What does 'Dermatologically Tested' Actually Mean?

At the finish!

Peripheral Venous Cannula

Marathon completed - 3 hours, 30 minutes and 37 seconds of pain (probably) never to be repeated. Still smiling at the end though!

Peripheral Venous Cannulas - A new study published in the Lancet this week looked at whether there was a difference in the incidence of phlebitis in patients who had their cannulas re-inserted after 3 days, compared to those where they were left alone. There was no greater incidence in phlebitis in either group. This could lead to an end of unnecessary replacement of IV cannulas on the wards. I think that the most important way to reduce risk of phlebitis and bloodstream infection is good, clean and sterile technique on insertion but I agree with the study conclusion that clinical judgement is the best way to decide if a cannula needs replaced.

'Gut Feeling' About Serious Infections in Children - This was an interesting study which asked whether 'gut feeling' had any merit in identifying acutely unwell children with normal parameters. The study researchers found that in children with a reassurring clinical assessment, serious illness was 25 times more likely in with gut feeling - parental concern was the feature most strongly associated with gut feeling. I expect that the 'gut feeling' principle could be extended to adults.

Is patient education the key to longevity? - As the competition rages for the election of the next US president, the observations column in the BMJ this week comes from America. Studies carried out across the pond have led to claims that education could actually be the fundamental cause of better health and longer life. According to the New York Times, poorly educated Americans die younger and life expectancy of those lacking a high school diploma is actually getting shorter. As doctors there may not be an awful lot that we can do to improve the education and economic status of a nation, however it may affect opinions when it comes to voting for future local and national elections.

Medicine and the Media - "Dermatologically Tested" - What does this phrase mean? I don't know, but I've seen it a lot on advertisements and skin products. Another doctor investigated further by getting in touch with several of the companies who promote their products in this way, such as Boots, Johnson and Johnson, Persil etc and found that they were reluctant to describe the testing processes which lead to these tags, quoting reasons such as 'commercial confidentiality' as the reasons for non-disclosure. It seems that there is not a common standard required to meet this label and that often it just means that there is an absence of proved harm, rather than evidence of benefit. There is a great deal of inconsistency in what these labels mean but currently a European Commision is working on a paper for creation of common criteria for claims made by cosmetic companies.

Long QT Interval - An interesting learning point. Long QT syndrome can lead to sudden cardiac arrest in previously asymptomatic individuals. It can either be genetic or caused by severe electrolyte imbablances and several drugs. A history of syncope or previous cardiac arrest are the strongest predictors of sudden cardiac death. A QT interval of greater than 450ms in males and 460ms in females is considered to be abnormal. The best ECG leads to measure the QT interval are II, V5 and V6.  In outpatients a beta-blocker should be prescribed and a pacemaker fitted with strenuous high intensity exercise avoided. First degree family members should undergo genetic screening for the condition.

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. 

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.