BAD Annual Meeting in Glasgow

The British Association of Dermatologists annual meeting was held in Glasgow this year from 1st - 3rd July with a huge variety of speakers from local and international dermatology departments. Sessions I attended were the BADGEM (British Assocaiation of Dermatologists Dermatology & Genetic Medicine) meeting, the main plenary session on the Tuesday afternoon, the 'Professors and Registrars' forum and the continuing professional development session as well as a couple of smaller 'break-out' sessions focusing on more specific topics.

The BADGEM meeting was the first of it's kind. Of particular note was the talk given by Professor Edel O'Toole on 'What's new in keratodermas' since there was some overlap with the Clouston Syndrome case reports which I have been working on recently. Another inteesting talk was the 'XP and DNA Repair' talk given by Dr Robert Sarkany, where he described the national xeroderma pigmentosum multi-disciplinary clinic which has been set up serving patients from around the whole of the UK suffering from this rare inherited skin disease.

The main plenary session lecture which I felt was of most interest was the talk given on 'Vitiligo - an Indian perspective' by Professor Amrinder J Kanwar about the huge amount of research which his team has undertaken to tackle the problem of vitiligo in India where it has a high prevalence and carries a significant socioeconomic burden. The Professors and Registrars forum is split between invited and submitted talks, often from registrars who have completed PhD work. It's both interesting and inspiring to hear about the work being carried out by dermatology registrars and certainly continues to encourage me in thinking about engaging in research at a later stage in my career.

In the final session, continuing professional development, Dr Rachel Clark from Boston gave a fascinating lecture entitled 'The magic and mayhem of human skin resident T cells' and talked about their role in health and skin disease. All in all a very successful conference in Glasgow and I hope to be able to attend the event next year where it will take place in Manchester.

Quality Improvement Projects - Further Information

Glencoe from the Devil's Staircase

Looking down towards Kinlochleven

Just back from walking the West Highland Way and Ben Nevis during a of annual leave: stunning scenery, here are a couple of photos.

Before leaving, I attended a one day course held by NES on 'Quality Improvement Training' at the Campanile Hotel in Glasgow. This course was a joint meeting for hospital and GP trainees which was designed to give an introduction and starting platform for developing new quality improvement projects. The course covered a lot of the theory of quality improvement, with the morning focusing on leadership skills and the afternoon spend discussing practical methods used to undertake projects such as criterion based audit, care bundles and PDSA (plan, do, study, act) cycles. 

Some of the theory was revision of material which I had covered before but it was much more in-depth and added more understanding. The plan for all of the doctors who attended this course to use the skills learnt to carry out an improvement project over the coming months in their place of work, and then to write-up the findings for submission to the BMJ's Quality Improvement Journal which I intend to do in the summer. I would definitely recommend this course to anyone interested in learning about QI methodology - here is the website link for further information. In addition here are some links to further QI resources which may be of interest.

BMJ Quality Improvement Website: http://quality.bmj.com

Quality Improvement Hub for NHS Scotland: http://www.qihub.scot.nhs.uk/default.aspx

Institute of Healthcare Improvement: http://www.ihi.org/Pages/default.aspx

Scottish Patient Safety Programme: http://www.scottishpatientsafetyprogramme.scot.nhs.uk/programme

Psoriasis: Comparing Biologics in Treatment and Incidence of Malignancy / Infections Compared to the General Population

Updates from the BJD February 2014

Incidence rates of malignancies and infections in psoriasis 

This paper is published in the BJD this month in the epidemiology and health services research section. It looks at comparing groups from the general population, those with psoriasis receiving treatment and those with psoriasis who are not receiving treatment, comparing the incidence of malignancies and hospitalised infectious events in patients in the USA (2005 - 2009). The findings reveal that there are higher rates of both in patients with psoriasis, however it is unclear as to whether these higher rates are associated with an underlying inflammatory state, treatments being given or perhaps both. The authors of the study wrote in their conclusions that the elevated rates of malignancy and serious infections found in patients with psoirasis may be due to biological reasons, since there was little difference in rates between treated and untreated groups. A lot is already known about the risk of cardiovascular disease in patients with psoriasis but this study adds more weight to the evidence of risk of other disease processes such as susceptibility to infections and malignant disease. 

Kimball AB et al. Incidence rates of malignancies and hospitalised infectious events in patients with psoriasis with or without treatment and a general population in the USA: 2005-2009. Br J Dermatol 2014; 170:366-373

Efficacy and safety of systemic treatments for moderate to severe psoriasis

This second paper published in the BJD in February is a systematic review of randomised controlled trials comparing the efficacy and safety of biologics used to treat psoriasis. The PASI (psoriasis area and severity index) was used as the primary measure of efficacy (at week 8-16). 48 RCTs were included in the review (total of 16,696 patients) and the conclusions for the authors were that both qualitative and quantitative outcome evidence was much stronger for patients receiving biological, compared with conventional treatments. Unfortunately, safety of treatments could not be pooled and this was due to a lack of standardisation of reporting across the trials. This shows that more work needs to be done to assess the safety of biologics and this can be achieved through a standardisation process for how safety events (rates of adverse events and withdrawals) are reported. 

Schmitt J et al. Efficacy and safety of systemic treatments for moderate-to-severe psoriasis: meta-analysis of randomised controlled trials. Br J Dermatol 2014; 170:274-304

The Checklist Manifesto (How to Get Things Right) - Review

I've just finished reading this book by Atul Gawande, the third book of his which I've read. He is a surgeon in Boston who lectures and teaches widely on patient safety and improving medical healthcare. His first two books 'Complications' and 'Better' looked at some of the common problems encountered in modern medicine and the stories of people trying to improve care.

This third book looks specifically at 'the checklist'. Atul Gawande was one of the team of professionals who helped develop the WHO Surgical Checklist - certainly as far as I'm aware, one of the best examples of how a simple checklist can help to make medicine safer. One of the chapters does focus on the WHO Surgical checklist including it's success and some of the barriers which had to be overcome for its implementation. But this book is not just about the WHO Surgical Checklist. He draws on examples from other professions, such as architecture, finance and the airline industry to show how simple checklists can help to ensure that in complex situations, important simple considerations are not forgotten, helping to reduce the frequency of errors.

The thing about checklists is that they are easy to create and design. All it takes is to look at errors which have been made and then try to put checks in place to stop them from happening. The difficult part is bringing them into practice, proving that they make things safer, overcoming the skeptics (there are always some!) and figuring out when and where to use these checklists. They also have to be designed in such a way that they are easy to use: not too long, not too short, readily available, with clear instructions about who is to use it and at what time. Is it a 'read-do' checklist (ie. do each task as the checklist is read), or a 'do-confirm' checklist (one where the task is completed and someone checks off the list that nothing has been missed). The results from the WHO surgical checklist in its initial trials were astonishing and Atul Gawande recalls in the final chapter about one of his patient's lives was saved when a check on the surgical list ensured that cross-matched blood units were available ('just in case') and a patient had a large unexpected haemorrage intra-operatively.

Checklists are starting to be introduced into medicine in the UK. A perfect example of how a checklist is being used in hospitals in Scotland is the 'Sepsis 6' checklist - a list of 6 simple tasks (oxygen, antibiotics, urine output monitoring, blood test for lactate level, intra-venous fluids and blood cultures) which should be completed in one hour for all patients diagnosed with sepsis - a common problem with a high rate of mortality if not treated rapidly.

The best way to introduce a checklist is via a small tests of change: 'plan, do, study, act' cycles. A checklist always requires modifications in the initial stages and testing in small numbers of patients at a time enables these tests to be observed. At the moment I'm trying to help introduce a 'ward-round checklist' in the medical wards to be used by doctors on ward rounds. I'd strongly recommend this book to anyone interesting in patient safety improvement.

Brugada Syndrome

The BMJ 'Picture Quiz' this week includes an interesting case scenario:

A young man is admitted to CCU with central chest pain which occurred two hours after an episode of epigastric pain. The chest pain was associated with vomiting, dizziness, shortness of breath and sweating but the pain resolved prior to hospital admission. Twelve lead ECG shows ST elevation that gradually descends into inverted T waves in V1/V2. Echocardiogram was normal. Later in the day, he becomes nauseated and pale with a transient episode of blurred vision, muffled hearing and paraesthesia but no chest pain on this occasion. His blood pressure drops to 89mmHg and the heart monitor shows a pause of 3 seconds before return of QRS complexes. He has recently been suffering from flu-like symptoms and has previously had episodes of syncope in the past. 

Brugada syndrome is an autosomal dominant inherited condition characterised by distinctive ECG changes causing arrhythmias, syncope and risk of sudden death due to ventricular arrhythmias. Clinical symptoms usually start in the 3rd / 4th decade of life and often occur during sleep. Diagnosis is based on ECG findings and clinical symptoms. Physical examination should be performed to rule out any other potential cause of syncope and imaging (ECHO) is required to rule out structural causes which may explain the patient's symptoms. An implanted cardioverter defibrillator is the definitive treatment for patients at risk. Advice for patients with Brugada syndrome is to avoid the development of a high fever and any arrythmogenic drugs. Electrolyte disturbances may also precipitate development of an arrythmia in these cases.