12th May 2017, Volume 130 Number 1455

Early death after discharge from emergency departments

The problem evaluated in this study is that many people die soon after being sent home from US emergency departments, and what aspects of patients and hospitals are linked to increased risk?

Data was obtained from the US Medicare programme. Patients with known life-threatening diseases, those receiving palliative care and those older than 90 were excluded from the analysis. Over 10 million patients were involved and apparently 0.12% died within seven days.

Atherosclerotic heart disease was the commonest cause of death. The researchers were unable to determine whether such outcomes were caused by medical error or whether they were preventable.

BMJ 2017; 356:j239

Tight glycaemic control in critically ill children?

Tight glycaemic control targeting a normal blood glucose level has not been shown to improve outcomes in critically ill adults or children after cardiac surgery. Studies involving critically ill children who have not undergone cardiac surgery are lacking.

In this trial, 713 appropriate patients were randomly assigned to one of two ranges of glycaemic control—lower target group (4.4 to 6.1mmol/Litre) or higher target group (8.3–10mmol/Litre). The trial was stopped early owing to a low likelihood of benefit and evidence of the possibility of harm. Patients in the lower target group had significantly higher rates of infection and severe hypoglycaemia.

The researchers concluded that critically ill children with hyperglycaemia did not benefit from tight glycaemic control. No significant differences were observed in mortality, severity of organ dysfunction or the number of ventilator-free days between the two groups.

N Engl J Med 2017; 376:729–41

Subcutaneous methotrexate in patients with moderate to severe plaque-type psoriasis

Methotrexate is one of the most commonly used systemic drugs for the treatment of moderate to severe psoriasis; however, high-quality evidence for its use is sparse and limited to use of oral dosing. In addition, the oral use of methotrexate may be the suboptimal route of administration.

In this randomised trial, 120 appropriate patients were assigned to receive either subcutaneous methotrexate at a starting dose of 17.5mg/week or placebo for the first 16 weeks, followed by methotrexate treatment of all patients up to 52 weeks (methotrexate–methotrexate vs placebo–methotrexate groups). Dose escalation to 22.5mg was allowed after eight weeks if patients had not achieved 50% reduction of their lesions.

The study results suggest that subcutaneous methotrexate has an acceptable safety profile and produces a more rapid and sustained response than that typically seen with oral regimens.

Lancet 2017; 389:528–37