Annals for Educators - 5 December 2017

Darren B. Taichman

doi:10.7326/AFED201712050

Clinical Practice Points

46-Year Trends in Systemic Lupus Erythematosus Mortality in the United States, 1968 to 2013. A Nationwide Population-Based Study

Diagnostic and treatment advances in systemic lupus erythematosus (SLE) have resulted in improved 5- and 10-year survival rates. This study describes trends in SLE mortality rates in the United States over a 46-year period.

Use this study to:

Start and end a teaching session with multiple-choice questions. We've provided 2 below!
Ask your learners to list the ways SLE might present. How is the diagnosis established? Use the information in DynaMed Plus: Systemic lupus erythematosus, a benefit of your ACP membership.
What are the potential complications of SLE? Which ones are life-threatening?
Teach at the bedside! Identify a patient on the medical service with SLE, and ask whether she or he would be willing (and even would appreciate) talking to your team about how SLE has affected her or his life. What has been the worst part? What has not been as bad as expected? Are your learners surprised by which manifestations of this disease are most troublesome in the patient's daily life?
How is SLE treated?
Look at the Figure in this paper with your learners. How do they interpret these findings? What do they tell us about our ability to manage the complications of SLE? Are your learners surprised by the sex, racial, and geographic discrepancies in mortality rates seen in Table 3? Why or why not?

Functional Impairment and Decline in Middle Age. A Cohort Study

Functional impairments, or limitations in performing activities of daily living (ADLs), are common among middle-aged adults. This article presents data on the incidence and clinical course of functional impairments among community-dwelling, middle-aged adults in the United States.

Use this study to:

Ask your learners to list ADLs and instrumental ADLs (IADLs). They are listed in the “Measures” subsection of the paper's Methods section.
Ask your learners how often they think middle-aged adults develop ADL impairments. Look at Figure 2. Are your learners surprised by these data?
Explore the interactive graphic that accompanies this paper. This allows your learners to visualize what happens to a group of people who have anywhere from 0 to 5 impairments. How many recover and become independent again? How many become and remain dependent?
Do your learners ask their patients about ADLs and IADLs? Should they? Why do they matter? Have your learners ask each of their patients about ADLs and IADLs before your next meeting. What did they learn? Were they surprised? Why don't we focus on these more routinely?
How can we help our patients with ADLs? Invite a rehabilitation physician to join your discussion. Invite an occupational therapist to talk to your team about what they do with patients and which types of impairments are more or less amenable to interventions.

Beyond the Guidelines

Should This Patient Receive Aspirin? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

The U.S. Preventive Services Task Force has concluded that for adults aged 50 to 59 years with a 10-year risk for cardiovascular disease (CVD) of 10% or greater, the benefit of aspirin for both CVD and colorectal cancer prevention moderately outweighs the risk for harm. Here, 2 experts discuss whether to recommend aspirin for a 57-year-old man who has a CVD risk greater than 10% but has concerns about gastrointestinal side effects.

Use this feature to:

Read the first 4 paragraphs of this paper with your learners for a summary of Mr. C's clinical issue. Then, watch the brief video interview with Mr. C.
Ask your learners each of the questions posed to the Beyond the Guidelines discussants: What are the potential benefits of daily low-dose aspirin, and how long do you need to take aspirin to achieve those benefits? What are the potential harms? How do you balance benefits and harms to individualize a risk-based decision for Mr. C in particular and for patients in general?
Now, review the answers of the discussants by either reviewing the paper (use the provided slides) or watching the video of the Grand Rounds presentations. Have your learners altered their opinions?
Answer the multiple-choice questions, and log on to enter your answers and earn CME/MOC credit for yourself!

In the Clinic

In the Clinic: Dyslipidemia

Dyslipidemia is an important risk factor for coronary artery disease and stroke. Long-term, prospective epidemiologic studies have consistently shown that persons with healthier lifestyles and fewer risk factors for coronary heart disease, particularly those with favorable lipid profiles, have reduced incidence of coronary heart disease. Prevention and sensible management of dyslipidemia can markedly alter cardiovascular morbidity and mortality. Are your learners ready?

Use this paper to:

Ask your learners whether they screen their patients for dyslipidemia. Which ones?
How should screening be performed? Should a fasting lipid panel be used? Should triglycerides be measured? How should the results be interpreted?
Ask your learners which drugs can cause dyslipidemia.
What behavioral modifications should be recommended? How do your learners choose therapy? Use the Table to help review options with your learners.
What are the goals of treatment, and how should patients be monitored? Is repeated testing necessary?
How will your learners counsel patients who are concerned about medication adverse effects? What will they say to a patient who wants to use alternative or complementary therapies?
Download the teaching slide set. Use the provided multiple-choice questions to help introduce topics during a teaching session. And, log on to enter your answers and earn CME/MOC credit for yourself!

Humanism and Professionalism

Annals Graphic Medicine - Dear Doctor II

KC expresses outrage at the insensitive behavior of the emergency room physician. How could things have gone so wrong?

Use this feature to:

Look at the cartoon (yes, a cartoon in a serious medical journal) with your learners.
Ask whether they believe the emergency room physician is likely to be as callous as he seemed to his patient's family members. Does it matter whether he meant to be rude? Is there another side to the story? The author makes clear that other members of the emergency department team were wonderful.
Do your learners think that their behavior has ever inadvertently offended patients or their families? What can we do to prevent this?

On Being a Patient

Terminal

Denial

In the first essay, Dr. Lederle describes his thoughts on “coming to terms” with his terminal diagnosis. In the second essay, Dr. Saxe reflects on how her own malignancies and her mother's dementia shattered her “protective wall of denial.”

Use these essays to:

Listen to an audio recording of each, read by Drs. Michael LaCombe and Virginia Hood.
Ask your learners whether hearing about a physician's devastating diagnosis affects them differently from hearing such news about a patient or a family member. Why?
Do we learn to put up walls between ourselves and our patients? In what ways are they detrimental? Are they useful in some way? Are there solutions to these opposing effects?
Do we all have to endure an illness ourselves or with a family member to shatter the wall?

MKSAP 17 Question 1

A 30-year-old woman is evaluated during a follow-up visit for systemic lupus erythematosus. She was diagnosed 3 months ago after presenting with pericarditis and arthritis. She was initially treated with prednisone, 40 mg/d, with improvement of her presenting symptoms. The prednisone has been tapered over 3 months to her current dose of 10 mg/d with no recurrence. She also takes vitamin D and a calcium supplement.

On physical examination, vital signs are normal. BMI is 25. Cardiac examination is normal. There is no evidence of arthritis. The remainder of the examination is normal.

Which of the following is the most appropriate next step in treating this patient?

A. Add azathioprine

B. Add hydroxychloroquine

C. Add mycophenolate mofetil

D. Add a scheduled NSAID

Correct Answer

B. Add hydroxychloroquine

Educational Objective

Treat mild systemic lupus erythematosus.

Critique

Hydroxychloroquine is an appropriate agent to address milder systemic manifestations of systemic lupus erythematosus (SLE) such as arthritis and pericarditis, and it can act as a glucocorticoid-sparing agent. All patients with SLE who can tolerate it should be taking hydroxychloroquine. Antimalarial therapy such as hydroxychloroquine in SLE has documented benefit for reducing disease activity, improving survival, and reducing the risk of SLE-related thrombosis and myocardial infarction.

Azathioprine is generally reserved for more severe manifestations of SLE not responsive to low-dose prednisone and hydroxychloroquine but can be associated with serious toxicity. Azathioprine has generally been supplanted by the use of mycophenolate mofetil in SLE.

Mycophenolate mofetil may be appropriate for this patient if she had more serious disease activity such as nephritis or if her arthritis or pericarditis recurred while taking hydroxychloroquine.

NSAIDs, often with colchicine, are first-line therapy for most patients with pericarditis, although glucocorticoids may be indicated in patients with pericarditis associated with a systemic inflammatory disease such as in this patient. However, there is no indication to start an NSAID now given resolution of her symptoms, and doing so would increase her risk of gastrointestinal complications if used along with her daily glucocorticoid.

Key Point

Antimalarial therapy such as hydroxychloroquine in systemic lupus erythematosus (SLE) has documented benefit for reducing disease activity, improving survival, and reducing the risk of SLE-related thrombosis and myocardial infarction.

Bibliography

Lee SJ, Silverman E, Bargman JM. The role of antimalarial agents in the treatment of SLE and lupus nephritis. Nat Rev Nephrol. 2011 Oct 18;7(12):718-29.

MKSAP 17 Question 2

A 35-year-old woman is evaluated for weakness in the right foot and left wrist with paresthesia in the right leg, right foot, left forearm, and left hand. She also reports facial erythema and joint stiffness. She has a 6-year history of systemic lupus erythematosus (SLE). Medications are hydroxychloroquine, prednisone, vitamin D, and calcium.

On physical examination, vital signs are normal. There is a new malar rash. Swelling of the second through fourth metacarpophalangeal joints of the hands is present. There is dorsiflexion weakness of the right ankle and a left wrist drop. Reflexes are normal. The remainder of the examination is normal.

Laboratory studies indicate that her SLE appears to be active with an elevation of erythrocyte sedimentation rate compared with baseline, leukopenia, and anemia typical of her previous SLE flares.

Which of the following is the most appropriate next step in management?

A. Discontinue hydroxychloroquine

B. Obtain electromyography/nerve conduction studies

C. Obtain MRI of the cervical spine

D. Obtain skin biopsy for small-fiber neuropathy

Correct Answer

B. Obtain electromyography/nerve conduction studies

Educational Objective

Evaluate a patient with systemic lupus erythematosus who has developed mononeuritis multiplex.

Critique

Electromyography (EMG) and nerve conduction studies (NCS) are appropriate for this patient with systemic lupus erythematosus (SLE) who most likely has mononeuritis multiplex. Mononeuritis multiplex is characterized by abnormal findings in the territory of two or more nerves in separate parts of the body. She has a foot drop with normal reflexes that suggests an injury to the peroneal nerve and wrist drop that suggests injury to the radial nerve. EMG/NCS would most likely document a peripheral neuropathy. Mononeuritis multiplex is highly specific for vasculitic disorders that affect the vasa vasorum or nerve vascular supply but can also occur in systemic inflammatory disorders such as SLE. The peroneal nerve is the most commonly affected nerve. Approximately 14% of patients with SLE have a peripheral neuropathy with the majority (60%) due to SLE. Risk factors for the development of SLE-associated peripheral neuropathy include moderate to severe disease and the presence of other neuropsychiatric SLE manifestations. Approximately two thirds of patients improve with more aggressive immunosuppression. EMG/NCS can identify a nerve (usually the sural nerve) that might be amenable to biopsy to document the vasculitis prior to aggressive immunosuppression.

Hydroxychloroquine can cause a neuromyopathy manifested by proximal muscle weakness and areflexia. Biopsy demonstrates vacuoles in the muscle cells. However, hydroxychloroquine has not been associated with mononeuritis multiplex.

SLE may rarely cause transverse myelitis, which is characterized by a rapidly progressing paraparesis associated with a sensory level. Autonomic symptoms, including increased urinary urgency, bladder and bowel incontinence, and sexual dysfunction, may be present. The patient has no symptoms suggesting transverse myelitis, and a spine MRI is not indicated.

A small-fiber neuropathy causes a burning pain in the extremities and has been associated with autoimmune diseases such as SLE but does not cause motor symptoms. Diagnosis is made by skin biopsy, which demonstrates a reduced density of small sensory nerve fibers in the skin.

Key Point

Mononeuritis multiplex is characterized by abnormal findings in the territory of two or more nerves in separate parts of the body and is highly specific for vasculitis but can occur in systemic inflammatory disorders such as systemic lupus erythematosus.

Bibliography

Florica B, Aghdassi E, Su J, et al. Peripheral neuropathy in patients with systemic lupus erythematosus. Semin Arthritis Rheum. 2011 Oct;41(2):203-11.

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Web Exclusives |5 December 2017

Annals for Educators - 5 December 2017 Free

Clinical Practice Points

46-Year Trends in Systemic Lupus Erythematosus Mortality in the United States, 1968 to 2013. A Nationwide Population-Based Study

Functional Impairment and Decline in Middle Age. A Cohort Study

Beyond the Guidelines

Should This Patient Receive Aspirin? Grand Rounds Discussion From Beth Israel Deaconess Medical Center