Aspirin for VTE, CABG and Fasting Lipids

Plenty of interesting research published this week and reviewed in the BMJ:

Aspirin Prevents Recurrent Venous Thromboembolism (N Eng J Med 2012; doi:10.1056/NEJMoa1210384) - At the moment gold standard treatment following VTE involves oral anticoagulation with warfarin after which treatment is either stopped altogether, or continued with increased risk of bleeding. Now research has been published which shows that long term treatment with aspirin may be good alternative to stopping altogether. Aspirin was shown in a placebo controlled trial to reduce the risk of major cardiovascular events in this group of patients although it did not significantly reduce the rate of VTE recurrence. Aspirin is cheap, easy to take, does not require monitoring and has a reasonable safety profile.

CABG not PCI for Adults with Diabetes (N Eng J Med 2012; doi:10.1056/NEJMoa1211585) - A newly published trial compared CABG vs. PCI in patients with diabetes and multivessel coronary artery disease and found that those treated with CABG lived significantly longer and had significantly fewer MIs than those treated with drug eluting stents. PCI has rapidly overtaken CABG as the most commonly used treatment for multi-vessel disease in the UK due to its increased affordability and availability, however this research may suggest that in patients with diabetes, CABG is still the gold-standard treatment and results in better outcomes.

Is Fasting Necessary before Lipid Tests? (Arch Intern Med 2012; doi:10.1001/archinternmed.2012.3708) - I recently asked a patient to attend the dermatology department for fasting lipids and this article caught my attention. Fasting overnight is inconvenient for the patient and unpleasant. A cross-sectional analysis of 209,180 results from Canada shows that overnight fasting makes little difference to total cholesterol and HDL cholesterol. The study adds to evidence that fasting may not offer any benefit for the patient or doctor in terms of predicting risk of cardiovascular disease.

And finally...interesting fact for the day - in pregnancy, 80% of DVTs occur in the left leg. Why? Well the reason for this is that pregnancy is a hypercoagulable state and this is exacerbated by venous stasis. This occurs when the gravid uterus obstructs the IVC, causing decreased venous tone in the legs, which is greater in the left leg than in the right.

In Defence of the Liverpool Care Pathway

Liverpool Care Pathway:

In the past couple of weeks the Liverpool Care Pathway has come under attack from the press with a number of damaging and critical headlines, such as accusations that the pathway is being used to kill terminally ill patients. The Liverpool Care Pathway was first described in 2004 as a means for allowing the rapid discharge home of the dying patient. It is now used in hospitals throughout the UK and has transformed the way end of life care is achieved in the UK. It was recognised that many patients terminally ill patients were dying in acute hospital wards before they could be transferred to a hospice. Before the introduction of the pathway, there was a lack of common consensus about the best way to ensure that patients at the final stages of life are kept comfortable and that distress is alleviated. All of the negative publicity focused around the pathway appears to be that it hastens death through withdrawal of fluid and nutrition. The pathway does not preclude artificial hydration but seeks to prevent harmful interventions such as IV cannulation which will be harmful and not in the best interests of the patient. These headlines have consequences for doctors, patients, families and healthcare staff. Scaremongering could lead to fears from doctors about using appropriate analgesia and reluctance to use the LCP, leading to more painful deaths. The LCP does have the flexibility to be rescinded if clinically appropriate (occurs in approximately 4% of cases). Fortunately a number of organisations have rallied in support of the LCP following these allegations and having been involved in use of the LCP in hospital I too am in favour and hope that there is an end to the irresponsible journalism which has led to this situation.

Content Area Experts for Reviews:

A couple of weeks ago I was discussing with one of the dermatologists about which article or topic to include for a 'journal club' discussion. One option would be to present a 'meta-analysis' or systematic review of a clinical topic. The purpose of this is to draw together and summarise all of the available evidence. I was surprised to hear that in some cases an expert in a field is asked to write the publication, while in others it may be someone who has no expertise in the field who writes the paper. Systematic reviews often include experts as authors, however this may be create bias. No studies exist which look at whether is is harmful or helpful to have content area experts as authors. Potential benefits could be inside knowledge of unpublished trials. Potential harms include strong opinions due to prior personal experience and differences in conclusions between specialists in the same field. An article in the BMJ this week argues against using experts in systematic reviews and this is not something which I had thought about before now. I assumed that it was always area experts who wrote reviews but I can see the reasons why this may not always be beneficial.

Psoriasis - New NICE Guidelines

The BMJ this week includes an article on summary of the new NICE Guidelines on assessment and management of Psoriasis. This common inflammatory skin condition affects 1.3-2.2% of the UK population and can be associated with psoriatic arthritis. It can have a serious impact on social, functional and psychological morbidity which is often under-recognised. This often occurs despite very effective treatments available to help improve outcomes.

Recommendations:

• A single point of contact for people with all types of psoriasis to aid access to appropriate information. 
• Assessment should include a 'physician's global assessment' and a 'patient's global assessment', body surface area affected, involvement of nails or difficult to treat areas eg. scalp, any systemic upset. Ask about how a patient's daily living is affected, how they are coping with their skin condition, and if any treatments are being used. 
• Indications for referral: diagnostic uncertainty, a severe or extensive type of psoriasis eg >10% body surface area, cannot be controlled by topical therapy, acute guttate psoriasis requiring phototherapy, nail disease with functional/cosmetic impact, psoriasis with major impact on social/psychological/physical well-being. Also any type of psoriasis in children and urgent/same day assessment for generalised pustular psoriasis/erythroderma.
• NICE recommend the Psoriasis Epidemiological Screening Tool for assessment of psoriatic arthritis.
• Cardiovascular risk assessment at presentation for adults with severe psoriasis of any type.
• Offer topical treatments as first line, followed by 2nd/3rd line if these do not succeed. Offer practical support and advice about the use and application of topical treatments delivered by trained healthcare professionals. 
• Arrange a review appointment after starting a new topical treatment (4 weeks in adults, 2 weeks in children).
• Phototherapy - offer narrowband UVB to patients with plaque or guttate psoriasis that cannot be controlled with topical treatments alone.
• For systemic, non-biological therapy the following conditions must be met: psoriasis cannot be controlled with topical therapy, it has a significant impact on physical, psychological or social wellbeing, is extensive (>10% body surface area affected) or localised and associated with significant functional impairment, or not suitable for phototherapy.
• Methotrexate should be offered as first line systemic treatment except if contra-indicated or the patients meet the criteria for ciclosporin (rapid or short term disease control, palmo-plantar pustulosis, considering conception and systemic therapy cannot be avoided).

I'll be presenting a summary of the new NICE Guidelines on Psoriasis and comparing them with the recent SIGN guidelines on psoriasis at a the dermatology journal club meeting on the 22nd November.