Both Ends of the Spectrum in Dermatology

The BMJ this week includes two very different and contrasting dermatological conditions. In one hand there is the extremely common but relatively benign basal cell carcinoma, whilst at the other end is the rare but potentially fatal toxic-epidermolysis-necrosis occurring as a result of an adverse drug reaction.

Facial Basal Cell Carcinoma:

BCC is the most common human cancer. The incidence of BCC is increasing and the cost to the NHS of treating non-melanoma skin cancers is high. Timely recognition and treatment of BCCs usually results in excellent outcomes but specialist intervention is required for BCCs in difficult to treat areas. The definition of BCC is locally invasive cancer if the epidermal basaloid cells. Up to 85% of BCCs are found on the head and neck. Early recognition can limit the extent of facial tissue involvement. The main risk factor for development of BCC is exposure to UV light, explaining why there are such geographical variations in the incidence of the cancer with sun exposure in childhood being of particular importance. BCCs are more common and more aggressive in men compared to women. BCCs are less likely to occur in pigmented skin due to the protection provided by melanin. Immunosuppression and radiotherapy are other risk factors.  Most patients describe a non-healing 'lump' or 'sore spot' which grows slowly but is otherwise asymptomatic. 

Different subtypes of BCC are: nodular, nodulo-ulcerative, superficial, morphoeic, or infiltrated and pigmented. Nodular BCC is the most common type found in the UK. Classic features include: overlying telangectasia, central crusting, raised rolled edge and ulceration. Following diagnosis, the risk of a further BCC is 10x greater than the general population. The differential diagnosis includes: solar keratosis, SCC, seborrhoeic keratosis, intradermal naevus, psoriasis and eczema. High risk BCCs are those >2cm in diameter, located in high risk anatomical areas, poorly defined edges and recurrent or poorly defined BCCs. Treatment options include wide local excision, MOHS microgaphic surgery, radiotherapy, photodynamic therapy, imiquimod, curettage and cautery, cryotherapy and lasers. Wide local excision can be used to treat most facial BCCs as long as there is a successful clearance margin. Most BCCs grow slowly and follow a non-aggressive course but if neglected for a long time they can offer a therapeutic challenge. 

Toxic Epidermolysis Necrosis:

A patient is prescribed amoxicillin for a sore throat and mouth. Five days later he is admitted to the general medical ward with a fever and rapidly spreading burning rash on his trunk, palms and soles. He also has painful red eyes and inflamed ulcers in his mouth. The next day he develops blisters and loss of the top layer of his skin on gentle touch. He then developed respiratory failure, requiring intubation and transfer to the Intensive Care Unit. 

The diagnosis is a severe adverse cutaneous drug reaction with epidermal detachment, classified as Stevens-Johnson syndrome - toxic epidermal necrolysis overlap. The diagnosis is confirmed by taking two skin biopsies - one for immediate cryosection and one for confventional formalin fixed analysis. Skin biopsy shows detatchment of the epidermis from the dermis and apoptosis of keratinocytes. The main causes of this syndrome are drug hypersensitivities but others include infections eg. Herpes Simplex Virus. Management is to withdraw the offending drug and provide supportive care in an intensive care environment with special attention to fluid resuscitation, skin care and eye care. 

Pelvic Organ Prolapse and the Use of Transvaginal Mesh

This week is a guest post from Jasmine McCarthy who works in the Public Outreach Department from www.drugwatch.com.

Pelvic organ prolapse (POP) is a condition that occurs when the internal structures that support pelvic organs become weakened or stretched to the point that they allow those organs to fall lower in the body, pressing into the vagina. While POP is not life-threatening, severe cases can cause an array of symptoms that have a substantial effect on a woman's quality of life.

Corrective surgery is often recommended in such cases, which can resolve symptoms in many women. However, over the last decade, the use of transvaginal mesh implants has become common in POP repair surgeries — an addition that has proven problematic for a significant number of women who have undergone these procedures.

Pelvic Organ Prolapse

Pelvic organs, such as the bladder, uterus and rectum, are supported by the pelvic floor, which is made up of muscles and connective tissues. Over a woman's lifetime, the pelvic floor can be gradually weakened and stretched as it is exposed to stress. The most common cause of that damage is childbirth, but factors like obesity, chronic constipation and a family history of POP can contribute.

When the pelvic floor is weakened significantly, one or several of the pelvic organs can drop out of their normal position, placing pressure on the vagina. Mild cases may produce no symptoms, but women with more serious POP may experience symptoms that include pain and pressure in the pelvic region, urinary leakage, difficult bowel movements, pain during sex, a bulge in the vagina, or organs that protrude through the vaginal opening.

Transvaginal Mesh and POP Procedures

Approved by the Food and Drug Administration (FDA) for POP repair procedures in 2002, transvaginal mesh is a medical device that is permanently implanted in patients to reinforce the weakened tissues that are at the root of pelvic organ prolapse. Constructed of synthetic surgical mesh, these devices are hammock-like in design to support prolapsed pelvic organs and are inserted into the pelvic region through the vagina. This method of POP repair has become quite prevalent, used in 75,000 procedures in 2010 alone.

Complications

The most common complication associated with transvaginal use for pelvic organ prolapse repair is mesh erosion. Also referred to as mesh extrusion, this occurs when rough edges of the mesh cut through the vaginal tissue and nearby organs. Results of mesh erosion can include organ perforation, infection, bleeding, pain, urinary issues and sexual dysfunction.

Mesh shrinkage is another common problem, and can cause vaginal shortening and intense pain. Addressing these complications often requires multiple surgeries, and since tissues grow into and around the mesh implants, they are not always effective. Thousands of women have been affected by these complications and have filed transvaginal mesh lawsuits against mesh manufacturers.

FDA Information

In a 2011 alert, the agency reported the results of a systematic review of scientific studies on the use of transvaginal mesh in pelvic surgeries. Those results showed that there is a significant risk of serious complications with the use of these products, and that those risks came with no significant benefits, since procedures that use transvaginal have not proven to be more effective than traditional POP repair.

According to that report, among the most common complications reported were mesh erosion, mesh shrinkage, organ perforation and infection, and reports of these serious complications rose fivefold between 2008 and 2010, as compared with reports during the previous three years.

Refusing Organ Donation

Organ Donation - In the BMJ this week Dr Shaw writes an article which I have no doubt will stir up some debate. He tackles the complex ethical issues of organ donation and particularly the situation when a family choose to over-rule a deceased patient's decision to donate their organs. Veto by the family is the main impediment to an increase in organ donation in this country and at least 10% of families refuse to allow organ donation in cases where the deceased has expressed an intention to donate their organs, eg. by carrying an organ donor card. 

While the family's wishes are respected in these situations, legally they have no grounds to over-ride the dead person's wishes. Clearly the stress and emotion of the situation affects the decision, but families often regret the decision not to allow the donation within two days. Dr Shaw argues that doctors who allow this to happen are not doing their jobs properly(!). The doctor's concerns about causing more distress to the family by pressing the issue may cause greater consequences in the long run if up to seven more lives are not saved due to the failed organ donation. Of course the family cannot be blamed for refusing to allow donation under such an awful situation, but the same cannot be said of the doctor. Ethically this is difficult because we have to consider the patient who has died, their family and the patients on the organ donor list who could die without a donation. As doctors we have a duty to promote the health of the public, and that includes patients on the organ donor register. However it must be an extremely difficult conversation to have with a family to persist in recommending that they allow the organs to be donated against their wishes. If the family have no legal grounds for over-ruling the patient's wishes, and there is evidence to show that those refusing donation later regret their decisions, perhaps we should be looking at whether families should play a part at-all in this complex end-of-life decision making. Although on the other hand, taking away the families' input into this process would seem harmful to the relationship between the public and the profession which would likely be a bad thing. In summary I think that although there is no easy answer, there is ample material for debate.

Implementing a National Early Warning Score - In order to help identify patients early who become acutely unwell in a hospital ward, the Royal Collect of Physicians has now introduced a national early warning score. The idea of this tool is that patients at risk are identified early through monitoring of basic clinical observations such as pulse rate and respiratory rate. Having a national early warning score system allows an adequate standard of care to be delivered to all patients, regardless of their geographical location. The hospital I work in now has an "Emergency Response Team" which can be called to patients who nurses or doctors feel may be deteriorating. The effect of this identification process has also been called "critical care outreach". This is the idea that a critical care department may help with deteriorating patients in the ward environment. Having just moved to work in a new hospital, I feel that standardising the approach to the acutely unwell patient is an important idea, which could ultimately mean that there is a common method for describing and acting on unwell patients throughout the UK.

Information Overload

Today, for the first time, I was asked to dictate a letter. This came after a following clinic encounter with a patient who had been referred to hospital by her GP. Having never dictated a letter before, I asked my supervisor what to include. I was told that a useful way to structure a clinic letter is to have the patient's details, followed by three headings:

Diagnosis

Management

Follow-Up

The bulk of the text should then follow. The reason for this is that it means the GP can read the headings and get a summary of the outcome of the clinic appointment without spending a lot of time reading all of the text. The rest of the letter is available in the patient's notes, should the GP or a doctor need to refer to it in the future.

I realised that this approach is almost exactly the same as how many doctors must try to keep up with new guidelines and evidence. Work is busy and often there is rarely enough time to trawl through journal articles to try to keep up-to-date with all of the medical news. With evidence changing all of the time there are lots of ways to keep up. Guidelines produced by the SIGN or NICE are developed by researchers who collate all of the relevant research into easy to access guidance. These guidelines are now being made more widely and easily available through websites, apps and publications. The BMJ offers a useful summary of some of the most relevant articles. BBC News will pick up on major new studies as they break however will often present them in a way which is more suited to the lay public. Another way to keep up is through reading publications from more specialty specific organisations, such as the British Journal of General Practice. Lectures, talks and presentations from experts are also a useful way to learn new information.

In my opinion, the weekly BMJ offers one of the best ways to keep up with new developments. It summarises key evidence with a 'study question', 'summary answer' and 'what this paper adds'. Realistically this is a sensible way to condense a large amount of information into a more digestible amount. For example one of this weeks articles relates to the risk of pneumonia associated with the use of ACE inhibitors.

Study question: Do ACE inhibitors and ARBs decrease the risk of pneumonia?

Study answer: ACE inhibitors may be important in reducing the risk of pneumonia. This data could discourage the withdrawal of ACE inhibitors in some patients with cough who are at particularly high risk of pneumonia.

What is known and what this paper adds: ACE inhibitors have secondary effects on the respiratory system, which may protect against pneumonia. In pooled results from interventional and observational studies, ACE inhibitors had a significant protective role against pneumonia.

In an attempt to do my bit to reduce the amount of information overload which is often starting to occur in medicine, I'll try and keep my letters, presentations and discussions short, because the danger is that if there is too much information, the key points of most importance could be lost.

And of course this week wouldn't complete without mentioning some of the amazing successes of Team GB in the Olympics! Congratulations to all of the medal winners - so great to see all of the hard work pay off.