Corticosteroid-Induced Osteoporosis

Route Planning, Glencoe

At the Drift Inn, Arran

Only 3 days to go now until the marathon. Can't wait to get it over with! Went out for the last run today and apart from a bit of 'runner's knee' feeling generally ok. The last couple of weekends have been busy so looking forward to a week off next week.

I've decided on a new audit to start whilst I'm working in the dermatology department. A couple of ideas were suggested, such as monitoring of second line psoriasis treatments eg. acitretin (too similar to my last audit) and investigating melanomas referred to secondary care as 'routine' when they should have been urgent (very interesting and important but difficult). I've settled on the topic which my supervisor had suggested - prevention and treatment of glucocorticoid-induced osteoprosis. The basis for this is that systemic glucocorticoids ie. prednisolone are commonly used and patients may be prescribed them long term for immunosuppression. Patients on prednisolone for greater than three months are at increased risk of complications eg. fragility fractures and avascular necrosis of the femoral head. National and local guidelines recommend that patients greater than old should be given bone-protective therapy at the time of starting corticosteroids, whilst those less than 65 years old should be assessed for bone density following three months of treatment to determine fracture risk.

I'm also going to get back involved in the gentamicin project now that the initial audit and change has been carried out. I've just emailed out to the FY1 doctors working at the Victoria this year to recruit some volunteers to repeat the audit, now that the new prescribing and monitoring form is in place. Hopefully we can repeat the audit and see if gentamicin is being prescribed in a safer way now that the new form is being used.

A Few Interesting Case Studies and Research Articles

Three weeks to go until the marathon! From this point on the running distances shorten, this past week has been the longest yet. Probably ran about 40-45 miles altogether, including a 22.6 mile run today - a long loop from the flat to the Clyde then linking the parks in the Southside of Glasgow (Bellahouston, Linn, Rouken-Glen and Pollok Country Park). Really pleased that the training seems to be paying off - for the past four long runs I've increased the pace while also increasing the distance:

Saturday 11th August - 16 miles - 2hrs 11mins - Pace: 8:13 per mile

Monday 20th August - 17 miles - 2hrs 15mins - Pace: 7:59 per mile

Friday 31st August - 20 miles - 2hrs 37mins - Pace: 7:54 per mile

Sunday 9th September - 22.6 miles - 2hrs 57mins - Pace: 7:50 per mile

Sunday 30th September - 26.2 miles - ???

That was the last of the 'long runs' but hopefully if I can keep up a good pace on the day I should be able to make 3hrs 25-30mins, that would be a brilliant time considering my initial aim was under 4 hours. I just hope I can get through the last 3 weeks without any set-backs and get the start line in a good condition!

Case Studies:

Back Pain in a Teenager - Psoas Abscess. A 'Picture Quiz' in this weeks BMJ. A 16 year old patient presents to A&E with a two week history of back pain in the left lower lumbar region. Onset was sudden after bending over and is now a dull ache. He has been feeling feverish. Urinalysis is positive for protein and blood. CRP, WCC and Neutropil count are raised. On examination there is tenderness over the left paraspinal region but no skin changes. MRI is carried out which shows a large paraspinal high signal area with lateral displacement of the left psoas muscle. Underlying causes should be considered, including immunocomprimise, inflammatory bowel disease and diverticulitis. Investigations include blood cultures, aspiration, CXR (?underlying TB) and consider colonoscopy +/- barium enema.

Skin rash in a preterm infant - HSV Infection. A BMJ Case Report: a baby girl born at 30 weeks gestation develops 3-5mm vesicular skin lesions on the face, trunk and chest at age 9 days. Shortly after this lesions appear on the hard palate. These develop into pustules with an erythematous base which soon erode, leaving a shallow ulcer. The pustules all resolve after four weeks with no scarring. Given the distribution of the vesicles and oral/baccal involvement, the most likely diagnosis is Herpes Simplex Virus, transmitted from the mother perinatally. Treatment is with IV aciclovir for 3 weeks in disseminated disease or CNS involvement. Complications include severe hepatitis, CNS involvement, ocular disease and neurodevelopmental delay.

Difficult to spot - Amelanotic Melanoma. Included in this weeks 'Picture Story' in the BMJ. A 45 year old woman presents with an 8 month history of a mildly pruritic lesion on her left thigh, measuring 1cm in diameter and with no dark pigment. Dermoscopy revealed scattered dotted vessels and no pigment network. Skin biopsy was carried out and histology revealed an amelanotic melanoma. These count for 2-8% of malignant melanomas and should be considered in the differential diagnosis of a new, red evolving patch or nodule.

Research:

Evidence for organic food lacking - A published article in the Annals of Internal Medicine this week looks at the evidence for organic food - and finds it lacking. A review of five studies of patients who ate only organic food looked at clinical outcomes. Apart from higher phosphorous levels and a 30% lower risk of contamination with pesticide residue, there were no differences in nutritional biomarker levels between patients eating organic vs non-organic food.

Longer resuscitation pays when cardiac arrest occurs in hospital - I feel like this is pretty topical given that I've just completed my ALS course, but a study published in the lancet this week reports that in an observational study of 64,339 cardiac arrests in US hospitals, survival to hospital discharge was more common in patients who were resuscitated for longer. One could speculate a number of reasons why this may be the case but perhaps we should be continuing CPR for longer. In 15.8% of cases resuscitation attempts lasted less than 10 minutes. Patients without systolic activity or a pulse had the worst outcomes. There was no difference in the proportion of patients who were discharged without major neurological impairments.