Central Middlesex Hospital

Background: Despite advances in pharmacologic management, achieving sustained remission in rheumatoid arthritis (RA) remains challenging, particularly among patients who exhibit suboptimal responses to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) such as methotrexate (MTX). The emergence of targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs), including Janus kinase (JAK) inhibitors, has expanded therapeutic options by directly modulating intracellular signaling pathways central to inflammation and immune activation. Among these, tofacitinib has demonstrated efficacy in clinical trials, yet its real-world performance, safety profile, and predictors of treatment response are less clearly defined. Real-world data, reflecting diverse patient populations and routine clinical practice, are essential for complementing randomized controlled trials (RCTs) and for guiding evidence-based, individualized treatment strategies in RA management.Methods: This retrospective real-world study included 450 RA patients treated with tofacitinib following MTX failure. Demographics, clinical characteristics, laboratory results, treatment history, and comorbidities were assessed. Outcomes included changes in disease activity score 28 (DAS28), Health Assessment Questionnaire (HAQ), pain, and stiffness at six months, along with adverse event monitoring. Exploratory data analysis and machine learning models (logistic regression, random forest, XGBoost, LightGBM, and support vector machine {SVM}) were applied to predict treatment response.Results: The mean age was 51.2±12.4 years, with 236 females (52.4%). At six months, DAS28 decreased significantly (5.4±1.1-3.2±1.0; p<0.001), with 286 patients (63.6%) achieving low disease activity and 142 patients (31.6%) reaching remission. HAQ improved from 1.5±0.6 to 0.9±0.5 (p<0.001). Adverse events occurred in 132 patients (29.3%), mostly mild infections. Machine learning models identified CRP, disease duration, and baseline DAS28 as key predictors; however, the predictive performance for treatment response was generally limited, with most models showing area under the curve (AUC) values below 0.65.Conclusion: Tofacitinib demonstrated significant clinical benefit in RA patients with inadequate MTX response, with acceptable safety. While machine learning highlighted key predictors, future work with larger datasets is needed to optimize predictive accuracy and personalize therapy.

Background: Rheumatoid arthritis (RA) refractory to conventional synthetic disease-modifying anti-rheumatic medications (DMARDs) remains a therapeutic challenge, necessitating the use of biologic agents such as tocilizumab.Objective: To prospectively evaluate the efficacy of tocilizumab in reducing disease activity, measured by DAS28 (ESR), and to assess its safety in terms of adverse events over a six-month follow-up in a real-world South Asian cohort.Methodology: This prospective observational study was conducted at the Department of Rheumatology, Abbas Institute of Medical Sciences, Muzaffarabad, over a two-year period (June 2022-May 2024). A total of 192 patients meeting the 2010 ACR/EULAR RA criteria, with inadequate response to at least two csDMARDs, including methotrexate and a baseline DAS28 (ESR) ≥5.1, were enrolled. Tocilizumab (4-8 mg/kg) was administered intravenously every four weeks for six months. DAS28 scores were recorded at baseline, 12 weeks, and 24 weeks. Safety was assessed through serial laboratory monitoring and systematic documentation of adverse events.Results: Of the 192 patients (77.08% female; mean age 44 ± 10.6 years), the mean DAS28 score decreased from 5.91 ± 0.42 at baseline to 3.76 ± 0.59 at 12 weeks and 2.43 ± 0.71 at 24 weeks (p < 0.001). Remission (DAS28 ≤ 2.6) was achieved in 112 patients (58.33%), while 58 (30.21%) showed partial response and 22 (11.46%) had no response. Adverse events were reported in 52 patients (27.08%), most commonly infections, lipid abnormalities, and gastritis.Conclusion: Tocilizumab is a highly effective and generally well-tolerated treatment option for RA patients unresponsive to csDMARDs, though longer follow-up and controlled comparisons are needed to confirm long-term safety and causality.

Faecal calprotectin (FC) is a marker of gastrointestinal (GI) inflammation that is widely used in primary care to identify patients who need to be referred for endoscopic assessment. Most guidelines advise against its use in older adults because of higher rates of colorectal cancer (CRC) in this group, and many studies include only younger adults, even though FC is still used in older adults. To evaluate FC performance in identifying inflammatory bowel disease (IBD) and significant organic pathology in adults aged ≥50 years, to help inform its use and interpretation in primary care. Where available, faecal immunochemical test (FIT) data were also analysed. A retrospective observational study of patients who were referred from primary care to secondary care for colonoscopy at Imperial College Healthcare NHS Trust. Patients who had undergone FC testing, followed by a colonoscopy, were recruited and grouped into younger adults (aged 18-49 years) and older adults (aged ≥50 years). Data were then collected using electronic health records to allow for analysis of FC diagnostic performance. In total, 669 patients were included: 423 aged 18-49 years and 246 aged ≥50 years. There were no significant differences in FC levels between the groups (median FC level: 71 µg/g versus 85.5 µg/g respectively, P = 0.29). An FC level of >50 µg/g showed a high sensitivity for inflammatory bowel disease (IBD) in both groups (94.1% in those aged 18-49 years and 93.8% in those aged ≥50 years), but the positive predictive value was low - particularly in those aged ≥50 years (12.8%) versus the younger cohort (20.9%). An FC level of >50 µg/g outperformed FIT (threshold 10 µg/g) for the diagnosis of IBD and organic pathology in both groups. However, in patients aged ≥50 years, FIT outperformed FC at 150 µg/g for the diagnosis of organic pathology, including CRC. These data show that FC remains a sensitive test in older adults. FC may have a role as a 'rule-out' test in adults aged ≥50 years who have lower GI symptoms and a negative FIT, when CRC is not suspected.

BackgroundWith 20–40% of patients who have inflammatory bowel disease (IBD) not responding to therapy, resource use and costs can be high. We performed a descriptive analysis of health-care data for IBD management in the National Health Service to explore potential areas for improvement.MethodsIn this exploratory study, we analysed real-world data from the Discover dataset for adults with a diagnosis of incident IBD recorded in northwest London, UK, between 31 March, 2016, and 31 March, 2020. We compared mean visit numbers and primary and secondary care costs per patient to examine resource use and costs for active disease versus remission.ResultsWe included 7,733 patients (5,872 with ulcerative colitis [UC], 1,427 with Crohn’s disease [CD], and 434 with codes for both [termed IBD-undefined in this study]). Remission was recorded in 19,218 (82%) of 23,488 observations for UC, 4,686 (82%) of 5,708 for CD, and 1,122 (65%) for IBD-undefined observations. Health-care resource use was significantly higher with active disease in all settings except primary care for UC. Total health-care costs were greater with active disease than remission for all diagnoses (all p < 0.0001). The main driver of costs was inpatient hospital care among those with active disease; elective inpatient costs were high among patients with UC and IBD-undefined in remission.ConclusionsHigher health-care resource use and costs were observed with active disease, which underscores the importance of early induction and maintenance of remission in UC and CD. Updated strategies that incorporate treat to target may offer cost benefits by the offsetting of biologic drug costs with a reduction in costly inpatient hospital stays.Trial registrationThis trial was not registered as it used pseudonymised retrospective data.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12876-024-03559-3.

Abstract BackgroundTherapeutic management of hair loss is frequently complicated by a lack of high‐quality evidence and reliant on the use of unlicensed therapies. Treatment decision‐making is predominantly based on expert opinion, local availability, personal experience, and cost, which make informed choices challenging for clinicians and patients in this area.ObjectivesThe aims were to determine prescribing patterns amongst UK Dermatologists with a special interest in hair disorders, when treating mild‐moderate alopecia areata (AA), severe AA (including alopecia totalis/alopecia universalis), female pattern hair loss (FPHL) and frontal fibrosing alopecia (FFA).MethodsConsultant members of the British Hair and Nail society, a special interest group affiliated to the British Association of Dermatologists, were invited to participate from across the United Kingdom. Participants were questioned on their current prescribing patterns in both NHS and private practice, were asked to rank their first‐to‐fifth line treatments for each condition and highlight the treatment they perceive as most effective for each disorder.ResultsTwenty‐six Consultant Dermatologists completed the questionnaire, from twenty‐three institutions. For treatment of mild‐moderate AA, topical corticosteroids were used first line amongst 65% (n = 17) of respondents, and 82% (n = 23) reported that intralesional corticosteroids were the most effective treatment. For severe AA, oral corticosteroids were used first line amongst 38% (n = 10) of respondents, and 25% (n = 8) reported that oral corticosteroids were the most effective treatment. For FPHL, topical minoxidil was used first line amongst 84% (n = 25) of respondents, and 42% (n = 10) reported that oral minoxidil was the most effective treatment. For FFA, topical corticosteroids were used first line amongst 62% (n = 16) of respondents, and 37% (n = 14) reported that hydroxychloroquine was the most effective treatment.ConclusionsThis study reports real‐world prescribing practices amongst dermatologists treating common hair loss conditions. These results aim to support clinicians with decision making for managing hair loss conditions.

Pearl Avery and Lisa Gower write about their experience of their first RCN Congress in Wales 2024. Pearl and Lisa went to Newport this year to represent the Gastrointestinal Forum at the RCN Congress; this was Pearl's first attendance in 23 years of membership. Although neither attended for the entire event, both discuss their views and enjoyment of the experience.

Abstract Surgical site infection (SSI) is frequently associated with adverse patient outcomes. SSI is often perceived as a preventable complication following elective surgery, and a wide array of strategies have been reported to reduce its occurrence. Despite this, colorectal surgery continues to have among the highest incidences of SSI, and there is considerable variation in the use of evidence-based practices in its prevention. There are currently no systematic reviews describing the full range of interventions to reduce SSI across the perioperative period of elective colorectal surgery. To determine which perioperative interventions are effective in reducing SSI following elective colorectal surgery. A systematic search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science databases as well as grey literature sources will be performed. Data extraction, risk of bias assessments and narrative synthesis will be performed by a team of trained, independent reviewers. Certainty of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations framework. This review will form the most comprehensive assessment to date of measures to reduce SSI following elective colorectal surgery. This will promote the adoption of evidence-based practice and the identification of future research needs.

Patient involvement in goals of care decision-making has shown to enhance satisfaction, affective-cognitive outcomes, allocative efficiency, and reduce unwarranted clinical variation. However, the involvement of patients in goals of care planning within hospitals remains limited, particularly where mismatches in shared understanding between doctors and patients are present. To identify and critically examine factors influencing goals of care conversations between doctors and patients during acute hospital illness. Realist systematic review following the RAMESES standards. A protocol has been published in PROSPERO (CRD42021297410). The review utilised realist synthesis methodology, including a scoping literature search to generate initial theories, theory refinement through stakeholder consultation, and a systematic literature search to support program theory. Data were collected from Medline, PubMed, Embase, CINAHL, PsychINFO, Scopus databases (1946 to 14 July 2023), citation tracking, and Google Scholar. Open-Grey was utilized to identify relevant grey literature. Studies were selected based on relevance and rigor to support theory development. Our analysis included 52 papers, supporting seven context-mechanism-output (CMO) hypotheses. Findings suggest that shared doctor-patient understanding relies on doctors being confident, competent, and personable to foster trusting relationships with patients. Low doctor confidence often leads to avoidance of discussions. Moreover, information provided to patients is often inconsistent, biased, procedure-focused, and lacks personalisation. Acute illness, medical jargon, poor health literacy, and high emotional states further hinder patient understanding. Goals of care conversations in hospitals are nuanced and often suboptimal. To improve patient experiences and outcome of care interventions should be personalised and tailored to individual needs, emphasizing effective communication and trusting relationships among patients, families, doctors, and healthcare teams. Inclusion of caregivers and acknowledgment at the service level are crucial for achieving desired outcomes. Implications for policy, research, and clinical practice, including further training and skills development for doctors, are discussed.

Background/ObjectivesThe acceptability of emerging intravitreal therapies for patients with Geographic Atrophy (GA) is currently unknown. This study therefore aimed to investigate the extent to which regular intravitreal injections may be acceptable to GA patients.Subjects/MethodsThirty UK-based individuals with GA secondary to age-related macular degeneration (AMD), recruited from two London-based hospitals, were interviewed in April-October 2021 regarding acceptability of new GA treatments. Participants responded to a structured questionnaire, as well as open-ended questions in a semi-structured interview. The Theoretical Framework of Acceptability (TFA) informed framework analysis of the qualitative data.ResultsTwenty participants (67%) were female, and median (interquartile range (IQR)) age was 83 (78, 87) years. 37% of participants had foveal centre-involving GA, and better eye median (IQR) logMAR visual acuity was 0.30 (0.17, 0.58). Data suggested that 18 participants (60% (95% CI: 41–79%)) would accept the treatment, despite awareness of potential drawbacks. Eight participants (27% (95% CI: 10–43%) were ambivalent or undecided about treatment, and four (13%) (95% CI: 0–26%) would be unlikely to accept treatment. Reducing the frequency of injections from monthly to every other month increased the proportion of participants who considered the treatments acceptable. Conversely, factors limiting acceptability clustered around: the limited magnitude of treatment efficacy; concerns about side effects or the increased risk of neovascular AMD; and the logistical burden of regular clinic visits for intravitreal injections. Misunderstandings of potential benefits indicate the need for appropriately-designed patient education tools to support decision-making.ConclusionsOur study suggests a majority of participants would be positive about intravitreal treatment for GA, in spite of potential burdens.