TNF blockers inhibit spinal radiographic progression in ankylosing spondylitis by reducing disease activity: results from the Swiss Clinical Quality Management cohort.

OBJECTIVES: To analyse the impact of tumour necrosis factor inhibitors (TNFis) on spinal radiographic progression in ankylosing spondylitis (AS). METHODS: Patients with AS in the Swiss Clinical Quality Management cohort with up to 10 years of follow-up and radiographic assessments every 2 years were included. Radiographs were scored by two readers according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) with known chronology. The relationship between TNFi use before a 2-year radiographic interval and progression within the interval was investigated using binomial generalised estimating equation models with adjustment for potential confounding and multiple imputation of missing values. Ankylosing Spondylitis Disease Activity Score (ASDAS) was regarded as mediating the effect of TNFi on progression and added to the model in a sensitivity analysis. RESULTS: A total of 432 patients with AS contributed to data for 616 radiographic intervals. Radiographic progression was defined as an increase in ≥2 mSASSS units in 2 years. Mean (SD) mSASSS increase was 0.9 (2.6) units in 2 years. Prior use of TNFi reduced the odds of progression by 50% (OR 0.50, 95% CI 0.28 to 0.88) in the multivariable analysis. While no direct effect of TNFi on progression was present in an analysis including time-varying ASDAS (OR 0.61, 95% CI 0.34 to 1.08), the indirect effect, via a reduction in ASDAS, was statistically significant (OR 0.75, 95% CI 0.59 to 0.97). CONCLUSION: TNFis are associated with a reduction of spinal radiographic progression in patients with AS. This effect seems mediated through the inhibiting effect of TNFi on disease activity.

Errors in palliative care: kinds, causes, and consequences: a pilot survey of experiences and attitudes of palliative care professionals.

BACKGROUND: Medical errors have recently been recognized as a relevant concern in public health, and increasing research efforts have been made to find ways of improving patient safety. In palliative care, however, studies on errors are scant. OBJECTIVE: Our aim was to gather pilot data concerning experiences and attitudes of palliative care professionals on this topic. METHODS: We developed a questionnaire, which consists of questions on relevance, estimated frequency, kinds and severity of errors, their causes and consequences, and the way palliative care professionals handle them. The questionnaire was sent to all specialist palliative care institutions in the region of Bavaria, Germany (n=168; inhabitants 12.5 million) reaching a response rate of 42% (n=70). RESULTS: Errors in palliative care were regarded as a highly relevant problem (median 8 on a 10-point numeric rating scale). Most respondents experienced a moderate frequency of errors (1-10 per 100 patients). Errors in communication were estimated to be more common than those in symptom control. The causes most often mentioned were deficits in communication or organization. Moral and psychological problems for the person committing the error were seen as more frequent than consequences for the patient. Ninety percent of respondents declared that they disclose errors to the harmed patient. For 78% of the professionals, the issue was not a part of their professional training. CONCLUSION: Professionals acknowledge errors-in particular errors in communication-to be a common and relevant problem in palliative care, one that has, however, been neglected in training and research.