Antiphospholipid antibody positivity in early systemic lupus erythematosus is associated with subsequent vascular events.

OBJECTIVE: aPL are found in the blood of 20-30% of patients with SLE. Although aPL cause vascular thrombosis in the antiphospholipid syndrome, it is not clear whether positive aPL levels in early SLE increase risk of subsequent vascular events (VE). In a previous analysis of 276 patients with SLE, we found that early positivity for ≥2 of IgG anti-cardiolipin (anti-CL), IgG anti-ß2-glycoprotein I (anti-ß2GPI) and anti-domain I of ß2-glycoprotein I (anti-DI) showed a possible association with VE. Here we have extended that analysis. METHODS: Serum samples taken from 501 patients with SLE early in their disease had been tested for IgG anti-CL, anti-ß2GPI and anti-DI by ELISA. Complete VE history was available for 423 patients of whom 23 were excluded because VE occurred before the diagnosis of SLE. For the remaining 400 patients we carried out Kaplan-Meier survival analysis to define groups at higher risk of VE. RESULTS: Of 400 patients, 154 (38.5%) were positive for one or more aPL, 27 (6.8%) were double/triple-positive and 127 (31.8%) were single-positive. There were 91 VE in 77 patients, of whom 42 were aPL-positive in early disease. VE were significantly increased in aPL-positive vs aPL-negative patients (P = 0.041) and in double/triple-positive vs single-positive vs aPL-negative patients (P = 0.0057). Omission of the IgG anti-DI assay would have missed 14 double/triple-positive patients of whom six had VE. CONCLUSION: Double/triple-positivity for IgG anti-CL, anti-ß2GPI and anti-DI in early SLE identifies a population at higher risk of subsequent VE.

Antiphospholipid antibody levels in early systemic lupus erythematosus: are they associated with subsequent mortality and vascular events?

OBJECTIVES: aPL are present in between 20 and 30% of patients with SLE. They can cause vascular events (VE) or pregnancy morbidity. aCL and anti-beta-2-glycoprotein I (anti-ß2GPI) are measured in clinical practice. Domain I (DI) of ß2GPI is the main site for aPL binding. We investigated the prevalence of IgG anti-DI, aCL and anti-ß2GPI antibodies in early SLE and their association with mortality and development of VE. METHODS: Samples from 501 patients with SLE that had been obtained and stored early during their disease were tested for IgG anti-DI, aCL and anti-ß2GPI antibodies by ELISA. LA status and history of VE were obtained by reviewing medical records. Kaplan-Meier analysis was used to investigate mortality and occurrence of VE, comparing groups with and without aPL in early disease. RESULTS: Of 501 patients, 190 (38%) had at least one of these aPL, of whom 112 had anti-DI alone. Of 276 patients with complete vascular history, 83 had experienced VE. The 39 patients who were double or triple-ELISA-positive for any combination of the three aPL were more likely to have or develop lupus anticoagulant (P<0.0001) than those who were single-ELISA-positive or negative. In Kaplan-Meier analysis, they showed a trend towards developing more VE (P = 0.06). CONCLUSION: IgG anti-DI antibodies were present in early serum samples from 29% of patients and were more common than IgG aCL or anti-ß2GPI. There was some evidence suggesting that double or triple-ELISA-positivity for these antibodies identified a group with worse outcomes.

Improving communication on medical ward rounds with patients who speak limited English with implementation of medical communication charts.

AIM: To improve communication on the medical ward round with patients with limited English through implementation of a medical communication chart. LOCAL PROBLEM: King's College Hospital (KCH), London, is situated in Southwark in which 11% of households have no members that speak English as a first language, 4.1% of London's population report they do not speak English well. Language barriers impair healthcare delivery including during daily ward rounds. This has been exacerbated by the need for PPE during the SARS-CoV2 pandemic. Effective communication between healthcare teams and patients is essential for high quality, patient-centred care. Communication tools commonly used include online, telephone and face-to-face translation services but these have limitations. METHODS: Face-to-face patient questionnaires were conducted in the pre-QIP (baseline) group to assess communication on medical ward rounds. Medical communication charts were designed by adapting pre-existing aids commonly used by speech and language therapy. Charts were translated into commonly spoken languages among KCH inpatients. Patients with limited English were selected from both COVID-19 and non-Covid wards. Preintervention and postintervention questionnaires were completed in three Plan-Do-Study-Act (PDSA) cycles. RESULTS: At baseline, patients agreed or strongly agreed that the ward round addressed physical symptoms (8/8), concerns or anxieties (7/8), ongoing needs (7/8). Only two of eight doctors felt they could communicate effectively with patients. In PDSA 1, four of five patients reported high satisfaction in communicating physical symptoms, anxieties or concerns preintervention with five of five postchart implementation. Five of five patients reported high satisfaction in communicating ongoing needs preintervention but only three of five postintervention. In PDSA 2, two of five patients reported increased satisfaction in communicating physical symptoms, concerns or anxieties with four of four doctors reporting improved satisfaction in communication in PDSA 2 and two of three doctors reporting higher satisfaction in communication in PDSA 3. CONCLUSION: Using communication charts in patients with limited English can improve bidirectional communication on medical ward rounds.