Consensus Document
Clinical Pathway for Patients With Acute or Chronic Urticaria: A Consensus Statement of the Andalusian Section of the Spanish Academy of Dermatology and Venereology (AEDV)
Proceso de atención al paciente con urticaria aguda y crónica. Documento de consenso de la sección territorial andaluza de la Academia Española de Dermatología y Venereología
R. Ruiz-Villaverdea,
, D. Moreno-Ramírezb, M. Galán-Gutierrezc, M. de Troyad, V. Reyes-Alcázare, M. Alcaldef, E.I. Garcíag, M. Linaresh, L. Martínezi, Á. Pulpilloj, C. Suárezk, A. Vélezl, E. García-Loraa, A. Torrese
Autor para correspondencia
a Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Virgen de las Nieves, Granada, Spain
b Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Virgen Macarena, Sevilla, Spain
c Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Complejo Hospitalario de Jaén, Jaén, Spain
d Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Costa del Sol, Marbella, Spain
e Agencia de Calidad Sanitaria de Andalucía, Sevilla, Spain
f Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Torrecárdenas, Almería, Spain
g Facultad de Enfermería, Universidad de Cádiz, Cádiz, Spain
h Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, Spain
i Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Regional de Málaga, Málaga, Spain
j Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
k Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Complejo Hospitalario de Huelva, Huelva, Spain
l Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Reina Sofía, Córdoba, Spain
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"apellidos" => "Torres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:12 [ 0 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Virgen de las Nieves, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Complejo Hospitalario de Jaén, Jaén, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Costa del Sol, Marbella, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Agencia de Calidad Sanitaria de Andalucía, Sevilla, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Torrecárdenas, Almería, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Facultad de Enfermería, Universidad de Cádiz, Cádiz, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Regional de Málaga, Málaga, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Complejo Hospitalario de Huelva, Huelva, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología Médico-quirúrgica y Venereología, Hospital Universitario Reina Sofía, Córdoba, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Proceso de atención al paciente con urticaria aguda y crónica. Documento de consenso de la sección territorial andaluza de la Academia Española de Dermatología y Venereología" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3705 "Ancho" => 3254 "Tamanyo" => 695736 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Flow chart of the urticaria patient's pathway through the different parts of the health care system. CMU refers to clinical management unit; UAS7, Urticaria Activity Score 7; DQLI, Dermatology Quality of Life Index.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Interest in urticarial skin disease has risen in the last 10 years. A simple search of the US National Library of Medicine databases reveals that the number of publications indexed under the keyword <span class="elsevierStyleItalic">urticaria</span> in just the last year easily exceeds 600. The reasons behind the growing interest were well summarized in a recent opinion article in this journal, in which authors Gimenez-Arnau et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> remarked on the following developments:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0010" class="elsevierStylePara elsevierViewall">the recent publication of European clinical practice guidelines,</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0015" class="elsevierStylePara elsevierViewall">our improved understanding of the pathogenesis of the disease,</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">the emergence of patient associations and the participation of a variety of professionals in World Urticaria Day, and most importantly,</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">the development of new biologic therapies available to treat the condition.</p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">A disease with a prevalence of nearly 1% in the United States<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and similar rates in other Western countries like Spain,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> naturally draws attention. Chronic urticaria affects middle-aged populations and has a resulting economic impact on employed persons as well as the use of hospital resources. The patient with urticaria is a high user of health care services through visits to the emergency department, primary care clinics, and specialists—mainly dermatologists, allergy specialists, or internists.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical practice guidelines updated in 2009<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and revised again in 2014<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> were based on a systematic review of the literature applying the GRADE scale (Grading of Recommendations Assessment, Development and Evaluation). The members of 21 Spanish and international associations involved in the management of urticaria participated in the effort, which established an easy-to-use treatment algorithm incorporating indications that are implicitly or explicitly in accordance with each drug's summary of product characteristics. (An example is cyclosporin, whose use in the treatment of urticaria refractory to conventional treatment with antihistamines is regulated in Andalusia by resolution SA352/2012 of November 15, 2012.) However, the guidelines have not yet been analyzed and filled out with revisions specific to each participating country.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">While our main objective in managing the diagnosis and treatment of urticaria is to achieve rapid and complete control over signs and symptoms by prescribing appropriate medications according to the best available evidence of safety and efficacy, meeting that goal requires individualized case management. However, tailored care is not incompatible with planning the pathway our patients should follow in the health care system so that duplicated effort and unnecessary interventions are avoided.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Here is where systematizing care through process planning becomes essential. A clinical pathway, or care plan, specifies the who, when, where and how that govern the delivery of care for a condition or a set of related ones.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our aim in this paper is to present the consensus reached by dermatologists of the national health service (NHS) of Andalusia regarding the care process for patients with urticaria. We describe the clinical pathway, the necessary steps and interventions, and the characteristics of quality of care for each act.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Defining the Clinical Pathway Required</span><p id="par0055" class="elsevierStylePara elsevierViewall">The need to define and develop a framework for providing quality care efficiently in the Andalusian NHS led the working group to map the care processes that have been in place since 2000. This strategy has a single fundamental aim: to guarantee the quality of NHS services.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The care process plan encompasses an overview of the actual path a patient will follow through the system. Work flows have been reordered and interventions that are of no use have been eliminated.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Elements intrinsic to the plan are<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">interventions designed to be patient-, or user-, centered,</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">the active involvement of health care professionals organized into multidisciplinary working groups,</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">clinical practice that is appropriate according to guidelines and care plans,</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">integrated recording of information, and finally,</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">continuity of care to ensure cooperation between the various levels of the health care system.</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">The only care process plan currently in use in clinical management units (CMUs) in dermatology in the autonomous community of Andalusia is the one for the integrated care of skin cancer.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Therefore, the Andalusian Regional Section of the Spanish Academy of Dermatology and Venereology (AEDV) took the portfolio of medical and surgical services in dermatology and the treatment of sexually transmitted infections of 2014<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> as its starting point and developed pathways for prioritized conditions and those for which no documentary support was currently in place. The conditions chosen were atopic dermatitis, sexually transmitted infections, benign cysts or tumors, and urticaria.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The Clinical Pathway and Characteristics Relevant to Quality of Care and Decision-Making</span><p id="par0100" class="elsevierStylePara elsevierViewall">The patient interacts with both primary care physicians and specialists after referral along the clinical pathway described in <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 1 and 2</a>, which define the who, what, where, when, and how of steps in the sequential phases of a process that guarantees continuity of care. (See <a class="elsevierStyleCrossRef" href="#sec0030">Appendix A</a> for the drafting process.)</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a> (primary care) and <a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a> (specialized care) list the activities of multidisciplinary teams of health care and other professionals who attend the patient with urticaria as part of a coordinated process. The organization of the tables follows the patient's pathway through a system that includes both health care and related services. Aspects and dimensions of quality of care, clinical effectiveness, critical safety points (CSPs), nursing care, information-oriented CSPs, nonclinical interventions, and the recommendations of experts have been incorporated into the tables. The flow chart (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) shows how specialist follow-up is carried out and offers a summary of a therapeutic approach rooted in the recently updated European guidelines.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methodology and Limitations</span><p id="par0110" class="elsevierStylePara elsevierViewall">The Metaplan approach<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> that was used to draft this paper is a qualitative focus-group method for generating ideas and solutions, exploring opinions and reaching consensus; the focus groups also formulate objectives, make recommendations, and draft action plans. The method gathers information on cards that can be posted on a board to add a visual component to discussions. A moderator leads the group and structures the analysis and discussion in keeping with the context for the activity.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The intention is to foster the full participation of all members equally without the moderator exercising influence over individuals’ opinions. The method seeks to facilitate focus and foster understanding of ideas, using visual aids (posted cards) to expand on the spoken word. Gaps are left so that participants can fill them by suggesting new ideas to add to the board in an orderly way. Experts agree that these techniques break complex statements down into simpler ones, making them easier for participants to grasp. Complex ideas may even be condensed visually to only a single word or two, clarifying them and bridging gaps created during spoken communication.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The dermatologists who drafted the present paper came from all the provinces and health centers in the autonomous community of Andalusia. Support in applying the method was given by professionals from the Spanish Society for Quality in Health Care (SECA).</p><p id="par0125" class="elsevierStylePara elsevierViewall">Finally, we note that the recommendations based on the consensus of experts with a wide range of clinical and management experience correspond to evidence level IV; this limitation applies to this paper.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">In conclusion, we propose a clinical pathway for urticaria, a condition that is commonly seen in dermatology practices. The dermatologist is clearly the best qualified specialist to manage patients with urticaria in an integrated way, in collaboration with allergy specialists, family practitioners, and other professionals. The dermatologist can confirm the diagnosis, ruling out possible alternative diagnoses such as other inflammatory or reactive skin conditions. The specialist can also assess severity and manage an exhaustive therapeutic plan that is well informed by appropriate clinical practice guidelines. The actions involved in clinical management, however, must be undertaken in an orderly way and in concert with other specialists and professionals. The patient, for whom continuity of care must be guaranteed, is at the center of this process. We believe the proposed clinical pathway is a dynamic starting point that will facilitate the approach we describe here.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres824810" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821286" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres824809" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821285" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Defining the Clinical Pathway Required" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "The Clinical Pathway and Characteristics Relevant to Quality of Care and Decision-Making" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Methodology and Limitations" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-11-02" "fechaAceptado" => "2015-11-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821286" "palabras" => array:4 [ 0 => "Urticaria" 1 => "Clinical pathway" 2 => "Continuity of care" 3 => "Patients" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec821285" "palabras" => array:4 [ 0 => "Urticaria" 1 => "Proceso asistencial" 2 => "Continuidad asistencial" 3 => "Paciente" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Attention has been focused on new ways to understand and manage urticaria ever since the recent addition of novel drugs to the therapeutic arsenal, the updating of clinical practice guidelines, and the publication of pathophysiologic insights. The Andalusian Section of the Spanish Academy of Dermatology and Venereology (AEDV) has developed a clinical pathway that defines quality-of-care characteristics and makes recommendations on decision-making affecting patients with urticaria. We present a patient-centered approach to care, in which the patient's clinical pathway through the health care system includes links between primary and hospital care to ensure continuity—a key feature of quality.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La incorporación de nuevos fármacos al arsenal terapéutico, la actualización de las guías de práctica clínica y los hallazgos fisiopatológicos recientemente comunicados hacen que el manejo y conocimiento de la urticaria sea un tema de candente actualidad. La Sección territorial andaluza de la AEDV ha desarrollado un proceso de atención en el que se describen el recorrido del paciente, las características de calidad de las actuaciones y las recomendaciones para la toma de decisiones en los pacientes con urticaria. Presentamos un enfoque centrado en el paciente, y en el que se muestra su devenir en el sistema sanitario y la interrelación entre la atención primaria y hospitalaria, garantizando un punto clave, su continuidad asistencial.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz-Villaverde R, Moreno-Ramírez D, Galán-Gutierrez M, de Troya M, Reyes-Alcázar V, Alcalde M, et al. Proceso de atención al paciente con urticaria aguda y crónica. Documento de consenso de la sección territorial andaluza de la Academia Española de Dermatología y Venereología. Actas Dermosifiliogr. 2016;107:482–488.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p> <p id="par0140" class="elsevierStylePara elsevierViewall">Abbreviations: DQLI, Dermatology Quality of Life Index; UAS7, Urticaria Activity Score 7.</p>" "etiqueta" => "Appendix 1" "titulo" => "Method for Drafting a Clinical Pathway to Manage a Disease" "identificador" => "sec0030" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3705 "Ancho" => 3254 "Tamanyo" => 695736 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Flow chart of the urticaria patient's pathway through the different parts of the health care system. CMU refers to clinical management unit; UAS7, Urticaria Activity Score 7; DQLI, Dermatology Quality of Life Index.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: CMU, clinical management unit; CSP, critical safety point affecting patients as listed by the health service of the government of Andalusia (the Junta).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Care in the primary care center or emergency service</span><br><span class="elsevierStyleItalic">Family practitioner, primary care nurse, primary care pediatrician</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">1. Medical history</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1.1 <span class="elsevierStyleItalic">Unequivocally identify the patient according to established procedures (a CSP)</span>.<br>1.2 <span class="elsevierStyleItalic">Take the patient's medical history, including the following information</span>:<br><span class="elsevierStyleHsp" style=""></span>1.2.1 The patient and family's past histories of urticaria, angioedema, and atopic dermatitis<br><span class="elsevierStyleHsp" style=""></span>1.2.2 The patient's history of other diseases (infections, inflammatory processes, allergies, digestive problems, psychosomatic diseases, stress, surgical implants), prior and current therapies (nonsteroidal anti-inflammatory drugs, hormone treatments, laxatives, immunizations, alternative medicine, etc.)<br><span class="elsevierStyleHsp" style=""></span>1.2.3 Factors or triggers associated with urticarial flare-ups: food, medications, physical stimuli, other<br><span class="elsevierStyleHsp" style=""></span>1.2.4 Prior treatments for urticaria<br><span class="elsevierStyleHsp" style=""></span>1.2.5 Symptoms, including the following:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pruritus (intensity and clinical course); pain and burning sensations<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Wheals: shape, size, location/distribution<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Angioedema: clinical course, frequency and duration of lesions, variations during the day; patterns on weekends, vacations or trips; joint pain; affective disorders, etc.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Systemic signs and symptoms: respiratory and digestive symptoms, headache, hypotension, fever, joint pain.<br><span class="elsevierStyleHsp" style=""></span>1.2.6 History of dependence/addiction (to alcohol, smoking, other); occupational history (profession, pastimes) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">2. Physical examination</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2.1 <span class="elsevierStyleItalic">Wash hands properly before and after the examination (a CSP)</span>.<br>Examine the patient to identify manifestations of urticarial disease (wheals, angioedema). The characteristic signs are wheals, papuloerythematous lesions, or pale lesions with white halos tending to coalesce. The lesions appear suddenly (within<span class="elsevierStyleHsp" style=""></span>minutes), are fleeting, and usually resolving in <<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>hours. Angioedema is marked by the swelling of mucosal tissues (especially the lips and eyelids but also the larynx) or other soft tissues; the swelling resolves more slowly than urticarial lesions and can last 48<span class="elsevierStyleHsp" style=""></span>hours. Often there are no signs on the skin surface or itching, but the condition might be painful. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">3. Documentation and provision of information</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3.1 <span class="elsevierStyleItalic">Record data from the medical history and examination in the patient's chart; also note the clinical diagnosis and plan of action (an information-oriented CSP)</span>.<br>3.2 <span class="elsevierStyleItalic">If urticaria is suspected, explain this clearly and precisely to the patient and family; record the clinical judgment in the patient's chart (an information-oriented CSP)</span>.<br>3.3. <span class="elsevierStyleItalic">The referral to a specialist should be arranged during the same visit. A system for priority referrals to the specialist must be established based on signs and symptoms for optimal efficiency and use of health care resources</span>.<br>3.4 <span class="elsevierStyleItalic">According to expert opinion, referral to a specialist is necessary in the following situations</span>:<br><span class="elsevierStyleHsp" style=""></span>3.4.1 When there is diagnostic uncertainty and a firm diagnosis is required (see Table 2, point 7.2, on differential diagnosis)<br><span class="elsevierStyleHsp" style=""></span>3.4.2 In chronic urticaria (lasting ><span class="elsevierStyleHsp" style=""></span>6 wk), to confirm physical, food, or medication triggers<br><span class="elsevierStyleHsp" style=""></span>3.4.3 Acute urticaria (lasting <<span class="elsevierStyleHsp" style=""></span>6 wk) that is refractory to first- and second-line therapies<br><span class="elsevierStyleHsp" style=""></span>3.4.4 Chronic urticaria (lasting ><span class="elsevierStyleHsp" style=""></span>6 wk) that does not respond to second-line therapies (second-generation H<span class="elsevierStyleInf">1</span> antihistamines at a dose 4-fold higher than usually prescribed)<br><span class="elsevierStyleHsp" style=""></span>3.4.5 In chronic urticaria (lasting ><span class="elsevierStyleHsp" style=""></span>6 wk), for additional tests<br>If referral is indicated, write a full report for the dermatology CMU to ensure the transfer of information between professionals in different care settings as well as to ensure continuity of care (a CSP). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">4. Treatment</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4.1 <span class="elsevierStyleItalic">When cases do not qualify for referral to the dermatology CMU, initiate general measures to manage the rash with first- or second-line treatments</span> (i.e., <span class="elsevierStyleItalic">second-generation H</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">antihistamines at the usual or 4-fold higher doses).</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386704.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Quality-of-Care Characteristics to Apply When Attending Persons With a Clinical Picture Compatible With a Diagnosis of Urticaria in Primary Care Centers and Emergency Departments.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: AE-QOL, Angioedema Quality of Life; CMU, clinical management unit; CSP, critical safety point affecting patients as listed by the health service of the government of Andalusia (the Junta); CU-Q2OL: Chronic Urticaria Quality of Life; DQLI: Dermatology Quality of Life index; EAACI/GA2LEN/EDF/WAO, European Academy of Allergy and Clinical Immunology/Global Allergy and Asthma European Network/European Dermatology Forum/World Allergy Organization; Ig, immunoglobulin; UAS7, Urticaria Activity Score 7.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Care in a dermatology CMU</span><br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Professionals: Dermatologists, dermatology CMU nurses</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">5. Medical history</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5.1 <span class="elsevierStyleItalic">Unequivocally identify the patient according to established procedures (a CSP).</span><br><span class="elsevierStyleHsp" style=""></span>5.2 <span class="elsevierStyleItalic">Update the patient's medical history as described in point 1.2</span> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>), <span class="elsevierStyleItalic">and expand it with the following information</span>:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5.2.1 Evaluate the severity of the urticaria (scored on the UAS7 scale).<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5.2.2 Evaluate the impact of urticaria on the patient's quality of life using an appropriate scale (e.g., the CU-Q2OL, AE-QOL, or DQLI). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">6. Physical examination and additional tests</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>6.1 <span class="elsevierStyleItalic">Wash hands adequately before and after the examination (a CSP).</span><br><span class="elsevierStyleHsp" style=""></span>6.2 <span class="elsevierStyleItalic">Update the physical examination described in point 2.2.</span><br><span class="elsevierStyleHsp" style=""></span>6.3 <span class="elsevierStyleItalic">Perform a dermatologic examination to describe the lesions, note their distribution and patterns formed (wheals, angioedema, anatomical location</span>, etc.).<br><span class="elsevierStyleHsp" style=""></span>6.4 <span class="elsevierStyleItalic">Evaluate patients with chronic urticaria as appropriate based on suspected triggers, using the following examinations and tests: pressure test (for pressure urticaria), ice-cube test (for cold urticaria), vortex provocation test (for vibratory urticaria), UV provocation test (for solar urticaria), stroking (for symptomatic dermatographism), wet gauze contact (for aquagenic urticaria), exercise (for cholinergic urticaria), and skin patch tests (for contact urticaria).</span><br><span class="elsevierStyleHsp" style=""></span>6.5 <span class="elsevierStyleItalic">The urticaria diagnosis: this is a clinical diagnosis based on medical history and/or physical examination of a pruriginous rash of wheals and/or angioedema that is fleeting</span> (<<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">24</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">hours).</span><br><span class="elsevierStyleHsp" style=""></span>6.6 <span class="elsevierStyleItalic">A skin biopsy may be ordered if the clinical diagnosis is uncertain. Inform the patient or caregiver of the reasons for taking the biopsy, its objectives, and possible complications (an information-oriented CSP)</span>. <span class="elsevierStyleItalic">Written informed consent is required before a biopsy can be performed (an information-oriented CSP).</span><br><span class="elsevierStyleHsp" style=""></span>6.7 <span class="elsevierStyleItalic">There are no laboratory or other types of tests that can differentiate or confirm a diagnosis of urticaria.</span><br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Complementary testing is not recommended in acute urticaria (strong recommendation based on clinician consensus).<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>The following routine test complement is recommended for all patients with chronic urticaria: complete blood count, eosinophil sedimentation rate, C-reactive protein level.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Depending on the patient's medical history, the following tests might be ordered: total serum immunoglobulin (Ig) E concentration, microbiologic processing, (e.g., for <span class="elsevierStyleItalic">Helicobacter pylori</span> detection), thyroid hormone level, antithyroid antibody assay, antinuclear antibody assay, and autologous serum skin test (for autoimmune urticaria). The search for trigger factors in chronic urticaria should be guided by information in the patient's medical history (strong recommendation, clinician consensus). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">7. Classification and differential diagnosis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7.1 <span class="elsevierStyleItalic">Current recommendations say that urticaria should be classified according to the 2013 EAACI/GA2LEN/EDF/WAO guidelines, which define the following types and subtypes</span>:<br>Types of urticaria:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>7.1.1 Acute urticaria: appearance of spontaneous wheals, angioedema or both for <<span class="elsevierStyleHsp" style=""></span>6 wk<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>7.1.2 Chronic urticaria: appearance of urticaria flare-ups (wheals, angioedema or both) for ><span class="elsevierStyleHsp" style=""></span>6 wk<br>Subtypes of chronic urticaria:<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>7.1.3 Chronic spontaneous urticaria: spontaneous appearance of wheals, angioedema or both lasting ≥<span class="elsevierStyleHsp" style=""></span>6 wk and due to known or unknown causes<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>7.1.4 Inducible urticaria: symptomatic dermographism, cold urticaria, delayed pressure urticaria, solar urticaria, heat urticaria, vibratory angioedema, cholinergic urticaria, contact urticaria, aquagenic urticaria<br><span class="elsevierStyleHsp" style=""></span>7.2 <span class="elsevierStyleItalic">Rule out the following diagnoses for each urticaria type:</span><br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>7.2.1 Acute urticaria: drug eruptions (IgE mediated, idiosyncratic, cell mediated), food reactions (IgE mediated or not), intravenous infusion reactions (to contrast agents, immunoglobulins), infections (childhood viral diseases, mononucleosis, prodromal period of hepatitis B viral infection), polymorphous erythema, allergic contact dermatitis.<br><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>7.2.2 Chronic urticaria: urticarial vasculitis, familial fever syndromes with urticaria-like eruptions, Schnitzler syndrome, mastocytosis, Wells syndrome, polymorphous erythema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">8. Documentation and provision of information</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8.1 <span class="elsevierStyleItalic">Record data from the medical history and examination as well as the clinical diagnosis and action plan (an information-oriented CSP)</span>.<br><span class="elsevierStyleHsp" style=""></span>8.2 <span class="elsevierStyleItalic">If lesions are present at the time of the visit, clinical and dermoscopic images are recommended. The patient's written informed consent must be given before photographs are taken (an information-oriented CSP).</span><br><span class="elsevierStyleHsp" style=""></span>8.3 <span class="elsevierStyleItalic">Patients with urticaria should take photographs of lesions during flare-ups to help with diagnosis and follow-up.</span><br><span class="elsevierStyleHsp" style=""></span>8.4 <span class="elsevierStyleItalic">If food or medication triggers are suspected, refer the patient to the CMU for allergies.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. <span class="elsevierStyleBold">Treatment</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>9.1 <span class="elsevierStyleItalic">First-line treatment: H</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">antihistamines at conventional doses</span><br><span class="elsevierStyleHsp" style=""></span>9.1 <span class="elsevierStyleItalic">Second-line treatment: H</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">antihistamines at up to 4-fold the usual dose</span><br><span class="elsevierStyleHsp" style=""></span>9.3 <span class="elsevierStyleItalic">Third-line treatment: cyclosporin or omalizumab at the recommended doses.</span> Systemic corticosteroids should only be used for occasional flare-ups and for no longer than 10 d. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">10. Follow-up</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patient follow-up must include a thorough medical history and a physical examination. Severity and effects on quality of life should be scored (UAS7 and DQLI, respectively).</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386703.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Quality-of-Care Characteristics to Apply When Attending Persons With Urticaria in Dermatology CMUs.</p>" ] ] 3 => array:5 [ "identificador" => "tbl0005" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Overall definition of the process</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Definition of the functions of the care process \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Time frame: start point, end point and byways of the process \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Persons responsible for care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Beneficiaries of care and aims of the process</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Beneficiaries of care and expectations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Outcomes and exit points \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Process components</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Elements of the process and resources applied \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Activities undertaken and quality-of-care characteristics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Flow-chart or graphic representation of the pathway</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Structure of indications for care</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of the subgroup of patients with the condition (e.g., urticaria) who will undergo additional tests \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wait time before referring a patient to a specialist \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Grouping of patients with the condition (e.g., urticaria) by severity and effect on quality of life (e.g., scoring with the UAS7 and DQLI, respectively) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386702.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic and therapeutic management of chronic urticaria by dermatologists and the role of dermatology departments" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "en nombre de Grupo de Opinión de Urticaria" "etal" => false "autores" => array:3 [ 0 => "A.M. 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"fecha" => "2015" "editorial" => "Sociedad Española de Calidad Asistencial" "editorialLocalizacion" => "Sevilla" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estrategias didácticas creativas en entornos virtuales para el aprendizaje" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Delgado Fernández" 1 => "A. Solano Gonzalez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Actual Investig Educ" "fecha" => "2009" "volumen" => "9" "paginaInicial" => "1" "paginaFinal" => "21" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010700000006/v2_201704050141/S1578219016300695/v2_201704050141/en/main.assets" "Apartado" => array:4 [ "identificador" => "6228" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Consensus document" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000006/v2_201704050141/S1578219016300695/v2_201704050141/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016300695?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 10 | 19 |
| 2024 Octubre | 85 | 47 | 132 |
| 2024 Septiembre | 62 | 20 | 82 |
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| 2024 Julio | 74 | 38 | 112 |
| 2024 Junio | 71 | 33 | 104 |
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| 2024 Febrero | 57 | 37 | 94 |
| 2024 Enero | 65 | 35 | 100 |
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| 2023 Noviembre | 133 | 25 | 158 |
| 2023 Octubre | 53 | 22 | 75 |
| 2023 Septiembre | 56 | 30 | 86 |
| 2023 Agosto | 40 | 14 | 54 |
| 2023 Julio | 75 | 35 | 110 |
| 2023 Junio | 49 | 21 | 70 |
| 2023 Mayo | 78 | 29 | 107 |
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| 2023 Marzo | 96 | 23 | 119 |
| 2023 Febrero | 109 | 21 | 130 |
| 2023 Enero | 43 | 38 | 81 |
| 2022 Diciembre | 73 | 46 | 119 |
| 2022 Noviembre | 38 | 20 | 58 |
| 2022 Octubre | 32 | 18 | 50 |
| 2022 Septiembre | 33 | 37 | 70 |
| 2022 Agosto | 26 | 34 | 60 |
| 2022 Julio | 31 | 39 | 70 |
| 2022 Junio | 31 | 26 | 57 |
| 2022 Mayo | 94 | 39 | 133 |
| 2022 Abril | 158 | 41 | 199 |
| 2022 Marzo | 147 | 46 | 193 |
| 2022 Febrero | 150 | 43 | 193 |
| 2022 Enero | 130 | 58 | 188 |
| 2021 Diciembre | 87 | 59 | 146 |
| 2021 Noviembre | 85 | 46 | 131 |
| 2021 Octubre | 85 | 55 | 140 |
| 2021 Septiembre | 63 | 44 | 107 |
| 2021 Agosto | 48 | 29 | 77 |
| 2021 Julio | 53 | 47 | 100 |
| 2021 Junio | 66 | 31 | 97 |
| 2021 Mayo | 59 | 56 | 115 |
| 2021 Abril | 133 | 69 | 202 |
| 2021 Marzo | 82 | 48 | 130 |
| 2021 Febrero | 73 | 37 | 110 |
| 2021 Enero | 47 | 26 | 73 |
| 2020 Diciembre | 48 | 24 | 72 |
| 2020 Noviembre | 55 | 23 | 78 |
| 2020 Octubre | 42 | 13 | 55 |
| 2020 Septiembre | 38 | 10 | 48 |
| 2020 Agosto | 27 | 28 | 55 |
| 2020 Julio | 33 | 13 | 46 |
| 2020 Junio | 38 | 44 | 82 |
| 2020 Mayo | 32 | 24 | 56 |
| 2020 Abril | 42 | 21 | 63 |
| 2020 Marzo | 32 | 14 | 46 |
| 2020 Febrero | 6 | 0 | 6 |
| 2020 Enero | 6 | 0 | 6 |
| 2019 Diciembre | 9 | 0 | 9 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 5 | 0 | 5 |
| 2019 Julio | 5 | 0 | 5 |
| 2019 Junio | 15 | 0 | 15 |
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| 2019 Marzo | 5 | 3 | 8 |
| 2019 Enero | 4 | 0 | 4 |
| 2018 Diciembre | 8 | 0 | 8 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 5 | 0 | 5 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Febrero | 33 | 6 | 39 |
| 2018 Enero | 42 | 18 | 60 |
| 2017 Diciembre | 65 | 6 | 71 |
| 2017 Noviembre | 46 | 5 | 51 |
| 2017 Octubre | 45 | 11 | 56 |
| 2017 Septiembre | 28 | 6 | 34 |
| 2017 Agosto | 36 | 8 | 44 |
| 2017 Julio | 27 | 5 | 32 |
| 2017 Junio | 33 | 7 | 40 |
| 2017 Mayo | 39 | 20 | 59 |
| 2017 Abril | 36 | 11 | 47 |
| 2017 Marzo | 23 | 18 | 41 |
| 2017 Febrero | 48 | 26 | 74 |
| 2017 Enero | 25 | 5 | 30 |
| 2016 Diciembre | 41 | 25 | 66 |
| 2016 Noviembre | 38 | 17 | 55 |
| 2016 Octubre | 40 | 18 | 58 |
| 2016 Julio | 0 | 2 | 2 |
| 2016 Junio | 0 | 4 | 4 |
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