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.

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.

Effects of a focused patient-centered care curriculum on the experiences of internal medicine residents and their patients.

BACKGROUND: Traditional residency training may not promote competencies in patient-centered care. AIM: To improve residents' competencies in delivering patient-centered care. SETTING/PARTICIPANTS: Internal medicine residents at a university-based teaching hospital in Baltimore, Maryland. PROGRAM DESCRIPTION: One inpatient team admitted half the usual census and was exposed to a multi-modal patient-centered care curriculum to promote knowledge of patients as individuals, improve patient transitions of care, and reduce barriers to medication adherence. PROGRAM EVALUATION: Annual resident surveys (N = 40) revealed that the intervention was judged as professionally valuable (90%) and important to their training (90%) and offered experiences not available during other rotations (88%). Compared to standard inpatient rotation evaluations (n = 163), intervention rotation evaluations (n = 51) showed no differences in ratings for traditional medical learning, but higher ratings for improving how housestaff address patient medication adherence, communicate with patients about post-hospital transition of care, and know their patients as people (all p < 0.01). On post-discharge surveys, patients from the intervention team (N = 177, score 90.4, percentile ranking 97%) reported greater satisfaction with physicians than patients on standard teams (N = 924, score 86.1, percentile ranking 47%) p < 0.01). DISCUSSION: A patient-centered inpatient curriculum was associated with higher satisfaction ratings in patient-centered domains by internal medicine residents and with higher satisfaction ratings of their physicians by patients. Future research will explore the intervention's impact on clinical outcomes.

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.

Inflammatory abdominal aortic aneurysm.

Inflammatory abdominal aortic aneurysm (AAA) accounts for 5% to 10% of all cases of AAA and differs from typical atherosclerotic AAA in many important ways. Although both inflammatory and atherosclerotic AAA most commonly affect the infrarenal portion of the abdominal aorta, patients with the inflammatory variant are younger and usually symptomatic, chiefly from back or abdominal pain. Unlike patients with atherosclerotic AAA, most with the inflammatory variant have an elevated erythrocyte sedimentation rate or abnormalities of other serum inflammatory markers. Computed tomography and magnetic resonance imaging are both sensitive for demonstrating the cuff of soft tissue inflammation surrounding the aneurysm that is characteristic of inflammatory AAA. In contrast to atherosclerotic AAA, the inflammatory variant is characterized pathologically by marked thickening of the aneurysm wall, fibrosis of the adjacent retroperitoneum, and rigid adherence of the adjacent structures to the anterior aneurysm wall. An extraordinary expansion of the adventitia due to inflammation also distinguishes inflammatory from atherosclerotic AAA. Although the pathogenesis of inflammatory AAA appears to involve an immune response localized to the vessel wall, the etiology of the inflammatory reaction is unknown. Inflammatory AAA is almost never associated with inflammation of other arteries. Male sex and smoking, the main risk factors for atherosclerotic AAA, are even stronger risk factors for the inflammatory variant. Smoking cessation is the first step of medical therapy. Corticosteroids or immunosuppressive therapies may also have roles. Although inflammatory AAA appears less likely to rupture than atherosclerotic AAA, surgical intervention appears prudent once the diameter of the aneurysm exceeds 5.5 cm. Knowing the features of inflammatory AAA should allow physicians to distinguish it from atherosclerotic AAA or from systemic vasculitis and to treat it with the appropriate combination of medical and surgical therapies.

52 precepts that medical trainees and physicians should consider regularly.

Being a physician is rewarding but also challenging in the complex health care system. As physicians, we are continually trying to deliver more effective and higher quality care to our patients. With improvement in mind, a list of precepts has been generated as a tool to remind all of us in clinical medicine about the exemplary characteristics, behaviors, and attitudes that are expected as the norm in this profession. The list is organized into four categories: promotion of relationships with patients, principles of the effective clinician, growth and improvement, and values to guide one's career in medicine. The list is envisioned as an instrument that may be helpful to medical learners and physicians by promoting reflection about ways to consistently perform at a high level while more fully appreciating the joy of practicing medicine. The list of precepts may also be useful to medical educators who wish to successfully mold the physicians of tomorrow.

The rate at which residents learn to use hand-held echocardiography at the bedside.

PURPOSE: Because there is little information about the training that general internists require to perform hand-carried cardiac ultrasonography (HCU), we studied the rate of learning of a group of medical residents performing HCU after minimal formal training. METHODS: Medical residents on the inpatient services at Johns Hopkins Bayview Medical Center received formal training in HCU consisting of 15-30 minutes of didactic instruction about the principles of echocardiography, followed by ongoing one-on-one instruction in performing HCU and subsequent ongoing one-on-one training from a certified echocardiography technician as they were doing scans. The residents were shown how to position the patient to obtain 2-dimensional echo images from the parasternal short and long axes and apical 4-chamber views, and how to obtain color-flow Doppler images across the mitral and aortic valves. Residents were asked to determine whether pericardial effusion was present and to assess left ventricular size, left ventricular function, and the mitral and aortic valves. The residents performed cardiac physical examination and HCU independently on patients who had a conventional transthoracic echocardiogram (CTTE) performed within 24 hours of the HCU. The residents' HCU results were compared with the CTTE results by a cardiologist specializing in echocardiography. The rates at which residents gained technical proficiency and skills in interpreting their studies were measured by linear regression to fit various outcome variables against their experience at scanning as gauged by the number of scans performed. RESULTS: Thirty medical residents performed a total of 231 HCU studies. Linear regression models showed that the residents' overall technical proficiency skills improved at the rate of 0.79 (95% confidence interval [CI] 0.53-1.04) points on an overall assessment index (0-3 scale) per 10 scans completed. Interpretation accuracy improved at a rate of 1.01 (95% CI 0.69-1.39) points per 10 scans as measured by an interpretation accuracy index (0-3 scale). Because scanning efforts and instruction in HCU occurred during residents' usual rotation duties, some residents gathered experience in HCU slowly and sporadically. CONCLUSION: This study, the first prospective, experimental effort of its kind, shows that residents as a group learned important aspects of HCU scanning and interpretation at a reasonably rapid rate.

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.