Biological drugs for the treatment of psoriasis in a public health system

OBJECTIVE To analyze the access and utilization profile of biological medications for psoriasis provided by the judicial system in Brazil.METHODSThis is a cross-sectional study. We interviewed a total of 203 patients with psoriasis who were on biological medications obtained by the judicial system of the State of Sao Paulo, from 2004 to 2010. Sociodemographics, medical, and political-administrative characteristics were complemented with data obtained from dispensation orders that included biological medications to treat psoriasis and the legal actions involved. The data was analyzed using an electronic data base and shown as simple variable frequencies. The prescriptions contained in the lawsuits were analyzed according to legal provisions.RESULTS A total of 190 lawsuits requesting several biological drugs (adalimumab, efalizumab, etanercept, and infliximab) were analyzed. Patients obtained these medications as a result of injunctions (59.5%) or without having ever demanded biological medication from any health institution (86.2%), i.e., public or private health services. They used the prerogative of free legal aid (72.6%), even though they were represented by private lawyers (91.1%) and treated in private facilities (69.5%). Most of the patients used a biological medication for more than 13 months (66.0%), and some patients were undergoing treatment with this medication when interviewed (44.9%). Approximately one third of the patients discontinued treatment due to worsening of their illness (26.6%), adverse drug reactions (20.5%), lack of efficacy, or because the doctor discontinued this medication (13.8%). None of the analyzed medical prescriptions matched the legal prescribing requirements. Clinical monitoring results showed that 70.3% of the patients had not undergone laboratory examinations (blood work, liver and kidney function tests) for treatment control purposes.CONCLUSIONS The plaintiffs resorted to legal action to get access to biological medications because they were either unaware or had difficulty in accessing them through institutional public health system procedures. Access by means of legal action facilitated long-term use of this type of medication through irregular prescriptions and led to a high rate of adverse drug reactions as well as inappropriate clinical monitoring.

The position effect of structural Eucalyptus round timber on the flexural modulus of elasticity

Round timber has great use in civil construction, performing the function of beams, columns, foundations, poles for power distribution among others, with the advantage of not being processed, such as lumber. The structural design of round timber requires determining the elastic properties, mainly the modulus of elasticity. The Brazilian standards responsible for the stiffness and strength determination of round timber are in effect for over twenty years with no technical review. Round timber, for generally present an axis with non-zero curvature according to the position of the element in the bending test, may exhibit different values of modulus of elasticity. This study aims to analyze the position effect of Eucalyptus grandis round timber on the flexural modulus of elasticity. The three-point bending test was evaluated in two different positions based on the longitudinal rotation of the round timber element. The results revealed that at least two different positions of the round timber element are desired to obtain significant modulus of elasticity.

Identification of flexural stiffness parameters of beams

A three degree of freedom model of the dynamic mass at the middle of a test sample, resembling a Stockbridge neutraliser, is introduced. This model is used to identify the hereby called equivalent complex cross section flexural stiffness (ECFS) of the beam element which is part of the whole test sample. This ECFS, once identified, gives the effective cross section flexural stiffness of the beam as well as its effective damping, measured as the loss factor of an equivalent viscoelastic beam. The beam element of the test sample may be of any complexity, such as a segment of stranded cable of the ACSR type. These data are important parameters for the design of overhead power transmission lines and other cable structures. A cost function is defined and used in the identification of the ECFS. An experiment, designed to measure the dynamic masses of two test samples, is described. Experimental and identified results are presented and discussed.

Identification of Flexural Stiffness Parameters of Beams

A three degree of freedom model of the dynamic mass at the middle of a test sample, resembling a Stockbridge neutraliser, is introduced. This model is used to identify the hereby called equivalent complex cross section flexural stiffness (ECFS) of the beam element which is part of the whole test sample. This ECFS, once identified, gives the effective cross section flexural stiffness of the beam as well as its effective damping, measured as the loss factor of an equivalent viscoelastic beam. The beam element of the test sample may be of any complexity, such as a segment of stranded cable of the ACSR type. These data are important parameters for the design of overhead power transmission lines and other cable structures. A cost function is defined and used in the identification of the ECFS. An experiment, designed to measure the dynamic masses of two test samples, is described. Experimental and identified results are presented and discussed.

Measurement of epidermal thickness in a patient with psoriasis by computer-supported image analysis

The aim of the present study was to measure full epidermal thickness, stratum corneum thickness, rete length, dermal papilla widening and suprapapillary epidermal thickness in psoriasis patients using a light microscope and computer-supported image analysis. The data obtained were analyzed in terms of patient age, type of psoriasis, total body surface area involvement, scalp and nail involvement, duration of psoriasis, and family history of the disease. The study was conducted on 64 patients and 57 controls whose skin biopsies were examined by light microscopy. The acquired microscopic images were transferred to a computer and measurements were made using image analysis. The skin biopsies, taken from different body areas, were examined for different parameters such as epidermal, corneal and suprapapillary epidermal thickness. The most prominent increase in thickness was detected in the palmar region. Corneal thickness was more pronounced in patients with scalp involvement than in patients without scalp involvement (t = -2.651, P = 0.008). The most prominent increase in rete length was observed in the knees (median: 491 µm, t = 10.117, P = 0.000). The difference in rete length between patients with a positive and a negative family history was significant (t = -3.334, P = 0.03), being 27% greater in psoriasis patients without a family history. The differences in dermal papilla distances among patients were very small. We conclude that microscope-supported thickness measurements provide objective results.

Psoriasis severity and hypothalamic-pituitary-adrenal axis function: results from the CALIPSO study

Psoriasis is a chronic inflammatory disease that significantly impacts life quality, being associated with stress and mental disorders. We investigated whether the activity of the hypothalamic-pituitary-adrenal (HPA) axis was associated with psoriasis severity, daily life stress and anxiety, and depressive symptoms. In this ancillary study, which was part of the CALIPSO (coronary artery calcium in psoriasis) study, saliva was collected from 102 patients with psoriasis immediately upon awakening, 30, and 60 min after awakening, at 2:00 pm and at bedtime (five time points) to determine salivary cortisol levels. We used Pearson's correlation coefficient to evaluate the association of clinical and psychopathological variables with HPA activity. We found a direct correlation between bedtime cortisol and psoriasis severity evaluated by the psoriasis area severity index (PASI; r=0.39, P<0.001). No correlations between other clinical and psychopathological variables or with other cortisol assessments were observed. The findings indicated that HPA dysfunction may be present in psoriasis, as bedtime cortisol was correlated with psoriasis severity. Our study is limited by the lack of a control group; therefore, we were not able to explore whether these cortisol values were different compared with a concurrent, healthy sample.

Decreased brain-derived neurotrophic factor plasma levels in psoriasis patients

Brain-derived neurotrophic factor (BDNF) is associated with neuroplasticity and synaptic strength, and is decreased in conditions associated with chronic stress. Nevertheless, BDNF has not yet been investigated in psoriasis, a chronic inflammatory systemic disease that is exacerbated by stress. Therefore, our aim was to determine BDNF plasma levels in psoriasis patients and healthy controls. Adult patients (n=94) presenting with psoriasis for at least 1 year were enrolled, and age- and gender-matched with healthy controls (n=307) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Participants had neither a previous history of coronary artery disease nor current episode of major depression. BDNF plasma levels were determined using the Promega ELISA kit. A general linear model was used to compare BDNF levels in psoriasis patients and controls, with age, gender, systolic blood pressure, serum fasting glucose, blood lipid levels, triglycerides, smoking status, and body mass index examined. After adjusting for clinical and demographic variables, significantly decreased BNDF plasma levels were observed in psoriasis patients (P=0.01) (estimated marginal means of 3922 pg/mL; 95%CI=2660-5135) compared with controls (5788 pg/mL; 95%CI=5185-6442). Similar BDNF levels were found in both mild and severe cases of psoriasis. Our finding, that BDNF is decreased in psoriasis, supports the concept of a brain-skin connection in psoriasis. Further studies should determine if BDNF is increased after specific psoriasis treatments, and associated with different disease stages.

Erythroderma: analysis of 247 cases

The profile of 247 patients with erythroderma during a 23 year period from January, 1962 through March, 1985, with a follow-up period ranging from 1 to 26 years were analysed. The patients presented with diffuse erythema, scaling and pruritus of more than 2 months' duration, and the age ranged from 16 to 60 years. Psoriasis was the most frequent underlying disease with an estimated frequency of 44.9%, the reaction to the use of drugs appeared in 7.3% of total cases and association with reticulosis showed a frequency of 4.1%. The cause of the erythroderma could not be determined in 29.2% of the cases. Sex differences in terms of underlying diseases were not observed. One or more skin biopsies along with the clinical findings were diagnostic or suggestive of the underlying disease in 63.6% of the cases. Repeated skin biopsies are recommended as the best method for etiologic diagnosis of erythroderma. At P=0.05 significance level, masculine/feminine ratio of 2 : 1 was found. The question arises wether causal agent of erythroderma may not be somehow related to different exposure by sex to environmental antigens.

Acute generalized exanthematous pustulosis (AGEP). Case report

Acute Generalized Exanthematous Pustulosis (AGEP) is a drug-induced dermatosis characterized by an acute episode of sterile pustules over erythematous-edematous skin. It is accompanied by an episode of fever, which regresses a few days after discontinuation of the drug that caused the condition or as a result of corticosteroid treatment. The main triggering drugs are antibiotics, mainly beta-lactam ones. Other medications, such as antifungal agents, non steroid anti-inflammatory drugs, analgesics, antiarrhythmic, anticonvulsant and antidepressant drugs, may also be responsible. Histologically, it is characterized by the existence of vasculitis, associated with non-follicular subcorneal pustules. A case of a Caucasian female outpatient unit of Dermatology with AGEP, who presented with generalized pustulosis lesions after the use of cephalosporin for urinary infection is related. The diagnosis was confirmed by the clinical and pathological correlations, the resolution of the dermatosis after discontinuation of the drug and use of systemic corticosteroid treatment, and the recurrence of the disorder after the introduction of a similar drug. The importance of the recognition of this drug-induced dermatosis is given by its main differential clinical and histological diagnoses: generalized pustular psoriasis and subcorneal pustulosis.

Terapia fotodinâmica: aspectos farmacológicos, aplicações e avanços recentes no desenvolvimento de medicamentos

Photodynamic Therapy (PDT) is a clinical procedure, which utilize a photosensitive compound and light. This is a new modality of treatment for cancer, aged related macular degenerescence (AMD), psoriasis, arthritis, arterial restenosis, etc which exhibits efficiency, less traumatic effects, low recovery time and few co-lateral effects. The first officially approved drug for PDT by the Food and Drug Administration (EUA) is Photofrinâ, which is applied for cancer. A new generation drug for PDT, Visudyneâ was recently approved to treat AMD; its photoactive compound is BPDMA, a benzoporphyrin mono-acid derivative (chlorin-type molecule). A concise history, technical information and some drugs for PDT are reported.

Avaliação das propriedades de compósitos de polipropileno reforçados com casca de aveia

The preparation of oat-reinforced polypropylene nanocomposites with different fiber contents by means of melt-processing was investigated. Composite properties were evaluated by Scanning Electron Microscopy (SEM), Flexural Modulus, Dynamic Mechanical Analysis (DMA), Differential Scanning Calorimetry (DSC) and Thermogravimetric Analysis (TGA). Findings confirmed that the oat composite properties were affected by fiber type and content. Improvements in mechanical properties were obtained using fiber contents < 20% w.t.

Characterization and treatment of sisal fiber residues for cement-based composite application

Sisal fiber is an important agricultural product used in the manufacture of ropes, rugs and also as a reinforcement of polymeric or cement-based composites. However, during the fiber production process a large amount of residues is generated which currently have a low potential for commercial use. The aim of this study is to characterize the agricultural residues by the production and improvement of sisal fiber, called field bush and refugo and verify the potentiality of their use in the reinforcement of cement-based composites. The residues were treated with wet-dry cycles and evaluated using tensile testing of fibers, scanning electron microscopy (SEM) and Fourier transform infrared (FTIR) spectroscopy. Compatibility with the cement-based matrix was evaluated through the fiber pull-out test and flexural test in composites reinforced with 2 % of sisal residues. The results indicate that the use of treated residue allows the production of composites with good mechanical properties that are superior to the traditional composites reinforced with natural sisal fibers.

Response of Grilage-Like Structures by the Mobility Approach

This work presents an application of the Mobility Approach to the analysis of the power flow through grillage-like structures. Such structures are usually found in offshore platforms, supporting large and heavy machines. Different wave kinds (longitudinal, flexural and torsional) were initially considered in the power flow analysis between two beams joined in L. Beams excited by an in-plane point force showed strong coupling between longitudinal-flexural waves, while that for out-of-plane point force excitation, flexural-torsional waves coupling represents the most important mechanism of energy transmission. The response determination of grillages by the mobility approach requires the structure to be separated into simple beam-like structural components. Equations for rotations and displacements at the joints of all beams are written for as mobility functions, and moments and forces acting at the joints. A system of equations relating all such internal forces and moments is obtained. This approach was applied to simple grillages. Response results showed good agreement when compared to those provided by Finite Elements.

An Inspection System to Identify Fatigue Damage on Steel-Bridge Structures

Crack formation and growth in steel bridge structural elements may be due to loading oscillations. The welded elements are liable to internal discontinuities along welded joints and sensible to stress variations. The evaluation of the remaining life of a bridge is needed to make cost-effective decisions regarding inspection, repair, rehabilitation, and replacement. A steel beam model has been proposed to simulate crack openings due to cyclic loads. Two possible alternatives have been considered to model crack propagation, which the initial phase is based on the linear fracture mechanics. Then, the model is extended to take into account the elastoplastic fracture mechanic concepts. The natural frequency changes are directly related to moment of inertia variation and consequently to a reduction in the flexural stiffness of a steel beam. Thus, it is possible to adopt a nondestructive technique during steel bridge inspection to quantify the structure eigenvalue variation that will be used to localize the grown fracture. A damage detection algorithm is developed for the proposed model and the numerical results are compared with the solutions achieved by using another well know computer code.

Evidence for the participation of nitric oxide in pemphigus

Pemphigus is an inflammatory autoimmune disorder of the skin. Nitric oxide (NO) is an inflammatory mediator linked to a variety of physiological and pathophysiological phenomena that include skin tumors, psoriasis, urticaria, and atopic dermatitis. Inflammatory cells present in pemphigus lesions are important sources of NO production. We investigated whether NO is involved in pemphigus. A prospective cohort study was conducted at the Dermatology Service of the Hospital Universitário Walter Cantídio of the Federal University of Ceará. All patients seen at the outpatient clinic between August 2000 and July 2001, with a clinically and histologically confirmed diagnosis of pemphigus were included. The median age was 42.5 years (range: 12-69 years) with a male to female ratio of 3:2. Total serum nitrite levels, used as a marker for NO production, were determined by the Griess reaction. Skin biopsies from pemphigus and breast surgery (control) patients were used for the detection of the inducible NO synthase (iNOS) by immunohistochemistry. Twenty-two (22) patients with pemphigus and eight (8) controls who did not differ in demographic characteristics were included. Total serum nitrite levels were significantly higher (>7 µmol/L) in pemphigus patients compared to controls (<6 µmol/L), regardless of the severity of the clinical activity of pemphigus (P < 0.0001). All pemphigus biopsies presented increased immunostaining for iNOS that was not detected in normal skin samples. These data are the first to demonstrate that pemphigus patients display increased serum NO levels that are associated with increased iNOS expression in the affected skin.