U.S. medical organizations and climate change advocacy: a review of public facing websites.

BACKGROUND: Climate change poses a risk of health catastrophes and must be expeditiously addressed across the health care sector. Physicians are considered trustworthy and are well positioned to discuss climate change with patients. A unified strategy by all U.S. medical societies is essential to effectively mitigate their carbon footprint and address health concerns. METHODS: We conducted a review of the public facing websites of member organizations of the AMA House of Delegates and the AMA, which were scored based on inclusion of content related to climate change in position statements or policies, task forces or committees, patient education materials, practice recommendations and any official society publications. Membership in the Medical Society Consortium on Climate and Health or participation in the organization My Green Doctor were recorded as indicators of a commitment to providing educational resources about mitigation and adaptation to climate change. The availability of a virtual option for annual meetings, as a potential means to reduce the carbon footprint of attendees, was trended from 2021 to 2022. RESULTS: Fifty out of 111 U.S. medical organizations (45%) had at least one metric with a reference to climate change and sixty-one organizations (55%) had no evidence of such website content. Out of 111 websites, only 20% (N = 22) had position statements or policies pertaining to climate change, 11% (N = 12) had committees or task forces dealing with climate change, 8% (N = 9) provided patient education resources on climate change, 21% (N = 23) included green practice recommendations and 45% (N = 50) had an article in an official society publication addressing climate change. Only 14% (N = 15) were listed as member societies of the Medical Consortium on Climate Change and 2% (N = 2) were participating organizations with My Green Doctor. CONCLUSIONS: Viewed through the lens of medical society websites, there was a wide variation in efforts to address climate change. The high performing organizations can serve as a guide for other societies to help mitigate and adapt to the climate emergency.

ATR-dependent phosphorylation of FANCA on serine 1449 after DNA damage is important for FA pathway function.

Previous work has shown several proteins defective in Fanconi anemia (FA) are phosphorylated in a functionally critical manner. FANCA is phosphorylated after DNA damage and localized to chromatin, but the site and significance of this phosphorylation are unknown. Mass spectrometry of FANCA revealed one phosphopeptide, phosphorylated on serine 1449. Serine 1449 phosphorylation was induced after DNA damage but not during S phase, in contrast to other posttranslational modifications of FA proteins. Furthermore, the S1449A mutant failed to completely correct a variety of FA-associated phenotypes. The DNA damage response is coordinated by phosphorylation events initiated by apical kinases ATM (ataxia telangectasia mutated) and ATR (ATM and Rad3-related), and ATR is essential for proper FA pathway function. Serine 1449 is in a consensus ATM/ATR site, phosphorylation in vivo is dependent on ATR, and ATR phosphorylated FANCA on serine 1449 in vitro. Phosphorylation of FANCA on serine 1449 is a DNA damage-specific event that is downstream of ATR and is functionally important in the FA pathway.

Active and latent tuberculosis in patients with systemic lupus erythematosus living in the United States.

BACKGROUND: The prevalence and clinical course of tuberculosis infection have not been well described in patients with systemic lupus erythematosus (SLE) in the United States. OBJECTIVE: This study documents the demographic, clinical, and laboratory characteristics and outcomes of patients with SLE and latent tuberculosis infection (LTBI) or active TB in an ethnically diverse clinic. METHODS: We conducted a retrospective review of clinical records of patients with SLE followed during 2005 in a county community hospital rheumatology clinic, with a large immigrant population. Clinical characteristics were analyzed according to the patients' ethnicity, tuberculin skin test (TST) results, and history of treatment for latent or active TB. RESULTS: Data regarding a history of active TB or TST status were available for 187 of 220 patients seen in 2005 (85%). The prevalence of TB infection was highest in patients from TB endemic areas. Fourteen patients (7%) had active TB and 33 patients (18%) had LTBI. Among the 6 patients who developed active TB after the onset of SLE, 2 had pulmonary, 1 had extrapulmonary, and 3 had disseminated TB. Laboratory features and treatment regimens for SLE were similar in patients with a history of TB infection and in patients with a negative TST. CONCLUSIONS: A significant number of patients with SLE in a county clinic population in the United States had LTBI or TB. Treatment of active TB and latent TB yielded good outcomes with no deaths. US clinicians should consider screening SLE patients for LTBI, especially those from TB endemic areas.

Adverse interactions between herbal and dietary substances and prescription medications: a clinical survey.

CONTEXT: Patients often combine prescription medications with herbal and dietary substances (herein referred to as herbal medicines). A variety of potential adverse herb-drug interactions exist based on the pharmacological properties of herbal and prescription medications. OBJECTIVE: To determine the incidence of potential and observed adverse herb-drug interactions in patients using herbal medicines with prescription medications. DESIGN: Consecutive patients were questioned about their use of herbal medicines in 6 outpatient clinics. Patients reporting use of these products provided a list of their prescription medications, which were reviewed for any potential adverse herb-drug interactions using a comprehensive natural medicine database. Any potential adverse herb-drug interactions prompted a review of the patient's chart for evidence of an observed adverse herb-drug interaction. MAIN OUTCOME MEASURE: The rate of potential and observed adverse herb-drug interactions. RESULTS: Eight hundred four patients were surveyed, and 122 (15%) used herbal medicines. Eighty-five potential adverse herb-drug interactions were found in 49 patients (40% of herbal medicine users). Twelve possible adverse herb-drug interactions in 8 patients (7% of herbal medicine users) were observed. In all 12 cases, the severity scores were rated as mild, including 8 cases of hypoglycemia in diabetics taking nopal (prickly pear cactus). CONCLUSIONS: A substantial number of potential adverse herb-drug interactions were detected and a small number of adverse herb-drug interactions observed, particularly in diabetics taking nopal. Screening for herbal medicine usage in 804 patients did not uncover any serious adverse interactions with prescription medications.

Reversible posterior leukoencephalopathy in patients with systemic lupus erythematosus.

BACKGROUND: The development of central nervous system (CNS) symptoms in patients with preexisting systemic lupus erythematosus (SLE) evokes a wide differential diagnosis. Reversible posterior leukoencephalopathy (RPLE) is a rapidly evolving neurologic syndrome with characteristic clinical and radiographic features. Conditions commonly associated with RPLE include hypertensive encephalopathy, eclampsia, immunosuppressive drugs, and inflammatory disorders. OBJECTIVES: To describe our experience with RPLE in patients with concomitant SLE and review the literature. METHODS: The details of 5 novel cases and a MEDLINE review of the literature concerning the development of RPLE in association with SLE are presented. RESULTS: All cases included patients with SLE who developed the acute onset of headache, altered mental status, visual changes, and seizures. Neuroimaging demonstrated posterior white matter edema involving the parietal, temporal, and occipital lobes. Complete clinical and radiographic recovery occurred with prompt antihypertensive treatment and supportive care. Literature review identified 16 additional cases of RPLE occurring in patients with active SLE; the majority of these reports was similar in presentation and outcome to our experience. CONCLUSIONS: It is likely that the clinical manifestations and neuroimages in these lupus patients were the result of the RPLE syndrome. Fortunately, this cause of "secondary" CNS symptoms in patients with SLE is readily reversible when diagnosed early and treated with blood pressure control and supportive care.

Brucellosis and sacroiliitis: a common presentation of an uncommon pathogen.

Musculoskeletal problems are the most common chief complaint in ambulatory medicine across all specialties, and back pain is one of the top 10 problems encountered by the general practitioner. The differential diagnosis of lower back pain is exhaustive, but a history significant for constitutional symptoms or unusual exposures should prompt a work-up for an infectious cause. We describe the case of a 25-year-old man with a Brucella abortus sacroiliitis and possible orchiitis after consumption of unpasteurized cheese imported from El Salvador. The patient was successfully treated with gentamycin, rifampin, and doxycycline. Though the presentations of brucellosis are myriad, osteoarticular involvement of the axial skeleton is the most common presentation of this zoonotic infection. In the United States brucellosis is rarely encountered and is typically limited to people who are exposed during travel to endemic areas. Here we review briefly the epidemiology and presentation of a Brucella infection and current recommendations for treatment.

The use of disease modifying antirheumatic drugs in women with rheumatoid arthritis of childbearing age: a survey of practice patterns and pregnancy outcomes.

OBJECTIVE: To describe the practices of rheumatologists when prescribing the disease modifying antirheumatic drugs (DMARD) methotrexate (MTX), leflunomide (LF), etanercept (ET), and infliximab (IN) to women of childbearing age with rheumatoid arthritis (RA) and the pregnancy outcomes of patients who become pregnant while taking these medications. METHODS: A questionnaire was mailed to 600 members of the American College of Rheumatology inquiring about their perception of fetal risk, their recommendations regarding the use of birth control in women of childbearing age taking DMARD, and the pregnancy outcomes of women with DMARD exposure. RESULTS: One hundred seventy-five rheumatologists (29%) returned completed surveys. Respondents were more likely to agree that pregnancy is contraindicated in women taking MTX (95%) or LF (92.7%) than for women taking ET (38.6%) or IN (46.5%). Accordingly, most required birth control for women taking MTX (95.7%) and LF (97.3%), and fewer for women taking ET (75.4%) or IN (73.4%). A total of 65 pregnancies exposed to these DMARD were reported (MTX 38, LF 10, ET 14, IN 2, MTX and ET 1). Only 3 congenital malformations, all in the MTX group, were reported among the 52 pregnancies with known outcomes. CONCLUSION: Rheumatologists agree that there is a risk of teratogenicity with MTX and LF and usually require the use of reliable methods of birth control in women taking these medications. There is no consensus about ET and IN; however, physicians still tend to discuss reliable birth control methods with their female patients. We have confirmed there is a risk of congenital malformations with in utero exposure to MTX. No malformations were reported in infants exposed to LF, ET, or IN, but the number of reported pregnancy outcomes was small.

GA-binding protein (GABP) and Sp1 are required, along with retinoid receptors, to mediate retinoic acid responsiveness of CD18 (beta 2 leukocyte integrin): a novel mechanism of transcriptional regulation in myeloid cells.

CD18 (beta(2) leukocyte integrin) is transcriptionally regulated in myeloid cells, but the mechanisms that increase its expression in response to retinoic acid (RA) have not been defined. The CD18 promoter was activated by RA treatment in stably transfected U937 myeloid cells. We identified a retinoic acid response element (RARE) that lies nearly 900 nucleotides upstream of the CD18 transcriptional start site that was bound by the RA receptors, retinoic acid receptor (RAR) and retinoic X receptor (RXR). This RARE accounted for one half of the RA responsiveness of CD18. However, unexpectedly, one half of the dynamic response to RA was mediated by the 96-nucleotide CD18 minimal promoter, which lacks a recognizable RARE. Binding sites for the ets transcription factor, GA-binding protein (GABP), and Sp1 were required for full RA responsiveness of both the CD18 minimal promoter and the full-length promoter. The ets sites conferred RA responsiveness on an otherwise unresponsive heterologous promoter, and RA responsiveness was directly related to the number of ets sites. The transcriptional coactivator p300/CBP physically interacted with GABP in vivo, and p300 increased the responsiveness of the CD18 promoter to RA. These studies demonstrate a novel role for non-RAR transcription factors in mediating RA activation in myeloid cells. They support the concept that transcription factors other than RARs are required for RA-activated gene expression. We hypothesize that a multiprotein complex--an enhanceosome--that includes GABP, other transcription factors, and coactivators, dynamically regulates CD18 expression in myeloid cells.

Participatory patient-physician communication and morbidity in patients with systemic lupus erythematosus.

OBJECTIVE: To examine associations between active patient-physician communication and measures of morbidity in patients with systemic lupus erythematosus (SLE). METHODS: Audiotapes of routine visits between 79 women with SLE and their rheumatologists were coded for active patient participation and the degree of patient-centered communication of the physician, using a validated coding scheme. Measures of SLE activity, functional disability, and permanent organ damage were recorded at the same visit. Permanent organ damage was reassessed in 68 patients after a median of 4.7 years. RESULTS: Patients who participated more actively in their visits had less permanent organ damage, as measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, and tended to accrue less organ damage over time. There were no associations between either active patient participation or physicians' patient-centered communication scores and measures of SLE activity or functional disability. CONCLUSIONS: Patients with SLE who participated more actively in their visits had less permanent organ damage, suggesting that involving patients more in their care may decrease morbidity.