Exploring nursing home resident and their care partner priorities for care using the Action-Project Method.

BACKGROUND: Nursing home (NH) residents' experiences are embedded within their relationships to others. Our objectives were to describe how residents and care partners (family or staff members) jointly construct, discuss, and act on care priorities. METHODS: We used Action-Project Method, a qualitative method focused on action within social context. We recruited 15 residents and 12 care partners (5 family and 7 staff members) from 3 urban NHs in Alberta, Canada. Residents and care partners participated in a video-recorded conversation about their experiences in the NH, then individually reviewed the video-recording to add context to the conversation. Following transcription, preliminary narrative construction, and participant feedback, the research team conducted in-depth analysis to identify participant actions, goals, and projects, including those jointly shared by dyad members. RESULTS: All participants' intentions could be broadly described as "making time in the NH as good as possible" and projects were grouped into five categories: resident identity, relationships (both presence and absence), advocacy, positivity, and respectful care. Participants often raised issues of short-staffing as a significant barrier to respectful care. Care partners, especially staff, used positivity to redirect residents from difficult topics. Joint projects could be identified in some, but not all, cases. CONCLUSIONS: We found that maintaining a sense of identity, fostering relationships, and receiving respectful care were important to residents but that short-staffing created barriers. Methods to capture these aspects of the resident experience are needed but should not be influenced by care partners' tendency towards positivity in resident interactions.

Risk of liver fibrosis associated with long-term methotrexate therapy may be overestimated.

BACKGROUND & AIMS: The risk of significant liver fibrosis from prolonged methotrexate (MTX) exposure has been estimated at around 5%, prompting intensive monitoring strategies. However, the evidence is derived from retrospective studies that under-reported risk factors for liver disease. We evaluated the risk of long-term MTX therapy on liver fibrosis in a longitudinal cohort study using two non-invasive markers. METHOD: Between 2014-2021, adult patients diagnosed with rheumatoid arthritis (RA) or psoriasis for ≥2 years were recruited prospectively from six UK sites. The MTX group included patients who received MTX for ≥6 months, whereas the unexposed group included those who never received MTX. All patients underwent full liver profiling, with transient elastography (TE) and enhanced liver fibrosis (ELF) marker measurements. RESULTS: A total of 999 patients (mean age 60.8 ± 12 years, 62.3% females) were included. Of 976 with valid TE values, 149 (15.3%) had liver stiffness ≥7.9 kPa. Of 892 with a valid ELF, 262 (29.4%) had ELF ≥9.8. Age and BMI were independently associated with elevated liver stiffness and ELF. Neither MTX cumulative dose nor duration was associated with elevated liver stiffness. Diabetes was the most significant risk factor associated with liver stiffness ≥7.9 kPa (adjusted odds ratio = 3.19; 95% CI 1.95-5.20; p <0.001). Regular use of non-steroidal anti-inflammatory drugs showed the strongest association with ELF ≥9.8 (odds ratio = 1.76; 95% CI 1.20-2.56; p = 0.003), suggesting the degree of joint inflammation in RA may confound ELF as a non-invasive marker of liver fibrosis. CONCLUSION: The risk of liver fibrosis attributed to MTX itself might have been previously overestimated; there is a need to consider modifying current monitoring guidelines for MTX. IMPACT AND IMPLICATIONS: Current guidelines recommend intensive (2-3 monthly) monitoring strategies for patients on long-term methotrexate therapy due to the potential risk of liver fibrosis. Evaluation of the association using two validated non-invasive markers of liver fibrosis, liver stiffness and enhanced liver fibrosis score, in a large cohort of patients with rheumatoid arthritis or psoriasis shows that the reported risk has previously been overestimated. The clinical focus should be to improve patients' metabolic risk factors, diabetes and BMI, that are independently associated with liver stiffness. There is a need to consider modifying current treatment monitoring guidelines for methotrexate.

Mindful parenting intervention for parents of children with skin conditions: a single group experimental cases series.

BACKGROUND: Parents of children with eczema or psoriasis experience high levels of parenting stress, which can negatively impact their child's mental and physical health. AIMS: We aimed to investigate the effectiveness, feasibility and acceptability of a mindful parenting intervention for parents of children with eczema or psoriasis. METHOD: Seven parents of children (4-12 years old) with eczema or psoriasis took part in an 8-week mindful parenting group intervention. A single-case experimental design was adopted, whereby parents completed daily idiographic measures of parenting stress related to their child's skin condition. Parents also completed standardised questionnaires measuring their parenting stress, depression, anxiety and quality of life, and children completed a quality of life measure, at four time points: baseline, pre-intervention, post-intervention and 6-week follow-up. Parents provided qualitative feedback after the intervention. RESULTS: All parents completed the intervention and showed improvements in idiographic measures of parenting stress from baseline to follow-up. Improvements in parenting stress were larger at follow-up than post-intervention, suggesting the benefits of intervention continue beyond the intervention. Six of seven parent-child dyads showed improvement in at least one of the wellbeing measures, from pre-intervention to post-intervention or follow-up. Feasibility was demonstrated through good participant retention, adherence to home practice, and treatment fidelity. Acceptability was demonstrated through positive parent evaluations of the intervention. CONCLUSIONS: Mindful parenting can be an effective, feasible and acceptable intervention for parents of children with eczema or psoriasis. Future studies should attempt to replicate the findings through randomised controlled trials.

Barriers and facilitators for implementation of a national recommended specialty core-curriculum across UK medical schools: a cross-sectional study using an online questionnaire.

OBJECTIVES: The National Health Service (NHS) Long-Term plan published in 2019 set out healthcare reforms to meet the healthcare demands of UK. Undergraduate specialty core-curricula like dermatology aligns well to the training needs of the future workforce but lacks representation, consistency and implementation. This study explores the barriers and facilitators influencing the implementation of a specialty-specific (dermatology) national core-curriculum across UK medical schools. DESIGN: A constructivist approach was used to develop an online questionnaire and data collected using mixed methodology. PARTICIPANTS: Undergraduate dermatology teaching leads across all UK medical schools. RESULTS: 30 out of 42 UK medical schools responded to the survey (71%). 16 out of 30 (53%) responders were unaware of the planned Medical Licensing Assessments (MLA) for all UK graduates in 2024-2025; 43% were unaware if dermatology was mapped to national standards; 50% were unsure if the dermatology was blueprinted on school curricula. Barriers to implementation included competing NHS service commitments, the specialty not seen as a priority and difficulty influencing curricula changes at school level. Facilitators included workforce planning and transparency in funding to support leadership in undergraduate education. Domains identified for curriculum implementation were: (1) awareness of the role of General Medical Council and the MLA, (2) medical education training for teaching leads, (3) lack of recognition and resources for leadership, (4) skills development to map, blueprint and assess specialty core-components, (5) medical school and specialty engagement. CONCLUSIONS: This study identifies the potential barriers and facilitators to specialty specific core-curricular implementation across UK medical schools. Lack of standardised training in medical education, time and resources undermine the role of specialty teaching leads as medical educators. Medical school engagement with specialties with mutual support would aid the forthcoming educational reforms.

Prospective epidemiological study of juvenile-onset systemic lupus erythematosus in the UK and Republic of Ireland.

OBJECTIVES: The primary objective was to define the incidence of JSLE in children <16 years of age in the UK and Republic of Ireland (ROI). The secondary objective was to describe presenting features, classification criteria, initial management and disease damage in newly presenting JSLE patients. METHODS: A prospective JSLE epidemiological study was undertaken between September 2017 and September 2019 with support of the British Paediatric Surveillance Unit and other professional groups involved in diagnosis and management of JSLE patients. Treating consultants reported all cases of JSLE seen. A follow-up study at 1 year examined management and progression of disease and treatment. RESULTS: There were 124 incident cases included in the final analysis. Incidence was estimated using ACR-1997 classification criteria (0.36/100 000), SLICC-2012 classification criteria (0.41/100 000) and clinician expert opinion (0.46/100 000). A high disease burden was seen, with 71.0% of patients requiring ongoing systemic CS treatment at 1 year; 98.2% receiving immunomodulatory treatment; and 20.4% accruing damage in the year following diagnosis (predominantly neuropsychiatric-related), with substantial involvement from multiple speciality teams. CONCLUSIONS: The minimum UK and ROI incidence of JSLE is between 0.36 and 0.46/100 000, depending on the case definition used. Challenges in classification of patients with JSLE are highlighted, but overall this study supports the use of SLICC-2012 classification criteria. The high levels of disease damage and ongoing CS use 1 year after diagnosis is concerning, highlighting the need for further interventions to improve outcomes in JSLE.

An analysis of client complaints and their effects on veterinary support staff.

BACKGROUND: Veterinarians and support staff have been reporting the negative mental health effects from client complaints (CC). A previous study was performed evaluating these effects in veterinarians however no such study has been performed on veterinary support staff (VSS). OBJECTIV: The purpose of this study was to investigate the frequency and effects of CCs on VSS. METHODS: A cross sectional anonymous survey using a web-based questionnaire was created evaluating the frequency, type, and effects from CC. The survey was distributed to five different VSS Facebook groups and respondents provided demographic information and reported the frequency and effects of such complaints. RESULTS: A total of 681 questionnaires were collected during the study period but 130 were incomplete and were excluded from analysis. This resulted in 551 completed questionnaires available for review. One hundred and ninety (34.4%) VSS reported being subject to a CC in the previous 6 months with cost of care the most common reason (78.6%). Two hundred and sixty VSS (47.2%) reported feeling depressed because of CCs made against them, 295 VSS (53.5%) stated CCs negatively affected their enjoyment of their job, and 146 (26.5%) have considered changing their career because of CCs. CONCLUSIONS: CC have detrimental effects on VSS career satisfaction, mental health and hospital practices. Further studies are warranted to mitigate the detrimental effects of CCs.

Behçet's syndrome in children and young people in the United Kingdom and the Republic of Ireland: a prospective epidemiological study.

OBJECTIVES: To define the incidence and prevalence of Behçet's syndrome (BS) in children and young people (CYP) up to the age of 16 years in the United Kingdom (UK) and Republic of Ireland (ROI). METHODS: A prospective epidemiological study was undertaken with the support of the British Paediatric Surveillance Unit (BPSU) and the British Society of Paediatric Dermatologists (BSPD). Consultants reported anonymised cases of BS seen. A follow-up study at one year examined progression of disease and treatment. RESULTS: Over a two-year period, 56 cases met the International Criteria for Behçet's Disease. For children under 16 years of age, the two-year period prevalence estimate was 4.2 per million (95% CI: 3.2, 5.4) and the incidence was 0.96 per million person years (95% CI: 0.66, 1.41). Mucocutaneous disease was the most common phenotype (56/100%), with ocular (10/56; 17.9%), neurological (2/56; 3.6%) and vascular involvement (3/56; 5.4%) being less common. Median age at onset was 6.34 years and at diagnosis was 11.72 years. There were slightly more female than male children reported (32/56; 55.6%). The majority of cases (85.7%) were white Caucasian. Apart from genital ulcers, which were more common in females, there were no significant differences in frequency of manifestations between male or females, nor between ethnicities. Over 83% of cases had three or more non-primary care healthcare professionals involved in their care. CONCLUSION: BS is extremely rare in CYP in the UK and ROI and most have mucocutaneous disease. Healthcare needs are complex, and coordinated care is key.

Plasma cell mucositis related to qat chewing: a report of 2 cases and review of the literature.

Plasma cell mucositis is a rare, benign mucosal condition with characteristic histological features of a dense polyclonal plasmacytic infiltrate. A variety of mucosal sites are affected and the presentation varies from a cobblestone to an intensely erythematous, lobulated appearance. Idiopathic cases are well documented and it has been attempted to define the entity as a hypersensitivity reaction, however reports show inconsistencies. The last two decades have highlighted an emerging association between qat (khat) chewing and plasma cell mucositis. This report provides a review of the most pertinent literature and describes two cases intimately related to qat chewing, whereby resolution occurred upon qat cessation. One case requiring systemic steroidal therapy due to severe symptoms. This highlights the need for an increased awareness amongst clinicians of a potential aetiological link between qat and plasma cell mucositis, emphasises the benefit of qat cessation and the scenarios whereby systemic steroidal therapy should be considered.

A Comparison of Psoriasis Severity in Pediatric Patients Treated With Methotrexate vs Biologic Agents.

Importance: Few studies have compared the use of methotrexate and biologics, the most commonly used systemic medications for treatment of moderate to severe psoriasis in children. Objective: To assess the real-world, 6-month reduction in psoriasis severity and long-term drug survival (rate and duration of adherence to a specific drug) of methotrexate vs biologics in plaque psoriasis in children. Design, Setting, and Participants: A retrospective medical records review was conducted at 20 European and North American centers. Treatment response was based on site-reported Psoriasis Area and Severity Index (PASI) and/or Physician Global Assessment (PGA) scores at baseline and within the first 6 months of treatment. Participants included all 234 consecutively seen children with moderate to severe psoriasis who received at least 3 months of methotrexate or biologics from December 1, 1990, to September 16, 2014, with sufficient data for analysis. Data analysis was performed from December 14, 2015, to September 1, 2016. Main Outcomes and Measures: PASI, with a range from 0 to 72 (highest score indicating severe psoriasis), and/or PGA, with a scale of 0 (clear), 1 (minimal), 2 (mild), 3 (moderate), 4 (severe), and 5 (very severe). Results: Of 234 pediatric patients (103 boys [44.0%]; 131 girls [56.0%]) treated with methotrexate and/or biologics, 163 patients (69.7%) exclusively received methotrexate, 47 patients (20.1%) exclusively received biologics, and 24 children (10.2%) received methotrexate and biologics sequentially. Of the latter cohort, 23 children were treated initially with methotrexate. Mean (SD) age at initiation was 11.6 (3.7) years for methotrexate and 13.3 (2.9) years for biologics (73.2% for etanercept) (P = .002). Among patients evaluated by a scoring method at 6-month follow-up, 75% or greater improvement in PASI (PASI75) was achieved in 12 of 30 patients (40.0%) receiving methotrexate and 20 of 28 patients (71.4%) receiving biologics, and PGA was clear/almost clear (PGA 0/1) in 41 of 115 patients (35.6%) receiving methotrexate and 18 of 37 patients (48.6%) receiving biologics. Achieving PASI75 and/or PGA 0/1 between baseline and 6 months was more likely with biologics than methotrexate (PASI75: odds ratio [OR], 4.56; 95% CI, 2.02-10.27; P < .001; and PGA 0/1: OR, 2.00; 95% CI, 0.98-4.00; P = .06). Decreased mean PASI and PGA scores were associated with biologics more than with methotrexate (PASI effect, -3.13; 95% CI, -4.33 to -1.94; P < .001; and PGA effect, -0.31; 95% CI, -0.56 to -0.06; P = .02). After 1, 3, and 5 years of use, overall drug survival rates for methotrexate were 77.5%, 50.3%, and 35.9%, and for biologics, the rates were 83.4%, 64.3%, and 57.1%, respectively. Biologics were associated with a better confounder-corrected drug survival than methotrexate (hazard ratio [HR], 2.23; 95% CI, 1.21-4.10; P = .01). Discontinuation owing to lack of response was comparable (HR, 1.64; 95% CI, 0.80-3.36; P = .18). Conclusions and Relevance: Methotrexate and biologics appear to be associated with improvement in pediatric psoriasis, although biologics seem to be associated with greater reduction in psoriasis severity scores and higher drug survival rates than methotrexate in the real-world setting. Additional studies directly comparing these medications should be performed for confirmation.

Interventions for treating oral lichen planus: corticosteroid therapies.

BACKGROUND: Oral lichen planus (OLP) is a relatively common chronic T cell-mediated disease, which can cause significant pain, particularly in its erosive or ulcerative forms. As pain is the indication for treatment of OLP, pain resolution is the primary outcome for this review. This review is an update of a version last published in 2011, but focuses on the evidence for corticosteroid treatment only. A second review considering non-corticosteroid treatments is in progress. OBJECTIVES: To assess the effects and safety of corticosteroids, in any formulation, for treating people with symptoms of oral lichen planus. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases to 25 February 2019: Cochrane Oral Health's Trials Register, CENTRAL (2019, Issue 1), MEDLINE Ovid, and Embase Ovid. ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. There were no restrictions on language or date of publication. SELECTION CRITERIA: We considered randomised controlled clinical trials (RCTs) of any local or systemic corticosteroid treatment compared with a placebo, a calcineurin inhibitor, another corticosteroid, any other local or systemic (or both) drug, or the same corticosteroid plus an adjunctive treatment. DATA COLLECTION AND ANALYSIS: Three review authors independently scanned the titles and abstracts of all reports identified, and assessed risk of bias using the Cochrane tool and extracted data from included studies. For dichotomous outcomes, we expressed the estimates of effects of an intervention as risk ratios (RR), with 95% confidence intervals (CI). For continuous outcomes, we used mean differences (MD) and 95% CI. The statistical unit of analysis was the participant. We conducted meta-analyses only with studies of similar comparisons reporting the same outcome measures. We assessed the overall certainty of the evidence using GRADE. MAIN RESULTS: We included 35 studies (1474 participants) in this review. We assessed seven studies at low risk of bias overall, 11 at unclear and the remaining 17 studies at high risk of bias. We present results for our main outcomes, pain and clinical resolution measured at the end of the treatment course (between one week and six months), and adverse effects. The limited evidence available for comparisons between different corticosteroids, and corticosteroids versus alternative or adjunctive treatments is presented in the full review. Corticosteroids versus placebo Three studies evaluated the effectiveness and safety of topical corticosteroids in an adhesive base compared to placebo. We were able to combine two studies in meta-analyses, one evaluating clobetasol propionate and the other flucinonide. We found low-certainty evidence that pain may be more likely to be resolved when using a topical corticosteroid rather than a placebo (RR 1.91, 95% CI 1.08 to 3.36; 2 studies, 72 participants; I² = 0%). The results for clinical effect of treatment and adverse effects were inconclusive (clinical resolution: RR 6.00, 95% CI 0.76 to 47.58; 2 studies, 72 participants; I² = 0%; very low-certainty evidence; adverse effects RR 1.48, 95% 0.48 to 4.56; 3 studies, 88 participants, I² = 0%, very low-certainty evidence). Corticosteroids versus calcineurin inhibitors Three studies compared topical clobetasol propionate versus topical tacrolimus. We found very low-certainty evidence regarding any difference between tacrolimus and clobetasol for the outcomes pain resolution (RR 0.45, 95% CI 0.24 to 0.88; 2 studies, 100 participants; I² = 80%), clinical resolution (RR 0.61, 95% CI 0.38 to 0.99; 2 studies, 52 participants; I² = 95%) and adverse effects (RR 0.05, 95% CI 0.00 to 0.83; 2 studies, 100 participants; very low-certainty evidence) . One study (39 participants) compared topical clobetasol and ciclosporin, and provided only very low-certainty evidence regarding the rate of clinical resolution with clobetasol (RR 3.16, 95% CI 1.00 to 9.93), pain resolution (RR 2.11, 95% CI 0.76 to 5.86) and adverse effects (RR 6.32, 95% CI 0.84 to 47.69). Two studies (60 participants) that compared triamcinolone and tacrolimus found uncertain evidence regarding the rate of clinical resolution (RR 0.86, 95% CI 0.55 to 1.35; very low-certainty evidence) and that there may be a lower rate of adverse effects in the triamcinolone group (RR 0.47, 95% CI 0.22 to 0.99; low-certainty evidence). These studies did not report on pain resolution. AUTHORS' CONCLUSIONS: Corticosteroids have been first line for the treatment of OLP. This review found that these drugs, delivered topically as adhesive gels or similar preparations, may be more effective than placebo for reducing the pain of symptomatic OLP; however, with the small number of studies and participants, our confidence in the reliability of this finding is low. The results for clinical response were inconclusive, and we are uncertain about adverse effects. Very low-certainty evidence suggests that calcineurin inhibitors, specifically tacrolimus, may be more effective at resolving pain than corticosteroids, although there is some uncertainty about adverse effects and clinical response to tacrolimus showed conflicting results.

Using Real-World Data to Guide Ustekinumab Dosing Strategies for Psoriasis: A Prospective Pharmacokinetic-Pharmacodynamic Study.

Variation in response to biologic therapy for inflammatory diseases, such as psoriasis, is partly driven by variation in drug exposure. Real-world psoriasis data were used to develop a pharmacokinetic/pharmacodynamic (PK/PD) model for the first-line therapeutic antibody ustekinumab. The impact of differing dosing strategies on response was explored. Data were collected from a UK prospective multicenter observational cohort (491 patients on ustekinumab monotherapy, drug levels, and anti-drug antibody measurements on 797 serum samples, 1,590 measurements of Psoriasis Area Severity Index (PASI)). Ustekinumab PKs were described with a linear one-compartment model. A maximum effect (Emax ) model inhibited progression of psoriatic skin lesions in the turnover PD mechanism describing PASI evolution while on treatment. A mixture model on half-maximal effective concentration identified a potential nonresponder group, with simulations suggesting that, in future, the model could be incorporated into a Bayesian therapeutic drug monitoring "dashboard" to individualize dosing and improve treatment outcomes.

Age, psychiatry admission status and linear mental capacity for treatment decisions.

The relationship between age and mental capacity among psychiatry inpatients is not fully understood. We aimed to assess mental capacity for treatment decisions in voluntary and involuntary psychiatry inpatients in Ireland and, in this analysis of our data-set, to elucidate the linear relationship, if any, between linear (as opposed to categorical) mental capacity and age. We used the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to assess mental capacity for treatment decisions in 215 psychiatry inpatients (176 voluntary and 39 involuntary) in four psychiatry admission units in Ireland. Mean age was 46.2 years and majorities were male (58.1%), never married (74.0%), unemployed (64.2%) and of Irish ethnicity (87.0%). The most common primary diagnoses were schizophrenia and related disorders (42.8%) followed by affective disorders (36.7%). On multi-variable linear regression analysis, linear mental capacity was significantly associated with voluntary admission status, being employed, having a primary diagnosis other than schizophrenia or a related disorder, and younger age. Together, these factors accounted for 44.4% of the variance in mental capacity between participants. Overall, while increased age is associated with diminished mental capacity, other factors appear more significant, including involuntary admission status which is likely an indicator of symptom severity. There is a need for further research to (a) elucidate the relationships between the significant factors identified in this study and the cognitive status of patients (which impacts on assessments of mental capacity); (b) identify and elucidate other factors of likely relevance to mental capacity (e.g. medical illness, medication use); and (c) translate these findings into targeted interventions to support decision-making in clinical practice among psychiatry inpatients, especially those with involuntary status.

Convergence or Divergence? Comparing Mental Capacity Assessments Based on Legal and Clinical Criteria in Medical and Surgical Inpatients.

Despite the high prevalence of mental incapacity for treatment decisions in hospitals (27.7%), there is little information about the relationship, if any, between mental capacity assessments based on clinical and legal criteria. We performed a cross-sectional study of mental incapacity for treatment decisions in 300 hospital inpatients in two hospitals in Ireland, using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the legal definition of mental incapacity in Ireland's incoming Assisted Decision-Making (Capacity) Act 2015. We found that patients who lacked mental capacity according to the legal criteria scored significantly lower on all four subscales of the MacCAT-T (Understanding, Appreciation, Reasoning, and Communication) compared to those who had mental capacity according to the legal criteria. In light of the similarity between Ireland's legal definition of mental incapacity and legislative definitions in other jurisdictions (e.g. England and Wales), we conclude that legal assessments of mental incapacity in these countries accord closely with clinical assessments (as reflected in the MacCAT-T). Ireland's new mental capacity legislation should be implemented promptly in order to further operationalize Ireland's new legal definition of mental incapacity and provide patients with the supports they need to optimize their mental capacity for treatment decisions in hospitals.

Association of Serum Ustekinumab Levels With Clinical Response in Psoriasis.

IMPORTANCE: High-cost biologic therapies have transformed the management of immune-mediated inflammatory diseases. To optimize outcomes and reduce costs, dose adjustment informed by measurement of circulating drug levels has been shown to be effective in various settings. However, limited evidence exists for this approach with the interleukin 12 and interleukin 23 inhibitor ustekinumab. OBJECTIVE: To evaluate clinical utility of therapeutic drug monitoring for ustekinumab in patients with psoriasis. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational cohort of 491 adults with psoriasis was recruited to the multicenter Biomarkers of Systemic Treatment Outcomes in Psoriasis study within the British Association of Dermatologists Biologic and Immunomodulators Register from June 2009 to December 2017; samples from some patients were taken between 2009 and 2011 as part of a pilot study with the same inclusion criteria. EXPOSURE: Serum ustekinumab level measured at any point during the dosing cycle using an enzyme-linked immunosorbent assay. MAIN OUTCOMES AND MEASURES: Disease activity measured using the Psoriasis Area and Severity Index (PASI) score. Treatment response outcomes were PASI75 (75% reduction in PASI score from baseline [primary outcome]), PASI90 (90% reduction of PASI score from baseline), and absolute PASI score of 1.5 or less. RESULTS: A total of 491 patients (171 women and 320 men; mean [SD] age, 45.7 [12.8] years) had 1 or more serum samples (total, 853 samples obtained 0-56 weeks from start of treatment) and 1 or more PASI scores within the first year of treatment. Antidrug antibodies were detected in only 17 of 490 patients (3.5%). Early measured drug levels (1-12 weeks after starting treatment) were associated with PASI75 response 6 months after starting treatment (odds ratio, 1.38; 95% CI, 1.11-1.71) when adjusted for baseline PASI score, age, and ustekinumab dose. However, this finding was not consistent across the other PASI outcomes (PASI90 and PASI score of ≤1.5). CONCLUSIONS AND RELEVANCE: This real-world study provides evidence that measurement of early serum ustekinumab levels could be useful to direct the treatment strategy for psoriasis. Adequate drug exposure early in the treatment cycle may be particularly important in determining clinical outcome.

Do we need a core curriculum for medical students? A scoping review.

OBJECTIVE: The General Medical Council (GMC) recommends medical schools to develop and implement curricula enabling students to achieve the required learning outcomes. UK medical schools follow the GMC's Outcomes for graduates, which are generic. GMC plans to introduce a national Medical Licensing Assessment (MLA) for the medical graduates wanting to practise medicine in the UK in 2022. With no standardised or unified undergraduate (UG) curriculum in UK, various specialties have expressed concerns about not being represented in medical schools and developed specialty-specific core curricula. The aim of this review was to identify learned bodies who have developed a core curriculum for UK medical schools and highlight the drivers, gaps and future approaches to curricular development and implementation. METHODS: A literature search was conducted using online databases (EMBASE, MEDLINE, ERIC, HMIC, PubMed and CDSR), search engines and related websites (Google and Google Scholar, Department of Health, GMC and BMA) for relevant articles from 1996 to 5 March 2019 (~20 years). A methodological framework to map the key concepts of UG medical curriculum was followed. Any relevant body with a core curriculum for UK medical UGs was included. RESULTS: A total of 1283 articles were analysed with 31 articles included in the qualitative synthesis, comprising 26 specialties (clinical n=18, foundation subjects n=4 and professionalism related n=4). WHO, European and national (eg, Royal Colleges of UK) specialty bodies provided specific core learning outcomes for the medical graduates. Patient safety, disease burden, needs of society and inadequate preparedness of medical graduates were drivers for the development of these curricula. CONCLUSIONS: This is the first comprehensive review of literature on UG core curricula recommending minimum standards on knowledge and skills, in alignment with GMC's Outcomes for graduates for all the UK medical students. Adopting and assessing unified standards would help reduce variability across UK medical schools for both generic and specialty-specific competencies.