 48. The baseline NAPSI score tended to be lower in women and significantly higher in patients over 65 years of age, family history of psoriasis, severe psoriasis and nail matrix involvement. In our series, 58.3% received classical treatment (acitretin, methotrexate, cyclosporin, PUVA, NUVB, REPUVA, RENUVB) and 41.7% received biological treatment (infliximab, efalizumab, etanercept, adalimumab).Significant reductions were found (P0.05) in the mean NAPSI scores at 12, 24 and 48 weeks with all the antipsoriatic agents except NUVB; significantly greater with cyclosporine (P0.01) and biological as infliximab and adalimumab at 12 and 24 weeks (differences between treatments disappeared at 48 weeks).The response to treatment is slower in the nail lesions than in the skin lesions. The improvement of nail psoriasis is significant both with the classical treatments significantly higher in cyclosporin; and biological treatment (infliximab and adalimumab at 12 and 24 weeks).

Standard compression therapy for venous ulcers of the legs does not promote healing. Although autografting accelerates tissue repair, it is difficult to use in patients with concomitant diseases or when multiple grafts are required. The amniotic membrane has been used as a covering material and promotes epithelialization, making it a good potential treatment option when autografts are not indicated.To analyze the literature on the safety and efficacy of amniotic membrane grafting and compare the cost of currently available grafts (autografts, amniotic membrane grafts, and biocompatible skin substitutes) to promote tissue repair in venous ulcers.A systematic review of the literature on the use of amniotic membrane grafts for the treatment of venous ulcers was performed up to 2010. A cost-minimization analysis of direct healthcare costs was then performed (at 3 and 6 months). A sensitivity analysis was performed to confirm the stability of the results.Only 1 study addressing safety and efficacy was identified. The cost-minimization analysis showed that autografts are always the least-expensive option (€ 1053 compared with € 1825 for amniotic membrane grafts and € 5767 for biocompatible skin grafts). At 6 months, however, amniotic membrane grafts would have cost € 6765 less than the use of biocompatible skin substitutes.Despite having excellent therapeutic potential for the re-epithelialization of venous ulcers that do not respond to conventional treatment, amniotic membrane transplant remains an experimental therapy. Autograft is the most efficient treatment but amniotic membrane graft is less expensive than the use of biocompatible skin substitutes.

In the last years, there has been a great increase of bacterial resistance to the most frequently used antibiotics. Several factors should be considered when deciding to treat a cutaneous infection with a systemic treatment: characteristics of the patient, infection severity, prevalence and local resistance patterns of pathogens, and properties of available drugs.

The slipping rib syndrome can be produced by a direct or indirect traumatism over the sternal tip of the costal cartilages 8, 9 and 10. The main complains are abdominal pain in the right or left upper abdominal, quadrants, and sometimes a sensation of rubbing or slipping of the ribs. The hoocking maneuver is useful in the diagnosis of this syndrome. Three clinical cases of the slipping rib syndrome are reported. This syndrome must be taken into account is the differential diagnosis of the abdominal pain in pediatric patients.

In 1964 Sweet described a new syndrome, characterized by the association of fever, neutrophilic leukocytosis, erythematous plaque affecting the extremities, neck and face, with histologically verified polymorphonuclear perivascular dermal infiltrates and a rapid response to corticosteroids. Although some 100 cases have since then been described the pathogenesis remains obscure. We present two cases which showed all criteria for Sweet's syndrome, in which the initial presentation of acute onset with fever, multiple skin lesions and especially the poor general state on one, made use at first think of an infectious process such as staphylococcal or gonococcal sepsis, in which case diagnosis must be differential. Only when the causal agent is known and an early skin biopsy is done can correct diagnosis and treatment be established.