Cumulative methotrexate dose is not associated with liver fibrosis in patients with a history of moderate-to-severe psoriasis.

BACKGROUND: There are established risk factors for liver fibrosis (LF), but data on the impact of methotrexate on LF in patients with psoriasis are lacking. OBJECTIVES: This cross-sectional study aimed to determine the prevalence of LF in patients with psoriasis and to evaluate the relationship between LF, cumulative methotrexate dose and other LF risk factors. METHODS: Adults with a history of moderate-to-severe chronic plaque psoriasis were recruited between June 2020 and March 2021. Patients underwent transient elastography to evaluate LF. Three values for liver stiffness measurement (LSM) were assessed, indicating mild or worse LF (≥ 7 kPa), moderate or worse LF (≥ 7.9 kPa) and advanced LF (≥ 9.5kPa). Cumulative methotrexate dose and other potential risk factors for LF were assessed. RESULTS: Overall, 240 patients were recruited and 204 participants with valid LSM values were included in the analysis [median age 48 years [interquartile range (IQR) 37-57]; 51% female sex; 56% body mass index (BMI) ≥ 30 (kg m-2) and a median Alcohol Use Disorders Identification Test (AUDIT) score of 4 (IQR 1-7, 23% score ≥ 8)]. In total, 91% had received methotrexate [median duration 36 months (IQR 14-78)]. Prevalence of LF was 36%, 25% and 17% using LSM ≥ 7 kPa, ≥ 7.9 kPa and ≥ 9.5 kPa, respectively. There was no association between cumulative methotrexate dose [median 2.16 (IQR 0.93-5.2)] and continuous LSM values [unstandardized coefficient 0.16, 95% confidence interval (CI) -0.49 to 0.82, P = 0.626] or using the categorical LSM cutoff values: ≥ 7 kPa [unadjusted odds ratio 1.06 (95% CI 0.97-1.15), P = 0.192], ≥ 7.9 kPa [unadjusted odds ratio 1.03 (95% CI 0.94-1.12), P = 0.577] and ≥ 9.5 kPa (unadjusted odds ratio 1.01, 95% CI 0.91-1.12; P = 0.843). The following risk factors were associated with higher LSM values: BMI (P ≤ 0.001), waist circumference (P ≤ 0.001), metabolic syndrome (P ≤ 0.001), AUDIT score (P = 0.020) and FIB-4 score (P = 0.03). BMI ≥ 28, diabetes and metabolic syndrome were shown to be better predictors of LF compared with FIB-4 score. CONCLUSIONS: This study confirms a high prevalence of significant LF in patients with psoriasis. Cumulative methotrexate dose was not associated with LF. Patients with BMI ≥ 28, metabolic syndrome and diabetes are at higher risk for LF. These risk factors may help to identify when a more detailed liver health assessment is needed.

Psoriasis is a common inflammatory skin disease affecting 3% of the UK population. People with psoriasis appear to have higher rates of liver fibrosis (scarring in the liver from injury or inflammation) compared with people without psoriasis. There are several risk factors for increasing chances of developing liver fibrosis, including obesity, alcohol and diabetes; however, there have been some concerns that methotrexate (a medicine used to treat psoriasis) could also contribute to liver fibrosis. The majority of people needing systemic therapy (such as oral medicines) will try methotrexate first as per National Institute for Health and Care Excellence (NICE) guidance. In this study carried out in the UK, we aimed to look at the relationship between the cumulative dose (total over time) of methotrexate and liver fibrosis and the relationship between other risk factors and liver fibrosis (e.g. body mass index (BMI) (a measure that uses your height and weight to work out whether your weight is healthy), diabetes, alcohol intake and metabolic syndrome (a combination of diabetes, high blood pressure and obesity)). Liver fibrosis was measured using transient elastography, which is a non-invasive technique similar to an ultrasound. We also aimed to find out whether the clinical risk factors for liver fibrosis and a simple test called a 'FIB-4 score' (measured using blood test values and age) can predict a person's chance of developing liver fibrosis, in order to determine which people will benefit most from transient elastography. From our results, we were able to confirm that liver scarring is prevalent in our patients with psoriasis. We did not find an association between cumulative methotrexate and liver scarring. However, BMI, diabetes, metabolic syndrome and FIB-4 score were associated with liver scarring. We found that BMI ≥ 28, metabolic syndrome and diabetes can be used to identify patients who require a liver health assessment. Overall, the study findings suggest that cumulative methotrexate dose is not associated with liver fibrosis in people with a history of moderate-to-severe psoriasis.

Cardiac Arrest in the Cardiac Catheterization Laboratory: Initial Experience With the Role of Simulation Setup and Training.

With rising complexity of percutaneous coronary interventions being performed, the incidence of cardiac arrest in the cardiac catheterization laboratory (CCL) is likely to increase. The authors undertook a series of multidisciplinary simulation sessions to identify practice deficiencies and propose solutions to improve patient care. Five simulation sessions were held at Western Health CCL to simulate different cardiac arrest scenarios. Participants included cardiologists, intensivists, anesthetists, nurses, and technicians. Post-simulation feedback was analyzed qualitatively. Challenges encountered were grouped into 4 areas: (1) communication and teamwork, (2) equipment, (3) vascular access and drugs, and (4) physical environment and radiation exposure. Proposed solutions included regular simulation training; increasing familiarity with the physical environment, utilization of specialized equipment; and formation of 2 team leaders to improve efficiency. Cardiac arrest in the CCL is a unique clinical event that necessitates specific training to improve technical and nontechnical skills with potential to improve clinical outcomes.

The value of bronchoscopy in patients with non-massive haemoptysis and a clear or benign computer tomogram scan.

INTRODUCTION: The preferred diagnostic pathway for patients presenting with non-massive haemoptysis and normal or benign computer tomography (CT) radiological findings is unclear. The common approach is to investigate with both CT and bronchoscopy, irrespective of patient-specific factors. The value of performing fibreoptic bronchoscopy (FOB) in patients with non-massive haemoptysis and clear or benign CT findings remains undetermined. We aimed to investigate its value using a large retrospective case series. MATERIAL AND METHODS: A retrospective review of 4376 FOBs performed in Northumbria Healthcare NHS Foundation Trust from January 2012 to December 2019 for patients presenting with haemoptysis and clear or benign CT findings. Statistical analysis was performed to describe patient-specific variables, clinical characteristics, pathological findings and subsequent management decisions. RESULTS: A total of 4376 FOBs were performed during the study period, 275 were indicated to investigate non-massive haemoptysis. Two hundred and fifty-nine patients underwent a CT scan (158 before and 101 after FOB); 16 never had a CT because the treating physician did not feel it was necessary. About 258 CT scans showed normal anatomy. All patients underwent FOB; 192 showed normal findings. Bronchoscopic findings did not alter clinical management in 274 patients. One patient was referred to the ear, nose and throat department following the identification of polypoid vocal cord lesion which, following thorough investigation, was confirmed as benign. CONCLUSION: FOB provides minimal value for identifying lung malignancies in patients with non-massive haemoptysis and a clear or benign CT scan irrespective of patient-specific risk factors. Cost savings would be associated if physicians altered practice accordingly.