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.

Adrenal Crisis, Public Health and Unilateral Leg Swelling

I thought that things were looking very Autumnal today when I was in Aberfoyle today - hence the reason for the photo.

Interesting articles which I've been reading this week in the BMJ:

Adrenal Crisis - Since I've been revising endocrinology today for the MRCP, this article was particularly relevant. There are two serious hormone deficiency syndromes which if left untreated can be fatal. Everyone knows about the first one - diabetic ketoacidosis, but a lot less is known about acute adrenocortical insufficiency. This requires urgent treatment with hydrocortisone, IV fluids and correction of biochemical abnormalities. If steroids are stopped in patients on long term steroid treatment (Addisons Disease) or during periods of increased stress / illness, a crisis can occur. Clinical features include hypotension, shock, hyponatraemia and hyperkalaemia. One trick is to never ignore an informed patient's request for steroids. Chances are that they have Addisons Disease and are aware of the consequences of under-treatment. Peri-operative is also a dangerous time for patients with Addisons Disease if they are not being correctly managed. Adrenal crisis is regularly seen in patients with congenital adrenal hyperplasia as they are unable to mount a normal cortical response to stress. Adrenal crisis has been reported in patients on high doses of topical steroids. Patients on steroids should carry a 'Medic-Alert' card or bracelet. Doctors must not suddenly stop steroid treatment in patients who are admitted to hospital. Ideally a 'Red-Flag' system needs to be identified to alert staff when these patients are admitted.

Chocolate at the Checkout - In most shops when you get to the check out there is an array of tasty treats awaiting the consumer. Who hasn't picked up the odd chocolate bar or drink at the check-out!? The public health team have picked up on this and are suggesting that such sales technique should be removed to stop tempting people. Impulse buys are particularly common when patients are tired and stressed. Maybe we should put chocolate bars in special locked cupboard behind the counter (like cigarettes) if that's the case! I don't think that the supermarkets and shops are going to change their marketing techniques very quickly on this one but any idea is worth pursuing to help reduce the growing incidence of obesity in the UK.

Discouraging Health Checks - It seems like a good idea. 'Free health checks to all'. A definite political winner. However a review of 16 large trials of health checks to asymptomatic adults aged 40-74 found that checks were unlikely to save any lives. The problem with this I think is that it's always the healthy people who are the ones coming forward for these checks. These are not the people that need to be targeted in this type of public health campaign. How to engage the people who really need checks is the golden question which public health researchers are going to be forever scratching their heads about.

Swollen Leg in the Middle of the Night - Finally, this appeared in the 'Picture Quiz' section of the BMJ and just serves as a reminder of the importance of clinical examination and considering a differential diagnosis when the symptoms and signs just don't quite match up with what you're thinking about.

A doctor reviews a 47 year old man in the night who is complaining of leg pain and swelling of his right thigh. The doctor diagnoses a DVT and heparin treatment is started, pending a Doppler  ultra-sound scan to confirm the diagnosis. Examination isn't documented. A few hours later the patient is in agony and a second doctor comes to review. The patient now has cool peripheries, tachycardia, hypothermia and an area of violaceous discolouration on his thigh. An X-ray is performed, and the findings are in keeping with necrotising fasciitis (caused by a Clostridium sp. bacteria in this case). Urgent fluid resuscitation, transfer to HDU, broad spectrum antibiotics and surgical debridement is required.

Punctate Palmoplantar Keratoderma

Scientists in Dundee Discover the Gene which Causes Palmo-Plantar Keratoderma

I saw this story on the BBC News website this morning. Another key discovery from Irwin McLean's team in the epithelial genetics lab in Dundee as they have discovered the gene which causes punctate palmoplantar keratoderma. Similar to Pachyonychia Congenita, it is a disorder which causes kyperkeratosis, most commonly of the palms and soles. This can become very painful and debilitating if the lesions on the soles in particular are diffuse. The condition one of a group of disorders classified as 'palmoplantar keratodermas'. It is inherited in an autosomal dominant manner and it is estimated that approximately one in 15,000 people in the UK are affected by the condition. The gene was primarily discovered using whole-genome sequencing, much less time consuming than the 'old fashioned way' of testing for inherited mutations using repeated PCR (polymerase chain-reactions) in the lab. Whole genome sequencing is becoming faster, more accessible and cheaper at a rapid rate and is likely to have a major impact on medicine in the coming 50 years.

The article can be found at: Haploinsufficiency for AAGAB causes clinically heterogeneous forms of punctate palmoplantar keratoderma. E. Pohler et al. Nature Genetics (2012) doi:10.1038/ng.2444 Published online 14/10/12.

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.