Two years of experience with etanercept in recalcitrant psoriasis

BACKGROUND

The safety and efficacy of etanercept have been demonstrated in patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Placebo-controlled trials have indicated the efficacy of etanercept in moderate to severe psoriasis.

OBJECTIVES

To observe the efficacy and safety profile of etanercept in patients with severe psoriasis resistant to other systemic agents over a 2-year period.

METHODS

In this retrospective study, 49 patients were treated with etanercept between March 2004 and March 2006. All patients were screened for tuberculosis with tuberculin test and a chest X-ray. Thirty-nine patients started on etanercept 25 mg twice weekly (BIW) and 10 started at 50 mg BIW when judged to be clinically indicated. In 19 of those on 25 mg BIW, the dose was increased to 50 mg BIW because of poor response and psoriasis flaring. Response to treatment was assessed by Psoriasis Area and Severity Index (PASI) and static Physician Global Assessment (PGA). Patients were reviewed at 8-week intervals, when clinical response and adverse effects were noted.

RESULTS

Forty-four patients (90%) had chronic plaque psoriasis, two (4%) were suberythrodermic, one (2%) had palmoplantar pustular psoriasis and two (4%) had acrodermatitis continua of Hallopeau. At least 75% reduction in PASI was achieved in 47% of patients at week 24 and 66% at week 48. At week 24, 44% had a PGA score of excellent, and at week 48, 58% scored excellent. In 12 who cleared, etanercept was stopped. Ten of these relapsed and etanercept was recommenced, while two remained in remission (mean 12.5 weeks). One patient developed extrapulmonary tuberculosis.

CONCLUSIONS

Etanercept was effective in severe psoriasis recalcitrant to other systemic medication. The drug was well tolerated. Development of tuberculosis in one patient underlines the need for rigorous tuberculosis screening.

Three years' experience with infliximab in recalcitrant psoriasis

BACKGROUND

In this retrospective study, we report our experience with infliximab for recalcitrant psoriasis.

METHODS

Twelve patients were treated between September 2001 and April 2005. Infliximab 5 mg/kg was given at 0, 2 and 6 weeks followed by 5 mg/kg at 8-week intervals. When two patients developed resistance to treatment, methotrexate was added at a dose of 5-7.5 mg weekly for all patients. Response to treatment was assessed with physician global assessment with a score of excellent, good, moderate, poor and failure. Ten patients had chronic plaque psoriasis, one had pustular palmoplantar psoriasis and one had acrodermatitis continua of Hallopeau.

RESULTS

Nine patients, including the patient with acrodermatitis continua, showed an excellent response. Two patients initially showed good response but became resistant to treatment. One patient failed to respond, and treatment was discontinued. With time, six patients with excellent response and two with good response developed side-effects that necessitated stopping treatment.

CONCLUSIONS

We have found infliximab to be very impressive, both in efficacy and speed of action, in severe psoriasis. Its use, however, is limited, as it requires hospital admission and by the need for concomitant methotrexate. Because of its powerful immunosuppressive action, the possibility of activating tuberculosis and inducing lymphoma remains a concern.

Popliteal-to-distal artery bypass for diabetic limb salvage

BACKGROUND

Poor long-term survival and significant co-morbidity among diabetic patients with limb ischaemia makes the shortest, simplest revascularisation procedure desirable.

AIM

Evaluate limb salvage, primary graft patency and peri-operative morbidity rates in diabetic patients undergoing popliteal-to-distal artery bypass for limb salvage.

METHODS

Patients undergoing popliteal-to-distal artery bypass for critical limb ischaemia over a seven-year period were retrospectively identified. Patients operative and follow-up data were entered into a database and limb salvage and patient survival determined using Kaplan Meier survival analysis.

RESULTS

During the study period 21 popliteal-to-distal artery bypasses were performed on 19 diabetic patients. Mortality rate after one year was 11%. Primary graft patency rates among surviving patients was 81%, 67% and 48% at 1, 2 and 6 years respectively. Amputation was required in three patients.

CONCLUSION

Popliteal-to-distal artery bypass produces favourable results in high-risk diabetic patients with critical limb ischaemia.

Cataract blindness and visual outcome of cataract surgery in a tribal area in Pakistan

AIM

To estimate the rates of cataract blindness and cataract surgical coverage and to assess the visual outcome of cataract surgery among individuals aged > or =50 years in Orakzai Agency, Pakistan.

METHODS

1600 individuals aged > or =50 years were selected using probability proportional to size sampling. The main outcome measure was bilateral cataract blindness which was defined as visual acuity of <3/60 in the better eye with best available correction and with obvious central lens opacities/absence of red reflex in both eyes.

RESULTS

A total of 1549 people were examined; the coverage rate was 96.8%. Of individuals who were examined, 958 (61.8%) were men. The overall prevalence of bilateral cataract blindness was 4.8% (95% CI: 3.8% to 5.9%). Women had a 2.1-fold greater prevalence of bilateral cataract blindness than men (7.1% (5.0% to 9.2%) v 3.4% (2.3% to 4.6%); p = <0.0001). However, cataract surgical coverage rates were lower for women than men. The overall quality of previous cataract surgery was poor: 43.1% eyes with cataract surgery had VA <6/60. 73.3% people with bilateral cataract blindness reported they could not undergo cataract surgery because they were too poor to afford its cost.

CONCLUSION

The unacceptably high rates of cataract blindness and poor affordability and visual outcome of cataract surgery calls for the establishment, in the agency, of static cataract surgical services that are high quality, affordable, and gender sensitive.

Bullying of junior doctors prevails in Irish health system: a bitter reality

Workplace bullying in health systems is a well known fact. It leads to not only breakdown in teamwork but also has significant affect on the individual's personal life. True prevalence of bullying in junior doctors working in Ireland is unknown. Our aim of study was to find out the prevalence of bullying in junior doctors working hospitals in south and western counties of Ireland and to assess its effects on the productivity of work and family life and to identify the common source of bullying. We carried out a questionnaire survey. A total of 950 questionnaires were sent. Response rate was 51%. Our sample is 15% of the target population of all the hospital junior doctors. 30% of the responders claimed to be subjected to one or more bullying behaviors. Doctors from European Union (EU) reported significantly less rate of bullying compares to non EU doctors. Our results are in line with the results of studies conducted in United Kingdom. This study shows the magnitude and source of the problem. We conclude that bullying is a common problem in Irish health system. Increased awareness and zero tolerance are required to eradicate bullying.

Cutaneous sarcoidal reaction in a patient with pulmonary tuberculosis

Sarcoidosis is a systemic disorder characterized by non-caseating epithelioid granulomas that may affect any organ system. The etiology of sarcoidosis is unknown, but several immune aberrations are thought to play a role in its pathogenesis. The possible role of mycobacterial infection in the pathogenesis of sarcoidosis has been suggested. In recent studies mycobacterial DNA was detected in lung tissues and bronchial lavage fluid of 30% to 50% of patients with sarcoidosis. We report a patient with pulmonary tuberculosis treated successfully three years earlier who developed cutaneous sarcoidosis with negative polymerase chain reaction (PCR) assay for mycobacterial DNA of the skin lesion.

Accuracy of admitting diagnosis in acute surgical patients by non consultant hospital doctors

The incidence of accurate diagnosis made by non-consultant hospital doctors (NCHDs) is unknown in acute surgical admissions. There is a common assumption that reliance is made on excessive and inappropriate investigations. The aim of study was to assess the accuracy of admitting diagnosis by the NCHDs and the appropriateness of radiological investigations ordered. Data were collected on 100 consecutive acute surgical admissions. A final diagnosis was made in all the patients. 79 patients had accurate initial diagnosis (NCHDs). 23 scans were performed which confirmed the initial diagnosis. Out of 21 initial inaccurate diagnoses, final diagnosis was made on repeated clinical examination in 10, on imaging alone in 5 and by endoscopy or surgery in the remaining 6 patients. 11 patients had scans and 7 were appropriate. We conclude that 79% of diagnoses made by NCHDs are the accurate final diagnoses. The utilization of diagnostic modalities especially radiological imaging is highly appropriate. Our study suggests that the physical presence of a consultant on site may not lead to significant improvement to the delivery of health care to the Irish population.

Pakistan’s experience of a bioterrorism-related anthrax scare

From November 2001 to March 2002, the National Institute of Health, Islamabad, Pakistan, received 230 samples from 194 different sources for analysis for anthrax spores. These samples were taken from letters/packages suspected of containing anthrax and from individuals exposed to them. When cultured on sheep blood agar, 141 samples yielded growth suggestive of Bacillus species. On the basis of growth characteristics, absence of beta-haemolysis, absent or doubtful motility and morphological characters of the isolates on Gram stain, 62 isolates were considered suspicious and were inoculated into guinea-pigs. Inoculated animals remained healthy well beyond the required observation period of 5 days. All the samples were therefore reported as negative for B. anthracis. Systems for h and ling and analysing suspected anthrax-contaminated materials are discussed

Pakistan's experience of a bioterrorism-related anthrax scare

From November 2001 to March 2002, the National Institute of Health, Islamabad, Pakistan, received 230 samples from 194 different sources for analysis for anthrax spores. These samples were taken from letters/packages suspected of containing anthrax and from individuals exposed to them. When cultured on sheep blood agar, 141 samples yielded growth suggestive of Bacillus species. On the basis of growth characteristics, absence of beta-haemolysis, absent or doubtful motility and morphological characters of the isolates on Gram stain, 62 isolates were considered suspicious and were inoculated into guinea-pigs. Inoculated animals remained healthy well beyond the required observation period of 5 days. All the samples were therefore reported as negative for B. anthracis. Systems for handling and analysing suspected anthrax-contaminated materials are discussed.