Evidence-based recommendations to assess psoriasis severity: systematic literature review and expert opinion of a panel of dermatologists.

BACKGROUND: Severity of psoriasis appears to be multidimensional and its assessment in everyday clinical practice requires a complex holistic approach. OBJECTIVES: To develop evidence-based recommendations to assess severity of plaque-type psoriasis in adult patients in everyday clinical practice. METHODS: A scientific committee (10 members identified on the basis of their expertise in psoriasis) using Delphi methodology selected eight questions in three domains: severity, health-related quality of life (HR-QoL) and comorbidities. Three systematic literature reviews (one per domain) of all studies published between January 1980 and June 2009 were performed based on Pub-Med, Cochrane and Embase database. Selected articles were systematically reviewed and evidence appraised according to the Oxford Levels of Evidence. On June 2009, a group of 44 French dermatologists both hospital and office based participated in a meeting including three separate rounds of discussions, plenary sessions, and modified Delphi technique votes. Recommendations for clinical practice based on systematic review and clinical experience were formulated by the group. Subsequently, agreements among the participants regarding these recommendations as well as potential impact on clinical practice were evaluated. RESULTS: A total of 10 642 references were identified, of which 154 articles were analysed. Ten key recommendations on the assessment of psoriasis severity were formulated: three recommendations relating to severity assessment, three recommendations relating to HR-QoL (including the use of the Dermatology Life Quality Index [DLQI] in clinical practice) and four recommendations relating to comorbidities (including systematic screening for peripheral or axial inflammatory joint damage, regardless of psoriasis severity). CONCLUSIONS: Ten recommendations to assess the severity of plaque-type psoriasis in adult patients in daily practice were developed. The recommendations are based on systematic appraisal of available evidence. They were developed and supported by a panel of dermatologists, which enhances their validity and practical relevance.

What are the best outcome measures for assessing plaque psoriasis severity? A systematic review of the literature.

BACKGROUND: A wide variety of scoring systems have been proposed to assess severity of psoriasis. Given its importance as a health issue both for patients and health care systems, it is critically important to evaluate the validity and reliability of existing outcome measures. OBJECTIVE: The objective of this systematic review was to assess the extent of validation including the validity, reliability, sensitivity to change and ease of use of available outcome measures for psoriasis. MATERIALS AND METHODS: We conducted a systematic review of all clinical studies (prospective and retrospective) investigating the severity of psoriasis patients and published between January 1980 and June 2009. The following methodological validation and quality criteria were recorded systematically: construct validity, content validity and internal consistency, intra-observer variation and inter-observer variation, sensitivity to change and acceptability/ease of use assessed as time required to perform measurement. RESULTS: Based on methodological validation and quality criteria, six clinical severity scores were selected and analysed (PASI, BSA, PGA, LS-PGA, SPI and SAPASI scores). We did not find substantial evidence of construct validity for any of the psoriasis clinical severity scores. Content validity was studied by considering the PASI score as gold standard. The relative content validity was good for the LS-PGA, PGA, and SPI scores, which correlated strongly with the PASI score. The SAPASI and PASI scores showed moderate correlation. Internal consistency was good for the PASI and LS-PGA scores. The PASI, BSA, PGA and LS-PGA scores displayed limited intra-observer variation. The inter-observer variation was low for LS-PGA (ICC < 0.5) and SAPASI, moderate for PASI, SPI and PGA and high for BSA (ICC > 0.8). The PASI score and the SAPASI displayed moderate sensitivity to change. DISCUSSION: Based on this systematic review, it appears that none of the severity scores used for psoriasis meets all of the validation criteria required for an ideal score. However, we can conclude that the PASI score is the most extensively studied psoriasis clinical severity score and the most thoroughly validated according to methodological validation criteria. Despite certain limitations, use of the PASI score can be recommended for scientific evaluation of the clinical severity of psoriasis.

Cardiovascular risk factors in patients with plaque psoriasis: a systematic review of epidemiological studies.

INTRODUCTION: Many epidemiological studies have associated psoriasis with an increased risk of coronary artery disease, resulting from a higher prevalence of cardiovascular risk factors in psoriasis patients compared with unmatched controls. However, the results of epidemiological studies vary depending upon the populations studied. The aim of this systemic review was to evaluate the risk of diabetes, hypertension, dyslipidaemia and obesity in adults with plaque psoriasis. In addition, we assessed the relationship between the risk of cardiovascular risk factors and psoriasis severity. METHODS: A systematic search was performed on Pubmed, Cochrane and Embase databases, using the key-words 'psoriasis', 'diabetes', 'hypertension', 'high blood pressure', 'dyslipidaemia', 'metabolic syndrome' and 'obesity', during the period from 1980 to June 2009. RESULTS: The initial literature search identified 353 articles. The final selection included 18 cross-sectional case-control studies. An increased risk of metabolic syndrome was observed in psoriatic patients (OR = 1.3-5.92), and a trend for a higher risk of obesity (OR = 1.18-5.49), especially in patients with severe psoriasis. For hypertension, hypertriglyceridaemia, and diabetes, the association was not significant in all studies. DISCUSSION: There was important heterogeneity in study design preventing from pooling results. Most often lifestyle factors such as smoking, alcohol consumption, physical activities were not taken into account. CONCLUSION: There is an increased risk of obesity and metabolic syndrome in psoriasis. For hypertension, diabetes and dyslipidaemia no consistency was found across studies. Prospective epidemiological studies with thorough recording of cardiovascular risk factors are required in psoriasis patients.

What are the best outcome measures for assessing quality of life in plaque type psoriasis? A systematic review of the literature.

BACKGROUND: The assessment of health-related quality of life (QOL) is important in psoriasis. Despite this, among the wide variety of QOL questionnaires used in psoriasis, there is no consensus as to which is the best. OBJECTIVE: The objective of this systematic review was to identify which of these measurements have acceptable evaluation criteria for both monitoring disease and research purposes. We looked at validity, reliability, sensitivity to change (responsiveness) and acceptability, which are common criteria for any score and specific criteria for QOL questionnaire. MATERIALS AND METHODS: We performed a systematic review of all clinical studies investigating the QOL of psoriasis patients, published between January 1988 and June 2009. RESULTS: Twenty-one QOL questionnaires were identified. Eight of these satisfied most of the validation criteria; they were multidimensional and had been used in clinical research: short form 36 (SF 36), Dermatology Life Quality Index (DLQI), Skindex 29, Skindex 17, Dermatology Quality of life Scale (DQOLS), Psoriasis Disability Index (PDI) Impact of Psoriasis Questionnaire (IPSO) and Psoriasis Index of Quality of Life (PSORIQOL). Construct validity, content validity and internal consistency were adequately assessed and good performance was achieved for all questionnaires. Reproducibility (undetermined for Skindex 17) and acceptability were good for all questionnaires. Sensitivity to change was determined good for the SF36, DLQI, Skindex 29 and PDI. Item bias, unidimensional structure and cross-cultural equivalence were poor for all but the Skindex 17 and SF36 questionnaires. CONCLUSION: On the basis of this systematic review, we can conclude that the DLQI is easy to use in clinical practice because of its brevity and simplicity. SF36 is widely used in clinical trials. Skindex 29 and Skindex 17, although rarely used, are interesting because of their cross-cultural validation.

Assessment of risk of psoriatic arthritis in patients with plaque psoriasis: a systematic review of the literature.

OBJECTIVE: The aim of this study was to determine the prevalence of psoriatic arthritis (PsA) in the patients with plaque psoriasis and to give recommendation for the diagnosis of PsA for dermatologists. METHODS: A systematic search was performed in Pubmed, Cochrane and Embase databases. The key-words used from the Medical Searching Heading (MeSH) were: 'Psoriasis', 'Arthritis, Psoriatic', 'Uveitis' and 'Dactylitis'. We selected cross-sectional epidemiological studies written in English or French between January 1980 and October 2009. RESULTS: The initial literature search identified 2171 references. Based on abstract reading and exclusion of studies not written in English or French, and without control group, the final selection included 20 epidemiological studies. With the eight studies using rheumatologically validated criteria, the prevalence of PsA among psoriasis patient spanned a wide range from 7% to 26%. CONCLUSION: Psoriasis arthritis may affect up to 24% of psoriasis patients. Dermatologist should be aware of main clinical sign of PsA to promote earlier recognition and treatment of PsA.

[Hydroxyzine premedication does not alter bispectral index changes following etomidate induction of general anaesthesia]. / La prémédication par l'hydroxyzine ne modifie pas les variations du BIS induites par l'administration d'étomidate.

OBJECTIVE: Various drugs including hydroxyzine are preoperatively administered to facilitate the induction of general anaesthesia. We investigated the effect of hydroxyzine premedication on BIS-based etomidate induction of general anaesthesia. PATIENTS AND METHODS: Sixty-seven ASA I-II consecutive patients were randomly allocated to receive oral hydroxyzine 1.5 mg/kg or placebo, 90 min prior to inducing general anaesthesia using intravenous etomidate alone 0.3 mg/kg. BIS values were continuously recorded. The times for the BIS to decrease to 50 and to loss of eyelid reflex; the evolution of arterial pressure and heart rate; and myoclonia rate and grade were investigated and compared. RESULTS: The results for the hydroxyzine and placebo groups were similar with respect to: a) time [median (range) (seconds)] to a BIS decrease to 50 [100 (21-266) versus 113 (30-510), P=0.1] and to loss of eyelid reflex [83 (21-210) versus 97 (30-300), P=0.1]; b) myoclonia frequency (yes/no) (9/26 versus 4/28, P=0.2) and grade (P=0.3); the evolution of mean arterial pressure and heart rate (P=0.3). CONCLUSION: Oral weight-related hydroxyzine premedication does not alter BIS-based etomidate induction of GA.

Field study of the efficacy of halofuginone and decoquinate in the treatment of cryptosporidiosis in veal calves.

Ninety, seven- to 10-day-old calves were allocated to three groups of 30 and treated daily for seven days with either 100 microg/kg halofuginone hydrobromide or 2.5 mg/kg decoquinate orally or left untreated as controls. The levels of diarrhoea and dehydration were monitored daily for 28 days from the first day of treatment (day 0) and samples of faeces were collected on days 0, 7, 14, 21 and 28, to quantify the excretion of Cryptosporidium parvum oocysts. The calves were weighed on days 3 and 28. The treatments had no effect on the levels of diarrhoea or dehydration, the proportions of diarrhoeic calves or the proportions of calves shedding oocysts. However, unlike decoquinate, halofuginone significantly reduced the excretion of oocysts on day 7 (P<0.0001), and decoquinate increased the average daily weight gain of the calves (P=0.049).

Bispectral index changes following etomidate induction of general anaesthesia and orotracheal intubation.

BACKGROUND: Etomidate-associated hypnosis has only been studied using standard clinical criteria and raw EEG variables. We conducted a BIS-based investigation of etomidate induction of general anaesthesia. METHODS: Thirty hydroxyzine-premedicated ASA I patients were randomly allocated to receive etomidate 0.2, 0.3, or 0.4 mg kg(-1) intravenously over 30 s. The BIS was continuously recorded. A tourniquet was placed on a lower limb to record purposeful movements and myoclonia. Tracheal intubation was facilitated using rocuronium 0.6 mg kg(-1) when the BIS value was 50. The times to disappearance of the eyelash reflex, to a decrease in the BIS to 50, and to tracheal intubation were compared. The BIS values 30 s following tracheal intubation, and mean arterial pressure (MAP) and heart rate (HR) at all time points were also recorded. RESULTS: The BIS value decreased to 50 for tracheal intubation with no purposeful movement in all but one patient in the 0.2 mg kg(-1) group. There was no difference between the etomidate groups (0.2, 0.3, and 0.4 mg kg(-1)) in regards to time to loss of the eyelash reflex (103 (67), 65 (34), 116 (86) s, P=0.2), or to a decrease in BIS to 50 (135 (81), 82 (36), 150 (84) s, P=0.1). Also, the BIS value 30 s after intubation (41 (10), 37 (4), 37 (4), P=0.4), and plasma etomidate concentrations (161 [29-998], 308 [111-730], 310 [90-869] ng ml(-1), P=0.2) did not differ between groups. The time to loss of the eyelash reflex was 12-140 s shorter than the time to a decrease in BIS to 50 in three patients in each group who received etomidate 0.2 and 0.4 mg kg(-1), and in four patients who received 0.3 mg kg(-1). No awareness was recorded. MAP and HR increases following tracheal intubation were comparable between groups. CONCLUSIONS: Etomidate induction doses do not predict the time for BIS to decrease to 50 as this variable varies markedly following three etomidate dose regimen.

[Maternal serum anti-D antibody concentration monitoring and transfusion practices in obstetrics in France: a preliminary study]. / Surveillance immuno-hématologique et pratiques transfusionnelles en obstétrique en France: étude préliminaire.

OBJECTIVES: In obstetrics, transfusion medicine is involved because of the risk of Rh isoimmunisation and of transfusion at delivery. In France, although these two situations have led to legal or professional recommendations, practices appear to be very different from one institution or one physician to another. STUDY DESIGN: Retrospective study. METHODS: A questionnaire using both direct questions and clinical cases was sent to all members of the French obstetric anaesthetists association (named CARO). RESULTS: One hundred and seventy-eight questionnaires (response rate 17.1%) were returned. Monitoring of anti-D antibody concentrations during pregnancy was performed in accordance with the legal recommendation (14/02/1992) in only 3.9% (Rh+) and 19% (Rh-) of women. Blood samples were performed either too often or too rarely in 39 to 72% of responses. At delivery, an immediate assessment of anti-D antibody concentration was required in almost 100% by the specialist on call in the blood bank while this measurement was considered necessary by only 80% of anaesthetists responding to the questionnaire. The distance between the maternity and the blood bank is greater than 14 km in 19% of responses and the largest time interval reported to obtain red cell concentrates was greater than 145 min in 18% of responses. Autologous blood transfusion is described as being used routinely in only 23% of responses. CONCLUSION: Significant failures in practice patterns and organisation of care are suggested by the responses to this questionnaire. This should stimulate a national debate to improve adequacy of practices to legal and professional recommendations and to review blood distribution to maternities in this country.

Medical responsibility and air transport.

When a medical emergency occurs during a flight operated by a commercial airline, the assistance of a physician-passenger fortuitously present aboard may be requested. This physician becomes bound by both his professional and civil responsibilities. However, in the case of a serious problem, he would usually ignore the question of the jurisprudence of the country where the emergency occurs. In discussing this issue, this paper analyses different situations and risks that the physician may incur and points out various defects in the law not currently covered by existing international conventions.

[Immunohistochemical characterization of a median raphe cyst of the penis]. / Caractérisations immunohistochimiques d'un kyste du raphé médian de la verge.

Cysts and canals found on the ventral surface of the penis have been ascribed to minor dysembryoplasia of the male genitalia. These lesions occur almost exclusively on the ventral surface of the penis along the median raphe and can extend from the urethral meatus to the anus. They are lined by stratified urothelium or squamous epithelium and they do not communicate with the urethra. Most cases are noted in early adulthood, they are usually asymptomatic but may become infected. Surgical removal is the adapted treatment. In this report we describe a case in which the urothelial origin of the cyst was documented by immunohistochemistry for cytokeratin 13.

Metabotropic receptor stimulation coupled to weak tetanus leads to long-term potentiation and a rapid elevation of cytosolic protein kinase C activity.

We have previously shown that short-term potentiation (STP) inducing weak tetanus induces long-term potentiation (LTP) when it is coupled with activation of metabotropic glutamate (mGlu) receptors by trans-(+/-)-1-amino-1,3-cyclopentanedicarboxylic acid (t-ACPD) in rat CA1 slices. In the present study, we examined if this conversion of STP to LTP involves activation of protein kinase C (PKC). Two minutes but not 30 min after coupling, there was a significant increase in the activator-dependent PKC activity in the cytosolic fraction. STP induction or t-ACPD application did not change PKC activity. There was no activity increase in the membrane fraction. STP was also induced by a co-application of gamma-amino-3-hydroxy-5-methyllisoxazole-4-propionic acid (AMPA) and N-methyl-D-aspartic acid (NMDA). Coupling this STP with t-ACPD, however, did not result in an LTP or PKC activity increase, indicating a requirement for synaptic activity. A rapid and transient (< 5 min) increase in cytosolic PKC activity was also seen after the induction of LTP by stronger tetanic stimulation. No LTP tested in the present study was accompanied by activator-independent, persistent increases in PKC activity. STP induction depends on NMDA receptor activation, and the activation of mGlu receptors results in the production of intracellular second messengers. Our results therefore indicate that these separate components may add and bring about PKC activation and LTP.

Enhancement of extracellular protein concentrations during long-term potentiation in the rat hippocampal slice.

The possibility that the enhancement of extracellular protein concentrations during long-term potentiation is related to the maintenance of long-term potentiation was examined in area CA1 of rat hippocampal slices. First, we found that during the 3 h after induction, long-term potentiation maintenance was correlated with a persistent enhancement of extracellular protein concentrations. Second, when the protein synthesis inhibitor cycloheximide was applied 10-15 min before long-term potentiation induction, the drug blocked both the maintenance of long-term potentiation and the elevation of extracellular protein concentrations. These results suggest that the elevation of extracellular protein concentrations requires new protein synthesis. The results further indicate that the newly synthesized proteins may play a role in the maintenance of long-term potentiation.

Developmental study of [3H]TCP and [3H]glycine binding sites in the rat hippocampus.

The postnatal development of [3H]thienylphencyclidine ([3H]TCP) sites in rat hippocampus has been studied autoradiographically and with membrane preparations. [3H]TCP binding increased progressively from birth to adulthood; this is due to a change in the maximal number of sites (Bmax) but not in the affinity (Kd). A different developmental pattern was found for strychnine-insensitive [3H]glycine binding which also increased after birth, but reached adult levels earlier than [3H]TCP binding. The ontogenesis of TCP or glycine sites also differed from that previously described for N-methyl-D-aspartate (NMDA) sites in the hippocampus. In neonatal, as in adult hippocampus, [3H]TCP binding was enhanced by NMDA or glycine and reduced by Mg2+. We suggest that TCP sites are functionally coupled to the NMDA receptor-ion channel complex in developing as in mature hippocampus, but that there are developmental changes in the receptor channel complex.