Pius Hospital de Valls

OBJECTIVE: Our goal in this study was to evaluate by means of MRI the clinical significance of tendon integrity, muscle fatty degeneration, and muscle atrophy in surgically repaired massive rotator cuff tears and to correlate these and other prognostic factors with intraoperative and clinical findings. MATERIALS AND METHODS: Twenty-eight surgically proven massive rotator cuff tears were retrospectively included in the study. Twenty-two patients underwent complete repair, and six patients underwent partial repair. Preoperative and postoperative clinical assessment was performed by using the University of California at Los Angeles score. Preoperative and postoperative MRI studies were evaluated for the presence and extent of rotator cuff tear and for the degree of fatty degeneration and atrophy of the rotator cuff muscles. RESULTS: At a mean 44.4 months' follow-up, 20 patients (71.4%) had a favorable result. A total of 25 patients (89.2%) showed postoperative full-thickness rotator cuff tear, 19 of which were reruptures. A sagittal preoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 100% for predicting a favorable outcome. A coronal postoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 85.7% and a positive predictive value of 92.9% for predicting a favorable outcome. A postoperative fatty degeneration of infraspinatus muscle less than or equal to 2 had a specificity of 87.5% and a positive predictive value of 90.9% for predicting a favorable outcome. CONCLUSION: Open repair of massive rotator cuff tears may reach a favorable outcome in a significant proportion of patients, despite a high rate of recurrent or residual tears. Oblique coronal sizes of the recurrent or residual tear of less than or equal to 34 mm and postoperative fatty degenerations of infraspinatus muscle of less than or equal to 2 may allow a favorable outcome.

Lipids are indispensable in the SARS-CoV-2 infection process. The clinical significance of plasma lipid profile during COVID-19 has not been rigorously evaluated. We aim to ascertain the association of the plasma lipid profile with SARS-CoV-2 infection clinical evolution. Observational cross-sectional study including 1411 hospitalized patients with COVID-19 and an available standard lipid profile prior (n: 1305) or during hospitalization (n: 297). The usefulness of serum total, LDL, non-HDL and HDL cholesterol to predict the COVID-19 prognosis (severe vs mild) was analysed. Patients with severe COVID-19 evolution had lower HDL cholesterol and higher triglyceride levels before the infection. The lipid profile measured during hospitalization also showed that a severe outcome was associated with lower HDL cholesterol levels and higher triglycerides. HDL cholesterol and triglyceride concentrations were correlated with ferritin and D-dimer levels but not with CRP levels. The presence of atherogenic dyslipidaemia during the infection was strongly and independently associated with a worse COVID-19 infection prognosis. The low HDL cholesterol and high triglyceride concentrations measured before or during hospitalization are strong predictors of a severe course of the disease. The lipid profile should be considered as a sensitive marker of inflammation and should be measured in patients with COVID-19.

RATIONALE: Antimicrobial therapy remains a controversial issue in nonsevere exacerbations of chronic obstructive pulmonary disease (COPD). OBJECTIVES: To evaluate the efficacy of antibiotic therapy in moderate exacerbations of mild-to-moderate COPD. METHODS: This study involved a multicenter, parallel, double-blind, placebo-controlled, randomized clinical trial. Patients aged 40 years or older, smokers, or ex-smokers of 10 pack-years or more with spirometrically confirmed mild-to-moderate COPD (FEV(1) > 50% predicted and FEV(1)/FVC ratio < 0.7) and diagnosed with an exacerbation were enrolled in the study. The patients were randomized to receive amoxicillin/clavulanate 500/125 mg three times a day or placebo three times a day for 8 days. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was clinical cure at end of therapy visit (EOT) at Days 9 to 11. A total of 310 subjects fulfilled all the criteria for efficacy analysis. A total of 117 patients with amoxicillin/clavulanate (74.1%) and 91 with placebo (59.9%) were considered cured at EOT (difference, 14.2%; 95% confidence interval, 3.7-24.3). The median time to the next exacerbation was significantly longer in patients receiving antibiotic compared with placebo (233 d [interquartile range, 110-365] compared with 160 d [interquartile range, 66-365]; P < 0.05). The best C-reactive protein serum cut-off for predicting clinical failure with placebo was 40 mg/L, with an area under the curve of 0.732 (95% confidence interval, 0.614-0.851). CONCLUSIONS: Treatment of ambulatory exacerbations of mild-to-moderate COPD with amoxicillin/clavulanate is more effective and significantly prolongs the time to the next exacerbation compared with placebo.

OBJECTIVE: The purpose of this study was to review and describe the MRI features of long-standing Morel-Lavallée lesions of the trochanteric region and proximal thigh in five patients with a history of trauma. CONCLUSION: Long-standing Morel-Lavallée lesions of the trochanteric region and proximal thigh may present various MRI patterns that reflect their variable composition and stage of development. MRI may prove especially useful for characterizing these lesions when the trauma is remote and progressive growth or pain is present.

BACKGROUND: Plant food allergy in the Mediterranean area is mainly caused by non-specific lipid transfer proteins (nsLTP). The aim of this study was to characterize peanut nsLTP in comparison with peach nsLTP, Pru p 3, and assess its importance in peanut allergy. METHODS: Peanut-allergic patients from Spain (n=32) were included on the basis of a positive case history and either a positive skin prick test or specific IgE to peanut. For comparison, sera of 41 peanut-allergic subjects from outside the Mediterranean area were used. Natural Ara h 9 and two isoforms of recombinant Ara h 9, expressed in Pichia pastoris, were purified using a two-step chromatographic procedure. Allergen characterization was carried out by N-terminal sequencing, circular dichroism (CD) spectroscopy, immunoblotting, IgE inhibition tests and basophil histamine release assays. RESULTS: Compared with natural peanut nsLTP, the recombinant proteins could be purified in high amounts from yeast supernatant (> or =45 mg/L). The identity of the proteins was verified by N-terminal amino acid sequencing and with rabbit nsLTP-specific antibodies. CD spectroscopy revealed similar secondary structures for all preparations and Pru p 3. The Ara h 9 isoforms showed 62-68% amino acid sequence identity with Pru p 3. IgE antibody reactivity to rAra h 9 was present in 29/32 Spanish and 6/41 non-Mediterranean subjects. Recombinant Ara h 9 showed strong cross-reactivity to nPru p 3 and similar IgE-binding capacity as nAra h 9. The two Ara h 9 isoforms displayed similar IgE reactivity. In peanut-allergic patients with concomitant peach allergy, Ara h 9 showed a weaker allergenic potency than Pru p 3 in histamine release assays. CONCLUSIONS: Ara h 9 is a major allergen in peanut-allergic patients from the Mediterranean area. Ara h 9 is capable of inducing histamine release from basophils, but to a lesser extent than Pru p 3.

BACKGROUND: The role of children in household transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains unclear. We describe the epidemiological and clinical characteristics of children with coronavirus disease 2019 (COVID-19) in Catalonia, Spain, and investigate the household transmission dynamics. METHODS: A prospective, observational, multicenter study was performed during summer and school periods (1 July 2020-31 October 2020) to analyze epidemiological and clinical features and viral household transmission dynamics in COVID-19 patients aged <16 years. A pediatric index case was established when a child was the first individual infected. Secondary cases were defined when another household member tested positive for SARS-CoV-2 before the child. The secondary attack rate (SAR) was calculated, and logistic regression was used to assess associations between transmission risk factors and SARS-CoV-2 infection. RESULTS: The study included 1040 COVID-19 patients. Almost half (47.2%) were asymptomatic, 10.8% had comorbidities, and 2.6% required hospitalization. No deaths were reported. Viral transmission was common among household members (62.3%). More than 70% (756/1040) of pediatric cases were secondary to an adult, whereas 7.7% (80/1040) were index cases. The SAR was significantly lower in households with COVID-19 pediatric index cases during the school period relative to summer (P = .02) and compared to adults (P = .006). No individual or environmental risk factors associated with the SAR. CONCLUSIONS: Children are unlikely to cause household COVID-19 clusters or be major drivers of the pandemic, even if attending school. Interventions aimed at children are expected to have a small impact on reducing SARS-CoV-2 transmission.

Teledermatology is one of the most important and commonly employed subsets of telemedicine, a special alternative to face-to-face (FTF) doctor--patient consultation that refers to the use of electronic telecommunication tools to facilitate the provision of healthcare between the "seeker" and "provider." It is used for consultation, education, second opinion, and monitoring medical conditions. This article will review basic concepts, the integration of noninvasive imaging technique images, artificial intelligence, and the current ethical and legal issues.

AIM: Assessing the effect of statin therapy (ST) at hospital admission for COVID-19 on in-hospital mortality. METHODS AND RESULTS: Retrospective observational study. Patients taking statins were 11 years older and had significantly more comorbidities than patients who were not taking statins. A genetic matching (GM) procedure was performed prior to analysis of the mortality risk. A Cox proportional hazards model was used for the cause-specific hazard (CSH) function, and a competing-risks Fine and Gray (FG) model was also used to study the direct effects of statins on risk. Data from reverse transcription-polymerase chain reaction-confirmed 2157 SARS-CoV-2-infected patients [1234 men, 923 women; age: 67 y/o (IQR 54-78)] admitted to the hospital were retrieved from the clinical records in anonymized manner. Three hundred and fifty-three deaths occurred. Five hundred and eighty-one patients were taking statins. Univariate test after GM showed a significantly lower mortality rate in patients on ST than the matched non-statin group (19.8% vs. 25.4%, χ2 with Yates continuity correction: P = 0.027). The mortality rate was even lower in patients (n = 336) who maintained their statin treatments during hospitalization compared with the GM non-statin group (17.4%; P = 0.045). The Cox model applied to the CSH function [HR = 0.58(CI: 0.39-0.89); P = 0.01] and the competing-risks FG model [HR = 0.60 (CI: 0.39-0.92); P = 0.02] suggest that statins are associated with reduced COVID-19-related mortality. CONCLUSIONS: A lower SARS-CoV-2 infection-related mortality was observed in patients treated with ST prior to hospitalization. Statin therapy should not be discontinued due to the global concern of the pandemic or in patients hospitalized for COVID-19.

OBJECTIVES: To assess the different types of antibiotic-taking behavior and to compare self-reported with objectively measured adherence to antibiotic regimens in respiratory infections. METHODS: This was a prospective study of patients with suspected bacterial pharyngitis and lower respiratory tract infections recruited from five primary care clinics in Catalonia. Adherence to various antibiotic regimens was assessed by the Medication Event Monitoring System (MEMS), which recorded every opening of the patient's bottle of tablets, and a self-reported adherence question. The outcome variables were antibiotic-taking adherence, correct dosing, and timing adherence. RESULTS: A total of 428 patients were included in the analysis. Five types of antibiotic use behavior were observed: excellent adherence (130 patients, 30.4%), acceptable adherence over time (53; 12.4%), declining adherence over time (123; 28.7%), non-adherence to correct dosing (108; 25.2%), and unacceptable adherence (14; 3.3%). Excellent adherence was significantly associated with the number of daily doses of antibiotic and antibiotic duration. A total of 254 patients reported never forgetting to take the antibiotic (59.3%), achieving a negative predictive value of 100% and a positive predictive value of 51.2%. CONCLUSIONS: Outpatients with respiratory infections treated with antibiotics showed poor adherence outcomes. Self-reported adherence was remarkably higher than that observed with the use of MEMS and failed to predict true patient adherence.

BACKGROUND: To assess the drug compliance observed among patients with lower respiratory tract infection treated with once-daily, twice-daily and thrice-daily antibiotic regimens. METHODS: We performed a prospective study in the primary care setting including patients with suspected bacterial lower respiratory tract infections, not allergic to beta-lactam antimicrobials, macrolides or quinolones, treated with several antibiotic regimens. Patient compliance was assessed by electronic monitoring. RESULTS: A total of 251 patients were enrolled (136 in the thrice-daily group, 70 in the twice-daily group and 45 in the once-daily group). The mean container openings ranged from 94.3 +/- 12.6% with once-daily antibiotics to 74.8 +/- 17.7% with thrice-daily drugs (P < 0.001). Seventy-five patients in the thrice-daily group took at least 80% of the medications (55.1%), being significantly less than those receiving twice-daily (71.4%) or once-daily (86.7%; P < 0.001) drugs. Only 20.6% of the patients assigned to the thrice-daily regimens opened the container every 8 +/- 4 h during at least 80% of the course. Among the patients assigned the same number of doses daily, compliance was better with the shortest antibiotic courses, being worse with schedules of 7 days or more. The percentage of patients who opened the MEMS container the satisfactory number of times a day was lower among the thrice-daily regimens. Moreover, the thrice-daily group more frequently forgot the afternoon dose. CONCLUSIONS: The rate of compliance was very low, mainly when antibiotics were administered thrice daily and in regimens of 7 days or more. New strategies addressed to improve antibiotic drug compliance are, therefore, necessary.

Age, sex, race and comorbidities are insufficient to explain why some individuals remain asymptomatic after SARS-CoV-2 infection, while others die. In this sense, the increased risk caused by the long-term exposure to air pollution is being investigated to understand the high heterogeneity of the COVID-19 infection course. We aimed to assess the underlying effect of long-term exposure to NO2 and PM10 on the severity and mortality of COVID-19. A retrospective observational study was conducted with 2112 patients suffering COVID-19 infection. We built two sets of multivariate predictive models to assess the relationship between the long-term exposure to NO2 and PM10 and COVID-19 outcome. First, the probability of either death or severe COVID-19 outcome was predicted as a function of all the clinical variables together with the pollutants exposure by means of two regularized logistic regressions. Subsequently, two regularized linear regressions were constructed to predict the percentage of dead or severe patients. Finally, odds ratios and effects estimates were calculated. We found that the long-term exposure to PM10 is a more important variable than some already stated comorbidities (i.e.: COPD/Asthma, diabetes, obesity) in the prediction of COVID-19 severity and mortality. PM10 showed the highest effects estimates (1.65, 95% CI 1.32–2.06) on COVID-19 severity. For mortality, the highest effect estimates corresponded to age (3.59, 95% CI 2.94–4.40), followed by PM10 (2.37, 95% CI 1.71–3.32). Finally, an increase of 1 µg/m3 in PM10 concentration causes an increase of 3.06% (95% CI 1.11%-4.25%) of patients suffering COVID-19 as a severe disease and an increase of 2.68% (95% CI 0.53%-5.58%) of deaths. These results demonstrate that long-term PM10 burdens above WHO guidelines exacerbate COVID-19 health outcomes. Hence, WHO guidelines, the air quality standard established by the Directive 2008/50/EU, and that of the US-EPA should be updated accordingly to protect human health.

BACKGROUND: Whether the observed clinical pattern of non-specific lipid transfer protein (nsLTP)-mediated food allergies is attributable to a primary sensitization by Pru p 3 from peach and subsequent cross-reactivity with Rosaceae- and non-Rosaceae-derived foods expressing homologous allergens is still unclear. OBJECTIVE: To investigate the allergenic properties of nsLTPs from Rosaceae and non-Rosaceae foods. METHODS: In peach-, cherry- or hazelnut-allergic patients, prevalence of sensitization, IgE-binding capacity, cross-reactivity and allergenic potency of Pru p 3 was compared with Pru av 3 (cherry) and Cor a 8 (hazelnut). RESULTS: Frequency of sensitization to corresponding nsLTPs was 88, 85, and 77% in peach-, hazelnut- and cherry-allergic patients, respectively. Concomitant allergic reactions to cherry and hazelnut were reported in 51 and 44% of peach-allergic patients, respectively. In contrast to cherry allergy, hazelnut allergy was not strictly associated to peach allergy. Sensitization to Cor a 8 or Pru av 3 was strongly correlated with IgE reactivity to Pru p 3, even when subjects tolerated peach. Specific IgE was highest for Rosaceae LTPs, and cross-inhibition experiments confirmed a stronger IgE-binding capacity of Pru p 3 than Cor a 8. The biological potency of Pru p 3 and Pru av 3 was similar but stronger for both nsLTPs than that of Cor a 8. CONCLUSION: Clinical cross-reactivity of food-allergic patients in the Mediterranean area is likely attributed to a primary sensitization to Pru p 3 and serological cross-reactivity with homologous food nsLTPs. In comparison to Cor a 8, Rosaceae nsLTPs showed a stronger IgE-binding capacity and allergenic potency indicating a different epitope pattern.

Electrochemotherapy (ECT) is a cancer therapy that conjugates the administration of a chemotherapy agent to the delivery of permeabilizing pulses released singularly or as bursts. This approach results in higher number of anticancer molecules delivered to their biological targets, but is also associated to undesirable side effects such as pain and muscular contractions. A new electroporator delivering train of eight biphasic pulses at the voltage of 1,300 V/cm lasting 50 + 50 µsec each, with a frequency of 1 Hz, and with 10-µsec interpulse intervals (total treatment time: 870 µsec/cm(2) of treated area) was tested in vitro on the human lung cancer cell line A549 and in vivo, both in mice xenografts and privately owned rabbits with spontaneous tumors. The tumor cell line was treated with electroporation using the new parameters, that showed improved drug efficacy in causing cell death. Mice with chemoresistant xenografts were treated as well with either the new parameters and with a previous protocol, confirming the higher tolerability and efficacy of the novel parameters. Finally, a cohort of six pet rabbits with advanced skin neoplasms were enrolled in a compassionate trial using the new parameters in adjuvant fashion. In terms of efficacy, none of the rabbits experienced tumor recurrence, showing minimal discomfort during the ECT sessions. The data described, demonstrate that the new permeabilizing protocol adopting biphasic electric pulses displays a significant higher efficacy compared to previous ECT treatments and substantial reduction of the associated morbidity.

The morphology of the different larval stages (zoea I, zoea II and megalopa) of the majid crab Maja squinado Herbst, 1788 Herbst, J. F. W. 1782–1804. Versuch einer Naturgeschichte der Krabben und Krebse, nebst einer systematischen Beschreibung ihrer verschiedenen Arten.. Berlin and Straslund, : 1–62. Vol. 1–3: 1–515 + p1 [Google Scholar] reared under laboratory conditions is described. The description of M. brachydactyla Balss, 1922 larvae is also revised, both from individuals reared in laboratory conditions and those collected from plankton samples. The larval stages of M. squinado are morphologically similar to those of the Atlantic species M. brachydactyla; the larval morphology does not justify the separation of M. squinado into two species. Larvae of M. brachydactyla obtained from the wild were similar to those reared under laboratory conditions. The morphology of the zoeal and megalopal stages of M. squinado and M. brachydactyla described in this paper have been compared with previous descriptions of the genus Maja, including M. brachydactyla (described as M. squinado).

The incidence of melanoma has been increasing worldwide during recent decades. The objective of the study was to analyse the trends in incidence for in situ and invasive melanoma in the Spanish region of Catalonia during the period of 2008-2017. We designed a cross-sectional study with an age-period-cohort analysis of melanoma patient data from the Network of Melanoma Centres in Catalonia. Our database covered a population of over seven million and included a total of 8626 patients with incident melanoma. The main outcome measures were crude and age-standardised incidence rates to the European 2013 standard population. Joinpoint regression models were used to evaluate the population trends. We observed an increase in the age-standardised incidence rate (per 100,000 population) of all melanoma subtypes from 11.56 in 2008 to 13.78 in 2017 with an average annual percent change (AAPC) of 3.5%. This incidence increase was seen exclusively in the older population. Moreover, the stratified analysis showed a statistically significant increase in the age-standardised incidence rate for invasive (AAPC 2.1%) and in situ melanoma (AAPC 6.5%). In conclusion, the incidence of melanoma has continued to increase in the elderly population over recent decades, with a rapidly increasing trend of in situ melanomas and the lentigo maligna subtype.

PURPOSE: Patients with isolated distal deep vein thrombosis (DVT) have lower rates of adverse outcomes (death, venous thromboembolism [VTE] recurrence or major bleeding) than those with proximal DVT. It is uncertain if such findings are also observed in patients with cancer. METHODS: Using data from the international Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, we compared the risks of adverse outcomes at 90 days (adjusted odds ratio [aOR]; 95% CI) and 1 year (adjusted hazard ratio [aHR; 95% CI]) in 886 patients with cancer-associated distal DVT versus 5,196 patients with cancer-associated proximal DVT and 5,974 patients with non-cancer-associated distal DVT. RESULTS: More than 90% of patients in each group were treated with anticoagulants for at least 90 days. At 90 days, the adjusted risks of death, VTE recurrence, or major bleeding were lower in patients with non-cancer-associated distal DVT than in patients with cancer-associated distal DVT (reference): aOR = 0.16 (0.11-0.22), aOR = 0.34 (0.22-0.54), and aOR = 0.47 (0.27-0.80), respectively. The results were similar at 1-year follow-up: aHR = 0.12 (0.09-0.15), aHR = 0.39 (0.28-0.55), and aHR = 0.51 (0.32-0.82), respectively. Risks of death, VTE recurrence, and major bleeding were not statistically different between patients with cancer-associated proximal versus distal DVT, both at 90 days: aOR = 1.11 (0.91-1.36), aOR = 1.10 (0.76-1.62), and aOR = 1.18 (0.76-1.83), respectively, and 1 year: aHR = 1.01 (0.89-1.15), aHR = 1.02 (0.76-1.35), and aHR = 1.10 (0.76-1.61), respectively. However, more patients with cancer-associated proximal DVT, compared with cancer-associated distal DVT, developed fatal pulmonary embolism (PE) during follow-up: The risk difference was 0.40% (95% CI, 0.23 to 0.58). CONCLUSION: Cancer-associated distal DVT has serious and relatively comparable outcomes compared with cancer-associated proximal DVT. The lower risk of fatal PE from cancer-associated distal DVT needs further investigation.

Introduction: Children younger than 2 years have an increased risk of complications associated with tuberculosis (TB) due to the immaturity of the innate and adaptive immune response. We aimed to identify TB clinical presentations and outcomes as well as risk factors for complications in this age group. Materials and Methods: Multicenter, retrospective, cross-sectional study of TB cases in children aged <2 years in Catalonia (2005-2013). Epidemiological and clinical data were collected from the hospital medical records. TB complications, sequelae included, were defined as any tissue damage generating functional or anatomical impairment after being diagnosed or after TB treatment being completed. Statistical analyses were based on bivariate chi-square and multivariate logistic regression, and it was carried out with Stata® version 13.1. Odds ratios (OR) and its 95% confidence intervals were calculated (CI). Results: A total of 134 patients were included, 50.7% were male, the median [IQR] age was 13[8-18] months, and 18.7% (25/134) showed TB-associated complications. Pulmonary TB was diagnosed in 94.0% (126/134) of children, and the most common complications were lobar collapse (6/126). TB meningitis was diagnosed in 14/134 (10.4%), and hydrocephalus and mental impairment occurred in 1 and 2 patients, respectively. Two patients with spinal TB developed vertebral destruction and paraplegia, respectively. Only one of the patients died. At multivariate level, tachypnea (OR=4.24; 95% CI 1.17-15.35) and meningeal (OR=52.21; 95% CI 10.05-271.2) or combined/extrapulmonary forms (OR=11.3; 95% CI 2.85-45.1) were associated with the development of TB complications. Discussion: TB complications are common in children under two years old. Extrapulmonary TB forms in this pediatric age remain a challenge and require prompt diagnosis and treatment in order to prevent them. The presence of tachypnea at the time of TB diagnosis is an independent associated factor to the development of TB complications in infants. This clinical sign should be closely monitored in patients in this age group. It is necessary to perform further studies in this age group in a prospective design in order to understand whether there are other factors associated to TB complications.

Community-Based Rehabilitation (CBR) is a strategy for community development endorsed by the World Health Organization (WHO), the International Labor Office (ILO) and the United Nations Educational, Scientific and Cultural Organization (UNESCO). It is designed to promote rehabilitation, equal opportunity and social inclusion of Disabled Persons (DP) in their home communities by fostering cooperation among disabled individuals, their families, and other concerned social actors, it encourages community leadership and full social participation by DP through multi-sector cooperation. This article explores the historical antecedents and basic features of CBR strategy through an analysis of a directed culture change initiative developed by a foundation in the Cochabamba administrative region of Bolivia. Especially in intercultural environments, certain aspects of the socio-cultural context may determine whether CBR programs succeed or fail.

Teledermatology is the most advanced clinical specialty in telemedicine. The development of teledermatology in specific countries has not been studied in depth. Our objective was to analyze teledermatology models in clinical practice in Spain. We paid special attention to organization, technical aspects, training, and the advantages/disadvantages as seen by teledermatologists. Two surveys were carried out (2009 and 2014). Teledermatology was used at 25 centers in 2009 and at 70 in 2014. The extended survey was completed by 21 centers in 2009 and 41 in 2014. Store-and-forward teledermatology was the main technique (83%) in 2014. Only 12% of centers used the real-time method, and 5% used a hybrid modality. Patients lived less than 25 km away in 75% of cases (urban teledermatology). Most centers used mid-range bridge cameras; only 12% used mobile phones. Teledermoscopy and tertiary teledermatology were each used in 15% of centers. Teledermatology was restricted to skin cancer in 25% of cases, and 66% of centers used it to train primary care physicians. The main advantages, assessed on a scale of 1 to 10, were prioritization in cancer screening (8.3), rapid emergency care (7.8), training of and communication with primary care physicians (7.6), screening for trivial conditions (7.6), and reduction in the number of face-to-face visits (7.6). The main disadvantages were poor image quality (6.3), fear of error (5.7), difficulty in coordinating with primary care physicians (3.8), and time commitment (3.3). Between 2009 and 2014, the number of centers using teledermatology and the number of teledermatologists increased, as did use of the store-and-forward and urban models. The technology used also improved. Teledermatology is an emerging technology that is becoming well established in Spain. More than 25% of dermatology centers in Spain have implemented a teledermatology model. Store-and-forward in an urban setting is the most widely used modality. Teledermatologists see this technology as an effective option with more advantages than disadvantages. General satisfaction is high, although there is room for significant improvement in some areas. La teledermatología (TD) es la especialidad clínica más desarrollada de la telemedicina. El desarrollo de la TD en un país completo no se ha estudiado previamente en profundidad. El objetivo fue analizar los modelos de TD en práctica real en España, centrándose en la organización, los aspectos técnicos, la docencia y las ventajas/desventajas percibidas por los teledermatólogos. Se realizaron 2 encuestas con teledermatólogos en 2009 y 2014. Se identificaron 25 centros utilizando TD en 2009 y 70 en 2014. La encuesta ampliada fue completada por 21 centros en 2009 y 42 en 2014. Las características generales en 2014 fueron: TD almacenamiento (TDA) fue la técnica predominante (83%), solo el 12% TD en tiempo real y el 5% TD híbrida. El 75% de los pacientes vistos en TD viven a menos de 25 km (TD urbana). La mayoría de los centros utilizan cámaras bridge de gama media y solo el 12% utiliza los teléfonos móviles. El 15% practica teledermoscopia y el 15% TD terciaria. En el 25%, la TD se restringió a la oncología cutánea; el 66% utiliza la TD para formación de médicos de primaria. Las ventajas principales (puntuación 0-10) fueron priorización en oncología (8,3), asistencia rápida de urgencias (7,8), la formación y la comunicación con los médicos de primaria (7,6), el cribado de enfermedad banal (7,6) y la disminución de las visitas presenciales (7,6). Los principales inconvenientes fueron (puntuación 0-10): la baja calidad de imágenes (6,3), el miedo al error (5,7), difícil coordinación con los médicos de primaria (MP) (3,8) y consumo de tiempo (3,3). La evolución 2009-2014 mostró más centros con TD y más teledermatólogos, mejor tecnología y aumento de los modelos TDA y urbano. La TD es una tecnología emergente que comienza su fase de consolidación en España. Más del 25% de los centros de dermatología en España han puesto en práctica un sistema de TD. El modelo predominante es TDA en un entorno urbano. Los dermatólogos perciben la TD como una opción efectiva con más ventajas que desventajas. La satisfacción general es alta, sin embargo, todavía hay áreas que necesitan mejoras significativas.

The technique of dermoscopy has come a long way since its inception for characterization of suspicious nevi for early detection of dysplastic changes in predisposed individuals. Not only has its scope expanded to aid in quick diagnosis of a majority of nonmelanocytic disorders of the skin, hair, and nails, but it is being rightfully exploited for a plethora of nondiagnostic uses. Its use in the diagnosis of various pigmentary, papulosquamous, and infectious disorders and disorders of the scalp and hair, nails, and mucosa bears testimony to the ongoing expansion of its protean indications across skin types. Dermoscopy has transformed the conventional approach to dermatological diagnosis from clinicopathological correlation to clinico-dermoscopic-pathological correlation. It aids in convincing an otherwise reluctant patient to agree to biopsy and guides the selection of optimum site for the same. Dermoscopic clues suggestive of stability or activity of the lesion and/or disease in various dermatoses are being accrued. Early assessment of therapeutic response to treatment is helpful for physicians, patients, and researchers conducting clinical studies. Aesthetic uses of dermoscopy are opulent and being explored. Dermoscopy has also provided the much-needed balancing act of interaction between practitioners and the new generation of patients. Last but not the least, dermoscopy has resulted in patients' better understanding of their disorders and improved compliance with treatment protocols.