Diagnosis, monitoring and treatment of systemic lupus erythematosus: a systematic review of clinical practice guidelines.

Objectives: Management of SLE is complex and variability in practices exists. Guidelines have been developed to help improve the management of SLE patients but there has been no formal evaluation of these guidelines. This study aims to compare the scope, quality and consistency of clinical practice guidelines on the diagnosis, monitoring and treatment of patients with systemic lupus erythematosus (SLE). Methods: Electronic databases were searched up to April 2014. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and textual synthesis was used to appraise and compare recommendations. Results: Nine clinical practice guidelines and five consensus statements were identified, which covered seven topics: diagnosis, monitoring, treatment, neuropsychiatric SLE, lupus nephritis, anti-phospholipid syndrome and other manifestations of lupus. The methodological quality of the guidelines was variable, with the overall mean AGREE II scores ranging from 31% to 75% out of a maximum 100%. Scores were consistently low for applicability, with only one guideline scoring above 50%. There was substantial variability in the treatments recommended for class II and V lupus nephritis, the recommended duration of maintenance therapy for class III/IV lupus nephritis (from 1 to 4 years), and timing of ophthalmological examination for patients on corticosteroids. Conclusion: Published guidelines on SLE cover a complex area of clinical care but the methodological quality, scope and recommendations varied substantially. Collaborative and multidisciplinary efforts to develop comprehensive, high-quality evidence-based guidelines are needed to promote best treatment and health outcomes for patients with SLE.DT is funded by a postgraduate scholarship from the Sydney Medical School, The University of Sydney

Longitudinal evaluation of cognitive functioning in young children with type 1 diabetes over 18 months

OBJECTIVE: Decrements in cognitive function may already be evident in young children with type 1 diabetes (T1D). Here we report prospectively acquired cognitive results over 18 months in a large cohort of young children with and without T1D. METHODS: 144 children with T1D (mean HbA1c: 7.9%) and 70 age-matched healthy controls (mean age both groups 8.5 years; median diabetes duration 3.9 yrs; mean age of onset 4.1 yrs) underwent neuropsychological testing at baseline and after 18-months of follow-up. We hypothesized that group differences observed at baseline would be more pronounced after 18 months, particularly in those T1D patients with greatest exposure to glycemic extremes. RESULTS: Cognitive domain scores did not differ between groups at the 18 month testing session and did not change differently between groups over the follow-up period. However, within the T1D group, a history of diabetic ketoacidosis (DKA) was correlated with lower Verbal IQ and greater hyperglycemia exposure (HbA1c area under the curve) was inversely correlated to executive functions test performance. In addition, those with a history of both types of exposure performed most poorly on measures of executive function. CONCLUSIONS: The subtle cognitive differences between T1D children and nondiabetic controls observed at baseline were not observed 18 months later. Within the T1D group, as at baseline, relationships between cognition (VIQ and executive functions) and glycemic variables (chronic hyperglycemia and DKA history) were evident. Continued longitudinal study of this T1D cohort and their carefully matched healthy comparison group is planned

The Relationships Among Social Capital, HIV Self-Management, and Substance Use in Women.

Women living with HIV (WLHIV) face unique challenges to successfully self-manage HIV including substance use and limited social capital. We conducted a 6-month mixed-methods study to describe how social capital influences HIV self-management and substance use among WLHIV. Participants completed a self-report survey and in-depth interview at baseline, and 3 and 6 months. Descriptive statistics, t-tests, and generalized estimating equations (GEEs) were used to examine quantitative relationships. Qualitative data were analyzed using qualitative description. Current substance users reported lower social capital compared with past substance users (2.63 vs. 2.80; p = .34). Over time, substance use and social capital were associated with HIV self-management (Wald χ2 = 28.43; p < .001). Qualitative data suggest that HIV self-management is influenced by overlapping experiences with social capital, including influential trust, community, and value of self can be complicated by ongoing substance use. Social capital can facilitate improved HIV self-management; however, substance use and trauma can weaken this relationship

Faecal haemoglobin and faecal calprotectin as indicators of bowel disease in patients presenting to primary care with bowel symptoms

OBJECTIVE: In primary care, assessing which patients with bowel symptoms harbour significant disease (cancer, higher-risk adenoma or IBD) is difficult. We studied the diagnostic accuracies of faecal haemoglobin (FHb) and faecal calprotectin (FC) in a cohort of symptomatic patients. DESIGN: From October 2013 to March 2014, general practitioners were prompted to request FHb and FC when referring patients with bowel symptoms to secondary care. Faecal samples were analysed for haemoglobin (EIKEN OC-Sensor io) and calprotectin (BÜHLMANN Calprotectin ELISA). Patients triaged to endoscopy were investigated within 6 weeks. All clinicians and endoscopists were blind to the faecal test results. The diagnostic accuracies of FHb and FC for identification of significant bowel disease were assessed. RESULTS: 1043 patients returned samples. FHb was detectable in 57.6% (median 0.4 µg/g, 95% CI 0.4 to 0.8; range 0–200). FC at 50 µg/g or above was present in 60.0%. 755 patients (54.6% women, median age 64 years (range 16–90, IQR 52–73)) returned samples and completed colonic investigations. 103 patients had significant bowel disease; the negative predictive values of FHb for colorectal cancer, higher-risk adenoma and IBD were 100%, 97.8% and 98.4%, respectively. Using cut-offs of detectable FHb and/or 200 µg/g FC detected two further cases of IBD, one higher-risk adenoma and no additional cancers. CONCLUSIONS: In primary care, undetectable FHb is a good ‘rule-out’ test for significant bowel disease and could guide who requires investigation

Patients' Attitudes and Experiences of Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis and Spondyloarthritis: A Qualitative Synthesis

Objective.Nonadherence to disease-modifying antirheumatic drugs (DMARDS) in rheumatoid arthritis (RA) and spondy-loarthritis (SpA) results in increased disease activity and symptoms and poorer quality of life. We aimed to describepatients’ attitudes and experiences of DMARDs in RA and SpA to inform strategies to improve medication adherence.Methods.Databases (MEDLINE, Embase, PsycINFO, and CINAHL) were searched to January 2016. Thematic synthesiswas used to analyze the findings.Results.From 56 studies involving 1,383 adult patients (RA [n=1,149], SpA [n=191], not specified [n=43]), we identified 6themes (with subthemes): intensifying disease identity (severity of sudden pharmacotherapy, signifying deteriorating health,daunting lifelong therapy), distressing uncertainties and consequences (poisoning the body, doubting efficacy, conflictingand confusing advice, prognostic uncertainty with changingtreatment regimens), powerful social influences (swayed byothers’ experiences, partnering with physicians, maintaining roles, confidence in comprehensive and ongoing care, valuingpeer support), privilege and right of access to biologic agents (expensive medications must be better, right to receive a biologicagent, fearing dispossession), maintaining control (complete ownership of decision, taking extreme risks, minimizing life-style intrusion), and negotiating treatment expectations (miraculous recovery, mediocre benefit, reaching the end of the line).Conclusion.Patients perceive DMARDs as strong medications with alarming side effects that intensify their disease iden-tity. Trust and confidence in medical care, positive experiences with DMARDS among other patients, and an expectationthat medications will help maintain participation in life can motivate patients to use DMARDs. Creating a supportive envi-ronment for patients to voice their concerns may improve treatment satisfaction, adherence, and health outcomes

Trends in AIDS-defining and non-AIDS-defining malignancies among HIV-infected patients: 1989-2002

In a comparison of rates of acquired immunodeficiency syndrome (AIDS)-defining malignancies (ADMs) for 1989-1996 versus 1997-2002, we found a decrease in ADMs (rate ratio, 0.31; P\u3c.0001) and a significant increase in non-AIDS-defining malignancies (non-ADMs; rate ratio, 10.87; P\u3c.0002). The mean CD4 cell count was lower among patients with ADMs than among those with non-ADMs. A longer duration of survival during highly active antiretroviral therapy might explain the increasing incidence of non-ADMs

The Added Complications of Climate Change: Understanding and Managing Biodiversity, Ecosystems, and Ecosystem Services Under Multiple Stressors.

Ecosystems around the world are already threatened by land-use and land-cover change, extraction of natural resources, biological disturbances, and pollution. These environmental stressors have been the primary source of ecosystem degradation to date, and climate change is now exacerbating some of their effects. Ecosystems already under stress are likely to have more rapid and acute reactions to climate change; it is therefore useful to understand how multiple stresses will interact, especially as the magnitude of climate change increases. Understanding these interactions could be critically important in the design of climate adaptation strategies, especially because actions taken by other sectors (eg energy, agriculture, transportation) to address climate change may create new ecosystem stresses