NHS Fife is an NHS board which provides healthcare services in Fife, Scotland. It is one of the fourteen regions of NHS Scotland.
In recent years there have been exciting developments in the diagnosis and treatment of mild cognitive impairment and dementia due to Alzheimer's disease. Robust biomarkers and potentially disease modifying therapies are now available, with multiple other agents in clinical trials alongside on-going validation studies of blood-based biomarkers. Recent and probable future developments in the diagnosis and care of people with Alzheimer's disease pathology warrants serious re-evaluation of the structure and function of cognitive clinical services. Here we report recommendations from the November 2024 Brain Health Scotland roundtable discussion of opportunities and challenges for modern memory services.
Abstract Dupilumab, a monoclonal antibody targeting interleukin-4 and interleukin-13 signalling, has transformed the management of severe atopic eczema. While dupilumab is generally well tolerated, granulomatous reactions are increasingly recognized as a rare adverse effect. We present three patients with severe atopic eczema who developed granulomatous eruptions after prolonged dupilumab therapy. Case 1. A 54-year-old woman developed erythematous papules and plaques around the ear and neck 3 years after starting dupilumab. Biopsy revealed naked epithelioid granulomas, and investigations for systemic sarcoidosis were negative. The eruption persisted for 15 months but resolved spontaneously without discontinuation of dupilumab. Case 2. A 38-year-old man presented with reddish plaques and patches on the upper arms 5 years into treatment. Histology demonstrated interstitial and epithelioid granulomas with central necrobiotic collagen. The eruption settled without intervention, and dupilumab was continued. Case 3. A 63-year-old man developed shiny red–brown papules on background telangiectatic skin on the chest and arms after 2 years and 7 months of therapy. Histopathology showed well-formed non-necrotizing epithelioid granulomas in a perifollicular and superficial dermal distribution. He remains under review. In all cases the special stains alcian blue, periodic acid–Schiff, Grocott, Ziehl-Neelson and Wade–Fite were negative for pathogens. These cases expand the spectrum of dupilumab-associated granulomatous cutaneous eruptions, which may present as granuloma annulare, sarcoid-like eruptions, lichenoid-granulomatous dermatitis or rosacea-like changes. The proposed mechanism involves T helper (Th)2 blockade with compensatory Th1/Th17 hyper-response, driving granulomatous inflammation. However, this may be reversible, and our cases demonstrate that it may be possible to continue dupilumab as these cutaneous eruptions can resolve without drug cessation. Importantly, clinicians using dupilumab should remain vigilant for systemic granulomatous conditions such as drug-induced sarcoidosis-like reactions, which may require broader evaluation beyond the skin.
Towards the end of life, people with multiple long-term conditions face an array of challenges associated with their growing healthcare needs including unclear illness trajectories and multifaceted uncertainty. Caregivers, most often family or friends, play a key role in providing and coordinating care at the end of life. This study aimed to explore, through the perspective of bereaved caregivers, the experiences of healthcare and support in the last year of life for people with multiple long-term health conditions. Interpretative Phenomenological Analysis was used to analyse semi-structured interviews with 12 bereaved caregivers who had cared for relatives with multiple long-term conditions over the last year of life. Public advisors with lived experience as caregivers were key contributors to this study, aiding in study conceptualisation, design and analysis. There were five key group experiential themes identified: (i) Multiple conditions mixed in together impacting prognostication, (ii) Dynamic, coordinated care from healthcare services supported caregivers, (iii) Information from various sources helped caregivers make person-centred decisions, (iv) Caregivers had to decide when and where to seek help, with a preference for known, trusted healthcare professionals and (v) Being a caregiver has a changing, persisting impact. Bereaved caregivers faced challenges in appraising the multiple conditions that their relative had towards the end of life. This, alongside prior healthcare experiences and information gathered by caregivers, influenced how they accessed healthcare and support for their relative. Empowering caregivers and integrating their experiences into clinical practice will be key to supporting them in providing necessary care for those close to them at the end of their life.
