Hydroxychloroquine can be resumed with close monitoring after retinopathy has developed, without major visual loss: Case Report.

PURPOSE: To present a patient with systemic lupus erythematosus on longstanding hydroxychloroquine (HCQ) use for whom HCQ was stopped due to signs of toxicity, and then resumed four years later due to dire systemic need. METHODS: Long term retrospective study. Humphrey visual fields (10-2 and 24-2), fundus autofluorescence imaging, and spectral domain OCT were used to follow progression over time. RESULTS: The patient was on HCQ for 26 years, with a cumulative dose over 3,000g. HCQ was stopped in 2011 due to macular toxicity. She remained off HCQ for four years, during which time she developed type 1 diabetes due to an immunologic attack on the pancreas, and then JC (John Cunningham) viremia after a period of treatment with mycophenolate, which put her at risk for progressive multifocal leukoencephalopathy. Mycophenolate was discontinued and HCQ was resumed with careful follow-up over the next 7 years. The toxic maculopathy showed only mild, slow progression since HCQ was resumed. CONCLUSION: Careful annual monitoring using HVF 10-2 and spectral domain OCT imaging remains the standard of care for patients on HCQ. However, it may be possible with close monitoring, when there is compelling systemic need, to resume HCQ after it has been stopped, with only slow progression of the retinopathy. This allowed the patient to have an improved quality of life and reduced the risk of severe morbidity and mortality.

The Effect of a Personalized Approach to Patient Education on Heart Failure Self-Management.

: Personalized tools relevant to an individual patient's unique characteristics may be an important component of personalized health care. We randomized 97 patients hospitalized with acute decompensated heart failure to receive a printout of an ultrasound image of their inferior vena cava (IVC) with an explanation of how the image is related to their fluid status (n = 50) or to receive no image and only generic heart failure information (n = 47). Adherence to medications, low-sodium diet, and daily weight measurement at baseline and 30 days after discharge were assessed using the Medical Outcomes Study Specific Adherence Scale, modified to a three-item version for heart failure (HF), (MOSSAS-3HF, maximum score = 15, indicating adherence all of the time). The baseline MOSSAS-3HF scores (mean ± standard deviation (SD)) were similar for intervention and control groups (7.4 ± 3.4 vs. 6.4 ± 3.7, p = 0.91). The MOSSAS-3HF scores improved for both groups but were not different at 30 days (11.8 ± 2.8 vs. 11.7 ± 3.0, p = 0.90). Survival without readmission or emergency department (ED) visit at 30 days was similar (82.6% vs. 84.1%, p = 0.85). A personalized HF tool did not affect rates of self-reported HF treatment adherence or survival without readmission or ED visit.

A Perspective on the Baltimore Freddie Gray Riots: Turning Tragedy Into Civic Engagement and Culture Change in an Academic Department of Medicine.

PROBLEM: The Johns Hopkins University School of Medicine Department of Medicine (DOM) sought ways of enhancing community engagement after the death of Freddie Gray and consequent unrest in Baltimore City. APPROACH: The DOM launched a five-part noon lecture series in May 2015-"Journeys in Medicine"-to facilitate discussion among DOM faculty, staff, trainees, and community residents regarding the city's unrest. This evolved into a department-wide civic engagement initiative in July 2016 to enhance employee and community engagement. The civic engagement committee is composed of two collaborative steering committees: Staff Engagement and Community Engagement. OUTCOMES: The DOM has sponsored and/or participated in programs to address major concerns raised during the Journeys in Medicine series-improving the strained relationship between police and the community, mentoring young people, involving more DOM employees in community activities, sharing research results with the community, and addressing cultural differences to enhance relationships and communication. To enhance staff engagement, a Nursing Diversity Council, complementing the Faculty Diversity Council, has been established. DOM faculty and staff have participated in and championed several disease-focused physical activity endeavors (e.g., walks) that, collectively, have raised over $40,000. Community service projects include supporting registration and screenings at a local health fair, a professional clothing drive, and DOM Days of Service. NEXT STEPS: The Johns Hopkins University School of Medicine DOM is developing an administrator leadership program and continuing to participate in meaningful activities, leading to tangible outcomes designed to strengthen connections to the surrounding neighborhood and enhance engagement among all DOM employees.

Immune-Modulating Therapy for Rheumatologic Disease: Implications for Patients with Diabetes.

Immune modulators used to treat rheumatologic disease have diverse endocrine effects in patients with diabetes. Providers should be aware of these effects given that diabetes and rheumatologic disease overlap in prevalence and cardiovascular morbidity. In patients with type 1 diabetes, clinical trials have demonstrated that immune modulators used early in the disease can improve pancreatic function, though their efficacy in adults with longstanding autoimmune diabetes is unknown. In patients with type 2 diabetes, hydroxychloroquine is an effective antihyperglycemic and may be preferred for rheumatologic use in patients with difficult glycemic control. In patients without diabetes, hydroxychloroquine and tumor necrosis factor (TNF) inhibitors have been found to decrease diabetes incidence in observational studies. Additionally, dapsone and sulfasalazine alter erythrocyte survival resulting in inaccurate HbA1c values. These multifaceted effects of immune modulators create a need for coordinated care between providers treating patients with diabetes to individualize medication selection and prevent hypoglycemic events. More research is needed to determine the long-term outcomes of immune modulators in patients with diabetes.

Telephone calls to patients after discharge from the hospital: an important part of transitions of care.

BACKGROUND: Teaching interns patient-centered communication skills, including making structured telephone calls to patients following discharge, may improve transitions of care. OBJECTIVE: To explore associations between a patient-centered care (PCC) curriculum and patients' perspectives of the quality of transitional care. METHODS: We implemented a novel PCC curriculum on one of four inpatient general medicine resident teaching teams in which interns make post-discharge telephone calls to patients, contact outpatient providers, perform medication adherence reviews, and engage in patient-centered discharge planning. Between July and November of 2011, we conducted telephone surveys of patients from all four teaching teams within 30 days of discharge. In addition to asking if patients received a call from their hospital physician (intern), we administered the 3-Item Care Transitions Measure (CTM-3), which assesses patients' perceptions of preparedness for the transition from hospital to home (possible score range 0-100). RESULTS: The CTM-3 scores (mean±SD) of PCC team patients and standard team patients were not significantly different (82.4±17.3 vs. 79.6±17.6, p=0.53). However, regardless of team assignment, patients who reported receiving a post-discharge telephone call had significantly higher CTM-3 scores than those who did not (84.7±16.0 vs. 78.2±17.4, p=0.03). Interns exposed to the PCC curriculum called their patients after discharge more often than interns never exposed (OR=2.78, 95% CI [1.25, 6.18], p=0.013). CONCLUSIONS: The post-discharge telephone call, one element of PCC, was associated with higher CTM-3 scores--which, in turn, have been shown to lessen patients' risk of emergency department visits within 30 days of discharge.