A concept for integrated care pathways for atopic dermatitis-A GA2 LEN ADCARE initiative.

INTRODUCTION: The integrated care pathways for atopic dermatitis (AD-ICPs) aim to bridge the gap between existing AD treatment evidence-based guidelines and expert opinion based on daily practice by offering a structured multidisciplinary plan for patient management of AD. ICPs have the potential to enhance guideline recommendations by combining interventions and aspects from different guidelines, integrating quality assurance, and describing co-ordination of care. Most importantly, patients can enter the ICPs at any level depending on AD severity, resources available in their country, and economic factors such as differences in insurance reimbursement systems. METHODS: The GA2 LEN ADCARE network and partners as well as all stakeholders, abbreviated as the AD-ICPs working group, were involved in the discussion and preparation of the AD ICPs during a series of subgroup workshops and meetings in years 2020 and 2021, after which the document was circulated within all GAL2 EN ADCARE centres. RESULTS: The AD-ICPs outline the diagnostic procedures, possible co-morbidities, different available treatment options including differential approaches for the pediatric population, and the role of the pharmacists and other stakeholders, as well as remaining unmet needs in the management of AD. CONCLUSION: The AD-ICPs provide a multidisciplinary plan for improved diagnosis, treatment, and patient feedback in AD management, as well as addressing critical unmet needs, including improved access to care, training specialists, implementation of educational programs, assessment on the impact of climate change, and fostering a personalised treatment approach. By focusing on these key areas, the initiative aims to pave the way for a brighter future in the management of AD.

Cerebral mansoni schistosomiasis: a systematic review of 33 cases published from 1989 to 2019.

BACKGROUND: We investigated the epidemiology, clinical presentation and outcomes of individuals affected by cerebral schistosomiasis. METHODS: This systematic review was planned in accordance with current guidelines for performing comprehensive systematic reviews and meta-analysis, including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. RESULTS: Most of patients presented with seizures (48.5%), which is a non-specific symptom despite its high prevalence. There was no specific clinical manifestation that could help the diagnosis, which was made in 69.7% by histopathological analysis of brain tissue. CONCLUSIONS: Seizures are a non-specific symptom to diagnose patients with cerebral schistosomiasis and accurate clinical indicators need to be derived through further studies.

Metotrexato em crianças e adolescentes com dermatite atópica: série de casos / Methotrexate in children and adolescents with atopic dermatitis: a case series

Introdução: A dermatite atópica é uma doença inflamatória crônica da pele que nas suas formas moderadas e graves afeta profundamente a qualidade de vida dos seus portadores e familiares. O metotrexato tem sido indicado off-label para casos graves e refratários em crianças e adolescentes, pois é uma opção terapêutica acessível e de baixo custo. Existe uma escassez de publicações envolvendo a medicação, sobretudo na faixa etária pediátrica. Objetivo e método: O presente estudo busca avaliar as características clínicas das crianças e adolescentes em uso atual ou prévio de metotrexato para tratamento de dermatite atópica moderada ou grave. Foram incluídos 10 pacientes, 60% do gênero masculino, mediana de idade no início do metotrexato de 14 anos (variando de 3 a 18 anos), e mediana do tempo de evolução da dermatite atópica de 14 anos (variando de 3 a 17 anos). Rinite alérgica e asma em 100% e 50% casos, respectivamente, e transtornos psíquicos em 60%. Resultados: Seis pacientes obtiveram melhora clínica com mediana de tempo de 9 meses (variando de 4 a 14 meses) e mediana do Scoring Atopic Dermatitis inicial de 50,5 (IIQ 13,8) e de 32,5 (IIQ 24,3) após 12 a 15 meses de tratamento. Efeitos adversos foram observados em 20% dos casos, e suspensão do metotrexato em apenas um paciente. Conclusão: Nesta série de casos com dez pacientes houve melhora clínica em seis, com poucos efeitos adversos, sendo uma alternativa terapêutica válida.

Introduction: Atopic dermatitis is a chronic inflammatory disease of the skin that in its moderate and severe forms profoundly affects the quality of life of patients and their families. Methotrexate has been used off-label for severe and refractory cases in children and adolescents, as it is an affordable and low-cost therapeutic option. There is a lack of publications addressing this medication, especially in the pediatric age group. Objective and method: The present study seeks to evaluate the clinical characteristics of children and adolescents in current or previous use of methotrexate for the treatment of moderate or severe atopic dermatitis. Ten patients were included, 60% were male, median age at the beginning of methotrexate use was 14 years (ranging from 3 to 18 years), and median time of course of atopic dermatitis was 14 years (ranging from 3 to 17 years). Allergic rhinitis and asthma were found in 100% and 50% of cases, respectively, and mental disorders in 60%. Results: Six patients achieved clinical improvement with a median time of 9 months (ranging from 4 to 14 months) and a median score in the initial Scoring Atopic Dermatitis of 50.5 (interquartile range, 13.8) and 32.5 (interquartile range, 24.3) after 12 to 15 months of treatment. Adverse effects were reported in 20% of cases, and methotrexate discontinuation in only one patient. Conclusion: In this case series of ten patients, methotrexate led to clinical improvement in six patients with few adverse effects, thus being a valid therapeutic alternative.

CROSS-CULTURAL ADAPTATION AND VALIDATION OF THE ITCHING SEVERITY SCALE IN CHILDREN AND ADOLESCENTS WITH ATOPIC DERMATITIS. / ADAPTAÇÃO TRANSCULTURAL E VALIDAÇÃO DA ESCALA DE GRAVIDADE DE PRURIDO EM CRIANÇAS E ADOLESCENTES COM DERMATITE ATÓPICA.

OBJECTIVE: To translate, adapt and validate the Itch Severity Scale to a Brazilian version (ISS-Ped) in order to measure the severity of pruritus in children and adolescents with atopic dermatitis. METHODS: This is a methodological study of validation of an instrument following recommended protocols. The translated version was evaluated by a group of experts including one professional with experience in instrument validation, three English teachers, one linguistics teacher and seven allergists. After this, the scale was applied to 42 parents of children aged between 2 and 18 years old with atopic dermatitis, and 42 parents of children without pruritic diseases. Results were evaluated according to the severity of atopic dermatitis and disease control, and they were compared between groups with and without atopic dermatitis. RESULTS: More than 90% of the questions were clear to the parents. The ISS-Ped showed a strong positive correlation with the severity of atopic dermatitis (Pearson: 0.74; p<0.001) and a good correlation with the control of dermatitis (point-biserial correlation coefficient: 0.65; p<0.001). The scale showed excellent internal consistency (Cronbach's α: 0.96) and adequate test and retest agreement (95% confidence interval of intraclass correlation coefficient: 0.89-0.99; p<0.001). CONCLUSIONS: The ISS-Ped is a feasible, valid, reliable and satisfactorily equivalent. The translated scale was appropriate to assess the severity of itching in children and adolescents with eczema, allowing comparisons in the clinical practice and in the research setting.

OBJETIVO: Realizar tradução, adaptação e validação da Itch Severity Scale (ISS-Ped) para medir a gravidade de prurido em crianças e adolescentes com dermatite atópica. MÉTODOS: Estudo metodológico de validação de instrumento, seguindo protocolos recomendados. Após a definição da versão traduzida, com participação de um profissional com experiência em validação de instrumentos, três professores de inglês, um professor de linguística e sete alergologistas, a Escala de Gravidade de Prurido (ISS-Ped) foi aplicada a 42 responsáveis por pacientes entre 2 e 18 anos de idade com dermatite atópica e a 42 responsáveis por indivíduos sem doença cutânea pruriginosa da mesma faixa etária. Resultados da escala foram comparados com a gravidade da dermatite atópica e o controle da doença, e entre os dois grupos. RESULTADOS: A clareza das questões foi maior que 90%. A ISS-Ped mostrou forte correlação positiva com a gravidade da dermatite atópica (Pearson: 0,74; p<0,001) e boa correlação com o controle da doença (coeficiente de correlação ponto bisserial: 0,65; p<0,001), além de ótima consistência interna (α de Cronbach: 0,96) e adequada reprodutibilidade pela concordância do teste e reteste (coeficiente de correlação intraclasse variando de 0,89 a 0,99 com IC95% e p<0,001). CONCLUSÕES: A ISS-Ped apresentou-se viável, válida e confiável, sendo atingida equivalência satisfatória. A escala traduzida mostrou-se adequada para avaliar a gravidade do prurido em crianças e adolescentes com dermatite atópica, permitindo comparações na prática clínica e entre pesquisas de diferentes centros.

Adaptação transcultural e validação da escala de gravidade de prurido em crianças e adolescentes com dermatite atópica / Cross-cultural adaptation and validation of the itching severity scale in children and adolescents with atopic dermatitis

RESUMO Objetivo: Realizar tradução, adaptação e validação da Itch Severity Scale (ISS-Ped) para medir a gravidade de prurido em crianças e adolescentes com dermatite atópica. Métodos: Estudo metodológico de validação de instrumento, seguindo protocolos recomendados. Após a definição da versão traduzida, com participação de um profissional com experiência em validação de instrumentos, três professores de inglês, um professor de linguística e sete alergologistas, a Escala de Gravidade de Prurido (ISS-Ped) foi aplicada a 42 responsáveis por pacientes entre 2 e 18 anos de idade com dermatite atópica e a 42 responsáveis por indivíduos sem doença cutânea pruriginosa da mesma faixa etária. Resultados da escala foram comparados com a gravidade da dermatite atópica e o controle da doença, e entre os dois grupos. Resultados: A clareza das questões foi maior que 90%. A ISS-Ped mostrou forte correlação positiva com a gravidade da dermatite atópica (Pearson: 0,74; p<0,001) e boa correlação com o controle da doença (coeficiente de correlação ponto bisserial: 0,65; p<0,001), além de ótima consistência interna (α de Cronbach: 0,96) e adequada reprodutibilidade pela concordância do teste e reteste (coeficiente de correlação intraclasse variando de 0,89 a 0,99 com IC95% e p<0,001). Conclusões: A ISS-Ped apresentou-se viável, válida e confiável, sendo atingida equivalência satisfatória. A escala traduzida mostrou-se adequada para avaliar a gravidade do prurido em crianças e adolescentes com dermatite atópica, permitindo comparações na prática clínica e entre pesquisas de diferentes centros.

ABSTRACT Objective: To translate, adapt and validate the Itch Severity Scale to a Brazilian version (ISS-Ped) in order to measure the severity of pruritus in children and adolescents with atopic dermatitis. Methods: This is a methodological study of validation of an instrument following recommended protocols. The translated version was evaluated by a group of experts including one professional with experience in instrument validation, three English teachers, one linguistics teacher and seven allergists. After this, the scale was applied to 42 parents of children aged between 2 and 18 years old with atopic dermatitis, and 42 parents of children without pruritic diseases. Results were evaluated according to the severity of atopic dermatitis and disease control, and they were compared between groups with and without atopic dermatitis. Results: More than 90% of the questions were clear to the parents. The ISS-Ped showed a strong positive correlation with the severity of atopic dermatitis (Pearson: 0.74; p<0.001) and a good correlation with the control of dermatitis (point-biserial correlation coefficient: 0.65; p<0.001). The scale showed excellent internal consistency (Cronbach's α: 0.96) and adequate test and retest agreement (95% confidence interval of intraclass correlation coefficient: 0.89-0.99; p<0.001). Conclusions: The ISS-Ped is a feasible, valid, reliable and satisfactorily equivalent. The translated scale was appropriate to assess the severity of itching in children and adolescents with eczema, allowing comparisons in the clinical practice and in the research setting.

Recurrence of chronic urticaria caused by reinfection by Helicobacter pylori.

OBJECTIVE: To describe a case of chronic urticaria in a female adolescent associated with Helicobacter pylori infection, confirmed in two different occasions, with improvement of urticaria after the antibacterial treatment. CASE DESCRIPTION: A 13-year-old female patient sought medical care with chronic urticaria and epigastric pain unresponsive to medical treatment. Laboratorial tests for further investigation were normal except for the upper gastrointestinal endoscopy with biopsy showing moderate chronic active gastritis associated with Helicobacter pylori. After specific and appropriate treatment, the patient had remission of the symptoms. A new upper gastrointestinal endoscopy to control the treatment after nine months was normal. After five years, the patient returned with recurrence of urticaria and epigastric pain. She was taking antihistamines, without any improvement. It was again submitted to screening protocol for chronic urticaria with normal results. She was submitted to upper gastrointestinal endoscopy, which showed positive urease test. The patient started a new treatment for Helicobacter pylori with disappearance of chronic urticaria and epigastric pain within seven days. COMMENTS: The reported case suggests a causal relationship between the positive diagnosis of Helicobacter pylori and the occurrence of chronic urticaria, showing the remission of symptoms after the institution of effective therapy for this agent. Chronic urticaria is a disease of complex etiology, and although controversial, there is growing evidence of Helicobacter pylori involvement with extraintestinal diseases, including chronic urticaria.

Recidiva de urticária crônica decorrente de reinfecção por Helicobacter pylori / Recurrence of chronic urticaria caused by reinfection by Helicobacter pylori / Recidiva de urticaria crónica decurrente de reinfección por Helicobacter pylori

OBJETIVO: Descrever, em uma adolescente do sexo feminino, o caso clínico de urticária crônica associado à infecção por Helicobacter pylori confirmado em dois momentos distintos, com melhora após a terapêutica antibacteriana. DESCRIÇÃO DO CASO: Paciente do sexo feminino, 13 anos, procurou atendimento médico com urticária crônica e dores epigástricas sem resposta ao tratamento medicamentoso. Os exames solicitados para investigação complementar apresentaram-se normais, exceto a endoscopia digestiva alta com biópsia, que evidenciou gastrite crônica ativa moderada associada ao Helicobacter pylori. Foi iniciado o tratamento adequado para a bactéria em questão e a paciente apresentou remissão dos sintomas. Nova endoscopia digestiva alta para controlar o tratamento após nove meses estava normal. Cinco anos depois, a paciente procurou novamente o ambulatório queixando-se de retorno do quadro de urticária e dores epigástricas. Ela se encontrava em uso de anti-histamínico, sem melhora. Foi novamente submetida a protocolo de exames para investigar urticária crônica, com resultados dentro da normalidade. Foi submetida à endoscopia digestiva alta, que apresentou teste da urease positivo. Iniciou-se então novo tratamento para Helicobacter pylori por sete dias, com desaparecimento da urticária crônica e das dores epigástricas. COMENTÁRIOS: O caso relatado sugere relação causal entre o diagnóstico positivo para o Helicobacter pylori e a ocorrência do quadro de urticária crônica, com instituição de terapêutica eficaz para tal bactéria e remissão dos sintomas. A urticária crônica é uma doença de etiopatogenia complexa e, apesar das controvérsias, as evidências do envolvimento do Helicobacter pylori com doenças extraintestinais vêm crescendo, entre elas a urticária crônica.

OBJECTIVE: To describe a case of chronic urticaria in a female adolescent associated with Helicobacter pylori infection, confirmed in two different occasions, with improvement of urticaria after the antibacterial treatment. CASE DESCRIPTION: A 13-year-old female patient sought medical care with chronic urticaria and epigastric pain unresponsive to medical treatment. Laboratorial tests for further investigation were normal except for the upper gastrointestinal endoscopy with biopsy showing moderate chronic active gastritis associated with Helicobacter pylori. After specific and appropriate treatment, the patient had remission of the symptoms. A new upper gastrointestinal endoscopy to control the treatment after nine months was normal. After five years, the patient returned with recurrence of urticaria and epigastric pain. She was taking antihistamines, without any improvement. It was again submitted to screening protocol for chronic urticaria with normal results. She was submitted to upper gastrointestinal endoscopy, which showed positive urease test. The patient started a new treatment for Helicobacter pylori with disappearance of chronic urticaria and epigastric pain within seven days. COMMENTS: The reported case suggests a causal relationship between the positive diagnosis of Helicobacter pylori and the occurrence of chronic urticaria, showing the remission of symptoms after the institution of effective therapy for this agent. Chronic urticaria is a disease of complex etiology, and although controversial, there is growing evidence of Helicobacter pylori involvement with extraintestinal diseases, including chronic urticaria.

OBJETIVO: Describir, en una adolescente del sexo femenino, el caso clínico de urticaria crónica asociado a la infección por Helicobacter pylori confirmado en dos momentos distintos, con mejora después de la terapéutica antibacteriana. DESCRIPCIÓN DEL CASO: Paciente del sexo femenino, 13 años, buscó atención médica con urticaria crónica y dolores epigástricas sin respuesta al tratamiento medicamentoso. Los exámenes solicitados para investigación complementar se presentaron normales, excepto por la endoscopía digestiva alta con biopsia, que evidenció gastritis crónica activa moderada asociada al Helicobacter pylori. Se inició el tratamiento adecuado para la bacteria en cuestión, y la paciente presentó remisión de los síntomas. Nueva endoscopía digestiva alta para controlar el tratamiento después de nueve meses estaba normal. Tras cinco años, la paciente buscó nuevamente el ambulatorio quejándose de retorno del cuadro de urticaria y dolores epigástricos. Ella estaba en uso de anti-histamínicos, sin mejoría. Fue nuevamente sometida al protocolo de exámenes para investigar urticaria crónica, con resultados dentro de la normalidad. Fue sometida a la endoscopía digestiva alta, que presentó prueba de ureasa positiva. Se inició entonces nuevo tratamiento para Helicobacter pylori por siete días, con desaparición de la urticaria crónica y de los dolores epigástricos. COMENTARIOS: El caso relatado sugiere relación causal entre el diagnóstico positivo para el Helicobacter pylori y la ocurrencia del cuadro de urticaria crónica, con institución de terapéutica eficaz para tal bacteria y remisión de los síntomas. La urticaria crónica es una enfermedad de etiopatogenía compleja y, a pesar de las controversias, las evidencias de la implicación del Helicobacter pylori con enfermedades extraintestinales vienen creciendo, entre ellas la urticaria crónica.