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.

Merry Christmas and Happy New Year!

That time of year again! A chance to wish everyone Merry Christmas and all the best for 2014!

MRCP Part 2 Notes

Three weeks today until Christmas - one week until Part 2! Managed to do some case-based learning sessions this afternoon with the Glasgow medical students up at the university (psoriasis & acne) then have got a further two cases to cover on Friday (melanoma and alopecia). The big news in Glasgow this week was of course the tragic helicopter crash at the Clutha pub in town which left 9 people dead - my thoughts go to all of the emergency workers involved in the aftermath of the crash and condolences to those who lost loved ones.

Some MRCP revison notes - this week taken from sample questions on the MRCP website:

Brugada Syndrome: A 26 year old is referred for assessment after their brother suffers a sudden cardiac death age 32. ECG shows sinus rhythm with a partial RBBB pattern and elevation of the ST segment in V1/V2. This history would be characteristic for Brugada syndrome. There may be no evidence of LVH. The condition is inherited in an autosomal dominant manner and there is an increased risk of cardiac death in these patients due to ventricular arrhythmias. 

Minimal-Change Nephropathy: A 22 year old man presents with leg swelling, chest pain, thrombosis and a right basal perfusion defect. What is the likely renal diagnosis? Minimal-change nephropathy. Treatment of this condition with corticosteroids often leads to a rapid resolution in symptoms. NB. In a patient with visible haematuria the most important investigation is cystoscopy to rule out bladder cancer, other investigations would only be carried out once the result of the cystoscopy was known.

Phenytoin overdose: Classical presentation would be with inco-ordination, slurred speech, reduced GCS and nystagmus. Serotonin Syndrome: Classic presentation is with agitation, hyperthermia, tachycardia and severe hypertension with neurological involvement (malignant hyperthermia is usually associated with anaesthetics whilst neuroleptic malignant syndrome typically presents with a 'lead-pipe' rigidity.

Basilar Migraine: Typical presentation would be an 18 year old woman with transient bilateral blindness, slurred speech, a severe occipital headache and neck stiffness.

 

Rheumatoid vasculitis: A 70 year old woman with a 20 year history of rheumatoid arthritis presents with weakness of the right leg and numbness of the right hand with foot drop and a sensory peripheral neuropathy. Examination reveals nail fold infarcts. This presentation has the appearances of a systemic vasculitis and in a patient with such long-standing RA, rheumatoid vasculitis would be the most likely diagnosis to consider. 

TB Diagnosis: The diagnosis relies on culturing of mycobacterium tuberculosis and bronchoscopy will produce the best specimen for acid-fast staining and mycobacterial culture. Routine sputum microscopy and culture will not isolate mycobacterium tuberculosis.

Blood transfusions in Hodgkin's Lymphoma: There is a risk in these patients of transfusion-associated graft vs. host disease (in immunocompromised individuals). These patients should receive X or gamma-irradiated blood. CMV seronegative products are reserved for CMV sero-negative individuals while HLA-matched platelets are used for patients refractory to platelet transfusions or in those who have developed anti-HLA or anti-platelet antibodies.

Some of the Issues Facing our NHS Today

We're in the new house! I now know that night shifts and moving house are a pretty bad combination but having a week off afterwards makes it all worth it. Move in was on Saturday, last box unpacked by Tuesday and the inevitable IKEA trip on the Wednesday. Still had a pot of cash left over from wedding presents so put that to good use. Only thing still missing is the curtains so that's a work in progress.

What's been going on over the past week... As ever, lots of NHS stories in the media, mostly coming from England and talks about big shake-ups to the way in which A&E services will be set out in the coming years, with a focus on greating fewer 'major' A&E departments which will cater for "heart attacks, strokes and major trauma", with a sub-section of 'minor' A&E departments. An interesting prospect, since centralisation of services seems to be a growing trend at the moment, although there are a lot more urgent conditions which have to be considered beyond what has been described here and a lot of clarification is needed. One reporter talked about the success of the recent changes (locally) in Forth Valley where two A&E departments and acute medical receiving units were combined to create one larger unit which was better staffed and has resulted in better patient outcomes.

Much of the talk about A&E seems to revolve around how to reduce the 'pressures on A&E' and there is a lot of talk about how the government's '4 hour waiting targets' were missed in many cases last year. There are still a lot of inappropriate attendances to A&E but the question is how can this be avoided? In Scotland we have an excellent GP out-of-hours service, which enable patients to see a GP out-with practice working hours. Although Amy assures me that GP OOH is very busy, I still feel that this has to be an under-utilised service. I think that a lot of people don't know that GP OOH exists and this leads to more A&E presentations. The GP service runs well so we need to direct more patients to it. Most GP OOH units are attached to A&E (often in the next building). Maybe GPs working out-of-hours could work at the front door of A&E departments to direct patients to the correct places (A&E or GP). GPs are often called the 'gate-keepers' to secondary care so why can't this extend to A&E attendances out-of-hours? The GP contracts have also been 're-drawn this week to reduce the amount of work on meeting targets and increase the amount of time GPs can spend with their patients.

On another note, the Royal College of Physicians of Edinburgh this week held a conference to address improving acute hospital services under times of increasing pressures. The Scottish government this year created a £50 million emergency care "action-plan" to speed up admissions and create more opportunities for treatment in the community. The recommendations from the college were as follows:

• An extension of seven day working by clinicians and support services in hospitals and the community in order to meet demand.
• Working towards "eliminating boarding" (patients being moved to wards inappropriate for their care during busy periods.
• Patients being seen immediately by the right, competent, clinical decision makers.
• A named professional responsible for the patient's care.
• Every acute medical receiving unit to have a dedicated multi-disciplinary team.

Many of these measures are already in place already, such as the named consultant responsible for a patient's care and extension of the working week. I feel that the extension of the working week has to apply to the specialties allied to medicine, such as physio, OT, social work etc. because often I find patients whose medical treatment is completed but are awaiting on-going physio and OT input prior to discharge. If this is the case on a Friday, there is often no progress by the next Monday, and there have been two more days spent in a hospital acute bed. There is no quick fix to improving services in our hospitals but it's reassuring that lots of work is being done to try to tackle these important issues.