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The relationship between psoriasis and metabolic syndrome is not well understood. Though multiple epidemiologic studies have suggested a link between psoriasis and metabolic syndrome, there is a lack of a comprehensive meta-analysis synthesizing the results of all available observational studies to date. In this meta-analysis, we examined global data on the relationship between psoriasis and odds of metabolic syndrome by searching for studies published between 1946–2016. Specifically, we analyzed the results from 35 observational studies from 20 countries with 1,450,188 total participants, of which 46,714 were psoriasis patients. The pooled odds ratio based on random effects analysis was 2.14 (95% CI 1.84–2.48). Publication bias was present, as evidenced by an Egger test and graphical visualization through a funnel plot (p = 0.001). Based on this comprehensive meta-analysis, psoriasis patients have higher odds of having metabolic syndrome when compared with the general population.

A lthough epidural analgesia is used widely for pain relief during labor, the failure rate ranges from 1.5% to 20%. This prospective, randomized, nonblinded study investigated whether ultrasound measurement of the depth from the skin to the epidural space before epidural placement decreases the failure rate of labor analgesia. The second objective of the study was to correlate the ultrasoundmeasured depth to the epidural space with the actual depth of the needle when the epidural space is reached.A total of 370 laboring parturients were randomized to undergo epidural placement by first-year anesthesia residents with or without prior ultrasound measurement of the depth to the epidural space. Patients in the ultrasound group underwent ultrasound visualization of the epidural space in the longitudinal median and transverse planes while in the sitting position. The ultrasound measurements were used to estimate the distance from the skin to the ligamentum flavum before the epidural catheter was inserted. The epidural was performed in both groups using the midline approach at the L3-4 or L4-5 vertebral interspace using a loss of resistance to saline technique. All patients received a 10 mL bolus of ropivacaine 0.1% + 100 mcg fentanyl and were then placed on a continuous maintenance epidural infusion of ropivacaine 0.1% and fentanyl 2 mcg/ mL. Outcomes measured included the incidence of epidural catheter replacement for failed analgesia, the number of epidural attempts, and the number of accidental dural punctures.The 189 patients in the ultrasound group and 181 in the control group did not differ significantly in age, height, weight, body mass index, gestation, or parity. The groups did not differ in cervical dilation, station at epidural placement, and initial visual analog score for pain. The use of ultrasound, undertaken by an investigator skilled in ultrasound epidural placement (not the learner), added 60 ± 15 seconds to the mean preparation time. The epidural block failed in 3 and 10 patients in the ultrasound and control groups, respectively, with one in the ultrasound and 6 in the control group considered early failures (within the first 90 min after placement), P = NS. Patients in the control group had more initial placement attempts (2 vs. 1), but the need for staff intervention was not significantly different. The ultrasoundestimated mean epidural depth was 4.6 ± 0.9 cm when measured in the longitudinal plane and 4.7 ± 1.0 cm as measured in the transverse plane showed a strong correlation with the actual clinical depth of the epidural space. No significant differences in staff interventions, need for additional top-ups, or delivery outcomes were determined.In conclusion, the investigators determined that the use of ultrasound to measure the depth of the epidural space before an epidural catheter is inserted for labor analgesia is an excellent teaching tool for neophyte learners of the clinical skill set necessary to locate the epidural space.

Importance Innovative, online models of specialty-care delivery are critical to improving patient access and outcomes. Objective To determine whether an online, collaborative connected-health model results in equivalent clinical improvements in psoriasis compared with in-person care. Design, Setting, and Participants The Patient-Centered Outcomes Research Institute Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to evaluate the effect of an online model for psoriasis compared with in-person care. Participant recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California, and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a primary care physician. Analyses were on an intention-to-treat basis. Interventions Participants were randomized 1:1 to receive online or in-person care (148 randomized to online care and 148 randomized to in-person care). The online model enabled patients and primary care physicians to access dermatologists online asynchronously. The dermatologists provided assessments, recommendations, education, and prescriptions online. The in-person group sought care in person. The frequency of online or in-person visits was determined by medical necessity. All participants were exposed to their respective interventions for 12 months. Main Outcomes and Measures The prespecified primary outcome was the difference in improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the online and in-person groups. Prespecified secondary outcomes included body surface area (BSA) affected by psoriasis and the patient global assessment score. Results Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person groups in the mean change in the self-administered PASI score during the 12-month study period was –0.27 (95% CI, –0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis between the 2 groups was –0.05% (95% CI, –1.58% to 1.48%). Between-group differences in the PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence between the 2 interventions. The difference in the mean change in the patient global assessment score between the 2 groups was –0.11 (95% CI, –0.32 to 0.10), which exceeded the equivalence margin, with the online group displaying greater improvement. Conclusions and Relevance The online, collaborative connected-health model was as effective as in-person management in improving c...