Systemic Lupus Erythematosus: Diagnosis and Treatment.

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects the cardiovascular, gastrointestinal, hematologic, integumentary, musculoskeletal, neuropsychiatric, pulmonary, renal, and reproductive systems. It is a chronic disease and may cause recurrent flare-ups without adequate treatment. The newest clinical criteria proposed by the European League Against Rheumatism/American College of Rheumatology in 2019 include an obligatory entry criterion of a positive antinuclear antibody titer of 1: 80 or greater. Management of SLE is directed at complete remission or low disease activity, minimizing the use of glucocorticoids, preventing flare-ups, and improving quality of life. Hydroxychloroquine is recommended for all patients with SLE to prevent flare-ups, organ damage, and thrombosis and increase long-term survival. Pregnant patients with SLE have an increased risk of spontaneous abortions, stillbirths, preeclampsia, and fetal growth restriction. Preconception counseling regarding risks, planning the timing of pregnancy, and a multidisciplinary approach play a major role in the management of SLE in patients contemplating pregnancy. All patients with SLE should receive ongoing education, counseling, and support. Those with mild SLE can be monitored by a primary care physician in conjunction with rheumatology. Patients with increased disease activity, complications, or adverse effects from treatment should be managed by a rheumatologist.

Adult Eye Conditions: Diabetic Retinopathy and Age-Related Macular Degeneration.

Diabetic retinopathy (DR), a microvascular complication of diabetes, is the most common cause of vision loss in adults ages 20 to 74 years in many countries. Initial screening for DR should occur within 5 years of a type 1 diabetes diagnosis and at the time of a type 2 diabetes diagnosis. Slowing of DR progression involves optimization of glycemic control, blood pressure management, control of diet and lipid levels, and lifestyle modification. Panretinal photocoagulation (PRP) can prevent progression of proliferative DR with minimal risk of damaging the macula. Ranibizumab, an anti-vascular endothelial growth factor (VEGF) drug, can be an effective alternative to PRP. Age-related macular degeneration (AMD) is a leading cause of visual impairment and vision loss in developed countries. AMD leads to progressive loss of central vision and distortion of images. Smoking is the strongest modifiable risk factor. Hypertension and hyperlipidemia also have been associated with AMD. The initial patient evaluation should include a comprehensive eye examination, visual acuity measurement, assessment with the Amsler grid, and fundus photography. Smoking cessation should be recommended for patients with AMD who smoke. For patients with wet, or neovascular, AMD, first-line therapy is an intravitreal anti-VEGF drug (ie, ranibizumab, bevacizumab, aflibercept [Eylea]).

Autoimmune Conditions: Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a complex autoimmune disease that can affect the musculoskeletal, integumentary, renal, neuropsychiatric, hematologic, cardiac, pulmonary, gastrointestinal, and reticuloendothelial systems. Most patients with suspected SLE are comanaged with a rheumatology subspecialist to confirm the diagnosis and assist in ongoing treatment. Management should focus on improving long-term outcomes, achieving remission, preventing tissue damage, and improving quality of life. Disease activity should be assessed at baseline and at follow-up visits using a validated instrument. Hydroxychloroquine is recommended for all patients with SLE and should be continued indefinitely unless contraindicated. Low-dose glucocorticoids can be used to manage most symptoms. When needed, immunosuppressive drugs and biologics can be used, depending on the affected body system.

Systemic Lupus Erythematosus: Primary Care Approach to Diagnosis and Management.

Systemic lupus erythematosus is an autoimmune disease that affects many systems, including the skin, musculoskeletal, renal, neuropsychiatric, hematologic, cardiovascular, pulmonary, and reproductive systems. Family physicians should be familiar with the manifestations of lupus to aid in early diagnosis, monitoring patients with mild disease, recognizing warning signs that require referral to a rheumatologist, and helping to monitor disease activity and treatment in patients with moderate to severe disease. The American College of Rheumatology has 11 classification criteria for lupus. If a patient meets at least four criteria, lupus can be diagnosed with 95% specificity and 85% sensitivity. All patients with lupus should receive education, counseling, and support. Hydroxychloroquine is the cornerstone of treatment because it reduces disease flares and other constitutional symptoms. Low-dose glucocorticoids can be used to treat most manifestations of lupus. The use of immunosuppressive and cytotoxic agents depends on the body systems affected. Patients with mild disease that does not involve major organ systems can be monitored by their family physician. Patients with increased disease activity, complications, or adverse effects from treatment should be referred to a rheumatologist. To optimize treatment, it is important that a rheumatologist coordinate closely with the patient's family physician to improve chronic care as well as preventive health services.

Caring for pregnant women and newborns with hepatitis B or C.

Family physicians encounter diagnostic and treatment issues when caring for pregnant women with hepatitis B or C and their newborns. When hepatitis B virus is perinatally acquired, an infant has approximately a 90 percent chance of becoming a chronic carrier and, when chronically infected, has a 15 to 25 percent risk of dying in adulthood from cirrhosis or liver cancer. However, early identification and prophylaxis is 85 to 95 percent effective in reducing the acquisition of perinatal infection. Communication among members of the health care team is important to ensure proper preventive techniques are implemented, and standing hospital orders for hepatitis B testing and prophylaxis can reduce missed opportunities for prevention. All pregnant women should be screened for hepatitis B as part of their routine prenatal evaluation; those with ongoing risk factors should be evaluated again when in labor. Infants of mothers who are positive for hepatitis B surface antigen should receive hepatitis B immune globulin and hepatitis B vaccination within 12 hours of birth, and other infants should receive hepatitis B vaccination before hospital dis- charge. There are no effective measures for preventing perinatal hepatitis C transmission, but transmission rates are less than 10 percent. Perinatally acquired hepatitis C can be diagnosed by detecting hepatitis C virus RNA on two separate occasions between two and six months of age, or by detecting hepatitis C virus antibodies after 15 months of age.